Sunday, July 31, 2011

IV Medications (Addictives)

The first seven steps here are exactly the same as IV Medications (Bolus). The two procedures are just slightly different.

Things Required:
  • IMR
  • Medications (usually powdered form)
  • Diluent (eg. H2O for injection)
  • Normal Saline
  • Syringes
  • Needle
  • Gloves
  • Alcohol swabs
  • Gauze
  • Kidney dish
  • IV set (if patient does not have an existing IV line running. If antibiotics are to be given, the IV should have a burette attached to it.)
Always check the items you take for expiry date and clarity (if applicable).

1. Check whether the order for that medication is a first dose for that patient. If it is the first dose, doctors are to administer them. Verify order and patient's need for this procedure.

2. Perform hand rub.

3. Withdraw an appropriate amount of diluent eg. 10ml (depends on what medications you are giving and the hospital policy/ guidelines) into a syringe. Ensure that there is no bubbles.

4. Swab the top of the medication bottle with an alcohol swab. Attach the needle to the syringe and inject the diluent into the medication. Dissolve the medication well by rolling the medication bottle in your palms, rather than shaking, which would introduce bubbles.

5. Withdraw the dissolved medication into the syringe and throw the needle into a sharp box.

6. Depending on hospital policy, withdraw 6-10ml of normal saline into another syringe. Place the IMR, syringes, alcohol swabs, gauze and gloves into the kidney dish before approaching patient.

7. Approach and identify patient with 2 patient identifiers again: patient’s name and IC by asking patient and verifying it with his wrist tag. Ensure that patient is not allergic to the medication by checking it with the IMR and by asking patient. Prepare the environment where necessary.

8. If patient do not have an existing IV line that is used for less than 72 hours, prepare a new IV set by priming it with normal saline. Inject the medications into the IV set and adjust the flow rate.

9. Attach a sticker stating the medication/ addictives added, the amount of addictives added, the date and time when it was added and your name to the IV set.

10. Document the procedure in the IMR and relevant notes. Note for patient's response and any adverse effects to the medication.

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IV Medications (Bolus)

Things Required:
  • IMR
  • Medications (usually powdered form)
  • Diluent (eg. H2O for injection)
  • Normal Saline
  • 2 Syringes
  • 2 Needles
  • Gloves
  • Alcohol swabs
  • Gauze
  • Kidney dish
Always check the items you take for expiry date and clarity (if applicable).

1.  Check whether the order for that medication is a first dose for that patient. If it is the first dose, doctors are to administer them. Verify order and patient's need for this procedure.

2. Perform hand rub.

3. Withdraw an appropriate amount of diluent eg. 10ml (depends on what medications you are giving and the hospital policy/ guidelines) into a syringe. Ensure that there is no bubbles.

4. Swab the top of the medication bottle with an alcohol swab. Attach the needle to the syringe and inject the diluent into the medication. Dissolve the medication well by rolling the medication bottle in your palms, rather than shaking, which would introduce bubbles.

5. Withdraw the dissolved medication into the syringe and throw the needle into a sharp box.

6. Depending on hospital policy, withdraw 6-10ml of normal saline into another syringe. Place the IMR, syringes, alcohol swabs, gauze and gloves into the kidney dish before approaching patient.

7. Approach and identify patient with 2 patient identifiers again: patient’s name and IC by asking patient and verifying it with his wrist tag. Ensure that patient is not allergic to the medication by checking it with the IMR and by asking patient. Prepare the environment where necessary.

8. Wear gloves. Stop and detach any IV lines connected to the patient and swab the patient's IV plug with an alcohol swab. Place a gauze underneath it.

9. Occlude the vein just above the plug to prevent blood from flowing out when you disconnect the stopper. Connect the syringe containing normal saline to the plug. Attempt to withdraw any blood clots near the plug. If only blood is withdrawn, "flush" the plug to check for its patency by pushing 3-5ml of normal saline into it. If there is any blood clots withdrawn, great resistance when pushing the normal saline in or if patient complains of pain and tenderness around the plug, stop the procedure and report it.

10. If there is no blood clots, little resistance and no pain, slowly inject the whole medications in at a constant rate.

11. "Flush" with the remaining normal saline.

12. Swab the plug again before reattaching any IV lines back.

13. Inform patient that the procedure is complete and ask him to report if he is feeling uncomfortable/ malaise or if there is pain at the plug site. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving.

14. Document the procedure in the IMR. Check for any adverse reactions/ patient's response to the medications and document in the relevant notes.

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Thursday, July 28, 2011

Medical-Surgical Posting (Ortho)

My impression of Mdm C was that she is a soft-spoken lady who cannot really express herself clearly. Every time when other nurses and I found her sliding or sleeping slanted, we would just inform her that we will be shifting her to an upright position and we would just shift her, sometimes even without waiting for her response, which would generally be lagged and inaudible.

Today, I was tasked with feeding Mdm C--our first "real" interaction. Throughout the whole process, she kept sliding to one side and kept her eyes closed. I thought she was just like one of the less responsive patients I sometimes see. Therefore, I did not even try to make small talk with her but just asked her to open her mouth when she stopped chewing and swallowing (ie. when she had already finished all the food in her mouth). However, from time to time, I would have to stop feeding just to drag and/or push her upright. Thus, the whole feeding process took up quite some time and became very draggy.

However, another student nurse who had been interacting with her for the past week came and talked to her. She asked Mdm C why she was eating with her eyes closed. Mdm C immediately responded by opening her eyes and smiled sheepishly! Furthermore, when that nurse asked her to sit up straight, she also responded and pushed herself upright! Oh my god! She is responsive! Had I known that or even try to talk to her in the first place, I could have saved myself all the trouble of dragging her upright by myself and that the both of us could have had a more enjoyable feeding time!

Moral of the story: Do not assume! I should talk to my patients instead of just focusing on my task. When I do that, I may just save myself some trouble and may even make my patients happier.

Back to Reflections

Tuesday, July 26, 2011

Simple Wound Dressing

Things Required: 
  • Septanol and tissue (to clean the wound trolley)
  • Gloves
  • Apron
  • IMR
  • Basic wound dressing pack
  • Normal saline solution
  • Micropore
  • Scissors and pen
  • Other wound dressing cleansing solutions or products like chlorhexidine, tegaderm, mepore
Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. Perform hand rub.

2. Clean wound dressing trolley. Wear apron.

3. Approach and identify patient again with 2 patient identifiers: patient’s name and IC by asking patient and verifying it with his wrist tag. If patient is in pain, ask for pain score and offer interventions like ice packs or pain relief medications. If patient refuses the procedure, explain the importance of the procedure and get patient to rest and mentally prepare himself first.

4. Prepare the environment like switching on the lights, switching off the fans, screening the curtains and ensuring the correct working height. Always position your trolley and stand such that your dominant hand is nearer to the patient.

5. Perform hand rub. Open the sterile wound dressing pack without touching anything inside. Arrange the items inside and take out the plastic bag by maneuvering them from the outside of the dressing pack (the non-sterile side).

6. Pour normal saline and open other excess items, carefully touching only the packaging.

7. Expose wound with gloves. Palpate around/ along the wound site and note any Colour, Odour, Consistency and Amount of exudates (if applicable).

8. Perform surgical handwash. Dry with the tissue paper provided in the dressing pack, picking it up by taking only its corner.

9. Drape the area where you are cleaning the wound. Be careful not to touch anywhere else (especially the patient) except the drape.

10. Soak and squeeze out excess water from the cotton balls and arrange any items in the sterile field (where necessary) using the forceps provided.

11. Using one cotton ball at a time and one swipe per cotton ball, clean the wound from the least contaminated area (ie. the inner of the wound) to the most contaminated area. Lastly, clean the area surrounding the wound. The technique for cleaning the wound would be to take a clean cotton ball using your non-dominant hand and pass it over to your dominant hand outside the sterile field and use the dominant hand to clean the wound. If patient seems uncomfortable or in pain, stop and ask the patient if he needs you to stop the procedure for a while etc.

12. Tap the cleaned areas dry with gauze.

13. Cover with suitable/ prescribed wound products and label the “date changed”.

14. Explain to patient that the procedure has been completed and ask if patient has any questions for you like “how is their wound healing?”, “how long will their wound take to heal?” etc. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

15. Discard soiled requisites, clean trolley and wash hands.

16. Record the procedure in the relevant documents like the nursing notes and wound chart. Report any abnormalities.

Note: If patient seems uncomfortable or in pain during any part of the procedure, ask if he needs a break, any pain relief medications, or try blowing or soothing (sayang) the area surrounding the wound.

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Psychiatric Posting

Just as teachers would not approach students like me – quiet, do my own stuffs and never get into trouble, Mr W is someone whom I would never approach during this attachment had it not been for my clinical instructor, Mr A, who had requested an interview from him on my behalf, as part of my attachment requirements. He was a quiet person, never saying much to my questions besides the very basic. I guessed he may even be having trouble with sitting down with me and answering my endless questions. Nevertheless, he sat through the interview and did his best though he left abruptly after my interview, without even telling me.

Throughout my attachment, I tried to interact with him, firstly due to the need to write my report about his progress and gradually, just to talk to him, hoping to make his day less boring. However, not all days were smooth sailing. When he was in a good mood and not mentally disturbed, he would be able to play a few games of checkers and/or English chess. On the other hand, when his condition (schizophrenia) “striked”, mostly after dinner every day, he would feel the need to hum and pace up and down the whole ward for more than a few times. In this case, our interaction would be disrupted. Someone explained that humming may just be to block out the internal clatter (auditory hallucinations) -- Mr W's coping mechanism.

Throughout the attachment, I feel that Mr W has the potential to get well especially if his symptom of humming could be controlled. On his good days, he was willingly to play more than just a game of checkers only and answer with words, instead of sounds.

On the last day of my attachment however, his condition was bothering him and interfering with our interaction and thus, I didn’t have a chance to introduce new chess mates to him as planned (I had hoped to introduce one or two chess mates to him so that he could play and interact with more people and hone his social skills). Though all the patients in the ward would have known that day was our last day there, I still wanted to tell him personally that it was my last day and that I would not be there to disturb him anymore even if he wanted. However, I kept dragging having to tell him because I thought we would still have a lot of time for that later. I should have known that there isn’t much time actually because normally most of the patients would have been asleep by 8+pm. Mr W was no exception. He was already sleeping when I finally wanted to bade him goodbye for the last time. I wanted to leave without saying goodbye but after some internal reflection and debate, I realized I would not be able to live with not saying goodbye for at least a few days. Thus, wanting a proper closure, I went to wake him up and told him. He was half-asleep and I finally left with the feeling of not knowing whether he would wake up tomorrow thinking it was all a dream or whether he would even remember it at all.Oh well, I sincerely wish him all the best in reintegrating into our society.

Well, take-away point here is that never to leave things, especially leaving things unspoken, till the last minute because you never know how much time you are left with..?

Back to Reflections

Monday, July 25, 2011

Urinary Catheterization for Females

Things required:
  • Septanol and tissue (to clean the trolley)
  • IMR/ doctor's orders
  • Sterile gloves 
  • Apron
  • Catheterization kit
  • 2-way urinary catheter (usually French 10/12)
  • KY jelly/ aqua jelly
  • Urine bag
  • Chlorhexidine solution
  • Syringe
  • H2O for injection
  • Blue sheet/ incontinence sheet
  • Micropore and scissors
  • Torchlight (if there is someone there to help you and where applicable)
Always check the items for expiry date and clarity (where applicable).

1. Verify order and patient's need for this procedure. Perform hand rub.

2. Clean trolley. Wear apron.

3. Approach and identify patient with 2 patient identifiers: patient’s name and IC again by asking patient and verifying it with his wrist tag. (Catheterization is usually ordered when patient is unable to void and there is a large volume of residual urine in the patient). Perform perineal care if needed.

4. Prepare the environment like switching on the lights, switching off the fans, screening the curtains and ensuring the correct working height. Stand on the patient's right side if you are right-handed.

5. Perform hand rub. Open the sterile urinary catheterization pack without touching anything inside. Arrange the items inside by maneuvering them from the outside of the catheterization pack.

6. Open items 6-11 into the catheterization pack. Remember to throw the first "non-sterile" part of the KY jelly and chlorhexidine solution away.

7. Assist patient to lie in the dorsal position with slightly-abducted legs, bent at the knees. Assist to remove patient's pants fully before covering them with a blanket. Place a blue sheet underneath the patient.

8. Perform surgical handwash. Dry with the tissue paper provided in the catheterization pack, picking it up by taking only its corner.

9. Don sterile gloves.

10. Test the catheter by filling its balloon up with the stated amount of water and observe for any leakage. Lubricate 3-5cm of the catheter tip with the KY jelly.

11. Close the urine bag drainage port.

12. Soak all cotton balls with chlorhexidine and squeeze out excess water, either with sterile gloves or using forceps.

13. Ask patient to remove the blanket and drape the perineum area to create a sterile field, exposing only the genitalia.

14. Take the plastic bag out and place it on the drape.

15. Place the two catheter trays on the sterile drape between the patient's legs. (The smaller tray should contain the cotton balls and a forceps while the other larger tray should contain the catheter and another forceps.)

16. With your dominant hand, use a forceps and the cotton balls to cleanse the genitalia in the following order: the labia majora, labia minora and lastly the urinary meatus. Use only one cotton ball at a time and one swipe per cotton ball. Use your non-dominant hand to separate the labia minora and expose the urethra until after insertion. Throw the forceps and the used cotton balls away.

17. Insert the urinary catheter into the urethra with another sterile forceps until urine first flows out of the catheter. Further advance the catheter around 2cm more and collect all the residual urine in the larger catheter tray by gently squeezing/ pushing down on the perineal area. The amount of residual urine should approximate the amount of residual urine shown by a bladder scan (which by right, would have been performed at least twice, depending on hospital policy, before catheterzation is ordered.)

18. Inflate the balloon with the recommended amount of water (the amount would be stated on the catheter packaging.) Gently tug the catheter to assure that it would not be displaced/ to ensure placement. When there is resistance (ie. the catheter can no longer be tugged out), push the catheter in by about 2cm.

19. Attach the urinary bag to the catheter and after tearing the drape, tape the catheter to the patient's thighs.

20. Place the urinary bag below the level of the patient's bladder to ensure there is no backflow of urine, without it touching the floor. Label "date changed" and "IDC-indwelling cathether" on the urinary bag.

21. Explain to patient that the procedure has been completed and ask if patient has any questions for you. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

22. Discard gloves and soiled requisites. Clean the trolley and wash hands.

23. Record the procedure in the relevant documents like the nursing notes and I/O-intake/output chart (COCA-colour, odour, consistency and amount of urine). Report any abnormalities like heavily blood stained urine or other abnormal discharges present in the urine.

24. Empty the urinary bag and measure the urine at least once during every shift or when full and record COCA in the I/O chart as per order.

Note: Observe the patient throughout the whole procedure. Ask patient to take in deep breaths and relax while you insert the catheter.If patient seems uncomfortable or in pain, stop for a while to allow patient to collect and prepare herself.

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