12/28/13

Administering Subcutaneous Medication

Administering Subcutaneous Medication

Equipment
■ Syringe and needle appropriate for volume and site.
■ Alcohol prep pad or CHG-alcohol product.
■ Gauze pad (optional).

Assessment
■ Check the area for previous injection sites.
■ Do focused assessments for the specific medication being administered.
■ Insulin—Be Safe! Check capillary blood sugar level, and determine when the patient will be having the next meal; check for signs of hypoglycemia or hyperglycemia.
■ Heparin Check aPTT and for signs of bleeding (e.g., bleeding from gums, IV sites, and so on).

Post-Procedure Reassessment
■ Reassess for anticipated response and adverse reaction to the medication.
■ Be Smart! For insulin, check blood glucose levels and clinical signs that patient’s blood sugar level has returned to normal. For heparin, observe that patient has no signs of bleeding.

Key Points
■ Maintain sterile technique and standard precautions.
■ Usually you will use a 1-mL syringe and a 25- to 27-gauge needle that is less than 1 in. long (usually 3/8 to 5/8 in.) For doses of a full mL or more (especially medications other than insulin or heparin), use a 3-mL syringe so you will be better able to aspirate.
■ Be Safe! A subcutaneous dose is typically no more than 1 mL.
■ Most common injection sites: outer aspect of the upper arms, abdomen, and anterior aspects of the thighs.
■ Pinch the skin to inject, as a general rule.
■ For an average-weight or thin client, inject at a 45° angle; for an obese client, inject at a 90° angle, as a general rule.
■ Aspiration is optional for most subcutaneous medications, but do not aspirate when injecting heparin or insulin.
■ Be Safe! Do not massage the site.

Documentation
■ Document scheduled medications on the MAR.
■ Document PRN medications in the nursing notes, including the reason given and response.
■ Chart medication, time, dose, and route given; therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Some agencies have a specific code for documenting subcutaneous injections, which allows exact site documentation on an outline of the body.
■ In nursing notes, document any related patient assessment findings, such as capillary blood sugar, signs of hypoglycemia or hyperglycemia, bruising, and so on.

Subcutaneous tissue injection using 45° and 90° angles
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Administering Intradermal Medication

Administering Intradermal Medication

Equipment
■ 1-mL syringe (tuberculin) with intradermal needle (25- to 28-gauge, 1/4 - to 5/8 -inch with short bevel).
■ Alcohol prep pad or CHG-alcohol product.
■ 2 in. 2 in. gauze pad; pen (ink or felt).

Assessment
■ Assess for previous reaction to skin testing and for all types of allergies.
■ Assess the skin at intradermal sites for bruising, swelling, tenderness, and other abnormalities.
■ Be Safe! Do not give intradermal skin tests if skin abnormalities are present. Also avoid giving them in areas where reading the results may be difficult, such as areas of heavy hair growth.

Post-Procedure Reassessment
■ Reassess 5 and 15 minutes after administration for allergic reactions.
■ Read the site within 48 to 72 hours of injection, depending on the test.
■ Observe that a wheal (about 6 to 8 mm in diameter) forms at the site and that it gradually disappears.
■ Observe for minimal bruising that may develop at the site of injection.

Key Points
■ Be Safe! Have appropriate antidotes for certain injections readily available before beginning the procedure.
■ Be Safe! Know the location of resuscitation equipment in case of a life-threatening adverse reaction.
■ Be Safe! Maintain sterile technique and standard precautions.
■ Be Smart! Be aware that an intradermal dose is small, usually about 0.01 to 0.1 mL.
■ Use a 1-mL syringe and a 25- to 28-gauge, 1/4- to 5/8-inch needle.
■ Choose a site on the ventral surface of the forearm, upper back, or upper chest.
■ Hold the syringe parallel to the skin at a 5° to 15° angle with the bevel up.
■ Stretch the skin taut to insert the needle.
■ Do not aspirate.
■ Inject slowly, and create a wheal or bleb.
■ Do not massage or bandage the site.

Documentation
■ Document medication, time, dose, and route given, lot numbers (check agency policy), and when the test is to be read.
■ Chart therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Record scheduled medications on the MAR and PRN medications in the nursing notes.
■ For PRN medications, include reason given and response.

Injecting intradermal medication
Inject at a 5 to 15 angle
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Recapping Needles Using One Handed Technique (Contaminated Needles)

Recapping Needles Using One Handed Technique (Contaminated Needles)

Equipment
■ Mechanical recapping device, if available.
■ Needle cover.
■ Safety syringe, if available.
■ Other supplies depending on the method used.

 Key Points
■ Be Safe!
■ Recap a contaminated needle only if you cannot avoid it.
■ Do not place either of your hands near the needle cap when recapping the needle or engaging the safety mechanism.
■ If you are using a safety needle, engage the safety mechanism to cover the needle.
■ Place the needle cap in a mechanical recapping device if one is available.
■ If recapping devices are not available and you must recap the needle for your own and/or the patient’s safety, use the one-handed scoop technique.

Documentation
■ No documentation needed for recapping needles.

Place needle cover on flat surface
Scoop the cap onto the needle
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Preparing, Drawing Up, and Mixing Medication (One Ampule & One Vial)

Preparing, Drawing Up, and Mixing Medication (One Ampule & One Vial)

Equipment
■ Medication vials, ampules, and/or prefilled syringe.
■ Alcohol prep pad (70% alcohol) or CHG-alcohol product.
■ Syringe of the appropriate size for medication volume and viscosity.
■ VAD, filter needle, or safety needle.
■ Gauze pad or ampule snapper.

Assessment
■ Check that the ampule and vial are intact, and that the medication is clear, with no discoloration, cloudiness, or particles. Post-Procedure Reassessment
■ Assess for a change in color, cloudiness, particles in the medication mixed.

Key Points
■ Be Smart! Before beginning, determine the total volume of all medications to be put in the syringe and whether that volume is appropriate for the administration site.
■ Be Safe! Make sure the medications are compatible.
■ Maintain the sterility of the needles and medication.
■ Be Smart! When drawing up from a single-dose vial and ampule, draw up from the vial first.
■ Scrub the stopper of a multidose vial using an alcohol wipe or CHG-alcohol product. Use povidone-iodine only when there is sensitivity to alcohol.
■ Draw up the same volume of air as the dose of medication ordered for the vial.
■ Inject air into the vial, being careful not to let the needle enter the fluid.
■ Then invert the vial and withdraw the dose; expel the air bubbles; and, when the dose is correct, withdraw the needle from the vial.
■ Be Safe! When opening ampules, protect yourself from injury by using an ampule snapper, folded gauze pad, or still-wrapped alcohol wipe.
■ Attach a filter needle or straw to withdraw medication from ampules; change to a needle of the proper length and gauge for administering the medication.
■ Flick or tap the top of the ampule to remove medication from the neck of the ampule.
■ Open the ampule by wrapping the neck with a folded gauze pad or an unopened alcohol wipe or use an ampule snapper. Snap open away from you.
■ Withdraw the second medication very carefully because the medications are mixed as you pull back the plunger; therefore, you must withdraw the exact amount. If there is any excess, you must discard the contents of the syringe and start over. You must avoid contaminating a multidose vial with the second medication.
■ Draw 0.2 mL of air into the syringe.
■ Confirm the dose is correct by holding the syringe vertically and checking the dose at eye level.
■ Be Smart! Always recap a sterile needle using a safety capping device or the one-handed scoop method.

Documentation
■ Document per MAR, according to agency policy.

Incorrect If the syringe is not vertical, air is trapped
Incorrect If the tip is down and the syringe is not vertical, air is trapped at the plunger
Correct Syringe is vertical
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Administering Metered Dose Inhaler Medication

Administering Metered Dose Inhaler Medication

Equipment
■ MDI.
■ Spacer.
■ Tissues.

Assessment
■ Assess respiratory status before administration of medication to establish a baseline for evaluating the effects of treatment.

Post-Procedure Reassessment
■ Be Safe! Assess for change in respiratory status, including VS, and oxygen saturation.

Key Points
■ Be Smart! Identify the number of remaining inhalations in the canister. The “float method” is no longer recommended for determining whether an MDI canister is empty.
■ Shake the inhaler. Remove the mouthpiece cap of the inhaler and
insert the mouthpiece into the spacer while holding the canister upright.
■ Remove the cap from the spacer.
■ Ask the patient to breathe out slowly and completely.
■ If the patient is unable to use the MDI independently, time the use of the device with the patient’s respirations.
■ Place the spacer mouthpiece into the patient’s mouth and ask him to seal his lips around the mouthpiece. Press down on the inhaler canister to discharge one puff of medication into the spacer.
■ Ask the patient to slowly inhale through the nose; then hold his breath for as long as possible.
■ If a second puff is needed, wait at least 1 minute and repeat.

Documentation
■ Chart scheduled medications in the MAR.
■ Chart PRN medications in the nursing notes, including reason given and response.
■ Record medication, time, dose, and route given; therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Document assessment data before, during, and after instillation.

Step 1: Shake the canister
Step 2: Remove cap. Discharge 2 puffs
Step 3: Deep breath out
Step 4: Press top. Inhale medication slowly
Step 5: Hold breath. Exhale slowly
Step 6: Remove inhaler from mouth. Wait 1 minute before next puff
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Applying Transdermal Medication

Applying Transdermal Medication

Equipment
■ Procedure gloves.
■ Transdermal medication.

Assessment
■ Assess for skin irritation, open lesions, area of hypersensitivity, or other skin abnormality.
■ Determine the presence of contraindications for dermal application. Post-Procedure Reassessment
■ Assess for rash, excoriation, hives, redness, swelling.
■ Ask the patient if he feels burning, itching, pain, tenderness, or other sensation to skin where medication was applied.

Key Points
■ Be Smart! Wear gloves to avoid absorbing the medication through your own skin and to avoid cross-contamination.
■ Remove the previous patch, folding the medicated side to the inside.
■ Dispose of the old patch carefully in a biohazard receptacle, keeping it away from children and pets.
■ Use soap and water to cleanse the skin of traces of remaining medication. Allow the skin to dry.
■ Remove the new patch from its protective covering, and then remove the clear, protective covering without touching the adhesive or the inside surface that contains the medication.
■ Apply the patch to a clean, dry, hairless (or little hair), intact skin area, pressing it down for about 10 seconds with your palm.
■ Rotate application sites. Common sites are the trunk, lower abdomen, lower back, and buttocks.
■ Remove gloves and wash your hands again.
■ Be Safe! Teach the patient to not use a heating pad over the area.
■ Be Safe! Do not apply medication to skin with open lesions, irritation, or known hypersensitivity.
■ Teach the patient to avoid exposure to ultraviolet light/sunlight after applying medication.
■ Use gentle technique when applying topical medication to fragile skin, which is typical in older adults. Take care to not over-apply the medication.

Documentation
■ Record scheduled medications in the MAR.
■ Record PRN medications in the nursing notes, including the reason given and response.
■ Record medication, time, dose, and route given; condition of skin if abnormalities are present, and complaints of discomfort during or after administration.
■ Document responses to medication (e.g., symptom relief, side effects); therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Document assessment data before, during, and after instillation.

Removing the clear, protective covering from a transdermal patchwithout touching the adhesive or the inside surface
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Inserting a Rectal Suppository

Inserting a Rectal Suppository 

Equipment
■ Suppository.
■ Water-soluble lubricant.
■ Toilet tissue.

Assessment
■ Assess the rectal area for hemorrhoids or irritation.
■ Be Smart! Before inserting the suppository, assess for contraindications, such as rectal surgery, rectal bleeding, or cardiac disease. Post-Procedure Reassessment
■ Assess for pain or burning during insertion of the medication.
■ Determine that the patient retained the suppository for the desired length of time (reinsertion may be required).
■ Assess for rectal pain, if indicated.

Key Points
■ Position the client in Sims’ position.
■ Lubricate the suppository.
■ Insert the suppository past the internal sphincter about 1/2 to 1 in. in infants and 1 to 3 in. in adults.
■ Be Safe! Never force the suppository during insertion.
■ Instruct the patient to stay on his side for 5 to 10 minutes and to retain (not expel) the suppository for about 30 minutes.

Documentation
■ Document:
■ Medication, time, dose, and route given.
■ Therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Condition of anal tissue if abnormalities are present.
■ Any complaints of discomfort outside of the expected range.
■ Length of time the suppository was retained.
■ Record assessment data before, during, and after administering the suppository.
■ Record PRN medications in the nursing notes, including reason given and response.

Inserting the rectal suppository past the internal sphincter
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Administering Vaginal Medication

Administering Vaginal Medication

Equipment
■ Medication (foam, jelly, cream, suppository, douche, or irrigating solution).
■ Applicator (if indicated).
■ Washcloth and warm water for perineal care as needed.
■ Water-soluble lubricant.
■ Toilet tissue.
■ Perineal pad.
■ Bath blanket.
■ For irrigation:
■ Waterproof pad.
■ Bedpan.
■ Vaginal irrigation set (may be disposable; consists of a solution container, nozzle, tubing, and clamp).
■ IV pole.

Assessment
■ Assess for:
■ Vaginal burning.
■ Pruritis.
■ Pain.

Post-Procedure Reassessment
■ Assess for:
■ Purulent vaginal discharge.
■ Vaginal burning.
■ Pruritis.
■ Pain.

Key Points
For Vaginal Suppository
■ Position the patient in a dorsal recumbent or Sims’ position.
■ Inspect and cleanse the vaginal area.
■ Apply a water-soluble lubricant to the rounded end of the suppository
and to the gloved index finger on your dominant hand.
■ Separate the labia with your nondominant hand.
■ Insert the suppository or applicator into the vagina along the posterior vaginal wall about 8 cm (3 in.).
■ Instruct the patient to maintain the position for 5 to 15 minutes.

Applicator Insertion of Cream, Foam, or Jelly
■ Position the patient in a dorsal recumbent or Sims’ position.
■ Inspect and cleanse the vaginal area.
■ Separate the labia with your nondominant hand.
■ Insert the applicator approximately 8 cm (3 in.) into the vagina along
the posterior vaginal wall.
■ Depress the plunger on the applicator. Dispose of the applicator. If it is reusable, place it on a paper towel and wash it later with soap and water.
■ Instruct the patient to remain in a supine position for 5 to 15 minutes.

For Irrigation (Douche)
■ Inspect and cleanse the vaginal area.
■ Warm the irrigation solution to approximately 105°F (40.6°C).
■ Hang the irrigation solution approximately 30 to 60 cm (1 to 2 ft)
above the level of the patient’s vagina.
■ Position the patient in a dorsal recumbent position on a waterproof pad and bedpan.
■ Insert the nozzle approximately 7 to 8 cm (3 in.) into the vagina, and start the flow of irrigation solution.

Documentation
■ Document:
■ Medication, time, dose, and route given.
■ Therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Condition of vaginal tissue and perineal area, if abnormalities are present.
■ Any complaints of discomfort outside of the expected range.
■ Length of time the suppository was retained.
■ For vaginal irrigations, chart:
■ Assessment.
■ Type and amount of solution administered.
■ Patient discomfort during the procedure.
■ Patient’s report of decreased vaginal pain, itching, and/or burning following the procedure.

Insert the suppository as far as possible along the posterior vaginal wall
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Administering Nasal Medication

Administering Nasal Medication

Equipment
■ Medication drops, spray, or aerosol.
■ Tissues.

Assessment
■ Check for nasal obstruction and congestion.
■ Assess nasal discharge for color, consistency, and odor. Note the color of nasal drainage.
■ Assess nasal mucous membranes for redness, color, moisture, excoriation, or trauma. Post-Procedure Reassessment
■ Assess for symptom relief 15 to 20 minutes after administration.

Key Points
■ Determine head position: Consider the indication for the medication and the patient’s ability to assume the position.
■ Explain to the patient that the medication may cause some burning, tingling, or unusual taste.
■ Position the patient with the head down and forward (for sprays) or supine with the head back (for drops).
■ Place the tip of the sprayer into the nostril, pointing the tip toward the outside of the nose (toward the outside corner of the right eye).
■ Be Safe! Never point the tip toward the middle of the nose (the septum) or straight up (toward the sinus).
■ Have the patient blow his nose, occlude one nostril, and exhale.
■ Squirt the spray into the nose while the patient inhales through his other nostril. Repeat for the other nostril.

Documentation
■ Record:
■ Premedication assessment.
■ Type and amount of solution administered, route.
■ Any patient discomfort during the procedure.
■ Patient’s report of response to the medication, (e.g., nasal discharge, obstruction, bleeding, or other complication).

Instilling nose spray
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Administering Otic Medication

Administering Otic Medication

Equipment
■ Ear drops.
■ Dropper with flexible rubber tip.
■ Cotton-tipped applicators.
■ Cotton ball.

Assessment
■ Assess the external ear and canal for erythema, drainage, and cerumen.
■ Assess for ear pain or hearing impairment. Post-Procedure Reassessment
■ Assess for discomfort or pain during the procedure and for relief afterward.
■ Evaluate for wax build-up, redness, swelling, or drainage.

Key Points
■ Warm the solution to be instilled.
■ Be Safe! Do not exceed body temperature.
■ Assist the patient to a side-lying position, with the affected ear facing up.
■ Straighten the ear canal. For an adult, pull the pinna up and back; for a child 3 years or younger, down and back.
■ Instill the ordered number of drops into the ear canal.
■ Be Safe! Do not force the solution into the ear or occlude the ear canal with the dropper.
■ Instruct the patient to remain on his side for 5 to 10 minutes.

Documentation
■ Record:
■ Medication, time, dose, and route given, and signature.
■ Amount, color, character, and odor of any drainage.
■ Swelling or redness in the ear canal.
■ Pain or discomfort and hearing loss.
■ Therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Document scheduled medications on the MAR, and PRN medications in the nursing notes (along with reason given and response).
■ Chart assessments before, during, and after instillation.

For infants and young children, pull pinna down and back
For instilling drops into an adult’s ear, pull pinna up and back
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Administering Ophthalmic Medication

Administering Ophthalmic Medication

Equipment
■ Eye drops or ointment.
■ Tissue.

Assessment
■ Assess the eyes for redness, drainage, or other signs of irritation or pain.
■ Determine the patient’s ability to cooperate with the procedure.
■ Assess whether the eyes need to be cleansed before administration of the medication.
■ Be Safe! Check the prescription for where to instill medication. (Note: We do not advise using these abbreviations they have been disallowed by The Joint Commission but you may still see them written in prescriptions: OD = right eye; OS = left eye; OU = both eyes.)

Key Points
■ Use a high-Fowler’s position, with the head slightly tilted back.
■ Work from the inner to outer canthus when cleansing or instilling medication.
■ Apply the medication into the conjunctival sac.
■ Be Safe! Do not apply the medication to the cornea.
■ Be Smart! Do not let the dropper or tube touch the eye.
■ For eye drops, press gently against the same side of the nose for 1 to 2 minutes to close the lacrimal ducts.
■ For eye ointment, ask the patient to gently close the eyes for 2 to 3 minutes.

Documentation
■ Document:
■ Medication, time, dose, and route given.
■ Assessment.
■ Therapeutic and adverse drug effects.
■ Nursing interventions, and teaching.
■ Assessment data before, during, and after instillation.
■ Be Safe! Record scheduled medications on the MAR and PRN medications in the nursing notes. For PRN medications, include reason given and response.
■ Be Smart! When a drug is not administered, document that on the MAR along with the reason, and inform the prescriber.
■ Be Safe! Do not document before giving the drug. Do not document for anyone else or ask them to document for you.

Instilling ophthalmic drops into the eye
Instilling ophthalmic ointment into the eye
Press lacrimal ducts to reduce systemic absorption
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Administering Medication Through an Enteral Tube

Administering Medication Through an Enteral Tube

Equipment
■ Procedure gloves.
■ Water (for diluting and flushing the feeding tube).
■ 60-mL catheter-tip syringe.
■ Stethoscope (e.g., to check the apical pulse before administering some cardiac medications).

Assessment
■ For NG tubes, check tube placement by aspirating stomach contents or measuring the pH of the aspirate, if possible.
■ Other, less accurate, methods are injecting air into the feeding tube and auscultating, or asking the patient to speak.
■ Be Safe! Never rely on only one bedside method for checking tube placement; use a combination of methods. Post-Procedure Reassessment
■ Evaluate the therapeutic effects of the medication.
■ Be Safe! Be alert for adverse reactions, side effects, or allergic reactions. If present, notify the appropriate care provider.

Key Points
■ If the patient is receiving a continuous tube feeding, disconnect it before giving the medications. Leave the tube clamped for a few minutes after administering the medication, according to agency protocol.
■ Prepare the medication.
■ Give the liquid form of medication, if possible. If the solution is hypertonic, dilute with 10 to 30 mL of sterile water before instilling through a feeding tube.
■ Be Smart! If pills must be given, verify that the medication can be crushed and given through an enteral tube.
■ Crush the tablet and mix it with about 20 mL of water.
■ If you are giving several medications, mix and administer each one separately and flush afterward.
■ Don nonsterile procedure gloves.
■ Place patient in a sitting (high-Fowler’s) position, if possible.
■ Check for residual volume.
■ Flush the tube. Based on the type of tube, use a piston tip or Luer-Lok syringe. Remove the bulb or plunger; attach the barrel to the tube;
and pour in 20 to 30 mL of water.
■ Depress the syringe plunger or using the barrel of the syringe as a funnel and pour in the medication. A smaller tube or thicker medication will require use of a 30- to 60-mL syringe.
■ Flush the medication through the tube by instilling more water.
■ Have the patient maintain a sitting position for at least 30 minutes after you administer the medication.

Documentation
■ Document:
■ Medication, time, dose, and route given, assessments.
■ Therapeutic and adverse drug effects, nursing interventions, and teaching.
■ Patency, residual volume, and placement of tube.
■ Any difficulty with administering the medications.
■ Record scheduled medications on the MAR and PRN medications in the nursing notes. For PRN medications, include reason given and response.
■ When a drug is not administered, document that on the MAR along with the reason, and inform the prescriber.
■ Be Smart! Document on the I&O record the amount of liquid medication and the water used for swallowing medication or flushing the tube.
■ Some providers prescribe a specific amount of water to flush with each medication or feeding.

Instilling medication through an enteral tube
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Procedure of Administering Oral Medication

Procedure of Administering Oral Medication

Equipment
■ MAR.
■ Medication drawer or portable cart with keys to the medication drawer, as needed.
■ Procedure gloves, as needed.
■ Other supplies and equipment needed for the specific procedure (e.g., water, alcohol wipes).

Assessment
■ Assess for factors that interfere with drug absorption (e.g., diarrhea, inadequate circulation, foods, other drugs).
■ Assess for factors that affect absorption and/or metabolism of the drug (e.g., impaired liver function, edema, inflammation, or agerelated changes).
■ Before the first administration, assess the patient’s knowledge about the medications being given.
■ Be Smart! Assess your knowledge of the medication (e.g., drug action, recommended dosage, time of onset and peak action, common side effects, and so on); and verify the prescribed dosage is appropriate for the patient’s age and weight.
■ Be Safe! Before giving the medication, assess VS and check lab studies to determine whether the drug can be safely administered.
■ Be Smart! Assess for situations in which administering the medication would not be reasonable (e.g., oral medications prescribed for a patient who is vomiting, who is sedated, or who has difficulty swallowing).
■ Be Safe! Check for history of allergies. Post-Procedure Reassessment
■ Evaluate the therapeutic effects of the medication. For example, check BP after administering an antihypertensive medication, or check pain level after an analgesic.
■ Be Safe! Be alert for side effects, allergic reactions, or other adverse reactions. If present, notify the primary care provider.

Key Points
■ Observe the “three checks” and the “rights of medication”: right patient, drug, dose, time, route, and documentation.
■ Tablets and capsules: Count the correct number aloud.
■ Liquids: Hold the medication cup at eye level to measure the dose.
■ Assist the patient to a high-Fowler’s position, if possible.
■ Administer the medication:
■ Powder: Mix with liquid, and give it to the patient to drink.
■ Lozenge: Instruct the patient not to chew or swallow it before it dissolves in her mouth.
■ Tablet or capsule: Place the tablet in her mouth or hand, or in a medication cup; instruct the patient to swallow with sips of liquid.
■ Sublingual: Instruct the patient to place the tablet under the tongue and hold it there until it is completely dissolved.
■ Buccal: Instruct the patient to place the tablet between the cheek and teeth and hold it there until it is completely dissolved.

Documentation
■ Scheduled medications are documented on the MAR.
■ Document:
■ Medication, time, dose, and route given, and assessments.
■ Therapeutic and adverse drug effects.
■ Nursing interventions.
■ Teaching.
■ Record PRN medications in the nursing notes; include reason given and response.
■ For parenteral medications, note the site of injection.

Hold the bottle with the label in your palm
Sublingual Place and hold the tablet under the tongue until it is completely dissolved
Buccal Place the tablet between the cheek and teeth or tongue
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Performing Otic Irrigation

Performing Otic Irrigation

Equipment
■ An ear irrigation system, such as the Welch Allyn ear wash system or an electronic jet ear irrigator.
■ Asepto syringe, or rubber bulb syringe (if an ear irrigation system is not available).
■ Irrigating solution (usually water, but may be an antiseptic solution), warmed to 98.6 F (37 C).
■ Bath towel and moisture-resistant towel.
■ A headlight if one is available.
■ Emesis basin.
■ Otoscope.
■ Cotton balls.
■ Procedure gloves.
■ Be Safe! Do not use a metal syringe, as it is considered dangerous.
■ Be Smart! An ear irrigation system is preferred over an Asepto or bulb syringe because of the better ability to control pressure and remove cerumen.

Assessment
■ Assess for pain and hearing loss.
■ Determine whether there are contraindications for ear irrigation (e.g., recent middle ear infection, cleft palate).
■ Assess the external ear for drainage, cerumen.
■ Assess the external ear canal for redness, swelling, or foreign objects; visualize the tympanic membrane.
■ Be Safe! Do not irrigate if drainage is present or you cannot visualize the tympanic membrane.
■ Be Smart! If a foreign object is present, attempt to remove it before irrigation. Post-Procedure Reassessment
■ Observe the quantity and quality of ear cerumen you removed, and the appearance of the ear canal.
■ Assess for complaints of pain or dizziness, and for improvement in hearing acuity.
■ Observe for drainage on the cotton ball.

Key Points
■ Warm the irrigating solution to body temperature.
■ Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear.
■ Adults: Straighten the ear canal by pulling up and back on the pinna.
■ Young children: Pull down and back to straighten the canal.
■ Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation.
■ Place the tip of the nozzle (or syringe) into the entrance of the ear canal, and direct the stream of irrigating solution slowly and gently along the top of the ear canal toward the back of the client’s head.
■ Continue irrigating until the canal is clean.
■ Perform an otoscopic examination.
■ Place a cotton ball loosely in the outer ear.

Documentation
■ Document:
■ The irrigation solution used.
■ The quantity, character, and odor of cerumen or drainage.
■ The condition of the ear canal and tympanic membrane after the irrigation.

Place the tip of the nozzle about 1 cm (1/2 in.) above the entrance to theear canal
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Procedure of Making an Occupied Bed

Procedure of Making an Occupied Bed

Equipment
■ Bottom and top sheets, drawsheet, pillowcase for each of the pillows.
■ Bath blanket.
■ Linen bag or hamper.
■ Procedure gloves (if exposure to body fluids is possible).
■ Moisture-proof gown (if heavy soiling of linens with body fluids is possible).

Assessment
■ Assess:
■ Ability to move.
■ Need for patient-handling devices.
■ Drainage or incontinence. Post-Procedure Reassessment
■ Assess how well the patient tolerated the procedure (e.g., discomfort, shortness of breath, etc.)
■ Ask the patient whether he feels comfortable.

Key Points
■ Be Safe! Maintain patient safety during the procedure. Always raise the siderail before moving to the other side of the bed.
■ Elevate the bed to working height, position patient laterally near the far siderail, and roll soiled linen under him.
■ Place clean linens on the side nearest you, and then tuck under the soiled linen.
■ Roll the patient over the “hump,” and position him on his other side, near you. Raise the near siderail.
■ Move to other side of bed; lower the siderail; pull soiled and clean linen through; and complete the linen change.
■ Be Smart! Don’t forget to miter corners and make a toe pleat.
■ Remove the bath blanket without exposing the patient.
■ Be Safe! Place the bed in a low position, raise the siderails, and fasten the call light to the pillow.

Documentation
■ Linen changes are generally recorded on a checklist.
■ A nursing note is needed only if something abnormal occurred.

Making a toe pleat
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Shampooing the Hair Using Rinse Free Shampoo

Shampooing the Hair Using Rinse Free Shampoo

Equipment
■ Rinse-free shampoo (no water is needed).
■ Conditioner (optional).
■ Bath towel.
■ Brush or hair pick.
■ Comb.
■ Procedure gloves (if scalp lesion or infestation present).

Assessment
■ Assess for:
■ Contraindications to a soap-and-water shampoo (e.g., limited head or neck movement, scalp sutures).
■ Ability to assist with the procedure.
■ Condition of the hair and scalp (e.g., dryness or irritation).
■ Ask the patient how she normally cares for her hair.
■ Be Smart! Assess the need for special hair care products (e.g., dandruff or lice require medicated shampoos; dry hair requires a conditioner). Post-Procedure Reassessment
■ Observe for patient discomfort or fatigue during the procedure.
■ Afterward, observe that the hair is clean, dry, and free of tangles.
■ Ask the patient how the hair and scalp feel.

Key Points
■ Obtain rinse-free shampoo and any other hair care products needed.
■ Elevate the head of the bed.
■ Place a protective pad or towel under the patient’s shoulders.
■ Don procedure gloves, and use fingers or a comb to remove tangles.
■ Apply enough rinse-free shampoo to thoroughly wet the hair. Work it through the hair, from the scalp down to the ends.
■ Towel-dry the hair.

Documentation
■ Chart that hair was shampooed; the method used; the condition of the hair and scalp; and the patient’s responses to the procedure.
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Providing Oral Care for an Unconscious Patient

Providing Oral Care for an Unconscious Patient

Equipment
■ Toothbrush with soft bristles or sponge oral swabs.
■ Toothpaste.
■ Denture cup, if patient has dentures.
■ 4 in. 4 in. gauze pad to remove dentures if present.
■ Tonsil-tip suction connected to suction source.
■ Tongue blade (padded) or bite-block.
■ Towel.
■ Waterproof linen protector.
■ Emesis basin.
■ Water-soluble lip moisturizer.
■ Procedure gloves and goggles.

Assessment
■ Assess the patient’s general oral health, including the condition of the teeth.
■ Observe oral mucosa and gums for hydration, inflammation, bleeding, or infection.
■ Determine whether the patient has dentures or partial plates. Assess the fit of dentures and the condition of the gums under the dentures.
■ Assess the patient’s gag reflex. Post-Procedure Reassessment
■ Inspect the teeth, gums, and mucous membranes for cleanliness.
■ Observe the patient’s overall responses to the procedure (e.g., gagging, coughing, VS, skin color).

Key Points
■ Lower the head of the bed unless contraindicated.
■ Position the patient side-lying with head turned to the side.
■ Place a waterproof pad and towel under the patient’s cheek and chin.
■ Use a padded tongue blade or bite-block as needed to keep the mouth open.
■ Place an emesis basin under the patient’s cheek.
■ Be Safe! For an unconscious patient, remove partial plates to prevent aspiration.
■ Suction secretions as needed.

Documentation
■ Document that oral care was given, any abnormal findings, and nursing interventions.
■ Typically, oral care is documented on a checklist or flowsheet.
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Providing Denture Care

Providing Denture Care

Equipment
■ Toothbrush or sponge toothettes.
■ Denture cleaning paste.
■ Emesis basin.
■ Towel.
■ Glass of water.
■ Mouthwash and/or lip moisturizer, if desired.
■ Procedure gloves.
■ Mask and goggles if splashing may occur.
■ Tonsil-tip suction connected to suction source (if aspiration is a concern).
■ Denture cup.

Assessment
■ Assess:
■ Patient’s ability to assist with oral care.
■ General oral health (e.g., presence of the gag reflex and condition of teeth, gums, and mucous membranes).
■ Swallowing ability.
■ Whether the patient has dentures, bridgework, or partial plates.
■ Assess patient’s usual oral care, including cultural practices.
■ Be Smart! If the patient has dentures, examine the mouth with and without the dentures. Post-Procedure Reassessment
■ Check to see that dentures are comfortable and fit properly.
■ Inspect the gums and mucous membranes to verify that they are free of food particles.
■ Inspect for abnormalities, such as bleeding, that may have been stimulated by mouth care.
■ Assess the patient’s tolerance of and satisfaction with the care.

Key Points
■ If the patient is at risk for choking, suction secretions as needed.
■ Remove (and replace) the top denture before the lower denture.
■ Tilt dentures slightly when removing and replacing.
■ Be Safe! Handle dentures carefully, and place the towel in the sink to avoid breaking the dentures if you drop them.
■ Use cool water and a stiff-bristled brush; brush all surfaces and rinse thoroughly.
■ Apply denture adhesive, if the patient uses it.
■ If dentures are dry, moisten them before reinserting.
■ Offer mouthwash.

Documentation
■ Document that oral care was given, the patient’s response, any abnormal findings, and nursing interventions.
■ Oral care is usually charted on a flowsheet.

Grasp the top denture with a gauze pad
Use thumbs to push up on bottom denture at gumline. Tilt to remove
Moisten the denture before reinserting if it is dry
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Providing Foot Care

Providing Foot Care

Equipment
■ Procedure gloves (if there are open lesions).
■ Pillow (if procedure is done with the patient in bed).
■ Basin for water.
■ Liquid no-rinse soap.
■ Bath towel.
■ Waterproof pad.
■ Washcloth.
■ Orangewood stick.
■ Toenail clippers.
■ Nail file.
■ Lotion or prescribed ointment or cream.

Assessment
■ Assess:
■ Bilateral dorsalis pedis pulses.
■ Skin color and warmth.
■ All areas of the feet for skin integrity, edema, condition of toenails, abnormalities.
■ Be Smart! Compare right and left feet.
■ Be Smart! Check carefully between the toes.
■ Assess the patient’s usual footwear; self-care ability for foot care (including vision and mobility); and knowledge about foot care, including usual foot care practices. Evaluate the need for a referral.
■ Be Smart! Verify that institutional policy allows a nurse to trim toenails. Obtain a prescription, if necessary. Post-Procedure Reassessment
■ Observe that feet are clean, and smooth; nails are trimmed and smooth; skin is pink, warm, and intact.
■ Identify and provide interventions for foot problems.
■ Ask the patient to demonstrate or describe correct foot care.

Key Points
■ Inspect the feet thoroughly for skin integrity, circulation, and edema.
■ Clean the feet with mild soap; clean the toenails; rinse; and dry well.
■ Trim the nails straight across, unless contraindicated or against agency policy
■ File the nails with an emery board.
■ Lightly apply lotion, except between the toes.
■ Ensure that footwear and bedding are not irritating to the feet.

Documentation
■ In most agencies, you will not document routine foot care (except, perhaps, on a checklist) unless there are problems.
■ If you do document, chart assessment findings and that foot care was given.
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Providing Perineal Care

Providing Perineal Care

Equipment
■ Procedure gloves.
■ Basin or perineal wash bottle.
■ Waterproof pad.
■ Bedpan or portable sitz tub (optional).
■ Towel.
■ Wash cloth.
■ Toilet tissue.
■ Cleansing solution or soap.
■ Perineal ointment if needed.

Assessment:
■ Assess:
■ Mobility.
■ Activity tolerance.
■ Ability to assist with perineal care.
■ Check for positioning or activity restrictions.
■ Identify specific needs regarding perineal care (e.g., cultural preferences, presence of a urinary drainage catheter, perineal surgery, or lesions).
■ Be Smart! If there are lesions or skin breakdown, you may need to
use special soaps and/or lotions.
■ Incontinence or drainage requires assessment and follow-up to
prevent Impaired Skin Integrity.

Key Points:
■ Provide privacy; keep the patient covered as much as possible.

■ For females: Fold a bath blanket into the shape of a diamond. Wrap the side points of the diamond around the patient’s legs.
■ For males: Place a bath blanket over the chest, then fold bed linens down to expose the groin.

■ Place a waterproof pad under the patient to protect the bed linen.
■ Use warm water (105 F, or 41 C).
■ Follow the principle of “clean to dirty” (front to back for women).

Documentation
■ You will usually chart perineal care on a flowsheet.
■ For a narrative note, also chart patient responses to the procedure, the condition of the perineal area, and the patient’s comfort status.

Drape for privacy
Wash the head of the penis first
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Bathing Providing a Complete Bed Bath

Bathing Providing a Complete Bed Bath

Equipment
■ Water basin.
■ Bath blanket.
■ 2 bath towels.
■ Washcloths.
■ Soap or liquid rinse-free soap.
■ Orangewood stick.
■ Deodorant, lotion, and/or powder as needed.
■ Clean gown (with shoulder snaps if the patient has an IV line) and bed linen.
■ Procedure gloves.
■ Bedpan or urinal.
■ Laundry bag.
■ Be Smart!You may need special soaps and lotions for older adults or patients with skin conditions, or skin breakdown; and additional washcloths and towels for patients with incontinence or drainage.

Assessment
■ Assess:
■ Mobility.
■ Activity tolerance.
■ Type of bath needed.
■ Ability to perform bathing self-care.
■ Personal and cultural issues regarding the bath.
■ Specific patient needs and preferences (e.g., special soaps
or lotions).
■ Check for positioning or activity restrictions.
■ Determine how many people you need to safely bathe and reposition
the patient.
■ Be Smart! Save time. While bathing the patient, assess level of consciousness, short- and long-term memory, ability to follow instructions, ROM, skin condition, activity tolerance, and self-care ability.

Key Points
■ Provide privacy, and offer patient a bedpan before beginning.
■ Use warm, not hot, water (105 F, or 41 C).
■ Protect bed linen with towels unless you will be changing them.
■ Wear procedure gloves if exposure to body fluids (e.g., draining wounds) is likely or if you have breaks in your skin.
■ Prevent chilling or tiring the patient (e.g., cover with bath blanket, expose only the body part you are washing).
■ Be Safe! Lower the siderail on the side where you are working; raise it when moving to the other side of the bed.
■ Be Safe! Do not disconnect an IV to remove the patient’s gown. Remove the gown first from the arm without the IV.
■ Follow the principles, “head to toe” and “clean to dirty” (bathe face, neck, arms and chest, abdomen, legs, feet, back, buttocks, perineum).
■ Change the water and don procedure gloves before cleansing the perineum; change the water whenever it becomes dirty or cool.
■ For extremities, wash and dry from distal to proximal.
■ Pat the skin dry; do not rub.
■ Perform hand hygiene when moving from a contaminated body part to bathe a clean body part.

Documentation
■ You will usually document hygiene care on checklists and flowsheets.
■ For nursing notes, chart:
■ The type of bath given.
■ Extent to which patient was able to help.
■ Tolerance of the procedure.
■ Mobility.
■ Any abnormal findings.

Wipe outward from the inner canthus
Wash rectal area from front to back
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Procedure of Using Restraints

Procedure of Using Restraints

Equipment:
■ Restraint of the appropriate size: belt, vest, wrist, ankle, or mitt.
■ Soft gauze or cotton padding for bony prominences.

Assessment:
■ Assess the need for restraints; that is, that the immediate physical safety of the patient, a staff member, or others is threatened.
■ Assess the patient’s risk for falls, including mobility status and level of awareness.
■ Determine that all less-restrictive measures have been tried unsuccessfully.
■ Identify the appropriate restraint; one that:
■ Is the least restrictive possible.
■ Does not interfere with care or exacerbate the patient’s medical condition.
■ Does not pose a safety risk to the patient.
■ Can be changed easily to keep it clean.

Post-Procedure Reassessment
■ Assess the initial restraint placement, circulation, and skin integrity.
■ Check the restraint every 30 minutes (more often for a behavioral restraint). Observe for pallor, cyanosis, and coolness of extremities.
■ Reassess the restraint, circulation, the patient’s response to the intervention, and the continuing need for the restraint every 2 hours; remove it as soon as it is no longer needed.

Key Points:
■ Follow agency policy, state laws, and professional guidelines.
■ Try alternative interventions first (e.g., bed/chair alarms, patient sitters hired to watch the patient).
■ Use the least restrictive method among the various types of restraints:
■ Verbal.
■ Chemical (e.g., antipsychotic or sedative medication).
■ Seclusion (safe containment to de-escalate).
■ Physical (4-point devices, tie-on, Velcro, leather).
■ Use restraints only to protect a patient and/or caregiver from injury;
not for the convenience of the caregiver or as a punishment.
■ Obtain the required consent form.
■ Obtain a medical order before restraining, except in an emergency.
■ Be Safe! Secure restraints in a way that allows for quick release.
■ Be Safe! Tie bed restraints to the bed frame, not to the siderails.
■ Be Safe! Ensure that restraints do not impair circulation or tissue integrity.
■ Be Safe! Check restraints every 30 minutes.
■ Be Smart! A prescriber must reassess and reorder the restraints every 24 hours.
■ Release restraints and assess every 2 hours (more often for behavioral restraints).

Documentation:
■ Document the following on fall risk assessment sheet, restraint flowsheet, and nursing notes per agency policy:
■ All nursing interventions that were done to eliminate the need for the restraint (e.g., moving patient closer to the nurses’ station, asking a family member to remain with the patient).
■ Reasons for placing the restraint (e.g., patient behaviors).
■ The initial restraint placement, including location, circulation, and skin integrity.
■ Patient and family teaching.
■ Circulation checks, range of motion, and restraint removal per agency protocol.

A quick-release knot
A vest restraint
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Using a Bed Monitoring Device

Using a Bed Monitoring Device

Equipment:
■ Bed or chair exit monitoring device (types: pressure sensitive, posture indicator, motion sensor, and pull-cord alarms). Assessment
■ Identify factors that increase risk for more severe injury in the case of a fall (e.g., anticoagulants, osteoporosis).
■ Check the alarm on the monitor to ensure that it is working properly.
■ Assess for factors that increase fall risk.
■ Intrinsic Factors, Examples:
• Age > 75.
• History of falls.
• Incontinence.
• Cognitive impairment.
• Dizziness.
• Medications.
• Medical problems (e.g., dementia, arthritis, depression).
■ Extrinsic (Environmental) Factors, Examples:
• Equipment.
• Wet/uneven floors.
• Footwear.
• Poor lighting.
• Clothing.
• Lack of grab rails.
• Furniture/adaptive aids in disrepair (e.g., bed rails)

Post-Procedure Reassessment:
■ Monitor fall risk per agency policy and as indicated by the patient’s physical and mental status.
■ If a fall occurs, perform a post-fall assessment to identify possible causes, and monitor more closely for 48 hours.

Key Points:
■ Select the correct type of alarm for your patient.
■ Explain to patient and family that a monitoring device alerts the staff when the patient tries to get out of the chair or bed.
■ Apply/place the device; connect the control unit to the sensor pad.
■ Connect the control unit to the nurse call system, if possible.
■ Explain that the patient will need to call for help when he wants to get up.
■ Place the patient on fall risk precautions according to agency policy.
■ Assess the sensitivity of the monitoring device, and adjust as needed to ensure that the alarm is activated if the patient tries to get out of the bed or chair.
■ Disconnect or turn off the alarm before assisting the patient out of the bed or chair.
■ Reactivate the alarm after helping the patient back to the bed or chair.
■ Be Safe! Bed alarms alone do not prevent falls; they are used to improve the timeliness of staff response. Patients who are at risk for falls require increased observation and surveillance.

Documentation:
■ Document on the fall risk assessment sheet, restraint flowsheet, and nursing notes according to agency policy.
■ Document the initial sensor placement, including type of sensor used and location of placement.
■ Follow agency policy for ongoing documentation of the use of a bed exit monitor.
■ Usually, the minimum documentation is every 8 hours.

Chair monitor
Leg sensor
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Adding Sterile Solutions to a Sterile Field

Adding Sterile Solutions to a Sterile Field

Equipment
■ An established sterile field.
■ Sterile bowl or receptacle.
■ The correct sterile solution.

 Key Points
■ Use a sterile bowl or receptacle if the sterile field is fabric or at risk for strike-through.
■ Unwrap the sterile bowl and grasp it through the sterile wrapper as you place it near the edge of the sterile field. You may also place the bowl next to, instead of on, the sterile field.
■ Confirm that the sterile solution is correct, and that the expiration date has not passed.
■ To remove the cap from the solution bottle, lift it directly up. Then discard it.
■ Holding the bottle 4 to 6 inches above the bowl, carefully pour the needed amount of the solution into the bowl.
■ Discard the remaining solution.
■ Before donning sterile gloves to perform the procedure, double-check that all supplies have been added to the field. Do not leave a sterile field unattended. Do not turn your back to the sterile field.

Hold the bottle 4 to 6 in. above the bowl. Pour carefully
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Setting up a Sterile Field & Adding Supplies to the Sterile Field

Setting up a Sterile Field & Adding Supplies to the Sterile Field

Equipment
■ Package of sterile supplies required for the procedure.
■ Sterile gloves of the correct size to use in performing the procedure.

Key Points 
Setting Up the Sterile Field
■ Prepare the sterile field as closely as possible to the time of use.
■ Do not cover the sterile field once established.
■ Do not turn away from the sterile field.
■ Inspect for package integrity, inclusion of sterile indicator, and/or expiration date. Do not use outdated items.
■ Clear space; prepare the patient before setting up the sterile field.
■ Create the sterile field with a sterile package wrapper or drape.

Adding Supplies to the Sterile Field
■ Hold the items several inches above the field.
■ Peel back the wrapper.
■ Gently drop each item onto the sterile field.

 Documentation
■ You do not need to document setting up the sterile field.
■ Record the procedure you perform, your reassessments of the area being treated, and the patient’s tolerance for the procedure.

Open the flap away from you first
Do not pass your arms over the sterile field as you drop the item
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Sterile Gloves (Open Method)

Sterile Gloves (Open Method)

Equipment
■ Sterile gloves of the correct size.
■ Flat surface to open the package.

Key Points
■ Remove all jewelry, including rings and watches.
■ Place the glove package on a clean, dry surface.
■ Open the inner package so that the cuffs are closest to you.
■ Apply the glove of your dominant hand first, touching only the inside of the glove’s folded-over cuff with your nondominant hand.
■ Apply the second glove by touching only the outer part of the glove with your already-gloved hand; keep your sterile thumb well away from your bare skin.
■ Do not touch the gloves to any unsterile items.
■ Be Smart! Sterile touches sterile; “dirty” touches “dirty.”

Documentation
■ No special documentation is needed for sterile gloving.
■ Record the procedure you perform and the patient’s responses.

Glove your dominant hand first
Glove your nondominant hand second
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