A guide to patient care; Georgia hospital nursing procedure manual

Gf.. H700 ,1
1954 2
c.2

A GUIDE FOR PATIENT CARE
PREFACE
This monograph is the product of the combined effort of nurses and administrators in the large and small hospitals of the State of Georgia, and nurses from various public health agencies who are interested in better patient care through improvement of the administrative and educational aspects of nursing.
The need for a general nursing manual, written on broad principles that could be applied in all nursing situations, was expressed by the nurses con- cerned.
In response to the need, Miss Mary E. Fitzpatrick, R, N., Nurse Consultant, Division of Hospital Services, Georgia Department of Public Health, called together a group of representative 'nurses to consider the problem, which resulted in the organization of the Nursing Procedure Committee. Miss Lillian Bischoff, R. N., Assistant Director of Public Health Nursing, Georgia State Department of Health, was elected Chairman of this Committee.
The question of why we need a manual, when books on the subject were available, was the first question to be answered by the Committee. The following statement is a summary of the report of the special Committee that considered the question. "The Manual should be so organized and written that it may be used in standardizing nursing procedures, in the most effective way, in all kinds of situations where nursing care is given. It was thought that the manual would serve as a guide to hospitals, nursing homes and public health nurses who teach and supervise those carrying out nursing procedures. "
Due to the problem of getting nurses from all over the State into one place, it was finally decided that the manual should be written by subcommittees. Thi s was done.
It was most gratifying to see the related forces at work. Among the members of the various committees were nurses from federal, state and private agencies, large and small hospitals both urban and rural, publich health nurses, directors of nursing service, nursing education and hospital administrators.
Many of the procedures were left as presented by the committees, while others were rearranged. Considerable variations exist throughout the manual which will, we hope, add interest for those who use and study it.
The question of what is and what is not a "principle" was fully discussed. There may be some disagreement, however, every effort was made to confirm the scientific truth underlying the statement of "principles" presented.
I

While this manual has been written primarily to provide hospitals, nursing homes and public health nurses with a guide to inservice education and training of both the graduate registered nurses and the non-professional nurses, it is hoped that the book will enable the hospital administrator and his Board of Directors, as well as various other groups within the hospital family and community. to a better realiaztion and understanding of the responsibilities for the constant improvement of nursing service to patients. The safety of the individual patient demands standardized methods based on scientific fact. The Committee has attempted to present both facts and methods.

A bibliography has not been assembled but separate acknowledgement has been made to specific references in the context.

All illustrations and diagrams were reprinted by permission of the various medical and surgical supply houses. The Committee wishes to thank them for the permission to reprint.

The index is not exhaustive but is adequate and will assist the reader in finding the material with little effort.

The Georgia Department of Public Health and the Nursing Procedure Committee wish to thank the following persons for their support, understanding, enocuragement and technical as sistance in the final compilation of this "Guide for Patient Care". Without their as sistance the completion of this monograph would not have been accomplished.

Dr. R. C. Williams

Director, Division of Hospital Services, Georgia Department of Public Health

Miss Theodora Floyd, R. N.

Director of Public Health Nursing, Georgia Department of Public Health

Dr. R. A. Vonderlehr

Southeastern Regional Medical Director, Region 6, Health, Education, and Welfare

Dr. T. J. Bauer

Medical Chief of C. D. C., Health, Education, and Welfare

Dr. D. S. Martin

Chief of Bacteriology Section, Laboratory Branch, Health, Education and Welfare

Dr. R. F. Spanjer

Secretary of the Hospital Section, Medical Association of Georgia

Mrs. Anna Laura Reid, R. N

Secretary of Better Health Council

Miss Jane Van de Vrede, R. N.

Treasurer, Georgia State Nurses Association

II

Mr. George Stenhouse Mr. Marion Kelley Mrs. Helen Pate Miss Ruth Newbill Mrs. Mary Louise Davis Mr. David Clark Mis s Joyce McElrath Mrs. Carleen Gould Mr. B. B. Peebles

- Director of Public Health Education, Georgia Department of Public Health
- Photographer, Georgia Department of Pubilc Health
- Clerk, Central Statistical Unit, Georgia Department of Public Health
- Stenographer, Division of Hospital Services, Georgia Department of Public Health
- Accountant, Division of Hospital Services, Georgia Department of Public Health
- Field Representative, Division of Hospital Services, Georgia Department of Public Health
- Stenographer, Division of Hospital Serivces, Georgia Department of Public Health
- Typist, Division of Hospital Services, Georgia Department of Public Health
- Print Shop Executive, Division of Central Administration, Georgia Department of Public Health

III

COMMITTEE MEMBERS
Miss Lillian Bischoff, R. N., B S., M. S. Chairman of Procedure Committee Assistant Director of Public Health Nursing Division of Nursing Georgia State Department of Public Health Atlanta, Georgia
Miss Ruth Henley, R. N. Vice-Chairman of Procedure Committee Chairman of Nursing Committee Director of Nursing Service Emory University Hospital Emory, Georgia
Miss Lucille Sommermeyer, R. N., B. S. , Ed. M. Secretary of Procedure Committee Chairman of Sanitization Committee Nursing Rexea~ch Laboratory Communicable Disease Center U. S. Public Health Service Chamblee, Georgia
Miss Mary E. Fitzpatrick, R. N., B. S., C. N. M. Editor of Manual Chairman of Steering Committee Hospital Nurse Consultant Division of Hospital Services Georgia Department of Public Health Atlanta, Georgia
Miss Shirley Gluck, R. N., B. S. Chairman of Operating Room Committee General Surgical Supervisor Grady Memorial Hospital Atlanta, Georgia
Miss Emeline McKie, R. N., M. S. Chairman of Diagnostic Procedure Committee Educational Director Georgia Baptist Hospital Atlanta, Georgia
IV

Mrs. Mary M. Melody, R N., M. S. Educational Director Chairman of Basic Nursing Procedure Lawson Veterans Administration Hospital Chamblee, Georgia
Mrs. Shirley Tally, R. N., B. S. Chairman of Central Supply Room Committee Head Nurse Central Supply Room Emory University Hospital Emory, Georgia
Sister M. Bonaventure, R. N., M. S. Chairman of Therapeutic Procedure Committee Hospital Administrator St. Josehp's Hospital Atlanta, Georgia
Miss Katherine Akin, R. N., A. B. Chronic Disease Consultant Nurse Associate Director of Public Health Nursing Georgia Department of Public Health Atlanta, Georgia
Mrs. Mary E. Atkins, P. N., B. S. Director of Nursing Service American Red Cross 488 Peachtree Street, N. E. Atlanta, Georgia
Miss Myra Bonner, R. N. Director of Nurses Milledgeville State Hospital Milledgeville, Georgia
Miss Vera L. Bowen, R. N. Operating Room Supervisor Lawson Veterans Administration Hospital Chamblee, Georgia
Miss Elizabeth Branch, R. N. Director of Nursing Service Upson County Hospital Thomaston, Georgia
V

Mrs. Ruth T. Bremer, R.N. Assistant Superintendent of Nurses Kennestone Hospital Marietta, Georgia
Mrs. Stewart D. Brown Hospital Administrator Cobb Memorial Hospital Royston, Georgia
Mrs. Florence Callahan, R. N , M. S. Regional Consultant Nurse U. S. Public Health Service 50 Seventh Street, N E. Atlanta, Georgia
Miss Sarah Carter, R. N. Supervisor in Medical Nursing Grady Hospital Atlanta, Georgia
Mrs. Jeanne Christopher, R. N. Director of Nursing Services Minnie G. Boswell Memorial Hospital Greensboro, Georgia
Mr. David C. Clark, R. N., B. A. Hospital Field Representative Division of Hospital Services Georgia Department of Public Health Atlanta, Georgia
Mrs. Lucille K. Coppage, R. N. Nursing Arts Instructor Piedmont Hospital Atlanta, Georgia
Sister M. Carlotta, R. N. Supervisor St. Mary's Hospital Athens, Georgia
Gladys Curren, R. N., M S. Director of Nursing Education Columbus City Hospital Columbus, Georgia
VI

Miss Effie Davis, R. N. Hospital Administrator Patterson Hospital Cuthbert, Georgia
Miss Clara W. Dietrich, R. N. Medical Supervisor Lawson Veterans Administration Hospital Chamblee, Georgia
Miss Helen Duke, R. N. Operating Room Nur se Lawson Veterans Administration Hospital Chamblee, Georgia
Miss Julia Fraher, R. N., M. S. Nursing Arts Instructor Emory University Hospital Emory, Georgia
Miss Lolita Garcia, R. N., B. S. Instructor St. Joseph's Hospital Atlanta, Georgia
Miss June G. Hall, R. N Phoebe Putney Memorial Hospital Albany, Georgia
Mrs. Mabel Hamrick, R. N., B. S. Assistant Professor of Maternal and Infant Nursing Emory University School of Nursing Emory, Ge orgia
Mrs. Nell Harbin, R. N. Superintendent of Nurses Cobb Memorial Hospital Royston, Georgia
Mis s Sybil W. Hartley, R. N. Georgia Baptist Hospital Atlanta, Georgia
Mr s. Elizabeth C. Hood, R. N. Director of Nurses Battey State Hospital Rome, Georgia
VII

Sister M. Imgard, R. N., B. S. Supervisor St. Mary's Hospital Athens, Georgia
Mrs. Dorothea Jackson, R. N. Assistant Head Nurse Central Service Emory University Hospital Emory, Georgia
Miss Bernice Killcrease, R. N Instructor in Pharmacology Grady Memorial Hospital Atlanta, Georgia
Miss Louise King, R. N., B. S. Instructor of Medical and Surgical Nursing Piedmont Hospital Atlanta, Georgia
Miss Virginia Klienhammer, R. N., M. S. Instructor of Nur sing Education Department of Nursing Education Atlanta Division University of Georgia Atlanta, Georgia
Miss Vivien Landrum, R. N. Operating Room Supervisor Piedmont Hospital Atlanta, Georgia
Sister M. Leandra, R. N., M. S. Hospital Administrator St. Mary's Hospital Athens, Georgia
Miss Sara Lyon, R. N. Director of Nursing Services Tift County Hospital Tifton, Georgia
Mrs. Alice B. Martin, R. N. Operating Room Supervisor Crawford W. Long Memorial Hospital Atlanta, Georgia
VIII

Miss Erma Mathews, R. N. Director of Nursing Service Griffin-Spalding County Hospital Griffin, Georgia
Mrs. Edith H. McCulloch, R. N. Director of Nursing Service Kennestone Hospital Marietta, Georgia
Miss Mary E. Nation, R. N Operating Room Supervisor Kennestone Hospital Marietta, Georgia
Miss Annie Lou Overton, R. N., B. S. Educational Supervisor State Board of Examiners of Nurses for Georgia, State Capitol Atlanta, Georgia
Miss Carolyn Pate, R. N. Hospital Administrator and Director of Nursing Services Walton County Hospital Monroe, Georgia
Mrs. Anna Laura Reid, R. N. Better Health Council of Georgia 875 Peachtree Street, N. E Atlanta, Georgia
Miss Mary Reiter, R. N., M. S. Pediatric Nursing Consultant Georgia Satte Department of Health Atlanta, Georgia
Miss Mary M. Reames, R. N. Director of Nursing Services Phoebe Putney Hospital Albany, Georgia
Miss Eula Mae Robbins, R. N. Assistant Operating Room Supervisor Lawson Veterans Administration Hospital Chamblee, Georgia
IX

Miss Janice Sams, R. N. Staff Nurse Lawson Veterans Administration Hospital Chamblee, Georgia
Miss May Sanders, R. N., M. S. Instructor in Nursing Education Department of Nursing Education Atlanta Division University of Georgia Atlanta, Georgia
Miss Ivarene Shivers, R. N. Night Supervisor Kennestone Hospital Marietta, Georgia
Miss Nellie A. Simmons, R. N., B. S. Education Director Macon City Hospital Macon, Georgia
Mrs. Martha Smith, R. N. Director of Nursing Services Newnan Hospital Newnan, Georgia
Miss Helen W. Steck, R. N., M. S. Mental Health Nur sing Consultant U. S. Public Health Service 50 Seventh Street, N. E. Atlanta, Georgia
Mis s Shella E. Stevens, R. N Central Service Supervisor Lawson Veterans Administration Hospitla Chamblee, Georgia
Miss Mary L. Taylor, R. N., M. S. Associate Dean, School of Nursing Emory University Emory, Georgia
Miss Jane Van de Vrede, R. N. Treasurer of Georgia State Nurses Association Har- Van-Hills, Route 1 Smyrna, Georgia
x

Mrs. Verna Vogel, B. S., M. A. Science Coordinator Georgia Baptist Hospital Atlanta, Georgia Miss Lucille Woodville, R. N., M. S. Regional Consultant Nurse Children's Bureau 50 Seventh Street, N. E. Atlanta, Georgia Mrs. Billie Jo Young, R. N. Operating Room Supervisor Minnie G. Boswell Hospital Greensboro, Georgia
Xl

TABLE OF CONTENTS

Page

PREFACE

I

COMMITTEE MEMBERS

IV

PART I

A CONCEPT OF NURSING

1

SOME PRINCIPLES TO BE CONSIDERED IN PERSONAL ADJUSTMENT

TO A HOSPITAL SITUATION

3

INTER-ACTION DURING HOSPITALIZATION WITH HOME, WO~K,

CHURCH AND SCHOOL

4

PART II

CURRENT AND TERMINAL DISINFECTION - SANITIZATION

7

HOUSEKEEPING PROCEDURES

10

Reference List for Housekeepers

16

DISPOSAL OF TRASH AND GARBAGE FROM WARD UNIT

17

DISHWASHING - SILVER -TRAYS

19

CARE AND STORAGE OF LINEN

23

HAND WASHING, FACE MASK AND GOWN TECHNIQUE

25

DffiECTIONS FOR :MAKING AND STERILIZING MASKS

27

TECHNIQUE OF WEARING AND HANDLING MASKS

29

MEDICAL ASEPSIS --TECHNIQUE OF PUTTING ON GOWN

30B

TERMINAL CLEANING OF WARD UNIT

34

PART III

BASIC NURSING PROCEDURES

37

Unoccupied Bed

39

Occupied Bed

42

Shock Bed - - Recovery or Anesthesia Bed

44

Cardiac Bed

46

Escorting and Transporting Patients

48

Wheelchair Transport

49

Moving Helpless Patient to Stretcher

51

Admission of New Patient

55

Meeting the Personal Needs of Patients Throughout the Day

59

Bed Bath

61

Morning and Afternoon Care

65

Tub Bath

67

Mouth Care for the Helpless Patient

70

XII

TABLE OF CONTENTS
Elimination Removing the Bedpan Feeding the Helpless Patient Preoperative Nursing Care Postoperative Nursing Care
PART IV
SPECIAL DIAGNOSTIC TESTS GENERAL PHYSICAL EXAMINATION TEMPERATURE, PULSE AND RESPIRATION
Temperature by Mouth Temperature by Rectum Temperature by Axilla or Groin BLOOD PRESSURE PROCTOSCOPIC EXAMINATION VAGINAL EXAMINATION LABORATORY TESTS Urinalysis COLLECTION OF SPECIMENS Urine Feces Sputum Nose and Throat Cultures BLOOD AMOUNTS AND TYPES OF CONTAINERS DIAGNOSTIC PROCEDURES Biliary Drainage Cholecystogram Gastric Analysis Renal Function Tests Phenolsulfonephthalein Test Glucose Tolerance Paracentesis
Abdominal Paracentesis Thoracentesis Lumbar Puncture Basal Metabolism Electrocardiogram Removal of Pericardial Fluid Preparation for Cystoscopic Examination
XIII

Page
73 74 75 77 80
83 85 87 88
90 91
92
95 97 99 99 103 103 106 107 108 110 111 113 115 117 119 120 122 124 125 128
132 136 138 139
141

TABLE OF CONTENTS
PART V
THERAPEUTIC PROCEDURES Principles of Therapeutics
BATHS - Medicated, Colloid, Starch, Bran and Oatmeal Baths Sodium Bicarbonate Potassium Permanganate Sitz
LOCAL APPLICATION OF HEAT AND COLD Hot Water Bottle Electric Heating Pad Hot stupes, Clean Compresses and Fomentations Sterile Hot Wet Compresses Ice Cap Cold Wet Compresses
IRRIGATIONS Ear Eye Indwelling Catheter Throat Nasal Perineal Irrigation using Forceps Perineal Irrigation without Forceps Vaginal Stomach Wound Rectal Colostomy
GASTRIC GAVAGE CATHETERIZATION - - followed by Bladder Irrigation ENEMA - - Cleansing or Evacuating
Medicated Retention Enema DRAINAGE OF STOMACH BY SUCTION ADMINISTRATION OF MEDICATIONS INJECTIONS
Hypodermic or Subcutaneous Subcutaneous Infusions Venoclysis ADMINISTRATION OF OXYGEN Nasal Catheter Oxygen Face Mask Oxygen Tent
XIV

Page
143 145 148 148 148 151 151 152 152 154 156 157
158 161 164 168 171 174 177 180 183 188 191 195 187 197 200 203 204 206 208 208 211 218 214 214 216 216

TABLE OF CONTENTS
PART VI
FORWORD INTRODUCTION TO CENTRAL SUPPLY SERVICE
Principles Applicable to Central Supply Service Physical Layout of Sterile Central Supply Service Organization of Central Service Administration of Central Service Standardization and Sterilization in the Central Supply FOLDING, PACKAGING, STERILIZING LINEN STERILIZATION BY AUTOCLAVE RELATION BETWEEN PRESSURE, AIR AND TEMPERATURE STERILIZATION TIME TABLE STERILIZATION CHART FOR PRESSURE STEAM AUTOCIAVE STERILIZATION TIME TABLE FOR HOT AIR NEEDLE SHARPENING TECHNIQUE Needle Point Repair Cleaning Needles Autoclaving Needles Hot Air Sterilization of Needles Determination of Size of Needle HYPODERMIC SYRINGE CONSTRUCTION CARE OF HYPODERMIC SYRINGES PROCESSING RUBBER GOODS TRAYS IN CENTRAL SUPPL Y
PART VII
THE OPERATING ROOM Organization and Administration of the Operating Room Essential Basic Supplies for Operating Room Shelves Surgical Hand Scrub Surgical Asepsis (Gown and Glove Technique) Preoperative Set Up Care of Surgical Instruments Surgical Instrument Sets

Page
224 226 227 227 228 228 229 230 239 242 243 244 246 248 248 248 249 249 249 257-260 258 264 268-311
312 313 317 320 322 329 339 341-352

XV

ILLUSTRATIONS
A Method of Packaging Needles for Sterilization Abbott Intravenous Set Appendectomy Instruments Arrangement of A Central Supply Room Arterial Transfusion Set Arterial Transfusion Table Auto-Transfusion Tray Bard-Parker Transfer Forceps Bladder Drainage Set Bladder Irrigation Set Bulk Hypodermic Supply Cardiac Resuscitation Catheter Tray Chole cyste ctomy Demonstrating Correct Method of Folding and Packaging Demonstrating Correct Method of Loading a Sterilizer Dilitation and Curettage (D and C) Douche Tray Draping of Portable Instrument Table Eleven types of Syringe Breakage Emergency Dressing Tray Emergency Medication Tray
XVI

Figure Page

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Illustrations
Excision of Lipoma Filling Basin with Solution Fully Equipped Nursing Unit Gastric Analysis Tray Gloves Hemorrhordectomy Herniorraphy Hot Compress Tray Individual Hypodermic Supply Individual Hypodermic Tray Instruments for Tonsil and Adenoidectomy Intravenous Set (Fedwal) Intravenous Set (Kelly) Laparotomy Liver Biopsy Tray Longitudional Cross Section of a Pressure Sterilizer Mastectomy Mayo Table Showing Instruments and Supplies Mayo Table Showing Instruments and Supplies Nasal Irrigation Tray Nasal, Tonsil Hemorrhage Tray Needle Construction
XVII

Figure Page

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Illustrations

Figure

Needle Point Repair

8

Needle Sterilization Chart

10

Non-boilab1e Catgut in Germicidal Solution

65

Opening Sterile Package

60

Opening Sterile Package

61

Orthopedic Prep Tray (Sterile)

32

Paracentesis Tray (Abdominal)

33

Perineal Irrigation Tray without Forceps

34

Pneumoarthrogram

35

Pouring Medication into Sterile Utensil

64

Recipient Set

36

Removing Instruments from High Speed Pressure Autoclave

63

Retrograde Irrigating Set

37

Sketches Illustrating Technique of Handling Masks

2A-2Q

Spinal Puncture Tray

38

Spinal Puncture Tray (Infant)

39

Spinal Sympathetic Block

40

Sternal Puncture Tray

41

Subcutaneous Set (Fenwa1)

42

Subcutaneous Set (Kelly)

43

Surgical Aseptic Technique

59A-59I

Syringe Construction

12A

Page 252 254 336 333 333 285 286 287 288 335 289 335 290 30A 291 292 293 294 295 296 324 256

XVIII

Illustrations
Thoracatomy Bottle and Tube Thoracentesis Tray Throat Irrigation Thyroidectomy Set Tidal Drainage Set Tracheotomy Tray Transfusion Set {Baby} Use of Davis Roller Vaginal Biopsy Vaginal Examination Tray Vein Ligation Venous Cut-Down and Suture Tray Venous Pressure Tray Ventriculogram Washing and Packaging Rubber Gloves

Figure Page

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XIX

PART I
A CONCEPT OF NURSING
"Medicine is the surgery of functions, as surgery proper is that of limbs and organs ...... And what nursing has to do in either case, is to put the patient in the best condition for nature to act upon him. "
-Florence Nightingale
Nursing is concerned with the care of people. It includes a range of activities requiring skills based on a knowledge of biological, physical, and social sciences. It aims not only to provide care during illness, but to promote health and happiness through an understanding of man both as an individual and as a member of the family and community group.
Nursing offers many opportunities to contribute to the betterment of society in general. Medical science advances so rapidly that the preventive and remedial aspects of disease cannot be left to chance. Every nurse has responsibility for keeping pace with these advances. She shares the duty of disseminating information useful in promoting good health and preventing disease. She must develop skill in helping people to analyze their needs and to utilize all health resources.
Leadership in nursing extends into the realm of technical research. Nursing technics and methods should keep abreast with scientific advancement, to fulfill the primary objective of service. Nursing technics must be continually studied to analyze their effectiveness. New skills must be developed as necessary, to enable the nursing profession to keep pace with the advances of related sciences.
Nursing involves relationships with many other groups- physicians, hospital and health agency administrators, social workers, X-ray and laboratoz:y specialists, epidemiologists, sanitarians, and ministers--all of whom share a basic humanitarian philosophy and are planning for positive health on all levels. This relationship calls for intelligent and sympathetic comprehension of each group in the work to be done, for without understanding and cooperation the total job cannot be accomplished. Good nursing administration presupposes the need for such coordination of efforts and activities, and makes plans for this in the organization. Hospitals and health agencies particularly need to recognize the significance of this factor in order that the objectives of all the groups concerned with the people's health may be realized on a greater scale and with more satisfaction both to the worker and people.
The nurse cannot accomplish her job without the helping hand of trained coworkers. Together they work as teams. The nursing team is a coordination of professional ann. nonprofessional workers who give cooperative nursing care
1

according to their preparation and experience. With careful planning, the coordinated nursing team can re!lder invaluable nursing service; but without such planning, it may prove detrimental both to the patient and to the nursing profession.
The success of nursing depends upon the adequacy of the teaching and supervision of nurses and nonprofessional workers. In training the latter group, careful consideration should be given to planning the program, teaching the participant, gradual induction of the individual into the work and continuous supervision on the job.
The professional nurse must be able to distinguish those activities which should be performed by professional nurses from those which may be delegated to the nonprofessional group without jeopardizing the care of the patients for whom she is responsible. The Committee who prepared the Guide to Patient Care attempted to write all the procedures for the professional nurse with this thought in mind. A written guide can enumerate only basic elements of care required in a nursing situation. The individual using the guide will need first to determine the quality of nursing to be given, and then devise methods for using these procedures to accomplish the work. The human relations factor differs with each person and with each situation; therefore, when the guide is used in the instruction and direction of nonprofessional persons performing nursing care, it must be adapted to the intelligence, preparation, experience, and understanding of such persons. Scientific principles have been stressed in the manual. But nurses are advised that the application of these principles to nursing care must be constantly re-evaluated and made current by use of the latest information available.
2

SOME PRINCIPLES TO BE CONSIDERED IN PERSONAL ADJUSTMENT TO A HOSPITAL SITUATION
1. All personal relationships affect therapy either positively or negatively. 2. Each person is an individual whose total needs must be recognized and
accepted. 3. Knowledge of tne person is essential to understanding him and his point of
view. 4. Recognition of one I s own feelings and responsibilities in relation to each
individual is essential to the building of effective relationship and service. 5. Nursing care plans should be made to meet the needs, desires and feelings
of the individual. 6. Nursing procedures must be scientifically sound and should include the
following factors: safety; therapeutic effectiveness; comfort; economy of time, material and effort; pleasing in appearance and workmanship; adaptablity to hospital and horne situations. They should be performed with skill and dexterity and should consider the learning and teaching elements. 7. Cooperative relationship among all community agencies insures continuity of medical and nursing care. 8. Interchange of information among agencies insures better relationship between patient, hospital facility, horne and community. 9. Procedures, systems of operations and policies governing nursing practice should be evaluated, reviewed, and revised at regtJ.larly planned intervals.
3

INTERAC TION DURING HOSPITALIZATION

WITH HOME, WORK, CHURCH, AND SCHOOL

EXPLANATION AND PURPOSE:

Confronted with an illness, the physician, the nurse, and the family may all believe the hospital to be the best place for the patient to receive the care he needs. The patient, however, may have totally different ideas and feelings about his need for hospital care. Entering the hospital, then creates for him a second problem-in addition to his illness-- that of adjusting to this new and strange physical environment, to unfamiliar sights, sounds, and smells, to regulations limiting his personal freedom, and to increase dependency upon others. The patient may have feelings about all these things. How he feels about them will determine. in large measure, his response to them.

The usual source of these satisfactions which meet our basic emotional needs are in the relationships existing in the home, the family, the school, the job, the church, and so forth. These sources of emotional satisfactions may be partially, sometimes totally, denied by hospital procedure. The tension and anxiety thus created affect the body physiology and augment the illness. To recognize and try to alleviate this tension and anxiety is a primary responsibility of the nurse.

PRINCIPLES:

1. Every physically ill person is potentially an emotionally upset person.

2. Illness causes the patient to become dependent with a consequent threat to his inner, personal security. He often becomes the victim of fears and fantasies and it is harder for him to recognize and manage his feelings.

3. His emotional needs must be met before the patient will be ready to accept help.

4. .The nurse must be aware of her own emotional needs to avoid over-indulging the patient, or satisfying her own need to feel important at the expense of the patient.

EQUIPMENT: Understanding, Patience, Tolerance, Charity

PROCEDURE:

Steps

Key Points

1. Warm, friendly, emotional support diminishes anxiety.

1. 1 Be a warm, sincere, understanding person.

4

2. It is the nurse's job to provide the therapeutic situation to meet these needs.
3. Maintain good relationships

1. 2 Be alert to expressions of fears, anxietie s, dependencie s. Example s: Frequent requests of the patient for simple ministrations; excessive complaints and/ or faultfinding to cover up fatigue and embarrassment; frequent questions about the hospital. (People need to talk to relieve distress and uneasiness. )
1. 3 Avoid moral judgments .. "~ood" behavior or "bad" conversations.
2.1 Display of professional competence and security.
2.2 The manner in which the patient is admitted to the new environment influences his degree of acceptance of the hospital, his illness, and the enforced separation from friends and family.
2. 3 Show that you are interested in the patient as a person, rather than his disease.
3.1 Be considerate of relatives and friends. Many people stand in awe of hospitals. They are ill at ease, bewildered, worried. Anticipate their needs by explaining hospital routines and regualtions to them.
3.2 Encourage visitors to talk of horne, children, pets, neighborhood and family activities, not the patients illness
3. 3 Encourage parents to write often or send gifts to patient if visits must be limited.
3.4 Permit member of family to stay with small child, acutely ill patient or patient in labor.
5

3.5 Help maintain relationships between the hospitalized patient and his home and community by use of visiting teacher, social service, minister and others.

3.6 Listen to patient talk in order to learn something about him and his way of life.

4. Participate in community programs of education. Example: Recreation, church, and social clubs.

4.1 Outside and correlated interests add zest and vigor to profe s siona1 life, and help broaden the scope of interest and action.

5. Devise system of interchange of information with participating agencies.

5.1 Bring various agency personnel together at stated intervals. Work jointly on a form that will be practical for exchanging information.

5.2 Invite agency personnel to assist with hospital programs, offer to participate and assist with other agency programs.

6

PART II
Concurrent and Terminal Disinfection
Sanitization
"Sanitation is a way of life. It is the quality of living that is expressed in the clean horne, the clean farm, the clean business and industry, the clean neighbor hood, the clean community. Being a way of life, it must corne from within the people; it is nourished by knowledge and grows as an obligation and ideal in human relations. " (Modern Sanitation, July, 1949, Pg. 11.) This quotation applies very closely to nursing in all of its phases.
General Principles
A. Important principles in human susceptibility
1. Individuals differ in their susceptibility to specific and nonspecific infections.
2. In general, susceptibility to infections is increased during illness.
3. The development of a human infection is dependent upon the number of organisms to which a person is exposed, the virulence of the organism, and the susceptibility of the individual.
4. The unbroken skin and mucous membranes are ~xcellent barriers against microorganisms. This is an important principle for nurses to remember.
5. An inflammation is the body reaction to an infection. The body defenses are attempting to wall off the infection from the surrounding tissues. This wall must be protected from trauma (example: squeezing) until the infection is localized. Drainage from any infectious process contains living microorganisms, pus, serum, and blood. Therefore, dressings from such infections must be carefully wrapped in at least two thicknesses of paper, adequately secured and burned immediately.
6. Fatigue, malnutrition, worry, and emotional stresses tend to increase general susceptibility to infection.
7. An unsanitary environment is potentially a greater source of infection.
7

B. lInportant principles relative to people and disease
1. In order to establish an infection, the organism must gain entrance into the body.
2. The entrance of organisms into the human body differs with the type of pathogenic organisms. Examples: the typhoid bacilli must enter the gastro-intestinal tract through the mouth. The hookworm larvae can enter the body either through the skin or by way of the gastro-intestinal tract. Insects may transport infectious organisms to suitable materials (flies, cockroaches). Insects may act as hosts for part of the life cycle of certain parasites (lice for typhus; mosquitoes f01" malaria). Certain pathogenic organisms may be introduced into body cavities, parenterally or in wounds by some nursing procedures which are potentially hazardous. Example: Isolation procedures, catheterizations, hypodermics, infusions, instillations and surgical procedures.
3. During the course of an infectious disease, pathogenic organisms leave the human body by specific routes. Examples: Tubercle organisms from pulmonary lesions are excreted in the sputum; respiratory pathogens are excreted in respiratory secretions; intestinal pathogens leave the body in feces; some infectious organisms of the central nervous system leave the host in respiratory secretions, namely menigococci. Typhoid organisms may leave the body in urine. Because this principle is true, pathogenic organisms must be destroyed as soon as they leave the portal of discharge in order to prevent transfer of infection to other people or reinfect the patient.
4. Vectors (example: insects, hands) transmit infectious organisms. Therefore, the environment must be kept free of insects such as flies and cockroaches and minute precautions should be taken in using the correct hand washing procedure.
5. The Commissioner of Health is the recognized authority on matters pertaining to health, including the disposal of infectious materials and quarantine. The State Department of Health provides consultation regarding doubtful diagnoses.
C. lInportant principles relative to resistance of microorganisms
1. Pathogenic microorganisms vary in their ability to resist destruction by physical (heat, cold, ultraviolet light) and chemical agents. Example:
Tubercle organisms are highly resistant and can survive 60 0 C. for ten
minutes.
2. Spore-forming bacteria are the most resistant microorganisms because the spores are difficult to penetrate. Example: Spores of the anthrax
8

tetanus, gas bacillus and botulinum can resist all known chemical agents for twenty-four hours. Spores of the above organisms require thirty minutes of autoclaving at l200 C. or two hours of hot air oven sterilization at 1600 - 170 0 C. for destructlOn. 3. Organic material (sputum, feces, pus, blood, food) interferes with the ability of a physical or chemical agent to destroy microogranisms present. This interference may be due to mechanical protection, chemical combination of the agent with the organic material, or to the production of coagulated protein which may harbor viable microorganisms. Therefore, in the presence of organic material, the time of exposure must be increased. Example: All vegetative non- sp'ore forming organisms of medical significance are readily killed by five minutes of contact with boiling water, if these organisms are not protected by organic material. Boiling time should be increased to ten minutes for any article which may have even a small amount of organic material. If food particles on dishes are excessive, the time factor should be increased to thirty minutes for safety. Neither boiling nor chemicals may be depended on to sterilize (kill spores). 4. Each chemical has a specific range of effective concentration. The nurse must be familiar with these concentration rates to utilize them most effe ctively. 5. Where sterility is required, the autoclave (thirty minutes at l200 C.) or hot air oven (two hours at 1600 - 1700 C.) must be used.
9

HOUSEKEEPING PROCEDURES DESIGNED TO REDUCE INCIDENCE OF INFECTION AND PRESERVE MATERIALS

EXPLANATION AND PURPOSE: Hospital housekeeping differs from housekeeping at home, in industry and in hotels, in that every area and article used in the hospital situation is potentially infectious. The hospital patient is acutely or chronically ill with conditions due to bacteria, virus or other disease -producing organisms that may be transferred to others by filth, fingers, food, flies and other vectors of disease. Housekeeping procedures are designed to keep cleanliness at the highest possible safety level, to maintain and preserve equipment, and furniture and to provide order as an aid to patient co.mfort and recovery.
PRINCIPLES:
1. Housekeeping procedures are based on sound principles of sanitation.
2. Cooperation with other departments is essential for effective work. Schedules for cleaning shall be planned in conference with other departments concerned. This is the most effective way of maintaining good relationship.
3. Efficient use of proven labor-saving devices is economical and effective.
4. Many hospitals have a housekeeping department, while others depend on the nursing department to maintain housekeeping.

CLEANING WOOD, TERRAZZO, LINOLEUM, PORCELAIN, STAINLESS STEEL, MONEL METAL, ENAMELWARE, BRASS, GLASS STERILIZERS, SHADES, VENETIAN BLINDS AND WOOD WORK.

.

-

EXPLANATION' AND PURPOSE: Hospital floors may be of wood, linoleum;

terrazzo and other floor coverings. It is of great importance that floors be kept

clean and that during the cleaning process, every precaution be taken to prevent

accidents.

PRINCIPLES:

1. Moisture should always be used when sweeping or dusting.

2. Floors may be contaminated with dirt that is brought in from the outside and/ or by infected materials that may be unintentionally dropped.

3. Clean articles dropped on the floor are contaminated.

10

4. Clean, well kept floors help prevent the spread of infections, increase confidence in the institution and add to the patients comfort.
EQUIPMENT: 1. Clean wet and dry mops. 2. Clean soft bristle push brooms. (Dry sweeping should not be done.) 3. Long handle radiator brusheR. 4. Mop buckets built on wheeled frame. 5. Mild neutral detergent (determined by kind of cleaning to be done, the policy of institution and composition of the floor. ) 6. Clean dust cloths. (Dry dusting should(e done.) 7. Basins or pails. 8. Polish as indicated. 9. Vacuum cleaner with attachments.
10. Wall washer.

PROCEDURES: Steps
1;- Plan a schedule.
2. Provide proper tools, detergents, and the like.

Key Points
1. 1 Work out floor cleaning schedule on hourly, daily and weekly basis in cooperation with housekeeping and other departments concerned.
1. 2 Floor cleaning plan should not interfere with patients rest, with treatments, or with diets.
1. 3 Provide for emergency service at any time of day or night.
2. 1 Utilize labor saving devices when possible.
2.2 Investigate composition of water supply and choose detergent accordingly.
11

Orient workers.
4. Clean hardwood floors. 5. Clean terrazzo.
Linoleum. Place warning sign at each end of work area.

3. 1 Have each employee undergo a period of orientation.
3.2 Demonstrate and supervise his return demonstration on each mechanical device used.
3.3 Demonstrate simplest method of cleaning process.
3.4 Emphasize economical use of materials and equipment.
3.5 Supervise each procedure until satisfactorily performed.
3.6 Give the worker a feeling of the importance of his work in relation to patients welfare.
4. 1 Use soft bristle broom and to keep floors free of dirt and debris. Clean daily and as often as necessary.
4.2 Wax, to preserve the flooring, according to schedule.
5. 1 Scatter moist sawdust over the area.
5.2 Sweep with soft bristle broom.
5.3 Mop with solution containing detergent recommended by manufacturer of flooring.
5.4 Rinse profusely to remove cleaning solution 3.nd abrasives.
5. 5 Follow instructions of manufacturer to gain full advantage of "sealing" new terrazzo.
6. 1 Solvents, harsh abrasives, high alkaline
detergents and acids and paste wax cause linoleum to become spongy or brittle.
6.2 Remove debris with soft bristle push broom.

12

7. Porcelain. 8. Stainless steel. 9. Monel metal.

6.3 Wash with warm water containing a mild detergent. Wring mop almost dry. Wash small area at a time.
6.4 Rinse carefully with clean warm water. 6.5 Apply water, emulsion, wax.
6.6 Buff the floor. Follow manufacturer's instructions for best results.
7. 1 Rinse with cold running water.
7.2 Wash with hot soapy water. Use a stiff, long handle brush to reach into deep bowls or basins.
7.3 Use abrasive to remove crusts and stains.
7.4 Rinse thoroughly.
7. 5 Dry and inspect.
8. I Rinse under cold running water.
8.2 Wash in hot soapy water.
8.3 Autoclave bath basins and other stainless steel items' when the patient leaves the unit.
8.4 Polish stainless steel by applying whiting, allow to dry and rub with a clean dry cloth.
9. 1 Monel metal is an alloy made of nickel, copper and other elements. It is highly resistant to corrosion and oxidation.
9. 2 Rinse with cold water.
9.3 Wash with solution containing mild alkali detergent.
9.4 Scrub with finely powered abrasive.
9. 5 Remove spots by adding small amount of oxalic acid (poison) to water and rinse thoroughly.
13

10. Enamel ware.
11. Brass. 12. Glassware. 13. Sterilizer s.
14. Shades.

10. 1 Soak with cold water to remove vegetable matter.

10.2 Wash with hot soapy water.

10.3 Scour with mild abrasive.

10.4 Rinse thoroughly. Test for leaks.

10.5

Steam sterilize basins, bedpans and other metal items when patient leaves the unit, or boil for 20 minutes if steam sterilization is not available.

11. 1 Polish with brass polish.

12. 1 Wash with soapy water.

12.2 Rinse with clean water.

12.3 Immerse in cold water and bring water to boil for 10 minutes.

12.4 Autoclave medicine glasses, drinking tubes, feeding cups after use.

13.1 Disconnect from electric socket.

13.2 Drain by opening valve.

13.3 Scrub inside with steel wool and abrasive.

13.4 Rinse with clean water.

13.5 Close the valve and refill with clear tap water.

13.6 Wash and polish outside.

14. 1 Remove shades from the window and take to the housekeeping shop to clean.

14.2 Place the shade on a flat surface and remove dust with the vaccum.

14.3 To wash, use solution that is recommended by the manufacturer.

14

15. Venetian blinds.
16. Woodwork, window sills, door facings.

14.4 Allow the shades to dry and replace.

15. 1 Vacuum blinds weekly or oftener as
indicated.

15.2

Wash blinds with solution containing mild detergent. A tub can be used for this purpose.

15.3 Rinse with warm claen water and dry with
soft clean cloths.

16. 1 Wash daily with warm soapy water, rinse and dry.

15

SUGGESTED REFERENCE BOOKS AND MAGAZINES FOR THE HOUSEKEEPER

BOOKS:

Art in Everyday Life, Harriet and Vetta Goldstein

Color Psychology and Color Therapy, Faber Berren, McGraw-Hill Book Co., Inc., New York and London 1941

Elements of Interior Decoration, Sherrill Whiton, J. B. Lippincott Co. , New York City, N. Y.

Furniture, Its Selection and Use, National Committee on Wood Utilization, U. S. Department of Commerce, Washington, D. C.

Hotel Management,

Lucius M. Boomer, Harper Bros. , New York City, N. Y.

Standard Practice Manuals for Hotel Operation, Ralph Hitz, Harper Bros. , New York City, N. Y.

Housekeeper I s Guide to Selection and Training of Employees, Crete M. Dahl and Grace H. Wooley, Dahl Publishing Co., Stamford, Conn.

MAGAZINES:

Hospital Management,
Crain Publishing Co., 200 East Illinois I Chicago, Ill.

Hotel Management,

Abrens Publishing Co., 71 Vanderbilt Ave. , New York City, N. Y.

Institutions Magazine, Domestic Engineering Co., 1801 Prairie Ave. , Chicago, Ill.

The Modern Hospital, The Modern Hospital Publishing Co., Inc., 919 North Michigan Ave., Chicago, Ill.

16

DISPOSAL OF TRASH AND GARBAGE FROM WARD UNIT

PURPOSE:

1. To make the environment safe from potential infections, from trash and garbage.

2. To dispose of infectious materials at the source.

PRINCIPLES:

1. Trash attracts flies, rats, roaches, ants and other vectors of disease.

2. Disease organisms find a favorable breeding place in the garbage and trash area.

3. Trash and garbage from the hospital is potentially infectious.

4. Trash and garbage create odors and detract from the esthetic factors in the environment. '

5. Burning is the safe method of dealing with trash and infectious materials.

PROCEDURES:

Steps

Key Points

1. Care of trash cans.

1. 1 Line waste baskets. trash cans, soiled dressing containers with two to four thicknesses of newspaper.

1. 2 Allow three inches at the top of the container to prevent contamination of the opening and to fold over when discarded.

2. Place trash cans in strategic areas.

2. 1 Place lined waste receptacles at convenient areas in the corridors and exits for the convenience of visitors, patients, and others.

2.2 Place sand filled jars for cigarette butts and matches at each elevator stop and at each exit.

3. Special care of soiled surgical dressings.

3. 1 Have paper bag or newspaper cornucopia available for each surgical dressing,

17

4. Special care of body excreta.

3.2 Fold top of bag, twist, and place in waste container until collected for burning.

4. 1 Sputum:

4. 11

Provide heavy paper bag for disposal of contaminated materials and place within convenient reach of the patient.

4. 12

Instruct patient to cover mouth with paper handkerchief when coughing and/ or sneezing. Deposit sputum in paper kerchief.

4.13 Replace waste paper bag frequently.

4. 14 Burn bags as soon as possible.

4.2 Other:

4.21

Feces, urine, vomitus may be flushed through the sewer with safety if patient is free of infectious or communicable disease.

4.22

Rinse utensils used to collect excreta with cold water, wash in warm soapy water. Rinse and sterilize with live stearn.

4.23 Feces, from a patient diagnosed as having dysentery or typhoid fever, must be exposed to a 5% saponified solution of aerosol or 5% chlorinated lime solution for a minimum of one hour before depositing it in the sewage.

18

DISHES - SILVER - TRAYS

PURPOSE:

To render dishes, silver, and trays free from pathogenic bacteria.

PRINCIPLES:

1. Dishes and other receptacles used to prepare food may transmit pathogenic organisms.

2. Organic materials that cling to the surface of dishes prevent the penetration of steam and the cleansing agent.

3. Dishes washed with reliable detergents of the proper concentration, for a suitable time, at a given temperature, and then rinsed thoroughly, are safe for use.

EQUIPMENT:

1. Detergent - liquid soap or soap powder

2. Dishwasher - mechanical or double sink

3. Covered paper-lined can for disposal of waste

4. Trays to process dishes and silver

PROCEDURE:

Steps

Key Points

1. Assemble trays.

1. 1 Remove the tray from the bedside and place on portable carrier.

1. 2 Report, to the head nurse the failure of a patient to eat his food. Report patients comments about the food.

1. 3 It is the responsibility of the head nurse to report a patient's preference for certain foods to the nutritionist and to the physician.

2. Bring trays with dishes into dishwashing area.

2. 1 Avoid noise and breakage of dishes by using proper transporting facility.

19

3. Rem.ove left-over foods. 4. Place dishes in dish rack.
5. Tem.perature.
6. Tim.e. 7. Maintain concentration
of detergent.

3. 1 Scrape left-over foods into garbage pail.
3.2 Rinse dishes with cold water to rem.ove organic m.aterial. Note: m.ost m.odern dishwashers are equipped with cold water spray.
3.3 Pour left-over liquid into sink.
4. 1 The water m.ust splash against all parts of each dish.
4.2 Place each dish individually on the rack at an angle indicated in book of instructions.
4. 3 Place top side of the tray in the direction of the spray.
4.4 Rack cups, glasses, tea pots, individually, bottom. side up to catch the spray and perm.it good drainage. Do not stack.
4.5 Silver - use special tray and avoid nesting.
5. 1 The best m.achines are equipped with a therm.ostat. Otherwise use therm.om.eter.
5.2 Wash tem.perature 1200 - 1600 F.
5.3 Rinse tem.perature 1800 - 1900 F.
6. 1 Wash - 30 to 40 seconds.
6.2 Rinse - 10 to 20 seconds.
Note: When water pressure is low, the tim.e for washing or rinsing should be lengthened accordingly.
7. 1 Use am.ount recom.m.ended by m.anufacturer.
7.2 Use non-clogging dispenser.
7.3 Use feeding devise.
7.4 Check concentrate frequently.

20

8. Keep the dishwashing

8. 1 Keep the machine clean.

machine in good condition.

Note: The directions

8. 11 Remove left-over foods from dishes.

that come with each machine

should be followed.

8. 12 Clean strainer pans.

8. 13 Avoid inferior soaps and compounds that form scale, scum, and sludge.

8.2 Lubricate - as directed by manufacturer.

8.3 Inspect machine daily.

8.31 Test filter valve.

8.32 Open and close rinse valve and look for leaks.

8.33 Check over-flow pipe for snug fit.

8.4 Avoid clogging nozzles. 8.41 Clean after use and remove seeds, fruit pits and other materials.

9. Keep auxiliary equ,ipment clean.

8.5 Keep spray nozzles in rip'ht positions.

8.51 Adjust nozzles so that the spray is directed against dishes and not against side of washer.

8.6 Maintain full pressure.

8.61 Keep pressure high.

8.62 Keep pump packed well.

8.7 Check heat controls.

9.1 Wash and rinse with live steam after use.

9. 11

Keep two or more refuse containers available. Allow one refuse container to dry in the sun while the other is in use.

21

10. Inspect dishes, silver and trays.

10. 1 Inspect and discard all broken, cracked and chipped dishes and glasses.

10.2 Inspect silver and trays for deterioration

NOTE:

This detailed procedure may not be needed by the nursing director or supervisor for purposes other than supervision and orientation of new personnel. When dishes are washed by hand the steps and procedures described herewith should be observed. A copy of the "Sanitary Code" published by the State Health Department is available to all personnel.

REFERENCES:

Plain Tap Sanitation of Eating Utensils - Modern Sanitation, July, 1951 (Reprint)

22

LINEN

PURPOSE To prevent the transfer of infection by safe handling of soiled lilens.

PRINCIPLES: 1. Contact with soiled linen may transfer pathogenic organisms.

2. Pathogenic organisms are destroyed by procedures used in modern laundries.

3. High temperatures and certain chemicals destroy synthetic materials, cottons, and silks.

4. Stains become set if not removed before linen is placed in the laundry vat.

EQUIPMENT:

1. Linen

2. Metal hamper rack

3. Canvas bag that fits and ties in hamper or individual mesh bags for each unit

PROCEDURE:

Steps

Key Points

1. Inspect linen for stains and 1. 1 Instruments, dentures, money, rings,

extraneous materials.

hot water bottles, rubber sheets, and

other items of per sonal and monetary

value are frequently lost and destroyed

in the laundry.

1.2 Separate all linen stained with blood or chemicals - either in individual unit or in the laundry, depending on policy of the hospital.

2. Place used linen in hamper. 2.1 Place linen hamper near soiled linen. Hold all used linen at arms length and place in hamper immediately.

23

3. Fill linen hamper twothirds full.
4. Close bag. 5. Remove soiled linen.
from work area.
6. Keep laundry chute clean.

2.2 Unnecessary agitation of linen by shaking or dragging on the floor or furniture spreads dirt and pathogens.
3. 1 Overfilled hampers causes contamination of surrounding areas.
3.2 Place all stained linen in a separate hamper.
4. 1 Fold the top flap of the bag and pull draw string tightly.
5. I Place the soiled linen in a central chute or store until collected by laundry pickup service.
6. 1 Interpret need for cleaning laundry chute. Hot soap and water followed with live steam is recommended. Caution is necessary as chute doors may open during the cleaning process and cause injury.

24

PROCEDURES DESIGNED TO PROTECT NURSES AND OTHERS: HANDWASHING, FACE MASK, GOWN TECHNIQUE
EXPLANATION AND PURPOSE: All techniques involved in this manual may well be included under this classification as asepsis is directed toward prevention of infection and protection of patients and all hospital employees. Handwashing, masks, gowns, hairnets, aprons, uniforms, the removal of rings, short finger nails, sensible rubber heeled shoes and other personal grooming factors contribute so specifically to the preventive aspects of nursing, that it is important to consider the factors that require special skills.
SOME PRINCIPLES:
1. Every person has a right to expect full protection against infectious materials that are potentially present in a hospital situation.
2. The use of gowns and masks are effective only when specific rules of technique are followed by each person concerned with the patient.
3. Provision for handwashing facilities is a responsibility of the administration.
4. Interpretation of the need, and the location of handwashing facilities is the responsibility of the nurse administrator, and others primarily concerned with their use.
5. Adequate facilities for handwashing not only helps prevent infection of the hospital staff and patients, but is economical in terms of saving time and steps.
HANDWASHING:
PURPOSE: To make hands free from potential infectious materials. It is said that the greatest single factor in the prevention of the transfer of disease organisms is the proper washing of hands.
PRINCIPLES:
1. Bacteria can be transmitted by hands.
2. Soap plus friction are effective in removing soil and micro-organisms.
3. Hands washed before and after each contact with patients creates a desirable safety factor for protection of self and others.
4. Rings may harbor bacteria and are difficult to clean.
25

5. Running water carries the soil away from the hands and prevents recontamination.

EQUIPMENT:

1. Hot and cold running water.

Z. Soap - liquid .oap in dispen.er is preferable.

3. Oranlewood .tick

4. Towel individual papeZ' towel.

PROCEOURE:

Step

Key Point.

1. When to wAlh hanc:ll.

1, 1 Befolle and &fteZ' each plloceduZ'e.

1. 2 BefoZ'e leavinl Z'oom of patient with communicable dlleau.

1. 3 Sefore and aftClZ' each contact with patient and hil enviZ'onment.

1.4 SefoZ'e .eZ'vinl food.

1.5 Patient. ob.erve and lain knowledae when the above pZ'ocedure. aZ'e carried out.

Z. Mohten hAnd. with WAl'm wateZ'.

2. 1 Hold hand. over link and allow wa.ter to flow gently.

3. Apply IgAp.

3. 1 PZ'u. dilpenuZ' and relea...oap into riaht hand.

:3. 2 Ihing hand. tOletheZ' and create a heAvy lAthell.

4. tru hiction and wluh
hand

4. 1 With finaeZ' tip. of oppoJite hand, chcle each fingeZ' with Z'otaZ'y motion from bau to tip. Give upecial attention to cuticlu and joint

4. Z Use orangewood .tick to remove material from under and around the nail.

26

4. 3 Rinse hands, lather again; wash hand well above the wrist.

5. Rinse.

5. I Allow warm water to flow gently over the hands until all soap has been removed. Flex elbows - allowing water to flow toward the elbow.

6. Dry.

6. I Pat hands dry with paper towel.

6. 2 Dry well. Hands rinsed and dried will
not become chapped so easily.

7. Apply hand lotion.

7. I Select a reliable lotion, apply smali amount to palm and rub it thoroughly into ~ll parts of the hands.

DIRECTIONS FOR MAKING, WASHING AND STERILIZING MASKS.

MATERIAL:

Cheese cloth 42x42 thread per square inch.

PATTERN: Two straight pieces cut lengthwise

1. 8x24 inches - accurately measured.

2. 5x15 inches accurately measured.

PROCEDURE:

1. Fold 8x24 inch material to three thicknesses, making 8 x 8" square.

2. Fold 5x15 inch material to three thicknes ses, making 5 x 5" square.

3. With loose stitch machine sew 5x5" square in the center of the thickness of the 8x8" square to prevent slipping.

Figure IA

27

4. Fold 8x8 inch material with interposed section inside .

Figure IB



5. Cut one inch from opposite corners.
6. Turn in edges and stitch. Make darts 1/2" deep at each side of cut off corners. Stitch the darts 1" to 1/2" toward center.

Figure lC



"Hospital Masks - Their. Bacterial Filtering Efficiency and Resistance to Air Flow" (Public Health Reports, July 11, 1941, United States Public Health Service. )
7. Attach tape 18" long to opposite corners.

Figure ID

8 Laundering masks.

Send to laundry in mesh bag.

9. Prepare mask for autoclave. a. Fold tape to tape; roll and wind tape about the mask. b. Tuck tape so that ends may be grasped easily. c. Place rolled mask in muslin bag and autoclave.

Figure IE

Pull to Shape

Ready for Bag
t

28

TECHNIQUE OF WEARING AND HANDLING MASKS.
EXPLANATION AND PURPOSE: Numerous studies have been made on the value of and dangers inherent in the use of face masks as a protection against infection. Careless technique, in which the mask is used over and over again is more dangerous to the wearer and the patient than no mask. A mask properly used serves as a filter of pathogenic organisms and helps to protect the wearer from potential droplet infection. In reverse, it protects the patient from potential droplet infection from the atterid,ant. In some conditions, it is advisable for the patient and the attendant 'to each wear a mask.
SOME PRINCIPLES:
1. Face masks serve as a two-way filter of pathogenic organisms when properly used.
2. A mask reused after it is once removed from the face may bring pathogenic organisms to the wearer.
3. Sterilization insures freedom from pathogenic organisms when the mask is first used.
4. It is the responsibility of the administration to furnish enough masks. It is the responsibility of the wearer to be economical and follow techniques.
5. Masks may impose a social stigma when procedure is not understood by all persons concerned.
EQUIPMENT:
1. Sufficient number of masks to provide one mask each time contact is made with patients suffering from respiratory infection.
2. Transfer forceps jar.
3. Jar of clean masks.
4. Table or shelf adjoining the area.
5. Mesh bag to receive used masks .
6. Muslin bag.
29

PROCEDURE: Steps
1. Wash hands . .2. Remove sterilized mask
from container. 3. Unfold mask. 4. Put mask on.
5. Proceed with work. 6. Remove mask.

Key Points 1. 1 Follow handwashing procedure. 2. 1 Use transfer forceps to remove mask.
3.1 Avoid unnecessary handling. 4. 1 Place mask under chin and over nose. 4. 2 Tie in a bow on top of head. 5. 1 Proceed to care for patient. 6. 1 Wash hands. 6.2 Untie strings. 6.3 Place mask in mesh bag. 6.4 Wash hands.

30

SKETCHES ILLUSTRATING TECHNIQUE OF HANDLING MASK
~ Putting on Mask

Figure 2A Wash your hands. Remove sterilized mask from container, using forceps.

Figure 2B Grasp mask by stitched edge. Avoid unnecessary handling of mask.

jI

Figure 2C

Unfold mask by untwisting and pulling

on the strings.

....

Ji
Figure 2D Place mask under the chin and over the nose. Tie firmly on top of the head.

Removing Mask

Coniominofed Masks

I
Figure 2E
Untie Mask. Touch strings only.

Figure 2F Place in container for used masks. Wash your hands.

Never wear a mask after removing it from your face. Change masks frequently.

30A

SKETCHES ILLUSTRATING TECHNIQUE OF PUTTING ON GOWN

Figure ~G Without touching contaminated side of gown, slip hands inside back opening. Grasp gown by shoulder seams and remove from hook.

I Figure 2H Lay gown across chest and guide back and neckband into place by use of shoulders, elbows, and thumbs.

~
----'

Figure 2 I Carefully work arms and hands through sleeves without touching outside of gown.

Figure 2J Place forefingers inside neckband in front, follow band to back and fasten. Do not touch outside of gown.

30B

PUTTING ON GOWN - Concluded

Fi"gure 2K With right hand, grasp back edge of right side of gown and bring forward. With left hand, grasp back edge of left side of gown and place it under right side.

Figure 2L Push right side into place so that gown is crossed in the back with left side extending under the right, completely covering the uniform.

)

(I

Figure ZM Cosrs string in back and tie in front. This holds gown securely closed in the back.

.I Figure 2N Draw up sleeves to a convenient working level. Rubber bands may be used to hold sleeves in place.

1. Do not roll sleeve s of gown. 2. Do not permit sleeves to slip down over contaminated arms. 3. Do not permit gown to hang open in the back while being wo:;.',.. 4. Select a gown that is somewhere near your size.

30C

. SKETCHES ILLUSTRATING REMOVAL AND HANGING OF GOWN

Figur-e 20 Untie b~1t strings and drop ,at sides.
(Loop in front if strings are long.)

Figure 2P Draw sleeves up em arms and wash over area of contamination, being careful not to touch cuffs of gown.

~/))
Figure 2Q Unfasten neck band.

Figure R Place two fingers of right hand under ~uff of left sleeve and pull it down over hand. Do not touch outside of gown.
30D

Figure 2S Through left sleeve, grasp outer part of right sleeve just above edge of cuff and work it off over right hand.

REMOVAL AND HANGING OF GOWN - Concluded

Figure 2T Slip out of gown by working hands up to shoulder seams and lifting it off shoulder s, keeping hands inside. Keep fingers in position and work thumbs to neckband, holding it upright. Bring ends of neckband together.
I I MISS SMITH

Figure 2U Withdraw one hand from inside of gown and grasp center front of gown below neckband. Work hand toward armhole by gathering up intervening gown material.
I MISS SMITH

/

)
Figure 2V Withdraw other hand and adjust back of gown so that edges approximat~ each other. Grasp gown below neckband and
work hand to armhole by gathering up intervening gown material.

Figure 2W Hang gown on hook, contaminated side out, neckband standing upright, edges of back opening together, strings hanging straight down on outside of gown. Wash your hands.

30E

DISCARDING GO WN

To discard contaIninated gown:

1. ReInove gown according to prescribed technique. See Page

2. Fold gown with clean side out, roll it neatly, and place in laundry

haInper provided for soiled gowns.

3. Wash hands.

-~~

"-

CARE OF ALL CONTAMINATED LINEN
1. All used linen is sorted as it is col.lected into striped laundry bags. Bags are tied securely, and reInoved to the hospital laudnry where they are eInptied directly into Inechanical washers.
2. The laundry process is adequate to render all linen pathogentically clean and ready for use with the following exception: the Inasks are returned to a central supply rOOIn where they are folded, placed in Inuslin bags, and sterilized by steaIn under pressure before they are issued for use.
30F

GOWN TECHNIQUE: EXPLANATION AND PURPOSE: A "gown" used by the nurse, physician or technician refers to a garment so constructed that, when worn, it covers the cotton uniform from the neckline to the knees (or below) including the forearms to the wrist. The gown opens in the back and is fastened with tapes at the neckline, and at the waist line . It is usually belted with a cord that ties in the back. The gown is worn during surgical procedures. The gown is worn by the nurse, doctor or attendant when a communicable disease is suspected or known; in premature and well baby nurseries; in pediatric wards and general admission wards. PRINCIPLES:
1. The gown serves as a two-way barrier by protecting the wearer from becoming contaminated by pathogenic entities and by preventing pathogenic entities from being carried to the clean area by the outer clothing of the worker.
2. A sterile gown is required when surgical asepsis is needed. A clean gown is worn when medical asepsis is needed.
3. Each worker needs a supply of gowns for use in the sick room. EQUIPMENT:
1. Regulation gown, - size to fit. 2. Space where clothing can be changed or gowns hung when not in use. NOTE: The following procedure desct'ibes the technique to be followed when
medical asepsis is needed.
31

MEDICAL ASEPSIS

PROCEDURE:

Putting on the gown.

Steps

Key Points

1. Wash hands..

1.1 Use hand washing procedure. (See hand washing procedure. )

1.2 Rinse thoroughly and dry.

2. Remove gown from hook. See Figure 2G

2. 1 Place palms together and slip hands inside opening at shoulder seams.

2. 2 Lift gown from hook at arms length being careful that contaminated side of gown does not touch outer clothing.

3. Put gown on. See Figure 2H, 21

3.1 Place hands in arm holes, and by holding arms up, the gown will fall into position with little effort.

4. Tie tape at neck band. See Figure 2J

4. 1 Tie tape at neckline without touching outside of the gown.

5. Tie waistline cord. See Figure 2M

5.1 Cross the back panels of the gown by grasping each back seam at the waistline, and bring the left side under the right to form a double back panel.

5.2 Cross ends of belt in the back and tie in the front.

6. Pull sleeves up.
See Figure 2N

6. 1 Adjust sleeves to convenient working
height and hold in place with rubber band if necessary.

7. Keep clean.

7. 1 Do not roll sleeves up.

7.2 Do not allow sleeves to slip down on contaminated arms.

7.3 Do not allow gown to swing open in the back.

32

7.4 Wear a gown that fits your size and height.

7.5 Do not leave the area while wearing the gown.

7. 6 Learn and follow the technique without variation.

PROCEDURE:

Removing the gown.

Steps

Key Points

1. Untie strings at belt line. See Figure 20

1. 1 Pull loop through and allow strings to drop at sides.

2. Wash hands.

2.1 Pull sleeves up to elbows and wash hands according to handwashing procedure.

3. Untie string at neck line. See Figure 2Q

3. 1 Pull loop through and allow strings to fall down center of back.

4. Pull hands through cuff. See Figure 2R

4. 1 Place index and middle fingers of right hand under cuff of left sleeve and pull the cuff over hand, do not touch outside of gown.

4. 2 With hand that is inside of left sleeve, grasp cuff and pull right hand up inside the sleeve.

5. Remove gown.
See Figure 2S

5.1 Hold arms down and with one hand and then the other, pull the sleeves forward until the palms are together at the neck band.

6. Hand the on the hook.

6. 1 Withdraw one hand from inside the gown

See Figure 2T, 2U, 2V, 2W

and grasp center front of gown below the

neck band.

6.2 Place gown on hook with shoulder seams over hook so that the contaminated side is outside and so that the back edges are together and toward the entrance ')f th~ room or discard gown.

33

7. Wash hands.

7.1 Wash hands according to procedure.

NOTE: 1. Supply a fresh gown each day or oftener as needed for each person caring for the patient.

2. Supply a striped or "different" color bag for contaminated linens and have the laundry personnel dump the bag directly into the mechanical washer without sorting.

TERMINAL CLEANING FOLLOWING OCCUPANCY

EXPLANATION AND PURPOSE: When a patient leaves his unit the area is given a thorough cleaning in preparation for the next occupant. Everything used by a patient must be washed and/ or sterilized to destroy remaining infection and to make the environment safe for the next person.

PRINCIPLE:

1. A patient unit is that part of the ward or room used by a patient during hospitalization.

2 General principles of sanitization are applicable to this procedure.

EQUIPMENT:

1. Cleaning basins.

2. Mild detergent. (All soaps are detergents. )

3. Cleaning cloths.

4. Cleaning cart or tray.

5. Laundry bag.

6. Fresh, clean rubber sheet.

PROCEDURE:

Steps

Key Points

1. Ventilate the room.

1. 1 Open the window if the room is vacant or get permission from other patients to ventilate room.

2. Inventory the unit.

2. 1 Check each item against" standard" for the unit.

34

3. Take cleaning materials to unit.
4. Clean bedside table.
5. Remove bed linen.
6. Wash chair.
7. Change mattress cover. 8. Wash upper springs. 9. Wash head, foot and side
rails and clean bell cord.
10. Wash over-bed table.

2.2 Give checked list to nurse supervisor.
2. 3 Give extraneous and "found" articles to the nurse supervisor; she will label personal items and send to finance office
3. 1 Screen the area if another patient is present.
4. 1 Place all trash in papelo-iined waste basket.
4.2 Examine bureau drawers for "things" the patient may have left.
5.1 Remove each piece of bed linen separately.
5.2 Examine linen for stains and for "lost" articles.
5. 3 Place linen in hamper.
5.4 Place blanket in laundry bag.
5.5 Place rubber sheet at top of bed.
6. 1 Wash chair with soapy water, rinse with
clean water and dry with clean cloth.
8. 1 Wash springs and coils with soapy water and rinse and dry.
9. 1 Wash head of bed with soapy water, rinse and dry.
9. 2 Complete one part at a time.
9. 3 Lift head and foot of gatch bed and wash thoroughly.
9.4 Remove bell cord from socket and wipe clean with damp cloth.
10. 1 Wash over-bed table using soapy water, rinse and dry.

35

11. Wash bedside stand.

11. 1

Scrub bedside table inside and out with soap and abrasive (if necessary), rinse and dry.

12. Arch mattress and expose 12. 1 Open the windows and/or expose to the sun to air and sunshine.

13. Remove, clean and replenish cleaning tray or cart.

13. 1 Send cleaning cloths to laundry.
13.2 Wash rubber sheet in utility room and hang on a rod to dry.

14. Arrange the unit.

14. 1

After the bed, mattress and room has lI a iredll for four hours, return to the area and complete the work.

14. 2 Make the bed according to procedure.

14.3 Place sterilized wash basin and soap dish in drawer of table.

14.4 Place toilet tissue, soap, fresh wash cloth and towel on bar of table.

15. Report needed repairs to nurse supervisor.

15.1 Check call bell and electric fixtures and report any needed repairs or replacements.

36

PART III
NURSING BASIC PROCEDURES EXPLANATION AND PURPOSE: There are some procedures in nursing that are common to all services. Each basic procedure is concerned with three fundamental factors: 1. Preparation or Pre-planning. 2. The Activity Itself. 3. Postoperation. Preparation in Part III of manual refers primarily to the environment and getting things ready to receive the patient, such as preparation of various types of beds, safe transportation to the room or ward and moving or lifting the helpless patient. The Activity Itself refers to the beginning interaction between the ward nurse and the patient as he is admitted to the room or ward and then meeting his personal needs. PostoperatioE ;:wolves recording of pertinent data concerning the patient and the disposition of uaed equipment. Postoperation is intergrated in each procedure. The above mentioned factor s are involved in all procedures included in this manual.
37

Figure 3 Fully equipped Nursing Unit demonstrating an U:loccupied bed.
38

UNOCCUPIED BED

PURPOSE OR EXPLANATION:

To provide a clean fresh bed which will be comfortable and inviting for the patient. When this is done for a new patient, the entire bed is tho~Nl'7hly cleaned and aired and fresh linen applied. On the other hand, if the bed ie, simply l'emade each day (or oftener as needed) for a patient who is out of bed, the nurse will be expected to decide how much of the linen may be reused; this will depend upon the need, the quantity of supplies available, and the policies of the institution.

PRINCIPLES: 1. A clean, firm bed adds to rest and comfort of the patient. See H-gl"~3il

EQUIPMENT:

1. Mattress cover

2. Rubber draw sheet (if indicated)

3. 2 muslin sheets - 98" x 108"

4. 1 spread

5. 1 draw sheet 36" x 72 11

6. Blankets as needed

7. Clothes hamper or laundry bag

PROCEDURES: Steps
1. Assemble equipment.

Key Points
1. 1 Provide clothes hamper or laundry bag for soiled linen.

1. 2 Arrange bed linen on chair back with pillow cases, spread, top sheet, draw sheet, and bottom sheet in the order that they will be placed on the bed.

39

2. Strip bed of s oiled linen.
3. Turn mattress and pull firmly to head of bed.
4. Place bottom sheet.
5. Place rubber draw sheet and muslin sheet.
6. Place top sheet. 7. Place blanket. 8. Place spread. 9. . Complete other side of
bed.

1. 21 Grasp pillow with left hand, holding the open part of the pillow case toward the ceiling.
2. 1 Loosen bedding on all sides by sliding hands along selvage edge of bottom sheet.
2.2 Fold spread in half lengthwise, in half again and place on chair.
2.3 Remove remaining linen and fold linen to be re-used.
3.1 Secure assistance for this step if'necessary.
4. 1 Place bottom sheet with finished side up so that center of sheet will be in center of mattress.
4.2 Tuck sheet under head of mattress at least 12 inches.
4. 3 Mitre corner at head of bed and tuck sheet in along side of bed.
5. 1 Place rubber draw sheet and cover with muslin draw sheet on middle third of bed.
5.2 Tuck both in at side of bed.
5.3 Go to other side of bed and repeat process starting with the bottom sheet.
6. 1 Arrange top sheet even with head of mattress, finished side down.
7. 1 Arrange blanket about eight inches from head of bed.
8. 1 Arrange spread 2 inches above blanket.
8.2 Turn top sheet over blanket and spread.
9.1 Go to other side of bed and repeat steps 6. I, 7. I, 8. I, 8.2.

40

10. Fini sh foot of bed.
11. Encase pillows and arrange at head of bed.
12. Align bed and tidy unit for comfort and safety.

10. 1 Go to foot of bed and tuck in top sheet, blanket and spread well under mattress.
10.2 Mitre corners.
11. 1 Place pillows, seam side to head of bed and open end away from door.
12. 1 Push bed cranks in.
12.2 Place bedside table at head of bed.
12.3 Inspect for completeness and neatness.

41

OCCUPIED BED

PURPOSE OR EXPLANATION:

To provide a clean, safe and comfortable bed for the bed patient.

To con/?erve patient's strength and energy.

.

PRINCIPLES:

1. Techniques used to change linen on an occupied bed is determined by diagnosis and condition of the patient.

2. Turning and moving the patient may increase relaxation.

3. Secure assistance if the patinet is entirely helpless.

EQUIPMENT:

1. Mattress cover

2. Rubber draw sheet (if indicated)

3. 2 sheets - 98" x 108"

4. 1 draw sheet - 36" x 72"

5. 1 spread

6. Pillow cas e s

7. Clothes hamper or laundry bag

8. Blankets as indicated

PROCEDURE: Steps
1. As semble equipment.

Key Points
1. 1 Place clothes hamper or laundry bag for soiled linen in convenient position within eash reach.

1. 2 Arrange bed linen "in order of use"* on clean chair seat. (*See unoccupied bed procedure. )

42

2. Explain procedure to patient.

2. 1 Explain procedure to patient to gain his cooperation.

3. Strip upper bedding and replace with bath blanket.

3. 1 Loosen bedding on all sides of bed by sliding one hand along help and selvage of bottom sheet.

4. Move patient to far side of
bed.
5. Roll bottom bedding to
patient's body.
6. Place foundation linen
as in bed making.

3.2 Fold linen in half, lengthwise and in half again twice, and place on back of chair, if to be used again; otherwise discard in hamper.
4. 1 As sist as much as needed.
4.2 Warn patient and make certain that he
does not fall out of bed.
5. 1 1 bottom sheet is not to be changed,
brush carefully and tighten.
6. 1 Place bottom sheet, rubber and muslin
draw sheet as in bed making rolling half of it close to the patient.

7. Move patient to clean side. 8. Make other side of bed.

7. 1 Assist patient as much as needed.
8. 1 Use same procedure as for bed making
being sure that the bottom sheet, rubber draw sheet and muslin sheet are tucked tightly.

9. Arrange top linen as in bed making.

9. 1 Ask patient to hold clean sheet while bath blanket is withdrawn.
9. 2 Make tuck at foot of bed to prevent pre ssure and to add to comfort.

10. Arrange pillows.

10.1

Adjust one or two pillows under patient's head and support any other part of the body indicated for comfort.

11. Adjust call cord.

11. 1

Place call button within easy reach and secure so that it may not slip from patient's reach.

12. Tidy unit. 13. Report and record.

12. 1 13.1

Pick up excess papers and trash.
Note and report patient's interest in selfhelp; pressure areas, . redness and rash.

43

SHOCK BED - RECOVERY OR ANAESTHETIC BED

EXPLANATION AND PURPOSE:

Shock is defined as "a disproportion between the circulating blood volu:me and cardiovascular tree. 111 The shock bed is an adaptation of the open bed. It is designed to 'Jrovide added warmth and safety and to facilitate the transfer of the patient from stretcher to bed af:: well as prevent greater shock.

PRINCIPLES:

1. Every " ac cident" and post-operative patient suffers varying degrees of shock.

2. Warmth, slightly higher than body temperature, should be maintained until normal balance is resumed.

EQUIPMENT:

For the bed

For the table

Clean linens - complete set

Paper mouthwipes

Bed blocks Bed protector - full length Pillow protector Blanket Cotton bath blanket

Paper bag Curved basin Hand towels (2) Tongue blades held together with bandage Sphygmomanometer

Extra sheet

PROCEDURE: Steps

Key Points

1. Remove all used linen and place in hamper.

1. 1 Turn the mattress. 1. 2 Pull mattress well to the top of the bed.

2. Make foundation.

2. 1 Make bottom of bed as in procedure for UNOCCUPIED BED.

1) Eliason; Ferguson and Scholtic, J. B.: Surgical Nursing, Ninth Edition, Philadelphia, Lippinc ott.

44

3. Place bed protector.

3. 1 Place bed protector over entire bed and tuck in on both sides.

3.2 Place sheet over bed protector and tuck in on each side.

4. Place bath blanket on foundation.

4. 1 Arrange the soft cotton bath blanket on the bed to cover the patient.

5. Place top covers on bed but do not tuck them in at the foot.

5. 1 Place the top sheet, blanket, and spread on the bed ip. the usual manner. Do not add extra blankets and/ or other heat as this increases diaphoresis and causes greater unbalance.

6. Fan top covers to foot of bed.

6. 1 Fold the top linen to the foot of the bed. This fold should be about six or eight inche s wide.

7. Place a pillow between rungs of the bed.

7. 1 Put a clean pillow case on the "protected" pillow, and attach it to the head board with a flat bandage or tuck the ends between the rungs of the bed.

7.2 Place hand towel across the top part of the bed where the patient's heat will lie.

8. Ventilate the room.

8. 1 Close the window and keep the room warm.

9. Place side rails on the bed.

9. 1 Secure and place side rails on the bed ready for use (if necessary).

10. Arrange bedside table.

10. 1

Arrange the curved basin, paper mouthwipes, tongue blades, note pad, and blood pressure apparatus on the bedside table.

10.2 Place shock blocks in convenient reach.

11. Check the room

11. 1 Check the room and bed for completeness, neatness and order.

NOTE: If hospital provides a Central Recovery Room, the above procedure would not be used on the wards.

45

THE CARDIAC BED
EXPLANATION AND PURPOSE: Many patients suffering from cardiac conditions have orthopnea due to con-
gestion, pressure and/ or myocardial failure. Adjustment of the position of patient relieves some pressure and makes breathing less difficult. SOME FACTORS RELATED TO THE REASON WHY PATIENTS WITH CARDIAC
DYSPNEA ARE MORE COMFORTABLE IN AN ERECT POSITION: 1. The ribs and muscles affected by respiration have greater freedom of movement. 2. The abdominal viscera gravitate downward relieving pressure on the diaphragm. 3. Pulmonary edema fluid gravitates to the base of the lungs, thus reducing the number of alveoli that are lined with a film of fluid. 4. Venous drainage from the respiratory center of the medulla is improved. 5. The load on the heart is reduced. The "cardiac bed" is designed to give support to the bed patient who is relieved when he is in an erect position.
PRINCIPLES: 1. Rest is the keynote of all cardiac nursing. 2. Recent research has demonstrated the "chair rest" is more comfortable for the patient. The same results are attained.
EQUIPMENT: 1. Gatch bed or 2. Bed with portable back rest 3. Pillows - five regular and one or two small
46

PROCEDURE: Steps
1. Elevate head of bed to as vertical position as possible.
2. Arrange pillows.for support.
3. Elevate knee rest very slightly.
4. Place foot board or box at foot of bed for support.
5. Place overbed table.
6. Keep body warm.

Key Points
1. 1 Crank the gatch bed head rest as far as possible.
2. 1 Place pillows to suit the patient.
3. 1 Elevate knee rest to relieve tension on leg muscles. If knee rest is raised too high the viscera and fluids may be pushed upward while the purpose is to have them gravitate downward.
4. 1 Arrange foot board or box at the bottom of the bed to keep the patient and mattress from sliding down and prevent foot drop.
5. 1 Raise height of overbed table to level of patient's chest.
5.2 Place a firm pillow lengthwise across the overbed table and tie securely at each end.
5. 3 Help the patient shift his position until pillows, overbed table, back and knee rests are adjusted to his comfort.
5. 4 Many patients find that they are most comfortable when sitting in a chair beside the bed and using the bed as a head rest. The position in bed should be as similar to this bedside position as possible.
6.1 Keep shoulders covered with bed jacket, pajama coat or small blanket.

47

ESCORTING AND TRANSPORTING PATIENTS

EXPLANATION AND PURPOSE:
To assist a patient safely and comfortably in going to and coming from various departments within the hospital. The patient may be ambulatory but will need to be escorted, or he may require transportation by wheel chair or stretcher. The professional nurse will give instructions regarding which method is to be used.

PRINCIPLES:
1. The hospital policies should determine who is responsible for a patient in transit.
2. Acutely ill, obstetrical patients in labor, premature infants and patients receiving intravenous medication should be escorted by a professional worker to insure complete safety.

ESCORT SERVICE:

PROCEDURE:

Steps

Key Points

1. Explain destination and purpose to patient.

1. 1 Determine to what extent the patient has been informed of his condition by the physician and keep instructions within that framework.

2. Prepare patient physically. 2. 1 Assist patient with bathrobe and slippers.

3. Escort patient to destination.

3. 1 Select the best route. Be courteous and on the lookout for safety precautions.

3.2 The chart, x-ray requests or other pertinent materials should accompany patient.

4. Introduce patient to department personnel and place patient where he will receive attention.

48

WHEEL CHAIR TRANSPORT

EXPLANATION:

To assist the patient in getting in and out of wheel chair safely and with a minimum. expenditure of energy.

EQUIPMENT:

Wheel chair

Bathrobe and slippers

Blanket and pillows

PROCEDURE:

Steps

Key Points

1. Prepare wheel chair.

1. 1 See that chair is in good working order for safety.

1,2 Position chair with back parallel to the foot of the bed. (Anchor securely if possible. )

1. 3 Drape with blanket if indicated.

2. Prepare the patient.

2. 1 Explain destination.
2.2 Note pulse, respiration and condition of patient.

2.3 Give adequate, clear instructions.

3. Assist patient to sit at side of bed, with feet dangling.
4. Assist patient to standing position.

4.1 Place patient's hands on nurse's shoulders.
4.2 Nurse places one hand on patient's outer arms and helps patient to standing position.

49

5. Seat patient in chair.

5. I Holding patient, side step to chair. Place foot on back part of chair and support until patient is seated.
5. 2 Make patient comfortable.
5.3 Check pulse and respiration again.
5. 4 Instruct patient to keep hands folded in lap.

50

MOVING HELPLESS PATIENT TO STRETCHER

EXPLANATION AND PURPOSE:

To lift patient from bed to stretcher with safety and comfort. If patient is helpless, there must be adequate help (three or four people, depending on size of patient). If patient can help himself, the professional nurse must determine from her knowledge of the rehabilitation plan, how the patient can best be instructed to cooperate and then she, in turn, as team-leader, instructs ward personnel. If the patient is receiving instruction in self-help from other departments, such as physiotherapy or corrective therapy, the nurse must have her teaching coincide with that of the physical instructor.

EQUIPMENT:

Stretcher

Blankets

PROCEDURE:

Steps 1. Prepare stretcher.

Key Points 1. 1 Inspect for safety in operation.

1. 2 Drape with blanket.

1. 3 Place stretcher perpendicular with foot of bed.

2. Prepare patient.

2. 1 Explain procedure in terms patient will understand.

2.2 Drape with bath blanket.

3. Lift to stretcher.

3. 1 Have lifting team stand at same side of bed.

3. 2 Place head of patient at movable wheels. Instruct team on method of lifting.
3.3 Have lifting team members (one at head and shoulders, second at hips and back, and third at legs and feet) lift simultaneously on signal and side step to stretcher. Place patient on stretcher. Fold patient's arms on chest.

51

4. Drape with blanket.

4. 1 Fold blanket over patient.

5. Obtain chart.

NOTE:

The Davis Roller is a new mechanical device for the transfer of uncon':: seious or helpless patients from stretcher to bed. In most instances only two workers are needed to perform the procedure. See Figure 4a, 4b, 4c and 4d. Courtesy of Gilbert Hyde Chick Company

52

Figure 4A Placing Davis Roller under patient
Figure 4B Rolling patient froIn table to cart
53

Figure 4C Patient on Davis Roller
Figure 4D Removal of Davis Roller
54

ADMISSION OF THE NEW PATIENT
EXPLANATION: Patients admitted to the hospital may be classified in numerous ways; by,
sex, age, race, and diagnosis in order that ward or departmental placements may be requested. To plan a prompt, adequate nursing care program, it is necessary to ascertain the condition of each patient as soon as possible. It is important to know to what' extent the patient can help himself; if he is ambulatory; if he can help himself independently; if he can help himself a little or if he is totally helpless; if he is acutely or chronically ill; 'if his general condition is critical, serious, fair, or good. The physician who reserves the room may supply this data. Ward and'bed space allocation is determined by these factors. PRINCIPLES:
1. Fears and anxieties may be relieved by the initial reception of the patient to the floor or ward.
Z. A friendly, warm reception by the nurse helps insure confidence in the the institution.
3. Adaptation of ward or floor space to that of the patient and his family will aid relationship and hasten patient's recovery.
4. Concentrated, undivided attention to the patient at the time of admission saves time and creates mutual trust.
5. An informed patient is a cooperative patient. 6. There is no better time nor place to practice the Golden Rule. EQUIPMENT AND MATERIALS: 1. Chart - completely assembled. Z. Fresh water. 3. Clean organized unit.
55

PROCEDURE: Steps
1. Prepare the environment and personnel to receive the patient.
2. Receive the new patient showing interest and concern for his welfare.
3. Escort the patient to his assigned unit.

Key Points
1. 1 Secure identifying data; orders and other information from the central admission office and/ or from the physician.
1. 2 Inform the staff and as sign the patient to the nurse responsible for the area. Explain diagnosis, probable needs, and peculiarities tnat may promote or hinder progress or recovery.
1.3 Assemble needed equipment.
1.4 Ventilate the room, turn bed clothes down, place pitcher of fresh water on table, and check room or unit for cleanlines s, towels, soap and other required equipment.
2. 1 Greet the new patient by name, introduce yourself and state your position in relation to his needs.
2.2 Bring the family or friend into the conversation and help them to feel at ease.
2.3 Observe the patient's general condition including physical signs and behavior.
2.4 Receive admission authority from attendant, volunteer, or clerk.
3. 1 Introduce the patient to other patients within range of his assigned unit.
3.2 Show the patient the physical facilities such as toilet, bath, library, chapel.
3.3 Explain briefly the house rules and schedules regarding meals, laboratory work, disposition of and responsibility for valuable s and clothe s .

56

4. Make the patient comfortable.
5. Help insure confidence and cooperation.
6. Complete admission schedule.
7. Record and report.

4. I Help the patient undress and unpack.
4. 2 Help him into bed, adjust the bed, light and ventilation as indicated.
4.3 Bathe or help bathe the patient if in your judgement this is necessary.
4.4 Secure pitcher of fresh drinking water unless contraindicated.
4.5 Offer food or nourishing drink to patients who may seem tired or fatigued following travel. Food may be given after consultation with physician.
5. I Place cord light within easy reach and instruct patient how to use it.
5.2 Ask patient about his dietary restrictions, food preferences, toilet and rest habits, and religious customs.
5.3 Let patient set the pace for conversation. By this means he will feel free to discuss any problem with you and ask questions about subjects that may be troubling him.
6. I Notify the physician.
6.2 Weigh the patient.
6.3 Take temperature, pulse and respiration.
6.4 Collect urine specimen.
6.5 Notify laboratory and X-ray departments that patient is ready for diagnostic procedures.
6.6 Send clothes to central clothes room or hang them in the room closet. Inspect clothe s for vermin as indicated.
7. I As semble forms into folder.

57

7. 2 Record identifying da.ta on each record form.

7.3 Fill out laboratory requests.

7.4 Request diet.

7. 5 Fill Kardex.

7. 6 Fill out medicine cards.

7. 7 Place identification card on door or bed.

7.8 Record T.P.R. and B.P.

7.9 Record on nurses notes:

7.91 Time of admission.

7.92 Ambulatory, wheelchair, or stretcher.

7. 93 Significant observations and information learned during admis sion procedure.

7.94 General symptoms, complaints.

7.95 Unusual behavior and/or attitude.

7. 96 Specimen collected and sent to laboratory.

7. 97 Kind of diet ordered.

7.98 Name of physician notified.

7.99

Medication and treatment started. Disposition of clothing and valuables (see procedure on care of clothes and valuables).

7. 100 Sign your name.

58

MEETING THE PERSONAL NEEDS OF THE PATIENT THROUGHOUT THE DAY
The Bed Bath; Morning, Afternoon and Evening Care; Elimination
INTRODUC TION:
Personal needs are the same when one is ill as when one is well. A well person attends to his own needs at the time and place that suits his convenience. When hospitalized, his freedom is limited by his particular illness. It is the responsibility of the nursing personnel to meet personal needs of patients with as little loss of patient freedom as possible. Some regimentation is necessary but individual differences must be considered if maximum mental and physical comforts are attained. Rigid adherence to some rules creates antagonisms and may cause the patient to lose respect and confidence. It is the responsibility of the physician or the professional nurse to determine the patient's ability to help himself. It is the responsibility of the nurse in charge to assign the properly qualified person to assist the patient with all or any part of his care that he is unable to do for himself.
PURPOSE:
To create a state of well-being by promoting comfort, relaxation, change of position and a feeling of refreshing cleanliness. Bath time is a social time. By working and talking with the person, it creates an atmosphere of friendliness and reveals many of his emotional patterns. This period allows an opportunity to evaluate and determine the person's individual needs. The informality of the situation affords opportunities for evaluation of family background or pattern of family health habits and economic resources. Since teaching is the function of every professional nurse, the personal care period provides an opportunity to share knowledge that will hasten his recovery and stimulate an awareness and motivation to continue the knowledge learned when he returns to his family and community.
It requires the jud~mentof a professional nurse (based on her knowledge of medical care plan) to determine the extent to which a patient may be encouraged to help himself. The nurse who adapts her conversation, teaching, and work skills to meet the needs of the person, gains confidence and greater cooperation for self-help.
PRINCIPLES:
1. Use of clean fresh essential materials constitutes a measure of safety.
2. Chilling through exposure or inadequate drying is a predisposing factor to colds and infections, and produces a feeling of irritation.
59

3. Keeping the bed linen dry during the bath prevents a loss of body heat by conduction.

4. Privacy helps to preserve the dignity of the individual. Every person has the right to expect privacy.

5. Skill of performance, pleasantness, a sense of fitness of things, and acceptance of the patient's timing aids recovery.

EQUIPMENT AND MATERIALS:

In Unit

Patient's Personal Property

Bath basin Dish with soap Mouthwash cup or glas s Bed pan

(If patient does not have personal items, obtain from supervisor)
Back lotion (oil preferred)
Comb, brush, nail file, orange wood stick, nail scissors, cleansing tissues

Emesis basin

Urinal

Additional

Bed linen

Towels

Washcloth

Laundry hamper

Bath blanket

Perineal tray

Paper bag

Safety pin

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1. THE BED BATH

PROCEDURES:

Key Steps

Key Points

1. Consult supervisor and

1. 1 Note whether patient is scheduled for

patient's record to determine

special tests, procedures, consultations,

patient's program for the day.

and time of such appointments and adjust

nursing care plan.

1. 2 Determine patient's condition, needs and the extent to which he is to be encouraged to help himself.

2. Assemble additional equipment and take to unit.

2. 1 Tidy unit and prepare working area.
2. 11 Check equipment for utility and cleanlines s.

3. Prepare patient.

3.1 Sense the person's need.

3. 11 Let the person set the pace for conversation. Be an interested listener.

3.2 If first experience, tell patient what is to be done, and advise him of your cooperation with him to hasten his recovery.

3.3 Screen patient and place bath blanket.

3.31 Remove gown or pajamas.

3. 32 Adjust bedding and pillows as comfortable as possible.

3. 33 Offer bedpan urinal.

3.34 See that heating, lighting, temperature, and ventilation are condusive to comfort.

4. Assist patient with
mouth care.

4. 1 Note condition of mouth and teeth.

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5. Bathe and dry face, ears and neck.
6. Bathe and dry arms and hands.
7. Bathe and dry chest. 8. Bathe and dry abdomen. 9. Bathe and dry legs and
feet.

4.2 Brush patient's teeth or give special mouth care including dentures if he is helpless.
5. I Note condition of eye s, ear s, nos e and skin.
5.2 Wash eyes with clean cloth (do not use soapy cloth). Use soap as indicated or desired on face. (Bath water U50 F.)
5.3 Keep ends of washcloth in palm of hand to prevent dragging cold wet ends.
5.4 Dry face, ears, and neck with face towel.
6. 1 Expose only one arm at a time.
6.2 Place bath towel under arm.
6.3 Either with soapy hands or soapy washcloth bathe forearm and arm. Rinse and dry.
6.4 Give special care to axilla.
6. 5 Have patient place hands in bath basin and
wash. Use nail brush or orange wood stick to clean nails .. Dry, trim nails; if indicated, use oil for cuticle.
7. 1 Bathe folds with soap, rinse and dry. Pay particular attention to breasts or obese areas.
8. I Pay special attention to umbilicus.
9. I Drape patient with bath blanket, exposing leg and thigh, and place bath blanket lengthwise on bed under limb.
9.2 Wash thigh and leg. Dry.
9. 3 Place basin on towel and ask patient to flex knee and lower feet into basin. Dry foot thoroughly between toes, note skin; moisten hands with oil, massage into foot.
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10. Change bath water.
11. Place per s on in position for back care.

10.1 Keep water clean and warm at desired temperature (1150 F).
11. 1 Turn patient on side or on abdomen and fold blanket so that back and buttocks are exposed.

11.2 Inspect bony parts for redness and pressure areas.

11. 3 Place bath towel on bed along patient's back.

11. 4 Wash and dry back.

11. 5 Wash and dry buttocks.

11. 6 Massage back with lotion when dry.

11. 7 Give special back care when indicated following doctor's orders.

12. Instruct patient to complete bath.

12. 1 Arrange basin within easy reach of patient.

12.2 Secure and instruct attendant to help male helpless patient complete his bath.

12.3 For female patients, place on bed pan and give perineal care as desired.

13. Help patient put on clean gown or pajamas.

14. Encourage interest in personal appearance.

14. 1 Comb hair for helpless patient.
14.2 Apply or have patient apply cosmetics as desired. Care for nails and cuticles.

15. Change bed linens.

15. 1 See procedure on making occupied bed.

16. Straighten unit and adjust 16. 1 surroundings for maximum comfort. 16.2

Secure signal cord within easy reach of patient.
Using safety pin attach paper bag within convenient reach of patient.

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17. Provide diversional activities.
18. Record and report.

16.3 Check for proper body alignment and adjust bed for comfort.

16.4 Adjust heating and ventilation and lighting for comfort.

16.5 Remove screen.

16.6 Clean and replace equipment.

17.1 Find out and provide for patient's interest.

17. 2 Explore hospital and other community agency resources for recreation.

17. 3

Before leaving unit see that patient has diversional activities indicated by his interest and compatable with his physical and mental condition.

18. 1 Time personal care was given.

18.2 General condition of patient.

18.3 Observations and remarks.

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II. MORNING, AFTERNOON AND EVENING CARE A planned program of patient care includes attention to personal needs at
specified intervals and at other times. Most persons feel the need to empty the bladder, cleanse teeth, wash the face and hands before meals and at bedtime. The following procedures are designed to meet these needs. EARLY MORNING CARE (BEFORE BREAKFAST) Unless otherwise ordered:
1. Offer bedpan and/ or urinal. 2. Bathe face and hands. Either offer pan of warm water, soap, cloth and
towel or assist the patient to the lavoratory. 3. Help the patient brush his teeth. 4. Make patient comfortable, in suitable position, to receive the food tray. 5. Straighten bedding and put room in order. 6. Offer patient a drink of fresh water unless contradicted. 7. Observe any change in physical and emotional condition and report. 8. Adjust light and ventilation as indicated. AFTERNOON CARE Afternoon care is usually planned after a rest period, after visiting hours and before supper. 1. Offer bedpan and/ or urinal. 2. Bathe face, hands, neck, and axille. 3. Comb hair. 4. Loosen top bed clothes, tighten bottom sheet, change if soiled and remake
the bed. 5. Offer fresh water unless contradicted. 6. Adjust light and air as indicated. 7. Note change in condition and report.
65

EVENING CARE "Putting the patient to bed" is one of the most important procedures in nursing care. Sleep and rest is essential to recovery. Fatigue is at its height at bedtime and anything that can be done to help the patient sleep naturally aids and speeds his recovery.
1. Help the patient clean his teeth. 2. Offer bedpan and/or urinal. 3. Check elimination. 4. Bathe the back of the bed patients. 5. Change the bottom sheet if linen is soiled. 6. Massage the back unless contraindicated. 7. Observe carefully and assure the patient that you will be near him
throughout the night. Urge him to call when he needs attention. 8. Apply side rails to beds of elderly patients, new postoperative patients, and
children. 9. Offer hot cup of tea or milk unless contraindicated. (Wakefulness is often
due to hunger. When supper is served at five and the person has entertained visitors in the interim, he may be hungry and will sleep better if he is offered a cup of tea or milk at bedtime. ) 10. Adjust light, bell cord, and ventilation. 11. Apply extra blanket if necessary.
66

TUB BATH

EXPLANATION AND PURPOSE:

To cleanse and refresh the ambulant patient. It is the responsibility of the professional nurse to instruct the patient or person responsible for the procedure in safety measures. Patients receiving tub or shower baths should have a doctor's order, and must be closely supervised to prevent falling, burning, electric shock and drowning.

PRINCIPLES:

1. A tub bath may stimulate or relax the patient depending on his condition and temperature of bath water.

2. Some skin conditions cause insensitivity to thermal temperatures; such patients are liable to be burned during this procedure.

EQUIPMENT:

Towels and washcloths Soap Clean cloths

Bath tub one -third (1/3) filled with water -1050 _ llOoF.
Bath thermometer

Bath mat - - suction type

PROCEDURE:
Steps
1. Prepare the bathroom and assemble equipment.

Key Points
1. 1 Shut off drafts.
1. 2 Have bathroom warm but well ventilated for comfort and safety.

1. 3 Provide privacy.

1. 4 Remove electrical appliance such as heater or fan from the room.

1. 5 Check the tub for cleanliness.

2. Draw water.

2. 1 Fill tub about one-third (1/3) fill, temperature 1050 - llOoF.

67

3. Prepare patient. 4. Assist into tub. 5. Assist with bath. 6. Observe patient.
7. As sist patient out of tub.
8. Dry the skin thoroughly.
9. Help the patient dress. 10. Escort to bed.

2.2 Pay special attention to temperature of water for aged, paralyzed, or debilitated patients to prevent burning.
2.3 Place mat in the tub.
3. 1 Avoid unnecessary exposure.
3.2 Pin a towel around the waist to relieve embarrassment.
4. 1 Illustrate safe method of getting in and out of tub.
5. 1 Wash back and/ or give bath as indicated.
6. 1 Observe for pallor, weakness, flushed skin.
6.2 Observe body for break in skin, redness, and other deviations from normal.
6.3 Discourage prolonged stay in tub (over ten minutes) .
7. 1 Allow water to run out of tub.
7.2 Secure assistance if the patient is helpless or partially helpless.
8. 1 Have patient seated on stool
8.2 Dry the skin by brisk use of towel. Rub skin if condition permits; or use a firm patting motion over entire body if the patient's skin is dehydrated, loose, and dry.
8.3 Rub the skin with lotion.
9. 1 Help the patient into fresh, dry clean clothing.
10. 1 Return the patient to his unit and help him into bed.
10.2 Adjust bedclothes and ventilate the room.
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11. Record.

10.3 Adjust light and offer reading or other diversional material.
10.4 Offer nourishment if desired and permitted 11. 1 Record time. 11. 2 Record condition of patient. 11. 3 Record effects of bath.

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MOUTH CARE FOR THE HELPLESS PATIENT
EXPLANATION: To provide cleanliness of mouth and dentures, to aid in comfort, hygiene and
well-being of the patient. This procedure prevents the destruction of tissues, aspiration of mouth content, and clogging of air passages. PRINCIPLES:
1. Patient's comfort and feeling of well-being is dependent on the condition of his mouth.
2. A dry mouth is a symptom of mouth breathing and/or dehydration and may be relieved with fluids and adequate nutrition.
3. Conditions resulting from poor aral hygiene are preventable. 4. Effective care of the mouth, dentures, and removable bridgework are
primary responsibilities of the nurse. 5. Adequate mouth care includes use of a tooth brush. Rinse mouth with
warm water after each meal. Wash teeth with tooth paste before breakfast and at bedtime. EQUIPMENT: 1. Soft applicator swabs 2. Towel and tissues 3. Mouth cup or glass 4. Emesis basin 5. Cleansing agent a. Tooth paste b. Salt and soda c. Lubricant for lip s
70

PROCEDURE: Key Steps
1. Explain procedure.
2. Place towel under chin and to side of face.
3. Support chin and instruct patient to open his lips.
4. Moisten swab with solution. Squeeze excess moisture against mouth cup.
5. Cleanse upper and lower
gums, teeth and dentures, if necessary.
6. CARE OF DENTURES

Key Points
1. 1 Prevent loss of energy and time.
1. 2 Assure readiness of the patient for treatment.
1. 3 Assure understanding and cooperation of patient.
2. 1 Protect procedure area.
3.1 Gain patient's cooperation by careful instruction.
4. 1 To prevent gagging patient and/ or aspiration of fluids.
5. 1 Use proper stroke from gum line to apex of teeth. Instruct the patient to use this technique. Clean systematically from the left side to the front and from the right side, to the front. Ask the patient to open his mouth and follow the same routine and techniques on the inside of teeth. Cleanse his teeth as you clean your own.
5.2 Clean tongue (very gently) from base to tip, to prevent gagging.
6. 1 Assist patient in removing dentures; receive them in a cleansing tissue.
6.2 Cleanse dentures (out of patient's sight) with prescribed dental powder and rinse thoroughly.
6.3 Return dentures to the patient in a glass of water.
6.4 Help patient to adjust dentures.

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7. Apply lubricant to lips. and outer areas of mouth.
8. Remove and clean equipment.
9. Adjust patient for comfort.

6.5 Dentures from unconscious patients should be cleansed and safely stored until patient's return to consciousness.
7. 1 Lubricant prevents chapping and promotes healing of tissues.
8. 1 Rinse all used articles under cold rinsing water.
8.2 Boil equipment.

10. Record.

10. 1 Record observations of condition of mouth, teeth, and gums.

10. 2 Report dry mouth to the physician.

NOTE: .

The dry parched mouth can be relieved by water and approved nutrition. Any attempt to remove the dry particles from patients lips may cause further damage.

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III. ELIMINATION

PURPOSE:

To help tneet the need for nortnal elitnination. The nurse tnust fatniliarize herself with the Medical and Nursing Care Plan and relate this knowledge to the tnethod of carrying out procedures with safety and cotnfort to the patient. Encourage good health habits.

PRINCIPLES:

1. The wastes of body tnetabolistn tnay be increased with disease.

2. Organs of elitnination tnay becotne inefficient due to enforced inactivity and a decreased diet or fluid intake.

3. Lack of privacy tnay inhibit a nortnal function of the organs of elitnination.

4. Tensions and fears associated with illness tnay effect the nortnal functions of the organs of elitnination.

5. Observation of the factors contributing to nortnal elitnination is the responsibility of the professional nurse. Alleviation of unfavorable factors is the responsibility of the teatn.

EQUIPMENT:

In Unit:

Bedpan and cover

Soap

Toilet tis sue

Hand towel

Wash basin

Powder

GIVING THE BEDPAN:

PROCEDURE:

Key Steps 1. Provide privacy.

Key Points 1. I Close door or screen patient.

1. 2 Avoid exposure.

2. Obtain wartn pan.

2. I Run wartn water over pan and dry.

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3. Place patient on pan.
4. Check proper body aligmnent.
5. Place toilet tissue within reach.

3. I Fold top cover to foot of bed without unduly exposing patient. Encourage patient to flex knees.
3.2 Dust small amount of talcum powder in the pan.
3. 3 Assist patient by placing left hand under small of back. With right hand slip pan into position.
4. I Elevate head of bed (unless contraindicated) and arrange bed for general comfort.

6. Place call signal within patient's reach.

6. I Instruct the patient to call for assistance or service.

REMOVING THE BEDPAN: PROCEDURE: 1. Answer call light promptly.

2. Remove pan. 3. Remove pan from unit.

2. I See that the patient is properly cleaned.
2.2 Assist patient as necessary in removing pan.
3. I Note amount, color, consistency, and odor.

3.2 If unusual, save for the physician.

3. 3 Place pan into bed pan washer or empty into hopper.
3.4 Wash pan with br lsh.

4. Wash hands.

3.5 Cleanse in steam sterilizer.
4. 1 Offer soap, warm water and a towel to the patient.

4.2 Wash your own hands thoroughly.

REPORT AND RECORD: Time, Amount and Character.

74

FEEDING THE HELPLESS PATIENT

EXPLANATION:

Meal time may be used to observe the patient's likes and dislikes of various foods. It is the responsibility of the professional nurse to see that the patient receives the prescribed diet. The environment should be as cheerful and healthful as possible. Patients are better able to eat and digest food in favorable atmosphere.

PRINCIPLES:

1. Maintenance and repair of the body is dependent on the food that is well as similated.

2. The amount of food a person needs is related to the amount of energy used in a given period.

3. The processes, leading to a normal appetite, are changed when an infection or other illness invades or inhibits body functions .

4. Feeding the helpless patient requires patience, understanding, and a sense of responsibility which the nurse must assume. The nurse must feed the patient at his own pace.

5. An accurate record of intake and output is a guide to treatment and progress.

PURPOSE:

1. To meet the nutritional needs of the patient.

2. To create a pleasant, social atmosphere as nearly like home as possible.

3. To provide the patient with the food that he enjoys as far as possible.

Steps 1. Prepare the patient.

Key Points
1. 1 1I0rder ll the environment, remove unpleasant odor s by airing the room.

1.2 Bathe the patient's face and hands or help him to do so.
1. 3 Create a pleasant atmoshepre by discussing an interest "outside the situation" if possible.

75

2. Check food tray. 3. Take tray to the
bedside. 4. Feed the patient.
5. Record.

1.4 Help the patient wash his teeth.
1. 5 Adjust the bed if necessary.
2. 1 Read orders to ascertain the type of diet ordered.
2.2 Arrange food attractively.
2.3 Check to see if everything is in readiness.
3. 1 Season food according to taste and to prescribed diet.
3.2 Place the tray in a position where the patient and the nurse will be in the most comfortable position.
3.3 Place the napkin in position.
4. 1 If possible, the same person should feed the patinet each meal. It is good to teach a member of the family how to do this and arrange to have them corne in at mealtime.
4.2 Offer small amounts each timeA
4.3 Allow the patient to indicate when he is ready for the next bite.
4.4 Encourage the patient to eat the full meal by explaining what he needs and why he needs it.
4.5 Make this as happy an experience for the patient as possil-Ie. This procedure is time consuming and should not be attempted until other pressing matters have been attended to.
5. 1 Record amount and kind of food eaten.
5.2 Record patient's attitude toward eating.
76

PREOPERATIVE NURSING CARE
EXPLANATION AND PURPOSE:
To prepare a patient for an operation. The preoperative prepreation of a surgical patient can reflect in the kind of recovery the patient makes, to the extent that in some hospitals the recovery ward is also the admission ward. This is done to ally hi"s fears and prevent tension that the patient experiences when he is uncertain of what will happen to him. On the recovery unit he can observe other patients, the care they receive and the satisfactory recovery they make.
If the above method is not employed, then the patient should be prepared psychologically for the new experience. The nurse while performing her duties should explain to the patient the routines necessary and what he can expect. Explain to patient that these routings are given to all operative patients. Treat the patient like a person-- not a "surgical admission". Be kind and sympathetic as well as "efficient". Spend a little time becoming acquainted with the patient and his family.
PRINCIPLES:
See that such things as visiting hours, number of visitors and time limits are understood.
Administration of anesthetic is difficult when patient is apprehensive and contributes to postoperative shock.
Some patients should be anesthetized in their rooms if possible, by use of a intravenous or rectal anesthesia for a starter. The administration of hyphotics and narcotics help relieve tension and tend to render an uneventful postoperative recovery.
Routine s which should be done for all patients:
1. Medical examination (see physical examination)
2. Nurse understanding of patient -- his requirements as well as performance of her professional duties toward her patient
3. Surgeon's visit
4. Anesthetist's visit
5. Laboratory tests
6. Signature affixed to operative permit
77

PROCEDURE:

Day of Operation

Steps

Key Points

1. Review chart with nursing team.

1. 1 See that physical examination has been done and recorded.

1.2 Review written orders (Kardex)

1. 3 Check chart for anesthesia sheet and recording of heart and lungs findings by physician.

2. Visit patient.

1. 4 Check laboratory sheet for completion.
2. 1 Visit patient primarily to reassure him and observe his physical and mental response to hospitalization. Did he have a restful night?

2.2 Has breakfast been withheld?

2.3 Was enema given with good results?

3. Prepare patient for Operating Room.

3.1 Wash patient's face, hands and assist him to clean his teeth.

3.2 Remove dentures, jewlery and artificial eye or limbs and store in safe place.

3.3 Assist patient to put on operating gown and boots.

3.4 Remove all bobby and hair pins.

4. Have patient empty bladder 4. 1 See Catheterization. (catheterize if ordered)

5. Administer hypodermic, if and when ordered.

5. 1 Chart medication and all other pertinent information.

6. The Operating Room will
call for patient.

6. 1 Assist patient to get on stretcher.
6.2 Go to Operating Room with patient to give him the moral support he needs.

78

7. Take chart to Operating Room.
8. Stay with patient until anesthetised.

7. 1 Place end of chart under cart mattre s s.
8. 1 This will depend on hospital policy but it is recommended.

79

IMMEDIATE POSTOPERATIVE CARE

EXPLANATION AND PURPOSE:

To render competent care to the unconscious patient until he recovers consciousness.

PRINCIPLES:

Careful movement of patient from stretcher to bed can 1es sen postoperative discomfort and strain on operative area.

Regardless of position of the patient the air passages should be free and body relaxed. The patient's head should be lower than his body to increase blood supply to brain centers and permit vomitives or drainage from mouth.

The anesthetist should accompany patient to the Central Recovery Room and observe his condition. (The anesthetist should be within easy access).

PROCEDURE:

Steps

Key Points

1. Reception of unconscious patient.

1. 1 Patient is placed in recovery bed in the dorsal recumbent position (unless otherwise specified by physician).

2. Care of patients in shock.

2.1 Symptoms of shock; pallor, cold clammy skin, weakness, irregular rapid pulse, air hunger and shallow breathing.

2.2 Notify doctor at once.

2.3 Place bed on shock blocks or use bed pins to elevate foot 6 - 12 inche s above patients' head.

2.4 Conserve body heat -- do not over heat. Keep patient on /ledge of chilliness".

2.5 Evidence of shock may be delayed.

3. Recovery from anesthesia.

3. 1 An unconscious patient.recovering from anesthesia should never be left alone.

80

4. Observation of patient is the responsibility of professional nurse.
5. Prevent postoperative discomforts.

3.2 Do not try to restrain patients' movements. Moderate movement is necessary.
3.3 Bed rails may be used to keep patient from falling out of bed.
4.1 Take temperature, pulse, respiration and blood pressure on admission to recovery ward. (See temperature, pulse, respiration and blood pre s sure. )
4.2 Repeat taking blood pressure, pulse and respiration every 15 minutes until patient is conscious.
5. 1 Ice cap, fresh air, reduction of fatigue and excitement will help prevent headaches.
5.2 Proper lifting, positioning of patient in bed after operation, back rubbing and changing position frequently will prevent backache.
5.3 Mouth wash frequent sips of tap water when tolerated will reduce disagreeable taste and thirst.
5.4 Nausea and vomiting for first few hours after local or general anesthesia is expec.ted. The use of suction should be considered if vomiting persists (by order of physician).
5.5 Intravenous or subcutaneous infusions are started for continued vomiting to prevent dehydration. (By doctor's orders.)
5.51 Empty emesis basin frequently.
5.53 Report character, amount of vomitus and frequency.
5.6 Relief from abdominal distention may be brought about by frequent change of position, insertion of rectal tube, drug to contract the intestinal muscles and application of hot water bottle (by orders of physician. )
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5.7 Early ambulation has reduced this annoying postoperative condition.
5.8 Early ambulation has reduced urinary retention.
5.9 Prevent nervousness and excitement. Relaxed patients are seldom unable to void.
5. 10 Catheterization of patient will depend on standing orders or physician's "stat order".
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PART IV
SPECIAL DIAGNOSTIC TESTS
Special Diagnostic Tests which the nurse may perform or assist with, depending on her preparation and on the practices of the physician and policies of the institution.
EXPLANATION AND PURPOSE:
Diagnosis and medical therapy is determined by the physician when symptoms, physical examination, chemical and microbiological facts are brought together and analyzed. Some of the most commonly used diagnostic test are included here for the purpose of giving basic directions for performing or participating in the collecting of specimen. Teamwork is essential to the successful diagnostic test program.
PRINCIPLES APPLICABLE TO DIAGNOSTIC TESTS:
1. An informed patient is a cooperative patient.
2. Diagnostic tests are based on scientific research; therefore, all elements relating to each test must be accurate in order that interpretation may be correct.
3. Specific orders as to what, when, where, how and who must be clearly understood by the persons delegated to pretest, test and post-test assignments.
4. Accuracy and reliability of the laboratory test is dependent on the preparation of the patient according to specific orders outlined in the procedure, preparation of the specimen, container used, aseptic techniques used in the collection of the specimen, on the correct label and delivery of the specimen to the right laboratory and on the expertness and exactness of the technician. Any deviation from the rule regarding a specimen violates the obligation assumed by professional workers.
83

GENERAL PHYSICAL EXAMINATION

EXPLANATION AND PURPOSE:

The examination is a method of appraising both positive and negative factors that affect the health of the individual and is recommended as a means for preventing illness and early diagnosis. The physician. may make a complete physical examination of the patient in his office or in the clinic prior to admis sion to the hospital or he may wait until after admis sion. A complete physical examination considers the total individual and may include anatomical structure, chemical and emotional action and reactions.

SOME PRINCIPLES:

1. Every person should have a general physical examination, including X-ray of lungs and heart, at least once each year or oftener if indicated.

2. A general physical examination includes history of past illness of self and family and present complaint; an overall inspection of body nutrition, posture, skin and appendages; blood pressure; temperature; weight; examination of heart and lungs by percussion and/or auscultation and X-ray and electrocardiogram; palpation; examination of the eyes, ears, nose, throat and teeth; neurological reactions; such tests as complete urinalysis; complete blood count; serological, sedimentation rate, Rh factor; and other special diagnostic tests as determined by the above findings.

3. Fears and anxieties regarding the general physical examination may indicate lack of understanding, false modesty, inability to "face reality" and/ or lack of available facilitie s.
EQUIPMENT:

1. Flashlight 2. Tongue depressors anc~ applicators 3. Head mirror
4. Tape measure 5. Skin pencil
6. Percussion hammer 7. Stethescope 8. Otoscope 9. Ophthalmoscope
10. Sphygmomanometer

11. Emesis basin 12. Bath towel 13. Sheets and hand towels 14. Surgical gown/nightingale 15. Gloves 16. Lubricating jelly 17. Vaginal speculum 18. Glass slides 19. Paper bageor newspaper
cornucopia

84

PROCEDURE: 1. Prepare the patient.
2. Make pre-examination tests.
3. Secure report of laboratory and other tests.
4. Assemble and arrange equipment at bedside and provide privacy.
5. Drape patient and assist the physician.

Key Points
1. 1 Ascertain the patient l s understanding of a general physical examination and asnwer questions as indicated.
1. 2 Urge the patient to void as a full bladder may hinder palpation.
1. 3 Tidy the environmen~.
1. 4 Help the patient put on the gown ( have the open part in front).
2. 1 Weigh the patient and record.
2.2 Take telnperature, pulse and respiration and record.
2.3 Take and record blood pressure.
3. 1 Secure report of urinalysis, blood count, and other tests that may have been completed.
4. 1 Secure physical examination tray from central supply room or from ward tray service.
4.2 Place the complete tray of equipment within easy reach of the physician.
4.3 Pull curtain or screen about the bedside and/or close the door.
4.4 Consult the physician to determine extent of examination and secure other equipment as directed.
5. 1 Anticipate the physician's movements and expose only the area that is being examined. The doctor usually arranges the sheet or towel as he works.

85

6. Place patient in position and drape for pelvic and/ or rectal examination.
7. Cleanse the area following pelvic examination.
8. Make the patient
comfortable.
9. Rearrange, cleanse and/ or return the tray.

5.2 Give the patient a gauze or paper kerchief and advise him to hold the kerchief over his mouth while his heart and chest is being examined.
5. 3 Instruct the patient to keep his head turned away from the physician to avoid direct contact with his breathing.
6. 1 The physician usually leaves the room while the female patient is being draped and placed in position for pelvic and/ or rectal examination.
6.2 Reassure the patient and stay near the head of the table during this part of the examination.
7.1 Use a cotton pledget and cleanse the area as soon as the pelvic or rectal examination is completed.
7.2 Give the patient soap, warm water, wash cloth and dry towel to cleanse the part.
8. 1 Rearrange and straighten the bed or
8.2 Assist the patient back to his bed.
9.1 Cleanse the used equipment.
9.2 Replenish supplies.
9. 3 Return tray to ward tray service or central supply room.

86

TEMPERATURE, PULSE AND RESPIRATION

PURPOSE:

1. Temperature:

To have an accurate record of variations in body temperature.

2. Pulse:

To count, record and report rate rhythm and volume of the heart beat.

3. Respiration:

To count, record, and report the rate depth, and character of the patient's respirations.

PRINCIPLES:

1. Disturbances of the balance between the heat generated and heat lost by the body may cause variation in normal temperature, pulse, and respiration.

2. Emotional disturbance, physical exercise, infection, drugs, and organic impairment of the heart, lung8 and nerve centers may affect the functions of vital organs.

3. Accurate measurement, recording, and reporting temperature, pulse, and respiration is a nursing responsibility. Variations in temperature may serve as an index of progress' and may influence diagnosis and treatment.

4. Thermometers may serve as vehicles for the transmission of disease.

5. Thorough cleansing and chemical sterilization will remove contamination which is potentially infectious.

6. The nurse must use her judgment to determine the method to be used in taking temperature. A child, an unconscious patient, or a delirious person may break the mouth thermometer and swallow the glass or cut his mouth.

EQUIPMENT:

1. Tray or receptacle for equipment (about 8" x 12").

2. Thermometer, one for each patient.

3. Receptacle for clean thermomete rs.

4. Receptacle for used thermometers.

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5. Antiseptic solution 0.5% - 1. 0% iodine in either 70% ethyl alcohol or 70% isopropyl alcohol.

6. Paper bag for waste.

7. Container and wipe s - - cotton, paper, or gauze

8. A solution of equal parts of 95% ethyl alcohol and tinture of green soap or a solution of equal parts of water and tincture of green soap.

9. Watch with second hand

10. Record book and pencil

1. TEMPERATURE BY MOUTH

Steps

Key Points

1. Organize the job.

1. 1 Case assignment: one person assumes full responsibility for two or more patients and takes temperature as a part of total care.

1. 2 Functional assignment: one person is assigned to take all temperatures on the floor or ward.

2. Wash hands and bring the clean equipment to the bedside.

2. 1 Equipment to be Brought to the bedside depends on how the temperature is to be taken and policies regarding as signment and equipment.

3. Discuss procedure with patient.

3. 1 A cheerful greeting is helpful. 3.2 Explain procedure if needed.

3.3 Ascertain activities of patient including recent ingestion of food or water.

4. Prepare equipment.

4. 1 Inspect the thermometer.

4.2 Take thermometer from tray and hold near the end opposite the bulb.

4. 3 Moisten thermometer with cold water.

4.4 Read and shake mercury to 950 or below.

88

5. Place thermometer in position.
6. Count pulse and
respiration.
7. Read the thermometer.
8. Record the temperature, pulse and respiration.
9. Wash and clean equipment.

5. 1 Place mercury bulb under the patient's tongue.
5. 2 Ask the patient to keep his lips closed without biting the thermometer.
5. 3 Leave the tnermometer in place for a minimum of three minutes.
6. 1 Count the radial pulse after placing the hand and arm at complete rest. Count thirty seconds and another thirty seconds to check accuracy, noting rhythm and volume.
6.2 Count respirations without having the patient aware of the process.
6.3 Note regularity, volume, rhythm. and other characteristic s.
7. 1 Remove the thermometer from the patient's mouth.
7.2 Wipe mucus from thermometer with dry cotton or tissue by using a firm, downward motion from finger tips to the bulb. Discard cotton pledget.
7.3 Read and record the temperature.
7.4 Place thermometer in container labeled used thermometers.
7.5 Repeat the procedure with another thermometer if the reading shows an abnornal deviation from previous readings.
8. 1 Record the temperature, pulse and resprration on the graphic sheet and. nurses notes as determined by individual hospital policy.
9. 1 Wash each thermometer with the green soap solution, being careful to cleanse each one thoroughly using a rotary motion from top to bulb end.
89

9. 2 Rinse under cold, running water.
9.3 Place thermometers in a clean container
and Cover with o. 5% - 1. 0% iodine in
either 70% ethyl or 70% isopropyl alcohol.
9.4 Leave thermometers in disinfectant for a minimum of 10 minute s. Remove the rmometer from solution or discard solution. If solution is not discorded, it is probably safe from 24 hours unless an excessive number of thermometers have been disinfected.
9.5 Wash containers with hot, soapy water and boil for ten minute s.
REFERENCES: Nursing Rf~search, Volume 1, No.2, October, 1952, Page 32.

II. RECTAL TEMPERATURE

EQUIPMENT:

Same as described in I, add water-soluble lubricant.

Steps

Key Points

Follow procedure 1 through 4

T'ake rectal temperaturen if patient is unconscious, non-cooperative, delirious, has mouth disease, an infant or a small child.

5. Place patient in position.

5. 1 Place adult patient on his side and flex upper knee.

6. Insert the thermometer.

5. 2 Hold a child on your lap with face down unles s physical condition contraindicates.
6. 1 Lubricate the thermometer with a very small amount water-soluble lubricant.

6.2 Separate buttocks with finger and thumb so that you can see anal orifice.
6.3 Insert the thermometer slowly and gently one to one and one-half inches.

90

7. Hold the thermometer.
8. Wash hands. Follow basic procedure 7 through 9

7. 1 Hold the thermometer in place for three minutes for a child, delirious or uncooperative patient.
Record that the temperature has been taken by rectum.

III. TEMPERATURE BY AXILLA OR GROIN

Follow procedure 1 through 5

6. Place the thermometer.

6. 1 Dry the arm pit or groin space with the patient's bath towel.

6.2 Place the bulb in the arm pit or groin creases and instruct the patient to keep thermometer firmly in place.

6. 3 Leave the thermometer in place for ten minutes.

Follow procedure 7 through 9

91

BLOOD PRESSURE
EXP LANATION: Blood pressure is the term used to represent the pressure or tension of the
blood in the arteries.
SOME PRINCIPLES TO BE OBSERVED IN TAKING BLOOD PRESSURE
DETERMINATION: 1. The blood pressure apparatus should be calibrated yearly and oftener if indicated - - Aneroid type against the mercury type. 2. The patient should be in a sitting or prone position, preferably in a sitting position ,with arm well supported.
3. Exercise and food affect blood pressure. A rest period of ten minutes will eliminate or minumize the se factor s.
4. A first reading may be influenced by patient's emotional state of apprehension, fear and anxiety.
5. Normal blood pressure for any individual depends on a correlation of age, weight, height and sex.
6. Accuracy in taking and reporting blood pressure readings may influence diagnosis and therapy.
PURPOSE: 1. To determine blood pressure readings at specified intervals and under varying conditions as indicated. 2. To report blood pressure reading at the time when significant change occurs.
3. To request calibration of the apparatus at specified intervals.
EQUIPMENT:
1. Sphygmomanometer - mercurial or aneroid
2. Paper napkin or towel
3. Watch with second hand
92

PROCEDURE: 1. Explain the procedure
to the patient.
2. Bring equipment to the bedside.
3. Place patient in position.
4. Adjust the cuff.
5. Locate brachial artery.
6. Close valve. 7. Inflate the cuff. 8. Release valve.

Key Points
1. 1 Explain that food, exercise, and excitement may affect blood pressure readings.
1. 2 Ask the patient to relax, read or sit quietly for ten to fifteen minutes.
2. 1 Assemble equipment on the bedside table within easy reach.
3. 1 Elevate the bed or place patient in sitting position unless contraindicated.
3. 2 Place the towel on the bed under the arm (this helps keep apparatus clean).
3. 3 Have patient push sleeve well above the elbow or remove sleeve.
4. 1 Wrap paper towel or napkin around arm to help keep cuff clean.
4.2 Hold the rubber bag part of the cuff in your hand and place it around the lower part of the arm just above the elbow. Wrap the cuff around the arm snugly and evenly with the lower edge about one inch above the antecubital space.
5. 1 Locate brachial artery with index finger on inner side of elbow and place bell of stethescope over this point, free of contact with the cuff.
6. 1 Close the valve near the bulb by turning the screw clockwise.
7. 1 Inflate cuff rapidly to about 30 mm. above the level at which the radial pulse can be palpated.
8. 1 Release valve on bulb with thumb and index finger and allow air to escape slowly (20 to 30 mm. Hg. per second).
93

9. Record the readings. 10. Repeat the procedure.

The level at which the first sound is heard regularly is considered the systolic pressure.

*8.2

Continue to listen as the air is gradually released from the cuff to the point at which the sound ceases. "It appears that the point of complete cessation is the best index of diastolic pressure. "

8.3 The difference between diastolic and systolic pressure readings is the pulse pressure.

9. 1 Record systolic readin, as numerator and diastolic as denominator of a fraction: 120 - S 80 - D

10. 1

Repeat the process at least twice if the readings vary significantly. Ask someone to check your reading if in doubt.

11. Remove cuff.

11. 1 Fold neatly and replace in the container.

12. R.eport.

12. 1 Report any systolic pressure above 130 140 or diast~lic pressure above 90.

REFERENCE:

Standardization of Blood Pressure Readings, American Heart Association, 1790 Broadway at 58th Street, New York City, New York.

*Recommendations for Human Blood Pressure Determination by Sphygmomanometers, American Heart As sociation.

94

PROC TOSCOPIC EXAMINATION

EXPLANATION AND PURPOSE:

This examination enables visual inspection of the inner mucosa of the rectum and sigmoid flexure and is of value in diagnosing such conditions as cancer, uicer s, hemorrhoids, mucous or ulcerative colitis. It makes it possible to collect specimens of exudate and similar material directly from the involved area.

THE EXAMINATION IS MADE OF:

The rectum and lower colon by means of an electrically lighted instrument for diagnostic purposes.

EQUIPMENT:

Request a proctoscopic tray from the Central Supply Room consisting of (set may vary in different hospitals):

1. Proctoscope

10. Lubricant

2. Inflation bulb

11. Gloves and powder

3. Battery

12. Gown

4. Light carrier

13. Large kidney basin

5. Window lens

14. Paper bag for waste

6. Biopsy forceps

15. Bath blanket

7. Extension cord

16. Wash basin

8. 2 extra globes

17. 2 safety pins

9. 6 wire applicators

18. Sterile glass slides or test tube if a biopsy is to be done.

PROCEDURE:

Key Points

1. Preparation of patient.

1. 1 Explain procedure and purpose to the patient.

95

2. Preparation of equipment.
3. Place patient in position.
4. As si st the doctor.
5. After care of the patient.
6. Care of the equipment.
7. Record procedure.

2. 1 Obtain proctoscopic set from Central Supply Room.
2. 2 Place proctoscope in pan of warm water.
2.3 Connect extension cord to battery.
2.4 Test light in carrier.
2. 5 Open paper bag and place in convenient place to receive waste.
3. 1 Fanfold bedding to foot of bed, replacing bedding with bath blanket.
3.2 Place patient in knee-chest position and drape.
3.3 Place towel across thighs and pin in such a way that only the anus is exposed.
4. 1 Assist with gown and gloves.
4.2 Have glass slides or test tubes ready in case of biopsy.
4.3 Doctor will place instrument in kidney basin.
4.4 The doctor should take care of the specimen.
5. 1 Remove bath blanket and make the patient comfortable.
6. 1 Remove used equipment to the utility room.
6.2 Remove light carrier from the protoscope; clean with a damp cloth.
6.3 Wash proctoscope well with cold water and then with warm soapy water.
6.4 Return equipment to the Central Supply Room.
7.1 Chart the procedure and time it was done and by whom. Record biopsy, if performed. Record removal of specimen to laboratory and by whom.

96

VAGINAL EXAMINATION
EXPLANATION AND PURPOSE: A vaginal examination yields valuable information about the condition of the
vulva, vagina, cervix, uterus, tubes and ovaries. Vaginal examinations are made on all gynecological patients and all obstetrical patients up to the eight month of pregnancy. PURPOSE:
To examine the vagina and cervix for evidence of cervical erosions, ulcers, polyps, cancer, blueing characteristic of pregnancy, and different types of discharges as an aid to diagnosis. EQUIPMENT:
1. Three sizes of bivalve specula. 2. Lubricating jelly. 3. Clean cotton balls. 4. Clean gloves. 5. Glass slides.
6. Labels for slide s.
7. Sterile applicators. 8. Dressing forceps.
9. Emesis basin.
10. Spot light or flash light. 11. Biopsy forceps. 12. Biopsy specimen container with 10% formalin or 70% alcohol. NOTE: This equipment may be maintained in the Central Supply Room or it may
be a part of the ward equipment.
97

PROCEDURE: Steps
1. Prepare the patient.
2. Arrange equipment. 3. Place patient on table.
4. As sist with the examination.
5. After care of patient.
6. Care of specimens.
7. After care of
equipment. 8. Record procedure.

Key Points
1. 1 Explain procedure and purpose.
1. 2 Have patient empty bladder. 1. 3 Instruct patient to remove clothing.
2. 1 Arrange conveniently for physician on stand near foot of table.
3. 1 Place patient on back. Support head by means of pillow.
3.2 Place feet in stirrups.
3. 3 Bring buttocks to lower edge of the table. 3.4 Have knees flexed and wide apart.
3.5 Drape with large sheet turned diagonally so that one cover is draped over each leg. Fold middle cover back to expose vU,lva.
3.6 Cover chest with bath blanket for warmth if indicated.
4. 1 Reassure the patient. Instruct her to breathe deeply through her mouth to aid in relaxation.
5. 1 Cleanse vulva with dry cotton.
5.2 Apply perineal pad if drainage is present.
5. 3 As sist patient to dres s.
5. 4 Place in comfortable position.
6. 1 Allow slide s to dry.
6.2 Label with patient's name, source of smear, date and doctor's name.
6.3 Send smears to laboratory. 7. 1 Wash specula and gloves under cold run-
ning water. 7.2 Return to central supply. 8.1 Record and sign procedure.
98

SOME LABORATORY TESTS THAT EACH NURSE SHOULD KNOW AND BE ABLE TO MAKE EITHER FOR SCREENING OR INDEXING PURPOSES

EXPLANATION AND PURPOSE:

The nurse in the hospital where laboratory services are not available all twenty-four hours of the day and the public health nurse serving in clinics and homes are expected to test the urine for albumin and sugar; test the hemoglobin content of the blood and may test the blood for coagulating time. It has been shown that a diseased condition not suspected from the history or physical examination may be first detected in a routine urinalysis and/ or hemoglobin test.

PRINCIPLES: General principles are applicable.

URINALYSIS: Albumin, sugar, reaction and specific gravity.

EQUIPMENT:

Tray containing

1. Litmus paper (red and blue) in small glass or cellophane cylinder.

2. Urinometer and urinometer cylihder.

3. Specimen bottle or paper cup.

-4. Medicine dropper or pipette.

5. Sulfo-salicylic acid 20%.

6. Benedict's solutiQll or clinitest tablets.

7. Test tubes.

PROCEDURE:

Key Points

1. Observe color.

1. 1 Urine is reported to be straw, amber and dark amber.

1. 2 Note turbidity.

2. Test for reaction.

2. 1 Use the forcep, select a slip of litmus paper and insert it in the specimen.

99

3. Test for specific gravity.
4. Albumin test.
Test # 1
5. Albumin test.
Test # 2

2.2 Note color. If litmus turns blue the reaction is alkaline; red, acid; unchanged, neutral.
3. 1 Fill urinometer cylinder 2/3 full of urine and set it on a level place.
3.2 Place urinometer into the cylinder where it will float.
3.3 Read figures on the urinometer scale opposite the level of urine.
3.4 Report abnormal findings to the physician. (normal specific gravity lies between 1. 012 and 1. 020).
4. 1 Fill two test tubes half full of urine.
4.2 Draw up a small amount of 20% sulfosalicylic acid into pipette or medicine dropper.
4. 3 Drdp two or three drops of the reagent into one test tube or urine.
4.4 Read the test by holding the two tubes of urine (one with and one without the reagent) against a dark background.
4.41 Cloudiness in the urine following the addition of reagent indicates presence of albumin.
4.42 Density of cloudiness indicates approximate am.ount of albumin.
4. 5 Record: Clear - negative Cloudy - positive
4.6 Report positive findings immediately.
5. 1 Filter urine by placing a funnel over the end of the test tube, fold filter paper to fit the funnel and pour urine from specimen bottle into the filter-lined funnel until the tube is 2/3 full.
1'-00 "'.

6. Test for sugar. Test # 1
Clinitest

5.2 Boil top portion of contents gently over a flame.
5.3 If a cloud forms, add five drops of 5% acetic acid and reheat.
5.4 Read the test. A precipitate that does not dissolve is considered albumin, while a precipitate which disappears upon addition of the acid consists essentially of phosphates.
5.5 Record: Clear - negative Cloudy - positive
5.6 Report positive findings to the physician.
6. 1 Drop five drops of urine into test tube.
6.2 Add ten drops of water.
6.3 Add one clinitest tablet. When the tablet comes in contact with the solution a gas is released and causes the solution to "boil" or "fizz".
6.4 Allow to stand fifteen seconds after boiling ceases.
6.5 Read the test:
6. 51 Compare the specimen with a color scale. *
6.52 If the solution passes through orange to darker shades it indicates four plus sugar.
*Ames Company, Incorporated, Elkhart, Indiana, Clinitest color scale is included in each bottle.
6.53 Report positive findings to the physician.
101

7. Test for sugar.
Test # 2
Benedict's Solution (Copper Sulphate)

7. 1 Pour 5 cc. of reagent into test tube and bring to a boil. Use test tube holder and hold tube over a slow flame.
7.2 Add five to ten drops of urine and bring to a boil very slowly.
7.3 Place in test tube rack and allow to stand and cool.
7.4 Read the test: Blue - negative Greenish yellow - trace of sugar Bright yellow or brick red - large amount of sugar
7.5 Report positive findings to the physician.

102

COLLECTION OF URINE SPECIMENS

EXPLANATION AND PURPOSE:

The collection of urine specimens is vitally important to diagnostic procedure and the report of urinalysis tests is utilized by the physician as a guide in the treatment of the patient. Specimens are collected routinely from each patient when he is admitted; daily from all patients taking sulfa drugs; and as schedules direct, from diabetic and other patients.

SOME PRINCIPLES:

1. Clean dry specimen collecting containers help insure accurate reports.

2. Time schedules that are followed and properly reported help facilitate the program.

3. The right label on the right container is essential to diagnosis and care.

4. An informed patient facilitates the process of collecting specimen.

EQUIPMENT:

1. Specimen container, 8 ounce wide mouth bottle is preferable.

2. Label

3. Gallon bottle for 24 hour specimen.

PROCEDURE:

Key Points

1. Collect voided specimen from each new patient.

1. 1 Instruct the female patient to use a toilet tis sue to sponge the area about the meatus and dry thoroughly before voiding.

1.2 Give specimen container to the ambulatory patient and ask him or her to void directly into the container.

1. 3 Place helpless patient on a dry clean bedpan.

1. 4 Collect at least four ounces of urine and put into clean dry specimen bottle.

103

2. Collect catheterized specimen from each obstetrical and other patients on admission as directed.
3. Collect specimen for Friedman Test.
4. Collect 24 hour
specimen.

2. 1 Secure catheterization tray from Central Supply Room. Explain the treatment to the patient giving the reassurance necessary.
2. 2 Catheterize the patient.
2.3 Place free end of catheter in the specimen container, and collect at least 4 ounces.
2.4 Label catheterized specimen. Send specimen of obstetrical patients' urine to laboratory immediately.
3. 1 Omit all drugs for 48 hours.
3.2 Omit all fluids after 7 P. M.
3. 3 Collect fir st specimen voided in the morning at 7 A. M.
3.4 Place specimen in refrigerator in the laboratory.
3.5 Label- Patient's name, date, number, "Urine for Friedman Test", doctor's name and ward.
4. 1 Explain the details of the procedure to the patient and urge him to accept his responsibility for assisting with this procedure.
4.2 Ndte the time in the presence of the patient and ask the patient to empty his bladder.
4.3 Place clean gallon jar in the patient's bath room or near his unit. Label clearly.
4.4 Ask the patient to see that all urine voided during the following 24 hour s is deposited in the gallon jar. If the patient is unable to do this, ask him to remind the person who removes the pan or urinal to pour all urine into the bottle.
4.5 Place sign on the bed - "Collecting 24 Hour Specimen. "
104

4. 6 Instruct each female patient to void and save the specimen before each defecation. Complete the collection at the end of 24 hours and send to the laboratory properly labeled.

5. Record.

5. 1 Record time the collection started.

5.2 Amount of urine collected.

5.3 Time the collection ended and time sent to laboratory.

NOTE:

Specimen containers are frequently a source of annoyance to the laboratory and the ward personnel. Disposable containers may be an answer to the problem. A system of standardizing the number of containers needed in each unit and charged to the unit is effective in many situations. The system requires the laboratory to have a stock of specimen containers. When specimens are brought to the laboratory exchange for a clean bottle.

105

COLLEC TION OF FECES SPECIMENS FECES FOR CULTURE, TYPHOID, DYSENTERY, PARASITES AND OVA.

EXPLANATION AND PURPOSE:

A stool to be exam.ined should be passed in a clean vessel without adm.ixture of

"'

urine. Exam.ination should not be delayed m.ore than a few hours because of changes

caused by decom.position. A stool to be exam.ined for parasite or ova should be

kept warm.. The purpose is to collect a specim.en of feces for culture, typhoid

bacillus or dysentery.

EQUIPMENT:

1. Clean, warm. bedpan.

2. Clean specim.en jar with lid.

3. Tongue blade s .

4. Sm.all container of hot water.

5. Newspaper.

PROCEDURE:

Steps

Key Points

1. Explain procedure to patient.

1. 1 Stool to be passed in bedpan without urine.

2. Collect specim.en in a warm. bedpan.

2. 1 Have patient discard toilet tissue in newspaper provided for that purpose.

3. Transfer specim.en of stool to jar.

3. 1 If to be exam.ined for parasites or ova, place jar in a container of hot water.

3.2 Use tongue blades to transfer stool.

4. Send specim.en to laboratory.

4. 1 Always call attention of the technician to the stool specim.en.

4.2 Label specim.en with patient's nam.e and room. num.ber, and accom.pany with the request for specific exam.ination.

106

COLLECTION OF SPUTUM SPECIMENS

EXPLANATION AND PURPOSE:

Sputum is the material from the bronchial tubes and trachea. An examination of sputum is made chiefly to learn of the presence of bacteria.

The purpose is to obtain a specimen of sputum for microscopic examination or culture to determine the presence of bacteria or cancer cells.

EQUIPMENT:

Specimen bottle or covered sputum cup.

PROCEDURE:

Key Points

1. Preparation of patient.

1. 1 Instruct patient to rinse mouth thoroughly.
1. 2 Be sure the specimen comes from lungs or bronchia and not from the nose and nasal pharynx.

1. 3 A distinct explosive cough will raise sputum from the lungs.

2. Instruct patient to cough and expectorate into the container provided.

3. Send specimen to laboratory.

3. 1 Keep outside of container clean. 3.2 Cover container.

3.3 Wash hands thoroughly.

3.4. Label container with patient's name and room number and send with request for specific examination to the laboratory.

4. Record collection of specimen and time sent to the laboratory.

107

COLLECTION OF SPECIMENS FROM THE NOSE AND THROAT

PURPOSE:

To obtain specimens of nose and throat discharges to be examined for evidence of abnormality or as an aid to diagnosis.

EQUIPMENT:

1. Sterile swabs

2. Tubes of culture media

3. Slides

4. Tongue blades

5. Flashlight or extension light

6. Mailing outfit (if laboratory is not near)

PRECAUTIONS:

Take the culture before any antiseptic has been applied to the nose or throat-or at least not before two hours have elapsed after use of an antiseptic.

PROCEDURE:

Steps

Key Points

1. Preparation of Patient.

1. 1 If patient is an adult explain the purpose and procedure.

1. 2 If patient is a child, have an assist"ant hold the head. It may be necessary to restrain the child's hands.

1. 3 Place the patient in comfortable, correct position and direct the light (natural or artificial) to obtain a clear view of the throat.

2. Depress the tongue.

2. 1 Depress the tongue with tongue blade to permit easy access.

108

3. Obtain throat specimen.
4. Transfer specimen to culture media or slide.
5. Obtain nasal specimen.
6. Label specimen and send to laboratory.
7. Record and Chart.

3. 1 Pass the swab back until it reaches the pharynx and rub it against the mucosa on membrane or whitish patches in tonsil area.
3. Z Withdraw quickly, avoiding contact with any part of mouth.
4. 1 Rub swab gently'over the culture media so as not to tear the surface, avoiding contact with anything but the culture media.
4. Z Make a smear about one inch long on two glass slides.
4.3 Discard the swab in paper and place where it can be burned.
4.4 Allow smear to dry thoroughly, mark the slide, and cover with a clean glass slide.
5. 1 Cleanse nasal orifice with gauze sponge.
5. Z Press the tip of nose upward and insert the swab gently into nasal passage- -do not force - - turn swab lightly, rest, turn again until swab reaches the nasopharynx, withdraw with same care.
5.3 Transfer to culture media or slide.
6. 1 Label the tubes or slides properly and send to laboratory with request slip for specific examination requested by the physician.
7. 1 Record that specimen was collected, time sent to laboratory, and the examination requested.

109

Test
Creatinine Chlorides COZCombining Power COZ Content Cell Volume Diastase Hemoglobin NPN Sugar Sulfa Drug Level Urea Nitrogen
Calcuim Chole sterol Icterus Index Phosphatase Phosphorus Serum Albumin Serum Globulin AIG Ratio
Agglutinations
Seriological ( Kline
Kahn W? .~ crnl.2.)
Culture 100 ce Tryptose Phosphate

AMOUNT OF BLOOD TO BE COLLECTED, TYPE CONTAINER

SYRINGE

Sec

IDee

ZOee

x x
x x x x x x x x x
x x x
x x x x
x

x

x

Test Tube

CONTAINER Oxa. Bottle Flask

x x x x x x x x x x x

x x
x

Amount
3ee 3ee Sec Sec lee 6ee lee 3ee 3ee 3ee 3ee Sec 4ee 4ee lSee Sec Sec Sec lSec Scc
6cc
10cc

LABORATORY

Chern.

Bact. Remarks

x

One or two extra ee I s

x

of blood under oil are

x

advisable.

x

x x

x

x

x

x

x

x

It is better to have

x

too much than too

x

little blood for a

x

specimen.

x

x x

x

Place at 4S o angle in refrigerator.
--
Place at 4So angle until blood has clotted. Refrigerate until speciman is sent to
Laboratory-. - -
x Flame top of culture
tube before and after
specimen is placed in
it. Take to bacteri-
ologist immediately.

110

DIAGNOSTIC PROCEDURES

PRINCIPLES APPLICABLE TO BASIC PROCEDURES IN THIS UNIT:

1. The nurse serves as the liaisonperson on the hospital team by assisting with the preparation of the patient for diagnostic tests and procedures, by posting procedures with the department indicated, and by collecting or assisting with the collection of various specimens.

1. PATIENT presents

2. DOCTOR orders

Flow Chart: 3. NURSE

r' LABORATORY

prepares patient

examines

problem

collects specimen

reports

5. NURSE

6. DOCTOR

7. PATIENT

receives

interprets

diagnosis

and posts

reports

and therapy

reports

2. Chemical, microscopic, serological, virus, pathological, x-ray, and other laboratory tests are essential to diagnosis and treatment of patients.

3. There is no variation in procedures relating to laboratory specimen. Specific regulations must be followed as outlined by the responsible division

4. Coordination of time among patients, nurses, and laboratory personnel is essential to full operation of each unit.

5. A specimen collected from the right patient, at the right time, in the right receptacle, in the right amount and delivered to the right laboratory saves time, money, discomfort, and insures confidence and good relationship between laboratory, doctor, nurse, and patient.

6. Routine procedures should be reviewed at specified intervals and revision made in light of new discoveries and alterations in equipment and techniques.

7. The written procedure relating to the collection of specimen should be posted on the bulletin board or placed in the Kardex by the nurse in charge when the order is written. She should tell the patient about the order and give him oral and written instructions to follow.

8. The nurse must read the order and the procedure before she collects the specimen or before she prepares the patient for a test.

9. The nurse must record the action as soon as it is started and completed.

III

10 .. All specimens must be clearly labeled to prevent mistake as to diagnosis and therapy. The label should show date, time, place, patient's full name and case number, doctor and nurse.
11. Reports of examination should be so prepared that the original may be posted on the chart. Copying increases errors.
12. Accuracy and reliability of the laboratory test is dependent on the preparation of the patient according to specific orders outlined in the procedure, the preparation of the specimen, container used, aseptic techniques used in the collection of the specimen, correct labeling, delivery of the specimen to the right laboratory and the expertness and exactness of the technician. Any deviation from the rule regarding the collection of a specimen violates the obligation assumed by professional workers.
13. The nurse or technician collects a specimen and/or makes the test and reports results. The physician interprets the findings.
112

BILIARY DRAINAGE

PURPOSE:

To aspirate the contents of the duodenum. to determine the free flow of bile and to collect a specimen for analysis.

EQUIPMENT:

Secure a tray from the central supply room.

PROCEDURE:

Key Points

1. Explain procedure.

1. 1 Ascertain patient's understanding of the procedure. Explain how and why he can help make the procedure less unpleasant.

2. Omit breakfast.

2. 1 No food, fluid, or cathartic may be taken ten hours prior to the test.

3. Provide privacy and place patient in position.

3. I Take patient to the laboratory, special treatment room, or screen his bed.

3.2 Place patient in comfortable sitting position. Avoid drafts and exposure.

3. 3 Place waterproof apron about his neck.

3. 4 Encourage the patient and explain that full cooperation and help on his part will facilitate the procedure.

4. Pass the duodenal tube. (Physician)

4. I The tube should be cold to make it easier to swallow.

5. Aspirate contents.

4.2 The physician passes the tip of the tube through the patient's mouth into the upper esophagus and the patient is told and encouraged to swallow the tubing until the twenty-two inch mark is reached.
5. 1 Aspirate the contents by attaching a 20cc. syringe to the tube and withdraw the plunger very slowly.

113

6. Place patient 6n right
side and advance tube.

6. 1 Have patient lie quietly on right side for
twenty nlinute s .

6.2 Advance the tube until the twenty-nine inch
nlark is reached.

7. Aspirate.

7.1 Aspirate. If fluid does not return readily, withdraw the tube six or seven inches, reinsert and aspirate again.

7. 2 Take patient to fluroscopic rOOnl for guidance of the tube if necessary.

8. Inject nlagnesiurn sulphate.

8. 1 Inject 30 cc. of warnl nlagnesiunl sulphate slowly through the tube to stinlulate bile.

9. Siphon the fluid.

9. 1 Allow the fluid to flow through the tube into the specinlen bottle which nlay be set lower than the bed level.

10. Record the procedure and send the specinlen to the laboratory.

NOTE: Absence of bile nlay denote evidence of obstruction.

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CHOLECYSTOGRAM (GALLBLADDER TEST)

EXPLANATION AND PURPOSE:

To determine the ability of the gallbladder to excrete dye. The presence of gallstones, the size and contour of the gallbladder, the ability of the gallbladder to fill, to concentrate bile, and to contract under the stimulus of a fatty meal may studied by x-ray when a medium is administered to the patient either intravenously or by mouth.

PRINCIPLES:

1. There is no absolute standard procedure acceptable to all physicians and radiologists so that the procedure to be used in anyone specific hospital must be written &r approved by the radiologi st.

2. Procedures may differ in relation to the manufacturer of the dye and method of administering the dye.

3. The oral method is simple and carries less severe untoward symptoms than the intravenous method but the intravenous method is more reliable when a dense shadow is desirable. The physician or radiologist is responsible for determining the method of administration.

EQUIPMENT:

Medication- - tablet or ampule

Intravenous tray

PROCEDURE:

1. ORAL METHOD

Steps

Key Points

1. Read the order and request the medication.

1. 1 The physician is responsible for choosing the method and for ordering the time for administration.

1. 2 The physician usually makes the appointment and posts the request with the radiologist.

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2. Pre-test preparation. Day before the test.
Day of the test.
3. Follow instructions for administration of the dye.
4. ~Send the patient to the X-ray department.
5. Follow through on instructions.
2 . INTRAVENOUS METHOD 1. Follow oral method
procedures: one, two, three, four, and five.

2. 1 Omit diet. Order and request fat-free restricted protein meal for supper preceding the day of the test.
2.2 Omit medication.
2.3 Explain the reasons for change in diet to the patient and give him oral and written instructions to follow.
2.4 Water is allowed during the night and tea may be permitted for breakfast unless the local procedure reads otherwise.
2.5 Give cleansing enema two hours preceding the test if ordered.
3. 1 The contrast medium is a white odorless powder that is soluble in alcohol. The tablets are packaged in individual envelopes and instruction for administration of the tablets, included in the package, should be followed only after clearing with the radiologist.
4. 1 Films are taken twelve to sixteen hours after the last dose of the opaque medium has been administered.
5. 1 Obtain instructions from radiologist regarding diet and time to return to X-ray.
5.2 Secure and serve 'Ifatty meal" if ordered.
5.3 Resume normal schedule when X-rays are complete unless ordered otherwise.
1. 1 Intern or physician will give the patient dye intravenously at 10 P. M. and follow with intravenous infusion or normal saline or glucose.
1. 2 Watch the patient for chill, nausea and vomiting or other signs and symptoms of reaction to the dye.

116

GASTRIC ANALYSIS

EXPLANATION AND PURPOSE:

Gastric analysis is a test of the contents of the stomach under controlled conditions to determine the presence, absence, or normal amount of gastric secretion. The procedure is frequently used to collect specimens for microscopic examination and culture.

PROCEDURE:

Steps

Key Points

1. Explain the procedure.

1. 1 As certain the patient's under standing of the procedure and explain the why and how.

1. 2 Explain to the patient what he is to do and acknowledge unpleasantness associated with the procedure.

2. Omit food and fluids.

2.1 Omit food six hours prior to the test.

3. Secure tray from Central Supply Room; label specimen bottles.

3. 1 See CENTRAL SUPPLY section of this manual for equipment needed.

3.2 Write name, date, ward, or room number, type of specimen, and kind of examination requested.

4. Provide privacy.

4. 1 Put the patient in the treatment room, or
send the patient to the clinic or laboratory for test.

4.2 Make patient comfortable and warm.

5. Position.

5. 1 Have patient sit in a chair or adjust bed
so that back is straight.

5.2 Instruct the patient to breathe through his
mouth and to swallow frequently.

6. Assist with procedure. # 1 Histamine

6. 1 Adjust apron about the neck.

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6.2 Introduce the iced (or very cold) tube, lubricated with mineral oil, into the patient's stomach either through the mouth or nose.

6.3 Attach a lOcc. syringe and aspirate the contents of the stomach and deposit in a container labeled "fasting".

6.4 Fasten tube to side of face and close end of tube by wrapping securely with rubber band.

6.5 Inject O.Scc. of a 1: 1000 solution of histamine subcutaneously.

6.6 Aspirate contents at end of forty minutes and deposit specimen into container labeled "content following histamine".

7. Assist with procedure.
# 2 Ewald test meal.

7. I Give patient two slices of white bread without crusts and two glasses of water.

7.2 Aspirate the contents (as described in number five) at the end of thirty and sixty minute intervals.

7.3 Follow other instructions described in number five.

8. Record the test.

8.1 Record time, doctor, name and when specimen was sent to laboratory.

NOTE: Microscopic examinations and culture are often made of stomach washings to determine presence of tubercle bacilli.

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RENAL FUNCTION TESTS

EXPLANATION AND PURPOSE:

Renal function tests include various tests of the urine and blood under controlled conditions to deter:mine the concentrating and excreting power of the kidneys. The :most co:m:mon tests are the urine concentration and phenolsulfonphthalein test. The exact procedures are not standardized so that the nurse should consult the physician regarding techniques.

URINE CONCENTRATION TEST

PURPOSE:

To :measure the kidneys I ability to concentrate after a period of dehydration.

PROCEDURE:

Key Points

1. Explain procedure.

1. 1 Explain the procedure and the patient's responsiiblity for the test.

2. Discontinue diet and post notices.

3. Withhold food for specified ti:me.

3.1 Usually fro:m 5 P. M. to 12 noon.

4. Discard first :morning speci:men.

4. 1 Patient usually voids when he awakens. Discard this urine and record sa:me.

5. Label speci:men bottles.

5.1 Collect a speci:men at 8, 9, 10, 11, and 12 0' clock noon.

6. Test specific gravity on each speci:men.

6.1 File urino:meter cylinder 2/3 full of urine. 6.2 Place urino:meter in the cylinder or' urine.

6.3 Read the scale at the top level of the urine.

6.4 Record findings.

NOTE: If specific gravity on any speci:men reaches 1. 025 or over no serious i:mpair:ment or kidney function is present.

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PHENOLSULFONPHTHALEIN TEST (PSP)

EXPLANATION AND PURPOSE:

Phenolsulfonphthalein is a red alkaline dye which is in solution. It turns yellow in an acid solution.

Normally this dye is excreted rapidly by the kidneys so that more than half of it appears in the urine within two hours after the injection.

EQUIPMENT:

1. Ampoule of phenolsulfonphthalein dye

2. Ampoule file

3. 2 cc. syringe

4. Intravenous needle

5. Tourniquet

6. Cotton balls or sponges in 70% alcohol

7. Three phenolsulfonphthalein urine specimen bottles

PROCEDURE:

Steps

Key Points

1. Explain procedure to patient. 1. 1 Explain the What and Why.

2. Have patient void.

2. 1 Save this specimen for a control.

3. Dye injected

3. 1 Inject in median vein (antibrachial).

3.2 Note exact time.

4. Have the patient drink at least two glasses of water.

4. 1 Exact amount varies. Generally fluids are forced.

5. Collect urine specimens.

5.1 Collect specimens at intervals of 15 minute s, thirty minute s, one hour and two hours unless directed otherwise.

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6. Send specimens to
laboratory.

5.2 Save entire specimen. Catheterize for specimens at end of one hour and again at end of two hours if the patient is unable to void.
6. 1 Send all specimens to the laboratory with request for examination.

6.2 Label each specimen with time, amount, patient's name and room number.

7. Record time, treatment, means of administration, time each specimen is collected and amount of water taken.

NOTE:

The dye imparts a bright red color to urine after it has been alkalized by the addition of Sodium hydroxide, and the quantity in the urine is easily measured by comparing the color of the alkalized urine (diluted to a certain volume) with standard dilutions of the dye itself.

1. If it is necessary to inject the dye intramuscularly, the first urine specimen is collected one hour and ten (10) minutes after the dye has been given. The second specimen is collected two hours after the injection.

121

GLUCOSE TOLERANCE

EXPLANATION AND PURPOSE:

Glucose tolerance test determines the capacity of the body to deal with a controlled amount of glucose within a specified time, and/ or to determine if a diabetic condition and other conditions exist.
EQUIPMENT:

Glucose tolerance tray.

PROCEDURE:

Steps

Key Points

1. Explain the procedure.

1. I Tell the patient why the test is being made what he must do to cooperate and not to eat no food or water after 7 P. M.

2. Omit food and medication.

2. 1 Post the test on the bulletin board; flag the Kardex; remove medicine card from the container; tag the bed and door with a notice of the test

3. Take blood specimen.

3.1 Withdraw 5 cc. of blood from the vein at 6:30 A. M. Deposit the specimen in a test tube or bottle containing oxalate. Shake thoroughly and send directly to the laboratory where it is refrigerated. Use autoc1aved syringe and needle and test tube. Collect urine specimen.

3.2 Label specimen: 6:30 Glucose tolerance.

4. Administer 100 grams glucose.

4. 1 Give the patient 100 grams (weighed) of glucose in 250 cc. cold water and flavored with lemon juice.

5. Collect specimen.

5. 1 Collect 5 cc. of blood at the end of thirty minutes, one hour, two hours, and three hours.

5. 2 Collect urine specimens at end of thirty minutes, one, two, and three hour intervals.

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6. Label specimens. 7. Record procedure.

6. 1 Label each specimen "Glucose
Tolerence". and time collected. Number specimens in sequence. It is well to label the specimen containers correctly before you begin the procedure and send them to the laboratory as soon as each one is collected.
7. 1 Record each step of the procedure.

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PARACENTESIS
PURPOSE: Withdrawal of fluid from a body cavity for diagnosis or therapy.
I. Abdominal Paracentesis II. Thoracentesis III. Lumbar Puncture SOME PRINCIPLES INVOLVED IN EACH PROCEDURE:
1. Sterile equipment and aseptic technique is essential to J?revent the introduction of infection into a caivty.
2. The patient's understanding of the procedure and the steps to be taken help insure cooperation and may lessen shock.
3. Recognition of favorable and unfavorable reactions before, during, and after each procedure is a nursing responsibility.
4. Any untoward symptoms promptly reported are a safeguard against complications.
5. Knowledge of the patient's physical condition, his attitude and understanding of his condition and treatment is essential to effective nursing assistance.
6. Accurate collection, labeling, and prompt transportation of specimen to the laboratory is of major importance to diagnosis and treatment.
EQUIPMENT THAT IS COMMON TO EACH PROCEDURE: Secure from central supply or operating room the following: 1. Preparation tray (this is kept in the central supply room) 2. Local anesthetic tray 3. Sterile tray as indicated by the order 4. Sterile gloves
124

I. ABDOMINAL PARACENTESIS

PURPOSE:

To withdraw ascitic fluid from. the peritoneal cavity.

EQUIPMENT:

1. Preparation tray

2. Local anaesthetic tray

3. Sterile abdom.inal paracentesis tray

4. Sterile gloves

5. Rubber bed protector

6. Back rest

7. Pail, bucket, bath tub or large basin

8. Dressing cart or tray

9. Three chairs

10. Hospital gown and surgical boots for the patient

11. Adrenalin

PROCEDURE:

Key Points

1. Ascertain patient's understanding of the procedure; explain uncertain points.

1. 1 Explain unpleasant and uncom.fortable factors.
1. 2 Answer questions scientifically, using term.s understandable to the patient.

1. 3 Assist patient into surgical gown and surgical boots.

2. Urge patient to em.pty the bladder. Catheterize if necessary.

2. 1 The bladder m.ay be punctured if it is distended.

125

3. Secure privacy.

3. I Close the door or place screen before the door if patient is in private room.

3. 2 Screen the bed or

3. 3 Transfer the bed to the examining or treatment room.

3.4 Turn the bed so that one side will be next to the wall.

4. Place patient in position.

4. l(a)Place the patient in a chair with legs spread apart or

(b)Help patient sit on side of bed and place each foot on a chair.

4. 2 Place portable back rest to the patient's back and arrange pillows so that the patient will sit as straight and comfort2.ble as possible.

4. 3 Arrange rubber bed protector.

4.4 , Place newspaper on the floor next 'to the area of operation and place the pail on the paper.

4.5 Cover back and chest with warm blanket or jacket.

5. Assemble equipment at the bedside.

6. Prepare the area of operation.

6. 1 Wash the area from umbilicus to pubes with soap and water.

6.2 Shave the area of operation.

6.3 Moisten guaze sponge with ether and sponge the shaved area.

6.4 Apply methiolate (or other antiseptic) to the area of operation as directed.

6.5 Sponge the area with 'alcohol if iodine is used.

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7. Open the sterile set and place treatment sheet in place.

7. I Remove sheet from tray with forceps. Grasp one corner and unfold.
7.2 Place the opening over the operative area.

8. Assist with the procedure.

8. I Place chair in position for the physician. 8.2 Reassure the patient.

8.3 Uncover the sterile tray. Place within easy reach.

8.4 Pour small amount of local anaesthetic into the sterile medicine g~ass. ASK THE PHYSICIAN TO READ THE LABEL ON THE BOTTLE before he uses the drug.

8.5 Physician performs the procedure by anaesthetizing the skin, making the incision, inserting the trocar at mid-line from two to four inches below the umbilicus and attaching the 6" rubber tubing to the cannula; the glass connecting tube to the rubber and the longer tube to the glas s connection.

8. 6 The fluid must be withdrawn slowly to prevent sudden release of intra-abdominal pressure and shock.

9. Observe the patient and offer encouragement.

9. 1 Count the pulse and respiration every five minutes during the operation.

9.2 Note change in patient's color, anxiety, drowsiness, and other symptoms.

9. 3 Bathe the face with hot or cold cloth, depending on the patients temperature.

9.4 If the procedure is prolonged, offer a glass of cold water or a cup of hot tea.

10. Remove trocar and cannula. 10. 1

The physician removes the cannula and trocar. He may close the incision and dress the wound. Apply heavy padded dressing to absorb drainage.

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11. Make patient comfortable. 11. 1 Place patient in his bed with back rest elevated to encourage drainage.

11. 2 Change bedding as necessary.

12. Apply abdominal binder.

12. 1

Apply firm, snug binder over the dressing to help support organs until readjustment is made following change in pressure.

13. Measure fluid.

13. 1 Note quantity of fluid withdrawn. Note color, consistency. and odor.

14. Prepare specimen.

14. 1 Read the order to determine kind of specimen to be collected.

14.2

Label the specimen - name, date, ward, room, bed, kind of specimen, physician's name, kind of examination.

15. Record.

15.1

Time. Doctor who performed the procedure. Quantity and quality of fluid withdrawn. Specimen to the laboratory.

16. Clean equipment.

16.1

Rinse all used articles in cold water, follow with warm soapy solution and rinse thor oughly.

16.2 Inspect and test each item.

16.3 Reset the trays.

16.4 Return to Central Supply Room.

II. THORACENTESIS

PURPOSE:
Withdrawal of fluid from pleural cavity to relieve respiratory or cardiac embarrassment, to promote absorption of fluid, to instill medication, or to obtain specimen. EQUIPMENT:
1. Preparation tray
2. Sterile local anaesthetic tray
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3. Sterile thoracentesis tray

4. Sterile gloves

5. Measuring cup 1000 cc.

6. Specimen container

7. Over bed table (or improvised rest)

8. Dressing cart

9. Procaine 2% (3 oz.) or other local anaesthetic as ordered

10. Protector

11. Adrenalin

PROCEDURE:

Key Steps

Key Points

1. Ascertain patient's under standing and explain uncertain points about the procedure.

1. 1 Explain the procedure and discuss discomfort.
1.2 Answer question regarding how and why.
1. 3 Assist patient into surgical gown.

1. 4 Offer the bedpan or urinal or advise the patient to empty bladder if possible to increase comfort and relaxation.

2. Ascertain privacy.

2. 1 Pull screen about the bed or door or wheel the bed to the treatment room.

3. Assemble equipment.

3. 1 Bring the trays and dressing cart to the bedside.

4. Attain position.

4. 1 Help patient to a sitting position.

4. 2(a)Instruct patient to fold his arms across the overbed table and to rest his forehead on his arms or

129

5. Prepare the area of operation.
6. Place treatment sheet in place.
7. Assist with the procedure.

(b)Bring patient to side of bed in semirecumbent position and have him lie on unaffected side.
4.3 Place small pillow under thorax.
4.4 Have patient place his fingers of hand on affected side on opposite shoulder to widen intercostal spaces.
5. 1 Wash the area from the arm pit to the end of the ribs and from the spine to the breast bone with soap and water.
5. Z Moisten guaze with ether and sponge the area of operation.
5.3 Apply iodine (or other antiseptic) to the area of operation as directed.
5. 4 Follow iodine application with alcohol.
5.5 Fold bedding around hipline.
5.6 Fold blanket or jacket around the shoulders.
6. 1 Remove treatment sheet from the sterile tray with forceps; grasp one corner and unfold.
6. Z Place the opening over the operative area.
7. 1 Arrange spotlight to the best advantabe. 7. Z Reassure the patient. Report character
and pulse and count of respiration to the physician. 7. 3 Uncover the tray and place within easy reach.
7.4 Pour small amount of procaine into the medicine glass. ASK THE PHYSICIAN TO READ THE LABEL BEFORE USING THE DRUG.
7. 5 As sist the physician.
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8. Observe the patient, offer encouragement, report any change.
9. Make the patient comfortable following the procedure.
10. Measure fluid.
11. Prepare specimen.
12. Record.
13. Clean equipment.

7. 6 The physician performs the procedure by anaesthetizing the local area, insertinG an aspirating needle 2 1/2 - 3 1/2 inches long, 18 or 19 gauge or larger, if empyema is suspected.

7.7 Suction is usually obtained by attaching the 20 or 30 cc. syringe to the aspirating needle.
7.8 The three-way stopcock is attached to the needle to prevent the entrance of air through the needle when the syringe is detached.
8. 1 Note and report patient I s color, puIs e respiration, skin, eyes and general reaction to treatment.

9. 1 Rearrange the patient in the bed; change linen as indicated; and stay with the patient for a while depending on his apprehensions and general condition. Observe carefully for several hours.

10. 1 Note quantity. 10. 2 Note color, consistency, odor, and record.

11. 1 Read order to determine kind of specimen to be collected.

11. 2

Label the specimen; name, date, ward, room, bed, kind of specimen, physician's name, kind of examination.

12. 1 Time. Doctor who performed the procedure. Specimen to laboratory.

13. 1

Rinse all used articles in cold water and follow with warm soapy solution and rinse thor oughly.

13.2 Inspect and test each item.

13.3 Reset the trays. 13.4 Return clean trays to central supply room.

131

III. LUMBAR PUNCTURE

EXPLANATION:

Withdrawal of fluid from the spinal canal by inserting a needle in a vertebral interspace in the lumbar area.

PURPOSE:

1. For spinal anesthetic.

2. Injection of medication.

3. Injection of air or dye for X-ray purposes.

4. To secure specimen.

EQUIPMENT:

1. Preparation tray

2. Local anesthetic tray (sterile)

3. Lumbar puncture tray (sterile)

4. Gloves

5. Bed protector

6. Chair s or stool

7. Bed clothes

8. Adrenalin

PROCEDURE:

Steps

Key Points

1. Ascertain patient's under standing of the purpose for the procedure and explain uncertain points.

1. 1 Explain importance of maintaining the position.
1.2 Restrain unconscious and obstreperous patients by securing the assistance of a strong male attendant.

132

2. Urge the patient to empty the bladder prior to the procedure.
3. Secure privacy. 4. Bring trays and equip-
ment to the bedside. 5. Place patient .in
position.
6. Restrain patient.
7. Prepare area of operation.

2. 1 An empty bladder increases physical comfort and aids relaxation.
3. 1 Move the patient to private quarters where space and light is adequate.
4. 1 Secure sterile trays from central supply room or prepare sterile trays.
5.1 Position will depend on the patient's condition and on the wishes of the physician.
5. 2(a)Have the patient straddle a straight backed chair; fold his hands on the top slat or board of the chair; rest his head on his hands. Push his hips toward the edge of the chair seat. This bows the back, allowing better space to work; or
(b)Bring the patient's body to the edge of the bed; t;urn on side facing away from the operator; bring knees and head as close together as possible so that back is bowed. The back is bowed to insure adequate separation of spinous processes and widening the intervertebral spaces.
6. 1 Place one hand at back of patient's head
and other hand over and around the knees and hold in this position. Restraint is necessary for children or unconscious and obstreperous patients.
7. 1 Place bed protector under the area of operation.
7.2 Place bath blanket over shoulders and arms.
7.3 Wash the lumbar and sacral area with soap and rinse well as indicated.
7.4 Mositen guaze square with commercial ether and sponge area of and around operation.

133

8. Drape the area of operation.
9. Assist with the procedure.
10. Observe the patient. 11. Make patient comfortable
following the procedure.

7.5 Apply merthiolate (or other antiseptic) to the operative area as directed.

7. 6 Sponge area with alcohol if iodine is used.

8. 1 The doctor usually places the operative sheet or sterile towel in position.

9. 1 Place chair in comfortable position for the physician.

9. Z Reassure the patient and warn him of the skin prick of the needle.

9.3 Keep all articles within easy reach of the doctor.

9.4 Pour procaine into medicine glass and ASK PHYSICIAN TO READ THE LABEL BEFORE HE USES THE DRUG.

9.5 Physician performs the operation by anaesthetizing the skin; inserting the spinal needle; withdrawing the cannula and allowing the fluid to flow. He measures the fluid pressure and may ask the nurse to record it; he collects one, two, or three or more specimens of fluid; measures the amount withdrawn; notes color, consistency, odor, flow, and other factors important to the diagnosis. He withdraws the needle and sponges the area with moist alcohol sponge.

10. 1

The nurse is responsible for "standing by" the patient, noting any change in behavior and reporting condition to the physician. Encourage the patient.

11. 1 Have the patient lie flat in bed for several hours or as directed by the physician.

11. Z Encourage him to drink hot tea, coffee, milk, or other fluids if not contraindicated.

11.3 Administer drug if ordered by the physician.

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12. Prepare specimen. 13. Record. 14. Clean equipment.

12. 1

Print name, ward, date, kind of specimen, doctor's name, and what specimen is to be examined for.

13. 1

Time and kind of procedure. Doctor's name. Amount and character of fluid withdrawn. Patient reaction.

14. 1 Rinse used equipment under cold running water.
14.2 Check equipment and return to Central Supply Room.

135

BASAL METABOLISM

EXPLANATION:

Basal metabolism test refers to the measurement of the amount of oxygen consumed by a person in a given period of time when the body is at rest. Basal metabolism is related to age, sex, weight, and height and is affected by fever, nervousness, and digestion.

EQUIPMENT:

Basal metabloism machine.

PROCEDURE:

Steps

Key Points

1. Allay fear and apprehension.

1. 1 Show the machine to the patient and discuss the principles of its operation.

1.2 Explain reason for fasting and resting before the test.

1.3 Give specific instructions verbally and in writing to the patient.

2. Inform all nur s e s on tour of duty.

2. 1 Post a notice of the test on the bulletin board.

2.2 Flag the Kardex.

2.3 Post a notice on the patient's bed and!or on his door.

3. Notify dietary department.

3. 1 Give written request for light supper. 3.2 Give written request to omit breakfast.

4. Give light supper and omit medication.

4. 1 Serve light supper. Patient may have very little water during the night.

4.2 Urge the patient not to smoke.

4.3 Omit medication.

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5. Give bedtime care.
6. Omit breakfast.
7. Weigh, measure, take temperature, pulse and respiration.
8. Transport the patient to the laboratory or bring the machine to the room.
9. Remove dentures.
10. Resume schedule.
11. Record test.

5. 1 Give usual bedtime care. Confirm understanding of directions regarding sleep, water, eating.
5.2 Encourage the patient to notify you if unable to sleep.
5.3 Inform the physician if the patient is unable to sleep.
6. 1 Leave patient quiet and allow to sleep
until time for the test.
7. 1 Record height, weight, and temperature, pulse and respiration.

8. 1 A portable machine may be wheeled into the patient's room for the test. or
8.2 Take the patient to the clinic or laboratory in a wheel chair or on a stretcher.

8. 3 Allow the patient to rest at least thirty minutes if he is wheeled to the laboratory. Make the room dark and close the door for quietness.

9.1 Remove dentures either in the room or in the laboratory. If the patient is more comfortable with his dentures in place, do not remove them until he is ready for the test.

9.2 Place them in a glass of cold water and keep them in a safe place until the test is complete.

10.1

When the test is completed, give or allow patient to take his own bath. Serve breakfast and resume medication and other schedules.

11. 1 Record time and test.

137

ELECTRO CARDIOGRAM

EXPLANATION AND PURPOSE:

An electro cardiogram is a photostatic record of the course of the electrical currents of the heart muscle and its conduction tissues. The test aids in differential diagnosis and in determining the progress of myocardial infarction due to a coronary thrombosis.

PRINCIPLES:

General principles are applicable.

EQUIPMENT:

The machine is a complete unit.

PROCEDURE:

Steps

Key Points

1. Allay fears.

1.1 Ascertain patient's understanding and explain unknown factor s .

1.2 Illustrate the machine to the patient on the day prior to the test if possible and if the person seems concerned.

2. Send or take patient to the laboratory at appointed time or
3. As sist technician.

2.1 Take or send the patient on a stretcher or wheel chair
or 3. 1 Assist the technician by introducing her
to the patient.

3.2 Offer other assistance if indicated.

4. Record.

4. 1 Record test, time started and finished.

138

REMOVAL OF PERICARDIAL FLUID PURPOSE:
To remove fluid from the pericardial space. To relieve pressure. For diagnostic purposes. PRINCIPLES: See general principles under Paracentesis. EQUIPMENT: Equipment described here is standard but may vary slightly to suit the special needs of the physician. l. Sterile tray from Central Supply.
l. Procedure towel 2. Needles
a. 25 gauge - 3/4 in. b. 20 gauge - 3 in. c. 18 gauge - 3 in. d. 16 gauge - 3 in. 3. Syringes a. 2 cc - Luer - Lok b. 20 cc c. 50 cc 4. Medicine glas s 5. 3-way stopcock
6. 2 pieces of 3 inch rubber tubing with adapter
7. 2 Kahn tubes with corks 8. 1 basin 9. Gauge
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OTHER EQUIPMENT:

1. Novocain 1%

2. Gloves for the doctor

3. Small rubber sheet

4. Dressings cart or tray

PROCEDURE:

Steps 1. Preparation of the patient.

Key Points 1. 1 Explain procedure, allay fears.

1. 2 Place in comfortable position with high back rest.

1. 3 Adjust bed jacket with opening in front.

2. Prepare area of puncture.
3. Doctor places procedure towel.
4. Pour the novocain into the medicine glas s .
5. Doctor inserts the needle and aspirates the fluid.

2. 1 Expose area to the left of lower sternum, from above the fourth to below the sixth rib.
2.2 Paint with iodine and wash off with alcohol 70%.
4. 1 8 cc. of novocain 1%.

6. Observe the patient.

6. 1 Watch closely for changes in pulse, respiration or color.

7. After care of the patient.

7. 1 Make patient comfortable.

8. After care of the equipment. 8. 1 Wash with cold running water and return to the Central Supply Room.

9. Send specimen to the laboratory.

9. 1 Properly label and send specimen to laboratory with request for specific examination as reque sted by the physician.

10. Record.

10. 1

Record treatment, time, doctor, amount and character of the fluid, reaction of the patient and specimen to the laboratory.

140

PREPARATION FOR CYSTOGRAM AND CYSTOSCOPIC EXAMINATION

PURPOSE:

The examination of the bladder and upper urinary tract by means of an electrically lighted instrument to detect any abnormality or functional disorder of the bladder or upper urinary tract so that diagnosis can be made.

EQUIPMENT:

This procedure is usually carried out in a special room equipped for this purpose.

PROCEDURE:

Key Points

1. Prepare and reassure the patient.

1. 1 Explain procedure to patient and tell him the examination will help to determine the cause of his trouble so that treatment can be inaugurated.

1. 2 The patient is given a laxative the night before or an enema may be given the morning of the procedure.

1. 3 Omit breakfast.
1. 4 Force fluids.
1. 5 Dress patient in tJ1e hospital gown and leggings.

2. Sedate the patient.

2. 1 Usually the doctor orders a sedative to be given 30 minutes before the procedure.

3. Accompany the patient to the cystoscopic room.

3. 1 Place the patient in the lithotomy position on the table as soon as the doctor is ready.

4. Record.

4. 1 Chart all that has been done for the patient.
Chart time the patient went to the cystoscopic room.

NOTE: During the procedure the nurse assists by having the necessary articles and supplies at hand and by collecting and caring for the specimens. If a cystogram is desired the bladder is filled with a solution such as sodium iodine or Skiodan. When the upper urinary tract is to be examined, the doctor introduces ureteral catheters into the ureters with the aid of the cystocope.

141

5. After care of the patient.
6. Record and report.

5. 1 Place patient in a warm bed after examination.
5.2 Watch for symptoms of chills, colic and urinary disturbances.
5.3 Reassure patient as he is apprehensive and uncomfortable.
5.4 Instruct the patient to drink water freely.
5.5 Note urinary output, color of urine, etc.
6. 1 Time the patient comes form the cystoscopic room.
6.2 Any signs or symptoms.'
6.3 Report discomfort.

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PART V
THERAPEUTIC PROCEDURES
EXPLANATION AND PURPOSE:
Therapeutics refer to treatment. Therapeutic procedures are designed to alleviate or change a condition either by physical and/ or chemical action. All procedures in this group are utilized in the treatment of persons suffering from various illnesses. The procedure is ordered by the physician usually after diagnosis is complete, either as a palliative or curative measure or to inhibit the progress of the condition.
PRINCIPLES APPLICABLE TO ALL PROCEDURES IN THIS GROUP:
1. Therapeutic procedures must be carried out by order of the physician.
2. Therapeutic procedures are based on scientific principles.
3. All persons do not respond to a given treatment in the same way.
4. Judgment is required to determine the effectiveness of many therapeutic measures and whether or not a treatment is continued depends on the observation and reports of the person who executes a treatment.
5. Judgment, based on knowledge and experience, is needed to change or alter therapeutic procedures. The nurse supervisor is the person best qualified to render such judgment as her education and experience is geared toward techniques and evaluation of the effectiveness of procedures. Her report to the physician frequently determines the continuation of a treatment.
6. Therapeutic procedures used by the nurses on each service should be accepted in cooperation with the medical staff serving in the situation.
7. Therapeutic procedures must be reviewed at planned intervals in the light of new knowledge.
8. Technical skill based on knowledge and understanding of the individual and on demonstrated proficiency is es sential to the safety factor in therapeutic procedures.
9. Washing hands before and after each procedure is essential to self protection and helps prevent cross infection.
143

10. Every patient has a right to privacy. NOTE: The primary purpose of therapeutic procedures is the preservation of life.
Many therapeutic procedures may destroy life if instructions are not followed explicitly. References: "Red Cross Home Nursing" - Civil Defense Supplement - The American National Red Cross. "The Principles and Practice of Nursing" - Homer and Henderson - 4th 4th Edition - MacMillan Company.
144

MEDICATED AND COLLOID BATHS ( STARCH, BRAN, OATMEAL)

EXPLANATION AND PURPOSE:

The colloid bath is designed to relieve inflaIlled, pruritic skin conditions. It should be reIlleIllbered that certain skin conditions Illay destroy the sensitivity of the skin to the extent that the patient is unaware of degrees of heat and cold, and thus, he Illay becoIlle critically burned if he is allowed to prepare his own bath.

PRINCIPLES:

1. When starch, bran or oatIlleal is added to water, the particles reIllain in suspension, thus forIlling a colloid.

2. The colloid bath relieves pruritic and inflaIlled skin by reIlloving outer crusts and exudate.

3. The colloid bath Illay forIll a slight fHIll over the healthy skin areas, thus inhibiting exudate froIll irritating newly infected areas.

4. The bath IllUSt be prepared by a responsible person to insure safety.

5. The patient IllUSt not be left alone as skin conditions are frequently Illanifestations of serious underlying conditions that Illay becoIlle exaggerated during this procedure.

EQUIPMENT:

Bath

TeIllp.

Substance Material Tub Water

Bath

Large

TherIlloIlleter Towels Robe Other

OatIlleal

x

x

95-100 0 F

x

2

x

Muslin Bag

Bran

x

x

95-1000 F

x

2

x

Muslin Bag

Starch

x

x

95-1000 F

x

2

x

Muslin Bag

PROCEDURE: 1. OatIlleal and Bran Bath

Key Points

1. Prepare the patient.

1. 1 Ascertain patient's understanding of what is to be done and why.

145

2. Oatmeal and bran porridge.
3. Prepare the solution.
4. Allow patient to remain ir: tub L - 15 minutes.
5. Assist the patient out of the tub.
6. Dry the patient. 7. Clean and sterilize
equipment. 8. Record.

1. 2 Explain points of uncertainty.
2. 1 Bring two quarts of water to a boil.
2.2 Add three cups of oatmeal or bran.
2.21 Pour oatmeal slowly and stir constantly.
2.3 Cook five minutes. Stir constantly.
2.4 Set aside to cool.
2.5 Place porridge in muslin bag and tie securely.
3. 1 Fill tub half full of water.
3.2 Test temperature with thermometer and adjust until lOOoF is reached.
3.3 Place the bag of porridge in the tub until water becomes whitish or opalescent.
3.4 Place bath towel about patient's hips in apron fashion.
3.5 Assist the patient into the tub slowly and gently as indicated.
4. 1 Stay with the patient.
4.2 Observe the patient's color and general reactions.
5. 1 Use every precaution to prevent falling. Do not hurry.
6. 1 Pat the skin dry with a soft towel.
7. 1 Scrub the tub with scouring powder.
8. 1 Record the procedure, time and reaction.

146

PROCEDURE:' 2. Starch Bath Steps
1. Prepare the patient. 2. Prepare the solution.
3. Fill the tub.
4. Help patient into the tub. Avoid exposure.
5. Time the procedure. 6. Assist patient out of tub. 7. Dry the skin.
8. Record. 9. Clean the tub.

Key Points 1. 1 Explain uncertain points of the
procedure.
2. 1 Dissolve one pound of starch in four quarts cold water and bring to a boil.
2.2 Pour starch solution into boiling water slowly and stir constantly.
3.1 Fill the tub half full of water lOOoF.
3.2 Test water with thermometer.
3. 3 Pour the starch water in the tub of water.
4. 1 Cover the hip area with a bath towel.
4.2 Give support and assistance if patient is helples s.
4.3 Cover exposed area with wet bath towels.
4.4 Observe reaction. 5. 1 Allow the patient to remain im-
mersed 10 - 15 minutes. 6. 1 Use every precaution to prevent
falling. Do not hurry.
7. 1 Pat the skin dry with fluffed gauze or s oft towel.
7. 2 Es cort the patient back to bed.
7. 3 Offer water, bedpan, and other indicated service.
7.4 Adjust bed and light for comfort.
8. 1 Record the procedure, time and reaction.
9. 1 Scrub the tub and rinse with steaming water.
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3. SODIUM BICARBONATE BATH 1. Dissolve two cups of soda bicarbonate in one half tub of water lOOoF. Continue procedure as described in Steps 1 and 2.
4. POTASSIUM PERMANGANATE BATH 1. Fill bath tub (1/2) one-half full of water 90 0 - Q5 0 F. 2. Add potassium permanganate to make 1:4000 solution. Continue procedure above.
NOTE: Potassium permanganate stains the enamel, towels and anything that comes in contact with the crystals or solution. Permanganate solution discolors skin and nails; warn the patient about this factor.
5. SITZ BATH EXPLANATION AND PURPOSE:
The sitz bath is a method of applying moist heat to the area of the body from the waist to the knees for treatment andlor comfort. Special tubs are designed for this purpose. A bath tub is usually used as a substitute. Hot moist heat applied to this area is expected to stimulate circulation and thus relieve congestion and pain. In some instances, the procedure is utilized to treat local infection. EQUIPMENT:
1. Sitz tub or bath tub. 2. Water 1050 F. 3. Bath thermometer. 4. Bath blanket. 5. Bath towels (2) . .6. Rubber air cushion or ring.
148

PROCEDURE:

Steps

Key Points

1. Prepare th~ patient.

1. 1 Explain procedure to the patient.

2. Prepare the bathroom and solution.

2. 1 Prevent drafts and warm the room as indicated.

2.2 Fill the sitz bath tub one-half full of water.

2. 3 Fill the bath tub with enough water to cover the patient's hips.
2.4 Regulate the water to l050 F.

3. Place rubber ring in the tub.

3. 1 Place an air ring in the center of the tub for comfort.

4. Help the patient into the tub.

4. 1 Work slowly and gently.

4.2 Secure assistance for helpless patient.

4. 3 Instruct the patient to sit on the rubber ring and elevate knees.

5. Protect patient.

5. 1 Place a small blanket, bed jacket or sheet across the shoulders if indicated.

6. Increase temperature of water to tolerance.

6. 1 Pour additional hot water into the tub.

6.2 Hold your hand in the tub of water between the patient and the flow of water to prevent the added hot water from burning the patient.

7. Observe the patient.

7. 1 Observe the color of the skin for evidence of redness.

7.2 Observe the expression and color of the face for anxiety and palene s s.
7.3 Count pulse before, during and after the treatment.

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8. Time the procedure.
9. Assist patient to get out of tub.
10. Clean the tub. 11. Record.

7.4 Discontinue treatment if any untoward symptoms appear.
8. 1 Stay with the patient during his treatment.
8.2 Continue the treatment for 20-30 minutes.
9. 1 Support and assist the patient. Do not hurry.
9.2 Dry thoroughly.
9.3 Assist the patient back to bed.
10. 1 Scour the tub thoroughly.
10.2 Rinse thoroughly.
11. 1 Record duration of treatment and patient's reaction.

150

LOCAL APPLICATION OF HEAT

EXPLANATION AND PURPOSE:

Heat is applied to the body for various therapeutic purposes - - usually when an inflammatory condition exists -- to give the patient comfort.

PRINCIPLES:

Heat brings more blood to the peripheral surface and relieves the discomfort of being cold.

Heat increases the rate of metabolism; relieves tension and softens tissues. Wet, hot applications to an area can soften inflammation and increase drainage.

Heat may be applied to one part of the body but simultaneously affect a very distant part.

Heat can act as a sedative or stimulant.

Bleeding can be checked with intense heat (cautery).

Hot water is a better conductor of heat that hot air.

Many conditions requiring application of heat are now treated by drug therapy.

EQUIPMENT:

Hot water bottle

Cover of heavy conton flannel.

PROCEDURE:

Steps

Key Points

1. Prepare hot water bottle.

1. 1 Te st bottle for leaks.

1. 2 Test the temperature of the water (120 0 Fto l500 F). Temperature depends on age of patient, type of skin, condition of area and doctor1s orders.

1. 3 Fill bag 1/3 full and expel all ai r .

151

2. Apply hot water bottle to area.
3. Watch so patient does not receive burn.

1.4 Cover rubber bottle completely with heavy hot water bottle cover.
2. 1 Instruct patient.
2.2 Note position in which hot water bottle is placed.

ELECTRIC HEATING PAD

There is always danger of an electric pad becoming over heated.

PROCEDURE:

Steps

Key Points

1. Protect pad from contact with moisture to prevent short circuit.

1. 1 The safest electric pad is incased in rubber.

2. Check pad.

2. 1 Observe patient frequently while pad is in use.

HOT STUPES, CLEAN COMPRESSES AND FOMENTATIONS

EQUIPMENT:

Thick gauze pads

Hot water bottle

Old woolen blanket squares or cellucotton pads
Solution to order Large or small basin Thermometer

Oiled silk tis sue Binder 1 part turpentine 1 part sweet oil 1 towel

152

PROCEDURE: Steps
1. Assemble materials. 2. Prepare skin area.
3. Prepare hot water bottle. 4. Prepare fomentation, clean
compress or stupe. 5. Apply compress to
affected part.
6. Replace compress.

Key Points
1. 1 Explain treatment to patient to gain his cooperation.
2. 1 Put binder in place.
2.2 Annoint patient's skin (with 1 part turpentine and 1 part sweet oil. )
2. 3 Cover with clean towel.
3.1 See preparation of hot water bottle.
4. 1 Wring flannel squares as dryas possible. Place in oiled tissue and take to patient's bedside on hot water bottle.
5. 1 Remove towel. Place hot compress slowly on affected area. Do not burn patient. If very hot allow steam to escape from flannel square.
5.2 Cover compress with clean dry flannel square, oiled tissue, hot water bottle and secure with binder.
5.3 Reassure patient.
6. 1 Compresses should be replaced
according to the type of compress.

7. Do not chill patient.
8. Annoint skin between compresses.
9. Continue treatment as ordered.

7. 1 Dry the part.
7.2 Cover area with clean dry towel until compress is replaced.
8. 1 Use turpentine and sweet oil.
8.2 Vaseline may be used to prevent burning.

153

10. Remove stupe.

10. 1

Cover treatment area with treatment towel and binder to prevent chilling.

10.2 Make patient comfortable.

STERILE HOT WET COMPRESS TO EYE OR WOUND

PURPOSE:

To relieve pain and swelling.

PRINCIPLE:

The therapeutic value of treatment is to give continuous hot wet applications to an area. Compresses must be sterile.

EQUIPMENT:

Sterile compresses

Gauze 4 x 4 or size indicated

Sterile forceps (2) and holder

Rubber sheet with towel

Sterile pan with cover

Electric stove

Sterile asepto syringe

Tray

Sterile rubber tissue Clean dry flannel square

Cavolite - - a water proof paper that will stand steam sterilization.

PROCEDURE:

Steps

Key Points

1. Obtain equipment from Central Supply.

1. 1 Explain procedure to patient. 1. 2 Place patient in recumbent position.

2. Take equipment to bedside.

2. 1 Put tray on patient's bedside table.
2.2 Arrange rubber sheet and towel under patient's head.

2.3 Attach stove to electric socket.

154

3. Protect unaffected eye with a shield.
4. Apply compresses to affected eye.
5. Change compresses at frequent intervals for next 20 minutes.

2.4 Heat solution in covered pan. 2.5 Open sterile compresses into pan.
4. 1 Wring compresses dry with sterile forceps, (temperature 120oF) and apply very gently to affected area.
5. 1 Almost constant change of compresses are necessary.
5.2 If eye is discharging discard contaminated compresses in paper container for burning.

155

LOCAL APPLICATIONS OF COLD

EXPLANATION AND PURPOSE:

Cold applications are used to ease pain, check inflammation and control hemorrhage by contracting the blood vessels in the area.

PRINCIPLES:

Cold contracts blood vessels and reduces the circulation of blood.

Cold is a depressant. It checks the growth of bacteria, contracts nerve endings and squeezes blood out of the affected area.

Prolonged cold application can destroy tissue.

EQUIPMENT:

Ice cap

Commercial ice bag

Ice collar

Cover of heavy Canton flannel

PROCEDURE:

Steps

Key Points

1. Select type of ice bag to suit affected part.

1, I Te st for leaks. 1. 2 Fill bag 1/2 full of ice.

1. 3 Expel air to reduce weight and make flexible.

1. 4 Cover with Canton flannel.

2. Apply ice cap to affected part.

2. 1 Instruct patient.
2.2 Inspect patient's skin and apply ice bag.

3. Check skin frequently.

3.1 Check area for numbness, mottling, or any discoloration and remove ice cap.

4. Commercial ice cap.

4. 1 Commercial ice caps are colder than ordinary ice caps due to lowered specific gravity of liquid in bag.

156

4.2 1 commercial ice cap is used, watch affected area more carefully to prevent tissue necrosis.

COLD WET COMPRESSES TO EYE

(Cold compresses are never sterile)

EQUIPMENT:

Basin

Tray

Large chunks of ice

Oiled silk tis sue

Compresses to fit area involved

PROCEDURE:

Steps

Key Points

1. Obtain equipment from central supply. Fill basin with ice (size of walnuts).

1.1 Explain procedure to patient.

2. Take equipment to bedside.

2. 1 Place tray on patient's bedside table.

2.2 Lower bed - protect pillow with oiled tissue and towel.

2.3 Make patient comfortable.

3. Administer treatment.

3. 1 Wring compress from water which is slightly above freezing point.

3.2 Place compress to affected area.

3. 3 Change every few seconds.

4. Do not cover compress.

4. 1 Body temperature is quickly attained if compress is covered.

5. Duration of compress.
6. Disposal of compresses.

5. 1 Treatments usually last 15 - 20 minutes and are repeated as ordered by physician.
6. 1 1 ear is infected deposit contami-
nated compresses in container and burn.

157

EAR IRRIGATION
PURPOSE: 1. To soften and remove impacted wax or foreign bodies. 2. To supply heat to relieve pain. 3. To remove purulent discharge. 4. To cleanse the ear before an operation.
PRINCIPLES: 1. The external auditory canal is a tubular passage about. 1 to 1 1/2 inches long. 2. The middle ear has five openings through which infection may be carried because of the continuity of tissue. Too forceful a flow may carry infection further into auditory canal. 3. The external auditory canal can be straightened by pulling the auricle upward and backward in adults and downward and backward in children. 4. Cotton packed tightly into the ear canal obstructs the flow of discharge. 5. Lying on the affected side after irrigation aids drainage by gravity. 6. Force or heat and cold on the eardrum produces dizziness, nausea or nystagmus.
EQUIPMENT: Rubber bulb ear syringe Rubber sheet and towel Emesis basin Solution which may be: Sodium bicarbonate 2-5% Boric acid 4% Hydrogen peroxide 1/2 strength
158

PROCEDURE: Steps
1. Assemble requisites at bedside.
2. Insure privacy and explain procedure to patient.
3. Position and drape.
4. Insert tip of bulb into external auditory canal.
5. Direct steady slow stream of solution into canal.
6. Dry external ear with sterile cotton pledget.

Key Points
1. 1 Read the originat order.
1. 2 Solution should be lOOoF. Amount varies with purpose.
2. 1 For best results, patient should understand the procedure and know what is expected of him.
3. 1 Place patient in lying or sitting position inclining head toward affected side.
3.2 Place small rubber protector under the head.
3.3 Instruct patient to hold basin against the cheek, under the ear to catch the return flow.
4. 1 Grasp auricle to straighten canal.
4.2 Only tip of syringe should enter ear.
5. 1 Note character of return flow.
5. 2 Watch and que stion patient for any unusual symptoms as dizzine s s, weakness and nausea.
5.3 Continue treatment until solution is used or cleansing purpose is accomplished.
5.4 After treatment is stopped allow patient to keep head inclined for a short time to allow all the fluid to return.
6. 1 Leave patient comfortable and unit
tidy.

159

7. Clean equipment and return to Central Supply.
8. Record on chart.

7. 1 Discard soiled pledgets into containers for burning.
7.2 Discard return fluid after noting its character and cleanse basin thoroughly with soap and water.
7.3 Clean other utensils in like manner and prepal"e for resterilization.
8. 1 Time and treatment. Strength, type and amount of solution. Amount and character of discharge. Effect on patient.

160

EYE IRRIGATION

PURPOSE:

1. To relieve congestion and pain.

2. To disinfect.

3. To remove foreign bodies.

PRINCIPLES:

1. Impairment or loss of vision makes the patient apprehensive.

2. Irrigating the eye from the inner to the outer canthus of the eye avoids contamination of the uninfected eye and entrance of the fluids into the lacrimal duct.

3. Irrigating with force or cold solution intensifies sensations of pain.

4. The mucous membrane lining the nasal cavity is continous with that lining the naso lacrimal duct and the conjunctiva.

5. The cornea has an abundant nerve supply and is therefore very sensitive.

EQUIPMENT:

Sterile

Unsterile

Bulb syringe

Emesis basin for return flow

Basin for solution

Rubber protector

Cotton pledgets

Towel

Solution which may be: Normal saline Boric acid 2% Sterile water

Cornucopia

PROCEDURE:

Steps

Key Points

1. Assemble requisites at bedside.

1. 1 Read the original order.

161

2. Insure privacy and explain procedure to patient.
3. Position and drape.
4. Clean eyelids first.
5. Fill bulb syringe and begin irrigation.

1.2 Arrange articles where they can be reached conveniently.
1. 3 Wash hands thoroughly.
2.1 Cooperation of the patient is necessary to prevent injury and spread of infection.
3. 1 The patient should be sitting up or lying down with the infected eye lower.
3.2 Place a rubber protector, covered by towel or sheet, where it will protect the patient and bed linen.
3.3 Instruct the patient to hold the emesis basin against the cheek to catch the return flow.
3.4 Cover unaffected eye with sterile cotton pledget.
4. 1 Remove crust from eye lids with moist sterile cotton pledget by gently passing the pledget from inner to outer canthus of the affected eye.
4.2 Discard waste in paper bag or cornucopia.
5. 1 Separate eye lids with thumb and forefinger making pressure on bony prominences.
5.2 Rest hand by holding syringe on bridge of nose.
5. 3 Allow the fluid to flow in a gentle steady stream, from the inner to outer canthus.
5.4 Prevent the tip of the syringe from touching the patient.

162

5. 5 Use about 250 to 500 cc. of the kind and strength of solution ordered.

5.6 Note character of return flow.

6. Dry eye with sterile cotton pledget.

6. 1 Leave patient comfortable and unit tidy.

7. Clean and return equipment.

7. 1 Burn soiled pledgets.

7.2 Wash utensils thoroughly with soap and water.

7.3 Prepare syringe and solution basin for resterilization.

8. Record and chart.

8. 1 Time of treatment. Strength and type of solution used. Amount and character of discharge. Condition of eye. Effects of treatment on patient.

NOTE: Hands must be washed thoroughly before and after this treatment.

163

INDWELLING CATHETER
PURPOSE: 1. Drainage of urinary bladder. 2. Cleanliness and comfort of the incontinent patient. 3. Prevention of straining, irritation and postoperative infection. 4." Aid in diagnosis. 5. To prevent formation of pressure sores in cases of involuntary voiding.
PRINCIPLES: 1. Sterile equipment and maintenance of aseptic technic throughout procedure prevents infection. 2. Gentleness in locating urethral orifioe and insertion of well-lubricated catheter prevents trauma and discomfort.
EQUIPMENT: 1. Sterile tray containing: Stainless steel basin - 1000 cc. - one Stainless steel cup - 30 cc. - two Cotton balls - six to eight Huck towels 10 x 18 - two Foley or mushroom catheters (size 16 - 24) Catheter guide or large stilet Syringe - 20 cc. Glass connecting tube - 2" x 1/4" - Towel to cover jug 2. Sterile gloves (optional) 3. Clear, glass jug (one gallon) and rubber tubing
164

4. Adhesive tape, safety pin (one)

5. Solutions:

Green soap

Sterile water

THIS PROCEDURE IS USUALLY PERFORMED BY THE PHYSICIAN FOLLOWING THE NURSE'S PREPARATION OF THE PATIENT.

PROCEDURE:

Steps

Key Points

1. Explain procedure to patient.

1. 1 Allay fears and explain why procedure is to be done.

2. Secure tray from. central supply
room. and bring to the bedside.

2. 1 Aseptic technique is im.portant in this procedure.

3. Place patient in lithotom.y position and drape.

3. 1 Make as com.fortable as possible.

4. Scrub hands for 3 m.inutes with phisoderm. and G 11.

4. 1 Use surgical handwashing procedure. (see surgical scrub).

5. Separate labia and cleanse urethral area using gentle downward strokes.

5. 1 Green soap followed by sterile water renders the area clean.

6. Select catheter and insert into

6. 1 Catheters with soft openings m.ay

urethra. Use the catheter guide

bend easily and m.ay obstruct the

or stilet to allow ,the entrance of

lum.en and thus inhibit the flow.

the catheter into the bladder.

(This procedure is always carried 6.2 Insert the catheter slowly and gently.

out by the physician. )

There m.ay be som.e retraction or

contraction of the urethral orifice

when the catheter first contacts the

area.

6.3 If the bladder is overdistended do not drain com.plete1y as this m.ay cause shock and/ or a chill.

165

7. Instill 20 cc of sterile water through the catheter to inflate the balloon.
8. Connect rubber tubing to the catheter by using a connecting link. Place the free end of the catheter in the drainage bottle.
9. Make the patient comfortable.
10. Observe the patient for untoward signs and symptoms and/or discomfort.
11. Send specimen to the laboratory.

7. 1 Catheter will not drain properly if the balloon is overdistended.

7.2 Instill the water slowly to prevent pressure. Ask for assistance from the physician"if there is any resistance to the introduction of the water.

8.1 Attach the catheter to the patient1s leg with adhesive to prevent the catheter from pulling out as the patient move s .

8.2 Observe the flow.

8. 3 Cover drainage bottle with towel.

9. 1 Make the patient comfortable with pillows or other necessary props.

9.2 Change his position as indicated and stay with him until the catheter feels comfortable.

9. 3 Explain that the catheter may come out if he turns without assistance.

9.4 Many elderly patients pull the catheter out without being conscious of their act. The catheter constitutes a foreign element and may be irritating.

10. 1 Report bleeding, pallor, and complaints to the physician.

10.2

Patient recovery may depend on prompt, accurate reporting of symptoms.

10.3 Observe color, amount, and general character of drainage.

11. 1 Label specimen correctly.

166

12. Irrigate the catheter as directed by the doctor I s written order.
13. Record the procedure.
14. Clean the equipment.

12. 1 Use kind and amount of irrigating solution ordered.

13. 1

Record: Time. Amount and character of urine withdrawn. Name of person who performed the procedure. Patient reaction.

14. 1 Rinse the used materials under cold running water.

14.2 Account for each item and return to central supply room.

167

THROAT IRRIGATION

PURPOSE:

1. To soften the mucus and remove accumulated secretions and discharges.

2. To stimulate the circulation and hasten absorption of inflammatory

products.

.

3. To relieve congestion, swelling, pain and to promote healing.

4. To stimulate and bring to a head the process of suppuration in such conditions as pharyngeal abscess so that it may be incised and drained.

PRINCIPLES:

1. Beneficial results are caused by mechanical cleansing and effect of heat rather than the type of solution.

2. Solutions at a temperature not tolerated by other parts of the body are comfortable in the mouth.

3. In order to obtain the desired results a continuous stream of the solution must reach the affected parts without making the patient gag.

4. The patient, if instructed, will feel more at ease and get better results if they give the treatment to themselves ..

EQIUPMENT~

Irrigating pole

Tubing with clamp and an irrigating tip

Irrigating can

Large round basin

Emesis basin

Rubber protector and towel

Paper tis sue s

Receptacle for waste

Solution which may be used for gargle, usually normal saline (temperature 1150 - l20 0 F. )

168

PROCEDURE: Steps
1. Assemble equipment at bedside.
2. Screen patient and explain procedure to him.
3. Position and drape

Key Points

1. 1 Read the original order.

1.2 Equipment should be handled with clean hands but need not be kept strictly sterile.

1.3 Size of receptacle for waste depends
on patient's position and amount of solution used.

1.4 Expel air from tubing after hanging can on irrigating pole -- clamp tubing.

2. 1 Cooperation of patient is absolutely necessary for success of treatment. Points included in instruction to patient are:

2. 11

How to hold the head so that solution can flow in a continuous stream without gagging him.

2. 12 Fluid must reach far back into pharynx.

2. 13 The longer the breath can be held the more continuous will be the contact.

3. 1 Most desirable position is sitting up in bed with overbed table in front of patient on which is placed large round basin.

3.2 Patient may also lie on side with emesis basin held under chin.

3.3 Protect bedding and patient with rubber sheet covered by towel.

3.4 Place wipes within reach of patient.

169

4. Insert tip into patient's mouth.
5. Attend to patient's comfort. 6. Remove tip and place
in paperwipe.
7. Record on chart.

4. 1 The first time, allow the solution to flow only for a short time.
4.2 As he gains confidence and learns how to hold his breath a more continuous flow may be allowed.
4.3 The fluid flows back over the lower lip or from corner of the mouth into receptacle.
4.4 Stop flow at patient's slightest inclination to gag or a sign of fatigue.
4.5 Continue treatment until desired effect is produced or patient shows signs of fatigue. Usual.amount is I to 1 1/2 lite~s.
5. I Patient usually perspires after treatment, 'therefore protect from drafts.
5.2 Leave patient comfortable and unit tidy.
6. I Note character of return flow before discarding.
6.2 Wash utensils thoroughly with soap and water.
6.3 Send irrigating tray to central supply for resterilization.
7.1 Time and duration of treatment. Amount and type of solution used. Character of return flow. Reaction of patient to the treatment.

170

NASAL IRRIGATION

PURPOSE:

1. To apply heat and medication in conditions such as sinusitis.

Z. To cleanse the nasal passages of accumulated discharges and crusts.

3. To combat disagreeable odors connected with chronic nasal infections.

PRINCIPLES:

1. Since the sinuses drain into the nose there is always danger of forcing infectious material into them.

Z. Hot solutions tolerated by the mouth and pharynx are painfully hot if applied to the nose.

3. Changes in pressure in the nasal or aural cavity may draw infectious material into the eustachian tube.

EQUIPMENT:

Irrigating can or

Paper wipes

Flask with rubber tubing

Waste receptacle

Clamp and nasal tip or Catheter Standard

Solution usually normal saline - 1000 cc. (temperature 1050 )
Basin for return

PROCEDURE:
Steps
1. Assemble equipment and carry to bedside.
Z. Insure privacy and explain procedure.

Key Points 1. 1 Handle equipment with clean hands.
Z. 1 Cooperation by the patient will lessen danger of infection of sinuses.

171

3. Place patient in position and drape.
4. Place can on irrigating stand and expel air from tubing, then clamp.
5. Gently insert nozzle.
6. Gently remove nozzle and dry patient's face.

2. 2 Explain to the patient that he must breathe through his mouth, and that he must not swallow or talk during the procedure as this may cause the infection to spread.
3. 1 Patient should be sitting with the head flexed on chest and held over sink or basin.
3.2 Place tissues near at hand where patient can reach them.
3. 3 Protect patient with rubber sheet and towel.
4. 1 Place irrigating can about 8 inches from patient's nose.
5. 1 The nozzle must fit tightly enough to prevent fluid from returning through same nostril. After being shown, the patient can usually do this better himself.
5.2 Allow a gentle, steady stream of fluid to pass up one ~ostril, bact into nasopharynx and around the septum. Discharges are washed out through opposite nostril.
5.3 If patient coughs or chokes, check flow immediately as this usually indicates some obstruction.
5.4 Doctor must state which nostril he prefers irrigated; otherwise, both sides may be used alternately. Use from 500 to 1000 cc. of solution..
6. 1 Instruct patient not to blow excess fluid from nose for several minutes after treatment as discharges may be forced up into the middle ear .

6.2 Protect patient from drafts.
172

7. Remove and clean utensils. 8. Record on chart.

7. 1 Note character of return flow before discarding.
7.2 Clean all utensils well with soap and water.
7.3 Return to central supply.
8. 1 Time and duration of treatment. Amount and kind of solution. Character of return flow. Reaction of the patient.

173

PERINEAL DOUCHE USING FORCEPS
PURPOSE: 1. To cleanse skin and mucus membranes under aseptic conditions after parturition, or following operations on the perineal or rectal structures. 2. To discourage growth of bacteria. 3. To encourage healing of perineal sutures by keeping them clean and dry.
PRINCIPLES: 1. Intact skin and mucous membranes are natural barriers to bacteria. 2. Infection in perineal wounds is likely to occur since the rectal and urethral orifices are nearby structures. 3. The skin surfaces around the vagina have many nerve endings rendering them sensitive to temperature and touch. 4. Normal vaginal secretions are bacteriocidal in their action.
EQUIPMENT: Perineal tray l8"x12"xl 1/2" containing: 2 containers of sterile cotton pledgets Covered pitcher or 2 quart irrigating can with warm tap water Container for waste Solution Zephiran 1:1000 (may be used) Bedpan with cover Sterile perineal pads Newspaper squares Surgical towel (fan folded) Thumb clamp Douche tip 174

PROCEDURE: Steps
1. Insure privacy and place patient on bedpan.
2. Prepare perineal tray.
3. Explain procedure and readjust patient's position.
4. Flush the external genitalia. 5. Dry genitals.

Key Points
1. 1 Remove soiled perineal pad in paper square.
1. 2 Place patient in sitting position (if not contraindicated) and allow sufficient time for patient to void.
2. 1 Fill pitcher with warm tap water.
2.2 Test on wrist or dorsum of hand.
2.3 Place a few drops of solution ordered in the pitcher.
2.4 Cover tray and carry to bedside.
3. 1 Lower head rest and have patient flex knees and separate legs.
3.2 Fold back covers, draping over knees exposing perineal area.
3. 3 Wash hands thoroughly before giving treatment.
4.1 Move pitcher back and forth over entire vulva pouring solution at the same time especially over center.
5. 1 Pick up a sterile cotton pledget with an instrument.
5. 2 With one downward stroke wipe between labia.
5.3 Use a clean pledget for each stroke and discard soiled one in waste container.
5. 4 If patient has perineal stitche s, special care should be taken in drying these as dryness promotes healing.

175

6. Place clean perineal pad over genitalia.
7. Remove and empty bed pan.
8. Return perineal tray to Central Supply.
9. Record on chart.

5.5 Be very gentle in drying these sutures as they are very painful. Note condition of tissues.
5.6 Spray sutures with antisceptic solution if ordered by physician.
6. 1 Do not allow patient to touch inside of this pad.
7. 1 Adjust covers and bed leaving patient comfortable.
8. 1 Empty waste container for burning. Refill cotton container.
9. 1 Time of treatment.; condition of sututes; any abnormal swelling and discharges.

176

PERINEAL CARE WITHOUT FORCEPS

EXPLANATION AND PURPOSE:

Perineal care is given to cleanse the external genitalia, prevent infection, promote healing, reduce odors and give comfort.

PRINCIPLE:

1. Discharges containing blood are excellent culture media and need to be removed from perineal area.

2. Always use downward stroke when cleansing labia to prevent contamination from rectal area.

3. All bed pans should be sterilized (bed pan washer does not sterilize).

EQUIPMENT:

Individual equipment:

Sterile covered pitcher containing warm tap water (9S0-l0S0F) or solution ordered

Sterile bedpan with clean cover

Sterile cotton balls (3 to S in each package. ) (Dennison's brown paper)

Sterile perineal pad (package) (Dennison's brown paper)

T-binder or sanitary belt

Safety pins (2)

PROCEDURE:

Steps

Key Points

1. Assemble equipment and take to bedside.

1. 1 Explain procedure to patient to gain cooperation.

2. Prepare patient for treatment.

2. 1 Screen patient, fold back covers and use treatment blanket or top sheet for draping.

177

3. Wash hands. 4. Place patient on bedpa.n. 5. Clean perineum.
6. Put on perineal pad.

3. 1 See surgical scrub.
4. 1 Unpin sanitary pad; remove pad using downward stroke (front to back) and place in bag for waste. Note type, amount and odor of discharge.
4.2 Place patient on bedpan. Make comfortable.
4.3 Open package of sponges and sanitary pad. Place covered pitcher containing warm tap water (950 -1050 F) on overbed table.
5. 1 Fold back treatment blanket.
5.2 Wash hands.
5.3 Pick up pitcher in left hand and pour warm tap water (or solution ordered) over perineum.
5.4 Pick up cotton ball with two fingers of right hand.
5.5 Cleanse labia using light steady stroke from top down first on one side then the other. Discard'sponge in waste bag.
5.6 Remove bedpan and cover
5. 7 Turn patient on side. Separate buttocks with left hand. Cleanse rectal area. Discard sponge~n waste bag.
6. 1 Turn patient on back.
6.2 Still using right hand pick up and place inside of folded pad on perineum.
6.3 Pin pad first in front; adjust and pin pad in back.
178

7. Make patient comfortable.
8. Remove equipment, bedpan and discard materials from. bedside
9. Wash hands. ~O Replace used equipment on
cart or send to Central Supply Room.

7. 1 Remove treatment blanket and arrange bed covers.
8. 1 Clean equipment and sterilize.
8.2 Discard contents of bedpan; clean and sterilize.
8.3 Place discarded materials in incinerator.
9. 1 Wash and dry hands thoroughly.

179

VAGINAL IRRIGATION

PURPOSE:

1. To cleanse

2. To disinfect

3. To relieve inflammation

4. To deodorize

5. To check hemorrhage

PRINCIPLES:

1. The direction of the vaginal canal with the patient in the dorsal position is downward and backward.

2. The height of the douche can controls the force and speed of the fluid.

3. Excessive force washes infectious material into the uterus and tubes and possibly into the peritoneal cavity. It also reduces the time of exposure of the parts to the action of the solution.

4. The internal and external openings of the cervix are normally closed except during menstruation and the later stages of pregnancy.

5. Vaginal discharges contain microorganisms.

6. The vaginal canal is a minimum of three inches anterior and 5 inches
posterior in length.

EQUIPMENT:

Sterile tray containing:

Douche can

Clamp

Rubber tubing (3 ft. )

Three small basins

Nozzle

Germicide - to cleanse external parts

Tray should be covered with sterile towel

180

.

Solutions which may be used are:

Potassium Permanganatel:5000

Sodium. Bicarbonate 2%

Boric Acid 2 1/2%

Bichloride 1: 5000 to 1: 10, 000

Normal Saline

Vinegar

Zephiran 1:2000

Temperature of solution will vary according to purpose such as:

1. Cleansing 1050 F.

2. Inflammation l15 0 F.

3. Hemorrhage 1200 F.

PROCEDURE: Steps
1. Scrub hands thoroughly. 2. Secure sterile pack from
central supply. 3. Prepare prescribed solution
in irrigating can. 4. Assemble other requisites.
5. Insure privacy and explain procedures to patient.
6. Prepare patient for treatment
and rearrange bed linens.

Key Points
1. 1 See Surgical Scrub.
2. 1 Open pack carefully without contaminating contents.
3. 1 Cover the tray with sterile towel and carry to bedside.
4.1 Rubber sheet and newspaper.
4.2 Bedpan and cover.
5. 1 Explain purpose to obtain best results.
6. 1 Place the patient in the dorsal re-
cumbent position with knees flexed and separated.
6. 2 F~n the upper bedding to the foot of.
the bed placing treatment blanket on patient.

181

7. Proceed with the treatment.
8. Remove bedpan and bed protector.
9. Replace the upper bedding. 10. Aftercare of equipment. 11. Record and report.

. 6.3 Place the protective rubber sheet and newspaper under the patient's buttocks. Place patient on the bed pan.
6.4 Drape the patient with treatment blanket.
7. 1 Protect thumb and index finger of left hand with cotton p1edgets or use gloves.
7.2 Separate labia and cleanse vulva. Use only one downward stroke with each pledget then discard into waste basin.
7. 3 Take the rubber tubing in the right hand unclamp and allow some solution to escape to warm the tubing and expel the air, then direct the flow over the vulva until clean.
7.4 Insert the nozzle gently about 3 inches following the normal curve of the canal.
7. 5 Hold the irrigating can about 18 inches above the level of the patient and rotate the nozzle gently.
7.6 Clamp the tubing before the can is
completely empty. Remove the nozzle and place it in the waste container.
7. 7 Dry the patient with sterile cotton pledgets.
8. 1 Note especially the character of the return flow.

10. 1

Wash with soap and water, rins ewell and dry throughly and return to cen~ral supply.

11. 1 Time treatment was given, kind and strength of solution, character of
return flow, and effects on patient.

182

STOMACH IRRIGATION

PURPOSE;

1. To cleanse the stomach of undigested food or toxic substances.

2. To cleanse the stomach in persistent vomiting.

3. To prepare the patient for gastric surgery.

4. To remove the gastric contents in acute dilation of the stomach.

PRINCIPLES:

1. The anatomical relationship of the esophagus and trachea increase the danger of aspiration of food into the lungs producing strangulation and infection.

2. Chilling of the rubber tubing and the action of swallowing facilitates insertion.

3. Compression of the tube on removal from the stomach prevents escape of fluids into the respiratory tract.

4. The action of the solutions used is either chemical, physical or physiological.

5. The evacuation of any cavity takes palce by siphonage or suction.

EQUIPMENT:

Stomach tube (4 1/2 to 5 ft. long) with funnel and bulb

Solution of lOOoF. which may be.l to 8 qts. of tap water.

Basin of cracked ice

Normal saline

Small rubber sheet

Boric acid 2%

Face towel Safety pin

Sodium bicarbonate 2-5% or any solution specified by physician or indicated by the nature of the toxic substances

Large pail for return flow

Glass of water

Small pitcher for pouring Mouth wash

Drinking tube (lubricant need not be used) Newspapers to protect floor

183

PROCEDURE: Steps
1. Insure privacy and explain procedure to patient.
2. Assemble requisites at bedside.
2. Prepare patient.
4. Physician, intern or nurse will insert tube, depending on hospital policies.

Key Points

1. 1 This treatment is often unpleasant. Proper instruction to patient will greatly facilitate matters.

2. 1 Place tube in basin of cracked ice.

2.2 Fill small pitcher from supply container.

2.3 Place newspaper on floor and set pail down on it.

3. 1 Best results are obtained if treatment is carried out before breakfast or from 4-6 hours after meals unless used in emer.gencies.

3.2 Place patient in sitting position.

3.3 Fasten rubber sheet and cover around patient's neck.

3.4 Remove dentures, if present.

4. 1 Remove tube from'ice, lubricate and give it to physician for insertion.

4.2 Reassure patient and encourage him to swallow as tube is gently inserted through nose or mouth. In unconscious or uncooperative patients the nasal route is more satisfactory.

4.3 Give patient sips of water to facilitate swallowing.

'4.4

1 patient chokes or becomes cyanotic, tube has most likely enteredtrachea and must be removed.

184

5. Fill funnel with irrigating solution and allow it to run in slowly.
6. Continue treatment by alternately introducing fluid into stomach and permitting it to run back.
7. After care of patient.

4.5 Location of tube can be ascertained by placing distal end in glass of water. If no bubbling occurs it may safely be assumed that tube is in the esophagus.
4.6 Using bulb syringe attempt to aspirate stomach content. If there is a ready return, tube is probably deep enough.
4.7 Attach funnel and invert over waste receptacle.
5. 1 Never allow the funnel to become completely empty thus permitting air to enter the stomach.
5.2 Allow about 500 cc. to run in before attempting to siphon it back.
5. 3 Again before funnel is empty pinch it off and invert over waste receptacle.
5.4 If flow does not come readily it may be necessary to use bulb syringe to get it started.
6. 1 This should be continued until amount specified is given or until return flow is clear.
6.2 If any medication is to be instilled it should be put in through tube as soon as all drainage has ceased.
6. 3 Then pinch or clamp off tube and withdraw it quickly.
7. 1 Allow patient to rinse his mouth.
7.2 Wipe patient's face and remove rubber protector.
7. 3 Adjust bed and covers and leave patient comfortable.

185

8. After care of equipment. 9. Record on chart.

8. 1 Remove all utensils from room.
8.2 Measure content of waste pail before discarding and note character of same.
8.3 Wash utensils thoroughly with soap and return to Central Supply.
9.1 Time of treatment.
9.2 Kind and amount of solution.
9. 3 Reaction of patient and after effects.
9.4 Character of return flow and amount of same.

186

GASTRIC GAVAGE EXPLANATION AND PURPOSE:
To introduce food into the stomach by means of a tube. PRINCIPLES:
The same principles as listed under gastric lavage apply to the gastric gavage. EQUIPMENT:
Same equipment as listed under Stomach Irrigation except for large pail for return flow and prescribed food in pitcher. PROCEDURE:
Food is introduced into stomach slowly and not allowed to return. See gastric lavage.
187

WOUND IRRIGA TION

PURPOSE:

1. To promote healing.

2. To cleanse and favor drainage.

3. To prevent reinfection.

4. To add to patient's comfort by removing unpleasant odors.

PRINCIPLES:

1. Predisposing cause s -- debility, malnutrition, metastatic disease -- all undermine the patient's resistance.

2. A healthy granulating wound offers great resistance to bacterial invasion. This resistance may be broken down by slight injuries, probing, removing or shifting a dressing.

3. Healthy granulating tissue is soft, gray or grayish red, gelatinous, and translucent with an irregular velvety surface, bleeding readily, but quite insensitive to pain because it contains no nerves.

4. Every individual has the right of aseptic treatment for his wounds.

5. Wounds such as compound fractures containing much traumatized muscle, fascia, and bone offer greater opportunity for growth of bacteria especially where the blood supply is impaired.

6. Chemicals such as germicides which devitalize wound surfaces are not put into wounds.

7. Moisture favors growth of bacteria.

EQUIPMENT:

Dressing tray 01." carriage Sterile gloves Sterile basin for irrigating
solution Emesis basin for return flow
188

Asepto syringe
Sterile instrument set containing: Surgical dressing scissors Bandage scissors Forceps Hemostat Adhesive Dressing (sterile)

Solution which may be Zephiran 1: 1000
PROCEDURE: Steps
1. Wash hands thoroughly. 2. Assemble equipment at
bedside. 3. Inform patient of procedure
and explain purpose. 4. Insure privacy and prepare
patient and bed.
5. Remove dressing.
6. Open sterile equipment.
7. Drape wound with sterile towels, and prepare patient's skin.
8. Irrigate wound with prescribed amount or solution using asepto syringe.

Normal saline or any other solution specified by doctor.
Key Points
2. 1 Arrange the tray at a convenient place on the bedside cabinet..
3. 1 Reassure patient with regard to the pos.sibility of inflicting pain.
4. 1 Screen patient.
4.2 Protect bed and patient's linen with rubber sheet and cover.
4.3 Fold back the beddiDg to expose the wound.
4.4 Place a newspaper or waste receptacle close by for soiled dressings.
5. 1 Place soiled dressings in waste receptacle for burning.
6.1 Use pickups to handle sterile supplies.
6.2 Use gloves in badly infected cases.
7. 1 Cleanse the area surrounding the wound with 70% alcohol p1edgets.
7. 2 Place basin against patient to catch return flow.
8. 1 Fill asepto syringe with solution and insert tip into drainage tube if this is present or into wound itself.
8.2 Empty solutio'.:. LJ.to wound and allow it to return. Having patient turn toward side wilJ. facilitate drainage.

189

9. Dry wound carefully with Gte rile gauze or sponge s.
10. Apply sterile dressings.
11. Readjust bed linen and make patient comfortable.
12. Place contaminated instruments in towel used to drape patient.
13. Clean equipment and return to central supply.
14. Record on chart.

8.3 Repeat this step till return flow is clear.

9. 1 It is important to keep the wound dry and clean at all times, since moisture encourages growth of bacteria.

10.1

Amount of dressing necessary depends on the flow of drainage. When this is profuse some soft absorbent material will be better than sponge s.

11. 1 Remove bed protectors.

11. 2 Change linen if necessary.

12. 1 Soiled dressings should be burned.

12.2 Carryall articles used from room leaving unit tidy.

13. 1

Contaminated instruments should first be soaked in some disinfectant
solu~ion.

13.2 Wash well with soap and water and prepare for resterilization.

13.3 Spill drainage in sink for waste and flush with water.

14. 1 The time of treatment.

14. 2 Type and amount of solution.

14.3 Describe condition of wound and amount and type of drainage.

14.4 The type of redressing done.

190

RECT AL (COLONIC) IRRIGATION

PURPOSE:

1. To cleanse the colon of mucous, feces and toxic substance.

2. To stimulate peristalsis and relieve distention and flatulence.

3. To supply heat and fluid to the body in hemorrhage, shock or dehydration when other methods are impossible.

4. To supply heat for relief of pain in colon or nearby pelvic or abdominal organs.

PRINCIPLES:

1. The rate of flow of fluid into the colon is determined by the elevation of the container above the level of the rectum and by the caliber of the tubing.

2. The mucous membrane lining the rectum and colon possesses the ability to absorb fluids.

3. The solution introduced into the rectum may have bacteriolytic, therapeutic and stimulating effects.

4. The rectum slants upward toward the left and is 5 - 8 inches in length.

5. This treatment is time consuming and may prove exhausting to the patient, therefore, every means to conserve his strength should be used.

EQUIPMENT:

Irrigating can with tubing and glass "Y" connection
Two rectal tubes (if two-tube method is used, an extra length of tubing is necessary for return flow)

Two clamps Lubricant Asepto syringe Standard

Tissue

Pail for return flow

Containers with total amount of solution which may be normal saline and tap v:J.ter
191

Rubber protector and cover
Sodium bicarbonate 1-2% or/and other solution specified by the physician.

PROCEDURE:

Steps

Key Points

1. Preliminary preparations.

1. 1 1 patient's bowels have not moved recently, a thorough cleansing enema should be given as large fecal particles will clog the drainage tube.

1.2 Irrigation should be delayed about 30 minute s as stimulation of the defecation reflex by the enema will interfere with the success of the irrigation.

1. 3 Have patient empty bladder.

2. Assemble necessary requisites at bedside.

2. 1 All of the solution to be used should not be heated at the same time as the solution will become cold.

2.2 Check to see that all articles necess2.ry are near at hand before beginning.

3. Explain procedure to patient and set up equipment.

3. 1 Patient should be cautioned against trying to expel fluid.
3.2 Insure privacy by screen or sign on door.

3. 3 Hang irrigating can on standard and allow solution to run through tubing to expel air. Clamp tubing.

3.4 Cover a stool with newspaper and set pail for outflow on it.

4. Place patient in position and drape.

4. 1 Have patient slide to edge of bed and place rubber protector and cover under buttocks.

4.2 192

Bed should be level and patient may lie on left side with knees flexed or
in dorsal recumbent position. The
latter is usually more comfortable. The important thing is to have the abdomen relaxed.

5. Insert rectal tube.

4.3 Have patient adequately covered with light blanket; only expose area about anus.
5. 1 Separate buttocks to expose anus to avoid trauma, especially if patient has hemorroids.
5.2 Have tube well lubricated.

6. Unclamp supply tube to allow solution to enter colon.
7. Clamp supply tube to allow solutoin to return into pail.

5.3 Be very gently, inserting 3 to 5 inches, forward and to the left.
6. 1 Let about 500 .cc. solution flow in at
rate of 100 cc. per minute unless patient cannot tolerate this amount.
7. 1 If outflow tube becomes clogged, use asepto syringe to reopen it.
7. 2 Speed of outflow can be increased by lowering pail.

8. Alternate in and outflow until irrigation is completed.

8. 1 The directions of the physician and the condition of the patient determine the amount of fluid to be used.

8.2 The ideal method is to continue until the return flow is clear but this is usually too exilausting for the patient in one treatment.
8.3 If not specified, about 4000 cc. IS the usual amount used.
8.4 When the irrigation is finis'hed allow the rectal tube to remain in place until all drainage has ceased.

9. Clamp tube and remove gently and quickly.
10. Cleanse patient and leave him comfortable and warm.

10. 1 The treatment may last an hour so the patient is usually tired.
10.2 Change any soiled or damp linen.
10.3 Do not serve food immediately after.

193

11. Establish order in unit.
12. Cleanse and replace equipment.
13. Record on chart.

11. 1 Remove all utensils used.
11.2 Note character and amount of return flow and discard.
12. 1 Wash all utensils thoroughly with soap and water and return to Central Supply.

194

COLOSTOMY IRRIGATION

PURPOSE:

1. To establish a more regular habit time for evacuation and thus reduce the number of redressings and lessen the odor.

2. To soften and remove impacted fecal matter.

3. To cleanse bowel in preparation for operation as closure of temporary colostomy.

PRINCIPLES:

1. Daily cleansing of colon prevents odor and embarrassment to patient.

2. Position of patient will facilitate drainage.

3. Mineral oil does not combine with gastric juices.

4. Vaseline prevents irritation and erosion of the skin which the constant presence of fecal matter may occasion.

5. The more the patient can be taught to do for himself the more normal can be his attitude in the acceptance of his condition.

EQUIPMENT:

Funnel connected to #18 or # 20 French Catheter
Pitcher with solution -tap water or saline

Paper to receive soiled dressings Receptacle for return flow

PROCEDURE:

Steps

Key Points

1. Screen patient and explain procedure.

1. 1 Teach the patient how to do the procedure.

2. Assemble equipment and prepare patient.

2. 1 Place patient in recumbent position. 2.2 Fold back covers to expose area.

195

3. Insert catheter about 2" into opening, after expelling air.
4. Pour solution into funnel and allow it to run into bowel.
5. Gently remove catheter when all drainage stops.
6. Cleanse area around colostomy.
7 . Make patient comfortable and tidy unit.
8. Clean and replace utensils, return to Central Supply.
9. Record on chart.

3. 1 Lubricate and insert gently.
3.2 Catheter may go in farther if ordered by physician.
4. 1 Use as much fluid as patient can tolerate then invert funnel and allow fluid. to return.
4.2 Turning patient on side according to position of opening will facilitate drainage.
4. 3 Repeat procedure until return is clear.
4.4 Sometimes results are obtained with patient in sitting position.
4.5 Massaging of the abdomen along the course of the bowel may help drainage.
6.1 Use mild soap and water. 6.2 Apply vaseline gauze, mineral oil or
other ointment prescribed by physician. 6.3 Cover with dry dressings or colostomy bag. 6.4 Use montgomery strips or binder to hold dressings in place.
8. 1 Burn soiled dressings.
9. 1 Time of treatment. Solution and amount used. Results and effect on patient.

196

CATHETERIZATION - FOLLOWED BY BLADDER IRRIGATION

PURPOSE: 1. To empty bladder and/ or relieve distension.

2. To relieve inflammation and pain.

3. To deodorize and disinfect.

PRINCIPLES:

1. Warm solution in contact with the bladder wall stimulates its circulation and aids the processes of repair.

2. Fluid introduced into a closed cavity exerts equal pres sure in all directions.

3. Strict aseptic technique lessens the danger of introducing bacteria into the bladder.

4. The normal capacity of the urinary bladder is about 12 ounce s.

5. The bladder is capable of considerable stretching.

6. The female urethra is about 1 1/2" in length.

7. Lubrication of the catheter reduces friction.

EQUIPMENT: Sterile pack

:F oric Acid 2%

Catheterization tray plus the following artide s :
Glass connecting tube
Rubber tubing and funnel
Medicine glas s
500 cc. graduate
Solution for irrigation which may be:

Acriflavine 1: 10, 000 Pot<tssium permanganatel: la, 000 Sterile glove s Rubber sheet and cover 1000 cc. graduate 1 fanfolded towel 1 asepto syringe

Normal saline

1 medicine glas s

Tray (l4"'x 8" x 11/2")

197

PROCEDURE: Steps
1. Obtain tray from central supply.
2. Wash the hands thoroughly. 3. Assemble requisites at
bed side. 4. Insure privacy and explain
procedure to patient.
S. Protect the bed and drape the patient.
6. Begin procedure.
7. Catheterize patient.

Key Points
1. 1 Prevent contamination.
1.2 Temperature of solution should be about l050 F.
3. 1 Place articles in convenient positions.
4. 1 Screen patient.
4.2 Cooperation of the patient will insure the best results.
4.3 If medication is to be instilled at end of procedure patient is to be instructed to retain medication as long as possible.
5. 1 Place the rubber sheet and cover under the patient.
5. 2 Fan bed linen to foot of bed and drape patient with sterile section sheet.
6.1 Wash hands. See Surgical Scurb.
6.2 Saturate a cotton pledget with antisceptic solution and cleanse vulva with a downward stroke and discard in waste basin.
7. 1 Lubricate catheter and insert into urethra gently and cautiously so as not to traumatize meatus.
7. 2 Allow catheter to remain in bladder.
7. 3 Empty the urine from the emesis basin to the sterile grad~ate to determine amount obtained.

198

8. Proceed with irrigation.
9. Repeat the procedure. 10. Instill medication for
retention. 11. Remove catheter and care
for patient and equipment.
12. Record on chart.

8. 1 Attach the catheter to the glas s connecting tube.
8.2 Hold the funnel at an angle; pour into it about 120 cc. of solution and allow it to run into the bladder.
8. 3 Invert the funnel and allow the solution to return into the emesis basin.
9. 1 The foregoing is repeated until the
return flow is clear or the specified amount of solution is given. The small emesis basin may have to be emptied into the sterile graduate several times before treatment is finished.
10. 1 The sterile medicine glass included on the tray is used for the medication.

10.2

The bladder is first allowed to empty itself of all the irrigating solution before the instillation is made.

11. 1

Catheter is removed gentlv and cautiously so as not to lose medication
or traumatize patient.

11. 2

Dry the external genitalia with sterile cotton pledget using one downward stroke.

11. 3

Bed protector s should be removed and bed linen rearranged for comfort of patient.

11. 4

Article s ar e to be thor oughly cleaned with soap and water and returned to Central Supply. Tray is to be resterilized.

12. 1 Time of treatment and amount of urine obtained by catheterization.

12.2 Type and amount ofirrigating solution.

12.3 12.4 199

Character of return flow. Effect on patient.

ENEMA CLEANSING OR EVACUATING

EXPLANATION AND PURPOSE:

The cleansing enema is usually given to stimulate evacuation, relieve flatulence and distention and render the patient more comfortable. Hard fecal matter (body waste) is softened by means of fluid which also inflates the colon and acts as an irritant.

PRINCIPLES:

The amount of fluid given Ll an enema should be determined by the physician as quantities vary from 500 cc. to 2000 cc. (the proctologist advises a maximum of 500 cc. for an enema.)

The temperature is general use is lOSoF. to llOoF. Fluid over 110oF. may injure the mucous membrane of the rectum.

Fluids should be administered under low pressure (hold enema can even with patient's hips). The rectal tube should be inserted inL) rectum 3 to 4 inches at a maximum. The position in which enema is given makes little difference.

A patient in the lateral position with knees flexed has greater abdominal relaxation and consequently less pressure against the flow of fluid.

The administration should supply sterile rectal-tubes and other necessary equipment. Dispensable rectal tubes are suggested for use.

EQUIPMENT:

Sterile velvet - eyed catheter no. 22 - 24 French
Sterile irrigating can or pitcher and funnel

Clamp and tubing Glass connecting tube Lubricant on tissue

Standard

Tray or basin

Solution ordered by physician

Tray cover

200

PROCEDURE: Steps
1. Preparation of patient.
2. Obtain emena set from central supply room.
3. Prepare fluid. 4. Proceed with treatment.
5. Allow patient to relax and become accustomed to feel of catheter.
6. Proceed with treatment.

Key Points 1.1 Since an enema is usually an uncom-
fortable treatment, the cooperation of the patient is secured. 1.2 The purpose and the procedure should be explained to the patient before treatment is begun. 1.3 Replace bedding with a treatment blanket. 1.4 Place protector on bottom sheet and screen patient to insure privacy.
3. 1 Check temperature and quantity. Allow for loss of heat.
3.2 Remove soap suds if soap is used. 4.1 Place tray on patient's bedside table. 4.2 Place patient in position comfortable
to him, on bedpan if necessary. 4.3 Lubricate end of catheter. 4.4 Expel air from catheter. 4.5 Have patient breathe deeply. Separate
buttocks and insert catheter 3 to 4 inches.
6. 1 Allow fluid to pass very slowly. into rectum. This will prevent paL.",:".

201

7. Do not leave patient alone for a long period of time.
8. Remove bed:pan.
t
9. Empty and clean bedpan.
10. Cleanse rectal area.
11. Remove and clean enema tray.

7. 1 Fainting as a result of an enema is not unusual. The enema tends to exhaust the patient.

8. 1 Remove bedpan, cleaning rectal area with tissue both before and after removal of pan) .

9. 1 Place in bedside table.

10. 1 Bathe buttock with warm soap and water.

10.2 Remove bed protector.

10.3 Replace bed clothes and remove treatment blanket.

10.4 Make patient comfortable.

11. 1

Remove all equipment to work ror-m. Clean tray and catheter with warm soap and water.

11. 2 Send to Ce'.'ltral Supply room for resterilization.

202

MEDICATED RETENTION ENEMAS EXP LANATION AND PURPOSE:
Medicated enemas are injections of small amounts of medicated fluids into the rectum. The medication is prescribed for the local effect upon the affected area. The medications are usually oils, salts, anthelmintics emollients and astrigents.
Medicated enemata that contain irritating solutions are usually syphoned off and followed by a cleansing enema.
Some medicated enemas are administered by the physician or anesthetist.
203

DRAINAGE OF STOMACH BY SUCTION

EXPLANATION AND PURPOSE:
\
In cases of intestinal obstruction,the constant removal of gas and liquid from the patient's stomach and intestinal tract by suction - siphon reduces flatus, vomiting and pain rendering the patient more comfortable.

PRINCIPLES:

Nausea and vomiting can be avoided if gas and fluids are suctioned from stomach and intestinal tract.

The suction - siphon exerts a negative pressure thereby causing a vacuum which is necessary for successful suction drainage; 2 feet 6 inches has been found to be a satisfactory distance between the second bottle and the end of the stomach tube. The pressure is increased as distance is increased between these two points.

EQUIPMENT (for two bottle suction):

Wangensteen tube with weighted tip

Lubricant or ice

Lavine tube or Miller - Abbott tube with perforated sides
2 - 4 liter calibrated bottles Rubber tubing Irrigating stand Clamp

Y connecting tube Flask of solution for irrigating tube Paper bag for waste Protector and treatment towels Rubber apron for physician

Syringe 50 cc.

PROCEDURE:

Steps

Key Points

1. The physician is usually responsible for explaining the necessity fo the suctionsiphon to patient. The nurse may explain treatment on doctor I s order s .

1. I Ascertain type of tUl-Ll"; physician wishes to use (mercury for MillerAbbot tube should be kept in Central Supply).

204

2. Obtain equipment (suctionsiphon) from Central Storage.

3. Obtain lavage tray from Central Supply.

4. Place Wangensteen or Levin tubing in ice.

4. I If tubing is ice cold it is easier for patient to swallow.

5. Proceed with treatment as described under Gastric Lavage.

6. Take all equipment to patient's room.

6. I Reassure the patient as this is an uncomfortable treatment.

7. Allow water from upper bottle to run into lower bottle to establish suction. Clamp. Uper bottle should contain 4000 cc. ; lower bottle 400 cc.

7. 2 Unclamp the stomach tube and allow the contents to suction back.

8. Attend to patient's comfort.

8. I The patient may move for comfort without dislodging tube.

8.2 Patient may have chewing gum or lemon slices to reduce phlegm caused by tubing.

9. Record the following.

8. 3 Water may be given by mouth up to 2000 cc. daily.
9. I Time suction was begun and ended.
9.2 Amount of fluid received daily.
9. 3 Amount of fluid and gas aspirated from intestines and stomach.

10. Remove tube.

10. I

Remove Wangensteen tube. Clean with soap and water and return to Central Supply.

10.2 Empty, wash and replace fluid in calibrated bottles.

NOTE: There are other methods of suction siphonage. The electric siphoR is easier to use and t~_Jes.ommended:.

205

ADMINISTRATION OF MEDICATIONS

EXP LANATION AND PURPOSE:

Some medicine such as the vitamins are given to promote health by supplying deficiencies so the body can resist infections. Vaccines are used to prevent infection by assisting the body to develop resistance Drugs are used to combat the progress of disease and to relieve pain and discomfort caused by disease. Drugs are used as stimulants.

PRINCIP LES:

It is the physician who prescribes in writing the medicine, dosage and .method of administration. The responsibility for administration of medications falls upon the graduate nurse who understands the drug, dosage action, method of administration and danger involved.

Knowledge of materia medica, along with knowledge and experience of patients I reaction to prescribed drugs, is essential for safe administration of all medication.

Some drugs have a cumulativ~ effect due to slow excret'ory proces ses. All orders for medicine should be written and signed by the physician. The nurse also signs her name after the dose has been administered to the patient.

The nursing team needs to know within what frame'vork they can function in answering patient's questions relating to medicatiU.i.ls ::~-.e patients are taking. Medications, particularly hypnotics and narcotics, should be in locked cupboards. All medications must be clearly and distinctly labeled by pharmacist only.

Factors Modifying Dosage and Effect of Drug

Age

"'(oung's rule (adult dose x age)

age +- 12

Sex

Adult dose is determined by sex and

weight.

Previous toleration

Drug or alcohol addiction would determine dosage.

Idiosyncrasy and susceptibility

Some drugs even in small quantities produce toxic symptoms in some patients.

Temperament

Easily excited people are more susceptible to drugs

206

Occupation Condition of patient For:m of :medication Object of :medication Type of ad:ministration

Sedentary occupations render persons :more susceptible to drugs.
Patients who have difficulty in breathing should receive s:mall doses of nG'-rcotics. In shock and collapse patients receive larger doses of a sti:mulant.
Liquid and powdered :medications are :more quickly absorbed than pills or tablets. All :medicine should be given with sufficient water
A :medication can be given in large doses to get one effect and s:mall doses to obtain another effect.
Medications can be given by :mouth, subcutaneously, intra:muscularly, intrader:mally, intl'::.venoulsy, by inunction, inhalation and rectally, by infusion and transfusion.

207

INJECTIONS

EXPLANATION AND PURPOSE:
Injections are given when immediate effect of a drug is required. For example; infusions are given when large quantities of fluid are required as for dehydration.
PRINCIPLES:
All equipment, including solution used in treatment, should be sterilized by live steam (free of spore-forming organisms).
Sterile commercial ampules and flasks of medicine are the most reliable solutions
Colorless 70% alcohol is possibly the safest skin preparation. Soap and water can be used. Drug should be given slowly to favor absorption. Needles used for all injections should be exposed to live steam by autoclave. Needles should be sharp to give maximum performance and minimum pain. Careful selection of the site of injection should be made to obtain the best results for the patient.
Solutions should be slightly higher than body temperature to prevent tissue destruc~ion. Drugs such as penicillin and streptomycin are exceptions. A pint of solution should take from 30 minutes to one hour to absorb.
The technique of injecting needles depends on the area into which the solution is given.
HypertoJlic glucose and saline solution help maintain intracranial and intervascular pressure.

HYPODERMIC OR SUBCUTANEOUS INJECTION

EQUIPMENT:

Tray contains:

Syringe 2 cc. , 5 cc. or 10 cc.

Sterile sponges in alcohol,70%

Medication to be used

Sterile sponges, dry

Fine needles for thin liquids
Short heavy needles for heavy liquids

Sterile glas s or metal container
Needles 1- 1 1/2 inches in length (gauge 1922) for arms and thighs or thin buttocks.

208

PROCEDURE: Steps
1. Prepare the hypodermic (the nurse who gives the hypodermic should prepare it).
2. Take equipment to bedside on small tray.
3. Expose part of body for injection.
4. Cleanse area.
5. Allow air to enter barrel of syringe.
6. Expel all air from syringe. 7. Give injection.

Key Points
2. 1 Explain to patient's satisfaction the procedure.
3. 1 If buttock is to be the site of injection, turn patient prone, his head to side, his knees bent.
3.2 Expose only hip and buttock. 4. 1 With alcohol sponge cleanse area
about 3 inches in diameter (the angle of the upper outer quadrant). 5. 1 This allows for diffusion of the drug.
7. 1 Flatten and fix the tissue of the upper outer quadrant of the buttock with one hand.
7.2 Thrust the needle 1/2 of desired depth.
7.3 Pull piston gently outward and try to aspirate.
7.4 If blood appears the needle is withdrawn.
7.5 If blood is not aspirated the medication is injected slowly into the muscle.
7.6 Massage gently after withdrawal of needle.

209

8. Alternate between the two buttocks if injections are repeated.
9. Report immediately if needle breaks and is not recovered by nurse.
10. A dressing is not necessary. 11. To relieve pain.
12. Technical errors may cause sciatica.
13. Induration, nodules.
14. Abscess.

11. l Apply hot moist applications of mag-
nesium sulphate on doctor's order.

11. 2 Massage.

11. 3 Patient moving about after injection.

12.1

An injection too deep and too near the sacral plexus will cause pain in the sciatic nerve.

13.1

Nodules and induration do develop and can be relieved by trauma to the part so that absorption can take place.

14.1

Abscess formation is rare if the hypodermic is sterile and treatment properly performed.

210

HYPODERMOCLYSIS OR SUBCUTANEOUS INFUSION

EXPLANATION AND PURPOSE:

When the patient is unable to take sufficient amounts of fluid by mouth, fluids are introduced'into the tissue by means of a needle to rapidly replace body fluids.

PRINCIPLES:

Adequate amounts of fluid, sodium, chloride (salt) and glucose are necessary to maintain life, and if lost must be replaced as soon as possible.

EQUIPMENT:

Flask of sterile solution

Standard

6 feet sterile rubber tubing or disposable tubing, usually 3/16 inches in diameter.

Clean-up tray Bed protector

Glass Y -- 14 inches from end of rubber tubing.
Adaptor

Spring clamp or old hemostat
Needles 19-22 gauge, 2 inches long Moderately long bevel.

Screw clamp

Drip bulb

PROCEDURE:

Key Points

1. Obtain infusion set and clean-up tray from Central Supply.

2. Prepare the patient.

2.1 If patient is not too ill explain the procedure to prevent undue excitement. The patient fears pain but may also as sociate the treatment with being dangerously ill.

3. Make patient comfortable; choose sight of injection.

3. 1 Place patient in comfortable position. 3. 2 Relieve strain on all parts of the body.

211

4. Clear space for treatment tray if treatment cart is not available.
5. Set up equipment for us e (this is a sterile procedure).
6. Policy of hospital.
7. Rate of flow. 8. Observe patient.

3.3 Fold bed covers back to sight of injection.
3.4 Adjust treatment blanket over exposed part of body.
3.5 Protect bed and bed clothes with moisture-proof oiled silk. Cover with sterile treatment towel.
4. 1 Bedside tab~e is usually used for treatment tray and clean-up tray.
5.1 Wash hands, open tray.
5.2 Connect tubing with solution bottle.
5. 3 Hang on stand 3 feet above level of bed. Attach needle to end of tubing. Put needle through center of sterile gauze square 4 x 4.
5.4 Cleanse skin area with alcohol 70% (shave area if neces sary).
5. 5 Allow fluid to run through tubing and needle into curved basin to expel.the air.
6. 1 The puncture and adjustment of needle is done by physician or nurse depending on hospital policy.
6.2 When needle is in place and fluid rate adjusted, the needle is secured with adhesive strips.
7. 1 Rate is determined by physician (usually 1 pint takes 30 minutes to 1 hour).
8. 1 The patient should be carefully watched by nurse for signs of discomfort.

212

9. Remove needle. 10. Record treatment.

8.2 Tissue should be observed for absorption ability and prevention of distention.
8.3 Patient may be left with member of family provided nurse makes frequent observations of the treatment and the patient's reaction to it.
9. 1 When treatment has ended withdraw
needle quickly.
9.2 With a sterile gauze flat put pressure over puncture area and fasten with adhesive.
10. 1 Report patient's reaction to treatment.
10.2 Type fluid, amount absorbed and time involved to complete treatment.

213

ADMINISTRATION OF OXYGEN

EXP LANATION AND PURPOSE:

Oxygen therapy in any step taken to increase the content of oxygen in the air which the patient breathes.

PRINCIPLE:

Oxygen is beneficial to the body when tissue i~ receiving an inadequate supply. Disease or obstruction in respiratory passage or lung, causing anoxemia, will limit amount of oxygen entering lung.

The atmosphere contains 20.93% oxygen. The oxygen tent can, under proper conditions, raise oxygen content to 50% within tent, which is safe concentration. A mask or catheter does not do this.

Convalescence of major surgical operative cases may be hastened by adrninistratration of oxygen.

Oxygen supports combustion. Nylon or other synthetic uniforms and slips should not be worn in hospital due to the static electricity created.

Carbon dioxide is a respiratory stimulant.

The regulation of humidity (50%) is important in the administration of oxygen.

Nasal Catheter Technique

EQUIPMENT:

Rubber catheter

Oxygen regulator

Rubber tubing (5 feet)

Cylinder of oxygen (or oxygen outlet)

Metal adaptor

Lubricant

Cold water bottle (1/2 - 2/3 full of water)

10-12 French catheter, perforated with fine hole s for 1 1/2 inche s, for adult.

214

PROCEDURE: Steps
1. Prepare patient. 2. Bring equipment to
bedside and proceed with treatment.
3. Reinsert a fresh catheter every 3 or 4 hours.
4. Oxygen dosage.

Key Points
1. 1 Explain to patient the need for treatment if patient is not too ill.
2. 1 Lubricate catheter.
2.2 Introduce tube along floor of nasopharynx until it touches posterior wall.
2.3 Withdraw about 1/4 inch and fasten with adhesive to patient's cheek.
2. 4 Attach catheter to rubber tubing, water bottle and oxygen supply.
4. 1 To maintain 48% concentration, a flow of 6 to 8 liters a minute is required.
4.2 If 6 to 8 liters of concentrated oxygen is ordered, two nasal catheters should be used to reduce the irritation and the force of the flow. Connect catheters with Y glass connector to oxygen supply.
4.3 4 liters of oxygen give a concentration of about 41%.
4.4 6 liters of oxygen give a concentration of about 47%.

215

OXYGEN FACE MASK

EXPLANATION AND PURPOSE:

A mask may be used to administer oxygen. It is an inexpensive method and patients prefer it to the "closed-in feeling ll of an oxygen tent. It also makes nursing care easier. There are several types of oxygen masks.

EQUIPMENT:

Mask

Ejector

Perforated rubber tubing

Adaptor with 0.6 em. (1/4 inch) hose

Rubber tubing, 3/4 inch, 5 feet long

PROCEDURE:

Steps

Key Points

1. Prepare patient.

1. 1 Explain procedure to the patient if he is not too ill.

2. Take equipment to bedside and proceed with treatment.

2.1 Adjust mask over patient's mouth and nose. Fasten head band securely.

2.2 6 liters of oxygen produces concen-
tration of about 42%. 10 liters a cencentration of about 50%.

OXYGEN TENT

EXPLANATION AND PURPOSE:

To maintain the accepted 50% oxygen concentration and 50% humidity control the oxygen tent has been found to be the be st method.

EQUIPMENT:

Oxygen Tent (electrical or pressure type)

Canopy Oxygen tank

216

PRINCIP LES:

Regular analysis of the air in an oxygen tent should be made at periodic intervals.

Cold air is heavier than warm air, therefore the pressure type of oxygen administration is adequate and can be used and regulated.

Less oxygen is required when using the pressure cylinder method.

Transparent plastic tents are more satisfactory to the patient.

PROCEDURE:

Steps

Key Points

1. Obtain oxygen tent from Central Storage.

1. 1 Prepare patient for this treatment as most patients are very apprehensive under an oxygen tent (the patient is usually quite ill who is placed in an oxygen tent).

1. 2 Place a small cotton or wool blanket over patient's shoulders.

1.3 It may also be necessary to protect the patient's head from the draft within the tent.

2. Place patient in the tent.

2. 1 Allow oxygen to flow freely into tent when first placed over bed.

2. 2 Tuck canopy well under the mattre s s.

3. Motorless oxygen tent.

3. 1 6 - 10 liters will supply about 50% concentration.

4. Motor driven oxygen tents. 5. Temperature.

4.1 6 - 12 liters of oxygen are necessary to supply about 50% concentration.
5. 1 Usual temperature is 64.SoF. Infants and older people require higher temperatures.

6. Treatments.

6.1 Do not remove patient from tent for treatments of any kind.

217

VENOCLYSIS AND VENIPUNCTURE
EXPLANATION AND PURPOSE:
Intravenous adm.inistration of medication, fluids, food, plasmas and whole blood has become, in recent years, a major factor in reducing shock and death and in maintaining life. The techniques of venipuncture and venoclysis are relatively simple when the details of procedure are followed precisely. Attention to the mechanical skills involved, application of the scientific knowledge of the therapeutic use and action of drugs and fluids; appreciation of time, speed of injection and rate of flow, preparation of equipment and appreciation of the patients I anxieties and fears are primary factors for the operator to consider. A chemically'- pure substance and pyrogen-free distilled water is basically fundamental to safety. The commercially manufactured solutions are almost universally used in hospitals as the safest, most reliable and the most economical source of supply.
Solutions for intravenous use must be mixed by a professional pharmacist.
SOME PRINCIPLES:
1. Properly cleaned and sterile equipment reduces the incidence of pyrogenic reactions.
2. The proper treatment of rubber tubing used for intravenous purposes reduces the incidence of reaction.
3. Disposable rubber tubing is preferable to the permanent type tubing.
4. A sharp needle reduces the pain and discomfort associated with venipuncture.
5. Placement of the tourniquet between 1" and 1 1/2 11 above the site of injection anchors the vein and places it on tension so that the vein is more easily entered.
6. Except in emergencies, an injection given slowly, prevents "speed shock. "
7. Other principles of administration of medication are applicable to venoclysis.
EQUIPMENT:
1. Flask of solution
2. Tubing, rubber or plastic
218

3. Clamps

4. Air filter

5. Needle adaptor

6. Needle - - 20 gauge, I" or 1 1/2" long or Needle - - 26 gauge, 5/8" long

7. Alcohol

8. Cotton sponge

9. Tourniquet

1O. Standard

11. Arm board

12. 2 cc. syringe and needle

13. Disposable set

14. Twelve dry test tubes and dry sterile 10 cc. syringe is needed when blood is to be collected.

PROCEDURES:

Key Points

1. Secure sterile tray from Central Supply

1. 1 The skin preparation tray and standard may be a part of ward or division equipment.

1.2 Autoclaved tray of materials are always ready.

2. Read the order s.

2. 1 Read the physician's orders to ascertain kind, amount, rate of flow. Review the progress notes, diagnosis and reaction to previous injections.

3. Assemble materials at bedside and discus s the procedures with the patient.

3.1 Bring autoclaved tray and other equipment to the bedside.
3.2 Discuss the procedures with the patient if he is not too ill.

219

4. Set up apparatus. 5. Select the site for injection. 6. Apply the tourniquet.
7. Select method or technique.

3.3 Administer sedative if ordered and if patient is restless and apprehensive.
4. 1 Attach the tubing to the flask.
4.2 Suspend the flask of solution two or three feet above the bed level.
4.3 The adaptors are encased in a sterile packet or left on the tray lmtil time to attach the needle.
5. 1 All veins are suitable for injection.
5.2 The vein in the antecubital fossa is large and easily accessible.
5. 3 Have the arm down in dependent position to increase distention in the veins.
5.4 Locate the vein by placing the forefinger over the area and roll the vein.
6.1 An inflated pressure cuff is one of the most efficient means of applying constriction.
6.3 A soft rubber tube held by a hemostat is adequate.
6. 3 Tie the tourniquet not more than two inches above the site where the needle is to be inserted.
6.4 Have the patient "make a fist" several times to help full the vein.
6.5 Application of heat to the area will help dilate the deep seated vein. This application may make the difference between a cut-down and a simple procedure.
7.1 One of two methods may be used with equally good re suits.

220

7. 11 Separate syringe and needle.
7. 12 The closed technique.
8. Cleanse the skin. 9 . Make the puncture.

7. 2 Fill tubing with fluid and expel air between flask and adaptor.

7. III Attach 2 cc. syringe to the needle.

7. 112 Insert needle.

7.113 Release tourniquet.

7. 114 Detach syringe from needle and attach adaptor to needle.

7. 121 Bring pinch clamps near the needle.

7. 122 Fill tubing beyond the pinch clamp.

7. 123

Collapse the tube between clamp and needle by pinching it alternately with the left and right hand; this shows that lumen of needle is patent.

7. 124 Kink tubing back of needle by pressing thumb against the end of the needle.

7. 125

Insert needle. The negative pressure in the tubing allows blood from the vein to enter the tubing.

8. 1 Use 70% alcohol to cleanse site of injection.

9. 1 Stretch the skin at site of puncture and anchor vein with the left thumb.

9. 2 Select a point about 1/2" below site of intended puncture and hold syringe and needle at 45 degree angle and slowly introduce through the skin. This step places the needle through the skin only.

221

10. Start infusion.
11. Apply ann board.
12. Inject supplementary medication when ordered by the physician. Do Not Puncture Plastic Tubing.

9.3 Direct needle parallel to long axis of the vein allowing skin to move laterally.

9.4 Move skin back so that needle lies against side of vein.

9. 5 With slow even movement forward, push the needle into the vein. Lift the vein slightly to prevent the needle from piercing the posterior side of the vein.

9.6 When blood appears freely in syringe or tubing, advance the needle until it lies well within lumen of the vein.

9. 7 Release tourniquet.

9.8 Remove the syringe and connect the adaptor and tubing to the needle.

10.1

Adjust pinch clamps and allow solution to flow slowly according to the order of the physician.

10.2

Observe site of injection for signs of swelling. Swelling indicates that needle is in the tissue and not in the vein. Discontinue immediately,

10.3 Anchor the needle firmly in place with adhesive tape.

11. 1

Place padded arm board under the arm, if antecubital fossa is used. Tie a broad bandage about the wrist and above the elbow to prevent the arm from moving or dislodging the needle.

12. 1

The tubing apparatus is set up with a small strip of gum tubing next to the needle adaptor designed for the purpose.

222

13. Observe the patient. 14. Record. 15. Clean equipment.

12.2

Swab the tubing with alcohol or tincture of metaphen. Insert needle and inject the medication in the solution.

13.1

Stay with the patient if possible; otherwise, have a member of the family stay with him and make frequent visits to observe patient.

14. 1

Record time started, kind of infusion given, amount, rate of flow and operator.

15. 1 Rinse all equipment under cold running water immediately after use.

15.2 Check tubing for holes and stickiness.

15.3 Wash with detergent and rinse thor oughly.

15.4

Wash all materials with mild solution of sodium hydroxide or soda bicarbonate.

15.5 Thoroughly rinse with hot running water.

15.6 Rinse thoroughly with freshly distilled, pyrogen-free water.

15.7 Allow to dry by evaporation.

15.8 Assemble parts.

15.9 Check, wrap and label.

15.10 Autoclave at 15 lbs. pressure for 15 minutes.

REFERENCE: The technique here described is taken for the most part, from a pamphlet entitled "Parenteral Therapy from the Bulk Container", Abbott Laboratorie",, :Nortn Chicago, Illinois.

223

CENTRAL SUPPLY SERVICES PART VI Foreword
The nursing conunittee that developed the Central Supply section hopes that the Hospital Administrator and the professional Nurse Director will consider the establishment of a Central Supply Service as a means of improving direct nursing services to patients and as a business management procedure directed toward efficiency and economy. In those hospitals where Central Supply Services operate successfully. it has been found that all nursing procedures are made safer for patients and that the department is self- supporting as a result of centralization. Adequate professional nurse supervision of personnel. supplies and equipment is recommended for the operation of the department.
It is suggested that all supplies for the operating rooms, obstetrical department. and wards be included in Central Supply Service. A delivery and pickup service is essential to economic and efficient operation in a large hospital. A system of accounting and bookeeping with clerical personnel is also essential to effective operation in a large hospital.
The committee is indebted to Mr. Robert F. Whitaker and the Central Supply Department at Emory University for their help and cooperation in obtaining the excellent photographs for the manual.
Appreciation is expressed to Abbott Pharmaceutical Company, American Sterilizer Company, and Beck and Dickinson for their permission to quote from and reproduce selected illustrations from their commercial publications.
224

-""<
B ) Cl
~
Dispensing

Overhead Shelf

Work Table

/

o Water Still
Solution Room
~

Flask Washin Sink g

Work Room
~- --

---
Unsterile Storage

Cou~t~~ith~:Jnd
J ITruck under ry
L ______

. f
II)
-Receiving

Figure 5. An idealistic arrangeIl1ent of the central sterile supply, planned by the DepartIl1ent of Research of the AIl1erican Sterilizer COIl1pany. The iIl1portant feature of this layout is that it provides for a continuity of flow of Il1aterials through the departIl1ent which greatly facilitates the work, eliIl1inates confusion. It has been widely used as a guide in planning by both governIl1ent and civilian institutions. Courtesy of AIl1erican Sterilizer COIl1pany.

225

CENTRAL SUPPLY SERVICES
INTRODUCTION:
The central supply service is a unit within the hospital that takes responsibility for dispensing diagnostic trays; nursing procedure trays; dressing carts; special machines such as portable oxygen, suction, aspirating; or'thopedic cart; and other items. Certain solutions may be prepared, autoclaved, and disJ?ensed from the central supply unit.
The extent of service,:; available in the central supply unit differs in each hospital. The emergency clinic or the operating room is often expanded to include this function.
The manual committee expressed unanimous approval of the central supply service unit as a business method of dealing with problems relating to sterilization, trays, and portable equipment. It was felt that the central supply service unit was the keynote to efficient and economic service.
The listing of equipment necessary for diagnostic and nursing procedures is repeated in other sections of this manual. If the institution does not have a central supply, the nurse responsible for any procedure that requires a tray setup or special equipment should refer to this part of the manual for direction.
EXPLANATION AND PURPOSE:
The purpose of a central supply unit is to provide a centralized service for those departments that assist in the diagnosis and nursing care of patients. Such a department means assurance of true bacteriologically safe sterilization with an adequate supply of sterile products both of which aid in providing the safest care of the patient. The central supply services have the following advantages to the patient, the doctor, the nurse and the hospital:
1. Sterile supplies are available for immediate and constant use.
2. Personnel time is utilized to the best advantage.
3. Standards are based on scientific and sound practice.
4. Safer results are obtained for the patient.
5. Loss and breakage of material and equipment is reduced.
6. Amount of stocks in circulation is reduced to a minimum.
226

SOME PRINCIPLES APPLICABLE TO CENTRAL SUPPLY:
1. Qualified professional nurse supervision is an assurance of safe, economic practice in the operation of the central supply room.
,2. An adequate amount and quality of supplies and equipment is essential to effective operation.
3. Clerical and "runner" service saves professional time and effort.
4. The kind and amount of materials on treatment trays must be approved by the medical, surgical, administrative and nursing staffs of the hospital.
5. Established policies concerning distribution, collection and charging should be understood and respected by all hospital personnel to insure cooperation.
6. All trays leaving and returning to the central supply room must be complete as shown by a check list attached to the tray.
7. An accounting system and board showing where each item is located at all times is essential to effective service.
8. Cooperation of all persons concerned with supplies and equipment is essential to economy, efficiency, and insures good realtionships.
9. Correct folding, distirbution of materials and rolling of lap-packs are factors which favor penetration of steam and result in sterile packages.
1. PHYSICAL LAYOUT:
1. 1 To facilitate service, locate the central supply room as nearly equidistant as possible from all patient divisions and other units of the hospital served by this department.
1. 2 Divide the floor spece into general areas:
1. 2 1 Receiving and clean up area* 1. 22 Clean work area 1. 23 Sterilizing area 1. 24 Sterlie storage area
* Separate the clean work areas from the areas used for unclean equipment; this prevents possiblity of issuing material which has not been processed properly.
227

1. 25 Solution area ( if commercial intravenous solutions are purchased, this area is not necessary except for a small space to prepare external solutions).

1. 26

If unsterile items such as oxygen tents, orthopedic equipment and aspirating machines are dispensed from central supply, a separate area or preferably a separate room is needed for this type of equipment.

2. ORGANIZATION:

2. 1 A professional nurse in charge is essential to the centralized service to insure organization, administration and supervision of all services.

2.2 Practical nurses, nurses' aides, orderlies and/or maids perform all necessary duties in relation to cleaning, processing, sterilizing, receiving and dispensing supplies under superivision .

2.3 A bookkeeper or secretary for eight hours each day is an essential member of the team in a large hospital.

2.4 Number of personnel depends on the size of the hospital and its particular service s.

2.5 The operating room supervisor seems the best qualified to supervise service in hospitals of fifty beds or less.

3. ADMINISTRATION:

3. 1 Extend the service over a twenty-four hour period. If size of hospital does not warrant night personnel, make sufficient supplies available and accessible for night staff.

3.2 The central services prepares and sterilizes all packs, basins and gloves. Instruments for the delivery room and operating room may be autoclaved in central supply.

3.3 Establish a messenger service with regular schedules to serve all units requiring supplies. The following are functions of this messenger service:

3.31 Establish a ward standard for each department.

3.32 Collect used equipment and return to central service.

3.33 Deliver sterile goods to units.

3.4 Emergency items are supplied at any hour necessary.

228

3.5 An adequate ward standard supply list should be considered by ward and central supply personnel to conserve tim.e and energy.
4. STANDARDIZATION AND STERILIZATION:
4. 1 A standard procedure for the preparation and sterilization of all supplies is adapted and m.aintained.
4.2 The num.ber and size of autoclaves depend on the size of the hospital and service rendered.
4. 3 Mechanical controls are placed on autoclaves to avoid hurn.an error in the operation of the autoclaves and as a point of reference for supervision.
4.4 The rectangular autoc'lave is the m.ost econom.ical from. the standpoint of load capacity.
4.5 A hot aiT autoclave is used for all powder, vaseline gauze, oil preparations, needles and glassware.
4. 6 A standard length of tim.e is set for the sterilization of all goods, for exam.ple:
4. 61 Rubber goods - - 15 m.inutes
4.62 Solutions - - 30 m.inutes
4.53 Pack trays, and other item.s -- 30 m.inutes
REFERENCES: 1. Walter, Carl W., The Aseptic Treatm.ent of Wounds, New York: The MacMillan Com.pany, 1948, pg. 3"(2. 2. Am.erican Sterilizer Com.pany "More About the Central Supply, II The Surgical Supervisor, Novem.ber 1945, pp. 3-14. 3. Am.erican Sterilizer Com.pany, Practical Planning of the Central Supply Departm.ent, Erie, Pennsylvania, Am.erican Sterilizer Com.pany, 1950.
4. Am.erican Sterilizer Com.pany, "Precision Sterilization with 'Cyclom.atic' Control, II The Manual, Erie, Pennsylvania, Am.erican Sterilizer Com.pany, May 1950.
229

FOLDING, PACKING AND STERILIZING LINENS
EXPLANATION AND PURPOSE:
1. All linen used during an operation must be free from holes, worn spots, missing strings and defects which would render an operative area unsafe.
2. Maintain sterility with a minumum expenditure of time and effort by folding linens by a standard specific method (see "Aseptic Treatment of Wounds"-- Carl Walter).
PRINCIPLES:
1. The more directly a sterile article reaches the operative field the more certain one can be of its asepsis.
2. Limit size of package to ensure steam penetrating the center of a package. In packing linens, allow enough space between the folds for the steam to circulate throguh the layers of material. Rolling heavy material instead of folding facilitates the circulation of steam (ex: laparotomy sheets).
3. The members of the surgical team are best qualified to establish standards for the institution as to what is needed for specific operations.
4. Once a standard has been established, new employees and visiting surgeons should adopt themselves to the procedure.
5. The goods must be arranged in such a manner that the fir st things to be used will be on top of the pack.
6. Four thicknesses of unbleached muslin are the best known wrappers for
linens.
7. Linens folded according to a rigid standard procedure, help insure aseptic technique.
EQUIPMENT:
1. Surgical gowns (doctor's and nurse's)
2. Treatment towels
3. Sheets
4. Mayo covers 5. Special drapes with apertures in sleeves.
230

PROCEDURE: Steps
1. Operating room gowns.
2. Treatment towels.
3. Sheet. 4. Mayo cover.

Key Points
1. 1 The last fold should present the collar uppermost. Open completely.
1.2 Grasp the shoulder inside.
1. 3 Invert the garment and fold in half so that the sleeves hang loosely within the garment and the two loose sides are on the inside.
1. 4 Smooth the garment by pulling gently on the seams at the armhole and hemline.
1. 5 Fold in half again but allow the label to remain visible.
1. 6 Fold up from the bottom four times.
2. 1 Fold in half bringing both hemmed areas together.
2. Z Fold in half again as above.
2.3 Fold in half again in the opposite direction.
2.4 Turn back the corners in opposite directions.
3. 1 Fold in half if the sheet is not double thickne s s.
3.2 Place out flat and fanfold both sides to the center in approximately four folds (when fanfolding always turn the open end towards the center).
3.3 Fold up from the bottom four times.
4.1 Open out flat and cuff the lower open edge about 3".
231

5. Laparotom.y Sheet. 6. Perineal Sheet.
7. Packaging a laparotom.y bundle.

4. 2. Fanfold the cuff up about three tim.es.
4.3 Place one bath towel plus two treatm.ent towels even with the closed edge and pin directly beyond the folded cuff.
4.4 Fold the entire item. in half, half again, and then in. thirds the oppoiste way.
5. I The shorter end is for area of patient's chest.
5.2. Open the sheet out flat.
5.3 Fanfold the sides to the center.
5.4 Roll both upper and lower ends toward the center. Allow the hole and the pin to be exposed.
6. I Place the pin towards the long side to m.ark the area that will go toward the head.
6.2. Open the sheet out flat.
6.3 Fold the legs up neatly.
6.4 Fanfold the sides of the sheet in to the center.
6.5 Fold up from. both ends as a lap sheet allowing the hole and pin to be exposed.
7.1 Place a wooden trough (55 x 33 x 2.2. cm.) at one end of work table.
7.2. Place a length of awning cord (3 m.eters long with a loop knot in one end) in the bottom. of the trough. Allow free end to extend over the unused portion of table.
2.32.

7.3 Place the wrapper 160 cm long and 120 cm. wide (folded crosswise and interleaved pamphlet-wise to form four thicknesses) in the trough on top of the cord and covering the sides of the trough. The wrapper will serve as a sterile drape when the package is opened.
7. 31 Drape in the trough with folded edge away from operator and the shortest leaves uppermost.
7.32 Arrange in the trough so that the whole table is covered.
7.4 Place the supplies needed during the operation (sponges, abdominal pads, additional towels, final dressings) on the bottom layer .
7. 5 Place the laparotomy sheet (fanfolded and rolled) in the center of the second layer. (The laparotomy sheet is the key to sucessful sterilization. When properly folded, rolled and suitably located in the bundle, it provides channels for ready penetration of stearn to the center of the bundle).
7. 6 Place three folded gowns to the right of the laparotomy sheet.
7.7 Place the nurse's gown on top of the towels to the left of the laparotomy sheet.
7. 8 Place the skin towels, folded for draping, on top of the laparotomy sheet.
7.9 Bring the two uppermost halves of the wrapper across the top.
7. 10 Turn back a cuff.
233

8. Sterilizing dressing and packs.
9. Adequate sterilization of packs depends upon:

7. 11 Pull the folded edge of the wrapper toward the operator. Cuff the edge.
7. 12 Bring the outer halves of the wrapper over to finish the pack.
7.13 Fold in the end flaps as with a paper wrapped package.
7. 14 Pick up the two ends of the cord and cross in the center of the package.
7. 15 Insert the free end of cord through the loop.
7.16 Carry the cord about the package.
7. 17 Pull tight and tie in a single bow knot.
8. 1 Place in the autoclave without crowding.
8. 2 Displace air in the chamber with stearn.
8.3 Expose to saturated stearn at l20oC. , 15 pounds pressure for 30 minutes.
9. 1 Proper wrapping.
9.2 Proper placement in autocalve to allow for the penetration of stearn.
9.3 Exposure to live stearn for sufficient time to guarantee sterilization.
9. 4 Standardization of exposure to saturated stearn to eliminate confusion and to guarantee safety.

234

Cyclomatic Control
Safety Valve

Operating Valve

Vent to Atmosphere

Gasket on Door

~

//

//

Screened

Steam

Outlet

Jacket

------~ Steam Deflector
/
~Ck Valve

Control Handle for Pressure Regulator
By-Pass ---+-+-11 ~~ Valve

ShutOff Valve for Chamber Discharge
Pressure Regulator
Steam Strainer

Steam Supply Valve

Vacuum Drier
Condensate to Waste
V
6

Figure 6A. Longitudinal cross sections of a pressure sterilizer showing the source of steam, the flow of steam and the pressure regulator. All discharges empties into the vertical riser through an open air break waste. Reprinted by permission of American Sterilizer Company, Eri.e, Pennsylvania.
235

-
o
Figure 6B. DeIllonstrating the correct method of loading a sterilizer. Courtesy of AIllerican Sterilizer COIllpany, Erie, Pennsylvania, U. S. A.
236

Figure 7A. Demonstrating the folding of a small sheet and the correct folding of a corner. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
Figure 7B. Demonstrating the correct method of packaging by rolling. Reprint by Courtesy of American Sterilizer Company, Erie Pennsylvania.
"
237

Figure 7C. Demonstrating the correct method of the folding and rolling linen. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
Figure 7D. Demonstrating a method of packaging metal equipment for sterilization. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
238

STERILIZATION BY AUTOCLAVE
EXPLANATION AND PURPOSE:
Saturated steam under pressure has become the universal method for sterilizing materials used in surgical asepsis. Although the initial cost for having enough needles, syringes, instruments and trays may seem great, the savings in terms of safety to patients and economy of personnel offsets the cost. The great convenience of having what you want, when you want it and how you want it, with the assurance that the materials have been properly cleaned, inspected and adequately sterilized creates confidence and good working relationships within the institution.
PRINCIPLES:
1. Qualified personnel in charge of sterilization procedures is a good insurance against,error in sterilization; reduces repair on autoclaves; and adds to efficiency in each working unit.
2. By autoclaving the bulk of material during the late evening and night, the institution gains maximum use of materials.
3. Saturated steam under pressure is a physical entity with properties that can be measured readily, penetrates materials and kills resistant spores upon relatively short exposure.
4. The pressure of steam merely makes possible the raISIng of the temperature in the autoclave. The latent heat in the steam which is given off upon condensation and coagulation of protoplasm, are the factors which cause the quick death of very resistant organisms.
5. It is the temperature and not the pressure that produces the sterilization. Therefore, all air must be evacuated from the autoclave by leaving drain open until thermostatically regulated. Check thermometer.
6. Arrange packs and other articles so that air pockets cannot form to keep steam from penetrating every surface. This is essential to the sterilization process.
7. Sufficient time must be allowed but destructive oversterilization must be avoided.
8. Frequent testing should be done to check efficiency of sterilization.
9. Articles sterilized in autoclave should be dried before removal from
sterilizer.
239

10. All linens should be sprinkled before sterilization.

11. A too tightly packed load prevents penetration of steam.

12. Some substances, such as metallic materials and leather goods are injured by the heat and moisture. ,

13. Oils and powder are not penetrated by steam. The hot air sterilizer is used for this proces s.

EQUIPMENT:

Standard autoclave materials

PROCEDURE:

Steps

Key Points

1. Provide reliable personnel. Human error may negate sterilization even with the best and most reliable autoclave.

1.1 Employ permanent personnel whose primary interest and assignment is related to and concerned with sterilization.
1. 2 Train the person for the job.

1.3 Supervise and give guidance.

2. Determine contents of packages to be autoclaved.

2. 1 Separate the materials to be autoclaved into bundles, solutions and rubber goods.

3. Determine the period necessary to sterilize the largest package.

3. 1 Check the chart to confirm the amount of pressure and time required to sterilize.

4. Load the sterilizer.

4.1 Place the items in the sterilizer to provide a horizontal path for the steam to excape.

4.2 Do not pack or overload the chamber of the autoclave.

4.3 Remove the top from all covered containers and tilt on side.

240

5. Read the thermometer.
6. Measure the period of continuous exposure of steam.
7. Adjust the schedule to meet the needs.
8. Secure mechanical check at regular intervals.

5. 1
6. 1
7.1 7.2 7.3 8. 1 8. 2

The temperature of the fluid in the exhaust line indicates whether the air or steam occupies the lower portion of the sterilizer.

5. 11

Pressure of 775 mm. (mercury
gauge) causes the temperature in the exhaust line to rise to 121o C, when saturated steam
displaces the air and fills the chamber.

A period of thirty consecutive minutes provides for complete penetration of a standard load.

Correlate the quantity of work to be done with the personnel and equipment provided to do it.

Report kind and number of items autoclaved per person assigned to the duty.

Interpret strong and weak characteristics of the unit to the director of nursing service.

Have an engineer check the autoclave at planned intervals.

Keep clearly illustrated, instructions posted near the operating area.

9. Read the graph.

9. 1 Read each autoclave graph as indicated.

REFERENCE:

Walters, Carl W . "Aseptic Treatment of Wounds 11 --Chapter VIII

241

RELATIONSHIPS BETWEEN PRESSURE, AMOUNT OF AIR DISCHARGED AND TEMPERATURE IN USE OF AUTOCLAVE

PRESSURE

TEMPERATURE

Pure Steam

1/2 Air Discharges

No Air Discharges

SIbs.

109C

94C

72C

10 Ibs.

11SoC

10SoC

90C

IS Ibs.

121C

112C

100C

20 lbs.

126C

11 SoC
.

109C

Adopted by Laboratory Services, Communicable Disease Center, U. S. Public Health Service, Chamblee, Georgia, from table prepared by American Sterilizer Company.

242

STERILIZATION TIME TABLE
EXPLANATION AND PURPOSE: Research studies have established specified minimum limits on sterilizing
methods and agents for rendering materials free of nonspore-forming awl sporeforming bacteria. PRINCIPLES:
1. Prevention of infection is a first line of defense in surgical procedures. 2. Sterilization of all items that are used in surgical procedures is essential
to the prevention of infection. 3. Exposure to l2l oC. for thirty consecutive minutes destroys both vegetative
bacteria and spore s. 4. The steam pressure makes possible the ralslng of the temperature. A
pressure of twenty pounds of pure steam automatically raises the temperature to l26C. 121 0 C. requires 15 pounds pressure 126C. requires 20 pounds pressure l320 C. requires 27 pounds pressure EQUIPMENT: 1. Standard autoclave - - steam under pressure 2. Standard hot air oven 3. Chemicals - - germicides and disinfectants REFERENCE: Underwood, W. B., Textbook on Sterilization, American Sterilizer Company, Lakeside Press, R. R. Donnelley & Sons, Chicago.
243

STERILIZATION CHART
FOR PRESSURE STEAM (AUTOCLAVE) STERILIZATION:
The sterilizer should be carefully regulated so that the maximum temperature indicated by the thermometer falls within the range of 2500 - 2540 F. (121 0 - 1230 C.). Time the performance when the thermometer indicates 240 0 F. (1150 C.) in its advance toward the maximum of 250 0 - 2540 F.

ARTICLE
BRONCHOSCOPES BONE WAX BOUGIES BRUSHES CATHETERS
(Gum Elastic or Woven Silk Base) CELLOPHANE CYSTOSCOPES DIAPERS DRAINS (gutta-percha, Rubber) DRESSINGS Loosely packed ELECTRIC CORDS ETHER CONES GLASSWARE--Test Tubes, Petri Dishes, Etc. GLYCERINE

METHOD
Autoclave Hot Air Chemical only Autoclave Chemical only
Autoclave Chemical only Autoclave Autoclave
Autoclave Autoclave Autoclave
Hot Air Hot Air
244

TIME 10 minutes 60 minutes
10 minutes
30 minutes
30 minutes 15 minutes 30 minutes 10 minutes 10 minutes 60 minutes 60 minutes

FOR PRESSURE STEAM (AUTOCLAVE) STERILIZATION (CONTINUED)

ARTICLE

METHOD

TIME

HARD RUBBER DETAILS

Chemical only

INSTRUMENTS Routine Emergency Extreme Emergency Scapels and Scissors Cataract Knives Tenotomes Ur ethrotome s

Autoclave
Same as above Chemical only Chemical only Chemical only

10 minutes 5 minutes 3 minutes

INTRAVENOUS SETS

Autoclave

20 minutes

IODOFORM

Do not sterilize

IODOFORM DRAINAGE MATERIAL. Assemble previously sterilized parts under strict aseptic conditions, or purchase sterile.

JARS--ENAMELWARE

Autoclave

30 minutes

LAMBS WOOL

Autoclave

30 minutes

LAMPS, DIAGNOSTIC

Chemical only

MATERNITY PACKS

Autoclave

30 rninutes

MILLER-ABBOTT TUBES

Chemical only

NEBULIZERS

Chemical only

NEEDLES- -Suture and Hypodermic

Hot Air

OILS- - Various

Hot Air

OPERATING MOTORS--See Manufacturer's Specifications

60 minutes 60 minutes

PARAFFIN GAUZE

Hot Air

120 minutes

PLASTIC WARE--See Manufacturer's Specifications

245

STERILIZATION CHART
FOR HOT AIR STERILIZATION:
The sterilizer should be regulated, unless otherwise specified below, so that the temperature indicated by thr thermometer comes within the range of 31So 32SoF. (lSSO-16SoC.). Do not start to time the performance until the prescribed temperature is indicated by the thermometer.

ARTICLE

METHOD

PROCTOSCOPES

Chemical only

RUBBER GOODS Catheters Gloves Sheeting Tubing

Autoclave

SCALPEL BLADES

I Autoclave

Spares - -in Medicine Bottles

SIGMOIDOSCOPES

Chemical only

SOLUTIONS- -AQUEOUS 2000 ml. Erlenmeyer Flask (Pyrex) thin glass 2000 ml. Florence Flask (Pyrex) thin glas s 1800 ml. Fenwal Flask (Pyrex) thick glass 1000 ml. Erlenmeyer Flask (Pyrex) thin glass 1000 rnl. Fenwal Flask (Pyrex) thick glass SOO rnl. thin glass 2S0 ml. thin glas s 12S ml. thin glass 2-4 ounce bottles, thick glass Test Tubes, ISO x 18 mm.

Autoclave

TIME
20 minutes IS minutes 20 minutes 20 minutes 30 minutes
20 minutes 20 minutes 30 minutes IS minutes 20 minutes 12 minutes 10 minutes
8 minutes 10 minutes
8 minutes

246

FOR HOT AIR STERILIZATION (CONTINUED)

ARTICLE

METHOD

SULFA DRUGS--Powder (at 300o -3150 F. --150 oC. only) in solution- - sa:me as other solutions

Hot Air

SURGICAL PACKS--Major Packs Cotton-filled Dressing Co:mbines, Cotton Napkins, Cellulose Napkins, Gauze Sponges, etc.

Autoclave

SUTURES Non-Boilable Tubes Boilable Tubes Silk, Cotton, Linen, Nylon

Che:mical only Autoclave Autoclave

SYRINGES- - Unasse:mbled

Hot Air Autoclave

TALCUM POWDER

Hot Air

THERMOMETERS

Che:mical only

TONGUE DEPRESSORS

Autoclave

TRANSFUSION SETS

Autoclave

TRAYS--All kinds URETHRAL CATHETERS URETHROSCOPES UTENSILS VASELINE (petrolatu:m) VASELINIZED GAUZE

Autoclave Autoclave Che:mical only Autoclave Hot Air Hot Air

ZINC PEROXIDE

Hot Air

(Hold Te:mperature at 2800 F - -l350 C. ).

247

TIME 90 :minutes
30 :minutes
20-30 :minutes
10 :minutes 10 :minutes 60 :minutes 20 :minutes 120 :minutes
30 :minutes 20 :minutes 20 :minutes 10 :minutes
15 :minutes 120 :minutes 120 :minutes
4 hours

READY REFERENCE CHART
NEEDLE SHARPENING TECHNIQUE CARE OF HYPODERMIC NEEDLES
Copied by Permission of: Becton, Dickinson & Co. , Rutherford, N. J.
HOW IS A NEEDLE POINT REPAIRED?
1. Use a 4X magnifying glass to detect burrs, "fishhooks" and dull, broken, misshaped points. To remove burr from inside ed,ges use a pointed stylet, trocar, or discarded needle.
2. Use a hard smooth oil stone (Arkansas Stone). A light mineral oil on the stone hastens sharpening, gives a smoother finish.
3. To hold needle more rigidly attach to a small syringe. Use index finger of other hand for gentle pressure. Place the needle bevel flush on the stone at the proper angle (see chart illustrations) and sharpen by sliding forward and backward and also moving laterally across the stone to prevent wearing grooves in stone. In sharpening a needle with a fitted stylet keep stylet in place so that perfectly matched bevels are maintained.
HOW IS A NEEDLE CLEANED?
1. Flush with cold water immediately after use.
2. Insert sytlet or needle wire through 'needle to make sure there is no clogging of cannula. (Always insert wire through the hub--not from the point. )
3. Place in basin of water and green soap and wash thoroughly inside and out using syringe to flush the cannula. Clean inside of hub with a tightly wound cotton applicator.
4. To remove stains use a fine powdered or caked household abrasive cleanser, such as Bon Ami or similar product and rinse well. To remove dried blood soak in water to which a small amount of a detergent, such as HaemoSol or similar product, has been added.
On stainless steel needles, blood can often be removed by soaking in peroxide solution. If a solvent other than water seems necessary, use Stoddard solvent or a similar nontoxic petroleum distillate.
5. Flush needle with alcohol then ether. For a very quick drying a B-D Needle Drier may be used.
248

HOW IS A NEEDLE AUTOCLAVED?
1. Put cotton in botto:m of a test tube. Place needle in the tube point down. (A B-D Needle Steritube :may be used which does not require cotton to protect the point).
2. Cover :mouth of test tube with square of :muslin and secure with thread or rubber band.
3. Mark size of the needle on the :muslin for easy identification. 4. Sterilize for 10 to 20 :minutes at 15 to 17 pounds pressure at about 250oF.
unless specific instructions are. given for a particular autoclave.
HOW IS HOT AIR STERILIZATION USED?
Many hospitals prefer hot air sterilization because needles are always dry. Needles are prepared the sa:me as for autoclaving. Sterilize for one hour at 320oF. unless otherwise specified by the :manufacturer.
HOW IS A NEEDLE BOILED?
No needle should be boiled. Disease is transferred by boiled needles. Spores are not killed by this :method.
HOW IS THE SIZE OF A NEEDLE DETERMINED?
The size of a needle is governed by four factors: safety, rate of flow, co:rnfort of patient and depth of penetration. There are three standard di:mensions -length, outside dia:meter of the cannula and wall-thickness. Regular needles are :measured for length fro:m where the cannula joins the hub to the tip of the point (hub not included). Special needles that have a "head" or stop on the cannula (such as the B-D "Security") are :measured fro:m the "head' to the tip of the point.
The outside dia:meter or "gauge" of a needle is :measured by a Stubb's English wire gauge, standard throughout the U. S. The dia:meter sizes are indicated by gauge nu:rnbers running fro:m 13 to 27 with deci:mal equivalents in thousandths of an inch. The higger the gauge nu:rnber indicated, the s:maller the dia:meter of the needle. Gauge nu:mbers are sta:mped on the flat of the hub for ready reference.
249

HOW HYPODERMIC SYRINGES ARE MADE
INDIVIDUALLY HAND MADE
Glass syringes are fashioned by hand. An expert glass blower sits at the bench and with the aid of a hot gas lame, air pressure and forming tools, skillfully produces barrels, tips and plungers.
FROM SPECIAL TUBING
The tubing from which syringes are made is from a specially prepared glass formula to withstand constant use and sterilization. It is a hard, shockproof, alkali free glas s. The tubing must be accurately gauged to insure uniformity of internal and external diameters and wall thicknesses.
PRECISION GRINDING
The inside of the barrels and outside of the plungers have apr eliminary grinding to within a thousandth of an inch of correct size. Syringe tips are ground the proper depth, diameter and pitch to fit standard Luer slip needles.
PRECISION FITTING
Every syringe is individually fitted by hand. The plunger is covered with suitable abrasives, spun at proper speed in a lathe and the barrel gradually worked over the plunger until it fits throughout its entire length. It takes skill and experience to produce a smooth-fitting syringe free from jumping and backflow.
TESTING FOR LEAKAGE
Because every syringe is individually fitted by hand, they must be individually tested. By forcing water through the tip of the syringe at seventy pounds pressure, (pressure much greater than ever required in an injection) and by revolving the plunger while tr~veling throughout the entire length of the barrel, the syringe is severely tested for possible leakage or backflow.
TESTING FOR STRENGTH OF TIP
B-D syringe tips are tested at about forty pounds lateral pressure for strength of tip. This is an important item as over 500/0 of syringe breakage occurs at the tips.
250

PRECISION ANNEALING The intense heat used in fashioning the syringe parts produces internal glass
strains which if not removed will cause excessive breakage. The strains are removed in electrically controlled annealing ovens. By the use of the polariscope any strains are easily made visible and the quality of the syringe verified. CALIBRATING
Syringes must be individually calibrated so as to measure highly potent drugs without danger. Accuracy of delivery is checked with the use of graduates approved by the U. S. Bureau of Standards. Accuracy of scale readings are checked with the use of pipettes approved by the U. S. Bureau of Standards. BAKING SCALE
To give a more durable scale for accurate readings, the colored pigments are fused into the glass in an electrically controlled baking oven.
251

NEEDLE SHARPENING TECHNIQUE

l.- Fronl Open Bevel

I

Sid. View Hee'

Top View

REGULAR POINT 1

L Closed bevel---l
:egg8

Side View

Lumen

H.el

Top View

HUBER POINT 1

Remove outward fishhook on Regular Poinl
2
Remove inward fishhook on Regular Poinl and grind bevel
3

Remove oulward fishhook on Huber Poinl
2
,(
f
Remove inward fI.hhook on Huber Poinl and grind bevel

Nole double angle used for grinding side bevels

Note double angle used for grinding >ide bevels

In all cases the original bevels on the needle point should be maintained

Finished Regular Point ready for Ule again

Fini.hed Huber Poinl ready for use agoin

Figure 8. Needle point repair. Becton, Dickinson and Company, Rutherford, N. J'
252

Figure 9. A suggested method of packaging needles for sterilization. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
253

Figure 10. Needle Standardization Chart. Reprint by Courtesy of Becton, Dickinson and Company, Rutherford, N. J.
254

What are you doing to correa these
11 TYPES of SYRINGE BREAKAGE?

I

.,,I

I

I

I

\

.... ,.,*'

"

.~

1. Impact BreJk. Object dropped on syringe.

2. "Blow-out" Break. CJused by boiling unc1eJn pJrts together.

3. Break typical of improperly annealed glass.

4. Bottom blown out by releasing plunger with finger over tip.

r-'1

I



I



I



9. Tip broken by lateral pressure on poorly annealed or scored tip.

10. Tip broken by removing stuck needle by twisting.

11. Tip chipped by knocking against sterilizer, or other -obj ect.

5. Break caused by wedging plunger when inserting in bJrrel.

6. "Tip Crush" caused by wedging improperly fitting needle on tip.

7. Split Tip caused by clearing tip with too large needle or wire.

8. Tip broken by too great lateral pressure.

"DON'TS" Some important

for SYRINGE performance

Don't boil syringes. Don't wedge plunger into barrel at an angle.
Don't exert lateral pressure on glass syringe tips. Don't test compression by covering tip hole, pulling back plunger and suddenly releasing it. This will almost cer tainly knock out barrel base. Don't discard a '"jumpy" syringe - clean it.

Don't soak syringes in strong alkali solutions. Don't play with syringes - they are medical instruments.
Don't stack syringes with other metal equipment. Don't leave barrel and plunger intact after using ... until thoroughly clean and ready for sterilization. Don't leave needles attached to syringe tips unless thoroughly cleaned.

Figure 11. Reprinted by Courtesy of Becton, Dickinson and Company.

255

Tip micrometer

Tip-groove

Assembly numbers

Adjustable plunger holder

gauged

Tip-bevel

-~ ---- ()'III'II\III\IIII\IIII\IIII4IIIII\III16II1IIII18I1~IIB1IaI1,r0 crcel

UI _-I,
of

Precision line

Scales baked in

shock proof glass

'~
Plunger individually fitted

for accurate reading

out barrel opening

Metal Luet"-Loktip

Reinforced flange

~-~\

0' B-D YALE LU E R- LOK -j

b.J

r, "~ o'O--=-:J ~0 '-=::;:::::;:::::;:::==---

Needle locked
by '/2 turn -

.) Metal Luer tip/'

'( Extra strong tip

Large tip bore

B-D YALE SYRINGE CONSTRUCTION

connection

Figure 12 A. Courtesy of Becton, Dickinson and Company.

lumen

Regular Point

. e 'oe'le\ \

~ \

'\

I ~ e bevel I

~-4~---T-~-p--V-ie-;- Heel

\ _rf~ bo'l"e\ ~t~b-=~----S-id.e.V.i.ew..-_.0)

CS==" ~ Side View

"2
Lumen

t - _lC ~ "7:=-==-==-=:-=-::::::::::::::::::===:::::!1 Side b

L

~

_ . 'oe'le\ \

Heel

\ S',oe

<c:::>J, Point /

~Jr-,-:O= - > Funnel shaped joint.............
"" .:t_ .. n~

Gauge No.

Beveled ~ntrance
Luer slip

Hyperchrome

"- - - - -

stainless steel cannula

Hub -

~

Lok-flange

B-D YALE LUER-LOK NEEDLE CONSTRUCTION

Figure 12 B. Courtesy of Becton, Dickinson and Company.

256

HYPODERMIC SYRINGE CONSTRUCTION
HOW IS SYRINGE WEAR REDUCED? A syringe made of hard, alkali-free glass resists excessive wear and the
erosive action of boiling water. Expert hand grinding and fitting of barrel and plunger using very fine grinding powder produces smooth, uniform surfaces, free from the irregularities that cause rapid wear and premature leakage.
HOW IS SYRINGE BREAKAGE REDUCED? A syringe tip accurately gauged and with a "tip bevel" and "tip groove"
reduces breakage. The B-D Yale Luer-Lock Syringe has a glass tip connection many times stronger than the barrel itself, reinforced by a permanently attached metal Lok-tip that practically eliminates accidental tip breakage. (See illustration.)
A syringe with a reinforced barrel base, flared out barrel openin?;, reinforced finger rest flat on two sideo and an adjustable metal plunger holder, numbered barrel and plunger reduces breakage and accidents. (See illustra.tion.)
HOW IS STERILIZATION BREAKAGE REDUCED? Syringes made of shock-proof and precision-annealed glass reduce sterili-
zation breakage.
WHAT PREVENTS NEEDLES JUMPING OFF? The metal Lock-tip on the B-D Yale Luer-Lock Syringe securely locks all B-D
standard Luer slip needles to the syringe tip by a simple half-turn.
HOW ARE NEEDLE ADAPTERS ELIMINATED FOR THE LARGER SYRINGES? The B-DYale Luer-Lock Syringe tips are the same on all sizes. No reducing
adapters are necessary for the larger syringes.
HOW ARE HEAVY FLUIDS MORE READILY INJECTED OR ASPIRATED? The bore of the tip on the B-D Yale Luer-Lock Syringe is equal in diamete r to
the largest needle commonly used with each size of syringe. This facilitates easier flow and reduces the possibility of clogging.
257

WHA T F ACILITATES ACCURATE DOSAGE? Syringes should be individually calibrated and certified for accurate dosage--
have scale markings baked into the glass and a precision line on the base of the plunger for easier reading.
WHAT INCREASES ECONOMY IN USE? By selecting syringes of the highest quality in materials and design.

CARE OF HYPODERMIC SYRINGES

HOW IS A STUCK NEEDLE REMOVED?
1. Grasp the square part of the needle hub firmly in a pair of pliers or with forceps. Never grasp the round part of hub.
2. Hold the pliers of forceps firmly, and rotate the syringe, not the forceps, counter-clockwise.

HOW ARE STAINS AND DEPOSITS REMOVED?

1. For alkali deposits use 10% sol. nitric acid.

2. For arsenic and iron stains use 10% sol. hydrochloric acid.

3. For gentian violet use 10% sol. nitric acid.

4. For Blood stains use 10% sol. nitric acid, sodium citrate or concentrated ammonia.

In above cases, swab carefully with cotton applicator dipped in the solution. Rinse thoroughly after each swabbing.

CAUTION:

Care must be used when using any acid solution with B-D Yale LuerLock Syringes or any syringes with metal parts. Do not let the solution corne in contact with any of the metal parts, not even the lumen of the metal tip. Never leave a glass syringe immersed in strong acids or alkalis. Syringes with metal parts should never be left immersed in solutions containing mercury or any of its derivatives.

258

HOW IS A STUCK SYRINGE SEPARATED? The use of the B-D Syringe Opener No. 26 saves much time and breakage.
This is an all metal syringe with a female Luer slip. Proceed as follows: 1. Fill air space of stuck syringe with warm water. (If you wish, this may be done with the syringe opener by attaching a No. LL/SL adaptor and needle, and injecting through the tip of the stuck syringe. ) 2. Fill the syringe opener with warm water. Attach it firmly to the tip of the stuck syringe, holding the syringe at the barrel base when doing so. Apply gentle, steady pressure, gradually increasing the pressure until water seeps around the plunger and reaches the top of the barrel. Do not grasp the stuck syringe, but let it hang free. Keep the pressure steady, and the plunger will gradually be expelled from the barrel of the stuck syringe. Avoid expulsive force. A bunched towel beneath syringe will prevent breakage if syringe jumps off. Other methods have been tried in the past to separate stuck parts but their success has not been uniform. These include: (1) Boiling the syringe in a 25% aqueous solution of glycerine, removing plunger while hot. (2) Place the syringe in ice water for five minutes and then immerse IIp to the flange in hot water for a few seconds, then quickly remove the contracted plunger from the expanded barrel.
259

HYPODERMIC NEEDLE CONSTRUCTION
HOW IS NEEDLE EROSION ELIMINA TED? This is only possible by selecting tested stainless steel of the highest quality.
Needles of "Hyperchrome" stainless steel are rustless throughout, resisting iodine, salts and most acids.
HOW IS NEEDLE BREAKAGE GREATLY REDUCED? This is done by selecting flexible steel and providing a special design of
needle hub. B-D Yale Needle Cannulae can be bent nearly double before breaking. The special funnel-shaped hub joint hinders breakage at the weakest point of the needle.
WHAT HINDERS JUMPING OFF, JAMMING, LEAKING, CLOGGING? Needles that have micrometer gauged Luer slips fit all standard gauge
syringes. The seamless cannula should be wire-reamed to insure a smooth unobstructed lumen. The" Lok" device locks the needle to the tip to prevent jumping off.
HQW ARE TRAUMA, PAIN AND SEEPAGE REDUCED? This depends on eliminating burrs and fishhooks, and on the design of needle
point. Needles must be carefully inspected. The points should have three bevels. The side bevels are foreshortened to dilate the tissue and prevent seepage.
HOW IS THE DANGER OF TISSUE PLUGS REDUCED? The inside edges of a needle point often punch out tissue plugs that may clog
the needle or get into the blood stream. The Huber Needle Point with a "closed bevel" gives a smooth sliding action through the tissue; this reduces this danger.
HOW IS COLLAPSE OF VEIN ON NEEDLE POINT PREVENTED? Free aspiration from the vein is accomplished by selecting the Huber Needle
Point and inserting the lateral opening down (the closed bevel up).
260

PROCESSING SYRINGES AND NEEDLES The photographic illustrations herewith are presented as a visual aid. It is obivous that the pictures are more "telling" than words. The photographs are taken form publications of the Abbot Pharmacutical Company and from :Becton, Dickinson and Company. The publications are available free of charge and some moving pictures are available also. Dry Heat Sterilization preserves the glas s, protects and prolongs the life of the needle.
261

Figure l3A. A suggested method for washing rubber gloves. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
Figure 13B. One method of the preparation of rubber gloves for packaging. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
262


r
I
Figure 13C. A method of packaging rubber for sterilization. Reprint by Courtesy of American Sterilizer Company, Erie, Pennsylvania.
Figure 13D. Demonstrating the final wrapping of a pair of rubber gloves. Reprinted by Courtesy of American Sterilizer Company, Erie, Pennsyl Pennsylvania.
263

PROCESSIl\iG RUBBER GOODS

EXPLANATION AND PURPOSE:

Articles of pure and synthetic rubber materials are used in the hospital. The cleaning and storage processes determine the life and usefulness of rubber goods to such an extent that there is no acceptable substitute for this procedure listed herewith.

PRINCIPLES:

1. Rubber deteriorates in the presence of heat.

2. Oily substances 'Idissolve" rubber surfaces.

3. Rubber breaks when reused.

4. Rubber surfaces "stickll after a short period of contact.

5. Inflation of rubber prevents adhesion of parts.

6. Soap deteriorates rubber after limited exposure.

7. Rubber sheeting should be hung over a long pole -- not folded.

EQUIPMENT:

1. Warm water

2. Mild detergent

3. Soft cleaning cloths

4. Powder

PROCEDURE:

Steps

Key Points

1. General rules

1. 1 Rinse under cold running water.

1. 2 Wash with soapy water.

1. 3 Rinse with warm clean water.

1.4 Dry thoroughly.

264

2. Rubber tubing and catheters.
3. Rubber gloves.
4. Rubber sheeting, pillow case, and mattress cover.

1. 5, Inflate with air.
1. 6 Hang in cool dry place.
2. 1 Open all clamps.
2.2 Allow cold water to run freely through the tube.
2.3 Remove adhesive marks with benzine.
2.4 Wash with warm soapy solution -force soapy solution through the tube by using a syringe.
2.5 Rinse throughly with cold clean water.
2. 6 Allow to dry by attaching a tube drying clip at one end and hang on a line or force warm dry air through the tube until dry.
2. 7 Sterilize by autoclave.
3. 1 Follow general rules from 1. 1 through 1. 4.
3.2 Inspect for leaks be inflating all fingers and then forming maximum amount of air into each finger separately.
3.3 Mend small holes using mending process adapted by the institution and suitable to the particular glove texture.
3.4 Autoclave for proper sterilization and preservation of the glove.
4. 1 Follow general rules 1. 1 through 1. 4.
4.2 Wash small area at a time, rinse and dry at once with clean cloths.

265

5. Rubber rings, hot water bottles, ice caps and collars.

4.3 Hang over pole to air.
4.4 Store in cool dry area by hanging on wide rod that prevents the sides from touching.
5.1 Follow general rules 1.1 through 1. 6.

266

Figure 14
GLOVES
1. Cloth insertion tab placed to give air passage through glove during sterilization.
2. Glove laid in wrapper so that the thwnbs will be up when wrapper is folded.
3. Powder envelope is placed so that the opening is toward the outside of the wrapper. When the wrapper is closed, the powder will not spill out.
267

Figure 15
ABBOTT INTRAVENOUS SET 1 tray (8 1/2 11 x 6 1/2" X 11/Z") (1) 1 dispensing cap and filter for Abbott solutions (Z) lIZ" piece 1. V. rubber tubing 3/1611 x 1/16" (3) 1 yent tube (4) 1 36" piece rubber tubing 3/16" x 1/16" (5) 1 glass needle adapter (6) 4 Z x Z sponges (7) 1 screw clamp (8) 1 HZO gauge 1 1/2" needle
Z68

Figure 16

AUTO-TRANSFUSION TRAY

1 tray (19 1/2" x 12 1/2" x 11/2")

(1) Instructions for using auto-transfusion tray.

(2) 1 10 cc. syringe

(3) 1 15 gauge needle and large adapter filled with cotton 2" piece of Latex rubber tubing'.

(4) 1 screw clamp

(5) Needles: 1 15 gauge x 2" 1 17 gauge x 11/2" 1 18 gauge xl 1/2" 1 21 gauge x 1 1/2"

in glass needle protectors

(6) 1 5 foot piece 1. V. rubber tubing 3/16" x 1/16" with slotted filter attached to one end and large adapter to other.

(7) 1 2" Latex rubber tubing 3/16" 10 - 3/32" Wall

(8) 1 211 Latex rubber tubing 3/16" 10 - 3/32" Wall, with slotted filter attached to one end.

(9) 1 5 foot piece 1. V. rubber tubing 3/16" x 1/16" with 15 gauge x 1 1/2" needle attached to one end.

269

Figure 17
BLADDER DRAINAGE SET 1 tray (18" x 12" x 1 1/2") (1) 2 clamps (2) 1 glass connector ( 3) (4) 2 36" pieces of 1. V. rubber tubing 3/16" x 1/16" (5) 1 Y connecting tube (6) 1 40" piece of 1. V. rubber tubing 3/16" x 1/16" (7) 1 Kelly flask, with 1 six inch piece 2" bandage around neck of flask 1 4 x 4 gauze square in mouth of flask
270

Figure 18 BLADDER IRRIGATION TRAY 1 tray (14" x 8" x 1 1/2") ( 1) 1 !anfo1ded towel (2) 1 1/2 ounce Asepto syringe (3) 1 medicine glass (4) 1 large kidney basin (5) 1 500 cc. gradutae
271

Figure 19

CARDIAC RESUSCITATION

1 tray (19 1/2" x 12" x 1/2")

(1) 4 5 1/2" Bachaus towel clamps (11) 3 medicine glasses

(2) 5 5 1/2" curved haemostats

(12) 1 5 cc. syringe

(3) 2 6" needle holders

(13) 1 rib retractor

(4) 2 5 1/2" straight haemostats
(5) 2 6" Allis forceps - 5 and 6 teeth
(6) 2 7" curved Kelly forceps
(7) 1 pair straight 5 1/2" suture scissors

(14) Needles: 2 Berbecker Fig. 40, size 3, 3/8 circle silkworm gut needles 2 Anchor brand 1824-# 1 needles 1 Keith abdominal Berbecker Fig. 431, size 2 1/2 11

(8) 1 pair 6 1/2" curved scissors

(15) 1 hypo #25x5/8 11 gauge needle

(9) 1 scalpel handle #3 Bard Parker (16) with # 10 blade

3 0 black silk - 9 feet
o black silk - 4 feet

( 10) 1 5 1/2" tissue forcep without

( 17) 8 2 x 2 sponges

teeth

( 18) 8 3 x 3 sponges

1 5 1/2" tissue forcep with teeth

(19) 4 4 x 4 sponges

TO ACCOMPANY TRAY:

Boat

#3 knife handle

(20) 5 t_owe1s

3 10 cc. syringes

1 each #18,19,20 gauge needles

1 Thoracotomy bottle

.

1 Thoracotomy tube

272

Figure 20
CATHETER TRAY
1 tray (18" x 12 11 x 1 1/2")
(1.1) 2 Robinson catheter s, size s /I 14, /I 16
(2) 1 round basin 6" x 3" (3) 1/2 underpad (4) 2 sponge cups with 5 cotton balls in each (5) 3 3 x 3 sponges in round basin (6) 1 kidney basin
1 4 x 4 sponge to cover and separate catheters When ready to use:
Sponges are covered with 10'0/0 Sterile Soap solution and 1: 1000 Cyanide solution in each bowl respectively.
K. Y. Jelly is put on 3 x 3 sponges in large round basin.
273

Figure 21
DOUCHE TRAY
1 tray (18" x 12" x 1 1/2") ( 1) 1 fanfolded surgical towel (2) 1 douche tip ( 3) 1 thumb clamp (4) 1 36" piece rubber tubing 1/4 x 1/16 ( 5) 1 kidney basin (6) 1 two quart irrigating can (7) 2 sponge bowls, 3" x 2" with cotton balls
5 cotton balls in one bowl 7 cotton balls in the other bowl (8) 1 1000 cc. graduate
274

Figure 22
EMERGENCY DRESSING TRAY
1 tray (15 1/2 11 x 10" X 11/2 11 ) ( 1) 1 curved 5 1/2" haemostat ( 2) 1 straight 5 1/2" haemostat (3) 1 clip remover (4) 1 pair 5 1/2 11 straight scissors (5) 1 scalpel handle #3 Bard Parker ( 6) 3 4 x 4 sponges
(7) 6 2 x 2 sponges
( 8) 1 # 11 scalpel blade 1 # 15 scalpel blade
..
275

Figure 23
VAGINAL EXAMINATION TRAY 1 tray (1411 x 10" x 1/2") Instrument Pack: (1) 1 vaginal speculum (2) 1 uterine dressing forcep 10 1/2" in wrapper (3) 1 fanfo1ded towel (4) 2 round covered containers, 4" x 3", with 6 cotton sponges in each When ready for use: Cover sponges in one container with 1: 1000 solution
of Cyanide, leave sponges in other container dry.
276

Figure 24 GASTRIC ANALYSIS TRAY 1 enamel tray (15 11 x 10 1/2" x 1 1/2") (1) 1 medicine glass (2) metal syringe adapter ( 3) 1 50 cc. syringe with special adapter
(4) 1 # 16 Levine tube
(5) 1 round basin 6" x 3" ( 6) 1 1000 cc. graduate
277

Figure 25
HOT COMPRESS TRAY 1 tray (15" x 12 1/2" x 1 1/2") ( 1) 1 hot plate (2) 1 plastic treatment sheet ( 3) 2 7" sponge forceps (4) 1 round basin 6" x 3" for compresses(5) 1 sponge forcep container Cover instruments with Zephirin solution
278

Figure 26
INTRAVENOUS SET (KELLY)
1 tray (19 1/2 11 x 12" X 1/2") (1) 1 #20 gauge 1 1/2" needle (2) 1 Kelly flask
1 6" piece-I. V. rubber tubing 3/16" x 1/16" 1 clamp 1 vent tube with a drip windoy.' 1 36" piece I. V. rubber tubing 1 glas s needle adapter 1 4 x 4 sponge in mouth of flask 1 6" piece, 2"bandage around neck of flask (3) 4 2 x 2 sponges
279

Figure 27
INTRAVENOUS SET (FENWAL) 1 tray (8 1/2 11 x 6 1/2 11 X 1 1/211 ) (1) 1 #20 gauge 1 1/2 11 needle (2) 1 4811 piece Latex rubber tubing (size 3/16" ID - 3/3"411 Wall) 1 Fenwal vent tube with drip window attached to one end 1 glass needle adapter attached to other end (3) 1 clatnp (4) 4 2 x 2 sponges
280

Figure 28

THORACENTESIS TRAY

1 tray (19 1/2 '1 x 12" X 11/12")
(1) Needles: 1 Keith abdominal neede1, fig. 431, size 2 1/2 - Berbecker 1 Berbecker needle, fig. 40, size 14 - (round and cutting. ) 17 gauge x 3 18 gauge x 3 19 gauge x 3 22 gauge x 1 1/2 25 gauge x 5/8
(2) 1 7 1/2'1 curved Kelly forcep
(3) 1 needle holder 5 1/2"
(4) 1 straight scissors 5 1/2,"
(5) 1 5 1/2" straight haemostat
(6) 1 scalpel handle # 3 Bard Parker with # 11 blade
(7) 1 50 cc. syringe
(8) 1 10 cc. syringe (Leur-Lock)

(9) 1 2 cc. syringe ( 10) 1 3-0 silk, 1 foot
1 o silk, 1 foot
( 11) 4 cotton balls ( 12) 3 15 x 125 m. m. test tubes
with corks
( 13) 4 61 applicators ( 14) 12" 1. V. rubber tubing, 3/16" x
1/16, with three-way stopcock ( 15) 3 medicine glasses ( 16) 2 4 x 4 sponges ( ( 17 4 2 x 2 sponges (18) 1 fanfolded towel (19) 1 treatment sheet
(20) 1 round basin

281

Figure 29

LIVER BIOPSY TRAY

1 tray (10" x 15 1/2" x 1/2")

( 1) 1 20 cc. syringe

(9) 4 cotton balls

( 2) 1 2 cc. Leur-Lock syringe
( 3) 1 curved 5 1/2 11 haemostat
~:~ 1 pair 5 1/2 '1 suture scissors
(5) 1 straight 5 1/2" haemostat
( 6) 1 scalpel handle # 3 Bard Parker with if 11 blade

(10) 3 liver biopsy need-les with cannulae
( 11) 4 6" applicators ( 12) 1 treatment sheet ( 13) 1 anolded towel
( 14) 3 4 x 4 sponges

(7) 3 medicine glasses

( 15) 3 3 x 3 sponges

( 8) Needles: 1 hypo needle 25 gauge x 5/8" 1 22 gauge x 11/2"

( 16) 4 2 x 2 sponges

282

Figure 30
N A SAL I R RIG A T ION T RAY 1 tray (19 I/Z" x 12"xl/2") ( 1) 1 Kelly flask 1 6" piece, 2'1 bandage around neck of flask 1 4 x 4 sponge in neck of flask ( 2) 1 36" piece of I. V. 3/16" X 1/16" rubber tubing ( 3) 1 clamp (4) 1 nasal irrigating tip
283

Figure 31

NASAL, TONSIL HEMORRHAGE TRAY

1 tra y ( 12" x 9" X 1")

( 1) 1 10 cc. Leur-Lock syringe with finger rings

( 14) 2 tonsil needles - 1 curved and 1 straight, 4"

( 2) 1 7" sponge forcep

( 15) 1 pair scissors, 5 1/2"

( 3) 2 7" tonsil haemostats (4) Catheters, size # 10 and #12
( 5) 1 6" needle holder
( 6) 1 Tieman's nasal speculum (7) 1 Jenning's mouth gag ( 8) 1 Bowworth's tongue depressor
(9) 1 medicine glass

( 16) Nasal packing nu- gauze, 1/2 "
c (17) 2 post nasal cotton packs
with 3 10" strings
( 18) 2 1/2 circle needles - Anchor brand (1824-6)
( 19) 2 1/2 curcle needlesAnchor brand (1824. 6
(20) 6 3 x 3 sponges

( 10) 1 suction tube (11) 1 5 1/2" probe ( 12) Laryngeal mirror, 8 1/2"

(21) 3 postal nasal plugs, with 5" strings
(22) 5 6" applicators

( 13) 1 Hurd's dissector and pillar retractor, 8 3/4"

(23) 1 towel

284

Figure 32

ORTHOPEDIC PREP TRAY (S'rERILE)

1 tray (17" x 9 1/2" x 2 1/2")

(1) 20 3 x 3 sponges

(7) 2 drapes, draw sheet size

( 2) 2 rolls 2" bandage ( 3) 1 straight razor (4) 1 nail file (5) 4 6" applicator s ( 6) 1 small prep sheet

( 8) 1 large basin for water, 5" x 2 1/21r
1 small basin for phisoderm, 4"x21/2"
(9) 2 fanfo1ded towels
( 10) 1 large prep sheet 1 haemostat - used for prepping

... 285

Figure 33

PARACENTESIS TRAY - ABDOMINAL

1 tray (19 1/2" x 12" x 1/2")

( 1) 1 2 cc. syringe

( 10) 1 4-0 card black silk suture

( 2) 1 7" curved Kelly forcep

( 11) 4 2 x 2 sponges

( 3) 1 6'1 needle holder
(4) 1 5 1/2" straight scissors ( 5) 1 5 1/2 straight haemostat

(12) 1 Kuke's trocar 12 fro 4" long, (trocar, canula, drainage tube)
( 13) Three-way stopcock

( 6) 1 scalpel handle #3 Bard Parker (14) 1 18" piece 3/16" x 1/16" 1. V.

with #15 blade

rubber tubing

(7) 4 6" applicators
( 8) 3 15 x 125 mm. test tubes with corks
(9) Needles:
1 #22 1 1/2" gauge needle 1 #25 x 5/8 gauge needle 2 Berbecker Fig. 40, size 14 round cutting suture needles

( 15) 3 medicine glasses ( 16) 1 treatment sheet ( 17) 1 towel (18) 4 cotton balls (19) 2 4 x 4 sponges

(20) 1 round basin, 6" x 3"

286

Figure 34 PERINEAL IRRIGATION TRAY WITHOUT FORCEPS
1 tray (15" x 8 1/2" x 2 1/2") (1) Brown Paper bags (2) Sanitary Belt (3) Packaged perineal pads (4) Packaged sponges (5) 1 solution pitcher with lid; solution optional (6) Combined package of sponges and pads (7) Paper towels
287

Figure 35
PNEUMOARTHROGRAM 1 tray (14" x 9" x 1/2") (1) 1 50 cc. syringe (2) 1 20 cc. syringe (Air filter - - fill syringe with gauze) ( 3) 1 5 1/2". straight haemostat (4) 1 two-way stopcock (5) Needles: 1 25 gauge 5/8" hypo. needle 1 20 gauge 1 1/2" hypo. needle ( 6) 2 medicine glasses (7) 6 2 x 2 sponges ( 8) 1 tap sheet (9) 2 towels
288

Figure 36

RECIPIENT SET (Used also for Amigen)

1 enamel tray (8 1/2" x 6 1/2" xl 1/2")

(1) Needles: 1 15 gauge 2 1/2" needle 1 19 gauge 1 1/2" needle

(2) 1 5 cc. syringe wrapped in sponge

(3) 4 2 x 2 sponges

(4) 1 clamp

FOR GIVING AMIGEN: FOR GIVING BLOOD:

1 Baxter set if ll-R 1 Baxter set. if 1f:-B.

289

Figure 37 RE T'ROG,RADE IRRIGAT ING SE T 1 tray (lb" x 10 1/2" X 1/2 11 ) (1) 1 Kelly flast 4 x 4 sponge in neck of flask 12" piece, 2" bandage around neck (2) 48" piece rubber tubing - 1/4 11 x 1/16" (3) 1 clam.p (4) 1 glas s nozzle with rubber shield (5) 2 4 x 4 sponges
290

Figure 38

SPINAL PUNCTURE TRAY

1 tray' (19 1/2" x 12" x 1/2")

( 1) 1 towel ( 2) 1 5 1/2 1' straight haemostat

(7) 1 spinal manometer
three-way stopcock on sterilizing tray

( 3) 1 10 cc. syringe

(8) 4 2 x 2 sponges

(4) 1 2 cc. syringe. Leur-Lock 1 2 cc. syringe. plain
( 5) 3 medicine glasses

(9) 1 treatment sheet
(10) 3 15 x 125 mm. te st tube s with cork stopper s

( 6) Needles: 3 spinal needle s #18x3". 20x3". 22 x 3" with stilettes 1 #22 x 1 1/21 with stilette 1 #18 x 11/21' needle 1 #25 x 5/8" hypo. needle

( 11) 4 6" applicators ( 12) 4 cotton balls ( 13) 2 4x4 sponges

291

Figure 39

SPINAL PUNCTURE TRAY - INFANT

1 tray (15 1/2" x 10" x 1/2")

(1) 1 10 cc. syringe

(6) 4 6" applicators

(2) 1 2 cc. syringe

(7) 4 2 x 2 sponges

( 3) Needles: 2 infant spinal needles #20 x 11/2", #22 x 11/2" 1 hypo needle 25x5/8

(8) 2 4 x 4 sponges
(9) 3 15 x 125 mm. test tubes with
corks wrapped in 4 x 4 sponge

(4) 1 6 1/2" curved Kelly forcep

( 10) 4 cotton balls

( 5) 3 medicine glas ses

( 11) 1 fanfolded treatment sheet

(12) 2 towels

292

Figure 40

SPINAL SYMPATHETIC BLOCK

1 tray (19 1/211 x 12 11 x 1/2 11 )

( 1) 3 medicine glasses

(8) 4 2 x 2 sponges

( 2) 1 10 cc. syringe ( 3) 1 20 cc. syringe (4) 1 5 1/2 11 straight haemostat (5) 2 towels (6) 6 spinal needles, ZO x 3l/Z 11 (7) 1 #2Z x 1 liZ II needle
1 hypo needle 25 x 5/8"

(9) 3 corked 15 x 125 mm. test tubes
(10) 4 cotton balls ( 11) 4 6" applicators ( lZ) Z 4 x 4 sponges ( 13) 1 treatment sheet

293

STERNAL pUNCTURE
Figure 41

STERNAL PUNCTURE TRAY

1 tray (10 1/2"x 12" x 11/2 11 )

( 1) 2 towels ( 2) 1 2 cc. syringe ( 3) 1 10 cc. syringe (4) 1 5 1/2" straight haemostat (5) 1 scalpel handle #3 Bard
Parker with # 15 blade

(7) 1 treatment sheet with 2" x 2" hole
( 8) 3 medicine glasses
(9) 4 cotton balls
(10) 4 6" applicators ( 11) 4 2 x 2 sponges

(6) Needles: 1 Turkel sternal puncture needle set (4 parts) 1 #22 gauge 1 1/2" needle 1 #25 gauge 5/8 11 needle

( 12) 2 4 x 4 sponges

294

Figure 42

SUBCUTANEOUS SET (FENWAL)

1 tray (11 1/2" x 12" x 1/2")

(1) 1 5 1/2" curved haemostat
(2) 2 #,20 2 1/2 11 hypo needles ( 3) 2 clamps

( 5) 1. 2 glas s adaptor s 2. 2 18 11 pieces tubing 3. 1 Y-glass connecting tube 4. 1 30" piece tubing 5. 1 vent tube

(4) 4 6" applicator s

( 6) 4 cotton balls

( 7) 4 2 x 2 sponges

(8) 2 4 x 4 sponges

295

Figure 43
SUBCUTANEOUS SET (KELLY) 1 tray (19 1/2"x 12 1/2 11 x 1 1/2") ( 1) 2 #20-2 1/2" needles (2) 2 cla:mps (3) 1 Kelly flask with 4 x 4 sponge in neck 1 12" piece 2" bandage around neck of flask 1 30" piece tubing 1 Y-glass connector 2 18" pieces tubing 2 glas s adaptor s (4) 4 6" applicators (5) 4 2 x 2 sponges (6) 2 4 x 4 sponges (7) 4 cotton balls
296

Figure 44

ARTERIAL TRANSFUSION SET

1 tray (19 1/2" x 12 1/2" x 11/2")

( 1) Needles: 3 cutting needles Berbecker Fig. 40, size 15 #25 x 5/8 gauge hypo Cannulae needles #18, 13, 12 gauge xl 1/2" #22 x 1 1/2" gauge hypo

(9) 2 claIIlps
(10) ( 11) 3 ft. Latex rubber tubing, size
3/16" ID - 3/32" Wall, connected to needle at one end and a IIletal IIlale connector attached to the other end.

(2) Black silk suture
3-0, 5 feet 2-0, 2 feet

( 12) 1 9" blood aspirating needle ( 13) 1 6" blood aspirating needle

( 3) 1 10 cc. syringe

( 14) 1 glass cannula with 3" tubing

(4) 1 pair straight 5 1/2" suture scissors

and a male connector tied to the other end.

( 5) 1 5 1/2" needle holder

( 15) 1 slotted filter with 2" rubber tubing

(6) 3 5 1/2" curved haeIIlostats

(16) 2 IIledicine glasses

(7) 1 5 1/2' tissue forcep without (17)

teeth

Towels

( 18)

. (8) 1 scalpel handle #3 Bard Parker

1 dozen 2 x 2 sponges

with # 15 blade

IMPORTANT: Use 2-0 black silk for tying all tubing and connectors.

Under ties of wrap put 1 Baxter #R 182 Blood Under Pressure Set.

297

Figure 45 THORACOTOMY BOTTLE AND TUBE ( 1) 1 amigen bottle (2) 1 glass drinking tube (3) 1 rubber cap with two holes (4) 1 piece glass tubing 12" long (5) 1 piece 1. V. 3/16" x 1/16" rubber tubing 6 feet long (6) 1 connecting tube (7) 1 mushroom catheter, (on separate tray) IMPORTANT: 350 cc. of distilled water is put in the amigen bottle. The glass tubing, 12" long, is put in the distilled water. Be sure the end of glass tubing is covered by the water. A towel is placed over the top of the "set up" bottle, and cover s all but the lower third of the bottle. The mushroom catheters (on separate tray) are in sizes 12, 14, 16, 18, 10, 22, 24, 26, 28, and 30.
298

Figure 46 THROAT IRRIGATION TRAY 1 tray (19 1/2" x 12" x 1 1/2") (1) a. Kelly flask b. 1 piece 2" bandage around neck of flask c. 1 4 x 4 sponge in neck of flask (2) 1 36" piece of rubber tubing; attach to one end of Kelly flask (3) 1 clamp (4) 1 throat irrigating tip, attach to end of tubing
299

Figure 47

TIDAL DRAINAGE SET

1 tray (15 1/2"x 10" x 1/2")

( 1) 1 Kelly bottle

(10) 8" piece IV 3/36" x1/16" rubber

1 4" x 4" gauze square to cover

tubing

bottle secured with rubber band

1 12" piece 2" bandage

( 11) 36" piece of 1. V. rubber tubing

(2) 8" piece of 1. V. 3/16" x 1/16" rubber tubing.
(3) 1 Murphy drip (4) 36" piece of 1. V. rubber tubing (5) 1 glass connector

( 12) 2 12" glass tubes ( 13) 1 2" piece of 1. V. rubber tubing ( 14) 1 rubber closed cap (15) 1 hypo. needle 25 x 5/8 gauge

( 6) 1 24" piece rubber tubing

(16) 1 glas s adapter

(7) Y tube

( 17) 1 #6 rubber stopper

(8) 1 88 11 piece 1. V. 3/36" x 1/16" rubber tubing

( 18) Z clamps

(9) Y tube

IMPORTANT: Gallon jug kept on ward is used with this set. 300

Figure 48

TRACHEOTOMY TRAY - 3

1 tray (17" x 10" x 2 1/2")

( 1) 4 towels
( 2) 6 tracheotomy tubes - #1, 2, 3, 4, 5, 6, (one each) with hernia tape 16" long
( 3) Robinson catheters, sizes 8, 12, 16
(4) 6 5" 'mosquito haemostats
(5) 6 5 1/2" curved haemostats
( 6) Scalpel handle - Bard Parker with # 15 blade
(7) 1 5 1/2" tissue forcep without teeth

(17) 1 pair 5 1/2" dissecting scissors
( 18) 1 pair 5 1/2" straight scissors (19) 1 Tracheal dilator (20) 1 Jansen's mastoid retractor (21) 1 Senn retractor (22) 1 Tracheal (rake) 3 prong
retractor (23) 1 5 1/2" vein retractor (24) 1 4 1/2" groved director
(25) 1 5 1/2'1 probe

1 5 1/2" tissue forcep with teeth (26) 2 5" skin retractors

( 8) 4 5 1/2" Bachaus towel clips

(27) 2 6" Allis forceps, 5 and 6 teeth

( 9) 2 pair 9 1/2" sponge forceps ( 10) 4 5 x 4 sponges ( 11) 12 3 x 3 sponges ( 12) 1 5 cc. syringe ( 13) 1 glas s irrigating tip ( 14) 3 medicine glasses ( Ii) 1 6" needle holder

(28) Needles: 1 cutting needle Berbecker Fig. 92, size 14 1 suture needle Berbecker Fig. 26, size 12 1 hypo gauge 20 x 1 1/2" 1 hypo gauge 22 x 1 1/2" 1 hypo gauge 25 x 5/8"

( 16) 1 pair curved 6 1/2" Mayo scissors(29) 1 card 3-0 black tiilk,41/2" long

301

"..
Figure 49 TRANSFUSION SET - BABY (1) 1 50 cc. syringe (2) 1 10 cc. syringe, Leur-Lock (3) 1 2 cc. syringe (4) Needles:
1. 1-15 x 1 1/2'1 needle 2. 1-18 x 1 1/2" needle 3. 1-19 xl 1/2" needle 4. 1-20 x 11/2" needle 5. 1-24 x 5/8" needle 6. 1-25 x 5/8" needle
(5) 1 3/16" x 1/16" rubber tubing 14" long, 2 three-way stopcocks (one on either end of the tubing; tie with black silk Just put in wrapper.
302

Figure 50 AR T ERIA L TRANSFU SION TAB LE USED WITH ARTERIAL TRANSFUSION SET (1) Used oxygen tank (2) Aneroid - Blood pressure instrument (3) Latex rubber tubing 12" (Size 3/H:" ID - 3/32" Wall) (4) Later rubber tubing 24" (Size 3/16" ID - 3/32" Wall) with a female metal connector wired on the end.
303

/
Figure 51 VAGINAL BIOPSY (1) (1) 1 Tenaculum 10" in sterile wrapper (2) 1 Biopsy forcep curve 8 1/2" in a sterile wrapper (3) 1 hand towel
304

Figure 52

VENOUS CUT-DOWN AND SUTURE TRAY

1 tray (17" x la" x 2 1/2")

( 1) 3 medicine glasses

( 12) Needles:

(2) 1 5 cc. syringe, Leur-Lock ( 3) 6 5 1/2" curved haemostats (4) 3 5" curved mosquito haemostats

2 Berbecker - Figure 155, size 3 curved needles 2 Berbecker - Figure 40, size 14 or 15 curved needles

( 5) 1 scalpel handle - #3 Bard Parker (13) 1 card 4- 0 black silk

( 6) 3 tissue forceps: 1 5 11 with teeth 1 5 1/2" with teeth 1 5 1/2" without teeth

( 14) Canula needles in varying sizes:
# 14, 16, 18, 20, 22 # 25 x 5/8 gauge hypo needle # 22 x 1/2 gauge needle

(7) 4 Backhaus towel clips - 5 1/4" ( 15) 1 5 1/2" needle holder

( 8) 4 6" applicators

(16) 1 straight 61/2 11 Mayo scissors

(9) 1 9 1/2" sponge forcep

( 17) 1 curved 6 1/2" Mayo scissors

( 10) 4 4 x 4 sponges
(1) 8 3 x 3 sponges 4 2 x 2 sponges

( 18) (19) 2 6 1/2" Kelly forceps (20) 4 cotton balls (21) 1 treatment sheet (22) 2 towels

305

Figure 53

VENOUS PRESSURE TRAY

1 tray (15" x 8 1/2" x 2 1/2")

(1) 4 2 x 2 sponges

( 2) 1 10 cc. syringe

(3) '1 20 cc. syringe

(4) Needles:

2 # 18 gauge 11/2 11 needles



1 25 gauge 5/81' needle

(5) 1 spinal manometer

( 6) 1 6" IV 3/16 x 1/16 rubber tubing 1 three-way stopcock attached to one end

306

Figure 5<t
VENTRIC ULOGRAM 1 tray (14" x 9" x 1/2") ( 1) 1 10 cc. syringe (2) 1 2 cc. syringe (t3) 1 6 1/2" straight Kelly clamp (4) 2 medicine glasses (5) Needles: 1 25 gauge 5/8" needle 1 20 gauge 1 1/2" needle 3 Frazier flanged exploring canula, 5, 6, 7 centimetres. 1 Frazier Trocar and canula, 10 centimeters (6) 6 prep sponges made according to directions (7) 6 4 x 4 sponges
307

Figure 55 INDIVIDUAL HYPODERMIC TRAY 1 tray (5" x 7") (1) Ointment jar 2 1/2 1 x 2 1/2" containing solution (20 Medicine card (3) Hypodermic syringe (4) Sponge (5) 2 swabs
308

Figure 56. BULK HYPODERMIC SUPPLY (1) 1 covered boat 8 1/2" x 5" x 3" containing sterile syringes (2) 2 covered boats 8 1/2" x 5" x 2" containing sterile needles (3) 1 open solution bowl 6" for discarded syringes (4) 1 covered container 4 1/2" x 7" containing cotton balls (5) 2 small solution cups for discarded needles (6) 1 covered container 4 1/2" x 7" containing medicine glasses and swabs (7) 1 pickup forcep and container
309

Figure 57

EMERGENCY MEDICATION TRAY

Adrenalin Cloride 1: 1000

)

Caffeine Sodium Benzoate 7 1/2 gr. )

Coramine

)

Digifolin

)

Metrazol

)

Sodium Phenobarbital 2 grain

)

Sodium Phenobarbital 5 grain

)

10 ampoules

Prostigmine 1:2000 Prostigmine 1:4000 Cedilanid O. 4 mg. Cedilanid O. 8 mg Aminophyllin 3 3/4 gr. Aminophyllin 7 1/2 gr. Levephed 4 cc

)

)

)

4 ampoules

)

)

)

)

Sodium Pentothal 0.5 gram Water for injection
Mayamine Pronestyl Dextran 5% Glucose in Distilled Water

2 ampoules 1 ampoule

1 Tourniquet 310

Figure 58 INDIVIDUAL HYPODERMIC SUPPLY ( 1) Individually packaged Tuberculin Syringes
I
(2) Individually packaged Insulin Syringes
I
( 3) Individually packaged 50 cc. Syringes (4) Individually packaged 20 cc. Syringes ( 5) Individually packaged 10 cc. Syringes ( 6) Individually packaged 5 cc. Syringes (7) Individually packaged needles ( 8) 1 flask of Normal Saline
(9) 1 flask of Distilled Water
311

PART VII
THE OPERATING ROOM EXPLANATION AND PURPOSE:
Nursing procedures concerned with the operating room are familiar to every professional nurse, yet they are so highly specialized that the job is usually left to the specialist in surgical nursing. This is particularly true in the larger hospitals located in the urban areas where the specialized nurse is most readily available. In cases of emergency, and when the nurse is doing a tour of evening or night duty (when the relief specialist is not available) the nurse that is available may have to assist with an operative procedure. It is for this nurse and the supervisor who is responsible for teaching, that this section of the manual is presented.
The content of Operating Room Techniques has been reduced to a minimum. The instrument lists are considered minimum for each operation and are the standard instruments used in a 100 bed hospital. We are indebted to Mr. Walter Atlman and Mrs. Edith McCulloch, R. N. of the Kennestone Hospital in Marrietta for their cooperation and help in obtaining these excellent photographs; to Mr. Marion Kelly, Photographic Laboratory, Georgia State Health Department, for the photography. The data presented here is based on the assumption that a professional nurse supervises the surgical theater and that a professional nurse is present in each room during each operation. It is further assumed, that the hospital administration provides sufficient number and kinds of instruments to meet the demands of the service. Sugge sted Reference: "Operating Room Technique" by Edythe Louise Alexander, R. N., 2nd Edition. "Aseptic Treatment of Wounds" by Carl W. Walters, M. D.
312

ORGANIZATION AND ADMINISTRATION OF AN OPERATING ROOM

PRINCIPLES:

1. The way in which the operating room is set up, controlled and managed influences directly the extent to which the aims of the department are realized.

2. Definite policies of procedure, posting, recording, kind and quality materials to be used should be formulated jointly by nursing, surgical, and administrative staffs.

3. The controlling policies and methods of the department should be formulated, adopted, interpreted and transmitted in such a way as to assure the maximum cooperation of all personnel.

4. The administrative procedures of the operating room should include planning, organizing, staffing, directing, coordinating, reporting and budgeting as does the administrative process in any well-managed enterprise.

5. The correct arrangement of instruments on tables directly facilitates their use to best advantage of physician and operating team.

PROCEDURE:

Steps

Key Points

1. Determine the policies and procedures.

1. 1 Policies and procedures should specify how the department shall operate.

2. To administer the department the following should be included:

2. 1 Responsibilities of personnel. 2.2 Staffing, professional and subsidiary.

2.3 Uniforms to be worn by the personnel.

2.4 Authority to use the facilities.

2.5 Scheduling of operations.

2.6 Anesthesia routines.

2.7 Safety precautions.

313

3. Selection of equipment and supplies.

2.8 Instrument selection, use, care and replacement.
2.9 Aseptic technics.
2. 10 Set-ups for surgical procedures.
2.11 Use, care and disposition of radioactive and other unusual substances.
2. 12 Laboratory and pathology routines.
2. 13 Departmental relationships.
2.14 Preparation of patients.
2. 15 Methods of transporting patients to and from the department.
2.16 Medical-legal responsibilities.
2. 17 Records.
2. 18 Disposition of "specimens" not requiring pathological examination.
2. 19 Sterilization procedure.
3. 1 Use supply catalogues and lists of standard equipment which are available to hospitals for information concerning the selection of equipment and supplies.

4. Arrange furniture in the room.

3.2 Consult surgeon regarding type of sutures and special instruments to be used.
4.1 Placement of furniture should consider:
4. 11 Floor space.
4. 12 Light.
314

5. Select personnel. 6. Conduct educational
programs for the personnel.
7. Provide administrative
devices.
8. Provide adequate
supervision.

4.13 Convenience.
4. 14 Safety.
5. 1 Write job descriptions covering the general duties, conditions of work, and the necessary qualifications of each person assigned to the department.
6. 1 Ed1;1cational programs should include:
6. 11 Orientation programs.
6.12 In-service programs.
6. 13 On-the-job training for sub-
sidiary workers.
6. 14 Professional staff education.
7. 1 Successful administration includes the maintenance of accurate records and reports.
7. 11 Check lists
7. 12 Inventories
7. 13 Time schedules
7. 14 Work schedules
7. 15 Manuals
6. 151 Manual of policies
6. 152 Administrative
directives
6. 153 Nursing procedure
8. 1 The functions of supervision are to:
8. 11 Set up standards for workers.

315

8. 12 Render guidance for those suprevised.
8. 13 Cooperate with workers in carrying out program..
8. 14 Conduct a program. of staff education with the workers as planners.
8. 15 Evaluate work.
316

ESSENTIAL BASIC SUPPLIES FOR OPERATING ROOM SHELVES OF A 30 BED HOSPITAL

Sutures:

Silk Sutures, No. 4-0, 12 each

Silk Sutures, No. 3-0, 12 each

Silk Sutures, No. 2-0, 12 each

Silk Sutures, No. 1-0, 12 each

Silk Sutures, No.1, 12 each

Intestional Suture 0, 1 can

Intestional Suture 00, 1 can

Plain Suture

0, 1 can

Plain Suture

00, 1 can

Plain Suture

1, 1 can

Chronic Suture 000, 1 can

Chronic Suture

00, 1 can

Chronic Suture

0, 1 can

Chronic Suture

I, 1 can

Chronic Suture

2, 1 can

Tonsil Suture Plain 0 with needle

Intestinal Silk 00 with needle

Intestinal Silk 000 with needle

Eye Suture 5.0 - 6.0 suture on atromatic needle.

Eye Suture 0000 - 00000 with needle

Individual Package:

Foley catheters 6, various sizes T-tubes French catheters Mushroom catheters Penrose drains 6-8 Stiletto Umbilical tape Tonsil sponge s Rubber tis sue drains Packages of powder, Bio-Sorb Small vaginal packs Dextrose 18% Novocain 1% Ephedrine -- Synkavite -- Coramine Ponticaine 10 mgm., 20 mgm. Novocain 100 mgm., 120 mgm., 150 mgm., 250 mgm. Normal Saline solution 3 quarts

317

Distilled water 2 quarts Gelfoam. Nupercaninal ointm.ent, 2 Kitner sponges (10 on safety pin) Perineal pads Rubber tubing (suction type) Counted sponges (10 to a pack) Eye dropper s Connecting tubes
STERILE: Slides Medicine glas ses Safety pins Bandages
Test tubes and slides Tongue blades Applicators A. B. D. pads Sterile towels Plain sponges 4" x 4" Tape sponges(X-ray Detectable) 70% alcohol K- Y Jelly 1 Sulfathiozol powder, 1 dozen packages Sufonilam.ide powder, 1 dozen package s Extra Spinal Puncture Needles size 20, 22 short and long

Place rubber band around these am.pules. Several bundles should be available if spinal anesthesia is being used in hospital.
Ponticaine Chloride 10 m.g. Dextrose 3 cc of 10% Novocain 120 m.g. Novocain 100 m.g. Ephederine Sulfate 1 cc of gr. 3/4
Novocain 2 cc of 1%

Hypoderm.ic Syringes in Packages:

2-5 cc. syringes

2-10 cc. syringes 2-20 cc. syringes

Autoclave all hypoderm.ic supplies

3-50 cc. syringes

Novocain 1%, 4-6 dozen Nu-gauze 1 inch (5 yards) Iodoform. gauze 5% (com.m.ercial package) Tincture of Iodine Phenol Sodium. Morrhuate 5% with Benzyl alcohol 2%, Vial 30 ce.

318

Aromatic Spirits of ammonia Razor for emergency only (Do not shave patients in operating room. ) Alcohol Methiolate Green soap Surplus "naterials : Venous packs Sodium Pentethol (1box) Flash light Wrist straps Stirrups Adhesive tape dispenser
319

SURGICAL HAND SCRUB

PURPOSE:

1. To remove the dirt, fats and transient organisms from the hands and to render them safe for participating in a surgical procedure.

EQUIPMENT:

Detergent (Phisoderm and G-ll)

Nail file

Running water

PRINCIPLE:

*1. A minimum of 10,000 organisms are present per square centimeter of normal skin.

*2. A successful scrubbing technique for the hands depends upon the deposition of an adherent, bactericidal, elastic, transparent film that is impermeable to bacteria.

3. The first time Phisoderm and G-ll is used, a ten minute wash is necessary. Those who scrub at intervals of more than three days should also wash for ten minutes.

PROCEDURE:

Steps

Key Points

1. Hold hands and arms under warm running water until wet.

2. Use two squirts of Phisoderm and G-ll and make a lather covering arms and hands.

3. Wash well for one minute.

3. 1 Disinfection should be based upon a habitual anatomic scrub rather than upon an arbitrary period of scrubbing.

4. Rinse.

4.1 Have warm water flow from finger tips toward elbows to prevent recontamination of hands and fingers.

320

5. Clean fingernails with metal nail file.

6. Repeat step #2.

7. Continue washing procedure 7. 1 A five minute (5 minute) scrub is

for two minutes.

necessary if one day has elapsed

between scrubs.

8. Rinse frequently.

9. Add detergent as needed but use sparingly.

10. Rinse well.
* Fr~m "Aseptic Treatment of Wounds, " by Carl W. Walters.

321

SURGICAL ASEPSIS GOWN AND GLOVE TECHNIQUE

PURPOSE:

To put on a sterile gown and to put on sterile gloves without contaminating the outer surfaces.

EQUIPMENT:

Sterile gown in package

Sterile glove s in package

PROCEDURE:

Steps

Key Points

1. Technic for putting on sterile gown.

1. 1 Open the gown carefully in front of body, touching only the inner side.

1. 2 Insert the right arm into the sleeve, holding the gown up with the left hand.

1. 3 Insert the left arm into the other sleeve.

1.4 Hold the strings up and backwards so that the circulating nurse can grasp them for tying without corning in contact with the sterile front of the gown.

1.5 Bear in mind that the gown, from the waist down and the back is not considered sterile. Therefore the back may never be turned on a sterile field.

2. Technic for putting on sterile gloves.

2. 1 Open the glove cas e and remove the powder envelope.

2. 2 Rub the powder into the hands.

322

2.21 Do not allow the powder to filter through the room when powdering hands.

2.3 Bear in mind that the skin is never to touch the outside of the glove.

2. 4 Pick up the fir st glove by the cuff ond pull on to the hand, leaving the cuff intact.

2.5 Insert the gloved hand under the cuff of the other glove and pull it over the hand and wristlet of the gown.

2.6 The gloved fingers are then to be slipped under the cuff of the first glove, and the cuff is to be pulled over the wristlet of the gown.

3. To remain surgically clean

3. 1 Cuff the gloves but do not remove them

between cases, care must be

from the hands. This is to protect the

exercised to avoid contact of

hands when the gown is pulled off.

the bare hands and arms with the

the outside of the gown.

3.2 The circulating nurse will untie the

gown and remove it.

3.3 Remove the gloves.

3.31 Insert the left gloved hand under the right cuff and pull the glove off.

3.32 Insert the clean right hand under the inner surface of the glove and pull glove off.

323

SURGICAL ASEPTIC TECHNIQUE
Figure 59A. Dry clean hands and arms with sterile towel, proceeding from fingers to elbow.
Figure 59B Dry forearm and elbow, using a rotation motion. Never bring towel back over dried area.
324

Figure 59C. Instrmnent nurse puts arm.s in gown holding the gown well off the contam.inated floor.
Figure 59D. Circulating nurse places hands inside of gown near shoulders and adjusts gown.
325

Figure 59E. Circulating nurse grasps end of gown string without touching any part of gown.
Figure 59F. Individual package of glove powder is used carefully by scrub nurse to prevent distribution of dust in operating room..
326

Figure 59G. Nurse does not touch outside of glove with her hands.
Figure 59H. Nurse slips gloved fingers under cuff of righ glove to put on right glove.
327

Figure 59!. Nurse slips glove finger under cuff of left glove and pulls glove over wrist.
328

PREOPERATIVE SETUP (Circulating and Scrub Nurse)

PURPOSE:

1. To assist in the performance of an operative procedure; to assume responsibility for the essential duties of a professional nurse which represent her contribution to the success of this procedure.

PRINCIPLES:

1. Operating room technics must be as simple as possible in order that the anesthetist, the nurse, and the surgeon prepare for the operation simultaneously.

2. Intelligent anticipation of the needs of the patient, should be uppermost in the mind of the surgical team at all times during the operative procedure.

3. Each participant should know his duties and possess proper skills to execute them for the patient's well being.

PROCEDURE:

Steps

Key Ponits

1. The unsterile or circulating nurse will dress in scrub dress and helmet or turban.

2. Check assignments for the day.

3. Set up scrub rooms.

3. 1 Bring from sterile supply room and open ready for use, sufficient supplies for the "scrub-up process.

4. See that autoclaves are ready for emergency use.

5. Dust inidvidual operating rooms.

5. 1 Wipe all furniture and lamps with "wash gauze" which has been wet with a disinfectant.

329

6. Plug in portable lights and other electrical equipment to see if they are in proper working condition.
7. See that items such as knee strap s, arm boards, sand bags, clysis stands, foot boards, rubber covered pillows or any other special equipment needed is in the room before operation is started.
8. Set up rooms with sterile packs and supplies according to individual operations to be performed in that room.
9. Assist nurse in putting on sterile gown. (See pictures)
10. Bring sterile instruments from autoclave and place on sterile area.
11. Pour necessary antiseptic.
12. Make complete and accurate sponge count with scrub nurse.
13. When patient is brought into room, circulating nurse assists the anesthetist and orderly in getting patient in the proper position on the table.

8. 1 When the scrub nurse has almost finished with the scrubbing process, the circulating nurse can then open the supplies. After these have been opened, the room should not be left without an attendant. Circulating nurse puts on two mask before opening sterile packs.

12. 1

Record sponge count immediately. If more sponges are needed during the operating, these sponges~!. also be counted by both the scrub nurse and circulating nurse simultaneously. This count is also reE:orded immediately.

13. 1

Once the patient is on the operating table, he must not be left alone. The anesthetist, nurse or orderly must stay with patient until patient is anesthetized.

330

14. Assist doctors with putting on sterile gowns.

15. Place sterile tables in most convenient position for surgeon and nurse.

16. Turn on lights and focus portable lights on operative area.

17. Connect suction apparatus.

18. Place kick buckets at most convenient places for- discarding soiled sponges.

19. See that foot stools are supplied for nurses and doctors as necessary.

20. Keep scrub nurse supplied with all necessary sterile items and solutions.

20. 1

Suture nurse and circulating nurse should read solution on drug-labels aloud before using.

21. Pick up fallen instruments, sponges, or any other articles from the floor immediately.

22. Keep room clean and in order during entire operation.

23. The scrub or suture nurse will dress in scrub dress, helmet or turban, and two masks before scrubbing:-

24. Scrub nurse sets up sterile tables and assists doctor s with draping the patient, handling instruments and sutures during the entire operation.

24. 1

A good scrub nurse will anticipate the doctor's needs so that he seldom has to ask for what is needed.

331

25. Assist with application of the dressing on the area after completion of operation. Also assist with transferring the patient to the Recovery Room.
26. Prepare specimen for the laboratory before cleaning dirty operative area.
27. Assist in cleaning operating room and setting up for next case.

25. 1 Some surgeons do not cover incisions with dressings.

26. 1

Complete pathology card with necessary and correct information, attach to specimen and send to the laboratory. The importance of this duty cannot be stressed too much.

27. 1

RemO\re all soiled and contaminated linen, instruments, and other supplies.

27. 2 Replace equ~pment ready for following case.

27.3 Have room cleaned well before preparing for next case.

332

Figure 60. Opening sterile
package. Circulating nur se pulls away wrapper and pulls back cover
Figure 61. Opening sterile package. Circulating nurse completes opening of inner pack by use of sterile transfer forceps. (BardParker forceps)
333

Figure 62. Bard-Parker transfer forceps. (The correct and safest transfer forcep available. )
334

Figure 63. Circulating nurse using correct method of removing instrument tray from high-speed pressure autoclave.
Figure 64. Pouring medication into sterile utensil. Circulating nurse keeps bottle well away from sterile field.
335

Figure 65. Non-boilable catgut sutures covered wi th germicidal solution in sterile container. Circulatin[ nurse demonstrates removal of suture with correct type of transfer for ceps.
Figure 66. Filling basin with solution. Shows circulating nurse correct distance from basin. Note that flask is used for solution container.
\ 336

Figure 67. Draping of portable instrument table. If drape is short a towel may be added as shown. Four thickne sses of materials covers stand.
Figure 68. Mayo table showing instruments and supplies.
337

Figure 69. Mayo table showing instruments and supplie s.
338

CARE OF SURGICAL INSTRUMENTS
EXPLANATION AND PURPOSE:
To reduce cost, render instruments clean, sharp and safe for sterilization, to prolong the life and increase the maximum use of instruments by following a few simple procedure s.
PRINCIPLES:
Few surgical instruments wear out. Most instruments are destroyed by misuse, faulty construction, improper cleaning, sterilization and storage. It is almost impossible to clean instruments manually particularly the lock. Soaking instruments in a suitable fat soluble detergent or an instrument washer sterilizer will render instruments clean.
The protective film on surgical instruments is removed by the use of abrasives. Shiny instruments may be wilfully destroyed by use of abrasive on a corrosion resistant surface.
Corrosion of instruments takes place during the storage period as the lock cannot be dried manually but must be exposed to dry heat. New stiff instruments usually are defective. Old stiff instruments are the result of baked dirt, blood and pus in the lock.
By use of No. 80 emory paste the locks pf instruments can be 'Ieasedll satisfactorily. Instruments should never be handled in large masses but in small sets and individually.
Chromium instruments are porous and brittle. Chromium does not adr.ere well to basic metal.
Nickle plating possibly gives the most satisfactory and lasting coat to basic metal.
No surgical instrument should be IImarked. II (Example 1I0p . R. ") Marks breaks through the protective coat.
Stainless steel (1118 and 8") is the ideal material of which surgical instruments are made. It is resistantto gasses, discoloration, air, water, steam and salt and other corrosive materials and lends itself to design.
All instruments should be open when sterilized so that steam can penetrate the lock. In the absence of an instrument washer sterilizer which is designed to loosen and remove oil and dirt from instruments, place instruments in a fat solvent detergent to remove the oil.
339

The oiled areas on instruments harbour dirt, spores and bacteria and unless oil is removed, these areas are not sterilized.
Before instruments are "stored" they should be completely dry. In the absence; of an instrument washer sterilizer, place instruments in autoclave; allow steam in jacket and keep door ajar for the escape of steam. Instruments exposed to to 270 oF. cycle 8 - 12 minutes will be sterile. All contam.inated instruments should be sterilized before washed by hand if an instrumentwwasher sterilizer is not available. REFERENCE:
"Aseptic Treatment of Wounds" Carl W. Walter, A. B., M. D., MacMillan Co., 1948
340

Figure 70
APPENDECTOMY 1. Forceps, Sponge (2) 2. Needle Holder, Long Handle (2) 3. Forceps, Holstead Mosquito Curved (6) 4. Hemostats , Kelly, Murphy Straight (12) 5. Hemostats, Rochester Peans Kelly's Curved (6) 6. Towel Clamps (6) 7. Scissors, Suture (2) 8. Allis Clamps (4)
9. Knife Handles #3 and #4 (2)
10. Forceps, Tissue Short with Teeth (I) Forceps, Tissue Short Without Teeth (I)
11. Retractor, Parker (2) 12. Scissors, Curved Tissue 13. Retractor, Richardson's Small Assorted 14. Retractor, Rake (2) 15. Forceps, Babcock's Long Handle (2) 16. Forceps, Tissue Long Without Teeth (1)
Forceps, Tissue Long with Teeth (1) 17. Needle Set and Needle Rack
341

Figure 71

CHOLECYSTECTOMY

1. Kochers, Straight (2)

17.. Gall Spoon, Mayo, Common Duct

2. Forceps, Stone, Stellis (4)

Spoon Set (5)

3. Forceps, Mayo, Blake, Gallstone (1) 18. Gall Probe Set, Dejardinis, (6)

4. Sponge Sticks (4)

19. Gallstone Scoops Set, Ferguson(6)

5. Sci s s or s, Metzenbaum, Curved ( 1)

20. Balfour Retractor and blade

6. Sponge Sticks (4)

21. Retractor, Deaver (2)

7. Scissors, Dissecting, Curved (1)

22. Balfour Retractor

8. Needle Holder, Long Handle (3)

23. Retractor, Richardsno' s

9. Scissors, Suture, Straight (2)

24. Mixter Curved Clamps (6)

10. Forceps, Schnidt's, Hemostatic,

25. Forceps, Babcock's (2)

Curved (3)

26. Thumb forceps, Extra Long Without

11. Forceps, Rochester, Pean's or

Teeth

Kelly's (6)

Thumb Forceps, Medium Without

12. Forceps, Kelly, Murphy,

Teeth

Straight ( 12)

27. Retractor, Parker's 2

13. Clamps, Towel (12)

28. Needles, Assorted with Holder

14. Allis Clamps (6)

29. Knife Handles #3 and #4

15. Mixter Curved Clamps (6)

30. Tissue Forceps, Short with Teeth

16. Dilators, Common Duct Set,

31. Knife Handle #7

Brake's (9)

342

,1.

15

If

Figure 72
DILITATION AND CURETTAGE (D AND C) 1. Speculum, Weighted (1) 2. Tenaculum, Double (1) 3. Probe, Uterine (1) 4. Dilators, Hegar's Ute.rine (I-Set) 5. Dilators, Goodell's Uterine (1)
6. Speculum, Grave's Vaginal, Medium (1)
7. Tenaculum, Single (1) 8. Forcep, Sponge (1) 9. Forcep, Sponge (1) 10. Speculum, Sims Vaginal (2) 11. Towel Clips (4) 12. Curretts, Uterine (4), Assorted Siz~s, Dull and Sharp 13. Forceps, Uterine Dressing (1) 14. Dilator, Starlinger's Uterine
343

t!- \II [[f

"

If

,..

~~f

/0

" n ..

'1

!

't

8'

Figure 73

EXCISION OF LIPOMA
1. Sponge Sticks (4) 2. Sponge Sticks (4) 3. Needle Holder, Large (2) 4. Towel Clips (6) 5. Hemostats, Mosquite (6) 6. Hemostats, Curved, Halstead (6) 7. Hemostats, Kelly, Murphy Straight (6) 8. Allis Forceps, Plain (4) 9. Retractor, Self Retaining (1) 10. Tissue Forceps, Short With Teeth (1)
Tissue Forceps, Short Without Teeth (1) 11. Scissors, Tissue (2) 12. Scissors, Suture (2) 13. Rochester Peans, Curved, Kelly Curved (6) 14. Retractor, Richardson's, Assorted Sizes (3) 15. Forceps, Intestinal, Babcock's (2) 16. Knife Handle #3 and #4 17. Groove Director (1) 18. Forceps, Long Tissue With Teeth (1)
Forceps, Long Tis sue Without Teeth (1) 19. Retractor, Parker (2) 20. Needle Set In Holder

344

Figure 74

HEMORRHOIDECTOMY

1. Forceps, Sponge (2)

2. Forceps, Sponge (2)

3. Needle Holder (2); Long Handle (1), Short Handle (1)

4. Clamps, Pennington (4)

5. Hemostats, Kelly, Murphy, Straight (6)

6. Hemostats, Pean's, Kelly's (6)

7. Clamps, Towel (4)

8. Allis Clamps (6)

9. Knife Handle #3 (1)

10. Probe and Groove Director (4)

11. Forceps, Tissue, Short With Teeth (1) Forceps, Tissue, Short Without Teeth (1)

12. Scissors, Tissue, Curved (1) Scissors, Suture (1)

13. Speculum, ,Rectal, Assorted (2)

14. Speculum, Rectal, Assorted (2)

15. Forceps, Tissue, Long With Teeth (1)

...

Forceps, Tissue, Long Without Teeth (1)

16. Needle Set With Rack

345

\
I
Ii;,
'I
10.

n
rr ,1.

18
''''
,~
15'

,

3

s-

u,

Figure 75
HERNIORRHAPHY 1. Forceps, Babcock (2) 2. Allis Clamps (6) 3. Forceps, Rochester Peans, Kelly' s Curved (6) 4. Forceps, Halstead (12) 5. Forceps, Halstead (12) 6. Forceps, Sponge (4) 7. Forceps, Sponge (4) 8. Knife Handle, #3 and #4 (2) 9, Towel Clips (6) 10. Needle Holder, Long (1) 11. Needle Holder, Short (1)
12. Retractor, Parker (2)
13. Forceps, Tissue With Teeth (1) Forceps, Tissue Without Teeth (1)
14. Scissors, Dissecting Curved (1) 15. Scissors, Suture (2) 16. Forceps, Tissue, Short With Teeth (1)
Forceps, Tissue, Short Without Teeth (1) 17. Retractors, Richardson, Assorted Sizes (3) 18. Needle Set In Holder

346

17

,

1

I

I.

"

u.
~~

1.-

3

"I

Figure 76
LAPOROTOMY
1. Needle Holder, Short Handle (1) 2. Needle Holder, Long Handle (2) 3. Knife Ha?<!le #3 and #4 (2) 4. Hemostats, Kelly, Murphy (12) 5. Allis Clamps (6) 6. Hemostats, Kelly, Curved (6) 7. Towel Clamps (12) 8. Uterine Tenaculum, Single (1) 9. Sponge Sticks (40 10. Sponge Sticks (4) 11. Forceps, Babcock's Long Handle (3) 12. Tissue Forceps With Teeth, Long and Short (2) 13. Retractors, Parker's (2) 14. Forceps, Tissue Without Teeth (2) 15-. Uterine Tenaculum, Double (1) 16. Scissors, Curved, Tissue (1) 17. Michael Wound Clips and Appliers (2) 18. Michael Wound Clips and Appliers (2) 19. Balfour Retractor With Blade 0) 20. Retractors 21. Balfour Retractor With Blade (1) 22. Needle Set (1) 23. Scissors, Curved, Suture (2)
347

[[ I.

"

q

Ie
!

'A

11"II..

re.,.

3 ~s "

Figure 77

MASTECTOMY
1. Forceps, Long Sponge (4) 2. Forceps, Long Sponge (4)
3. Needle Holder, Long Handle (2) 4. Towel Clips (12) 5. Forceps, Halstead, Mosquito, Straight (12)
6. Forceps, Kelly, Murphy, Straight (12)
7. Forceps, Rochester Peans or Kelly's (12) 8. Allis Clamps (6) 9. Knife Handles #3 and #4 (2) 10. Forceps, Tissue, Short With Teeth (1)
Forceps, Tissue, Short Without Teeth (1) 11. Forceps, Tissue, Long With Teeth (1)
Forceps, Tissue, Long Without Teeth (1) 12. Scissors, Dissecting, Curved (1) 13. Scissors, Suture, Straight (2) 14. Retractor, Richardson's, Small (2) 15. Retractor, Beckman's, Self Retaining (1) 16. Retractor, Rake, Assorted Sizes (2) . 17. Retractor, Rake, As sorted Sizes (2) 18. Retractor, Parker (2) 10. Needles, Assorted

348

Figure 78

THYROIDECTOMY

1. Sponge Sticks (4)

14. Scissors, Tissue, Curved (1)

2. Sponge Sticks (4)

15. Scissors, Suture (2) (

3. Needle Holders (3); Short Handle (2), Long Handle (1)
4. Towel Clips (8)
5. Forceps, Halstead's Mosquito, Curved (12)
6. Forceps, Halstead's, Mosquito, Curved (12)

16. Lehey's Clamps, Tenaculum (4) 17. Mastons Muscle Clamp (4) 19. Retractor, Beckman's Self
Retaining (1) 20. Forceps, Babcock's (3)
21. Retractors, Rake, Assorted (4)

7. Hemostats, Straight, Kelly, Murphy (12)22. Retractors, Rake, Assorted (4)

8. Allis Clamps (6)

23. Retractor, Parker's (2)

9. Hemostats, Rochester Peans, Kelly's, 24. Tracheotomy Tuber Set

Curved (12)

25. Needle Set, Rack

10. Groove Director and Probe (1)

26. Michael Wound Clips and Appliers

11. Knife Handle #3 and #4 (2) 12. Forceps, Tissue, Long (2)

27. Michael Wound Clips and Appliers

13. Forceps, Tissue, Short With Teeth (2) \ Forceps, Tissue, Short Without Teeth (1)

349

I
)9

1
,13 2."
,.,

Figure 79
VEIN LIGATION
1. Forceps, Sponge (4) 2. Forceps, Sponge (4) 3. ,Knife Handles #3 and #4 (2) 4. Forceps, Halstead's, Mosquito, Curved (12) 5. Forceps, Halstead's, Mosquite, Curved (12) 6. Hemostats, Kelly, Murphy (6) 7. Allis Clamp s (4) 8. Forceps, Rochester's Pean's, Kelly's Curved (6( 9. Needle Holder, Short ( 1) 10. Needle Holder, Long (2) '11. Retractor, Beckman's, Self Retaining (1) 12. Forceps, Tissue, Short With Teeth (1)
Forceps, Tissue, Short Without Teeth (1) 13. Retractor, Rake 14. Probe and Groove Retractor (1) 15. Scissors, Tissue, Small Curved (1) 16. Scissors, Tissue, Curved (1) 17. Forceps, Babcock's (2) 18. Towel Clamps (6) 19. Retractor, Parker's (2) 20. Retractor, Vein (2) 21. Retractor, Vein (2) 22. Retractor, Rake (2) 23. Needle Set (1) 24. Scissors, Suture (2)
350

Figure 80
INSTRUMENTS FOR TONSIL AND ADENOID OPERATION 1. La Force Adenotome 2. La Force Adenotome 3. Coakley Needle Holder 4. Tonsil Seiging Forceps 5. Toneculum
6. Scissors, Curved
7. Scissors, Straight 8. Tivnen Tonsil Seiging Forcep
9. Jennings Mouth Gag
10. Weder Tongue Depressor 11. Weder Tongue Depressor 12. Gwathmey Vapor Hook 13. Evans Tonsil Snare 14. Beck Tonsil Snare 15. Yankover Suction Tip 16. Emesis Basin 17. Tonsil Sponges 18. Bard-Parker Knife Handle 19. Hurd Pillar Retractor 20. R\l.bber Suction Hose
351

OPERATING ROOM SAFETY
As minimum protection, hospitals are urged to carry out the following 10 recommendations:
1. Wool blankets, plastic sheets and most of the usual synthetic fabric materials should not be used around anesthetic gas equipment or patients ane sthetized with combustible gas mixture s.
2. Conductive rubber mattresses, pads and pillows should be substituted the ordinary variety as soon as they are available. (Conductive substances pass on electricity before charges can be built up to the sparking point. )
3. Conductive shoes should be worn by all personnel working around combustible anesthetic or anesthetized patients.
4. Conductive rubber breathing tubes, masks and bags should be installed on existing anesthesia machines as soon as they can be obtained and should be standard equipment on all new machines.
5. Conductive floors should be installed in all opearting and delivery rooms and in other rooms where combustible anesthetics are administered.
6. Stools with smooth, round feet and bare-metal tops are the most satisfactory and should be used.
7. Nonconductive casters, tires, and stool-leg tips should be replaced by conductive rubber or other suitable material on all equipment in the danger area.
8. Outer garments of wool, silk or synthetic materials, such as rayon, nylon, orIon, should be prohibited in anesthetizing locations.
9. Receptacles and plugs that cannot be pulled apart accidentally should be installed where needed.
10. A suitable measuring instrument should be installed in a convenient and safe place for testing the conductivity of shoes of all persons entering areas where explosive gaseous anesthetics are administered.
From a document titled "Static Electricity in Hospital Operating Suites and Direct and Related Hazards and Pertinent Remedies." For those who want to read all the documented evidence, the report may be obtained without cost by writing U. S. Bureau of Mines, 4800 Forbes Street, Pittsburgh 13.
352

INDEX
Abbott Intravenous Set Abdominal Paracentesis Administration of Central Supply Administration of Medications Administration of Operating Room Administration of Oxygen
Face Mask Oxygen Tent Admission of New Patient Anesthetic Bed Appendectomy Instruments Application of Cold, Local Cold Wet Compresses Application of Heat Hot Water Bottle Electric Pad Hot Stupes Compresses Fomentations Sterile Wet Compresses Atrerial Transfusion Set Arterial Transfusion Table Asepsis, Medical Asepsis, Surgical Autoclave Sterilization Autotransfusion Set Axillary Temperature
Basal Metabolism Basic Procedures, Nursing Bath, Bed
Afternoon Care Morning Care Tub Baths Bran Medicated and Colloid Oatmeal Potassium Permanganate Sitz Starch
353

Page
268 124, 286
228 206
313
214 216 216
55 44 341 156 157 151 151 152 152 152 152 154 297
303
32 322 239 269
91
136 37 59, 61 65 65 67 145 145 145 146 148 148 147

INDEX- -Continued
Bedpan, Giving Removing
Beds Anesthetic Cardiac Occupied Recovery Shock Unoccupied
Biliary Drainage Biopsy Tray Bladder Drainage Set Bladder Irrigation Tray Blood, Amount to be Collected Blood Containers, Type Blood Pressure
Care of Hypodermic Needles Autoclaving Breakage of Syringe Cleaning Construction of Needles Construction of Syringes Determine Size Hot Air Sterilization How Syringes are Made Repair Stuck Syringe
Cardiac Bed Cardiac Resuscitation Care of Mouth
Dentures Care of Surgical Instruments Catheter, Indwelling Catheterization Catheter Tray Central Supply
Administration Physical Layout Organization Services Standardization Central Supply Room Arrangement
354

Page
73 74 42 44 46 42 42 44
.39 113 282 270 271 110 110 92
248, 258, 260 249 255 248 256 256 249 249 250 248 259 46 272 70 71 339 164 197 273 224
ZZ8 ZZ7 ZZ8 ZZ6 ZZ9 ZZ5

INDEX- -Continued
Central Supply Services Chart for Sterilizing
Hot Air Stearn Pressure Cholecystogram Intravenous Method Oral Method Cholecystectomy Instruments Cold Wet Compresses Collection of Feces Specimens Collection of Sputum Specimens Nose and Throat Specimens Collection of Urine Specimens Colonic Irrigation Colostomy Irrigation Compresses Concept of Nursing Construction of Hypodermic Syringes Containers, Blood Cystogram Cystoscopic Examination
Davis Roller Dentures, Care Diagnostic Procedures
Biliary Drainage Cholecystogram Diagnostic Tests Dilitation and Curettage Instruments Dishwashing Water Temperature Disinfection, Concurrent Terminal Douche, Perineal Douche, Tray Dressing Tray, Emergency Dysentery Specimen
Ear Irrigation Electric Pad Electr ocardiogr am Elimination Emergency Dressing Tray
355

Page
224, 226 244 246 244 115 116 115 342 157 106 107 108 103 191 195 152
1
256, 257, 260 110 141 141
53 71 111 113 115 83 343 19 20
7 7 174, 177
274 275 106
158 152 138 59,73 275

INDEX- -Continued
Emergency Medication Tray Enema
Medicated Retention Escorting Patients Evening Care Excision of Lipoma, Instruments Eye Compresses Eye Irrigation
Face Mask Face Masks
Handling Making Sterilizing Washing Wearing Feces Collection Feces for Culture Feces Disposal Feeding Helpless Patient Fenwal Set Folding, Packaging and Sterilizing Linens Fomentations
Garbage Disposal Gastric Alanysis Gastric Analysis Tray Gastric Gavage Gloves Glucose Tolerance Test Gown and Glove Technique Gown Technique
Hand Scrub, Surgical Handwashing
Procedure Helpless Patient
Davis Roller Feeding Moving Hemorrhage Tray Nasal Tonsil
356

Page
310 200 203
48 59,65
344 154 161
216 27 30A 27 27 27 29
106 106
18 75 295 230 152
17 117 277 187 267 122 322
30B
320 25 26 51 53 75 51
284 284 284

INDEX--Continued
Hemorroidectomy Instruments Herniorrhaphy Instruments Hospitalization, Interaction Housekeeping Procedures
.Cleaning Suggested Readings Hot Compress Tray Hot Stupes Hot Water Bottle Hypodermic Needles, Care Autoclaving Breakage of Syringes Construction of Needle s Construction of Syringes Cleansing Determine Size Hot Air Sterilization How Syringes are Made Repair Stuck Syringe Hypodermic Supply, Bulk Hypodermic Supply, Individual Hypodermic Tray, Individual Hypodermoclysis
Infant Spinal Puncture Tray Injections Intravenous Set (Abbott) Intravenous Set (Fenwal) Intravenous Set (Kelly) Instruments, Surgical Irrigations
Bladder Colostomy Ear Eye Nasal Perineal Douche Rectal Stomach Throat Vaginal Wound
357

Page
345 346
4
10 10 16 278 152 151 . 248, 258, 260 249 255 256 256 248 249 249 250 248 259 309
311
308
211
292 208 268 280 279 341- 352 158 197 195 158 161 171 174 191 183 168 180 188

INDEX- - Continued
Kelly Subcutaneous Set
Laboratory Tests Urinalysis
Laporatomy Instruments Linen, Care
Contaminated Linens
Folding Packaging Sterilizing Liver Biopsy Tray Lumbar Puncture
Masks Making Sterilizing Washing Wearing
Mask, Oxygen Face Mastectomy Instruments Medical Asepsis Medicated and Colloid Baths Medicated Enema Medication Tray, Emergency Medications, Administration Metabolism, Basal Morning Care Mouth Care Mouth Temperature
Nasal Hemorrhage Tray Nasal Irrigation Nasal Irrigation Tray Nose and Throat Specimens Nursing Care
Postoperative Preoperative Nursing, Concept Nursing Procedures Nursing Team Nursing Unit
358

Page
296
99 99 347 23 30F 230 230 230 230 282 132
27 27 27 27 29 216 348 32 145 203 310 206 136 59,65 70 88
284 171 283 108 77 80 77
1 37
1 38

INDEX- -Continued

Oatmeal Bath Occupied Bed Operating Room Operating Room Safety Organization of Central Supply Organizaiton of Operating Room Orthopedic Prep Tray Oxygen, Administration
Paracentesis Abdominal
Paracentesis Tray, Abdominal Parasites and Ova Patient, Admission Pericardial Fluid, Removal Perineal Douche Perineal Irrigation Tray Personal Adjustment to Hospital Situation Phenolsulfonphthalein Test Physical Examination Physical Layout of Central Supply Pneumarthrogram Postoperative Nursing Care Potassium Permanganate Preoperative Nursing Care Preoperative Setup Processing Rubber Goods Proctoscopic Examination

Recipient Set

Recovery Bed

Rectal Irrigation

Rectal Temperature

Relationships

Renal Function Tests

Phenolsulfonphthalein

Resuscitation, Cardiac

Retention Enemas



Retrograde Irrigating Set

Rubber Goods, Processing

Safety in Operating Room
Services of Central Supply Shelves of Operating Room

359

Page
146 42 312 352 228 313 285 214
124 125 286 106 55 139 174, 177 287
3 120
85 227 288
80 148
77 329 264
95
289 42 191 90 5 119 120
272 203 290 264
352 226 317

INDEX- -Continued
Shock Bed Sitz Baths Sodium Bicarbonate Spinal Puncture Tray
Adult Infant Spinal Sympathetic Block Sputum Disposal Sputum Specimens, Collection Standardization of Central Supply Starch Bath Sterilization by Autoclave Air Discharge Pressure Temperature Sterilizing Chart Hot Air Steam Pressure Sterilizing Time Table Hot Air Steam Pressure Stomach Drainage Stomach Irrigation Stomach Suction Stretcher Transportation Subcutaneous Infusion Subcutaneous Set, (Fenwal) Subcutaneous Set, (Kelly) Suction of Stomach Supplies for Operating Room Shelves Surgical Asepsis Surgical Hand Scrub Surgical Instruments, Care Sympathetic Block
Team Nursing Temperature
Axilla or Grain Mouth Rectum Temperature, Pulse and Respiration Tent, Oxygen Terminal Disinfection Patient Unit, Disinfection
360

Page
44 148 148 291 294 292 293 18 107 229 147 239 242 242 242 244 246 244 243 246 244 204 183 204
51 211 295 296 204 317 322 320 339 293
1 88 91 88 90 87 216
7 34

INDEX- -Continued
Tests, Diagnostic Therapeutic Procedures Thoracentesis Thoracentesis Tray Thoracotomy Bottle and Tube Throat Irrigation Throat Irrigation Tray Thyroidectomy Instruments Tidal Drainage Set Time Table for Sterilizing Tonsil and Adenoid Instruments Tonsil Hemorrhage Tray Tracheotomy Tray Transfusion Set, Arterial Transfusion Set, Infant Transfusion Table, Arterial TransPQrting Patients
Stretcher Wheelchair Trash Disposal Trays in Central Supply Typhoid Specimen.
Unoccupied Bed Procedure for Making
Urinalysis Urine Specimen Collection
Vaginal Biopsy Vaginal Examination Vaginal Examination Tray Vaginal Irrigation Vein Ligation Instruments Venipuncture Venoclysis Venous Cut Down Venous Pressure Ventriculogram
Wheelchair Transportation Wound Irrigation
361

Page
83 143 128 281 298 168 299 349 300 243 351 284 301 297 302 303
48 51 49 17 267- 311 106
38 39 99 103
304 97
276 180 350 218 218 305 306 307
49 188