Cadiopulmonary Arrest (Hospital Settings)

If you suspect a patient has collapsed,

1. Try to rouse the patient by calling his name and tapping him (eg. "Mr Tan, are you ok?" while tapping his shoulders)

2. If there is no response, take his pillow away and lie his head supine (ie. flat) on his bed.

3. Open airway by doing "head tilt, chin lift". If the patient has a cervical injury, perform jaw thrush instead. Inspect for any loose teeth, dentures or other foreign objects that may obstruct airway and remove these obstructions.

4. Check for presence of breathing by doing "look, listen & feel". Look for signs of breathing like chest rising; listen for breath sounds; feel for air exhaled from the patient.

5. Check for presence of circulation by feeling for the carotid pulse. If there is no pulse, activate "CODE BLUE" immediately.  

If there is pulse, provide oxygen to the patient at a rate of 12 breaths/ min using a bag-valve-mask (BVM). ie. provide oxygen (by squeezing the bag), 2-a-thousand, 3-a-thousand, 4-a-thousand, 5-a-thousand, provide oxygen...

6. If the patient is pulseless, lock and pull the bed out a little before locking it back, set the height of the bed to the level of your thigh, remove the headboard and screen the patient for privacy.

7. Bring the cord side down, shift the patient more to his other side to allow more room for yourself and commence cardiopulmonary rescue (CPR).

8. When the e-trolley is pushed in by another nurse B, get her to attach the 3 leads electrocardiogram (ECG) and stop CPR to obtain the heart's rhythm. Once obtained, continue CPR. The doctor would prepare to "shock" the patient if it is a "shock-able" rhythm; either ventricular fibrillation (VF) or pulseless ventricular tachycardia (pulseless VT).

If sinus rhythm resumes after "shocking" the patient, continue CPR for a minute before checking for pulse unless patient shows signs of circulation eg. moving.

9. If patient's heart rhythm remains the same, nurse B would then insert oropharyngeal airway of suitable size (it should measure from the tragus of the ear to the tip of the mouth on the same side of the patient) to maintain patient's airway. Wear clean plastic gloves as there is a risk of contact with patient's body fluids (ie. saliva, in this case).

10. Nurse B would also assemble the BVM and provide 100% oxygen (15litres) to the patient at a rate of 30 compressions: 2 breaths if pulse is still absent. If pulse is present, continue providing 100% oxygen to the patient at a rate of 12 breaths/ min.

11. If the patient has an IV access, another nurse, C, would check for its patency by withdrawing any blood clots (if any) and then injecting 3-5ml of normal saline; "flushing". Maintain this IV access by running normal saline at a slow rate. If there is no IV plug in situ, prepare for the insertion of an IV plug.

12. Nurse C would also prepare for drugs to be administered when the doctor requests for it (usually, it is 1ml of adrenaline in 9ml of normal saline/ water for injection). If intubation is required, nurse C would prepare the requisites for intubation and suctioning equipment as well.

13. Once intubated, the patient's breathing would be taken over by the ventilator. If pulse returns, prepare to send patient to intensive care unit (ICU). Maintain therapeutic hypothermia for the patient. If pulse has not return, the doctor may administer more drugs/ shock the patient again, depending on the condition.

14. Nurse C should then document all the events/ procedures that happened during the resuscitation eg. the amount and type of drugs infused to the patient at ____ hours and the patient's response to that particular intervention etc.

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Subcutaneous Medications (Insulin)

Insulin is basically available in two forms: 1) pen-like structure that stores a certain amount of insulin and can deliver a certain unit (depending on the order) each time its button is pushed or 2) bottled liquid form where you need syringe and needle to deliver the insulin. This post shall focus on the second form of insulin, where preparations are slightly more complicated.

Things Required:

• IMR
• Medications (this post shall explain how to serve a short-acting eg. Actrapid and a long-acting insulin simultaneously. If your order requires only one type of medication, just take that medication and ignore the second one)
• Syringe
• 3 Needles (2 x 19G, 21G)
• Gloves
• Alcohol swabs
• Kidney dish

Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. For example, if a patient is on sliding scale (ie. the amount of insulin needed is dependent on his hypocount), he may not need the insulin if his hypocount is of desirable value. Perform hand rub.

2. Get the correct medications out from the fridge (as insulin is usually stored there) and rub the bottles in your palms to warm them. Insulin, when injected cold, may be painful for the patient.

3. Swab the top of the bottles with alcohol swabs. Attach a 19G needle to the syringe and inject air equivalent to the unit of long-acting insulin needed into the long-acting (more cloudy appearance) insulin bottle and then inject air equivalent to the unit of short-acting insulin needed into the short-acting (clearer appearance) insulin bottle. Injecting air first will reduce the resistance when drawing the insulin.

That is, if I need 2 units of long-acting insulin and 3 units of short-acting insulin, I would inject 2 units of air into the bottle containing long-acting insulin first and then inject 3 units of air into the bottle containing short-acting insulin.

4. After injecting air, draw the required units of short-acting insulin. Change to another 19G needle and discard the first needle to avoid cross-contamination of the different insulin. Using the new 19G needle, draw the units of long-acting insulin needed. Discard the needle. Attach the 21G needle to the syringe.

5. 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: adequate lighting, suitable working height, screening of the patient, who would have to expose himself)

6. Perform hand rub and wear gloves (wearing of gloves is dependable on hospital policy).

7. In Singapore, any subcutaneous injections are almost only performed in the abdomen area for adults. Thus, get patient to expose his abdomen and ask where was his last injection site (right or left side of the umbilicus) and avoid it. This is because injecting the same area over and over again with insulin will result in lipodystrophy, where the area would be slightly dented and insulin absorption diminished.

8. If patient's last injection site was to the right side of the umbilicus, measure two finger spacings away from the umbilicus on the left side and clean that area with alcohol swab.

9. Lightly pinch the area with your thumb and forefinger of your non-dominant hand. With your dominant hand holding the syringe like a dart, inject the needle fully, at 90 degrees to the skin and administer the insulin slowly.

10. Release the pinched area and take a piece of alcohol swab. Withdraw the needle and use the alcohol swab to apply pressure to the injection site for around 10 seconds. Do not rub the area as this would increase insulin absorption.

11. Inform patient that the procedure is completed and to inform you if he feels giddy. Remind him to have his meal or some food 30 minutes later. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

12. In the IMR, record that subcutaneous insulin had been given. Check for any adverse reactions/ patient's response to the medications and document in the relevant notes.

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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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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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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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