Basic Hospital Corps School FOREWORD Handbook III FOREWORD

MISSION OF NAVAL HOSPITAL CORPS SCHOOL

To train Sailors to perform as basic Navy Hospital Corpsmen.

The Student Handbook series was written to be used in the fourteen-week curriculum of the Basic Hospital Corps School. There are three Handbooks in the series:

Handbook I - Fundamentals

Handbook II - Emergency Care

Handbook III - Nursing Care

The Student Handbooks contain reading and study material to supplement the classroom lectures and demonstrations conducted during the course. Each topic in the course has a section in one of the Handbooks. The text is followed by a Worksheet, which provides study questions based on the learning objectives. The Worksheet questions are similar to those on the written examinations.

Tips for Success, eight pages of study techniques, test taking strategies, and suggestions for time management follow the Foreword in Handbook I.

The Student Handbooks are best used to read and prepare for upcoming classroom lectures, to re-read and fill-in the worksheet assignments and finally, re-reading as many times as necessary in preparation for written examinations and laboratory performance.

Students who keep their Handbooks after graduation will find them to be an excellent study guide for advancement examinations and an outstanding reference during future duty assignments.

Study smart or study hard, the choice is yours.

Naval Hospital Corps School is accredited by the Council on Occupational Education

i FOREWORD Basic Hospital Corps School Handbook III

ii Hospital Corps School TABLE OF CONTENTS Handbook III TABLE OF CONTENTS

Foreword...... i

Table of Contents...... iii

Lesson 3.01 Military Health Records...... 1 Military Health Records Worksheet ...... 7

Lesson 3.02 Basic ...... 11 Basic Physical Examination Worksheet ...... 17

Lesson 1.22 Preventive Medicine ...... 19 Preventive Medicine Worksheet ...... 27

Lesson 3.03 Care Documentation ...... 31 Patient Care Documentation Worksheet...... 37 Patient Care Documentation Scenarios...... 41 Patient Care Documentation Forms ...... 47

Lesson 3.05 Admission and Discharge ...... 53 Admission and Discharge Worksheet...... 57 Admission and Discharge Scenario ...... 61 Admission and Discharge Forms ...... 63

Lesson 3.04 Inpatient Clinical Record ...... 73 Inpatient Clinical Record Worksheet...... 77 Inpatient Clinical Record Scenario ...... 81 Inpatient Clinical Record Forms...... 83

Lesson 3.07 Nasogastric Tubes...... 89 Nasogastric Tubes Worksheet...... 95

Lesson 3.06 Inpatient Care...... 99 Inpatient Care Worksheet ...... 101

Lesson 3.08 Range of Motion and Patient Positioning ...... 103 Range of Motion and Patient Positioning Worksheet...... 115

Lesson 3.09 Restraining a Patient ...... 119 Restraining a Patient Worksheet...... 123

Lesson 3.10 Isolation Techniques & Blood Borne Pathogens ...... 125 Isolation Techniques & Blood Borne Pathogens Worksheet...... 138

Lesson 3.11 Surgical Asepsis ...... 143 Surgical Asepsis Worksheet ...... 154

iii TABLE OF CONTENTS Hospital Corps School Handbook III

Lesson 3.14 Urinary Catheterization...... 160 Urinary Catheterization Worksheet ...... 172

Lesson 3.13 Specimens...... 178 Specimens Worksheet...... 188

Lesson 3.12 Wound Management...... 192 Wound Closure Management...... 196

Lesson 1.23 DOD Immunization Program...... 198 DOD Immunization Program Worksheet ...... 200

Lesson 3.16 Introduction to Administration ...... 202 Introduction to Medication Administration Worksheet ...... 208

Lesson 3.15 Pharmacology and Toxicology ...... 210 Pharmacology and Toxicology Worksheet ...... 228

Lesson 3.18 Dosage Calculations ...... 232 Dosage Calculations Worksheet ...... 236

Lesson 3.19 Oral Administration ...... 240 Oral Medications Administration Worksheet ...... 246

Lesson 3.17 Storage of Medications ...... 256 Storage of Medications Worksheet ...... 258

Lesson 3.20 Sublingual/Topical/Rectal Medication Administration ...... 262 Sublingual/Topical/Rectal Medication Administration Worksheet ...... 266

Lesson 3.21 Intramuscular and Subcutaneous Medications Administration...... 270 Intramuscular and Subcutaneous Medications Administration Worksheet ...... 282

Lesson 3.24 Venipuncture...... 286 Venipuncture Worksheet ...... 290

Lesson 3.25 Introduction to Intravenous Therapy ...... 294 Introduction to Intravenous Therapy Worksheet ...... 300

Lesson 3.26 Maintenance of Intravenous Therapy ...... 304 Maintenance of Intravenous Therapy Worksheet ...... 310

Lesson 3.27 Intravenous Insertion ...... 316 Intravenous Insertion Worksheet ...... 324

Lesson 3.22 Pain Management...... 330 Pain Management Worksheet ...... 334

iv Hospital Corps School TABLE OF CONTENTS Handbook III

Lesson 3.29 Cast Care...... 338 Cast Care Worksheet...... 342

Lesson 3.30 Chest Tubes...... 344 Chest Tubes Worksheet ...... 356

Lesson 3.28 Respiratory Care ...... 360 Respiratory Care Worksheet ...... 368

Lesson 3.23 Pre-operative and Postoperative Nursing Care ...... 372 Pre-operative and Postoperative Nursing Care Worksheet...... 384 Pre-operative and Postoperative Nursing Care Scenario ...... 388 Pre-operative and Postoperative Nursing Care Forms...... 390

Lesson 3.31 Death and Dying ...... 396 Death and Dying Worksheet...... 402

Lesson 3.32 Transferring and Ambulating a Patient…………………………………………………. 406 Transferring and Ambulating a Patient Worksheet………………………………………412

Appedix1 ...... A-1-1

v TABLE OF CONTENTS Hospital Corps School Handbook III

vi Basic Hospital Corps School Lesson 3.01 Military Health Records Handbook III Lesson 3.01

Military Health Records

Terminal Objective:

3.01 Know how to maintain and use military health records.

Enabling Objectives:

3.01.01 List the categories of health records.

3.01.02 State the use for each health record form.

3.01.03 List the sequence of forms in a health record.

3.01.04 List regulatory provisions concerning maintenance of health records.

CATEGORIES OF HEALTH When an active duty member retires, his/her RECORDS Health Record is retired with the service record. An Outpatient Treatment Record is initiated for There are three categories of health or the retiree. A COPY of the Health Record contents treatment records. The outpatient record for active may be placed into the retiree's Outpatient duty members of the uniformed services is called Treatment Record. Other beneficiaries for medical the Health Record, which is used to document care include foreign military personnel attached to medical care provided to members of the United States military units or bases, their eligible uniformed services. The Dental Record, which is family members, and civilian employees of our used to document dental care provided to active government (civil service). duty members, is not normally maintained by hospital corpsman. These are two separate records, An Inpatient (Clinical) Record is used to although they may be filed together with the dental document hospital inpatient care given to all record inside the . beneficiaries of Navy medical care.

The record used for the documentation of LOCATION, NAME AND PURPOSE outpatient medical care provided to all OF FORMS IN HEALTH RECORDS except active duty members of the uniformed services is called the Outpatient Treatment Health records serve three main purposes. Record. The Outpatient Treatment Record is used First, they provide a chronological record of for retired military personnel and eligible family physical examination, illnesses, injuries and members of: treatment, and susceptibility to illnesses. Second, the forms in the health record provide a means of a. Active duty members communication between the practitioner responsible for the patient's care and all other b. Deceased active duty members members of the health care team. If an active duty member is evaluated by the physician on his/her c. Retired military personnel. ship and then sent for further evaluation at a hospital, the evaluation of the ship's doctor will be

1 Lesson 3.01 Military Health Records Basic Hospital Corps School Handbook III available in the health record for the doctor at the Chronological Record of HIV Testing receiving hospital to read. Third, these records are NAVMED 6000/2 is the next form in Part 1. This a medical/legal document that may be used as form contains a listing of all HIV tests drawn and evidence in both military and civilian courts of the results. law. Baseline Audiogram DD 2215, required for Forms that are in health records have different all active duty personnel, is used as a reference purposes and special locations that enable the audiogram to determine possible hearing changes Hospital Corpsman to locate and use them quickly. or loss. The record is divided into four parts. PART 2: RECORD OF MEDICAL Part 1: Record of Preventive Medicine and CARE AND TREATMENT Occupational Health The following three forms are interfiled Part 2: Record of Medical Care and chronologically with the most recent visit (by date) Treatment on top:

Part 3: Physical Qualifications Chronological Record of Medical Care SF 600 documents the individual's current medical Part 4: Record of Ancillary Studies, Inpatient history, e.g. sick call or clinic visit Care, & Miscellaneous Forms Emergency Care and Treatment Record SF All reports and forms are stored in the 558 documents care given in an emergency Treatment Record Folder NAVMED 6150/21- situation, e.g. Emergency Room visit 30. The forms are filed in a specific order in every record so they can be easily located. When there Consultation Sheet SF 513 used by medical are multiple copies of the same form, they are filed department personnel to request information or chronologically, with the most recent dated form advice from a specialist concerning the diagnosis on top. The forms discussed in this handbook are or treatment of a patient some of the most commonly seen forms, generally available in each health record. There are many PART 3: PHYSICAL more forms and each one is filed in a specific location in the health record. QUALIFICATIONS

PART 1: Record of Preventive Medicine The Report of Medical Examination DD 2808 is filled out by a medical officer to provide a and Occupational Health. complete report of medical examination. This report is filled out (1) upon entry into the military The Summary of Care Form NAVMED service, (2) special purposes, and (3) upon 6150/20 is the topmost form in Part 1 of the health discharge or retirement. The Report of Medical record. It is a record of ambulatory (outpatient) History DD 2807-1 is filled out by the individual health care. It includes, but is not limited to, patient upon entry into the military service, upon significant medical and surgical conditions, discharge, and when a physical examination is or untoward reactions to drugs, current or required. It provides a complete recently used medication, and routine medical and any additional pertinent medical information. examinations or tests. The DD 2808 and DD 2807-1 are filed as a pair for the same examination. Officer Physical The next form is the Immunization Record Examination Questionnaire NAVMED 6120/2, SF 601 on which prophylactic immunizations is a record of an officer's personal medical history (tetanus, typhoid, etc.) and information concerning is attached to the corresponding DD 2808 for the hypersensitivities are recorded.

2 Basic Hospital Corps School Lesson 3.01 Military Health Records Handbook III same examination. The NAVMED 6120/2 is filed MAINTENANCE OF A HEALTH in place of the SF 93 when it is used. RECORD

The next form is Abstract of Service and Treatment records and their contents are the Medical History NAVMED 6150/4. This form property of the Federal Government and must be provides a chronological history of the stations and maintained at the authorized medical treatment ships to which the member is assigned for duty facility, which provides care for the patient. A and medical treatment. It is an abstract (diagnostic patient may NOT retain custody of his/her health summary only) of medical history for each record. The records are preserved for the long-term admission to the Sick List. interest of the patient and the government.

Record of Disclosure - Privacy Act of 1974 The Commanding Officer (CO) of the OPNAV 5211/9, is used to record release of treatment facility is ultimately responsible for medical information health records maintained at his/her activity and is designated as the systems manager. The CO Privacy Act Statement - Health Care designates, in writing, a Medical Records Record DD 2005, is used as an all inclusive Administrator who is responsible for the routine privacy statement in the health record. This form upkeep and annual verification of all records and documents that the patient was informed of the correction of any errors found in the records. purpose and use of information in a health record. Periodically, health records are inspected for It is not a consent form. Signature of the member accuracy and completeness by the CO or a is not mandatory. designated representative of the CO.

The Record of Disclosure OPNAV 5211/9 is Contents of the health record are considered preprinted at the back of section 3. If the record is privileged information. The information in the being established, the preprinted form will be health record may be released only to the patient used. If an existing record is converted to the four- or the patient's legal guardian. If a written part record, file the existing OPNAV 5211/9 after authorization is provided from the individual, the NAVMED 6150/4 Abstract of Service and health record information can be released to any Medical History. The Privacy Act Statement - designated individual. Hospital Corpsmen may Health Care Records DD 2005 is preprinted on the NOT release patient health data to anyone, inside right cover of the record folder. If an EXCEPT the patient or legal guardian. Record of already existing record is being converted to the Disclosure OPNAV 5211/9 is completed and filed four-part system, the DD 2005 is filed at the end of in that patient's record whenever information is Part 3. If new record is being started, the disclosed from a health record. preprinted form at the back of Part 4 is to be used. Health record forms and reports are PART 4: RECORD OF ANCILLARY permanently stored in Treatment Record Folder STUDIES, INPATIENT CARE, & NAVMED 6150/21-30. Identifying data on the MISCELLANEOUS FORMS outside of the folder is written in black permanent marker indicating to whom the record The top form in this section is Radiologic belongs, as well as the service, status and, if an Consultation Requests/Reports SF 519, the eligible family member, relationship to the backing sheet that is used to display x-ray reports, sponsor. Data includes name of the individual and SF 519As. Beneath this is the Laboratory social security number (SSN) of the service Report Display SF 545, used to mount laboratory member. Eligible family members use the SSN of reports. the service member.

The Family Member Prefix code (FMP) is written within the two diamonds prior to the SSN.

3 Lesson 3.01 Military Health Records Basic Hospital Corps School Handbook III

The FMP code for active duty members is 20, the treatment record subcategories, (1) military (for FMP code for spouses of members is 30. The health records of military members only), (2) treatment record folder has the second to last digit retired or (3) nonmilitary (for outpatient treatment of the SSN preprinted on it. The preprinted records) are also marked with the requested number also matches the last digit of the form information. The record category tape on the number, e.g. the preprinted digit of NAVMED right back edge is color coded to indicate the 6150/28 is 8. The treatment record jacket color is record is that of an active duty member (red) or all determined by the second to last digit of the other categories (black). service member's SSN. For example, if an SSN were 123-45-6789, the 8 would be used to identify On the bottom left front is the special the color for the record (pink, in this case). programs block. If the record belongs to an Different colored folders indicate different SSNs. individual who is a food handler or is exposed to The SSN serves three purposes. First, it is used as radiation, the appropriate boxes are checked. The a unique identifier. Second, it is used to group annual verification box on the right front edge of family members records together. Third, it is used the folder, is blackened after the record is verified to file the health record. each year.

Last digit tape is used on the jacket to aid in The inner left leaf also contains information locating misfiled records. Black tape is used to that is useful in locating service members and their cover the last digit of the SSN on both number families. This information is entered in pencil and scales, on the right side of the folder and on the top changed as the individual moves from one duty of the folder. station to another and includes: date of arrival, projected departure date, home address and The name of the patient (last, first, middle telephone number, and the member's/sponsor's initial) is written on the right front of the record duty station and telephone number. folder. The Alert Box is checked if the record's owner has an or sensitivity. All forms in the health record are required to include the following information The treatment record category, health or outpatient, is marked on the left front. The

4 Basic Hospital Corps School Lesson 3.01 Military Health Records Handbook III

DATA EXAMPLE

(1) family member prefix and SSN 20/123-45-6789

(2) name - last, first, middle initial Smith, John D.

(3) rank/grade or title LT/O-3, Mrs.

(4) status of patient or sponsor AD = Active Duty Ret = Retired FMW =Family Member Wife FMH = Family Member Husband FMD = Family Member Daughter FMS = Family Member Son

(5) branch of service (of Active duty USN (Navy) member or sponsor) USA (Army) USAF (Air Force) USMC (Marine Corps) USCG (Coast Guard) PHS (Public Health Service)

(6) sex/gender Male or Female

(7) date of birth 10 OCT 72

(8) organization/command to which USS ______member/sponsor is assigned

(9) name and address of organization NMC Norfolk, VA maintaining patient's treatment record.

5 Lesson 3.01 Military Health Records Basic Hospital Corps School Handbook III

FIGURE 3.01.01 Treatment Record Jacket NAVMED 6150/10-19

6 Basic Hospital Corps School Lesson 3.01 Military Health Records Worksheet Handbook III Lesson 3.01

Military Health Records Worksheet

1. List the categories of health or treatment records.

a. ______

b. ______

c. ______

2. List the individuals who use the outpatient treatment record.

a. ______

b. ______

c. ______

d. ______

e. ______

3. When is the Inpatient (clinical) record used?

______

______

4. What purposes do the forms in a Health Record serve?

______

______

______

5. What is the title of Part 1 on the Health Record?

______

6. What is the purpose of the Summary of Care NAVMED 6150/20?

______

______

______

7 Lesson 3.01 Military Health Records Worksheet Basic Hospital Corps School Handbook III

7. What is the use of the Reference Audiogram DD 2215?

______

______

8. Where in the Health Record is the Report of Medical History DD 2807-1 filed?

______

______

9. What is recorded on the Consultation Sheet SF 513?

______

______

______

10. What form is used to record release of medical information?

______

______

11. Where is the Emergency Care and Treatment Record SF 558 filed in relation to the Chronological Record of Medical Care SF 600?

______

______

12. Who is ultimately responsible for maintenance of the Health Records?

______

13. Health records are subject to inspection every ______by a designated representative of the CO.

a. month

b. year

c. 5 years at the time of the patients annual physical exam

d. 10 years

8 Basic Hospital Corps School Lesson 3.01 Military Health Records Worksheet Handbook III

14. Treatment records and their contents:

a. are the property of the individual.

b. are the property of the Federal Government.

c. can be kept in the patients home.

d. must be preserved because of long term interest to the individual.

15. Information in the Health Record:

a. can be released to the spouse of the patient without written permission.

b. is not privileged information.

c. can be released by the HM to anyone who asks.

d. can be released to any designated individual with written permission from the patient.

16. Health Records are filed by color and ______.

17. List the identifying information that is on the left inside cover of the Health Record folder.

______

______

______

18. What information is required on Health Record forms?

______

______

______

19. List the military service represented by the following letters.

USA______USN______

USAF______USMC______

USCG______PHS______

9 Lesson 3.01 Military Health Records Worksheet Basic Hospital Corps School Handbook III

NOTES/COMMENTS

10 Basic Hospital Corps School Lesson 3.02 Basic Physical Examination Handbook III Lesson 3.02

Basic Physical Examination

Terminal Objective

3.02 State the Hospital Corpsman's role, and equipment used, in a basic physical examination.

Enabling Objectives:

3.02.01 State the Hospital Corpsman's responsibilities during a physical examination.

3.02.02 List and describe diagnostic equipment used in a basic physical examination.

3.02.03 State basic maintenance and troubleshooting guidelines for selected physical examination equipment.

3.02.04 State commonly used procedures for performing visual examinations.

3.02.05 State the procedure for taking a 12 lead electrocardiogram.

3.02.06 State the Hospital Corpsman's role for assisting with a .

3.02.07 State the steps and equipment used to weigh and measure an infant.

3.02.08 Perform basic troubleshooting and maintenance of selected physical examination equipment.

Hospital Corpsmen have many responsibilities PHYSICAL EXAMINATION during a physical examination. They set up for the EQUIPMENT exam by readying the environment, gathering and troubleshooting all the equipment, and getting the The diagnostic equipment utilized in a basic patient ready. The patient may be nervous, require physical examination includes: emotional support, or need assistance changing positions during the exam. Corpsmen may 1. Otoscope -- An instrument used to inspect complete lab or X-ray requests, assist the examiner the auditory canal and tympanic membrane. It may during the exam, and complete the medical be portable or wall mounted, Figure 3.02.01. history. Corpsmen may also be required to act as a Troubleshooting includes changing batteries standby, providing protection for the physician and and/or light bulb, when needed, and simply the patient from allegations of improper behavior. tightening the connections. A standby is usually the same sex as the patient. 2. Ophthalmoscope -- Hand-held instrument A thorough physical examination consists of a utilized to check pupillary reaction to light and medical history, a head to toe examination, and inspect the inner eye, Figure 3.02.02 This diagnostic studies such as blood work-ups, chest instrument needs routine maintenance of batteries X-ray, visual acuity, etc. Proper sequencing and and light bulb. accurate recording of all data on appropriate forms is essential.

11 Lesson 3.02 Basic Physical Examination Basic Hospital Corps School Handbook III

3. Stethoscope -- Used to auscultate the 14. Tissues -- Used to wipe instruments. May heart, lungs, abdomen/bowels, and . also be used by patients to remove excess lubricant If the earpieces are missing, or the tubing or from membranes after the examination. diaphragm cracked, these parts must be replaced to ensure accurate transmission of sounds. TROUBLESHOOTING PHYSICAL EXAM EQUIPMENT 4. /reflex hammer -- A rubber hammer used to assess reflexes, a gross assessment The physical condition of all tubing, hoses, of brain, spinal cord, or peripheral nerve wires, and gauges should be checked prior to each impairment, Figure 3.030.03. use of any equipment to assess it is functioning properly and/or within standards. 5. Tape measure -- Used to measure circumference of an infant's head and obtain body Basic maintenance and upkeep of the length; circumference of extremities or abdominal Oto/Ophthalmoscope will ensure proper function. girth, as well as specified body measurements used Areas of concern on this piece of exam equipment to calculate body fat percentage. It is used on a are: Battery condition, if battery operated; patient with a draining wound, it should be cleaned condition of the charging unit; light bulbs, if they immediately after use and kept with the same function; and if all the connections are snug and patient. secure and if the unit is plugged in, if applicable. Before using an electronic thermometer check to 6. Scale -- Used to obtain patient's weight. see that the digital read-out registers 90 degrees F. To obtain a correct weight, the scale must be The probe must be tightly connected to the unit to calibrated to zero prior to use. get an accurate temperature reading. Return the thermometer to the recharging unit after use so it 7. Vaginal speculum -- Used to inspect the will be ready for the next use. vagina and cervix. The screws that adjust opening and closing of the speculum should be checked EQUIPMENT FOR VISUAL ACUITY prior to use. Basic Hospital Corpsmen are NOT authorized to use the speculum. A Snellen Chart is used to assess basic visual

acuity. The Snellen Chart for adult patients 8. Water soluble lubricant (KY Jelly) -- consists of a series of letters of decreasing size, Used to lubricate examiner's gloved hand when Figure 3.02.04. The pediatric Snellen E Chart performing rectal/vaginal assessments. makes note of the direction the letter E is facing in

decreasing sizes. The patient is positioned 20 feet 9. Exam gloves -- Used when palpating the from the chart. The 20/20 line must be 64 inches buccal (oral) cavity, genitals, and perineal region. above the floor. Exams are performed without

corrective lenses first, then tested again with 10. Tongue blades -- Used to examine buccal corrective lenses or glasses. Test each eye (oral) cavity and oropharynx. individually. Have the patient cover the right eye

completely while the left eye is tested. Cover the 11. Sphygmomanometer -- Used to measure left eye completely while the right eye is tested. blood pressure. The gauge should register at zero Then test the eyes together by having the patient prior to use to ensure accuracy. The bladder and read the Snellen Chart with both eyes uncovered. tubing should be replaced as needed. Record the results on the appropriate form.

12. Electronic thermometer -- Used to The Armed Forces Vision Tester (AFVT) is obtain a patient's body temperature. a semi-portable machine for testing near/distant

visual acuity, depth perception, and horizontal and 13. Watch/clock with second hand -- Used vertical phorias. This machine is commonly used to time the /respirations of a patient. at Drivers License Examining Centers. To use the

12 Basic Hospital Corps School Lesson 3.02 Basic Physical Examination Handbook III

AFVT, have patient place forehead in the genitalia and pelvic contours. The role of the appropriate place and adjust the machine to the Hospital Corpsman is to prepare the equipment, patient's height. Follow manufacturer's directions instruct the patient, and provide for safety, privacy, for turning the knobs for each test and using the education, and comfort and assist during the exam. scoring key provided. Record the results on the The HM may serve as a standby during a pelvic appropriate form. exam. Start by having the patient void prior to the exam. OBTAINING AN ELECTROCARDIOGRAM The HM will wash hands and prepare the following equipment: examination light, vaginal The electrocardiograph is an instrument for speculum, gloves, water soluble lubricant, exam recording the electrical activity of the heart. The table with stirrups, and culture swabs or media electrocardiogram (ECG/EKG) is a recorded plates as necessary. image of the heart's activity. The HM will then assist the patient into the To obtain an EKG, begin by washing hands lithotomy position, Figure 3.02.06, for the exam, and gathering the equipment. Make sure the drape the patient for privacy, and assist the machine is unplugged before moving. Establish practitioner. After the exam, assist the patient from patient identification by using the three ID checks, the table and provide an area to clean up and dress. name plate on bed, ID bracelet, and ask the patient to state his/her name. Provide for safety, privacy, WEIGHING AND and comfort. The patient should remove all MEASURING INFANTS jewelry, including watch and dog tags, and remove all clothing above the waist. Socks and shoes must In the ambulatory care aspect of patient care, be removed. Place patient in a supine or semi- routine measuring of infant's height and weight fowler's position, turn on machine, and follow the may become necessary. When obtaining an infant's manufacturer's instructions to enter data into the weight, the HM will wash hands, drape the scale computer. Apply the 4 limb/extremity and 6 chest with protective paper covering and zero the scale. leads ensuring the correct lead is in the proper After removing the infant's clothing, gently place location, Figure 3.02.05. Ask the patient to relax, infant on scale tray. NEVER leave the infant NOT to move and to breathe normally. Start the unattended and ensure that the infant does NOT recorder and obtain the EKG. Do not remove the become chilled. Note the weight in pounds and leads until a nurse or physician has reviewed the ounces OR kilograms and grams. Remove the EKG printout. If the EKG is of poor quality, verify infant from the scale, dress infant and return to correct lead placement and perform the test again. parent or crib. After completing procedure, wash hands, and record infant's weight on chart. Upon completion of EKG, remove all leads, allow patient to clean and dress. Clean the To obtain the height of an infant, begin by equipment and store all leads and attachments. washing your hands. Cover the measuring board Record the procedure on SF 600. File the EKG in with a clean towel or exam paper. Place the infant Health Record or Inpatient Clinical Record. on the measuring board FACE UP. Measure infant from the crown of the head to the heels with legs PELVIC EXAMINATION straight. Remove infant from measuring surface PROCEDURES and return to parent or crib. Wash hands and record height of infant on chart. Pelvic exams are a visual and digital assessment of the external and internal female

13 Lesson 3.02 Basic Physical Examination Basic Hospital Corps School Handbook III

FIGURE 3.02.01 FIGURE 3.02.02 Otoscope Opthalmoscope

FIGURE 3.02.03 FIGURE 3.02.04 Percussion/Reflex Hammer Snellen Chart

14 Basic Hospital Corps School Lesson 3.02 Basic Physical Examination Handbook III

FIGURE 3.02.05 Chest Lead Sites

FIGURE 3.02.06 Lithotomy Position

15 Lesson 3.02 Basic Physical Examination Basic Hospital Corps School Handbook III

NOTES/COMMENTS

16 Basic Hospital Corps School Lesson 3.02 Basic Physical Handbook III Examination Worksheet Lesson 3.02

Basic Physical Examination Worksheet

1. Circle the tasks a Hospital Corpsman may perform before and during a physical examination.

a. Set up for the exam

b. Check to see that the equipment is in working condition

c. Assist the patient

d. Troubleshoot equipment

2. What equipment would be used to check for swelling on a patient with a complaint of a painful right calf?

a. Otoscope

b. Ophthalmoscope

c. Tape Measure

d. Percussion Hammer

3. What tool is used to examine a patient's eyes? ______

4. What tool is used to test neurological status (reflex)? ______

5. What tool is used to examine the vagina and cervix? ______

6. Who may use the tool to examine the vagina and cervix? ______

7. List two pieces of physical assessment equipment that should be calibrated to zero before use.

a. ______

b. ______

8. List three things to check if an otoscope or ophthalmoscope is not working.

a. ______

b. ______

c. ______

17 Lesson 3.02 Basic Physical Basic Hospital Corps School Examination Worksheet Handbook III

9. Match each physical examination element in Column B to the medical equipment used to examine it in Column A.

A B

a. Otoscope ______1. Heart, lung, abdomen

b. Ophthalmoscope ______2. Auditory canal and TM

c. Stethoscope ______3. Aids in access to buccal cavity

d. Percussion/reflex hammer ______4. Pupillary reaction, inspect inner eyes

e. Tape Measure ______5. Neurological assessment

f. Scale ______6. Circumference/Body fat %

g. Tongue Blade ______7. Time pulse, respirations

h. Sphygmomanometer ______8. Weight

i. Thermometer ______9. Remove lubricant

j. Watch/Clock ______10. Exam of oral cavity, genitals and perineal region.

k. Tissue ______11. Measure blood pressure

l. Exam gloves ______12. Body temperature

10. What is the procedure for troubleshooting a stethoscope?

______

______

18 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Handbook III Lesson 1.22

Preventive Medicine

Terminal Objective:

1.22 State the basic principles of preventive medicine.

Enabling Objectives:

1.22.01 Define terms associated with preventive medicine.

1.22.02 List the modes of transmission of communicable diseases.

1.22.03 List the basic characteristics of selected communicable diseases.

1.22.04 List basic methods for controlling and preventing communicable diseases.

1.22.05 List methods by which sexually transmitted diseases are transmitted.

1.22.06 List the , diagnosis, and treatment of selected sexually transmitted diseases.

1.22.07 List methods of prevention of common sexually transmitted diseases.

1.22.08 State the basic principles of field sanitation.

1.22.09 State the procedure for ensuring water is potable.

1.22.10 State the components of a health and comfort inspection.

1.22.11 State the basic principles of foot care.

A primary mission of the medical department TERMINOLOGY is to safeguard and promote the health of Navy and Marine Corps personnel. This is accomplished CARRIER -- A person or animal that harbors largely through a preventive medicine program a specific infectious agent in the absence of emphasizing the preservation of health and discernible clinical disease and serves as a maximum effectiveness of the individual. It is a potential source of infection for man. multifaceted state of the art program that cannot be covered in its entirety within this chapter. COMMUNICABLE DISEASE -- An illness However, this lesson will familiarize you with a due to a specific infectious agent or its toxic small section of the program. products, which may pass or be carried from a reservoir to a susceptible host either directly or indirectly.

19 Lesson 1.22 Preventive Medicine Basic Hospital Corps School Handbook III

EPIDEMIC -- The occurrence in a region, of DIRECT TRANSMISSION an illness, clearly in excess of normal expectancy numbers, and originating from a common source. Direct and essentially immediate transfer of infectious agents to a receptive portal of entry. HOST -- A human or other living animal affording nourishment to an infectious agent under DIRECT CONTACT: Such as touching, natural conditions. biting, kissing, or sexual intercourse.

INCUBATION PERIOD -- The time interval DIRECT PROJECTION (OR DROPLET between exposure to an infectious agent and the SPREAD): Droplets spray onto the conjunctiva or appearance of the clinical manifestations of the mucous membranes of the eye, nose, or mouth disease. during sneezing, coughing, spitting, singing, or talking. INFECTION -- The entry and development or multiplication of infectious agents in the body INDIRECT TRANSMISSION of man or animals. Contaminated inanimate materials such as INFECTIOUS AGENT -- An organism toys, bedding, surgical instruments, water, food, capable of producing infection or infectious milk, biological products (containing blood, disease serum, plasma, tissues or organs), or any substance serving as an intermediate means by which an NOSOCOMIAL INFECTION -- An infectious agent is transported to a susceptible host infection acquired during hospitalization. through a suitable portal of entry. May be called vehicle-borne transmission. PORTAL of ENTRY -- The means of entry for an infectious agent into a host, e.g., breaks in VECTOR-BORNE the skin, respiratory tract, urinary tract, bloodstream, and gastrointestinal tract. a. Mechanical: Includes simple mechanical

carriage by a crawling or flying insect RESERVOIR -- A habitat on which an through soiling its feet or by passage of infectious agent depends primarily for survival. organisms through its intestinal tract. The agent lives, multiplies, and reproduces so that it can be transferred to a susceptible host. b. Biological: Transmission may be by

injection of salivary gland fluid during SUSCEPTIBLE HOST -- Nonresistant man biting, by regurgitation, feces of an animal or other living animal to an infectious agent. that is capable of penetrating the skin via

scratching or rubbing, e.g., common house TRANSMISSION -- Any mechanism by fly. which an infectious agent is spread from a source or reservoir to a person. c. Airborne: Dissemination of microbial

aerosols to a portal of entry, usually the SEXUALLY TRANSMITTED DISEASE respiratory tract. (STD) -- Contagious disease transmitted by sexual contact. CONGENITAL MODES OF TRANSMISSION a. Spread of infectious agent from mother to

unborn fetus. Communicable diseases are spread by specific routes of transmission.

20 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Handbook III

SELECTED COMMUNICABLE (3) anorexia DISEASES (4) nausea VIRAL DISEASES (5) discomfort followed within a few days

by jaundice 1. Chickenpox

b. Modes of transmission a. Signs and symptoms

(1) fecal/oral route (1) fever

(2) associated with uncooked shellfish, (2) characteristic skin eruptions are first, fruit, vegetables, and contaminated then a granular scab water

(3) itching associated with skin eruptions 4. Hepatitis B (HBV) -- serum hepatitis

b. Modes of transmission a. Signs and symptoms -- onset is insidious

(1) airborne droplet spread (1) anorexia

(2) direct contact with skin lesion (2) vague abdominal discomfort

2. Influenza (3) nausea and vomiting

a. Signs and symptoms (4) arthralgia and rash often progressing

to jaundice (1) abrupt onset of fever

b. Modes of transmission (2) chills

(1) sexual contact with infected host (3)

(2) direct contact with infected blood (4) myalgia, sometimes with prostration products

(5) runny nose and sore throat (3) transmitted via parenteral, sexual, and

prenatal routes (6) cough -- often severe and drawn out

(4) has been isolated in saliva, tears, b. Mode of transmission blood, seminal fluid, CSF, breast milk,

urine, and feces (1) Airborne or droplet spread

(5) complications include chronic liver 3. Hepatitis A (HAV) -- formerly called disease, cirrhosis, and primary infectious hepatitis hepatocellular cancer

a. Signs and symptoms 5. Hepatitis D (HDV) -- is a co-infection with

Hepatitis B and is parenterally transmitted. (1) fever

(2) malaise

21 Lesson 1.22 Preventive Medicine Basic Hospital Corps School Handbook III

6. Hepatitis E (HEV) -- is enterically transmitted 4. Meningitis by fecal/oral route through contaminated food or water. a. Signs and symptoms

BACTERICAL DISEASES (1) high fever

1. Strep throat (2) neck pain

a. Signs and symptoms (3) back pain

(1) fever (4) nausea

(2) sore throat (5) lethargy

(3) exudative tonsillitis (6) photosensitivity

(4) pharyngitis (7) petechial rash

b. Mode of transmission (8) altered level of consciousness (as severe as convulsions) (1) airborne or droplet spread b. Mode of transmission 2. Rheumatic fever (1) airborne or droplet spread a. Follows inadequately treated strep throat (2) direct contact with nasopharyngeal b. May result in varying degrees of damage secretions of infected host to heart tissue PARASITIC DISEASE 3. Tuberculosis 1. Hookworm a. Signs and Symptoms a. Signs and symptoms (1) weight loss (1) ground itch -- A rash at the site of (2) fever larval penetration

(3) cough b. Mode of transmission

(4) chest pain (1) direct contact

(5) in advanced stages, hoarseness and 2. Malaria. There are four types of malaria. The from the lungs. following information is for falciparum malaria that is the most serious type and is b. Mode of transportation considered a medical emergency.

(1) Respiratory or droplet. The bacteria is a. Signs and Symptoms discharged in the sputum (1) fever

(2) chills and sweating

22 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Handbook III

(3) headache controlling communicable diseases. These practices together will help control communicable (4) jaundice diseases:

(5) blood coagulation defects 1. Breaking the chain of infection. There are six elements in the chain of infection. (6) shock Controlling or eliminating any one of these can stop the spread of a disease. The elements (7) renal and liver failure include: the infective agent, the reservoir, the portal of exit, the means of transmission, the (8) disorientation and delirium portal of entry, and the susceptible host.

b. Mode of transmission The infectious agent can be killed through sterilization or other treatment. The reservoir (1) bite of the female Anopheles can be interrupted or eliminated through mosquito in tropical areas sterilization or disinfection. Proper disposal of waste and contaminated articles will break the (2) contaminated needles and syringes means of exit through a portal. The means of transmission can be eliminated by blocking FUNGAL DISEASE the route. For example, frequent hand washing and isolation procedures will eliminate the 1. Tinea (ringworm) transport link of the chain. Entry (portal of entry) into new host can be controlled with a. Signs and symptoms practice of strict aseptic technique and maintenance of healthy, intact skin. The (1) Tinea capitis (ringworm of the scalp) susceptible host is guarded by use of begins as a small papule and spreads protective isolation procedures, receipt of peripherally, leaving a small area of adequate nutrition, and early recognition. baldness or broken brittle hair. Abstinence will prevent the spread of STDs.

(2) Tinea corporis (ringworm of the body) 2. Immunizations. Protection against certain diseases before exposure can be provided by (3) Tinea pedis (ringworm of the foot). an immunization. The medical department is Starts between the toes and spreads responsible to ensure military personnel and along the bottom of the foot. their families receive the required immunizations and their records are properly b. Modes of transmission maintained.

(1) direct contact 3. Hygiene. Good personal hygiene promotes health and prevents disease. It will further (2) indirect transmission through contact enhance your professional image as a member with contaminated objects of the health care team.

CONTROL OF COMMUNICABLE 4. Sanitation. Obtaining food and water, including ice, from approved sources, will DISEASES assist in preventing food borne illnesses. Preparation of food must be in accordance Control and prevention of communicable with acceptable practices as directed by diseases is an important role of the Hospital military instruction. Proper sanitation will Corpsman. Health and well-being of assigned decrease and control insect and rodent personnel are promoted by preventing and

23 Lesson 1.22 Preventive Medicine Basic Hospital Corps School Handbook III

populations, thus deleting another transmission Diagnosis is based on symptoms, personal link in the chain of infection. history, or sexually transmitted disease contact referral. The diagnosis is confirmed by 5. Mechanical prophylaxis. A latex condom, identification of the gonococcus through gram- coated with Noxinyll will assist in preventing stained smears and exudate specimen cultures. In the spread of STDs. females, repeated cervical and rectal cultures may be necessary to detect residual infection. SEXUALLY TRANSMITTED DISEASES Treatment: (Under the supervision of a medical officer.) Penicillin, Spectinomycin, Sexually transmitted diseases (STD) are tetracycline or ceftiriaxone. contagious diseases transmitted by sexual contact. STDs are found in many forms and are among the NONGONOCOCCAL URETHRITIS most common communicable diseases. (NGU OR NSU) Unfortunately, due to embarrassment, lack of information, and in some cases, lack of common Nongonococcal urethritis is a sexually sense, many cases go untreated. More lenient transmitted urethritis of males not associated with views towards sexual behavior and asymptomatic the gonococcus. Clinical manifestations are either carriers have also added to the problems of control indistinguishable from gonorrhea or somewhat and prevention. milder.

STDs are transmitted through direct contact, Symptoms for males include mucopurulent usually sexual intercourse. However, medical discharge, urethral itching, dysuria, burning during personnel with open wounds may develop STDs if urination, and occasional hematuria. they fail to follow universal precautions. Transmission can also be congenital. A pregnant Symptoms for females include a persistent woman, with an active STD, may pass the disease vaginal discharge or recurrent cystitis for which no to the newborn by placental transfer or during a cause can be found, or cervicitis. Women are often normal vaginal delivery. When identified prior to asymptomatic but show signs of urethral or delivery, most doctors will deliver the infant by cervical infection on physical examination. Cesarean section. Diagnosis is provided by patient history, The corpsman should be aware of all STDs microscopic examination of discharge, and their signs and symptoms. However, symptomology, and failure to demonstrate discussion will be limited to the five most neisseria gonorrhea. prevalent STDs. Treatment: (Under a medical officer's GONORRHEA (GONOCOCCAL supervision) doxycycline tetracycline, followed by URETHRITIS, CLAP, STRAIN) sulfonamide and erythromycin. Females may also require further treatment with a sulfa vaginal Gonorrhea is an infectious disease of the cream. epithelium of the urethra, cervix, and rectum, but may also affect other areas of the body. Follow-up blood tests are conducted to rule out syphilis. Patients should be examined by a In males, the symptoms include burning and medical officer on follow-up. urinary frequency and a purulent discharge.

In females, symptoms are slight or nonexistent but may include vaginal discharge and cystitis. Frequently females are asymptomatic.

24 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Handbook III

MUCOPURULENT CERVICITIS GENITAL HERPES

Mucopurulent cervicitis is an inflammation of Herpes genitals is a contagious infection of the the cervix. Signs and symptoms include a yellow genital skin and mucosa. It is the most common discharge visible in the vaginal canal and vaginal form of genital ulceration. discharge or bleeding following intercourse. Diagnosis is based on a cervical gram stain. Signs and symptoms include itching and soreness, blisters, blebs, and ulcers that become Treatment. If the patient is at high risk of circular lesions on genitourinary surfaces, pain, gonorrhea, treat as indicated for gonorrhea. If the and burning sensation when urinating, and patient is at high risk of chlamydia, treat as difficulty walking. indicated for chlamydia. Diagnosis is by symptoms and laboratory Follow-up should be recommended for the specific analysis of lesion serum. infection being treated. Treatment. There is no cure. The lesions SYPHILIS usually recur throughout life. Analgesics and warm baths will relieve the pain. The first episode Syphilis is a contagious disease that can attack any may be treated with acyclovir for symptomatic organ in the body and is characterized by periods relief. of active manifestations and symptomless latency. It can be passed from mother to unborn child. ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) There are three stages, which can be divided into other substages of infectiousness and latency. The Human Immunodeficiency Virus (HIV) Primary syphilis is the stage when the primary has been found in blood, semen, vaginal fluid, and lesion (chancre) appears. Secondary syphilis in small quantities in saliva, tears, breast milk, and follows close behind and is characterized by skin urine. All body fluids should be regarded as disorders that may mimic other dermatological infectious. It appears that a relatively large problems. Tertiary syphilis follows a latent inoculum of virus is required to cause an infection. period of two or more years. Despite intensive inquiry, and thousands of cases, transmission appears to occur in only four ways: Diagnosis is by symptoms, sexually transmitted disease contact referral, personal 1. Intimate sexual contact: rectal, vaginal, or history, serologic tests (STS), blood tests (VDRL, oro-genital intercourse. RPR, ART, FTA-ABS) and dark field microscopic exam of skin scraping from the chancre. 2. Transfusion of infected blood or blood products. Treatment. For primary and secondary syphilis: a one-time dose of Penicillin-G, 2.4 3. Sharing of dirty needles: usually IV drug million units given intramuscularly. Erythromycin, abusers. doxycycline, or tetracycline may be given to penicillin-sensitive patients. 4. Perinatally or in utero from mother to baby.

Follow-up. Blood test should be repeated, treat Diagnosis is by HTLV-III or HIV test, enzyme contacts of patient, and have patient examined by a linked immunosorbent assay (ELISA) test, or medical officer. Western Blot Test.

25 Lesson 1.22 Preventive Medicine Basic Hospital Corps School Handbook III

Treatment: No known treatment for the FIELD SANITATION underlying immune deficiency. Treatment is limited to systemic relief. The primary objective of field sanitation is to keep as many personnel free of communicable Department of Defense concerns/reasons disease as possible. Corpsmen are responsible to for testing: assist in supervising and instructing personnel in sanitation procedures. Personnel education a. Protect battlefield blood supply. includes: information on food sources, disease prevention, sexually transmitted diseases and b. Protect the individual member. The water sources and treatment methods. member cannot receive live virus vaccinations. Also, personnel cannot be POTABLE WATER assigned duty in areas with exotic diseases. Water that is suitable and safe for drinking is referred to as potable water. In the field the HM Implications of a positive test: approves water sources and disinfection procedures when necessary. 1. The test does not mean that you have AIDS, and does not automatically mean that you will All water if the field is considered unsafe until develop AIDS in the future. it has been tested and disinfected if necessary. Procedures to produce potable water are boiling 2. The test does mean that at some time in the (use only in emergencies), use of iodine tablets or past, you were infected with the HIV virus. calcium hypochlorite ampules. However, there is no way to tell if you still have the virus in your body. It is likely that HEALTH AND COMFORT most people with a positive test still carry the INSPECTIONS virus, and will carry it indefinitely. Health and comfort inspections are conducted PREVENTION OF STD to determine and ensure the security, military fitness and good order and discipline of the The best method of prevention is, of course, organization. Components of an inspection abstinence, but as this is not realistic, the practice include: cleanliness, sanitation, safety and of safe sex is important. Personnel should avoid examination for unnecessary hazards and unlawful indiscriminate sexual contacts, use mechanical weapons or other contraband. prophylactics (condoms), maintain personal hygiene, recognize and seek treatment for FOOT CARE symptoms. To maintain personal hygiene, males should urinate as soon as possible after exposure Proper foot care is a vital factor in the overall and both partners should shower thoroughly with performance of personnel. Corpsmen monitor foot soap and water. Uncircumcised males should conditions and teach foot care. The basic retract foreskin back for thorough washing. principles are: proper fitting shoes and socks, Females should not douche which advances the clean and dry feet regularly, use foot powder and organisms to the tubes and ovaries and could cause change socks boots/shoes regularly especially in Pelvic Inflammatory Disease. Diagnosed cases wet environments. should inform partners and avoid further contacts during the communicable period. All personnel should be provided health education about STD transmission, prevention, and treatment.

26 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Worksheet Handbook III Lesson 1.22

Preventive Medicine Worksheet

1. Define communicable disease.

______

______

2. A human or living animal affording nourishment to an infectious agent under natural conditions is called a: ______

3. List three examples of a portal of entry.

a. ______

b. ______

c. ______

4. What is a susceptible host?

______

5. Define transmission, in relation to communicable diseases.

______

6. List three characteristics of influenza.

a. ______

b. ______

c. ______

7. What bacterial disease can follow inadequately treated strep throat? ______

8. What is another name for tinea pedis? ______

9. Mechanical and biological transmissions are examples of ______transmissions.

10. The normal and most suitable portal of entry for airborne transmission is ______.

27 Lesson 1.22 Preventive Medicine Worksheet Basic Hospital Corps School Handbook III

11. List four signs/symptoms of strep throat.

a. ______

b. ______

c. ______

d. ______

12. Describe two types of direct transmission of a disease.

a. ______

b. ______

13. Define indirect transmission of a disease.

______

14. List four methods for the control of communicable disease.

a. ______

b. ______

c. ______

d. ______

15. Immunizations provide protection against: ______

______

16. STDs are transmitted by ______and ______.

17. STDs can be transmitted through open wounds.

a. True b. False

18. STDs are among the most common communicable diseases.

a. True b. False

19. List the three stages of syphilis.

a. ______

b. ______

c. ______

28 Basic Hospital Corps School Lesson 1.22 Preventive Medicine Worksheet Handbook III

20. Acyclovir is the curative treatment for genital herpes.

a. True b. False

21. List four ways AIDS can be transmitted.

a. ______

b. ______

c. ______

d. ______

22. All HTLV-III/HIV positive patients will develop AIDS.

a. True b. False

23. List two of the Department of Defense's concerns/reasons for the HTLV-III/HIV screening program.

a. ______

b. ______

24. What is the best method to prevent STDs? ______

25. List five methods for the prevention of STDs.

a. ______

b. ______

c. ______

d. ______

e. ______

26. What is the primary objective of field sanitation?

______

27. In the field, all water is considered safe.

a. True b. False

29 Lesson 1.22 Preventive Medicine Worksheet Basic Hospital Corps School Handbook III

28. List the four areas personnel should be educated in prior to deployment.

a. ______

b. ______

c. ______

d. ______

29. List three procedures to produce potable water.

a. ______

b. ______

c. ______

30. List the five components of a Health and Comfort inspection.

a. ______

b. ______

c. ______

d. ______

e. ______

31. List three principles of foot care.

a. ______

b. ______

c. ______

30 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Lesson 3.03

Patient Care Documentation

Terminal Objective:

3.03 Document patient care.

Enabling Objectives:

3.03.01 List the purpose for documenting patient care.

3.03.02 List types of patient records used by the US Navy.

3.03.03 List types of patient care information to be documented.

3.03.04 List the components and guidelines for writing a SOAP note.

3.03.05 Chart inpatient care on a Nursing Note SF 510.

3.03.06 Chart outpatient care, using SOAP Note format, on a Chronological Record of Medical Care SF 600.

Nursing Notes SF 510 are a written PATIENT CARE TO BE account of a patient's condition during DOCUMENTED hospitalization. They include the patient's progress and response to care and treatments The type of information that must be given. Nursing Notes are written and used by documented in a Nursing Note includes the nurses and corpsmen directly involved in Mental Status Assessment, the Physical giving the patient care. They are part of the Assessment, all nursing care, treatments, patient's permanent hospital record. Nursing procedures, and patient education performed. Notes are a legal document of care given to the patient. Nursing Notes should include pertinent information about the patient's condition, As a legal document, Nursing Notes may progress, and response to care and treatment. be used in court. It is extremely important for A complete head to toe physical assessment the notes to be accurate, legible, and complete. must be made on each patient at the beginning Incomplete, illegible or inaccurate Nursing of each shift. ONLY the assessment findings Notes may be used as evidence for malpractice that have changed since the last entry need to litigation. Properly completed Nursing Notes be written in the Nursing Notes. If the patient's may prevent legal action. are abnormal, the values are written in the note along with the whom was notified, Nursing Notes that provide proper and any action that was taken. documentation help to prevent omission of care and duplication of treatments. This helps to ensure continuity of care.

31 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Handbook III

The physical assessment includes examining vaginal (color, odor, the following systems: amount, consistency)

Musculoskeletal gait -- ambulatory status, Sensory/perceptual mental status -- alert, use of assistive devices combative, confused special equipment –

fixative devices Neurological level of consciousness complaint of pain awake, stuporous, casts, , splints comatose range of motion (ROM) orientation to person, muscle strength place and time edema pupillary response sleep pattern or sleep difficulty Nursing Notes should include any complaints of discomfort or other Skin condition -- color, malfunctions of body systems including a temperature, turgor description of duration, location, intensity, lesions or skin severity, and frequency of complaint. Mental breakdown status observations should include general Respiratory respirations -- rate, orientation to the environment, observed rhythm, depth moods and behavior and any expressed (shallow or deep) concerns. Anything abnormal or out of the breath sounds -- clear, ordinary should be documented as well as how wheezes, rales these findings were handled. cough productive or non—productive (color, odor, amount) Nursing Notes should reflect all nursing dyspnea -- difficult, care given to the patient. Examples: painful, or labored respirations 1. All personal hygiene care such as bed baths, showers, and tub baths. Cardiovascular pulse -- rate, rhythm, quality, location blood pressure 2. Oral hygiene care, including condition of circulation – capillary mouth, teeth, etc. refills -- regular, 3. Skin care should be noted. irregular, muffled These may be charted on the Activities of

Daily Living or ADL Flowsheets. Gastrointestinal mouth, gums, and teeth odor, condition) Types of treatments and procedures to appetite/diet chart include the following: bowel function bowel sounds – 1. Wound care/ changes. hypoactive, hyperactive presence of distention 2. Any addition or discontinuation of any equipment.

Genitourinary elimination pattern -- 3. Specimen collection. spontaneous void or Foley 4. Suture, staple or clip removal. bladder function presence of lesions discharge -- urethral or 5. Respiratory treatments.

32 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III

Safety measures are always taken to 6. IV site care. avoid harm or injury to the patient. Examples are the use of side rails or patient restraint 7. IV tubing changes. devices. If a patient is non-compliant with hospital safety rules or regulations, this must 8. IV solution changes. also be documented as a Nursing Note.

9. Insertion or removal of Foley catheter. A patient's arrival and departure from a ward must be documented. This includes 10. Any type of isolation precautions and how where the patient is going or returning from, patient is psychologically responding to method of travel, and the time and date the isolation. event occurred.

Documentation of treatments and In addition, any visits made by pertinent procedures should include who performed the people, such as physicians, Commanding procedure. If the corpsman performs the Officer, chaplain, etc., need to be noted. The procedure, his/her signature appears at the end condition of the patient prior to his transfer or of the Nursing Notes. However, if someone discharge from one ward to another is to be other than the corpsman who is charting documented. Also any discharge planning, performed the procedure, that individual's instructions or referrals made prior to name should appear in the Nursing Notes. In discharge should be included. The actual name addition to who performed the treatment or and rank of physician or nurse notified about procedure, the patient's tolerance of the an abnormality or change in patient's condition procedure should be noted, and any change in should be noted. patient's condition (improved or worsened) as a result of the procedure. Any adverse effects GUIDELINES FOR NURSING should also be noted, e.g., unusual amounts of NOTES pain during or after procedure. There are several components of the Any teaching a patient receives needs to Nursing Notes SF 510. Standard form be documented. The Nursing Note entry identification numbers are found on the should describe the patient's level of bottom right corner of the page. The column to comprehension, ability to repeat the skill or the extreme left side of the page is used to ability to demonstrate how to do a task. record the current date and month using Certain medications require a Nursing , e.g. military format, e.g., 11 Jul. The year is anti-acid for stomach ache; all STAT orders, entered in the box with the word. The hour e.g., Benadryl for hives; all pre-operative column is divided into two columns for AM medication, e.g., sedatives) and all PRN and PM hours, which are recorded using the medications, e.g., Tylenol for pain. If a PRN 24 hour clock. The main body of the page is medication is given to the patient, then the below the heading entitled Observations. This results of taking that medication must be is the space used for recording observations recorded. Following any medication made by the corpsman and/or nurse. The administration, the patient must be observed bottom left corner of the page is reserved for for adverse reaction to the medication. If a patient identification. The patient's reaction occurs, documentation should include addressograph stamp is placed in this space. type or signs and symptoms of the reaction, The information can be handwritten, if who was notified and what was done for the necessary. patient. Abnormal or out of the ordinary occurrences and their follow up must also be Nursing Notes are written in chronological documented. order. Each entry is identified by date and time

33 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Handbook III in the appropriate column. Nursing Notes are to be. When recording patient observations, be placed in the chart so they read progressively objective. Describe the facts or actual events; like a book. The most recent entries are in the what you see. Leave out opinions. The back of the Nursing Note section. The format following are sample Nursing Note entries: for Nursing Notes is dictated by local 1. Restless, crying, and holding his right command policy. The most commonly used side. (OBJECTIVE). format is block. This style documents what, where and how in brief paragraphs. The 2. Complains of abdominal pain. format called charting by exception documents (SUBJECTIVE). unusual or unexpected problems or responses to treatment. The usual or routine care and 3. Sleeping for long periods. Refused lunch findings are recorded in Activities of Daily meal. (OBJECTIVE). Living (ADL) flowsheets. 4. Stated I have been nauseated all morning. Each Nursing Notes entry is signed by the (SUBJECTIVE). person writing the note. The signature consists of the following: first name, last name, and 5. Stated I feel a little depressed. rate. It is placed on the right side of the page (SUBJECTIVE). following the entry. A line should be drawn through any extra space occurring between the 6. Consumed only 10% of breakfast. last word of the entry and the signature. The Vomited 100 cc of clear yellow fluid 15 writer's name is to be printed or stamped minutes later. (OBJECTIVE). following the signature. 7. Respirations rapid, labored, rate 30 per There are a few general instructions for minute. (OBJECTIVE). writing Nursing Notes: Do not write entries that leave room for 1. Do not skip lines between Nursing Notes. misinterpretation. Be clear and concise. Do There should be no empty spaces. not write Doctor Smith examined patient on floor. Instead write Doctor Smith examined 2. All entries must be made using a black patient in treatment room. ballpoint pen, (for microfiche and Xerox reproduction purposes). Filter pertinent from unnecessary information and record only pertinent 3. Legible handwriting or printing is information. Pertinent information includes essential. that which is relevant to the patient's treatment and/or progress. The following are examples 4. Be brief! Omit unnecessary words. Each of pertinent and not pertinent entries: entry need not be a complete sentence, but should contain sufficient words to convey 1. Assisted with feeding. (PERTINENT). complete thoughts. 2. Complete linen change done. (NOT When writing Nursing Notes, subjective PERTINENT). and objective information is used. Subjective information is what the patient states or relates 3. Breakfast tray delivered. (NOT as a symptom, in his/her own words and are PERTINENT). identified by quotation marks, whenever possible. This is especially important when 4. Consumed 100% of regular diet. related to mental status and emotional (PERTINENT). feelings. Avoid personal judgments and the use of such phrases as appears to be or seems 5. Visited with the chaplain. (PERTINENT).

34 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III

of the entry. Within the Nursing Notes entry, 6. Unable to void postoperatively. identify the actual time the occurrence or (PERTINENT). observation took place.

7. Watching TV and working crossword puzzle. (NOT PERTINENT--May be SOAP NOTE GUIDELINES pertinent in certain cases e.g., psychiatric patients). The format for recording data in the outpatient treatment record is called the SOAP 8. Dry sterile dressing change to RLQ. note format. SOAP stands for: (PERTINENT). S -- Subjective: This is what the patient 9. Old dressing removed. Sterile field relates as his/her . It should be established. Wound covered with a new written in the patient's own words. sterile 4x4 and secured with tape. (NOT PERTINENT). O -- Objective: These are the physical findings observed during an examination of 10. Wound area is slightly reddened and warm the patient. In evaluating a specific problem, it to touch. (PERTINENT). is necessary only to examine the area(s) which are pertinent to the problem. The frequency of Nursing Note entries depends upon the patient's condition and/or A -- Assessment: This is an analysis of local policy. However, nursing care should be the problem or the . In recorded only after the care has been given. certain cases, a diagnosis may be clear, such Standard medical and non-medical as a fracture or laceration. In other cases, there abbreviations should be used when writing may be several likely possibilities. Nursing Notes. P -- Plan: The plan includes everything It is important to note that local that is done to the patient as well as advice and commands may have overprinted Nursing instructions given to the patient. Treatment Notes. These are used for routine occurrences prescribed to resolve the problem might common to a particular ward. include laboratory tests ordered, x-ray studies ordered, medications (including dosage, Examples: strength, and directions for use), and instructions for follow up. 1. Admission/discharge Nursing Note overprints. Generally, the HM will only be responsible for documenting the Subjective 2. Postoperative care overprint. and Objective data on the Chronological Record of Medical Care SF 600 or Emergency There are guidelines that must be followed Care and Treatment Record SF 558. The when correcting mistakes that occur while physician will determine the assessment and writing Nursing Notes. First draw a single line plan the course of action to treat the problem through the error. Next write error and initial the patient is experiencing. over the single line. After this is completed, continue the Nursing Notes with the correct Ensure that the patient's identification information. If the time of Nursing Notes is information is on the lower left corner each earlier than the last Nursing Note entry, a late form. All health record entries must be either Nursing Notes entry is needed. To do this, typed or written with a black ballpoint pen. write late entry in the AM/PM column. Below Felt tip pen entries bleed over time and cause these words, record the current date and time writing on the reverse side of the page to

35 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Handbook III become unreadable. The time and date is included on the left upper side of the SF 600 -- chief complaint and history of and the date must be written in the complaint (subjective data.) day/month/year format, e.g. 1000 01 JAN 95. Next, the ship or station is placed directly next -- physical exam and clinical findings to the date in the symptoms, diagnosis, and (objective data.) treatment column. This appears as the classification of facility, city, and state, e.g., -- analysis of clinical findings (assessment.) NAS, Memphis, TN or Naval Hospital, Bremerton, WA. The address must also be -- treatment accomplished and follow-up included if the ship or station is overseas. care, in addition to medication prescribed or used (plan.) The SOAP Note entry is a concise record Each entry must be signed with the of the patient's condition, treatment applied signature of the person writing the note. The and response to treatment. The initial entry on signature is placed on the line immediately the SF 600 also MUST include: below the last entry. Following the signature, print or stamp your name.

36 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Worksheet Lesson 3.03

Patient Care Documentation

1. What is the purpose of the Nursing Notes SF 510?

a. A written account of patient's condition, progress and response to care and treatment while hospitalized.

b. Written and used by nurses and corpsman directly involved in giving the patient care.

c. Part of the patient's permanent hospital record. Represents a legal document of care given to the patient.

d. All of the above.

2. All of the following are true of the SF 510 except:

a. may be used in a court of law.

b. incomplete or inaccurate nursing notes may be grounds for malpractice litigation.

c. may be completed in any color ink.

d. properly completed Nursing Notes may prevent legal action.

3. Nursing Notes may be written by:

a. nurses.

b. corpsmen.

c. doctors.

d. both a and b.

4. All entries on the Nursing Notes must be clearly written.

a. True b. False

5. Persons signing a Nursing Note are not required to include their:

a. first name.

b. last name.

c. social security number.

d. rate.

37 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Worksheet Handbook III

6. Where on the Nursing Notes would you print your name and rate?

a. Before your signature.

b. After your signature.

c. Directly below your signature.

7. Where is the standard form identification number on the SF 510?

a. Bottom left and upper right hand corner.

b. Upper left and bottom right hand corner.

c. Bottom right hand corner.

d. Bottom left and right hand corner.

8. The most recent Nursing Notes entry would be found in the back of the Nursing Notes SF 510 form.

a. True b. False

9. Hours are recorded using ______in ______or

______columns

10. Pertinent information which should be recorded in the Nursing Notes does not include:

a. assisted with feeding.

b. changed linen.

c. consumed 100% regular diet.

d. visited with chaplain.

11. When should Nursing Notes entries be made?

a. After the care has been given.

b. At the completion of the shift.

c. During your lunch break.

d. After completing your rounds.

38 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Worksheet

12. What information may be obtained during the physical assessment of the respiratory system?

______

______

13. If a patient's vital signs are abnormal, what information is documented in Nursing Notes? ______

______

14. Which of the following physical conditions are considered pertinent and would be noted on the SF 510?

a. Skin condition

b. Respiratory status

c. Appetite/diet

d. All of the above

15. After performing a procedure, the procedure and any adverse reactions should be recorded on the:

a. Patient Profile

b. Chronological Record of Medical Care

c. Nursing Notes

d. Doctor's Orders

16. Circle all steps that must be performed if a patient refuses treatment.

a. Order him/her to accept the treatment.

b. Inform the nurse.

c. Record the refusal on the Nursing Notes.

17. Circle all medications that must be recorded on Nursing Notes after being given.

a. One time drug orders

b. All stat orders

c. PRN drugs

39 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Worksheet Handbook III

18. Circle the treatments that must be recorded in the SF 510.

a. Wound care/dressing change

b. Suture, staple, or clip removed

c. Catheterization

19. Define the parts of a SOAP Note.

______

______

______

______

20. What section of the SOAP Note contains pertinent patient history information?

______

21. What is the difference between subjective and objective data.

______

______

22. What items are recorded under the PLAN of a SOAP Note?

______

______

23. What initial entries are required on the Chronological Record of Medical Care SF 600?

______

______

24. How should the date appear in the left-hand column of the SF 600?

______

______

25. If a patient is assigned to a ship or station overseas, what is included in the patient identification data?

______

40 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Scenarios Lesson 3.03

Nursing Notes Scenario AM Shift

The morning staff reported on duty at 0645 on 15 July 1999. You (the corpsman) are assigned At 0930, she was taken to x-ray by wheelchair several patients, including HMC Pat L. King, for a routine PA and lateral chest x-ray. USN, AD who is a 35-year-old female admitted five days ago with Cholecystitis. At 1030, she was taken directly from x-ray to the cardiology clinic, where she had an A Cholecystectomy was performed on 11 July electrocardiogram (EKG) tracing. 1999. You begin your shift by making rounds on all your patients. At 1100, she returned to the ward by wheelchair. Her lunch arrived at 1200. She drank At 0800, Chief King was served a low fat diet. the milk and ate a bowl of mixed fruit. HMC King Her appetite was good and she consumed the told you, I guess it took more out of me than I entire meal. expected. I'm worn out and feel faint. She slept from noon until 1400 and then visited with her At 0900, her doctor visited her during morning family for half an hour. Next she went to the rounds. You assisted Dr. Sullivan when he solarium to watch television. performed an examination of the patient's heart, lungs, abdomen, and legs. The incision on her At 1445, the nurse notifies you that the doctor right upper abdomen appears to be healing well. A has ordered Chief King to be on complete bed rest small amount of clear yellow drainage, but no with her right leg elevated to reduce the leg edema. swelling or redness is noted, and a clean, dry You inform Chief King of the changes and she dressing applied. The doctor noticed some returns to her room at 1450. You make sure the swelling and slight redness of the right leg and call bell is attached to her pillow. stated that she has developed thrombophlebitis. You are directed to maintain close observation of The evening staff reported on duty at 1445 and the leg. After this, you assisted Chief King with a the morning staff reported off at 1500. bed bath and made her bed. She ambulated to the solarium.

41 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Scenarios Handbook III Nursing Notes Scenario PM and NOC Shifts

At 1600, you take Chief King's vital signs. At 2000, her temperature, pulse, respirations, You notice that her right ankle is extremely puffy and blood pressure were taken and recorded. Her and she is sitting in a chair. She complains that her blood pressure was 160/100. Since this seemed leg is hot and very tender. You tell her to return to high to you and higher than previously recorded, bed and keep her leg elevated then report this to you notified the nurse corps officer. the nurse. You explain to Chief King the reason the doctor has ordered the complete bed rest. You At 2030, you straightened out Chief King's also recheck her abdominal dressing at this time. bed, gave her fresh water and a back rub. She There is no drainage and the dressing is well brushed her teeth with assistance. At 2200, Chief applied. She tells you her incision is not giving her King told you her right leg felt much better and any discomfort. asked you to turn off the lights so she could go to sleep. The night staff reported on duty at 2245, and At 1730, Chief King ate a low fat diet. Due to the evening staff reported off duty at 2300. her awkward position, she needed assistance, but ate well. She ate all of the food on her tray. You make the rounds every hour and each time the patient is asleep. At 0600, she was At 1900, she had two visitors, her mother and awakened for vital signs. Blood was drawn for a her father, who stayed for an hour. Concerned CBC and a urine specimen collected for a routine about her condition, they also asked to speak to the urinalysis and taken to the laboratory. You assisted charge nurse. Chief King to brush her teeth and wash her face.

At 0700, the night staff reported off duty.

42 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Scenarios Scenario #1 for SOAP Notes

On 25 November 1999, two Hospital It is determined that a rapid assessment will be Corpsmen arrive by ambulance at the scene of a conducted on scene. Assessment of head reveals motor vehicle accident. They find a young male no deformities or contusions. On the forehead Caucasian lying beside a motor cycle. He is there is a 4-centimeter abrasion with minimal moving restlessly. He has multiple abrasions on bleeding, no burns, slight tenderness across his forehead and right forearm and is complaining forehead, no lacerations, swelling or crepitation. of pain in his right thigh. Neck was examined prior to applying the cervical collar. Chest assessment reveals no DCAP-BTLS, The corpsmen identify themselves and obtain lung sounds present and equal, no crepitation permission to treat the patient. The patient has a noted. Abdominal assessment reveals no DCAP- patent airway, respirations are regular, and his BTLS, no firmness or distention. Abdomen is soft pulse is strong and rapid. The patient complains of in all quadrants. Pelvic assessment reveals no pain in his right leg. DCAP-BTLS, no pain, motion or tenderness noted. Lower extremities reveal no DCAP-BTLS The first corpsman calms the patient, in the left leg and deformity and tenderness in the maintains an open airway, applies cervical right thigh. Good , motor, and sensation in immobilization and begins interviewing the both legs. Upper extremities reveal no DCAP- patient. The second corpsman finds minimal DTLS in the left arm and multiple abrasions in the bleeding from the facial and right forearm right arm. Good pulses, motor, and sensation in abrasions. Neck was examined for DCAP-DTLS. both arms. No abnormalities noted. Veins and trachea are normal. A cervical collar is then applied. Baseline vitals reveal: Pulse 90 and strong, respirations 24 and regular, and blood pressure When questioned the patient says he lost 108/70. control of his motorcycle when he hit some sand on the turn. He states that, I hit my head on the A Hare traction splint is applied to the right bike. He denies being unconscious at anytime. His leg. Abrasions of the right forearm and forehead name is SN Charles Jones, USN, SSN 123-45- are dressed with sterile 4x4's and Kerlex. 6789, born 01 March 1977. He is stationed at Service School Command. He further states I am Patient is further immobilized and prepared for at the corner of 22nd street and Lewis. Today is transport using a long spine board. Vital signs are Friday morning, 25 November 1999. He denies monitored every 5 minutes. Report is given and any allergies, is taking Dimetapp for a cold and the patient is transported to the Naval Hospital, by has been healthy all his life. He had breakfast at ambulance. 0500 this morning.

43 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Scenarios Handbook III SOAP Notes

S: 18 year old male Caucasian involved in Right -- DCAP- BTLS. Tenderness in right thigh motorcycle accident this A.M. States that he has a mid shaft deformity. Pulse, motor, sensation intact. lot of pain in his right leg. He further states; I hit my head on the bike. Denies being unconscious as Upper Extremities: Left -- No DCAP--BTLS. any time. Negative medical history, no known Strong radial pulse, rapid capillary refill, sensory allergies. Presently taking Dimetapp for cold. Last and motor intact. meal was 0500 this A.M. Right -- Forearm multiple abrasions noted. Radial pulse is strong, rapid capillary refill. No O: Pt. is restless and skin color appears normal. DCAP-BTLS, sensory and motion intact.

Head: Oriented X 3, 4 centimeter abrasion on A: forehead, slight tenderness and minimal bleeding. No palpable deformity of skull, no major bleeding, 1. Painful, deformed right upper leg. no drainage in ears or nose. The pupils are equal and reactive to light. 2. R/O head injury.

Neck: No DCAP-BTLS or crepitation. Veins not 3. Multiple abrasions on forehead and right distended. Trachea mid-line. forearm.

Chest: No DCAP-BTLS. Good breath sounds P: heard in all lung fields. No crepitation 1. Cervical collar applied. Abdomen: No DCAP-BTLS noted in abdomen. Abdomen is soft and supple in all quadrants. No 2. HARE traction splint applied to right leg. distention noted. 3. Sterile 4x4's and Kerlex dressing to forehead Posterior: No DCAP-BTLS and right forearm.

Pelvis: No DCAP-BTLS, no pain, motion, or 4. V.S. monitored every 5 minutes. tenderness. 5. Immobilized using long spine board. Lower Extremities: Left - No DCAP-BTLS. Motor, sensory, circulatory intact. 6. Transport via ambulance to Naval Hospital in stable condition.

44 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Scenarios Scenario #2 for Soap Notes

At 0700 sick call, SA Teresa Jones (21 year A strep test was performed which was positive old Caucasian female) checked into sick call for group A Beta Hemolytic Strep. Orthostatic complaining of nasal congestion, sore throat, blood pressures were obtained with results: lying painful swallowing, and headache. She reports BP = 100/64, P = 74; standing BP = 90/50, P = having nausea with two episodes of vomiting this 104. An IV was started using a 16 gauge Jelco morning after breakfast. She states she is very tired catheter in the antecubital fossa of the right arm. and I haven't felt good the past 2 days. No known Patient received 2000 cc of Lactated Ringer's in a drug allergies and reports she is not taking any 60 minute period. After IV was discontinued, medication. patient voided 300 cc of slightly concentrated urine. Vital signs upon check-in to sick call are temperature = 101.2 F (orally), pulse = 104, blood Patient was given an IM injection of 1.2 pressure = 100/64. Skin temperature is warm and million units of Procaine Penicillin. Provided with dry. Patient weighs 120 pounds. Physical prescription for Pen V-K 250 mg QID for 7 days. examination reveals that she complains of a Instructed patient to take clear liquids for the next frontal/temporal headache. Percussion to frontal 24 hours and then advance diet as tolerated. She sinuses is not painful. Her mouth is pink and was placed in an SIQ status for 24 hours and moist, the pharynx is very red and inflamed, with informed to return to sick call at that time. Patient post nasal drainage present. No pustules noted on stated that she understood the tonsils. Tympanic membranes are pearly gray Directions. without retraction and with good light reflex.

She is able to move her neck easily and without pain. of her neck reveals tender pre-auricular and anterior cervical lymph nodes. Normal breath sounds are heard in all lung fields. Bowel sounds are present in all quadrants of the abdomen. No rebound tenderness with palpation of the abdomen.

45 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Scenarios Handbook III

NOTES/COMMENTS

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48 Basic Hospital Corps School Lesson 3.03 Patient Care Documentation Handbook III Forms

49 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Forms Handbook III

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51 Lesson 3.03 Patient Care Documentation Basic Hospital Corps School Forms Handbook III

52 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Handbook III Lesson 3.05

Admission and Discharge

Terminal Objective:

3.05 State admission and discharge procedures.

Enabling Objectives:

3.05.01 Define two types of patient admissions to the Hospital.

3.05.02 List the responsibilities of the Hospital Corpsman when admitting a patient to the ward.

3.05.03 List the responsibilities of a Nurse Corps officer when admitting a patient to the ward.

3.05.04 List the purpose and procedure for filling out a Patient Valuables Envelope NAVMED 6010/8.

3.05.05 State the procedure for discharging a patient.

3.05.06 List the basic procedure to enter a patient into the computer information system.

Admission is a process that occurs when a HOSPITAL CORPSMAN patient enters a health-care agency for care and RESPONSIBILITIES DURING treatment. Two types of admissions are routine and ADMISSIONS emergency. A routine admission starts at the

Admitting Office where the patient or family When the patient arrives on the ward, you member is interviewed to obtain information such should greet him/her in a calm, professional as next of kin, place of employment, hospital manner, introducing yourself observing insurance data, home address, etc., and the appropriate military courtesy. Escort the patient to admission paperwork is completed. An his/her room, introduce to roommates, and orient identification bracelet and embossed the patient to the ward environment including, addressograph card are made. The patient arrives location of bathroom, kitchen area, and lounge on the ward after completing the admitting process area. Teach the patient how to use the bed controls in the Admitting Office. An emergency to change position of the bed, TV remote control, admission occurs when a patient is given initial and telephone. Use and location of the call bell treatment in the emergency room, then transferred should be explained. An initial height, weight, and to the ward. Personnel from the Admitting Office set of vital signs are obtained and recorded on will come to the ward to interview the patient or Nursing Notes SF 510, Vital Signs Record SF 511, family members will go to the Admitting Office to and appropriate local forms. Identify bed by provide the necessary information. placing bed tag on the foot of the bed. Also mark

bedside locker and stand with patient's name.

Provide patient with pajamas, robe, slippers,

washcloth and towel unless the patient brought

own personal items. Ask the patient about allergies and record on admission Nursing Notes SF 510. Explain the purpose of the Patient Data Base

53 Lesson 3.05 Admission and Discharge Basic Hospital Corps School Handbook III

NAVMED 6500/14 and direct patient or family responsible for items of value that the patient member to complete Section I of the form. Ensure wishes to keep in their possession while patient uses a black ballpoint pen. Provide patient hospitalized. Patients should be encouraged to with copy of ward rules/regulations and have send valuable items home with a family member. him/her sign expressing understanding of stated If a family member is not available, the items are rules. inventoried, placed in the Patient Valuables Envelope NAVMED 6010/8 and delivered to NURSE CORPS OFFICER appropriate personnel for safekeeping. Local RESPONSIBILITIES DURING command policy will dictate the person or ADMISSION department responsible for patient valuable safekeeping.

The Nurse Corps officer also introduces A routine admission will also bring from the himself/herself to the patient observing appropriate Admitting Office the completed admission military courtesy. The nurse performs the initial paperwork, identification bracelet, and embossed patient assessment of the patient's physical and addressograph card. Before applying the ID mental status. The physician is notified that the bracelet or stamping paperwork with the patient has arrived to the ward and the Doctor's addressograph card, check with the patient to see Orders are checked for special instructions or that the information is correct, especially the STAT orders. The Doctor's Orders are transcribed spelling of the patient's name and the Social by the nurse or checked by the nurse if transcribed Security Number. The ID bracelet on the wrist by the Hospital Corpsman or ward clerk. The Food provides a positive and consistent means of Service Department is notified of the patient's identifying patients. Correctly identify the patient arrival and the diet as specified in the Doctor's prior to performing any treatment, procedure, or Orders is ordered. After the patient completes giving a medication. The correct identification Section I of the Patient Data Base NAVMED procedure includes checking the bed tag, the ID 6550/14 the nurse reviews and clarifies the wristband, and asking the patient to state his/her information provided by the patient. In addition to name. recording the initial assessment in the Nursing

Notes SF 510, pertinent observations are recorded The patient may also bring his/her Military in Section II of the Patient Data Base by the nurse. Health (medical) Record or Outpatient (medical) Information provided on the Patient Data Base and Dental Record when admitted. These records NAVMED 6550/14 is transferred to the top are generally kept at the nursing station or secured portion of the Patient Profile NAVMED 6550/12, according to local command policy. e.g., glasses, needs assistance with daily activities, and wears dentures. The nurse will also use the information the patient provides and the data PATIENT VALUABLES obtained during the assessment to write the Patient Care Plan NAVMED 6550/13. If patient valuables are unable to be taken or sent home, the Patient Valuables Envelope ITEMS PATIENTS BRING TO THE NAVMED 6010/8 is used to inventory and safeguard valuables while the patient is WARD hospitalized. If the patient is a commissioned officer or a civilian, two officers conduct the Personal items that patients commonly bring inventory. If the patient is enlisted, an officer and to the ward when admitted include personal an enlisted member conduct the inventory. The hygiene items such as toothbrush, toothpaste, forms attached to the envelope must be completed. comb, and hairbrush. They may also bring and Part A is the identification of the patient including wear their own pajamas or nightgown and slippers. name, social security number, rank/rate, and Some patients also bring large quantities of service. Part is the inventory of the valuables money, credit cards, money orders, and jewelry. deposited. Record the exact amount of any money Explain to the patient that the hospital cannot be deposited. List any negotiable instruments such as

54 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Handbook III credit cards, checks, and money orders. When b. Times of administration. listing the credit cards, record only a portion of number, i.e., 4602 **** **** 7910. Describe c. Side effects. jewelry using terms as yellow or white metal instead of gold or silver. Stones in jewelry are d. Reason for taking the medication. described as white or red instead of diamond or ruby since staff members are not certified jewelers. 6. Symptoms that require immediate follow-up. After completing the inventory, signatures are obtained in Part C of the Patient Valuables After the discharge instructions have been Envelope NAVMED 6010/8. The inventory given, the patient or his/her significant other is officer, witness, and custodial officer sign in the instructed to gather all personal belongings. Then appropriate space. The envelope is delivered to the the patient or significant other is directed to the appropriate personnel or department as dictated by discharge section of Patient Affairs, the Collection local command policy. The receipts attached to the Agent and the Pharmacy (if there are any envelope are distributed according to the color prescriptions to be filled.) Complete the discharge code at the bottom on the envelope. Nursing Note and send the completed Clinical Record to Patient Affairs. Finally clean the unit PATIENT DISCHARGE and prepare it for the next patient. PROCEDURE Entering a patient into the Discharging a patient involves a variety of computer information system actions. It starts with the doctor writing an order to discharge the patient. This order includes specific information on medication or treatment that will Most patients will be enrolled and listed in need to be continued at home and follow-up a computer data base system. Hospital computer appointments. information systems have numerous administrative

capabilities. After entering the patient/sponsor's After verification of the discharge order, the social security number, prescriptions may be discharge instructions are explained to the patient ordered, diagnostic tests can be obtained and and/or the family. Patients must verbalize and nursing notes can be typed. Once the patient demonstrate an understanding of the discharge arrives to the ward the nurse or HM will verify the instructions, which include: patient/sponsor’s social security number in the

computer system and verify eligibility for care. 1. Follow-up appointments. The date the patient is admitted and discharged is

entered in the computer information system per 2. Self-care instructions. local policy. The computer information systems

are excellent means for tracking and coordinating 3. Activity instructions. the patient’s care. When orienting to a hospital,

new staff members will receive computer 4. Diet restrictions. information training specific to the system they are

using and they will receive a password to help 5. Medication administration. Be sure the patient protect patient’s privacy has an understanding of:

. a. Proper dose and route.

55 Lesson 3.05 Admission and Discharge Basic Hospital Corps School Handbook III

NOTES/COMMENTS

56 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Worksheet Handbook III Lesson 3.05

Admission and Discharge Worksheet

1. Explain how an emergency admission to the hospital is different from a routine admission.

______

______

2. Circle each procedure that is not the responsibility of the HM during a routine admission.

a. Orient patient to the ward environment.

b. Ask the patient about food, drug, or other allergies.

c. Have the patient read and sign ward regulations.

d. Notify the emergency room.

3. When escorting a newly admitted patient to the assigned bed, the corpsman should:

a. ______

b. ______

c. ______

4. The patient or significant other is required to complete what form during admission?

a. Patient Data Base NAVMED 6550/14

b. Patient Valuable's Envelope NAVMED 6010/8

c. Patient Profile NAVMED 6550/12

d. Unit Report NAVMED 6550/2

5. The patient's admission height, weight, and vital signs are recorded on what forms?

a. ______

b. ______

c. ______

57 Lesson 3.05 Admission and Discharge Worksheet Basic Hospital Corps School Handbook III

6. List items that are provided to a patient on admission to the ward.

a. ______

b. ______

c. ______

d. ______

7. Circle each procedure that is NOT the responsibilities of the Nurse Corps officer during the admission of a patient.

a. Notify physician of admission of patient

b. Complete Patient Data Base NAVMED 6550/14, Section I

c. Check Doctor's Orders SF 508 for STAT orders

d. Write Patient Care Plan NAVMED 6550/13

8. What items will a routine admission bring with them from the Admitting Office?

a. ______

b. ______

c. ______

9. What should be done with patient valuables brought to the ward?

a. Kept in bedside stand

b. Sent home with a family member

c. Hidden under the bed

d. Kept at nurse's station

10. The purpose of the ID bracelet is:

______

11. List the three items that are checked to identify a patient prior to performing any treatment or giving any medication.

a. ______

b. ______

c. ______

58 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Worksheet Handbook III

12. Upon arrival to the ward, the ID band is checked with the patient to verify:

a. ______

b. ______

13. If valuables are not sent home with a family member, they are:

a. the responsibility of the hospital.

b. inventoried and placed in the Patient Valuables Envelope NAVMED 6010/8.

c. returned to the patient who will have to take them home prior to admission.

d. given to the CO for safekeeping.

14. Who inventories a civilian patient's valuables? ______.

15. The patient reports that she has a gold wedding band with 3 diamonds that she would like to have inventoried for safekeeping. How is it described in the inventory of valuables?

______

16. List the six areas that should be covered in patient discharge instructions.

a. ______

b. ______

c. ______

d. ______

e. ______

f. ______

17. What three offices of the hospital is the patient sent to immediately following discharge from the ward?

a. ______

b. ______

c. ______

18. The completed clinical record is sent to ______after the patient is discharged.

19. The nurse or HM should verify the patient/sponsor’s social security number in the computer information system and verify ______.

59 Lesson 3.05 Admission and Discharge Worksheet Basic Hospital Corps School Handbook III

NOTES/COMMENTS

60 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Handbook III Scenario

Admission Scenario

Today, Pat L. King, HMC/N/AD, was admitted to the ward with a diagnosis of cholecystitis. HMC King is 32 years old, 5'10" and weighs 175 lbs. She is Caucasian and reports she practices the Catholic faith. Vital signs are BP =132/88, P = 84, R = 20, T = 98.6. She is accompanied by her significant other. States she is allergic to Aspirin and Betadine and reacts to both with itching and hives. Medications taken are Digoxin 0.25 mg PO QD -- last dose this AM. She has this medication in her purse. She brought her Military Health (medical) Record with her to the hospital.

HMC King has not been hospitalized before. She states she has upper dentures and wears glasses for reading. No reported problems with bowel or bladder function, sleeps an average of 7 hours per night. Denies any problems other than N&V and RUQ pain following fatty foods. She is wearing a Timex quartz watch, gold diamond ring and wedding band set, and gold ball earrings. She states she has one credit card with her and some change.

At 1600 HMC King is instructed to go to the lab and x-ray and is accompanied by her significant other. At 1730 they return to the ward and said they enjoyed their walk. At 1830, Dr. Jones visits and answers their questions.

Doctor's Orders

1. Admit to ward, Dr. Jones

2. Diagnosis - Cholecystitis

3. Allergies - Aspirin and Betadine

4. V.S. q 4 hr

5. Diet - low fat, NPO after midnight.

6. Activity - up ad lib

7. Chest x-ray, CBC, RPR, UA with C&S now

8. Dalmane 30mg PO qHS PRN

9. Digoxin 0.25 mg PO q AM

/s/ B. Jones

LT/MC/ USNR

Using the above information, complete the following forms:

Admission Nursing Notes SF 510 Overprint Unit Report NAVMED 6550/2 Patient Valuables Envelope NAVMED 6010/8

61 Lesson 3.05 Admission and Discharge Basic Hospital Corps School Scenario Handbook III

NOTES/COMMENTS

62 Basic Hospital Corps School Lesson 3.05 Admission and Discharge Handbook III Forms

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72 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Lesson 3.04

Inpatient Clinical Record

Terminal Objective:

3.04 Use and maintain an inpatient record.

Enabling Objectives:

3.04.01 List inpatient clinical record forms and define their purpose.

3.04.02 List the proper sequencing of inpatient clinical record forms.

3.04.03 List the Hospital Corpsman's responsibilities in maintaining an inpatient clinical record.

3.04.04 Record temperature, pulse, respiration, and blood pressure on the Vital Signs Record SF 511 and Plotting Chart SF 512.

The Inpatient Clinical Record provides a including signs, symptoms, duration of concise record of a patient's condition and progress complaints and circumstances of admission on during hospitalization. The record includes past this form. medical care, occupational and military history, and response to treatment. This information aids HISTORY PART 2 and 3 SF 505 - After the doctor in making a diagnosis or prescribing interviewing the patient, or a significant other, treatment. or reviewing the outpatient record, the physician documents occupation, military A series of standard clinical forms make up history, childhood and adult injuries and the Inpatient Clinical Record or inpatient chart. illnesses, drug sensitivities, and allergies on this Every form is assigned a number in the Standard form. Form (SF) series. Each form has a specific purpose. Every form will NOT be used for all PHYSICAL EXAM SF 506 - The results of patients, but each record should have the following the physical examination are recorded on this forms arranged in chronological and numerical form, including the patient's physical and order. mental characteristics.

NARRATIVE SUMMARY SF 502 - This form DOCTOR'S ORDERS SF 508 - The physician is used by the physician to summarize clinical data writes instructions to direct the care and and treatments during hospitalization. The form treatment of the patient on this form. Some SF usually has a carbon copy. The original is filed in 508s have a carbon copy so medication orders the Outpatient or Military Health Record and the can be easily sent to the pharmacy. duplicate is filed with the Inpatient Clinical Record. PROGRESS NOTES SF 509 - The physician uses this form to document the patient's HISTORY PART 1 SF 504 - The physician response to treatment and other pertinent records the course of the current hospitalization, information related to the patient's case. Other medical personnel, e.g., dietitian, physical

73 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Handbook III therapist, may also record observations on the SF ELECTROCARDIOGRAPHIC REPORT 509. SF 520 - Used to request an EKG and document the findings when the EKG is NURSING NOTES SF 510 - Observations, completed. patient progress, treatments, and some medications are recorded on this form by nurses and corpsmen. REQUEST FOR ADMINISTRATION OF Special overprints may be developed by the local ANESTHESIA AND FOR command to standardize documentation. PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES SF 522 - This form VITAL SIGNS RECORD SF 511 - Temperature is completed to document the patient's and pulse are graphed on this form. Blood understanding and agreement to an operation or pressure, respirations, weight, and height are also special procedure. Often called a permit or op recorded on this form. The patient's 24-hour total permit. input and output can be recorded on this form. ABBREVIATED MEDICAL RECORD SF PLOTTING CHART SF 512 - Used to record 539 - Used in place of the SF 502, SF 504 and blood pressures taken more frequently than every SF 506 for a patient who is admitted for less four hours, e.g. after special procedures. Also used than 48 hours. It has sections to record a brief to record other frequently monitored parameters of history and physical examination, Doctor's the patient's progress, e.g., TPR and CVP (central Orders, Progress Notes, and Nursing Notes. venous pressure). LABORATORY REPORT DISPLAY SF CONSULTATION SHEET SF 513 - Used to 545 - A backing sheet for mounting laboratory request assessment or assistance from a specialist, chits (SF 546 - SF 557). Chits are attached so e.g., physical therapist, dietitian. they may be seen easily, with the most recent report on top of previous reports. OPERATION REPORT SF 516 - Following an invasive procedure or operation, the physician SF 546 -557 - Lab chits are forms used to dictates a summary of the procedure which is request and document lab tests on specimens. typed on this form. SERIOUS/VERY SERIOUS LIST ANESTHESIA REPORT SF 517 - Completed by NAVMED 6320/5 - Used to document the physician or nurse who administers anesthesia, notification of Next of Kin (NOK), parent documenting the patient's vital signs/responses command, and the hospital chain of command throughout the procedure. when a patient is identified as seriously ill, or very seriously ill. The physician indicates by BLOOD OR BLOOD COMPONENT writing Doctor's Orders that the patient be TRANSFUSION SHEET SF 518 - Initiated when placed on the SL/VSL. blood or blood components are ordered for a patient. Lab personnel use this form to record MEDICATION ADMINISTRATION blood evaluations. The form is also utilized by RECORD (MAR) NAVMED 6550/8 - This ward personnel to document a patient's response to form is used to document medications the administration of the blood or blood administered during a seven-day period. components. Medications ordered by the physician on the Doctor's Order SF 508 are transcribed onto the RADIOGRAPHIC REPORTS SF 519 - X-ray MAR. reports SF 519A are displayed on this form. PATIENT PROFILE NAVMED 6550/12 - RADIOGRAPHIC CONSULTATION Used to standardize treatment and provide a REQUEST/REPORT SF 519A - Used to order ready reference for the care to each patient. The radiographic studies (x-rays). Patient Profile provides pertinent patient

74 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III information such as diagnosis, orders for SF 503, SF 504, etc., followed by the medications, treatments, activity, diet, vital signs, NAVMED 6550/8, NAVMED 6550/13, then bath, and intake and output. This form is not a DD 792, etc. When more than one copy of the permanent record, but is kept for a period of time same form is used, forms are placed in after the patient is discharged and then discarded. chronological order with the newest form on the bottom. The most recent date will be on the PATIENT CARE PLAN NAVMED 6550/13 - bottom or toward the back of the chart, e.g., 08 This form is a permanent part of the clinical record AUG 97, 12 AUG 97, 15 AUG 97. Follow the and is placed in the chart at discharge, in front of local policy of your facility. the Patient Data Base, NAVMED 6550/14. It is written by a nurse, based on input from the CLINICAL RECORD hospital staff concerning the patient's needs while MAINTENANCE in the hospital and in preparation for discharge. Nursing care problems, expected outcomes, and The Hospital Corpsman has several actions needed to resolve identified problems are responsibilities in maintaining the clinical listed on this form. Some of the problems are record during a 24-hour period. On admission, obtained from the Patient Data Base. This form the patient is given an addressograph card provides a format for establishing discharge which is embossed with 1) his/her name, 2) objectives which are nursing goals for the patient FMP code (family member prefix) and active to achieve prior to discharge or during duty member's or sponsor's social security convalescence. number, 3) patient's date of birth, 4) member's or sponsor's status: AD; RET; FMH; FMD; etc., PATIENT DATA BASE NAVMED 6550/14 - 5) member's or sponsor's branch of service: Section I of this form is filled out by the patient or Navy (N), Marine Corps (MC), Coast Guard significant other upon admission to the hospital. It (CG), Army (A), Air Force (AF), and Public is a summary of the patient's health history, which Health Service (PHS), 6) admission date, 7) may identify actual or potential nursing care hospital register number, and 8) religious problems. A nurse must review the information preference. and summarize the observations of the patient's statement and conditions in Section II. When the The information on the card is transferred form is completed, it is placed in the inpatient to the lower left corner of each page by an chart before the Nursing Notes SF 510. addressograph machine, which is similar to stamping a credit card. If the addressograph TWENTY-FOUR HOUR INTAKE AND plate is not available, then the patient's name, OUTPUT WORKSHEET DD 792 - Used to social security number, branch of service, and document an accurate account of the patient's fluid status are hand written on each form. All forms intake and output over a 24-hour period. are checked for proper identification because they are parts of a legal record, which may be PRIVACY ACT STATEMENT DD 2005 - used in a court of law. The corpsman should Signed by patient, parent, or guardian on also check the record each day and add blank admission to the hospital to document the patients’ forms as needed. After the physician has acknowledgment of the Privacy Act regulations. reviewed and initialed any laboratory and X-ray reports, they are attached to the correcct forms. SEQUENCING OF FORMS Ensure that only authorized personnel have access to the patient's record. Forms are placed in the inpatient clinical record by type with Standard Forms first, RECORDING VITAL SIGNS NAVMED forms second, DD forms third, and local forms last. Forms are filed in numerical order Vital Signs are written in the TPR log and beginning with the lowest numbered in each transferred to the Vital Signs Record SF 511. respective group. The SF 502 is followed by the

75 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Handbook III

Any time a temperature is 100 degrees F or three boxes in the AM column and three in the above, it must be circled in red in the vital signs PM column for recording the blood pressure. log. If the pulse or respirations are abnormal, i.e., The systolic and diastolic values are recorded irregular, slow or , it should also be recorded in as a fraction. If the blood pressure is taken the Nursing Notes. The Vital Signs Record SF more frequently the q4hr, the SF 512 must be 511, is divided into seven major columns, one for used. Height and weight are recorded on each day. Each column is subdivided into an AM admission and subsequent weights can be and PM section. The subdivisions are further charted in the appropriate date columns. There divided by two vertical dotted lines. Dotted lines are also spaces for the total intake and output divide the horizontal spaces into five even for each day. divisions. PLOTTING BLOOD PRESSURE Black ink is to be used for all entries. Fill in heading at the top of the page. The day of The Plotting Chart SF 512, may be admission is the first hospital day. The day of used to graph blood pressures, comparisons of operation or delivery is lettered Day of Surgery TPR, or CVP. The purpose of the graph is (DOS) or Day of Delivery (DOD) and the printed on the top of the graph. Increments are following days labeled DOS 1, DOS 2, or DOD 1, marked along the vertical portion of the graph. DOD 2. The hours the TPRs are taken are also Both vertical and horizontal scales should be recorded. definite and progress uniformly. Time increments should be noted along the horizontal Temperature and pulse taken every four hours portion of the graph. The meaning of symbols (q4hr) and twice a day (BID) are charted between used in the graph should be shown in a key to the dotted lines. Vital signs taken four times a day the side of the graph. As with all forms, the (QID) are charted on the dotted lines. Vital signs lower left corner should be labeled with the obtained more frequently than every four hours are addressograph. Vital signs are recorded on the recorded on the Plotting Chart SF 512. SF 512 in the following manner. Blood Temperatures are recorded with a dot the size of a pressures are plotted by drawing a heavy line, pinhead. The dot is placed in a spot corresponding two horizontal spaces wide, for systolic and vertically to the hour and horizontally to the diastolic values. The area between clearly numerical value. The dots are connected by a identifies the blood pressure. Temperature is solid line. A capital (R) for rectal or (A) for recorded at the top of the graph with a axillary route is placed next to the temperature. numerical value, e.g., 98.6. Respiration rate is Pulse rate is charted using a small, open circle recorded at the bottom of the graph. Pulse rate corresponding vertically to the hour and is recorded as a small circle corresponding to horizontally to the numerical value. These are also the hour and the numerical value. All vital connected by a solid line. Respiration rate is signs taken at a specific time are recorded recorded at the bottom of the graph in the space within a vertical line, two spaces wide. corresponding vertically to the hour. There are

76 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Worksheet Lesson 3.04

Inpatient Clinical Record Worksheet

1. Match each description in column B to the correct form number in column A

A B

A. Narrative Summary SF 505 ______1. Records blood pressures taken Q2 hours

B. Physical Exam SF 506 ______2. SF 546-557 forms are mounted on this form C. Nursing Notes SF 510 ______3. Permanent record of medications given to a 7 day period D. Radiographic Report SF 519 ______4. Ready reference for data used to care for a patient E. Doctor’s Orders SF 508 ______5. May identify actual nursing care F. History Part I SF 504 ______problems

G. Intake and Output DD 792 ______6. Provides a format for discharge objectives

H. Plotting Chart SF 512 ______7. Summarizes inpatient data of hospitalized patient I. MAR NAVMED 6550/8 ______8. Used by Corpsmen to document J. Patient Profile NAVMED 6550/12 ______treatments

9. Records course of present illness K. Laboratory Report ______Display SF 545 10. Doctor records mental and physical findings from exams on this L. Patient Care Plan NAVMED 6550/13 ______11. Instructions for directing care and M. Patient Data Base NAVMED 6550/14 ______treatment of patient are written here

12. Records fluid intake or output

13. X-ray reports are displayed on this form

2. Inpatient clinical forms are placed in the chart in numerical order.

a. True b. False

77 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Worksheet Handbook III

3. If several of the same form is used in an inpatient clinical record, they are placed in ______order.

4. To be properly identified, a form must have ______in the lower left corner.

5. Write out the status indicated by the following abbreviations.

AD ______

FMW ______

FMS ______

RET ______

DEC ______

6. Proper patient identification includes:

a. register number, birth date, branch of service, status, Social Security Number of sponsor and name.

b. name, Social Security Number, bed number and ward number, birth date.

c. name, Social Security Number, admission number, ward number and branch of service.

d. name, Social Security Number, branch of service and status.

7. If an addressograph plate for the patient is not available, the name, SSN, branch of service and status may be written in pencil on each form.

a. True b. False

8. The entire clinical record is reviewed and new forms are added:

a. once a shift.

b. every other day.

c. once every 24 hours.

9. A patient may review his/her record whenever desired.

a. True b. False

10. ______ink is used for all entries on the SF 511.

11. In the vital sign log, elevated temperatures (greater than 100) are circled in ______.

78 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Worksheet

12. Circle each item that is recorded at the top of the SF 511.

a. Date of admission

b. Postoperative day or day of delivery

c. Hours vital signs were taken.

13. QID vital signs are recorded between the dotted lines on the SF 511.

a. True b. False

14. Small circles connected by a solid line are used to record ______on the SF 511.

15. How is an axillary temperature charted on the SF 511?

______

16. The Plotting Chart SF 512 is used to record vital signs taken more frequently than

______.

17. Circle the steps for preparing the Plotting Chart SF 512.

a. Put patient identification in lower left corner.

b. Print purpose across the top of the form.

c. Enter date and time at top of form.

18. Systolic and diastolic blood pressure values are recorded as ______.

19. Temperature, pulse, and respiriation are charted on the SF 512.

a. True b. False

20. Who is ultimately responsible for the medical care a patient receives?

a. The senior nurse.

b. The senior corpsman.

c. The physician.

d. The ward nurse.

79 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Worksheet Handbook III

21. In regard to Doctor's Orders, the nurse and/or corpsman are ultimately responsible for:

a. the medical care of the patient.

b. the carrying out Doctor's Orders.

c. the treatment of the patient.

d. completing the Doctor's Orders.

22. Who can accept a Doctor's Order by telephone? ______

23. Entries on the Patient Profile that are made in pencil include all of the following except:

a. activity.

b. bath.

c. treatments.

d. fluids.

24. Where are lab requests recorded on the Patient Profile?

a. Front top portion

b. Back right column

c. Back left column

d. Front bottom portion

80 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Scenarios

On the fourth day this patient had surgery. SCENARIO FOR SF 511 Doctor’s Orders include: TPR q4H. BP Q4H

10 Oct BM1 A.B. Coe was admitted to the Naval Hospital at 2200 on 07 Oct 95. Admission Vital Signs were T-101.6, 0200 0600 0100 T 98.6 99.4 In surgery P-92, R-24, Blood pressure was P-R 84-16 82-18 134/92. Height 6'1" and weight 192 BP 118/76 122/84 118/82 lbs. Doctor's Orders included:

1) Weight daily x 2 days 1400 1800 2200 2) V/S q 4 H T 99.8 98.6 99 P-R 82-18 72-18 78-22 BP 118/82 112/78 132/88

2nd day – 8 Oct On the fifth day the VS order was changed 0200 0600 0100 to: TPR and BP QID

T 100.4R 101.2R 100.6R

P-R 88-20 106-22 100-24 11 Oct BP 110/80 120/82 128/86

WT 192 0200 0600 0100 T 99.1 97.4 98.0 1400 1800 2200 P-R 80-20 68-14 76-16 T 1.034R 102R 101R BP 112/78 120/80 122/82 P-R 124-28 104-16 96-20 BP 130/88 120/84 12/86 2400 T 98.8 3rd day 9 Oct P-R 80-20 BP 118/76 0200 0600 0100 T 100.8 101.0 101.0 P-R 94-20 94-20 96-22 BP 124/82 120/82 120/80 On the sixth day the VS order was WT 191 changed to: TPR and BP BID

12 Oct 1400 1800 2200 T 101.6 100.6 100 P-R 104-24 94-22 92-20 0600 1800 BP 118/74 120/78 124/86 T 98.6 98.8 P-R 84-16 88-20

BP 114/76 16/78

81 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Scenarios Handbook III SF 512 Scenario

Graph the following post—operative blood pressures for BM1 A.B. Coe. They were taken o his fourth day (10 Oct) in the Hospital.

TIME B/P PULSE RESP TEMP 1200 110/70 90 16 98.6 1215 112/68 78 18 98.7 1230 120/62 64 20 98.6 1245 116/60 82 16 99.0 1300 114/62 90 14 99.2 1315 116/64 68 14 100.0 1330 118/64 76 24 101.0 1345 118/60 80 24 99.0 1400 112/66 84 16 101.0 1430 118/70 72 18 101.5 1500 116/72 90 2 98.6 1530 120/80 68 22 98.8 1600 120/76 74 24 99.0 1700 118/74 80 18 99.2 1900 114/62 86 16 100.0 2100 112/68 94 14 102.0

82 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Forms

83 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Forms Handbook III

84 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Forms

85 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Forms Handbook III

86 Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record Handbook III Forms

87 Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School Forms Handbook III

88 Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Handbook III Lesson 3.07

Nasogastric Tubes

Terminal Objective:

3.07 List concepts and principles for insertion, placement, checking placement irrigation, tube feeding, and removal of nasogastric tubes.

Enabling Objectives:

3.07.01 State the purpose for nasogastric tube insertion.

3.07.02 List equipment used for insertion, maintenance and discontinuation of the nasogastric tube.

3.07.03 State the procedure for inserting a nasogastric tube and checking its placement.

3.07.04 State the procedure for administering a nasogastric tube feeding.

3.07.05 State patient care and nasogastric tube maintenance needs.

3.07.06 State the procedure for removal of a nasogastric tube.

3.07.07 State the procedure for recording nasogastric tube insertion, irrigation, removal, and feeding.

Nasogastric tubes (NG tubes) are made of soft a collection device. A regulator allows the type plastic or rubber, and are passed through the nose and amount of suction applied to be adjusted. or mouth into the stomach. Two primary uses of Suction can be continuous or intermittent and high nasogastric tubes are: the introduction of food and or low. Low intermittent suction is the most fluids; and the removal of fluids, gas, and poisons. frequently used setting. Intermittent suction prevents a build up of negative pressure in the Feeding by NG tube is also referred to as stomach, and prevents damage to gastric tissue. gavage feeding. In addition to providing liquid Occasionally, the NG tube may be attached to a nutrients, medications and irrigations can be given collection bag and allowed to drain by gravity. through a NG tube. Diagnostic tests, such as a gastric analysis can be performed on aspirated stomach contents. Removal of fluids may follow irrigation. Lavage is a term for washing out the stomach by EQUIPMENT FOR NASOGASTRIC instilling fluid and removing that fluid. A patient TUBES who has taken a drug overdose needs to have his/her stomach contents diluted and removed. An NG tube can be a single lumen (one hole), called a Levin tube or a double lumen (two hole) Decompression is the removal of fluid and air called a Salem Sump. Levin tubes are single lumen from the gastrointestinal tract. The NG tube is rubber tubes which are less common today. attached to a suction device such as a portable Plastics have replaced rubber, and double lumen machine or in-wall suction. Most hospitals have tubes have replaced single lumen tubes. Sump vacuum tubing built into the walls, which attach to tubes typically have a smaller blue port which

89 Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School Handbook III keeps the stomach open to air. This blue port is 7. Rubber band or clamp used only to inject air. However, some facilities may only use Levin tubes. The French (Fr.) scale 8. Safety pin is used to size NG tubes. NG tubes commonly inserted are between 14 and 18 Fr. for adults and 9. Stethoscope 10 or 12 Fr. for children. 10. Drinking straw NG tubes for specific purposes may be used, but are often inserted by doctors or technicians. In 11. Tissues the , an Ewald or Levacuator tube may be placed for rapid 12. Water soluble lubricant evacuation of gastric contents. These tubes are large bore (>20 Fr.), and are removed soon after 13. Penlight lavage has been completed. Feeding tubes are smaller (8 or 10 Fr.) and have a weight at the distal 14. Disposable gloves end. Feeding tubes are designed to work through the stomach into the duodenum or farther. 15. Tongue blade Weighted tubes must have their location verified by X-ray before feeding is started. NASOGASTRIC TUBE INSERTION

Rubber tubes are usually placed in ice for a After verifying the Doctor's Orders, gather the few minutes to provide the firmness required necessary equipment for NG insertion and take it during insertion. Plastic tubes, on the other hand, to the bedside. Wash your hands. Perform the three may be too stiff, and can be placed in warm water patient identification checks. Explain the for softening. Single lumen tubes may become procedure to the patient, including what you are stuck against the gastric lining when suction is going to do, and why the NG tube is needed. applied and a partial vacuum is created in the Provide for privacy, safety, and comfort by placing stomach. Double lumen tubes were developed to the patient in a Semi or High Fowler's position, prevent this. The second port, (the sump or air drawing the curtain, and checking side rails and port), is used to allow atmospheric air to enter the wheel locks. stomach. The stomach pressure remains equal to the atmosphere, so the tube does not fasten itself to With the patient in a sitting position, cover the the mucosa. The airport is only used to insert air chest with a Chux or towel to protect the patient's into the stomach. Do not aspirate through this port clothing and linen. Remove dentures before or connect this port to suction at any time. starting the procedure. Use the penlight to examine the nostrils for possible obstruction or deformities. Equipment needed for inserting a nasogastric If both nostrils are obstructed, notify the nurse or tube. physician. Ask if the patient has ever broken his/her nose or has a deviated septum. Have the 1. Nasogastric tube patient blow his/her nose, if able.

2. Adhesive tape Determine the length of the tube to be inserted. Measure the distance from the patients nose to the 3. Curved basin earlobe then from the earlobe to the tip of the xyphoid process. Mark this distance with a piece 4. Glass of water or ice chips of tape.

5. Toomey syringe Observe the natural curve of the NG tube. The tube should follow the natural curve of the 6. Chux pad or towel nasopharynx. Lubricate the first 6 inches of the tube with water-soluble lubricant. Lubrication

90 Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Handbook III reduces friction and injury during insertion. For also be used to secure the tube to the gown. By optimal control, hold the tube just past the securing the tube, the possibility that it will lubrication. become tangled or dislodged is reduced.

Instruct the patient to breath through his/her When the procedure has been completed, mouth. Gently pass the tube through a nostril to remove all equipment. Wash your hands and make the nasopharynx, Figure 3.07.01. Pause to give the the patient comfortable. Record pertinent patient a chance to prepare for the rest of the observations on Nursing Notes SF 510 and insertion. Do not force the tube if you meet an Twenty-Four Hour Intake & Output Worksheet obstruction. You may want to repeat the attempt DD 792. using the other nostril. NASOGASTRIC TUBE IRRIGATION Have the patient swallow continuously, or, if allowed, sip water through a straw or eat ice chips. Nasogastric tubes can easily be clogged by Swallowing helps advance the tube and causes the mucus, food, or pieces of gastric mucosa. When epiglottis to close the opening to the trachea. Ask the tube is not draining properly, you may be the patient to flex his/her head slightly. This asked to irrigate it to restore patency. After reduces the chance that the tube will enter the verifying the Doctor's Orders, perform patient trachea and makes swallowing easier. Rotating the identification checks, explain the procedure to the tube may help it advance. patient, and provide for privacy, safety, and comfort. As the patient swallows, continue to advance the tube to the mark. Tell the patient to stop Gather the equipment: swallowing. Without releasing your grasp, verify that the tube is in the stomach. 1. Chux pad

The most common method of verification is to 2. Irrigation solution aspirate stomach contents, Figure 3.07.02. Attach a Toomey syringe to the free end of the NG tube and 3. Irrigation kit or a Toomey syringe and a gently pull back on the plunger. Stomach contents container (fluids or partially digested food) should be visible if the tube is in the stomach. No other anatomic 4. Stethoscope structure contains secretions with the characteristics of gastric fluid. Wash your hands and don clean gloves. Place a Chux pad to protect the patient's gown and bed Another way to verify the tube is in stomach is linen. It is common for stomach contents or to inject 30 cc of air into the NG tube using the irrigating fluid to leak during NG irrigation. Toomey syringe while listening over the stomach Unclamp or disconnect the NG tube from suction with a stethoscope. (A partner may listen for you.) or other attachment if indicated. NG tubes used for Place the stethoscope on the abdomen immediately feedings may be clamped between meals. below the rib margin. As air is injected rapidly through the tubing, a swooshing sound will be Verify the tube placement. Always check tube heard if the tube is in the stomach. An X-ray can placement before putting anything down a NG be used to verify placement of a feeding tube. tube. Fill the Toomey syringe with irrigation fluid. Attach the filled syringe to the end of the gastric Once the position has been verified, tape the tube. (Remember that the blue port of sump tubes tube to the patient's nose. Connect the tube to is only for air.) Inject the solution slowly and suction or clamp as ordered. Attach the tube to the gently. If resistance is felt, check the tube for patient's gown by placing a flag of tape around the kinks. Proceed when the resistance is relieved. Do proximal end of the tube. A safety pin is used to not force the fluid; instead notify the nurse or secure the tape flag to the gown. Rubber bands can doctor. When you have inserted the specified

91 Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School Handbook III amount of fluid, withdraw by pulling back gently your hands, perform the patient identification but steadily on the plunger. Observe the contents checks, explain the procedure, provide privacy, for color, odor, consistency and amount. Repeat comfort, safety, and position the patient. Use PRN until the tubing is clear. gravity to your advantage. Elevate the head of the bed (Semi-Fowler's or High Fowler's position) When the irrigation is complete, reattach the during feeding and for 30 minutes afterward to NG tube to suction, clamp, or gravity as indicated. decrease the risk of regurgitation and aspiration. Be sure the suction is turned on. Record the irrigation on the Twenty-Four Hour Intake & Don clean gloves, place a Chux pad to protect Output Worksheet DD 792 as intake and output. the linen and pajamas, and remove the clamp or Ensure you have measured the amount instilled cap from the feeding tube. Verify NG tube and the amount returned. Note the procedure on placement. Aspirate the stomach contents with a the Nursing Notes SF 510. Provide care to the Toomey syringe. The aspirated fluid is called the patient's mouth, nose, and lips. Moisturize or residual. Return the residual to the patient. If the lubricate the lips and nose. Observe the nares for residual is more than half the volume of the irritation or skin breakdown. previous feeding, notify the nurse before administering this feeding. A large residual means NASOGASTRIC TUBE FEEDING that the patient is not tolerating the feeding or that the amount may need to be adjusted. Some patients who are unable to take food or fluid by mouth may receive nutrition via tube Connect the clamped feeding setup to the feedings, which are also known as gavage feeding tube. Hang the set on the IV pole. Pour the feedings. Unconscious patients, patients with feeding formula into the feeding container. mouth or throat surgery, and patients who have an Feeding is usually given at room temperature to endotracheal tube may be fed through a tube. avoid cramping and diarrhea. Unclamp the tubing Several commercially prepared tube feedings are and adjust the flow rate with the roller clamp or by available. The doctor will order a solution which raising or lowering the feeding setup. An infusion meets the patient’s needs. Feeding can be pump may be used at some treatment facilities. A intermittent or continuous. feeding should infuse over 20-30 minutes. Observe the patient for breathing or choking difficulties for Equipment needed to administer a tube a few minutes. feeding includes: Follow the feeding with one to two ounces of 1. Clean gloves water to clear the tubing. Feeding formula is thick and sticky, and can easily occlude a NG tube. 2. Chux Assist the patient with oral and nasal hygiene measures. Rinse and clean equipment for storage 3. Stethoscope or dispose of properly. Record the procedure on Nursing Notes SF 510 and Twenty-Four Hour 4. IV pole Intake & Output Worksheet DD 792.

5. Toomey syringe or irrigation kit MAINTENANCE

6. Prepared formula Most NG tube maintenance is related to tubes used for drainage, but the same principles apply to 7. Feeding set. A feeding set may be single-use feeding tubes. To prevent tube displacement and or it can be used up to 24 hours, depending on the need for replacement, make certain that the local policy. tube is placed correctly and taped securely in place. Most NG tubes are taped to the patient's The procedure for intermittent feedings is: nose. Avoid excess pressure on the nostrils. verify the Doctor's Orders, gather equipment, wash Pressure from the tube against the nare can cause

92 Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Handbook III ulceration, and tape can irritate the skin. Pin the the patient and the linen. Remove the anchoring tube to the patient's gown to prevent accidental tape gently. removal. Clamp off or pinch the tube to prevent Check tubing at frequent intervals (at least drainage. Instruct the patient to take a deep breath Q4H) to ensure functioning and patency. Observe and slowly exhale. As the patient exhales, pull the for movement of gastric contents along the tubing tube out in one continuous motion. Wrap the tube and watch to see if the collection bottle is filling. If in the Chux and discard per local policy. Remove the NG tube is not functioning well, inform the any tape residue from the patients nose. Make the nurse. If directed, the corpsman may move the patient comfortable and offer oral hygiene. tube in and out about 1-2 inches to determine if the Measure the final drainage in the collection bottle end of the tube is above or below the fluid level in and note characteristics before disposal. Clean and the stomach. You may be asked to milk the tube to store the equipment as appropriate. Record the assist thick secretions move along the length of the procedure on Nursing Notes SF 510 and Twenty- tube. Irrigate the tube when ordered. Four Hour Intake & Output Worksheet DD 792.

Provide frequent mouth and nasal care to ease RECORDING NASOGASTRIC TUBE nose and throat irritation. NG tubes will cause INFORMATION some discomfort. Gargles and lozenges, mouth care Q2H and PRN, and moving the position of the All documentation should include the date and tape periodically will increase comfort and time of the procedure, instructions given the decrease irritation. patient, and the patients tolerance of the procedure. After insertion, on the Nursing Notes SF 510, An informed patient is usually more record the type and size of the tube used, which cooperative, so be sure to explain all procedures. nare was used, fluid obtained, difficulties You may need to remind some patients that they encountered, and whether the tube was attached to are NPO. Provide psychological support as suction, gravity, or clamped. needed. Documentation of NG tube irrigation should NASOGASTRIC TUBE REMOVAL include the type and amount of solution used, the characteristics of the aspirated contents, and any When the physician determines that the comfort measures performed. nasogastric tube is no longer needed, it will be removed. Verify the Doctor's Order and gather the Following removal of the NG tube, note the equipment: clean gloves, a Chux pad, and supplies characteristics of the drainage and care done for for oral hygiene. the nose.

Wash your hands, perform the patient After a tube feeding, record the amount and identification checks, explain the procedure, type of the feeding used, the rate of administration, provide privacy, comfort, safety, and position the and the patients' response. patient. All patients with NG tubes should be on I&O. Place the patient in Semi- or High Fowler's Remember to record all irrigations and gavage position. Turn off the suction, if applicable. Don feedings as intake. Aspiration of fluid following gloves; place the Chux under the tubing to protect irrigation and fluid collected in a drainage bottle are recorded as output.

93 Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School Handbook III

FIGURE 3.07.01 Nasogastric Tube Insertion

FIGURE 3.07.02 Final Placement of Nasogastric Tube

94 Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Worksheet Handbook III Lesson 3.07

Nasogastric Tubes Worksheet

1. The removal of fluid and air from the gastrointestinal tract through an NG tube is called:

a. lavage.

b. gavage.

c. decompression.

d. irrigation.

2. Providing liquid food or nutrients through an NG tube is called:

a. lavage.

b. gavage.

c. milking.

d. irrigation.

3. NG tubes may be made of:

a. ______

b. ______

4. A Salem Sump tube has how many lumen?

a. 1

b. 2

c. 3

d. 4

95 Lesson 3.07 Nasogastric Tubes Worksheet Basic Hospital Corps School Handbook III

5. List equipment needed for NG tube insertion.

a. ______

b. ______

c. ______

d. ______

e. ______

6. How is the length of an NG tube to insert measured?

______

______

7. What position is the patient placed in for NG tube insertion?

______

8. List three methods to verify NG tube placement.

a. ______

b. ______

c. ______

9. You have instilled 30 cc of normal saline into a NG tube. When attempting to aspirate the stomach contents, only 5 cc returns. The next action should be:

a. aspirate forcefully to get the rest of the fluid.

b. return the 5 cc to the stomach and attach the tube to suction.

c. record 5 cc of output on Twenty-Four Hour Intake & Output Worksheet DD 792.

d. record 5 cc of output on Nursing Notes SF 510.

10. What position is a patient placed in for gavage feeding?

a. Prone

b. Supine

c. High or Semi-Fowler's

d. Trendelenburg

96 Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Worksheet Handbook III

11. How long should it take to infuse a tube feeding?

______

12. If you aspirate a residual which is more than half the amount of the tube feeding you are going to give, you should: ______

13. Why should the NG be flushed tube with water after each feeding?

14. Circle each technique for maintaining flow in an NG tube.

a. Move the tube in and out 1-2 inches.

b. Milk the tube to assist in moving thick secretions.

c. Irrigate the tube as ordered.

d. Move tube in and out 4-6 inches.

15. To prevent accidental dislodging of the NG tube, secure it to the patient's gown.

a. True b. False

16. To remove an NG tube, pull the tube:

a. slowly, advancing with each breath.

b. quickly while the patient holds his/her breath.

c. in one continuous motion during exhalation.

d. as the patient takes sips of water through a straw.

17. NG tube drainage should be:

a. labeled infectious waste.

b. discarded before it begins to smell.

c. kept in the collection bottle.

d. observed, measured, recorded, and discarded.

18. What is recorded in the Nursing Notes SF 510 following removal of an NG tube?

______

______

______

97 Lesson 3.07 Nasogastric Tubes Worksheet Basic Hospital Corps School Handbook III

NOTES/COMMENTS

98 Basic Hospital Corps School Lesson 3.06 Inpatient Care Handbook III Lesson 3.06

Inpatient Care

Terminal Objective:

3.06 Know procedures for AM and PM Care.

Enabling Objectives:

3.06.01 Define AM and PM Care.

3.06.02 State the purposes of AM and PM Care.

3.06.03 State the general guidelines for performing and recording AM and PM care.

3.06.04 Perform AM and PM Care.

3.06.05 Document AM and PM Care.

People look better and feel better when they depending on the patients capability), back care, a continue their usual activities of daily living linen change (for occupied or unoccupied bed), during a hospital stay. Activities often taken for hair care. AM care promotes comfort and safety. granted, like brushing teeth, taking a shower, Patients and their equipment are cleaned. AM care combing hair, or shaving make people feel normal. results in improved circulation and relaxation. Communication with your patient and observation Hygiene deals with the establishment and of his/her overall condition are easily preservation of well being through personal care. accomplished during morning hygiene. This chapter discusses common practices that contribute to well being through cleanliness and PM care is personal hygiene care given during grooming. evening hours in preparation for sleep, which includes offering the patient a bedpan or urinal, A person's health values and health perception providing an opportunity for oral hygiene, washing can be associated with his degree of self-care the patients hands, face, and back, (sponge bath), including personal hygiene. A primary concern for back care, straightening and tightening linen, the health care provider is that personal care be arranging the pillows on the patients bed, and carried out in a manner that promotes health. The adjusting lights and temperature. health care provider should reinforce and encourage appropriate hygiene practices among For safety purposes, the side rails need to be healthy individuals. For a patient that is ill, the up at night. Provide fresh water at the bedside for health care provider may substitute the care that a patient convenience. Remember that some patients patient is unable to perform. have fluid restrictions, so know the amount of water that you are giving fluid-restricted patients. AM AND PM CARE PM care provides the patient with an AM care is personal hygiene care performed opportunity to empty the bladder and bowels. daily, which includes oral hygiene, a bath, (this Personal hygiene prior to bedtime, promotes may be a bed bath, a tub bath, or shower relaxation to ensure a good night's sleep, and

99 Lesson 3.06 Inpatient Care Basic Hospital Corps School Handbook III allows additional opportunity for communication the patients' condition, and knowing the with and observation of the patient. procedures needed to give the proper care. Health care team members need to establish rapport with each patient.

The patient's safety is of the utmost SAFETY, PRIVACY, EDUCATION importance. Ignoring the safety of patient care may AND COMFORT DURING harm not only the patient, but endangers staff as PATIENT CARE well. Be sure to lock the wheels and raise the side rails on the bed.

The patient's privacy, safety, and comfort must Use patient restraints only when necessary. be provided when carrying out any procedure. In Health care providers should adjust the bed height providing for privacy the health care provider must to waist level to decrease or eliminate the need to remember to close doors and draw the curtains bend at the waist. This will reduce back strain. Be around the patient's bed. Remember to expose only sure to return the bed to the lowest level after what is necessary when providing treatment. performing a procedure.

Talk to the patient in a soft voice, so you do not broadcast treatment that you are giving to the rest of the ward. A patient's right to privacy is not DOCUMENTING AM AND PM CARE only an ethical issue but it is also a legal issue, so avoid elevator talk. Document all pertinent information on the ADL sheet and on the SF 510. Basic entries are: When providing for patient comfort, consider AM care completed and or PM care completed. the physical and emotional needs of the individual. Include patient tolerance or the response to care. To provide for the physical comfort of the patient, Note any assessment of the patient you performed, fluff and straighten pillows, place the patient in a and the general condition noticed during care comfortable position, and make sure the patient is given, Figure 3.06.01. warm but not over heated. FIGURE 3.06.01 Approach the mental and emotional aspect of Sample AM Care Nursing Note patient comfort as if you were caring for a close friend or family member. This includes providing for the privacy of the patient, an understanding of

100 Basic Hospital Corps School Lesson 3.06 Inpatient Care Worksheet Handbook III Lesson 3.06

Inpatient Care Worksheet

1. Define AM Care.

______

______

2. Define PM Care.

______

______

3. Patient safety, privacy, education and comfort should be provided before any procedure.

a. True b. False

4. When you have placed a bed pan or urinal, give the patient the call bell cord.

a. True b. False

5. AM and PM care are recorded where?

______

101 Lesson 3.06 Inpatient Care Worksheet Basic Hospital Corps School Handbook III

NOTES/COMMENTS

102 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning Lesson 3.08

Range of Motion and Patient Positioning

Terminal Objective:

3.08 Perform range of motion exercises and patient positioning.

Enabling Objectives:

3.08.01 Define range of motion, active, active-assistive, passive and continuous passive motion exercises.

3.08.02 State the purpose of range of motion exercises.

3.08.03 List guidelines and procedures for performing range of motion exercises.

3.08.04 List information to be documented after range of motion exercises.

3.08.05 List equipment used to maintain proper patient body positions.

3.08.06 List and describe selected patient positions.

3.08.07 Performs passive range of motion exercises.

3.08.08 Performs patient positioning using principles of patient safety, privacy, education, and comfort.

3.08.09 Document performance of range of motion exercise and patient positioning.

motorized exercise machinery that keeps a joint in Healthy people are active people. Activity is constant slow motion. essential for health. Patients confined to bed or having a physical limitation require care that RANGE OF MOTION EXERCISES includes activity and exercise. Range of motion exercises can provide this necessary activity. Range of motion (ROM) exercises are designed to help the patient stay in good physical DEFINITIONS

Range of motion is the degree of ability to condition by maintaining muscle tone when move a joint in flexion and extension, defined in activity is limited. ROM exercises: the degrees of a circle. Active exercises are those performed by the patient. Active-assistive 1. help maintain muscle and joint function exercises are those performed by the patient with some assistance from the Hospital Corpsman. 2. Prevent muscle deterioration (atrophy) Passive exercises are those performed by the corpsman when the patient is unable to move a 3. prevent muscle contractures, prevent pooling body part independently. Continuous passive of blood in veins motion (CPM) exercises are performed by

103 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Handbook III

4. prevent skin breakdown and below the joint. Avoid jerky or irregular movements. Work in a logical sequence. Begin at Tightness and other musculoskeletal changes the head and work down the body, or vice versa. can occur as early as 48 hours after a patient loses When the exercise is finished, return the extremity movement of an extremity. Muscle tightness is an to normal alignment. early stage of contracture - a permanently flexed joint that occurs with shortened muscle tissue. A partial listing of ROM exercises includes: Prolonged flexion or extension of muscles (opposing muscle groups are involved, meaning 1. Exercises of the neck: that some muscles surrounding a joint are flexed when others are extended) causes contractures. (1) Flex, extend, and hyperextend the Unless prevented, contractures may cause neck permanent damage to a joint. (2) Rotate head and neck from side to side When blood pools in veins, the patient may (3) Perform circumduction develop phlebitis, a thrombus, or thrombophlebitis. An embolus may break loose following clot 2. Exercises of the upper extremities: formation, leading to further complications. Exercise also relieves pressure on tissues, which a. Shoulder allows better blood flow. Muscle movement brings blood to the area, which maintains tissue health. (1) Flex, extend, and hyperextend the shoulder GUIDELINES FOR RANGE OF (2) Abduct and adduct the shoulder MOTION EXERCISE (3) Rotate the shoulder, internally and externally Before performing range of motion exercises, (4) Circumduct the shoulder the corpsman will provide for the patient's privacy, safety, and comfort. Measures such as keeping the b. side rails up on the side opposite from where you are working and draping or clothing the patient to (1) Flex and extend the elbow avoid exposure are appreciated. Explain and demonstrate the procedure the first time, and PRN. c. Wrist and hand The physical therapist or physical therapy technician may do this. In fact, some patients will (1) Flex, extend, and hyperextend have an order for range of motion exercises to be the wrist done by the physical therapy (PT) department. (2) Rotate, abduct, and adduct the wrist Verify the Doctor's Orders, especially for (3) Flex and extend the fingers and patients with an injured or diseased joint. The the thumb, then touch each physician must authorize exercises to injured or finger to the thumb diseased joints. Perform the exercises at least twice (4) Abduct and adduct the fingers a day, or according to the Doctor's Orders. and thumb

Start gradually, and work slowly so as not to 3. Exercises of the lower extremities: fatigue the patient. Begin with sets of three each, and work up to sets of five each for each exercise. a. Hip The purpose of ROM exercise is to maintain tone, not to tax or exhaust the patient. Move each joint (1) Flex, extend, and hyperextend the until there is resistance, but not to the point of hip pain. Support the extremity being exercised above (2) Abduct and adduct the hip

104 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning

(3) Rotate the hip, externally then reduces pressure areas caused by body weight, and internally may be the only exercise some patients get. (4) Circumduct the hip Health care providers b. Knee Body alignment by health care providers is (1) Flex and extend the knee important as well. To achieve correct body alignment when standing, start with a good base of c. Ankle and foot support. Place your feet parallel about 6 to 8 inches apart. Distribute your weight evenly on (1) Perform dorsiflextion and plantar both feet. Keep your knees flexed to serve as flexion of the foot shock absorbers. A stable base will save energy by (2) Invert and evert the ankle minimizing the work muscles must do. (3) Flex and extend the toes Tuck in your buttocks, to help straighten the PERFORMING RANGE OF MOTION lumbar spine. By pulling the abdomen in, you will EXERCISES decrease strain on your back. Keeping the rib cage up and the chest out prevents a humped back. Hold Use Figures 3.08.01 - 3.08.14 as a guide to your head erect to keep the spine in proper performing range of motion exercises. alignment. Taking care of yourself will make you better able to care for your patients. RECORDING RANGE OF MOTION EXERCISES EQUIPMENT FOR POSITIONING

Document pertinent information regarding Various pieces of equipment to keep patients ROM exercises. Include the type of ROM used in good position. A footboard is a board placed at (active, active-assistive, passive), the body part or the foot of the bed that supports the feet at right parts exercised, the length of time performed, angles to the body. Footboards are used to prevent including repetitions and sets, and the patient's foot drop and pressure on the toes. In some cases, tolerance of the procedure. For example: patients are placed in high top sneakers to achieve Performed active ROM to upper extremities X 10 the same purpose. A bedboard (or fracture board) minutes. (3 sets of 3 each.) Tolerated well, showed is a board placed under the mattress to provide full ROM. John Brown, HN. additional support to the patient's back. Backboards are generally only needed when using MAINTAINING CORRECT BODY older beds that do not have a metal foundation for POSITION the mattress. Hand rolls are gauze or washcloths placed in the palms to keep hands in the position

of function. Sandbags are used to immobilize Patients injured or potentially injured body parts. A sling can be used to provide support and prevent Properly positioning the patient in bed is dislocation of the shoulder. Pillows are all-purpose essential to comfort and will provide correct body position aids. They can be placed as needed to alignment. Correct body position when standing is support the patient in a particular position. similar to proper positioning when lying. Think of Trochanter rolls are made from rolled blankets or a person standing in alignment when placing a sheets. They are placed along the leg (at the bedridden patient in proper alignment. greater trochanter) supporting a patient (especially

the leg) in a particular position, usually as a means Immobilized patients need to have their body of preventing external rotation. position changed at least every two hours. Mobile humans automatically change their body position. Hospital Corpsmen should be familiar with Movement prevents prolonged strain on muscles, some positions that may be specified (or preferred)

105 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Handbook III for treatment or variety. The supine position has the lying patient flat on his/her back, Figure 3.08.15. Support the head and extremities with pillows and/or rolls. Prone position has the patient on his/her stomach with the head turned to one side, Figure 3.08.16. Pillows are placed under the abdomen and lower legs. There are several variations of the Fowler's position. High Fowler's is the result of raising the head of the bed to a 90-degree angle, Figure 3.08.17. The patient is sitting straight up. Semi-Fowler's results from raising the head 45-degree. Low Fowler's provides 30-degree of elevation. Often, the knee gatch is raised to prevent the patient from sliding down in bed.

Sim's position is a side-lying position that has the patient on either side, with the top leg flexed up toward the abdomen, Figure 3.08.18. Support the flexed leg, top arm, and back with pillows.

The Trendelenburg position, Figure 3.08.19, is also called the shock position. The patient is lying supine, with the foot of the bed raised at a 45 degree angle. Older hospital beds which are not adjustable can be placed in the Trendelenburg position by raising the foot of the bed about 12 inches using blocks.

The lithotomy position, Figure 3.08.20, has the patient lying supine with the knees and hips flexed. The dorsal recumbent position, Figure 3.08.21, has the patient lying supine with the knees flexed. To provide privacy, the patient should be draped.

106 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning

FIGURE 3.08.01 FIGURE 3.08.02 Flexion/Extension of Thumb Flexion/Extension of Fingers

FIGURE 3.08.03 Flexion/Extension of Wrist 107 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Handbook III

FIGURE 3.08.04 FIGURE 3.08.05 Pronation/Supination of the Internal/External Rotation Hand and Forearm of Shoulder

FIGURE 3.08.06 FIGURE 3.08.07 Adduction of the Shoulder Abduction/Adduction of Shoulder

108 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning

FIGURE 3.08.08 FIGURE 3.08.09 Flexion /Extension of Shoulder Dorsiflexion/Plantar flexion of the Toes

FIGURE 3.08.10 FIGURE 3.08.11 Dorsiflexion/Plantar flexion of Foot Eversion/Inversion of Ankle

109 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Handbook III

FIGURE 3.08.12 FIGURE 3.08.13 Rotation of Ankle Flexion/Extension of Hip and Knee

FIGURE 3.08.14 Abduction/Adduction of Hip

110 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning

FIGURE 3.08.15 Supine Position

FIGURE 3.08.16 Prone Position

FIGURE 3.08.17 High Fowler’s Position

111 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Handbook III

FIGURE 3.08.18 Sim’s Position

FIGURE 3.08.19 Trendelenburg Position

112 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning

FIGURE 3.08.20 Lithotomy Position

FIGURE 3.08.21 Dorsal Recumbent Position

113 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning Worksheet Lesson 3.08

Range of Motion and Patient Positioning Worksheet

1. Match each definition in column B to the correct exercise in column A.

A B

a. Range of motion ______1. Performed by the corpsman

b. Active ______2. Performed by motorized machinery

c. Active-assistive ______3. Defined in degrees of a circle

d. Passive ______4. Performed by the patient

e. Continuous passive motion ______5. Performed by the patient and corpsman

2. Range of motion exercises help prevent muscle deterioration and atrophy.

a. True b. False

3. Properly performed range of motion exercise may cause permanent damage to a joint.

a. True b. False

4. Range of motion exercises must not be performed unless ordered by a physician.

a. True b. False

5. When performing ROM exercises:

a. work quickly so as not to fatigue the patient.

b. move each joint until there is resistance, but not pain.

c. start with sets of five, and work up to sets of fifteen.

d. always exercise all joints.

115 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Worksheet Handbook III

6. Range of motion exercises should be:

a. performed at least Q4H.

b. done on legs, then head, then hands, then feet.

c. done by supporting the extremity above and below the joint.

d. done only by a physical therapist.

7. Match each movement in column B to the body part that is exercised in column A. Answers may be used more than once.

A B

a. Neck ______1. Rotate b. Head ______c. Shoulder and elbow ______2. Flex d. Shoulder ______e. Wrist and hand ______3. Extend f. Fingers ______g. Thumb ______4. Abduct h. Knee ______i. Ankle ______5. Adduct j. Back ______

8. Circle each item that is documented on the SF 510 after performing ROM exercises.

a. Type of range of motion

b. Body part or parts exercised

c. Patient's tolerance of the procedure

116 Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient Handbook III Positioning Worksheet

9. Body position of immobilized patients should be changed at least every two hours.

a. True b. False

10. List five pieces of equipment that may be used for patient positioning.

a. ______

b. ______

c. ______

d. ______

e. ______

11. Match each description in column B to the correct position in column A.

A B

a. Supine ______1. On either side, free leg is flexed up toward abdomen b. Prone ______2. Patient on stomach with head turned to one side.

c. High Fowler’s ______3. Also called shock position

d. Semi Fowler’s ______4. Head of bed is elevated 90 degrees

e. Sim’s ______5. Head of bed is elevated 45 degrees

f. Trendelenburg ______6. Patient is flat on his/her back

117 Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School Positioning Worksheet Handbook III

NOTES/COMMENTS

118 Basic Hospital Corps School Lesson 3.09 Restraining a Patient Handbook III Lesson 3.09

Restraining a Patient

Terminal Objective:

3.09 List concepts and principles for restraining a patient.

Enabling Objectives:

3.09.01 List types of patient restraint equipment.

3.09.02 State three situations which indicate restraints are required.

3.09.03 List guidelines for applying patient restraints.

3.09.04 List physical and psychological nursing care procedures for restrained patients.

3.09.05 List the procedure for applying wrist restraints.

3.09.06 List the procedure for applying a restraining vest.

3.09.07 Record care of a restrained patient.

USING RESTRAINTS SAFELY An ankle or wrist restraint (soft restraint) is used to secure a patient's hands Protective restraints are devices that limit and feet. Made of strong cloth about 3" wide a person's movement to prevent harm. and 8-10" long, it is padded to prevent injury Movement is essential to life. Restricting to the patients skin, Figure 3.09.01 and Figure movement can cause injury to the patient. The 3.09.02 health care provider who makes the decision to use a restraint also has serious A waist restraint (Posey belt) keeps a responsibilities to protect the well being of the patient in a bed while allowing the patient to patient. In general, a temporary restraint is turn from side to side. Made of canvas or other necessary if a patient becomes so restless or strong material, they are tied under the bed. irrational that he may harm himself, other patients, or staff members. Several different A restraining vest (Posey vest) prevents types of restraints are listed below. the patient from leaving the wheelchair or bed and provides support to the upper body. Made PATIENT RESTRAINT of a strong material, it fits over the patient's chest and has straps or ties which are fastened EQUIPMENT behind the wheelchair or bed.

Safety belts are used to restrain a patient Leather wrist and ankle restraints are to a gurney, a wheel chair, an exam table, or a used for restraining an extremely combative spine board. Made of webbing or strong patient. Made of leather, they are adjustable material, they are available in a variety of lengths, usually 5-6 feet long.

119 Lesson 3.09 Restraining a Patient Basic Hospital Corps School Handbook III and have a lock and key. Only trained Tests requiring the patient to be immobilized personnel may apply them. is another reason restraints may be used.

Mitts keep the patient from scratching or APPLYING RESTRAINTS picking at the skin or pulling out tubes. Made of cotton, they cover the patient's hands. Always check with the nurse before Tubular gauze or socks may also be applied to restraining a patient. All restraints require a the patient’s hands if mitts are not available. written Doctor's Orders. Check the equipment prior to use. Look for worn padding and A papoose board is used to immobilize missing straps or buckles. With leather infants and children during procedures, Figure restraints, ensure that the lock and key are 3.09.03. A commercially available board with present. head, arm, and leg straps, it wraps around the extremities and body and fastens with wide Have enough personnel to apply the strips of Velcro. A blanket or sheet wrapped restraint. A combative patient will require at around the patient's body may be substituted least four people to apply the restraint. for a papoose board, if necessary. Assistance may be needed for infants and children, as well. Follow local policy when SITUATIONS WHEN applying restraints. RESTRAINTS ARE INDICATED Fasten the restraint so it may be easily Restrain someone only when you are removed in an emergency. Never tie restraints concerned for the patient's safety and there is to the bed rails; a patient may be injured if the no other means of preventing harm. Use the rails are accidentally lowered. least restrictive type of restraint that will protect the patient. Soft restraints made from PHYSICAL CARE PROCEDURES fabric are preferable to leather ones. Apply the restraint for the shortest amount of time Ensure the restraining device is applied possible. The vest restraint may only be correctly. A carelessly applied restraint can be necessary while a patient is sitting in a more dangerous than no restraint at all. wheelchair. Provide for as much movement as Underlying tissue should be well padded to possible, even though the patient may need to prevent skin damage. Ensure that the patient's be restrained. The waist restraint protects the breathing is not inhibited. Avoid the supine patient from falling or crawling out of bed, but position when restraining an unconscious still allows the patient to change position patient or a patient who has just been fed independently. Restrain the fewest limbs or because of the possibility of aspiration. Place body parts possible. Apply wrist restraints any an unconscious patient on his/her side or time leg restraints are necessary. If wrist abdomen. restraints are not used, the patient may remove the leg restraints or become accidentally hung Perform circulation checks and skin care by his heels. Fasten the restraints to the bed to restrained extremities per local policy, but frame, which is more stable than the side rails, at least every two hours. Assess the patient for to prevent harm to the patient or others. skin redness and irritation from the restraints. The skin should be cleaned and powdered. Mental confusion may be a situation in Administer range of motion exercises every which restraints are indicated. A patient may two hours. wander, become confused, and attempt to disconnect the IV's, catheters, NG tubes, etc. Restraints are used during diagnostic tests for children and infants to facilitate examination.

120 Basic Hospital Corps School Lesson 3.09 Restraining a Patient Handbook III

PSYCHOLOGICAL CARE APPLYING A RESTRAINING Assess the patient's mental status and VEST provide emotional support. Explain to the patient and his or her significant others why When applying a restraining vest, gather the restraints are needed. Use the term “safety the equipment and wash your hands. Perform device” instead of restraint. Since it is a less patient identification checks, explain the threatening term, you may get a more procedure to the patient and assist the patient favorable response and less resistance. in putting on the vest. The straps should be at Emphasize to the patient that restraints are not the patient's back. Wrap and secure the straps punishment. Communicate with the patient around the back of the wheelchair or to the verbally to assure him/her of the availability of bed frame. Ensure that the vest does not assistance when needed. Be sure that the interfere with breathing or circulation. For patient call button is easily accessible. Some patients in bed, ensure that the call bell is restrained patients require constant within easy reach. Record the procedure in observation. Ensure the patient's privacy at all the Nursing Notes. times. Providing a patient psychological care helps to maintain a patient’s right to dignity RECORDING RESTRAINT CARE while in restraints. Record the application, type, location, and APPLYING WRIST RESTRAINTS purpose of the restraint. Record the patient's reaction, your signature and rate. To apply a soft wrist restraint, gather the equipment, including sheepskin, washcloth, or Sample: ABD pad, Kerlex rolls, and tape. Wash your hands and perform patient identification 2 June 1300 Vest restraint applied to chest checks. Approach the patient slowly and for safety due to patient's confusion. Tolerated calmly. Explain the procedures to the patient. application without resistance.---Signature, Speak in a soft and controlled voice. Use the Rate. patient's name and make eye contact. When a continuous restraint is required, Measure the Kerlex, ensuring it is long documentation should include removal of the enough to allow limited patient movement and restraint for ROM or skin care at least every that it reaches to the bed frame. Wrap the wrist two hours. Skin condition under the restraint, to be restrained with padding, protecting any circulation checks, the patient's tolerance of bony points or fragile skin that may be injured the restraint, and your signature and rate. by the restraint. Apply the Kerlex to the padded wrist, securing each end to the bed Sample: frame.

2 June 1730 Removed wrist restraints Ensure the patient is placed in a every two hours for skin care and ROM, wrist comfortable position and the call bell is within without signs of skin breakdown. Restraint easy reach before leaving the bedside. Record reapplied, capillary refill less than two the reasons for the initial and continued use of seconds, skin warm. Tolerating restraint well, a restraint in the Nursing Notes. Reassess the without agitation.---Signature, Rate. patient's circulation to the hands per local policy, but at least every two hours.

121 Lesson 3.09 Restraining a Patient Basic Hospital Corps School Handbook III

FIGURE 3.09.01 FIGURE 3.09.02 Making a Wrist Restraint Wrist Restraint

FIGURE 3.09.03 Papoose Board

122 Basic Hospital Corps School Lesson 3.09 Restraining a Patient Worksheet Handbook III Lesson 3.09

Restraining a Patient Worksheet

1. Which restraint would be used on a child needing facial sutures?

a. Posey vest

b. Papoose board

c. Soft restraints

d. Leather restraints

2. Mitts can be used to prevent a patient from pulling out I. V. lines.

a. True b. False

3. The best device to use for safety of an elderly patient in a wheelchair is/are:

a. safety belt.

b. soft restraints.

c. mitts.

d. papoose board.

4. Restraints are used to:

a. punish a patient.

b. limit limb movement.

c. keep side rails up.

d. protect a patient from harm.

5. Restraints are used on:

a. alert patients.

b. all angry patients.

c. confused patients.

d. all elderly patients.

123 Lesson 3.09 Restraining a Patient Worksheet Basic Hospital Corps School Handbook III

6. After application of restraints, limbs should be assessed for adequate circulation at least every:

a. hour.

b. two hours.

c. shift.

d. day.

7. The term safety device is generally less threatening than the term restraint.

a. True b. False

8. A confused patient does not need the restraint procedure explained before application of restraints.

a. True b. False

9. After applying a vest restraint, check to be sure that the patient can breathe adequately.

a. True b. False

10. Check restraint equipment prior to use for:

a. ______

b. ______

c. ______

11. List three pieces of equipment needed to apply soft restraints.

a. ______

b. ______

c. ______

12. List nursing care for a patient in wrist restraints that is to be performed every two hours.

a. ______

b. ______

c. ______

d. ______

124 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens Lesson 3.10

Isolation Techniques and Blood Borne Pathogens

Terminal Objective:

3.10 List concepts and principles of isolation techniques.

Enabling Objectives:

3.10.01 Define terms related to patient isolation.

3.10.02 State the purpose of universal precautions.

3.10.03 State the protective measures of universal precautions.

3.10.04 List the types of isolation and their purposes.

3.10.05 State the psychological impact of isolation on the patient and significant others.

3.10.06 List patient safety, privacy, education, and comfort considerations in an isolation environment.

3.10.07 List the procedure for initiating patient isolation.

3.10.08 State the procedure for donning and removing protective isolation clothing and accessories.

3.10.09 State the methods for removing contaminated articles from an isolation room.

3.10.10 List how healthcare personnel are exposed to blood borne pathogens.

3.10.11 State actions to be taken if exposed to blood borne pathogens.

Before discussing the purpose of isolation Pathogen – microorganisms that can cause and different isolation techniques, some terms infection or contagious disease. need to be defined to make this lesson more understandable. Nonpathogen – any non-disease producing microorganism. MEDICAL ASEPSIS TERMS Sepsis -- the presence of pathogens. Microorganism -- a tiny, living animal or plant. Asepsis -- the absence of pathogens.

125 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

Medical asepsis -- practices that reduce the Highly susceptible patient -- patient with number and spread of microorganisms. Also impaired skin integrity or with a compromised called clean technique. immune system who has a greater probability of acquiring an infection. Contaminate -- to make something unclean or unsterile. Direct contact -- a route of spreading pathogens when one is with or touches an Cross contaminate -- the transfer of infected person. pathogens from: Indirect contact -- a route of spreading A. One person to another. pathogens by touching contaminated objects.

B. One area to another on a patient. Double bagging -- removing a bag of contaminated items from an isolation room by C. Equipment to a person. placing it in another clean bag held by someone outside the room. Disinfection -- the process by which pathogenic organisms but not spores, are Universal Precautions -- preventive practices destroyed on inanimate objects. that protect health--care workers from acquiring blood borne viruses from Disinfectant -- a chemical that kills unidentified, infected persons. Also called microorganism but not their spores. (Not body substance isolation intended for use on persons.) Blood borne pathogen exposure - direct Antimicrobial agent -- a chemical that kills contact with another's body fluid or any item or suppresses growth of microorganisms. contaminated with another's body fluids.

Antiseptic -- a chemical that prevents or OSHA Standard - Department of Labor, inhibits the growth of microorganisms. Safe to Occupational Safety and Health use on living tissue. Administration regulation (29CFP Part 1910) for general industry. Terminal disinfection -- cleaning of the patient's contaminated room, equipment, and PURPOSE OF UNIVERSAL supplies after discharge. PRECAUTIONS

Nosocomial infection -- infection acquired in Universal precautions (sometimes called a hospital setting. standard precautions) are an approach to infection control designed to prevent ISOLATION TERMS transmission of blood borne diseases in health care settings. Universal precautions should be Isolation -- confinement of pathogens to a used anytime there is the possibility of given area to prevent their spread. contacting a person's body fluid such as: blood, semen, vaginal secretions, cerebro- Infection control techniques -- practices that spinal fluids, amniotic fluid, peritoneal fluid, prevent the spread of pathogens. Also called pleural fluid, synovial fluid, and salvia, or isolation techniques. mucous membranes and non-intact skin.

Contagious disease – an illness that is easily Universal precautions must be used spread to others. Also called communicable consistently with all patients. disease.

126 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens

UNIVERSAL PRECAUTIONS To avoid accidental punctures, needles and syringes must be disposes of in puncture Health care workers are exposed to body resistant (Sharps) containers. Needles are fluids and secretions that may contain placed in these containers uncapped. unknown contaminants. Since medical history and exams cannot consistently identify high- Disposable ventilation devices should be risk contacts, universal precautions are used every time there is need for mouth to initiated on all patients. The purpose of mouth resuscitation of a patient. universal precautions is to prevent skin and mucous membrane contamination of the Contaminated clothing and linen is to be providers through exposure to the patients’ separated from other dirty clothing and blood, body fluids, mucous membranes, non- disposed of according to local policy. intact skin or potentially contaminated patient care equipment. TYPES AND PURPOSES OF ISOLATION Protective measures of universal precautions include: Isolation techniques are practices and procedures that limit the transmission of Gloves MUST be worn whenever contact with microorganisms from a reservoir to a blood, other potentially infectious materials, susceptible patient through the use of certain mucous membranes or non-intact skin is practices and procedures. These practices are expected. Avoid direct patient care and designed to break the 4th link in the chain of handling of soiled equipment if your skin is infection, the transmission of the not intact. Thoroughly wash hands microorganism to a susceptible host. immediately after removing gloves. One purpose of isolation techniques is to Masks must be worn during procedures that protect individuals in the general environment are likely to generate aerosol droplets or from pathogens released from an infected splashes of blood and other potentially person. Another purpose is to protect a highly contaminated materials. Masks prevent susceptible patient from microorganisms in the exposure of mucous membranes of the nose general environment. and mouth Strict Isolation prevents the transmission of Goggles or other protective eyewear are diseases by direct contact and airborne routes. required during procedures that are likely to It requires that the patient have a private room generate aerosol droplets, splashes, spray or with the door shut. Patients with the same splatter of blood and other potentially disease may share a room. All persons infectious materials. entering the room must wear a mask, gloves, and gown. Articles taken out of the room Gowns or aprons must be worn during must be double bagged before being sent for procedures that are likely to generate splashes disinfection or sterilization. Hands must be of blood or other potentially infectious washed upon entering and leaving the room. materials. Plaque, diphtheria and small pox are diseases that require strict isolation. Figures 3.10.01 Handwashing is one of the most effective and 3.10.02. means of infection control. Thoroughly wash hands with soap and water immediately after Respiratory isolation prevents the any contact with blood or body fluids, mucous transmission of contagious diseases that are membranes, secretions or excretions, and after spread by the airborne route via coughing, removing gloves.

127 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III sneezing, or breathing. Protective measures contact. Masks are worn if there is any danger for this type of isolation include a private of being splashed. Hands must be washed room, keeping the door shut, and masks for upon entering and leaving the room. those who come close to the patient. Patients Potentially infected articles must be double with the same disease may share a room. Any bagged. Diseases requiring drainage/secretion articles taken from the room must be double precautions include abscesses, infected burns, bagged. Hands must be washed upon entering conjunctivitis, infected decubitus ulcers, skin and leaving the room. Diseases requiring infections and wound infections. Figures respiratory isolation include meningitis, 3.10.09 and 3.10.10. mumps, measles, whooping cough and tuberculosis. Figures 3.10.03 and 3.10.04. Protective or reverse isolation prevents contact between potentially pathogenic Enteric isolation prevents the transmission of organisms and a patient who has a seriously contagious diseases through direct or indirect impaired resistance against infection. All of contact with infected feces. Protective the types of isolation discussed so far are measures include wearing gowns if soiling is intended to protect the individual on the possible. Gloves must be used when having outside from pathogens an infected patient direct contact with the patient or with articles may harbor. Simply speaking, in reverse contaminated with feces. Private rooms are isolation the patient is being protected from indicated for children or for anyone who contamination. Protective measures include a cannot be relied upon to wash their hands. private room and keeping the door closed. Hands must be washed upon entering and Gowns and masks must be worn by anyone leaving the room. All articles leaving the room entering the room. Gloves are required by must be double bagged. Diseases requiring anyone in direct contact with the patient. A enteric isolation include cholera, hepatitis - hair cap and shoe covers are worn if the type A, and typhoid fever. Figures 3.10.05 and patient has a compromised immune system. 3.10.06. Hands must be washed upon entering and leaving the room. All articles brought into the Contact isolation prevents the transmission of room must be sterile or disinfected. Patients highly contagious or significantly important requiring protective isolation include those infections by direct or indirect contact. These with extensive burns, certain cases of diseases may not warrant Strict Isolation. A leukemia, organ transplant patients, or others private room is indicated. Gowns, gloves, and with suppressed immune systems. masks are worn if contact with infectious material is possible. Hand washing is required PSYCHOLOGICAL IMPACT OF upon entering and leaving the room. All ISOLATION contaminated articles must be double bagged prior to leaving the room. Acute respiratory A common patient response to initiation of infections (croup, influenza) in infants, rabies, isolation procedures is fear. Patients are scabies, and skin infections caused by generally frightened by disease. They tend to staphylococcus are examples of diseases feel unclean because the staff is always requiring contact isolation. Figures 3.10.07 washing their hands and carefully handling and 3.10.08. contaminated articles. Isolated patients may feel lonely and neglected because they cannot Drainage/secretion precautions prevent the leave their room and visitors may visit transmission of organisms by contact with infrequently. Minimize feelings of loneliness infected wounds, body secretions and heavily by encouraging family visits. Emphasize that contaminated articles. (Sometimes referred to as long as precautions are followed, visitors as wound and skin precautions.) Gowns and are not likely to contact the disease. Plan gloves are indicated for use when soiling is frequent patient contact. Do NOT limit your likely or when there will be direct patient

128 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens interactions to only the minimum needed for place it outside the room. Stock it with gowns, patient care. gloves, masks, and trash bags. Notify food services that the patient is in isolation. The Isolated patients are prevented from meals may need to be sent in disposable participating in activities outside the room and containers. Never take the clinical record into may have sensory deprivation and depression. the isolation room because it will be Help the patient to experience a variety of contaminated. sensory stimulation. Provide reading materials, a radio, or a television to decrease ISOLATION GEAR boredom. If possible arrange the bed so the DONNING ISOLATION GEAR patient can look out the window All the equipment needed for people who PATIENT EDUCATION, enter an isolation room should be in the PRIVACY, SAFETY, AND isolation cart. COMFORT IN AN ISOLATION ENVIRONMENT Remove jewelry and wash your hands.

Show acceptance of patients by Position the mask by placing it over the encouraging them to express their feelings. nose and mouth and adjust it for comfort. Pass Explain the purpose of isolation including any the top strings over the ears and tie them, then special procedures, e.g., handwashing and tie the lower strings around the neck, Figure proper disposal contaminated items, etc. Stress 3.10.11. Change the mask when it becomes that it is the microorganism, not the patient moist, after wearing for a prolonged period of that is unwanted. Precautions are intended to time, or follow the manufacturer's prevent the spread of contagious diseases. recommendation. Never lower the mask around the neck. As with all patients, provide for privacy, safety and comfort. Assure that the bed wheels Next, pick up the gown. Holding it by the are locked and the side rails are up. Change neck, allow the gown to open and fall to full the bed linen and patient's gown if they length without touching the floor. Position the become wet or soiled. Draw the curtain around back opening towards you, place your arms the bed whenever performing a procedure. into the sleeves, then pull the gown over the shoulders and around the neck and secure it. INITIATING ISOLATION Overlap the edges of the gown in back at the waist and secure the ties, Figure 3.10.12. PROCEDURES Don shoe covers and cap if required. If a private room is required, place the patient in a room that is designated for Last, don clean gloves, bringing the cuffs isolation. These rooms have special features of the gloves over the cuffs of the gown. such as an anteroom with a sink. Post the appropriate isolation card on the door and You may now enter the isolation room and ensure that all personnel and visitors adhere to proceed with patient care. Avoid bringing the special precautions listed, e.g., hand gloved hands towards your face or hair so you washing upon entering and leaving the room, do not spread contamination. wearing appropriate garb, etc. Stock the room with equipment such as a blood pressure cuff, stethoscope, and a disposable thermometer or a glass thermometer. The glass thermometer is REMOVING ISOLATION GEAR left soaking in a disinfectant solution at the patent’s bedside. Obtain an isolation cart and

129 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

First, untie the waist closure of the gown These are known as melt-away bags. As if it is tied in front. The front of the gown is laundry accumulates, remove it from the the most contaminated area, therefore, ties in room. If the linen is soiled with blood, body the front should be untied with gloves still on. fluids, or contaminated drainage, it should be transported to the laundry in plastic bags that Next, remove the gloves by holding the prevent leakage. Bag should be marked cuff of one hand and pulling it off with the Isolation Linen. other gloved hand. Reach your fingers inside the glove and pull the second glove off. DISPOSING OF BURNABLE Discard gloves in the trash and wash your TRASH hands. All trash receptacles in the isolation room Next, remove the mask by untying the should be lined with isolation trash bags. All upper and lower strings. Discard the mask in burnable trash is deposited in these lined the trash by holding only the strings (they are receptacles. At the end of each shift, or considered clean). Avoid touching the mask. whenever trash is emptied, the bag is secured with tape, and using the double-bagging Finally, unfasten the neck of the gown and method, is removed from the room. Double waist ties (if fastened in back). Insert the bagging is accomplished as follows: fingers of one hand under the cuff of the sleeve and pull the sleeve over the hand. Pull Trash from the patient's room is deposited the other cuff over the hand by grasping it into a second plastic bag outside the patient's with the hand that is already inside the sleeve. room. Slip out of the gown, fold it with the outside of the gown to the inside, hold the gown away The person outside the room turns down from your uniform and roll gently. Discard the the cuff of the clean outer bag and holds the gown in the trash. bag under the cuff to prevent contamination.

Wash your hands after removing isolation The outer bag is securely tied and clearly clothing. Use paper towels to turn off the marked Infectious Waste. faucet and to open the door to exit the room. DISPOSING OF NON-BURNABLE Now you are ready to go on to your next patient without fear of spreading ITEMS contamination. Non-burnable items, such as stainless steel REMOVING CONTAMINATED equipment, should be cleaned with soap and water in the patient's room, double bagged and ARTICLES FROM ISOLATION sent for sterilization. Needles and syringes are ROOMS placed in specially marked, puncture resistant Sharps containers to prevent accidental needle DISPOSING OF LINEN punctures. Whenever possible, use disposable basins, bedpans and urinals for patients on Gather all soiled linen and washable isolation. This will eliminate the need for items, such as reusable isolation gowns, bed sterilization and the potential spread of linen, towels, and patient gowns and place contagious diseases. them in a laundry bag inside the patient's room. Some bags appear to be ordinary plastic bags when dry, but melt or disintegrate when washed in hot water so that laundry workers REMOVING SPECIMENS do not need to touch contaminated linen.

130 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens

Specimens such as blood, sputum, urine, be taken to avoid or minimize exposure due stool from a patient in isolation can be to: submitted to the lab. When collecting a specimen, protect the outside of the container a. needle stick from contamination. If the outside of the container potentially comes in contact with a b. cuts from items that have been pathogen, the specimen must be bagged upon contaminated by exposure to a patient's bodily removal from the room and the lab chit fluid attached to the outside of the bag. Universal precautions are used when handling all c. allowing bodily fluid from a patient to laboratory specimens. contact an open wound or broken skin

TRANSPORTING THE PATIENT d. splashes of a patient's bodily fluid

There are times when it is necessary to e. patient's bodily fluid contacting transport an isolation patient to various mucous membranes departments within the hospital, such as for an X-ray or other procedures. When transporting EVERY occurrence of being exposed to a a patient from the isolation room, notify the patient's body fluid in any of these means is to receiving department that an isolation patient be handled as an exposure to a blood borne is arriving and what precautions are necessary. pathogen. Cover the surface of the wheelchair or gurney with a clean sheet and use a second sheet to ACTION FOR EXPOSURE TO cover as much as the patients body as possible. BLOOD BORNE PATHOGENS Provide items such as a mask or gown for the patient if applicable. The person transporting As a healthcare provider, ANY time you the patient must also wear gloves/gown/mask are exposed to a blood borne pathogen you when indicated. After returning the patient to MUST: the room, disinfect the wheelchair or gurney. a. Seek medical assessment/treatment EXPOSURE TO BLOOD BORNE PATHOGENS b. File incident report

Healthcare providers and others involved c. Inform appropriate supervisors with patients may be exposed to blood borne pathogens in a number of ways. Care needs to d. Follow local protocol for additional actions and safety precautions.

131 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

FIGURE 3.10.01 Isolation Door Card for Strict Isolation

FIGURE 3.10.02 List of Diseases Requiring Strict Isolation

132 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens

FIGURE 3.10.03 Isolation Door Card for Respiratory Isolation

FIGURE 3.10.04 List of Diseases Requiring Respiratory Isolation

133 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

FIGURE 3.10.05 Isolation Door Card for Enteric Precautions

FIGURE 3.10.06 List of Diseases Requiring Enteric Precautions

134 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens

FIGURE 3.10.07 Isolation Door Card for Drainage/Secretion Precautions

FIGURE 3.10.08 List of Diseases Requiring Drainage/Secretion Precautions

135 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

FIGURE 3.10.09 Isolation Door Card for Contact Isolation

FIGURE 3.10.10 List of Disease Requiring Contact Isolation

136 Basic Hospital Corps School Lesson 3.10 Isolation Techniques Handbook III and Blood Borne Pathogens

FIGURE 3.10.11 Wearing a Mask

FIGURE 3.10.12 Donning Isolation Gown

137 Lesson 3.10 Isolation Techniques Basic Hospital Corps School and Blood Borne Pathogens Handbook III

NOTES/COMMENTS

138 Basic Hospital Corps School Lesson 3.10 Isolation Techniques and Blood Handbook III Borne Pathogens Worksheet Lesson 3.10

Isolation Techniques and Blood Borne Pathogens Worksheet

1. Define sepsis. ______.

2. Define contaminate. ______.

3. Isolation is:

a. a disease that is easily spread to others.

b. practices that prevent the spread of pathogens.

c. confinement of pathogens to a given area to prevent their spread.

d. practices that reduce the number and control the spread of microorganisms.

4. A highly susceptible patient is ______

______.

5. Universal precautions are used to prevent the transmission of blood borne viruses by contact with:

a. ______

b. ______

c. ______

d. ______

6. When should universal precautions be used? ______

7. The protective measures of universal precautions that the health care provider can wear are:

a. ______

b. ______

c. ______

d. ______

8. When performing rescue breathing, what is a way to protect yourself from contacting diseases?

______

139 Lesson 3.10 Isolation Techniques and Blood Basic Hospital Corps School Borne Pathogens Worksheet Handbook III

9. State the purposes of isolation.

a. ______

b. ______

10. Explain the purpose of strict isolation.

______

11. Patient require respiratory isolation because their disease is spread by

______

12. Enteric isolation is initiated to prevent transmission of contagious diseases via what route? ______

13. What are the isolation gear/garb is used with a patient on drainage / secretion precautions? ______

14. How does protective isolation vary from other types of isolation?

______

15. What are some of the emotional feelings that patients in isolation may experience?

______

16. You should show acceptance of an isolated patient by letting him/her express his/her feelings.

a. True b. False

17. List areas of patient education that a corpsman would give to an isolation patient.

a. ______

b. ______

c. ______

18. List the equipment that would be placed in the isolation room.

______

19. List the equipment that would be stocked on the isolation cart.

______

______

140 Basic Hospital Corps School Lesson 3.10 Isolation Techniques and Blood Handbook III Borne Pathogens Worksheet

20. Why is an isolation card placed on the door of the room of an isolated patient?

______

21. Why is the clinical record not taken into the isolation room?

______

22. List actions taken prior to donning isolation gear.

a. ______

b. ______

23. List the order to apply protective isolation clothing.

a. ______

b. ______

c. ______

d. ______

24. Which item of isolation clothing/garb is removed first?

a. Mask

b. Gown

c. Gloves

25. Describe how a melt-away bag works. ______

______

26. What technique is used to remove burnable isolation trash and nonburnable items from the room?

______

27. Describe what precautions are taken when transporting an isolation patient.

______

______

28. Any exposure to a potential blood borne pathogen is to be treated as if it were an actual exposure?

a. True b. False

141 Lesson 3.10 Isolation Techniques and Blood Basic Hospital Corps School Borne Pathogens Worksheet Handbook III

29. List three ways healthcare providers may be exposed to potential blood borne pathogens.

a. ______

b. ______

c. ______

30. List the actions to be taken for any exposure to potential blood borne pathogens.

a. ______

b. ______

c. ______

d. ______

142 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III Lesson 3.11

Surgical Asepsis

Terminal Objective:

3.11 Perform surgical aseptic techniques.

Enabling Objectives:

3.11.01 Define terms related to surgical asepsis and wound care.

3.11.02 List selected methods of sterilization.

3.11.03 List principles of surgical asepsis.

3.11.04 List the types of dressing changes and equipment needed to perform them.

3.11.05 List guidelines for wound cleansing and irrigation.

3.11.06 List patient safety, privacy, education, and comfort considerations when utilizing sterile technique and performing wound care.

3.11.07 List guidelines for establishing a sterile field.

3.11.08 List guidelines for using sterile solutions.

3.11.09 List guidelines for donning and removing sterile gloves.

3.11.10 List documentation requirements for a dressing change.

3.11.11 Perform a sterile dressing change for a closed incision.

3.11.12 Perform a sterile dressing change for a deep-packed wound.

Microorganisms are everywhere. of microorganisms, has already been Although they cannot be seen with the naked discussed. eye, they cover everything. They are present in water, food, air, and our bodies. When the skin is broken and an open Microorganisms that cause disease or infection wound is present, the individual's natural are called pathogens. Harmless defense against invasion by microorganisms is microorganisms are called nonpathogens. impaired. To prevent the onset of infection in Health care workers strive to prevent disease a wound or during an invasive procedure of and infection and, therefore, take measures to the body, health care workers take measures to prevent the spread of harmful microorganisms. prevent any microorganisms from entering the Medical asepsis, which includes practices that body. These measures, termed surgical help reduce the number and inhibit the growth asepsis or sterile technique, include practices

142 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III that render and keep objects and areas free of HEMOSTATS -- two-pronged instrument all microorganisms. This is often done by with scissor-like handles. Used to hold items sterilization, a process that destroys such as grasping a dressing. microorganisms. INFLAMMATION – body’s defensive GLOSSARY reaction to tissue injury, characterized by localized pain, heat, redness, and swelling of STERILE -- free from living microorganisms, tissue and wound edges. including spores PENROSE DRAIN -- a thin-walled, latex tube STERILIZATION -- the process of destroying that is surgically placed in a wound to allow and eliminating all microorganisms, including drainage to escape form a body cavity. spores TAPE -- material to secure dressings. Types SURGICAL ASEPSIS -- practices that render available include adhesive and hypoallergenic and keep objects and areas free of all tapes. If a patient is allergic to adhesive tape microorganisms (sterile technique). and exhibits symptoms of redness, edema, and blister formation where the tape touches the STERILE FIELD -- work area free from living skin, paper or silk tape may be used. Paper microorganisms tape is extremely flammable and must be used with caution. STERILE DRESSING -- one of various materials utilized for covering and protecting a MONTGOMERY STRAPS -- Tie straps with wound, free from living microorganisms tape remain in place when the dressing is including spores. changed. Decreases the possibility of injury to the skin by allowing the tape to remain in OPEN WOUND -- break in the continuity of place between dressing changes, Figure the skin or mucous membrane. 3.11.01.

INCISION -- a clean separation of skin and METHODS OF STERILIZATION tissue with smooth, even edges. A surgically created wound. Any article that is used for an invasive procedure or that will enter a sterile area of the SUTURES-- material used to join several body must be sterilized. There are several edges of tissue together (stitches). methods used to render the item totally free of all microorganisms. It is important to know STAPLES -- wire skin closures. Frequently the effect that the method has on a particular used in place of sutures. Sometimes called article. For instance, chemicals can corrode clips. metals. Pressurized steam may damage rubber or plastic and may dull sharp instruments. DEHISCENCE -- partial to complete separation of previously joined (sutured) Pressurized steam (known as wound edges. autoclaving) is one of the quickest, most economical and widely used sterilization DRAINAGE -- discharge from a wound or methods. It combines moist heat, pressure, and body cavity. high temperature to destroy all organisms and spores. DEBRIDEMENT -- the removal of damaged tissue and cellular debris in order to prevent Using a gas such as ethylene oxide is infection and promote healing. another method of sterilization. The gas is able

143 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III to permeate articles that may be destroyed by objects when turning and sterility cannot be the high temperatures required with ensured without continuous observation. pressurized steam. Contact with the gas over a period of time can kill all organisms. The Principle -- Sterile objects must be article must aerate for 24 hours after maintained above waist or table level. sterilization to allow the residue of gas to escape. Explanation -- Areas below the waist are out of sight and could become contaminated Aqueous glutaraldehyde is an example of without your knowing. a liquid chemical that may be used for sterilization. The articles must be immersed in Principle -- Talking, coughing, and sneezing a specific solution for a specific period of over a sterile field must be avoided. time. Explanation -- Microorganisms are present in Irradiation in the form of ionizing the moisture from respiratory secretion. These radiation has significant penetrating power as droplets can fall onto sterile areas, causing a sterilizing agent. Sterile gloves, syringes, contamination. needles, and urinary catheterization trays may be irradiated for sterilization by the Principle -- NEVER reach across a sterile manufacturer prior to being distributed for use. field.

PRINCIPLES OF SURGICAL Explanation -- Reaching across an area could ASEPSIS cause contamination through accidental contact or by dropping particles of dust or lint. Sterile technique must be strictly followed when dealing with open wounds, doing Principle -- Open windows, air conditioning invasive procedures, or when an article enters units, and fans near a sterile field create the a sterile area of the body. The following is a potential for contamination. list of principles that must be followed when performing surgical asepsis. Explanation -- Air currents can carry organisms that can then be deposited onto Principle -- An item that has been only sterile items. disinfected is not considered sterile. Principle -- A sterile object becomes Explanation -- Disinfection does not destroy contaminated when touched by unsterile all microorganisms. Some microorganisms objects. may become active and cause infection. Explanation -- Even clean objects contain Principle -- A sterile area should never be left microorganisms. Sterile objects may only unattended. touch other sterile objects.

Explanation -- Leaving sterile areas and Principle -- Spilling liquid on a non- equipment provides a situation in which waterproof sterile field contaminates the undetected contamination may occur. sterile field.

Principle -- Always keep the sterile field in Explanation -- Moisture on sterile cloth or view. Never turn your back to a sterile field. paper can pull microorganisms from the contaminated surface by capillary action. Explanation -- It is possible that contaminated areas of the body or clothing may touch sterile Principle -- The inside of the lid of a sterile container is considered free of microorganisms

144 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III as long as it is not placed directly on a Explanation -- In the process of creating a contaminated surface. sterile field, the edges are the most likely place for accidental contamination. You are allowed Explanation -- Place a lid upside down (rim to touch the one inch edge of the wrapper with up) if the lid cannot be held while removing your ungloved hand therefore you cannot contents from the container/bottle. Care must touch this one inch border after donning sterile be taken that the edges do not become gloves. The edges of the field off the table contaminated when the lid is replaced. could potentially come in contact with contaminated areas of the body or clothing. Principle -- Sterile instruments may be picked up with the ungloved hand. Principle -- Do not use equipment and supplies if there is any doubt about its sterility. Explanation -- While the handles will become contaminated, the untouched tips that will be Explanation -- Because organisms cannot be in contact with the wound or sterile supplies seen, it is far better to err on the side of safety will remain sterile. than to take a chance and have the patient acquire an infection. Principle -- The inside of a wrapper and its contents are sterile. They should not be Basic concepts of sterility: touched with the bare hand. Sterile gloves or sterile instruments should be used if the 1. Sterile + sterile = sterile. contents must be rearranged. 2. Sterile + clean = unsterile. Explanation -- Touch only the outer wrapper or underneath surface of the wrapper. The 3. Sterile + contaminated = unsterile. inside is sterile, the outside contaminated. 4. Sterile + unknown = unsterile. Principle -- Sterile gloves are worn when performing a sterile procedure. Before opening a sterile package inspect it for signs of contamination. Check the Explanation -- When applied correctly, sterile condition of the package wrapper for tears or gloves may be safely used to handle sterile holes, any indication that it has become damp supplies and prevent contamination of sterile or wet, and whether the sterile package had equipment, the wound, or transmission of been dropped on the floor. Do not use the item microorganisms into the environment of the if any of these conditions are present. Hospital patient. prepared packages must be double wrapped and will have an expiration date and Principle -- Keep gloved hands in sight and sterilization indicator. The sterilization above waist level. Do not touch unsterile indicator may be found inside and outside the objects. package and will change color if the article was sterilized. Do NOT use the item if it is Explanation -- When hands are removed from past its expiration date or there is no area of critical viewing (out of line of sight), expiration date. they potentially could become contaminated by touching unsterile items. TYPES OF DRESSING CHANGES

Principle -- Treat the edges of a sterile field as Tissues of open and closed wounds are if they were contaminated. Any part of the more susceptible to additional injury than is field off the table is considered contaminated. healthy, intact tissue. Two goals of wound care are to prevent further injury and to promote tissue healing. The type of dressing

145 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III change and materials used depends on the type WOUND CLEANSING AND of injury. IRRIGATION

A dry, sterile dressing is a gauze applied A closed incision and the surrounding to keep the wound clean and prevent entry into areas may be cleansed to remove debris and to the wound by microorganisms. The highly aid in healing. When cleaning a wound, use absorbent nature of the dressing material is the first swab and wipe once downward from able to collect large amounts of wound top of incision to bottom, then discard swab. drainage. The gauze can also hold antiseptic The second swab is used to wipe once down ointment next to the wound and protect the the far side of the incision and then discarded. wound from further injury. If the dressing The third swab cleans the near side of the adheres to the wound during removal, it may incision using the same top to bottom motion. be moistened slightly with sterile saline or The fourth swab cleans the center of the sterile water to decrease pain the patient may wound again. Using one swab for each stroke experience. prevents introducing organisms from the skin into the wound or from transferring organisms Surface debridement of a wound is from one area of the wound to another. accomplished by applying a wet to dry Equipment needed to cleanse a wound include dressing. The moistened dressing material the following sterile items: basin, irrigating keeps the wound area soft and traps debris in solution and gauze sponges in addition to the the wound as the material dries. When the items required for the dressing change. dressing is changed, the once moist gauze is now almost dry. The dried gauze debrides the Wound irrigation involves the instillation wound as it is removed from the wound. Do of a solution into an open wound. It may be not moisten the dried dressing when removing ordered to cleanse the wound by removing it from the wound. The wet dressing is drainage and debris, to increase circulation to covered with a dry cover dressing for patient an open wound to aid in healing, or to prevent comfort. further infection (using an antiseptic solution). Equipment needed to perform an irrigation A wet to wet dressing can be ordered includes an irrigating syringe (50-100 cc when the wound is to be kept moist to promote syringe with a plunger or compression bulb), a wound healing. To limit growth of pathogens sterile basin (to hold the irrigating solution), in the moist wound environment, the liquid irrigating solution as ordered by the physician, used to moisten the gauze may contain an and a basin to receive the soiled solution as it antiseptic. A granulating solution may be drains away from the body. placed in the wound to promote tissue growth. A wet to wet dressing is similar to a wet to dry PROVIDING PRIVACY, SAFETY, dressing except it is heavily moistened when applied to prevent it from drying out between COMFORT AND EDUCATION dressing changes. Before carrying out a sterile procedure on The equipment needed to perform a a patient, perform patient identification checks dressing change depends on the type of to ensure you have the right patient. Explain dressing change. Items required include sterile what you are about to do in order to gain the gauze sponges (2x2's, 4x4's), tape or patient's cooperation. Since the patient must Montgomery straps, clean gloves, sterile not contaminate the sterile field, ask him/her gloves, biohazard bag (for disposal of to keep hands away from the wound or sterile contaminated dressing after removal), sterile field once established. Also instruct the patient irrigating solution, and a sterile field or to turn his/her head away from the sterile field wrapped sterile basin. Hemostats and an ABD to talk, laugh, sneeze, or cough. Ask the dressing may also be required. patient to be very still during the procedure.

146 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III

Safety measures include ensuring the opened away from the corpsman first, Figure siderail is up on the side opposite of where 3.11.02. The sides of the wrapper may be you are working and that the bed wheels are unfolded by touching areas that will be in the locked. Ask the patient about any allergies, underneath surface when the package is especially if using Betadine solution or completely opened and by touching only the adhesive tape. area within one inch from the edge of the wrapper. The last corner should be pulled Before beginning, pull the curtain around toward the person opening the package. This the bed and/or close the door to the room. helps avoid the possibility of touching or Drape the patient so that no more is exposed reaching across the sterile field. that what must be for the procedure. The inner wrapper is opened in the same For the patient's comfort, allow him/her to manner. Any part of the wrapper hanging over tend to hygiene needs such as voiding before the edge of the table and a one-inch border beginning. Position the patient in a from the edge of the table or edge of the comfortable position. If the procedure is wrapper is now considered unsterile. If the painful, give the patient pain medication 30 sterile field needs to be repositioned, it must minutes prior to the procedure if possible. For be done before opening the inner wrapper. your own comfort and safety, raise the bed to This is because, in turning the field, what was a comfortable working level to prevent strain originally hanging over the edge of the table to your back. may now be on top of the table and incorrectly considered sterile. ESTABLISHING A STERILE FIELD Items such as dressing material added to the sterile field must also be sterile. Stand A sterile field is a work area free of away from the sterile field when opening microorganisms. Sterile fields may be packages, Remember that the outside of commercially prepared by a manufacturer of dressing wrappers are unsterile and must not medical supplies. To open a commercial, come into contact with either the sterile field disposable sterile field place sterile package or the sterile dressing. To open the wrapper of on a flat, level surface. Peel wrapper a sterile dressing, read the directions provided completely open. If the wrapper tears and the by the manufacturer. Grasp the flaps at the top torn edge comes in contact with contents, the of the package and peel down carefully, If the item is contaminated and must be discarded. wrapper tears incorrectly, the outside will Pick up corner of field and lift field straight come into contact with the dressing; the up. Do NOT drag the field over the edge of the dressing is then contaminated and must not be wrapper. Keep the sterile field away from your used. Since the edge of the wrapper is body and furniture. unsterile, the dressing also must not be allowed to slide over the contaminated edge. Open field, touching only the one-inch To drop the dressing onto the sterile field, the border designated as unsterile. Holding field edge of the wrapper should be folded under or by two corners, drape it over table, placing it the dressing should be allowed to fall in such a from back to front. Placing field front to back way that the dressing and wrapper edge do not will cause you to lean across sterile field. This come into contact. may cause accidental contamination through direct contact or through dust or lint dropping POURING STERILE SOLUTION on field. INTO A CONTAINER Before opening an envelope-type sterile package, place it flat on a level surface. The To pour sterile solution into a container on a outer most corner of the wrapper should be sterile field, first double-check that you have

147 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III the correct solution. Also check the expiration flaps from recoiling. The fingers of the gloves date of the solution and observe for any should be facing away from you. foreign particle or discoloration. Since one the bottle of sterile solution has been opened it is 5. Use the thumb and fingers of the non- considered sterile for only 24 hours, check to dominant hand to pick up the inside folded see the date and time it was opened. If the cuff of the glove that will cover the bottle has not been opened before, write the dominant hand. The folded cuff area is date, time, and your initials on the label of the actually the inside of the glove and may be bottle. touched. Pick the glove up straight up to avoid dragging it over the edge of the Remove the cap from the bottle of sterile wrapper, Figure 3.11.04. solution without touching the rim. Place the cap upside-down on the table or hold it in your 6. Holding onto the folded cuff, stretch and hand making sure you do not touch the inside pull the glove on over the fingers of the of the cap to maintain the sterility of the inner dominant hand being careful to handle just surface. Pour the solution into the sterile basin the inside portion of the cuff, Figure without touching the rim of the bottle of the 3.11.05. basin, about one-inch above the basin rim. Be very careful not to splash the solution out of 7. Place four fingers of the gloved hand the basin onto the sterile field. When your UNDER the cuff of the second glove and hold the bottle, cover the label with your palm lift it straight up from the sterile wrapper. (palm the label), so that any drips of solution You may hold the one-inch edge of the down the side of the bottle do not make the sterile glove wrapper with your ungloved label unreadable. Re-cap the bottle and set hand to keep the wrapper from moving. aside. 8. Keeping the gloved thumb away from the DONNING STERILE GLOVES second glove, pull the glove onto the non- dominant hand by maintaining a firm pull Because the hands cannot be rendered under the cuff, Figure 3.11.06. sterile, sterile gloves must be worn during a sterile procedure to prevent microorganisms 9. Adjust the position of the fingers in the from the hand from contaminating the sterile gloves until they fit comfortably. field. The procedure for donning gloves involves the following steps: 10. Do not touch or adjust the cuff of the glove. It is too close to the skin of the 1. Obtain the correct size of gloves. wrist and potentially contaminated.

2. Remove jewelry and wash and dry hands 11. Keep the hands in sight and above the thoroughly. waist. Do not touch unsterile objects.

3. Place the glove package on a work area 12. If the glove is torn or becomes about waist level. contaminated, discard it and start over.

4. Peel down the outer wrapper of the glove When removing gloves, use the glove to package, Figure 3.11.03. Grasp the inner glove, skin to skin method to avoid envelope wrap and place it on the work area. contaminating hands with whatever is now on Open the inner wrapper by touching only the the outside of the gloves. To do this, remove one-inch folded back portion of the paper. As the first glove by placing the opposite gloved you open the inner wrapper all the way, fold hand on the outside of the glove near the cuff the upper and lower edges down to prevent the (glove to glove). Pull the first glove off turning it inside out and ball it up into the

148 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III hand that is still gloved. Next, remove the as they should. Also document any incisional second glove by reachng UNDER the glove, pain the patient is experiencing and any (skin to skin) and pulling the glove off inside change in the appearance or condition of the out so that the first glove end up inside the wound. If a drain (such as a penrose drain) second glove. Discard gloves and wash your was inserted and is supposed to be in place, hands. document whether or not it still intact.

DOCUMENTING A DRESSING Document the type, amount, color and CHANGE odor of any drainage present. Sanguineous drainage is bloody, red drainage. Serous Careful observations must be made of the drainage is the clear, slightly straw-colored drainage and condition of the wound during serum portion of the blood. A combination of the dressing changes so that it can be serous and sanguineous drainage is called documented accurately in the Nursing Notes serosanguineous. Purulent drainage contains SF 510. Document the location of the wound pus and is an indicator of infection. Be as and the type of dressing change, e.g., dry, specific as possible about the amount of sterile dressing; wet to dry dressing, wet to drainage. On a dry dressing, the amount of wet dressing. Mention the solution used if a drainage can be described as quarter sized or wet to dry or wet to wet dressing is applied. two inches in diameter A wet dressing may be estimated as small (medium, or large) amount. Document the type of dressing applied Sometimes wet dressings are weighed to (e.g. 2 x 2, 4 x 4, “repacked with 4 x 4 and determine the amount of drainage present. covered with a sterile ABD pad”). Wound care is an importance part of the Note any discoloration of the skin such as job of a corpsman. The corpsman's vigilance redness or ecchymosis (bruising). Look for in using sterile technique, performing dressing any signs of inflammation (a defensive changes, making careful observations of reaction of tissue to injury) such as localized wounds, and reporting any abnormalities pain, heat, redness, and swelling of the tissue could make the difference in a patient's and wound edges. In a closed incision, notice recovery. whether the edges of the wound come together

149 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III

FIGURE 3.11.01 Montgomery Straps

FIGURE 3.11.02 Opening an Envelope Type Package

150 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III

FIGURE 3.11.03 Opening a Package of Sterile Gloves

FIGURE 3.11.04 Picking up the First Glove

151 Lesson 3.11 Surgical Asepsis Basic Hospital Corps School Handbook III

FIGURE 3.11.05 Putting on the First Glove

FIGURE 3.11.06 Putting on the Second Glove

152 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Handbook III

NOTES/COMMENTS

153 Lesson 3.11 Surgical Asepsis Worksheet Basic Hospital Corps School Handbook III Lesson 3.11

Surgical Asepsis Worksheet

1. Surgical asepsis and sterile technique mean the same thing.

a True b. False

2. Wire skin closures are called:

a. dressings.

b. bandages.

c. staples.

d. sutures.

3. Debridement is:

a. separation of previously joined wound edges.

b. the removal of damaged tissue and cellular debris in order to prevent infection and promote healing.

c. discharge from a wound or body cavity.

d. material used to close a surgical or traumatic wound with stitches.

4. A penrose drain is used to:

a. secure dressings.

b. cover and protect a wound.

c. allow the escape of drainage from a body cavity.

d. destroy and eliminate all microorganisms, including spores.

5. The most widely used method of sterilization is ______.

6. How does pressurized steam destroy microorganisms and spores?

______

7. Sterile instrument tips remain sterile even if the handle is picked up without sterile gloves.

a. True b. False

154 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Worksheet Handbook III

8. Circle each factor that is a principle of surgical asepsis.

a. A sterile field should never be left unattended

b. You may reach across a sterile field to pick up instruments.

c. Do not use equipment and supplies if there is a doubt about their sterility.

d. A sterile object becomes contaminated when touched by unsterile objects.

9. Sterile gloves are worn when performing a sterile procedure to:

a. ______

b. ______

10. List the four basic concepts of sterility.

a. ______

b. ______

c. ______

d. ______

11. List three types of dressing changes.

a. ______

b. ______

c. ______

12. A wet to dry sterile dressing is used to debride a wound.

a. True b. False

13. List two purposes of a wet to wet dressing change.

a. ______

b. ______

14. When cleansing a closed incision you may use the same swab four times.

a. True b. False

155 Lesson 3.11 Surgical Asepsis Worksheet Basic Hospital Corps School Handbook III

15. List three purposes for wound irrigation.

a. ______

b. ______

c. ______

16. An irrigation syringe is a ______cc syringe with a compression bulb or plunger.

17. List four things that should be explained to a patient before starting a dressing change.

a. ______

b. ______

c. ______

d. ______

18. If a dressing change is going to be a painful procedure, the patient should be medicated minutes prior to the procedure.

19. List three ways to maintain patient privacy when performing a dressing change.

a. ______

b. ______

c. ______

20. On a sterile field, a ______border is designated as unsterile.

21. List the correct procedure for opening a sterile package.

______

______

22. When opening a double wrapped package, how is the sterile field repositioned?

______

23. When adding sterile items to a sterile field, the outside of dressing wrappers may touch the sterile field.

a. True b. False

24. When pouring a sterile solution, the bottle rim should rest the edge of the basin.

a. True b. False

156 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Worksheet Handbook III

25. List four checks done on a bottle of sterile solution before use.

a. ______

b. ______

c. ______

d. ______

26. How do you maintain sterility of bottle cap of a sterile solution when you are using the bottle?

______

27. When applying gloves, which hand is gloved first?

______

28. When donning the first sterile glove, what portion of the glove is allowed to touch your skin?

______

29. List the procedure for donning the second sterile glove.

______

______

30. How do you remove sterile gloves to avoid contaminating your hands?

______

______

31. List the four characteristics of wound drainage that must be documented.

a. ______

b. ______

c. ______

d. ______

32. Purulent drainage from a wound is considered normal.

a. True b. False

33. A dressing is sometimes weighed to determine the amount of drainage it holds.

a. True b. False

157 Lesson 3.11 Surgical Asepsis Worksheet Basic Hospital Corps School Handbook III

158 Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Worksheet Handbook III

159 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III Lesson 3.14

Urinary Catheterization

Terminal Objective:

3.14 Perform a urinary catheterization, collect a specimen, and remove an indwelling catheter.

Enabling Objectives:

3.14.01 Define terms related to urinary catheterization.

3.14.02 State the purposes of urethral catheterization.

3.14.03 List equipment for insertion of straight and indwelling catheters.

3.14.04 List guidelines for inserting an indwelling catheter.

3.14.05 List guidelines for inserting a straight catheter.

3.14.06 List guidelines for nursing care of a patient with an indwelling catheter.

3.14.07 List guidelines for obtaining a urine specimen from an indwelling catheter.

3.14.08 List documentation requirements for catheterization and specimen collection.

3.14.09 List guidelines for removal of an indwelling catheter.

3.14.10 List guidelines for nursing care of a patient after removal of an indwelling catheter.

3.14.11 List documentation requirements for removal of an indwelling catheter.

3.14.12 Insert an indwelling catheter.

3.14.13 Obtain a urine sample from an indwelling catheter.

3.14.14 Remove an indwelling catheter.

The urinary tract is a route from which A catheter is a hollow tube for instilling wastes are excreted from the body. Most of the and removing fluids. Catheterization is the act time a patient is able to empty his/her bladder of introducing a catheter into a body cavity or unaided by a process called urination or a body organ. Urinary catheterization is the voiding. There are circumstances when it process of introducing a sterile catheter becomes necessary to assist the patient in this through the urethra into the bladder in order to elimination process by inserting a urinary remove urine. catheter.

160 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III

PURPOSES OF URETHRAL EQUIPMENT FOR CATHETERIZATION CATHETERIZATION

A straight catheter can be inserted to: There are two basic types of catheters that are used in urinary catheterization. One is 1. Obtain a sterile urine specimen, entirely straight catheter, also called a nonretention or free of contamination in and out catheter, Figure 3.14.01. It is inserted into the bladder and immediately 2. Measure residual urine -- urine left in the removed from the bladder after use. This bladder after a patient has voided. single lumen (space within a tube) tube has one or more holes near its proximal end. The 3. Relieve urinary retention, such as when a second type of catheter is an indwelling patient is unable to void postoperatively. catheter. This catheter is inserted into the The urine accumulates in the bladder and bladder and secured there to provide for can cause significant discomfort from continuous drainage of urine. Since the pressure on the adjacent body structures. catheter is retained in the bladder, it is also called a retention catheter. A Foley catheter is An indwelling catheter can be inserted to: a type of indwelling catheter that is retained in the bladder by an inflatable balloon. A Foley 1. Provide continuous drainage of urine. catheter may have two or three lumens. One lumen is for the drainage of urine. The second 2. Monitor urine output to assess fluid lumen is used to carry the fluid to inflate the balance and kidney function. Urine output balloon once the catheter is in the bladder, is closely monitored in critically ill Figure 3.14.02. The third lumen (on a triple patients. When a patient is in shock, less lumen catheter) is used to instill irrigation urine is produced because there is fluid. Triple lumen catheters are commonly decreased blood flow to the kidneys. used after genitourinary surgery to continuously irrigate the bladder. 3. Preoperative preparation -- to keep the bladder empty of urine during the surgery. Both straight and indwelling catheters This prevents accidental injury of a full come in various sizes. Common sizes for bladder with surgical instruments and also adults include number 14, 16, and 18 French. prevents urinary retention during long The term French refers to a measuring system surgical procedures. that indicates the diameter of the catheter. One French unit equals 1/3 millimeter in diameter. 4. Control incontinence -- when a patient is Catheters in sizes 6, 8 and 10 Fr. are used for unable to control the sphincter which children. retains urine in the bladder and therefore unintentionally urinates, a catheter will Prior to inserting a urinary catheter, obtain provide a dry environment. Placement of a the catheter appropriate for the procedure and catheter should be the last resort and take reason catheter is being inserted. Also obtain a place only if the patient shows signs of catheterization kit, a prepared sterile tray skin breakdown. Frequent hygiene and which normally contains: linen changes present fewer risks than those possible with the use of a catheter. 1. Sterile gloves

2. Two sterile drapes -- one fenestrated (with an opening) and one non--fenestrated without an opening)

161 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III

3. Cotton balls and Betadine solution OR Betadine swabs. Position the patient for the procedure. Males are placed in a supine position. A 4. Plastic forceps (for use with cotton balls female patient is in a dorsal recumbent only) position, on her back with knees flexed, thighs apart, with her feet about 24 inches apart. 5. Water soluble lubricant. After opening the catheter kit and donning 6. Sterile specimen container. sterile gloves, aseptically drape the patient. Males have the nonfenestrated drape placed 7. 10-ml syringe prefilled with sterile water over the thighs. The fenestrated drape is or normal saline (for indwelling catheter placed over the penis, allowing the penis to only). protrude through the opening. For a female patient, place the nonfenestrated drape 8. Disposable drainage tubing and urine between the legs, close to the perineum. Place collection bag (for indwelling catheter the fenestrated drape over the perineum so that only) only the labia are exposed.

Additional supplies that are needed for While both gloved hands are sterile, catheterization include a protective pad (Chux) prepare all equipment that requires the use of to protect the bedding, tape or manufactured two hands. catheter holder (for indwelling catheters only), and a light source. A good light source is 1. Test the balloon for leakage by attaching especially important when catheterizing a the prefilled syringe to the catheter's female patient. A gooseneck lamp or flashlight inflation port and instilling the contents of may be needed to provide adequate light. the syringe into the balloon. Observe the balloon for signs of leaks. Pull back on the GUIDELINES FOR INSERTING syringe, ensuring that the balloon deflates. AN INDWELLING CATHETER Leave the syringe attached to the inflation port and set it aside in the sterile tray. When dealing with any patient, it is important to keep in mind the whole patient as 2. Check the drainage bag for tears and you insert a catheter. Explain what you are ensure that the drainage clamp is closed. about to do, why the doctor ordered the procedure, and that the patient must not move 3. Open and pour Betadine solution over his/her legs to not contaminate the sterile field. cotton balls or open Betadine swabs. Reassure the patient that the procedure will not hurt, but there may be a sensation of 4. Open the lubricant package and squeeze pressure as the catheter is advanced. Talk to lubricant out onto the sterile field. the patient throughout the procedure to calm and reassure him/her. Because inserting the Whenever you touch the labia or penis, catheter requires exposing the patient's genital use your non-dominant hand. Once the non- area, it is important that you maintain as much dominant hand touches the patient's genitals, privacy as possible. Draw the curtain around that hand becomes contaminated and must the bed. Drape the patient with a sheet during remain in place until catheterization is insertion, exposing no more than necessary. completed. Your dominant hand will be used Remember patient safety, lowering the bed rail to clean the meatus and insert the catheter. only on the side where you are working. If you need to leave the bedside, remember to raise the bed rail. Be sure to ask about allergies.

162 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III

To clean the urinary meatus: After the catheter is inserted, hold it in place until the balloon is inflated. Inject the 1. Males -- grasp the penis and retract the specified amount of sterile water into the foreskin (for uncircumcised males) to balloon. The size of the balloon is generally expose the meatus. Using your dominant written on the distal end of the catheter. hand, cleanse the meatus with a Betadine Gently pull on the catheter until resistance is swab or Betadine soaked cotton ball held met. Resistance indicates that the balloon is with plastic forceps. Wipe in a circular correctly positioned and holding the catheter motion away from the urethral opening in the bladder. In uncircumcised males, gently downward to the junction of the glans and replace retracted foreskin. the penile shaft. Repeat the cleaning three times, using a separate cotton ball or swab Secure the catheter with tape to avoid for each wipe. tension on the catheter. For males, tape the catheter laterally to the thigh or on the lower 2. Females -- separate labia using thumb and abdomen to prevent pressure and irritation index finger to expose the meatus. Using between the penis and the scrotum. Tape the the dominant hand, clean the labia and catheter to the inner thigh of females or use meatus using the Betadine swab or cotton the manufactured catheter holder. ball. Use a front-to-back stroke, from just above the meatus toward the rectum. When attaching the collection bag to the Clean the area four times, using a clean bed, be sure the bag is lower than the patient's swab for each wipe. Wipe once down the bladder. Allow sufficient tubing for the patient center, once on each side and once again to move about in bed. You may secure the down the center. coiled tubing with a rubber band and safety pin the rubber band to the bottom sheet. The Prior to inserting the catheter in the tubing may be placed over the patient's thigh meatus, lubricate 4-6 inches of the catheter tip to prevent the weight of his/her body from well. This will aid in ease of insertion. When compressing the tubing closed. inserting the catheter hold the penis at a 90- degree angle to the thighs to minimize the GUIDELINES FOR INSERTING A curve of the urethra, Figure 3.14.03. When STRAIGHT CATHETER inserting the catheter in a female, keep the labia separated to allow for better visualization The procedure for inserting a straight of the meatus, Figure 3.14.04. If resistance is catheter is almost the same as inserting an met, ask the patient to breathe deeply and indwelling catheter. Since a straight catheter rotate the catheter slightly before going does not remain in the bladder, there is no further. This may relaxes the sphincter. Never balloon use force. If unable to advance the catheter, to check for leaks when beginning the remove it and notify the nurse. procedure. Also, there is no tubing and urine collection device to inspect. After the catheter Advance the catheter until urine flows, is inserted in the urethra, continue to advance then insert one inch further. Since the balloon the catheter until urine flows, then advance is located about 1 inch from the tip of the one additional inch. Hold the catheter in place catheter, inserting the catheter additional while the urine drains into the sterile distance after obtaining urine, ensures that the collection tray. If a urine specimen is ordered, balloon will be within the bladder when it is place the distal end of the catheter over the inflated. Inflating the balloon when it is still in opening of the sterile specimen container the urethra would be extremely painful to the (included in the catheterization kit) and collect patient. a sample of urine.

163 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III

Allow urine to drain out of catheter into all times to prevent backflow of urine into the the collection tray until urine stops flowing or bladder. Be sure to instruct the patient to until volume has reached the maximum follow these guidelines also. amount specified by local policy. Some hospitals limit the amount drained at one time To maintain patency of the catheter, to decrease the possibility of bladder spasms. encourage the patient to increase his/her fluid Once the flow of urine has stopped, pinch the intake, unless this is contraindicated. A catheter and gently and slowly remove it. generous fluid intake of 2,500-3,000 ml per Leave the patient dry, comfortable and day keeps the urine dilute and free flowing. covered. The prompt drainage of urine acts as a natural irrigant and prevents obstruction and infection. NURSING CARE OF PATIENT WITH AN INDWELLING Check the catheter frequently to make sure CATHETER it is draining properly. If the catheter is not draining, check for any mechanical

obstructions such as kinking or twisting, or Patients with indwelling catheters require dislocation from the bladder. If no mechanical special nursing care to prevent complications. obstructions are found, notify the nurse. The most common complication of an Minimum acceptable urine output is 30 ml per indwelling catheter is a urinary tract infection. hour in adult patients. Less output may mean The catheter provides a means for bacteria to that either the patient is not producing enough enter the bladder that is normally a sterile part urine or the catheter is obstructed. of the body. In order to decrease the possibility of an infection, you must maintain An indwelling catheter may need to be a closed drainage system. Do not disconnect changed (removed and a new one reinserted) the catheter from the drainage tube unless depending on the policy established at your absolutely necessary, such as for a bladder institution. The usual length of time between irrigation. If the catheter must be the need for catheter changes varies from five disconnected, make sure both ends remain days to two weeks. sterile until they are connected again.

To decrease the chance of infection, wash If the drainage bag or tubing become the patient's perineal area with soap and water contaminated at either the catheter end or the twice a day. Rinse the area well and pat dry. drainage outlet, replace the tubing and Cleanse the meatus and portion of the catheter drainage system. Do not place the drainage near the meatus, removing any dried bag on the floor and to not allow the emptying secretions. If the patient is able, he/she may be port to touch the floor. Wear gloves whenever instructed to perform this care. Avoid using handling the urine drainage system and wash powders and lotions after cleannsing as these your hands before and after handling the urine substances may trap and retain organisms drainage system. leading to a urinary tract infection. Always

observe for signs of irritation or urinary tract Unobstructed urine flow must be infection. Signs include fever, discharge maintained. Gravity assists to keep urine around the catheter, cloudy urine, foul flowing away from the bladder. Eliminate smelling urine and hematuria. uphill flow of the urine as it courses its way through the drainage tubing. Avoid kinks and After an indwelling catheter has been twisting of the catheter or drainage tubing. removed, the patient should void within 8-12 Avoid occlusion of the tubing by the patient's hours. It is not uncommon for patients to have body weight or by the side rails or dysuria after catheter removal, so it is mechanisms of the bed. Keep the drainage important to monitor the urine output. Instruct collection bag below the level of the bladder at the patient to void in a urinal, bedpan, or urine

164 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III hat for the first few voidings after the catheter system; drainage tubing does not need to be has been removed. Also instruct the patient to disconnected from the catheter. notify the nursing staff of any feeling of urgency (sudden urgent need to void), Use the antiseptic swab to cleanse the frequency (needing to void often, but only specimen collection port. If there is no small amounts of urine), burning, bleeding or collection port, cleanse an area on the catheter inability to void. These signs may be proximal to the clamp. Insert the needle at a temporary and normal due to the irritation of 90-degree angle into the specimen port (15- the urethra by the catheter, but it could also degree angle into the catheter) and withdraw indicate possible urinary tract infection. the urine specimen. The port and the catheter are self-sealing and will seal after the needle is SPECIMEN REMOVAL FROM AN withdrawn, preventing microorganisms from INDWELLING CATHETER entering. Aseptically transfer the collected urine from the syringe into the specimen The urinary bladder is normally a sterile container. Remember to unclamp the drainage part of the body. If a urinary tract infection is tubing after the urine specimen is obtained. suspected, a urine specimen will be ordered for culture and sensitivity (checking for RECORDING microorganisms and what antibiotics will CATHETERIZATION AND work to destroy the particular microorganism). SPECIMEN COLLECTION If a urine specimen is ordered for a patient PROCEDURES who has an indwelling catheter in place, a sterile specimen can be obtained directly from Proper documentation is important with the catheter or specimen port on the drainage any nursing procedure. Insertion of a urethral tubing. catheter must be noted in the Nursing Notes

SF 510, Twenty-Four Hour Intake and Output The supplies needed to obtain a sterile Worksheet DD 792, and Patient Profile specimen from an indwelling catheter are: NAVMED 6550/12.

1. Antiseptic swab (alcohol or Betadine) The Nursing Notes SF 510 entry, Figure

3.14.05, should include: 2. 22-25-gauge needle and 10 cc syringe.

1. Type and size of catheter. 3. Specimen container with label.

2. Reason for catheterization. 4. Lab request form (chit) -- appropriate for

ordered test. 3. Amount of urine obtained.

5. Clean gloves. 4. Description of urine, including color, any

unusual odor, and any abnormalities such Prior to obtaining the specimen, clamp the as sediment or blood clots. drainage tube immediately below the specimen sample port for 10-15 minutes. If the 5. Patient's toleration of the procedure. drainage tubing has no specimen collection port, clamp tubing just distal to the connection 6. Specimen sent to the lab, if applicable. of the catheter and the drainage tubing. This allows fresh urine to collect at the specimen On the Twenty-Four Hour Intake and port. The specimen can be obtained without Output Worksheet DD 792, Figure 3.14.06, interrupting the integrity of the drainage indicate the time the catheter was inserted in the remarks section on the output page.

165 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III

Record time and amount of urine obtained confirming the doctor’s order, gather the under urine section of the output page, Figure following equipment: 3.14.07. On the back of the Patient Profile NAVMED 6550/12, record specimen 1. 10cc syringe collection and date sent to lab (if specimen 2. Clean gloves obtained). If an indwelling catheter was 3. Chux pad inserted, indicate the date, time, catheter type, 4. Urinal and size on the front of the Patient Profile, 5. Washcloth Figure 3.14.08. 6. Soap and water

To record a specimen collection from an Explain the procedure to the patient. Wash indwelling catheter, indicate on the Nursing your hands and don clean gloves. Provide for Notes SF 510, the type of specimen collected the patient’s privacy and safety. After and its disposition (sent to lab). Include a removing the tape from the patient’s leg, description of the urine collected, e.g., cloudy, attach the syringe to the catheter port and contained sediment. On the Twenty-four Hour aspirate to deflate the catheter balloon. Intake and Output Worksheet DD 792, record Withdraw all the sterile water to deflate the the volume of urine removed and sent for balloon. Detach the syringe, empty it, and testing. On the back of the Patient Profile reattach to withdraw more water if needed. NAVMED 6500/12 record the date the Gently pull the catheter out of the meatus, specimen was collected. hold the catheter in chux pad to prevent spillage, and inspect the catheter for any When a specimen is obtained using a damage. Discard the catheter in the straight catheter, include on the Nursing Notes contaminated trash and measure the amount of SF 510: urine in the bag.

1. Catheter type and size used. NURSING CARE FOR A PATIENT AFTER REMOVAL OF AN 2. Amount of urine obtained -- specimen INDWELLING CATHETER volume and amount in collection tray. After removal of an indwelling catheter, clean 3. Description of urine. the urinary meatus with water and mild soap. Ensure the patient has a urinal/bed pan 4. Patient's tolerance of the procedure. available since many patients need to void immediately after removal of the catheter. 5. Type of specimen obtained and Continue to monitor Intake & Output per local disposition. protocol or doctor’s order.

Record the amount of urine output on the RECORDING REMOVAL OF AN Twenty-Four Intake and Output Worksheet INDWELLING CATHETER DD 792. On the back of the Patient Profile NAVMED 6550/12, record date specimen was On the Twenty-Four Hour Intake and collected. Output Worksheet DD 792, indicate the time the catheter was removed and the amount of GUIDELINES FOR REMOVAL urine in the collection bag. Continue to OF AN INDWELLING CATHETER monitor urine output of each voiding for 24 hours until a normal voiding pattern is A doctor’s order must be obtained before established. removal of an indwelling catheter. After

166 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III

FIGURE 3.14.01 Non-Retention Catheter

FIGURE 3.14.02 Indwelling Catheters a. Double Lumen b. Triple Lumen

167 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III

FIGURE 3.14.03 Catheter Insertion for Males

FIGURE 3.14.04 Catheter Insertion for Females

168 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III

FIGURE 3.14.05 Recording Catheterization on Nursing Notes

FIGURE 3.14.06 Urinary Catheter Recorder on DD 792 (Lower)

169 Lesson 3.14 Urinary Catheterization Basic Hospital Corps School Handbook III

FIGURE 3.14.07 Urine Output Recorded on DD 792 (Upper)

FIGURE 3.14.08 Catheter Card Order on Patient Profile

170 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Handbook III

NOTES/COMMENTS

171 Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School Handbook III Lesson 3.14

Urinary Catheterization Worksheet

1. Define urinary catheterization.

______

______

2. A straight catheter is used to monitor urine output.

a. True b. False

3. To provide for continuous drainage of urine, insert a ______catheter.

4. Which is not a purpose of indwelling catheterization?

a. To measure residual urine

b. To control incontinence

c. To monitor urine output

d. Preoperative preparation

5. To decrease the likelihood of the bladder being injured during abdominal or pelvic surgery, an indwelling catheter may be ordered by the doctor to be inserted prior to surgery.

a. True b. False

6. An indwelling catheter is:

a. also called a retention catheter.

b. left in place after insertion to provide for continuous urine drainage.

c. a double or triple lumen tube with an inflatable balloon near the tip.

d. all of the above.

7. A fenestrated drape is one with an opening in it.

a. True b. False

172 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet Handbook III

8. What measuring unit is used to indicate the size of urinary catheter?

a. Gauge

b. French

c. Millimeters

d. International units

9. A catheterization kit would include:

a. sterile gloves, sterile drapes, Betadine swabs, water-soluble lubricant.

b. sterile gloves, Betadine swabs, protective pad, specimen container.

c. sterile drapes, water soluble lubricant, 10 cc syringe, tape.

10. List three items that are needed when inserting an indwelling catheter but not a straight catheter.

a. ______

b. ______

c. ______

11. The correct position for a female patient who is being catheterized is:

a. prone with legs apart.

b. supine with legs apart.

c. dorsal recumbent with knees flexed, thighs apart.

d. Semi-Fowlers.

12. When placing the fenestrated drape on a female patient, place it over the perineum so that the labia are exposed.

a. True b. False

13. When cleansing the urinary meatus of a female, use at least four Betadine swabs, always stroking from back to front.

a. True b. False

14. Before inserting a urinary catheter into a male, gently lift the penis to a 90 degree angle to the thighs in order to minimize the urethral curve.

a. True b. False

173 Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School Handbook III

15. When inserting a straight catheter, insert the catheter until urine flows, then pull back one inch.

a. True b. False

16. Urinary tract infection is a common complication of an indwelling catheter.

a. True b. False

17. A catheterized patient should be instructed to limit fluid intake.

a. True b. False

18. List equipment needed to remove a urine specimen from an indwelling catheter.

a. ______

b. ______

c. ______

d. ______

e. ______

19. When obtaining a specimen from an indwelling catheter without a specimen port, insert the needle directly into the:

a. drainage bag.

b. specimen port at a 90o angle.

c. catheter at a 15o angle.

d. plastic drainage tubing.

20. List three locations where insertion of an indwelling catheter should be recorded.

a. ______

b. ______

c. ______

21. After obtaining a urine specimen from either a straight catheter or an indwelling catheter, the time and amount of the urine output must be recorded on the I&O Worksheet.

a. True b. False

174 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet Handbook III

22. List four items that should be included in the description of catheter insertion in the Nursing Notes.

a. ______

b. ______

c. ______

d. ______

23. List three locations where a urine specimen obtained from a catheter must be documented.

a. ______

b. ______

c. ______

24. Circle each element that is included when documenting a urine specimen obtained from an indwelling catheter on the Nursing Notes.

a. Date, time, and type of specimen collected

b. Size of needle and syringe used

c. Angle at which the needle was inserted

d. Signature and rate

175 Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School Handbook III

176 Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet Handbook III

177 Lesson 3.13 Specimens Basic Hospital Corps School Handbook III Lesson 3.13

Specimens

Terminal Objective:

3.13 List concepts and principles for collecting and testing specimens.

Enabling Objectives:

3.13.01 List the procedures for obtaining and recording random, clean-catch and 24-hour urine specimens.

3.13.02 Distinguish between the normal and abnormal appearance of urine specimens.

3.13.03 List the procedures for obtaining, testing, and recording urine tests for specific gravity, sugar, ketones and protein, including their normal values.

3.13.04 List the procedures for obtaining and recording capillary blood collection and glucose testing.

3.13.05 List the procedures for obtaining and recording a stool specimen and testing specimen for blood.

3.13.06 Distinguish between normal and abnormal stool specimens.

3.13.07 List the procedures for obtaining and recording a throat culture.

3.13.08 List the procedures for obtaining and recording a sputum specimen.

3.13.09 List the procedures for labeling specimens and completing basic laboratory chits.

Hospital Corpsmen routinely perform laboratory specimens. ID checks are done by patient care before, during, and after specimen using the lab chit and comparing it with the: collection and testing. The corpsman may teach a patient a procedure and assist with 1. Bed tag collecting, labeling, and testing the specimen. Thorough patient education is critical to obtain 2. Patient's name bracelet a good specimen. Carefully explain the procedure in terms the patient can understand, 3. Patient's stated name. then ask questions to assess comprehension. Provide for privacy, safety, and comfort by Diligent hand washing must be performed closing doors, pulling the curtains around the before and after collecting specimens to patient's area, and ensuring the side rails are prevent the transmission of microorganisms. up. Raise the head of the bed, when applicable. Three patient identification (ID) checks must be performed before obtaining

178 Basic Hospital Corps School Lesson 3.13 Specimens Handbook III

URINE SPECIMENS Recording the Procedure

Methods of urine collection include routine, Urine collection is recorded on the clean-catch, and 24-hour specimens. following forms: Equipment and methodology vary for each type of specimen. 1. Nursing Notes SF 510 entry for any urine specimen is to contain: Routine Urine Specimen a. Description of the urine specimen

(including color, odor, clarity, The routine and microscopic test (R&M) amount) is a frequent urine test that only takes a few minutes to perform. Equipment needed to b. Type of test requested (UA) collect a routine urine specimen includes:

c. disposition of the specimen (usually 1. Clean specimen container with lid & label sent to the lab).

2. Urine collection device, if needed (urinal, 2. Patient Profile NAVMED 6550/12 - The bedpan, urine hat) appropriate section should be marked with the

date the specimen was sent. 3. Urinalysis chit SF 550, Figure 3.13.01

3. Twenty-Four Hour Intake & Output 4. Clean gloves Worksheet DD 792 (if applicable) - enter the

amount of patient output. As with any procedure involving a patient, be sure to provide for patient privacy. Explain the procedure to the patient. Provide a urinal Clean Catch Specimen or position the patient on the bedpan. Ambulatory patients may go to the head and A laboratory test order for culture and void directly into a clean specimen container. sensitivity (C&S) with microbiology testing is Don clean gloves and transfer urine from collected aseptically in a sterile specimen bedpan/urinal or other collection device into a container using the clean-catch or mid-stream clean specimen container. Obtain a minimum collection method. the clean-catch specimen of 15 cc of urine in the specimen container. is collected to identify urinary tract infections. Label the container and take the specimen to In the laboratory, the urine is put on a petri the laboratory within the hour. Urine at room disk of media where, if present, bacteria will temperature allows bacteria to grow, which grow. The bacteria are then examined and may alter the test results if allowed to tested to determine if they are a pathogenic. accumulate. Pathogenic bacteria are tested for sensitivity to antibiotics. It takes 24-48 hours to complete Lab personnel will perform two categories culture and sensitivity testing. Normal urine of tests. The routine tests, usually done with does not contain bacteria. an indicator strip, include: pH, occult blood, ketones, protein, and glucose. Specific gravity Equipment needed to collect a clean catch and color of the urine are also noted. a specimen include: microscopic examination of urine includes examining and identifying elements such as 1. Sterile specimen container and label white blood cells, red blood cells, skin or epithelial cells, bacteria, and mucus. 2. Disposable antiseptic cleaning towelettes or swabs

3. Clean gloves

179 Lesson 3.13 Specimen Basic Hospital Corps School Handbook III

4. Urine collection device, if needed Recording the Procedure

5. Microbiology I chit SF 553, Figure Urine collection is recorded on the 3.13.02 following forms:

Begin by explaining the procedure to the 1. Nursing Notes SF 510 entry for any urine patient. If the patient is able, he or she may specimen is to contain: collect the specimen. Provide detailed instructions on how to cleanse the genitalia a. Description of the urine specimen using the antiseptic towelettes or swabs. If the (clouding color, odor, clarity, amount) patient must be assisted, cleanse the genitalia as follows: b. Type of test requested (C&S)

a. Females, separate labia to expose the c. Disposition of the specimen (usually meatus. Using only one front-to-back sent to the lab). stroke per towelette, wipe each side of the labia. Finish, using the third 2. Patient Profile NAVMED 6550/12 - The towelette, down the middle, covering appropriate section should be marked with the the meatus, to remove secretions from date the specimen was sent. mucous folds of the vulva and perineum. 3. Twenty-Four Hour Intake & Output Worksheet DD 792 (if applicable) - enter the b. Males, retract foreskin, if amount of patient output. uncircumcised, prior to cleaning glans. Use a circular motion from the 24-Hour Urine Specimen meatus down to the junction of the

glans and the shaft. Use three A 24-hour urine specimen involves antiseptic towelettes or swabs to collecting ALL the urine produced by a patient ensure complete cleansing. during a 24-hour period. Accidentally

discarding any urine will negate the test. With While keeping the labia separated or this specimen, laboratory personnel may foreskin retracted, the patient starts to void perform a variety of tests. Guidance from (into bedpan, urinal, or commode), stops, laboratory personnel should be sought positions sterile container, and then starts to concerning the specimen container, type of void again into the sterile specimen container. preservative, handling and type of request chit Care must be taken not to touch the inside of the sterile cup or lid. The equipment needed for 24-hour

specimen collection includes: This procedure allows the first portion of the urine to wash out the urethra. Only the a. 24-hour specimen container with lid middle or clean part of the urine is caught and saved for testing. The specimen is labeled and b. Lab request chit specific for the sent to the lab within the hour. In most cases, ordered test the patient will collect the specimen on his/her own, so it is crucial that the procedure be c. Urine collection device explained thoroughly.

The procedure begins by explaining to the patient that all urine is saved and placed in a large specimen container. Have the patient void, then discard this urine. The twenty-four

180 Basic Hospital Corps School Lesson 3.13 Specimens Handbook III hour clock is started immediately after this if the urine specimen is abnormal and record voiding. Instruct the patient to void in the on Nursing Notes SF 510. urine collection device for the next 24 hours. Transfer urine to collection container after URINE TESTING each voiding. The container may be kept refrigerated or on ice during the 24 hour Not all urine testing is performed in the period. At the end of the 24-hour period, have laboratory. Depending on local policy, ward the patient void one last time and pour this personnel may test urine for specific gravity, urine into the collection container. Send the sugar, ketones, and protein. urine to the laboratory with the lab request form. Procedures for using Indicator Strips

Recording the Procedure Indicator strips are plastic strips treated with chemicals that indicate the presence of various Urine collection is recorded on the substances. (Sometimes they are called test following forms: strips.)

1. Nursing Notes SF 510 entry for any urine Equipment Needed: specimen is to contain: 1. Specimen container a. Description of the urine specimen (including color, odor, clarity, 2. Indicator strips with chart (on bottle) amount) 3. Clean gloves b. Disposition of the specimen (usually sent to the lab). 4. Watch with second hand or stopwatch

2. Patient Profile NAVMED 6550/12 - The Check the expiration date on the bottle of appropriate section should be marked with indicator strips and follow manufacturer's the date the specimen was sent. directions to use. Have the patient void in a clean container. Don clean gloves and remove 3. Twenty-Four Hour Intake & Output one indicator strip from the bottle, being Worksheet DD 792 (if applicable) - enter careful not to touch the chemically treated the amount of patient output areas. Replace the bottle lid. Dip the indicator area of the strip completely, but URINE EVALUATION briefly, in urine. the container label depicts a color chart for each test area on the strip. In caring for patients, corpsmen will make Carefully match the indicator test area to the a general evaluation of urine specimens. color chart of the container, noting the time Normal urine is clear, pale yellow to dark factor for each test. Values for each test are amber, and has a faint odor. Normal output is written by the color chart blocks. 1,000-1,500 cc daily with an average output of 1,200 cc every 24 hours. Abnormal urine Record the results on the Nursing Notes may indicate an abnormal medical condition. SF 510, including the test results and any Urine with a red reddish-brown, or smokey nursing action taken. The information may appearance indicates hematuria, brown urine also be recorded on the Diabetic Flow Sheet may indicate liver disease, orange or blue (for glucose/sugar and acetone/ketones). If the urine usually result from medications. Other patient is on I&O, also record the urine anomalies in urine include: foamy appearance, volume on the Twenty-Four Hour Intake and mucous, pus, and cloudiness. Inform the nurse Output Worksheet DD 792.

181 Lesson 3.13 Specimen Basic Hospital Corps School Handbook III

Specific gravity is the weight of urine as it is also more expensive. Its main advantage compared to the weight of water. It measures is that it reveals the patient's actual blood the diluting and concentrating ability of the glucose level, rather than approximating it by kidneys. measuring the level of metabolized sugar in the urine. The normal range for specific gravity is 1.005 to 1.025. Collection and Evaluation blood for glucose level Glucose/sugar, acetone/ketones and protein testing After verifying the Doctor's Orders, gather the necessary equipment: Normal urine contains no glucose/sugar. This would be recorded as negative or no 1. Alcohol preps sugar. Any other value is abnormal and must be reported. The abnormal values would be 2. Sterile blood lancet located on the color chart on the container label. Abnormal values would be recorded as 3. Indicator strip - check expiration date. 1/4%, 1/2%, 1%, or 2%. 4. Watch with second hand or stopwatch Normal urine has no acetone/ketones. Presence of acetone/ketones in the urine 5. 2x2 gauze pads indicates the need for further evaluation. Abnormal urine acetone/ketone values, 6. Clean gloves determined by using the scale on the container label, are recorded using a scale that ranges The procedure for obtaining and from small to large. A diabetic patient with evaluating blood glucose is: acetone/ketone bodies in the urine suggests that the blood sugar is not adequately 1. Select site, ideally near the edge of a controlled and adjustments of either the fingertip. medication or the diet need to be made. In a non-diabetic patient, the presence of 2. Wipe the fingertip with the alcohol prep acetone/ketone bodies indicates a minimal and allow to air dry. amount of carbohydrate metabolism and excessive fat metabolism that are symptoms of 3. Don clean gloves and open the blood starvation such as anorexia or dieting. lancet aseptically.

Normal urine contains no protein. 4. Grasp the patient's finger firmly with one The presence of any protein is abnormal. hand and quickly pierce skin with a Abnormal values are measured from trace to stabbing motion. greater than 4+. 5. Squeeze (milk) the area to produce a large CAPILLARY BLOOD drop of blood. COLLECTION FOR GLUCOSE TESTING 6. Cover the entire indicator strip pad with the drop of blood. Many wards and clinics test patient glucose level by taking a drop of capillary 7. Have patient hold 2x2 over puncture site. blood and placing it on an indicator strip. While this method of glucose testing is more 8. Time for exactly the interval specified by accurate than using the urine dipstick method, the indicator strip manufacturer.

182 Basic Hospital Corps School Lesson 3.13 Specimens Handbook III

stool from the bedpan or commode with 9. Blot blood off indicator strip using a 2x2. tongue blade and place it in specimen cup. If patient passes blood, mucus, or pus with stool, 10. Read test results after waiting the time includes it with the specimen. specified in the manufacturer directions by comparing the color on the indicator strip Cover, label the container, and transport to the color chart on the bottle. the specimen to the lab immediately. The test for parasites must be done on a warm 11. Dispose of all contaminated supplies specimen. Ensure that the patient has an following local policy. Dispose of the opportunity to cleanse himself/herself, lancet in a puncture resistant container. assisting as needed. Indicate the color, character, and amount of stool, the test Recording the Specimen Collection requested, and disposition of specimen (to lab) and Results in the Nursing Notes SF 510. Any abnormalities should also be recorded in the The capillary blood glucose test result is Nursing Notes and reported to the nurse. On recorded on the Diabetic Flow Sheet and in the Patient Profile NAVMED 6500/12, write the Nursing Notes SF 510, including results of the date the specimen was sent to the lab. Note the test and nursing actions taken. the color, character, and amount of stool on the Twenty-Four Hour Intake & Output STOOL SPECIMENS Worksheet DD 792, if indicated.

Stool evaluation Collection

A stool specimen is examined on the ward Stool specimens are commonly collected for color, consistency, and amount. Normal to analyze for abnormal components and stool is a brown, formed, semisolid mass. parasites. The following equipment and Many patients have one bowel movement a supplies are needed: day, although this varies from person to

person. Instead of measuring the exact amount 1. Bedpan/portable commode of stool, the amount is usually described as

small, moderate, or large. The odor of the 2. Toilet paper stool varies with the pH of food consumed.

3. Lab request chit, for example Parasitology Common stool abnormalities include a SF 552, Figure 3.13.03 black or tarry color, which indicates upper GI

bleeding; bright blood which indicates lower 4. Tongue blades GI bleeding; clay-colored which indicates

absence of bile (sign of gall bladder or liver 5. Clean stool specimen container with label disease); and very watery stool which (sterile specimen container is indicated indicates irritation or infection of bowels only if a C&S is required) resulting in fluid loss.

6. Clean gloves The following equipment is needed to

perform a stool specimen examination for Before collecting a specimen, explain the blood: procedure to the patient, emphasizing that the stool must not be contaminated with urine or 1. Hemoccult slide (guaiac paper) toilet paper. Provide patient comfort and assist onto and off the bedpan or commode. Don 2. Hemoccult developing solution clean gloves. Remove at least 1-2 teaspoons of

183 Lesson 3.13 Specimen Basic Hospital Corps School Handbook III

3. Wooden applicator or tongue blade 1. Laboratory request chit, for example Microbiology I, Figure 3.13.06 4. Clean gloves 2. Sterile culturette Collecting the specimen 3. Specimen label Prior to beginning, check the expiration date of the developing solution. After donning 4. Tongue blade clean gloves, collect a small amount of stool using the wooden applicator or a gloved 5. Clean gloves finger. Place the smear of stool to the hemoccult slide (guaiac paper). Close the Collecting the specimen cover over the stool and turn the slide over. Open the flap on the opposite side and place Gather equipment, wash hands, and two drops of developing solution on each proceed to the patient's room. Explain the section of the slide and one drop on the center procedure to the patient. Have the patient sit of the control strip. Read the results 30 to 60 up with head tilted back. Remove the seconds after applying the solution. A positive culturette cap aseptically. Have the patient test is indicated by the development of a open his/her mouth open to expose the bluish ring around the stool specimen on the pharynx, then depress the tongue with a hemoccult slide. A positive test indicates the tongue blade. Swab both tonsillar areas and presence of blood in the stool. A negative test posterior pharynx gently with applicator, has no color change that means no blood in the being careful not to touch the swab to external stool. The control strip is used to verify a valid surfaces or other internal structures. Return the test. applicator to the holder and snap the liquid capsule at the bottom of the culturette. Label Record the results in Nursing Notes SF the specimen and send to the laboratory with 510 including the type of test performed and the lab chit. Wash hands and discard the results. If the specimen is sent to the lab disposable equipment. Record the procedure for guaiac testing, indicate the date the by marking the date sent on the back of the specimen is sent on the Patient Profile Patient Profile NAVMED 6550/12 and NAVMED 6550/12. making a Nursing Notes SF 510 entry. Indicate the type of specimen, abnormal THROAT CULTURES findings, patient tolerance for procedure, and disposition of the specimen.

The ring of lymphoid tissue that encircles the nasopharynx and oropharynx frequently is SPUTUM CULTURES the site of acute infection. Such an infection is most often caused by the organisms that cause Mucus secretions from the lungs, bronchi, the common cold, but may also result from a and trachea that are expelled from the mouth variety of pathogenic agents including viruses, by coughing are called sputum. It can be hemolytic streptococci, and staphylococci. differentiated from saliva by its greater Because streptococcal infections can cause viscosity and thickness. A sputum specimen serious complications (such as rheumatic may be ordered to examine for bacteria or fever) if left untreated, throat cultures are abnormal cell structure. routinely performed on patients with sore throats to determine the presence of the The usual method of sputum collection is streptococci bacteria. Equipment needed to expectoration (coughing up sputum), that may perform a throat culture includes: require postural drainage or chest percussion to obtain a good specimen.

184 Basic Hospital Corps School Lesson 3.13 Specimens Handbook III

Collecting the specimen 2. Social security number Gather equipment, including: 3. Rate/rank or dependency status 1. Glass of water 4. Branch of service including active duty 2. Sterile specimen cup with label status or retired.

3. Facial tissue COMPLETING BASIC LABORATORY REQUEST 4. Emesis basin FORMS

5. Clean gloves The laboratory request chit must be filled Wash hands. Explain procedure to patient out properly to ensure appropriate tests are to ease anxiety and promote cooperation. The performed. The laboratory chit requires the: patient should sit in a chair or be place in high Fowlers position if bedridden. Have patient 1. Patient's name rinse mouth with water to moisten mucous membranes and to reduce specimen 2. Social security number contamination by oral bacteria and food particles. Don clean gloves. Instruct the 3. Rate/rank or dependency status patient to take several deep breaths and cough deeply, expectorating directly into specimen 4. Branch of service including active duty cup. Collect at least 15 ml in the sterile status or retired container. Clean/dispose of equipment, remove gloves, and wash hands. Label the 5. Urgency. Indicate routine unless Doctor's container and send to lab with completed Order states otherwise sputum examination request form within 30 minutes of collection. Record by entering date 6. Specimen source (sputum, urine, blood) sent to the lab on the Patient Profile. Make a Nursing Notes entry with time and type of 7. Date and time the specimen was taken procedure, patients’ tolerance, and disposition of specimen. 8. Requesting physician's name and initials of person completing the request LABELING SPECIMENS 9. Any pertinent comments concerning A specimen label may be prepared with patient’s diagnosis, isolation requirements, the addressograph, if available, but the label and antibiotic therapy. must include the following information: 10. Test to be completed. 1. Patient's name

185 Lesson 3.13 Specimen Basic Hospital Corps School Handbook III

FIGURE 3.13.01 Urinalysis Chit SF 550 for Routine and Microscopic

FIGURE 3.13.02 Microbiology I Chit SF 553 for Culture and Sensitivity

186 Basic Hospital Corps School Lesson 3.13 Specimens Handbook III

FIGURE 3.13.03 Parasitology Chit SF 552 for Occult Blood

FIGURE 3.13.04 Parasitology Chit SF 552 for Ova and Parasites

187 Lesson 3.13 Specimens Worksheet Basic Hospital Corps School Handbook III Lesson 3.13

Specimens Worksheet

1. A ______specimen is collected for Culture and Sensitivity testing.

a. 24-hour

b. clean-catch

c. routine urine

2. Which of the following is not part of the procedure for obtaining a clean catch urine specimen?

a. Cleanse the genitalia with a mild antiseptic solution

b. Provide for patient safety, privacy, and comfort

c. Collect specimen in sterile container

d. Ensure that only the first portion of the urine stream is collected

3. To obtain a 24-hour urine specimen, instruct the patient to:

a. void every hour for 24 hours.

b. collect the total amount of urine excreted in 24 hours.

c. collect only the urine voided every night at midnight.

d. not void for 24 hours, then collect a specimen.

4. What is the normal appearance of urine?

a. Cloudy, with red streaks

b. Clear, pale yellow

c. Light green

d. Dark brown

5. Glucose is normally present in urine.

a. True b. False

6. Urine that is brownish colored may indicate ______disease?

188 Basic Hospital Corps School Lesson 3.13 Specimens Worksheet Handbook III

a. heart

b. kidney

c. liver

d. colon

7. What is the normal range for the specific gravity of urine?

a. 1.000 - 1.005

b. 1.005 - 1.025

c. 1.030 - 1.035

d. 1.100 - 1.200

8. What condition may cause ketones in the urine?

a. Anorexia

b. Cancer

c. Angina

d. Heart disease

9. Healthy patients may have a trace amount of protein in their urine.

a. True b. False

10. List two items to include in Nursing Notes for urine testing.

a. ______

b. ______

11. When using indicator strips to evaluate urine:

a. check the expiration date prior to using.

b. hold the indicator strip at the test area.

c. hold the indicator strip in urine for at least 5 minutes.

189 Lesson 3.13 Specimens Worksheet Basic Hospital Corps School Handbook III

12. When performing blood glucose testing, after placing the drop of blood on the indicator strip, read the results:

a. immediately.

b. after 15 seconds.

c. after 60 seconds.

d. after the amount of time specified by the manufacturer.

13. A hemoccult test is performed to identify ______in the stool.

a. glucose

b. blood

c. ketones

d. parasites

14. A positive hemoccult test is indicated by a red ring surrounding the specimen on the test paper.

a. True b. False

15. Normally, stool is a ______mass.

a. brown, semi-solid

b. dark black, solid

c. brown, watery

16. A sputum specimen should be sent to the lab within ______of collection.

a. 15 minutes

b. 30 minutes

c. 1 hour

d. 2 hours

190 Basic Hospital Corps School Lesson 3.13 Specimens Worksheet Handbook III

17. List the information that is included on a sputum specimen label.

a. ______

b. ______

c. ______

d. ______

18. When completing a laboratory request form, include your initials, along with the doctor's name, on the laboratory chit.

a. True b. False

191 Lesson 3.12 Wound Management Basic Hospital Corps School Handbook III Lesson 3.12

Wound Management

Terminal Objective:

3.12 List concepts and principles of wound closure and management.

Enabling Objectives:

3.12.01 List the three phases of wound healing.

3.12.02 Define the three classifications of wound healing.

3.12.03 List the general rules for managing sutured wounds.

HISTORY These white blood cells also consume dead and dying tissue particles caused by the injury. As early as 400 BC, Hippocrates mentioned the use of ligatures (sutures) to Serum protein dries and seals the wound control bleeding. From then until about 1885, to prevent further fluid loss and bacterial the suturing of wounds was rarely done since invasion. The second or proliferative phase there were so many hazards. Although occurs as fibrin and collagen cells glue the surgeons recognized the need to join together wound edges together and a scab is formed. severed wound tissues, without knowledge of New capillaries are formed to supply oxygen aseptic procedures, their efforts caused death to the replacement epithethial cells as they from gangrene, tetanus, anthrax, and other regenerate and multiply to fill the injured area. infection processes. After the development of aseptic technique, there appeared a great During the third or maturation phase, the change in the desirability to close wounds with epithelical cells rebuild to normal thickness sutures. and the scab sloughs off the wound. Collagen fibers become more organized and the blood PHASES OF WOUND HEALING vessels in the area return to normal.

The sequence of healing is essentially CLASSIFICATION OF HEALING undisturbed and occurs in roughly three phases. The first or inflammatory phase There are three classifications of healing: begins immediately after injury. The body's first intention, second intention, and third response to the irritation at the injury site is to intention. First intention healing occurs dilate local blood vessels which causes the when tissue is cleanly incised or lacerated and injured area to become red and warm. The reapproximated shortly after injury, and repair injured blood vessel walls leak serum into the occurs without complications. When a wound surrounding tissues resulting in edema. Pain is closed shortly after injury and allowed to also follows due to the pressure on the nerve heal by first intention, this is known as a endings by the edema in the tissues. White primary closure. Second intention healing is blood cells enter the injured area and act as the healing of an open wound through scavengers to destroy bacteria in the wound. formation of granulation tissue. with eventual

192 Basic Hospital Corps School Lesson 3.12 Wound Management Handbook III coverage of the defect by migration of worse. The removal of the suture will promote epithelial cells. Most infected wounds and drainage and prevent further trauma. The burns heal by second intention. Third physician may apply gentle pressure to the intention healing occurs when a wound with skin proximal to the wound to excise the widely separated edges accomplishes the first drainage and therefore promote healing. If the phases of healing while the wound is left open. wound is infected, application of heat is A delayed primary closure is then performed sometimes ordered to increase blood flow to to finish the healing process by first intention. the area and speed the healing process. In grossly contaminated wounds, infection can often be avoided by leaving the wound open Areas of the body heal at a different rate for 3 to 5 days and then closing it, which is an and some are more prone to scarring. Because example of third intention healing. Skin grafts of these differences, sutures are removed at are also an example of third intention healing. different time.

MANAGEMENT OF SUTURED a. Face: As a general rule, 4 or 5 days. WOUNDS Better cosmetic results are obtained by removing every other stitch and any stitch After a wound is sutured, it is important to with redness around it on the 3rd day, and monitor it for signs of infection. The wound the remaining on the 5th day. should be checked and the dressing changed every 24 hours for the first four days. b. Body and scalp: 7 days.

Patients should be instructed to keep the c. Soles, palms, back, or over joints: 10 sutured area clean and dry. Any suture with days unless excess tissue reaction is evidence of purulent drainage, hematoma, or apparent around the suture, in which infection should be reported to the physician's case, they should come out sooner. assistant or physician. These sutures will be removed (generally by the physician) since the presence of the suture may make the infection

193 Lesson 3.12 Wound Management Basic Hospital Corps School Handbook III

FIGURE 3.12.01 Suturing Needles

FIGURE 3.12.02 Placing a Suture

194 Basic Hospital Corps School Lesson 3.12 Wound Management Handbook III

FIGURE 3.12.03 Suture Techniques

FIGURE 3.12.04 Suture Removal

195 Lesson 3.12 Wound Management Basic Hospital Corps School Worksheet Handbook III Lesson 3.12

Wound Management Worksheet

1. Match each definition in column B with the correct healing phase in column A.

A B

1. Inflammatory phase ______a. Scab sloughs off

b. Epithelial tissue regenerates, new capillaries 2. Proliferation phase ______formed

c. Immediately after injury, redness and warmth 3. Maturation phase ______occurs.

2. White blood cells scavenge dead tissue during the proliferation phase.

a. True b. False

3. Edema in surrounding tissue develops and pain occurs during the proliferation phase.

a. True b. False

4. ______intention healing occurs when a wound is left to accomplish the first phase of healing while the wound is left open.

5. Healing which occurs when tissue is cleanly incised or lacerated and reapproximated shortly after injury is called ______intention healing.

6. Sutures in the face should be removed after ______to ______days.

7. Any suture with pus or signs of infection around it should be ______.

8. Once sutures are removed a ______dressing should be applied to the area.

196 Basic Hospital Corps School Lesson 3.12 Wound Management Handbook III Worksheet

NOTES/COMMENTS

197 Lesson 1.23 DOD Immunization Program Basic Hospital Corps School Handbook III Lesson 1.23

DOD Immunization Program

Terminal Objective:

1.23 List the principles of the DOD Immunization Program

Enabling Objectives:

1.23.01 Define terms related to the control of communicable diseases by prophylaxis.

1.23.02 List the communicable diseases in the DOD Immunization Program.

1.23.03 List the basic guidelines for administering DOD immunizations.

1.23.04 Summarize the recording procedures in the DOD Immunization Program.

Hospital Corpsmen perform an important role Service needs change. The primary instructions for in the DOD Immunization Program, so it is the Navy are in the BUMEDINST 6230 series. necessary to understand the terminology used in These instructions provide guidelines, updates, and the discussion of immunizations. eligibility requirements of the current program. All personnel responsible for administering the COMMON TERMS program should be thoroughly familiar with the contents of these instructions. Prophylaxis -- A means of preventing the occurrence of a disease, either by mechanical or SPECIFIC DISEASES chemical (medication) recourse. The following diseases are covered in the Immunization – The process by which DOD Immunization Program. Directives require resistance to infectious disease is induced or the protection of Navy and Marine Corps augmented. personnel against these diseases.

Vaccine -- A preparation that consists of a Tetanus-Diphtheria treated live virus (attenuated), a killed and prepared virus, or a preparation of antibodies that Polio are used as a prophylactic immunization. Influenza Dosage – Measured quantity of therapeutic agent to be administered. Measles

Immune - - Resistant to disease. Rubella

The Department of Defense has a number of Meningitis (Quadrivalent) instructions and notices that govern the immunization program. These are updated as Yellow Fever

198 Basic Hospital Corps School Lesson 1.23 DOD Immunization Program Handbook III

Defibrillating and cardiac monitoring equipment Typhoid will also be immediately available. Cholera (As needed by travel requirements) When administering immunizations:

Plague (As needed by travel requirements) 1. Never mix two or more agents in a vial or syringe so as to permit a single injection. Hepatitis B Virus 2. It is highly desirable to allow a minimum of Smallpox *only under DOD directive 6205.3 thirty days between doses in order to permit (Biological Warfare Defense) the establishment of satisfactory immunity without interference. GENERAL POLICIES FOR ADMINISTERING IMMUNIZATIONS 3. There is no absolute contraindication to concurrent administration of vaccines when Always ask patients if they have any allergies, the 30-day interval is not practical. especially to eggs, chickens, feathers, or horses. 4. Follow recommendations established by A physician with a current certification in manufacturer. Advanced Cardiac Life Support (ACLS) should be present or nearby during the administration of 5. Follow guidelines established by the Navy. immunizations, in case a patient has an allergic or anaphylactic reaction. Immunization clinics or RECORDING PROCEDURES areas should be located near the treatment room. If this is not possible, ensure that there is an ACLS Commanding Officers are responsible for certified physician and medical treatment within ensuring all personnel, military and non-military, an 8-minute transport distance. under their jurisdiction receive required immunizations and that appropriate records of When immunizations must be administered to administration are maintained. Actual active duty personnel with little warning, e.g., performance of these immunizations and record during an operational emergency, Medical keeping is the responsibility of the Medical Department members other than physicians, who Department. have current ACLS certification, may be designated in writing by the Senior Medical Maintaining personnel in a current immune Officer to be present during immunizations. status is a command responsibility. The Medical Department maintains a tickler system for recall At sea, routine immunizations will only be and update of immunizations. This enables administered in the presence of an ACLS certified personnel to be maintained in a combat ready physician. This restriction does not apply to status so departure can be readily implemented in individual clinical situations in which there is a the event of a national emergency. clear medical indication for expedited vaccine or biologic administration, e.g., post-exposure rabies All immunizations are recorded on the prophylaxis or the routine administration of TB Immunization Record SF 601, which is divided skin tests. into specific sections. Public Health Service Form 731 (PHS 731) is utilized for further During all immunization procedures, an documentation. The PHS 731 is commonly emergency medical treatment cart, or appropriately referred to as the Yellow Card and is normally stocked kit will be available. This includes oxygen held by the service member. administration apparatus and appropriate medications as required for adequate ACLS.

199 Lesson 1.23 DOD Immunization Program Basic Hospital Corps School Worksheet Handbook III Lesson 1.23

DOD Immunization Program Worksheet

1. Match each definition in Column B with the correct term in Column A.

A B

a. Prophylaxis ______1. Measured quantity of therapeutic agent to be administered

b. Immunization ______2. A therapeutic preparation that is administered to produce or increase immunity to a particular disease

c. Dosage ______3. To make immune by administration of vaccines

d. Immune ______4. Measures designed to prevent the spread of disease and preserve health

e. Vaccine ______5. Resistant to disease

2. List five diseases covered by the DOD immunization program.

a. ______

b. ______

c. ______

d. ______

e. ______

200 Basic Hospital Corps School Lesson 1.23 DOD Immunization Program Handbook III Worksheet

3. List five guidelines for administering immunizations.

a. ______

b. ______

c. ______

d. ______

e. ______

4. Why should an ACLS certified physician be present or nearby during the administration of immunization?

______

______

5. Who is responsible for ensuring all military and non-military personnel under his/her jurisdiction are adequately immunized?

______

6. All immunizations are recorded on which health record form?

a. SF 600

b. SF 506

c. SF 601

d. SF 602

201 Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School Handbook III Lesson 3.16

Introduction to Medication Administration

Terminal Objective:

3.16 List concepts and principles of medication administration.

Enabling Objectives:

3.16.01 Define medical abbreviations/symbols commonly used in medication administration.

3.16.02 Define terms related to medication administration.

3.16.03 State characteristics of routes for medication administration.

3.16.04 State factors that affect route selection.

3.16.05 State the five drug rights.

3.16.06 State guidelines for safe medication administration.

3.16.07 State the procedure for reporting medication errors.

3.16.08 State safety precautions for administering medications to children, the elderly, the confused, disoriented, or the combative patient.

MEDICAL 4. c -- With. ABBREVIATIONS/SYMBOLS 5. Cap -- Capsule. Many abbreviations are used in medication administration. Each hospital, 6. DC -- Discontinued. clinic, or other facility should have a list of authorized abbreviations available. Medical 7. I.D. -- Intradermal. abbreviations can be written in all capital letters or small letters. Authorized 8. I.M. -- Intramuscular. abbreviations and symbols pertaining to medication administration include: 9. I.V. -- Intravenous.

1. A.C -- Before meals. 10. S.C. -- Subcutaneous.

2. Amp -- Ampule. 11. H.S. -- Hour of sleep.

3. B.I.D. -- Two times a day. 12. NS -- Normal saline.

202 Basic Hospital Corps School Less 3.16 Introduction to Medication Administration Handbook III

13. NSS -- Normal saline solution. 39. CC -- Cubic centimeter. 14. p -- after. 4.0 GTT -- Drop. 15. P.C. -- After meals. 41. ML -- Milliliter. 16. P.O. -- By mouth. 42. L -- Liter. 17. P.R.N. -- When necessary, or as needed. 43. GR -- Grain. 18. Q -- Every. 44. GM -- Gram. 19. Q.D.-- Every day. 45. MG or MGM -- Milligram. 20. Q.H. -- Every hour. 46. PT. -- Pint. 21. Q3H -- Every 3 hours. 47. QT. -- Quart. 22. Q4H -- Every 4 hours. 48. TBSP or T -- Tablespoon. 23. Q.I.D. -- Four times a day. 49. tsp or t -- Teaspoon. 24. Q.O.D. -- Every other day. 50. U -- Unit. 25. Q.S. -- Sufficient quantity. 51. O.S. -- Left eye. 26. s -- without. 52. O.D. -- Right eye. 27. ss -- One half. 53. O.U. -- Both eyes. 28. Stat. -- Immediately. 54. Otic -- Pertaining to the ears. 29. Tab -- Tablet. 55. Ophthalmic -- Pertaining to the eyes. 30. T.I.D.-- Three times a day. 56. Topical -- Pertaining to the skin. 31. TR. or Tinc. -- Tincture. 57. A.D. -- Right ear. 32. Sol. -- Solution. 58. A.S. -- Left ear. 33. X6 -- For six doses only. 59. A.U. -- Both ears. 34. X6D -- For six days only. 60. ETH -- Elixir or Terpin Hydrate. 35. M -- Minimum. 61. K -- Potassium. 36. GTT -- Drop. 62. I -- Iodine. 37. DR -- Dram. 63. Fe -- Iron. 38. OZ -- Ounce.

203 Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School Handbook III

64. Cl -- Chloride. Tincture -- A diluted alcohol solution varying in strengths from 10% to 20%. 65. PR -- Per Rectum. Unit Dose Supply -- A drug storage system 64. Susp -- Suspension. that employs pharmacy control in supplying individual doses of drugs for each patient. 66. AA or aa -- Of each. Vial -- A rubber-capped glass bottle TERMINOLOGY containing one or several doses of a particular injectable medication. The following terms are used when ordering medication. Routes

Ampule -- Contains sterile solution of Oral (p.o.) -- Medication is ingested through medication sealed in a glass or plastic the mouth and is absorbed in the container. gastrointestinal tract with a systemic effect (medication affects the body as a whole). Dilute -- To diminish the strength of a mixture by adding another substance. Subcutaneous (s.c.) -- Sterile medication is injected into the subcutaneous tissue with a Diluent -- Substance capable of dissolving a needle inserted at a 45-degree angle. It can drug substance and holding it in a solution. produce either a systemic or local effect (effecting only the area in which the Elixir -- A drug dissolved in flavored or medication is applied). Subcutaneous sweetened water and/or alcohol. medications produce a more rapid systemic effect than oral medications. Expectorant -- A drug that increases bronchial secretions and the ability to remove Intramuscular (I.M.) -- Sterile medication is or cough up the secretions. injected into a muscle, gluteus maximums or deltoid, with a needle inserted at a 90-degree Floor Stock Supply -- A drug storage system angle. Intramuscular medications produce a in which bulk doses of medication are more rapid systemic effect than either oral or prepared for patients by ward personnel. subcutaneous medications.

Reconstitution -- Restoring a dehydrated Intravenous (I.V.) -- Sterile medication is substance to its previous liquid form by adding injected directly into a vein; produces a very water. rapid systemic effect.

Solute -- A drug substance which can be Intradermal (I.D.) -- Sterile medication is dissolved in liquid injected into the superficial layers of the skin with a needle at a 15-degree angle. Allergy Suppository -- A cone shaped or cylindrical and tuberculosis testing are administered in medication made from insertion into a body this fashion. cavity, (rectum or vagina), where the suppository is dissolved and its components Sublingual (s.l.) -- Medication is dissolved absorbed. Suppositories are made of cocoa under the tongue and absorbed through the butter or glycerin, and usually a medication. mucous membrane. Medication is not swallowed or chewed. Suspension -- A preparation of an undissolved Instillation -- Administration of a liquid drop substance maintained in a liquid substance. by drop into the nose, ears, or eyelids.

204 Basic Hospital Corps School Less 3.16 Introduction to Medication Administration Handbook III

Inhalation -- A vapor form of steam or soiled or unreadable, return the bottle to the medication that is inhaled into the lungs. It pharmacy. To make a positive medication produces a local effect on the respiratory tract identification follow this procedure: Identify with possible systemic effects. Some types of the drug with the medication card or anesthetics are inhaled which cause a loss of Medication Administration Record (MAR) consciousness necessary to perform surgical before removing the bottle from the procedure; commonly known as general medication locker or unit dose cart. Check the anesthesia. drug against the medication card or MAR before preparing the mediation. Identify the Rectal (R) -- Medication that is placed in the drug with the medication card before returning rectum for absorption through a mucous the medication to the medication locker, if membrane. applicable.

Topical -- Medication that is applied directly RIGHT DOSE on the surface of the skin producing a local or systemic effect. Make sure the dosage is computed and prepared correctly. Route Selection Factors RIGHT ROUTE There are several physical factors that affect route selection including age and body The Doctor's Order will specify the proper build (e.g., muscular, obese, emaciated). The route. The Hospital Corpsman may not speed of absorption varies with the route. A interchange routes without a Doctor's Order. drug must enter the bloodstream before a systemic effect is obtained. The chemical RIGHT PATIENT nature of the drug is also important. The drug may not be absorbed by all tissues and/or the When using the unit dose cart, make the drug may be irritating to certain tissues. following checks. Compare the patient's name Patient comfort, convenience, and on the MAR with the name on the medication accessibility of the site are also concerns. drawer. Check the patient's bed tag and wristband with the MAR and ask the patient to Certain drugs may be contraindicated for verbalize his/her name. patients with a specific diagnosis or medical history. Be aware of the patient's medical and When using the floor stock, compare mental condition as well. Combative, patient's bed tag and wristband with the disorientated, or unconscious patients may Medication/Treatment card. Ask the patient to aspirate an oral drug. verbalize his/her name.

The Five Drug Rights RIGHT TIME

To eliminate the potential of error in Medication may be given 30 minutes medication administration, the Hospital before or after the stated time. If administering Corpsman must know the Five Rights of a PRN medication, always check the MAR to medication administration. note the last time the medication was given to ensure that the minimum time ordered has RIGHT MEDICATION elapsed.

Compare the name of the medication on the card to the label on bottle. Labels are only to be changed by the pharmacy. If a label is

205 Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School Handbook III

Guidelines for Safe Medication been canceled or changed, or why it was Administration received. If this should happen, verify the Doctor's Orders and inform the patient of your Always ensure that there is sufficient light verification. If a patient is still uncertain, when administering any medication. This notify the nurse. Never force a patient to take ensures the medication is correct and permits a medication against his/her will. Withhold the proper identification of the patient. Note the medication if the patient reports any previous patient's appearance before and after reaction to the drug and report this to the medication is administered. nurse.

During medication administration avoid Always administer a drug in the form interruptions that might cause delays, prescribed by the physician. If another form contribute to errors when attention is diverted, seems indicated, report your observations and or require leaving medication unattended. recommendations. Do not allow a patient to Only the individual who prepares the take drugs that were not prescribed by the medication will administer and record the physician and prepared by the pharmacy staff. medication. You should never give a never allow a patient to share medication with medication without a medication card or the another patient. A parent may give medication MAR. Pour all the medications for one patient to a child with supervision. Chart a medication before pouring medication for the next patient. only after the patient has consume it or it has actually been administered. Observe the Administer all medication with a positive patient for desired and undesired effects of the attitude and a sense of assurance. Know the medication. drug the patient is about to receive, especially the usual dose, indication, and adverse Reporting Medication Errors reactions. After immediately notifying the nurse of a Do NOT return unused medication to a medication error, observe the patient for bottle or transfer medication from one bottle to adverse effects of the medication. An error another. There is a risk of accidentally mixing results from faulty technique in preparation, or placing medications in a wrong container. administration, or the recording of medication. This practice also creates the possibility of cross-contamination. Place an asterisk in the proper place on the MAR and state in the Nursing Notes that a When administering medication from a medication error was made. Include tray or cart, never leave the medication medication given, amount given, route, time unattended. If medication is to be taken before given, and action taken. Complete any form or or after meals, take it to the patient on time. If report as required by local instructions or the patient is not present, do not leave the policies, e.g., Incident report. medication at the patient's bedside. When a sleeping medication is ordered, take it to the Precautions patient at the time prescribed or requested. Remember, medications must be given within You must always practice safety 30 minutes before or after the scheduled time. precautions when administering medication to Notify the nurse if the patient is missing or a children, the elderly, disoriented, or combative medication delay occurs for any reason. patients. Avoid using essential foods to dilute medications for children. Make sure the child Withhold the medication if the patient swallows the medication. If you are unable to questions the dose, size, shape of pills or convince a child through salesmanship, do not capsules, whether or not the medication has use physical force. When giving a liquid

206 Basic Hospital Corps School Less 3.16 Introduction to Medication Administration Handbook III medication to an infant, use a half-filled of the tongue will stimulate the swallowing spoon, medicine dropper, or a syringe without reflex. Never rush a patient and always be a needle. Place the medication under the alert to excessive difficulty in swallowing. A tongue and give it slowly. patient's physical condition may require special techniques when giving injections. Never prepare injections or display needles in front of children. Restraining of Never administer tablets or capsules to a children is justified for safety when giving confused, disoriented, or combative patient. If injections (to be sure that the child does not there is a significant change in the patient's move.) Obtain assistance as required. Physical condition, withhold all medications and notify restrictions should be effective but gentle, the nurse. Medications for psychiatric patients accompanied by soothing, friendly are usually supplied in a liquid form and conversation. The injection would be carried administered under close supervision out quickly. The injection site should never be conditions. If an injection is ordered, ensure slapped. adequate staff assistance is available to restrain the patient so that the medication may Elderly patients may have dysphagia due be administered safely. to a tight esophageal sphincter. To assist them with this problem have the patient elevate the head and take a sip of water to relax the esophageal muscle. Placing tablets at the base

207 Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School Worksheet Handbook III

Lesson 3.16

Introduction to Medication Administration Worksheet

1. What is the abbreviation for "of each"?

______

2. What term pertains to the ears?

______

3. Define reconstitution.

______

4. A diluted alcohol solution varying in strengths from 10% to 20% is know as:

______

5. An intramuscular injection produces a very rapid systemic effect.

a. True b. False

6. Circle medication administration routes that do not produce a local effect.

a. Subcutaneous

b. Topical

c. Intramuscular

7. Who is authorized to change the label on a medication bottle?

______

8. When giving medication, a Hospital Corpsman may interchange routes without Doctor's Orders if the patient requests

a. True b. False

208 Basic Hospital Corps School Lesson 3.16 Introduction to Medication Administration Handbook III Worksheet

9. A patient reports that a medication caused a reaction. You withhold the medication and:

a. tell the other Hospital Corpsman.

b. notify the Doctor.

c. notify the Nurse.

d. call the pharmacy.

10. To save time, medications are charted before administering them to the patient.

a. True b. False

11. What is the first step in reporting a medication error?

______

12. What information is documented in the Nursing Notes when a medication error is made?

______

______

13. What should be used to administered liquid medications to infants?

______

14. Elderly patients should be encouraged to take medications quickly.

a. True b. False

15. An IM medication has been ordered for a psychiatric patient. What should be done to ensure this procedure is carried out safely?

______

209 Basic Hospital Corp School Lesson 3.15 Pharmacology and Toxicology Handbook III Lesson 3.15

Pharmacology and Toxicology

Terminal Objective:

3.15 State selected drug classifications based on their general actions, indications for use, contraindications, and adverse reactions.

Enabling Objectives:

3.15.01 Define terms related to pharmacology.

3.15.02 List sources of drug information.

3.15.03 Define the major classifications of drugs.

3.15.04 State the general actions of drugs by their major classification.

3.15.05 State the indications for use of the drugs by their major classification.

3.15.06 State the contraindications and adverse reactions of drugs by major classification.

3.15.07 State special considerations for administration of medications.

3.15.08 Make drug index cards for drugs in each major drug classification.

Pharmacology is the scientific study of the Drug -- any chemical compound, other origin, nature, and effects of drugs. Some of than food, used in the diagnosis, treatment, or the terms used in connection with prevention of disease. pharmacology and doses are: Drug hypersensitivity -- abnormal Adverse reaction -- an effect of a drug reaction or sensitivity to a drug. which may be unfavorable to the patient's health. An action or effect, other than that Generic name -- describes the principle which is desired, such as an allergic reaction. ingredients. It is the formal name of the drug.

Chemical Name -- describes the chemical Indication -- disease or condition for make-up of a drug. which a drug is prescribed.

Contraindication -- any condition for Lethal dose -- smallest dose that will which administration of a drug is undesirable produce death. or the administration may produce undesirable effects when administered with another drug. Maximum dose -- largest quantity that can be given without probable harmful effects.

210 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

Minimum dose -- smallest quantity which manufacturers with their products. The blue can produce a medicinal effect section is a therapeutic index. The yellow section is a drug, chemical, and Recommended dose -- unofficial dose pharmacological index to drugs. The white extracted from current literature. section is a list of the major products of manufacturers with information on Side Effect --action other than desired. composition, action, uses, administration, dosage, precautions, contraindications, and Therapeutics -- treatment of disease. supply of each drug.

Toxic dose -- amount which produces The final section contains full size color poisoning. photographs to aid in medication identification. Toxicology -- scientific study of the nature and effects of toxic substances. The Hospital Formulary is produced locally by each Medical Treatment Facility. Trade/Brand name -- name created by The formulary lists all medications in a the manufacturer. It indicates the name is particular hospital's pharmacy. registered and protected by law. Its use is restricted to the company that legally owns the Manufacturer Drug Package Inserts are a name. concise description of the product, drug actions, interactions, indications, Usual/Therapeutic dose -- amount of a contraindications, and precautions in clinical drug necessary to produce a desired effect. use, guidance for dosage, known adverse actions, and side effects. Federal law requires SOURCES OF DRUG that a brochure approved by the Food and INFORMATION Drug Administration accompany each package of the product. A number of sources containing information on drug actions, uses, and specific A variety of Nursing Drug HandBooks indications, contraindications, adverse exist, and most wards or clinics have one or reactions, and dosage are usually available on more. each ward. The Physician's Desk Reference, formulary, and drug package inserts are all CLASSIFICATION OF DRUGS excellent sources for information concerning drugs. This section identifies drugs according to their pharmacological classification. It is imperative that anyone administering a medication be familiar with information ANTIHISTAMINES -- Suppress pertinent to that medication. Hypersensitivity symptoms caused by histamine in the body. to a drug is ALWAYS a contraindication to When histamine is released, it dilates the the administration of that drug. Special capillaries and stimulates secretions associated precautions must be followed for pregnant with allergic disorders. women and lactating mothers. Indications: Symptomatic relief of allergic The Physicians' Desk Reference, PDR, disorders such as allergic cough and sneezing, which is published annually, is a listing of rhinitis (runny nose), allergic conjunctivitis drugs arranged in five sections. The pink (inflammation of the inner eyelids), excessive section is a comprehensive alphabetic listing lacrimation, urticaria, nighttime sleep aid, and of brand name products and a list of adjunctive therapy in anaphylactic reactions.

211 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

Contraindications: Acute asthma ANTITUSSIVE -- Agents that suppress coughing Adverse reactions: Drowsiness, confusion, dryness of mouth, thickening of bronchial Indications: Nonproductive coughs. secretion, disturbed coordination, epigastric distress and dizziness. Adverse reactions: Respiratory depression (associated with codeine), nausea and Drugs in the category: vomiting, constipation, dizziness, drowsiness.

1. Benadryl (Diphenhydramine HCL) Drugs in the category:

2. Chlor-Trimeton (Chlorpheniramine 1. Robitussin DM (Guaifenesin and Maleate) Dextromethorphan).

EXPECTORANTS -- Agents that thin or 2. ETH with Codeine (Elixir of Terpin liquefy mucous from the lung, bronchi, and Hydrate with Codeine) -- a controlled trachea. substance.

Indications: Relief of respiratory ANTIHISTAMINES/ conditions characterized by dry, DECONGESTANT nonproductive cough due to the presence of mucus in respiratory tract Because no single agent relieves all symptoms

of the common cold, combination products are Contraindications: Cough accompanied by manufactured. excessive secretions and persistent cough of more than one week. Indications: Symptomatic relief of

seasonal hay fever. Adverse reactions: GI disturbance, nausea and vomiting. Contraindications: Newborn or premature

infants and lower respiratory diseases. Drug in the category:

Adverse reactions: Drowsiness, sedation, 1. Robitussin (Guaifenesin) and thickening of bronchial secretions.

DECONGESTANTS -- Agents that shrink Drug in the category: swollen mucous membranes, reduce nasal congestion, and increase nasal patency. 1. Actifed (Triprolidine HCL and

Pseudoephedrine HCL). Indications: Temporary relief of nasal congestion due to the common cold or hay BRONCHODILATORS -- Medications that fever. Promotes nasal or sinus drainage and ease contractions of the bronchi by relaxing for relief of eustachian tube congestion. the smooth muscles of the air passageway and

reducing swelling of the mucous membranes Contraindications: Severe hypertension. of these passages.

Adverse reactions: Restlessness, Indications: Relief of bronchospasm nervousness, palpitations, and tachycardia. (acute wheezing and shortness of breath)

associated with acute and chronic bronchial Drug in the category: asthma, emphysema, or other obstructive

pulmonary diseases. 1. Sudafed (Pseudoephedrine HCL).

212 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

Contraindications: Cardiac arrhythmia Indications: Bacteriostatic agent used in a associated with tachycardia. wide range of gram--positive and gram-- negative organisms, e.g., Rickettsiae (Rocky Adverse reactions: Restlessness, Mountain Spotted Fever) and Typhus Fever; apprehension, nausea, vomiting, palpitations, and infection in patients allergic to penicillin. changes of blood pressure, tachycardia. Contraindications: Children under 8 years Drugs in the category: old.

1. Ventolin (Albuterol). Adverse reactions: Anorexia, nausea, vomiting, diarrhea, and photosensitivity. 2. Aminophylline. WARNING: Long term use may cause ANTIBIOTICS -- Agents that inhibit the permanent discoloration to teeth of infants and growth of bacteria (bacteriostatic) or destroy children up to 8 years of age. Caution should bacteria (bacteriocidal). In 1929, Fleming be used during pregnancy. Also, advise patient discovered the bacteriolytic effects of the against taking dairy products, antacids, or iron mold Penicillium. In 1936, at Oxford products when taking tetracyclines. University, Florey and his assistants isolated the active principle and named it penicillin. Drugs in the category:

Penicillin 1. Achromycin V (Tetracycline).

Indications: Treatment of mild to 2. Vibramycin (Doxycycline). moderately severe infections caused by penicillin-sensitive microorganisms. Also used 3. Erythromycin in the treatment of venereal diseases, and prophylaxis for rheumatic fever/ endocarditis. Indications: Treatment of infection for Several forms of penicillin have been patients that are hypersensitive to penicillin. identified and designated as F, G, K, 0, V, and Also used in infections of the upper and lower X. Commercial preparations principally respiratory tract caused by streptococcus or contain penicillin G. mycoplasma pneumonia and Legionnaires Disease. Adverse reactions: Anaphylactic shock -- including acute circulatory failure, loss of Adverse reactions: Abdominal cramps and consciousness, and facial or laryngeal edema. discomfort, nausea, vomiting diarrhea, and Delayed hypersensitive reactions include skin anorexia. rash, urticaria, itching, nausea, vomiting, diarrhea, and fever. Drugs in the category:

Drugs in the category: 1. Eryc (Erythromycin base).

1. V-Cillin-K (Penicillin V potassium). 2. Ilosone (Erythromycin Estolate).

2. Polycillin (Ampicillin). Sulfonamides -- synthetic agents which suppress bacterial growth and reproduction. 3. Polymox (Amoxicillin). Indications: Treatment of urinary tract Tetracyclines infections, acute otitis media, and meningitis.

213 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

Contraindications: Use with caution for 1. ANALGESIC relief of mild to moderate patients with G6PD deficiency. pain from injuries, illness and dysmenorrhea. Adverse reactions: Nausea, vomiting, anorexia, aplastic anemia, diarrhea, abdominal 2. ANTIPYRETIC reduces fever in viral and pains, and crystalluria (crystals in the urine). bacterial illnesses.

Drugs in the category: 3. ANTI-INFLAMMATORY -- Drug of choice for most inflammatory reactions in 1. Gantrisin (Sulfisoxazole). rheumatic diseases and injuries.

2. Septra, Bactrim (Trimethoprim and 4. ANTICOAGULANT -- Low dosage of Sulfisoxazole). aspirin is used to decrease platelet aggregation and prevent blood clots for patients ANTIFUNGALS -- Drugs used to treat susceptible to stroke or myocardial infarction. fungal infections. In general, there are two types of fungal infections: systemic fungal Contraindications: Asthma, chronic infections and dermophytic infections of the urticaria, or nasal polyps; bleeding ulcers skin, hair, and nails. (ASA irritates ulcer); hemophilia; hemorrhagic states; and hypersensitivity to Indications: Treatment of susceptible salicylates or NSAID. strains of systemic (severe) infections, and dermophytic infections such as Athlete's Foot Adverse reactions: GI upset, gastric (tinea pedis), ringworm of the body (tinea bleeding, occult (hidden) bleeding, tinnitus corporis), and jock itch (tinea cruris). (ringing of the ears). ASA prolongs coagulation of blood. Contraindications: Metabolic disorders affecting the liver. Tylenol (Acetaminophen)

Adverse reactions: Headache, dizziness, Indications: Mild to moderate pain from nausea, vomiting, diarrhea, insomnia, and injury or illness, fever from viral or bacterial photosensitivity. illness, discomfort due to colds and influenza, and patients with a hypersensitivity to aspirin. WARNING: Due to the toxic nature of these drugs, for prolonged use, baseline liver studies Adverse reactions: Rare. should be made and routinely reevaluated. NARCOTIC ANALGESICS -- Alleviate Drugs in category: moderate to severe pain without loss of consciousness. These drugs are subject to 1. Tinactin (Tolnaftate) Topical Use Only. control under the Federal Comprehensive Drug Abuse Prevention and Control Act of 2. Gris-Peg, Grifulvin V (Griscofulvin) -- 1970. systemic use only. Indications: Relief of moderate to severe MILD ANALGESICS -- Agents that acute and chronic pain. Also used pre-- alleviate mild to moderate pain. operatively to sedate and allay apprehension.

Aspirin (Acetylsalicylic Acid, abbreviated Contraindications: Closed head injuries, ASA) respiratory depression, and undiagnosed acute abdominal pain. Indications:

214 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

Adverse reactions: Respiratory distress, treatment of primary dysmenorrhea, and acute nausea, vomiting, constipation, hypotension, gouty arthritis. circulatory depression, shock, and cardiac arrest. Narcotics can cause increased Contraindications: History of allergic intracranial pressure, dizziness, reaction to ASA or other non-steroidal anti- lightheartedness, euphoria, dysphoria, and inflammatory drugs. sedation. Adverse reactions: GI bleeding and WARNING: Habitual use and/or physical disturbances, epigastric pain, diarrhea, dependency may occur; therefore, federal constipation, nausea and vomiting. regulations governing narcotics must be obeyed. WARNING: Anti-inflammatory agents should not be taken with other anti- Drugs in the category: inflammatory agents or with products containing aspirin. Should be taken with food 1. Morphine Sulfate. or milk.

2. Demerol (Meperidine HCL). Drugs in the category:

3. Tylenol III (Codeine phosphate and 1. Motrin (Ibuprofen). Acetaminophen). 2. Indocin (Indomethacin). GENITOURINARY ANALGESICS -- Act on the mucosa of the urinary tract to relieve LOCAL ANESTHETICS -- Produce loss of pain, burning, urgency and frequency. sensation and motor activity within a limited area of the body by blocking nerve Indications: Symptomatic relief of conduction. The important action of this group discomfort from irritation of the lower urinary of drugs is paralysis of the peripheral sensory tract caused by infection, trauma, or surgery. nerves. They block all sensations, including taste and smell, although their chief effect is Contraindications: Renal insufficiency. on the nerves of pain.

Adverse reactions: Occasional G.I. Indications: Any procedure where a short disturbances or headache. term anesthetic effect is desired, such as suturing small wounds, dental procedures, and WARNING: The patient should be warned debridement of wounds. that pyridium will cause a reddish-orange discoloration of the urine. Contraindications: Should not be given in cases of severe shock or heart block, due to Drugs in the category: the possibility of vascular dilation, or if an injection site is inflamed. 1. Pyridium (Phenazopyridine HCL). Adverse reactions: Hypotension, NONSTEROIDAL ANTI- hypertension, cardiopulmonary arrest tremors INFLAMMATORY DRUGS (NSAID) -- A and convulsions. group of drugs having analgesic, antipyretic, and anti-inflammatory properties. WARNING: Resuscitative equipment and drugs should be immediately available when Indications: Rheumatoid arthritis and any local anesthetic is used. osteoarthritis, relief of mild to moderate pain,

215 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

CAUTION: Lidocaine with epinephrine is treatment of seizures occurring during or never injected into fingers, nose, toes, ear following neurosurgery. lobes, or penis due to vasoconstrictor effects. Contraindications: Sinus bradycardia and Drugs in the category: sinoatrial block.

1. Xylocaine HCL (Lidocaine HCL). Adverse reactions: Gastrointestinal disturbances (nausea, vomiting, constipation), 2. Xylocaine HCL with epinephrine ataxia, tremors, CNS depression, inflammation (Lidocaine HCL with epinephrine). and/or thickening of the gums, and slurred Epinephrine prolongs the effect of the speech. anesthetic. Drugs in the category: SEDATIVE/HYPNOTICS -- Produce varying degrees of Central Nervous System 1. Dilantin (Phenytoin sodium). depression. Small doses reduce restlessness, emotional tension, and help to induce sleep in 2. Phenobarbital. irritable, apprehensive patients. This group includes the barbiturates. ANTI-ANXIETY AGENTS -- CNS depressants used to reduce mild to moderate Indications: Pre-anesthetic medications or degrees of anxiety, agitation, fear or tension. short-term treatment for insomnia. They produce mild sedation that is unlikely to adversely effect the quality of motor Contraindications: Severe respiratory performance or clarity of consciousness. distress and respiratory disease where dyspnea or obstruction is present, impaired renal Indications: Management of anxiety; relief function, and marked impairment of liver of apprehension, tension, or fear; and function. treatment of alcohol withdrawal symptoms (Delirium Tremors). Administered pre- Adverse reactions: Sleepiness, nausea, operatively to reduce patient apprehension. vomiting, respiratory depression, vertigo, Diazepam is the drug of choice for treatment (dizziness), drowsiness, lethargy, and ataxia of status epilepticus and is frequently used as a (uncoordinated muscle movements). musculoskeletal relaxant.

WARNING: Avoid activities that require Contraindications: Psychosis. Acute, alertness and physical coordination. narrow angle glaucoma.

Drugs in the category: Adverse reactions: Transient drowsiness, ataxia, or confusion. 1. Versed (Midazolam HCL). WARNING: The patient should be warned 2. Seconal (Sodium secobarbital). not to combine alcohol and tranquilizers or engage in hazardous tasks. ANTICONVULSANT -- CNS depressants, used to terminate convulsive episodes and to Drugs in the category: prevent or decrease the occurrence of seizures for patients with epilepsy. 1. Librium (Chlordiazepoxide HCL).

Indications: Control of grand mal seizures, 2. Valium (Diazepam). psychomotor seizures, prevention and

216 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

CENTRAL ACTING MUSCLE Used during major surgical procedures when RELAXANTS -- Skeletal muscle relaxants complete unconsciousness is desired. are used to produce muscular relaxation during surgical anesthesia and are used in Contraindications: Liver disease. connection with the treatment of muscle spasms due to various conditions. Adverse reactions: Respiratory depression, coughing, bronchospasm, laryngeal spasms, Indications: Relief of skeletal muscle and transient hypotension. spasms due to discomfort associated with acute, painful musculoskeletal conditions. Drug in the category:

Adverse reactions: Drowsiness, dizziness, 1. Pentothal Sodium (Thiopental Sodium) nausea, urticaria, rash, urine discoloration (brown, black, or green). ANTACIDS -- Drugs to counteract or neutralize acidity in the stomach or to correct Drugs in the category: a low alkalinity in body fluids. Normal stomach fluids are acid in nature. Stomach 1. Robaxin (Methocarbamol). contents which become too acidic irritate the mucous membranes and cause symptoms 2. Flexeril (Cyclobenzaprine HCL). commonly spoken of as indigestion or dyspepsia. Antacids such as sodium GENERAL ANESTHETICS -- These agents bicarbonate, magnesium oxide, magnesium depress the Central Nervous System (CNS) to carbonate, or milk of magnesia are indicated cause a loss of sensation affecting the whole in this condition. The intestinal tract is body. This is essential when complete normally slightly alkaline. As a result of unconsciousness, reduced reflex action, and disease it may become acid, which usually adequate muscular relaxation are desired. causes diarrhea. When movement of the patient may imperil the success of the operation, in lengthy Indications: Hyperacidity associated with operations, and where spinal anesthesia is not peptic ulcer or heartburn (burning sensation in safe (as in thoracic surgery), general the esophagus), prevention (prophylaxis) of anesthesia is also indicated. General gastrointestinal bleeding or stress ulcers. anesthetics that are administered by inhalation Simethicone aids in the relief of mucus, are safer because they are eliminated from the entrapped air or gas. blood very rapidly -- being volatile, they are excreted quickly by the lungs. Ultra-short Contraindications: Impaired renal acting barbiturates are used because they have function, because of possible toxic effects of a quick reversal. magnesium. Do NOT give antacids with oral Tetracycline. The loss of sensation, which occurs before complete loss of consciousness, seems to be Adverse reactions: Diarrhea, nausea, and due to an effect on the spinal cord. In vomiting. sufficient dosage, general anesthetics can paralyze the spinal cord, the cerebrum, the WARNING: Do not give with oral vital centers in the medulla, usually affecting tetracyclines. respiratory responses first then the vasomotor mechanism. Drugs in the category:

Indications: Rapid-acting intravenous 1. Maalox (Magnesium and Aluminum anesthetic that causes a loss of consciousness, Hydroxide). but has a relatively weak analgesic effect.

217 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

2. Mylanta (Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone). 2. Milk of Magnesia USP (MOM).

ANTIDIARRHEALS -- Used for the ANTIEMETICS -- Prevent or relieve nausea symptomatic treatment of diarrhea (acute or or vomiting. chronic increase in the fluidity and frequency of the stools caused by infection, poisoning, Indications: Management of nausea and allergy, GI lesions, or inflammation). vomiting and treatment of motion sickness or vertigo, (nausea, vomiting, and dizziness). Indication: Diarrhea. Adverse reactions: Dryness of mouth and Contraindications: Under 2 years old throat, drowsiness, restlessness, and blurred (Lomotil), diarrhea from poisons, or diarrhea vision. caused by organisms that penetrate the intestinal mucosa. WARNING: Patients should be cautioned that drowsiness may occur, so driving or other Adverse reactions: GI disturbances, hazardous tasks should not be performed. nausea, vomiting, constipation, anorexia, drowsiness, dizziness, and depression. Drying Drug in the category: of skin and mucous membranes can occur with Lomotil. 1. Antivert (Meclizine).

Drugs in the category: CARDIOTONICS -- Help restore the normal functions of the heart by increasing 1. Kaopectate (Kaolin and pectin). contractibility of a failing heart muscle which results in an increased stroke volume and 2. Lomotil (Diphenoxylate HCL with cardiac output atropine sulphate). Indications: Treatment of congestive heart LAXATIVES -- Agents which facilitate the failure. passage of feces through the colon and elimination through the rectum. Adverse reactions: Anorexia (loss of appetite), nausea, vomiting, diarrhea, Indications: Short term treatment of abdominal pain, blurring of vision, cardiac constipation. Preparation for lab studies (X- dysrhythmia, decrease in pulse, and ray), examinations (proctoscopy), and gynecomastia. preoperative and postoperative preparation. WARNING: An apical pulse must be taken Contraindications: Nausea, vomiting, and prior to administration of Lanoxin (Digoxin.) other symptoms of appendicitis, acute If the pulse is less than 60 or greater than 100, abdomen, fecal impaction, bowel obstruction, hold the medication and notify the physician and undiagnosed abdominal pain. (usually done by the charge nurse.)

Adverse reactions: Abdominal cramping, Drug in the category: diarrhea, and laxative dependence with loss of normal bowel function may develop with 1. Lanoxin (Digoxin). prolonged use. DIURETICS -- Reduce circulatory volume Drugs in the category: fluid and prevent or eliminate edema by increasing urinary excretion. 1. Dulcolax (Bisacodyl).

218 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

Indications: Congestive heart failure, Contraindications: Severe anemia or generalized edema, hypertension, edema increased intracranial pressure. associated with liver disease, or premenstrual fluid retention. Adverse reactions: Headache or hypotension. Contraindications: Anuria (absence of urine excretion) and electrolyte imbalance. WARNING: Medication should be taken only while seated due to hypotensive reaction, Adverse reactions: Gastrointestinal upset dizziness, and vertigo. headache, fatigue, dizziness, dehydration, and electrolyte imbalance. Drug in the category:

Drugs in the category: 1. Nitrostat (Nitroglycerin).

1. Esidrex (Hydrochlorothiazide abbreviated TOPICAL DERMATOLOGICAL HCTZ). AGENTS -- Agents commonly used to provide symptomatic relief or promote the 2. Lasix (Furosemide). healing process of many dermatological disorders. These agents come in creams, VASOCONSTRICTORS -- Agents that ointments, lotions and balms, which are constrict the blood vessels, causing the blood applied directly to the skin. Some topical pressure to elevate. preparations (scabicides) destroy itch mites and lice. Scabicides are discussed here. Indications: Anaphylactic shock and acute asthma attack. Used to prolong the effects of Indications: Treatment of parasitic local anesthesia and as cardiac stimulant in infestations by scabies, head lice, and crab lice cardiac arrest. and their nits (juvenile lice) and eggs.

Contraindications: Shock, other than Contraindications: Do not exceed anaphylactic and local anesthesia of the prescribed dosage, especially in children; and fingers, toes, ears, nose and penis. pregnant or nursing women.

Adverse reactions: Changes in blood Adverse reactions: Eye, skin, or mucosa pressure, palpitations, anxiety, and headache. irritation. Toxic if absorbed in large amounts.

Drug in the category: Drug in the category:

1. Adrenalin (Epinephrine HCL). Kwell (Lindane).

VASODILATORS -- Agents that dilate the DRUG CARDS blood vessels causing the blood pressure to be lowered. Drug index cards are used as a guide in preparing individual drug cards for personal Indications: Acute angina pectoris. use, Figure 3.15.01. Prophylaxis for angina and control of blood pressure.

219 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

BRAND/TRADE NAME: Nitroglycerin______PRONUNCIATION: NI-TRO-GLIS-ER-IN______GENERIC/CHEMICAL NAME: Glyeril trinitrate______CLASSIFICATION: Vasodilator______INDICATIONS: Treatment of acute attack or prevention of expected attacks in chest pains of angina pectoris ACTIONS Improves blood flow of oxygenated blood through the coronary arteries, relieving _____ ischemia and hypoxia. Reduces the work of the heart______CONTRAINDICATIONS/PRECAUTIONS Generally no more than three tabs should be taken___ without relief and physician notification. Patient should sit or lie to prevent postural hypotension__. Use with caution in glaucoma. ADVERSE REACTIONS/SIDE EFFECTS: Headache, skin flushing and postural hypotension___ (dizziness, weakness, faintness); may lead to collapse. Nausea, vomiting, and drug rash______. ROUTE/DOSE: Sublingual/0.2-0.6 mg, repeated up to three times in 15 minutes______

Figure 3.15.01 Drug Index Card

220 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

221 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

222 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

223 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

224 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

225 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School Handbook III

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

BRAND/TRADE NAME ______PRONUNCIATION: ______GENERIC/CHEMICAL NAME ______CLASSIFICATION: ______INDICATIONS: ______ACTIONS: ______CONTRAINDICATIONS/PRECAUTIONS: ______ADVERSE REACTIONS/SIDE EFFECTS: ______ROUTE/DOSE: ______

226 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III

NOTES/COMMENTS

227 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corps School Worksheet Handbook III Lesson 3.15

Pharmacology and Toxicology Worksheet

1. Match each definition in column B with the correct term in column A.

A B

a. Pharmacology ______1. An action other than desired

b. Contraindication ______2. The formal name of a drug

c. Generic Name ______3. The scientific study of drugs

d. Indication ______4. A name created by the manufacturer

e. Side Effect ______5. A condition for which a drug is prescribed

f. Trade Name ______6. A condition where administration of a drug may be undesirable

2. List three sources of drug information.

a. ______

b. ______

c. ______

3. Which classification of drugs is used to relieve acidity in the stomach?

a. Antihistamines

b. Cardiotonics

c. Laxatives

d. Antacids

4. Narcotics are used to control moderate-to-severe pain.

a. True b. False

5. Anticonvulsants are used to decrease the occurrence of seizures.

a. True b. False

228 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III Worksheet

6. Which classification of drugs inhibits the growth of, or destroys bacteria?

a. Antacids

b. Antibiotics

c. Antiemetics

d. Analgesics

7. Diuretics reduce or eliminate edema by increasing:

a. evaporation of water.

b. blood flow to the liver.

c. urinary excretion.

d. sodium retention.

8. Which drug is a sedative/hypnotic?

a. Kwell

b. Meperidine

c. Lanoxin

d. Versed

9. Which drug is a narcotic?

a. Seconal

b. Meperidine

c. Ibuprofen

d. Pyridium

10. A contraindication for administering an antihistamine is:

a. acute asthma.

b. dry cough.

c. acute sinusitis.

d. advanced age.

229 Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corps School Worksheet Handbook III

11. One adverse reaction to morphine is:

a. asthma.

b. sedation.

c. diarrhea.

d. hypotension.

12. Drug index cards are used to sort medications before administration.

a. True b. False

230 Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology Handbook III Worksheet

NOTES/COMMENTS

231 Lesson 3.18 Dosage Calculations Basic Hospital Corps School Handbook III Lesson 3.18

Dosage Calculations

Terminal Objective:

3.18 Solve medical mathematical problems.

Enabling Objectives:

3.18.01 Compute medicine dosage using liquid weights and measures.

3.18.02 Compute medicine dosage based on a patient's weight.

3.18.03 Compute intravenous flow rates.

COMPUTING DOSAGES FOR 3. Example: The medical officer ordered 650 LIQUID/WEIGHT MEASURES mg of a medication. The vial contains 325 mg of the drug per 2 ml. How many milliliters should the patient receive? Many medications are supplied in dosages different than the dose ordered. You need to 650 mg is the desired dose be able to compute dosages accurately in order to give medications safely. 325 mg is the dosage the drug comes in.

1. Liquid and Weight Conversion Formula: 2 ml is the vehicle.

Desired Dose X Vehicle = Dosage to be a. 650 mg X 2 ml Dosage on Hand 1 Administered 325 mg 1

Desired Dose: dosage the doctor has ordered. b. 2 (desired dose)

325 ) 650 Dosage on Hand: dosage the drug comes in. 650

0 Vehicle: the means by which the medication is dispensed, could be tablet, capsule, or liquid. c. 2 (desired dose)

X 2 ml (vehicle) 2. Steps in Formula Conversion: 4 ml (dosage to be administered)

a. Convert desired dose and dosage on hand into like terms. COMPUTING DOSAGES BASED ON PATIENT'S WEIGHT b. Divide dosage on hand into desired dose. Some medications are ordered by the patient's body weight in kilograms. Use the c. Multiply desired dose times the following formula when you need to calculate vehicle. doses by body weight.

232 Basic Hospital Corps School Lesson 3.18 Dosage Calculations Handbook III

4. Body Weight Formula: 3. IV Rate Flow Formula: Desired Dose = Drops/Minute = Patient's Weight in Pounds X Dose 2.2 pounds/kilograms 1 kilogram mls given every hr X Drop factor 60 Minutes 1. Steps in Formula: IV tubing comes in many different sizes. a. Convert pounds to kilograms by That is, the internal diameter of the tubing is dividing patient's weight in pounds by larger or smaller, depending on the 2.2 pounds/kilogram. manufacturer. Tubing size affects the number of drops required to make one ml. The b. Multiply the body weight in kilograms manufacturer's drop factor is the number of by the dose/kilogram. drops required to make 1 cc. (1 cc = 1 ml) A drop factor can be found on the IV 2. Example: The medical officer ordered 15 administration set package (IV tubing set.) mg of a medication per kilogram of body Common drop factors are 10, 15, 20, and 60 weight. How many grams will the patient drops per ml. receive if he weighs 176 lbs? 4. Calculate flow rate. a. 176 lbs. 2.2 a. Calculate ml to be given every hour.

b. 2.2) 176.0 b. Multiply ml per hour times drop factor. c. 80 kilograms 22)1760 c. Divide by 60 minutes.

d. 80 (kilograms) 5. Example: The medical officer ordered 15 mg (dose per kilogram) 1000 ml D5W to be infused over 10 hours. 1200 mg or 1.2 grams The manufacturer's drop factor is 20. How many drops per minute will be the IV flow 1200 mg or 1.2 grams is the dosage to be rate? administered. a. 1000 ml D5W every 10 hours = 100 COMPUTING INTRAVENOUS ml/hour. FLOW RATES b. 100 ml X 20 gtts = 2000 gtts Many treatment facilities use infusion hr ml hr pumps to deliver IV fluids accurately. Some situations or locations do not have IV pumps. c. 2000 = 33.3 Corpsmen will calculate IV flow rates 60 manually in those situations. A formula for IV rate calculation follows. Or 33 gtts/minute.

233 Lesson 3.18 Dosage Calculations Basic Hospital Corps School Handbook III

WEIGHTS AND MEASURES CONVERSION TABLE

METRIC WEIGHT MEASURE

1 Kilogram (Kg) = 100 grams (Gm) 1 Gram (Gm) 1 Gram (Gm) = .001kilogram (Kg) 1 Gram = 1000 milligrams (mg) 1 Milligram (mg) = .001 gram (Gm) 1 Milligram = 1000 Microgams (mcg) 1 Microgram (Mcg) = .001 Milligram (mg)

METRIC FLUID MEASURE

1 Liter (L) = 1000 milliliters (ml) 1 Milliliter (ml) = .001 liter (L) 1 Milliliter (ml) = 1 cubic centimeter

US LIQUID MEASUREMENTS AND METRIC FLUID MEASURES U.S. Liquid Metric

1 drop (gtt) = .06 milliliter (ml) 15 drops (gtts) = 1 milliliter (ml) 1 teaspoon (tsp) = 4 milliliters (ml) 1 tablespoon (Tbsp) = 15 milliliters (ml) 1 ounce (oz) = 30 milliliters (ml) 1 cup (c) = 240 milliliters (ml) 1 pint = 480 milliliters (ml) 1 quart = 960 milliliters (ml) 4 cups (c) = 960 milliliters (ml)

APOTHECARY WEIGHT TO METRIC SYSTEM

1 grain (gr) = .065 gram = 65 milligrams (sometimes considered to be 60 to 64 milligrams)

WEIGHT CONVERSION

1 kg = 2.2 lbs

234 Basic Hospital Corps School Lesson 3.18 Dosage Calculations Handbook III

NOTES/COMMENTS

235 Lesson 3.18 Dosage Calculation Basic Hospital Corps School Worksheet Handbook III Lesson 3.18

Dosage Calculations Worksheet

1. The Medical Officer ordered 500 mg of a medication. The label indicates 250 mg of the drug per 5 ml. How many milliliters should the patient receive?

2. The Medical Officer ordered the patient to receive 1,000 mg of a medication. Each tablet contains 325 mg. How many tablets should the patient receive?

Doctor's Order Medication Label Reads Needed

3. Surfak 240 mg P.O. Surfak 120 mg/tablet ______Tablets

4. Alupent 50 mg P.O. Alupent 10 mg/tablets ______Tablets

5. Robitussin 100 mg P.O. Robitussin 50 mg/Tbsp. ______ml

6. Tylenol Elixir 25 mg P.O. Tylenol Elixir 5 mg/gtt ______gtts

7. Insulin 50 units SC Insulin 100 units/ml ______ml

8. Convert the following patient weights from pounds to kilograms:

a. 110 lbs = ______kg

b. 198 lbs = ______kg

c. 143 lbs = ______Kg

9. The doctor ordered 25 mg of a medication per kilogram of body weight. The medication comes 250 mg/tablet. How many tablets should a 154 lbs patient receive? ______Tablets

10. The doctor ordered 10 mg of a medication per kilogram of body weight. The patient weighs 242 lbs. How many grams of medication should the patient receive? ______Grams

11. The Medical Officer ordered 5 mg of a medication per kilogram of body weight. The medication comes 10 mg/gtt. How many drops should a 22 lbs child receive? ______Drops

12. The Medical Officer ordered 20 mg of a medication per kilogram of body weight. The medication comes 200 mg/ml. How many milliliters should a 187 lbs patient receive? ______ml

236 Basic Hospital Corps School Lesson 3.18 Dosage Calculation Handbook III Worksheet

SOLUTION INFUSING TIME DROP FACTOR DROPS/MINUTE

13. 1,000 ml D5W 10 hrs 15 ______

14. 1,000 ml D5NS 8 hrs 20 ______

15. 1,000 ml RL 6 hrs 10 ______

16. 1,000 ml D5 1/2NS 5 hrs 15 ______

17. 1,000 ml NS 4 hrs 10 ______

18. 1,000 ml D5W 13.3 hrs 20 ______

19. 500 ml D5NS 4 hrs 15 ______

20. Convert the following patient weights from pounds to kilograms:

a. 220 lbs = ______kg

b. 176 lbs = ______kg

c. 66 lbs = ______kg

d. 150 lbs = ______kg

e. 264 lbs = ______kg

f. 198 lbs= ______kg

21. The Medical Officer ordered 15 mg of a medication per kilogram of weight. The medication comes 300 mg/tablet. How many tablets should a 176 pound patient receive? ______Tablets.

22. A doctor ordered 50 mg of a drug per kilogram body weight. How many milligrams should a 198 pound patient receive? ______mg

23. The doctor ordered 50 mg of Ampicillin per kilogram of body weight. Ampicillin comes 250 mg/5 cc. How many cc's should a 44 pound child receive? ______cc

24. The doctor ordered 50 mg of a drug per kilogram of body weight. How many grams of the medication should a 220 pound patient receive? ______Gm

25. The doctor ordered 10 mg of a drug per kilogram of body weight. How many milligrams should a 110 pound patient receive? ______mg

26. The Medical Officer ordered 50 mg of a medication per kilogram of body weight. Medication on hand comes 1000 mg/tablet. How many tablets should a 242 pound patient receive? ______Tablets

27. A 65 kg patient weights______lbs.

237 Lesson 3.18 Dosage Calculation Basic Hospital Corps School Worksheet Handbook III

MAR Says Medication Label Says Needed

28. Erythromycin 500 mg PO Erythromycin 250 mg/tab ______Tablets

29. Oretic 50 mg PO Oretic 25 mg/tab ______Tablets

30. Terbutabline Sulfate 0.25 mg SC Terbutabline Sulfate 1 mg/ml ______ml

31. Thyroid 30 mg PO Thyroid 1/4 gr/tab ______Tablets

32. Inderal 60 mg PO Inderal 20 mg/tab ______Tablets

33. Lasix 120 mg IVP Lasix 10 mg/ml ______ml

34. Polymox Suspension 250 mg PO Polymox Suspension 125 mg/5 cc ______cc

35. Ferrous S04 Drops 24 mg PO Ferrous S04 Drops 4 mg/gtt ______gtt

36. ETH 170 mg PO ETH 85 mg/5ml ______ml

37. Ephedrine75 mg PO Ephedrine 25 mg/cap ______caps

38. Sudafed Syrup 60 mg PO Sudafed Syrup 30 mg/5 cc ______cc

39. Benadryl 100 mg PO Benadryl 25 mg/cap ______caps

40. Digitoxin 0.2 mg PO Digitoxin 0.1 mg/tab ______Tablets

41. Polymox Suspension 375 mg PO Polymox Suspension 125 mg/5 cc ______cc

42. Atarax Syrup 30 mg PO Atarax Syrup 2 mg/ml ______ml

43. Morphine Sulfate 8 mg IM Morphine Sulfate 10 mg/cc ______cc

44. Dilaudid 4 mg PO Dilaudid 1 mg/ml ______ml

45. Pronestyl 500 mg PO Pronestyl 250 mg/cap ______caps

46. Procainammide 500 mg PO Procainamide250 mg/cap ______caps

47. Dalmane 30 mg PO Dalmane 15 mg/cap ______caps

238 Basic Hospital Corps School Lesson 3.18 Dosage Calculation Handbook III Worksheet

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239 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Handbook III Lesson 3.19

Oral Medication Administration

Terminal Objective:

3.19 Prepare and administer oral medications.

Enabling Objectives:

3.19.01 Define the terms for oral medication administration.

3.19.02 List patient safety, privacy, education, and comfort considerations when administering oral medications.

3.19.03 List guidelines for administering oral medications.

3.19.04 List documentation requirements for oral medication administration.

3.19.05 Administer oral medications from floor stock.

3.19.06 Administer oral medications from the unit dose cart.

MEDICATION TERMS Medication Administration Record (MAR) -- form used to schedule and Terminology for medication document drug administration. administration may introduce some terms that are new. Accurate medication administration Floor stock system -- quantity of requires that corpsmen know these terms. The frequently prescribed drugs maintained on the most common route for medication ward. administration is oral. Familiarize yourself with the following terms used when giving Sublingual -- drug administration route oral medications: that involves placing the medication under the tongue. Buccal -- drug administration route that involves placing the medication in the mouth Suspension -- mixture of undissolved against the mucous membranes on the inside particles in a liquid. of the cheek. Unit Dose System -- 24-hour supply of a Oral medications -- drugs that are either medication, with each dose labeled and swallowed, or instilled through a tube leading packaged separately from the others. to the stomach. Meniscus -- crescent shaped structure appearing at the surface of a liquid.

Enteric coating -- covering placed on tablets which delays absorption until the tablet

240 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III has passed through the stomach into the NAVMED 6550/12 for each patient. Any intestine. Used to reduce gastric irritation. discrepancies are noted and reported to the nurse. Completeness of the medication order is checked before any drugs are given. EDUCATION, PRIVACY, SAFETY, AND COMFORT Ensure aseptic technique is used when administering medications. Wash your hands Explain the procedure to the patient, name before beginning. Do not touch tablets or the medication, ask if they have taken the capsules, pour them into a medication cup. medication previously and explain the purpose of this medication. Provide for the patient's Before giving any drug, perform three privacy. Ask the patient if he or she has any medication checks. Using the phrase “I allergies. Ensure safety and comfort by seeing need...” (to indicate the dose you want to that the bed wheels are locked and that the bed give), “I have...” ( to show the actual dose you rail is up on the opposite side of the bed. are holding), compare the information on the Position the patient in Fowler's position (for medication label to the MAR. Look to be sure comfort) unless contraindicated. Give the that the name of the medication, the dose of medication to the patient along with a glass of the medication, the route for administration, water. Stay with the patient during medication and the expiration date of the medication label administration. Be sure the medicine has been match the information on the MAR. These swallowed. Observe for initial reactions to the checks further ensure that the correct drug is medication. Discard the medicine cup, if used. being given. Check on the patient in 15-30 minutes for delayed adverse reactions. Some medications are stored on the ward if they are used frequently. This is known as In order to safely administer a medication, Floor Stock. follow the Five Rights of drug administration. All patients must get the 1) right drug, in the When administering medications from 2) right dose, by the 3) right route, at the 4) floor stock perform the three medication right time, making sure that you have the, 5) checks. The first check is done as you locate right patient. the medication on the shelf in the medication cabinet. A second check is done as you Perform patient identification checks using the remove the mediation from the shelf. The MAR: compare name on MAR to bed tag, ID third check is performed when you return the bracelet, and the patient's stated name. medication to the shelf.

Maintain the patient's privacy by pulling The Unit Dose System uses two medication the curtain or closing the room door. Provide checks for pre-prepared medications. (In the for the patient's comfort by positioning the unit dose system, one check has been done by patient in the Fowler's position. If the pharmacy, so you will perform two contraindicated, turn patient into side. checks.)

GUIDELINES FOR Perform the first medication check by comparing the MAR and the medicine for the ADMINISTERING ORAL name of the medication, dosage, route of MEDICATIONS administration, and the expiration.

At the beginning of each shift the Prepare the medication after medication corpsman will compare the calculating the dosage necessary, then perform Medication Administration Record (MAR) the second medication check by comparing NAVMED 6550/8 with the Patient Profile the MAR and the medication for the name of

241 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Handbook III the medication, dosage, route, and time of Provide fresh water or juice to take with the administration. medication. Fluids increase the rate of decomposition of tablets and absorption of the When pouring a liquid medication from medication. floor stock use these steps: Do not touch pills or capsules during a. Do not shake medication because it may administration. (Occasionally, tablets may cause air bubbles that will interfere with need to be divided to give a dose. This is an accurate measurement exception to the rule.)

b. Agitate medication of there is any Do not rush the patient. precipitate Always supervise each patient during c. After removing cap, place on counter rim medication administration. Never leave any up to prevent contamination medication at the patient's bedside or on the food tray to be taken later. For example, don't d. Hold bottle with palm covering label to leave AC, PC, or sleeping medication for the minimize soiling label patient to take later. The patients may forget to

take the medication, it may be accidentally e. Place calibrated medication cup at eye sent back to the kitchen on the food tray, the level on a flat surface patient may hoard or discard the medication, f. If too much medication is poured, obtain or the medication may be stolen. a second cup and pour the correct amount from the first cup into the second cup. Place a recumbent patient in a supported Discard first cup with excess medication position if possible. If not possible, turn the patient on his/her side. g. When measuring liquid medications there will be a meniscus. Use the lowest point of If the patient feels nauseated, withhold the curvature to indicate the liquid level. medication and report the nausea to the nurse. The patient may need to receive the h. Clean top and sides of bottle screw medication by another route. threads with a paper wipe before replacing cap. If a patient vomits within half an hour after taking a medication, notify the nurse. A If the medication is ordered to be decision will be made whether the dose should administered by droplets, use these be repeated. techniques: Enteric coated tablets delay decomposition a. Count drops aloud when using a dropper of the drug until it reaches the intestines. To prevent a change in the absorption of enteric- b. If dropper is curved hold it at a 45-degree coated tablets, do not give these pills with angle milk or antacids and do not crush them.

c. If the dropper is straight, hold it at a 90- Never substitute a syrup or liquid form of a degree angle medication for a tablet or capsule without a Doctor's Order. Liquid is more completely d. Do not turn the dropper upside down. absorbed, so the dose may need to be adjusted. Medication may flow into the bulb. (Syrups are often used instead of tablets or capsules for disoriented patients, children, the e. Do not use the last drop in a dropper. It elderly or anyone who has difficulty may contain air. swallowing.)

242 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III

RECORDING MEDICATIONS When administering cough syrups with other medications, cough syrups should be Record the medication on the MAR. given last. Check that the MAR is stamped with the patient's correct addressograph plate. Record a Never give liquid medications to an drug only when you have administered the unconscious, sleeping, or sedated patient. medication. Document administration while still at the patient's bedside. Do not forcefully administer any medication. Notify the nurse if the patient Locate the medication on the MAR. refuses a medication. Routine medications are on the front of the MAR, single orders, pre-op medications and Do not give medications that have been stat medication are on back, top portion of the prepared by another patient. EVER! MAR. PRN medications are on the bottom portion of the MAR. Allow time to assist patients who require help with taking medications. Compare the unit dose package to the MAR for name of the medication, dosage, Omit giving a drug if the patient has route, time and date of administration. Record symptoms suggesting an undesirable reaction by entering your initials in the appropriate to a previous administration of the drug. (For square for date and hour square for routine example, a patient who has received a narcotic medications. Enter the date, time and initials and is hard to wake.) in the appropriate horizontal line for single order and pre-operative medications. For PRN, Do not give a medication that the patient variable dose medications enter date, time, says is different than what he/she has been dose and initials vertically in the appropriate receiving. Be sure that a mistake has not been column. made. Enter your initials, full signature and rate Check the patient in 30 minutes for in the initial code section at the bottom of the desired and undesired effects. MAR. This matches the person who has given a PRN medication with their initials in the Unpleasant tasting medications may be PRN box used. disguised by following them with an orange slice, fruit juice, candy or sugarless gum. A Nursing Notes entry is required when Dilute distasteful medication in fruit juice or administering a PRN medication, a single dose chocolate milk. Ensure that any substance order, a Pre-op medication or a stat used is not contraindicated by the patient's medication. The note should include the time condition or diet. and date, route, medication and dosage, reason for giving the medication, patient's response, Large tablets can be crushed and mixed adverse reactions (if any), your signature and with liquids (ice cream, applesauce, etc.), rate. except enteric coated tablets.

243 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Handbook III

FIGURE 3.19.01 Floor Stock Liquid Medication with its Cap (Rim Up)

FIGURE 3.19.02 Placing Drops in Medication Cup a. Curved Dropper b. Straight Dropper

244 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III

245 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Worksheet Handbook III Lesson 3.19

Oral Medication Administration Worksheet

1. When assigned to administer medications, which two records should be compared at the beginning of each shift?

a. MAR to Nursing Notes

b. MAR to Patient Profile

c. Patient Profile to Nursing Notes

d. MAR to Doctor's Orders

2. When using the unit dose system, what is used as a reference to perform the patient identification check?

a. MAR

b. Medication card

c. Patient Profile

d. Patient chart

3. When is the medication administration recorded on the MAR with the unit dose system?

a. While at the bedside, prior to passing the medication

b. While at the bedside, after the patient has taken the medication

c. At the nurse's station, prior to administering the medication

d. At the nurse's station, after administering the medication

246 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III Worksheet

4. How many medication checks are there when using the unit dose system?

a. 1

b. 2

c. 3

d. 4

5. When using the unit dose cart, when are medication dosages calculated?

a. Before doing any medication checks

b. After the medication second check

c. Before the second check

d. Before the medication third check

6. When using a unit dose cart, the second medication check should include:

a. name of medication.

b. dosage of medication.

c. route of medication.

d. all of the above.

7. A liquid form of a medication may be substituted for a tablet if the patient requests it.

a. True b. False

8. How many medication checks are performed when working with the floor stock medication system?

a. 1

b. 2

c. 3

d. 4

247 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Worksheet Handbook III

9. When using floor stock, the first medication check is done:

a. at the patient's bedside.

b. before removing the medication from the shelf.

c. before unlocking the medication cabinet.

d. for all medications at the beginning of each shift.

10. The first medication check includes:

a. ______

b. ______

c. ______

d. ______

11. After removing a medication bottle cap, place it on the counter top with the rim up.

a. True b. False

12. Liquids should be poured at waist level.

a. True b. False

13. If too much liquid medication is poured, what is done with the excess?

a. Give it to the patient

b. Pour it back in the bottle

c. Discard it

d. Send it to the pharmacy

14. When medication is measured with a dropper, ensure the last drop is counted for accurate measurement.

a. True b. False

248 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III Worksheet

15. A curved dropper should be held at a ______degree angle when counting drops.

a. 30

b. 45

c. 75

d. 90

16. List the three items checked when performing a patient identification check.

a. ______

b. ______

c. ______

17. When giving oral medications, patient safety and comfort include:

a. locking bed wheels.

b. warming medications to room temperature.

c. putting the patient in Sim's position.

d. using restraints PRN.

18. When administering capsules or tablets, a glass of water should be provided for the patient.

a. True b. False

19. Once medication is delivered to the patient, immediately move to the next patient so all medications are administered on time.

a. True b. False

249 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Worksheet Handbook III

20. When are floor stock medications recorded?

a. After each patient receives his/her medication, at the bedside

b. At the beginning of each shift, after checking all MARs

c. After all medications have been administered for the specific time

d. Just before giving a medication, at the patient's bedside

21. Routine medications are recorded on the ______side of the MAR.

22. When PRN medications are recorded on the MAR, you include:

a. name of medication, dose, and time.

b. name of medication, time, and your initials.

c. date, time, and your initials.

d. date, time, dose, and your initials.

23. Enteric tablets can be crushed to make swallowing easier.

a. True b. False

24. Unpleasant tasting medications may be disguised with an orange slice.

a. True b. False

25. When administering medications, encourage the patients to hurry so everyone can get their medication on time.

a. True b. False

26. Medication should not be left at the bedside or on food tray to be taken later.

a. True b. False

250 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III Worksheet

27. If a patient feels he/she may vomit:

a. withhold the medication and notify the nurse.

b. give the medication and notify the nurse.

c. give a liquid form of the medication.

d. stand to one side when giving the medication

28. If a patient has difficulty swallowing a large tablet, it can be crushed and mixed with applesauce or ice cream.

a. True b. False

29. Medications that are ordered to be taken after meals should be placed on the patient's food tray to remind him/her to take the medication.

a. True b. False

251 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Worksheet Handbook III

252 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III Worksheet

253 Lesson 3.19 Oral Medication Administration Basic Hospital Corps School Worksheet Handbook III

254 Basic Hospital Corps School Lesson 3.19 Oral Medication Administration Handbook III Worksheet

255 Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School Handbook III Lesson 3.17

Storage of Medications

Terminal Objective:

3.17 List the storage requirements for medications.

Enabling Objectives:

3.17.01 State the characteristics of the floor stock system.

3.17.02 State the characteristics of the unit dose system.

3.17.03 State the characteristics of the narcotic locker.

3.17.04 List the security measures to be taken for ward medications and the narcotic locker and its contents.

3.17.05 List the characteristics of the emergency cart/box.

FLOOR STOCK SYSTEM nitroglycerin, are removed from floor stock system and stored at the patient's bedside for The Floor Stock System is a drug system easy access and to prevent cross in which bulk orders of drugs are supplied to contamination. the ward. Individual doses of medications are prepared from the bulk supplies by the ward Medications may be stored in a personnel. A locked medicine cabinet is used refrigerator to maintain potency. Some to ensure secure storage of the bulk supplies. medications are affected by heat and The keys are kept by the medication decompose or spoil unless they are kept cool. corpsman. The medicine cabinet contains Vaccines, insulin, some antibiotics internal and external medications that are (Augmentin or Ampicillin in liquid form) and shelved by type (liquid, pills, and drops) and some reconstituted medications (such as arranged in alphabetical order. External steroids) are routinely stored in a refrigerator. medications, such as ointments and lotions, Other medications are effected by heat and are stored separately from internal will melt at room temperature (such as medications. This cabinet is kept locked at all suppositories.) Refrigeration maintains them times when not in use. in a solid form. Some medications are more palatable when cold, including Maalox Supplies to prepare/dispense medications Mylanta, Magnesium Citrate and Glucola Use are also kept on the medication cabinet, e.g., this refrigerator ONLY for medications. All medicine cups, needles and syringes, tongue other materials, e.g., food, batteries, must be blades, a water pitcher, water cups, a blade for stored elsewhere. scored tablets, a mortar and pestle, juices and straws. Needles and syringes are stored in a locked drawer in the cabinet. Some medications, e.g., eye drops, eardrops, and

256 Basic Hospital Corps School Lesson 3.17 Storage of Medication Worksheet Handbook III

UNIT DOSE SYSTEM administration. If a narcotic is accidentally contaminated, it must be accounted for in the The Unit Dose System employs pharmacy narcotic log. Usually two nurses record control over individual doses of drugs for each contamination and disposal of the narcotic. patient. A unit dose cart with locks is used to Follow local policy. store individual doses until they are dispensed. The cart is taken from room to room when SECURITY MEASURES FOR medications are administered to patients. Each WARD MEDICATIONS patient receiving medications has a separate drawer labeled with his/her patient The medication cart or floor stock cabinet identification. Drawers are arranged must be kept locked at all times, except to numerically in room and bed order. Each remove drugs. The keys must remain in the medication is stored in an individual envelope possession of the medication corpsman or (or wrapper.) The drawers may be divided to medication nurse. Do not leave the keys in the separate medications given on each shift. The locks of the medication cart or floor stock cart is usually stored in a locked or secured cabinet. Keys should never be passed to area when not in use. The cart should always another staff member without a legitimate be kept locked when it is not in the sight of the need. medication corpsman. EMERGENCY CART OR BOX NARCOTIC LOCKER The emergency cart or box is portable, The narcotic locker is a double locked sealed cart or small hand carried box drawer, box, cupboard or room. This locker containing emergency drugs. The emergency contains federally controlled drugs such as cart should be readily accessible. Inventory narcotics, hypnotics, and alcoholic beverages. checks are performed at regular intervals to ensure a complete inventory of supplies and The narcotic locker must be double locked medications. Between inventory checks, a at all times when not in use. The keys are held breakable seal secures the container. If the seal by a Nurse Corps Officer or other R.N. is broken, the cart is checked and restocked by Federal law prescribes that a registered nurse the pharmacy. or qualified personnel administer narcotics. Local policy will designate individuals allowed to administer narcotics. A narcotic logbook is maintained to record each narcotic

257 Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School Handbook III Lesson 3.17

Storage of Medications Worksheet

1. Circle each statement that describes the floor stock medication system.

a. The cabinet is locked when it contains narcotics.

b. The medications are arranged according to patients' preference.

c. Medications are shelved by size.

d. Medications are placed in alphabetical order.

2. In the floor stock system, individual doses of medications are prepared from bulk supplies by pharmacy personnel.

a. True b. False

3. Which medication storage system provides bulk drugs for ward supply?

a. Unit Dose

b. Narcotic locker

c. Floor stock

d. Emergency box

4. The medicine cabinet does not contain:

a. internal medications.

b. external medications.

c. medication cart keys.

d. supplies needed to prepare and dispense medications.

5. The medication keys always remain in the custody of the nurse.

a. True b. False

6. The unit dose cart must remain in a secured area when not in use.

a. True b. False

258 Basic Hospital Corps School Lesson 3.17 Storage of Medications Worksheet Handbook III

7. The cassette drawer of the unit dose cart for each patient is labeled with:

a. times each medication will be given.

b. patient's age.

c. patient identification.

d. a list of all medication it contains.

8. Circle each statement that describes the unit dose medication system.

a. The drawers may be divided to separate drugs for different shifts.

b. The drawers are arranged alphabetically according to patient's names.

c. The cart is locked at night and on weekends.

d. Medications in drawers are placed in alphabetical order.

9. In the unit dose system individual doses of medications are prepared from bulk supplies by the pharmacy personnel.

a. True b. False

10. Which medication storage system utilizes pharmacy control?

a. Unit dose

b. Narcotic locker

c. Floor stock

d. Emergency box

11. Which of the following medications are kept in the narcotic locker?

a. Antibiotics

b. Hypnotics

c. Cardiotonics

d. Insulin

12. According to federal regulations, a narcotic locker must have two locks.

a. True b. False

259 Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School Handbook III

13. Narcotic locker keys are the responsibility of a nurse.

a. True b. False

14. Federal law prescribes that only a registered nurse may administer narcotics.

a. True b. False

15. List three purposes for storing medications in a refrigerator. a. ______b. ______c. ______

16. Inventory checks are completed at regular intervals by pharmacy personnel to ensure completeness of the emergency cart

a. True b. False

260 Basic Hospital Corps School Lesson 3.17 Storage of Medications Worksheet Handbook III

NOTES/COMMENTS

261 Lesson 3.20 Sublingual, Topical, and Rectal Basic Hospital Corps School Medication Administration Handbook III Lesson 3.20

Sublingual, Topical, and Rectal Medication Administration

Terminal Objective:

3.20 List concepts and principles of administering sublingual, topical, and rectal medications.

Enabling Objectives:

3.20.01 Define terms related to medication administration.

3.20.02 List patient safety, privacy, education, and comfort considerations when administering medications.

3.20.03 List the procedure for administering sublingual medications.

3.20.04 List the procedure for administering topical medications.

3.20.05 List the procedure for administering rectal medications.

3.20.06 List the procedure for documenting the administration of medications.

Non-parenteral medications are those enzymes. The most common drug that are given by routes other than by injection administered by this method is Glyceryl (intravenous, intramuscular, or subcutaneous). Trinitrate, also known as Nitroglycerin. The Medications given by mouth are the most effects of medications administered common group of non-parenteral medication. sublingually are usually felt in one to five The other routes of medication administration, minutes. Patients are not allowed to eat, chew, sublingual, topical, and rectal, will be drink, or smoke until the medication is discussed in this lesson. dissolved and absorbed.

Sublingual route -- placing the Topical route -- placing the medication medication under the tongue. The medication on the skin or mucous membranes. Topical will be absorbed through the blood vessels medications can have a local and/or a systemic under the tongue. effect, however, most are given for direct effect on the tissue to which the medication is The sublingual route uses the thin applied. Ointments, lotions, oils, creams, and epithelium and the rich network of capillaries solutions are examples of topical medications. on the underside of the tongue to gain rapid absorption and drug action. Drugs absorbed Rectal route -- insertion of medication from the sublingual route have increased into the rectum. These medications are used potency since they enter the bloodstream primarily for their local effect(s) and include directly without being metabolized by the liver suppositories, creams, and solutions (enemas). or being affected by gastric and intestinal Rectal medications are used as an alternative

262 Basic Hospital Corps School Lesson 3.20 Sublingual, Topical, and Rectal Handbook III Medication Administration to the intramuscular and intravenous routes. ADMINISTERING SUBLINGUAL Due to an abundant surface blood supply, this MEDICATION route is particularly useful for children with fever or patients with nausea or vomiting. Preparation of sublingual medication is done essentially the same as oral medication A suppository is an oval or cone shaped using the unit dose or floor stock system. solid substance designed for easy insertion When administering a sublingual medication into a body cavity. A suppository is designed you must have the patient's cooperation. to melt a body temperature. The most common He/she must be conscious and able to indication for use is to promote the expulsion understand instructions. Never give sublingual of feces and flatus. medications to an unconscious patient. Help the patient into a sitting position (unless An enema is the introduction of a contraindicated) and instruct the patient to solution into the large intestines. The most place the medication under the tongue. The common type is a cleansing enema that is used patient should not eat, chew, or smoke until to empty feces from the lower intestinal tract. the medication is dissolved and absorbed. An enema may also be used to relieve Remain with the patient, watching for possible distention, for destruction of internal parasites, side effects, until the medication is absorbed. or to supply the body with fluids or nutrients. APPLYING TOPICAL PATIENT PRIVACY, SAFETY, MEDICATION TO THE SKIN EDUCATION, AND COMFORT Wash your hands and don clean gloves to Patient care, always involves education, prevent absorption through your skin.. Cleanse privacy, safety, and comfort. A full the patients skin prior to application of a explanation of what is going to happen and topical medication. why the procedure is necessary will help you obtain cooperation and ensure proper Topical medications are applied and administration of the medication. Patients absorbed through the skin in two ways. Oils, should know the purpose of the medication lotions, and ointments, are rubbed into the and the potential side effects. Always close the skin. This procedure is called inunction. door and/or pull the curtains around the patient's bed for privacy. Expose only the Transdermal topical medications are areas necessary for the procedure. Remember applied via a patch and are absorbed through to lock the bed wheels and to raise the the hair follicles and sweat glands. Place the opposite side rail to ensure the safety of the patch on a non-hairy skin surface. The two patient. Prior to administering any medication, best locations are on the chest wall or the ask if the patient has any allergies. Proper upper arm of the patient. Since transdermal patient positioning will assist in accomplishing patches stay on the skin for extended periods the procedure. For your (and the patient's) of time, rotate application sites to avoid skin comfort and safety raise the bed to a irritation. After administering the medication comfortable working level. remove your gloves and wash your hands.

Refer to Oral Medications lesson for APPLYING TOPICAL detailed instructions regarding medication administration. The five drug rights and MEDICATION TO THE EYES identification checks for patients apply to all medication administration. Wash your hands. Cleanse the patients eyelid and lashes from inner to outer canthus using normal saline (NS) or water. Place the patient in a supine or sitting position with the

263 Lesson 3.20 Sublingual, Topical, and Rectal Basic Hospital Corps School Medication Administration Handbook III head tilted back and to the side on which contraindicated have the patient blow his/her administration will take place. Have the nose before administering the medication. patient look away from you when the solution Instruct the patient to breathe through his/her is administered so it will not enter the tear mouth during administration of the duct. Place a thumb or two fingers below the medication. Draw enough solution into the margin of the eyelashes under the lower lid dropper for both nares. Do not return unused and gently pull the lower lid down exposing solution to the bottle to avoid contamination of the conjunctiva. Tell the patient to look up the remaining solution. Instill the correct during administration of the medication. Instill number of drops by holding the dropper drops into the center of the lower conjunctiva. slightly above the nostril then carefully Instill ointment by applying a ribbon of inserting the tip of the dropper into the nares. medication from the inner to the outer canthus Instruct patient to remain in position and not of the lower eyelid. Do not allow the to blow nose for five minutes. Wash your applicator to touch the eye at any time during hands. administration of medication. If both drops and ointment are ordered, instill drops first ADMINISTERING and ointment last. SUPPOSITORIES

Following instillation, instruct the patient Wash your hands and don clean gloves. to gently close both eyes and move the eyes Position the patient in the left Sim's position around. Instruct the patient not to rub his/her exposing only the buttocks. Remove the eyes. Wipe or sponge any excess medication wrapper and lubricate the suppository and from the patient's skin and wash your hands. your gloved finger. Separate the buttocks so the anus is in plain view. Instruct the patient to APPLYING TOPICAL take deep breaths to help relax the anal MEDICATION TO THE EARS sphincters. Insert the suppository beyond the internal sphincter, about a finger length. The Wash your hands and position patient with suppository should be in contact with the the affected ear up. Straighten the auditory mucous membrane and should not be canal of an adult patient by gently pulling the embedded in stool. Instruct the patient to ear up and back. Straighten the auditory canal retain the suppository until he/she has the urge of a child patient by gently pulling the ear to defecate, normally 15 to 45 minutes. down and back. Instill the correct number of Remove your gloves and wash your hands. drops by directing the medication along the side of the ear canal, not directly on the ADMINISTERING ENEMAS eardrum. If ordered, place cotton loosely in the ear and instruct patient to remain in position The most common solutions for enemas for five minutes. Wash your hands. are soap and water, normal saline, and a highly concentrated hypertonic solution. A Eye and ear instillation should be done hypertonic solution is commonly used to with the medication at room temperature to cleanse the lower intestinal tract for several avoid discomfort to the patient. Never return reasons. Hypertonic solution draws fluid from unused medication to the bottle, to prevent body tissues into the bowel, so only a small contamination of the remaining solution. amount of solution is needed (120 ml). These solutions are available in commercially APPLYING TOPICAL prepared, disposable containers. Hypertonic MEDICATION TO THE NOSE solutions minimize patient distress and fatigue. Patients can easily self-administer Wash your hands and position patient with hypertonic enemas. his/her head tilted backwards. Unless

264 Basic Hospital Corps School Lesson 3.20 Sublingual, Topical, and Rectal Handbook III Medication Administration

Wash your hands and don clean gloves. RECORDING THE Position the patient in a knee-chest position, if ADMINISTRATION OF not contraindicated. Otherwise position the MEDICATIONS patient lying in bed on his/her back or on either side. Insert the prelubricated tip Medication administration is recorded completely within the rectum. While applying after the medication has been administered. gentle, steady pressure on the solution Routine medications are recorded on the front container, instill the solution. Instillation of the Medication Administration Record should take one to two minutes, with results (MAR). On the back, top portion of the MAR, expected in two to eight minutes. Remove the record single order, pre-op, and STAT gloves and wash your hands. medications. On the back, bottom portion of

the MAR, record PRN medications. A Nursing Note is required for single order, pre-op, STAT, and PRN medications.

265 Lesson 3.20 Sublingual, Topical and Rectal Basic Hospital Corps School Medication Administration Worksheet Handbook III Lesson 3.20

Sublingual, Topical, and Rectal Medication Administration Worksheet

1. Match each definition in column B with the correct term in column A.

A B

a. Sublingual Route ______1. An oval or cone shaped solid substance that melts at body temperature.

b. Topical Route ______2. Medication placed on the skin or mucous membrane

c. Rectal Route ______3. Introduction of a solution into large intestines.

d. Suppository ______4. Medication is placed under the tongue.

e. Enema ______5. Insertion of medication into rectum.

2. Circle each method for providing patient privacy.

a. Close the door to the patient's room.

b. Pull the curtain around the bed.

c. Expose only the area necessary.

3. Sublingual medications are administered:

a. orally.

b. intramuscularly.

c. subcutaneously.

d. by placing medication under the patient's tongue.

4. The epithelium and the rich network of capillaries of the underside of the tongue provide ______absorption of drugs and ______drug action.

266 Basic Hospital Corps School Lesson 3.20 Sublingual, Topical and Rectal Handbook III Medication Administration Worksheet

5. Sublingual medication gain access to the general circulation:

a. by going through the liver.

b. after being affected by gastric and intestinal enzymes.

c. by direct absorption of the drug.

d. after being absorbed by the muscles.

6. Circle each reason medication may be administered sublingually.

a. The medication gains access to general circulation without going through the liver or intestines

b. The medication is absorbed through the thin epithelium and the rich network of capillaries on the underside of the tongue.

c. The medication is rapidly absorbed.

d. The medication increases potency by interaction with gastric and intestinal enzymes.

7. For the administration of sublingual medications the patient should be placed in the ______position.

8. Sublingual medication should not be administered to ______patients.

9. Water should be offered to the patient after administration of a sublingual medication to help with swallowing.

a. True b. False

10. List the ways topical medications are absorbed through the skin.

a. ______

b. ______

11. Transdermal absorption means absorption:

a. through hair follicles and sweat glands.

b. through the skin glands.

c. by inunction.

d. through mucus membranes

267 Lesson 3.20 Sublingual, Topical and Rectal Basic Hospital Corps School Medication Administration Worksheet Handbook III

12. The best patient position for instillation of eye drops is:

a. supine with the patient's head tilted back.

b. prone with the head looking toward the floor.

c. head back, looking away from the person administering medication.

d. patient on his/her side, head looking toward the ceiling.

13. Eye drops or ointments are instilled into the ______of the lower conjunctival sac.

14. How do you straighten the auditory canal for an adult? ______

15. When instilling topical medications to the ear the patient should be positioned with the

______

16. Eardrops should be placed directly on the eardrum.

a. True b. False

17. Eardrops are administered at room temperature to:

a. avoid discomfort to the patient.

b. ensure maximum effectiveness of the medication.

c. promote ease of administration.

d. to avoid damage to the medication with temperature changes.

18. When instilling topical medications to the nose, position the patient:

a. with head tilted forward and to the side.

b. with head tilted backwards.

c. supine, looking at the feet.

d. with head tilted backwards and to the side.

19. After instillation of nose drops, the patient should remain in position for 10 minutes.

a. True b. False

20. When administering suppositories how is the patient positioned?

______

268 Basic Hospital Corps School Lesson 3.20 Sublingual, Topical and Rectal Handbook III Medication Administration Worksheet

21. A suppository is inserted:

a. about two inches.

b. to the internal sphincter.

c. three to five inches.

d. beyond the internal sphincter, about a finger length.

22. After insertion of a suppository, instruct the patient to retain it for 15 to 45 minutes.

a. True b. False

269 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III Lesson 3.21

Intramuscular and Subcutaneous Medication Administration

Terminal Objective:

3.21 Administer medications using the intramuscular and subcutaneous routes.

Enabling Objectives:

3.21.01 List equipment for administering medications using the intramuscular and subcutaneous routes.

3.21.02 List common intramuscular and subcutaneous injection sites.

3.21.03 List basic concepts and guidelines for administering medications using the intramuscular and subcutaneous routes.

3.21.04 List documentation requirements for administering medications using the intramuscular and subcutaneous routes.

3.21.05 Prepare and administer a medication using the intramuscular route.

3.21.06 Prepare and administer a medication using the subcutaneous route.

The term parenteral refers to all routes of prepared and given using principles of surgical medication administration except oral. asepsis. Using sterile technique minimizes the However, parenteral is used most commonly danger of injecting pathogens into the patient. to indicate intravenous and injection routes. Drugs injected intramuscularly or EQUIPMENT subcutaneously are absorbed from the injection site into the blood capillaries and the Parenteral medications are usually lymphatic system. Absorption from an administered by needles and syringes. Both injection is more rapid and complete than are available in various sizes and each has absorption from the gastrointestinal tract individual parts that must always remain because destruction and inactivation of drugs sterile and other parts that may be touched. by digestive juices is avoided. The effects of medications administered by injection are A needle consists of the: shaft, hub, prompt and predictable, and a more accurate lumen, hilt, bevel, and needle guard, Figure dosage can be attained. However, injury to the 3.21.01. The shaft is the long, cylindrical patient and complications may arise due to hollow tube. This portion is usually made of faulty injection technique. Drugs that are stainless steel and must remain sterile. The administered by parenteral methods must be hollow inside diameter of the shaft is called

270 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration the lumen. The hub is the wide base portion liquid must be added to reconstitute the of the needle that fits over the syringe tip. This medication before use. Air equal to the area is frequently plastic and is color-coded amount of medication to be withdrawn must with the specific gauge size of the needle. The be injected into a vial before withdrawing the hilt is the junction between the hub and shaft, drug. An ampule is a sealed glass container and must remain sterile. The bevel is the that must be broken in order to withdraw the distal, tapered open end of the shaft that must liquid medication. Any unused medication in remain sterile. For subcutaneous injections, an ampule must be discarded after the dosage the position for insertion is bevel up. In this is withdrawn. position, the sharpened or pointed end of the bevel enters the skin first, which will create an A prefilled medication cartridge is a incision, making it possible for the rest of the commercially prepared single dose medication needle to enter the body tissue. The final part that has a needle permanently attached to a is the needle guard. This is a cap that protects calibrated barrel. There is no plunger, so a the needle and helps maintain sterility. cartridge holder is used to administer the medication. A cartridge holder is a reusable Needles are available in different lengths metal or plastic holder that fits the prefilled and gauges. The gauge is the diameter of the medication cartridge. needle lumen. The size of the needle to be used will depend upon the tissue of the Additional equipment needed to injection site. Needle length can vary from 1/2 administer an injection includes: antiseptic to 2 1/2 inches, Figure 3.21.02. swabs, sterile gauze pads, clean gloves, and Band-Aids. The syringe is a graduated tubular outer portion (the barrel) and a solid inner portion SITE SELECTION (the plunger). The barrel is hollow. The outer wall of the barrel has a scale calibrated in cc's Selecting the appropriate site for or minims and cc's. (CAUTION: Ensure cc's subcutaneous and intramuscular injections are used to prevent medication error.) The ensures that the medication solution will be outer portion of the syringe wall is unsterile most readily absorbed by the body and also and will be handled when administering and ensures the safety of the patient. preparing the medication. At the end of the barrel is the tip. The tip is the small end that An intramuscular (IM) injection is the fits into the needle hub when assembling the administration of a solution containing needle and syringe together. The final part of medication into a muscle or muscle group. the syringe is the plunger that is the inner Deep muscles contain very few nerve endings, movable section. On its end, is the knob. The so irritating drugs are commonly given by knob is the only part of the plunger which can intramuscular injection. Medication injected be touched in order to maintain sterility, intramuscularly is absorbed more rapidly than Figure 3.21.03. Syringes are available in sizes any other route, except intravenously. Various from 1 cc to 50 cc. muscles may be used as IM injection sites. In order to select an injection site, the corpsman Medication may be packaged in a variety must know how to identify certain landmarks of containers. A vial, which is a glass or to avoid injuring large nerves, striking bones, plastic container that has a self-sealing rubber or entering blood vessels. Muscles commonly stopper, may be single dose, containing one used for the intramuscular administration of dose, or multi-dose, containing many doses, medications are located in the upper arm, Figure 3.21.04. A multi-dose container must thigh, and buttock. There are advantages and be dated when opened and may require disadvantages associated with the muscles in refrigeration after opening. Medication may be each of these particular injection sites. premixed or in powder form, which means a

271 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III

A site for an IM injection in the upper arm specifically the anterior and lateral aspect, is the deltoid muscle, Figure 3.21.05. Figure 3.21.11. However, caution must be taken since this is a small and shallow muscle. Only small INJECTION GUIDELINES amounts of medication (1 cc or less) can be injected here. A one-inch or shorter needle There are important factors that affect the must be used to avoid hitting the humerus. Do proper site selection. 1) Amount and type of not use this site for infants or children due to solution. Use large muscles for amounts inadequate muscle development. greater than 2 cc. Type and characteristic of medication is an important consideration. Any Another favored site is the thigh, thick (viscous) or irritating solution should be particularly the vastus lateralis muscle given in a large muscle (avoid the deltoid). 2) located on the lateral thigh. This injection site The general condition of the patient. contains no major nerves or vessels. This site Overall, the patient's general nutritional status is an excellent choice for use in children or will be reflected in the muscular development thin, debilitated adults. The rectus femoris and fatty deposits present. Note any muscle is located on the anterior aspect of the restrictions of movement the patient exhibits. thigh. This site is commonly used in infants Note the general appearance of the injection since it is highly visible and easily located, site. It should be free of skin lesions, Figure 3.21.06. inflammation, rashes, or moles. Try to avoid extremely hairy sites, as this may set up local The dorsogluteal muscle is located on the tissue reactions. 3) Frequency of injections in back of the hip and is the outer aspect of the specific sites indicates the need for rotation of upper outer quadrant, Figure 3.21.07. Proper sites. Signs of irritation (puncture marks, identification of the dorsogluteal site is redness, and swelling) indicate the need for essential to avoid entry into major nerves such rotation of sites. The MAR NAVMED 6550/8 as the sciatic nerve and blood vessels. This has a list of injection site codes to assist the site is commonly used for IM injections health care provider with site selection. This, because it can receive large volumes of fluid along with the corpsman's knowledge of with minimal pain. Do not use for children anatomical location of large nerves and blood under three years old, due to inadequate vessels is imperative to avoid damage to these muscle development. areas.

The final IM site is the ventrogluteal that Be sure to acquire and administer the is located on the side of the hip, just below the correct medication to the correct patient. This iliac crest, Figure 3.21.08. There are no large process starts with verifying the MAR nerves or blood vessels in this area. NAVMED 6550/8 with the Patient Profile NAVMED 6550/12 at the beginning of the A subcutaneous (SC) injection involves shift. If there is a discrepancy, compare the the administration of a medication into the MAR with the original Doctor's Orders SF tissues and blood vessels that lie between the 508 to identify the transcription error. epidermis and the muscle. The medication is absorbed fairly rapidly and begins acting Perform three medication checks to ensure within one-half hour after being administered, the correct dose of the correct medication is figure 3.21.09. prepared. The first medication check is performed when locating the medication in the There are two preferred sites for a drawer or on the shelf. The second subcutaneous injection: the lateral aspect of medication check occurs after the needle and the upper arm, specifically the middle third of syringe are assembled. Next, the medication the arm, Figure 3.21.10 and the abdomen, dose is calculated. The third medication check occurs after the medication has been

272 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration prepared in the syringe. The repetition of the Supporting of the flesh during needle insertion medication checks helps to guard against will also help decrease tissue trauma. When errors. When performing the medication administering an IM injection, spread the checks, verbally state, “I need...” when flesh taut. Use 20-23 gauge needles that are 1- reading the MAR and “I have...” when looking 1 1/2 to 2 inches in length for adults or 1 inch at the vial or syringe. length for children. To administer a SC injection, pinch the flesh into a cushion. Use PATIENT CONSIDERATIONS 23-25 gauge needles that are 1/2 to 5/8 inches in length. The primary considerations include explaining the procedure to the patient and Insert the needle rapidly and without ensuring privacy, safety, and comfort at all hesitation. Always aspirate to avoid times during the procedure. inadvertent injection into a blood vessel. To aspirate: pull back on the plunger of the Always explain the procedure you will be syringe before injecting the solution into the performing and its rationale to the patient prior tissue. While aspirating, observe for blood in to beginning any action. This information will the hub of the needle or tip of the syringe. If eliminate any misunderstandings and will none is present, continue with the injection. If elicit better patient cooperation. blood is present, withdraw the needle, apply direct pressure to injection site, and discard It is important, as well as common the medication. Prepare a new injection and courtesy, to provide for the patient's privacy. select a new injection site. Accomplish this by using bed drapes or screens prior to beginning the procedure. Hold the syringe steady and inject the Ensure safety of the patient by locking the bed drug slowly. Then withdraw the needle rapidly wheels and raising the side rail on the opposite at the same angle as insertion Finally, rotate side so the patient won't fall out of bed. injection sites to diminish tissue trauma of Finally, be certain of the patient's comfort repeated injection in the same site. during the procedure. Position the patient so that the injection can be given safely and as EQUIPMENT DISPOSAL comfortably as possible. After administrating the injection, massage the area to aid To prevent injury, proper disposal of absorption, unless contraindicated. contaminated equipment is essential. NEVER RECAP A USED OR CONTAMINATED INJECTION COMPLICATIONS NEEDLE. The used medication cartridge is disassembled from the cartridge holder and the The corpsman should be constantly on cartridge is discarded in a puncture resistant alert for signs of complications when a patient Sharps container. The cartridge holder is not is receiving medication by means of injection. discarded since it is reusable. If the cartridge The best safeguards against complications are holder becomes soiled, follow the local policy maintaining aseptic technique during for cleaning. The syringe and needle that was preparation and administration and utilizing assembled to administer the SC injection is proper injection technique. Always check discarded together in a puncture resistant equipment (needle and syringe) for possible Sharps container. Never dispose of used contamination and check the medication for injection equipment in the general trash. particles floating in the solution before use.

Tissue trauma can be minimized by selecting the proper injection site as well as the proper needle length and gauge.

273 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III

RECORDING MEDICATION c. Medication refusals are indicated with ADMINISTRATION an asterisk in the medication time/dose box. Administration of all medications is recorded on the MAR NAVMED 6550/8. 5. Enter initials, full signature, and rate in Administration of PRN medications or a Initial Code Box Section if not already refusal of medication are also recorded in the done. Nursing Notes SF 510. Use the following guidelines: 6. Nursing Notes SF 510 entries are also needed for: 1. Ensure MAR is stamped with the patient's correct addressograph. a. Patient refusal of medication.

2. Record only after administration of the b. PRN medications medication. (1) Enter reason for medicating. 3. Locate medication on MAR. (2) Enter administration of 4. Record your initials in appropriate square medication. on MAR (3) Enter effectiveness of medication. a. Utilize an injection site code to help with rotation of sites, located on lower c. Side effects and adverse reactions. right front of MAR. 7. Some medications, such as b. Enter the circled site code number in immunizations, also require a Health initial code square with your initials. Record entry.

274 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration

FIGURE 3.21.01 Parts of a Needle

FIGURE 3.21.02 Needle Gauges

275 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III

FIGURE 3.21.03 Various Size Syringes and Their Parts

FIGURE 3.21.04 Medication Containers A. Ampule B. Vial

276 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration

FIGURE 3.21.05 Intramuscular Injection Site (Deltoid Muscle)

FIGURE 3.21.06 Intramuscular Injection Sites (Vastus Lateralies & Rectus Fermoris)

277 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III

FIGURE 3.21.07 Intramuscular Injection Site (Dorsal Gluteal)

FIGURE 3.21.08 Intramuscular Injection Site (Ventrogluteal)

278 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration

FIGURE 3.21.09 Tissue Penetration

FIGURE 3.21.10 Site of Subcutaneous Injection (Side View)

279 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Handbook III

FIGURE 3.21.11 Subcutaneous Injection Sites (Abdomen)

280 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration

NOTES/COMMENTS

281 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration Worksheet Lesson 3.21

Intramuscular and Subcutaneous Medication Administration Worksheet

1. What is the correct gauge and length needle for an intramuscular injection?

a. 21 gauge, 1 1/2 inch length

b. 22 gauge, 3/4 inch length

c. 23 gauge, 1 1/4 inch length

d. 25 gauge, 1/2 inch length

2. The proper gauge and needle length for a subcutaneous injection is 22 gauge with one-inch length.

a. True b. False

3. Which of the following is not part of a needle?

a. Tip

b. Hub

c. Bevel

d. Lumen

4. The dorsogluteal injection site should be avoided in patients 6 years of age or older.

a. True b. False

5. When withdrawing medication from an ampule, first draw in air equal to the dose of medication to be withdrawn.

a. True b. False

6. What syringe part fits into the hub of the needle?

a. Tip

b. Knob

c. Bevel

d. Barrel

282 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Worksheet Handbook III

7. Circle the preferred sites for subcutaneous injections.

a. Thigh - rectus femoris

b. Upper arm - deltoid

c. Upper arm - middle 1/3 outer lateral surface

8. List three factors that affect injection site selection.

a. ______

b. ______

c. ______

9. Which preferred site for intramuscular injections requires the use of a short needle to avoid injury to the patient?

a. Dorsogluteal

b. Upper arm - middle 1/3 outer lateral surface

c. Upper arm - deltoid

d. Ventrogluteal

10. When withdrawing medication from a vial, it is necessary to inject air from the syringe into the vial.

a. True b. False

11. To dispose of equipment after administration of an injection:

a. discard cartridge and holder in the sharps container.

b. discard needle and syringe in the sharps container.

c. re-cap needle and discard in the sharps container.

d. discard syringe only in trash.

283 Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous Handbook III Medication Administration Worksheet

12. Which position is considered best for administering an intramuscular injection into the dorsogluteal muscle?

a. Prone

b. Supine

c. Sim's

13. During an injection, blood is noted upon aspiration. What should be the next step?

a. Change to a different site and continue to inject the medication.

b. Discard medication and record as wasted.

c. Continue to inject the medication and report the occurrence to the nurse.

d. Discard the medication and prepare a new injection.

14. When is the administration of medication recorded?

a. At the time the medication is ordered

b. After administration of the medication

c. Right after shift change

d. Just before going to the patient's room/bedside

15. If a patient refuses a medication, how is it recorded?

a. Leave the medication square on the MAR blank since no medication was given

b. Initial the appropriate square on the MAR

c. Place an asterisk in the appropriate square on the MAR

d. Only on the Nursing Notes SF 510

16. Immunizations for active duty members admitted to the hospital are recorded where?

a. Nursing Notes SF 510 only

b. Health record

c. MAR

284 Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School Medication Administration Worksheet Handbook III

17. A Nursing Notes SF 510 entry is not required for:

a. PRN medications.

b. medication refusal.

c. routine medications.

d. adverse reactions.

285 Lesson 3.24 Venipuncture Basic Hospital Corps School Handbook III Lesson 3.24

Venipuncture

Terminal Objective:

3.24 Perform venipuncture.

Enabling Objectives:

3.24.01 List basic concepts and guidelines for venipuncture.

3.24.02 List the supplies needed to perform venipuncture.

3.24.03 Define common complications of venipuncture.

3.24.04 List documentation requirements for venipuncture.

3.24.05 Perform venipuncture to collect a laboratory specimen.

The laboratory analysis of blood and its Veins should be chosen that are located in components is a common process used to aid uninjured extremities since scar tissue may in making an accurate clinical diagnosis. The interfere with correct location of the vein and most common method of obtaining blood successful insertion of the needle. Veins specimens is by venipuncture, the therapeutic chosen for venipuncture should not be act of puncturing a vein. The purposes of proximal to a site where fluids are being venipuncture are to: infused as this will result in abnormal lab results. Thrombosed (clotted), tortuous 1. obtain blood specimens. (crooked), or rolling veins should not be used for venipuncture. A straight and stable vein 2. infuse fluids and blood. affords the best opportunity for successful venipuncture. 3. administer medication. The veins in the bend of the elbow 4. draw blood for diagnostic testing. (antecubital space) are the preferred venipuncture location, Figure 3.24.01. In order for venipuncture to be completed However, variables such as patient choice, successfully the vein must be: age, medical conditions, and other treatments may necessitate the use of other sites for 1. large enough to receive the shaft of the venipuncture. As in any procedure where you needle may have contact with a patient's blood or body fluids, protect yourself by using 2. visible and palpable after the tourniquet is Universal Precautions. If no vein is correctly placed immediately visible after placement of a tourniquet, you can promote vein distention 3. intact (without lacerations). by:

286 Basic Hospital Corps School Lesson 3.24 Venipuncture Handbook III

1. patient clenching and unclenching the fist (multidraw needle). Vacutainer tubes are a vacuum test tube sealed with a colored rubber 2. tapping the area lightly. stopper, Figure 3.24.02. The tubes come in various sizes with the color of the rubber 3. patient lowering the arm stopper top depending on the preservatives or anticoagulants in the tube. If unsure as to the 4. applying warm compress over the type of vacutainer tube to use for a particular intended venipuncture site ten to twenty test, consult the laboratory manual, ask minutes. Be sure to release the tourniquet laboratory personnel, or contact a nurse or while the compress is in place. physician. Two commonly used tubes are the red topped tube for evaluation of serum SUPPLIES contents and the lavender topped tube for evaluation of different blood cells. Performing venipuncture can be easy with the proper equipment and a good knowledge COMPLICATIONS OF of the procedure. Start by determining the lab VENIPUNCTURE test to be performed and fill out the laboratory request form (chit) correctly. It must include As with any procedure the patient will the patient's name, social security number, rate need to be monitored for complications after or dependency status, branch of service, and venipuncture. The following are commonly duty status (active or retired). The laboratory seen complications: chit must include the date and time the specimen was drawn, the source and the Hematoma -- collection of blood usually specific test requested. Fill in the requesting clotted, in an organ, space or tissue that physician's name and your initials. Enter any develops after a break in a vessel wall or due. pertinent remarks in remarks section such as A hematoma may develop if insufficient direct the patient's diagnosis, or anything that might pressure is applied to the puncture site after affect the test in any way. the needle is removed. Commonly called a bruise. Additional equipment required includes a specimen label, protective pad (Chux), Phlebitis -- inflammation of a vein. It may tourniquet, vacutainer holder, multidraw or result from repeated puncture of a vein, and/or single draw vacutainer needles, the proper use of improper venipuncture technique. vacutainer tube, antiseptic swabs, sterile 2x2, Band-Aid, and clean gloves. Septicemia -- systemic disease caused by the presence of pathogenic microorganisms or The specimen label must include the their toxins in the blood. It may result from patient's full name, Social Security Number of improper technique or the use of contaminated Family Member Prefix, rate/rank, or equipment. dependency status, branch of service, and active duty or retired. Trauma -- Injury to underlying tissues usually caused by probing with the needle The tourniquet is used to restrict venous during venipuncture in attempts to locate the blood flow distal to where the tourniquet is vein. applied. The vacutainer holder is a disposable plastic barrel or sleeve that connects the DOCUMENTING vacutainer needle to the selected vacutainer VENIPUNCTURE tube. The vacutainer needle is a sterile needle that is used to collect one vacutainer tube of Venipuncture needs to be documented on blood (single draw) or can remain in the vein the Patient Profile NAVMED 6550/12. Note while numerous blood specimens are obtained

287 Lesson 3.24 Venipuncture Basic Hospital Corps School Handbook III the date the test sample was sent to the lab. aseptically clean. Remove the needle guard, The Nursing Notes SF 510 entry should grasp the patients extremity with you non- include the date and time the specimen was dominate hand so the thumb rests on the skin 2 drawn, the specific test ordered, disposition of inches distal to the site of venipuncture and the specimen, the patient’s tolerance of the exert tension pulling the skin toward the procedure, and the location the specimen was patients hand, Figure 3.24.04 and 3.24.05. drawn from. Holding the vacutainer at a 15-degree angle with the bevel up, insert the needle into the INITIATING VENIPUNCTURE vein, Figure 3.24.06. Steady your hand against the patient's arm. Release the skin and This section explains the step by step advance the tube, puncturing the rubber process for performing venipuncture for stopper (using your non-dominate hand). obtaining a blood specimen in a safe, effective Blood flow should start immediately if the manner. needle is in the vein. Release the tourniquet. Once the tube is full, you may discontinue the Many wards or clinics have all the venipuncture. equipment in a specific tray used for venipuncture. After gathering the equipment, DISCONTINUING wash your hands and assemble the needle and VENIPUNCTURE holder. Insert blood tube until edge of stopper meets the guideline on the vacutainer holder. To discontinue, ensure the tourniquet is Next, take the equipment into the patient's released. Remove tube from the holder. Place room. Check patient identification comparing a sterile 2x2 lightly over the puncture site, and it to the lab chit; ask about allergies. Explain withdraw the needle quickly. Apply pressure the procedure and provide for patient privacy to the puncture site or until bleeding stops. Do and safety. Place the Chux pad under the not recap needle. Carefully dispose of needle patient's arm. Place a tourniquet about three and vacutainer holder (without disassembling) inches above the selected site (usually a fairly in a puncture resistant container. Apply a large, convenient vein in the antecubital Band-Aid over the venipunture site. Dispose space), Figure 3.24.03. Evaluate the site and of remaining equipment. Attach the lab chit don clean gloves. If necessary, promote vein and the specimen label with the patient's distention. Once a suitable vein has been addressograph to the vacutainer tube of blood. located, cleanse the area with an antiseptic Remove gloves and wash hands. Transport swab by using a circular motion from center of specimen to the laboratory. Document the site outward. The selected site is now procedure. Wash hands and document the procedure.

FIGURE 3.24.01 FIGURE 3.24.02 Common Venipuncture Sites Vacutainer 288 Basic Hospital Corps School Lesson 3.24 Venipuncture Handbook III

FIGURE 3.24.03 FIGURE 3.24.04 Tourniquet Placement Venipuncture

FIGURE 3.24.05 FIGURE 3.24.06 Venipuncture Needle Insertion

289 Lesson 3.24 Venipuncture Worksheet Basic Hospital Corps School Handbook III Lesson 3.24

Venipuncture Worksheet

1. Venipuncture is defined as ______.

2. List the purposes of venipuncture.

a. ______

b. ______

c. ______

d. ______

3. Characteristics of a vein suitable for use in venipuncture is one that is:

a. tortuous and thrombosed.

b. visible and palpable after tourniquet placement.

c. located on an injured extremity.

d. smaller than the shaft of the venipuncture needle.

4. Circle each way to promote venous distention.

a. Raise patients arm

b. Tap lightly on selected vein

c. Apply cool compresses

d. Have patient clench and unclench fist

5. The purpose of a tourniquet in performing a venipuncture is ______.

6. If you are unsure of the type or color of vacutainer tube to use, what reference sources are available to assist you?

a. Patient

b. Ward nurse

c. Laboratory manual

d. Pharmacy personnel

290 Basic Hospital Corps School Lesson 3.24 Venipuncture Worksheet Handbook III

7. Which of the following best describes hematoma?

a. Inflammation of a vein

b. Collection of blood, usually clotted, in an organ, space or tissue

c. The therapeutic act of puncturing a vein

d. Restriction of venous flow to obtain blood

8. Trauma to underlying tissues is caused by ______.

9. Venipuncture of a patient is recorded on the:

a. ______

b. ______

10. When performing a venipuncture, where is the tourniquet applied in relation to the selected site for venipuncture?

a. 3 inches below the selected site

b. 3 inches above the selected site

c. 1 inch below the selected site

d. 1 inch above the selected site

11. When performing venipuncture, at what angle is the needle inserted into the vein?

a. 15 degrees

b. 30 degrees

c. 45 degrees

d. 90 degrees

291 Lesson 3.24 Venipuncture Worksheet Basic Hospital Corps School Handbook III

292 Basic Hospital Corps School Lesson 3.24 Venipuncture Worksheet Handbook III

293 Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School Handbook III Lesson 3.25

Introduction to Intravenous Therapy

Terminal Objective:

3.25 List concepts and principles of intravenous therapy.

Enabling Objectives:

3.25.01 List the purposes of intravenous therapy.

3.25.02 List common intravenous fluids and their specific indications.

3.25.03 List complications of intravenous therapy and measures to prevent their occurrence.

3.25.04 List principles and guidelines of blood transfusion.

3.25.05 List the signs and symptoms of adverse transfusion reactions.

3.25.06 List basic emergency care for adverse transfusion reactions.

3.25.07 State the purpose for monitoring intake and output.

3.25.08 State methods of assessing fluid balance.

3.25.09 List sources of intake fluids and output fluids.

3.25.10 State the procedure for initiating the measurement of intake and output.

3.25.11 State the procedures for measuring and recording intake and output.

3.25.12 Distinguish between intake fluids and output fluids.

3.25.13 Demonstrate documentation of intake and output.

PURPOSES OF INTRAVENOUS and most efficient way for medications to THERAPY reach all parts of the body. The third reason for IV therapy is to provide blood expansion Intravenous (IV) infusions are started for in case of severe hemorrhage. Their role is to three primary reasons. First, to provide a route replace a depleted intravascular volume. for replacement of fluids, electrolytes, or blood products that may have been lost TYPES OF IV FLUIDS through diarrhea and vomiting, diseases such as cancer, or burns. Second, to administer There are several types of intravenous fluids drugs to assure their prompt access into the and blood volume expanders. Normal Saline circulatory system. The IV route is the fastest (0.9% NS) and Lactated Ringers (LR) are

294 Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy Handbook III the most common fluid and electrolyte of ensuring that all air has been removed from solutions. Electrolytes are substances capable the IV tubing before connecting it to the of breaking into ions and developing an patient. It is also important to monitor the electrical charge when in solution. IV's of NS tubing during administration to ensure that the and LR help to correct losses due to vomiting, solution does not completely drain from the diarrhea, and severe diaphoresis. They can bag before a new bag has been hung. also be used as a medium to infuse drugs. LR solutions contain the electrolytes sodium, Circulatory overload -- administering too potassium, calcium, and chloride. much IV fluid too quickly. Symptoms include headache, dyspnea, flushed skin, rapid pulse, Solutions containing 5% Dextrose in Water and pulmonary edema. Prevention of (D5W) are most commonly used as a medium circulatory overload includes frequent to infuse drugs. The dextrose is easily monitoring of the infusion and careful control metabolized and the water is distributed to all of the flow rate. NEVER try to catch up an IV body fluid compartments. in case it gets behind, as the increased flow rate may cause circulatory overload. Whole blood is used when blood replacement is required, such as with Infiltration -- IV solution going into tissue, hemorrhage, severe burn, surgery, NOT the vein. It occurs when the hemodialysis, and to treat peripheral vascular needle/catheter has dislodged from the vein collapse or shock. In some cases, the patient and the solution escapes into the surrounding does not need all of the components of whole tissue. Symptoms include edema, localized blood. Packed Red Blood Cells (PRBC's) pain, and coolness at the insertion site. A slow may be given to restore a low red blood cell flow rate or flow stopping completely also (RBC) count or to treat low hemoglobin. The indicates that the IV has infiltrated. Prevention added serum of whole blood may cause of infiltration includes carefully securing the circulatory overload and left--sided heart needle or catheter and limiting the movement failure so only PRBC's may be indicated. of the arm by applying an armboard.

After the RBC's are separated from whole Nerve damage -- can result from a tight blood the remaining liquid portion is plasma. armboard that compresses the nerves. Plasma is commonly used to treat clotting Symptoms are numbness and tingling of the deficiencies and can also be used as a blood extremity. Prevention of nerve damage volume expander. Plasma Protein Fraction includes padding armboards before use and (PPF) and Albumin are the proteins found in making neurological checks during rounds. plasma. They are frequently used a blood Completely encircling the arm with tape when volume expanders. applying the armboard can also lead to nerve damage. COMPLICATIONS OF INTRAVENOUS THERAPY Phlebitis -- inflammation of a vein is called phlebitis. Phlebitis is caused by IV fluids that While intravenous therapy is a common are particularly irritating to the vein or if the procedure, there are some complications that needle/catheter is left in the same site for a may occur. Some of these complications prolonged period of time. Symptoms include include: pain, redness, and edema with warmth along the vein. Phlebitis can be prevented by Air embolism -- a bubble of air circulating changing the infusion site every 72 hours and in the blood. Symptoms of an air embolism are by changing the IV site dressing every 24 cyanosis, hypotension, and a weak and rapid hours (or as indicated by local policy). Proper pulse. Prevention of an air embolism consists documentation on the IV site dressing label

295 Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School Handbook III and in the Nursing Notes SF 510 will help obtaining the necessary supplies and ensure that these changes are made. monitoring the patient during the transfusion.

Pyrogenic contamination -- bacterial There are some special considerations to contamination of the IV tubing, fluid, or site. remember when handling blood products. The Symptoms are restlessness, fever, chills, and unit of blood should not be obtained from the headache. Prevention consists of using aseptic blood bank until it is needed and there is technique whenever working with IV's, someone available to administer the changing the tubing every 48 hours (in transfusion. Blood must not remain on the accordance with local policy), and performing ward for more than 30 minutes prior to IV site dressing changes every 24 hours (or administration. It cannot be stored in the ward per local policy). The IV fluid container needs refrigerator prior to administration as the to be changed at least every 24 hours even temperature is not sufficiently well controlled when the infusion rate is slow and there is still for blood storage. If the transfusion is not fluid in the bag at the end of the 24 hour started within 30 minutes after obtaining it period. from the blood bank, the blood product must be returned to the blood bank. BLOOD TRANSFUSION The special equipment needed for a Blood transfusion means the transfer of transfusion includes: blood administration Y human blood or its components from a donor tubing with microfilter, Normal Saline to a recipient. The purpose of a blood solution for IV administration, and an IV transfusion is to restore the quantity and catheter that is an 18 gauge needle or larger. quality of a patient's circulating blood. The patient requires very close monitoring Blood transfusion plays an important role in during administration of a blood transfusion. treating battlefield casualties who have lost Immediately prior to starting the transfusion, significant amounts of blood from wounds, take and record baseline vital signs. The surgery, or burns. An example of the patient must be observed constantly during the effectivess of blood transfusions can be cited first 15 minutes of the transfusion to monitor in the Falkland Island conflict. The battlefield for signs and symptoms of transfusion hospital on the island saved every wounded reactions. Vital signs are taken every 5 soldier that was brought in alive. Many of the minutes during the first 15 minutes of the hundreds they treated required blood transfusion. After the initial 15 minutes, vital transfusion. signs are taken and recorded as per local policy. Prior to a blood transfusion, it must be determined that the blood of the donor and the TRANSFUSION REACTIONS recipient are compatible. Incompatible blood types react with each other and can cause Transfusion reactions are potentially life severe reactions and even death of the threatening. There are different reasons a recipient. Blood is categorized into four main patient may have a reaction. While the groups - A, B, AB, and O, depending on the reasons for a transfusion reaction may vary, type of protein on the red blood cells. The the signs and symptoms are similar. It is blood type of the donor and the blood type of important to recognize them and to respond the recipient are tested (cross-matched) to quickly. Signs of a transfusion reaction determine compatibility. include: fever, anaphylaxis, hematuria (blood in the urine), facial flushing, and hives. Blood transfusions are only administered by Symptoms include: discomfort and anxiety, authorized personnel (usually Nurses). shortness of breath, chills, pain in neck, chest Hospital Corpsmen may be involved in or flank area, headache, and itching. When

296 Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy Handbook III these signs and symptoms are evident, the ASSESSING FLUID BALANCE transfusion must be stopped immediately by closing the flow clamp on the blood tubing. Assessing a patient's fluid balance can be Do not remove the IV catheter. Disconnect vital in providing proper care. The simplest blood IV tubing. Access to the vascular method to assess fluid balance is to compare system is maintained by infusing the Normal the amount of fluid taken in with fluid Saline solution at a very rapid rate, using new eliminated by the body. In particular, look for tubing. Notify the nurse, physician and fluid loss or fluid retention. laboratory personnel immediately. Take and record the patients vital signs every five Fluid loss is a warning sign that the patient minutes until otherwise directed. A urine is at risk for fluid imbalance. Typical reasons specimen and a blood specimen will also be for loss include: Diaphoresis due to fever or obtained from the recipient. The partially used exercise. Patients with a fever may lose more blood bag and blood tubing will be sent to the water than one whose temperature is normal. blood bank for further analysis. Nausea and a poorly balance diet may precede vomiting or diarrhea. Increased urination (over MONITORING INTAKE AND 2,000 ml per day) can be measured easily. OUTPUT Wound or body drainage (such as chest tube drainage or nasogastric tube drainage) adds to Water is essential to life. An individual fluid loss. Blood loss from surgery, trauma, or can survive only a few days without water. an ulcer is considered fluid loss as well. Human bodies are approximately 45-75% water. The exact amount depends upon the Fluid retention indicates a fluid imbalance, age, gender, and body composition (lean or and is usually associated with kidney disease fat) of the individual. All water in the human or failure. Retention also occurs with heart body contains dissolved chemicals. The term disease and liver failure. body fluid is used to discuss this mixture of chemicals and water. INTAKE AND OUTPUT FLUIDS

The purpose for monitoring a patient's Fluid Intake is determined by measuring intake and output is to maintain an accurate the amount of fluid taken into the body. Intake account of fluid balance. Fluid balance is the can be oral (PO), by gastric tube feeding, state in which water remains in normal intravenous (IV), or by irrigation or amounts and percentages within various instillation. Oral intake is liquid taken by locations of the body. Healthy people maintain mouth, including solid foods which would be fluid balance automatically; the amount of liquid if kept at room temperature (ice cream, fluid in each area tends to remain fixed. gelatin, sherbet, and ice.) When a patients During an illness, body fluids may become medical condition prevents oral food/fluid unbalanced. intake, a specially prepared infant formula-like liquid is administered via a gastrostomy or Intracellular fluid is fluid within cells. nasogastric tube. Most body fluid is intracellular. Intravenous fluids includes all intake Extracellular fluid is all fluid not in cells: administered through a vein. IV solutions, blood, and blood derivatives are sources of IV 1) intravascular all the fluid within the intake. IV solutions are usually a combination blood, also known as plasma or serum of water, sugar, and salt(s). Irrigations or instillations wash or rinse parts of the body or 2) interstitial - fluid between cells. tubes, as in nasogastric, bladder, or bowel irrigations. The solution is usually water or

297 Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School Handbook III water with salt. In many cases, the solution RECORDING INTAKE AND will return from the body quickly. After being OUTPUT counted as intake, irrigation fluid that returns will become counted as output. The Twenty-Four Hour Intake and Output Worksheet DD 792 is the primary tool for Fluid output is the total of all liquids measurement of I&O, but a local form may be eliminated from the body. The primary source used. A list of intake equivalents is at the of fluid output is urine. Fluid lost through bottom of the DD 792. It documents how tubes such as a Foley catheter, chest tube, many cc/mls are in a serving of ice cream or a Penrose drain, Jackson-Pratt (JP) drain, or cup of coffee. Liquid intake and output is nasogastric tube is output. recorded in cc/ml's. Unless ordered to do so, or unless a specimen is needed, after noting Emesis, diarrhea (liquid feces or stool), the amount, discard any output, using blood wound drainage, and irrigations or aspirations and body fluid precautions. are also sources of output. In some cases, you will be required to measure liquid lost in Record the time, type, and amount of fluid dressings, linen, and diapers. To do so, weigh intake and fluid output on Twenty-Four Hour the linen or dressing before and after Intake and Output Worksheet DD 792. absorption of liquid, or use an average dry Remember to record irrigations as both intake weight to compare against the soaking wet and output. Some conditions require aspirating weight. fluid from a tube or body cavity. This fluid is also output. For example: when instilling 50 Water lost from the lungs and skin during ml of water into a nasogastric tube, and expiration and rapidly evaporating sweat is aspirating 40 ml using a syringe, record 50 ml referred to as insensible loss of fluid. intake and 40 ml output.

MEASUREMENT OF INTAKE A running total of all fluid consumed is AND OUTPUT (I & O) kept in the accumulated total column. Maintain a cumulative total in the grand total Initiate I&O by verifying the Doctor's column and record the result at the end of 24 Orders SF 508 for intake and output. This can hours. When each DD 792 is completed place also be found on the Patient Profile NAVMED it in the back of the patient's inpatient clinical 6550/12. Stamp the Twenty-Four Intake and record (unless local policy directs otherwise.) Output Worksheet DD 792 with the patient's Every 24 hours, a new DD 792 is started as addressograph card, or write in standard long as the patient remains on I&O. Following patient identification information. Record the discharge, follow local policy regarding date and starting/stopping time on the I&O disposition of DD 792 forms. Worksheet. At the bottom of Vital Signs Record SF Begin documenting I&O when you 511, record I&O as special data in the space receive the order. Time and date the Twenty- provided. On the SF 511, record the 24 hour Four Intake and Output Worksheet DD 792 grand total and the cumulative total for each each day the patient remains on I&O. Place type of fluid (PO, IV, tube drainage, tube the dated worksheet at the patient's bedside. feeding, etc.) The patient may be actively involved in his/her care by recording intake and output on a piece of paper. Educate the patient on the importance of accurate I&O.

298 Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy Handbook III

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299 Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School Worksheet Handbook III Lesson 3.25

Introduction to Intravenous Therapy Worksheet

1. Match each use in column B to the correct IV fluid in column A.

A B

a. Normal Saline ______1. To treat low hemoglobin

b. Dextrose in water ______2. To correct losses due to dehydration

c. Whole Blood ______3. To treat clotting deficiencies

d. Packed Red Blood Cells ______4. As a medium to infuse drugs

e. Plasma ______5. To treat severe hemorrhage

2. Match each definition in column B to the correct term in column A.

A B

a. Infiltration ______1. Prevented by clearing all the air from the IV tubing prior to connecting

b. Circulatory overload ______2. Needle/catheter dislodges from vein and fluid or a catheter left in one place too long.

c. Air embolism ______3. Inflammation of a vein by irritating IV fluid or a catheter left in one place to long

d. Pyrogenic contamination ______4. Armboard too tight, compressing on nerve

e. Phlebitis ______5. Administering too much fluid too quickly

f. Nerve damage ______6. Prevented by maintaining strict aseptic technique whenever working with IVs

3. Blood for a transfusion must not be kept on the ward for longer than ______minutes.

4. An IV catheter used to administer blood should be no smaller than ______gauge.

300 Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy Handbook III Worksheet

5. List the purposes of intravenous therapy.

a. ______

b. ______

c. ______

6. What is plasma?______

7. Symptoms of phlebitis include:

a. edema.

b. coolness at site.

c. pain.

d. redness.

8. Circle each sign/symptom that indicates an air embolism.

a. Weak and rapid pulse

b. Hypotension

c. Numbness and tingling in fingers

d. Cyanosis

9. At what interval are vital signs taken during a blood transfusion?

a. ______

b. ______

10. List six signs/symptoms of a transfusion reaction.

a. ______

b. ______

c. ______

d. ______

e. ______

f. ______

301 Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School Worksheet Handbook III

11. What is the initial treatment for a patient with signs or symptoms of a transfusion reaction?

______

12. What is the purpose for monitoring intake and output?

______

13. Tube feedings are considered both intake and output.

a. True b. False

14. Urine is the primary form of fluid output.

a. True b. False

15. Which form is used to record intake and output each 24 hours?

______

16. Irrigation is both intake and output.

a. True b. False

17. Match each definition in Column B with the correct term in column A.

A B

a. Intracellular Fluid ______1. Water located in the blood, also known as plasma or serum. b. Extracellular Fluid ______2. Body fluid located outside the cells.

c. Intravascular Fluid ______3. Water that is contained within cells.

302 Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy Handbook III Worksheet

NOTES/COMMENTS

303 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Handbook III Lesson 3.26

Maintenance of Intravenous Therapy

Terminal Objective:

3.26 Perform selected intravenous therapy procedures.

Enabling Objectives:

3.26.01 List equipment for changing intravenous tubing, solution container and performing IV site care.

3.26.02 List guidelines for preparing equipment used to change intravenous tubing and IV solution container.

3.26.03 Calculate intravenous flow rate within "plus or minus" one drop per minute.

3.26.04 List guidelines for changing intravenous solution container and tubing.

3.26.05 List guidelines for performing intravenous site care.

3.26.06 List guidelines for documenting intravenous tubing change, solution container change, and site care.

3.26.07 Change an intravenous bag and tubing.

3.26.08 Perform intravenous site care while providing patient safety, privacy, education, and comfort.

3.26.09 Record intravenous tubing and bag changes, and intravenous site care.

EQUIPMENT FOR consists of the drip chamber, tubing and flow MAINTAINING IV THERAPY regulator clamp, Figure 3.26.01

Routine care of existing IV therapy IV solution -- physician uses the Doctor's includes monitoring for correct rate of Order to specify the type of solution desired infusion, caring for the insertion site, changing for a patient. Obtain and prepare the ordered solution containers, and changing infusion solution. tubing. The following is a list of equipment needed for routine care of existing IVs. Antiseptic swabs -- Betadine sponges or alcohol swabs are used to cleanse around the IV administration set -- allows the flow insertion site. of solution to be regulated from the IV container to the patient's arm. The IV set Tape -- various widths of tape are used to anchor the catheter, secure the IV tubing, time

304 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III tape the IV solution container, label the IV evidence of contamination. There should be no container, label the IV tubing, and label the cloudiness, discoloration or particles floating site dressing. in the solution. Ensure the ports are sealed. If discrepancies are noted, discard and obtain Sterile dressing -- placed after routine site another container. care/cleaning or when the old dressing becomes contaminated or damaged. The Time tape and label container -- The principle of asepsis is very important when time tape is a marker strip that is placed on the placing the sterile dressing over the insertion container of solution so the flow rate can be site. The site is a direct line to the bloodstream easily monitored. It allows staff personnel to and pathogens may circulate easily to other tell at a glance whether the solution is being parts of the body. infused at the proper rate. A commercially made time tape or a long strip of adhesive tape Chux pad -- used during routine IV is attached length--wise to the IV container, therapy to provide patient comfort and prevent Figure 3.26.02. The entire time tape is the need for unnecessary linen changes. prepared by marking lines or points to denote the start time, hourly IV rate (ml/hr) ordered Gloves -- barrier against blood borne by the physician, and time the IV container is pathogens and are to be worn when working expected to run out. (The actual times are around the IV insertion site or when changing placed on these lines immediately after the IV tubing at the catheter hub connection. infusion has been started.) (Local policy will determine if sterile or clean gloves are to be used.) The container label is placed across the top of the IV container, to identify the IV Pole -- IV solution container is prepared container and its contents. The label suspended on a pole above the level of the must include the date, patient's name, type of puncture site to allow the fluid to infuse by IV fluid and total volume in container, gravity. container number, any medications added, the rate of infusion (ml/hr), and the initials of the Infusion Pump -- electronic device that person preparing the container. infuse IV solutions at a preset rate. Prepare administration set -- Check for PREPARATION OF IV the drop factor (gtts/ml) on the package. The EQUIPMENT rate, or speed, that the solution drops into the drip chamber IV set is called the tubing's drop Verify order -- To complete a routine factor and is based on the internal diameter of tubing change and solution container the IV tubing. It is measured by drops per replacement, verify the Doctor's Orders SF milliliter (gtts/ml). This means the number of 508 for the correct IV solution, amount, and drops released into the administration set drip rate of infusion. Select the appropriate chamber to make one ml, or cc, of IV solution. container from storage. IV solutions are dispensed in bottles or in collapsible plastic The drop factor varies according to the bags and come in volumes of 1,000 ml, 500 manufacturer of the product. To determine the ml, 100 ml, and 50 ml. drop factor of an administration set, look at the package it came in. Examples of drop factors Examine container -- Remove the IV are 10 gtts/ml, 15 gtts/ml, 20 gtts/ml and 60 solution container from the protective plastic gtts/ml. A macro drip administration set is one covering. Inspect the container and its contents that allows larger amounts of IV solution to for physical damage such as cracks, breaks, or flow through its chamber and is mainly used holes. Observe for the expiration date and any for adult patients requiring a high fluid volume. A micro drip administration set is

305 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Handbook III mainly used for pediatric patients or patients prepared or changed, and the initials of the who can only tolerate a slower rate and small person preparing the tubing. amounts of fluid. Remove the IV administration set from the IV pole or infusion pump -- IV solutions package and uncoil the tubing. Do NOT allow generally infuse by gravity. The IV container the tubing to touch the floor. Slide the flow is hung on an IV pole attached to the bed or on regulator clamp along the tubing to position it a portable pole. Since the pressure in a directly under the drip chamber and ensure the patient's vein is greater than atmospheric clamp is in the closed position. Inspect the pressures, the container must be maintained tubing and drip chamber for cracks or breaks. 18-24 inches above the puncture site for the fluid to infuse properly. If the container is Attach and prime tubing -- The adapter lowered, the flow of solution will decrease. spike on the tubing will be inserted into the When the container is raised, the solution will port of the IV container. Aseptically remove infuse more rapidly. and discard the cover from the adapter spike and the cover on the port. The spike and the An infusion pump is a machine that port must remain sterile. To ensure these accurately regulates the volume and rate of parts are not contaminated, do NOT touch the infusion. When used properly, an infusion tubing adapter spike to the outside of the IV pump can increase patient safety. Audible and container port. Carefully insert the adapter visual alarms indicate when IV flow is not spike into the port of the IV container using a progressing as ordered. Since there are slight twisting motion. numerous types of pumps produced, the manufacturer's operating directions should be Hang the IV container on an IV pole. followed for the particular model. However, Squeeze and release the drip chamber of the when in use, never assume the infusion pump IV administration set to fill the chamber half is accurate. IV flow rate checks need to be full with IV solution, Figure 3.26.03. If fluid continued as directed by local policy. does not readily enter the drip chamber, check to ensure the adapter spike has punctured the CALCULATION OF IV FLOW seal of the IV container. Bubbles will rise in RATE the IV solution container as air from the drip chamber enters the container. To carry out a Doctor's Order for IV therapy, calculations are needed to determine The distal end of the administration set correct flow rate. The physician will order the (IV tubing) will connect into the IV catheter type, amount, and rate of solution to be hub. The distal end of the IV tubing must infused. The rate will be ordered in one of two remain sterile. Aseptically remove the cover ways: protecting the distal tip of tubing and set it aside, ensuring the cover is NOT 1. Number of hours to infuse total volume. contaminated. Hold the distal end of the IV Example: 1,000 ml LR over 10 hours. tubing over a sink or wastebasket and open the regulator clamp to allow IV solution to clear 2. Hourly rate desired. Example: LR at 100 the tubing of air. Once the air is purged from cc/hour. the IV tubing, reclamp the flow regulator, replace the cover aseptically, and inspect to Calculate the drops per minute in order to ensure no air bubbles remain in the tubing. maintain the IV flow at the ordered rate. The flow rate is calculated to within plus or minus Label IV tubing -- Use a commercially one drop per minute. made tubing label or a length of adhesive tape to document the time and date the tubing was

306 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III

FORMULA TO CALCULATE 4. Complete the calculations: FLOW RATE: a) Cancel like terms:

100 ml 20 gtts 2,000 gtts gtts/minute = hr x ml = hr

# of ml/hr X Drop Factor b) divide by 60 minutes per hour 60 minutes ______60 min )2,000 gtts/hr = 33.3 or 33 gtts/min

STEPS TO PERFORM FLOW This value is used to set the flow rate after RATE CALCULATION: the IV solution has been initiated and to maintain an ongoing infusion rate. In the 1. Find manufacturer's drop factor on above example, 33 gtts of solution will enter the drip chamber every minute. It is package of administration set. acceptable to count the number of drips for 30 seconds and multiply by 2 to obtain 2. Determine ml (cc) /hr. If the order is the 60-second rate. written for # of ml/hr use it in the formula. Example #1: LR at 100 ml/hr. Use Another problem: formula: 5. Drop factor on package = 15 gtts / ml gtts/minute = 6. IV order = 1,000 ml of D5W over 8 hours 100 ml/hr x Drop Factor ______60 minutes 8 ) 1,000 = 125 ml / hr

7. Enter values into formula: Example #2: 1,000 ml LR over 10 hours. Before you can enter a value into the flow rate # ml/hr x drop factor formula you must find the amount of ml to be 60 minutes = gtts/minute administered in one hour. This is done by dividing total volume by total time to infuse 125 ml/hr x 15 gtts/ml 1,000 by 10 (1,000/10 = 100 ml/hr), Enter 60 minutes value into formula as: 8. Complete the calculation gtts/minute = a. 125 ml 15 gtts 1,875 gtts 100 ml/hr x Drop Factor hr x ml = hr 60 minutes ______b. 60 min) 1,875 gtts/hr = 31.25 or 3. Enter the value for manufacturer's drop factor. If package states drop factor is 20 31gtts / min gtts/ml, then:

100 ml/hr x 20 gtts/ml 60 minutes = gtts/minute

307 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Handbook III

CHANGING THE IV SOLUTION from escaping from the hub when the tubing is CONTAINER AND TUBING disconnected.

Use universal precautions whenever there Use aseptic technique whenever is the potential to contact a patient's blood or connecting the distal end of IV tubing to hub body fluids. Through hand washing should be of the IV catheter. The catheter is a direct line done before and after applying gloves. Gloves to the bloodstream and pathogens may are a barrier against blood borne pathogens circulate easily to other parts of the body. and are to be worn when working around the IV insertion site or when changing IV tubing Secure IV tubing to patient's skin with at the catheter hub connection. tape. The weight of the tubing may cause the catheter to dislodge if the tubing is not well Gather all equipment needed to change IV secured. A loop of tubing over the patient's container and tubing and prepare equipment hand or lower arm allows slack to prevent away from the patient's bedside. Entering the dislodging of the catheter from tension on the room with all supplies ready helps decrease IV line. patient apprehension about the procedure. Identify the patient by comparing bed tag, Adjust the flow regulator clamp to wrist bracelet and patient's stated name with establish ordered flow rate, Figure 3.26.04. labeled IV container. Provide for patient Count the number of drops for 30 seconds and safety, privacy, education, comfort. multiply by 2 to determine the rate per minute. Explaining the procedure to the patient will Adjust as needed to maintain flow at ordered help him/her cooperate during and after the rate. Monitor the flow rate at least hourly. procedure. Since the tubing will be Many factors can influence the flow rate of an disconnected from the hub of the IV catheter, IV including the height of the IV fluid reassure the patient that the catheter will not container in relation to the patient, the position be removed. Remind the patient to NOT move of the patient's arm, total or partial occlusion suddenly during the procedure as it may of the tubing by the patient's body weight, dislodge the catheter. A Chux pad placed kinks in the tubing and parts of the bed as they under the IV site will prevent soiling of the move and operate. Cold IV fluid may cause bed linen. the blood vessels to constrict and thus slow the rate of infusion. The IV catheter will need a continuous flow of IV solution in order to keep the IV solution containers are not left in place catheter patent. Blood will clot at the tip of the more than 24 hours, to reduce the potential for catheter in the vein when the solution flow is bacteria growth in the solution. Tubing should stopped. Close the flow regulator clamp be changed every 48 hours for the same immediately before removing old IV tubing. reason, per guidelines from the Centers for Hold new IV tubing in place and open clamp Disease Control (CDC). to allow for minimal IV fluid flow to keep vein open (KVO) as soon as the new IV tubing If the patient is receiving continuous IV is connected to the catheter hub. fluids, the solution container should be replaced when it becomes nearly empty. Support the hub securely with the thumb Prepare the new IV container about one hour and forefinger when removing the old IV before it is needed and apply time strip. To tubing. If the tubing is difficult to remove, a prevent air from entering the IV tubing, hemostat may be used to hold catheter hub change container when there is still fluid in the while the tubing is removed using a twisting drip chamber. Prior to changing IV containers, motion. Occlude the vein at the end of the decrease the flow rate by tightening the flow catheter with the ring finger to prevent blood regulator. Remove the almost empty container from the IV pole and hold on a slant when

308 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III removing adapter spike from container. Do Use tape to secure the catheter hub to the NOT touch the adapter spike. Remove seal patient's skin. Do NOT cover the hub or from new IV container and immediately insert tubing connection site. Different techniques adapter spike into new container. Hang new of taping (chevron or goal-post) may be used container on IV pole and regulate IV flow rate to minimize catheter movement. Cover the by adjusting flow regulator clamp. Fill in insertion site with a sterile dressing to protect times on time tape. the wound. Label the dressing with time and date of dressing change, your initials, and IV SITE CARE gauge of catheter. This information near the catheter entry site provides a quick reminder Routine IV site care should be performed when the dressing change needs to be every 24 hours unless a transparent dressing is performed next. used. A transparent dressing allows the site to be seen without removing the dressing. Follow RECORDING OF TUBING local policy for changing transparent dressing. CHANGE, SOLUTION A non-transparent dressing (Band-Aid or 2x2) CONTAINER CHANGE, AND must be removed daily to examine the IV site. SITE CARE Since there is a potential for contact with the patient's blood, use universal precautions An entry is made on the Nursing Notes SF when performing IV site care. 510, after the procedures are completed. The

following should be included: the bottle Use aseptic technique when performing number of the IV container removed with type IV site care. The puncture site is a type of and amount of fluid that the patient received; open wound. The wound and catheter provides the amount, type of solution, and bottle a direct line to the bloodstream and pathogens number of the IV container started; rate of may circulate easily to other parts of the body. flow in ml (cc's) per hour; location and It is important to inspect, dress the wound, and appearance of insertion site; completion of site document its condition at routine intervals. care, completion of tubing change; and how

the patient tolerated the procedure. Supporting the hub of the catheter, remove all dressing from the IV insertion site and tape Patients on IV therapy may also need from the catheter hub. The tape securing the intake/output monitoring. This may be tubing may be left in place if it does not directed by Doctor's Orders or local policy. interfere with the dressing change. Observe Documentation completed on the Twenty- the insertion site and surrounding tissue for Four Hour Intake and Output Worksheet DD complications such as phlebitis, infiltration, 792 includes: the time current IV container infection, and edema. Cleanse around the taken down, amount of solution received, and insertion site with Betadine or alcohol swabs. cumulative total, time the new IV container Do NOT contaminate the site. Wipe outward started, initial amount in the container, type of from the insertion site, using a new swab for solution, and bottle number, Figure 3.26.05 each outward wipe.

309 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Worksheet Handbook III Lesson 3.26

Maintenance of Intravenous Therapy Worksheet

1. The IV administration set allows regulation of fluid flow from an IV container into a patient's vein.

a. True b. False

2. Asepsis is not a concern when working with IVs.

a. True b. False

3. List the four checks of an IV container prior to use.

a. ______

b. ______

c. ______

d. ______

4. List eight items to include on the IV container label.

a. ______

b. ______

c. ______

d. ______

e. ______

f. ______

g. ______

h. ______

5. Where is the drop factor for the IV tubing found? ______

6. What is the purpose of priming the IV tubing? ______

310 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III Worksheet

7. An IV infusion pump is used to:

a. remove the need for frequent monitoring of the IV.

b. accurately regulate the amount and rate of IV fluid infused.

c. eliminate the need to change IV tubing.

d. increase patient safety when administering IV fluids.

8. Using the order given, calculate the flow rate within plus or minus one drop per minute.

a. Order: 1000 cc RL at 150 cc/hr (drop factor = 10 gtts/ml) Flow rate ______

b. Order: 500 cc D5 1/2 NS q 10 hours (drop factor = 60 gtts/ml) Flow rate ______

c. Order: 1000 cc NS at 50 cc/hr (drop factor = 20 gtts/ml) Flow rate ______

d. Order: 250 cc D5RL q 5 hrs (drop factor = 60 gtts/ml) Flow rate ______

e. Order: 1000 cc D5W at 200 cc/hr (drop factor = 10 gtts/ml) Flow rate ______

9. When changing IV tubing the flow regulator clamp may be closed for extended periods of time without harm to the site and the patient.

a. True b. False

10. KVO means ______.

11. Circle each factor that can influence the rate of flow of an IV.

a. Height of the IV fluid container

b. Position of the patient's arm

c. Occluded or twisted tubing

d. Temperature of the IV fluid

12. The maximum time a single container of IV fluid can hang is ______.

13. Circle each item listed on the IV site dressing label.

a. Gauge of the IV catheter

b. Drop factor of the tubing being used

c. Time and date of dressing change

d. Your initials

311 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Worksheet Handbook III

14. How frequently should IV site care be performed when using a non-transparent dressing? ______

15. List the items to include in a Nursing Notes when documenting an IV tubing and container change, and IV site care.

a. ______

b. ______

c. ______

d. ______

e. ______

312 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III Worksheet

313 Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School Worksheet Handbook III

314 Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy Handbook III Worksheet

315 Lesson 3.27 Intravenous Insertion Basic Hospital Corps School Handbook III Lesson 3.27

Intravenous Insertion

Terminal Objective:

3.27 Perform an intravenous insertion.

Enabling Objectives:

3.27.01 List the equipment needed to perform intravenous insertion.

3.27.02 List common peripheral intravenous insertion sites.

3.27.03 List factors for selecting an intravenous insertion site.

3.27.04 List guidelines for intravenous insertion.

3.27.05 List guidelines for documenting intravenous insertion.

3.27.06 List guidelines for discontinuing intravenous therapy.

3.27.07 List guidelines for documenting discontinuation of intravenous therapy.

3.27.08 Perform an intravenous insertion using principles of patient safety, privacy, education, and comfort.

3.27.09 Discontinue intravenous insertion.

3.27.10 Document discontinuation of intravenous therapy on appropriate forms.

Initiation of intravenous therapy involves INTRAVENOUS INSERTION venipuncture, an invasive procedure in which EQUIPMENT the skin is punctured by a hollow needle and the needle or a catheter is inserted into a vein. The over-the-needle catheter, butterfly needle, through-the-needle catheter and hypodermic To initiate IV therapy the following items needle are all types of venipuncture devices are needed: used for IV therapy. The solution to be administered and the condition of the patient IV administration set, IV solution as will determine which type of device will be ordered, tourniquet, antiseptic swabs, tape, used. sterile dressing, Chux pads, IV pole, gloves and IV catheter.

The over-the-needle catheter, also called an Angiocath or Jelco, is used for most routine patient care situations and is the best choice

316 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Handbook III for most patients, Figure 3.27.01. This type of PURPOSES FOR DIFFERENT catheter is a plastic tube that is threaded into GAUGE SIZES: the vein over a metal needle. The metal needle The gauge of the needle is the extends beyond the tip of the catheter to measurement of the internal diameter of the provide a sharp bevel to puncture the skin and lumen, the space within the needle shaft, vein. Once the vein has been entered, the sometimes called the needle bore. A needle catheter is advanced into the vein and the with a large lumen will have a low gauge needle is withdrawn. The use of a blunt, number (16g, 18g). A small lumen will have a flexible catheter reduces the incidence of high gauge number (22g, 24g). infiltration with prolonged therapy. 1. 16 gauge - used for patients receiving A butterfly needle, also called a winged- treatment for acute trauma, undergoing tip or scalp vein needle, is a short metal needle major surgery, or receiving multiple blood with plastic wings or tabs, Figure 3.27.02. The transfusions. tabs allow ease of handling during insertion and lay flat to the skin for ease in securing. 2. 18 - 20 gauge - for general use in patients This type of needle is used for short-term receiving IV fluids or blood transfusions. administration of IV fluids since there is a An 18 gauge catheter is preferred for use high risk of damage to the vein with prolonged with blood transfusions. use. A butterfly needle is good choice for use in adults with small or fragile veins, children, 3. 22 gauge - used to minimize discomfort and infants. during venipuncture procedure. The smaller size also reduces the risk of A through-the-needle catheter, also complications. called an intracath, is a flexible plastic tube that is inserted into the vein through a metal 4. 24 gauge - used for infants, children and needle. A needle is used to enter the skin and adults with small veins or fragile skin.. the vein and then withdrawn. The needle remains attached to the tubing with the tip of Select the largest gauge number the needle covered to prevent puncturing the needle/catheter (small lumen) to accomplish patient or the tubing. A through-the-needle the intended purpose. The effects of catheter is generally inserted in a large vein, needle/catheter size include: e.g., internal jugular or subclavian veins. Large volumes of fluid can be infused through an intracath in a critical care or trauma High Gauge Number Low Gauge Number situation. Doctors or specially trained personnel usually insert a through-the-needle catheter. Less trauma to vein More trauma to vein

In an emergency situation where proper equipment may not be available, such as in the More blood flow Less blood flow field, a hypodermic needle may be used to through vein through vein infuse fluids or blood components. Infiltration is common due to the sharp metal edges and the inflexibility of the needle. The hypodermic Less infusion of More infusion of needle is the least desirable device to use for solution solution IV fluid administration.

More potential for Less potential for

catheter clotting catheter clotting

317 Lesson 3.27 Intravenous Insertion Basic Hospital Corps School Handbook III

PERIPHERAL INSERTION SITES quickly. In order to place a large bore catheter, a vein large enough to permit the passage of Placement and selection of IV insertion the catheter needs to be selected. Peripheral site will vary with each patient. The most sites in the antecubital area can accommodate common sites for IV insertion are found on the a large bore catheter (low gauge number), back of the hand, forearm, and antecubital while smaller hand sites generally cannot. area. The antecubital site is very accessible Certain types of fluids that are thick or and it is fairly easy to insert a needle or irritating solutions require the use of a larger catheter at this site. A disadvantage is that an vein to decrease irritation to the vessel. IV at this site severely limits the mobility of Because the blood flow is greater in larger the extremity and may be uncomfortable to the veins, the vessel is less likely to become patient. irritated. Certain types of medications in solution can cause tissue damage if infiltration Avoid using foot and leg veins as IV occurs, therefore a large bore catheter (low insertion sites unless other sites are not gauge number) is used for these medications. accessible. Circulation is often reduced in the lower extremities and there is a greater risk of In an emergency situation, IV insertion thrombus and embolus formation when will take place any where a site can be located. placing a catheter in these veins. Although the A large lumen catheter is desirable to replace foot and legs are common IV insertion sites fluids and blood quickly. When an IV catheter for infants and small children, they should be is inserted preoperatively, a large lumen used only when other sites are not accessible. catheter (low gauge number) is desirable due to the potential for an emergency situation to FACTORS INFLUENCING SITE develop. Do NOT place an IV in the same SELECTION extremity where surgery will occur.

If possible, avoid using the patient's Selecting the best possible venipuncture dominant hand or arm. The nondominant site is influenced by numerous factors. The side will be used infrequently during daily age of the patient is one consideration. Infants activities and the potential for displacing the and children will not protect an IV site. A catheter will be less. The patient will be less peripheral site must be well secured to prevent likely to feel inconvenienced or restricted if it from being dislodged. Peripheral veins are the catheter is placed in his/her nondominant often difficult to locate in an infant. Scalp hand or arm. Try to place the catheter in a veins are commonly used as IV sites in distal branch of a large vein. If the patient infants. remains on IV therapy for a prolonged period

of time, proximal sites can be used for The health and physical status of the subsequent IV insertion sites. patient will influence site selection. Infusions should NOT be administered on the same side as recent extensive breast surgery due to GUIDELINES FOR possible circulation problems in the area. A INTRAVENOUS INSERTION patient with burns on both arms will not have accessible forearm vessels. A normal vein is During intravenous insertion, there is the smooth, pliable, and resilient. A straight vein possibility that you may come into contact facilitates threading of the catheter. Do NOT with the patient's blood. To protect yourself, use sclerotic veins or scarred veins. use universal precautions. Wash your hands before and after the procedure and wear gloves The ordered flow rate may also influence when performing the venipuncture. the site selection. A larger bore catheter (16g - 18g) will allow fluid to be infused more

318 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Handbook III

Aseptic technique is required when that is fairly straight and approximately the inserting an IV catheter. If the site is not length of the catheter or needle. If unable to cleansed properly prior to inserting the locate a vein, promote venous distention by catheter or contaminated while performing the having the patient open and close the fist or procedure, pathogens can be introduced into lower arm below the level of the heart. The the bloodstream. Local policy will dictate skin over the vein can also be stroked distally whether clean or sterile gloves are worn when or a warm compress can be applied to the starting IVs. intended site for 10-15 minutes. Be sure to that the tourniquet is not applied to the arm during After verifying the Doctor's Orders SF this 10-15 minute period. 508, select and prepare the equipment away from the patient's bedside. Entering the room Don clean gloves and cleanse the intended prepared helps to decrease patient anxiety site with antiseptic swabs, using a circular about the procedure. Collecting all the motion, moving outward from the site. (Sterile supplies prior to starting ensures that the gloves may be used depending on local procedure will not be interrupted once it is policy.) Thorough cleansing of the skin prior started. Obtain the correct IV solution, insert to insertion of the needle will reduce the adapter spike into container, and purge the possibility of pathogens entering the blood tubing of air. Apply the time tape, container stream. The antiseptic needs time to dry to label, and tubing label. reach its maximum antimicrobial effect. Once the site is cleansed, do NOT touch the area. Take all prepared equipment to the The site will require recleansing if the area is patient's room. Identify the patient using the touched. labeled IV container. Ask about allergies, particularly noting sensitivity to latex, tape, or When inserting an over-the-needle Betadine. Provide for patient safety, privacy, catheter, anchor the vein about 2 inches below and comfort. Explain the procedure; patients the intended site. Apply tension in the will cooperate more easily if they understand opposite direction to which the needle will be what is about to happen. Place a protective inserted, using the thumb of the non-dominant (Chux) pad under the patient's arm to protect hand. This anchoring will stabilize the vein the bed linen. and minimize rolling. Insert the catheter/needle at a 45 degree angle with the Hang the primed IV container and tubing bevel up. Decrease the angle of the catheter to within easy reach. Prepare and inspect all 10-15 degrees once the skin is penetrated. A needed supplies, then place them so they are lower angle will reduce the potential of accessible during the procedure. Tear the puncturing the posterior wall of the vein after pieces of tape that will be used to secure the the needle has entered the vein. You may feel IV catheter and tubing in place. Having the a pop when the blood vessel wall is punctured. tape pieces prepared allows the catheter to be Once the needle is in the vein, a backflow of secured when insertion is completed and is blood will appear in the needle hub. Securely easier to accomplish when ungloved. Remove hold the needle and continue to advance only the protective covering from the the catheter into the vein until the hub rests on catheter/needle without contaminating the the skin. catheter and check the catheter tip for tears or splitting prior to inserting. Release the tourniquet. Immediately apply pressure with your fingers on the patient's skin To select an appropriate insertion site, proximal to the internal tip of the catheter to apply a tourniquet on the arm about 2-4 inches prevent blood flow from the catheter hub until above the intended site. Observe and palpate the tubing is applied. Dispose of the to determine general condition and suitability contaminated needle in the Sharps container. of veins. Feel and look for an area in the vein Hold tubing in place at catheter hub and open

319 Lesson 3.27 Intravenous Insertion Basic Hospital Corps School Handbook III flow regulator clamp on IV tubing to allow a Documentation on the Twenty-Four Hour keep vein open (KVO) rate to infuse through Intake and Output Worksheet DD 792 for a the catheter. Observe the site for signs and inpatient includes: symptoms of infiltration once fluid is flowing. 1. Time container hung. Wipe excess blood from skin using a sterile 2x2. Secure the hub of the catheter to 2. Amount of solution in container. the patient's skin using tape. Do NOT contaminate the insertion site when applying 3. Type of solution and container number. the tape to the catheter hub. Adjust the flow regulator clamp to obtain the correct flow rate. DISCONTINUING INTRAVENOUS THERAPY Cover the site with a sterile dressing using a Band-Aid, sterile 2x2, or transparent An IV catheter may need to be removed if dressing according to local policy. Secure IV the current site shows signs of infiltration, tubing to the patient's arm to prevent tension infection, or phlebitis. To prevent the vein on the tubing during patient movement. Do from becoming irritated with prolonged use, NOT apply the tape so it completely encircles the site is changed every 72 hours (follow the arm as it may act as a tourniquet if the arm local policy). Once IV therapy is no longer becomes edematous. A loop of tubing below required, the infusion is discontinued and the the IV insertion site will prevent dislodging of catheter removed. the catheter if the tubing is accidentally pulled. Gather the equipment needed to DOCUMENTING INTRAVENOUS discontinue the infusion, including: gloves, INSERTION protective (Chux) pad, sterile 2x2, Band-Aid, puncture resistant Sharps container, and a Insertion of an IV and the initiation of IV biohazard waste bag for disposal of the IV therapy are documented on the Nursing Notes tubing. SF 510 when it is completed on the hospital ward patient. When an IV is inserted on an When discontinuing intravenous therapy, outpatient in the Emergency Room or the there is the possibility that you may come into clinic, the procedure is documented on either contact with the patient's blood. To protect the Emergency Medical Treatment Record SF yourself, use universal precautions. Wash your 558 or on the Chronological Record of hands before and after the procedure and wear Medical Care SF 600. Narrative gloves when performing the procedure. documentation includes: After verifying the Doctor's Orders that 1. Time and date inserted. the infusion is to be discontinued, proceed to the patient's room. Identify the patient, explain 2. Type and gauge of catheter. the procedure and provide for safety, privacy, and comfort. Close the flow regulator clamp to 3. Location and condition of site. stop the flow of solution through the catheter. The lack of IV fluid flow will cause blood to 4. Type and amount of fluid being infused. clot at the tip of the catheter.

5. Infusion rate. After removing all the tape and the dressing, place a sterile 2x2 lightly over the 6. Patient tolerance of the procedure. insertion site. Smoothly and quickly remove the catheter from the vein, following the 7. Signature and rate. course of the vein. Do NOT raise, lower, or

320 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Handbook III twist catheter when removing as this action either the Emergency Medical Treatment may cause damage to the posterior wall of the Record SF 558 or on the Chronological vessel. Apply pressure to the insertion site Record of Medical Care SF 600. Narrative until the bleeding stops and then cover site documentation includes: with a sterile dressing. 1. Time and date removed. Place contaminated catheter in a puncture resistant Sharps container. The empty 2. Type and amount of fluid infused. container is discarded in the garbage. Local policy may dictate the procedure for disposal 3. Location and condition of site. of IV tubing. It may be discarded in regular garbage or in biohazard garbage if the tubing 4. Condition of catheter upon removal. contains blood. 5. Signature and rate. DOCUMENTING DISCONTINUATION OF Documentation on the Twenty-Four Hour INTRAVENOUS Intake and Output Worksheet DD 792 for a inpatient includes: THERAPY 1. Amount of solution infused. Removal of an IV and the discontinuation of IV therapy are documented on the Nursing 2. Time container removed. Notes SF 510 when it is completed on the hospital ward patient. When an IV is removed 3. Cumulative amount of today's IV fluids. on an outpatient in the Emergency Room or the clinic, the procedure is documented on

321 Lesson 3.27 Intravenous Insertion Basic Hospital Corps School Handbook III

FIGURE 3.27.01 Over-the-needle Catheter

FIGURE 3.27.02 Butterfly Needle

322 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Handbook III

NOTES/COMMENTS

323 Lesson 3.27 Intravenous Insertion Worksheet Basic Hospital Corps School Handbook III Lesson 3.27

Intravenous Insertion Worksheet

1. Match the IV catheters in column B with their use in column A. (Catheters in column B may be used more than once.)

A B

a. Short term administration ______1. Butterfly needle of fluids 2. Through-the-needle catheter b. Best choice for acute trauma ______3. Over-the-needle catheter c. Best choice for most patients ______4. Hypodermic needles d. Good choice for infants ______

e. Usually inserted into jugular ______vein, subclavian vein or cephalic vein.

f. Routine situations ______

g. Field use ______

2. The larger the gauge number of a catheter, the larger the lumen.

a. True b. False

3. The IV site that offers the patient the greatest mobility will be veins found in the antecubital space.

a. True b. False

4. Small veins are used for thick or irritating solutions.

a. True b. False

5. Placement of the initial IV catheter in the non-dominant hand is preferred in a patient expecting to be on long-term IV therapy.

a. True b. False

324 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Worksheet Handbook III

6. Circle the procedures that are methods to promote venous distention.

a. Patient opening and closing hand.

b. Patient waving arm.

c. Patient dangling arm over side of bed.

d. Patient holding the arm above the head,

e. Corpsman gently slapping site.

f. Corpsman applying heat to selected site.

7. An IV catheter is inserted into the skin at a 15 to 30 degree angle.

a. True b. False

8. What information is required on the Twenty-Four Hour Intake and Output Worksheet DD 792 when recording intravenous insertion?

a. ______

b. ______

c. ______

9. List the equipment needed to discontinue an IV.

______

______

10. When discontinuing an IV, the flow regulator clamp is:

a. regulated to maintain a KVO rate.

b. closed after the IV catheter is removed.

c. closed before the IV catheter is removed.

d. not used during the discontinuation process.

11. List the components of the narrative documentation when an IV is discontinued.

______

______

325 Lesson 3.27 Intravenous Insertion Worksheet Basic Hospital Corps School Handbook III

326 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Worksheet Handbook III

327 Lesson 3.27 Intravenous Insertion Worksheet Basic Hospital Corps School Handbook III

328 Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Worksheet Handbook III

329 Lesson 3.22 Pain Management Basic Hospital Corps School Handbook III Lesson 3.22

Pain Management

Terminal Objective:

3.22 List concepts and principles of pain management.

Enabling Objectives:

3.22.01 Define terms related to pain.

3.22.02 List influencing factors related to pain.

3.22.03 List the physical and psychological symptoms of pain.

3.22.04 State how to assess pain.

3.22.05 List methods to control pain.

3.22.06 List requirements to record pain, related pain control methods, and their effectiveness.

Patients come for medical treatment with a diseased area. A common example is a patient variety of medical conditions. Whether illness, experiencing a heart attack complaining of injury, surgical condition, or depression, most pain in his/her jaw or arm. patients are in pain. It is imperative that they be treated appropriately, both psychologically Quality refers to the patient's description and physically. of how the pain feels. Adjectives used to describe the quality of pain are interpreted by PAIN TERMINOLOGY their common meaning. Words that describe pain quality include: cutting, dull, jabbing, Asking a patient to describe the pain that knife-like, pounding, sharp, throbbing, is being experienced is very important for an cramping, crushing, and burning. accurate assessment. Assessment involves gathering information/data about the quality, Intensity is the extent, degree of strength, intensity, duration, and location of the pain. or force of the pain. Slight or mild pain is Each of these terms is further subdivided into noticeable but interferes little with activity. categories or classifications. Moderate pain is definitely noticeable and interferes with activity. Severe pain is Location of pain is where the patient feels persistent and makes it impossible to carry out the pain. Diffuse pain is discomfort that activities. covers a large area of the body, such as the entire back or abdomen. Shifting pain moves Duration is the length of time patient from one area of the body to another, such as experiences the pain. Acute pain is discomfort from the lower abdomen to the chest. of short duration from which relief is Referred pain describes discomfort expected. Chronic pain is always present. experienced at a location other than the Intermittent pain comes and goes.

330 Basic Hospital Corps School Lesson 3.22 Pain Management Handbook III

Phantom pain occurs after amputation of PHYSICAL AND a body part. The patient experiences pain from PSYCHOLOGICAL SYMPTOMS that part as if the limb were still present. The OF PAIN physiological transmission of the pain impulse is similar to normal physical pain. Patients in pain exhibit various signs and

symptoms. Symptoms of pain include: INFLUENCING FACTORS 1. Elevated pulse, blood pressure, and No matter how slight the condition or respiration. trivial the cause, pain is very real to the patient. There are no signs or symptoms that 2. Dilated pupils. always demonstrate the severity of a patient's pain. Pain is subjective in nature. It can only 3. Perspiration. be described by the person who is feeling it and knows how much it hurts. Every person 4. Muscle tension. reacts differently to pain. The ability of an individual to endure the discomfort from pain 5. Nonverbal communications such as: is called pain tolerance. a. crying. Feelings of pain are not necessarily proportionate to the amount of damage or b. moaning. severity of the injury. A patient with minor hemorrhoids may be in more pain than a c. frowning. patient with cancer. Consciousness and attention are necessary to experience pain. An d. rubbing the painful area. unconscious patient is unaware of pain and will have no memory of it. A conscious A patient in pain may exhibit symptoms in patient may be aware of trauma suffered combination with or separate from physical during activity but not notice it until later, signs. Symptoms include: often when he/she ceases the activity. Once a person becomes aware of pain, its intensity 1. Verbal complaint. increases. 2. Constant focus on pain. The cultural background of the patient is another consideration in the management of 3. Agitation or depression. pain. Different cultures have different ways of dealing with and expressing pain. In some 4. Refusal of treatment which causes pain, cultures, bearing pain is a means of learning e.g., deep breathing, coughing. sturdiness and bravery, thus a patient may not complain even though severe pain is being 5. Change in normal activities of daily experienced. Other cultures openly express living. pain and a patient may show great concern for even slight pain. (Also refer to Lesson Topic: ASSESSMENT OF PAIN Interpersonal Communications and

Relationships.) In order to control pain, it must be

assessed. A battery of tests is not needed to

make a baseline assessment. For example: In

an accident, the patient may have slammed

his/her head and chest into a steering wheel. He/she complains of a headache and appears

331 Lesson 3.22 Pain Management Basic Hospital Corps School Handbook III to have difficulty during inspiration. It is safe 2. Change soiled linens and dressings as to deduce head and chest trauma, render indicated. This comfort measure is appropriate emergency care, and transport the normally performed when patient is in patient. If the mechanism of injury is not inpatient status. In the field, dressings are apparent on examination, knowing what is not NOT removed. causing the pain is helpful. For example: A 50 year-old patient is complaining of pain in 3. Use distractions to take patient's attention his/her left arm and jaw. There is no history away from the pain. In the field, talking of trauma. It is safe to assume that the patient with the patient or playing music helps is not suffering from an injury. The patient take attention away from the pain. In an may be experiencing a hear attack. inpatient setting, music, television, books/magazines, visitors, or back rubs It is important to assess the features of provide distraction from pain. pain: its quality, intensity, duration, and location. Watching for the signs and 4. Stay and talk with patient, as time permits. symptoms of pain will assist in assessing pain. In multiple casualties situations this may Verbal and nonverbal responses must be not be possible. considered. A patient with elevated vital signs, who rubs his/her leg and complains that it 5. Instruct patient in relaxation techniques hurts has most likely injured that leg. Once such as deep breathing or focusing pain relief measures have been initiated, it is attention on something else. important to evaluate the patient's response to all efforts. In the event that non-pharmaceutical management does not provide enough relief, CONTROLLING PAIN medications may be employed as an adjunct. When using medication for pain relief, always Once the pain has been assessed, it can be use the mildest, most effective agent! The controlled. The prime consideration for intensity of the patient's pain will be a guide to control of pain is management of the cause. the appropriate medication. Non-pharmaceutical management techniques should be used to the greatest extent possible 1. Mild pain -- Use mild analgesics such as before using pharmaceutical management. Aspirin or Acetaminophen (Tylenol).

Non-pharmaceutical management includes: 2. Moderate pain -- An opiate such as Codeine Sulfate or Non-Steroidal Anti- 1. Immobilizing/splinting of Inflammatory Drugs may be used. fractures/suspected fractures. 3. Severe pain -- Opiates such as Morphine 2. Immobilizing impaled/imbedded foreign Sulfate or Demoral (a synthetic opiate) are objects. used.

3. Bandaging wounds. Injectable medications begin to take effect approximately 15 minutes after injection. Oral 4. Relieving a full bladder. medications begin to take effect approximately 30 minutes after administration. Non-pharmaceutical comfort measures:

1. Change patient's position, unless contraindicated.

332 Basic Hospital Corps School Lesson 3.22 Pain Management Handbook III

RECORDING OF PAIN, Finally, document the effectiveness of CONTROL MEASURES, AND control measures. Even if the measure did not EFFECTIVENESS OF CONTROL help the patient or if it caused increased pain, the control measure and its results must be MEASURES documented. This may provide clues for additional conditions. When documenting the All aspects of patient care are documented effectiveness of medications, evaluation in order to monitor the patient's progress, should be made after 15 minutes for determine which treatments are effective, and medication injected intramuscularly or 30 provide medico-legal documentation. First, minutes for medication administered orally. describe the pain. Note the patient's complaint Description of pain, control measures, and of pain, its quality, intensity, duration, and effectiveness are recorded on: location. Next, relate steps taken to manage the pain. List treatments used to manage the 1. Medications Administration Record cause of the pain, e.g., bandaging, splinting, NAVMED 6550/8 and Nursing Notes SF and the use of medication. 510 - for inpatients

If the medications were used to control the 2. Chronological Record of Medical Care, pain, the type, dosage, route, date, and time SF 600 or Emergency Treatment Record the medication was received must be noted. (ETR) SF 558 - for outpatients. This prevents accidentally overdosing the patient by giving medications too close 3. Field Medical Card DD 1380 - for patients together. treated in the field or in mass casualty situations.

333 Lesson 3.22 Pain Management Worksheet Basic Hospital Corps School Handbook III Lesson 3.22

Pain Management Worksheet

1. What classification is given to pain that is noticeable, but interferes little with activity?

a. Severe

b. Unbearable

c. Moderate

d. Slight

2. What classification is given to pain which is persistent, making it impossible to carry out activities?

a. Moderate

b. Severe

c. Slight

d. Excruciating

3. Pain that comes and goes is called ______pain.

a. chronic

b. acute

c. intermittent

d. transitory

4. Diffuse pain is best described as pain that:

a. covers a large area of the body.

b. is removed from the disease or injury.

c. moves from one area to another.

d. is always present.

5. Pain is objective in nature.

a. True b. False

334 Basic Hospital Corps School Lesson 3.22 Pain Management Worksheet Handbook III

6. A pain that moves from the chest to the abdomen is called ______pain.

a. shifting

b. diffuse

c. referred

7. Circle each statement that is correct.

a. Regardless of its cause, pain is real to the patient.

b. Pain is proportionate to the damage within the body.

c. Consciousness and attention are necessary to experience pain.

d. An unconscious person is not aware of pain.

8. Awareness of pain ______the intensity of pain.

a. decreases

b. minimizes

c. increases

d. neutralizes

9. The eyes of a person in pain will usually exhibit:

a. edematous conjunctival.

b. detached retinas.

c. constricted pupils.

d. dilated pupils.

10. Circle each nonverbal communication that may indicate that a patient is in pain.

a. Crying.

b. Rubbing the painful part.

c. Frowning.

335 Lesson 3.22 Pain Management Worksheet Basic Hospital Corps School Handbook III

11. What is the primary consideration for controlling pain?

a. Immobilizing fractures

b. Treating for shock

c. Managing the cause

d. Maintaining an open airway

12. Codeine sulfate may be prescribed for the management of which type of pain?

a. Mild

b. Moderate

c. Severe

d. Intermittent

13. Which form is used to record pain management in the field?

a. Nursing Notes SF 510

b. Chronological Record of Medical Care SF 600

c. Field Medical Card DD 1380

d. Medication Administration Record NAVMED 6550/8

14. Which form is used to record pain management during outpatient treatment?

a. Nursing Notes SF 510

b. Chronological Record of Medical Care SF 600

c. Field Medical Card DD 1380

d. Medication Administration Record NAVMED 6550/8

15. The effect of oral pain medication administration is noted and recorded after ______minutes.

a. 15

b. 30

c. 50

d. 60

336 Basic Hospital Corps School Lesson 3.22 Pain Management Worksheet Handbook III

16. The effect of intramuscular morphine administration is noted and recorded after ______minutes.

a. 15

b. 20

c. 30

d. 45

337 Lesson 3.29 Cast Care Basic Hospital Corps School Handbook III Lesson 3.29

Cast Care

Terminal Objective:

3.29 List concepts and principles for cast care.

Enabling Objectives:

3.29.01 Define terms related to cast care.

3.29.02 State the purposes for applying a cast.

3.29.03 State the purpose and procedure of cast care.

A cast is a stiff dressing made of 3. Infection soaked with a hardening material. Originally casts were made from plaster of paris. Now, 4. Circulatory compromise materials such as polyurethane and fiberglass are also used. These materials dry more 5. Nerve damage rapidly, but are more expensive. Decreased blood circulation in an affected Before a cast is applied, a fracture must be limb could result in permanent nerve damage. reduced. Reduction is the procedure used to Constriction of the cast can slow blood flow reposition the broken ends of a bone. There through an extremity or put pressure on blood are two types of reduction, closed and open. vessels and nerves. Closed reduction is the realigning of bone by manual manipulation without making A newly applied (wet) cast requires incisions in the skin. Open reduction special care. The wet cast should be elevated realigns the broken ends through surgery, with to prevent edema of the injured extremity. incisions. Elevation helps promote circulation and prevents problems of pressure from swelling. Casts are used to immobilize injured structures. A fracture, sprain, or damaged An important aspect of wet cast care is to ligaments may be immobilized with a cast so protect the contour of the cast. Wet plaster is proper healing may occur. easily dented, which may create pressure points. Placing the cast on a hard surface or The purpose of cast care is to promote lifting a cast with your fingertips could cause patient comfort and to give the care provider denting. Decubitus ulcers can result from such an opportunity to recognize any pressure. When lifting a cast, use the palms of complications, including: your hands to support the cast. Ensure that the mattress does not sag. Support the full length 1. Excessive bleeding of the cast using soft objects, such as pillows, to elevate the cast. Plastic covered pillows are 2. Skin breakdown used to prevent patient to patient

338 Basic Hospital Corps School Lesson 3.29 Cast Care Handbook III contamination. Do not cover the cast itself, Keep the cast uncovered, and turn the patient, allow it to air dry. so that all sides of the cast can air-dry. In some instances, a cast dryer may be used, Encourage patient cooperation by usually in the cast room by an orthopedic explaining cast care thoroughly. Inform the technician. Extreme care should be taken to patient that the plaster of paris will become avoid exposing the cast to intense heat. very warm during the drying process. Identify Intense heat could burn the patient, crack the precautions such as care in supporting and cast, or dry the outside of the cast while the lifting a wet cast to ensure that the cast is inside stays wet and becomes moldy. allowed to dry without complications. The inner lining of stockinette should be Circulation and neurovascular checks pulled to the outside of the cast and taped must be performed at regular intervals for a securely. patient with a newly applied cast. Observe the fingers or toes of the affected extremity for After the cast has dried, there is a need to signs of circulatory compromise or nerve continue general principles of care. The damage, such as: patient should be turned as ordered, maintaining the proper body alignment at all 1. cool temperature times. Skin care should be performed every shift. Cast edges and body should be checked 2. cyanosis or pallor frequently for pressure points. Muscle tone and joint mobility are maintained by 3. numbness, tingling, or burning sensation performing ROM to unaffected extremities every two hours. 4 edema When in bed, or sitting up in a chair, the 5. poor blanching and inadequate capillary cast should be elevated on plastic covered refill (more than 3 seconds) pillows to provide support. If a patient is confined to bed, a trapeze should be placed on 6. pain the bed frame to help the patient lift his/her body off the bed. 7. variance of pulse between like extremities Patients should be instructed not to insert 8. decreasing movement foreign objects underneath the cast. Scratching under the cast can cause lacerations In addition, observe the newly applied cast that easily become infected. Pediatric patients for drainage or bleeding. Check the cast every may need frequent reinforcement of this hour for the first 24 hours, then every 4 hours instruction. for the next 2 to 3 days, then every shift, as ordered. Encourage good nutritional intake to promote bone healing. If a stain appears on the cast draw a ring around it to help in noting any increase in size. As always, safety is an important The first time you observe any drainage, note consideration in good patient care. The the date and time, and initial the site. Check patient with a cast must have the side rails up for enlargement of the bleeding area at least and should be assisted with ambulation aids every 1 to 3 hours. such as crutches and walkers.

Allow the cast to dry. Plaster will be wet The cast must be protected from moisture, for 24 to 48 hours. Fiberglass and which can destroy the cast and contribute to polyurethane casts will dry in 5 to 15 minutes. skin break down. Waterproof material should

339 Lesson 3.29 Cast Care Basic Hospital Corps School Handbook III be used around edges near the buttocks and pertinent observations to be recorded on the perineal area. An orthopedic bedpan, Nursing Notes SF 510: designed for easier insertion, is extremely helpful for a patient with a cast who is on bed 1. Drainage or bleeding rest. A patient who is allowed to shower needs to have the cast protected from moisture a. color by covering it with plastic. b. odor Evidence of the following complications should be monitored every shift, and reported c. consistency to the nurse: d. amount (size of stain on cast) 1. Sharp edges of plaster 2. Time of observation 2. Wrinkles 3. Unusual symptoms or observations 3. Odors that may indicate a. Pain a. moisture b. Pressure areas b. mold c. Change in neurovascular circulation c. skin breakdown checks

d. infection The Neurological Circulation Check Sheet is used to record the following information: 4. Neurological or circulatory problems 1. Skin temperature of distal fingers or toes Instruct the patient on cast care. Concentrate on giving information that will 2. Presence and quality of distal pulse allow the patient to recognize problems that require follow up care. (Edema, pain, 3. Movement drainage, foul odor, etc.) 4. Sensation in fingers and toes Cast care should be recorded following standard procedures for documentation. Other 5. Color of fingers and toes

340 Basic Hospital Corps School Lesson 3.29 Cast Care Handbook III

NOTES/COMMENTS

341 Lesson 3.29 Cast Care Worksheet Basic Hospital Corps School Handbook III Lesson 3.29

Cast Care Worksheet

1. What is a cast? ______

2. A cast is used to:

a. seal a fracture.

b. stop bleeding.

c. immobilize a fracture.

d. reduce a dislocation.

3. Open reduction is used to align a broken bone:

a. without incisions.

b. through surgery.

c. before surgery.

d. after surgery.

4. List three complications that may be avoided by proper cast care.

a. ______

b. ______

c. ______

5. Circulatory compromise can result in nerve damage.

a. True b. False

6. If a stain is noted on a cast, draw a ring an inch larger than the stain on the cast.

a. True b. False

7. Skin care for a patient with a cast should be performed every shift.

a. True b. False

342 Basic Hospital Corps School Lesson 3.29 Cast Care Worksheet Handbook III

8. List four signs to note during a circulation check.

a. ______

b. ______

c. ______

d. ______

9. During the first 24 hours after application, a cast is to be checked ______for drainage or bleeding?

a. hourly

b. every two hours

c. every three hours

d. every four hours

10. A plaster cast should dry within ______hours and a fiberglass cast should dry within ______minutes.

11. To protect a cast from moisture:

a. do not bathe the patient.

b. do not allow the patient to shower.

c. use waterproof material around the edges.

d. use waterproof paint to seal the plaster.

12. Record on the Nursing Notes SF 510 the size of any drainage or stain on a cast.

a. True b. False

13. Record on the Neurovascular Circulation Check Sheet:

a. drainage noted.

b. pain in affected extremity.

c. presence of central pulses.

d. sensation in toes and fingers.

343 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III Lesson 3.30

Chest Tubes

Terminal Objective:

3.30 List concepts and principles for using chest tubes.

Enabling Objectives:

3.30.01 State the purpose of chest tubes.

3.30.02 Describe the anatomy and physiology of the respiratory system.

3.30.03 List the equipment used for chest tube insertion.

3.30.04 State medical, surgical, and traumatic non-surgical conditions requiring a chest tube.

3.30.05 List the nursing care procedure for a patient with a chest tube.

3.30.06 State the common complications and nursing interventions for a patient with a chest tube.

A chest tube is a firm, flexible plastic 3.30.01. The upper airway consists of the drain with several openings at the distal end nasopharynx and the oropharynx where air inserted into the pleural space to drain fluid or enters the respiratory system from the blood, or to remove air. Removal of fluid, air, atmosphere, and the trachea, which lets air and blood permits reexpansion of a collapsed travel to the lower airway. The lower airway lung. Once inserted, a chest tube is sutured to consists of the bronchi, bronchioles, and the skin and securely taped to prevent alveoli. Bronchi branch from the trachea into accidental removal. A chest tube is attached to the right and left lungs, then further divide into a drainage system that collects drainage from the smaller elements called bronchioles before the pleural cavity. Chest drainage systems are ending at the alveoli, Figure 3.30.02. closed systems, meaning they are not open to the air. Water is used as a seal to prevent air Gas exchange takes place in the lungs. In from entering the pleural space. The drainage the alveoli, carbon dioxide created by system acts as one-way valve, preventing back metabolism in the cells is given up and oxygen flow into the pleural space by means of from atmospheric air diffuses into the blood gravity or suction. Chest drainage re- stream. This process is referred to as 02-CO2 establishes or maintains the negative pressure exchange. It is this exchange that provides normally present in the pleural cavity. The oxygen to the body's cells so that they may system assists in re-expansion of lungs by carry out the functions of reproduction and draining fluid, blood, or air. growth.

THE RESPIRATORY SYSTEM The lungs have a total of five lobes; three in the right lung and two in the left lung. They The respiratory system is composed of are located in the pleural cavity inside the upper and lower airway structures, Figure chest wall (the rib cage and associated

344 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III muscles) and are separated from the capillaries and the peripheral tissues of the abdominal cavity by the diaphragm. The body (internal respiration.) Oxygen needs at diaphragm is the main muscle of respiration. the peripheral tissues are communicated by During inspiration, the diaphragm contracts, chemical and nerve signals. increasing the size of the chest cavity, which allows the lungs to fill with atmospheric air. The rhythmical movements of breathing During exhalation the diaphragm relaxes, are controlled by the respiratory center in the decreasing the space in the chest cavity, medulla of the brain. Receptors in the carotid forcing air and C02 out of the lungs. Normal, arteries and the aorta react to small changes in quiet breathing is accomplished almost CO2 concentration, and send signals to the entirely with the diaphragm. medulla. Nerves from the medulla pass down through the neck to the chest wall and the Lungs are surrounded by two membrane diaphragm. The nerve to the diaphragm is linings (the pleurae) that assist the respiratory called the phrenic nerve. The nerve to the muscles (diaphragm, intercostal and larynx is the vagus nerve, and the nerves to the abdominal) in breathing. The visceral pleura muscles of the thorax are called the intercostal covers the external surface of the lungs. The nerves. parietal pleura lines the internal surface of the thorax (chest wall). Between these two layers, As the respiratory center of the brain is a suction-like seal exists, similar to placing stimulated by chemical changes in the blood, two pieces of plastic wrap together. This seal the respiratory center responds by stimulating is maintained by a minimal amount of fluid the nerves controlling respiratory movements. (about 4 ml) that fills the pleural space The is increased, and the body between the visceral and parietal pleura. rids itself of the excessive carbon dioxide.

The pleural space is called a potential The muscles of respiration normally act space because when the lungs are functioning automatically. The respiratory cycle consists normally, the space is barely noticeable. The of: fluid in the pleural space reduces friction between the two linings during movement that 1. Ventilation -- movement of air into and occurs upon inspiration and expiration. The out of the lungs. potential space becomes an actual space if there is a break in the seal between the pleural 2. Inspiration -- diaphragm contracts and the linings, and the normal function of the lung is ribs are elevated, producing negative altered. pressure in the chest, along with increased pressure in the abdomen (the chest cavity The pleural space can fill with air, blood increases in size.) This change in pressure or other secretions created by disease or causes air to be drawn into the lungs. trauma to the lungs. As the pleural space fills, lung capacity is decreased. The lungs can 3. Exhalation -- the diaphragm relaxes and totally collapse if a significant amount of air the elasticity of the chest wall and pleura or fluid fills the pleural space. Chest tubes are causes the chest to return to its original inserted into the pleural space to drain the air size. Gasses are expelled from the lungs as or fluid that is compressing the lung. the size of the chest cavity decreases.

PHYSIOLOGY OF RESPIRATION 4. Rest is an interval between breaths.

Respiration includes not only the 5. Normal adult respiration is 12 to 20 exchange of oxygen and carbon dioxide in the breaths per minute. lungs (external respiration), but also the exchange that takes place between the

345 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III

When the chest wall expands during second shorter tube is placed next to the long inspiration, the pleurae are stretched and lung tube and is above the water level and open to volume increases. Elastic recoil begins after the atmosphere. This second tube acts as an air the pleurae are stretched, starting the vent allowing air to escape as the drainage or expulsion of gas through exhalation. An air from the pleural cavity collects in the interruption in the continuity of either pleural drainage system. layer will allow air or fluid to enter the pleural space and cause the lung to collapse. Because bottles must be changed as fluid accumulates, it is customary to use a three- EQUIPMENT FOR CHEST TUBE bottle system where the tubing of the first INSERTION bottle is attached to the chest tube from the patient and acts as a collection bottle. The Hospital Corpsmen are primarily other two bottles are used as the water seal, air responsible for assisting the physician with vent, and for additional fluid collection. insertion of chest tubes. Maintaining the patency of the tubes and assisting the patient A third type of drainage system commonly in respiratory exercises are additional tasks used is called a Pleur-evac, Figure 3.30.05. It performed by corpsmen. Prior to the insertion is a portable system that functions using the of the chest tube, the corpsman should same principle as the three-bottle water seal. assemble the following equipment at the In addition, this systems acts as a suction patient's bedside: sterile chest tube insertion control. Major advantages of the Pleur-evac tray (usually obtained from the Central Supply system are the ability to control suction levels, Department), sterile gloves, sterile 4x4 gauze portability, and they are disposable. pads, sterile antiseptic swabs, sterile distilled water, petroleum jelly gauze, an occlusive When it is not possible to attach the chest tube dressing (usually done with tape), and suturing to a drainage system (such as in the field), a material. Tubing of several kinds is also Heimlich valve can be utilized to prevent air needed: chest tubes appropriate sized, (for an that has left the pleural space through the chest adult usually a 26 - 36 French), straight tube from re-entering. A Heimlich valve connecting tubing (a rigid, short tube), flexible provides a temporary seal for a chest tube. (rubber) suction tubing, are required, and Exhaled air escapes through the valve so that tubing clamps (used only in emergencies). An accumulation of air in the pleural space is appropriate suction apparatus should be set up. prevented. Wall suction units are present on most wards, but you may need to get a portable suction unit Miscellaneous equipment that will be from Central Supply. needed includes: a stethoscope for of the lungs (pre and post-chest A Pleur-evac or other three chamber tube insertion), 1% Lidocaine solution for portable suction unit must be set up before numbing the insertion site, benzoin ointment chest tube insertion. The drainage system for to facilitate adhesion of the occlusive dressing, closed chest drainage is a collection of bottles waterproof tape, antiseptic solution, and a and a water seal to prevent air from returning completed x-ray request chit SF 519 for a to the pleural space through the chest tube. post-insertion chest x-ray. Water seal drainage acts as a one-way valve that allows air and fluid out of the pleural CONDITIONS REQUIRING space but not back into the pleural space. The CHEST TUBE PLACEMENT simplest drainage system is a single bottle with one long tube attached to the chest tube Several conditions can cause an with the opposite end at least 3 - 5 cm below interruption in the pleural lining. These the level of the water, Figure 3.30.04. A conditions are grouped into medical, surgical,

346 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III and traumatic non-surgical causes. All of these Lobectomy or pneumonectomy - the conditions require placement of a chest tube surgical or invasive removal of a lobe or an by the physician to assist in re-expansion of entire lung. When a disease such as the lung. tuberculosis, a pulmonary abscess, a cyst or cancer, has damaged the lung tissue the lobe Medical conditions that require chest (lobectomy) or the entire lung tube placement include: (pneumonectomy) can be removed and the remaining bronchus sutured. During surgery, Spontaneous pneumothorax occurs air may enter the pleural space. A closed chest when air enters the pleural space from a drainage system is used to drain air and blood ruptured alveolus. This can occur in from the pleural space post-operatively to adolescents during sudden growth spurts or in keep the lung from collapsing. adults with sudden changes in atmospheric pressures. In rare cases it occurs without a Pleural abrasion is a surgical procedure definite cause. where a caustic substance, (usually an antibiotic such as tetracycline), is injected into Empyema is purulent fluid in the pleural the pleural space through a chest tube. This cavity from infection. Conditions that create causes scarring of the tissue to seal the empyema are chronic respiratory infections visceral and parietal pleura. Pleural abrasion such as fibrosis or fluid-secreting tumors. may be used in cases of recurrent spontaneous Trauma from a penetrating chest wound, the pneumothorax. spread of infection from other structures, such as the lungs, mediastinum, or chest wall, can Any surgical procedure that interrupts the also lead to empyema, Figure 3.30.03. In cases pleural lining will allow air and blood to enter of chronic empyema, resistant to antibiotic the pleural space, requiring initiation of a therapy, closed chest drainage may be used to chest drainage system. drain the cavity and allow the lung to re- expand. The exudate must be thin enough to Traumatic nonsurgical conditions drain through a chest tube, for this treatment to requiring chest tube placement include: be effective. Tension pneumothorax pressure builds Tuberculosis is a communicable, up in the pleural space, causing the lung to infectious disease caused by mycobacterium collapse and push against the mediastinum. bovis. It can occur in many places in the body, but commonly affects the pulmonary system. Hemothorax blood in the pleural space. It may be acquired by drinking unpasteurized milk from infected cattle or by living in close Open pneumothorax air entering from an proximity to other individuals with an active opening in the chest wall. infection. When the bacteria attach to the lung wall, the tissue of the lung and white blood These conditions can result from a variety cells encapsulate them. The tissue under the of causes, including diagnostic and therapeutic encapsulated bacteria then becomes necrotic. measures such as biopsy or subclavian vein As the process continues, lesions may form catheterization. Either procedure can create a cavities that require drainage. tension pneumothorax, which requires chest Fluid secreting tumors may encapsulate tube placement. and create an empyema or they may simply secrete fluid into the pleural space, causing compression of the lung.

Surgical conditions that require chest tube placement include:

347 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III

ASSISTING WITH CHEST TUBE cavity. The chest tube dressing should be INSERTION changed only when ordered by the physician. It is critical to observe the dressing site at least The insertion of a chest tube is a highly every shift for signs of infection such as specialized skill that requires rapid, efficient purulent drainage, foul odor, edema or redness movements to avoid further trauma to the around the site. In addition, the corpsman lung. Hospital Corpsmen are in a position to should listen for sucking noises that would assure patient privacy, comfort, and safety indicate that there is air leaking from the throughout the procedure. This procedure pleural space. requires strict surgical asepsis. To insert the tube, the physician makes a small lateral The patient should be observed for any incision in the chest wall, between the ribs that signs and symptoms of respiratory distress lie just below the affected area of the lung. such as sudden onset of dyspnea, rapid, Positioning the patient prior to the procedure shallow breathing, or cyanosis. Complaints of eases insertion, Figure 3.30.06. After the chest pressure should be assessed physician makes the incision, the pleural immediately. Air that leaks into the cavity is punctured with a sharp object (scalpel subcutaneous tissue around the chest tube site or hemostats), Figure 3.30.07. A sudden rush results in a condition called subcutaneous of expelled air or fluid, whichever has been emphysema. Subcutaneous emphysema can be filling the pleural space is expected. Speed is recognized by skin that appears slightly lumpy essential. The chest tube and equipment and may crackle when palpated. Any of these should be readily available to the physician. symptoms should be promptly reported to the Once the tube has been inserted into the nurse. A functioning closed chest drainage pleural space it will be attached to the system will have continual fluctuation in the drainage collection and suction system. The water seal chamber. This indicates that air is physician will suture the chest tube to the skin draining from the pleural space. Bubbling in of the exterior chest wall and apply an the water seal chamber indicates that there is occlusive dressing. Securing the tube with an air leak in the system and the nurse should sutures and tape prevents accidental removal. be notified. Once the tube has been secured, the x-ray department should be notified of the need for a When assessing the patency of a chest chest x-ray. tube and closed drainage system, work in a systematic and organized fashion, starting At all times during the insertion with the patient and ending at the drainage procedure, the corpsman should be observing system. Observe the patient for any signs of the patient for signs of respiratory distress. If respiratory distress. Observe the dressing, the patient appears to be in distress (becomes ensuring that it remains occlusive. Observe the extremely dyspneic, cyanotic or faints), alert area around the insertion site for signs of the physician immediately and prepare to infection or subcutaneous emphysema. Follow administer supplemental oxygen (if the patient the tubing toward the collection bottles. is awake) or initiate airway resuscitation. Ensure that all connections are tightly sealed with waterproof tape. Look at the drainage CARE OF PATIENTS WITH system and the water seal to ensure proper functioning. If the drainage system is attached CHEST TUBES to a wall or portable suction unit make certain that the suction is set at the appropriate level. Nursing care of the patient with a chest Make certain that there are no kinks or twists tube centers on the maintenance of an intact in the tubing. Excess tubing should be coiled drainage system and facilitating adequate next to the patient on the bed to avoid kinking respiratory function. An occlusive dressing is and prevent loops that might interfere with used to prevent air from entering the pleural drainage.

348 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III

If the tubing appears to be clogged with a nurse should be notified immediately. These blood clot or viscous drainage, the doctor may changes are indicative of serious order it to be milked to ensure patency. complications and may necessitate immediate Milking requires a Doctor's Order. Proceed by action. If the drainage suddenly stops, check applying lotion to the hand used to milk the for blockage and milk the tube (if there is a tubing. Secure and occlude the tubing with the Doctor's Order to do so.) other hand just below the connection to the chest tube. With the lubricated hand about two Although chest tube clamps should always be inches below the other hand, occlude and milk available at the bedside, clamp the tubing the tubing by sliding your hand down the close to the chest and notify the nurse drainage tube. Release the tubing slowly to immediately. A clamped chest tube can result avoid a snap of air back into the patient's in a tension pneumothorax. Observe the chest. patient carefully for signs of tension pneumothorax. Keep the tubing free of kinks Measurement and recording of chest tube and twists and maintain the drainage apparatus drainage is essential to assist the physician in below the level of insertion at all times. making decisions about when to discontinue suction. Noting the amount and characteristics Respiratory care of a patient with a chest of drainage can be an important indicator of tube includes breathing exercises as well as possible complications. Drainage should be maintaining normal activity levels. The patient measured and recorded, a minimum of once should be instructed on appropriate coughing per shift. Mark the level of fluid on the and deep breathing techniques. It is usually collection chamber (note the date and time.) It beneficial to have the patient use an incentive is important for the bottle to be at eye level spirometer prior to coughing and deep when marking the fluid level. The output for breathing. (Instruct the patient in the use of the the shift is calculated by subtracting the incentive spirometer if necessary.) The current level from the amount of the previous incentive spirometer provides forced lung mark. This amount should be recorded on the expansion that will aid in getting oxygen to Twenty-Four Hour Intake and Output the alveoli, thereby increasing the Worksheet DD 792 and in the Nursing Notes effectiveness of coughing and deep breathing. SF 510, Figures 3.30.08 and 3.30.09. When documenting chest tube drainage on the Whenever possible, instruct the patient Nursing Notes, record the at of the previous about breathing exercises prior to chest tube mark. This amount should be recorded on the insertion. Have the patient demonstrate Twenty-Four Hour Intake and Output breathing exercises to make certain he/she has Worksheet DD 792 and in the Nursing Notes a clear understanding of the purpose and SF 510, Figures 3.30.08 and 3.30.09. When technique. Exercises are usually performed documenting chest tube drainage on the every two hours. Post insertion pain may Nursing Notes, record the amount, type and interfere with the patient's ability to perform color of the drainage. If drainage output respiratory exercises. exceeds 60 ml per hour, notify the nurse and begin measuring and recording the drainage Maintenance of normal activity level will hourly. 60 ml per hour is a large amount of facilitate respiratory function and promote a output at any time other than the first few sense of well being. Assist the patient with post-operative hours. ambulation when it is ordered. Patients may be afraid to get up to walk, due to the pain during If there is a sudden change in the color or movement and fear of pulling out the tube. If type of drainage, such as previously pain medication is ordered, pre-medicate the serosanguinous drainage becoming sanguinous patient approximately 15 - 30 minutes prior to or a chest tube that had no output for the exercise. This will decrease pain and facilitate previous shift suddenly drains 60 - 100 ml, the lung expansion and ventilation.

349 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III

If the closed chest drainage system is with an analgesic should be done 15 - 30 attached to a suction apparatus, there must be minutes before the ROM exercises. a written Doctors Order for ambulation because the suction will be off while the To maintain patient comfort, it is often patient is ambulating. Before ambulating, beneficial to have the patient lie on the instruct the patient on the purpose of operative side. In addition to promoting ambulation and the technique for getting out comfort, lying on the operative side will of bed. Education will alleviate some of the facilitate expansion of the unaffected lung and patient's fear about pulling out the tube. drainage of fluids from the affected lung. When assisting the patient with coughing, To assist the patient in getting out of bed, deep breathing and incentive spirometer elevate the head of the bed approximately 45 exercises, encourage your patient to splint the degrees. Have the patient roll onto his/her chest wall on the affected side. It is best to side, then swing the legs over the edge of the plan procedures so that the patient will have bed while you assist him/her into a sitting the benefit of pain medications. Expect to position. Have the patient sit at the edge of the premedicate patients before insertion or bed for a few minutes before standing to removal of chest tubes. lessen dizziness or light-headedness. Once the patient is sitting, unplug the suction apparatus. A patient with a chest tube may have Keep the drainage apparatus below the many fears related to the insertion of the tube level of insertion at all times. Inadvertently itself, unfamiliar equipment, coughing out the allowing the drainage system to be above the tube, accidentally pulling out the tube, or level of insertion can allow drainage to flow issues related to the diagnosis (cancer, death, back into the chest cavity. The patient can disability). Encouraging the patient to support the tube by holding it in his/her hand verbalize these fears can help lessen the fears while ambulating. and promote a sense of well being. Patient education about the purpose and procedure of While ambulating, observe the patient for chest tube insertion and removal, tube care, signs of respiratory distress. If the patient respiratory exercises and activity limitations appears to be in distress, allow him/her to sit can be extremely beneficial in helping the and rest for short periods. Document in the patient adjust to this invasive procedure. Nursing Notes SF 510, the length of time the patient tolerated the activity, if he/she was pre- A knowledgeable patient is often a medicated, and any complications that the cooperative patient. By having the patient patient experienced during the exercise. verbalize understanding of instructions and Record findings from auscultation of the procedures, the corpsman can assess the lungs. Auscultation should be done at least patient's comprehension. You can then be Q4H to assess air exchange in the affected confident that the patient knows what to do in lungs. the event of damage to the closed system (clamping the chest tube and calling for help), Because a chest tube may be in place for a that he/she knows to help maintain a closed number of days, provide range of motion system, and that he/she will be ready to exercises (ROM) to the arm on the affected ambulate when allowed. side to maintain muscle function and avoid discomfort from the tube. Range of motion COMPLICATIONS OF CHEST exercises should be performed at least once TUBES per shift. Active-assistive exercises for patients with chest tubes includes ROM of the Complications can arise after the insertion shoulder girdle, flexion-extension exercises of of a chest tube. the upper arm and forearm and hand grasp exercises. As with ambulation, premedication

350 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III

Traumatic removal of the chest tube can If you suspect a tension pneumothorax, notify occur any time there is excessive force applied the nurse immediately. If ordered, milk the to the tube, for example if the tube gets caught tubing to maintain patency. on a bed rail and the side rail is pulled. Since the tube is sutured in place, traumatic removal Hypoxia, a condition where there is by may be quite painful. A pneumothorax or poor oxygenation of body tissues, can result hemothorax may occur if the pleural space from poor ventilation or a decrease in lung becomes filled with air or blood when the tube capacity (perhaps due to surgery). The patient is pulled out. In the event of a traumatic should be encouraged to perform respiratory removal, apply an occlusive dressing (using exercises as directed. Administer oxygen, if petroleum gauze) to prevent air from entering ordered. the pleural cavity. If significant bleeding is present, apply a pressure dressing to control Occlusion of the chest tube can occur hemorrhage. Notify the nurse or medical from clots or viscous (thick) drainage in the officer immediately. tubing. Milk the tube, if ordered, to maintain patency. If the tubing is occluded, the patient Infection can be recognized by the should be observed for signs and symptoms of presence of purulent drainage, erythema or respiratory distress and the nurse should be swelling at the dressing site. (The drainage notified. from the tube may be purulent as well.) An elevated temperature is another sign of Disconnection of the tubing can occur at infection. If the patient's temperature is any connection in the closed chest drainage elevated but there are no signs of infection at system. Clamp the tubing close to the patient's the insertion site, it is possible that the patient chest and notify the nurse immediately. has an atelectasis (or collapsed lung.) The care of a patient with a chest tube can A clamped or occluded tube can cause be very complex. Application of the principles tension pneumothorax. A clamped tube of good respiratory care and surgical asepsis allows a buildup of pressure in the contents of can minimize the potential complications of the pleural space without an exit. This is a life- this invasive procedure. threatening situation and requires prompt treatment. If the tubing is clamped, release the clamp and reclamp it at the end of exhalation.

351 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III

FIGURE 3.30.01 Structure of the Respiratory System

FIGURE 3.30.02 FIGURE 3.30.03 Lower Airway Empyema

352 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III

FIGURE 3.30.04 Lower Airway

FIGURE 3.30.05 FIGURE 3.30.06 Pleu-Evac Position for Chest Tube Insertion

353 Lesson 3.30 Chest Tubes Basic Hospital Corps School Handbook III

FIGURE 3.30.07 Chest Tube in Pleural Space

FIGURE 3.30.08 Nursing Notes SF 510 Entry

354 Basic Hospital Corps School Lesson 3.30 Chest Tubes Handbook III

FIGURE 3.30.09 Twenty-Four Hour Intake & Output Worksheet DD 792 Entry

355 Lesson 3.30 Chest Tubes Worksheet Basic Hospital Corps School Handbook III Lesson 3.30

Chest Tubes Worksheet

1. A tube that assists in the re-expansion of the lungs is called a ______.

2. List three things drained using a chest tube.

a. ______

b. ______

c. ______

3. The muscle that aids in respiration and divides the chest cavity from the abdominal cavity is the:

a. deltoid.

b. masseter.

c. diaphragm.

d. gluteus.

4. The right lung has ______lobes.

5. The left lung has ______lobes.

6. The visceral pleura lines the surface of the ______.

7. The parietal pleura lines the surface of the ______.

8. The potential space between the visceral and parietal pleura is called the ______.

9. The mechanism of breathing is controlled by the:

a. brain.

b. heart.

c. lungs.

d. diaphragm.

10. The movement of air into and out of the lungs is called: ______.

356 Basic Hospital Corps School Lesson 3.30 Chest Tubes Worksheet Handbook III

11. An interruption in the continuity of the pleura may allow air or fluid to enter the pleural space and cause the lungs to collapse.

a. True b. False

12. Which of the following medical department personnel may insert chest tubes?

a. Hospital Corpsman

b. Nurse

c. Physician

d. Medical student

13. Mark the two types of suction units used for thoracic suction.

a. Wall unit

b. Portable unit

c. Floor unit

d. Bed unit

14. Chest tube placement must be verified by a CAT scan after insertion.

a. True b. False

15. A portable, disposable thoracic suction system with three chambers is called a ______.

16. A one-way valve used in the field that provides a temporary seal for chest tubes by allowing exhaled air to escape through the valve, but prevents the return of air into the pleural space is a:

______

17. Circle the equipment necessary to maintain a chest tube.

a. Sterile occlusive dressing

b. Drainage system

c. Suction unit

d. Airway

18. The surgical removal of a lobe of the lung is called ______.

19. Injection of a caustic substance into the pleural space through a chest tube to cause scarring and sealing of the lung surface is called: ______.

357 Lesson 3.30 Chest Tubes Worksheet Basic Hospital Corps School Handbook III

20. Circle each traumatic non-surgical condition that would require chest tube placement.

a. Tension pneumothorax

b. Open heart surgery

c. Puncture wounds

d. Open pneumothorax

21. When maintaining a chest tube, a/an ______dressing should always be used.

22. List three signs/symptoms of chest tube insertion complication.

a. ______

b. ______

c. ______

23. Bubbling in the water seal chamber indicates a/an ______.

24. The technique of cleaning the tubing to maintain chest tube patency is called declotting.

a. True b. False

25. Chest tube drainage is recorded on the:

a. ______

b. ______

26. If there is a sudden change in the color or type of drainage from a chest tube:

a. tell the patient.

b. immediately notify the nurse.

c. immediately note it on the Nursing Notes SF 510.

d. ignore it, because it is normal.

27. Chest tube drainage output that exceeds 60 ml per hour should be measured hourly.

a. True b. False

28. A chest tube should be clamped if the drainage system is destroyed.

a. True b. False

358 Basic Hospital Corps School Lesson 3.30 Chest Tubes Worksheet Handbook III

29. List three techniques that aid the respiratory care of the patient with a chest tube.

a. ______

b. ______

c. ______

30. When ambulating a patient with a chest tube, the drainage apparatus should be kept above the level of insertion at all times.

a. True b. False

31. Administration of pain medication 15-30 minutes prior to ambulation will increase patient comfort.

a. True b. False

32. Traumatic removal of a chest tube may result in what complications?

______

33. In the event of traumatic chest tube removal what kind of dressing should be applied to prevent air from exiting?

______

34. Purulent drainage, erythema, and swelling at the insertion site and fever are signs of:

a. tension pneumothorax.

b. infection.

c. hypoxia.

d. occlusion.

35. Poor ventilation or a decreased lung capacity may result in a/an:

a. tension pneumothorax.

b. infection.

c. hypoxia.

d. occlusion.

36. A disconnected chest tube should be clamped as close as possible to the suction apparatus.

a. True b. False

359 Lesson 3.34 Respiratory Care Basic Hospital Corps School Handbook III Lesson 3.28

RESPIRATORY CARE

Terminal Objective:

3.28 List concepts and principles of respiratory care.

Enabling Objectives:

3.28.01 Define medical terms related to respiratory care.

3.28.02 State the purposes and procedures for assisting a patient with effective coughing, deep breathing and an incentive spirometer.

3.28.03 State the purpose and describe the procedure for postural drainage, chest percussion and vibration.

3.28.04 State the purpose and procedure to collect an arterial blood gas.

3.28.05 State the purpose, procedure, and special considerations related to tracheostomy tube care.

Respiratory care is important to all Bronchial - refers to the sound of air patients in the hospital because they have a rushing through the larger airways. decreased level of activity. Less activity leads to less chest and lung expansion. Secretions Dyspnea - difficult or labored breathing. can accumulate, providing an opportunity for bacteria to multiply. Some patients are Expectorant - substance which aids in admitted for care related to the respiratory loosening and removal of secretions. system. Others will have surgery, and need respiratory care to prevent post-operative Expectorate - to cough up and spit out complications. Basic terminology and mucus or sputum. respiratory care will be covered in this lesson. Hyperventilation - increase in the rate TERMS and/or depth of respiration, which alters CO2 exchange. Apnea - cessation of breathing; also called respiratory arrest. Hypoxemia - decreased oxygen concentration in the blood. Atelectasis - the collapse of alveoli in the lungs. It may be caused by poor ventilation or Hypoxia - reduction of oxygen in the poor chest expansion. body tissues.

Bradypnea - abnormal slowness of Incentive Spirometer - mechanical breathing. device that provides a means of lung volume

360 Basic Hospital Corps School Lesson 3.28 Respiratory Care Handbook III measurement when performing deep breathing operatively due to decreased ventilation from exercises. anesthesia and pain. For example, an incision can be painful when moved or stretched, Orthopnea - condition in which breathing which happens when taking a deep breath. is easier when the patient is in a sitting or standing position. To assist a patient with effective coughing and deep breathing, use this procedure: Pneumonia - inflammation of the lungs, usually caused by an infectious agent. 1. Medicate the patient 30 minutes before deep breathing, if necessary. Rales (or crackles) - crackling, rattling, or bubbling sounds that occur when air enters 2. Wash hands. Gather equipment - emesis smaller, fluid filled airways during inspiration. basin, tissues, and stethoscope.

Rhonchi - rumbling or gurgling sounds 3. Explain all procedures, including the heard on expiration as air moves through importance of deep breathing and larger airways containing fluid or secretions. coughing. Rhonchi are often described as snoring sounds. 4. Auscultate the lungs before the procedure.

Tachypnea - respiration rate that is 5. Assist the patient into a sitting position, excessively rapid. with his/her feet on the floor. (If necessary, the patient can lie in bed on the Tracheostomy - an artificial hole or back or side with the knees flexed.) This opening (stoma) made into the trachea to position allows the patient to use allow air passage into and out of the lungs. abdominal muscles that help to deliver a forceful expiration. The feet give stability Tracheostomy tube - cannula inserted and aid in pushing during forceful into an artificial opening in the trachea. expiration.

Vesicular sounds - normal inspiratory 6. Splint painful areas to decrease pain and sounds with little or no noise heard throughout permit a more forceful expiration. A exhalation. folded sheet, a pillow, a sandbag, or hands (yours or the patient's) are used to support Wheezing - high pitched whistling sounds tissue, especially incisions or chest tube that occur in a partial airway obstruction insertion sites. Decreased movement of during inspiration or expiration. these structures means less pain for the patient. COUGHING AND DEEP BREATHING 7. Instruct the patient to take a deep breath through his/her mouth while counting to Coughing and deep breathing are used to five or seven, at one second per count. prevent respiratory complications such as Encourage him/her to use the diaphragm. atelectasis and pneumonia, and to move secretions to the large airways to be coughed 8. Have the patient hold his/her breath for out. Patients need to be well hydrated to thin three seconds, then exhale through pursed secretions for easier removal. Often, patients lips for twelve to fifteen seconds. will be taught how to cough and deep breathe (Exhaling through pursed lips causes back effectively as part of preoperative care. pressure which keeps the alveoli Atelectasis and pneumonia occur post- expanded.) As the patient exhales, tell

361 Lesson 3.28 Respiratory Care Basic Hospital Corps School Handbook III

him/her to contract the abdomen toward the spine. 3. Explain the procedure and its purpose to the patient. Set the spirometer to the initial 9. Repeat this procedure three or four times, desired goal (usually 500-ml.) resting for a few seconds between each breath. 4. Auscultate lungs to establish a baseline for later evaluation. 10. Have patient cough. Ask him/her to inhale deeply, splint the abdomen, and give two 5. Position the patient sitting at the bedside or three (deep) coughs while exhaling. If or in high Fowler's position. sputum is expectorated, hand the patient a tissue. 6. Instruct the patient to exhale, emptying the lungs as much as possible. 11. Auscultate the lungs to reassess the patient's breath sounds. 7. Have the patient seal his/her lips around the mouthpiece of the spirometer and 12. Repeat the exercise Q2H. immediately inhale. Encourage the patient to take a deep breath, maintaining a seal 13. After the procedure, provide comfort around the mouthpiece. measures as needed. 8. The patient holds the inspiration for three 14. Document the procedure on the Nursing to five seconds. Notes SF 510. Note the number of deep breathing exercises performed, the quality 9. After holding the inspiration, the patient of the cough, breath sounds before and may relax and exhale. Have him/her take after the procedure, whether sputum was several breaths before repeating the produced (if so, describe it in terms of incentive spirometer exercise. (A typical color, odor, consistency, and amount), and exercise set is ten repetitions, each taking the patient's tolerance of the procedure. about one minute.)

INCENTIVE SPIROMETER 10. Increase the patient's goal level when he/she can easily reach the current level. An incentive spirometer may be used to prevent atelectasis and to move secretions to 11. Encourage the patient to cough after a the large airways to be coughed out. The deep breath, using the basic principals of device allows the staff and the patient a means effective coughing and deep breathing. of seeing his/her current respiratory volume at Splint the abdomen as necessary. work. Patients can follow their own progress, and reach for realistic higher levels. The 12. Auscultate the lungs to reassess the procedure for using the incentive spirometer patient's breath sounds. is: 13. Record the procedure in the Nursing Notes 1. Medicate the patient, if ordered, 30 SF 510. Note the procedure done, how minutes before the procedure. many times done and the average volume attained with each maximal inspiration. 2. Wash hands. Gather equipment - Incentive Describe the quality of the cough, and spirometer, tissues, emesis basin, and a characteristics of any sputum produced stethoscope. (Incentive spirometers are (color, odor, consistency, and amount.) disposable items used for one patient only. Document the breath sounds before and The spirometer stays at the bedside after the procedure and the patient's between uses.) tolerance of the exercise.

362 Basic Hospital Corps School Lesson 3.28 Respiratory Care Handbook III

POSTURAL DRAINAGE 10. Auscultate the lungs to reassess the patient's breath sounds.

Postural drainage is a technique for 11. Perform oral hygiene and reposition the clearing secretions from air passageways by patient for comfort after the procedure. placing the patient in various positions.

Gravity is used to promote drainage. The 12. Record the procedure on the Nursing procedure for postural drainage is: Notes SF 510. Note the type of treatment

performed, the lobes of the lung which 1. Verify the Doctor's Orders for area(s) to were drained, the length of the treatment, be drained. and the quality of the cough. Describe the

sputum produced, document the breath 2. Wash your hands. Gather the equipment - sounds before and after the procedure, and emesis basin, tissues, towel, and the patient's tolerance of the procedure. stethoscope.

3. Explain the procedure and its purpose to CHEST PERCUSSION AND the patient. VIBRATION

4. Assess the patient's breath sounds to Chest percussion and vibration (also establish a baseline for later evaluation. called chest physiotherapy) should be done in conjunction with postural drainage to aid in 5. Position patient in the desired or breaking up respiratory secretions so that they prescribed drainage position. Incorrect can be coughed up. The procedure for chest positioning will let secretions drain deeper percussion and vibration is: into the lungs. Common areas to be drained include the posterior basilar 1. Verify the Doctor's Orders for the area(s) segments, the right middle lobe and to be percussed and vibrated. (Plan to do lingular (nipple line) segment of the left percussion and vibration in conjunction lung, and the apical segments of the upper with postural drainage.) lobes. Prepare the patient for comfort, since postural drainage positions may be 2. Wash your hands. Gather the equipment - held for up to 45 minutes (as tolerated.) emesis basin, tissues, towel, and Assess for respiratory distress when the stethoscope. patient is in a drainage position. 3. Auscultate the lungs anteriorly and 6. Have the emesis basin and tissues ready to posteriorly prior to beginning the catch secretions, within easy reach of the treatment to establish a baseline for later patient. evaluation.

7. Protect any exposed skin area with a 4. Position the patient in the desired or towel. prescribed postural drainage position.

8. Encourage the patient to cough. 5. Protect any exposed skin area with a towel. 9. Discontinue the procedure if any of the following complications occur: 6. Percuss over the desired segments and/or Tachycardia, palpitations, dyspnea, chest lobes with your hands held in a cupped pain, fatigue, or lightheadedness. Be alert fashion. Never percuss over the kidneys, for nausea. soft tissue (like the breast), the sternum or

363 Lesson 3.28 Respiratory Care Basic Hospital Corps School Handbook III

the spine. Instruct the patient to inhale patient's acid/base balance and oxygen and slowly and deeply, then exhale passively carbon dioxide levels. Critical information for through pursed lips while percussing. clinical decisions is obtained from ABG (Exhaling through pursed lips causes back results. ABG specimens are collected by pressure which keeps the alveoli physicians, certified technicians, or registered expanded.) Vibrate the chest wall while nurses. This is a potentially dangerous the patient is exhaling. Place one hand on procedure because an artery must be top of the other over the affected segment punctured to obtain the specimen. Corpsmen of the chest. Apply gentle vibration over often assist with ABG collection. The the affected segment. Ask the patient to following procedure is: breathe deeply four to six times with prolonged expiration. Encourage the 1. Wash hands and gather the equipment - a patient to cough, using abdominal blood gas chit, blood gas syringe, needle, muscles, after three or four vibrations. clean gloves, sterile gauze, and container of ice. 7. Continue percussion and vibration for at least three to five minutes per lobe. 2. Explain the procedure and its purpose to the patient. 8. Position the patient to allow secretions to drain from the lower areas of the lungs to 3. After the specimen is drawn, apply firm, the large air passages, promoting more direct pressure to the puncture site. efficient removal of secretions. Manual pressure is maintained for 5-10 minutes until the bleeding stops. A 9. Discontinue chest physiotherapy if any of pressure dressing is applied after the these adverse changes occur: Fatigue, manual pressure. tachycardia, palpitations, dyspnea, lightheadedness, or chest pain. 4. Immediately after the ABG specimen is drawn, the specimen is placed in a 10. Auscultate the lungs anteriorly and container of ice to reduce the continued posteriorly, reevaluating the breath sounds metabolism of oxygen and production of after percussion and vibration. carbon dioxide. (Blood cells are living, and will continue metabolic processes.) 11. After the procedure, perform oral hygiene Any air bubbles are removed to prevent and reposition the patient in a comfortable contamination of the specimen with position. atmospheric oxygen before the sample is placed on ice. ABG samples are sent to 12. Record the procedure on the Nursing the lab as soon as possible. Notes SF 510. Indicate the lobes drained, the type of treatment performed, the 5. Observe the puncture site every 15-30 length of the treatment, and the quality of minutes for bleeding. If bleeding or the cough. Describe the character of the swelling starts, reapply pressure and notify sputum produced, the breath sounds the nurse. before and after the treatment, and the patient's tolerance of the procedure. 6. Clean and dispose of all equipment.

ARTERIAL BLOOD GAS 7. Record the procedure on the Patient SPECIMENS Profile NAVMED 6550/12 on the backside, right hand column, in the Lab Arterial blood gas (ABG) specimens are test section. (Enter the date the specimen collected to provide information about a was sent to the lab.) On the Nursing Notes

364 Basic Hospital Corps School Lesson 3.28 Respiratory Care Handbook III

SF 510 record the procedure and the patient's tolerance to the procedure. 5. Open the suction set and the tracheostomy care kit aseptically. TRACHEOSTOMY TUBE CARE 6. Don clean gloves.

A tracheostomy is an artificial hole or 7. Preoxygenate the patient before suctioning opening (stoma) into the trachea to allow air by hyperventilating him/her with 100% passage in and out of the lungs. The oxygen connected to the bag-valve-mask tracheostomy cannula is inserted into the unit. (Suctioning the patient will remove opening to maintain the patency of the oxygen from the lungs.) artificial airway and to prevent infection of the lungs. Patients with tracheostomy tubes cannot 8. Discard clean gloves and don sterile filter air through the mouth and nose. Sputum gloves. Open the water cup, and have an is coughed out through the tube, which can assistant pour sterile water into the cup. (If become plugged with secretions. Suctioning is the kit allows you may pour the water done to prevent the accumulation of before donning the sterile gloves.) secretions, or to clear a clogged tracheostomy tube. At times, a doctor may order collection 9. Use aseptic technique during the of a sputum specimen from a tracheostomy. procedure to prevent infection.

Most tracheostomy tubes are made of 10. Attach the sterile suction catheter to the plastic and have two pieces, an inner cannula suction tubing. One hand will become and an outer cannula. The inner cannula must contaminated, so be sure to keep the be cleaned periodically to prevent infection. sterile hand sterile. Most facilities require tracheostomy care Q8H

(and PRN.) Inner cannulas may be reusable or 11. Lubricate the first few inches of the disposable. Disposable inner cannulas are suction catheter with sterile water to ease removed (wear clean gloves) and discarded, its passage into the cannula. then a new, sterile inner cannula is inserted quickly but gently. Reusable inner cannulas 12. Test the suction by covering the hole near are replaced by using this procedure: the distal end of the catheter with the

contaminated (now considered a clean 1. Check the Patient Profile NAVMED glove) hand. 6550/12 for the procedure to be

performed. 13. Insert the catheter slowly and carefully

about six to ten inches into the 2. Wash hands and gather equipment - clean tracheostomy. Stop if you meet resistance. and sterile gloves, tracheostomy care kit, (Do not suction while inserting the sterile suction set, sterile water, oxygen catheter.) delivery device (bag-valve-mask device),

suction device, and when needed, a sterile 14. Apply suction for no longer than 15 specimen container. seconds, as the catheter is withdrawn.

3. Place the patient in high Fowler's position 15. Flush the catheter with sterile water. if possible. Assess breath sounds. Allow the patient to rest between passes.

Repeat the procedure until the tube is 4. Wipe away any secretions that have clear. accumulated at the tracheostomy opening.

Use a lint free wipe, since the patient may

inhale lint directly into the lungs.

365 Lesson 3.28 Respiratory Care Basic Hospital Corps School Handbook III

16. To collect a sputum specimen, use a sterile before and after the treatment, and the sputum trap attached to the suction tubing. patient's tolerance of the procedure Keep the trap upright or the contents will Tracheostomy tubes require special be sucked into the drainage tubing. considerations:

17. After suctioning, remove the inner cannula 1. Always use sterile suctioning technique and replace with another reusable inner because the tracheostomy leads directly to cannula. Most patients will have one clean the trachea and lungs. cannula ready. When a spare inner cannula is not available, clean and replace 2. Prior to obtaining a specimen, the inner cannula within five minutes of hyperventilate patient with 100% oxygen, removal. because suctioning will remove oxygen from the airway. 18. Replace the tracheostomy ties PRN, and always be sure that the ties in place are 3. Ensure you know how to use the special securely fastened. suction trap to obtain the specimen.

19. Reassess breath sounds. Provide comfort 4. The inner cannula should be cleaned at measures. least every eight hours. Once the inner tube has been removed, it must be 20. Clean and dispose of all equipment. replaced within five minutes.

21. Document the care provided on the 5. Ensure the tracheostomy tube is securely Nursing Notes SF 510. Note the type of fastened before leaving the patient. treatment performed, the character of the sputum produced, the breath sounds

366 Basic Hospital Corps School Lesson 3.28 Respiratory Care Handbook III

NOTES/COMMENTS

367 Lesson 3.28 Respiratory Care Worksheet Basic Hospital Corps School Handbook III Lesson 3.28

Respiratory Care Worksheet

1. Match each definition in column B to the correct term in column A.

A B

a. Apnea ______1. Rumbling or gurgling sounds heard as air moves through larger airways. b. Dyspnea ______2. Difficult or labored breathing. c. Hypoxia ______3. Exhalation which has little or no noise. d. Hypoxemia ______4. Cessation of breathing e. Rales ______5. Reduction in oxygen in body tissues. f. Rhonchi ______6. Crackling sounds heard during inspiration. g. Vesicular ______7. Decreased oxygen concentration in the blood.

2. Coughing and deep breathing is used to:

a. explain pre-operative respiratory care.

b. prevent post-operative atelectasis.

c. move secretions to smaller airways.

d. increase ventilation during anesthesia.

3. Patients should be in a sitting position for coughing and deep breathing.

a. True b. False

4. An expectorant aids in loosening and removal of secretions.

a. True b. False

368 Basic Hospital Corps School Lesson 3.28 Respiratory Care Worksheet Handbook III

5. Splint painful areas during coughing and deep breathing to:

a. prevent wound dehiscence.

b. prevent pathological fractures.

c. decrease pain during coughing.

d. immobilize strained muscles.

6. List three items that may be used to splint painful areas during coughing and deep breathing.

a. ______

b. ______

c. ______

7. An incentive spirometer is a mechanical device that forces air in and out of the lungs.

a. True b. False

8. The patient should exhale as much as possible just before using the incentive spirometer.

a. True b. False

9. List three areas that commonly need postural drainage.

a. ______

b. ______

c. ______

10. List four reasons to discontinue postural drainage.

a. ______

b. ______

c. ______

d. ______

11. Chest percussion and vibration should be done in conjunction with postural drainage.

a. True b. False

369 Lesson 3.28 Respiratory Care Worksheet Basic Hospital Corps School Handbook III

12. Percussion may be performed over:

a. lung lobes or segments.

b. either kidney.

c. soft tissue, like the breast.

d. the sternum or spine.

13. Vibration is done while the patient is exhaling.

a. True b. False

14. Arterial blood gas specimens are collected:

a. when the doctor asks for a fresh blood sample.

b. routinely during admission to the hospital.

c. only on pediatric patients.

d. to get information on a patients oxygen/carbon dioxide levels.

15. ABG may be collected by any corpsman.

a. True b. False

16. The ABG sample must be kept warm until delivered to the lab.

a. True b. False

17. A tracheostomy tube must:

a. be suctioned periodically to prevent infection.

b. be removed every hour for cleaning.

c. never be touched because it keeps the airway open.

d. be sutured to the patient's skin for security.

18. Most local protocols require that a tracheostomy tube be suctioned at least every ______hours.

a. 2

b. 4

c. 8

d. 12

370 Basic Hospital Corps School Lesson 3.28 Respiratory Care Worksheet Handbook III

19. Before suctioning a tracheostomy:

a. place the patient in the Trendelenburg position.

b. always perform chest percussion and vibration.

c. hyperventilate the patient with 100% oxygen.

d. make sure that the breath sounds are clear.

20. During tracheostomy cleaning, suction is applied for no longer than 15 seconds, and only when withdrawing the catheter.

a. True b. False

371 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III Lesson 3.23

Preoperative and Postoperative Care

Terminal Objective:

3.23 List concepts and principles of preoperative and postoperative medical care.

Enabling Objectives:

3.23.01 Define the types of anesthesia used in surgery.

3.23.02 List guidelines for preparing the patient for surgery.

3.23.03 List guidelines for meeting the psychological needs of a preoperative patient.

3.23.04 List guidelines for documenting preoperative nursing care.

3.23.05 List supplies and equipment used for postoperative nursing care.

3.23.06 State nursing care measures performed upon arrival of the postoperative patient to the ward.

3.23.07 State observations of postoperative patients that should be reported or recorded.

3.23.08 State nursing interventions for treatment of postoperative complications or symptoms.

3.23.09 State guidelines for patient safety, privacy, education, and comfort for postoperative patients.

3.23.10 Report and record pertinent observations on postoperative patients.

Skilled nursing care given during the the unavoidable feeling of loss of control are preoperative time will aid in preparing the prominent fears of many patients. patient for surgery, both physically and emotionally. All members of the health care Anesthesia refers to the loss of sensation team will focus on the needs of the patient in to an area and is desired to eliminate the administering care. uncomfortable sensations associated with an invasive procedure such as surgery. The ANESTHESIA following are the major types of anesthesia that are usually used during surgical During physical preparation of the patient, procedures. or during preoperative teaching, staff may be questioned about the types and effects of General anesthesia is administered by anesthesia. Honest and simple answers may do inhalation or intravenous injections and much to prepare the patient mentally for produces a state of unconsciousness. It causes surgery. The anticipated sensation of pain and a lack of sensation throughout the body.

372 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care

Regional anesthesia is a lack of sensation Preoperative teaching is documented in the due to an interruption of the nerve sensation in Nursing Notes SF 510. any region of the body. Does not result in loss of unconsciousness. Field block is a type of Numerous procedures assist in preparing regional anesthesia. The blocking of nerve the patient for surgery. Physical preparations impulses in the particular field or area results include skin preparation such as a bath or when local anesthetics are injected into shower with an antibacterial soap. A shave of surrounding tissues of an area to be operated the operative site may also be ordered, Figure on, such as an arm, a leg, a finger, etc. 3.23.01. A cleansing enema may be ordered to reduce postoperative abdominal distention and Spinal anesthesia is another type of constipation. Explain to the patient that he/she regional anesthesia. The anesthetic agent is will be NPO from 2400 until the surgery is injected in the subarachnoid space of the completed. The lack of food in the stomach at spinal cord. Sensations the body will be lost the time of surgery prevents aspiration in the distal to the injected area. This anesthesia is event the patient vomits. Place an NPO sign at not used for surgery above the diaphragm as it the bedside to remind the patient and all staff could cause breathing difficulties. members that the patient is NPO.

PREOPERATIVE PREPARATION The morning of surgery, the final preparations for the patient's trip to the Essential to preparing the patient for operating room takes place. Vital signs are surgery is to ensure adequate rest, nutrition taken prior to the patient leaving the ward and and hydration, and to complete preoperative recorded on the Vital Signs Record SF 511 teaching. Teaching should include instructions and on the preoperative checklist. During on events that will occur before surgery and surgery, the preoperative vital signs will be those that will be occurring after surgery. Pre- used as the baseline to determine high and low op events to be explained include: values. The patient needs to remove all jewelry. If the patient objects to having the 1. skin preparation -- shower, scrub, and wedding band removed, it may be secured to shave of surgical area the finger with tape or gauze. If the jewelry is not sent home with a family member, it must 2. pre-op medication be inventoried using the Valuables Envelope NAVMED 6010/8 and secured per local 3. equipment -- IVs, NG tube, Foley catheter policy.

4. procedures -- lab tests, x-rays, enemas All prosthetic devices will be removed - dentures, eyeglasses, contact lenses, artificial 5. NPO from 2400 until surgery limbs. Local policy will indicate that hearing aids may be worn to the operating room so the Teaching about postoperative events will patient can follow instructions prior to facilitate patient compliance and decrease receiving anesthesia. Hairpieces, combs, postoperative complications. Postoperative bobby pins, barrettes are all removed. Nail events include polish is removed from fingers and toes.

1. respiratory care When the operating room staff notify the ward that they are ready to receive the patient, 2. foot and leg exercises the final On-Call preparations are made. Re- confirm the patient's identity and ensure that 3. pain control the correct identification bracelet is secured to his/her wrist. Instruct the patient to void prior 4. wound care to receiving the preoperative medication. After

373 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III the preoperative medication is given instruct remember to refer to someone more qualified the patient to remain in bed. To ensure patient if you do not know the answer. Be aware of safety, raise the bed rails and place the call bell the importance of providing spiritual support. within reach. Document administration of the Individual religious differences should be medication of the Medication Administration recognized. Listen carefully for patients who Record (MAR) NAVMED 6550/8, the indicate a need or desire for spiritual support. Nursing Notes SF 510, and on the preoperative Contact a chaplain for the patient when checklist. requested.

The patient may go to the operating room DOCUMENTATION wearing only a hospital gown or be sent without any clothes. Provide for patient Documentation of preoperative nursing privacy when transferring to the gurney and care is done in the preoperative checklist and when being transported in the hallway. in the Nursing Notes SF 510. The various procedures on the preoperative checklist The ward staff must review the entire should be checked and initialed as they are preoperative clinical record and check for completed. While the checklist format may completeness. The chart should contain a pre- vary between hospitals, the items on the op pack of clinical forms. The staff should preoperative checklist will include: ensure that all forms are properly addressographed and that the front hard cover 1. Physical preparation of the patient: of the clinical record has the following attached: a. skin preparation (shower, scrub, and shave) 1. Patient's Addressograph card, b. NPO status 2. Allergy label, if applicable, c. enema 3. Pre-op checklist, with check marks and initials to indicated completed orders and d. urinary tract preparation (voiding/catheter procedures in preparation for surgery. placed)

PSYCHOLOGICAL NEEDS OF e. bath/shower PREOPERATIVE PATIENTS f. oral hygiene - dentures removed The need for psychological support will vary greatly according to the patient's age, g. jewelry removed or secured diagnosis, cultural and educational background, family, and occupations. There h. prosthesis, eyeglasses removed are numerous ways the staff can help meet the psychological needs of a pre-op patient. To i. hairpins and hairpieces removed help reduce apprehension, use laymen's terms when explaining pre-op and postoperative j. nail polish removed activities. Try to empathize with the patient to anticipate their concerns and need for 2. Most recent vital signs emotional support. Since family members have many of the same concerns as the patient, 3. Correct ID band on patient every effort should be made to include family members during patient teaching. Answer 4. Consent forms signed questions as completely as you can, but 5. Pre-op medications given

374 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care

6. Lab test results in chart 6. Forms

A Nursing Notes SF 510 entry should include a. Nursing Notes SF 510 to record post- the physical preparation of the patient (shower, op observations. shave, and medications), emotional preparation, education and patient b. Plotting Chart SF 512 to record post- comprehension, and safety measures provided. op vital signs. An entry is also made when the patient leaves the ward and should include mode of transport c. Twenty-Four Hour Intake & Output to the operating room and the name of the Worksheet DD 792 to record intake person accompanying the patient. and output.

POSTOPERATIVE NURSING d. Completed Recovery Room Record. CARE EQUIPMENT e. Anesthesia Report SF 517. Equipment that will be needed for the immediate care of the postoperative patient f. Post-op Doctor's Orders SF 508. includes: NURSING CARE MEASURES 1. Postoperative bed with linen fan-folded back and side rails attached. Prior to the patient's arrival on the nursing care ward, the Recovery Room personnel will 2. IV pole have called a report to the ward nursing staff. It should be a nurse to nurse report. The report 3. Emesis basin generally includes a brief synopsis of the surgical procedure, any complication 4. Respiratory aids: encountered during surgery and recovery from anesthesia, condition of the dressing, IV a. Artificial airway solution and intake, any tubes or drains in place and the amount of drainage from them, b. Suction equipment condition of the dressing, urinary output, and any medication given along with time of c. Oxygen equipment administration.

d. Pillow/folded sheet for abdominal Quickly read the recovery room report, support Anesthesia Report SF 517, and post-op Doctor's Order SF 508. The post-op orders e. Incentive spirometer should be reviewed with particular attention to the following information: IV solution, vital f. Tissues signs regime, N2O administration, any medications needed, intake and output, food 5. Vital signs equipment: and fluids to be given, activity level, wound care, and any laboratory work needing to be a. Sphygmomanometer completed. In addition the Anesthesia Report should be reviewed for the agent used, any b. Stethoscope complications, and time extubated. The Recovery Room Record should also be briefly c. Thermometer reviewed for the patient's general condition, intake and output during the recovery phase, medications given during this period, and level of consciousness.

375 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III

Upon the patient's arrival to the ward, The general condition of the patient should assist with transferring the patient from the be closely monitored. Cardiovascular function gurney to the bed, while supporting and should be assessed by observing skin color, protecting the head, extremities, drainage body temperature, capillary refill, and color of tubes, and all IVs. Make sure the patient is mucus membranes. Take a few minutes to adequately covered during the transfer closely observe the patient's skin to ensure procedure. there are no abrasions or bruises that may have inadvertently occurred during the transfer from A patent airway must be maintained at all bed to gurney, and from restraining straps times. Keep the patient's chin up and pull the utilized in the operating room. jaw forwarded if it is necessary to maintain the airway. (Similar to the modified jaw thrust Most importantly, observe the site of the used in BLS.) The patient should be positioned operation. Check the location and size of the on one side, or have the head turned to one dressing frequently (with vital signs.) All side to facilitate mouth drainage if the patient's drainage (type and amount) should be noted condition permits. If necessary, or if ordered, and recorded. If a dressing becomes heavily the patient should be suctioned. Most patients saturated, reinforce it and notify the nurse. Do return to the ward without an airway in place, not change the dressing unless ordered to do since it usually is removed in the operating so. The first dressing change is usually done room, or the recovery room. If the patient still by the physician. In addition, check under the has an artificial airway, do not remove it until patient for any drainage. The dressing may be the gag reflex has returned. dry and intact, but the patient may actually be lying in a pool of blood. Gravity will cause the Vital signs should be monitored according drainage to pool under the patient. to the patient's condition and the physician's postoperative Doctors Orders, generally every All tubes and drains should be located 15 minutes until stable. A common early in the postoperative phase of nursing postoperative routine is vital signs every 15 care. If you are unsure of the presence of minutes for an hour, every 30 minutes for two, drainage tubes, refer to the Anesthesia Record every hour for 4 hours, then every four hours. or the Recovery Room Record for Vital signs taken in the postoperative period documentation of their presence. A Penrose should be compared to the baseline drain may be underneath the dressing. If it is preoperative vital signs. present, you can expect more drainage.

The patient should be observed for A Hemovac, or a Jackson-Pratt drain may recovery from anesthesia. Two types of be in place. A drain removes fluid to collapse anesthesia are used in surgery, general skin flaps against underlying tissue through anesthesia or regional anesthesia. General the use of constant, gentle suction. Drains are anesthesia causes a completed loss of inserted by the surgeon during the operation sensation and consciousness, and is and sutured in place, with collection devices administered via gas or as an intravenous that are exterior to the dressing. The patient medication. The patient is fully recovered may also have a chest tube. the tubing and from general anesthesia when he/she is alert collection device should be monitored for type and oriented. Regional anesthesia is and amount of drainage. In addition, output administered by injection, which causes a loss from NG tubes and Foley catheters should be of sensation to a particular area. With regional closely monitored. anesthesia the patient does not lose consciousness. Recovery from this anesthesia All IV intake must be closely monitored is complete when full sensation and voluntary and documented. Check the rate and type of movement returns to the anesthetized area. infusion ordered. Frequently the patient will

376 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care arrive on the ward with a different IV solution surgery. Patient and family anxiety can be hanging than what is specified in the Doctor's alleviated by a brief visit. Provide Orders SF 508. (Fluids are managed by the spiritual/emotional support as needed. anesthesiologist during surgery.) Check the Reinforce preoperative teaching as needed, postoperative Doctors Orders to verify type and as the patient recovers. and rate of infusion. Note the amount of fluid received in the Operating Room and Recovery All pertinent observations should be Room (RR or PACU.) These need to be documented on the Nursing Notes SF 510 as recorded on the Twenty-Four Hour Intake and soon as possible. Notify the nurse immediately Output Worksheet DD 792. The IV site should of any unusual observations. Record the be monitored for infiltration, phlebitis, edema, following on the SF 510: inflammation, and tubing obstruction/patency as discussed in the IV therapy lesson. Record 1. Time patient was received from the IV intake on the DD 792. Recovery Room or Operating Room.

Basic nursing care is imperative to ensure 2. Vital signs on arrival to the ward. full recovery of the postoperative patient. Position the patient on one side until he/she is 3. Assessment of the airway. fully conscious and has an adequate gag reflex. If the patient has not fully recovered 4. Level of Consciousness/Recovery from from anesthesia, stay with the patient. anesthesia. Respiratory exercises should be initiated as quickly as the patient's condition permits. 5. Color and condition of the skin. Refer to the Doctor's Orders SF508 for appropriate respiratory care. The patient 6. Condition and location of dressing, drains, should be instructed to turn, cough, and deep tubes, and catheters. breathe at least every two hours. This should have been taught during the preoperative 7. IV solution, flow rate, bag number, and period. The Hospital Corpsman needs to site. reinforce this teaching, and assist the patient as necessary. If incentive spirometry is ordered, 8. Pain location and type. ensure that the patient completes the exercises. 9. Complications. All safety precautions must be closely observed. Ensure all side rails are up, even if 10. Diet and toleration of the diet. you are nearby. A groggy patient with a side rail down presents a dangerous situation. 11. Elimination and any problems. Remember, the patient's safety is your responsibility. Instruct the patient not to 12. Activity level. ambulate or sit on the side of the bed unless you are there. Ensure the call bell is within the 13. Other pertinent observations. patient's reach at all times. 14. Presence of family/significant others. Family members should be incorporated into the patient's postoperative care as soon as Vital signs are recorded on the Plotting feasible. As soon as the patient has been Chart SF 512. All oral and IV intake should returned to bed and assessed, family members be documented on the Twenty-Four Hour should be allowed to visit briefly. The Input & Output Worksheet DD 792. attending physician should contact the family and provide current information concerning the patient's condition as soon as possible after

377 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III

2. Restrict the patient's activity and CIRCULATORY elevate the affected leg in straight COMPLICATIONS alignment.

The most life threatening circulatory 3. Do not massage legs or restrict complications are hemorrhage and shock. circulation in any way. Hemorrhage may be internal, external, or both. A change in vital signs or level of 4. Hot moist packs may be ordered by consciousness may be the only external the doctor for the affected leg. indication of internal bleeding. While observing the dressing for drainage, monitor An embolus is a blood clot that dislodges external bleeding. and moves through the circulatory system. It may lodge in a vital organ, resulting in an Hemorrhage and shock should be embolism that could cause severe disability or suspected when there is excessive sanguineous death. Again, the best treatment of this drainage, cool, moist skin, and/or cyanosis, a condition is prevention. If the patient develops falling blood pressure, and an increased heart an embolism, he/she will be placed on strict rate. bed rest to reduce the possibility of the clot dislodging. Symptoms may vary depending on Treatment includes: where the embolism lodges. Signs and symptoms include: Chest pain (pulmonary or 1. Keep the patient warm and in the cardiac), difficulty breathing (pulmonary), and Trendelenburg position. neurological manifestations (cerebral).

2. Reinforce the dressing, applying Treatment includes: pressure if necessary. 1. Notify the nurse immediately, if signs 3. Monitor temperature, pulse, and symptoms are present. Treatment respiration, and blood pressure. will be directed at the affected system.

4. Notify the nurse immediately. RESPIRATORY COMPLICATIONS Thrombophlebitis of the lower extremities may occur as a result of several Respiratory complications are fairly factors: injury to the vein, slowed circulation common, yet easy to prevent. Vigorous postoperatively, and dehydration. Signs and pulmonary exercises will aid tremendously in symptoms include: pain, redness, swelling, a preventing these potentially life threatening positive Homan's sign, and heat. complications. The signs and symptoms include: restlessness, anxiety, dyspnea, and As with most post-op complication, cyanosis. prevention is the key to success. Thrombophlebitis can be prevented in part by Treatment includes: early ambulation and patient education. 1. Check airway for obstruction and Treatment includes: reposition the head as necessary.

1. The physician may order 2. Suction the oropharynx as needed. antiembolism stockings to prevent the condition. 3. Administer oxygen.

378 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care

4. Administer medications ordered by d 1. Turning, coughing, deep breathing (T, doctor. C, DB) Q2H.

5. Aids for lung expansion: 2. Incentive spirometer use Q2H

a. Turn, cough, deep breath (T, C, D 3. Early ambulation. B) Q2H. 4. Maintaining hydration, push fluids if b. Incentive spirometer Q2H. not contraindicated.

c. Postural drainage as ordered by WOUND COMPLICATIONS doctor. Wound complications may also occur, 6. Notify the nurse. depending upon the underlying disease condition, physical and nutritional state of the Postoperative Pneumonia is a relatively patient, and the type of incision. common postoperative respiratory complication that results from stasis of Wound dehiscence is a separation of the secretions. Signs and symptoms include: a wound edges. It generally occurs 7-10 days productive cough, shallow respirations, postoperatively. Causes of dehiscence may elevated temperature, rhonchi, rales, and include wound infections, straining during diminished breath sounds (especially in the coughing, poor nutrition leading to slow lower lobes). Treatment measures are aimed at wound healing, and premature suture removal. prevention. Dehiscence may include all layers of the wound, or merely the superficial layers. Signs Treatment includes: and symptoms include: pain, swelling and redness, drainage, odor, separation of wound 1. Early and daily ambulation. (This is edges, and elevated vital signs - temperature, more a preventive measure than a pulse, and respirations. treatment.) Treatment includes: 2. Turning, coughing, deep breathing (T, C, DB) Q2H. 1. Notify nurse.

3. Incentive spirometer Q2H. 2. Cover wound with sterile gauze.

4. Provide respiratory therapy as ordered: Signs and symptoms of a wound infection include: pain, heat, swelling, redness, a. Oxygen therapy. drainage, foul odor, and elevated vital signs - temperature, pulse, respirations and blood b. Chest percussion/vibration and pressure. postural drainage. Treatment includes: 5. Notify nurse/doctor. 1. Notify the nurse or doctor. Atelectasis is often caused by mucus that has plugged a bronchiole. Signs and symptoms 2. Change dressings as ordered by include: tachypnea, decreased breath sounds doctor. on the affected side, cough, and fever. 3. Give medications as ordered by Treatment includes prevention by: doctor.

379 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III

4. Irrigate wounds as ordered by doctor. URINARY TRACT PROBLEMS

5. Maintain sterile technique when Postoperative patients may encounter indicated. urinary problems. Prompt identification and treatment are essential. Check the recovery Pain is expected after surgery. It is a room record to assess whether or not the subjective symptom that can be felt only by patient voided before returning to the ward, the patient. Signs and symptoms include: and if a catheter was used during the surgical restlessness, anxiety, crying, increased pulse procedure and immediate postoperative period. and increased blood pressure. Assess the urine for color, odor, consistency, and amount. Signs and symptoms of urinary Treatment includes: tract difficulties include: retention, dysuria, and incontinence. 1. Determine the location, type, and intensity of the pain to assist in Treatment includes: treatment of the cause. 1. Ensure patient voids within 8 - 12 2. Reassurance: hours postoperatively.

a. Stay with patient, as time permits. 2. Observe for any signs and symptoms of bladder distention and urinary tract b. Use a calm, supportive touch. infections. Notify the nurse or doctor, if present. 3. Activities that assist in the relief of pain, anxiety, and general discomfort 3. Catheterization may be ordered by the include: doctor.

a. Change position (unless 4. Medication may be ordered by the contraindicated). doctor.

b. Splinting the incision. GASTROINTESTINAL COMPLICATIONS c. Application of an abdominal

binder if available and ordered by General anesthesia and pain medications doctor. often cause discomfort to the postoperative

patient. Signs and symptoms of upper 4. Use techniques to distract patient: gastrointestinal complications include:

anorexia, nausea, and vomiting. a. Visit and talk with the patient.

Treatment includes: b. Music could be used to relax the

patient. 1. Place patient in Sim's position to

prevent aspiration of vomitus. Suction 5. Encourage the patient to relax through as needed. rhythmic breathing.

2. Start slowly with sips of liquid once 6. Medicate as necessary per Doctor's oral fluids are allowed, per Doctor's Order. Orders.

a. 30 minutes prior to painful dressing changes or T, C, & DB.

380 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care

3. If the patient has anorexia, encourage DISORIENTATION a slow increase in dietary ingestion, per Doctor's Orders, which will assist Disorientation may occur postoperatively in the healing process. and is generally due to anesthesia and medication. It is essential to complete a Signs and symptoms of lower baseline mental status on the postoperative gastrointestinal complications include: patient so that changes can be promptly noted. abdominal distention, constipation, Some disorientation is normal upon return to absent/hypoactive bowel sounds, and the the ward. Signs and symptoms include: patient's complaint of gastrointestinal speaking incoherently, bizarre statements, or cramping/discomfort. attempting to get out of bed (especially when reminded not to). Treatment includes: Treatment includes: 1. Ambulation when tolerated. 1. Notify the nurse immediately if the 2. The doctor may order an NG tube to disorientation progresses. relieve distention. 2. Maintain patient safety by: 3. Laxatives or cathartics may be ordered to assist bowel movements. a. Maintaining a continuous presence at the bedside. 4. NPO as ordered by doctor. b. Restrain patient as necessary.

c. Re-orientation to reality (time, place, person).

381 Lesson 3.23 Preoperative & Basic Hospital Corps School Postoperative Care Handbook III

FIGURE 3.23.01 Sites for Pre-Operative Shave Preps

382 Basic Hospital Corps School Lesson 3.23 Preoperative & Handbook III Postoperative Care

NOTES/COMMENTS

383 Lesson 3.23 Preoperative and Postoperative Basic Hospital Corps School Care Worksheet Handbook III Lesson 3.23

Preoperative and Postoperative Care Worksheet

1. Circle the steps for checking the completeness of a chart.

a. Ensure the operative permit has been filled out and signed by the patient or legal guardian.

b. Give preoperative medication before consent is signed.

c. Ensure the laboratory reports are displayed on chart prior to going to the operating room.

d. Ensure the preoperative checklist, Addressograph, and allergy label are displayed on the front of chart.

2. What type of anesthesia produces unconsciousness?

______

3. What are the types of anesthesia that do not produce unconsciousness? ______

______

4. Circle the steps that are part of the physical preparation of a patient for surgery.

a. Ensure adequate rest and nutrition.

b. Shave of operative site.

c. Shower with an anti-bacterial soap.

d. Applying nail polish to fingers and toes.

384 Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative Handbook III Care Worksheet

5. List six items or events that need to be included in the preoperative teaching of a patient.

a. ______

b. ______

c. ______

d. ______

e. ______

f. ______

6. Why is a patient NPO prior to surgery? ______.

7. List three items on the front of the chart when the patient goes to surgery.

a. ______

b. ______

c. ______

8. List three factors that may affect a patient's need for psychological support.

a. ______

b. ______

c. ______

9. List three ways to meet the psychological needs for a preoperative patient.

a. ______

b. ______

c. ______

10. List two forms where pre-op nursing care is documented.

a. ______

b. ______

385 Lesson 3.23 Preoperative and Postoperative Basic Hospital Corps School Care Worksheet Handbook III

11. List respiratory equipment needed to care for a postoperative patient.

______

______

12. Post-op vital signs are recorded on what form? ______

13. A postoperative patient should be transferred from the gurney to the bed while supporting the

______and ______.

14. What is the difference between general and regional anesthesia?

______

______

15. During initial postoperative care, the operative dressing should be observed for location and size.

a. True b. False

16. List two assessments that should be made for all drains and tubes.

______

______

17. List five observations that should be recorded for the post-op patient.

a. ______

b. ______

c. ______

d. ______

e. ______

18. The most life threatening circulatory complications during post-op recovery are dehiscence and pulmonary emboli.

a. True b. False

19. A blood clot that moves through the circulatory system is known as a/an ______.

386 Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative Handbook III Care Worksheet

20. List three aids for lung expansion when a patient experiences respiratory complications.

a. ______

b. ______

c. ______

21. List the signs and symptoms of atelectasis.

a. ______

b. ______

c. ______

d. ______

22. A patient should be medicated ______minutes before painful dressing changes or T, C, & DB.

a. 5

b. 15

c. 30

d. 60

23. Ensure that the patient has voided 8 - 12 hours postoperatively.

a. True b. False

387 Lesson 3.23 Patient Care Documentation Basic Hospital Corps School Scenarios Handbook III Lesson 3.23

Postoperative Scenario

1400 TM3 Jones has just returned from an POST-OP DOCTOR'S ORDERS. emergency appendectomy. Recovery room personnel report he has RLQ incision and dressing. 1. Return to 5E S/P appendectomy. Dressing is heavily saturated with serosanguineous drainage and was reinforced X1. Oral airway is 2. VS Q15" x 4, Q 30" x 4, Q 1H x 4, then Q 4H. out, gag reflex is present and patient is awake and moving all four extremities, but remains groggy. 3. NPO until 1800, then clear liquid diet. Foley catheter removed at 1200 and patient has not voided. NG tube removed at 1230, no nausea or 4. Advance diet as tolerated. vomiting since that time. During exam, you note the following: TM3 Jones moves all four 5. IV D5W 125 cc/hr x 2 liters, then DC if taking extremities and answers you appropriately. He fluids. drifts off to sleep frequently. Respirations are even and unlabored. Skin is warm and dry, 6. Ambulate tonight. abdomen is tense, and he is complaining of lower abdominal pain. He is unable to turn without 7. TC & DB Q1H. assistance. He is complaining of nausea and feels as though he may vomit. There is an IV of LR of 8. Incentive spirometry Q2H. 150 cc/hr in the right forearm. 9. Phenergan 25 mg IM Q6H PRN nausea.

10. Demerol 50 mg IM Q4H PRN pain.

11. I & O.

388 Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative Handbook III Care Scenario

NOTES/COMMENTS

389 Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School Nursing Care Forms Handbook III

390 Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative Handbook III Nursing Care Forms

391 Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School Nursing Care Forms Handbook III

392 Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative Handbook III Nursing Care Forms

393 Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School Nursing Care Forms Handbook III

394 Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative Handbook III Nursing Care Forms

395 Lesson 3.31 Death and Dying Basic Hospital Corps School Handbook III Lesson 3.31

Death and Dying

Terminal Objective:

3.31 List concepts and principles for physical, psychological, and spiritual care for death and dying.

Enabling Objectives:

3.31.01 State the five stages of coping with a terminal illness or death.

3.31.02 State the fears of the terminal patient and their significant others.

3.31.03 State measures that support physical, emotional, and spiritual needs of a dying patient.

3.31.04 List feelings and attitudes of health care providers concerning death and post-mortem care.

3.31.05 State the procedure for preparing a body for viewing.

3.31.06 State the procedure for preparing a body for discharge.

FIVE STAGES OF COPING culture. Individual reactions are based on a variety of factors such as age, the value we Modern society often seems to be focused attach to the dying individual, past experiences on youth and the future. In the early years of with death, religious beliefs, and cultural our lives, it is rare that we are exposed to a heritage. The quality of care given to a terminal illness or death. terminally ill patient depends on the attitudes and values of the health care personnel Generally, the terminally ill are taken out involved. of the home and cared for in a high tech institution where miracles happen every day. Take a few minutes to think about the Life is given through new hearts, lungs, and following: If I had a choice, when would I die? kidneys. Again and again, life triumphs over How would I choose to die? How do I react to death. In the United States, due to continued a young person's death? Is my reaction to the advances in technology, life expectancy death of senior citizen different? What do I continues to increase for both men and want to accomplish before I die? women. But we have not yet achieved immortality. Even though life spans are Now that you have thought about death on longer, death is inevitable. a personal level, change your focus to a professional level. A terminal illness is one in Rarely do we think about death, at least which there is no realistic hope of recovery. not until we must face our death or that of a Patients faced with a terminal illness, and their significant other. Reactions to death vary own mortality, go through several greatly from person to person and culture to psychological stages. Not all people go

396 Basic Hospital Corps School Lesson 3.31 Death and Dying Handbook III through the stages in the same order. A person grief in some form. Grieving is generally the may skip a stage or fall back a stage. Stages emotional and physical feelings dealing with may overlap. The length of a stage may range separation and loss. from a few hours to a few months. Significant others and health care staff also may go Emotional responses such as fear are through these stages and may need help. The typical for a terminally ill patient and family stages of coping with death are: members. Fears are as varied as people's attitudes towards death. Fears and the attitude 1. Denial - a psychological technique in toward death may change over time. Most which the individual believes that certain people fear death because it represents a force information may not be true. The patient over which we have no control. Common fears may say, No, not me, and think that there associated with dying are: has been a mistake. 1. Fear of Abandonment -- Many dying 2. Anger -- hostility is projected onto the patients feel isolated and alone. Such fear patient's environment, involving people may be reduced when shared with others. and situations at random. The patient may ask, Why me?, with hostility directed 2. Fear of suffering and extreme pain -- towards family members, friends, or Discomfort that cannot be relieved and is health care providers. both physically and emotionally exhausting. 3. Bargaining -- trying to make some sort of arrangement to postpone the inevitable. 3. Fear of loss of control -- Fear related to The patient may say, Yes, me, but..., often the inability to control bodily functions, bargaining with God or other higher diminished intellectual capacity, or the power. inability to maintain a previously held role. 4. Depression -- characterized by mourning for self and loss of life in general. A 4. Fear of dependence -- Most adults resent downward or inward displacement, a having to rely on others for measures that hollowness. The patient feels sadness and once were performed independently. often cries, as though mourning his/her own death. 5. Fear of body alterations -- Some terminal illnesses involve surgical removal 5. Acceptance -- Coming to terms with of body structures. Drug therapy may illness or outcome. This is the final stage cause hair loss or other changes in of coping and is not always achieved. The appearance. Patients may feel they repulse patient at this stage says, I am ready. This others. is characterized by a positive feeling and a readiness for death. This stage is usually 6. Fear of loss of dignity -- The hospital peaceful and tranquil. setting and use of highly technical equipment may cause a patient to fear As a health care provider, you are caring being treated as an object rather than as a not only for the patient, but for the entire person. family group as they move through these stages. Each stage is preparation for the next. 7. Financial ruin -- Medical expenses Some individuals reach the acceptance stage accumulate during lengthy illness, very early and others never reach it. In potentially leaving a family financially addition to patients and family, staff members devastated. involved in the care of dying patients often go through these stages. Everyone will experience

397 Lesson 3.31 Death and Dying Basic Hospital Corps School Handbook III

8. Fear of the unknown -- Threatening and unknown experiences produce fear. Such 1. Help the patient to look beyond the body fear may be reduced when shared with distortions that the illness has caused. others. 2. Assist and support efforts to conceal or SUPPORT MEASURES lessen the impact of disfigurement, such as using a wig, prosthesis, make-up, etc. In addition to the emotional components involved in the grieving process, the 3. Allow the patient as much control over terminally ill patient may require complete his/her life as possible. physical care. At this point, the primary goal of nursing care is to provide for physical needs Allow for individuality of the experience. and patient comfort: During the final stages of death, organize staff and family support so someone is with the 1. Nutritional support. patient.

2. Physical care and hygiene. Attitudes toward death are influenced by various cultural factors, including religion. 3. Pain relief. During the process of dying, there is often a difference between the patient's stated 4. Comfort and safety measures. religious beliefs, and the patient's feelings expressed during this time. Do not assume that 5. Adequate rest and sleep. involvement in a specific religion means acceptance of the beliefs or practices of the Since emotional needs are very important religion. Use a variety of ways to meet the during the dying process, help the patient and patient's spiritual needs. family to separate those things that can be known from those that cannot, while 1. Contact the chaplain or clergy if the sustaining realistic hope. Provide and patient or family desires. encourage human (social) contact. Set aside time to be with the patient. Be a good listener. 2. Respect the patient's religious beliefs. Establish rapport with the patient and his/her family. FEELING AND ATTITUDES

1. Provide consistency in patient care Your own attitude and values will affect assignments. the care that you give. At this point in your career, discussing and thinking about the 2. Be flexible in enforcing visiting hours and concept of death will help prepare you to care age restrictions. for a terminally ill patient.

3. Support the patient in his/her grief over Post-mortem care is a solemn experience losses and encourage him/her to continue requiring the utmost respect for the deceased. activities in to the extent possible. Care of the deceased includes preparing the body for viewing, preparing the body for 4. Encourage significant others to participate discharge from the ward, and completing ward in patient care. forms. The terms family member and next of kin are intended to include significant others, Allow the patient and family to talk about as applicable. the illness and dying. Maintain the self-respect and dignity of the patient and family members Death is a part of life, but may be an at all times. experience that you have not faced. Corpsmen

398 Basic Hospital Corps School Lesson 3.31 Death and Dying Handbook III may experience fear or uneasiness when indicate the equipment used to wrap a body for preparing the body. These are normal feelings. discharge. Often, a commercially At times, corpsmen feel anger, especially if the manufactured post-mortem pack is used. death was unexpected or a child. You may fear Obtain the post-mortem pack, which contains your own death. A feeling of peace can follow identification tags, absorbent padding, and a the death of a patient who had suffered a shroud or plastic sheet. Complete three chronic illness, e.g., cancer. Family members identification tags with the patient's name, may need support or may be angry. Allow social security number, grade, rank, or status, yourself, other staff members, and family diagnosis, ward, date and time of death, and members to discuss any feelings that result the name of the physician certifying the death. from a patient's death. Chaplains and experienced staff members can be a source of Place the tags on the right wrist, the right support. great toe of an adult (use the right ankle for an infant or very small child), and on the outside PREPARING A BODY FOR of the wrapping sheet at chest level. Mummy VIEWING wrap the body in the sheet. Follow local policy regarding placement of padding and ties. Some

morticians prefer that extremities not be tied to After a death, move any roommates out of prevent damaging the skin. Notify the morgue the room, when possible. Roommates should when the body is ready and transport the body be moved out before a death, if possible. to the morgue on a gurney. Some facilities Preparation of a body for viewing is the last have a special gurney to carry bodies to the privacy you can give the individual. The goal morgue. It masks the fact a deceased patient is is for the body to present a natural appearance. being transported through the hospital. Upon

return from the morgue, clean the unit, Do not remove tubes and drains unless complete the paperwork, and send the Clinical directed by local policy. In most cases, tubes Record to the Patient Affairs Office. Return and lines are tied off. (You may cut off excess the roommates to the room if applicable. lengths of tubing.) Close the patient's eyes.

Bathe the body, and change any soiled linen. Replace dentures and other prosthetic devices. ADMINISTRATIVE These items are important for embalming PROCEDURES purposes. Place the body in a supine position, with the head slightly elevated. Remove all Documentation of a death must be excess and used equipment from the room, completed along with the care of the body. e.g., IV poles, suction machines. Several administrative forms are required

Provide empathy and support to the The Seriously or Very Seriously III List family. (A statement such as, I'm so sorry that NAVMED 6320/5 is used to inform your relative died may be consoling to a commands (hospital and patient's) and notify grieving family.) Allow the next of kin to view the next of kin of the seriousness of the the body, giving them as much privacy as patient's condition. The physician completes possible. Viewing the body helps the family this form and the patient is removed from the work through the grief process. list upon death. The galley and pharmacy must be notified of the patient's death and the PREPARING A BODY FOR patient's name should be removed from the DISCHARGE bed and room.

An inventory of the patient's valuables and When the family has viewed the body and personal effects is conducted to safeguard the left the hospital, prepare the body for patient's belongings when he/she is placed on discharge to the morgue. Local policy will

399 Lesson 3.31 Death and Dying Basic Hospital Corps School Handbook III the SL/VSL or if deceased. The Patient's and attitudes that corpsmen experience while Valuables Envelope NAVMED 6010/8 is used caring for the deceased. Care of the deceased for money, credit cards, jewelry, etc., and the should be carried out solemnly and with the inventory of personal effects (local form) utmost respect for the deceased and the family is used to safeguard items such as clothing, of the deceased. Staff members will work toiletry items, etc. together to deal with the feelings brought on by the death of a patient. Until you experience the death of a patient, it is hard to understand the feelings

400 Basic Hospital Corps School Lesson 3.31 Death and Dying Handbook III

SCENARIO A only wants her mother. Leann's mother cannot be reached. Jim is a 55-year-old laborer with a diagnosis of terminal cancer. He has been a During the course of the afternoon, the patient for the last two months. The charge child's behavior becomes more and more nurse has taken care to assign the same staff withdrawn. You note that her B/P is dropping members to care for him to ensure his trust and and her pulse is rising steadily. All physicians cooperation in his treatment regime. He has are notified and are in attendance at her just finished his last chemotherapy treatment bedside. Leann is placed on a cardiac monitor and is failing rapidly. Generally, Jim is an at 1400. At 1430 the curtains are drawn around even-tempered man and his family is her bed. As the junior medical student leaves, extremely cooperative in his care. Family he tells you, Leann just died. Call her parents members have always been included in his and tell them. I can't do it. The medical student daily care. It is not unusual for his wife or son leaves the room in tears. to assist with his bed bath and daily hygiene. You took time to teach the family about his SCENARIO C physical needs and allowed the family to ask questions or discuss concerns they had. John Doe arrives in the Emergency Department at approximately 0215. He is 24 You have just returned from a one-week years old and has been in a hit and run leave period. During morning routine, as you accident. John Doe was a pedestrian struck by enter Jim's room, you notice that he glares at a drunk driver. On arrival, John Doe had no you. He then turns and faces the window, pulse, and was in respiratory arrest. You note refusing to look at you or communicate in any his pupils are fixed and dilated. There is a way. All your attempts at conversation fail, at depression on his left temporal lobe, with bone the end of your shift, you go into his room to fragments protruding inward. A full code is in attempt to find out what is troubling him. You progress with no results. After approximately find him lying face down on the floor. As you 30 minutes of resuscitation there is no return turn him over, you note his skin is cold, and he of vital signs. John Doe is pronounced dead at is not breathing. 0245.

SCENARIO B SCENARIO D

Leann is 6 year old female with a Mrs. Mary Jones is 82 years old and has diagnosis of terminal cancer. She is the darling been suffering from heart disease for twenty of the ward, everyone's favorite patient. She years. She is in the end stage of Congestive has been home on a weekend pass. When she Heart Failure and must be maintained on a returns to the hospital, Leann doesn't look ventilator to survive. The physician writes a well. You are unable to determine the NO CODE order. Twenty-four hours later, problem. Vital signs are stable, skin is warm Mrs. Jones, who has been in pain all day, goes and dry. There are no physical symptoms. The into cardiac arrest. No member of the medical child's physicians are also unable to determine staff makes any intervention, her primary any physical abnormalities. Leann, states that physician is at the bedside during this time. He she is going to die today and refuses to drink is talking to Mrs. Jones, generally trying to or eat anything, even though you offer all of make her comfortable. You cannot understand her favorites. Leann refuses to talk to you and why no attempt was made to save this woman's life. After all, isn't that our job?

401 Lesson 3.31 Death and Dying Worksheet Basic Hospital Corps School Handbook III Lesson 3.31

Death and Dying Worksheet

1. List the five stages of coping with a terminal illness.

a. ______

b. ______

c. ______

d. ______

e. ______

2. All stages of coping are demonstrated by every individual during a terminal illness.

a. True b. False

3. When a patient asks “Why me?”, he/she is in which stage of coping with death? ______

4. List eight fears that are common to patients and family members during a terminal illness.

a. ______

b. ______

c. ______

d. ______

e. ______

f. ______

g. ______

h. ______

5. Establishing a rapport with the terminally ill patient and his/her family is not necessary.

a. True b. False

6. Fear and uneasiness are normal when providing post-mortem care.

a. True b. False

402 Basic Hospital Corps School Lesson 3.31 Death and Dying Worksheet Handbook III

7. List the types of nursing care support you can render to a terminally ill patient.

a. ______

b. ______

c. ______

d. ______

e. ______

8. List two ways can you help to meet the spiritual needs of a terminally ill patient.

a. ______

b. ______

9. Your ______and ______will affect the care you give to terminally ill patients.

10. Post-mortem care is a solemn experience requiring the utmost respect for the deceased.

a. True b. False

11. List three feelings that a corpsman may experience following the death of a patient.

a. ______

b. ______

c. ______

12. List five steps to prepare a body for viewing.

a. ______

b. ______

c. ______

d. ______

e. ______

13. All tubes and drains are removed from a deceased body prior to viewing by family members.

a. True b. False

403 Lesson 3.31 Death and Dying Worksheet Basic Hospital Corps School Handbook III

14. How many tags are prepared and placed on a deceased body?

a. 1

b. 2

c. 3

d. 4

15. Circle each item recorded on the identification tags attached to a deceased patient.

a. Patient's name

b. Patient's age

c. Patient's social security number

d. Patient's address

e. Date and time of death

f. Name of the physician certifying the death

16. List two areas in the hospital that must be notified when a patient dies.

a. ______

b. ______

404 Basic Hospital Corps School Lesson 3.31 Death and Dying Worksheet Handbook III

405 Lesson 3.32 Transferring Basic Hospital Corps School and Ambulating a Patient Handbook III

Lesson 3.32

Transferring and Ambulating a Patient

Terminal Objective:

3.32 Transfer and ambulate a patient.

Enabling objectives:

3.32.01 State the location and proper use of safety devices on a wheelchair, gurney, and bed.

3.32.02 List the procedure for transferring a patient from a bed to a wheelchair.

3.32.03 List the procedure for transferring a patient from a bed to a gurney.

3.32.04 State considerations for patient safety, privacy, education, compliance, and comfort when assisting with ambulation.

3.32.05 State considerations for assisting a patient to ambulate without ambulation aids.

3.32.06 List the procedure for assisting a patient to ambulate with a cane.

3.32.07 List the procedure for assisting a patient to ambulate with crutches

3.32.08 List the procedure for assisting a patient to ambulate with a walker.

3.32.09 Transfer and ambulate a patient using various devices.

3.32.10 Record ambulation assistance on Nursing Notes SF 510

HOMEWORK

1. Reading Assignment: Read Transferring, and Ambulating Information Sheet

2. Written Assignment: Complete Worksheet 3.32.

LABORATORY:

1. The laboratory for this lesson is Performance Checklist 3.32.

406 Basic Hospital Corps School Lesson 3.32 Transferring and Ambulating a Patient Handbook III

TRANSFERRING AND AMBULATING INFORMATION SHEET

Introduction the bed to the High Fowler's position and fan fold the top sheet towards the foot of the bed. Before transferring a patient (moving a patient from one place to another), the move needs to be Place the wheelchair on the patient's strongest planned. Planning will decrease the chance of side, parallel to the bed. The foot pieces should be injury to the patient and corpsman, and make the moved to the side or removed for safer and easier move go smoother. Before moving a patient, you access. Lock the wheels. should know the patient's diagnosis, capabilities, and weaknesses. Be familiar with the equipment Assist the patient to sit on the edge of the bed and follow safety guidelines. with legs over the side. Have patient place stronger leg slightly in front of other leg. Place SAFETY DEVICES one arm around the patient's shoulder or waist, and the other arm over or under the knees. Pivot your Wheeled equipment (wheelchairs, gurneys, body to assist the patient to a sitting position. and beds) is normally equipped with lockable Watch for signs of weakness or fainting. Sudden wheels. Wheelchairs commonly have removable position changes can cause postural hypotension. and/or adjustable sides and foot pieces. These Let the patient rest as needed. make it easier for a patient to be seated in the chair. Be sure that pieces are locked in place Assist the patient into a bathrobe and place during use. Seat belts are not standard equipment slippers or shoes on his/her feet. on most wheelchairs, but can be very useful for some patients. Help the patient stand and get in the wheelchair. Face the patient and place your arms Many types of side rails are available on under the patient's arms with his/her hands on your gurneys. Most gurneys have built-in safety straps. shoulders. Assume a forward-backward stance Beds also have a variety of side rails. Some beds (one foot forward, the other backward). Support, have safety straps, but most do not. Bed safety but do not lift, the patient under the axilla to avoid straps would only for a patient who needs specific injury to major nerves and blood vessels. protection from falling. Assist the patient to lean forward from the TRANSFERRING FROM BED TO waist. On your signal, the patient will assist with WHEELCHAIR standing as you lift. Support the patient's knees by using your knee as a brace. Pivot the patient so Provide patient safety, education, and privacy that his/her back is toward the wheelchair. Have before the transfer. Explain the destination and the patient place one hand on the wheelchair arm procedures to the patient. State the reasons for and then bend the knees. Smoothly lower the safety precautions. Use good body mechanics to patient into the chair. Adjust the foot and leg rests prevent injury. Lock the wheels on the bed, check (replace them PRN) and secure all tubing and I.V. tubing for free movement, and be sure that drainage systems. dressings are secure. Remove any obstacles that may make the transfer more difficult, such as Patients who cannot stand require modification chairs and bed side tables. Place adjustable beds in of the procedure. Usually, an additional person is low position or level with the wheelchair. Adjust required to transfer such a patient.

407 Lesson 3.32 Transferring Basic Hospital Corps School and Ambulating a Patient Handbook III

As the patient's condition warrants, secure a lift the patient from the bed to the gurney. Lift the seat belt around the patient. Cover the patient's patient only high enough to clear the mattress. Use legs with a blanket (or sheet), unlock the wheel movements that are as smooth as possible during locks, and transport. Return patients to bed by lifting. The patient will feel more secure during a reversing the steps of the procedure. Document smooth transfer. Some patients will be able to pertinent information on Nursing Notes SF 510. assist fully or partially in the transfer from bed to gurney. In such cases, the corpsman provides for TRANSFERRING FROM BED TO GURNEY safety by keeping the gurney secure as the patient moves from the bed. Provide patient safety, education, and privacy before the transfer. Explain the destination and Cover the patient with a sheet or blanket, procedures to the patient. State the reasons for secure the gurney straps, and raise the side rails on safety precautions. Use good body mechanics to the gurney. Transport the patient by standing at the prevent injury. Lock the wheels on the bed, check head of the gurney and push the gurney foot first. I.V. tubing for free movement, and be sure that Return the patient to bed by following the same dressings are secure. Remove any obstacles that procedure in reverse. Document patient may make the transfer more difficult, such as instructions and use of the gurney for chairs and bed side tables. Adjust the height of the transportation on Nursing Notes SF 510. bed to a position level with the gurney. Depending on the size of the patient, up to six people may USING AMBULATION AIDS assist with the transfer. Two corpsmen of small stature cannot safely lift and carry a large patient. Provide for privacy, education, compliance, Harm could come to the patient or the staff comfort, and safety. Explain and/or demonstrate member. the correct procedure for ambulation with a cane, crutches, or a walker. Discuss the rationale for the Lower the side rails on the bed, making sure use of assistive devices. Close doors or pull the that someone is positioned on each side of the bed curtains when transferring the patient from the for safety. Loosen the draw sheet on both sides of bed. Keep the patient appropriately clothed or the bed. For best results, the draw sheet should be covered. beneath the patient from the shoulders to the thighs. When there is no draw sheet on the bed, Ensure that the floors are dry and litter free. use the bottom sheet. Place the gurney next to the Remove any obstacles that may make ambulation bed and lock the wheels. Stand at the side of the more difficult such as chairs, and bed side tables. gurney, with the second person on the opposite Have the patient wear well fitting shoes with firm side of the bed. When more assistants are soles. Slippers should be evaluated to be sure that necessary, divide them equally beside the bed and they do not increase the chance that a patient will the gurney. trip.

Ask the patient to position his/her arms across Inspect the ambulation aid. Look at the rubber the abdomen or chest. This prevents injury to the pads on top of crutches and on the crutch hand upper extremities and interference from the arms pieces. Inspect the rubber tips on the bottom of during the transfer. Ensure that tubing is free of crutches, canes, and walkers. Replace any worn or tangles and that tubing moves with the patient missing parts. during the transfer. Foley catheters, I.V.s, and NG tubes can pull out during a transfer if they get If the patient is unable to walk independently, caught between the bed and the gurney. have him/her wear a walking belt, which is a web belt worn around the patient's waist which the Roll the sides of the draw sheet or bottom corpsman can hold to provide assistance. Explain sheet close to the patient's body. On signal (usually the safety guidelines to the patient. Do not allow the person at the head gives the signal) gently slide the patient to use ambulation equipment alone the patient to the edge of the bed. Again on signal, until he/she has mastered the technique.

408 Basic Hospital Corps School Lesson 3.32 Transferring Handbook III and Ambulating a Patient

the side of the toes. Measure and adjust the hand To increase comfort, keep all movements slow pieces to allow the 20 degrees of flexion. and smooth. Periodically ask the patient about his/her level of comfort. Be alert for fatigue, Instruct the patient to support his/her weight especially the first few times a patient is on the hand pieces not the under arm pieces. ambulatory. Prolonged pressure on the axilla can result in damage to the nerves of the brachial plexus, ASSISTING WITH A CANE producing crutch paralysis. A patient can be measured in bed horizontally Canes are used for balance and support, Figure 3.32.01. Patients with musculoskeletal from the anterior fold of the axilla to the sole of deficiencies can compensate for functions the foot. Add two inches to this distance for an normally performed by the skeletal system by approximation of the proper crutch length. using a cane. Pressure placed on weight-bearing joints can be relieved through use of a cane. Crutch walking requires balance, coordination, strength, and endurance. Practice will result in A cane may be wood or aluminum. improved skill. Different gaits are used to meet the Aluminum canes have the advantage of being variety of needs placed on crutch walking patients. adjustable. Some aluminum canes have four feet The three-point gait is used when weight instead of one, and are called quad cantes. Wooden bearing is permitted on one foot. The three-point canes come in various lengths. gate is used when a cast or other condition

prevents or limits one foot from bearing weight. The top of the cane should reach the level of To use the three-point gait, the patient will bear the great trochanter. This will prevent leaning on weight on the unaffected leg and advance the the cane and poor posture. The cane is positioned weaker (or affected) leg and the crutches at the about four inches to the side of the body on the same time. The stronger leg is then moved forward unaffected side. while putting most body weight on the crutch hand pieces. When walking with a cane, the patient advances the cane at the same time as the affected The swing-through gait is a quick gait used leg is moved. When a corpsman needs to walk when the patient is able to bear weight on both feet with the patient, stay on the opposite side from the (or one foot if an amputee). Have the patient lift cane to protect your patient from falling. both feet off the ground simultaneously. Swing the body forward through the crutches while pushing ASSISTING WITH CRUTCHES up on the crutches, bearing body weight on both hands. Crutches are artificial supports used to assist patients who need help with walking because of Two-point and four-point gaits are also used. injury, birth defect, or disease, Figure 3.32.02. The These gaits constantly shift the weight between upper extremities bear body weight in crutch crutch and legs. walking. ASSISTING WITH A WALKER Like canes, wood and aluminum crutches are available. Unlike canes, both types of crutches are A walker provides a patient who does not have adjustable. To measure a patient for crutches, have good balance more support than a cane or the patient stand in a relaxed position. Adjust the crutches, Figure3.32.03. Walkers are often used by crutches so they are two inches from the axilla (the patients who are weakened following prolonged top of the crutch should come to two inches below bed rest. A walker provides stability, but does not the arm pit), when the rubber tip is on the floor allow a normal walking pattern. four inches in front of the patient and six inches to

409 Lesson 3.32 Transferring Basic Hospital Corps School and Ambulating a Patient Handbook III

When teaching a patient to use a walker, or without aids. Document your observation of instruct him/her to stand behind the walker. Be patient difficulties and/or progress with ready to give assistance to ensure patient safety. ambulation. The patient should not put his/her entire weight on the walker. Have him/her hold the hand grips at the sides of the walker. Adjust the height to permit 20-30 degrees of flexion in elbows. Instruct patient to move one foot and place it in front of himself/herself, then step into the walker and repeat the process. The corpsman should walk on the side and slightly behind the patient's affected extremity. Encourage independent ambulation, after observing that the patient is walking safely.

AMBULATION WITHOUT AMBULATION AIDS

Provide for privacy, education, compliance, comfort, and safety. Instruct the patient on ambulation without the use of ambulation aids, including safety guidelines. Close doors or pull the curtains when transferring the patient from the bed. Keep the patient appropriately clothed or covered.

Ensure that the floors are dry and litter free. Remove any obstacles that may make ambulation more difficult such as chairs and bed side tables. Have the patient wear well fitting shoes with firm soles. Slippers should be evaluated to be sure that they do not increase the chance that a patient will trip. Use a walking belt PRN.

Walk alongside the patient, keeping your arm under the patient's arm. Be alert for weakness or fainting. If the patient begins to feel faint, the corpsman should slide an arm or both arms up into the patient's axillary area. Place one foot to the side to form a wide base of support. Lower the patient to the floor by sliding him/her down your hip and thigh as smoothly as possible. Some patients will go down to the floor. Your job is to be aware of the patient's condition, prevent falls if possible, and to provide a safe transfer to the floor if necessary.

Recording Ambulation Assistance

Nursing Notes SF 510 are used to document ambulation assistance. Record any patient instruction or education related to ambulation with

410 Basic Hospital Corps School Lesson 2.02 Lifting and Moving Patients Handbook II

FIGURE 3.32.01 FIGURE 3.32.02 Ambulating With A Cane Standing With Crutches

FIGURE 3.32.03 Ambulating With A Walker

411 Lesson 3.32 Transferring and Basic Hospital Corps School Ambulating a Patient Worksheet Handbook III

Lesson 3.32

Transferring and Ambulating a Patient Worksheet

1. The______is a method of transferring a patient from the bed to the stretcher by grasping and pulling the loosened bottom sheet of the bed.

2. Unresponsive patients without suspected spinal injury should be placed in the ______position.

3. List three safety devices used on beds, gurneys, and wheelchairs.

a. ______

b. ______

c. ______

4. A gurney should be pushed from the head of the gurney, moving the patient feet first.

a. True b. False

5. When transferring a patient from bed to a wheelchair, place the wheelchair on the:

a. left side of the bed.

b. patient's strongest side.

c. right side of the bed.

d. patient's weakest side.

6. When transferring a patient from a bed to a wheelchair, be alert for signs of:

a. weakness and fainting.

b. bleeding and hemorrhage.

c. abdominal evisceration.

d. Alzheimer's disease.

412 Basic Hospital Corps School Lesson 3.32 Transferring and Ambulating a Handbook III Patient Worksheet

7. Before transferring a patient from a bed:

a. clamp the Foley catheter.

b. discontinue all I.V. lines.

c. sedate the patient.

d. secure all tubing.

8. When ambulating a patient, have the patient walk three steps ahead of the corpsman.

a. True b. False

9. When walking with a cane, the patient should hold a cane on the affected side.

a. True b. False

10. Crutches should be adjusted so the top is 2" below the axilla.

a. True b. False

11. The three-point gait is used when a patient using crutches can bear weight on either foot.

a. True b. False

12. When using the swing-through gait, a patient with crutches should lift:

a. both feet off the ground at the same time.

b. the crutches one at a time.

c. one foot, and swing the other through the crutches.

d. the crutches off the ground as much as possible.

13. A correctly adjusted walker permits _____ degrees of elbow flexion.

a. 10-20

b. 20-30

c. 30-40

d. 40-50

413 APPENDIX 1

WEIGHTS AND MEASURES CONVERSION TABLE

METRIC WEIGHT MEASURE

1 Kilogram (Kg) =1000 grams (Gm)1 Gram (Gm) 1 Gram (Gm) =.001 kilograms (Kg) 1 Gram =1000 milligrams (mg) 1 Milligram (mg) =.001 gram (Gm) 1 Milligram =1000 Micrograms (mcg) 1 Microgram (mcg) =.001 Milligram (mg)

METRIC FLUID MEASURE

1 Liter (L) =1000 milliters (ml) 1 Milliliter (ml) =.001 liter (L) 1 Milliliter (ml) =1 cubic centimeter

US LIQUID MEASUREMENTS AND METRIC FLUID MEASURES

U.S. Liquid Metric 1 drop (gtt) = .06 milliliter (ml) 15 drops (gtts) = 1 milliliter (ml) 1 teaspoonful (tsp) = 4 milliliters (ml) 1 tablespoonful (Tbsp) = 15 milliliters (ml) 1 ounce (oz) = 30 milliliters (ml) 1 cup (c) = 240 milliliters (ml) 1 pint = 480 milliliters (ml) 1 quart = 960 milliliters (ml) 4 cups (c) = 960 milliliters (ml)

APOTHECARY WEIGHT TO METRIC SYSTEM 1 grain (gr) = .065 gra = 65 milligrams (sometimes considered to be 60 to 64 milligrams)

WEIGHT CONVERSION 1 kg = 2.2 lbs

A-1-1