NRS521 - PRACTICAL CHECK LIST NRS521 - edited 2nd (1)

Centre for Nursing Studies

PRACTICAL CHECK LIST

Student’s name: ……………………………………………………..
Matriculation number: ……………………………………………

No Procedure Date / time Signature
(Lecturer/Clinical
Nursing skills Related to Neurology & Emergency:
instructor)
1 Assisting in lumbar puncture.
2 Performing neurological assessment – Glasgow coma scale

(GCS)
3 Care For unconscious patient
4 Assisting in intubation
5 Performing gastric lavage
6 Performing T&S (Toilet and suturing)
7 Insertion of IV branula
8 Venipuncture/blood specimen taking
9 Managing Emergency trolley

Page 1 Prepared by Suzana Yusof

Centre for Nursing Studies

SKILL 1: ASSISTING IN LUMBAR PUNCTURE

AIM To obtain a specimen of CSF for laboratory examination
 To administer drugs
 To measure the pressure of CSF


Assessment
 Check doctor’s orders
 Assess client’s level of knowledge about the procedure
 Reinforce doctor’s explanation
 Ensure consent form is signed
 Check vital signs: BP, PR & RR
 Take history of allergy to anaesthetic drug or antiseptic solution
 Encourage client to empty bladder
 Assess environment

PLANNING
Prepare equipment:

1. Lumbar puncture set
2. Lignocaine 1%
3. Sterile gloves
4. Face mask
5. Solution
6. Povidone/tincture iodine
7. Alcohol 70%
8. Antiseptic spray (act as protective dressing)
9. Linen protector
10.Elastoplast
11.Specimen bottles
12.Syringe: 5ml
13.Needles : 23G & 21G
14.Laboratory investigation forms: FEME, C&S, Gram stain
15.Sponge holding forceps
16.Swabs & gauze

IMPLEMENTATION 1. To gain co-operation and reduce
1. Greet client and explain the procedure. anxiety.
2. Provide privacy.
 To maintain client’s self-image.

3. Place client in lateral C-shaped position.  To widen space between vertebra and
to facilitate needle insertion.

4. Expose only lumbar region that is involved in  To maintain client’s privacy.
procedure.

5. Place linen protector underneath the area  To protect linen.
needed to be punctured.

6. Wash hands using medical asepsis technique.  To minimize transfer of microorganism
on skin and to prevent cross-infection.

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7. Put on face mask and gloves.  To maintain aseptic technique.
8. Assist doctor to:
 To facilitate procedure.
 Open set
 Open glove pack  To give emotional support.
 Pour solution  Initial drop might be mixed with blood.
 Offer local anaesthetic  To act as protective dressing and to
 Add other items as required
9. Observe or monitor the following: prevent bacteria invasion.
 Client  To give pressure to punctured wound,
 Skin color
 Respiration pattern to reduce pain and prevent leakage of
 PR cerebrospinal fluid (CSF).
 Pain  Ensure client’s comfort.
 Fluid specimen  To avoid instability of intracranial
 Amount pressure, leakage of CSF and headache.
 Color  To reduce the risk of headache.
 Content  To note any abnormalities.
 Viscosity  To obtain accurate and fast results.
10. Be with client throughout the procedure.
11. Assist doctor in collection of specimen –
discard initial drop of fluid specimen.

12. Spray punctured wound with antiseptic spray.

13. Place client in supine position, lie on
punctured wound about 4 – 24 hours.

14. Ask if client is in pain.

15. Treat client as CRIB for 24 hours.

16. Encourage client to take fluid if not
contraindicated.

17. Record amount and characteristic of CSF in
nursing notes.

18. Label and send specimens to the laboratory as
soon as possible.

19. Clean equipment and unit.

Evaluation & Documentation  To assess level of pain
 To detect signs and symptoms of
1. Monitor general condition:
 Skin color & temperature instability in intracranial pressure,
 Facial expression – pain leakage of CSF or infection.
 Level of consciousness
 Neurologic status  To identify client’s problem.

2. Listen to client’s complaint: Prepared by Suzana Yusof
 Headache
 Nausea

Page 3

3. Check vital signs: Centre for Nursing Studies
 BP
 Temperature – 4 hourly  To detect and to prevent any
 PR complications so that immediate
 RR & O2 saturation actions can be taken.

#Frequency  To ensure immediate actions can be
 Every 15 min for 1 hour taken.
 Every 30 min for 2 hours
 Every hour until stable

4. Observe puncture wound for:
 Bleeding & redness
 Swelling
 Tenderness
5. Report any abnormalities.

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SKILL 2: PERFORMING NEUROLOGICAL ASSESSMENT – GLASGOW COMA SCALE (GCS)

Purpose

The GCS is a 15-point scoring system designed to objectively assess cortical cerebral function
in conjunction with pupillary function and limb strength assessment.

Assessment
To assess degrees of coma, three aspects of functioning are considered:

 Eye-opening.
 Verbal response.
 Motor movement.

Documentation
To record a response on the ICU flowchart or the Neurological Observations (GCS) Chart: place a
dot in the middle of the box.

Sequence of Stimulation
• Arousal – the patient's wakefulness (brainstem).
• Awareness - the `thinking' aspect (cerebral cortex).
⇒ Speak, then shout
⇒ Shout and shake
⇒ Use of pain/noxious stimulus
⇒ Score the best response

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IMPLEMENTATION
1. Greet patient and introduce self.
2. Assess client level of consciousness using Glasgow coma scale (GCS)

INFANT ADULT

EYE OPENING (E) EYE OPENING (E)

- Spontaneous [4] - Spontaneous [4]

- Reacts to speech [3] - Reacts to speech [3]

- Reacts to pain [2] - Reacts to pain [2]

- No response [1] - No response [1]

- Eyes closed [c] - Eyes closed [c]

BEST VERBAL RESPONSE (V) BEST VERBAL RESPONSE (V)
- Orientated
- Babbles, follows objects[5] - Confused [5]
- Inappropriate words [4]
- Irritable, cries [4] - Incomprehensible [3]
- No response [2]
- Cries to pain [3] - ETT or Tracheotomy [1]
[T]
- Moans and grunts [2]

- No response [1]

- ETT or Tracheotomy [T]

BEST MOTOR RESPONSE (M) BEST MOTOR RESPONSE (M) [6]
- Spontaneous [6] - Obey commands [5]
- Localized to pain [5] - Localized to pain [4]
- Withdraws from pain [4] - Withdraws from pain [3]
- Flexion (decorticate posture) [3] - Flexion (decorticate posture) [2]
- Extension (decerebrate posture) [2] - Extension (decerebrate posture) [1]
- No response [1] - No response

3. Check both pupil size [1 – 8 mm] # to be done Using penlight
during eye opening assessment.
4. Check both pupil reaction
[+ = reacts, - = no reaction, c = eye closed]

5. Test for both limb movement: arms and legs
(right & left side):
[normal power]
[mild weakness]
[Severe weakness]
[spastic flexion]
[Extension]
[No Response]

# Record R & L separately if there is a difference
between two sides.
6. Check vital signs (BP, PR, RR, T & SPO2) and
document.
7. Comfort the client.

8. Report any abnormalities.  To ensure immediate actions can be taken.

# Using the table provided, assign the patient a score for each criteria. Additional all individual score to

calculate the total GCS score (3-15)

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SKILL 3: CARE FOR UNCONSCIOUS PATIENT

INTRODUCTION:

● The patient is unaware of what is going on around him and is unable to make purposeful
movement.

● The basic principle - the unconscious patient is completely dependent on others for all
of his needs.

● Any omissions in basic nursing care or any failure to protect the unconscious patient in
his helpless state may inhibit recovery or greatly prolong his convalescence because of
complications that might have been prevented.

GENERAL CARE:

1) Monitor and record vital signs and neurological status accurately or as ordered. Report
changes to the doctor immediately.

2) Always address the patient by name and tell him what you are going to do, even though
he makes no response.

3) Refrain from any conversation about the patient's condition while in the patient's
presence.

Regularly observe and record the patient's vital signs and level of consciousness:

a) Always assess patient’s temperature to observe any abnormalities that can occur.
b) Report changes in vital signs to the doctor.
c) Note changes in response to stimuli.
d) Note the return of protective reflexes such as blinking the eyelids or swallowing saliva.

Airway and Breathing:

a) Maintain a patent airway by proper positioning of the patient. Position the patient on his
side with the chin extended. This prevents the tongue from obstructing the airway.
✓ This lateral recumbent position is often referred to as the "coma position."
✓ It is the safest position for a patient who is left unattended.

b) Suction the mouth, pharynx, and trachea as often as necessary to prevent aspiration of
secretions.

c) Reposition the patient from side-to-side 2 hourly to prevent pooling of mucous and
secretions in the lungs.

d) Administer oxygen as ordered to increase percentage of ventilation.
e) Always have suction available to prevent aspiration of vomitus.

Client Safety:

a) Keep side rails up at all times.
b) Avoid restraint at all (if possible).
c) Observe patient carefully for seizures and intervene to avoid precipitating factors: fever,

hypoxia, electrolyte imbalance.
d) Protect client if seizure occurs.
e) Speak softly and use client’s name during nursing care.
f) Touch client as gently as possible.

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g) Protect patient’s eyes from corneal irritation. Neglect can result in permanent damage to
the cornea since the normal blink reflex and tear-washing mechanisms may be absent. Use
only cleansing solutions and eye drops ordered by the physician.
✓ Check for corneal reflex.
✓ Instill methyl cellulose solutions (artificial tears) as ordered.
✓ Use eye patch if ordered.

Nutritional Needs:
A patient who is unconscious is normally fed and medicated by gavage.
a) Always observe the patient carefully when administering anything by gavage.
b) Do not leave the patient unattended while gavage feeding.
c) Keep accurate records of all intake (feeding formula, water, liquid medications etc.)

When gavage feeding an unconscious patient, it is best to place the patient in a sitting
position (Fowler's or semi-Fowlers) and support with pillows.
✓ This permits gravity to help move the feeding or medication.
✓ The chance of aspiration of feeding into the airway is reduced.
Fluids are maintained by IV therapy.
✓ Keep accurate records of IV intake and urine output.
✓ Observe the patient for signs of dehydration or fluid overload.

Skin Care:
a) The unconscious patient should be given a complete bath every day. This prevents drying of

the skin. The patient's face and perineal area should be bathed daily.
✓ The skin should be lubricated with moisturizing lotion after bathing.
✓ The nails should be kept short.
b) Provide oral hygiene at least twice per shift. Include the tongue, all tooth surfaces, and all
soft tissue areas. The unconscious patient is often a mouth breather. This causes saliva to
dry and adhere to the mouth and tooth surfaces.
✓ Always have suction apparatus immediately available when giving mouth care to the

unconscious patient.
✓ Apply petrolatum to the lips to prevent drying.
c) Keep the nostrils free of crusted secretions. Prevent drying with a light coat of lotion,
petrolatum, or water-soluble lubricant.
d) If the patient is incontinent, the perineal area must be washed and dried thoroughly after
each incident.
✓ Change the bed linen if damp or soiled.
✓ Observe the skin for evidence of skin breakdown.
e) Skin care should be provided each time the patient is turned.
✓ Examine the skin for areas of irritation or breakdown.
✓ Apply lotion.
✓ Gently massage the skin to stimulate circulation.

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Elimination – bowel:
a) The bowel should be evacuated regularly to prevent impaction of stool.

Keep accurate record of bowel movements. Note time, amount, color, and consistency.
Report any abnormalities if occurs.
b) A liquid stool softener may be ordered by the physician to prevent constipation or
impaction. It is generally administered once per day.
c) Assess for fecal impaction. The patient may be incontinent of stool, yet never completely
evacuate the rectum. Small, frequent, loose stools may be the first signs of an impaction as
the irritated bowel forces liquid stools around the retained feces.
d) If enemas are ordered, use proper technique to ensure effective administration and
effective return of feces and solution.

Elimination – urine:
a) The bladder should be emptied regularly to prevent infection or stone formation (calculi).
b) Adequate fluids should be given to prevent dehydration.
c) Keep accurate intake and output records.
d) Report low urine output to the doctor.
e) Provide catheter care at least once per shift to prevent infection in catheterized patients.

Positioning:
a) When positioning the unconscious patient, pay particular attention to maintaining proper

body alignment. The unconscious patient cannot tell he is uncomfortable or is experiencing
pressure on a body part.
✓ Limbs must be supported in a position of function. Do not allow flaccid limbs to rest

unsupported.
✓ When turning the patient, maintain alignment and do not allow the arms to be caught

under the torso.

b) Utilize a foot board at the end of the bed to decrease the possibility of foot drop.
✓ When joints are not exercised in their full range of motion each day, the muscles will
gradually shrink, forming contracture. Passive exercises must be provided for the
unconscious patient to prevent contractures.
✓ Exercises with a range of motion (ROM) are performed. It is a nursing care responsibility
to maintain the patient's range of motion.
✓ Precautions must be taken to prevent the development of pressure sores.
✓ Utilize a protective mattress such as a flotation mattress, alternating pressure mattress,
or ripple mattress.
✓ Change the patient's position at least every two hours.
✓ Unless contraindicated, get the patient out of bed and into a cushioned, supportive
chair.

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SKILL 4: ASSISTING IN INTUBATION

Intubation: insertion of endotracheal tube (ETT) into the trachea via orally or nasally to provide
artificial ventilation.

Indication:
1. to maintain clear airway
2. to protect airway

Equipment:
 Resuscitator bag with reservoir
 Face mask (adult)
 Lighted laryngoscope with handle and blades of various size (curved & straight)
 Stylet
 ETT size 7.5 – 8.5 mm
 Magills forceps
 Yaunkers sucker
 ETT introducer
 Lignocaine gels 1%
 Water soluble lubricant
 10mls syringe
 Sterile gloves
 Portable suction machine
 Sterile suction tubing and bottle
 Sterile suction catheter
 Sterile gallipot
 Oxygen supply complete with outflow meter and tubing
 Plater
 Scissors
 Inj. suxamethenium (Scoline)
 Inj. midazolam (Dormicum)
 Inj. adrenaline/atropine (as standby)

Nurse’s responsibilities
Before intubation:

1. Greet client and explain procedure.
2. Check baseline vital signs: Sa02 and cardiac rhythm
3. Get ready of all equipment
4. Provide privacy
5. Position client in supine position with the head near to the edge of the bed
6. Check the light of the laryngoscope by snapping the appropriate size blade in place
7. Using sterile technique, open the package containing the ETT tube
8. Lubricate the first 2.5cm of the distal end of the ETT with water soluble lubricant
9. Keep in mind a stylet may be used for oral intubation to stiffen the tube (make sure the

stylet does not protrude from the tube)

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During intubation
1. Preoxygenate client with 100% oxygen
2. Give injection as ordered
3. Clear airway by suctioning
4. Apply cricoid pressure on client
5. Assist in intubation
6. Attach the syringe to the port on the tube’s exterior pilot cuff and slowly inflate the cuff 5 to

10ml of air
7. To do suctioning via orally or ETT (PRN)
8. Closely monitor client’s vital signs, SaO2 and cardiac rhythm
9. Observe chest movement are equal bilaterally when bagging the client
10.Anchor the ETT with plaster, securely after auscultated by Dr that both air entry are equal
11.Connect ETT with ventilator set - by Dr

After intubation
1. Check client’s vital signs, cardiac rhythm, chest movement, SaO2 and color
2. Document the findings in the observation chart
3. Keep client clean and tidy
4. Clear the trolley

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SKILL 5: PERFORMING GASTRIC LAVAGE

AIM
1. To remove gastric contents
2. To obtain gastric contents for toxicology investigations

Assessment
1. Level of consciousness
o To ensure client’s safety because an unconscious client does not have gag reflex and
this may cause aspiration of stomach contents

2. Check doctor’s order for gastric lavage
o To ensure correct order

3. Check doctor’s notes for
o Type of poison/medication ingested
 To ensure gastric lavage is not contraindicated as for example certain types
of acidic and alkaline poisonous substances
o Time of ingestion
 To ensure gastric lavage is not carried out for overdose of more than 6 hours
because absorption has already occurred

4. Environment
o Allow adequate working space

Planning
1. Prepare equipment :
 Gastric lavage set
 Gargle set or oral cleansing set
 Gloves
 Disposable linen protector/plastic draw sheet
 1 small jug
 Basin – to receive gastric contents
 Specimen bottle – depend on type of test ordered
 Mouth gag – if necessary
 Normal saline or distilled water – temperature less than 38o C
 Vomit bowl

2. Assistant if necessary

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IMPLEMENTATION 2. To obtain full co-operation and to
1. Greet client and explain the procedure. reduce anxiety.

2. Place client on right lateral position with the  To encourage fluid flow through gravity
head lower than the legs. and prevent gastric contents aspiration.

3. Place disposable linen protector to patient’s  To protect client’s clothes and bed linen
chest wall.
 To enable client to use when client feels
4. Place vomit bowl and tissue paper near the like vomiting.
client.
 To prevent cross-infection.
5. Wash hands.  To practice standard precautions
6. Put on gloves.  To estimate the length of tube to be
7. Measure the length of tube from side of the
inserted into the stomach.
mouth to the pinna of the ear and to the
sternum 4 to 5 cm below xiphoid process and  To lubricate tube and reduce irritation
mark with the plaster. and to facilitate insertion of tube.
8. Lubricate end of tube with water.
 To facilitate the process of tube
9. Insert the gastric tube: insertion and reduce trauma to the
- Instruct client to open mouth (use mouth gag client.
if client is semi-conscious or unconscious)
- Insert tube until the pharynx is reached  To ensure that the tube is in the
- Instruct client to swallow while slowly stomach and to prevent complications
inserting the tube until the tube reaches the of aspiration of stomach contents.
marked section (advance the tube into the
marked section slowly for client who is semi-  To avoid discomfort to client.
conscious or unconscious).
 To remove the gastric contents by
10. Check placement of the tube in the stomach: lowering the funnel below the level of
- Litmus paper stomach this then will allow stomach
contents to flow out.
11. Clamp the tube. Pour 500 ml (depend on Dr’s
order) of NS into the funnel. Allow to flow  To reduce the risk of gastric contents
slowly by releasing clamp slowly. flowing into the lungs as the tube is
being removed.
12. Lower the funnel before it empties and inverts
the funnel to allow gastric contents to flow  To reduce pain/discomfort.
into the basin.

13. Observe the gastric content:
- Amount
- Smell
- Color
- Contents

14. Repeat step 11 to 13 until the return gastric
contents are clean.

15. Clamp at the end of the tube, instruct client to
take a deep breath and hold breath (if client is
conscious)

16. Remove the tube quickly but carefully.

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17. Give mouth gargle or clean the mouth if client  To provide oral comfort /cleanliness.
is semi-conscious or unconscious.
 To ascertain type of poison ingested by
18. Make the client comfortable. conducting toxicological studies.
19. Send the specimen bottle to the lab.
 For reference if medico-legal
20. Clean and keep all equipment. Wash hands. implications arise. Ingestion dangerous
21. Document and report the findings chemicals are amongst the cases that
need to be reported to the police.
- Type of solution used
- The amount of solution used
- Characteristics of the gastric contents.

Evaluation:
1. Check:

 General condition
 Level of consciousness (conscious, drowsy, confused)
 Evidence of presence of poison / medication used

2. Monitor vital signs such as
 Breathing
 Pulse
 Blood pressure

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SKILL 6: PERFORMING TOILET & SUTURING (T&S) – SIMPLE INTERUPTED

EQUIPMENT

1. T&S set consist of
a. Kidney dish
b. Gallipot x 3
c. Stitch scissors
d. Toothed & non toothed dissecting forceps
e. Sponge holder
f. Artery forceps
g. Needle holder
h. Gauze
i. Dressing towel
j. Handle blade
k. Allis clamps (inspect tissue or remove blood clot)

2. Sterile gloves & mask
3. Sutures & suturing needles
4. Gauze/cotton
5. Lotion (normal saline/povidone iodine/ flavine)
6. Local anesthetic (LA) e.g lignocaine 1%
7. Alcohol swabs
8. Needle & syringes
9. Sharp bin
10. Clinical waste bin
11. General waste bin

Implementation

1. Verify the medical order. Greet client and inform procedure. Check the patient’s chart for
allergies.

2. Wash hands and wear gloves.

3. Clean the skin with antiseptics. Irrigate wound with saline using 50cc syringe if needed.

4. Give LA subcutaneously.

5. Start suturing:

Step 1. Step 2.

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Step 3. Centre for Nursing Studies
Step 5. Step 4.
Step 7.
Step 6.

Step 8.

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Step 9.

6. Keep suturing until all wound have been covered.
7. Clean the sutured wound with normal saline and dry it well.
8. Cover the sutured wound with gauze or op-site dressing (follow hospital policy)
9. Explain to client to keep the dressing dry and intact.
10. Thank the client for giving good cooperation.
11. Clean equipment and comfort the client.
12. Document procedure in nursing notes.

Evaluation
1. Observe dressing
2. Observe for signs and symptoms of infection

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SKILL 7: INSERTION OF IV CANNULA / BRANULA

AIM
The access device is inserted on the first attempt, using sterile technique.

Equipment

- Non sterile gloves - sharp bin

- Tourniquet - clinical waste bin

- Cotton balls - general waste bin

- Alcohol wipes

- IV branula

- micropore / transparent dressing e.g. Tegaderm, Opsite

- kidneydish

IMPLEMENTATION
1. Verify the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies.
Know techniques for IV insertion, precautions, and medications if ordered.

2. Gather all equipment and bring to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed / close the door to the room, if possible. Explain what you are
going to do and why you are going to do it to the patient. Ask the patient about allergies to
medications, tape, or skin antiseptics, as appropriate. If considering using a local anesthetic,
inquire about allergies for these substances as well.
6. If using a local anesthetic, explain the rationale and procedure to the patient. Apply the
anesthetic to a few potential insertion sites. Allow sufficient time for the anesthetic to take
effect.
Initiate Peripheral Venous Access

7. Place patient in low Fowler’s position in bed. Place protective towel or pad under patient’s
arm.
8. Provide emotional support, as needed.

9. Select and palpate for an appropriate vein.

10. If the site is hairy, follow agency policy permits.

11. Put on clean gloves.

12. Apply a tourniquet 3 to 4 inches above the venipuncture site to obstruct venous blood flow
and distend the vein. Direct the ends of the tourniquet away from the entry site. Make sure the
radial pulse is still present.

13. Instruct the patient to hold the arm lower than the heart.

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14. Ask the patient to open and close the fist. Observe and palpate for a suitable vein. Try the
following techniques if a vein cannot be felt:

a. Massage the patient’s arm from proximal to distal end and gently tap over intended
vein.

b. Remove tourniquet and place warm, moist compresses over intended vein for 10 to
15 minutes.

15. Clean the patient’s skin at the selected puncture site with the antimicrobial swab. Using
alcohol swab, wipe in a circular motion spiralling outward. Allow the skin to dry before
performing the venipuncture.

16. Use the non-dominant hand, placed about 1 or 2 inches below the entry site, to hold the skin
taut against the vein. Avoid touching the prepared site. Ask the patient to remain still while
performing the venipuncture.

17. Enter the skin gently, holding the catheter by the hub in your dominant hand, bevel side up,
at a 10- to 15-degree angle. Insert the catheter from directly over the vein or from the side of
the vein. While following the course of the vein, advance the needle or catheter into the vein.

18. When blood returns through the lumen of the needle or the flashback chamber of the
catheter, advance either device into the vein until the hub is at the venipuncture site. The exact
technique depends on the type of device used.

19. Release the tourniquet. Stabilize the catheter or needle with your non-dominant hand.

20. Continue to stabilize the catheter or needle and flush gently with the saline, observing the
site for infiltration and leaking. Place stopper to the branula hub.
21. Place sterile transparent dressing or catheter securing/stabilization device over venipuncture
site.

22. Label the IV dressing with the date and time.

23. Remove equipment and return the patient to a position of comfort. Lower bed, if not in
lowest position.
24. Remove additional PPE, if used. Perform hand hygiene.

25. Ask the patient if he or she is experiencing any pain or discomfort related to the inserted IV
branula.

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SKILL 8: VENIPUNCTURE/BLOOD SPECIMEN TAKING

AIM
An uncontaminated specimen is obtained without causing anxiety, injury, or infection to the
patient

EQUIPMENT

- Tray /kidney dish

- Non sterile gloves - sharp bin

- Tourniquet - clinical waste bin

- Cotton balls - general waste bin

- Alcohol wipes

- Skin plaster bandage/micropore

- Needle and syringes

- Blood specimen tubes (depend on blood test ordered)

IMPLEMENTATION

1. Gather the necessary supplies. Check product expiration dates. Identify ordered tests and
select the appropriate blood-collection tubes.

2. Bring necessary equipment to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient. Explain the procedure. Allow the patient time to ask questions and
verbalize concerns about the venipuncture procedure.

5. Close curtains around bed and close the door to the room, if possible.
6. Check the specimen label with the patient’s identification bracelet. Label should include the
patient’s name and identification number, time specimen was collected, route of collection,
identification of the person obtaining the sample, and any other information required by agency
policy.
7. Provide for good light.
8. Assist the patient to a comfortable position, either sitting or lying. If the patient is lying in bed,
raise the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8
Patient Safety Center, 2009).

9. Determine the patient’s preferred site for the procedure based on his or her previous
experience. Expose the arm, supporting it in an extended position on a firm surface, such as a
tabletop. Position self on the same side of the patient as the site selected.

10. Put on gloves. Assess the veins using inspection and palpation to determine the best
puncture site.
11. Apply a tourniquet to the upper arm on the chosen side approximately 3 to 4 inches above
the potential puncture site. Apply sufficient pressure to impede venous circulation but not
arterial blood flow.

12. Assemble the needle to the syringe and loosen the cover.

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13. Palpate the vein - to choose suitable vein.

14. Clean the patient’s skin at the selected puncture site with the antimicrobial swab. Using
alcohol, wipe in a circular motion spiraling outward. Allow the skin to dry before performing the
venipuncture.
15. Hold the patient’s arm in a downward position with your nondominant hand. Align the
needle and syringe with the chosen vein, holding them in your dominant hand. Use the thumb
or first finger of your nondominant hand to apply pressure and traction to the skin just below
the identified puncture site.
16. Inform the patient that he or she is going to feel a pinch. With the bevel of the needle up,
insert the needle into the vein at a 15-degree angle to the skin until blood can be seen at the
hub.
17. Grasp the syringe securely to stabilize it in the vein with your nondominant hand.
18. Pull the piston slowly until the required amount of blood is obtained.

19. Remove the tourniquet as soon as blood flows adequately into the tube.

20. Continue to hold syringe in place in the vein.

21. Place a cotton over the puncture site and slowly and gently remove the needle from the vein.
Engage needle guard. Do not apply pressure to site until the needle has been fully removed.

22. Apply gentle pressure to the puncture site for 2 to 3 minutes or until bleeding stops

23. After bleeding stops, apply an adhesive bandage.

24. Place blood in prepared specimen bottles.
25. Remove equipment and return the patient to a position of comfort. Raise side rail and lower

bed.
26. Discard syringe and needle into sharps container.

27. Remove gloves and other PPE if used, then perform hand hygiene.
28. Place label on the container per facility policy. Place specimen bottles/container in plastic,
sealable biohazard bag.
29. Check the venipuncture site to see if a hematoma has developed.
30. Transport the specimen to the laboratory immediately. If immediate transport is not
possible, check with laboratory personnel or policy manual whether refrigeration is
contraindicated.

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SKILL 9: MANAGING EMERGENCY TROLLEY

Definition:
Trolley for storage of tools / medicines used in handling emergencies for patients.

Aim:
1. Standardizing the contents of the emergency trolley from each department in accordance
with the standards set by the Hospital.
2. There is no buildup of stock & equipment / drugs or overstock
3. Handling to patients can be effective and efficient.
4. The responsibility for filling emergency trolley is under the supervision of:

- Nurse Manager
- All registered nurses

Policy:
1. All nurses who work in hospital are obliged to carry out nursing procedures in accordance
with the SOP made by the hospital.
2. The SOP is a reference that becomes the starting point for implementing nursing services.
3. The SOP can be adapted to the development of nursing science and technology and its validity
has been proven scientifically.

Procedure:
1. Emergency trolley drawer 1 containing injection medicine.
2. Emergency trolley drawer 2 containing medical devices.
3. Emergency trolley drawer 3 containing IV fluids.
4. Emergency trolley drawers 4 containing resuscitation tools.
5. Fill in the emergency trolley to check the completeness of each consumable according to
hospital policy. (e.g each shift or daily).
6. Daily checking if in a locked state, simply line with black ink and write down no. the key, but if
the key is open (consumables), fill in the trolley drawer to be checked again and record the serial
number of the new key installed in red ink.
7. Immediately make a replacement if there are tools / drugs in use.

Things that must be considered:
1. In the supply of equipment / medicine, the number and size / number of the equipment will
be adjusted to the needs of the room
2. Make sure that the tools are ready to use.
3. Regular check-ups by room nurses.
4. Drugs and tools that are approaching expired date.
5. Check the emergency trolley every shift especially for the CCU, ER, NICU section
6. Document the key number and name of the officer who checks correctly and clearly
7. List of contents of Emergency Trolley in Hospital: see attachment: example of Hospital Policy
for Emergency trolley

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References
Pamela Lynn & Marilee LeBon (2011) Skill Checklists for Taylor’s Clinical Nursing Skills: A Nursing
Process Approach (3RD ed.). Lippincott Williams & Wilkins: United States of America.
http://www.mccc.edu/nursing/documents/glasgowcomascale.pdf
https://www.ambulance.qld.gov.au/clinical.html
https://www.scribd.com/document/373987249/SOP-Trolly-Emergency-Rev-02-Doc-for-SHARE

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