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HANDWASHING
PURPOSES
To reduce the number of microorganisms in the hands
To reduce the rick of transmission
To reduce the risk of cross-contamination among clients
To reduce the rick of transmission of infectious organisms to one self
ASSESSMENT
Determine the clients
Presence of factors increasing susceptibility of infection and possibility of
undiagnosed infection (e.g., HIV).
Use of immunosuppressive medications.
Recent diagnostic procedures or treatment that penetrated the skin of body
cavity.
Current nutritional status.
Signs and symptoms indicating the presence of an infection.
Localized signs such as swelling, redness, pain or tenderness with palpation
or movement, palpable heat at site, loss of function of affected body part,
presence of exudates.
Systemic indications, such as fever, increased pulse and respiratory rates,
lack of energy, anorexia, enlarged lymph nodes.
PLANNING
Determine the location of running water and soap or soap substitutes.
DELEGATION
-The technique of hand washing is identical for all health care providers,
including unlicensed assistive personnel (UAP). Health care team members
are accountable for the implementation of appropriate hand washing
procedures by themselves and others.
Equipment
Soap
Warm running water
Disposable or sanitized towels
IMPLEMENTATION
Preparation
Assess the hands.
Nails should be kept short.
Rationale: Short, natural nails are less likely to harbour microorganisms,
scratch a client, or puncture gloves. Most agencies do not permit health care
workers in direct contact with clients who have any form of artificial nails.
Remove all jewelry.
Rationale: Microorganisms can lodge in the setting of jewelry and under
rings. Removal facilitates proper cleaning of the hands and arms.
Check hands for breaks in the skin, such as hangnails or cuts.

1.

2.

a)
b)
c)
d)
e)

3.

4.

Rationale: A nurse who has open sores may require a work assignment with
decreased risk for transmission of infectious organisms due to the chance of
acquiring or passing on an infection.
PERFORMANCE
If you are your hands where the client can observe you, introduce
yourself and explain to the client what you are going to do and why it is
necessary .
Turn on the water and adjust the flow.
There are five common types of faucet controls:
Hand-operated handles
Knee levers. Move these with the knee to regulate the flow and the
temperature.
Foot pedals. Press these with the foot to regulate flow and temperature.
Elbow controls. Move these with the elbows instead of the hands.
Infrared control. Motion in front of the sensor causes water to start and
stop flowing automatically.
Adjust the flow so that the water is warm.
Rationale: Warm water removes less of the protective oil of the skin than
hot water.
Wet the hands thoroughly by holding them under the running water and
apply the soap to the hands.
Hold the hands lower than the elbows so that the water flows from the arms
to the fingertips
Rationale: The water should flow from the least contaminated to the most
contaminated area; the hands are generally considered mor4e contaminated
than the lower arms. Note that this is a different technique than is used when
performing surgical hand washing. Nurses will learn to perform that level of
hand washing if they are working in the operating room.
If the soap is liquid, apply 2 to 4 ml (1 tsp). If it is a bar soap, granules, or
sheets, rub them firmly between the hands.
Thoroughly wash and rinse the hands.
Use firm, rubbing, and circular movements to wash the palm, back, and the
wrist of each hand. Be sure to include the heel of the hand. Interlace the
fingers and thumbs, and move the hands back and forth.

Continue this motion for at least 15 seconds (Boyce and Pittet, 2002;
Houghton, 2006).
Rationale: The circular action creates friction that helps remove
microorganisms mechanically. Interlacing the fingers and thumbs cleans the
interdigital spaces.
Rub the fingertips against the palm of the opposite hand.
Rationale: The nails and fingertips are commonly missed during hand
washing.
Rinse the hands.

5.
Thoroughly pat dry the hands and arms.
Dry hands and arms thoroughly with a pare towel without scrubbing.
Rationale: Moist skin becomes chapped readily as does dry skin that is
rubbed vigorously; chapping produces lesions.
Discard the paper towel in the appropriate container.
6.
Turn off the water.
Use a new paper towel to grasp a hand-operated control.
Rationale: This prevents the nurse from picking up organisms from the
faucet
handles.
VARIATION: Hand Washing Before
STERILE TECHNIQUES
Apply the soap and wash as described in step 4, but hold the hands higher
than the elbows during this hand wash. Wet the hand and fore arms under
running water, letting it run from fingertips to the elbows so that the hands
become cleaner than the elbows.
Rationale: In this way, the water runs from the area that now has the
fewest microorganisms to area with a relatively greater number.
After washing and rinsing, use a towel to dry one hand thoroughly in a
rotating motion from fingers to the elbow. Use a new towel to dry the other
hand and arm.
Rationale: A clean towel prevents the transfer of microorganisms from one
elbow (least clean area) to the other hand (cleanest are)
EVALUATION
There is no traditional evaluation of the effectiveness of the individual
nurses hand washing. Institutional quality control departments monitor the
occurrence of client infections and investigate those situations in which
health care providers are implicated in the transmission of infectious
organisms. Research has repeatedly shown positive impact of careful hand
cleansing on client health associated with prevention of infection.
Reference:
Kozier and Erbs FUNDAMENTALS OF NURSING
Eight edition
VOLUME 1
pp. 684-686
Naso-Gastric Tube Insertion
Prepared By: Abigail Parinas

Delegation Considerations:
This skill requires problem solving and knowledge application unique to a
professional nurse. For this reason, delegation of this skill to assistive
personnel is inappropriate.
Equipments:
Nasogastic or nasointestinal tube( 8-12 Fr) with guide wire or stylet.
Stethoscope
60 ml or larger luer-lok or catheter-tip syringe
Hypoallergenic tape and tincture or benzoin or tube fixation device
Ph indicator strip (scale 0.0-14.0)
Glass of water and straw
Emesis basin
Safety pin
Rubber band
Towel
Facial tissues
Clean gloves
Suction equipment in case of aspiration
Penlight to check placement in nasopharynx
Tongue blade
STEPS
1.)Asses client for enteral tube feeding:NPO or
insufficient intake for more than 5 days, functional GI
tract, unable to ingest sufficient nutrients.
2.)Perform hand hygiene. Asses patency nares. Have
client close each nostril alternately and breathe. Examine
each naris for patency and skin breakdown.
3.)Asses for gag reflex. Place tongue blade in clients
mouth, touching uvula to induce gag response.

RATIONALE
Identifying clients who need tube feedings before t
become nutritionally depleted may help to prevent
complications related to malnutrition.
Evaluate nares for patency. Nares may be obstructe
irritated, or septal defect may be present.

Identifies ability to swallow and determines if ther

risk for aspiration.

4.)Review clients medical history for nasal problems(e.g., Nasoenteric tubes are contraindicated in clients wi
nosebleeds, oral and facial surgery, past history of
recent nasal surgery, facial traumas, nosebleeds and
aspiration, or anticoagulation therapy).
receives anticoagulation. This includes clients with
surgical procedures requiring a transpheriod appro
used to remove pituitary tumor, because there is a r
improper tube placement.
5.)Review physicians order for type of tube and enteral
Procedure and tube feedings require a physicians o
feeding schedule.
6.)Auscultate abdomen for bowel sounds.
Absence of bowel sounds may indicate decreases o
peristalsis and increased risk for aspiration and/or
abdominal distention.
7.)Perform hand hygiene.
Reduce transfer of microorganisms.
8.)Explain procedure to client and how to communicate
Reduces anxiety and helps client to assist in inserti
during intubation by raising index finger to indicate
gagging or discomfort.
9.)Stand on same side of bed as naris for insertion, and
Allows easier manipulation of tube. Fowlers posit
assist client to high fowlers positin unless
reduces risk of aspiration and promotes effective
contraindicated. Place pillow behind head and shoulders.
swallowing.
10.)Place bath towel over chest. Keep facial tissues within Prevents soiling of gown. Insertion of tube may pro
reach.
tearing.
11.)Determine length of tube to be inserted and mark with Length approximates distance from nose to stomac
tape:
98% of clients. For duodenal or jejuna placement,
a.) Traditional method: measure distance from tip of nose additional 20 to 30 cm is required.
to earlobe to xiphoid process to sternum.
12.)Prepare nasogastric or nasointestinal tube for
intubation:
Tubes will become stiff and inflexible, causing trau
a.) public tube should not be iced.
mucus membranes.
Aids in guide wire or stylet insertion.
b.) inject 10ml of water from 30ml or larger luer-lok or
catheter-tip syringe into the tube.
Promotes smooth passage of tube into GI tract.
c.) make certain that guide wire is securely positioned
Improperly positioned stylet can induce serious tra
against weighted tip and that both luer-lok connections are
snugly fitted together.
13.)Cut tape 10cm long or prepare tube fixation device.
To be used to anchor tubing following insertion.
14.)Put on clean gloves.
Reduces transmission of microorganisms.
15.)Dip tube with surface lubricant into glass of water.
Activates lubricant to facilitate passage of tube into
to GI tract.
16.)Insert tube through nostril to back of throat(posterior
Natural contour facilitates passage of tube into GI
nasopharynx). Aim back and down toward ear.
and reduces gagging by client.
17.)Have client flex head toward chest after tube has
Closes off glottis and reduces risk of tube entering
passed through nasopharynx.
18.)Emphasize need to mouth breathe and swallow during Helps facilitate passage of tube and alleviates clien
the procedure.
during the procedure.
19.)When tip of tube reaches the carina (about 25cm in an If air is heard, the tube could be in the respiratory t
adult), stop, hold end to tube near ear and listen for air
remove tube and start over. This step should never

exchange from the distal portion of the tube.

20.)Advance tube each time client swallows until desired
length has been passed.
21.)Check for position of tube in back of throat with
penlight and tongue blade.
22.)Perform measures to verify placement of the tube.
23.)After gastric aspirates are obtained, anchor tube to
nose and avoid pressure on nares. Mark exit site with
indelible ink. Select one of the following options.
a.) Apply tape
(1) Apply tincture of benzoin or other skin adhesive on tip
of clients nose and tube and allow it to become tacky.
(2) Remove gloves and split one end of tape lengthwise
5cm
(3) Place the intact end of tape over brdge of clients nose.
Wrap each of the 5cm strips around tube as it exits nose.
b.) Apply tube fixation device using shaped adhesive
patch.
(1) Apply wide end of patch to bridge of nose.
(2) Slip connector around tube as it exits nose.
24.)Fasten end of nasogastric tube to clients gown by
looping rubber hand around tube in slipknot. Pin rubber
band to gown.
25.)For intestinal placement, position client on right side
when possible until radiological confirmation of correct
placement has been verified. Removed gloves, perform
hand hygiene, and assist client to a comfortable position.
26.)Obtain X-ray film of abdomen.
27.)Apply clean gloves, and administer oral hygiene.

for tube verification.

Reduces discomfort and trauma to client.
Tube may be coiled, kinked, or entering trachea.

A properly secured tube allows the client more mo

and prevents trauma to nasal mucosa.
Helps tape adhere better. Protects skin.
Securing tapes to nares prevents tissue necrosis.
Secures tube and reduces friction on naris.

Reduces traction on the naris if tube moves.

Promotes passage of the tube into the small into th

intestine (duodenum or jejunum).

Placement of the tube is verified by x-ray examina

Promotes client comfort and integrity of oral muco
membranes.
Reduces transmission of microorganisms.

28.)Remove gloves, dispose of equipment, and perform

hand hygiene.
29.)Inspect naris and oropharynx for any irritation after
Insertion was difficult, irritation of naris or oropha
insertion.
may have occurred.
30.)Ask if client feel comfortable.
Evaluates clients level of comfort.
31.)Observe clients for any difficulty breathing, coughing, Malposition of the tube may cause these symptoms
or gagging.
32.)Auscultate lung sound.
Abnormal lung sounds can be early sign of aspirati
Unexpected Outcomes and Related Interventions
1.) Aspiration of stomach contents into the respiratory tract (immediate
response), evidenced by coughing, dysnea, cyanosis, auscultation of crackles
or wheezes
a.
Position client on side.
b.
Suction nasotracheally and oral tracheally.
c.
Consult physician immediately to order chest x-ray examination.

2.)

Aspiration of stomach contents into respiratory tract (delayed response),

evidenced by dysnea, fever, auscultation of crackles or wheezes
a.
Consult physician to obtain order for chest x-ray film.
b.
Prepare for possible initiation of antibiotics.
3.) Displacement of feeding tube to another site (e.g., from duodenum to
stomach, mark at exit site if tube is moved); may occur when client coughs
or vomits
a.
Aspirate GI contents and measure pH.
b.
Remove displaced tube and insert and verify placement of new tube.
c.
If there is a question of aspiration, obtain chest x-ray film.
4.) Clogging of feeding tube
a.
Aspirate gastric contents to assas patency of tube.
b.
Irrigate tube.
5.) Irritation of naris or nasal mucosa
a.
Provide hygiene and removing tube and inserting into other naris
(physician order required).

Suctioning
PURPOSE:
To assist in the removal of bronchial secretions that cannot be expectorated
by the
patient spontaneously.
EQUIPMENT:
Sub-micron mask
Suction Regulator/Equipment
Suction cannister
Connective tubing
02 flow meter
Resuscitation bag
Sterile suction catheter
Sterile gloves
Sterile cup (if needed)
Sterile H20
Stethoscope
Metered vials of normal saline (for tenacious secretions) or other irrigant
Water soluble lubricant (for N-T auctioning) Personal Protective Equipment
(gown,
goggles, gloves
INDICATIONS:
1. Visible presence of secretions in tube orifice
2. Coarse tubular breath sounds on auscultation
in patient unable to cough or without artificial airway in place.

3. Patient with an artificial airway

Explain procedure to patient.
Assemble equipment.
Perform hand hygiene.
Adjust bed to comfortable working position. Lower side rail closet to you.
Place patient in a semi-Fowlers position if he or she is conscious. An
unconscious patient should be placed in the lateral position facing you.
Place towel or waterproof pad across patients chest.
Turn suction to appropriate pressure.
Wall unit

Adult: 100 to 120 cm Hg

Child: 95 to 110 cm Hg

Infant: 50 to 95 cm Hg
Portable unit

Adult: 10 to 15 cm Hg

Child: 5 to 10 cm Hg

Infant: 2 to 5 cm Hg
Open sterile suction package. Set up sterile container, touching only the
outside surface, and pour sterile saline into it.
Don sterile gloves. The dominant hand that will handle catheter must
remain sterile, whereas the nondominant hand is considered clean rather
than sterile.
With sterile gloves. The dominant hand, pick up sterile catheter and
connect to suction tubing held with unsterile hand.
Moisten catheter by dipping it into container of sterile saline. Occlude Ytube to check suction.
Estimate the distance form earlobe to nostril and place thumb and
forefinger of gloved hand at that point on catheter.
Gently insert catheter with suction off by leaving the vent on the Yconnector open. Slip catheter gently along the floor of an unobstructed
nostril toward trachea to suction the nasopharynx. Or insert catheter along
side of mouth toward trachea to suction the oropharynx. Never apply suction
as catheter is introduced.
Apply suction by according suctioning port with your thumb. Gently rotate
catheter as it is being withdraw. Do not allow suctioning to continue for more
than 10 to 15 seconds at a time.
Flush the catheter with saline and repeat suctioning as needed and
according to patients toleration of the procedure.
Allow at least a 20- to 30-second interval if additional suctioning is needed.
The nares should be alternated when repeated suctioning required. Do not
force the catheter through the nares. Encourage patient to cough and
breathe deeply between suctioning.

 When suctioning is completed, remove gloves inside out and dispose of

gloves, catheter, and container with solution in proper receptacle. Perform
hand hygiene.
Use auscultation to listen to chest and breath sounds to assess
effectiveness of suctioning.
Record time of suctioning and nature and amount of secretions. Also note
the character of the patients respirations before and after suctioning.
Offer oral hygiene after suctioning.