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Basic Hospital Corps School FOREWORD

Handbook III
FOREWORD


MISSION OF NAVAL HOSPITAL CORPS SCHOOL

To train Sailors to perform as basic Navy Hospital Corpsmen.


The Student Handbook series was written to be used in the fourteen-week curriculum of the Basic Hospital
Corps School. There are three Handbooks in the series:

Handbook I - Fundamentals

Handbook II - Emergency Care

Handbook III - Nursing Care

The Student Handbooks contain reading and study material to supplement the classroom lectures and
demonstrations conducted during the course. Each topic in the course has a section in one of the Handbooks.
The text is followed by a Worksheet, which provides study questions based on the learning objectives. The
Worksheet questions are similar to those on the written examinations.

Tips for Success, eight pages of study techniques, test taking strategies, and suggestions for time
management follow the Foreword in Handbook I.

The Student Handbooks are best used to read and prepare for upcoming classroom lectures, to re-read and
fill-in the worksheet assignments and finally, re-reading as many times as necessary in preparation for written
examinations and laboratory performance.

Students who keep their Handbooks after graduation will find them to be an excellent study guide for
advancement examinations and an outstanding reference during future duty assignments.

Study smart or study hard, the choice is yours.





Naval Hospital Corps School is accredited by the Council on Occupational Education












i
FOREWORD Basic Hospital Corps School
Handbook III

ii
Hospital Corps School TABLE OF CONTENTS
Handbook III
TABLE OF CONTENTS

Foreword................................................................................................................................. i

Table of Contents..................................................................................................................iii

Lesson 3.01 Military Health Records......................................................................................................... 1
Military Health Records Worksheet...................................................................................... 7

Lesson 3.02 Basic Physical Examination................................................................................................. 11
Basic Physical Examination Worksheet .............................................................................. 17

Lesson 1.22 Preventive Medicine............................................................................................................ 19
Preventive Medicine Worksheet.......................................................................................... 27

Lesson 3.03 Patient Care Documentation................................................................................................ 31
Patient Care Documentation Worksheet.............................................................................. 37
Patient Care Documentation Scenarios................................................................................ 41
Patient Care Documentation Forms..................................................................................... 47

Lesson 3.05 Admission and Discharge.................................................................................................... 53
Admission and Discharge Worksheet.................................................................................. 57
Admission and Discharge Scenario..................................................................................... 61
Admission and Discharge Forms......................................................................................... 63

Lesson 3.04 Inpatient Clinical Record..................................................................................................... 73
Inpatient Clinical Record Worksheet................................................................................... 77
Inpatient Clinical Record Scenario...................................................................................... 81
Inpatient Clinical Record Forms.......................................................................................... 83

Lesson 3.07 Nasogastric Tubes................................................................................................................ 89
Nasogastric Tubes Worksheet.............................................................................................. 95

Lesson 3.06 Inpatient Care....................................................................................................................... 99
Inpatient Care Worksheet .................................................................................................. 101

Lesson 3.08 Range of Motion and Patient Positioning.......................................................................... 103
Range of Motion and Patient Positioning Worksheet........................................................ 115

Lesson 3.09 Restraining a Patient.......................................................................................................... 119
Restraining a Patient Worksheet........................................................................................ 123

Lesson 3.10 Isolation Techniques & Blood Borne Pathogens............................................................... 125
Isolation Techniques & Blood Borne Pathogens Worksheet............................................. 138

Lesson 3.11 Surgical Asepsis ................................................................................................................ 143
Surgical Asepsis Worksheet ............................................................................................. 154


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TABLE OF CONTENTS Hospital Corps School
Handbook III
Lesson 3.14 Urinary Catheterization...................................................................................................... 160
Urinary Catheterization Worksheet . ................................................................................. 172

Lesson 3.13 Specimens. ......................................................................................................................... 178
Specimens Worksheet........................................................................................................ 188

Lesson 3.12 Wound Management.......................................................................................................... 192
Wound Closure Management............................................................................................. 196

Lesson 1.23 DOD Immunization Program............................................................................................. 198
DOD Immunization Program Worksheet .......................................................................... 200

Lesson 3.16 Introduction to Medication Administration ...................................................................... 202
Introduction to Medication Administration Worksheet ................................................... .208

Lesson 3.15 Pharmacology and Toxicology ......................................................................................... 210
Pharmacology and Toxicology Worksheet........................................................................ 228

Lesson 3.18 Dosage Calculations .......................................................................................................... 232
Dosage Calculations Worksheet....................................................................................... 236

Lesson 3.19 Oral Medications Administration ...................................................................................... 240
Oral Medications Administration Worksheet ................................................................... 246

Lesson 3.17 Storage of Medications ..................................................................................................... 256
Storage of Medications Worksheet ................................................................................... 258

Lesson 3.20 Sublingual/Topical/Rectal Medication Administration .................................................... 262
Sublingual/Topical/Rectal Medication Administration Worksheet................................... 266

Lesson 3.21 Intramuscular and Subcutaneous Medications Administration.......................................... 270
Intramuscular and Subcutaneous Medications Administration Worksheet ...................... 282

Lesson 3.24 Venipuncture...................................................................................................................... 286
Venipuncture Worksheet .................................................................................................. 290

Lesson 3.25 Introduction to Intravenous Therapy ................................................................................. 294
Introduction to Intravenous Therapy Worksheet .............................................................. 300

Lesson 3.26 Maintenance of Intravenous Therapy................................................................................ 304
Maintenance of Intravenous Therapy Worksheet ............................................................. 310

Lesson 3.27 Intravenous Insertion......................................................................................................... 316
Intravenous Insertion Worksheet....................................................................................... 324

Lesson 3.22 Pain Management............................................................................................................... 330
Pain Management Worksheet............................................................................................ 334




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Hospital Corps School TABLE OF CONTENTS
Handbook III
Lesson 3.29 Cast Care............................................................................................................................ 338
Cast Care Worksheet.......................................................................................................... 342

Lesson 3.30 Chest Tubes........................................................................................................................ 344
Chest Tubes Worksheet..................................................................................................... 356

Lesson 3.28 Respiratory Care................................................................................................................ 360
Respiratory Care Worksheet.............................................................................................. 368

Lesson 3.23 Pre-operative and Postoperative Nursing Care.................................................................. 372
Pre-operative and Postoperative Nursing Care Worksheet................................................ 384
Pre-operative and Postoperative Nursing Care Scenario................................................... 388
Pre-operative and Postoperative Nursing Care Forms....................................................... 390

Lesson 3.31 Death and Dying................................................................................................................ 396
Death and Dying Worksheet.............................................................................................. 402


Lesson 3.32 Transferring and Ambulating a Patient. 406
Transferring and Ambulating a Patient Worksheet412

Appedix1 ........................................................................................................................................A-1-1
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TABLE OF CONTENTS Hospital Corps School
Handbook III

vi
Basic Hospital Corps School Lesson 3.01 Military Health Records
Handbook III
Lesson 3.01

Military Health Records

Terminal Objective:

3.01 Know how to maintain and use military health records.

Enabling Objectives:

3.01.01 List the categories of health records.

3.01.02 State the use for each health record form.

3.01.03 List the sequence of forms in a health record.

3.01.04 List regulatory provisions concerning maintenance of health records.


CATEGORIES OF HEALTH
RECORDS

There are three categories of health or
treatment records. The outpatient record for active
duty members of the uniformed services is called
the Health Record, which is used to document
medical care provided to members of the
uniformed services. The Dental Record, which is
used to document dental care provided to active
duty members, is not normally maintained by
hospital corpsman. These are two separate records,
although they may be filed together with the dental
record inside the medical record.

The record used for the documentation of
outpatient medical care provided to all patients
except active duty members of the uniformed
services is called the Outpatient Treatment
Record. The Outpatient Treatment Record is used
for retired military personnel and eligible family
members of:

a. Active duty members

b. Deceased active duty members

c. Retired military personnel.

When an active duty member retires, his/her
Health Record is retired with the service record.
An Outpatient Treatment Record is initiated for
the retiree. A COPY of the Health Record contents
may be placed into the retiree's Outpatient
Treatment Record. Other beneficiaries for medical
care include foreign military personnel attached to
United States military units or bases, their eligible
family members, and civilian employees of our
government (civil service).

An Inpatient (Clinical) Record is used to
document hospital inpatient care given to all
beneficiaries of Navy medical care.

LOCATION, NAME AND PURPOSE
OF FORMS IN HEALTH RECORDS

Health records serve three main purposes.
First, they provide a chronological record of
physical examination, illnesses, injuries and
treatment, and susceptibility to illnesses. Second,
the forms in the health record provide a means of
communication between the practitioner
responsible for the patient's care and all other
members of the health care team. If an active duty
member is evaluated by the physician on his/her
ship and then sent for further evaluation at a
hospital, the evaluation of the ship's doctor will be
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Lesson 3.01 Military Health Records Basic Hospital Corps School
Handbook III
available in the health record for the doctor at the
receiving hospital to read. Third, these records are
a medical/legal document that may be used as
evidence in both military and civilian courts of
law.

Forms that are in health records have different
purposes and special locations that enable the
Hospital Corpsman to locate and use them quickly.
The record is divided into four parts.

Part 1: Record of Preventive Medicine and
Occupational Health

Part 2: Record of Medical Care and
Treatment

Part 3: Physical Qualifications

Part 4: Record of Ancillary Studies, Inpatient
Care, & Miscellaneous Forms

All reports and forms are stored in the
Treatment Record Folder NAVMED 6150/21-
30. The forms are filed in a specific order in every
record so they can be easily located. When there
are multiple copies of the same form, they are filed
chronologically, with the most recent dated form
on top. The forms discussed in this handbook are
some of the most commonly seen forms, generally
available in each health record. There are many
more forms and each one is filed in a specific
location in the health record.

PART 1: Record of Preventive Medicine
and Occupational Health.

The Summary of Care Form NAVMED
6150/20 is the topmost form in Part 1 of the health
record. It is a record of ambulatory (outpatient)
health care. It includes, but is not limited to,
significant medical and surgical conditions,
allergies or untoward reactions to drugs, current or
recently used medication, and routine medical
examinations or tests.

The next form is the Immunization Record
SF 601 on which prophylactic immunizations
(tetanus, typhoid, etc.) and information concerning
hypersensitivities are recorded.
Chronological Record of HIV Testing
NAVMED 6000/2 is the next form in Part 1. This
form contains a listing of all HIV tests drawn and
the results.

Baseline Audiogram DD 2215, required for
all active duty personnel, is used as a reference
audiogram to determine possible hearing changes
or loss.

PART 2: RECORD OF MEDICAL
CARE AND TREATMENT

The following three forms are interfiled
chronologically with the most recent visit (by date)
on top:

Chronological Record of Medical Care SF
600 documents the individual's current medical
history, e.g. sick call or clinic visit

Emergency Care and Treatment Record SF
558 documents care given in an emergency
situation, e.g. Emergency Room visit

Consultation Sheet SF 513 used by medical
department personnel to request information or
advice from a specialist concerning the diagnosis
or treatment of a patient

PART 3: PHYSICAL
QUALIFICATIONS

The Report of Medical Examination DD
2808 is filled out by a medical officer to provide a
complete report of medical examination. This
report is filled out (1) upon entry into the military
service, (2) special purposes, and (3) upon
discharge or retirement. The Report of Medical
History DD 2807-1 is filled out by the individual
patient upon entry into the military service, upon
discharge, and when a physical examination is
required. It provides a complete medical history
and any additional pertinent medical information.
The DD 2808 and DD 2807-1 are filed as a pair
for the same examination. Officer Physical
Examination Questionnaire NAVMED 6120/2,
is a record of an officer's personal medical history
is attached to the corresponding DD 2808 for the
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Basic Hospital Corps School Lesson 3.01 Military Health Records
Handbook III
same examination. The NAVMED 6120/2 is filed
in place of the SF 93 when it is used.

The next form is Abstract of Service and
Medical History NAVMED 6150/4. This form
provides a chronological history of the stations and
ships to which the member is assigned for duty
and medical treatment. It is an abstract (diagnostic
summary only) of medical history for each
admission to the Sick List.

Record of Disclosure - Privacy Act of 1974
OPNAV 5211/9, is used to record release of
medical information

Privacy Act Statement - Health Care
Record DD 2005, is used as an all inclusive
privacy statement in the health record. This form
documents that the patient was informed of the
purpose and use of information in a health record.
It is not a consent form. Signature of the member
is not mandatory.

The Record of Disclosure OPNAV 5211/9 is
preprinted at the back of section 3. If the record is
being established, the preprinted form will be
used. If an existing record is converted to the four-
part record, file the existing OPNAV 5211/9 after
the NAVMED 6150/4 Abstract of Service and
Medical History. The Privacy Act Statement -
Health Care Records DD 2005 is preprinted on the
inside right cover of the record folder. If an
already existing record is being converted to the
four-part system, the DD 2005 is filed at the end of
Part 3. If new record is being started, the
preprinted form at the back of Part 4 is to be used.

PART 4: RECORD OF ANCILLARY
STUDIES, INPATIENT CARE, &
MISCELLANEOUS FORMS

The top form in this section is Radiologic
Consultation Requests/Reports SF 519, the
backing sheet that is used to display x-ray reports,
SF 519As. Beneath this is the Laboratory
Report Display SF 545, used to mount laboratory
reports.



MAINTENANCE OF A HEALTH
RECORD

Treatment records and their contents are the
property of the Federal Government and must be
maintained at the authorized medical treatment
facility, which provides care for the patient. A
patient may NOT retain custody of his/her health
record. The records are preserved for the long-term
interest of the patient and the government.

The Commanding Officer (CO) of the
treatment facility is ultimately responsible for
health records maintained at his/her activity and is
designated as the systems manager. The CO
designates, in writing, a Medical Records
Administrator who is responsible for the routine
upkeep and annual verification of all records and
correction of any errors found in the records.
Periodically, health records are inspected for
accuracy and completeness by the CO or a
designated representative of the CO.

Contents of the health record are considered
privileged information. The information in the
health record may be released only to the patient
or the patient's legal guardian. If a written
authorization is provided from the individual,
health record information can be released to any
designated individual. Hospital Corpsmen may
NOT release patient health data to anyone,
EXCEPT the patient or legal guardian. Record of
Disclosure OPNAV 5211/9 is completed and filed
in that patient's record whenever information is
disclosed from a health record.

Health record forms and reports are
permanently stored in Treatment Record Folder
NAVMED 6150/21-30. Identifying data on the
outside of the folder is written in black
permanent marker indicating to whom the record
belongs, as well as the service, status and, if an
eligible family member, relationship to the
sponsor. Data includes name of the individual and
social security number (SSN) of the service
member. Eligible family members use the SSN of
the service member.

The Family Member Prefix code (FMP) is
written within the two diamonds prior to the SSN.
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Lesson 3.01 Military Health Records Basic Hospital Corps School
Handbook III
The FMP code for active duty members is 20, the
FMP code for spouses of members is 30. The
treatment record folder has the second to last digit
of the SSN preprinted on it. The preprinted
number also matches the last digit of the form
number, e.g. the preprinted digit of NAVMED
6150/28 is 8. The treatment record jacket color is
determined by the second to last digit of the
service member's SSN. For example, if an SSN
were 123-45-6789, the 8 would be used to identify
the color for the record (pink, in this case).
Different colored folders indicate different SSNs.
The SSN serves three purposes. First, it is used as
a unique identifier. Second, it is used to group
family members records together. Third, it is used
to file the health record.

Last digit tape is used on the jacket to aid in
locating misfiled records. Black tape is used to
cover the last digit of the SSN on both number
scales, on the right side of the folder and on the top
of the folder.

The name of the patient (last, first, middle
initial) is written on the right front of the record
folder. The Alert Box is checked if the record's
owner has an allergy or sensitivity.

The treatment record category, health or
outpatient, is marked on the left front. The
treatment record subcategories, (1) military (for
health records of military members only), (2)
retired or (3) nonmilitary (for outpatient treatment
records) are also marked with the requested
information. The record category tape on the
right back edge is color coded to indicate the
record is that of an active duty member (red) or all
other categories (black).

On the bottom left front is the special
programs block. If the record belongs to an
individual who is a food handler or is exposed to
radiation, the appropriate boxes are checked. The
annual verification box on the right front edge of
the folder, is blackened after the record is verified
each year.

The inner left leaf also contains information
that is useful in locating service members and their
families. This information is entered in pencil and
changed as the individual moves from one duty
station to another and includes: date of arrival,
projected departure date, home address and
telephone number, and the member's/sponsor's
duty station and telephone number.

All forms in the health record are required to
include the following information


















4
Basic Hospital Corps School Lesson 3.01 Military Health Records
Handbook III
DATA EXAMPLE

(1) family member prefix and SSN 20/123-45-6789

(2) name - last, first, middle initial Smith, J ohn D.

(3) rank/grade or title LT/O-3, Mrs.

(4) status of patient or sponsor AD =Active Duty
Ret =Retired
FMW =Family Member Wife
FMH =Family Member Husband
FMD =Family Member Daughter
FMS =Family Member Son

(5) branch of service (of Active duty USN (Navy)
member or sponsor) USA (Army)
USAF (Air Force)
USMC (Marine Corps)
USCG (Coast Guard)
PHS (Public Health Service)

(6) sex/gender Male or Female

(7) date of birth 10 OCT 72

(8) organization/command to which USS ________
member/sponsor is assigned

(9) name and address of organization NMC Norfolk, VA
maintaining patient's treatment record.
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Lesson 3.01 Military Health Records Basic Hospital Corps School
Handbook III
FIGURE 3.01.01
Treatment Record Jacket NAVMED 6150/10-19
6
Basic Hospital Corps School Lesson 3.01 Military Health Records Worksheet
Handbook III
Lesson 3.01

Military Health Records Worksheet

1. List the categories of health or treatment records.

a. ___________________________________________________________

b. ___________________________________________________________

c. ___________________________________________________________

2. List the individuals who use the outpatient treatment record.

a. ___________________________________________________________

b. ___________________________________________________________

c. ___________________________________________________________

d. ___________________________________________________________

e. ___________________________________________________________

3. When is the Inpatient (clinical) record used?

__________________________________________________________________________________

__________________________________________________________________________________

4. What purposes do the forms in a Health Record serve?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

5. What is the title of Part 1 on the Health Record?

__________________________________________________________________________________

6. What is the purpose of the Summary of Care NAVMED 6150/20?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________
7
Lesson 3.01 Military Health Records Worksheet Basic Hospital Corps School
Handbook III
7. What is the use of the Reference Audiogram DD 2215?

__________________________________________________________________________________

__________________________________________________________________________________

8. Where in the Health Record is the Report of Medical History DD 2807-1 filed?

__________________________________________________________________________________

__________________________________________________________________________________

9. What is recorded on the Consultation Sheet SF 513?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

10. What form is used to record release of medical information?

__________________________________________________________________________________

__________________________________________________________________________________

11. Where is the Emergency Care and Treatment Record SF 558 filed in relation to the Chronological Record
of Medical Care SF 600?

__________________________________________________________________________________

__________________________________________________________________________________

12. Who is ultimately responsible for maintenance of the Health Records?

__________________________________________________________________________________

13. Health records are subject to inspection every _________ by a designated representative of the CO.

a. month

b. year

c. 5 years at the time of the patients annual physical exam

d. 10 years





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Basic Hospital Corps School Lesson 3.01 Military Health Records Worksheet
Handbook III
14. Treatment records and their contents:

a. are the property of the individual.

b. are the property of the Federal Government.

c. can be kept in the patients home.

d. must be preserved because of long term interest to the individual.

15. Information in the Health Record:

a. can be released to the spouse of the patient without written permission.

b. is not privileged information.

c. can be released by the HM to anyone who asks.

d. can be released to any designated individual with written permission from the patient.

16. Health Records are filed by color and __________________.

17. List the identifying information that is on the left inside cover of the Health Record folder.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

18. What information is required on Health Record forms?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

19. List the military service represented by the following letters.

USA_________________________________ USN__________________________________

USAF________________________________ USMC________________________________

USCG________________________________ PHS_______________________________ _
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Lesson 3.01 Military Health Records Worksheet Basic Hospital Corps School
Handbook III
NOTES/COMMENTS

10
Basic Hospital Corps School Lesson 3.02 Basic Physical Examination
Handbook III
Lesson 3.02

Basic Physical Examination

Terminal Objective

3.02 State the Hospital Corpsman's role, and equipment used, in a basic physical examination.

Enabling Objectives:

3.02.01 State the Hospital Corpsman's responsibilities during a physical examination.

3.02.02 List and describe diagnostic equipment used in a basic physical examination.

3.02.03 State basic maintenance and troubleshooting guidelines for selected physical examination
equipment.

3.02.04 State commonly used procedures for performing visual examinations.

3.02.05 State the procedure for taking a 12 lead electrocardiogram.

3.02.06 State the Hospital Corpsman's role for assisting with a pelvic examination.

3.02.07 State the steps and equipment used to weigh and measure an infant.

3.02.08 Perform basic troubleshooting and maintenance of selected physical examination equipment.


Hospital Corpsmen have many responsibilities
during a physical examination. They set up for the
exam by readying the environment, gathering and
troubleshooting all the equipment, and getting the
patient ready. The patient may be nervous, require
emotional support, or need assistance changing
positions during the exam. Corpsmen may
complete lab or X-ray requests, assist the examiner
during the exam, and complete the medical
history. Corpsmen may also be required to act as a
standby, providing protection for the physician and
the patient from allegations of improper behavior.
A standby is usually the same sex as the patient.

A thorough physical examination consists of a
medical history, a head to toe examination, and
diagnostic studies such as blood work-ups, chest
X-ray, visual acuity, etc. Proper sequencing and
accurate recording of all data on appropriate forms
is essential.
PHYSICAL EXAMINATION
EQUIPMENT

The diagnostic equipment utilized in a basic
physical examination includes:

1. Otoscope -- An instrument used to inspect
the auditory canal and tympanic membrane. It may
be portable or wall mounted, Figure 3.02.01.
Troubleshooting includes changing batteries
and/or light bulb, when needed, and simply
tightening the connections.

2. Ophthalmoscope -- Hand-held instrument
utilized to check pupillary reaction to light and
inspect the inner eye, Figure 3.02.02 This
instrument needs routine maintenance of batteries
and light bulb.

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Lesson 3.02 Basic Physical Examination Basic Hospital Corps School
Handbook III
3. Stethoscope -- Used to auscultate the
heart, lungs, abdomen/bowels, and blood pressure.
If the earpieces are missing, or the tubing or
diaphragm cracked, these parts must be replaced to
ensure accurate transmission of sounds.

4. Percussion/reflex hammer -- A rubber
hammer used to assess reflexes, a gross assessment
of brain, spinal cord, or peripheral nerve
impairment, Figure 3.030.03.

5. Tape measure -- Used to measure
circumference of an infant's head and obtain body
length; circumference of extremities or abdominal
girth, as well as specified body measurements used
to calculate body fat percentage. It is used on a
patient with a draining wound, it should be cleaned
immediately after use and kept with the same
patient.

6. Scale -- Used to obtain patient's weight.
To obtain a correct weight, the scale must be
calibrated to zero prior to use.

7. Vaginal speculum -- Used to inspect the
vagina and cervix. The screws that adjust opening
and closing of the speculum should be checked
prior to use. Basic Hospital Corpsmen are NOT
authorized to use the speculum.

8. Water soluble lubricant (KY J elly) --
Used to lubricate examiner's gloved hand when
performing rectal/vaginal assessments.

9. Exam gloves -- Used when palpating the
buccal (oral) cavity, genitals, and perineal region.

10. Tongue blades -- Used to examine buccal
(oral) cavity and oropharynx.

11. Sphygmomanometer -- Used to measure
blood pressure. The gauge should register at zero
prior to use to ensure accuracy. The bladder and
tubing should be replaced as needed.

12. Electronic thermometer -- Used to
obtain a patient's body temperature.

13. Watch/clock with second hand -- Used
to time the pulse/respirations of a patient.

14. Tissues -- Used to wipe instruments. May
also be used by patients to remove excess lubricant
from membranes after the examination.

TROUBLESHOOTING PHYSICAL
EXAM EQUIPMENT

The physical condition of all tubing, hoses,
wires, and gauges should be checked prior to each
use of any equipment to assess it is functioning
properly and/or within standards.

Basic maintenance and upkeep of the
Oto/Ophthalmoscope will ensure proper function.
Areas of concern on this piece of exam equipment
are: Battery condition, if battery operated;
condition of the charging unit; light bulbs, if they
function; and if all the connections are snug and
secure and if the unit is plugged in, if applicable.
Before using an electronic thermometer check to
see that the digital read-out registers 90 degrees F.
The probe must be tightly connected to the unit to
get an accurate temperature reading. Return the
thermometer to the recharging unit after use so it
will be ready for the next use.

EQUIPMENT FOR VISUAL ACUITY

A Snellen Chart is used to assess basic visual
acuity. The Snellen Chart for adult patients
consists of a series of letters of decreasing size,
Figure 3.02.04. The pediatric Snellen E Chart
makes note of the direction the letter E is facing in
decreasing sizes. The patient is positioned 20 feet
from the chart. The 20/20 line must be 64 inches
above the floor. Exams are performed without
corrective lenses first, then tested again with
corrective lenses or glasses. Test each eye
individually. Have the patient cover the right eye
completely while the left eye is tested. Cover the
left eye completely while the right eye is tested.
Then test the eyes together by having the patient
read the Snellen Chart with both eyes uncovered.
Record the results on the appropriate form.

The Armed Forces Vision Tester (AFVT) is
a semi-portable machine for testing near/distant
visual acuity, depth perception, and horizontal and
vertical phorias. This machine is commonly used
at Drivers License Examining Centers. To use the
12
Basic Hospital Corps School Lesson 3.02 Basic Physical Examination
Handbook III
AFVT, have patient place forehead in the
appropriate place and adjust the machine to the
patient's height. Follow manufacturer's directions
for turning the knobs for each test and using the
scoring key provided. Record the results on the
appropriate form.

OBTAINING AN
ELECTROCARDIOGRAM

The electrocardiograph is an instrument for
recording the electrical activity of the heart. The
electrocardiogram (ECG/EKG) is a recorded
image of the heart's activity.

To obtain an EKG, begin by washing hands
and gathering the equipment. Make sure the
machine is unplugged before moving. Establish
patient identification by using the three ID checks,
name plate on bed, ID bracelet, and ask the patient
to state his/her name. Provide for safety, privacy,
and comfort. The patient should remove all
jewelry, including watch and dog tags, and remove
all clothing above the waist. Socks and shoes must
be removed. Place patient in a supine or semi-
fowler's position, turn on machine, and follow the
manufacturer's instructions to enter data into the
computer. Apply the 4 limb/extremity and 6 chest
leads ensuring the correct lead is in the proper
location, Figure 3.02.05. Ask the patient to relax,
NOT to move and to breathe normally. Start the
recorder and obtain the EKG. Do not remove the
leads until a nurse or physician has reviewed the
EKG printout. If the EKG is of poor quality, verify
correct lead placement and perform the test again.

Upon completion of EKG, remove all leads,
allow patient to clean and dress. Clean the
equipment and store all leads and attachments.
Record the procedure on SF 600. File the EKG in
Health Record or Inpatient Clinical Record.

PELVIC EXAMINATION
PROCEDURES

Pelvic exams are a visual and digital
assessment of the external and internal female



genitalia and pelvic contours. The role of the
Hospital Corpsman is to prepare the equipment,
instruct the patient, and provide for safety, privacy,
education, and comfort and assist during the exam.
The HM may serve as a standby during a pelvic
exam. Start by having the patient void prior to the
exam.

The HM will wash hands and prepare the
following equipment: examination light, vaginal
speculum, gloves, water soluble lubricant, exam
table with stirrups, and culture swabs or media
plates as necessary.

The HM will then assist the patient into the
lithotomy position, Figure 3.02.06, for the exam,
drape the patient for privacy, and assist the
practitioner. After the exam, assist the patient from
the table and provide an area to clean up and dress.

WEIGHING AND
MEASURING INFANTS

In the ambulatory care aspect of patient care,
routine measuring of infant's height and weight
may become necessary. When obtaining an infant's
weight, the HM will wash hands, drape the scale
with protective paper covering and zero the scale.
After removing the infant's clothing, gently place
infant on scale tray. NEVER leave the infant
unattended and ensure that the infant does NOT
become chilled. Note the weight in pounds and
ounces OR kilograms and grams. Remove the
infant from the scale, dress infant and return to
parent or crib. After completing procedure, wash
hands, and record infant's weight on chart.

To obtain the height of an infant, begin by
washing your hands. Cover the measuring board
with a clean towel or exam paper. Place the infant
on the measuring board FACE UP. Measure infant
from the crown of the head to the heels with legs
straight. Remove infant from measuring surface
and return to parent or crib. Wash hands and
record height of infant on chart.
13
Lesson 3.02 Basic Physical Examination Basic Hospital Corps School
Handbook III






FIGURE 3.02.01
Otoscope
FIGURE 3.02.02
Opthalmoscope
FIGURE 3.02.03
Percussion/Reflex Hammer
FIGURE 3.02.04
Snellen Chart
14
Basic Hospital Corps School Lesson 3.02 Basic Physical Examination
Handbook III
FIGURE 3.02.05
Chest Lead Sites
FIGURE 3.02.06
Lithotomy Position
15
Lesson 3.02 Basic Physical Examination Basic Hospital Corps School
Handbook III
NOTES/COMMENTS

16
Basic Hospital Corps School Lesson 3.02 Basic Physical
Handbook III Examination Worksheet
Lesson 3.02

Basic Physical Examination Worksheet

1. Circle the tasks a Hospital Corpsman may perform before and during a physical examination.

a. Set up for the exam

b. Check to see that the equipment is in working condition

c. Assist the patient

d. Troubleshoot equipment

2. What equipment would be used to check for swelling on a patient with a complaint of a painful right
calf?

a. Otoscope

b. Ophthalmoscope

c. Tape Measure

d. Percussion Hammer

3. What tool is used to examine a patient's eyes? _____________________________________

4. What tool is used to test neurological status (reflex)? _______________________________

5. What tool is used to examine the vagina and cervix? ________________________________

6. Who may use the tool to examine the vagina and cervix? ____________________________

7. List two pieces of physical assessment equipment that should be calibrated to zero before use.

a. _____________________________________________________

b. _____________________________________________________

8. List three things to check if an otoscope or ophthalmoscope is not working.

a. _____________________________________________________

b. _____________________________________________________

c. _____________________________________________________



17
Lesson 3.02 Basic Physical Basic Hospital Corps School
Examination Worksheet Handbook III
9. Match each physical examination element in Column B to the medical equipment used to examine it
in Column A.

A B


a. Otoscope _______

b. Ophthalmoscope _______

c. Stethoscope _______

d. Percussion/reflex hammer _______

e. Tape Measure _______

f. Scale _______

g. Tongue Blade _______

h. Sphygmomanometer _______

i. Thermometer _______

j. Watch/Clock _______

k. Tissue _______

l. Exam gloves _______

1. Heart, lung, abdomen

2. Auditory canal and TM

3. Aids in access to buccal cavity

4. Pupillary reaction, inspect inner eyes

5. Neurological assessment

6. Circumference/Body fat %

7. Time pulse, respirations

8. Weight

9. Remove lubricant

10. Exam of oral cavity, genitals and perineal region.

11. Measure blood pressure

12. Body temperature


10. What is the procedure for troubleshooting a stethoscope?

___________________________________________________________________________

___________________________________________________________________________



18
Basic Hospital Corps School Lesson 1.22 Preventive Medicine
Handbook III
Lesson 1.22


Preventive Medicine

Terminal Objective:

1.22 State the basic principles of preventive medicine.

Enabling Objectives:

1.22.01 Define terms associated with preventive medicine.

1.22.02 List the modes of transmission of communicable diseases.

1.22.03 List the basic characteristics of selected communicable diseases.

1.22.04 List basic methods for controlling and preventing communicable diseases.

1.22.05 List methods by which sexually transmitted diseases are transmitted.

1.22.06 List the signs and symptoms, diagnosis, and treatment of selected sexually transmitted diseases.

1.22.07 List methods of prevention of common sexually transmitted diseases.

1.22.08 State the basic principles of field sanitation.

1.22.09 State the procedure for ensuring water is potable.

1.22.10 State the components of a health and comfort inspection.

1.22.11 State the basic principles of foot care.


A primary mission of the medical department
is to safeguard and promote the health of Navy and
Marine Corps personnel. This is accomplished
largely through a preventive medicine program
emphasizing the preservation of health and
maximum effectiveness of the individual. It is a
multifaceted state of the art program that cannot be
covered in its entirety within this chapter.
However, this lesson will familiarize you with a
small section of the program.




TERMINOLOGY

CARRIER -- A person or animal that harbors
a specific infectious agent in the absence of
discernible clinical disease and serves as a
potential source of infection for man.

COMMUNICABLE DISEASE -- An illness
due to a specific infectious agent or its toxic
products, which may pass or be carried from a
reservoir to a susceptible host either directly or
indirectly.

19
Lesson 1.22 Preventive Medicine Basic Hospital Corps School
Handbook III
EPIDEMIC -- The occurrence in a region, of
an illness, clearly in excess of normal expectancy
numbers, and originating from a common source.

HOST -- A human or other living animal
affording nourishment to an infectious agent under
natural conditions.

INCUBATION PERIOD -- The time interval
between exposure to an infectious agent and the
appearance of the clinical manifestations of the
disease.

INFECTION -- The entry and development
or multiplication of infectious agents in the body
of man or animals.

INFECTIOUS AGENT -- An organism
capable of producing infection or infectious
disease

NOSOCOMIAL INFECTION -- An
infection acquired during hospitalization.

PORTAL of ENTRY -- The means of entry
for an infectious agent into a host, e.g., breaks in
the skin, respiratory tract, urinary tract,
bloodstream, and gastrointestinal tract.

RESERVOIR -- A habitat on which an
infectious agent depends primarily for survival.
The agent lives, multiplies, and reproduces so that
it can be transferred to a susceptible host.

SUSCEPTIBLE HOST -- Nonresistant man
or other living animal to an infectious agent.

TRANSMISSION -- Any mechanism by
which an infectious agent is spread from a source
or reservoir to a person.

SEXUALLY TRANSMITTED DISEASE
(STD) -- Contagious disease transmitted by sexual
contact.

MODES OF TRANSMISSION

Communicable diseases are spread by specific
routes of transmission.

DIRECT TRANSMISSION

Direct and essentially immediate transfer of
infectious agents to a receptive portal of entry.

DIRECT CONTACT: Such as touching,
biting, kissing, or sexual intercourse.

DIRECT PROJ ECTION (OR DROPLET
SPREAD): Droplets spray onto the conjunctiva or
mucous membranes of the eye, nose, or mouth
during sneezing, coughing, spitting, singing, or
talking.

INDIRECT TRANSMISSION

Contaminated inanimate materials such as
toys, bedding, surgical instruments, water, food,
milk, biological products (containing blood,
serum, plasma, tissues or organs), or any substance
serving as an intermediate means by which an
infectious agent is transported to a susceptible host
through a suitable portal of entry. May be called
vehicle-borne transmission.

VECTOR-BORNE

a. Mechanical: Includes simple mechanical
carriage by a crawling or flying insect
through soiling its feet or by passage of
organisms through its intestinal tract.

b. Biological: Transmission may be by
injection of salivary gland fluid during
biting, by regurgitation, feces of an animal
that is capable of penetrating the skin via
scratching or rubbing, e.g., common house
fly.

c. Airborne: Dissemination of microbial
aerosols to a portal of entry, usually the
respiratory tract.

CONGENITAL

a. Spread of infectious agent from mother to
unborn fetus.



20
Basic Hospital Corps School Lesson 1.22 Preventive Medicine
Handbook III
SELECTED COMMUNICABLE
DISEASES

VIRAL DISEASES

1. Chickenpox

a. Signs and symptoms

(1) fever

(2) characteristic skin eruptions are first,
then a granular scab

(3) itching associated with skin eruptions

b. Modes of transmission

(1) airborne droplet spread

(2) direct contact with skin lesion

2. Influenza

a. Signs and symptoms

(1) abrupt onset of fever

(2) chills

(3) headache

(4) myalgia, sometimes with prostration

(5) runny nose and sore throat

(6) cough -- often severe and drawn out

b. Mode of transmission

(1) Airborne or droplet spread

3. Hepatitis A (HAV) -- formerly called
infectious hepatitis

a. Signs and symptoms

(1) fever

(2) malaise
(3) anorexia

(4) nausea

(5) discomfort followed within a few days
by jaundice

b. Modes of transmission

(1) fecal/oral route

(2) associated with uncooked shellfish,
fruit, vegetables, and contaminated
water

4. Hepatitis B (HBV) -- serum hepatitis

a. Signs and symptoms -- onset is insidious

(1) anorexia

(2) vague abdominal discomfort

(3) nausea and vomiting

(4) arthralgia and rash often progressing
to jaundice

b. Modes of transmission

(1) sexual contact with infected host

(2) direct contact with infected blood
products

(3) transmitted via parenteral, sexual, and
prenatal routes

(4) has been isolated in saliva, tears,
blood, seminal fluid, CSF, breast milk,
urine, and feces

(5) complications include chronic liver
disease, cirrhosis, and primary
hepatocellular cancer

5. Hepatitis D (HDV) -- is a co-infection with
Hepatitis B and is parenterally transmitted.

21
Lesson 1.22 Preventive Medicine Basic Hospital Corps School
Handbook III
6. Hepatitis E (HEV) -- is enterically transmitted
by fecal/oral route through contaminated food
or water.

BACTERICAL DISEASES

1. Strep throat

a. Signs and symptoms

(1) fever

(2) sore throat

(3) exudative tonsillitis

(4) pharyngitis

b. Mode of transmission

(1) airborne or droplet spread

2. Rheumatic fever

a. Follows inadequately treated strep throat

b. May result in varying degrees of damage
to heart tissue

3. Tuberculosis

a. Signs and Symptoms

(1) weight loss

(2) fever

(3) cough

(4) chest pain

(5) in advanced stages, hoarseness and
bleeding from the lungs.

b. Mode of transportation

(1) Respiratory or droplet. The bacteria is
discharged in the sputum



4. Meningitis

a. Signs and symptoms

(1) high fever

(2) neck pain

(3) back pain

(4) nausea

(5) lethargy

(6) photosensitivity

(7) petechial rash

(8) altered level of consciousness (as
severe as convulsions)

b. Mode of transmission

(1) airborne or droplet spread

(2) direct contact with nasopharyngeal
secretions of infected host

PARASITIC DISEASE

1. Hookworm

a. Signs and symptoms

(1) ground itch -- A rash at the site of
larval penetration

b. Mode of transmission

(1) direct contact

2. Malaria. There are four types of malaria. The
following information is for falciparum
malaria that is the most serious type and is
considered a medical emergency.

a. Signs and Symptoms

(1) fever

(2) chills and sweating
22
Basic Hospital Corps School Lesson 1.22 Preventive Medicine
Handbook III
(3) headache

(4) jaundice

(5) blood coagulation defects

(6) shock

(7) renal and liver failure

(8) disorientation and delirium

b. Mode of transmission

(1) bite of the female Anopheles
mosquito in tropical areas

(2) contaminated needles and syringes

FUNGAL DISEASE

1. Tinea (ringworm)

a. Signs and symptoms

(1) Tinea capitis (ringworm of the scalp)
begins as a small papule and spreads
peripherally, leaving a small area of
baldness or broken brittle hair.

(2) Tinea corporis (ringworm of the body)

(3) Tinea pedis (ringworm of the foot).
Starts between the toes and spreads
along the bottom of the foot.

b. Modes of transmission

(1) direct contact

(2) indirect transmission through contact
with contaminated objects

CONTROL OF COMMUNICABLE
DISEASES

Control and prevention of communicable
diseases is an important role of the Hospital
Corpsman. Health and well-being of assigned
personnel are promoted by preventing and
controlling communicable diseases. These
practices together will help control communicable
diseases:

1. Breaking the chain of infection. There are
six elements in the chain of infection.
Controlling or eliminating any one of these
can stop the spread of a disease. The elements
include: the infective agent, the reservoir, the
portal of exit, the means of transmission, the
portal of entry, and the susceptible host.

The infectious agent can be killed through
sterilization or other treatment. The reservoir
can be interrupted or eliminated through
sterilization or disinfection. Proper disposal of
waste and contaminated articles will break the
means of exit through a portal. The means of
transmission can be eliminated by blocking
the route. For example, frequent hand washing
and isolation procedures will eliminate the
transport link of the chain. Entry (portal of
entry) into new host can be controlled with
practice of strict aseptic technique and
maintenance of healthy, intact skin. The
susceptible host is guarded by use of
protective isolation procedures, receipt of
adequate nutrition, and early recognition.
Abstinence will prevent the spread of STDs.

2. Immunizations. Protection against certain
diseases before exposure can be provided by
an immunization. The medical department is
responsible to ensure military personnel and
their families receive the required
immunizations and their records are properly
maintained.

3. Hygiene. Good personal hygiene promotes
health and prevents disease. It will further
enhance your professional image as a member
of the health care team.

4. Sanitation. Obtaining food and water,
including ice, from approved sources, will
assist in preventing food borne illnesses.
Preparation of food must be in accordance
with acceptable practices as directed by
military instruction. Proper sanitation will
decrease and control insect and rodent
23
Lesson 1.22 Preventive Medicine Basic Hospital Corps School
Handbook III
populations, thus deleting another transmission
link in the chain of infection.

5. Mechanical prophylaxis. A latex condom,
coated with Noxinyll will assist in preventing
the spread of STDs.

SEXUALLY TRANSMITTED
DISEASES

Sexually transmitted diseases (STD) are
contagious diseases transmitted by sexual contact.
STDs are found in many forms and are among the
most common communicable diseases.
Unfortunately, due to embarrassment, lack of
information, and in some cases, lack of common
sense, many cases go untreated. More lenient
views towards sexual behavior and asymptomatic
carriers have also added to the problems of control
and prevention.

STDs are transmitted through direct contact,
usually sexual intercourse. However, medical
personnel with open wounds may develop STDs if
they fail to follow universal precautions.
Transmission can also be congenital. A pregnant
woman, with an active STD, may pass the disease
to the newborn by placental transfer or during a
normal vaginal delivery. When identified prior to
delivery, most doctors will deliver the infant by
Cesarean section.

The corpsman should be aware of all STDs
and their signs and symptoms. However,
discussion will be limited to the five most
prevalent STDs.

GONORRHEA (GONOCOCCAL
URETHRITIS, CLAP, STRAIN)

Gonorrhea is an infectious disease of the
epithelium of the urethra, cervix, and rectum, but
may also affect other areas of the body.

In males, the symptoms include burning and
urinary frequency and a purulent discharge.

In females, symptoms are slight or nonexistent
but may include vaginal discharge and cystitis.
Frequently females are asymptomatic.
Diagnosis is based on symptoms, personal
history, or sexually transmitted disease contact
referral. The diagnosis is confirmed by
identification of the gonococcus through gram-
stained smears and exudate specimen cultures. In
females, repeated cervical and rectal cultures may
be necessary to detect residual infection.

Treatment: (Under the supervision of a
medical officer.) Penicillin, Spectinomycin,
tetracycline or ceftiriaxone.

NONGONOCOCCAL URETHRITIS
(NGU OR NSU)

Nongonococcal urethritis is a sexually
transmitted urethritis of males not associated with
the gonococcus. Clinical manifestations are either
indistinguishable from gonorrhea or somewhat
milder.

Symptoms for males include mucopurulent
discharge, urethral itching, dysuria, burning during
urination, and occasional hematuria.

Symptoms for females include a persistent
vaginal discharge or recurrent cystitis for which no
cause can be found, or cervicitis. Women are often
asymptomatic but show signs of urethral or
cervical infection on physical examination.

Diagnosis is provided by patient history,
microscopic examination of discharge,
symptomology, and failure to demonstrate
neisseria gonorrhea.

Treatment: (Under a medical officer's
supervision) doxycycline tetracycline, followed by
sulfonamide and erythromycin. Females may also
require further treatment with a sulfa vaginal
cream.

Follow-up blood tests are conducted to rule
out syphilis. Patients should be examined by a
medical officer on follow-up.





24
Basic Hospital Corps School Lesson 1.22 Preventive Medicine
Handbook III
MUCOPURULENT CERVICITIS

Mucopurulent cervicitis is an inflammation of
the cervix. Signs and symptoms include a yellow
discharge visible in the vaginal canal and vaginal
discharge or bleeding following intercourse.
Diagnosis is based on a cervical gram stain.

Treatment. If the patient is at high risk of
gonorrhea, treat as indicated for gonorrhea. If the
patient is at high risk of chlamydia, treat as
indicated for chlamydia.

Follow-up should be recommended for the specific
infection being treated.

SYPHILIS

Syphilis is a contagious disease that can attack any
organ in the body and is characterized by periods
of active manifestations and symptomless latency.
It can be passed from mother to unborn child.

There are three stages, which can be divided
into other substages of infectiousness and latency.
Primary syphilis is the stage when the primary
lesion (chancre) appears. Secondary syphilis
follows close behind and is characterized by skin
disorders that may mimic other dermatological
problems. Tertiary syphilis follows a latent
period of two or more years.

Diagnosis is by symptoms, sexually
transmitted disease contact referral, personal
history, serologic tests (STS), blood tests (VDRL,
RPR, ART, FTA-ABS) and dark field microscopic
exam of skin scraping from the chancre.

Treatment. For primary and secondary
syphilis: a one-time dose of Penicillin-G, 2.4
million units given intramuscularly. Erythromycin,
doxycycline, or tetracycline may be given to
penicillin-sensitive patients.

Follow-up. Blood test should be repeated, treat
contacts of patient, and have patient examined by a
medical officer.



GENITAL HERPES

Herpes genitals is a contagious infection of the
genital skin and mucosa. It is the most common
form of genital ulceration.

Signs and symptoms include itching and
soreness, blisters, blebs, and ulcers that become
circular lesions on genitourinary surfaces, pain,
and burning sensation when urinating, and
difficulty walking.

Diagnosis is by symptoms and laboratory
analysis of lesion serum.

Treatment. There is no cure. The lesions
usually recur throughout life. Analgesics and
warm baths will relieve the pain. The first episode
may be treated with acyclovir for symptomatic
relief.

ACQUIRED IMMUNE DEFICIENCY
SYNDROME (AIDS)

The Human Immunodeficiency Virus (HIV)
has been found in blood, semen, vaginal fluid, and
in small quantities in saliva, tears, breast milk, and
urine. All body fluids should be regarded as
infectious. It appears that a relatively large
inoculum of virus is required to cause an infection.
Despite intensive inquiry, and thousands of cases,
transmission appears to occur in only four ways:

1. Intimate sexual contact: rectal, vaginal, or
oro-genital intercourse.

2. Transfusion of infected blood or blood
products.

3. Sharing of dirty needles: usually IV drug
abusers.

4. Perinatally or in utero from mother to baby.

Diagnosis is by HTLV-III or HIV test, enzyme
linked immunosorbent assay (ELISA) test, or
Western Blot Test.

25
Lesson 1.22 Preventive Medicine Basic Hospital Corps School
Handbook III
Treatment: No known treatment for the
underlying immune deficiency. Treatment is
limited to systemic relief.

Department of Defense concerns/reasons
for testing:

a. Protect battlefield blood supply.

b. Protect the individual member. The
member cannot receive live virus
vaccinations. Also, personnel cannot be
assigned duty in areas with exotic
diseases.

Implications of a positive test:

1. The test does not mean that you have AIDS,
and does not automatically mean that you will
develop AIDS in the future.

2. The test does mean that at some time in the
past, you were infected with the HIV virus.
However, there is no way to tell if you still
have the virus in your body. It is likely that
most people with a positive test still carry the
virus, and will carry it indefinitely.

PREVENTION OF STD

The best method of prevention is, of course,
abstinence, but as this is not realistic, the practice
of safe sex is important. Personnel should avoid
indiscriminate sexual contacts, use mechanical
prophylactics (condoms), maintain personal
hygiene, recognize and seek treatment for
symptoms. To maintain personal hygiene, males
should urinate as soon as possible after exposure
and both partners should shower thoroughly with
soap and water. Uncircumcised males should
retract foreskin back for thorough washing.
Females should not douche which advances the
organisms to the tubes and ovaries and could cause
Pelvic Inflammatory Disease. Diagnosed cases
should inform partners and avoid further contacts
during the communicable period. All personnel
should be provided health education about STD
transmission, prevention, and treatment.


FIELD SANITATION

The primary objective of field sanitation is to
keep as many personnel free of communicable
disease as possible. Corpsmen are responsible to
assist in supervising and instructing personnel in
sanitation procedures. Personnel education
includes: information on food sources, disease
prevention, sexually transmitted diseases and
water sources and treatment methods.

POTABLE WATER

Water that is suitable and safe for drinking is
referred to as potable water. In the field the HM
approves water sources and disinfection
procedures when necessary.

All water if the field is considered unsafe until
it has been tested and disinfected if necessary.
Procedures to produce potable water are boiling
(use only in emergencies), use of iodine tablets or
calcium hypochlorite ampules.

HEALTH AND COMFORT
INSPECTIONS

Health and comfort inspections are conducted
to determine and ensure the security, military
fitness and good order and discipline of the
organization. Components of an inspection
include: cleanliness, sanitation, safety and
examination for unnecessary hazards and unlawful
weapons or other contraband.

FOOT CARE

Proper foot care is a vital factor in the overall
performance of personnel. Corpsmen monitor foot
conditions and teach foot care. The basic
principles are: proper fitting shoes and socks,
clean and dry feet regularly, use foot powder and
change socks boots/shoes regularly especially in
wet environments.
26
Basic Hospital Corps School Lesson 1.22 Preventive Medicine Worksheet
Handbook III
Lesson 1.22


Preventive Medicine Worksheet

1. Define communicable disease.

___________________________________________________________________________________

___________________________________________________________________________________

2. A human or living animal affording nourishment to an infectious agent under natural conditions is
called a:
___________________________________________________________________________________

3. List three examples of a portal of entry.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

4. What is a susceptible host?

___________________________________________________________________________________

5. Define transmission, in relation to communicable diseases.

___________________________________________________________________________________

6. List three characteristics of influenza.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

7. What bacterial disease can follow inadequately treated strep throat? ______________________________

8. What is another name for tinea pedis? _____________________________________________________

9. Mechanical and biological transmissions are examples of _________________________ transmissions.

10. The normal and most suitable portal of entry for airborne transmission is ________________________.



27
Lesson 1.22 Preventive Medicine Worksheet Basic Hospital Corps School
Handbook III
11. List four signs/symptoms of strep throat.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

12. Describe two types of direct transmission of a disease.

a. _______________________________________________________________________

b. _______________________________________________________________________

13. Define indirect transmission of a disease.

_____________________________________________________________________________________

14. List four methods for the control of communicable disease.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

15. Immunizations provide protection against: _________________________________________________

_____________________________________________________________________________________

16. STDs are transmitted by ________________________ and ________________________.

17. STDs can be transmitted through open wounds.

a. True b. False

18. STDs are among the most common communicable diseases.

a. True b. False

19. List the three stages of syphilis.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________
28
Basic Hospital Corps School Lesson 1.22 Preventive Medicine Worksheet
Handbook III

20. Acyclovir is the curative treatment for genital herpes.

a. True b. False

21. List four ways AIDS can be transmitted.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

22. All HTLV-III/HIV positive patients will develop AIDS.

a. True b. False

23. List two of the Department of Defense's concerns/reasons for the HTLV-III/HIV screening program.

a. _____________________________________________________________________________

b. _____________________________________________________________________________

24. What is the best method to prevent STDs? ____________________________________________

25. List five methods for the prevention of STDs.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

e. _______________________________________________________________________

26. What is the primary objective of field sanitation?

_______________________________________________________________________________

27. In the field, all water is considered safe.

a. True b. False





29
Lesson 1.22 Preventive Medicine Worksheet Basic Hospital Corps School
Handbook III
28. List the four areas personnel should be educated in prior to deployment.

a. _________________________________________

b. _________________________________________

c. _________________________________________

d. _________________________________________

29. List three procedures to produce potable water.

a. _________________________________________

b. _________________________________________

c. _________________________________________

30. List the five components of a Health and Comfort inspection.

a. _________________________________________

b. _________________________________________

c. _________________________________________

d. _________________________________________

e. _________________________________________

31. List three principles of foot care.

a. _________________________________________

b. _________________________________________

c. _________________________________________


30
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III
Lesson 3.03

Patient Care Documentation

Terminal Objective:

3.03 Document patient care.

Enabling Objectives:

3.03.01 List the purpose for documenting patient care.

3.03.02 List types of patient records used by the US Navy.

3.03.03 List types of patient care information to be documented.

3.03.04 List the components and guidelines for writing a SOAP note.

3.03.05 Chart inpatient care on a Nursing Note SF 510.

3.03.06 Chart outpatient care, using SOAP Note format, on a Chronological Record of
Medical Care SF 600.


Nursing Notes SF 510 are a written
account of a patient's condition during
hospitalization. They include the patient's
progress and response to care and treatments
given. Nursing Notes are written and used by
nurses and corpsmen directly involved in
giving the patient care. They are part of the
patient's permanent hospital record. Nursing
Notes are a legal document of care given to
the patient.

As a legal document, Nursing Notes may
be used in court. It is extremely important for
the notes to be accurate, legible, and complete.
Incomplete, illegible or inaccurate Nursing
Notes may be used as evidence for malpractice
litigation. Properly completed Nursing Notes
may prevent legal action.

Nursing Notes that provide proper
documentation help to prevent omission of
care and duplication of treatments. This helps
to ensure continuity of care.

PATIENT CARE TO BE
DOCUMENTED

The type of information that must be
documented in a Nursing Note includes the
Mental Status Assessment, the Physical
Assessment, all nursing care, treatments,
procedures, and patient education performed.

Nursing Notes should include pertinent
information about the patient's condition,
progress, and response to care and treatment.
A complete head to toe physical assessment
must be made on each patient at the beginning
of each shift. ONLY the assessment findings
that have changed since the last entry need to
be written in the Nursing Notes. If the patient's
vital signs are abnormal, the values are written
in the note along with the whom was notified,
and any action that was taken.



31
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Handbook III
The physical assessment includes examining
the following systems:

Sensory/perceptual mental status -- alert,
combative, confused

Neurological level of consciousness
awake, stuporous,
comatose
orientation to person,
place and time
pupillary response
sleep pattern or sleep
difficulty

Skin condition -- color,
temperature, turgor
lesions or skin
breakdown

Respiratory respirations -- rate,
rhythm, depth
(shallow or deep)
breath sounds -- clear,
wheezes, rales
cough productive or
nonproductive
(color, odor, amount)
dyspnea -- difficult,
painful, or labored
respirations

Cardiovascular pulse -- rate, rhythm,
quality, location
blood pressure
circulation capillary
refills
heart sounds -- regular,
irregular, muffled



Gastrointestinal mouth, gums, and teeth
odor, condition)
appetite/diet
bowel function
bowel sounds
hypoactive,
hyperactive
presence of distention


Genitourinary elimination pattern --
spontaneous void or
Foley
bladder function
presence of lesions
discharge -- urethral or
vaginal (color, odor,
amount, consistency)

Musculoskeletal gait -- ambulatory status,
use of assistive devices
special equipment
fixative devices
complaint of pain
casts, bandages, splints
range of motion (ROM)
muscle strength
edema

Nursing Notes should include any
complaints of discomfort or other
malfunctions of body systems including a
description of duration, location, intensity,
severity, and frequency of complaint. Mental
status observations should include general
orientation to the environment, observed
moods and behavior and any expressed
concerns. Anything abnormal or out of the
ordinary should be documented as well as how
these findings were handled.

Nursing Notes should reflect all nursing
care given to the patient. Examples:

1. All personal hygiene care such as bed
baths, showers, and tub baths.

2. Oral hygiene care, including condition of
mouth, teeth, etc.

3. Skin care should be noted.

These may be charted on the Activities of
Daily Living or ADL Flowsheets.

Types of treatments and procedures to
chart include the following:

1. Wound care/dressing changes.

2. Any addition or discontinuation of any
equipment.

3. Specimen collection.

4. Suture, staple or clip removal.

5. Respiratory treatments.
32
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III

6. IV site care.

7. IV tubing changes.

8. IV solution changes.

9. Insertion or removal of Foley catheter.

10. Any type of isolation precautions and how
patient is psychologically responding to
isolation.

Documentation of treatments and
procedures should include who performed the
procedure. If the corpsman performs the
procedure, his/her signature appears at the end
of the Nursing Notes. However, if someone
other than the corpsman who is charting
performed the procedure, that individual's
name should appear in the Nursing Notes. In
addition to who performed the treatment or
procedure, the patient's tolerance of the
procedure should be noted, and any change in
patient's condition (improved or worsened) as
a result of the procedure. Any adverse effects
should also be noted, e.g., unusual amounts of
pain during or after procedure.

Any teaching a patient receives needs to
be documented. The Nursing Note entry
should describe the patient's level of
comprehension, ability to repeat the skill or
ability to demonstrate how to do a task.
Certain medications require a Nursing , e.g.
anti-acid for stomach ache; all STAT orders,
e.g., Benadryl for hives; all pre-operative
medication, e.g., sedatives) and all PRN
medications, e.g., Tylenol for pain. If a PRN
medication is given to the patient, then the
results of taking that medication must be
recorded. Following any medication
administration, the patient must be observed
for adverse reaction to the medication. If a
reaction occurs, documentation should include
type or signs and symptoms of the reaction,
who was notified and what was done for the
patient. Abnormal or out of the ordinary
occurrences and their follow up must also be
documented.

Safety measures are always taken to
avoid harm or injury to the patient. Examples
are the use of side rails or patient restraint
devices. If a patient is non-compliant with
hospital safety rules or regulations, this must
also be documented as a Nursing Note.

A patient's arrival and departure from a
ward must be documented. This includes
where the patient is going or returning from,
method of travel, and the time and date the
event occurred.

In addition, any visits made by pertinent
people, such as physicians, Commanding
Officer, chaplain, etc., need to be noted. The
condition of the patient prior to his transfer or
discharge from one ward to another is to be
documented. Also any discharge planning,
instructions or referrals made prior to
discharge should be included. The actual name
and rank of physician or nurse notified about
an abnormality or change in patient's condition
should be noted.

GUIDELINES FOR NURSING
NOTES

There are several components of the
Nursing Notes SF 510. Standard form
identification numbers are found on the
bottom right corner of the page. The column to
the extreme left side of the page is used to
record the current date and month using
military format, e.g., 11 J ul. The year is
entered in the box with the word. The hour
column is divided into two columns for AM
and PM hours, which are recorded using the
24 hour clock. The main body of the page is
below the heading entitled Observations. This
is the space used for recording observations
made by the corpsman and/or nurse. The
bottom left corner of the page is reserved for
patient identification. The patient's
addressograph stamp is placed in this space.
The information can be handwritten, if
necessary.

Nursing Notes are written in chronological
order. Each entry is identified by date and time
33
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Handbook III
in the appropriate column. Nursing Notes are
placed in the chart so they read progressively
like a book. The most recent entries are in the
back of the Nursing Note section. The format
for Nursing Notes is dictated by local
command policy. The most commonly used
format is block. This style documents what,
where and how in brief paragraphs. The
format called charting by exception documents
unusual or unexpected problems or responses
to treatment. The usual or routine care and
findings are recorded in Activities of Daily
Living (ADL) flowsheets.

Each Nursing Notes entry is signed by the
person writing the note. The signature consists
of the following: first name, last name, and
rate. It is placed on the right side of the page
following the entry. A line should be drawn
through any extra space occurring between the
last word of the entry and the signature. The
writer's name is to be printed or stamped
following the signature.

There are a few general instructions for
writing Nursing Notes:

1. Do not skip lines between Nursing Notes.
There should be no empty spaces.

2. All entries must be made using a black
ballpoint pen, (for microfiche and Xerox
reproduction purposes).

3. Legible handwriting or printing is
essential.

4. Be brief! Omit unnecessary words. Each
entry need not be a complete sentence, but
should contain sufficient words to convey
complete thoughts.

When writing Nursing Notes, subjective
and objective information is used. Subjective
information is what the patient states or relates
as a symptom, in his/her own words and are
identified by quotation marks, whenever
possible. This is especially important when
related to mental status and emotional
feelings. Avoid personal judgments and the
use of such phrases as appears to be or seems
to be. When recording patient observations, be
objective. Describe the facts or actual events;
what you see. Leave out opinions. The
following are sample Nursing Note entries:
1. Restless, crying, and holding his right
side. (OBJ ECTIVE).

2. Complains of abdominal pain.
(SUBJ ECTIVE).

3. Sleeping for long periods. Refused lunch
meal. (OBJ ECTIVE).

4. Stated I have been nauseated all morning.
(SUBJ ECTIVE).

5. Stated I feel a little depressed.
(SUBJ ECTIVE).

6. Consumed only 10% of breakfast.
Vomited 100 cc of clear yellow fluid 15
minutes later. (OBJ ECTIVE).

7. Respirations rapid, labored, rate 30 per
minute. (OBJ ECTIVE).

Do not write entries that leave room for
misinterpretation. Be clear and concise. Do
not write Doctor Smith examined patient on
floor. Instead write Doctor Smith examined
patient in treatment room.

Filter pertinent from unnecessary
information and record only pertinent
information. Pertinent information includes
that which is relevant to the patient's treatment
and/or progress. The following are examples
of pertinent and not pertinent entries:

1. Assisted with feeding. (PERTINENT).

2. Complete linen change done. (NOT
PERTINENT).

3. Breakfast tray delivered. (NOT
PERTINENT).

4. Consumed 100% of regular diet.
(PERTINENT).

5. Visited with the chaplain. (PERTINENT).
34
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III

6. Unable to void postoperatively.
(PERTINENT).

7. Watching TV and working crossword
puzzle. (NOT PERTINENT--May be
pertinent in certain cases e.g., psychiatric
patients).

8. Dry sterile dressing change to RLQ.
(PERTINENT).

9. Old dressing removed. Sterile field
established. Wound covered with a new
sterile 4x4 and secured with tape. (NOT
PERTINENT).

10. Wound area is slightly reddened and warm
to touch. (PERTINENT).

The frequency of Nursing Note entries
depends upon the patient's condition and/or
local policy. However, nursing care should be
recorded only after the care has been given.
Standard medical and non-medical
abbreviations should be used when writing
Nursing Notes.

It is important to note that local
commands may have overprinted Nursing
Notes. These are used for routine occurrences
common to a particular ward.

Examples:

1. Admission/discharge Nursing Note
overprints.

2. Postoperative care overprint.

There are guidelines that must be followed
when correcting mistakes that occur while
writing Nursing Notes. First draw a single line
through the error. Next write error and initial
over the single line. After this is completed,
continue the Nursing Notes with the correct
information. If the time of Nursing Notes is
earlier than the last Nursing Note entry, a late
Nursing Notes entry is needed. To do this,
write late entry in the AM/PM column. Below
these words, record the current date and time
of the entry. Within the Nursing Notes entry,
identify the actual time the occurrence or
observation took place.


SOAP NOTE GUIDELINES

The format for recording data in the
outpatient treatment record is called the SOAP
note format. SOAP stands for:

S -- Subjective: This is what the patient
relates as his/her chief complaint. It should be
written in the patient's own words.

O -- Objective: These are the physical
findings observed during an examination of
the patient. In evaluating a specific problem, it
is necessary only to examine the area(s) which
are pertinent to the problem.

A -- Assessment: This is an analysis of
the problem or the differential diagnosis. In
certain cases, a diagnosis may be clear, such
as a fracture or laceration. In other cases, there
may be several likely possibilities.

P -- Plan: The plan includes everything
that is done to the patient as well as advice and
instructions given to the patient. Treatment
prescribed to resolve the problem might
include laboratory tests ordered, x-ray studies
ordered, medications (including dosage,
strength, and directions for use), and
instructions for follow up.

Generally, the HM will only be
responsible for documenting the Subjective
and Objective data on the Chronological
Record of Medical Care SF 600 or Emergency
Care and Treatment Record SF 558. The
physician will determine the assessment and
plan the course of action to treat the problem
the patient is experiencing.

Ensure that the patient's identification
information is on the lower left corner each
form. All health record entries must be either
typed or written with a black ballpoint pen.
Felt tip pen entries bleed over time and cause
writing on the reverse side of the page to
35
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Handbook III
become unreadable. The time and date is
included on the left upper side of the SF 600
and the date must be written in the
day/month/year format, e.g. 1000 01 JAN 95.
Next, the ship or station is placed directly next
to the date in the symptoms, diagnosis, and
treatment column. This appears as the
classification of facility, city, and state, e.g.,
NAS, Memphis, TN or Naval Hospital,
Bremerton, WA. The address must also be
included if the ship or station is overseas.
-- chief complaint and history of
complaint (subjective data.)

-- physical exam and clinical findings
(objective data.)

-- analysis of clinical findings (assessment.)

-- treatment accomplished and follow-up
care, in addition to medication prescribed or
used (plan.)
Each entry must be signed with the
signature of the person writing the note. The
signature is placed on the line immediately
below the last entry. Following the signature,
print or stamp your name.

The SOAP Note entry is a concise record
of the patient's condition, treatment applied
and response to treatment. The initial entry on
the SF 600 also MUST include:





36
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Worksheet
Lesson 3.03

Patient Care Documentation

1. What is the purpose of the Nursing Notes SF 510?

a. A written account of patient's condition, progress and response to care and treatment while
hospitalized.

b. Written and used by nurses and corpsman directly involved in giving the patient care.

c. Part of the patient's permanent hospital record. Represents a legal document of care given to the
patient.

d. All of the above.

2. All of the following are true of the SF 510 except:

a. may be used in a court of law.

b. incomplete or inaccurate nursing notes may be grounds for malpractice litigation.

c. may be completed in any color ink.

d. properly completed Nursing Notes may prevent legal action.

3. Nursing Notes may be written by:

a. nurses.

b. corpsmen.

c. doctors.

d. both a and b.

4. All entries on the Nursing Notes must be clearly written.

a. True b. False

5. Persons signing a Nursing Note are not required to include their:

a. first name.

b. last name.

c. social security number.

d. rate.
37
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Worksheet Handbook III

6. Where on the Nursing Notes would you print your name and rate?

a. Before your signature.

b. After your signature.

c. Directly below your signature.

7. Where is the standard form identification number on the SF 510?

a. Bottom left and upper right hand corner.

b. Upper left and bottom right hand corner.

c. Bottom right hand corner.

d. Bottom left and right hand corner.

8. The most recent Nursing Notes entry would be found in the back of the Nursing Notes SF 510 form.

a. True b. False

9. Hours are recorded using ___________________________ in ___________________________ or

___________________________ columns

10. Pertinent information which should be recorded in the Nursing Notes does not include:

a. assisted with feeding.

b. changed linen.

c. consumed 100% regular diet.

d. visited with chaplain.

11. When should Nursing Notes entries be made?

a. After the care has been given.

b. At the completion of the shift.

c. During your lunch break.

d. After completing your rounds.





38
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Worksheet
12. What information may be obtained during the physical assessment of the respiratory system?

_____________________________________________________________________________________

_____________________________________________________________________________________

13. If a patient's vital signs are abnormal, what information is documented in Nursing Notes?
_____________________________________________________________________________________

_____________________________________________________________________________________

14. Which of the following physical conditions are considered pertinent and would be noted on the SF 510?

a. Skin condition

b. Respiratory status

c. Appetite/diet

d. All of the above

15. After performing a procedure, the procedure and any adverse reactions should be recorded on the:

a. Patient Profile

b. Chronological Record of Medical Care

c. Nursing Notes

d. Doctor's Orders

16. Circle all steps that must be performed if a patient refuses treatment.

a. Order him/her to accept the treatment.

b. Inform the nurse.

c. Record the refusal on the Nursing Notes.

17. Circle all medications that must be recorded on Nursing Notes after being given.

a. One time drug orders

b. All stat orders

c. PRN drugs





39
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Worksheet Handbook III
18. Circle the treatments that must be recorded in the SF 510.

a. Wound care/dressing change

b. Suture, staple, or clip removed

c. Catheterization

19. Define the parts of a SOAP Note.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

20. What section of the SOAP Note contains pertinent patient history information?

_____________________________________________________________________________________

21. What is the difference between subjective and objective data.

_____________________________________________________________________________________

_____________________________________________________________________________________

22. What items are recorded under the PLAN of a SOAP Note?

_____________________________________________________________________________________

_____________________________________________________________________________________

23. What initial entries are required on the Chronological Record of Medical Care SF 600?

_____________________________________________________________________________________

_____________________________________________________________________________________

24. How should the date appear in the left-hand column of the SF 600?

_____________________________________________________________________________________

_____________________________________________________________________________________


25. If a patient is assigned to a ship or station overseas, what is included in the patient identification data?

_____________________________________________________________________________________

40
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Scenarios
Lesson 3.03

Nursing Notes Scenario
AM Shift

The morning staff reported on duty at 0645 on
15 J uly 1999. You (the corpsman) are assigned
several patients, including HMC Pat L. King,
USN, AD who is a 35-year-old female admitted
five days ago with Cholecystitis.

A Cholecystectomy was performed on 11 J uly
1999. You begin your shift by making rounds on
all your patients.

At 0800, Chief King was served a low fat diet.
Her appetite was good and she consumed the
entire meal.

At 0900, her doctor visited her during morning
rounds. You assisted Dr. Sullivan when he
performed an examination of the patient's heart,
lungs, abdomen, and legs. The incision on her
right upper abdomen appears to be healing well. A
small amount of clear yellow drainage, but no
swelling or redness is noted, and a clean, dry
dressing applied. The doctor noticed some
swelling and slight redness of the right leg and
stated that she has developed thrombophlebitis.
You are directed to maintain close observation of
the leg. After this, you assisted Chief King with a
bed bath and made her bed. She ambulated to the
solarium.

At 0930, she was taken to x-ray by wheelchair
for a routine PA and lateral chest x-ray.

At 1030, she was taken directly from x-ray to
the cardiology clinic, where she had an
electrocardiogram (EKG) tracing.

At 1100, she returned to the ward by
wheelchair. Her lunch arrived at 1200. She drank
the milk and ate a bowl of mixed fruit. HMC King
told you, I guess it took more out of me than I
expected. I'm worn out and feel faint. She slept
from noon until 1400 and then visited with her
family for half an hour. Next she went to the
solarium to watch television.

At 1445, the nurse notifies you that the doctor
has ordered Chief King to be on complete bed rest
with her right leg elevated to reduce the leg edema.
You inform Chief King of the changes and she
returns to her room at 1450. You make sure the
call bell is attached to her pillow.

The evening staff reported on duty at 1445 and
the morning staff reported off at 1500.

41
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Scenarios Handbook III
Nursing Notes Scenario
PM and NOC Shifts

At 1600, you take Chief King's vital signs.
You notice that her right ankle is extremely puffy
and she is sitting in a chair. She complains that her
leg is hot and very tender. You tell her to return to
bed and keep her leg elevated then report this to
the nurse. You explain to Chief King the reason
the doctor has ordered the complete bed rest. You
also recheck her abdominal dressing at this time.
There is no drainage and the dressing is well
applied. She tells you her incision is not giving her
any discomfort.

At 1730, Chief King ate a low fat diet. Due to
her awkward position, she needed assistance, but
ate well. She ate all of the food on her tray.

At 1900, she had two visitors, her mother and
her father, who stayed for an hour. Concerned
about her condition, they also asked to speak to the
charge nurse.

At 2000, her temperature, pulse, respirations,
and blood pressure were taken and recorded. Her
blood pressure was 160/100. Since this seemed
high to you and higher than previously recorded,
you notified the nurse corps officer.

At 2030, you straightened out Chief King's
bed, gave her fresh water and a back rub. She
brushed her teeth with assistance. At 2200, Chief
King told you her right leg felt much better and
asked you to turn off the lights so she could go to
sleep. The night staff reported on duty at 2245, and
the evening staff reported off duty at 2300.

You make the rounds every hour and each
time the patient is asleep. At 0600, she was
awakened for vital signs. Blood was drawn for a
CBC and a urine specimen collected for a routine
urinalysis and taken to the laboratory. You assisted
Chief King to brush her teeth and wash her face.

At 0700, the night staff reported off duty.

42
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Scenarios
Scenario #1 for SOAP Notes

On 25 November 1999, two Hospital
Corpsmen arrive by ambulance at the scene of a
motor vehicle accident. They find a young male
Caucasian lying beside a motor cycle. He is
moving restlessly. He has multiple abrasions on
his forehead and right forearm and is complaining
of pain in his right thigh.

The corpsmen identify themselves and obtain
permission to treat the patient. The patient has a
patent airway, respirations are regular, and his
pulse is strong and rapid. The patient complains of
pain in his right leg.

The first corpsman calms the patient,
maintains an open airway, applies cervical
immobilization and begins interviewing the
patient. The second corpsman finds minimal
bleeding from the facial and right forearm
abrasions. Neck was examined for DCAP-DTLS.
No abnormalities noted. Veins and trachea are
normal. A cervical collar is then applied.

When questioned the patient says he lost
control of his motorcycle when he hit some sand
on the turn. He states that, I hit my head on the
bike. He denies being unconscious at anytime. His
name is SN Charles J ones, USN, SSN 123-45-
6789, born 01 March 1977. He is stationed at
Service School Command. He further states I am
at the corner of 22nd street and Lewis. Today is
Friday morning, 25 November 1999. He denies
any allergies, is taking Dimetapp for a cold and
has been healthy all his life. He had breakfast at
0500 this morning.
It is determined that a rapid assessment will be
conducted on scene. Assessment of head reveals
no deformities or contusions. On the forehead
there is a 4-centimeter abrasion with minimal
bleeding, no burns, slight tenderness across
forehead, no lacerations, swelling or crepitation.
Neck was examined prior to applying the cervical
collar. Chest assessment reveals no DCAP-BTLS,
lung sounds present and equal, no crepitation
noted. Abdominal assessment reveals no DCAP-
BTLS, no firmness or distention. Abdomen is soft
in all quadrants. Pelvic assessment reveals no
DCAP-BTLS, no pain, motion or tenderness
noted. Lower extremities reveal no DCAP-BTLS
in the left leg and deformity and tenderness in the
right thigh. Good pulses, motor, and sensation in
both legs. Upper extremities reveal no DCAP-
DTLS in the left arm and multiple abrasions in the
right arm. Good pulses, motor, and sensation in
both arms.

Baseline vitals reveal: Pulse 90 and strong,
respirations 24 and regular, and blood pressure
108/70.

A Hare traction splint is applied to the right
leg. Abrasions of the right forearm and forehead
are dressed with sterile 4x4's and Kerlex.

Patient is further immobilized and prepared for
transport using a long spine board. Vital signs are
monitored every 5 minutes. Report is given and
the patient is transported to the Naval Hospital, by
ambulance.


43
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Scenarios Handbook III
SOAP Notes

S: 18 year old male Caucasian involved in
motorcycle accident this A.M. States that he has a
lot of pain in his right leg. He further states; I hit
my head on the bike. Denies being unconscious as
any time. Negative medical history, no known
allergies. Presently taking Dimetapp for cold. Last
meal was 0500 this A.M.

O: Pt. is restless and skin color appears normal.

Head: Oriented X 3, 4 centimeter abrasion on
forehead, slight tenderness and minimal bleeding.
No palpable deformity of skull, no major bleeding,
no drainage in ears or nose. The pupils are equal
and reactive to light.

Neck: No DCAP-BTLS or crepitation. Veins not
distended. Trachea mid-line.

Chest: No DCAP-BTLS. Good breath sounds
heard in all lung fields. No crepitation

Abdomen: No DCAP-BTLS noted in abdomen.
Abdomen is soft and supple in all quadrants. No
distention noted.

Posterior: No DCAP-BTLS

Pelvis: No DCAP-BTLS, no pain, motion, or
tenderness.

Lower Extremities: Left - No DCAP-BTLS.
Motor, sensory, circulatory intact.

Right -- DCAP- BTLS. Tenderness in right thigh
mid shaft deformity. Pulse, motor, sensation intact.

Upper Extremities: Left -- No DCAP--BTLS.
Strong radial pulse, rapid capillary refill, sensory
and motor intact.
Right -- Forearm multiple abrasions noted.
Radial pulse is strong, rapid capillary refill. No
DCAP-BTLS, sensory and motion intact.

A:

1. Painful, deformed right upper leg.

2. R/O head injury.

3. Multiple abrasions on forehead and right
forearm.

P:

1. Cervical collar applied.

2. HARE traction splint applied to right leg.

3. Sterile 4x4's and Kerlex dressing to forehead
and right forearm.

4. V.S. monitored every 5 minutes.

5. Immobilized using long spine board.

6. Transport via ambulance to Naval Hospital in
stable condition.

44
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Scenarios
Scenario #2 for Soap Notes

At 0700 sick call, SA Teresa J ones (21 year
old Caucasian female) checked into sick call
complaining of nasal congestion, sore throat,
painful swallowing, and headache. She reports
having nausea with two episodes of vomiting this
morning after breakfast. She states she is very tired
and I haven't felt good the past 2 days. No known
drug allergies and reports she is not taking any
medication.

Vital signs upon check-in to sick call are
temperature =101.2 F (orally), pulse =104, blood
pressure =100/64. Skin temperature is warm and
dry. Patient weighs 120 pounds. Physical
examination reveals that she complains of a
frontal/temporal headache. Percussion to frontal
sinuses is not painful. Her mouth is pink and
moist, the pharynx is very red and inflamed, with
post nasal drainage present. No pustules noted on
tonsils. Tympanic membranes are pearly gray
without retraction and with good light reflex.

She is able to move her neck easily and
without pain. Palpation of her neck reveals tender
pre-auricular and anterior cervical lymph nodes.
Normal breath sounds are heard in all lung fields.
Bowel sounds are present in all quadrants of the
abdomen. No rebound tenderness with palpation of
the abdomen.


















A strep test was performed which was positive
for group A Beta Hemolytic Strep. Orthostatic
blood pressures were obtained with results: lying
BP =100/64, P =74; standing BP =90/50, P =
104. An IV was started using a 16 gauge J elco
catheter in the antecubital fossa of the right arm.
Patient received 2000 cc of Lactated Ringer's in a
60 minute period. After IV was discontinued,
patient voided 300 cc of slightly concentrated
urine.

Patient was given an IM injection of 1.2
million units of Procaine Penicillin. Provided with
prescription for Pen V-K 250 mg QID for 7 days.
Instructed patient to take clear liquids for the next
24 hours and then advance diet as tolerated. She
was placed in an SIQ status for 24 hours and
informed to return to sick call at that time. Patient
stated that she understood the
Directions.

45
Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Scenarios Handbook III
NOTES/COMMENTS
46
Basic Hospital Corps School Lesson 3.03 Patient Care Documentation
Handbook III Forms
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Lesson 3.03 Patient Care Documentation Basic Hospital Corps School
Forms Handbook III




















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Handbook III Forms
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III
Lesson 3.05

Admission and Discharge

Terminal Objective:

3.05 State admission and discharge procedures.

Enabling Objectives:

3.05.01 Define two types of patient admissions to the Hospital.

3.05.02 List the responsibilities of the Hospital Corpsman when admitting a patient to the ward.

3.05.03 List the responsibilities of a Nurse Corps officer when admitting a patient to the ward.

3.05.04 List the purpose and procedure for filling out a Patient Valuables Envelope NAVMED
6010/8.

3.05.05 State the procedure for discharging a patient.

3.05.06 List the basic procedure to enter a patient into the computer information system.

Admission is a process that occurs when a
patient enters a health-care agency for care and
treatment. Two types of admissions are routine and
emergency. A routine admission starts at the
Admitting Office where the patient or family
member is interviewed to obtain information such
as next of kin, place of employment, hospital
insurance data, home address, etc., and the
admission paperwork is completed. An
identification bracelet and embossed
addressograph card are made. The patient arrives
on the ward after completing the admitting process
in the Admitting Office. An emergency
admission occurs when a patient is given initial
treatment in the emergency room, then transferred
to the ward. Personnel from the Admitting Office
will come to the ward to interview the patient or
family members will go to the Admitting Office to
provide the necessary information.






HOSPITAL CORPSMAN
RESPONSIBILITIES DURING
ADMISSIONS

When the patient arrives on the ward, you
should greet him/her in a calm, professional
manner, introducing yourself observing
appropriate military courtesy. Escort the patient to
his/her room, introduce to roommates, and orient
the patient to the ward environment including,
location of bathroom, kitchen area, and lounge
area. Teach the patient how to use the bed controls
to change position of the bed, TV remote control,
and telephone. Use and location of the call bell
should be explained. An initial height, weight, and
set of vital signs are obtained and recorded on
Nursing Notes SF 510, Vital Signs Record SF 511,
and appropriate local forms. Identify bed by
placing bed tag on the foot of the bed. Also mark
bedside locker and stand with patient's name.
Provide patient with pajamas, robe, slippers,
washcloth and towel unless the patient brought
own personal items. Ask the patient about allergies
and record on admission Nursing Notes SF 510.
Explain the purpose of the Patient Data Base
53
Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Handbook III
NAVMED 6500/14 and direct patient or family
member to complete Section I of the form. Ensure
patient uses a black ballpoint pen. Provide patient
with copy of ward rules/regulations and have
him/her sign expressing understanding of stated
rules.

NURSE CORPS OFFICER
RESPONSIBILITIES DURING
ADMISSION

The Nurse Corps officer also introduces
himself/herself to the patient observing appropriate
military courtesy. The nurse performs the initial
patient assessment of the patient's physical and
mental status. The physician is notified that the
patient has arrived to the ward and the Doctor's
Orders are checked for special instructions or
STAT orders. The Doctor's Orders are transcribed
by the nurse or checked by the nurse if transcribed
by the Hospital Corpsman or ward clerk. The Food
Service Department is notified of the patient's
arrival and the diet as specified in the Doctor's
Orders is ordered. After the patient completes
Section I of the Patient Data Base NAVMED
6550/14 the nurse reviews and clarifies the
information provided by the patient. In addition to
recording the initial assessment in the Nursing
Notes SF 510, pertinent observations are recorded
in Section II of the Patient Data Base by the nurse.
Information provided on the Patient Data Base
NAVMED 6550/14 is transferred to the top
portion of the Patient Profile NAVMED 6550/12,
e.g., glasses, needs assistance with daily activities,
and wears dentures. The nurse will also use the
information the patient provides and the data
obtained during the assessment to write the Patient
Care Plan NAVMED 6550/13.

ITEMS PATIENTS BRING TO THE
WARD

Personal items that patients commonly bring
to the ward when admitted include personal
hygiene items such as toothbrush, toothpaste,
comb, and hairbrush. They may also bring and
wear their own pajamas or nightgown and slippers.
Some patients also bring large quantities of
money, credit cards, money orders, and jewelry.
Explain to the patient that the hospital cannot be
responsible for items of value that the patient
wishes to keep in their possession while
hospitalized. Patients should be encouraged to
send valuable items home with a family member.
If a family member is not available, the items are
inventoried, placed in the Patient Valuables
Envelope NAVMED 6010/8 and delivered to
appropriate personnel for safekeeping. Local
command policy will dictate the person or
department responsible for patient valuable
safekeeping.

A routine admission will also bring from the
Admitting Office the completed admission
paperwork, identification bracelet, and embossed
addressograph card. Before applying the ID
bracelet or stamping paperwork with the
addressograph card, check with the patient to see
that the information is correct, especially the
spelling of the patient's name and the Social
Security Number. The ID bracelet on the wrist
provides a positive and consistent means of
identifying patients. Correctly identify the patient
prior to performing any treatment, procedure, or
giving a medication. The correct identification
procedure includes checking the bed tag, the ID
wristband, and asking the patient to state his/her
name.

The patient may also bring his/her Military
Health (medical) Record or Outpatient (medical)
and Dental Record when admitted. These records
are generally kept at the nursing station or secured
according to local command policy.

PATIENT VALUABLES

If patient valuables are unable to be taken or
sent home, the Patient Valuables Envelope
NAVMED 6010/8 is used to inventory and
safeguard valuables while the patient is
hospitalized. If the patient is a commissioned
officer or a civilian, two officers conduct the
inventory. If the patient is enlisted, an officer and
an enlisted member conduct the inventory. The
forms attached to the envelope must be completed.
Part A is the identification of the patient including
name, social security number, rank/rate, and
service. Part is the inventory of the valuables
deposited. Record the exact amount of any money
deposited. List any negotiable instruments such as
54
Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III
b. Times of administration. credit cards, checks, and money orders. When
listing the credit cards, record only a portion of
number, i.e., 4602 **** **** 7910. Describe
jewelry using terms as yellow or white metal
instead of gold or silver. Stones in jewelry are
described as white or red instead of diamond or
ruby since staff members are not certified jewelers.
After completing the inventory, signatures are
obtained in Part C of the Patient Valuables
Envelope NAVMED 6010/8. The inventory
officer, witness, and custodial officer sign in the
appropriate space. The envelope is delivered to the
appropriate personnel or department as dictated by
local command policy. The receipts attached to the
envelope are distributed according to the color
code at the bottom on the envelope.

c. Side effects.

d. Reason for taking the medication.

6. Symptoms that require immediate follow-up.

After the discharge instructions have been
given, the patient or his/her significant other is
instructed to gather all personal belongings. Then
the patient or significant other is directed to the
discharge section of Patient Affairs, the Collection
Agent and the Pharmacy (if there are any
prescriptions to be filled.) Complete the discharge
Nursing Note and send the completed Clinical
Record to Patient Affairs. Finally clean the unit
and prepare it for the next patient.
PATIENT DISCHARGE
PROCEDURE

Entering a patient into the
computer information system

Discharging a patient involves a variety of
actions. It starts with the doctor writing an order to
discharge the patient. This order includes specific
information on medication or treatment that will
need to be continued at home and follow-up
appointments.


Most patients will be enrolled and listed in
a computer data base system. Hospital computer
information systems have numerous administrative
capabilities. After entering the patient/sponsor's
social security number, prescriptions may be
ordered, diagnostic tests can be obtained and
nursing notes can be typed. Once the patient
arrives to the ward the nurse or HM will verify the
patient/sponsors social security number in the
computer system and verify eligibility for care.
The date the patient is admitted and discharged is
entered in the computer information system per
local policy. The computer information systems
are excellent means for tracking and coordinating
the patients care. When orienting to a hospital,
new staff members will receive computer
information training specific to the system they are
using and they will receive a password to help
protect patients privacy

After verification of the discharge order, the
discharge instructions are explained to the patient
and/or the family. Patients must verbalize and
demonstrate an understanding of the discharge
instructions, which include:

1. Follow-up appointments.

2. Self-care instructions.

3. Activity instructions.

4. Diet restrictions.

5. Medication administration. Be sure the patient
has an understanding of:


.
a. Proper dose and route.

55
Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Handbook III
NOTES/COMMENTS
56
Basic Hospital Corps School Lesson 3.05 Admission and Discharge Worksheet
Handbook III
Lesson 3.05

Admission and Discharge Worksheet

1. Explain how an emergency admission to the hospital is different from a routine admission.

____________________________________________________________________________

____________________________________________________________________________

2. Circle each procedure that is not the responsibility of the HM during a routine admission.

a. Orient patient to the ward environment.

b. Ask the patient about food, drug, or other allergies.

c. Have the patient read and sign ward regulations.

d. Notify the emergency room.

3. When escorting a newly admitted patient to the assigned bed, the corpsman should:

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

4. The patient or significant other is required to complete what form during admission?

a. Patient Data Base NAVMED 6550/14

b. Patient Valuable's Envelope NAVMED 6010/8

c. Patient Profile NAVMED 6550/12

d. Unit Report NAVMED 6550/2

5. The patient's admission height, weight, and vital signs are recorded on what forms?

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________




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Lesson 3.05 Admission and Discharge Worksheet Basic Hospital Corps School
Handbook III
6. List items that are provided to a patient on admission to the ward.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

d. ______________________________________________________

7. Circle each procedure that is NOT the responsibilities of the Nurse Corps officer during the admission
of a patient.

a. Notify physician of admission of patient

b. Complete Patient Data Base NAVMED 6550/14, Section I

c. Check Doctor's Orders SF 508 for STAT orders

d. Write Patient Care Plan NAVMED 6550/13

8. What items will a routine admission bring with them from the Admitting Office?

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

9. What should be done with patient valuables brought to the ward?

a. Kept in bedside stand

b. Sent home with a family member

c. Hidden under the bed

d. Kept at nurse's station

10. The purpose of the ID bracelet is:

___________________________________________________________________________

11. List the three items that are checked to identify a patient prior to performing any treatment or giving
any medication.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge Worksheet
Handbook III

12. Upon arrival to the ward, the ID band is checked with the patient to verify:

a. ______________________________________________________

b. ______________________________________________________

13. If valuables are not sent home with a family member, they are:

a. the responsibility of the hospital.

b. inventoried and placed in the Patient Valuables Envelope NAVMED 6010/8.

c. returned to the patient who will have to take them home prior to admission.

d. given to the CO for safekeeping.

14. Who inventories a civilian patient's valuables? _________________________________________ .

15. The patient reports that she has a gold wedding band with 3 diamonds that she would like to have
inventoried for safekeeping. How is it described in the inventory of valuables?

______________________________________________________________________________

16. List the six areas that should be covered in patient discharge instructions.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

e. ____________________________________________________________________________

f. ____________________________________________________________________________

17. What three offices of the hospital is the patient sent to immediately following discharge from
the ward?

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

18. The completed clinical record is sent to _____________________ after the patient is discharged.

19. The nurse or HM should verify the patient/sponsors social security number in the computer
information system and verify ______________________________________.
59
Lesson 3.05 Admission and Discharge Worksheet Basic Hospital Corps School
Handbook III
NOTES/COMMENTS
60
Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III Scenario
Admission Scenario

Today, Pat L. King, HMC/N/AD, was admitted to the ward with a diagnosis of cholecystitis. HMC
King is 32 years old, 5'10" and weighs 175 lbs. She is Caucasian and reports she practices the
Catholic faith. Vital signs are BP =132/88, P =84, R =20, T =98.6. She is accompanied by her
significant other. States she is allergic to Aspirin and Betadine and reacts to both with itching and
hives. Medications taken are Digoxin 0.25 mg PO QD -- last dose this AM. She has this medication in
her purse. She brought her Military Health (medical) Record with her to the hospital.

HMC King has not been hospitalized before. She states she has upper dentures and wears glasses for
reading. No reported problems with bowel or bladder function, sleeps an average of 7 hours per night.
Denies any problems other than N&V and RUQ pain following fatty foods. She is wearing a Timex
quartz watch, gold diamond ring and wedding band set, and gold ball earrings. She states she has one
credit card with her and some change.

At 1600 HMC King is instructed to go to the lab and x-ray and is accompanied by her significant
other. At 1730 they return to the ward and said they enjoyed their walk. At 1830, Dr. J ones visits and
answers their questions.

Doctor's Orders

1. Admit to ward, Dr. J ones

2. Diagnosis - Cholecystitis

3. Allergies - Aspirin and Betadine

4. V.S. q 4 hr

5. Diet - low fat, NPO after midnight.

6. Activity - up ad lib

7. Chest x-ray, CBC, RPR, UA with C&S now

8. Dalmane 30mg PO qHS PRN

9. Digoxin 0.25 mg PO q AM

/s/ B. J ones

LT/MC/ USNR

Using the above information, complete the following forms:

Admission Nursing Notes SF 510 Overprint
Unit Report NAVMED 6550/2
Patient Valuables Envelope NAVMED 6010/8
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Scenario Handbook III
NOTES/COMMENTS
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III Forms
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III Forms
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III Forms
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
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Basic Hospital Corps School Lesson 3.05 Admission and Discharge
Handbook III Forms
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
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Handbook III Forms
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Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
Lesson 3.05 Admission and Discharge Basic Hospital Corps School
Forms Handbook III
72

72
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III
Lesson 3.04

Inpatient Clinical Record

Terminal Objective:

3.04 Use and maintain an inpatient record.

Enabling Objectives:

3.04.01 List inpatient clinical record forms and define their purpose.

3.04.02 List the proper sequencing of inpatient clinical record forms.

3.04.03 List the Hospital Corpsman's responsibilities in maintaining an inpatient clinical record.

3.04.04 Record temperature, pulse, respiration, and blood pressure on the Vital Signs Record SF 511
and Plotting Chart SF 512.


The Inpatient Clinical Record provides a
concise record of a patient's condition and progress
during hospitalization. The record includes past
medical care, occupational and military history,
and response to treatment. This information aids
the doctor in making a diagnosis or prescribing
treatment.

A series of standard clinical forms make up
the Inpatient Clinical Record or inpatient chart.
Every form is assigned a number in the Standard
Form (SF) series. Each form has a specific
purpose. Every form will NOT be used for all
patients, but each record should have the following
forms arranged in chronological and numerical
order.

NARRATIVE SUMMARY SF 502 - This form
is used by the physician to summarize clinical data
and treatments during hospitalization. The form
usually has a carbon copy. The original is filed in
the Outpatient or Military Health Record and the
duplicate is filed with the Inpatient Clinical
Record.

HISTORY PART 1 SF 504 - The physician
records the course of the current hospitalization,
including signs, symptoms, duration of
complaints and circumstances of admission on
this form.

HISTORY PART 2 and 3 SF 505 - After
interviewing the patient, or a significant other,
or reviewing the outpatient record, the
physician documents occupation, military
history, childhood and adult injuries and
illnesses, drug sensitivities, and allergies on this
form.

PHYSICAL EXAM SF 506 - The results of
the physical examination are recorded on this
form, including the patient's physical and
mental characteristics.

DOCTOR'S ORDERS SF 508 - The physician
writes instructions to direct the care and
treatment of the patient on this form. Some SF
508s have a carbon copy so medication orders
can be easily sent to the pharmacy.

PROGRESS NOTES SF 509 - The physician
uses this form to document the patient's
response to treatment and other pertinent
information related to the patient's case. Other
medical personnel, e.g., dietitian, physical
73
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Handbook III
therapist, may also record observations on the SF
509.

NURSING NOTES SF 510 - Observations,
patient progress, treatments, and some medications
are recorded on this form by nurses and corpsmen.
Special overprints may be developed by the local
command to standardize documentation.

VITAL SIGNS RECORD SF 511 - Temperature
and pulse are graphed on this form. Blood
pressure, respirations, weight, and height are also
recorded on this form. The patient's 24-hour total
input and output can be recorded on this form.

PLOTTING CHART SF 512 - Used to record
blood pressures taken more frequently than every
four hours, e.g. after special procedures. Also used
to record other frequently monitored parameters of
the patient's progress, e.g., TPR and CVP (central
venous pressure).

CONSULTATION SHEET SF 513 - Used to
request assessment or assistance from a specialist,
e.g., physical therapist, dietitian.

OPERATION REPORT SF 516 - Following an
invasive procedure or operation, the physician
dictates a summary of the procedure which is
typed on this form.

ANESTHESIA REPORT SF 517 - Completed by
the physician or nurse who administers anesthesia,
documenting the patient's vital signs/responses
throughout the procedure.

BLOOD OR BLOOD COMPONENT
TRANSFUSION SHEET SF 518 - Initiated when
blood or blood components are ordered for a
patient. Lab personnel use this form to record
blood evaluations. The form is also utilized by
ward personnel to document a patient's response to
the administration of the blood or blood
components.

RADIOGRAPHIC REPORTS SF 519 - X-ray
reports SF 519A are displayed on this form.

RADIOGRAPHIC CONSULTATION
REQUEST/REPORT SF 519A - Used to order
radiographic studies (x-rays).
ELECTROCARDIOGRAPHIC REPORT
SF 520 - Used to request an EKG and
document the findings when the EKG is
completed.

REQUEST FOR ADMINISTRATION OF
ANESTHESIA AND FOR
PERFORMANCE OF OPERATIONS AND
OTHER PROCEDURES SF 522 - This form
is completed to document the patient's
understanding and agreement to an operation or
special procedure. Often called a permit or op
permit.

ABBREVIATED MEDICAL RECORD SF
539 - Used in place of the SF 502, SF 504 and
SF 506 for a patient who is admitted for less
than 48 hours. It has sections to record a brief
history and physical examination, Doctor's
Orders, Progress Notes, and Nursing Notes.

LABORATORY REPORT DISPLAY SF
545 - A backing sheet for mounting laboratory
chits (SF 546 - SF 557). Chits are attached so
they may be seen easily, with the most recent
report on top of previous reports.

SF 546 -557 - Lab chits are forms used to
request and document lab tests on specimens.

SERIOUS/VERY SERIOUS LIST
NAVMED 6320/5 - Used to document
notification of Next of Kin (NOK), parent
command, and the hospital chain of command
when a patient is identified as seriously ill, or
very seriously ill. The physician indicates by
writing Doctor's Orders that the patient be
placed on the SL/VSL.

MEDICATION ADMINISTRATION
RECORD (MAR) NAVMED 6550/8 - This
form is used to document medications
administered during a seven-day period.
Medications ordered by the physician on the
Doctor's Order SF 508 are transcribed onto the
MAR.

PATIENT PROFILE NAVMED 6550/12 -
Used to standardize treatment and provide a
ready reference for the care to each patient. The
Patient Profile provides pertinent patient
74
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III
information such as diagnosis, orders for
medications, treatments, activity, diet, vital signs,
bath, and intake and output. This form is not a
permanent record, but is kept for a period of time
after the patient is discharged and then discarded.

PATIENT CARE PLAN NAVMED 6550/13 -
This form is a permanent part of the clinical record
and is placed in the chart at discharge, in front of
the Patient Data Base, NAVMED 6550/14. It is
written by a nurse, based on input from the
hospital staff concerning the patient's needs while
in the hospital and in preparation for discharge.
Nursing care problems, expected outcomes, and
actions needed to resolve identified problems are
listed on this form. Some of the problems are
obtained from the Patient Data Base. This form
provides a format for establishing discharge
objectives which are nursing goals for the patient
to achieve prior to discharge or during
convalescence.

PATIENT DATA BASE NAVMED 6550/14 -
Section I of this form is filled out by the patient or
significant other upon admission to the hospital. It
is a summary of the patient's health history, which
may identify actual or potential nursing care
problems. A nurse must review the information
and summarize the observations of the patient's
statement and conditions in Section II. When the
form is completed, it is placed in the inpatient
chart before the Nursing Notes SF 510.

TWENTY-FOUR HOUR INTAKE AND
OUTPUT WORKSHEET DD 792 - Used to
document an accurate account of the patient's fluid
intake and output over a 24-hour period.

PRIVACY ACT STATEMENT DD 2005 -
Signed by patient, parent, or guardian on
admission to the hospital to document the patients
acknowledgment of the Privacy Act regulations.

SEQUENCING OF FORMS

Forms are placed in the inpatient clinical
record by type with Standard Forms first,
NAVMED forms second, DD forms third, and
local forms last. Forms are filed in numerical order
beginning with the lowest numbered in each
respective group. The SF 502 is followed by the
SF 503, SF 504, etc., followed by the
NAVMED 6550/8, NAVMED 6550/13, then
DD 792, etc. When more than one copy of the
same form is used, forms are placed in
chronological order with the newest form on
the bottom. The most recent date will be on the
bottom or toward the back of the chart, e.g., 08
AUG 97, 12 AUG 97, 15 AUG 97. Follow the
local policy of your facility.

CLINICAL RECORD
MAINTENANCE

The Hospital Corpsman has several
responsibilities in maintaining the clinical
record during a 24-hour period. On admission,
the patient is given an addressograph card
which is embossed with 1) his/her name, 2)
FMP code (family member prefix) and active
duty member's or sponsor's social security
number, 3) patient's date of birth, 4) member's
or sponsor's status: AD; RET; FMH; FMD; etc.,
5) member's or sponsor's branch of service:
Navy (N), Marine Corps (MC), Coast Guard
(CG), Army (A), Air Force (AF), and Public
Health Service (PHS), 6) admission date, 7)
hospital register number, and 8) religious
preference.

The information on the card is transferred
to the lower left corner of each page by an
addressograph machine, which is similar to
stamping a credit card. If the addressograph
plate is not available, then the patient's name,
social security number, branch of service, and
status are hand written on each form. All forms
are checked for proper identification because
they are parts of a legal record, which may be
used in a court of law. The corpsman should
also check the record each day and add blank
forms as needed. After the physician has
reviewed and initialed any laboratory and X-ray
reports, they are attached to the correcct forms.
Ensure that only authorized personnel have
access to the patient's record.

RECORDING VITAL SIGNS

Vital Signs are written in the TPR log and
transferred to the Vital Signs Record SF 511.
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Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Handbook III
Any time a temperature is 100 degrees F or
above, it must be circled in red in the vital signs
log. If the pulse or respirations are abnormal, i.e.,
irregular, slow or fast, it should also be recorded in
the Nursing Notes. The Vital Signs Record SF
511, is divided into seven major columns, one for
each day. Each column is subdivided into an AM
and PM section. The subdivisions are further
divided by two vertical dotted lines. Dotted lines
divide the horizontal spaces into five even
divisions.

Black ink is to be used for all entries. Fill in
heading at the top of the page. The day of
admission is the first hospital day. The day of
operation or delivery is lettered Day of Surgery
(DOS) or Day of Delivery (DOD) and the
following days labeled DOS 1, DOS 2, or DOD 1,
DOD 2. The hours the TPRs are taken are also
recorded.

Temperature and pulse taken every four hours
(q4hr) and twice a day (BID) are charted between
the dotted lines. Vital signs taken four times a day
(QID) are charted on the dotted lines. Vital signs
obtained more frequently than every four hours are
recorded on the Plotting Chart SF 512.
Temperatures are recorded with a dot the size of a
pinhead. The dot is placed in a spot corresponding
vertically to the hour and horizontally to the
numerical value. The dots are connected by a
solid line. A capital (R) for rectal or (A) for
axillary route is placed next to the temperature.
Pulse rate is charted using a small, open circle
corresponding vertically to the hour and
horizontally to the numerical value. These are also
connected by a solid line. Respiration rate is
recorded at the bottom of the graph in the space
corresponding vertically to the hour. There are
three boxes in the AM column and three in the
PM column for recording the blood pressure.
The systolic and diastolic values are recorded
as a fraction. If the blood pressure is taken
more frequently the q4hr, the SF 512 must be
used. Height and weight are recorded on
admission and subsequent weights can be
charted in the appropriate date columns. There
are also spaces for the total intake and output
for each day.

PLOTTING BLOOD PRESSURE

The Plotting Chart SF 512, may be
used to graph blood pressures, comparisons of
TPR, or CVP. The purpose of the graph is
printed on the top of the graph. Increments are
marked along the vertical portion of the graph.
Both vertical and horizontal scales should be
definite and progress uniformly. Time
increments should be noted along the horizontal
portion of the graph. The meaning of symbols
used in the graph should be shown in a key to
the side of the graph. As with all forms, the
lower left corner should be labeled with the
addressograph. Vital signs are recorded on the
SF 512 in the following manner. Blood
pressures are plotted by drawing a heavy line,
two horizontal spaces wide, for systolic and
diastolic values. The area between clearly
identifies the blood pressure. Temperature is
recorded at the top of the graph with a
numerical value, e.g., 98.6. Respiration rate is
recorded at the bottom of the graph. Pulse rate
is recorded as a small circle corresponding to
the hour and the numerical value. All vital
signs taken at a specific time are recorded
within a vertical line, two spaces wide.

76
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Worksheet
Lesson 3.04

Inpatient Clinical Record Worksheet

1. Match each description in column B to the correct form number in column A

A B


A. Narrative Summary SF 505 _______

B. Physical Exam SF 506 _______

C. Nursing Notes SF 510 _______


D. Radiographic Report SF 519 _______


E. Doctors Orders SF 508 _______

F. History Part I SF 504 _______

G. Intake and Output DD 792 _______


H. Plotting Chart SF 512 _______

I. MAR NAVMED 6550/8 _______

J . Patient Profile NAVMED 6550/12 _______


K. Laboratory Report _______
Display SF 545

L. Patient Care Plan NAVMED 6550/13 _______

M. Patient Data Base NAVMED 6550/14 _______

1. Records blood pressures taken Q2 hours

2. SF 546-557 forms are mounted on this
form

3. Permanent record of medications given
to a 7 day period

4. Ready reference for data used to care for
a patient

5. May identify actual nursing care
problems

6. Provides a format for discharge
objectives

7. Summarizes inpatient data of
hospitalized patient

8. Used by Corpsmen to document
treatments

9. Records course of present illness

10. Doctor records mental and physical
findings from exams on this

11. Instructions for directing care and
treatment of patient are written here

12. Records fluid intake or output

13. X-ray reports are displayed on this form

2. Inpatient clinical forms are placed in the chart in numerical order.

a. True b. False

77
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Worksheet Handbook III
3. If several of the same form is used in an inpatient clinical record, they are placed in
_________________________ order.

4. To be properly identified, a form must have ______________________________ in the lower left
corner.

5. Write out the status indicated by the following abbreviations.

AD ____________________________________________

FMW ____________________________________________

FMS ____________________________________________

RET ____________________________________________

DEC ____________________________________________

6. Proper patient identification includes:

a. register number, birth date, branch of service, status, Social Security Number of sponsor and name.

b. name, Social Security Number, bed number and ward number, birth date.

c. name, Social Security Number, admission number, ward number and branch of service.

d. name, Social Security Number, branch of service and status.

7. If an addressograph plate for the patient is not available, the name, SSN, branch of service and status
may be written in pencil on each form.

a. True b. False

8. The entire clinical record is reviewed and new forms are added:

a. once a shift.

b. every other day.

c. once every 24 hours.

9. A patient may review his/her record whenever desired.

a. True b. False

10. ___________________ ink is used for all entries on the SF 511.

11. In the vital sign log, elevated temperatures (greater than 100) are circled in _____________________.


78
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Worksheet
12. Circle each item that is recorded at the top of the SF 511.

a. Date of admission

b. Postoperative day or day of delivery

c. Hours vital signs were taken.

13. QID vital signs are recorded between the dotted lines on the SF 511.

a. True b. False

14. Small circles connected by a solid line are used to record _________________________________ on
the SF 511.

15. How is an axillary temperature charted on the SF 511?

______________________________________________________________________________

16. The Plotting Chart SF 512 is used to record vital signs taken more frequently than

_____________________.

17. Circle the steps for preparing the Plotting Chart SF 512.

a. Put patient identification in lower left corner.

b. Print purpose across the top of the form.

c. Enter date and time at top of form.

18. Systolic and diastolic blood pressure values are recorded as _________________________________ .

19. Temperature, pulse, and respiriation are charted on the SF 512.

a. True b. False

20. Who is ultimately responsible for the medical care a patient receives?

a. The senior nurse.

b. The senior corpsman.

c. The physician.

d. The ward nurse.





79
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Worksheet Handbook III
21. In regard to Doctor's Orders, the nurse and/or corpsman are ultimately responsible for:

a. the medical care of the patient.

b. the carrying out Doctor's Orders.

c. the treatment of the patient.

d. completing the Doctor's Orders.

22. Who can accept a Doctor's Order by telephone? ___________________________________________

23. Entries on the Patient Profile that are made in pencil include all of the following except:

a. activity.

b. bath.

c. treatments.

d. fluids.


24. Where are lab requests recorded on the Patient Profile?

a. Front top portion

b. Back right column

c. Back left column

d. Front bottom portion

80
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Scenarios
SCENARIO FOR SF 511


BM1 A.B. Coe was admitted to the
Naval Hospital at 2200 on 07 Oct 95.
Admission Vital Signs were T-101.6,
P-92, R-24, Blood pressure was
134/92. Height 6'1" and weight 192
lbs. Doctor's Orders included:

1) Weight daily x 2 days
2) V/S q 4 H



2nd day 8 Oct

0200 0600 0100
T 100.4R
P-R 88-20
BP 110/80
101.2R
106-22
120/82
WT 192
100.6R
100-24
128/86

1400 1800 2200
T 1.034R
P-R 124-28
BP 130/88

102R
104-16
120/84
101R
96-20
12/86


3rd day 9 Oct

0200 0600 0100
T 100.8
P-R 94-20
BP 124/82
101.0
94-20
120/82
WT 191
101.0
96-22
120/80

1400 1800 2200
T 101.6
P-R 104-24
BP 118/74
100.6
94-22
120/78
100
92-20
124/86





On the fourth day this patient had surgery.
Doctors Orders include: TPR q4H. BP Q4H


10 Oct

0200 0600 0100
T 98.6
P-R 84-16
BP 118/76
99.4
82-18
122/84
In surgery

118/82

1400 1800 2200
T 99.8
P-R 82-18
BP 118/82
98.6
72-18
112/78
99
78-22
132/88


On the fifth day the VS order was changed
to: TPR and BP QID


11 Oct

0200 0600 0100
T 99.1
P-R 80-20
BP 112/78
97.4
68-14
120/80
98.0
76-16
122/82

2400
T 98.8
P-R 80-20
BP 118/76



On the sixth day the VS order was
changed to: TPR and BP BID

12 Oct

0600 1800
T 98.6
P-R 84-16
BP 114/76
98.8
88-20
16/78
81
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Scenarios Handbook III
SF 512 Scenario

Graph the following postoperative blood pressures for BM1 A.B. Coe. They were taken o
his fourth day (10 Oct) in the Hospital.


TIME B/P PULSE RESP TEMP
1200
1215
1230
1245
110/70
112/68
120/62
116/60
90
78
64
82
16
18
20
16
98.6
98.7
98.6
99.0
1300
1315
114/62
116/64
90
68
14
14
99.2
100.0
1330
1345
118/64
118/60
76
80
24
24
101.0
99.0
1400
1430
112/66
118/70
84
72
16
18
101.0
101.5
1500
1530
116/72
120/80
90
68
2
22
98.6
98.8
1600 120/76 74 24 99.0
1700 118/74 80 18 99.2
1900 114/62 86 16 100.0
2100 112/68 94 14 102.0


82
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Forms
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Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Forms Handbook III
84
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Forms
85
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Forms Handbook III
86
Basic Hospital Corps School Lesson 3.04 Inpatient Clinical Record
Handbook III Forms
87
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Forms Handbook III
Lesson 3.04 Inpatient Clinical Record Basic Hospital Corps School
Forms Handbook III
88

88
Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes
Handbook III
Lesson 3.07

Nasogastric Tubes

Terminal Objective:

3.07 List concepts and principles for insertion, placement, checking placement irrigation, tube feeding, and
removal of nasogastric tubes.

Enabling Objectives:

3.07.01 State the purpose for nasogastric tube insertion.

3.07.02 List equipment used for insertion, maintenance and discontinuation of the nasogastric tube.

3.07.03 State the procedure for inserting a nasogastric tube and checking its placement.

3.07.04 State the procedure for administering a nasogastric tube feeding.

3.07.05 State patient care and nasogastric tube maintenance needs.

3.07.06 State the procedure for removal of a nasogastric tube.

3.07.07 State the procedure for recording nasogastric tube insertion, irrigation, removal, and feeding.


Nasogastric tubes (NG tubes) are made of soft
plastic or rubber, and are passed through the nose
or mouth into the stomach. Two primary uses of
nasogastric tubes are: the introduction of food and
fluids; and the removal of fluids, gas, and poisons.

Feeding by NG tube is also referred to as
gavage feeding. In addition to providing liquid
nutrients, medications and irrigations can be given
through a NG tube.

Removal of fluids may follow irrigation.
Lavage is a term for washing out the stomach by
instilling fluid and removing that fluid. A patient
who has taken a drug overdose needs to have
his/her stomach contents diluted and removed.

Decompression is the removal of fluid and air
from the gastrointestinal tract. The NG tube is
attached to a suction device such as a portable
machine or in-wall suction. Most hospitals have
vacuum tubing built into the walls, which attach to
a collection device. A regulator allows the type
and amount of suction applied to be adjusted.
Suction can be continuous or intermittent and high
or low. Low intermittent suction is the most
frequently used setting. Intermittent suction
prevents a build up of negative pressure in the
stomach, and prevents damage to gastric tissue.
Occasionally, the NG tube may be attached to a
collection bag and allowed to drain by gravity.
Diagnostic tests, such as a gastric analysis can be
performed on aspirated stomach contents.

EQUIPMENT FOR NASOGASTRIC
TUBES

An NG tube can be a single lumen (one hole),
called a Levin tube or a double lumen (two hole)
called a Salem Sump. Levin tubes are single lumen
rubber tubes which are less common today.
Plastics have replaced rubber, and double lumen
tubes have replaced single lumen tubes. Sump
tubes typically have a smaller blue port which
89
Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School
Handbook III
keeps the stomach open to air. This blue port is
used only to inject air. However, some facilities
may only use Levin tubes. The French (Fr.) scale
is used to size NG tubes. NG tubes commonly
inserted are between 14 and 18 Fr. for adults and
10 or 12 Fr. for children.

NG tubes for specific purposes may be used,
but are often inserted by doctors or technicians. In
the Emergency Department, an Ewald or
Levacuator tube may be placed for rapid
evacuation of gastric contents. These tubes are
large bore (>20 Fr.), and are removed soon after
lavage has been completed. Feeding tubes are
smaller (8 or 10 Fr.) and have a weight at the distal
end. Feeding tubes are designed to work through
the stomach into the duodenum or farther.
Weighted tubes must have their location verified
by X-ray before feeding is started.

Rubber tubes are usually placed in ice for a
few minutes to provide the firmness required
during insertion. Plastic tubes, on the other hand,
may be too stiff, and can be placed in warm water
for softening. Single lumen tubes may become
stuck against the gastric lining when suction is
applied and a partial vacuum is created in the
stomach. Double lumen tubes were developed to
prevent this. The second port, (the sump or air
port), is used to allow atmospheric air to enter the
stomach. The stomach pressure remains equal to
the atmosphere, so the tube does not fasten itself to
the mucosa. The airport is only used to insert air
into the stomach. Do not aspirate through this port
or connect this port to suction at any time.

Equipment needed for inserting a nasogastric
tube.

1. Nasogastric tube

2. Adhesive tape

3. Curved basin

4. Glass of water or ice chips

5. Toomey syringe

6. Chux pad or towel

7. Rubber band or clamp

8. Safety pin

9. Stethoscope

10. Drinking straw

11. Tissues

12. Water soluble lubricant

13. Penlight

14. Disposable gloves

15. Tongue blade

NASOGASTRIC TUBE INSERTION

After verifying the Doctor's Orders, gather the
necessary equipment for NG insertion and take it
to the bedside. Wash your hands. Perform the three
patient identification checks. Explain the
procedure to the patient, including what you are
going to do, and why the NG tube is needed.
Provide for privacy, safety, and comfort by placing
the patient in a Semi or High Fowler's position,
drawing the curtain, and checking side rails and
wheel locks.

With the patient in a sitting position, cover the
chest with a Chux or towel to protect the patient's
clothing and linen. Remove dentures before
starting the procedure. Use the penlight to examine
the nostrils for possible obstruction or deformities.
If both nostrils are obstructed, notify the nurse or
physician. Ask if the patient has ever broken
his/her nose or has a deviated septum. Have the
patient blow his/her nose, if able.

Determine the length of the tube to be inserted.
Measure the distance from the patients nose to the
earlobe then from the earlobe to the tip of the
xyphoid process. Mark this distance with a piece
of tape.

Observe the natural curve of the NG tube. The
tube should follow the natural curve of the
nasopharynx. Lubricate the first 6 inches of the
tube with water-soluble lubricant. Lubrication
90
Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes
Handbook III
reduces friction and injury during insertion. For
optimal control, hold the tube just past the
lubrication.

Instruct the patient to breath through his/her
mouth. Gently pass the tube through a nostril to
the nasopharynx, Figure 3.07.01. Pause to give the
patient a chance to prepare for the rest of the
insertion. Do not force the tube if you meet an
obstruction. You may want to repeat the attempt
using the other nostril.

Have the patient swallow continuously, or, if
allowed, sip water through a straw or eat ice chips.
Swallowing helps advance the tube and causes the
epiglottis to close the opening to the trachea. Ask
the patient to flex his/her head slightly. This
reduces the chance that the tube will enter the
trachea and makes swallowing easier. Rotating the
tube may help it advance.

As the patient swallows, continue to advance
the tube to the mark. Tell the patient to stop
swallowing. Without releasing your grasp, verify
that the tube is in the stomach.

The most common method of verification is to
aspirate stomach contents, Figure 3.07.02. Attach a
Toomey syringe to the free end of the NG tube and
gently pull back on the plunger. Stomach contents
(fluids or partially digested food) should be visible
if the tube is in the stomach. No other anatomic
structure contains secretions with the
characteristics of gastric fluid.

Another way to verify the tube is in stomach is
to inject 30 cc of air into the NG tube using the
Toomey syringe while listening over the stomach
with a stethoscope. (A partner may listen for you.)
Place the stethoscope on the abdomen immediately
below the rib margin. As air is injected rapidly
through the tubing, a swooshing sound will be
heard if the tube is in the stomach. An X-ray can
be used to verify placement of a feeding tube.

Once the position has been verified, tape the
tube to the patient's nose. Connect the tube to
suction or clamp as ordered. Attach the tube to the
patient's gown by placing a flag of tape around the
proximal end of the tube. A safety pin is used to
secure the tape flag to the gown. Rubber bands can
also be used to secure the tube to the gown. By
securing the tube, the possibility that it will
become tangled or dislodged is reduced.

When the procedure has been completed,
remove all equipment. Wash your hands and make
the patient comfortable. Record pertinent
observations on Nursing Notes SF 510 and
Twenty-Four Hour Intake & Output Worksheet
DD 792.

NASOGASTRIC TUBE IRRIGATION

Nasogastric tubes can easily be clogged by
mucus, food, or pieces of gastric mucosa. When
the tube is not draining properly, you may be
asked to irrigate it to restore patency. After
verifying the Doctor's Orders, perform patient
identification checks, explain the procedure to the
patient, and provide for privacy, safety, and
comfort.

Gather the equipment:

1. Chux pad

2. Irrigation solution

3. Irrigation kit or a Toomey syringe and a
container

4. Stethoscope

Wash your hands and don clean gloves. Place
a Chux pad to protect the patient's gown and bed
linen. It is common for stomach contents or
irrigating fluid to leak during NG irrigation.
Unclamp or disconnect the NG tube from suction
or other attachment if indicated. NG tubes used for
feedings may be clamped between meals.

Verify the tube placement. Always check tube
placement before putting anything down a NG
tube. Fill the Toomey syringe with irrigation fluid.
Attach the filled syringe to the end of the gastric
tube. (Remember that the blue port of sump tubes
is only for air.) Inject the solution slowly and
gently. If resistance is felt, check the tube for
kinks. Proceed when the resistance is relieved. Do
not force the fluid; instead notify the nurse or
doctor. When you have inserted the specified
91
Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School
Handbook III
amount of fluid, withdraw by pulling back gently
but steadily on the plunger. Observe the contents
for color, odor, consistency and amount. Repeat
PRN until the tubing is clear.

When the irrigation is complete, reattach the
NG tube to suction, clamp, or gravity as indicated.
Be sure the suction is turned on. Record the
irrigation on the Twenty-Four Hour Intake &
Output Worksheet DD 792 as intake and output.
Ensure you have measured the amount instilled
and the amount returned. Note the procedure on
the Nursing Notes SF 510. Provide care to the
patient's mouth, nose, and lips. Moisturize or
lubricate the lips and nose. Observe the nares for
irritation or skin breakdown.

NASOGASTRIC TUBE FEEDING

Some patients who are unable to take food or
fluid by mouth may receive nutrition via tube
feedings, which are also known as gavage
feedings. Unconscious patients, patients with
mouth or throat surgery, and patients who have an
endotracheal tube may be fed through a tube.
Several commercially prepared tube feedings are
available. The doctor will order a solution which
meets the patients needs. Feeding can be
intermittent or continuous.

Equipment needed to administer a tube
feeding includes:

1. Clean gloves

2. Chux

3. Stethoscope

4. IV pole

5. Toomey syringe or irrigation kit

6. Prepared formula

7. Feeding set. A feeding set may be single-use
or it can be used up to 24 hours, depending on
local policy.

The procedure for intermittent feedings is:
verify the Doctor's Orders, gather equipment, wash
your hands, perform the patient identification
checks, explain the procedure, provide privacy,
comfort, safety, and position the patient. Use
gravity to your advantage. Elevate the head of the
bed (Semi-Fowler's or High Fowler's position)
during feeding and for 30 minutes afterward to
decrease the risk of regurgitation and aspiration.

Don clean gloves, place a Chux pad to protect
the linen and pajamas, and remove the clamp or
cap from the feeding tube. Verify NG tube
placement. Aspirate the stomach contents with a
Toomey syringe. The aspirated fluid is called the
residual. Return the residual to the patient. If the
residual is more than half the volume of the
previous feeding, notify the nurse before
administering this feeding. A large residual means
that the patient is not tolerating the feeding or that
the amount may need to be adjusted.

Connect the clamped feeding setup to the
feeding tube. Hang the set on the IV pole. Pour the
feeding formula into the feeding container.
Feeding is usually given at room temperature to
avoid cramping and diarrhea. Unclamp the tubing
and adjust the flow rate with the roller clamp or by
raising or lowering the feeding setup. An infusion
pump may be used at some treatment facilities. A
feeding should infuse over 20-30 minutes. Observe
the patient for breathing or choking difficulties for
a few minutes.

Follow the feeding with one to two ounces of
water to clear the tubing. Feeding formula is thick
and sticky, and can easily occlude a NG tube.
Assist the patient with oral and nasal hygiene
measures. Rinse and clean equipment for storage
or dispose of properly. Record the procedure on
Nursing Notes SF 510 and Twenty-Four Hour
Intake & Output Worksheet DD 792.

MAINTENANCE

Most NG tube maintenance is related to tubes
used for drainage, but the same principles apply to
feeding tubes. To prevent tube displacement and
the need for replacement, make certain that the
tube is placed correctly and taped securely in
place. Most NG tubes are taped to the patient's
nose. Avoid excess pressure on the nostrils.
Pressure from the tube against the nare can cause
92
Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes
Handbook III
ulceration, and tape can irritate the skin. Pin the
tube to the patient's gown to prevent accidental
removal.

Check tubing at frequent intervals (at least
Q4H) to ensure functioning and patency. Observe
for movement of gastric contents along the tubing
and watch to see if the collection bottle is filling. If
the NG tube is not functioning well, inform the
nurse. If directed, the corpsman may move the
tube in and out about 1-2 inches to determine if the
end of the tube is above or below the fluid level in
the stomach. You may be asked to milk the tube to
assist thick secretions move along the length of the
tube. Irrigate the tube when ordered.

Provide frequent mouth and nasal care to ease
nose and throat irritation. NG tubes will cause
some discomfort. Gargles and lozenges, mouth
care Q2H and PRN, and moving the position of the
tape periodically will increase comfort and
decrease irritation.

An informed patient is usually more
cooperative, so be sure to explain all procedures.
You may need to remind some patients that they
are NPO. Provide psychological support as
needed.

NASOGASTRIC TUBE REMOVAL

When the physician determines that the
nasogastric tube is no longer needed, it will be
removed. Verify the Doctor's Order and gather the
equipment: clean gloves, a Chux pad, and supplies
for oral hygiene.

Wash your hands, perform the patient
identification checks, explain the procedure,
provide privacy, comfort, safety, and position the
patient.

Place the patient in Semi- or High Fowler's
position. Turn off the suction, if applicable. Don
gloves; place the Chux under the tubing to protect
the patient and the linen. Remove the anchoring
tape gently.

Clamp off or pinch the tube to prevent
drainage. Instruct the patient to take a deep breath
and slowly exhale. As the patient exhales, pull the
tube out in one continuous motion. Wrap the tube
in the Chux and discard per local policy. Remove
any tape residue from the patients nose. Make the
patient comfortable and offer oral hygiene.
Measure the final drainage in the collection bottle
and note characteristics before disposal. Clean and
store the equipment as appropriate. Record the
procedure on Nursing Notes SF 510 and Twenty-
Four Hour Intake & Output Worksheet DD 792.

RECORDING NASOGASTRIC TUBE
INFORMATION

All documentation should include the date and
time of the procedure, instructions given the
patient, and the patients tolerance of the procedure.
After insertion, on the Nursing Notes SF 510,
record the type and size of the tube used, which
nare was used, fluid obtained, difficulties
encountered, and whether the tube was attached to
suction, gravity, or clamped.

Documentation of NG tube irrigation should
include the type and amount of solution used, the
characteristics of the aspirated contents, and any
comfort measures performed.

Following removal of the NG tube, note the
characteristics of the drainage and care done for
the nose.

After a tube feeding, record the amount and
type of the feeding used, the rate of administration,
and the patients' response.

All patients with NG tubes should be on I&O.
Remember to record all irrigations and gavage
feedings as intake. Aspiration of fluid following
irrigation and fluid collected in a drainage bottle
are recorded as output.




93
Lesson 3.07 Nasogastric Tubes Basic Hospital Corps School
Handbook III

















FIGURE 3.07.01
Nasogastric Tube Insertion





















FIGURE 3.07.02
Final Placement of Nasogastric Tube
94
Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Worksheet
Handbook III
Lesson 3.07

Nasogastric Tubes Worksheet

1. The removal of fluid and air from the gastrointestinal tract through an NG tube is called:

a. lavage.

b. gavage.

c. decompression.

d. irrigation.

2. Providing liquid food or nutrients through an NG tube is called:

a. lavage.

b. gavage.

c. milking.

d. irrigation.

3. NG tubes may be made of:

a. ___________________________________________________

b. ___________________________________________________

4. A Salem Sump tube has how many lumen?

a. 1

b. 2

c. 3

d. 4










95
Lesson 3.07 Nasogastric Tubes Worksheet Basic Hospital Corps School
Handbook III
5. List equipment needed for NG tube insertion.

a. ___________________________________________________

b. ___________________________________________________

c. ___________________________________________________

d. ___________________________________________________

e. ___________________________________________________

6. How is the length of an NG tube to insert measured?

____________________________________________________________________________________

____________________________________________________________________________________

7. What position is the patient placed in for NG tube insertion?

____________________________________________________________________________________

8. List three methods to verify NG tube placement.

a. ___________________________________________________

b. ___________________________________________________

c. ___________________________________________________

9. You have instilled 30 cc of normal saline into a NG tube. When attempting to aspirate the stomach
contents, only 5 cc returns. The next action should be:

a. aspirate forcefully to get the rest of the fluid.

b. return the 5 cc to the stomach and attach the tube to suction.

c. record 5 cc of output on Twenty-Four Hour Intake & Output Worksheet DD 792.

d. record 5 cc of output on Nursing Notes SF 510.

10. What position is a patient placed in for gavage feeding?

a. Prone

b. Supine

c. High or Semi-Fowler's

d. Trendelenburg

96
Basic Hospital Corps School Lesson 3.07 Nasogastric Tubes Worksheet
Handbook III
11. How long should it take to infuse a tube feeding?

____________________________________________________________________________________

12. If you aspirate a residual which is more than half the amount of the tube feeding you are going to give,
you should: __________________________________________________________________

13. Why should the NG be flushed tube with water after each feeding?

14. Circle each technique for maintaining flow in an NG tube.

a. Move the tube in and out 1-2 inches.

b. Milk the tube to assist in moving thick secretions.

c. Irrigate the tube as ordered.

d. Move tube in and out 4-6 inches.

15. To prevent accidental dislodging of the NG tube, secure it to the patient's gown.

a. True b. False

16. To remove an NG tube, pull the tube:

a. slowly, advancing with each breath.

b. quickly while the patient holds his/her breath.

c. in one continuous motion during exhalation.

d. as the patient takes sips of water through a straw.

17. NG tube drainage should be:

a. labeled infectious waste.

b. discarded before it begins to smell.

c. kept in the collection bottle.

d. observed, measured, recorded, and discarded.

18. What is recorded in the Nursing Notes SF 510 following removal of an NG tube?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
97
Lesson 3.07 Nasogastric Tubes Worksheet Basic Hospital Corps School
Handbook III
NOTES/COMMENTS

98
Basic Hospital Corps School Lesson 3.06 Inpatient Care
Handbook III
Lesson 3.06

Inpatient Care

Terminal Objective:

3.06 Know procedures for AM and PM Care.

Enabling Objectives:

3.06.01 Define AM and PM Care.

3.06.02 State the purposes of AM and PM Care.

3.06.03 State the general guidelines for performing and recording AM and PM care.

3.06.04 Perform AM and PM Care.

3.06.05 Document AM and PM Care.

People look better and feel better when they
continue their usual activities of daily living
during a hospital stay. Activities often taken for
granted, like brushing teeth, taking a shower,
combing hair, or shaving make people feel normal.

Hygiene deals with the establishment and
preservation of well being through personal care.
This chapter discusses common practices that
contribute to well being through cleanliness and
grooming.

A person's health values and health perception
can be associated with his degree of self-care
including personal hygiene. A primary concern for
the health care provider is that personal care be
carried out in a manner that promotes health. The
health care provider should reinforce and
encourage appropriate hygiene practices among
healthy individuals. For a patient that is ill, the
health care provider may substitute the care that a
patient is unable to perform.

AM AND PM CARE

AM care is personal hygiene care performed
daily, which includes oral hygiene, a bath, (this
may be a bed bath, a tub bath, or shower
depending on the patients capability), back care, a
linen change (for occupied or unoccupied bed),
hair care. AM care promotes comfort and safety.
Patients and their equipment are cleaned. AM care
results in improved circulation and relaxation.
Communication with your patient and observation
of his/her overall condition are easily
accomplished during morning hygiene.

PM care is personal hygiene care given during
evening hours in preparation for sleep, which
includes offering the patient a bedpan or urinal,
providing an opportunity for oral hygiene, washing
the patients hands, face, and back, (sponge bath),
back care, straightening and tightening linen,
arranging the pillows on the patients bed, and
adjusting lights and temperature.

For safety purposes, the side rails need to be
up at night. Provide fresh water at the bedside for
patient convenience. Remember that some patients
have fluid restrictions, so know the amount of
water that you are giving fluid-restricted patients.

PM care provides the patient with an
opportunity to empty the bladder and bowels.
Personal hygiene prior to bedtime, promotes
relaxation to ensure a good night's sleep, and
99
Lesson 3.06 Inpatient Care Basic Hospital Corps School
Handbook III
allows additional opportunity for communication
with and observation of the patient.




SAFETY, PRIVACY, EDUCATION
AND COMFORT DURING
PATIENT CARE

The patient's privacy, safety, and comfort must
be provided when carrying out any procedure. In
providing for privacy the health care provider must
remember to close doors and draw the curtains
around the patient's bed. Remember to expose only
what is necessary when providing treatment.

Talk to the patient in a soft voice, so you do
not broadcast treatment that you are giving to the
rest of the ward. A patient's right to privacy is not
only an ethical issue but it is also a legal issue, so
avoid elevator talk.

When providing for patient comfort, consider
the physical and emotional needs of the individual.
To provide for the physical comfort of the patient,
fluff and straighten pillows, place the patient in a
comfortable position, and make sure the patient is
warm but not over heated.

Approach the mental and emotional aspect of
patient comfort as if you were caring for a close
friend or family member. This includes providing
for the privacy of the patient, an understanding of
the patients' condition, and knowing the
procedures needed to give the proper care. Health
care team members need to establish rapport with
each patient.

The patient's safety is of the utmost
importance. Ignoring the safety of patient care may
harm not only the patient, but endangers staff as
well. Be sure to lock the wheels and raise the side
rails on the bed.

Use patient restraints only when necessary.
Health care providers should adjust the bed height
to waist level to decrease or eliminate the need to
bend at the waist. This will reduce back strain. Be
sure to return the bed to the lowest level after
performing a procedure.


DOCUMENTING AM AND PM CARE

Document all pertinent information on the
ADL sheet and on the SF 510. Basic entries are:
AM care completed and or PM care completed.
Include patient tolerance or the response to care.
Note any assessment of the patient you performed,
and the general condition noticed during care
given, Figure 3.06.01.

FIGURE 3.06.01
Sample AM Care Nursing Note

















100
Basic Hospital Corps School Lesson 3.06 Inpatient Care Worksheet
Handbook III
Lesson 3.06

Inpatient Care Worksheet


1. Define AM Care.

_____________________________________________________________________________

_____________________________________________________________________________

2. Define PM Care.

_____________________________________________________________________________

_____________________________________________________________________________

3. Patient safety, privacy, education and comfort should be provided before any procedure.

a. True b. False

4. When you have placed a bed pan or urinal, give the patient the call bell cord.

a. True b. False

5. AM and PM care are recorded where?

____________________________________________________________________________
101
Lesson 3.06 Inpatient Care Worksheet Basic Hospital Corps School
Handbook III
NOTES/COMMENTS
102
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning
Lesson 3.08

Range of Motion and Patient Positioning

Terminal Objective:

3.08 Perform range of motion exercises and patient positioning.

Enabling Objectives:

3.08.01 Define range of motion, active, active-assistive, passive and continuous passive motion exercises.

3.08.02 State the purpose of range of motion exercises.

3.08.03 List guidelines and procedures for performing range of motion exercises.

3.08.04 List information to be documented after range of motion exercises.

3.08.05 List equipment used to maintain proper patient body positions.

3.08.06 List and describe selected patient positions.

3.08.07 Performs passive range of motion exercises.

3.08.08 Performs patient positioning using principles of patient safety, privacy, education, and comfort.

3.08.09 Document performance of range of motion exercise and patient positioning.


Healthy people are active people. Activity is
essential for health. Patients confined to bed or
having a physical limitation require care that
includes activity and exercise. Range of motion
exercises can provide this necessary activity.

DEFINITIONS

Range of motion is the degree of ability to
move a joint in flexion and extension, defined in
the degrees of a circle. Active exercises are those
performed by the patient. Active-assistive
exercises are those performed by the patient with
some assistance from the Hospital Corpsman.
Passive exercises are those performed by the
corpsman when the patient is unable to move a
body part independently. Continuous passive
motion (CPM) exercises are performed by
motorized exercise machinery that keeps a joint in
constant slow motion.

RANGE OF MOTION EXERCISES

Range of motion (ROM) exercises are
designed to help the patient stay in good physical


condition by maintaining muscle tone when
activity is limited. ROM exercises:

1. help maintain muscle and joint function

2. Prevent muscle deterioration (atrophy)

3. prevent muscle contractures, prevent pooling
of blood in veins

103
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Handbook III
4. prevent skin breakdown

Tightness and other musculoskeletal changes
can occur as early as 48 hours after a patient loses
movement of an extremity. Muscle tightness is an
early stage of contracture - a permanently flexed
joint that occurs with shortened muscle tissue.
Prolonged flexion or extension of muscles
(opposing muscle groups are involved, meaning
that some muscles surrounding a joint are flexed
when others are extended) causes contractures.
Unless prevented, contractures may cause
permanent damage to a joint.

When blood pools in veins, the patient may
develop phlebitis, a thrombus, or thrombophlebitis.
An embolus may break loose following clot
formation, leading to further complications.
Exercise also relieves pressure on tissues, which
allows better blood flow. Muscle movement brings
blood to the area, which maintains tissue health.

GUIDELINES FOR RANGE OF
MOTION EXERCISE

Before performing range of motion exercises,
the corpsman will provide for the patient's privacy,
safety, and comfort. Measures such as keeping the
side rails up on the side opposite from where you
are working and draping or clothing the patient to
avoid exposure are appreciated. Explain and
demonstrate the procedure the first time, and PRN.
The physical therapist or physical therapy
technician may do this. In fact, some patients will
have an order for range of motion exercises to be
done by the physical therapy (PT) department.

Verify the Doctor's Orders, especially for
patients with an injured or diseased joint. The
physician must authorize exercises to injured or
diseased joints. Perform the exercises at least twice
a day, or according to the Doctor's Orders.

Start gradually, and work slowly so as not to
fatigue the patient. Begin with sets of three each,
and work up to sets of five each for each exercise.
The purpose of ROM exercise is to maintain tone,
not to tax or exhaust the patient. Move each joint
until there is resistance, but not to the point of
pain. Support the extremity being exercised above
and below the joint. Avoid jerky or irregular
movements. Work in a logical sequence. Begin at
the head and work down the body, or vice versa.
When the exercise is finished, return the extremity
to normal alignment.

A partial listing of ROM exercises includes:

1. Exercises of the neck:

(1) Flex, extend, and hyperextend the
neck
(2) Rotate head and neck from side to
side
(3) Perform circumduction

2. Exercises of the upper extremities:

a. Shoulder

(1) Flex, extend, and hyperextend the
shoulder
(2) Abduct and adduct the shoulder
(3) Rotate the shoulder, internally and
externally
(4) Circumduct the shoulder

b. Elbow

(1) Flex and extend the elbow

c. Wrist and hand

(1) Flex, extend, and hyperextend
the wrist
(2) Rotate, abduct, and adduct the
wrist
(3) Flex and extend the fingers and
the thumb, then touch each
finger to the thumb
(4) Abduct and adduct the fingers
and thumb

3. Exercises of the lower extremities:

a. Hip

(1) Flex, extend, and hyperextend the
hip
(2) Abduct and adduct the hip
104
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning

(3) Rotate the hip, externally then
internally
(4) Circumduct the hip

b. Knee

(1) Flex and extend the knee

c. Ankle and foot

(1) Perform dorsiflextion and plantar
flexion of the foot
(2) Invert and evert the ankle
(3) Flex and extend the toes

PERFORMING RANGE OF MOTION
EXERCISES

Use Figures 3.08.01 - 3.08.14 as a guide to
performing range of motion exercises.

RECORDING RANGE OF MOTION
EXERCISES

Document pertinent information regarding
ROM exercises. Include the type of ROM used
(active, active-assistive, passive), the body part or
parts exercised, the length of time performed,
including repetitions and sets, and the patient's
tolerance of the procedure. For example:
Performed active ROM to upper extremities X 10
minutes. (3 sets of 3 each.) Tolerated well, showed
full ROM. J ohn Brown, HN.

MAINTAINING CORRECT BODY
POSITION

Patients

Properly positioning the patient in bed is
essential to comfort and will provide correct body
alignment. Correct body position when standing is
similar to proper positioning when lying. Think of
a person standing in alignment when placing a
bedridden patient in proper alignment.

Immobilized patients need to have their body
position changed at least every two hours. Mobile
humans automatically change their body position.
Movement prevents prolonged strain on muscles,
reduces pressure areas caused by body weight, and
may be the only exercise some patients get.

Health care providers

Body alignment by health care providers is
important as well. To achieve correct body
alignment when standing, start with a good base of
support. Place your feet parallel about 6 to 8
inches apart. Distribute your weight evenly on
both feet. Keep your knees flexed to serve as
shock absorbers. A stable base will save energy by
minimizing the work muscles must do.

Tuck in your buttocks, to help straighten the
lumbar spine. By pulling the abdomen in, you will
decrease strain on your back. Keeping the rib cage
up and the chest out prevents a humped back. Hold
your head erect to keep the spine in proper
alignment. Taking care of yourself will make you
better able to care for your patients.

EQUIPMENT FOR POSITIONING

Various pieces of equipment to keep patients
in good position. A footboard is a board placed at
the foot of the bed that supports the feet at right
angles to the body. Footboards are used to prevent
foot drop and pressure on the toes. In some cases,
patients are placed in high top sneakers to achieve
the same purpose. A bedboard (or fracture board)
is a board placed under the mattress to provide
additional support to the patient's back.
Backboards are generally only needed when using
older beds that do not have a metal foundation for
the mattress. Hand rolls are gauze or washcloths
placed in the palms to keep hands in the position
of function. Sandbags are used to immobilize
injured or potentially injured body parts. A sling
can be used to provide support and prevent
dislocation of the shoulder. Pillows are all-purpose
position aids. They can be placed as needed to
support the patient in a particular position.
Trochanter rolls are made from rolled blankets or
sheets. They are placed along the leg (at the
greater trochanter) supporting a patient (especially
the leg) in a particular position, usually as a means
of preventing external rotation.

Hospital Corpsmen should be familiar with
some positions that may be specified (or preferred)
105
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Handbook III
for treatment or variety. The supine position has
the lying patient flat on his/her back, Figure
3.08.15. Support the head and extremities with
pillows and/or rolls. Prone position has the patient
on his/her stomach with the head turned to one
side, Figure 3.08.16. Pillows are placed under the
abdomen and lower legs. There are several
variations of the Fowler's position. High Fowler's
is the result of raising the head of the bed to a
90-degree angle, Figure 3.08.17. The patient is
sitting straight up. Semi-Fowler's results from
raising the head 45-degree. Low Fowler's
provides 30-degree of elevation. Often, the knee
gatch is raised to prevent the patient from sliding
down in bed.

Sim's position is a side-lying position that has
the patient on either side, with the top leg flexed
up toward the abdomen, Figure 3.08.18. Support
the flexed leg, top arm, and back with pillows.

The Trendelenburg position, Figure 3.08.19,
is also called the shock position. The patient is
lying supine, with the foot of the bed raised at a 45
degree angle. Older hospital beds which are not
adjustable can be placed in the Trendelenburg
position by raising the foot of the bed about 12
inches using blocks.

The lithotomy position, Figure 3.08.20, has
the patient lying supine with the knees and hips
flexed. The dorsal recumbent position, Figure
3.08.21, has the patient lying supine with the knees
flexed. To provide privacy, the patient should be
draped.
106
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning

107
FIGURE 3.08.01
Flexion/Extension of Thumb
FIGURE 3.08.02
Flexion/Extension of Fingers
FIGURE 3.08.03
Flexion/Extension of Wrist
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Handbook III
108
FIGURE 3.08.04
Pronation/Supination of the
Hand and Forearm
FIGURE 3.08.05
Internal/External Rotation
of Shoulder
FIGURE 3.08.06
Adduction of the Shoulder
FIGURE 3.08.07
Abduction/Adduction of Shoulder
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning

109
FIGURE 3.08.08
Flexion /Extension of Shoulder
FIGURE 3.08.09
Dorsiflexion/Plantar flexion of the
Toes
FIGURE 3.08.10
Dorsiflexion/Plantar flexion of Foot
FIGURE 3.08.11
Eversion/Inversion of Ankle
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Handbook III
110
FIGURE 3.08.14
Abduction/Adduction of Hip
FIGURE 3.08.13
Flexion/Extension of Hip and Knee
FIGURE 3.08.12
Rotation of Ankle
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning
111
FIGURE 3.08.17
High Fowlers Position
FIGURE 3.08.16
Prone Position

FIGURE 3.08.15
Supine Position
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Handbook III
112
FIGURE 3.08.19
Trendelenburg Position
FIGURE 3.08.18
Sims Position
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning

113

FIGURE 3.08.20
Lithotomy Position
FIGURE 3.08.21
Dorsal Recumbent Position
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning Worksheet
Lesson 3.08

Range of Motion and Patient Positioning
Worksheet

1. Match each definition in column B to the correct exercise in column A.

A B


a. Range of motion ________

b. Active ________

c. Active-assistive ________

d. Passive ________

e. Continuous passive motion ________

1. Performed by the corpsman

2. Performed by motorized machinery

3. Defined in degrees of a circle

4. Performed by the patient

5. Performed by the patient and corpsman

2. Range of motion exercises help prevent muscle deterioration and atrophy.

a. True b. False

3. Properly performed range of motion exercise may cause permanent damage to a joint.

a. True b. False

4. Range of motion exercises must not be performed unless ordered by a physician.

a. True b. False

5. When performing ROM exercises:

a. work quickly so as not to fatigue the patient.

b. move each joint until there is resistance, but not pain.

c. start with sets of five, and work up to sets of fifteen.

d. always exercise all joints.





115
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Worksheet Handbook III
6. Range of motion exercises should be:

a. performed at least Q4H.

b. done on legs, then head, then hands, then feet.

c. done by supporting the extremity above and below the joint.

d. done only by a physical therapist.

7. Match each movement in column B to the body part that is exercised in column A. Answers may be used
more than once.

A B


a. Neck __________

b. Head __________

c. Shoulder and elbow __________

d. Shoulder __________

e. Wrist and hand __________

f. Fingers __________

g. Thumb __________

h. Knee __________

i. Ankle __________

j. Back __________

1. Rotate



2. Flex



3. Extend



4. Abduct



5. Adduct



8. Circle each item that is documented on the SF 510 after performing ROM exercises.

a. Type of range of motion

b. Body part or parts exercised

c. Patient's tolerance of the procedure






116
Basic Hospital Corps School Lesson 3.08 Range of Motion and Patient
Handbook III Positioning Worksheet
9. Body position of immobilized patients should be changed at least every two hours.

a. True b. False

10. List five pieces of equipment that may be used for patient positioning.

a. ___________________________________________________________________

b. ___________________________________________________________________

c. ___________________________________________________________________

d. ___________________________________________________________________

e. ___________________________________________________________________

11. Match each description in column B to the correct position in column A.

A B


a. Supine ________


b. Prone ________


c. High Fowlers ________


d. Semi Fowlers ________


e. Sims ________


f. Trendelenburg ________

1. On either side, free leg is flexed up toward
abdomen

2. Patient on stomach with head turned to one side.


3. Also called shock position


4. Head of bed is elevated 90 degrees


5. Head of bed is elevated 45 degrees


6. Patient is flat on his/her back

117
Lesson 3.08 Range of Motion and Patient Basic Hospital Corps School
Positioning Worksheet Handbook III
NOTES/COMMENTS
118
Basic Hospital Corps School Lesson 3.09 Restraining a Patient
Handbook III
Lesson 3.09

Restraining a Patient

Terminal Objective:

3.09 List concepts and principles for restraining a patient.

Enabling Objectives:

3.09.01 List types of patient restraint equipment.

3.09.02 State three situations which indicate restraints are required.

3.09.03 List guidelines for applying patient restraints.

3.09.04 List physical and psychological nursing care procedures for restrained patients.

3.09.05 List the procedure for applying wrist restraints.

3.09.06 List the procedure for applying a restraining vest.

3.09.07 Record care of a restrained patient.


USING RESTRAINTS SAFELY

Protective restraints are devices that limit
a person's movement to prevent harm.
Movement is essential to life. Restricting
movement can cause injury to the patient. The
health care provider who makes the decision
to use a restraint also has serious
responsibilities to protect the well being of the
patient. In general, a temporary restraint is
necessary if a patient becomes so restless or
irrational that he may harm himself, other
patients, or staff members. Several different
types of restraints are listed below.

PATIENT RESTRAINT
EQUIPMENT

Safety belts are used to restrain a patient
to a gurney, a wheel chair, an exam table, or a
spine board. Made of webbing or strong
material, they are available in a variety of
lengths, usually 5-6 feet long.
An ankle or wrist restraint (soft
restraint) is used to secure a patient's hands
and feet. Made of strong cloth about 3" wide
and 8-10" long, it is padded to prevent injury
to the patients skin, Figure 3.09.01 and Figure
3.09.02

A waist restraint (Posey belt) keeps a
patient in a bed while allowing the patient to
turn from side to side. Made of canvas or other
strong material, they are tied under the bed.

A restraining vest (Posey vest) prevents
the patient from leaving the wheelchair or bed
and provides support to the upper body. Made
of a strong material, it fits over the patient's
chest and has straps or ties which are fastened
behind the wheelchair or bed.

Leather wrist and ankle restraints are
used for restraining an extremely combative
patient. Made of leather, they are adjustable
119
Lesson 3.09 Restraining a Patient Basic Hospital Corps School
Handbook III
and have a lock and key. Only trained
personnel may apply them.

Mitts keep the patient from scratching or
picking at the skin or pulling out tubes. Made
of cotton, they cover the patient's hands.
Tubular gauze or socks may also be applied to
the patients hands if mitts are not available.

A papoose board is used to immobilize
infants and children during procedures, Figure
3.09.03. A commercially available board with
head, arm, and leg straps, it wraps around the
extremities and body and fastens with wide
strips of Velcro. A blanket or sheet wrapped
around the patient's body may be substituted
for a papoose board, if necessary.

SITUATIONS WHEN
RESTRAINTS ARE INDICATED

Restrain someone only when you are
concerned for the patient's safety and there is
no other means of preventing harm. Use the
least restrictive type of restraint that will
protect the patient. Soft restraints made from
fabric are preferable to leather ones. Apply the
restraint for the shortest amount of time
possible. The vest restraint may only be
necessary while a patient is sitting in a
wheelchair. Provide for as much movement as
possible, even though the patient may need to
be restrained. The waist restraint protects the
patient from falling or crawling out of bed, but
still allows the patient to change position
independently. Restrain the fewest limbs or
body parts possible. Apply wrist restraints any
time leg restraints are necessary. If wrist
restraints are not used, the patient may remove
the leg restraints or become accidentally hung
by his heels. Fasten the restraints to the bed
frame, which is more stable than the side rails,
to prevent harm to the patient or others.

Mental confusion may be a situation in
which restraints are indicated. A patient may
wander, become confused, and attempt to
disconnect the IV's, catheters, NG tubes, etc.
Restraints are used during diagnostic tests for
children and infants to facilitate examination.
Tests requiring the patient to be immobilized
is another reason restraints may be used.

APPLYING RESTRAINTS

Always check with the nurse before
restraining a patient. All restraints require a
written Doctor's Orders. Check the equipment
prior to use. Look for worn padding and
missing straps or buckles. With leather
restraints, ensure that the lock and key are
present.

Have enough personnel to apply the
restraint. A combative patient will require at
least four people to apply the restraint.
Assistance may be needed for infants and
children, as well. Follow local policy when
applying restraints.

Fasten the restraint so it may be easily
removed in an emergency. Never tie restraints
to the bed rails; a patient may be injured if the
rails are accidentally lowered.

PHYSICAL CARE PROCEDURES

Ensure the restraining device is applied
correctly. A carelessly applied restraint can be
more dangerous than no restraint at all.
Underlying tissue should be well padded to
prevent skin damage. Ensure that the patient's
breathing is not inhibited. Avoid the supine
position when restraining an unconscious
patient or a patient who has just been fed
because of the possibility of aspiration. Place
an unconscious patient on his/her side or
abdomen.

Perform circulation checks and skin care
to restrained extremities per local policy, but
at least every two hours. Assess the patient for
skin redness and irritation from the restraints.
The skin should be cleaned and powdered.
Administer range of motion exercises every
two hours.




120
Basic Hospital Corps School Lesson 3.09 Restraining a Patient
Handbook III
PSYCHOLOGICAL CARE

APPLYING A RESTRAINING
VEST

Assess the patient's mental status and
provide emotional support. Explain to the
patient and his or her significant others why
the restraints are needed. Use the term safety
device instead of restraint. Since it is a less
threatening term, you may get a more
favorable response and less resistance.
Emphasize to the patient that restraints are not
punishment. Communicate with the patient
verbally to assure him/her of the availability of
assistance when needed. Be sure that the
patient call button is easily accessible. Some
restrained patients require constant
observation. Ensure the patient's privacy at all
times. Providing a patient psychological care
helps to maintain a patients right to dignity
while in restraints.

When applying a restraining vest, gather
the equipment and wash your hands. Perform
patient identification checks, explain the
procedure to the patient and assist the patient
in putting on the vest. The straps should be at
the patient's back. Wrap and secure the straps
around the back of the wheelchair or to the
bed frame. Ensure that the vest does not
interfere with breathing or circulation. For
patients in bed, ensure that the call bell is
within easy reach. Record the procedure in
the Nursing Notes.

RECORDING RESTRAINT CARE


Record the application, type, location, and
purpose of the restraint. Record the patient's
reaction, your signature and rate.
APPLYING WRIST RESTRAINTS

To apply a soft wrist restraint, gather the
equipment, including sheepskin, washcloth, or
ABD pad, Kerlex rolls, and tape. Wash your
hands and perform patient identification
checks. Approach the patient slowly and
calmly. Explain the procedures to the patient.
Speak in a soft and controlled voice. Use the
patient's name and make eye contact.

Sample:

2 J une 1300 Vest restraint applied to chest
for safety due to patient's confusion. Tolerated
application without resistance.---Signature,
Rate.


When a continuous restraint is required,
documentation should include removal of the
restraint for ROM or skin care at least every
two hours. Skin condition under the restraint,
circulation checks, the patient's tolerance of
the restraint, and your signature and rate.
Measure the Kerlex, ensuring it is long
enough to allow limited patient movement and
that it reaches to the bed frame. Wrap the wrist
to be restrained with padding, protecting any
bony points or fragile skin that may be injured
by the restraint. Apply the Kerlex to the
padded wrist, securing each end to the bed
frame.

Sample:

2 J une 1730 Removed wrist restraints
every two hours for skin care and ROM, wrist
without signs of skin breakdown. Restraint
reapplied, capillary refill less than two
seconds, skin warm. Tolerating restraint well,
without agitation.---Signature, Rate.
Ensure the patient is placed in a
comfortable position and the call bell is within
easy reach before leaving the bedside. Record
the reasons for the initial and continued use of
a restraint in the Nursing Notes. Reassess the
patient's circulation to the hands per local
policy, but at least every two hours.
121
Lesson 3.09 Restraining a Patient Basic Hospital Corps School
Handbook III
122

FIGURE 3.09.01
Making a Wrist Restraint
FIGURE 3.09.02
Wrist Restraint
FIGURE 3.09.03
Papoose Board
Basic Hospital Corps School Lesson 3.09 Restraining a Patient Worksheet
Handbook III
Lesson 3.09

Restraining a Patient Worksheet

1. Which restraint would be used on a child needing facial sutures?

a. Posey vest

b. Papoose board

c. Soft restraints

d. Leather restraints

2. Mitts can be used to prevent a patient from pulling out I. V. lines.

a. True b. False

3. The best device to use for safety of an elderly patient in a wheelchair is/are:

a. safety belt.

b. soft restraints.

c. mitts.

d. papoose board.

4. Restraints are used to:

a. punish a patient.

b. limit limb movement.

c. keep side rails up.

d. protect a patient from harm.

5. Restraints are used on:

a. alert patients.

b. all angry patients.

c. confused patients.

d. all elderly patients.


123
Lesson 3.09 Restraining a Patient Worksheet Basic Hospital Corps School
Handbook III
6. After application of restraints, limbs should be assessed for adequate circulation at least every:

a. hour.

b. two hours.

c. shift.

d. day.

7. The term safety device is generally less threatening than the term restraint.

a. True b. False

8. A confused patient does not need the restraint procedure explained before application of
restraints.

a. True b. False

9. After applying a vest restraint, check to be sure that the patient can breathe adequately.

a. True b. False

10. Check restraint equipment prior to use for:

a. ________________________________________________________

b. ________________________________________________________

c. ________________________________________________________

11. List three pieces of equipment needed to apply soft restraints.

a. ________________________________________________________

b. ________________________________________________________

c. ________________________________________________________

12. List nursing care for a patient in wrist restraints that is to be performed every two hours.

a. _________________________________

b. _________________________________

c. _________________________________

d. _________________________________
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Lesson 3.10

Isolation Techniques and Blood Borne
Pathogens

Terminal Objective:

3.10 List concepts and principles of isolation techniques.

Enabling Objectives:

3.10.01 Define terms related to patient isolation.

3.10.02 State the purpose of universal precautions.

3.10.03 State the protective measures of universal precautions.

3.10.04 List the types of isolation and their purposes.

3.10.05 State the psychological impact of isolation on the patient and significant others.

3.10.06 List patient safety, privacy, education, and comfort considerations in an isolation
environment.

3.10.07 List the procedure for initiating patient isolation.

3.10.08 State the procedure for donning and removing protective isolation clothing and
accessories.

3.10.09 State the methods for removing contaminated articles from an isolation room.

3.10.10 List how healthcare personnel are exposed to blood borne pathogens.

3.10.11 State actions to be taken if exposed to blood borne pathogens.


Before discussing the purpose of isolation
and different isolation techniques, some terms
need to be defined to make this lesson more
understandable.

MEDICAL ASEPSIS TERMS

Microorganism -- a tiny, living animal or
plant.

Pathogen microorganisms that can cause
infection or contagious disease.

Nonpathogen any non-disease producing
microorganism.

Sepsis -- the presence of pathogens.

Asepsis -- the absence of pathogens.

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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
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Medical asepsis -- practices that reduce the
number and spread of microorganisms. Also
called clean technique.

Contaminate -- to make something unclean or
unsterile.

Cross contaminate -- the transfer of
pathogens from:

A. One person to another.

B. One area to another on a patient.

C. Equipment to a person.

Disinfection -- the process by which
pathogenic organisms but not spores, are
destroyed on inanimate objects.

Disinfectant -- a chemical that kills
microorganism but not their spores. (Not
intended for use on persons.)

Antimicrobial agent -- a chemical that kills
or suppresses growth of microorganisms.

Antiseptic -- a chemical that prevents or
inhibits the growth of microorganisms. Safe to
use on living tissue.

Terminal disinfection -- cleaning of the
patient's contaminated room, equipment, and
supplies after discharge.

Nosocomial infection -- infection acquired in
a hospital setting.

ISOLATION TERMS

Isolation -- confinement of pathogens to a
given area to prevent their spread.

Infection control techniques -- practices that
prevent the spread of pathogens. Also called
isolation techniques.

Contagious disease an illness that is easily
spread to others. Also called communicable
disease.

Highly susceptible patient -- patient with
impaired skin integrity or with a compromised
immune system who has a greater probability
of acquiring an infection.

Direct contact -- a route of spreading
pathogens when one is with or touches an
infected person.

Indirect contact -- a route of spreading
pathogens by touching contaminated objects.

Double bagging -- removing a bag of
contaminated items from an isolation room by
placing it in another clean bag held by
someone outside the room.

Universal Precautions -- preventive practices
that protect health--care workers from
acquiring blood borne viruses from
unidentified, infected persons. Also called
body substance isolation

Blood borne pathogen exposure - direct
contact with another's body fluid or any item
contaminated with another's body fluids.

OSHA Standard - Department of Labor,
Occupational Safety and Health
Administration regulation (29CFP Part 1910)
for general industry.

PURPOSE OF UNIVERSAL
PRECAUTIONS

Universal precautions (sometimes called
standard precautions) are an approach to
infection control designed to prevent
transmission of blood borne diseases in health
care settings. Universal precautions should be
used anytime there is the possibility of
contacting a person's body fluid such as:
blood, semen, vaginal secretions, cerebro-
spinal fluids, amniotic fluid, peritoneal fluid,
pleural fluid, synovial fluid, and salvia, or
mucous membranes and non-intact skin.

Universal precautions must be used
consistently with all patients.

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UNIVERSAL PRECAUTIONS

Health care workers are exposed to body
fluids and secretions that may contain
unknown contaminants. Since medical history
and exams cannot consistently identify high-
risk contacts, universal precautions are
initiated on all patients. The purpose of
universal precautions is to prevent skin and
mucous membrane contamination of the
providers through exposure to the patients
blood, body fluids, mucous membranes, non-
intact skin or potentially contaminated patient
care equipment.

Protective measures of universal
precautions include:

Gloves MUST be worn whenever contact with
blood, other potentially infectious materials,
mucous membranes or non-intact skin is
expected. Avoid direct patient care and
handling of soiled equipment if your skin is
not intact. Thoroughly wash hands
immediately after removing gloves.

Masks must be worn during procedures that
are likely to generate aerosol droplets or
splashes of blood and other potentially
contaminated materials. Masks prevent
exposure of mucous membranes of the nose
and mouth

Goggles or other protective eyewear are
required during procedures that are likely to
generate aerosol droplets, splashes, spray or
splatter of blood and other potentially
infectious materials.

Gowns or aprons must be worn during
procedures that are likely to generate splashes
of blood or other potentially infectious
materials.

Handwashing is one of the most effective
means of infection control. Thoroughly wash
hands with soap and water immediately after
any contact with blood or body fluids, mucous
membranes, secretions or excretions, and after
removing gloves.

To avoid accidental punctures, needles
and syringes must be disposes of in puncture
resistant (Sharps) containers. Needles are
placed in these containers uncapped.

Disposable ventilation devices should be
used every time there is need for mouth to
mouth resuscitation of a patient.

Contaminated clothing and linen is to be
separated from other dirty clothing and
disposed of according to local policy.

TYPES AND PURPOSES OF
ISOLATION

Isolation techniques are practices and
procedures that limit the transmission of
microorganisms from a reservoir to a
susceptible patient through the use of certain
practices and procedures. These practices are
designed to break the 4th link in the chain of
infection, the transmission of the
microorganism to a susceptible host.

One purpose of isolation techniques is to
protect individuals in the general environment
from pathogens released from an infected
person. Another purpose is to protect a highly
susceptible patient from microorganisms in the
general environment.

Strict Isolation prevents the transmission of
diseases by direct contact and airborne routes.
It requires that the patient have a private room
with the door shut. Patients with the same
disease may share a room. All persons
entering the room must wear a mask, gloves,
and gown. Articles taken out of the room
must be double bagged before being sent for
disinfection or sterilization. Hands must be
washed upon entering and leaving the room.
Plaque, diphtheria and small pox are diseases
that require strict isolation. Figures 3.10.01
and 3.10.02.

Respiratory isolation prevents the
transmission of contagious diseases that are
spread by the airborne route via coughing,
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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
and Blood Borne Pathogens Handbook III
sneezing, or breathing. Protective measures
for this type of isolation include a private
room, keeping the door shut, and masks for
those who come close to the patient. Patients
with the same disease may share a room. Any
articles taken from the room must be double
bagged. Hands must be washed upon entering
and leaving the room. Diseases requiring
respiratory isolation include meningitis,
mumps, measles, whooping cough and
tuberculosis. Figures 3.10.03 and 3.10.04.

Enteric isolation prevents the transmission of
contagious diseases through direct or indirect
contact with infected feces. Protective
measures include wearing gowns if soiling is
possible. Gloves must be used when having
direct contact with the patient or with articles
contaminated with feces. Private rooms are
indicated for children or for anyone who
cannot be relied upon to wash their hands.
Hands must be washed upon entering and
leaving the room. All articles leaving the room
must be double bagged. Diseases requiring
enteric isolation include cholera, hepatitis -
type A, and typhoid fever. Figures 3.10.05 and
3.10.06.

Contact isolation prevents the transmission of
highly contagious or significantly important
infections by direct or indirect contact. These
diseases may not warrant Strict Isolation. A
private room is indicated. Gowns, gloves, and
masks are worn if contact with infectious
material is possible. Hand washing is required
upon entering and leaving the room. All
contaminated articles must be double bagged
prior to leaving the room. Acute respiratory
infections (croup, influenza) in infants, rabies,
scabies, and skin infections caused by
staphylococcus are examples of diseases
requiring contact isolation. Figures 3.10.07
and 3.10.08.

Drainage/secretion precautions prevent the
transmission of organisms by contact with
infected wounds, body secretions and heavily
contaminated articles. (Sometimes referred to
as wound and skin precautions.) Gowns and
gloves are indicated for use when soiling is
likely or when there will be direct patient
contact. Masks are worn if there is any danger
of being splashed. Hands must be washed
upon entering and leaving the room.
Potentially infected articles must be double
bagged. Diseases requiring drainage/secretion
precautions include abscesses, infected burns,
conjunctivitis, infected decubitus ulcers, skin
infections and wound infections. Figures
3.10.09 and 3.10.10.

Protective or reverse isolation prevents
contact between potentially pathogenic
organisms and a patient who has a seriously
impaired resistance against infection. All of
the types of isolation discussed so far are
intended to protect the individual on the
outside from pathogens an infected patient
may harbor. Simply speaking, in reverse
isolation the patient is being protected from
contamination. Protective measures include a
private room and keeping the door closed.
Gowns and masks must be worn by anyone
entering the room. Gloves are required by
anyone in direct contact with the patient. A
hair cap and shoe covers are worn if the
patient has a compromised immune system.
Hands must be washed upon entering and
leaving the room. All articles brought into the
room must be sterile or disinfected. Patients
requiring protective isolation include those
with extensive burns, certain cases of
leukemia, organ transplant patients, or others
with suppressed immune systems.

PSYCHOLOGICAL IMPACT OF
ISOLATION

A common patient response to initiation of
isolation procedures is fear. Patients are
generally frightened by disease. They tend to
feel unclean because the staff is always
washing their hands and carefully handling
contaminated articles. Isolated patients may
feel lonely and neglected because they cannot
leave their room and visitors may visit
infrequently. Minimize feelings of loneliness
by encouraging family visits. Emphasize that
as long as precautions are followed, visitors
are not likely to contact the disease. Plan
frequent patient contact. Do NOT limit your
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Handbook III and Blood Borne Pathogens
interactions to only the minimum needed for
patient care.

Isolated patients are prevented from
participating in activities outside the room and
may have sensory deprivation and depression.
Help the patient to experience a variety of
sensory stimulation. Provide reading
materials, a radio, or a television to decrease
boredom. If possible arrange the bed so the
patient can look out the window

PATIENT EDUCATION,
PRIVACY, SAFETY, AND
COMFORT IN AN ISOLATION
ENVIRONMENT

Show acceptance of patients by
encouraging them to express their feelings.
Explain the purpose of isolation including any
special procedures, e.g., handwashing and
proper disposal contaminated items, etc. Stress
that it is the microorganism, not the patient
that is unwanted. Precautions are intended to
prevent the spread of contagious diseases.

As with all patients, provide for privacy,
safety and comfort. Assure that the bed wheels
are locked and the side rails are up. Change
the bed linen and patient's gown if they
become wet or soiled. Draw the curtain around
the bed whenever performing a procedure.

INITIATING ISOLATION
PROCEDURES

If a private room is required, place the
patient in a room that is designated for
isolation. These rooms have special features
such as an anteroom with a sink. Post the
appropriate isolation card on the door and
ensure that all personnel and visitors adhere to
the special precautions listed, e.g., hand
washing upon entering and leaving the room,
wearing appropriate garb, etc. Stock the room
with equipment such as a blood pressure cuff,
stethoscope, and a disposable thermometer or
a glass thermometer. The glass thermometer is
left soaking in a disinfectant solution at the
patents bedside. Obtain an isolation cart and
place it outside the room. Stock it with gowns,
gloves, masks, and trash bags. Notify food
services that the patient is in isolation. The
meals may need to be sent in disposable
containers. Never take the clinical record into
the isolation room because it will be
contaminated.

ISOLATION GEAR
DONNING ISOLATION GEAR

All the equipment needed for people who
enter an isolation room should be in the
isolation cart.

Remove jewelry and wash your hands.

Position the mask by placing it over the
nose and mouth and adjust it for comfort. Pass
the top strings over the ears and tie them, then
tie the lower strings around the neck, Figure
3.10.11. Change the mask when it becomes
moist, after wearing for a prolonged period of
time, or follow the manufacturer's
recommendation. Never lower the mask
around the neck.

Next, pick up the gown. Holding it by the
neck, allow the gown to open and fall to full
length without touching the floor. Position the
back opening towards you, place your arms
into the sleeves, then pull the gown over the
shoulders and around the neck and secure it.
Overlap the edges of the gown in back at the
waist and secure the ties, Figure 3.10.12.

Don shoe covers and cap if required.

Last, don clean gloves, bringing the cuffs
of the gloves over the cuffs of the gown.

You may now enter the isolation room and
proceed with patient care. Avoid bringing
gloved hands towards your face or hair so you
do not spread contamination.



REMOVING ISOLATION GEAR

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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
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First, untie the waist closure of the gown
if it is tied in front. The front of the gown is
the most contaminated area, therefore, ties in
the front should be untied with gloves still on.

Next, remove the gloves by holding the
cuff of one hand and pulling it off with the
other gloved hand. Reach your fingers inside
the glove and pull the second glove off.
Discard gloves in the trash and wash your
hands.

Next, remove the mask by untying the
upper and lower strings. Discard the mask in
the trash by holding only the strings (they are
considered clean). Avoid touching the mask.

Finally, unfasten the neck of the gown and
waist ties (if fastened in back). Insert the
fingers of one hand under the cuff of the
sleeve and pull the sleeve over the hand. Pull
the other cuff over the hand by grasping it
with the hand that is already inside the sleeve.
Slip out of the gown, fold it with the outside of
the gown to the inside, hold the gown away
from your uniform and roll gently. Discard the
gown in the trash.

Wash your hands after removing isolation
clothing. Use paper towels to turn off the
faucet and to open the door to exit the room.

Now you are ready to go on to your next
patient without fear of spreading
contamination.

REMOVING CONTAMINATED
ARTICLES FROM ISOLATION
ROOMS

DISPOSING OF LINEN

Gather all soiled linen and washable
items, such as reusable isolation gowns, bed
linen, towels, and patient gowns and place
them in a laundry bag inside the patient's
room. Some bags appear to be ordinary plastic
bags when dry, but melt or disintegrate when
washed in hot water so that laundry workers
do not need to touch contaminated linen.
These are known as melt-away bags. As
laundry accumulates, remove it from the
room. If the linen is soiled with blood, body
fluids, or contaminated drainage, it should be
transported to the laundry in plastic bags that
prevent leakage. Bag should be marked
Isolation Linen.

DISPOSING OF BURNABLE
TRASH

All trash receptacles in the isolation room
should be lined with isolation trash bags. All
burnable trash is deposited in these lined
receptacles. At the end of each shift, or
whenever trash is emptied, the bag is secured
with tape, and using the double-bagging
method, is removed from the room. Double
bagging is accomplished as follows:

Trash from the patient's room is deposited
into a second plastic bag outside the patient's
room.

The person outside the room turns down
the cuff of the clean outer bag and holds the
bag under the cuff to prevent contamination.

The outer bag is securely tied and clearly
marked Infectious Waste.

DISPOSING OF NON-BURNABLE
ITEMS

Non-burnable items, such as stainless steel
equipment, should be cleaned with soap and
water in the patient's room, double bagged and
sent for sterilization. Needles and syringes are
placed in specially marked, puncture resistant
Sharps containers to prevent accidental needle
punctures. Whenever possible, use disposable
basins, bedpans and urinals for patients on
isolation. This will eliminate the need for
sterilization and the potential spread of
contagious diseases.



REMOVING SPECIMENS

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Basic Hospital Corps School Lesson 3.10 Isolation Techniques
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Specimens such as blood, sputum, urine,
stool from a patient in isolation can be
submitted to the lab. When collecting a
specimen, protect the outside of the container
from contamination. If the outside of the
container potentially comes in contact with a
pathogen, the specimen must be bagged upon
removal from the room and the lab chit
attached to the outside of the bag. Universal
precautions are used when handling all
laboratory specimens.

TRANSPORTING THE PATIENT

There are times when it is necessary to
transport an isolation patient to various
departments within the hospital, such as for an
X-ray or other procedures. When transporting
a patient from the isolation room, notify the
receiving department that an isolation patient
is arriving and what precautions are necessary.
Cover the surface of the wheelchair or gurney
with a clean sheet and use a second sheet to
cover as much as the patients body as possible.
Provide items such as a mask or gown for the
patient if applicable. The person transporting
the patient must also wear gloves/gown/mask
when indicated. After returning the patient to
the room, disinfect the wheelchair or gurney.

EXPOSURE TO BLOOD BORNE
PATHOGENS

Healthcare providers and others involved
with patients may be exposed to blood borne
pathogens in a number of ways. Care needs to
be taken to avoid or minimize exposure due
to:

a. needle stick

b. cuts from items that have been
contaminated by exposure to a patient's bodily
fluid

c. allowing bodily fluid from a patient to
contact an open wound or broken skin

d. splashes of a patient's bodily fluid

e. patient's bodily fluid contacting
mucous membranes

EVERY occurrence of being exposed to a
patient's body fluid in any of these means is to
be handled as an exposure to a blood borne
pathogen.

ACTION FOR EXPOSURE TO
BLOOD BORNE PATHOGENS

As a healthcare provider, ANY time you
are exposed to a blood borne pathogen you
MUST:

a. Seek medical assessment/treatment

b. File incident report

c. Inform appropriate supervisors

d. Follow local protocol for additional
actions and safety precautions.
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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
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FIGURE 3.10.01
Isolation Door Card for Strict Isolation

FIGURE 3.10.02
List of Diseases Requiring Strict Isolation
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Basic Hospital Corps School Lesson 3.10 Isolation Techniques
Handbook III and Blood Borne Pathogens
FIGURE 3.10.03
Isolation Door Card for Respiratory Isolation

FIGURE 3.10.04
List of Diseases Requiring Respiratory Isolation
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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
and Blood Borne Pathogens Handbook III
FIGURE 3.10.05
Isolation Door Card for Enteric Precautions
FIGURE 3.10.06
List of Diseases Requiring Enteric Precautions
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Basic Hospital Corps School Lesson 3.10 Isolation Techniques
Handbook III and Blood Borne Pathogens

FIGURE 3.10.07
Isolation Door Card for Drainage/Secretion Precautions

FIGURE 3.10.08
List of Diseases Requiring Drainage/Secretion Precautions
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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
and Blood Borne Pathogens Handbook III


FIGURE 3.10.09
Isolation Door Card for Contact Isolation




FIGURE 3.10.10
List of Disease Requiring Contact Isolation
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Basic Hospital Corps School Lesson 3.10 Isolation Techniques
Handbook III and Blood Borne Pathogens

















FIGURE 3.10.11
Wearing a Mask






















FIGURE 3.10.12
Donning Isolation Gown
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Lesson 3.10 Isolation Techniques Basic Hospital Corps School
and Blood Borne Pathogens Handbook III
NOTES/COMMENTS
138
Basic Hospital Corps School Lesson 3.10 Isolation Techniques and Blood
Handbook III Borne Pathogens Worksheet
Lesson 3.10

Isolation Techniques and Blood Borne
Pathogens Worksheet

1. Define sepsis. _________________________________________________________ .

2. Define contaminate. _________________________________________________________ .

3. Isolation is:

a. a disease that is easily spread to others.

b. practices that prevent the spread of pathogens.

c. confinement of pathogens to a given area to prevent their spread.

d. practices that reduce the number and control the spread of microorganisms.

4. A highly susceptible patient is __________________________________________________

__________________________________________________________________________ .

5. Universal precautions are used to prevent the transmission of blood borne viruses by contact with:

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________

6. When should universal precautions be used? __________________________________________

7. The protective measures of universal precautions that the health care provider can wear are:

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________

8. When performing rescue breathing, what is a way to protect yourself from contacting diseases?

______________________________________________________________________________
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Lesson 3.10 Isolation Techniques and Blood Basic Hospital Corps School
Borne Pathogens Worksheet Handbook III
9. State the purposes of isolation.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

10. Explain the purpose of strict isolation.

______________________________________________________________________________

11. Patient require respiratory isolation because their disease is spread by

______________________________________________________________________________

12. Enteric isolation is initiated to prevent transmission of contagious diseases via what route?
______________________________________________________________________________

13. What are the isolation gear/garb is used with a patient on drainage / secretion precautions?
______________________________________________________________________________

14. How does protective isolation vary from other types of isolation?

______________________________________________________________________________

15. What are some of the emotional feelings that patients in isolation may experience?

______________________________________________________________________________

16. You should show acceptance of an isolated patient by letting him/her express his/her feelings.

a. True b. False

17. List areas of patient education that a corpsman would give to an isolation patient.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

18. List the equipment that would be placed in the isolation room.

______________________________________________________________________________

19. List the equipment that would be stocked on the isolation cart.

______________________________________________________________________________

______________________________________________________________________________


140
Basic Hospital Corps School Lesson 3.10 Isolation Techniques and Blood
Handbook III Borne Pathogens Worksheet
20. Why is an isolation card placed on the door of the room of an isolated patient?

______________________________________________________________________________

21. Why is the clinical record not taken into the isolation room?

______________________________________________________________________________

22. List actions taken prior to donning isolation gear.

a. ________________________________________________________________________

b. ________________________________________________________________________

23. List the order to apply protective isolation clothing.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________

24. Which item of isolation clothing/garb is removed first?

a. Mask

b. Gown

c. Gloves

25. Describe how a melt-away bag works. _______________________________________________

______________________________________________________________________________

26. What technique is used to remove burnable isolation trash and nonburnable items from the room?

______________________________________________________________________________

27. Describe what precautions are taken when transporting an isolation patient.

____________________________________________________________________________

____________________________________________________________________________

28. Any exposure to a potential blood borne pathogen is to be treated as if it were an actual
exposure?

a. True b. False

141
Lesson 3.10 Isolation Techniques and Blood Basic Hospital Corps School
Borne Pathogens Worksheet Handbook III
29. List three ways healthcare providers may be exposed to potential blood borne pathogens.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

30. List the actions to be taken for any exposure to potential blood borne pathogens.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________
142
Lesson 3.11 Surgical Asepsis Basic Hospital Corps School
Handbook III
Lesson 3.11

Surgical Asepsis

Terminal Objective:

3.11 Perform surgical aseptic techniques.

Enabling Objectives:

3.11.01 Define terms related to surgical asepsis and wound care.

3.11.02 List selected methods of sterilization.

3.11.03 List principles of surgical asepsis.

3.11.04 List the types of dressing changes and equipment needed to perform them.

3.11.05 List guidelines for wound cleansing and irrigation.

3.11.06 List patient safety, privacy, education, and comfort considerations when utilizing sterile
technique and performing wound care.

3.11.07 List guidelines for establishing a sterile field.

3.11.08 List guidelines for using sterile solutions.

3.11.09 List guidelines for donning and removing sterile gloves.

3.11.10 List documentation requirements for a dressing change.

3.11.11 Perform a sterile dressing change for a closed incision.

3.11.12 Perform a sterile dressing change for a deep-packed wound.


Microorganisms are everywhere.
Although they cannot be seen with the naked
eye, they cover everything. They are present in
water, food, air, and our bodies.
Microorganisms that cause disease or infection
are called pathogens. Harmless
microorganisms are called nonpathogens.
Health care workers strive to prevent disease
and infection and, therefore, take measures to
prevent the spread of harmful microorganisms.
Medical asepsis, which includes practices that
help reduce the number and inhibit the growth
of microorganisms, has already been
discussed.

When the skin is broken and an open
wound is present, the individual's natural
defense against invasion by microorganisms is
impaired. To prevent the onset of infection in
a wound or during an invasive procedure of
the body, health care workers take measures to
prevent any microorganisms from entering the
body. These measures, termed surgical
asepsis or sterile technique, include practices
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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis
Handbook III
that render and keep objects and areas free of
all microorganisms. This is often done by
sterilization, a process that destroys
microorganisms.

GLOSSARY

STERILE -- free from living microorganisms,
including spores

STERILIZATION -- the process of destroying
and eliminating all microorganisms, including
spores

SURGICAL ASEPSIS -- practices that render
and keep objects and areas free of all
microorganisms (sterile technique).

STERILE FIELD -- work area free from living
microorganisms

STERILE DRESSING -- one of various
materials utilized for covering and protecting a
wound, free from living microorganisms
including spores.

OPEN WOUND -- break in the continuity of
the skin or mucous membrane.

INCISION -- a clean separation of skin and
tissue with smooth, even edges. A surgically
created wound.

SUTURES-- material used to join several
edges of tissue together (stitches).

STAPLES -- wire skin closures. Frequently
used in place of sutures. Sometimes called
clips.

DEHISCENCE -- partial to complete
separation of previously joined (sutured)
wound edges.

DRAINAGE -- discharge from a wound or
body cavity.

DEBRIDEMENT -- the removal of damaged
tissue and cellular debris in order to prevent
infection and promote healing.

HEMOSTATS -- two-pronged instrument
with scissor-like handles. Used to hold items
such as grasping a dressing.

INFLAMMATION bodys defensive
reaction to tissue injury, characterized by
localized pain, heat, redness, and swelling of
tissue and wound edges.

PENROSE DRAIN -- a thin-walled, latex tube
that is surgically placed in a wound to allow
drainage to escape form a body cavity.

TAPE -- material to secure dressings. Types
available include adhesive and hypoallergenic
tapes. If a patient is allergic to adhesive tape
and exhibits symptoms of redness, edema, and
blister formation where the tape touches the
skin, paper or silk tape may be used. Paper
tape is extremely flammable and must be used
with caution.

MONTGOMERY STRAPS -- Tie straps with
tape remain in place when the dressing is
changed. Decreases the possibility of injury to
the skin by allowing the tape to remain in
place between dressing changes, Figure
3.11.01.

METHODS OF STERILIZATION

Any article that is used for an invasive
procedure or that will enter a sterile area of the
body must be sterilized. There are several
methods used to render the item totally free of
all microorganisms. It is important to know
the effect that the method has on a particular
article. For instance, chemicals can corrode
metals. Pressurized steam may damage rubber
or plastic and may dull sharp instruments.

Pressurized steam (known as
autoclaving) is one of the quickest, most
economical and widely used sterilization
methods. It combines moist heat, pressure, and
high temperature to destroy all organisms and
spores.

Using a gas such as ethylene oxide is
another method of sterilization. The gas is able
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to permeate articles that may be destroyed by
the high temperatures required with
pressurized steam. Contact with the gas over a
period of time can kill all organisms. The
article must aerate for 24 hours after
sterilization to allow the residue of gas to
escape.

Aqueous glutaraldehyde is an example of
a liquid chemical that may be used for
sterilization. The articles must be immersed in
a specific solution for a specific period of
time.

Irradiation in the form of ionizing
radiation has significant penetrating power as
a sterilizing agent. Sterile gloves, syringes,
needles, and urinary catheterization trays may
be irradiated for sterilization by the
manufacturer prior to being distributed for use.

PRINCIPLES OF SURGICAL
ASEPSIS

Sterile technique must be strictly followed
when dealing with open wounds, doing
invasive procedures, or when an article enters
a sterile area of the body. The following is a
list of principles that must be followed when
performing surgical asepsis.

Principle -- An item that has been only
disinfected is not considered sterile.

Explanation -- Disinfection does not destroy
all microorganisms. Some microorganisms
may become active and cause infection.

Principle -- A sterile area should never be left
unattended.

Explanation -- Leaving sterile areas and
equipment provides a situation in which
undetected contamination may occur.

Principle -- Always keep the sterile field in
view. Never turn your back to a sterile field.

Explanation -- It is possible that contaminated
areas of the body or clothing may touch sterile
objects when turning and sterility cannot be
ensured without continuous observation.

Principle -- Sterile objects must be
maintained above waist or table level.

Explanation -- Areas below the waist are out
of sight and could become contaminated
without your knowing.

Principle -- Talking, coughing, and sneezing
over a sterile field must be avoided.

Explanation -- Microorganisms are present in
the moisture from respiratory secretion. These
droplets can fall onto sterile areas, causing
contamination.

Principle -- NEVER reach across a sterile
field.

Explanation -- Reaching across an area could
cause contamination through accidental
contact or by dropping particles of dust or lint.

Principle -- Open windows, air conditioning
units, and fans near a sterile field create the
potential for contamination.

Explanation -- Air currents can carry
organisms that can then be deposited onto
sterile items.

Principle -- A sterile object becomes
contaminated when touched by unsterile
objects.

Explanation -- Even clean objects contain
microorganisms. Sterile objects may only
touch other sterile objects.

Principle -- Spilling liquid on a non-
waterproof sterile field contaminates the
sterile field.

Explanation -- Moisture on sterile cloth or
paper can pull microorganisms from the
contaminated surface by capillary action.

Principle -- The inside of the lid of a sterile
container is considered free of microorganisms
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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis
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as long as it is not placed directly on a
contaminated surface.

Explanation -- Place a lid upside down (rim
up) if the lid cannot be held while removing
contents from the container/bottle. Care must
be taken that the edges do not become
contaminated when the lid is replaced.

Principle -- Sterile instruments may be picked
up with the ungloved hand.

Explanation -- While the handles will become
contaminated, the untouched tips that will be
in contact with the wound or sterile supplies
will remain sterile.

Principle -- The inside of a wrapper and its
contents are sterile. They should not be
touched with the bare hand. Sterile gloves or
sterile instruments should be used if the
contents must be rearranged.

Explanation -- Touch only the outer wrapper
or underneath surface of the wrapper. The
inside is sterile, the outside contaminated.

Principle -- Sterile gloves are worn when
performing a sterile procedure.

Explanation -- When applied correctly, sterile
gloves may be safely used to handle sterile
supplies and prevent contamination of sterile
equipment, the wound, or transmission of
microorganisms into the environment of the
patient.

Principle -- Keep gloved hands in sight and
above waist level. Do not touch unsterile
objects.

Explanation -- When hands are removed from
area of critical viewing (out of line of sight),
they potentially could become contaminated
by touching unsterile items.

Principle -- Treat the edges of a sterile field as
if they were contaminated. Any part of the
field off the table is considered contaminated.

Explanation -- In the process of creating a
sterile field, the edges are the most likely place
for accidental contamination. You are allowed
to touch the one inch edge of the wrapper with
your ungloved hand therefore you cannot
touch this one inch border after donning sterile
gloves. The edges of the field off the table
could potentially come in contact with
contaminated areas of the body or clothing.

Principle -- Do not use equipment and
supplies if there is any doubt about its sterility.

Explanation -- Because organisms cannot be
seen, it is far better to err on the side of safety
than to take a chance and have the patient
acquire an infection.

Basic concepts of sterility:

1. Sterile +sterile =sterile.

2. Sterile +clean =unsterile.

3. Sterile +contaminated =unsterile.

4. Sterile +unknown =unsterile.

Before opening a sterile package inspect it
for signs of contamination. Check the
condition of the package wrapper for tears or
holes, any indication that it has become damp
or wet, and whether the sterile package had
been dropped on the floor. Do not use the item
if any of these conditions are present. Hospital
prepared packages must be double wrapped
and will have an expiration date and
sterilization indicator. The sterilization
indicator may be found inside and outside the
package and will change color if the article
was sterilized. Do NOT use the item if it is
past its expiration date or there is no
expiration date.

TYPES OF DRESSING CHANGES

Tissues of open and closed wounds are
more susceptible to additional injury than is
healthy, intact tissue. Two goals of wound
care are to prevent further injury and to
promote tissue healing. The type of dressing
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change and materials used depends on the type
of injury.

A dry, sterile dressing is a gauze applied
to keep the wound clean and prevent entry into
the wound by microorganisms. The highly
absorbent nature of the dressing material is
able to collect large amounts of wound
drainage. The gauze can also hold antiseptic
ointment next to the wound and protect the
wound from further injury. If the dressing
adheres to the wound during removal, it may
be moistened slightly with sterile saline or
sterile water to decrease pain the patient may
experience.

Surface debridement of a wound is
accomplished by applying a wet to dry
dressing. The moistened dressing material
keeps the wound area soft and traps debris in
the wound as the material dries. When the
dressing is changed, the once moist gauze is
now almost dry. The dried gauze debrides the
wound as it is removed from the wound. Do
not moisten the dried dressing when removing
it from the wound. The wet dressing is
covered with a dry cover dressing for patient
comfort.

A wet to wet dressing can be ordered
when the wound is to be kept moist to promote
wound healing. To limit growth of pathogens
in the moist wound environment, the liquid
used to moisten the gauze may contain an
antiseptic. A granulating solution may be
placed in the wound to promote tissue growth.
A wet to wet dressing is similar to a wet to dry
dressing except it is heavily moistened when
applied to prevent it from drying out between
dressing changes.

The equipment needed to perform a
dressing change depends on the type of
dressing change. Items required include sterile
gauze sponges (2x2's, 4x4's), tape or
Montgomery straps, clean gloves, sterile
gloves, biohazard bag (for disposal of
contaminated dressing after removal), sterile
irrigating solution, and a sterile field or
wrapped sterile basin. Hemostats and an ABD
dressing may also be required.
WOUND CLEANSING AND
IRRIGATION

A closed incision and the surrounding
areas may be cleansed to remove debris and to
aid in healing. When cleaning a wound, use
the first swab and wipe once downward from
top of incision to bottom, then discard swab.
The second swab is used to wipe once down
the far side of the incision and then discarded.
The third swab cleans the near side of the
incision using the same top to bottom motion.
The fourth swab cleans the center of the
wound again. Using one swab for each stroke
prevents introducing organisms from the skin
into the wound or from transferring organisms
from one area of the wound to another.
Equipment needed to cleanse a wound include
the following sterile items: basin, irrigating
solution and gauze sponges in addition to the
items required for the dressing change.

Wound irrigation involves the instillation
of a solution into an open wound. It may be
ordered to cleanse the wound by removing
drainage and debris, to increase circulation to
an open wound to aid in healing, or to prevent
further infection (using an antiseptic solution).
Equipment needed to perform an irrigation
includes an irrigating syringe (50-100 cc
syringe with a plunger or compression bulb), a
sterile basin (to hold the irrigating solution),
irrigating solution as ordered by the physician,
and a basin to receive the soiled solution as it
drains away from the body.

PROVIDING PRIVACY, SAFETY,
COMFORT AND EDUCATION

Before carrying out a sterile procedure on
a patient, perform patient identification checks
to ensure you have the right patient. Explain
what you are about to do in order to gain the
patient's cooperation. Since the patient must
not contaminate the sterile field, ask him/her
to keep hands away from the wound or sterile
field once established. Also instruct the patient
to turn his/her head away from the sterile field
to talk, laugh, sneeze, or cough. Ask the
patient to be very still during the procedure.
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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis
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Safety measures include ensuring the
siderail is up on the side opposite of where
you are working and that the bed wheels are
locked. Ask the patient about any allergies,
especially if using Betadine solution or
adhesive tape.

Before beginning, pull the curtain around
the bed and/or close the door to the room.
Drape the patient so that no more is exposed
that what must be for the procedure.

For the patient's comfort, allow him/her to
tend to hygiene needs such as voiding before
beginning. Position the patient in a
comfortable position. If the procedure is
painful, give the patient pain medication 30
minutes prior to the procedure if possible. For
your own comfort and safety, raise the bed to
a comfortable working level to prevent strain
to your back.

ESTABLISHING A STERILE
FIELD

A sterile field is a work area free of
microorganisms. Sterile fields may be
commercially prepared by a manufacturer of
medical supplies. To open a commercial,
disposable sterile field place sterile package
on a flat, level surface. Peel wrapper
completely open. If the wrapper tears and the
torn edge comes in contact with contents, the
item is contaminated and must be discarded.
Pick up corner of field and lift field straight
up. Do NOT drag the field over the edge of the
wrapper. Keep the sterile field away from your
body and furniture.

Open field, touching only the one-inch
border designated as unsterile. Holding field
by two corners, drape it over table, placing it
from back to front. Placing field front to back
will cause you to lean across sterile field. This
may cause accidental contamination through
direct contact or through dust or lint dropping
on field.
Before opening an envelope-type sterile
package, place it flat on a level surface. The
outer most corner of the wrapper should be
opened away from the corpsman first, Figure
3.11.02. The sides of the wrapper may be
unfolded by touching areas that will be in the
underneath surface when the package is
completely opened and by touching only the
area within one inch from the edge of the
wrapper. The last corner should be pulled
toward the person opening the package. This
helps avoid the possibility of touching or
reaching across the sterile field.

The inner wrapper is opened in the same
manner. Any part of the wrapper hanging over
the edge of the table and a one-inch border
from the edge of the table or edge of the
wrapper is now considered unsterile. If the
sterile field needs to be repositioned, it must
be done before opening the inner wrapper.
This is because, in turning the field, what was
originally hanging over the edge of the table
may now be on top of the table and incorrectly
considered sterile.

Items such as dressing material added to
the sterile field must also be sterile. Stand
away from the sterile field when opening
packages, Remember that the outside of
dressing wrappers are unsterile and must not
come into contact with either the sterile field
or the sterile dressing. To open the wrapper of
a sterile dressing, read the directions provided
by the manufacturer. Grasp the flaps at the top
of the package and peel down carefully, If the
wrapper tears incorrectly, the outside will
come into contact with the dressing; the
dressing is then contaminated and must not be
used. Since the edge of the wrapper is
unsterile, the dressing also must not be
allowed to slide over the contaminated edge.
To drop the dressing onto the sterile field, the
edge of the wrapper should be folded under or
the dressing should be allowed to fall in such a
way that the dressing and wrapper edge do not
come into contact.

POURING STERILE SOLUTION
INTO A CONTAINER

To pour sterile solution into a container on a
sterile field, first double-check that you have
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the correct solution. Also check the expiration
date of the solution and observe for any
foreign particle or discoloration. Since one the
bottle of sterile solution has been opened it is
considered sterile for only 24 hours, check to
see the date and time it was opened. If the
bottle has not been opened before, write the
date, time, and your initials on the label of the
bottle.

Remove the cap from the bottle of sterile
solution without touching the rim. Place the
cap upside-down on the table or hold it in your
hand making sure you do not touch the inside
of the cap to maintain the sterility of the inner
surface. Pour the solution into the sterile basin
without touching the rim of the bottle of the
basin, about one-inch above the basin rim. Be
very careful not to splash the solution out of
the basin onto the sterile field. When your
hold the bottle, cover the label with your palm
(palm the label), so that any drips of solution
down the side of the bottle do not make the
label unreadable. Re-cap the bottle and set
aside.

DONNING STERILE GLOVES

Because the hands cannot be rendered
sterile, sterile gloves must be worn during a
sterile procedure to prevent microorganisms
from the hand from contaminating the sterile
field. The procedure for donning gloves
involves the following steps:

1. Obtain the correct size of gloves.

2. Remove jewelry and wash and dry hands
thoroughly.

3. Place the glove package on a work area
about waist level.

4. Peel down the outer wrapper of the glove
package, Figure 3.11.03. Grasp the inner
envelope wrap and place it on the work area.
Open the inner wrapper by touching only the
one-inch folded back portion of the paper. As
you open the inner wrapper all the way, fold
the upper and lower edges down to prevent the
flaps from recoiling. The fingers of the gloves
should be facing away from you.

5. Use the thumb and fingers of the non-
dominant hand to pick up the inside folded
cuff of the glove that will cover the
dominant hand. The folded cuff area is
actually the inside of the glove and may be
touched. Pick the glove up straight up to
avoid dragging it over the edge of the
wrapper, Figure 3.11.04.

6. Holding onto the folded cuff, stretch and
pull the glove on over the fingers of the
dominant hand being careful to handle just
the inside portion of the cuff, Figure
3.11.05.

7. Place four fingers of the gloved hand
UNDER the cuff of the second glove and
lift it straight up from the sterile wrapper.
You may hold the one-inch edge of the
sterile glove wrapper with your ungloved
hand to keep the wrapper from moving.

8. Keeping the gloved thumb away from the
second glove, pull the glove onto the non-
dominant hand by maintaining a firm pull
under the cuff, Figure 3.11.06.

9. Adjust the position of the fingers in the
gloves until they fit comfortably.

10. Do not touch or adjust the cuff of the
glove. It is too close to the skin of the
wrist and potentially contaminated.

11. Keep the hands in sight and above the
waist. Do not touch unsterile objects.

12. If the glove is torn or becomes
contaminated, discard it and start over.

When removing gloves, use the glove to
glove, skin to skin method to avoid
contaminating hands with whatever is now on
the outside of the gloves. To do this, remove
the first glove by placing the opposite gloved
hand on the outside of the glove near the cuff
(glove to glove). Pull the first glove off
turning it inside out and ball it up into the
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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis
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hand that is still gloved. Next, remove the
second glove by reachng UNDER the glove,
(skin to skin) and pulling the glove off inside
out so that the first glove end up inside the
second glove. Discard gloves and wash your
hands.

DOCUMENTING A DRESSING
CHANGE

Careful observations must be made of the
drainage and condition of the wound during
the dressing changes so that it can be
documented accurately in the Nursing Notes
SF 510. Document the location of the wound
and the type of dressing change, e.g., dry,
sterile dressing; wet to dry dressing, wet to
wet dressing. Mention the solution used if a
wet to dry or wet to wet dressing is applied.

Document the type of dressing applied
(e.g. 2 x 2, 4 x 4, repacked with 4 x 4 and
covered with a sterile ABD pad).

Note any discoloration of the skin such as
redness or ecchymosis (bruising). Look for
any signs of inflammation (a defensive
reaction of tissue to injury) such as localized
pain, heat, redness, and swelling of the tissue
and wound edges. In a closed incision, notice
whether the edges of the wound come together
as they should. Also document any incisional
pain the patient is experiencing and any
change in the appearance or condition of the
wound. If a drain (such as a penrose drain)
was inserted and is supposed to be in place,
document whether or not it still intact.

Document the type, amount, color and
odor of any drainage present. Sanguineous
drainage is bloody, red drainage. Serous
drainage is the clear, slightly straw-colored
serum portion of the blood. A combination of
serous and sanguineous drainage is called
serosanguineous. Purulent drainage contains
pus and is an indicator of infection. Be as
specific as possible about the amount of
drainage. On a dry dressing, the amount of
drainage can be described as quarter sized or
two inches in diameter A wet dressing may be
estimated as small (medium, or large) amount.
Sometimes wet dressings are weighed to
determine the amount of drainage present.

Wound care is an importance part of the
job of a corpsman. The corpsman's vigilance
in using sterile technique, performing dressing
changes, making careful observations of
wounds, and reporting any abnormalities
could make the difference in a patient's
recovery.

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FIGURE 3.11.01
Montgomery Straps





















FIGURE 3.11.02
Opening an Envelope Type Package
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FIGURE 3.11.03
Opening a Package of Sterile Gloves





















FIGURE 3.11.04
Picking up the First Glove
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FIGURE 3.11.05
Putting on the First Glove





















FIGURE 3.11.06
Putting on the Second Glove
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NOTES/COMMENTS
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Lesson 3.11 Surgical Asepsis Worksheet Basic Hospital Corps School
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Lesson 3.11

Surgical Asepsis Worksheet

1. Surgical asepsis and sterile technique mean the same thing.

a True b. False

2. Wire skin closures are called:

a. dressings.

b. bandages.

c. staples.

d. sutures.

3. Debridement is:

a. separation of previously joined wound edges.

b. the removal of damaged tissue and cellular debris in order to prevent infection and promote
healing.

c. discharge from a wound or body cavity.

d. material used to close a surgical or traumatic wound with stitches.

4. A penrose drain is used to:

a. secure dressings.

b. cover and protect a wound.

c. allow the escape of drainage from a body cavity.

d. destroy and eliminate all microorganisms, including spores.

5. The most widely used method of sterilization is ______________________________________.

6. How does pressurized steam destroy microorganisms and spores?

_____________________________________________________________________________

7. Sterile instrument tips remain sterile even if the handle is picked up without sterile gloves.

a. True b. False

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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Worksheet
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8. Circle each factor that is a principle of surgical asepsis.

a. A sterile field should never be left unattended

b. You may reach across a sterile field to pick up instruments.

c. Do not use equipment and supplies if there is a doubt about their sterility.

d. A sterile object becomes contaminated when touched by unsterile objects.

9. Sterile gloves are worn when performing a sterile procedure to:

a. _________________________________________________________

b. _________________________________________________________

10. List the four basic concepts of sterility.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

d. _________________________________________________________

11. List three types of dressing changes.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

12. A wet to dry sterile dressing is used to debride a wound.

a. True b. False

13. List two purposes of a wet to wet dressing change.

a. _________________________________________________________

b. _________________________________________________________

14. When cleansing a closed incision you may use the same swab four times.

a. True b. False




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15. List three purposes for wound irrigation.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

16. An irrigation syringe is a ________cc syringe with a compression bulb or plunger.

17. List four things that should be explained to a patient before starting a dressing change.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

d. _________________________________________________________

18. If a dressing change is going to be a painful procedure, the patient should be medicated
minutes prior to the procedure.

19. List three ways to maintain patient privacy when performing a dressing change.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

20. On a sterile field, a ____________________________ border is designated as unsterile.

21. List the correct procedure for opening a sterile package.

_____________________________________________________________________________

_____________________________________________________________________________

22. When opening a double wrapped package, how is the sterile field repositioned?

_____________________________________________________________________________

23. When adding sterile items to a sterile field, the outside of dressing wrappers may touch the sterile
field.

a. True b. False

24. When pouring a sterile solution, the bottle rim should rest the edge of the basin.

a. True b. False
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25. List four checks done on a bottle of sterile solution before use.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

d. _________________________________________________________

26. How do you maintain sterility of bottle cap of a sterile solution when you are using the bottle?

_____________________________________________________________________________

27. When applying gloves, which hand is gloved first?

_____________________________________________________________________________

28. When donning the first sterile glove, what portion of the glove is allowed to touch your skin?

_____________________________________________________________________________

29. List the procedure for donning the second sterile glove.

_____________________________________________________________________________

_____________________________________________________________________________

30. How do you remove sterile gloves to avoid contaminating your hands?

_____________________________________________________________________________

_____________________________________________________________________________

31. List the four characteristics of wound drainage that must be documented.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

d. _________________________________________________________

32. Purulent drainage from a wound is considered normal.

a. True b. False

33. A dressing is sometimes weighed to determine the amount of drainage it holds.

a. True b. False
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Basic Hospital Corps School Lesson 3.11 Surgical Asepsis Worksheet
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159

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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
Handbook III
Lesson 3.14

Urinary Catheterization

Terminal Objective:

3.14 Perform a urinary catheterization, collect a specimen, and remove an indwelling catheter.

Enabling Objectives:

3.14.01 Define terms related to urinary catheterization.

3.14.02 State the purposes of urethral catheterization.

3.14.03 List equipment for insertion of straight and indwelling catheters.

3.14.04 List guidelines for inserting an indwelling catheter.

3.14.05 List guidelines for inserting a straight catheter.

3.14.06 List guidelines for nursing care of a patient with an indwelling catheter.

3.14.07 List guidelines for obtaining a urine specimen from an indwelling catheter.

3.14.08 List documentation requirements for catheterization and specimen collection.

3.14.09 List guidelines for removal of an indwelling catheter.

3.14.10 List guidelines for nursing care of a patient after removal of an indwelling catheter.

3.14.11 List documentation requirements for removal of an indwelling catheter.

3.14.12 Insert an indwelling catheter.

3.14.13 Obtain a urine sample from an indwelling catheter.

3.14.14 Remove an indwelling catheter.


The urinary tract is a route from which
wastes are excreted from the body. Most of the
time a patient is able to empty his/her bladder
unaided by a process called urination or
voiding. There are circumstances when it
becomes necessary to assist the patient in this
elimination process by inserting a urinary
catheter.

A catheter is a hollow tube for instilling
and removing fluids. Catheterization is the act
of introducing a catheter into a body cavity or
a body organ. Urinary catheterization is the
process of introducing a sterile catheter
through the urethra into the bladder in order to
remove urine.

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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
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PURPOSES OF URETHRAL
CATHETERIZATION

A straight catheter can be inserted to:

1. Obtain a sterile urine specimen, entirely
free of contamination

2. Measure residual urine -- urine left in the
bladder after a patient has voided.

3. Relieve urinary retention, such as when a
patient is unable to void postoperatively.
The urine accumulates in the bladder and
can cause significant discomfort from
pressure on the adjacent body structures.

An indwelling catheter can be inserted to:

1. Provide continuous drainage of urine.

2. Monitor urine output to assess fluid
balance and kidney function. Urine output
is closely monitored in critically ill
patients. When a patient is in shock, less
urine is produced because there is
decreased blood flow to the kidneys.

3. Preoperative preparation -- to keep the
bladder empty of urine during the surgery.
This prevents accidental injury of a full
bladder with surgical instruments and also
prevents urinary retention during long
surgical procedures.

4. Control incontinence -- when a patient is
unable to control the sphincter which
retains urine in the bladder and therefore
unintentionally urinates, a catheter will
provide a dry environment. Placement of a
catheter should be the last resort and take
place only if the patient shows signs of
skin breakdown. Frequent hygiene and
linen changes present fewer risks than
those possible with the use of a catheter.




EQUIPMENT FOR
CATHETERIZATION

There are two basic types of catheters that
are used in urinary catheterization. One is
straight catheter, also called a nonretention or
in and out catheter, Figure 3.14.01. It is
inserted into the bladder and immediately
removed from the bladder after use. This
single lumen (space within a tube) tube has
one or more holes near its proximal end. The
second type of catheter is an indwelling
catheter. This catheter is inserted into the
bladder and secured there to provide for
continuous drainage of urine. Since the
catheter is retained in the bladder, it is also
called a retention catheter. A Foley catheter is
a type of indwelling catheter that is retained in
the bladder by an inflatable balloon. A Foley
catheter may have two or three lumens. One
lumen is for the drainage of urine. The second
lumen is used to carry the fluid to inflate the
balloon once the catheter is in the bladder,
Figure 3.14.02. The third lumen (on a triple
lumen catheter) is used to instill irrigation
fluid. Triple lumen catheters are commonly
used after genitourinary surgery to
continuously irrigate the bladder.

Both straight and indwelling catheters
come in various sizes. Common sizes for
adults include number 14, 16, and 18 French.
The term French refers to a measuring system
that indicates the diameter of the catheter. One
French unit equals 1/3 millimeter in diameter.
Catheters in sizes 6, 8 and 10 Fr. are used for
children.

Prior to inserting a urinary catheter, obtain
the catheter appropriate for the procedure and
reason catheter is being inserted. Also obtain a
catheterization kit, a prepared sterile tray
which normally contains:

1. Sterile gloves

2. Two sterile drapes -- one fenestrated (with
an opening) and one non--fenestrated
without an opening)

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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
Handbook III
3. Cotton balls and Betadine solution OR
Betadine swabs.

4. Plastic forceps (for use with cotton balls
only)

5. Water soluble lubricant.

6. Sterile specimen container.

7. 10-ml syringe prefilled with sterile water
or normal saline (for indwelling catheter
only).

8. Disposable drainage tubing and urine
collection bag (for indwelling catheter
only)

Additional supplies that are needed for
catheterization include a protective pad (Chux)
to protect the bedding, tape or manufactured
catheter holder (for indwelling catheters only),
and a light source. A good light source is
especially important when catheterizing a
female patient. A gooseneck lamp or flashlight
may be needed to provide adequate light.

GUIDELINES FOR INSERTING
AN INDWELLING CATHETER

When dealing with any patient, it is
important to keep in mind the whole patient as
you insert a catheter. Explain what you are
about to do, why the doctor ordered the
procedure, and that the patient must not move
his/her legs to not contaminate the sterile field.
Reassure the patient that the procedure will
not hurt, but there may be a sensation of
pressure as the catheter is advanced. Talk to
the patient throughout the procedure to calm
and reassure him/her. Because inserting the
catheter requires exposing the patient's genital
area, it is important that you maintain as much
privacy as possible. Draw the curtain around
the bed. Drape the patient with a sheet during
insertion, exposing no more than necessary.
Remember patient safety, lowering the bed rail
only on the side where you are working. If you
need to leave the bedside, remember to raise
the bed rail. Be sure to ask about allergies.

Position the patient for the procedure.
Males are placed in a supine position. A
female patient is in a dorsal recumbent
position, on her back with knees flexed, thighs
apart, with her feet about 24 inches apart.

After opening the catheter kit and donning
sterile gloves, aseptically drape the patient.
Males have the nonfenestrated drape placed
over the thighs. The fenestrated drape is
placed over the penis, allowing the penis to
protrude through the opening. For a female
patient, place the nonfenestrated drape
between the legs, close to the perineum. Place
the fenestrated drape over the perineum so that
only the labia are exposed.

While both gloved hands are sterile,
prepare all equipment that requires the use of
two hands.

1. Test the balloon for leakage by attaching
the prefilled syringe to the catheter's
inflation port and instilling the contents of
the syringe into the balloon. Observe the
balloon for signs of leaks. Pull back on the
syringe, ensuring that the balloon deflates.
Leave the syringe attached to the inflation
port and set it aside in the sterile tray.

2. Check the drainage bag for tears and
ensure that the drainage clamp is closed.

3. Open and pour Betadine solution over
cotton balls or open Betadine swabs.

4. Open the lubricant package and squeeze
lubricant out onto the sterile field.

Whenever you touch the labia or penis,
use your non-dominant hand. Once the non-
dominant hand touches the patient's genitals,
that hand becomes contaminated and must
remain in place until catheterization is
completed. Your dominant hand will be used
to clean the meatus and insert the catheter.




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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
Handbook III
To clean the urinary meatus:

1. Males -- grasp the penis and retract the
foreskin (for uncircumcised males) to
expose the meatus. Using your dominant
hand, cleanse the meatus with a Betadine
swab or Betadine soaked cotton ball held
with plastic forceps. Wipe in a circular
motion away from the urethral opening
downward to the junction of the glans and
the penile shaft. Repeat the cleaning three
times, using a separate cotton ball or swab
for each wipe.

2. Females -- separate labia using thumb and
index finger to expose the meatus. Using
the dominant hand, clean the labia and
meatus using the Betadine swab or cotton
ball. Use a front-to-back stroke, from just
above the meatus toward the rectum.
Clean the area four times, using a clean
swab for each wipe. Wipe once down the
center, once on each side and once again
down the center.

Prior to inserting the catheter in the
meatus, lubricate 4-6 inches of the catheter tip
well. This will aid in ease of insertion. When
inserting the catheter hold the penis at a 90-
degree angle to the thighs to minimize the
curve of the urethra, Figure 3.14.03. When
inserting the catheter in a female, keep the
labia separated to allow for better visualization
of the meatus, Figure 3.14.04. If resistance is
met, ask the patient to breathe deeply and
rotate the catheter slightly before going
further. This may relaxes the sphincter. Never
use force. If unable to advance the catheter,
remove it and notify the nurse.

Advance the catheter until urine flows,
then insert one inch further. Since the balloon
is located about 1 inch from the tip of the
catheter, inserting the catheter additional
distance after obtaining urine, ensures that the
balloon will be within the bladder when it is
inflated. Inflating the balloon when it is still in
the urethra would be extremely painful to the
patient.

After the catheter is inserted, hold it in
place until the balloon is inflated. Inject the
specified amount of sterile water into the
balloon. The size of the balloon is generally
written on the distal end of the catheter.
Gently pull on the catheter until resistance is
met. Resistance indicates that the balloon is
correctly positioned and holding the catheter
in the bladder. In uncircumcised males, gently
replace retracted foreskin.

Secure the catheter with tape to avoid
tension on the catheter. For males, tape the
catheter laterally to the thigh or on the lower
abdomen to prevent pressure and irritation
between the penis and the scrotum. Tape the
catheter to the inner thigh of females or use
the manufactured catheter holder.

When attaching the collection bag to the
bed, be sure the bag is lower than the patient's
bladder. Allow sufficient tubing for the patient
to move about in bed. You may secure the
coiled tubing with a rubber band and safety
pin the rubber band to the bottom sheet. The
tubing may be placed over the patient's thigh
to prevent the weight of his/her body from
compressing the tubing closed.

GUIDELINES FOR INSERTING A
STRAIGHT CATHETER

The procedure for inserting a straight
catheter is almost the same as inserting an
indwelling catheter. Since a straight catheter
does not remain in the bladder, there is no
balloon
to check for leaks when beginning the
procedure. Also, there is no tubing and urine
collection device to inspect. After the catheter
is inserted in the urethra, continue to advance
the catheter until urine flows, then advance
one additional inch. Hold the catheter in place
while the urine drains into the sterile
collection tray. If a urine specimen is ordered,
place the distal end of the catheter over the
opening of the sterile specimen container
(included in the catheterization kit) and collect
a sample of urine.
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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
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Allow urine to drain out of catheter into
the collection tray until urine stops flowing or
until volume has reached the maximum
amount specified by local policy. Some
hospitals limit the amount drained at one time
to decrease the possibility of bladder spasms.
Once the flow of urine has stopped, pinch the
catheter and gently and slowly remove it.
Leave the patient dry, comfortable and
covered.

NURSING CARE OF PATIENT
WITH AN INDWELLING
CATHETER

Patients with indwelling catheters require
special nursing care to prevent complications.
The most common complication of an
indwelling catheter is a urinary tract infection.
The catheter provides a means for bacteria to
enter the bladder that is normally a sterile part
of the body. In order to decrease the
possibility of an infection, you must maintain
a closed drainage system. Do not disconnect
the catheter from the drainage tube unless
absolutely necessary, such as for a bladder
irrigation. If the catheter must be
disconnected, make sure both ends remain
sterile until they are connected again.

If the drainage bag or tubing become
contaminated at either the catheter end or the
drainage outlet, replace the tubing and
drainage system. Do not place the drainage
bag on the floor and to not allow the emptying
port to touch the floor. Wear gloves whenever
handling the urine drainage system and wash
your hands before and after handling the urine
drainage system.

Unobstructed urine flow must be
maintained. Gravity assists to keep urine
flowing away from the bladder. Eliminate
uphill flow of the urine as it courses its way
through the drainage tubing. Avoid kinks and
twisting of the catheter or drainage tubing.
Avoid occlusion of the tubing by the patient's
body weight or by the side rails or
mechanisms of the bed. Keep the drainage
collection bag below the level of the bladder at
all times to prevent backflow of urine into the
bladder. Be sure to instruct the patient to
follow these guidelines also.

To maintain patency of the catheter,
encourage the patient to increase his/her fluid
intake, unless this is contraindicated. A
generous fluid intake of 2,500-3,000 ml per
day keeps the urine dilute and free flowing.
The prompt drainage of urine acts as a natural
irrigant and prevents obstruction and infection.

Check the catheter frequently to make sure
it is draining properly. If the catheter is not
draining, check for any mechanical
obstructions such as kinking or twisting, or
dislocation from the bladder. If no mechanical
obstructions are found, notify the nurse.
Minimum acceptable urine output is 30 ml per
hour in adult patients. Less output may mean
that either the patient is not producing enough
urine or the catheter is obstructed.

An indwelling catheter may need to be
changed (removed and a new one reinserted)
depending on the policy established at your
institution. The usual length of time between
the need for catheter changes varies from five
days to two weeks.

To decrease the chance of infection, wash
the patient's perineal area with soap and water
twice a day. Rinse the area well and pat dry.
Cleanse the meatus and portion of the catheter
near the meatus, removing any dried
secretions. If the patient is able, he/she may be
instructed to perform this care. Avoid using
powders and lotions after cleannsing as these
substances may trap and retain organisms
leading to a urinary tract infection. Always
observe for signs of irritation or urinary tract
infection. Signs include fever, discharge
around the catheter, cloudy urine, foul
smelling urine and hematuria.

After an indwelling catheter has been
removed, the patient should void within 8-12
hours. It is not uncommon for patients to have
dysuria after catheter removal, so it is
important to monitor the urine output. Instruct
the patient to void in a urinal, bedpan, or urine
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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
Handbook III
hat for the first few voidings after the catheter
has been removed. Also instruct the patient to
notify the nursing staff of any feeling of
urgency (sudden urgent need to void),
frequency (needing to void often, but only
small amounts of urine), burning, bleeding or
inability to void. These signs may be
temporary and normal due to the irritation of
the urethra by the catheter, but it could also
indicate possible urinary tract infection.

SPECIMEN REMOVAL FROM AN
INDWELLING CATHETER

The urinary bladder is normally a sterile
part of the body. If a urinary tract infection is
suspected, a urine specimen will be ordered
for culture and sensitivity (checking for
microorganisms and what antibiotics will
work to destroy the particular microorganism).
If a urine specimen is ordered for a patient
who has an indwelling catheter in place, a
sterile specimen can be obtained directly from
the catheter or specimen port on the drainage
tubing.

The supplies needed to obtain a sterile
specimen from an indwelling catheter are:

1. Antiseptic swab (alcohol or Betadine)

2. 22-25-gauge needle and 10 cc syringe.

3. Specimen container with label.

4. Lab request form (chit) -- appropriate for
ordered test.

5. Clean gloves.

Prior to obtaining the specimen, clamp the
drainage tube immediately below the
specimen sample port for 10-15 minutes. If the
drainage tubing has no specimen collection
port, clamp tubing just distal to the connection
of the catheter and the drainage tubing. This
allows fresh urine to collect at the specimen
port. The specimen can be obtained without
interrupting the integrity of the drainage
system; drainage tubing does not need to be
disconnected from the catheter.

Use the antiseptic swab to cleanse the
specimen collection port. If there is no
collection port, cleanse an area on the catheter
proximal to the clamp. Insert the needle at a
90-degree angle into the specimen port (15-
degree angle into the catheter) and withdraw
the urine specimen. The port and the catheter
are self-sealing and will seal after the needle is
withdrawn, preventing microorganisms from
entering. Aseptically transfer the collected
urine from the syringe into the specimen
container. Remember to unclamp the drainage
tubing after the urine specimen is obtained.

RECORDING
CATHETERIZATION AND
SPECIMEN COLLECTION
PROCEDURES

Proper documentation is important with
any nursing procedure. Insertion of a urethral
catheter must be noted in the Nursing Notes
SF 510, Twenty-Four Hour Intake and Output
Worksheet DD 792, and Patient Profile
NAVMED 6550/12.

The Nursing Notes SF 510 entry, Figure
3.14.05, should include:

1. Type and size of catheter.

2. Reason for catheterization.

3. Amount of urine obtained.

4. Description of urine, including color, any
unusual odor, and any abnormalities such
as sediment or blood clots.

5. Patient's toleration of the procedure.

6. Specimen sent to the lab, if applicable.

On the Twenty-Four Hour Intake and
Output Worksheet DD 792, Figure 3.14.06,
indicate the time the catheter was inserted in
the remarks section on the output page.
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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
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Record time and amount of urine obtained
under urine section of the output page, Figure
3.14.07. On the back of the Patient Profile
NAVMED 6550/12, record specimen
collection and date sent to lab (if specimen
obtained). If an indwelling catheter was
inserted, indicate the date, time, catheter type,
and size on the front of the Patient Profile,
Figure 3.14.08.

To record a specimen collection from an
indwelling catheter, indicate on the Nursing
Notes SF 510, the type of specimen collected
and its disposition (sent to lab). Include a
description of the urine collected, e.g., cloudy,
contained sediment. On the Twenty-four Hour
Intake and Output Worksheet DD 792, record
the volume of urine removed and sent for
testing. On the back of the Patient Profile
NAVMED 6500/12 record the date the
specimen was collected.

When a specimen is obtained using a
straight catheter, include on the Nursing Notes
SF 510:

1. Catheter type and size used.

2. Amount of urine obtained -- specimen
volume and amount in collection tray.

3. Description of urine.

4. Patient's tolerance of the procedure.

5. Type of specimen obtained and
disposition.

Record the amount of urine output on the
Twenty-Four Intake and Output Worksheet
DD 792. On the back of the Patient Profile
NAVMED 6550/12, record date specimen was
collected.

GUIDELINES FOR REMOVAL
OF AN INDWELLING CATHETER

A doctors order must be obtained before
removal of an indwelling catheter. After
confirming the doctors order, gather the
following equipment:

1. 10cc syringe
2. Clean gloves
3. Chux pad
4. Urinal
5. Washcloth
6. Soap and water

Explain the procedure to the patient. Wash
your hands and don clean gloves. Provide for
the patients privacy and safety. After
removing the tape from the patients leg,
attach the syringe to the catheter port and
aspirate to deflate the catheter balloon.
Withdraw all the sterile water to deflate the
balloon. Detach the syringe, empty it, and
reattach to withdraw more water if needed.
Gently pull the catheter out of the meatus,
hold the catheter in chux pad to prevent
spillage, and inspect the catheter for any
damage. Discard the catheter in the
contaminated trash and measure the amount of
urine in the bag.

NURSING CARE FOR A PATIENT
AFTER REMOVAL OF AN
INDWELLING CATHETER

After removal of an indwelling catheter, clean
the urinary meatus with water and mild soap.
Ensure the patient has a urinal/bed pan
available since many patients need to void
immediately after removal of the catheter.
Continue to monitor Intake & Output per local
protocol or doctors order.

RECORDING REMOVAL OF AN
INDWELLING CATHETER

On the Twenty-Four Hour Intake and
Output Worksheet DD 792, indicate the time
the catheter was removed and the amount of
urine in the collection bag. Continue to
monitor urine output of each voiding for 24
hours until a normal voiding pattern is
established.
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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
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FIGURE 3.14.01
Non-Retention Catheter









FIGURE 3.14.02
Indwelling Catheters
a. Double Lumen
b. Triple Lumen
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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
Handbook III
FIGURE 3.14.03
Catheter Insertion for Males

FIGURE 3.14.04
Catheter Insertion for Females
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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
Handbook III














FIGURE 3.14.05
Recording Catheterization on Nursing Notes






















FIGURE 3.14.06
Urinary Catheter Recorder on DD 792 (Lower)
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Lesson 3.14 Urinary Catheterization Basic Hospital Corps School
Handbook III













FIGURE 3.14.07
Urine Output Recorded on DD 792 (Upper)






FIGURE 3.14.08
Catheter Card Order on Patient Profile
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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization
Handbook III
NOTES/COMMENTS
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Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.14

Urinary Catheterization Worksheet

1. Define urinary catheterization.

_______________________________________________________________________

_______________________________________________________________________

2. A straight catheter is used to monitor urine output.

a. True b. False

3. To provide for continuous drainage of urine, insert a ____________________
catheter.

4. Which is not a purpose of indwelling catheterization?

a. To measure residual urine

b. To control incontinence

c. To monitor urine output

d. Preoperative preparation

5. To decrease the likelihood of the bladder being injured during abdominal or pelvic surgery, an
indwelling catheter may be ordered by the doctor to be inserted prior to surgery.

a. True b. False

6. An indwelling catheter is:

a. also called a retention catheter.

b. left in place after insertion to provide for continuous urine drainage.

c. a double or triple lumen tube with an inflatable balloon near the tip.

d. all of the above.

7. A fenestrated drape is one with an opening in it.

a. True b. False




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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet
Handbook III
8. What measuring unit is used to indicate the size of urinary catheter?

a. Gauge

b. French

c. Millimeters

d. International units

9. A catheterization kit would include:

a. sterile gloves, sterile drapes, Betadine swabs, water-soluble lubricant.

b. sterile gloves, Betadine swabs, protective pad, specimen container.

c. sterile drapes, water soluble lubricant, 10 cc syringe, tape.

10. List three items that are needed when inserting an indwelling catheter but not a straight catheter.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

11. The correct position for a female patient who is being catheterized is:

a. prone with legs apart.

b. supine with legs apart.

c. dorsal recumbent with knees flexed, thighs apart.

d. Semi-Fowlers.

12. When placing the fenestrated drape on a female patient, place it over the perineum so that the
labia are exposed.

a. True b. False

13. When cleansing the urinary meatus of a female, use at least four Betadine swabs, always stroking
from back to front.

a. True b. False

14. Before inserting a urinary catheter into a male, gently lift the penis to a 90 degree angle to
the thighs in order to minimize the urethral curve.

a. True b. False

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Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School
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15. When inserting a straight catheter, insert the catheter until urine flows, then pull back one inch.

a. True b. False

16. Urinary tract infection is a common complication of an indwelling catheter.

a. True b. False

17. A catheterized patient should be instructed to limit fluid intake.

a. True b. False

18. List equipment needed to remove a urine specimen from an indwelling catheter.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

d. ______________________________________________________

e. ______________________________________________________

19. When obtaining a specimen from an indwelling catheter without a specimen port, insert the
needle directly into the:

a. drainage bag.

b. specimen port at a 90
o
angle.

c. catheter at a 15
o
angle.

d. plastic drainage tubing.

20. List three locations where insertion of an indwelling catheter should be recorded.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

21. After obtaining a urine specimen from either a straight catheter or an indwelling catheter, the
time and amount of the urine output must be recorded on the I&O Worksheet.

a. True b. False




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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet
Handbook III
22. List four items that should be included in the description of catheter insertion in the Nursing
Notes.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

d. ______________________________________________________

23. List three locations where a urine specimen obtained from a catheter must be documented.

a. ______________________________________________________

b. ______________________________________________________

c. ______________________________________________________

24. Circle each element that is included when documenting a urine specimen obtained from an
indwelling catheter on the Nursing Notes.

a. Date, time, and type of specimen collected

b. Size of needle and syringe used

c. Angle at which the needle was inserted

d. Signature and rate
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Lesson 3.14 Urinary Catheterization Worksheet Basic Hospital Corps School
Handbook III
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Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet
Handbook III
Basic Hospital Corps School Lesson 3.14 Urinary Catheterization Worksheet
Handbook III
177

177
Lesson 3.13 Specimens Basic Hospital Corps School
Handbook III
Lesson 3.13

Specimens

Terminal Objective:

3.13 List concepts and principles for collecting and testing specimens.

Enabling Objectives:

3.13.01 List the procedures for obtaining and recording random, clean-catch and 24-hour urine
specimens.

3.13.02 Distinguish between the normal and abnormal appearance of urine specimens.

3.13.03 List the procedures for obtaining, testing, and recording urine tests for specific gravity,
sugar, ketones and protein, including their normal values.

3.13.04 List the procedures for obtaining and recording capillary blood collection and glucose
testing.

3.13.05 List the procedures for obtaining and recording a stool specimen and testing specimen for
blood.

3.13.06 Distinguish between normal and abnormal stool specimens.

3.13.07 List the procedures for obtaining and recording a throat culture.

3.13.08 List the procedures for obtaining and recording a sputum specimen.

3.13.09 List the procedures for labeling specimens and completing basic laboratory chits.


Hospital Corpsmen routinely perform
patient care before, during, and after specimen
collection and testing. The corpsman may
teach a patient a procedure and assist with
collecting, labeling, and testing the specimen.
Thorough patient education is critical to obtain
a good specimen. Carefully explain the
procedure in terms the patient can understand,
then ask questions to assess comprehension.
Provide for privacy, safety, and comfort by
closing doors, pulling the curtains around the
patient's area, and ensuring the side rails are
up. Raise the head of the bed, when
applicable. Three patient identification (ID)
checks must be performed before obtaining
laboratory specimens. ID checks are done by
using the lab chit and comparing it with the:

1. Bed tag

2. Patient's name bracelet

3. Patient's stated name.

Diligent hand washing must be performed
before and after collecting specimens to
prevent the transmission of microorganisms.



178
Basic Hospital Corps School Lesson 3.13 Specimens
Handbook III
URINE SPECIMENS

Methods of urine collection include routine,
clean-catch, and 24-hour specimens.
Equipment and methodology vary for each
type of specimen.

Routine Urine Specimen

The routine and microscopic test (R&M)
is a frequent urine test that only takes a few
minutes to perform. Equipment needed to
collect a routine urine specimen includes:

1. Clean specimen container with lid & label

2. Urine collection device, if needed (urinal,
bedpan, urine hat)

3. Urinalysis chit SF 550, Figure 3.13.01

4. Clean gloves

As with any procedure involving a patient,
be sure to provide for patient privacy. Explain
the procedure to the patient. Provide a urinal
or position the patient on the bedpan.
Ambulatory patients may go to the head and
void directly into a clean specimen container.
Don clean gloves and transfer urine from
bedpan/urinal or other collection device into a
clean specimen container. Obtain a minimum
of 15 cc of urine in the specimen container.
Label the container and take the specimen to
the laboratory within the hour. Urine at room
temperature allows bacteria to grow, which
may alter the test results if allowed to
accumulate.

Lab personnel will perform two categories
of tests. The routine tests, usually done with
an indicator strip, include: pH, occult blood,
ketones, protein, and glucose. Specific gravity
and color of the urine are also noted. a
microscopic examination of urine includes
examining and identifying elements such as
white blood cells, red blood cells, skin or
epithelial cells, bacteria, and mucus.


Recording the Procedure

Urine collection is recorded on the
following forms:

1. Nursing Notes SF 510 entry for any urine
specimen is to contain:

a. Description of the urine specimen
(including color, odor, clarity,
amount)

b. Type of test requested (UA)

c. disposition of the specimen (usually
sent to the lab).

2. Patient Profile NAVMED 6550/12 - The
appropriate section should be marked with the
date the specimen was sent.

3. Twenty-Four Hour Intake & Output
Worksheet DD 792 (if applicable) - enter the
amount of patient output.

Clean Catch Specimen

A laboratory test order for culture and
sensitivity (C&S) with microbiology testing is
collected aseptically in a sterile specimen
container using the clean-catch or mid-stream
collection method. the clean-catch specimen
is collected to identify urinary tract infections.
In the laboratory, the urine is put on a petri
disk of media where, if present, bacteria will
grow. The bacteria are then examined and
tested to determine if they are a pathogenic.
Pathogenic bacteria are tested for sensitivity to
antibiotics. It takes 24-48 hours to complete
culture and sensitivity testing. Normal urine
does not contain bacteria.

Equipment needed to collect a clean catch
specimen include:

1. Sterile specimen container and label

2. Disposable antiseptic cleaning towelettes
or swabs

3. Clean gloves
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Lesson 3.13 Specimen Basic Hospital Corps School
Handbook III
4. Urine collection device, if needed

5. Microbiology I chit SF 553, Figure
3.13.02

Begin by explaining the procedure to the
patient. If the patient is able, he or she may
collect the specimen. Provide detailed
instructions on how to cleanse the genitalia
using the antiseptic towelettes or swabs. If the
patient must be assisted, cleanse the genitalia
as follows:

a. Females, separate labia to expose the
meatus. Using only one front-to-back
stroke per towelette, wipe each side of
the labia. Finish, using the third
towelette, down the middle, covering
the meatus, to remove secretions from
mucous folds of the vulva and
perineum.

b. Males, retract foreskin, if
uncircumcised, prior to cleaning
glans. Use a circular motion from the
meatus down to the junction of the
glans and the shaft. Use three
antiseptic towelettes or swabs to
ensure complete cleansing.

While keeping the labia separated or
foreskin retracted, the patient starts to void
(into bedpan, urinal, or commode), stops,
positions sterile container, and then starts to
void again into the sterile specimen container.
Care must be taken not to touch the inside of
the sterile cup or lid.

This procedure allows the first portion of
the urine to wash out the urethra. Only the
middle or clean part of the urine is caught and
saved for testing. The specimen is labeled and
sent to the lab within the hour. In most cases,
the patient will collect the specimen on his/her
own, so it is crucial that the procedure be
explained thoroughly.




Recording the Procedure

Urine collection is recorded on the
following forms:

1. Nursing Notes SF 510 entry for any urine
specimen is to contain:

a. Description of the urine specimen
(clouding color, odor, clarity, amount)

b. Type of test requested (C&S)

c. Disposition of the specimen (usually
sent to the lab).

2. Patient Profile NAVMED 6550/12 - The
appropriate section should be marked with the
date the specimen was sent.

3. Twenty-Four Hour Intake & Output
Worksheet DD 792 (if applicable) - enter the
amount of patient output.

24-Hour Urine Specimen

A 24-hour urine specimen involves
collecting ALL the urine produced by a patient
during a 24-hour period. Accidentally
discarding any urine will negate the test. With
this specimen, laboratory personnel may
perform a variety of tests. Guidance from
laboratory personnel should be sought
concerning the specimen container, type of
preservative, handling and type of request chit

The equipment needed for 24-hour
specimen collection includes:

a. 24-hour specimen container with lid

b. Lab request chit specific for the
ordered test

c. Urine collection device

The procedure begins by explaining to the
patient that all urine is saved and placed in a
large specimen container. Have the patient
void, then discard this urine. The twenty-four
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Basic Hospital Corps School Lesson 3.13 Specimens
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hour clock is started immediately after this
voiding. Instruct the patient to void in the
urine collection device for the next 24 hours.
Transfer urine to collection container after
each voiding. The container may be kept
refrigerated or on ice during the 24 hour
period. At the end of the 24-hour period, have
the patient void one last time and pour this
urine into the collection container. Send the
urine to the laboratory with the lab request
form.

Recording the Procedure

Urine collection is recorded on the
following forms:

1. Nursing Notes SF 510 entry for any urine
specimen is to contain:

a. Description of the urine specimen
(including color, odor, clarity,
amount)

b. Disposition of the specimen (usually
sent to the lab).

2. Patient Profile NAVMED 6550/12 - The
appropriate section should be marked with
the date the specimen was sent.

3. Twenty-Four Hour Intake & Output
Worksheet DD 792 (if applicable) - enter
the amount of patient output

URINE EVALUATION

In caring for patients, corpsmen will make
a general evaluation of urine specimens.
Normal urine is clear, pale yellow to dark
amber, and has a faint odor. Normal output is
1,000-1,500 cc daily with an average output of
1,200 cc every 24 hours. Abnormal urine
may indicate an abnormal medical condition.
Urine with a red reddish-brown, or smokey
appearance indicates hematuria, brown urine
may indicate liver disease, orange or blue
urine usually result from medications. Other
anomalies in urine include: foamy appearance,
mucous, pus, and cloudiness. Inform the nurse
if the urine specimen is abnormal and record
on Nursing Notes SF 510.

URINE TESTING

Not all urine testing is performed in the
laboratory. Depending on local policy, ward
personnel may test urine for specific gravity,
sugar, ketones, and protein.

Procedures for using Indicator Strips

Indicator strips are plastic strips treated with
chemicals that indicate the presence of various
substances. (Sometimes they are called test
strips.)

Equipment Needed:

1. Specimen container

2. Indicator strips with chart (on bottle)

3. Clean gloves

4. Watch with second hand or stopwatch

Check the expiration date on the bottle of
indicator strips and follow manufacturer's
directions to use. Have the patient void in a
clean container. Don clean gloves and remove
one indicator strip from the bottle, being
careful not to touch the chemically treated
areas. Replace the bottle lid. Dip the
indicator area of the strip completely, but
briefly, in urine. the container label depicts a
color chart for each test area on the strip.
Carefully match the indicator test area to the
color chart of the container, noting the time
factor for each test. Values for each test are
written by the color chart blocks.

Record the results on the Nursing Notes
SF 510, including the test results and any
nursing action taken. The information may
also be recorded on the Diabetic Flow Sheet
(for glucose/sugar and acetone/ketones). If the
patient is on I&O, also record the urine
volume on the Twenty-Four Hour Intake and
Output Worksheet DD 792.

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Lesson 3.13 Specimen Basic Hospital Corps School
Handbook III
Specific gravity is the weight of urine as
compared to the weight of water. It measures
the diluting and concentrating ability of the
kidneys.

The normal range for specific gravity is
1.005 to 1.025.

Glucose/sugar, acetone/ketones and
protein testing

Normal urine contains no glucose/sugar.
This would be recorded as negative or no
sugar. Any other value is abnormal and must
be reported. The abnormal values would be
located on the color chart on the container
label. Abnormal values would be recorded as
1/4%, 1/2%, 1%, or 2%.

Normal urine has no acetone/ketones.
Presence of acetone/ketones in the urine
indicates the need for further evaluation.
Abnormal urine acetone/ketone values,
determined by using the scale on the container
label, are recorded using a scale that ranges
from small to large. A diabetic patient with
acetone/ketone bodies in the urine suggests
that the blood sugar is not adequately
controlled and adjustments of either the
medication or the diet need to be made. In a
non-diabetic patient, the presence of
acetone/ketone bodies indicates a minimal
amount of carbohydrate metabolism and
excessive fat metabolism that are symptoms of
starvation such as anorexia or dieting.

Normal urine contains no protein.
The presence of any protein is abnormal.
Abnormal values are measured from trace to
greater than 4+.

CAPILLARY BLOOD
COLLECTION FOR GLUCOSE
TESTING

Many wards and clinics test patient
glucose level by taking a drop of capillary
blood and placing it on an indicator strip.
While this method of glucose testing is more
accurate than using the urine dipstick method,
it is also more expensive. Its main advantage
is that it reveals the patient's actual blood
glucose level, rather than approximating it by
measuring the level of metabolized sugar in
the urine.

Collection and Evaluation blood for
glucose level

After verifying the Doctor's Orders, gather
the necessary equipment:

1. Alcohol preps

2. Sterile blood lancet

3. Indicator strip - check expiration date.

4. Watch with second hand or stopwatch

5. 2x2 gauze pads

6. Clean gloves

The procedure for obtaining and
evaluating blood glucose is:

1. Select site, ideally near the edge of a
fingertip.

2. Wipe the fingertip with the alcohol prep
and allow to air dry.

3. Don clean gloves and open the blood
lancet aseptically.

4. Grasp the patient's finger firmly with one
hand and quickly pierce skin with a
stabbing motion.

5. Squeeze (milk) the area to produce a large
drop of blood.

6. Cover the entire indicator strip pad with
the drop of blood.

7. Have patient hold 2x2 over puncture site.

8. Time for exactly the interval specified by
the indicator strip manufacturer.
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Basic Hospital Corps School Lesson 3.13 Specimens
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9. Blot blood off indicator strip using a 2x2.

10. Read test results after waiting the time
specified in the manufacturer directions by
comparing the color on the indicator strip
to the color chart on the bottle.

11. Dispose of all contaminated supplies
following local policy. Dispose of the
lancet in a puncture resistant container.

Recording the Specimen Collection
and Results

The capillary blood glucose test result is
recorded on the Diabetic Flow Sheet and in
the Nursing Notes SF 510, including results of
the test and nursing actions taken.

STOOL SPECIMENS

Collection

Stool specimens are commonly collected
to analyze for abnormal components and
parasites. The following equipment and
supplies are needed:

1. Bedpan/portable commode

2. Toilet paper

3. Lab request chit, for example Parasitology
SF 552, Figure 3.13.03

4. Tongue blades

5. Clean stool specimen container with label
(sterile specimen container is indicated
only if a C&S is required)

6. Clean gloves

Before collecting a specimen, explain the
procedure to the patient, emphasizing that the
stool must not be contaminated with urine or
toilet paper. Provide patient comfort and assist
onto and off the bedpan or commode. Don
clean gloves. Remove at least 1-2 teaspoons of
stool from the bedpan or commode with
tongue blade and place it in specimen cup. If
patient passes blood, mucus, or pus with stool,
includes it with the specimen.

Cover, label the container, and transport
the specimen to the lab immediately. The test
for parasites must be done on a warm
specimen. Ensure that the patient has an
opportunity to cleanse himself/herself,
assisting as needed. Indicate the color,
character, and amount of stool, the test
requested, and disposition of specimen (to lab)
in the Nursing Notes SF 510. Any
abnormalities should also be recorded in the
Nursing Notes and reported to the nurse. On
the Patient Profile NAVMED 6500/12, write
the date the specimen was sent to the lab. Note
the color, character, and amount of stool on
the Twenty-Four Hour Intake & Output
Worksheet DD 792, if indicated.

Stool evaluation

A stool specimen is examined on the ward
for color, consistency, and amount. Normal
stool is a brown, formed, semisolid mass.
Many patients have one bowel movement a
day, although this varies from person to
person. Instead of measuring the exact amount
of stool, the amount is usually described as
small, moderate, or large. The odor of the
stool varies with the pH of food consumed.

Common stool abnormalities include a
black or tarry color, which indicates upper GI
bleeding; bright blood which indicates lower
GI bleeding; clay-colored which indicates
absence of bile (sign of gall bladder or liver
disease); and very watery stool which
indicates irritation or infection of bowels
resulting in fluid loss.

The following equipment is needed to
perform a stool specimen examination for
blood:

1. Hemoccult slide (guaiac paper)

2. Hemoccult developing solution

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Lesson 3.13 Specimen Basic Hospital Corps School
Handbook III

3. Wooden applicator or tongue blade

4. Clean gloves

Collecting the specimen

Prior to beginning, check the expiration
date of the developing solution. After donning
clean gloves, collect a small amount of stool
using the wooden applicator or a gloved
finger. Place the smear of stool to the
hemoccult slide (guaiac paper). Close the
cover over the stool and turn the slide over.
Open the flap on the opposite side and place
two drops of developing solution on each
section of the slide and one drop on the center
of the control strip. Read the results 30 to 60
seconds after applying the solution. A positive
test is indicated by the development of a
bluish ring around the stool specimen on the
hemoccult slide. A positive test indicates the
presence of blood in the stool. A negative test
has no color change that means no blood in the
stool. The control strip is used to verify a valid
test.

Record the results in Nursing Notes SF
510 including the type of test performed and
the results. If the specimen is sent to the lab
for guaiac testing, indicate the date the
specimen is sent on the Patient Profile
NAVMED 6550/12.

THROAT CULTURES

The ring of lymphoid tissue that encircles
the nasopharynx and oropharynx frequently is
the site of acute infection. Such an infection is
most often caused by the organisms that cause
the common cold, but may also result from a
variety of pathogenic agents including viruses,
hemolytic streptococci, and staphylococci.
Because streptococcal infections can cause
serious complications (such as rheumatic
fever) if left untreated, throat cultures are
routinely performed on patients with sore
throats to determine the presence of the
streptococci bacteria. Equipment needed to
perform a throat culture includes:

1. Laboratory request chit, for example
Microbiology I, Figure 3.13.06

2. Sterile culturette

3. Specimen label

4. Tongue blade

5. Clean gloves

Collecting the specimen

Gather equipment, wash hands, and
proceed to the patient's room. Explain the
procedure to the patient. Have the patient sit
up with head tilted back. Remove the
culturette cap aseptically. Have the patient
open his/her mouth open to expose the
pharynx, then depress the tongue with a
tongue blade. Swab both tonsillar areas and
posterior pharynx gently with applicator,
being careful not to touch the swab to external
surfaces or other internal structures. Return the
applicator to the holder and snap the liquid
capsule at the bottom of the culturette. Label
the specimen and send to the laboratory with
the lab chit. Wash hands and discard
disposable equipment. Record the procedure
by marking the date sent on the back of the
Patient Profile NAVMED 6550/12 and
making a Nursing Notes SF 510 entry.
Indicate the type of specimen, abnormal
findings, patient tolerance for procedure, and
disposition of the specimen.

SPUTUM CULTURES

Mucus secretions from the lungs, bronchi,
and trachea that are expelled from the mouth
by coughing are called sputum. It can be
differentiated from saliva by its greater
viscosity and thickness. A sputum specimen
may be ordered to examine for bacteria or
abnormal cell structure.

The usual method of sputum collection is
expectoration (coughing up sputum), that may
require postural drainage or chest percussion
to obtain a good specimen.
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Basic Hospital Corps School Lesson 3.13 Specimens
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Collecting the specimen

Gather equipment, including:


2. Social security number

3. Rate/rank or dependency status

1. Glass of water
4. Branch of service including active duty
status or retired.
2. Sterile specimen cup with label

COMPLETING BASIC
LABORATORY REQUEST
FORMS
3. Facial tissue

4. Emesis basin


5. Clean gloves
The laboratory request chit must be filled
out properly to ensure appropriate tests are
performed. The laboratory chit requires the:

Wash hands. Explain procedure to patient
to ease anxiety and promote cooperation. The
patient should sit in a chair or be place in high
Fowlers position if bedridden. Have patient
rinse mouth with water to moisten mucous
membranes and to reduce specimen
contamination by oral bacteria and food
particles. Don clean gloves. Instruct the
patient to take several deep breaths and cough
deeply, expectorating directly into specimen
cup. Collect at least 15 ml in the sterile
container. Clean/dispose of equipment,
remove gloves, and wash hands. Label the
container and send to lab with completed
sputum examination request form within 30
minutes of collection. Record by entering date
sent to the lab on the Patient Profile. Make a
Nursing Notes entry with time and type of
procedure, patients tolerance, and disposition
of specimen.

1. Patient's name

2. Social security number

3. Rate/rank or dependency status

4. Branch of service including active duty
status or retired

5. Urgency. Indicate routine unless Doctor's
Order states otherwise

6. Specimen source (sputum, urine, blood)

7. Date and time the specimen was taken

8. Requesting physician's name and initials
of person completing the request

LABELING SPECIMENS
9. Any pertinent comments concerning
patients diagnosis, isolation requirements,
and antibiotic therapy.

A specimen label may be prepared with
the addressograph, if available, but the label
must include the following information:

10. Test to be completed.
1. Patient's name
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Lesson 3.13 Specimen Basic Hospital Corps School
Handbook III
186
FIGURE 3.13.01
Urinalysis Chit SF 550 for Routine and Microscopic
FIGURE 3.13.02
Microbiology I Chit SF 553 for Culture and Sensitivity
Basic Hospital Corps School Lesson 3.13 Specimens
Handbook III

FIGURE 3.13.03
Parasitology Chit SF 552 for Occult Blood




















FIGURE 3.13.04
Parasitology Chit SF 552 for Ova and Parasites
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Lesson 3.13 Specimens Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.13

Specimens Worksheet

1. A _______________________ specimen is collected for Culture and Sensitivity testing.

a. 24-hour

b. clean-catch

c. routine urine

2. Which of the following is not part of the procedure for obtaining a clean catch urine specimen?

a. Cleanse the genitalia with a mild antiseptic solution

b. Provide for patient safety, privacy, and comfort

c. Collect specimen in sterile container

d. Ensure that only the first portion of the urine stream is collected

3. To obtain a 24-hour urine specimen, instruct the patient to:

a. void every hour for 24 hours.

b. collect the total amount of urine excreted in 24 hours.

c. collect only the urine voided every night at midnight.

d. not void for 24 hours, then collect a specimen.

4. What is the normal appearance of urine?

a. Cloudy, with red streaks

b. Clear, pale yellow

c. Light green

d. Dark brown

5. Glucose is normally present in urine.

a. True b. False



6. Urine that is brownish colored may indicate ______________ disease?
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Basic Hospital Corps School Lesson 3.13 Specimens Worksheet
Handbook III

a. heart

b. kidney

c. liver

d. colon

7. What is the normal range for the specific gravity of urine?

a. 1.000 - 1.005

b. 1.005 - 1.025

c. 1.030 - 1.035

d. 1.100 - 1.200

8. What condition may cause ketones in the urine?

a. Anorexia

b. Cancer

c. Angina

d. Heart disease

9. Healthy patients may have a trace amount of protein in their urine.

a. True b. False

10. List two items to include in Nursing Notes for urine testing.

a. _________________________________________________________________

b. _________________________________________________________________

11. When using indicator strips to evaluate urine:

a. check the expiration date prior to using.

b. hold the indicator strip at the test area.

c. hold the indicator strip in urine for at least 5 minutes.

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Lesson 3.13 Specimens Worksheet Basic Hospital Corps School
Handbook III
12. When performing blood glucose testing, after placing the drop of blood on the indicator strip,
read the results:

a. immediately.

b. after 15 seconds.

c. after 60 seconds.

d. after the amount of time specified by the manufacturer.

13. A hemoccult test is performed to identify ____________________ in the stool.

a. glucose

b. blood

c. ketones

d. parasites

14. A positive hemoccult test is indicated by a red ring surrounding the specimen on the test paper.

a. True b. False

15. Normally, stool is a __________________ mass.

a. brown, semi-solid

b. dark black, solid

c. brown, watery

16. A sputum specimen should be sent to the lab within __________________ of collection.

a. 15 minutes

b. 30 minutes

c. 1 hour

d. 2 hours

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Basic Hospital Corps School Lesson 3.13 Specimens Worksheet
Handbook III
17. List the information that is included on a sputum specimen label.

a. _________________________________________________________________

b. _________________________________________________________________

c. _________________________________________________________________

d. _________________________________________________________________

18. When completing a laboratory request form, include your initials, along with the doctor's name,
on the laboratory chit.

a. True b. False

191
Lesson 3.12 Wound Management Basic Hospital Corps School
Handbook III
Lesson 3.12

Wound Management

Terminal Objective:

3.12 List concepts and principles of wound closure and management.

Enabling Objectives:

3.12.01 List the three phases of wound healing.

3.12.02 Define the three classifications of wound healing.

3.12.03 List the general rules for managing sutured wounds.


HISTORY

As early as 400 BC, Hippocrates
mentioned the use of ligatures (sutures) to
control bleeding. From then until about 1885,
the suturing of wounds was rarely done since
there were so many hazards. Although
surgeons recognized the need to join together
severed wound tissues, without knowledge of
aseptic procedures, their efforts caused death
from gangrene, tetanus, anthrax, and other
infection processes. After the development of
aseptic technique, there appeared a great
change in the desirability to close wounds with
sutures.

PHASES OF WOUND HEALING

The sequence of healing is essentially
undisturbed and occurs in roughly three
phases. The first or inflammatory phase
begins immediately after injury. The body's
response to the irritation at the injury site is to
dilate local blood vessels which causes the
injured area to become red and warm. The
injured blood vessel walls leak serum into the
surrounding tissues resulting in edema. Pain
also follows due to the pressure on the nerve
endings by the edema in the tissues. White
blood cells enter the injured area and act as
scavengers to destroy bacteria in the wound.
These white blood cells also consume dead
and dying tissue particles caused by the injury.

Serum protein dries and seals the wound
to prevent further fluid loss and bacterial
invasion. The second or proliferative phase
occurs as fibrin and collagen cells glue the
wound edges together and a scab is formed.
New capillaries are formed to supply oxygen
to the replacement epithethial cells as they
regenerate and multiply to fill the injured area.

During the third or maturation phase, the
epithelical cells rebuild to normal thickness
and the scab sloughs off the wound. Collagen
fibers become more organized and the blood
vessels in the area return to normal.

CLASSIFICATION OF HEALING

There are three classifications of healing:
first intention, second intention, and third
intention. First intention healing occurs
when tissue is cleanly incised or lacerated and
reapproximated shortly after injury, and repair
occurs without complications. When a wound
is closed shortly after injury and allowed to
heal by first intention, this is known as a
primary closure. Second intention healing is
the healing of an open wound through
formation of granulation tissue. with eventual
192
Basic Hospital Corps School Lesson 3.12 Wound Management
Handbook III
coverage of the defect by migration of
epithelial cells. Most infected wounds and
burns heal by second intention. Third
intention healing occurs when a wound with
widely separated edges accomplishes the first
phases of healing while the wound is left open.
A delayed primary closure is then performed
to finish the healing process by first intention.
In grossly contaminated wounds, infection can
often be avoided by leaving the wound open
for 3 to 5 days and then closing it, which is an
example of third intention healing. Skin grafts
are also an example of third intention healing.

MANAGEMENT OF SUTURED
WOUNDS

After a wound is sutured, it is important to
monitor it for signs of infection. The wound
should be checked and the dressing changed
every 24 hours for the first four days.

Patients should be instructed to keep the
sutured area clean and dry. Any suture with
evidence of purulent drainage, hematoma, or
infection should be reported to the physician's
assistant or physician. These sutures will be
removed (generally by the physician) since the
presence of the suture may make the infection
worse. The removal of the suture will promote
drainage and prevent further trauma. The
physician may apply gentle pressure to the
skin proximal to the wound to excise the
drainage and therefore promote healing. If the
wound is infected, application of heat is
sometimes ordered to increase blood flow to
the area and speed the healing process.

Areas of the body heal at a different rate
and some are more prone to scarring. Because
of these differences, sutures are removed at
different time.

a. Face: As a general rule, 4 or 5 days.
Better cosmetic results are obtained by
removing every other stitch and any stitch
with redness around it on the 3rd day, and
the remaining on the 5th day.

b. Body and scalp: 7 days.

c. Soles, palms, back, or over joints: 10
days unless excess tissue reaction is
apparent around the suture, in which
case, they should come out sooner.



193
Lesson 3.12 Wound Management Basic Hospital Corps School
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FIGURE 3.12.01
Suturing Needles





















FIGURE 3.12.02
Placing a Suture
194
Basic Hospital Corps School Lesson 3.12 Wound Management
Handbook III


FIGURE 3.12.03
Suture Techniques






















FIGURE 3.12.04
Suture Removal
195
Lesson 3.12 Wound Management Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.12

Wound Management Worksheet

1. Match each definition in column B with the correct healing phase in column A.

A B


1. Inflammatory phase __________


2. Proliferation phase __________


3. Maturation phase __________

a. Scab sloughs off

b. Epithelial tissue regenerates, new capillaries
formed

c. Immediately after injury, redness and warmth
occurs.

2. White blood cells scavenge dead tissue during the proliferation phase.

a. True b. False

3. Edema in surrounding tissue develops and pain occurs during the proliferation phase.

a. True b. False

4. _____________________________ intention healing occurs when a wound is left to accomplish
the first phase of healing while the wound is left open.

5. Healing which occurs when tissue is cleanly incised or lacerated and reapproximated shortly after
injury is called _________________________ intention healing.

6. Sutures in the face should be removed after ________ to ________ days.

7. Any suture with pus or signs of infection around it should be ________________________.

8. Once sutures are removed a ____________ dressing should be applied to the area.

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Basic Hospital Corps School Lesson 3.12 Wound Management
Handbook III Worksheet
NOTES/COMMENTS
197
Lesson 1.23 DOD Immunization Program Basic Hospital Corps School
Handbook III
Lesson 1.23


DOD Immunization Program

Terminal Objective:

1.23 List the principles of the DOD Immunization Program

Enabling Objectives:

1.23.01 Define terms related to the control of communicable diseases by prophylaxis.

1.23.02 List the communicable diseases in the DOD Immunization Program.

1.23.03 List the basic guidelines for administering DOD immunizations.

1.23.04 Summarize the recording procedures in the DOD Immunization Program.


Hospital Corpsmen perform an important role
in the DOD Immunization Program, so it is
necessary to understand the terminology used in
the discussion of immunizations.

COMMON TERMS

Prophylaxis -- A means of preventing the
occurrence of a disease, either by mechanical or
chemical (medication) recourse.

Immunization The process by which
resistance to infectious disease is induced or
augmented.

Vaccine -- A preparation that consists of a
treated live virus (attenuated), a killed and
prepared virus, or a preparation of antibodies that
are used as a prophylactic immunization.

Dosage Measured quantity of therapeutic
agent to be administered.

Immune - - Resistant to disease.

The Department of Defense has a number of
instructions and notices that govern the
immunization program. These are updated as
Service needs change. The primary instructions for
the Navy are in the BUMEDINST 6230 series.
These instructions provide guidelines, updates, and
eligibility requirements of the current program. All
personnel responsible for administering the
program should be thoroughly familiar with the
contents of these instructions.

SPECIFIC DISEASES

The following diseases are covered in the
DOD Immunization Program. Directives require
the protection of Navy and Marine Corps
personnel against these diseases.

Tetanus-Diphtheria

Polio

Influenza

Measles

Rubella

Meningitis (Quadrivalent)

Yellow Fever
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Basic Hospital Corps School Lesson 1.23 DOD Immunization Program
Handbook III

Typhoid
Cholera (As needed by travel requirements)

Plague (As needed by travel requirements)

Hepatitis B Virus

Smallpox *only under DOD directive 6205.3
(Biological Warfare Defense)

GENERAL POLICIES FOR
ADMINISTERING IMMUNIZATIONS

Always ask patients if they have any allergies,
especially to eggs, chickens, feathers, or horses.

A physician with a current certification in
Advanced Cardiac Life Support (ACLS) should be
present or nearby during the administration of
immunizations, in case a patient has an allergic or
anaphylactic reaction. Immunization clinics or
areas should be located near the treatment room. If
this is not possible, ensure that there is an ACLS
certified physician and medical treatment within
an 8-minute transport distance.

When immunizations must be administered to
active duty personnel with little warning, e.g.,
during an operational emergency, Medical
Department members other than physicians, who
have current ACLS certification, may be
designated in writing by the Senior Medical
Officer to be present during immunizations.

At sea, routine immunizations will only be
administered in the presence of an ACLS certified
physician. This restriction does not apply to
individual clinical situations in which there is a
clear medical indication for expedited vaccine or
biologic administration, e.g., post-exposure rabies
prophylaxis or the routine administration of TB
skin tests.

During all immunization procedures, an
emergency medical treatment cart, or appropriately
stocked kit will be available. This includes oxygen
administration apparatus and appropriate
medications as required for adequate ACLS.
Defibrillating and cardiac monitoring equipment
will also be immediately available.
When administering immunizations:

1. Never mix two or more agents in a vial or
syringe so as to permit a single injection.

2. It is highly desirable to allow a minimum of
thirty days between doses in order to permit
the establishment of satisfactory immunity
without interference.

3. There is no absolute contraindication to
concurrent administration of vaccines when
the 30-day interval is not practical.

4. Follow recommendations established by
manufacturer.

5. Follow guidelines established by the Navy.

RECORDING PROCEDURES

Commanding Officers are responsible for
ensuring all personnel, military and non-military,
under their jurisdiction receive required
immunizations and that appropriate records of
administration are maintained. Actual
performance of these immunizations and record
keeping is the responsibility of the Medical
Department.

Maintaining personnel in a current immune
status is a command responsibility. The Medical
Department maintains a tickler system for recall
and update of immunizations. This enables
personnel to be maintained in a combat ready
status so departure can be readily implemented in
the event of a national emergency.

All immunizations are recorded on the
Immunization Record SF 601, which is divided
into specific sections. Public Health Service Form
731 (PHS 731) is utilized for further
documentation. The PHS 731 is commonly
referred to as the Yellow Card and is normally
held by the service member.

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Lesson 1.23 DOD Immunization Program Basic Hospital Corps School
Worksheet Handbook III
Lesson 1.23


DOD Immunization Program
Worksheet

1. Match each definition in Column B with the correct term in Column A.

A B


a. Prophylaxis __________


b. Immunization __________



c. Dosage __________


d. Immune __________


e. Vaccine __________

1. Measured quantity of therapeutic agent to be
administered

2. A therapeutic preparation that is administered
to produce or increase immunity to a particular
disease

3. To make immune by administration of vaccines


4. Measures designed to prevent the spread of
disease and preserve health

5. Resistant to disease


2. List five diseases covered by the DOD immunization program.

a. ______________________________________________________________________________

b. ______________________________________________________________________________

c. ______________________________________________________________________________

d. ______________________________________________________________________________

e. ______________________________________________________________________________








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Basic Hospital Corps School Lesson 1.23 DOD Immunization Program
Handbook III Worksheet
3. List five guidelines for administering immunizations.

a. ______________________________________________________________________________

b. ______________________________________________________________________________

c. ______________________________________________________________________________

d. ______________________________________________________________________________

e. ______________________________________________________________________________

4. Why should an ACLS certified physician be present or nearby during the administration of immunization?

________________________________________________________________________________

________________________________________________________________________________

5. Who is responsible for ensuring all military and non-military personnel under his/her jurisdiction are
adequately immunized?

________________________________________________________________________________

6. All immunizations are recorded on which health record form?

a. SF 600

b. SF 506

c. SF 601

d. SF 602


201
Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School
Handbook III
Lesson 3.16

Introduction to Medication
Administration

Terminal Objective:

3.16 List concepts and principles of medication administration.

Enabling Objectives:

3.16.01 Define medical abbreviations/symbols commonly used in medication administration.

3.16.02 Define terms related to medication administration.

3.16.03 State characteristics of routes for medication administration.

3.16.04 State factors that affect route selection.

3.16.05 State the five drug rights.

3.16.06 State guidelines for safe medication administration.

3.16.07 State the procedure for reporting medication errors.

3.16.08 State safety precautions for administering medications to children, the elderly,
the confused, disoriented, or the combative patient.


MEDICAL
ABBREVIATIONS/SYMBOLS

Many abbreviations are used in
medication administration. Each hospital,
clinic, or other facility should have a list of
authorized abbreviations available. Medical
abbreviations can be written in all capital
letters or small letters. Authorized
abbreviations and symbols pertaining to
medication administration include:

1. A.C -- Before meals.

2. Amp -- Ampule.

3. B.I.D. -- Two times a day.

4. c -- With.

5. Cap -- Capsule.

6. DC -- Discontinued.

7. I.D. -- Intradermal.

8. I.M. -- Intramuscular.

9. I.V. -- Intravenous.

10. S.C. -- Subcutaneous.

11. H.S. -- Hour of sleep.

12. NS -- Normal saline.

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Basic Hospital Corps School Less 3.16 Introduction to Medication Administration
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13. NSS -- Normal saline solution.

14. p -- after.

15. P.C. -- After meals.

16. P.O. -- By mouth.

17. P.R.N. -- When necessary, or as needed.

18. Q -- Every.

19. Q.D.-- Every day.

20. Q.H. -- Every hour.

21. Q3H -- Every 3 hours.

22. Q4H -- Every 4 hours.

23. Q.I.D. -- Four times a day.

24. Q.O.D. -- Every other day.

25. Q.S. -- Sufficient quantity.

26. s -- without.

27. ss -- One half.

28. Stat. -- Immediately.

29. Tab -- Tablet.

30. T.I.D.-- Three times a day.

31. TR. or Tinc. -- Tincture.

32. Sol. -- Solution.

33. X6 -- For six doses only.

34. X6D -- For six days only.

35. M -- Minimum.

36. GTT -- Drop.

37. DR -- Dram.

38. OZ -- Ounce.

39. CC -- Cubic centimeter.

4.0 GTT -- Drop.

41. ML -- Milliliter.

42. L -- Liter.

43. GR -- Grain.

44. GM -- Gram.

45. MG or MGM -- Milligram.

46. PT. -- Pint.

47. QT. -- Quart.

48. TBSP or T -- Tablespoon.

49. tsp or t -- Teaspoon.

50. U -- Unit.

51. O.S. -- Left eye.

52. O.D. -- Right eye.

53. O.U. -- Both eyes.

54. Otic -- Pertaining to the ears.

55. Ophthalmic -- Pertaining to the eyes.

56. Topical -- Pertaining to the skin.

57. A.D. -- Right ear.

58. A.S. -- Left ear.

59. A.U. -- Both ears.

60. ETH -- Elixir or Terpin Hydrate.

61. K -- Potassium.

62. I -- Iodine.

63. Fe -- Iron.

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Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School
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64. Cl -- Chloride.

65. PR -- Per Rectum.

64. Susp -- Suspension.

66. AA or aa -- Of each.

TERMINOLOGY

The following terms are used when
ordering medication.

Ampule -- Contains sterile solution of
medication sealed in a glass or plastic
container.

Dilute -- To diminish the strength of a mixture
by adding another substance.

Diluent -- Substance capable of dissolving a
drug substance and holding it in a solution.

Elixir -- A drug dissolved in flavored or
sweetened water and/or alcohol.

Expectorant -- A drug that increases
bronchial secretions and the ability to remove
or cough up the secretions.

Floor Stock Supply -- A drug storage system
in which bulk doses of medication are
prepared for patients by ward personnel.

Reconstitution -- Restoring a dehydrated
substance to its previous liquid form by adding
water.

Solute -- A drug substance which can be
dissolved in liquid

Suppository -- A cone shaped or cylindrical
medication made from insertion into a body
cavity, (rectum or vagina), where the
suppository is dissolved and its components
absorbed. Suppositories are made of cocoa
butter or glycerin, and usually a medication.

Suspension -- A preparation of an undissolved
substance maintained in a liquid substance.

Tincture -- A diluted alcohol solution varying
in strengths from 10% to 20%.

Unit Dose Supply -- A drug storage system
that employs pharmacy control in supplying
individual doses of drugs for each patient.

Vial -- A rubber-capped glass bottle
containing one or several doses of a particular
injectable medication.

Routes

Oral (p.o.) -- Medication is ingested through
the mouth and is absorbed in the
gastrointestinal tract with a systemic effect
(medication affects the body as a whole).

Subcutaneous (s.c.) -- Sterile medication is
injected into the subcutaneous tissue with a
needle inserted at a 45-degree angle. It can
produce either a systemic or local effect
(effecting only the area in which the
medication is applied). Subcutaneous
medications produce a more rapid systemic
effect than oral medications.

Intramuscular (I.M.) -- Sterile medication is
injected into a muscle, gluteus maximums or
deltoid, with a needle inserted at a 90-degree
angle. Intramuscular medications produce a
more rapid systemic effect than either oral or
subcutaneous medications.

Intravenous (I.V.) -- Sterile medication is
injected directly into a vein; produces a very
rapid systemic effect.

Intradermal (I.D.) -- Sterile medication is
injected into the superficial layers of the skin
with a needle at a 15-degree angle. Allergy
and tuberculosis testing are administered in
this fashion.

Sublingual (s.l.) -- Medication is dissolved
under the tongue and absorbed through the
mucous membrane. Medication is not
swallowed or chewed.
Instillation -- Administration of a liquid drop
by drop into the nose, ears, or eyelids.

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Basic Hospital Corps School Less 3.16 Introduction to Medication Administration
Handbook III
Inhalation -- A vapor form of steam or
medication that is inhaled into the lungs. It
produces a local effect on the respiratory tract
with possible systemic effects. Some types of
anesthetics are inhaled which cause a loss of
consciousness necessary to perform surgical
procedure; commonly known as general
anesthesia.

Rectal (R) -- Medication that is placed in the
rectum for absorption through a mucous
membrane.

Topical -- Medication that is applied directly
on the surface of the skin producing a local or
systemic effect.

Route Selection Factors

There are several physical factors that
affect route selection including age and body
build (e.g., muscular, obese, emaciated). The
speed of absorption varies with the route. A
drug must enter the bloodstream before a
systemic effect is obtained. The chemical
nature of the drug is also important. The drug
may not be absorbed by all tissues and/or the
drug may be irritating to certain tissues.
Patient comfort, convenience, and
accessibility of the site are also concerns.

Certain drugs may be contraindicated for
patients with a specific diagnosis or medical
history. Be aware of the patient's medical and
mental condition as well. Combative,
disorientated, or unconscious patients may
aspirate an oral drug.

The Five Drug Rights

To eliminate the potential of error in
medication administration, the Hospital
Corpsman must know the Five Rights of
medication administration.

RIGHT MEDICATION

Compare the name of the medication on
the card to the label on bottle. Labels are only
to be changed by the pharmacy. If a label is
soiled or unreadable, return the bottle to the
pharmacy. To make a positive medication
identification follow this procedure: Identify
the drug with the medication card or
Medication Administration Record (MAR)
before removing the bottle from the
medication locker or unit dose cart. Check the
drug against the medication card or MAR
before preparing the mediation. Identify the
drug with the medication card before returning
the medication to the medication locker, if
applicable.

RIGHT DOSE

Make sure the dosage is computed and
prepared correctly.

RIGHT ROUTE

The Doctor's Order will specify the proper
route. The Hospital Corpsman may not
interchange routes without a Doctor's Order.

RIGHT PATIENT

When using the unit dose cart, make the
following checks. Compare the patient's name
on the MAR with the name on the medication
drawer. Check the patient's bed tag and
wristband with the MAR and ask the patient to
verbalize his/her name.

When using the floor stock, compare
patient's bed tag and wristband with the
Medication/Treatment card. Ask the patient to
verbalize his/her name.

RIGHT TIME

Medication may be given 30 minutes
before or after the stated time. If administering
a PRN medication, always check the MAR to
note the last time the medication was given to
ensure that the minimum time ordered has
elapsed.




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Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School
Handbook III
Guidelines for Safe Medication
Administration

Always ensure that there is sufficient light
when administering any medication. This
ensures the medication is correct and permits
proper identification of the patient. Note the
patient's appearance before and after
medication is administered.

During medication administration avoid
interruptions that might cause delays,
contribute to errors when attention is diverted,
or require leaving medication unattended.
Only the individual who prepares the
medication will administer and record the
medication. You should never give a
medication without a medication card or the
MAR. Pour all the medications for one patient
before pouring medication for the next patient.

Administer all medication with a positive
attitude and a sense of assurance. Know the
drug the patient is about to receive, especially
the usual dose, indication, and adverse
reactions.

Do NOT return unused medication to a
bottle or transfer medication from one bottle to
another. There is a risk of accidentally mixing
or placing medications in a wrong container.
This practice also creates the possibility of
cross-contamination.

When administering medication from a
tray or cart, never leave the medication
unattended. If medication is to be taken before
or after meals, take it to the patient on time. If
the patient is not present, do not leave the
medication at the patient's bedside. When a
sleeping medication is ordered, take it to the
patient at the time prescribed or requested.
Remember, medications must be given within
30 minutes before or after the scheduled time.
Notify the nurse if the patient is missing or a
medication delay occurs for any reason.

Withhold the medication if the patient
questions the dose, size, shape of pills or
capsules, whether or not the medication has
been canceled or changed, or why it was
received. If this should happen, verify the
Doctor's Orders and inform the patient of your
verification. If a patient is still uncertain,
notify the nurse. Never force a patient to take
a medication against his/her will. Withhold the
medication if the patient reports any previous
reaction to the drug and report this to the
nurse.

Always administer a drug in the form
prescribed by the physician. If another form
seems indicated, report your observations and
recommendations. Do not allow a patient to
take drugs that were not prescribed by the
physician and prepared by the pharmacy staff.
never allow a patient to share medication with
another patient. A parent may give medication
to a child with supervision. Chart a medication
only after the patient has consume it or it has
actually been administered. Observe the
patient for desired and undesired effects of the
medication.

Reporting Medication Errors

After immediately notifying the nurse of a
medication error, observe the patient for
adverse effects of the medication. An error
results from faulty technique in preparation,
administration, or the recording of medication.

Place an asterisk in the proper place on the
MAR and state in the Nursing Notes that a
medication error was made. Include
medication given, amount given, route, time
given, and action taken. Complete any form or
report as required by local instructions or
policies, e.g., Incident report.

Precautions

You must always practice safety
precautions when administering medication to
children, the elderly, disoriented, or combative
patients. Avoid using essential foods to dilute
medications for children. Make sure the child
swallows the medication. If you are unable to
convince a child through salesmanship, do not
use physical force. When giving a liquid
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Basic Hospital Corps School Less 3.16 Introduction to Medication Administration
Handbook III
medication to an infant, use a half-filled
spoon, medicine dropper, or a syringe without
a needle. Place the medication under the
tongue and give it slowly.

Never prepare injections or display
needles in front of children. Restraining of
children is justified for safety when giving
injections (to be sure that the child does not
move.) Obtain assistance as required. Physical
restrictions should be effective but gentle,
accompanied by soothing, friendly
conversation. The injection would be carried
out quickly. The injection site should never be
slapped.

Elderly patients may have dysphagia due
to a tight esophageal sphincter. To assist them
with this problem have the patient elevate the
head and take a sip of water to relax the
esophageal muscle. Placing tablets at the base
of the tongue will stimulate the swallowing
reflex. Never rush a patient and always be
alert to excessive difficulty in swallowing. A
patient's physical condition may require
special techniques when giving injections.

Never administer tablets or capsules to a
confused, disoriented, or combative patient. If
there is a significant change in the patient's
condition, withhold all medications and notify
the nurse. Medications for psychiatric patients
are usually supplied in a liquid form and
administered under close supervision
conditions. If an injection is ordered, ensure
adequate staff assistance is available to
restrain the patient so that the medication may
be administered safely.





207
Lesson 3.16 Introduction to Medication Administration Basic Hospital Corps School
Worksheet Handbook III

Lesson 3.16

Introduction to Medication
Administration Worksheet

1. What is the abbreviation for "of each"?

________________________________________________________________________

2. What term pertains to the ears?

________________________________________________________________________

3. Define reconstitution.

________________________________________________________________________

4. A diluted alcohol solution varying in strengths from 10% to 20% is know as:

________________________________________________________________________

5. An intramuscular injection produces a very rapid systemic effect.

a. True b. False

6. Circle medication administration routes that do not produce a local effect.

a. Subcutaneous

b. Topical

c. Intramuscular

7. Who is authorized to change the label on a medication bottle?

________________________________________________________________________

8. When giving medication, a Hospital Corpsman may interchange routes without Doctor's Orders if
the patient requests

a. True b. False







208
Basic Hospital Corps School Lesson 3.16 Introduction to Medication Administration
Handbook III Worksheet
9. A patient reports that a medication caused a reaction. You withhold the medication and:

a. tell the other Hospital Corpsman.

b. notify the Doctor.

c. notify the Nurse.

d. call the pharmacy.

10. To save time, medications are charted before administering them to the patient.

a. True b. False

11. What is the first step in reporting a medication error?

________________________________________________________________________

12. What information is documented in the Nursing Notes when a medication error is made?

________________________________________________________________________

________________________________________________________________________

13. What should be used to administered liquid medications to infants?

________________________________________________________________________


14. Elderly patients should be encouraged to take medications quickly.

a. True b. False

15. An IM medication has been ordered for a psychiatric patient. What should be done to ensure this
procedure is carried out safely?

________________________________________________________________________


209
Basic Hospital Corp School Lesson 3.15 Pharmacology and Toxicology
Handbook III
Lesson 3.15

Pharmacology and Toxicology

Terminal Objective:

3.15 State selected drug classifications based on their general actions, indications for use,
contraindications, and adverse reactions.

Enabling Objectives:

3.15.01 Define terms related to pharmacology.

3.15.02 List sources of drug information.

3.15.03 Define the major classifications of drugs.

3.15.04 State the general actions of drugs by their major classification.

3.15.05 State the indications for use of the drugs by their major classification.

3.15.06 State the contraindications and adverse reactions of drugs by major classification.

3.15.07 State special considerations for administration of medications.

3.15.08 Make drug index cards for drugs in each major drug classification.


Pharmacology is the scientific study of the
origin, nature, and effects of drugs. Some of
the terms used in connection with
pharmacology and doses are:

Adverse reaction -- an effect of a drug
which may be unfavorable to the patient's
health. An action or effect, other than that
which is desired, such as an allergic reaction.

Chemical Name -- describes the chemical
make-up of a drug.

Contraindication -- any condition for
which administration of a drug is undesirable
or the administration may produce undesirable
effects when administered with another drug.

Drug -- any chemical compound, other
than food, used in the diagnosis, treatment, or
prevention of disease.

Drug hypersensitivity -- abnormal
reaction or sensitivity to a drug.

Generic name -- describes the principle
ingredients. It is the formal name of the drug.

Indication -- disease or condition for
which a drug is prescribed.

Lethal dose -- smallest dose that will
produce death.

Maximum dose -- largest quantity that
can be given without probable harmful effects.

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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
Minimum dose -- smallest quantity which
can produce a medicinal effect

Recommended dose -- unofficial dose
extracted from current literature.

Side Effect --action other than desired.

Therapeutics -- treatment of disease.

Toxic dose -- amount which produces
poisoning.

Toxicology -- scientific study of the
nature and effects of toxic substances.

Trade/Brand name -- name created by
the manufacturer. It indicates the name is
registered and protected by law. Its use is
restricted to the company that legally owns the
name.

Usual/Therapeutic dose -- amount of a
drug necessary to produce a desired effect.

SOURCES OF DRUG
INFORMATION

A number of sources containing
information on drug actions, uses, and specific
indications, contraindications, adverse
reactions, and dosage are usually available on
each ward. The Physician's Desk Reference,
formulary, and drug package inserts are all
excellent sources for information concerning
drugs.

It is imperative that anyone administering
a medication be familiar with information
pertinent to that medication. Hypersensitivity
to a drug is ALWAYS a contraindication to
the administration of that drug. Special
precautions must be followed for pregnant
women and lactating mothers.

The Physicians' Desk Reference, PDR,
which is published annually, is a listing of
drugs arranged in five sections. The pink
section is a comprehensive alphabetic listing
of brand name products and a list of
manufacturers with their products. The blue
section is a therapeutic index. The yellow
section is a drug, chemical, and
pharmacological index to drugs. The white
section is a list of the major products of
manufacturers with information on
composition, action, uses, administration,
dosage, precautions, contraindications, and
supply of each drug.

The final section contains full size color
photographs to aid in medication
identification.

The Hospital Formulary is produced
locally by each Medical Treatment Facility.
The formulary lists all medications in a
particular hospital's pharmacy.

Manufacturer Drug Package Inserts are a
concise description of the product, drug
actions, interactions, indications,
contraindications, and precautions in clinical
use, guidance for dosage, known adverse
actions, and side effects. Federal law requires
that a brochure approved by the Food and
Drug Administration accompany each package
of the product.

A variety of Nursing Drug HandBooks
exist, and most wards or clinics have one or
more.

CLASSIFICATION OF DRUGS

This section identifies drugs according to
their pharmacological classification.

ANTIHISTAMINES -- Suppress
symptoms caused by histamine in the body.
When histamine is released, it dilates the
capillaries and stimulates secretions associated
with allergic disorders.

Indications: Symptomatic relief of allergic
disorders such as allergic cough and sneezing,
rhinitis (runny nose), allergic conjunctivitis
(inflammation of the inner eyelids), excessive
lacrimation, urticaria, nighttime sleep aid, and
adjunctive therapy in anaphylactic reactions.

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Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School
Handbook III
Contraindications: Acute asthma

Adverse reactions: Drowsiness, confusion,
dryness of mouth, thickening of bronchial
secretion, disturbed coordination, epigastric
distress and dizziness.

Drugs in the category:

1. Benadryl (Diphenhydramine HCL)

2. Chlor-Trimeton (Chlorpheniramine
Maleate)

EXPECTORANTS -- Agents that thin or
liquefy mucous from the lung, bronchi, and
trachea.

Indications: Relief of respiratory
conditions characterized by dry,
nonproductive cough due to the presence of
mucus in respiratory tract

Contraindications: Cough accompanied by
excessive secretions and persistent cough of
more than one week.

Adverse reactions: GI disturbance, nausea
and vomiting.

Drug in the category:

1. Robitussin (Guaifenesin)

DECONGESTANTS -- Agents that shrink
swollen mucous membranes, reduce nasal
congestion, and increase nasal patency.

Indications: Temporary relief of nasal
congestion due to the common cold or hay
fever. Promotes nasal or sinus drainage and
for relief of eustachian tube congestion.

Contraindications: Severe hypertension.

Adverse reactions: Restlessness,
nervousness, palpitations, and tachycardia.

Drug in the category:

1. Sudafed (Pseudoephedrine HCL).
ANTITUSSIVE -- Agents that suppress
coughing

Indications: Nonproductive coughs.

Adverse reactions: Respiratory depression
(associated with codeine), nausea and
vomiting, constipation, dizziness, drowsiness.

Drugs in the category:

1. Robitussin DM (Guaifenesin and
Dextromethorphan).

2. ETH with Codeine (Elixir of Terpin
Hydrate with Codeine) -- a controlled
substance.

ANTIHISTAMINES/
DECONGESTANT

Because no single agent relieves all symptoms
of the common cold, combination products are
manufactured.

Indications: Symptomatic relief of
seasonal hay fever.

Contraindications: Newborn or premature
infants and lower respiratory diseases.

Adverse reactions: Drowsiness, sedation,
and thickening of bronchial secretions.

Drug in the category:

1. Actifed (Triprolidine HCL and
Pseudoephedrine HCL).

BRONCHODILATORS -- Medications that
ease contractions of the bronchi by relaxing
the smooth muscles of the air passageway and
reducing swelling of the mucous membranes
of these passages.

Indications: Relief of bronchospasm
(acute wheezing and shortness of breath)
associated with acute and chronic bronchial
asthma, emphysema, or other obstructive
pulmonary diseases.
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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
Contraindications: Cardiac arrhythmia
associated with tachycardia.

Adverse reactions: Restlessness,
apprehension, nausea, vomiting, palpitations,
changes of blood pressure, tachycardia.

Drugs in the category:

1. Ventolin (Albuterol).

2. Aminophylline.

ANTIBIOTICS -- Agents that inhibit the
growth of bacteria (bacteriostatic) or destroy
bacteria (bacteriocidal). In 1929, Fleming
discovered the bacteriolytic effects of the
mold Penicillium. In 1936, at Oxford
University, Florey and his assistants isolated
the active principle and named it penicillin.

Penicillin

Indications: Treatment of mild to
moderately severe infections caused by
penicillin-sensitive microorganisms. Also used
in the treatment of venereal diseases, and
prophylaxis for rheumatic fever/ endocarditis.
Several forms of penicillin have been
identified and designated as F, G, K, 0, V, and
X. Commercial preparations principally
contain penicillin G.

Adverse reactions: Anaphylactic shock --
including acute circulatory failure, loss of
consciousness, and facial or laryngeal edema.
Delayed hypersensitive reactions include skin
rash, urticaria, itching, nausea, vomiting,
diarrhea, and fever.

Drugs in the category:

1. V-Cillin-K (Penicillin V potassium).

2. Polycillin (Ampicillin).

3. Polymox (Amoxicillin).

Tetracyclines

Indications: Bacteriostatic agent used in a
wide range of gram--positive and gram--
negative organisms, e.g., Rickettsiae (Rocky
Mountain Spotted Fever) and Typhus Fever;
and infection in patients allergic to penicillin.

Contraindications: Children under 8 years
old.

Adverse reactions: Anorexia, nausea,
vomiting, diarrhea, and photosensitivity.

WARNING: Long term use may cause
permanent discoloration to teeth of infants and
children up to 8 years of age. Caution should
be used during pregnancy. Also, advise patient
against taking dairy products, antacids, or iron
products when taking tetracyclines.

Drugs in the category:

1. Achromycin V (Tetracycline).

2. Vibramycin (Doxycycline).

3. Erythromycin

Indications: Treatment of infection for
patients that are hypersensitive to penicillin.
Also used in infections of the upper and lower
respiratory tract caused by streptococcus or
mycoplasma pneumonia and Legionnaires
Disease.

Adverse reactions: Abdominal cramps and
discomfort, nausea, vomiting diarrhea, and
anorexia.

Drugs in the category:

1. Eryc (Erythromycin base).

2. Ilosone (Erythromycin Estolate).

Sulfonamides -- synthetic agents which
suppress bacterial growth and reproduction.

Indications: Treatment of urinary tract
infections, acute otitis media, and meningitis.

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Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School
Handbook III
Contraindications: Use with caution for
patients with G6PD deficiency.

Adverse reactions: Nausea, vomiting,
anorexia, aplastic anemia, diarrhea, abdominal
pains, and crystalluria (crystals in the urine).

Drugs in the category:

1. Gantrisin (Sulfisoxazole).

2. Septra, Bactrim (Trimethoprim and
Sulfisoxazole).

ANTIFUNGALS -- Drugs used to treat
fungal infections. In general, there are two
types of fungal infections: systemic fungal
infections and dermophytic infections of the
skin, hair, and nails.

Indications: Treatment of susceptible
strains of systemic (severe) infections, and
dermophytic infections such as Athlete's Foot
(tinea pedis), ringworm of the body (tinea
corporis), and jock itch (tinea cruris).

Contraindications: Metabolic disorders
affecting the liver.

Adverse reactions: Headache, dizziness,
nausea, vomiting, diarrhea, insomnia, and
photosensitivity.

WARNING: Due to the toxic nature of these
drugs, for prolonged use, baseline liver studies
should be made and routinely reevaluated.

Drugs in category:

1. Tinactin (Tolnaftate) Topical Use Only.

2. Gris-Peg, Grifulvin V (Griscofulvin) --
systemic use only.

MILD ANALGESICS -- Agents that
alleviate mild to moderate pain.

Aspirin (Acetylsalicylic Acid, abbreviated
ASA)

Indications:
1. ANALGESIC relief of mild to moderate
pain from injuries, illness headaches and
dysmenorrhea.

2. ANTIPYRETIC reduces fever in viral and
bacterial illnesses.

3. ANTI-INFLAMMATORY -- Drug of
choice for most inflammatory reactions in
rheumatic diseases and injuries.

4. ANTICOAGULANT -- Low dosage of
aspirin is used to decrease platelet aggregation
and prevent blood clots for patients
susceptible to stroke or myocardial infarction.

Contraindications: Asthma, chronic
urticaria, or nasal polyps; bleeding ulcers
(ASA irritates ulcer); hemophilia;
hemorrhagic states; and hypersensitivity to
salicylates or NSAID.

Adverse reactions: GI upset, gastric
bleeding, occult (hidden) bleeding, tinnitus
(ringing of the ears). ASA prolongs
coagulation of blood.

Tylenol (Acetaminophen)

Indications: Mild to moderate pain from
injury or illness, fever from viral or bacterial
illness, discomfort due to colds and influenza,
and patients with a hypersensitivity to aspirin.

Adverse reactions: Rare.

NARCOTIC ANALGESICS -- Alleviate
moderate to severe pain without loss of
consciousness. These drugs are subject to
control under the Federal Comprehensive
Drug Abuse Prevention and Control Act of
1970.

Indications: Relief of moderate to severe
acute and chronic pain. Also used pre--
operatively to sedate and allay apprehension.

Contraindications: Closed head injuries,
respiratory depression, and undiagnosed acute
abdominal pain.
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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
Adverse reactions: Respiratory distress,
nausea, vomiting, constipation, hypotension,
circulatory depression, shock, and cardiac
arrest. Narcotics can cause increased
intracranial pressure, dizziness,
lightheartedness, euphoria, dysphoria, and
sedation.

WARNING: Habitual use and/or physical
dependency may occur; therefore, federal
regulations governing narcotics must be
obeyed.

Drugs in the category:

1. Morphine Sulfate.

2. Demerol (Meperidine HCL).

3. Tylenol III (Codeine phosphate and
Acetaminophen).

GENITOURINARY ANALGESICS -- Act
on the mucosa of the urinary tract to relieve
pain, burning, urgency and frequency.

Indications: Symptomatic relief of
discomfort from irritation of the lower urinary
tract caused by infection, trauma, or surgery.

Contraindications: Renal insufficiency.

Adverse reactions: Occasional G.I.
disturbances or headache.

WARNING: The patient should be warned
that pyridium will cause a reddish-orange
discoloration of the urine.

Drugs in the category:

1. Pyridium (Phenazopyridine HCL).

NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS (NSAID) -- A
group of drugs having analgesic, antipyretic,
and anti-inflammatory properties.

Indications: Rheumatoid arthritis and
osteoarthritis, relief of mild to moderate pain,
treatment of primary dysmenorrhea, and acute
gouty arthritis.

Contraindications: History of allergic
reaction to ASA or other non-steroidal anti-
inflammatory drugs.

Adverse reactions: GI bleeding and
disturbances, epigastric pain, diarrhea,
constipation, nausea and vomiting.

WARNING: Anti-inflammatory agents
should not be taken with other anti-
inflammatory agents or with products
containing aspirin. Should be taken with food
or milk.

Drugs in the category:

1. Motrin (Ibuprofen).

2. Indocin (Indomethacin).

LOCAL ANESTHETICS -- Produce loss of
sensation and motor activity within a limited
area of the body by blocking nerve
conduction. The important action of this group
of drugs is paralysis of the peripheral sensory
nerves. They block all sensations, including
taste and smell, although their chief effect is
on the nerves of pain.

Indications: Any procedure where a short
term anesthetic effect is desired, such as
suturing small wounds, dental procedures, and
debridement of wounds.

Contraindications: Should not be given in
cases of severe shock or heart block, due to
the possibility of vascular dilation, or if an
injection site is inflamed.

Adverse reactions: Hypotension,
hypertension, cardiopulmonary arrest tremors
and convulsions.

WARNING: Resuscitative equipment and
drugs should be immediately available when
any local anesthetic is used.

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Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School
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CAUTION: Lidocaine with epinephrine is
never injected into fingers, nose, toes, ear
lobes, or penis due to vasoconstrictor effects.

Drugs in the category:

1. Xylocaine HCL (Lidocaine HCL).

2. Xylocaine HCL with epinephrine
(Lidocaine HCL with epinephrine).
Epinephrine prolongs the effect of the
anesthetic.

SEDATIVE/HYPNOTICS -- Produce
varying degrees of Central Nervous System
depression. Small doses reduce restlessness,
emotional tension, and help to induce sleep in
irritable, apprehensive patients. This group
includes the barbiturates.

Indications: Pre-anesthetic medications or
short-term treatment for insomnia.

Contraindications: Severe respiratory
distress and respiratory disease where dyspnea
or obstruction is present, impaired renal
function, and marked impairment of liver
function.

Adverse reactions: Sleepiness, nausea,
vomiting, respiratory depression, vertigo,
(dizziness), drowsiness, lethargy, and ataxia
(uncoordinated muscle movements).

WARNING: Avoid activities that require
alertness and physical coordination.

Drugs in the category:

1. Versed (Midazolam HCL).

2. Seconal (Sodium secobarbital).

ANTICONVULSANT -- CNS depressants,
used to terminate convulsive episodes and to
prevent or decrease the occurrence of seizures
for patients with epilepsy.

Indications: Control of grand mal seizures,
psychomotor seizures, prevention and
treatment of seizures occurring during or
following neurosurgery.

Contraindications: Sinus bradycardia and
sinoatrial block.

Adverse reactions: Gastrointestinal
disturbances (nausea, vomiting, constipation),
ataxia, tremors, CNS depression, inflammation
and/or thickening of the gums, and slurred
speech.

Drugs in the category:

1. Dilantin (Phenytoin sodium).

2. Phenobarbital.

ANTI-ANXIETY AGENTS -- CNS
depressants used to reduce mild to moderate
degrees of anxiety, agitation, fear or tension.
They produce mild sedation that is unlikely to
adversely effect the quality of motor
performance or clarity of consciousness.

Indications: Management of anxiety; relief
of apprehension, tension, or fear; and
treatment of alcohol withdrawal symptoms
(Delirium Tremors). Administered pre-
operatively to reduce patient apprehension.
Diazepam is the drug of choice for treatment
of status epilepticus and is frequently used as a
musculoskeletal relaxant.

Contraindications: Psychosis. Acute,
narrow angle glaucoma.

Adverse reactions: Transient drowsiness,
ataxia, or confusion.

WARNING: The patient should be warned
not to combine alcohol and tranquilizers or
engage in hazardous tasks.

Drugs in the category:

1. Librium (Chlordiazepoxide HCL).

2. Valium (Diazepam).

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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
CENTRAL ACTING MUSCLE
RELAXANTS -- Skeletal muscle relaxants
are used to produce muscular relaxation
during surgical anesthesia and are used in
connection with the treatment of muscle
spasms due to various conditions.

Indications: Relief of skeletal muscle
spasms due to discomfort associated with
acute, painful musculoskeletal conditions.

Adverse reactions: Drowsiness, dizziness,
nausea, urticaria, rash, urine discoloration
(brown, black, or green).

Drugs in the category:

1. Robaxin (Methocarbamol).

2. Flexeril (Cyclobenzaprine HCL).

GENERAL ANESTHETICS -- These agents
depress the Central Nervous System (CNS) to
cause a loss of sensation affecting the whole
body. This is essential when complete
unconsciousness, reduced reflex action, and
adequate muscular relaxation are desired.
When movement of the patient may imperil
the success of the operation, in lengthy
operations, and where spinal anesthesia is not
safe (as in thoracic surgery), general
anesthesia is also indicated. General
anesthetics that are administered by inhalation
are safer because they are eliminated from the
blood very rapidly -- being volatile, they are
excreted quickly by the lungs. Ultra-short
acting barbiturates are used because they have
a quick reversal.

The loss of sensation, which occurs before
complete loss of consciousness, seems to be
due to an effect on the spinal cord. In
sufficient dosage, general anesthetics can
paralyze the spinal cord, the cerebrum, the
vital centers in the medulla, usually affecting
respiratory responses first then the vasomotor
mechanism.

Indications: Rapid-acting intravenous
anesthetic that causes a loss of consciousness,
but has a relatively weak analgesic effect.
Used during major surgical procedures when
complete unconsciousness is desired.

Contraindications: Liver disease.

Adverse reactions: Respiratory depression,
coughing, bronchospasm, laryngeal spasms,
and transient hypotension.

Drug in the category:

1. Pentothal Sodium (Thiopental Sodium)

ANTACIDS -- Drugs to counteract or
neutralize acidity in the stomach or to correct
a low alkalinity in body fluids. Normal
stomach fluids are acid in nature. Stomach
contents which become too acidic irritate the
mucous membranes and cause symptoms
commonly spoken of as indigestion or
dyspepsia. Antacids such as sodium
bicarbonate, magnesium oxide, magnesium
carbonate, or milk of magnesia are indicated
in this condition. The intestinal tract is
normally slightly alkaline. As a result of
disease it may become acid, which usually
causes diarrhea.

Indications: Hyperacidity associated with
peptic ulcer or heartburn (burning sensation in
the esophagus), prevention (prophylaxis) of
gastrointestinal bleeding or stress ulcers.
Simethicone aids in the relief of mucus,
entrapped air or gas.

Contraindications: Impaired renal
function, because of possible toxic effects of
magnesium. Do NOT give antacids with oral
Tetracycline.

Adverse reactions: Diarrhea, nausea, and
vomiting.

WARNING: Do not give with oral
tetracyclines.

Drugs in the category:

1. Maalox (Magnesium and Aluminum
Hydroxide).

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Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School
Handbook III
2. Mylanta (Aluminum Hydroxide,
Magnesium Hydroxide, and Simethicone).

ANTIDIARRHEALS -- Used for the
symptomatic treatment of diarrhea (acute or
chronic increase in the fluidity and frequency
of the stools caused by infection, poisoning,
allergy, GI lesions, or inflammation).

Indication: Diarrhea.

Contraindications: Under 2 years old
(Lomotil), diarrhea from poisons, or diarrhea
caused by organisms that penetrate the
intestinal mucosa.

Adverse reactions: GI disturbances,
nausea, vomiting, constipation, anorexia,
drowsiness, dizziness, and depression. Drying
of skin and mucous membranes can occur with
Lomotil.

Drugs in the category:

1. Kaopectate (Kaolin and pectin).

2. Lomotil (Diphenoxylate HCL with
atropine sulphate).

LAXATIVES -- Agents which facilitate the
passage of feces through the colon and
elimination through the rectum.

Indications: Short term treatment of
constipation. Preparation for lab studies (X-
ray), examinations (proctoscopy), and
preoperative and postoperative preparation.

Contraindications: Nausea, vomiting, and
other symptoms of appendicitis, acute
abdomen, fecal impaction, bowel obstruction,
and undiagnosed abdominal pain.

Adverse reactions: Abdominal cramping,
diarrhea, and laxative dependence with loss of
normal bowel function may develop with
prolonged use.

Drugs in the category:

1. Dulcolax (Bisacodyl).

2. Milk of Magnesia USP (MOM).

ANTIEMETICS -- Prevent or relieve nausea
or vomiting.

Indications: Management of nausea and
vomiting and treatment of motion sickness or
vertigo, (nausea, vomiting, and dizziness).

Adverse reactions: Dryness of mouth and
throat, drowsiness, restlessness, and blurred
vision.

WARNING: Patients should be cautioned that
drowsiness may occur, so driving or other
hazardous tasks should not be performed.

Drug in the category:

1. Antivert (Meclizine).

CARDIOTONICS -- Help restore the normal
functions of the heart by increasing
contractibility of a failing heart muscle which
results in an increased stroke volume and
cardiac output

Indications: Treatment of congestive heart
failure.

Adverse reactions: Anorexia (loss of
appetite), nausea, vomiting, diarrhea,
abdominal pain, blurring of vision, cardiac
dysrhythmia, decrease in pulse, and
gynecomastia.

WARNING: An apical pulse must be taken
prior to administration of Lanoxin (Digoxin.)
If the pulse is less than 60 or greater than 100,
hold the medication and notify the physician
(usually done by the charge nurse.)

Drug in the category:

1. Lanoxin (Digoxin).

DIURETICS -- Reduce circulatory volume
fluid and prevent or eliminate edema by
increasing urinary excretion.

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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
Contraindications: Severe anemia or
increased intracranial pressure.
Indications: Congestive heart failure,
generalized edema, hypertension, edema
associated with liver disease, or premenstrual
fluid retention.

Adverse reactions: Headache or
hypotension.
Contraindications: Anuria (absence of
urine excretion) and electrolyte imbalance. WARNING: Medication should be taken only
while seated due to hypotensive reaction,
dizziness, and vertigo. Adverse reactions: Gastrointestinal upset
headache, fatigue, dizziness, dehydration, and
electrolyte imbalance.

Drug in the category:

1. Nitrostat (Nitroglycerin). Drugs in the category:

TOPICAL DERMATOLOGICAL
AGENTS -- Agents commonly used to
provide symptomatic relief or promote the
healing process of many dermatological
disorders. These agents come in creams,
ointments, lotions and balms, which are
applied directly to the skin. Some topical
preparations (scabicides) destroy itch mites
and lice. Scabicides are discussed here.
1. Esidrex (Hydrochlorothiazide abbreviated
HCTZ).

2. Lasix (Furosemide).

VASOCONSTRICTORS -- Agents that
constrict the blood vessels, causing the blood
pressure to elevate.

Indications: Anaphylactic shock and acute
asthma attack. Used to prolong the effects of
local anesthesia and as cardiac stimulant in
cardiac arrest.
Indications: Treatment of parasitic
infestations by scabies, head lice, and crab lice
and their nits (juvenile lice) and eggs.

Contraindications: Do not exceed
prescribed dosage, especially in children; and
pregnant or nursing women.
Contraindications: Shock, other than
anaphylactic and local anesthesia of the
fingers, toes, ears, nose and penis.

Adverse reactions: Eye, skin, or mucosa
irritation. Toxic if absorbed in large amounts.
Adverse reactions: Changes in blood
pressure, palpitations, anxiety, and headache.

Drug in the category: Drug in the category:

Kwell (Lindane). 1. Adrenalin (Epinephrine HCL).

DRUG CARDS
VASODILATORS -- Agents that dilate the
blood vessels causing the blood pressure to be
lowered.

Drug index cards are used as a guide in
preparing individual drug cards for personal
use, Figure 3.15.01.
Indications: Acute angina pectoris.
Prophylaxis for angina and control of blood
pressure.







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Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corp School
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BRAND/TRADE NAME: Nitroglycerin______________________________________________________
PRONUNCIATION: NI-TRO-GLIS-ER-IN_____________________________________________________
GENERIC/CHEMICAL NAME: Glyeril trinitrate_____________________________________________
CLASSIFICATION: Vasodilator____________________________________________________________
INDICATIONS: Treatment of acute attack or prevention of expected attacks in chest pains of angina pectoris
ACTIONS Improves blood flow of oxygenated blood through the coronary arteries, relieving _____
ischemia and hypoxia. Reduces the work of the heart_______________________________________
CONTRAINDICATIONS/PRECAUTIONS Generally no more than three tabs should be taken___
without relief and physician notification. Patient should sit or lie to prevent postural hypotension__.
Use with caution in glaucoma.
ADVERSE REACTIONS/SIDE EFFECTS: Headache, skin flushing and postural hypotension___
(dizziness, weakness, faintness); may lead to collapse. Nausea, vomiting, and drug rash_________.
ROUTE/DOSE: Sublingual/0.2-0.6 mg, repeated up to three times in 15 minutes_______________


Figure 3.15.01
Drug Index Card



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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III
BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________



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BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________



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BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________



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BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________



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BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________



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BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________





BRAND/TRADE NAME ____________________________________________________________
PRONUNCIATION: ________________________________________________________________
GENERIC/CHEMICAL NAME _______________________________________________________
CLASSIFICATION: ________________________________________________________________
INDICATIONS: ___________________________________________________________________
ACTIONS: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
CONTRAINDICATIONS/PRECAUTIONS: ____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ADVERSE REACTIONS/SIDE EFFECTS: _____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ROUTE/DOSE: ___________________________________________________________________
_________________________________________________________________________________
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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
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NOTES/COMMENTS
227
Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.15

Pharmacology and Toxicology Worksheet

1. Match each definition in column B with the correct term in column A.

A B


a. Pharmacology _______

b. Contraindication _______

c. Generic Name _______

d. Indication _______

e. Side Effect _______

f. Trade Name _______

1. An action other than desired

2. The formal name of a drug

3. The scientific study of drugs

4. A name created by the manufacturer

5. A condition for which a drug is prescribed

6. A condition where administration of a drug
may be undesirable

2. List three sources of drug information.

a. _____________________________________________________________________

b. _____________________________________________________________________

c. _____________________________________________________________________

3. Which classification of drugs is used to relieve acidity in the stomach?

a. Antihistamines

b. Cardiotonics

c. Laxatives

d. Antacids

4. Narcotics are used to control moderate-to-severe pain.

a. True b. False

5. Anticonvulsants are used to decrease the occurrence of seizures.

a. True b. False

228
Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III Worksheet
6. Which classification of drugs inhibits the growth of, or destroys bacteria?

a. Antacids

b. Antibiotics

c. Antiemetics

d. Analgesics

7. Diuretics reduce or eliminate edema by increasing:

a. evaporation of water.

b. blood flow to the liver.

c. urinary excretion.

d. sodium retention.

8. Which drug is a sedative/hypnotic?

a. Kwell

b. Meperidine

c. Lanoxin

d. Versed

9. Which drug is a narcotic?

a. Seconal

b. Meperidine

c. Ibuprofen

d. Pyridium

10. A contraindication for administering an antihistamine is:

a. acute asthma.

b. dry cough.

c. acute sinusitis.

d. advanced age.


229
Lesson 3.15 Pharmacology and Toxicology Basic Hospital Corps School
Worksheet Handbook III
11. One adverse reaction to morphine is:

a. asthma.

b. sedation.

c. diarrhea.

d. hypotension.

12. Drug index cards are used to sort medications before administration.

a. True b. False



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Basic Hospital Corps School Lesson 3.15 Pharmacology and Toxicology
Handbook III Worksheet
NOTES/COMMENTS
231
Lesson 3.18 Dosage Calculations Basic Hospital Corps School
Handbook III
Lesson 3.18

Dosage Calculations

Terminal Objective:

3.18 Solve medical mathematical problems.

Enabling Objectives:

3.18.01 Compute medicine dosage using liquid weights and measures.

3.18.02 Compute medicine dosage based on a patient's weight.

3.18.03 Compute intravenous flow rates.


COMPUTING DOSAGES FOR
LIQUID/WEIGHT MEASURES

Many medications are supplied in dosages
different than the dose ordered. You need to
be able to compute dosages accurately in order
to give medications safely.

1. Liquid and Weight Conversion Formula:

Desired Dose X Vehicle = Dosage to be
Dosage on Hand 1 Administered

Desired Dose: dosage the doctor has ordered.

Dosage on Hand: dosage the drug comes in.

Vehicle: the means by which the medication is
dispensed, could be tablet, capsule, or liquid.

2. Steps in Formula Conversion:

a. Convert desired dose and dosage on
hand into like terms.

b. Divide dosage on hand into desired
dose.

c. Multiply desired dose times the
vehicle.

3. Example: The medical officer ordered 650
mg of a medication. The vial contains 325
mg of the drug per 2 ml. How many
milliliters should the patient receive?

650 mg is the desired dose

325 mg is the dosage the drug comes in.

2 ml is the vehicle.

a. 650 mg X 2 ml
325 mg 1

b. 2 (desired dose)
325 ) 650
650
0

c. 2 (desired dose)
X 2 ml (vehicle)
4 ml (dosage to be administered)

COMPUTING DOSAGES BASED
ON PATIENT'S WEIGHT

Some medications are ordered by the
patient's body weight in kilograms. Use the
following formula when you need to calculate
doses by body weight.

232
Basic Hospital Corps School Lesson 3.18 Dosage Calculations
Handbook III
4. Body Weight Formula:

Desired Dose =

Patient's Weight in Pounds X Dose
2.2 pounds/kilograms 1 kilogram

1. Steps in Formula:

a. Convert pounds to kilograms by
dividing patient's weight in pounds by
2.2 pounds/kilogram.

b. Multiply the body weight in kilograms
by the dose/kilogram.

2. Example: The medical officer ordered 15
mg of a medication per kilogram of body
weight. How many grams will the patient
receive if he weighs 176 lbs?

a. 176 lbs.
2.2

b. 2.2) 176.0

c. 80 kilograms
22)1760

d. 80 (kilograms)
15 mg (dose per kilogram)
1200 mg or 1.2 grams

1200 mg or 1.2 grams is the dosage to be
administered.

COMPUTING INTRAVENOUS
FLOW RATES

Many treatment facilities use infusion
pumps to deliver IV fluids accurately. Some
situations or locations do not have IV pumps.
Corpsmen will calculate IV flow rates
manually in those situations. A formula for IV
rate calculation follows.

3. IV Rate Flow Formula:

Drops/Minute =

mls given every hr X Drop factor
60 Minutes

IV tubing comes in many different sizes.
That is, the internal diameter of the tubing is
larger or smaller, depending on the
manufacturer. Tubing size affects the number
of drops required to make one ml. The
manufacturer's drop factor is the number of
drops required to make 1 cc. (1 cc =1 ml) A
drop factor can be found on the IV
administration set package (IV tubing set.)
Common drop factors are 10, 15, 20, and 60
drops per ml.

4. Calculate flow rate.

a. Calculate ml to be given every hour.

b. Multiply ml per hour times drop
factor.

c. Divide by 60 minutes.

5. Example: The medical officer ordered
1000 ml D5W to be infused over 10 hours.
The manufacturer's drop factor is 20. How
many drops per minute will be the IV flow
rate?

a. 1000 ml D5W every 10 hours =100
ml/hour.

b. 100 ml X 20 gtts = 2000 gtts
hr ml hr

c. 2000 =33.3
60

Or 33 gtts/minute.

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Lesson 3.18 Dosage Calculations Basic Hospital Corps School
Handbook III

WEIGHTS AND MEASURES CONVERSION TABLE

METRIC WEIGHT MEASURE

1 Kilogram (Kg) =100 grams (Gm) 1 Gram (Gm)
1 Gram (Gm) =.001kilogram (Kg)
1 Gram =1000 milligrams (mg)
1 Milligram (mg) =.001 gram (Gm)
1 Milligram =1000 Microgams (mcg)
1 Microgram (Mcg) =.001 Milligram (mg)

METRIC FLUID MEASURE

1 Liter (L) =1000 milliliters (ml)
1 Milliliter (ml) =.001 liter (L)
1 Milliliter (ml) =1 cubic centimeter

US LIQUID MEASUREMENTS AND METRIC FLUID MEASURES
U.S. Liquid Metric

1 drop (gtt) =.06 milliliter (ml)
15 drops (gtts) =1 milliliter (ml)
1 teaspoon (tsp) =4 milliliters (ml)
1 tablespoon (Tbsp) =15 milliliters (ml)
1 ounce (oz) =30 milliliters (ml)
1 cup (c) =240 milliliters (ml)
1 pint =480 milliliters (ml)
1 quart =960 milliliters (ml)
4 cups (c) =960 milliliters (ml)

APOTHECARY WEIGHT TO METRIC SYSTEM

1 grain (gr) =.065 gram
=65 milligrams (sometimes considered
to be 60 to 64 milligrams)

WEIGHT CONVERSION

1 kg =2.2 lbs
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Basic Hospital Corps School Lesson 3.18 Dosage Calculations
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NOTES/COMMENTS
235
Lesson 3.18 Dosage Calculation Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.18

Dosage Calculations Worksheet

1. The Medical Officer ordered 500 mg of a medication. The label indicates 250 mg of the drug per
5 ml. How many milliliters should the patient receive?

2. The Medical Officer ordered the patient to receive 1,000 mg of a medication. Each tablet contains
325 mg. How many tablets should the patient receive?

Doctor's Order Medication Label Reads Needed

3. Surfak 240 mg P.O. Surfak 120 mg/tablet ______ Tablets

4. Alupent 50 mg P.O. Alupent 10 mg/tablets ______ Tablets

5. Robitussin 100 mg P.O. Robitussin 50 mg/Tbsp. ______ ml

6. Tylenol Elixir 25 mg P.O. Tylenol Elixir 5 mg/gtt ______ gtts

7. Insulin 50 units SC Insulin 100 units/ml ______ ml

8. Convert the following patient weights from pounds to kilograms:

a. 110 lbs =__________ kg

b. 198 lbs =__________ kg

c. 143 lbs =__________ Kg

9. The doctor ordered 25 mg of a medication per kilogram of body weight. The medication comes
250 mg/tablet. How many tablets should a 154 lbs patient receive? ___________ Tablets

10. The doctor ordered 10 mg of a medication per kilogram of body weight. The patient weighs 242
lbs. How many grams of medication should the patient receive? ___________ Grams

11. The Medical Officer ordered 5 mg of a medication per kilogram of body weight. The medication
comes 10 mg/gtt. How many drops should a 22 lbs child receive?
___________ Drops

12. The Medical Officer ordered 20 mg of a medication per kilogram of body weight. The medication
comes 200 mg/ml. How many milliliters should a 187 lbs patient receive? ___________ ml







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Basic Hospital Corps School Lesson 3.18 Dosage Calculation
Handbook III Worksheet
SOLUTION INFUSING TIME DROP FACTOR DROPS/MINUTE

13. 1,000 ml D5W 10 hrs 15 _______________

14. 1,000 ml D5NS 8 hrs 20 _______________

15. 1,000 ml RL 6 hrs 10 _______________

16. 1,000 ml D5 1/2NS 5 hrs 15 _______________

17. 1,000 ml NS 4 hrs 10 _______________

18. 1,000 ml D5W 13.3 hrs 20 _______________

19. 500 ml D5NS 4 hrs 15 _______________

20. Convert the following patient weights from pounds to kilograms:

a. 220 lbs = ___________________ kg

b. 176 lbs = ___________________ kg

c. 66 lbs = ___________________ kg

d. 150 lbs = ___________________ kg

e. 264 lbs = ___________________ kg

f. 198 lbs= ___________________ kg

21. The Medical Officer ordered 15 mg of a medication per kilogram of weight. The medication
comes 300 mg/tablet. How many tablets should a 176 pound patient receive?
________________ Tablets.

22. A doctor ordered 50 mg of a drug per kilogram body weight. How many milligrams should a 198
pound patient receive? ________________ mg

23. The doctor ordered 50 mg of Ampicillin per kilogram of body weight. Ampicillin comes 250
mg/5 cc. How many cc's should a 44 pound child receive? ________________ cc

24. The doctor ordered 50 mg of a drug per kilogram of body weight. How many grams of the
medication should a 220 pound patient receive? ________________ Gm

25. The doctor ordered 10 mg of a drug per kilogram of body weight. How many milligrams should a
110 pound patient receive? ________________ mg

26. The Medical Officer ordered 50 mg of a medication per kilogram of body weight. Medication on
hand comes 1000 mg/tablet. How many tablets should a 242 pound patient receive?
________________ Tablets

27. A 65 kg patient weights________________ lbs.
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Lesson 3.18 Dosage Calculation Basic Hospital Corps School
Worksheet Handbook III

MAR Says Medication Label Says Needed

28. Erythromycin 500 mg PO Erythromycin 250 mg/tab ______ Tablets

29. Oretic 50 mg PO Oretic 25 mg/tab ______ Tablets

30. Terbutabline Sulfate 0.25 mg SC Terbutabline Sulfate 1 mg/ml ______ ml

31. Thyroid 30 mg PO Thyroid 1/4 gr/tab ______ Tablets

32. Inderal 60 mg PO Inderal 20 mg/tab ______ Tablets

33. Lasix 120 mg IVP Lasix 10 mg/ml ______ ml

34. Polymox Suspension 250 mg PO Polymox Suspension 125 mg/5 cc ______ cc

35. Ferrous S04 Drops 24 mg PO Ferrous S04 Drops 4 mg/gtt ______ gtt

36. ETH 170 mg PO ETH 85 mg/5ml ______ ml

37. Ephedrine75 mg PO Ephedrine 25 mg/cap ______ caps

38. Sudafed Syrup 60 mg PO Sudafed Syrup 30 mg/5 cc ______ cc

39. Benadryl 100 mg PO Benadryl 25 mg/cap ______ caps

40. Digitoxin 0.2 mg PO Digitoxin 0.1 mg/tab ______ Tablets

41. Polymox Suspension 375 mg PO Polymox Suspension 125 mg/5 cc ______ cc

42. Atarax Syrup 30 mg PO Atarax Syrup 2 mg/ml ______ ml

43. Morphine Sulfate 8 mg IM Morphine Sulfate 10 mg/cc ______ cc

44. Dilaudid 4 mg PO Dilaudid 1 mg/ml ______ ml

45. Pronestyl 500 mg PO Pronestyl 250 mg/cap ______ caps

46. Procainammide 500 mg PO Procainamide250 mg/cap ______ caps

47. Dalmane 30 mg PO Dalmane 15 mg/cap ______ caps









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239
Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Handbook III
Lesson 3.19

Oral Medication Administration

Terminal Objective:

3.19 Prepare and administer oral medications.

Enabling Objectives:

3.19.01 Define the terms for oral medication administration.

3.19.02 List patient safety, privacy, education, and comfort considerations when administering
oral medications.

3.19.03 List guidelines for administering oral medications.

3.19.04 List documentation requirements for oral medication administration.

3.19.05 Administer oral medications from floor stock.

3.19.06 Administer oral medications from the unit dose cart.


MEDICATION TERMS

Terminology for medication
administration may introduce some terms that
are new. Accurate medication administration
requires that corpsmen know these terms. The
most common route for medication
administration is oral. Familiarize yourself
with the following terms used when giving
oral medications:

Buccal -- drug administration route that
involves placing the medication in the mouth
against the mucous membranes on the inside
of the cheek.

Oral medications -- drugs that are either
swallowed, or instilled through a tube leading
to the stomach.



Medication Administration Record
(MAR) -- form used to schedule and
document drug administration.

Floor stock system -- quantity of
frequently prescribed drugs maintained on the
ward.

Sublingual -- drug administration route
that involves placing the medication under the
tongue.

Suspension -- mixture of undissolved
particles in a liquid.

Unit Dose System -- 24-hour supply of a
medication, with each dose labeled and
packaged separately from the others.

Meniscus -- crescent shaped structure
appearing at the surface of a liquid.

Enteric coating -- covering placed on
tablets which delays absorption until the tablet
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Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III
has passed through the stomach into the
intestine. Used to reduce gastric irritation.


EDUCATION, PRIVACY,
SAFETY, AND COMFORT

Explain the procedure to the patient, name
the medication, ask if they have taken the
medication previously and explain the purpose
of this medication. Provide for the patient's
privacy. Ask the patient if he or she has any
allergies. Ensure safety and comfort by seeing
that the bed wheels are locked and that the bed
rail is up on the opposite side of the bed.
Position the patient in Fowler's position (for
comfort) unless contraindicated. Give the
medication to the patient along with a glass of
water. Stay with the patient during medication
administration. Be sure the medicine has been
swallowed. Observe for initial reactions to the
medication. Discard the medicine cup, if used.
Check on the patient in 15-30 minutes for
delayed adverse reactions.

In order to safely administer a medication,
follow the Five Rights of drug administration.
All patients must get the 1) right drug, in the
2) right dose, by the 3) right route, at the 4)
right time, making sure that you have the, 5)
right patient.

Perform patient identification checks using the
MAR: compare name on MAR to bed tag, ID
bracelet, and the patient's stated name.

Maintain the patient's privacy by pulling
the curtain or closing the room door. Provide
for the patient's comfort by positioning the
patient in the Fowler's position. If
contraindicated, turn patient into side.

GUIDELINES FOR
ADMINISTERING ORAL
MEDICATIONS

At the beginning of each shift the
medication corpsman will compare the
Medication Administration Record (MAR)
NAVMED 6550/8 with the Patient Profile
NAVMED 6550/12 for each patient. Any
discrepancies are noted and reported to the
nurse. Completeness of the medication order is
checked before any drugs are given.

Ensure aseptic technique is used when
administering medications. Wash your hands
before beginning. Do not touch tablets or
capsules, pour them into a medication cup.

Before giving any drug, perform three
medication checks. Using the phrase I
need... (to indicate the dose you want to
give), I have... ( to show the actual dose you
are holding), compare the information on the
medication label to the MAR. Look to be sure
that the name of the medication, the dose of
the medication, the route for administration,
and the expiration date of the medication label
match the information on the MAR. These
checks further ensure that the correct drug is
being given.

Some medications are stored on the ward
if they are used frequently. This is known as
Floor Stock.

When administering medications from
floor stock perform the three medication
checks. The first check is done as you locate
the medication on the shelf in the medication
cabinet. A second check is done as you
remove the mediation from the shelf. The
third check is performed when you return the
medication to the shelf.

The Unit Dose System uses two medication
checks for pre-prepared medications. (In the
unit dose system, one check has been done by
the pharmacy, so you will perform two
checks.)

Perform the first medication check by
comparing the MAR and the medicine for the
name of the medication, dosage, route of
administration, and the expiration.

Prepare the medication after
calculating the dosage necessary, then perform
the second medication check by comparing
the MAR and the medication for the name of
241
Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Handbook III
the medication, dosage, route, and time of
administration.

When pouring a liquid medication from
floor stock use these steps:

a. Do not shake medication because it may
cause air bubbles that will interfere with
accurate measurement

b. Agitate medication of there is any
precipitate

c. After removing cap, place on counter rim
up to prevent contamination

d. Hold bottle with palm covering label to
minimize soiling label

e. Place calibrated medication cup at eye
level on a flat surface

f. If too much medication is poured, obtain
a second cup and pour the correct amount
from the first cup into the second cup.
Discard first cup with excess medication

g. When measuring liquid medications there
will be a meniscus. Use the lowest point of
curvature to indicate the liquid level.

h. Clean top and sides of bottle screw
threads with a paper wipe before replacing
cap.

If the medication is ordered to be
administered by droplets, use these
techniques:

a. Count drops aloud when using a dropper

b. If dropper is curved hold it at a 45-degree
angle

c. If the dropper is straight, hold it at a 90-
degree angle

d. Do not turn the dropper upside down.
Medication may flow into the bulb.

e. Do not use the last drop in a dropper. It
may contain air.
Provide fresh water or juice to take with the
medication. Fluids increase the rate of
decomposition of tablets and absorption of the
medication.

Do not touch pills or capsules during
administration. (Occasionally, tablets may
need to be divided to give a dose. This is an
exception to the rule.)

Do not rush the patient.

Always supervise each patient during
medication administration. Never leave any
medication at the patient's bedside or on the
food tray to be taken later. For example, don't
leave AC, PC, or sleeping medication for the
patient to take later. The patients may forget to
take the medication, it may be accidentally
sent back to the kitchen on the food tray, the
patient may hoard or discard the medication,
or the medication may be stolen.

Place a recumbent patient in a supported
position if possible. If not possible, turn the
patient on his/her side.

If the patient feels nauseated, withhold the
medication and report the nausea to the nurse.
The patient may need to receive the
medication by another route.

If a patient vomits within half an hour after
taking a medication, notify the nurse. A
decision will be made whether the dose should
be repeated.

Enteric coated tablets delay decomposition
of the drug until it reaches the intestines. To
prevent a change in the absorption of enteric-
coated tablets, do not give these pills with
milk or antacids and do not crush them.

Never substitute a syrup or liquid form of a
medication for a tablet or capsule without a
Doctor's Order. Liquid is more completely
absorbed, so the dose may need to be adjusted.
(Syrups are often used instead of tablets or
capsules for disoriented patients, children, the
elderly or anyone who has difficulty
swallowing.)
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Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III
RECORDING MEDICATIONS
When administering cough syrups with
other medications, cough syrups should be
given last.

Record the medication on the MAR.
Check that the MAR is stamped with the
patient's correct addressograph plate. Record a
drug only when you have administered the
medication. Document administration while
still at the patient's bedside.

Never give liquid medications to an
unconscious, sleeping, or sedated patient.

Do not forcefully administer any
medication. Notify the nurse if the patient
refuses a medication.

Locate the medication on the MAR.
Routine medications are on the front of the
MAR, single orders, pre-op medications and
stat medication are on back, top portion of the
MAR. PRN medications are on the bottom
portion of the MAR.

Do not give medications that have been
prepared by another patient. EVER!

Allow time to assist patients who require
help with taking medications.

Compare the unit dose package to the
MAR for name of the medication, dosage,
route, time and date of administration. Record
by entering your initials in the appropriate
square for date and hour square for routine
medications. Enter the date, time and initials
in the appropriate horizontal line for single
order and pre-operative medications. For PRN,
variable dose medications enter date, time,
dose and initials vertically in the appropriate
column.

Omit giving a drug if the patient has
symptoms suggesting an undesirable reaction
to a previous administration of the drug. (For
example, a patient who has received a narcotic
and is hard to wake.)

Do not give a medication that the patient
says is different than what he/she has been
receiving. Be sure that a mistake has not been
made.


Enter your initials, full signature and rate
in the initial code section at the bottom of the
MAR. This matches the person who has given
a PRN medication with their initials in the
PRN box used.
Check the patient in 30 minutes for
desired and undesired effects.

Unpleasant tasting medications may be
disguised by following them with an orange
slice, fruit juice, candy or sugarless gum.
Dilute distasteful medication in fruit juice or
chocolate milk. Ensure that any substance
used is not contraindicated by the patient's
condition or diet.

A Nursing Notes entry is required when
administering a PRN medication, a single dose
order, a Pre-op medication or a stat
medication. The note should include the time
and date, route, medication and dosage, reason
for giving the medication, patient's response,
adverse reactions (if any), your signature and
rate.

Large tablets can be crushed and mixed
with liquids (ice cream, applesauce, etc.),
except enteric coated tablets.

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Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Handbook III



















FIGURE 3.19.01
Floor Stock Liquid Medication with its Cap (Rim Up)

FIGURE 3.19.02
Placing Drops in Medication Cup
a. Curved Dropper
b. Straight Dropper
244
Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III

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Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.19

Oral Medication Administration
Worksheet

1. When assigned to administer medications, which two records should be compared at the
beginning of each shift?

a. MAR to Nursing Notes

b. MAR to Patient Profile

c. Patient Profile to Nursing Notes

d. MAR to Doctor's Orders

2. When using the unit dose system, what is used as a reference to perform the patient
identification check?

a. MAR

b. Medication card

c. Patient Profile

d. Patient chart

3. When is the medication administration recorded on the MAR with the unit dose system?

a. While at the bedside, prior to passing the medication

b. While at the bedside, after the patient has taken the medication

c. At the nurse's station, prior to administering the medication

d. At the nurse's station, after administering the medication







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Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
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4. How many medication checks are there when using the unit dose system?

a. 1

b. 2

c. 3

d. 4

5. When using the unit dose cart, when are medication dosages calculated?

a. Before doing any medication checks

b. After the medication second check

c. Before the second check

d. Before the medication third check

6. When using a unit dose cart, the second medication check should include:

a. name of medication.

b. dosage of medication.

c. route of medication.

d. all of the above.

7. A liquid form of a medication may be substituted for a tablet if the patient requests it.

a. True b. False

8. How many medication checks are performed when working with the floor stock
medication system?

a. 1

b. 2

c. 3

d. 4
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Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Worksheet Handbook III
9. When using floor stock, the first medication check is done:

a. at the patient's bedside.

b. before removing the medication from the shelf.

c. before unlocking the medication cabinet.

d. for all medications at the beginning of each shift.

10. The first medication check includes:

a. ________________________________________________________________

b. ________________________________________________________________

c. ________________________________________________________________

d. ________________________________________________________________

11. After removing a medication bottle cap, place it on the counter top with the rim up.

a. True b. False

12. Liquids should be poured at waist level.

a. True b. False

13. If too much liquid medication is poured, what is done with the excess?

a. Give it to the patient

b. Pour it back in the bottle

c. Discard it

d. Send it to the pharmacy

14. When medication is measured with a dropper, ensure the last drop is counted for accurate
measurement.

a. True b. False




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Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III Worksheet
15. A curved dropper should be held at a ____________ degree angle when counting drops.

a. 30

b. 45

c. 75

d. 90

16. List the three items checked when performing a patient identification check.

a. _____________________________________________________________

b. _____________________________________________________________

c. _____________________________________________________________

17. When giving oral medications, patient safety and comfort include:

a. locking bed wheels.

b. warming medications to room temperature.

c. putting the patient in Sim's position.

d. using restraints PRN.

18. When administering capsules or tablets, a glass of water should be provided for the
patient.

a. True b. False

19. Once medication is delivered to the patient, immediately move to the next patient so all
medications are administered on time.

a. True b. False









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Lesson 3.19 Oral Medication Administration Basic Hospital Corps School
Worksheet Handbook III
20. When are floor stock medications recorded?

a. After each patient receives his/her medication, at the bedside

b. At the beginning of each shift, after checking all MARs

c. After all medications have been administered for the specific time

d. J ust before giving a medication, at the patient's bedside

21. Routine medications are recorded on the _____________________ side of the MAR.

22. When PRN medications are recorded on the MAR, you include:

a. name of medication, dose, and time.

b. name of medication, time, and your initials.

c. date, time, and your initials.

d. date, time, dose, and your initials.

23. Enteric tablets can be crushed to make swallowing easier.

a. True b. False

24. Unpleasant tasting medications may be disguised with an orange slice.

a. True b. False

25. When administering medications, encourage the patients to hurry so everyone can get
their medication on time.

a. True b. False

26. Medication should not be left at the bedside or on food tray to be taken later.

a. True b. False








250
Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III Worksheet
27. If a patient feels he/she may vomit:

a. withhold the medication and notify the nurse.

b. give the medication and notify the nurse.

c. give a liquid form of the medication.

d. stand to one side when giving the medication

28. If a patient has difficulty swallowing a large tablet, it can be crushed and mixed with
applesauce or ice cream.

a. True b. False

29. Medications that are ordered to be taken after meals should be placed on the patient's
food tray to remind him/her to take the medication.

a. True b. False

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Worksheet Handbook III
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Handbook III Worksheet
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Worksheet Handbook III
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Basic Hospital Corps School Lesson 3.19 Oral Medication Administration
Handbook III Worksheet
255

Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.17

Storage of Medications

Terminal Objective:

3.17 List the storage requirements for medications.

Enabling Objectives:

3.17.01 State the characteristics of the floor stock system.

3.17.02 State the characteristics of the unit dose system.

3.17.03 State the characteristics of the narcotic locker.

3.17.04 List the security measures to be taken for ward medications and the narcotic locker and
its contents.

3.17.05 List the characteristics of the emergency cart/box.


FLOOR STOCK SYSTEM

The Floor Stock System is a drug system
in which bulk orders of drugs are supplied to
the ward. Individual doses of medications are
prepared from the bulk supplies by the ward
personnel. A locked medicine cabinet is used
to ensure secure storage of the bulk supplies.
The keys are kept by the medication
corpsman. The medicine cabinet contains
internal and external medications that are
shelved by type (liquid, pills, and drops) and
arranged in alphabetical order. External
medications, such as ointments and lotions,
are stored separately from internal
medications. This cabinet is kept locked at all
times when not in use.

Supplies to prepare/dispense medications
are also kept on the medication cabinet, e.g.,
medicine cups, needles and syringes, tongue
blades, a water pitcher, water cups, a blade for
scored tablets, a mortar and pestle, juices and
straws. Needles and syringes are stored in a
locked drawer in the cabinet. Some
medications, e.g., eye drops, eardrops, and
nitroglycerin, are removed from floor stock
system and stored at the patient's bedside for
easy access and to prevent cross
contamination.

Medications may be stored in a
refrigerator to maintain potency. Some
medications are affected by heat and
decompose or spoil unless they are kept cool.
Vaccines, insulin, some antibiotics
(Augmentin or Ampicillin in liquid form) and
some reconstituted medications (such as
steroids) are routinely stored in a refrigerator.
Other medications are effected by heat and
will melt at room temperature (such as
suppositories.) Refrigeration maintains them
in a solid form. Some medications are more
palatable when cold, including Maalox
Mylanta, Magnesium Citrate and Glucola Use
this refrigerator ONLY for medications. All
other materials, e.g., food, batteries, must be
stored elsewhere.




256
Basic Hospital Corps School Lesson 3.17 Storage of Medication Worksheet
Handbook III
UNIT DOSE SYSTEM

The Unit Dose System employs pharmacy
control over individual doses of drugs for each
patient. A unit dose cart with locks is used to
store individual doses until they are dispensed.
The cart is taken from room to room when
medications are administered to patients. Each
patient receiving medications has a separate
drawer labeled with his/her patient
identification. Drawers are arranged
numerically in room and bed order. Each
medication is stored in an individual envelope
(or wrapper.) The drawers may be divided to
separate medications given on each shift. The
cart is usually stored in a locked or secured
area when not in use. The cart should always
be kept locked when it is not in the sight of the
medication corpsman.

NARCOTIC LOCKER

The narcotic locker is a double locked
drawer, box, cupboard or room. This locker
contains federally controlled drugs such as
narcotics, hypnotics, and alcoholic beverages.

The narcotic locker must be double locked
at all times when not in use. The keys are held
by a Nurse Corps Officer or other R.N.
Federal law prescribes that a registered nurse
or qualified personnel administer narcotics.
Local policy will designate individuals
allowed to administer narcotics. A narcotic
logbook is maintained to record each narcotic
administration. If a narcotic is accidentally
contaminated, it must be accounted for in the
narcotic log. Usually two nurses record
contamination and disposal of the narcotic.
Follow local policy.

SECURITY MEASURES FOR
WARD MEDICATIONS

The medication cart or floor stock cabinet
must be kept locked at all times, except to
remove drugs. The keys must remain in the
possession of the medication corpsman or
medication nurse. Do not leave the keys in the
locks of the medication cart or floor stock
cabinet. Keys should never be passed to
another staff member without a legitimate
need.

EMERGENCY CART OR BOX

The emergency cart or box is portable,
sealed cart or small hand carried box
containing emergency drugs. The emergency
cart should be readily accessible. Inventory
checks are performed at regular intervals to
ensure a complete inventory of supplies and
medications. Between inventory checks, a
breakable seal secures the container. If the seal
is broken, the cart is checked and restocked by
the pharmacy.




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Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.17

Storage of Medications Worksheet

1. Circle each statement that describes the floor stock medication system.

a. The cabinet is locked when it contains narcotics.

b. The medications are arranged according to patients' preference.

c. Medications are shelved by size.

d. Medications are placed in alphabetical order.

2. In the floor stock system, individual doses of medications are prepared from bulk supplies by
pharmacy personnel.

a. True b. False

3. Which medication storage system provides bulk drugs for ward supply?

a. Unit Dose

b. Narcotic locker

c. Floor stock

d. Emergency box

4. The medicine cabinet does not contain:

a. internal medications.

b. external medications.

c. medication cart keys.

d. supplies needed to prepare and dispense medications.

5. The medication keys always remain in the custody of the nurse.

a. True b. False

6. The unit dose cart must remain in a secured area when not in use.

a. True b. False



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Basic Hospital Corps School Lesson 3.17 Storage of Medications Worksheet
Handbook III
7. The cassette drawer of the unit dose cart for each patient is labeled with:

a. times each medication will be given.

b. patient's age.

c. patient identification.

d. a list of all medication it contains.

8. Circle each statement that describes the unit dose medication system.

a. The drawers may be divided to separate drugs for different shifts.

b. The drawers are arranged alphabetically according to patient's names.

c. The cart is locked at night and on weekends.

d. Medications in drawers are placed in alphabetical order.

9. In the unit dose system individual doses of medications are prepared from bulk supplies by the
pharmacy personnel.

a. True b. False

10. Which medication storage system utilizes pharmacy control?

a. Unit dose

b. Narcotic locker

c. Floor stock

d. Emergency box

11. Which of the following medications are kept in the narcotic locker?

a. Antibiotics

b. Hypnotics

c. Cardiotonics

d. Insulin

12. According to federal regulations, a narcotic locker must have two locks.

a. True b. False



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Lesson 3.17 Storage of Medications Worksheet Basic Hospital Corps School
Handbook III
13. Narcotic locker keys are the responsibility of a nurse.

a. True b. False

14. Federal law prescribes that only a registered nurse may administer narcotics.

a. True b. False

15. List three purposes for storing medications in a refrigerator.

a. _________________________________________________________

b. _________________________________________________________

c. _________________________________________________________

16. Inventory checks are completed at regular intervals by pharmacy personnel to ensure
completeness of the emergency cart

a. True b. False



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Basic Hospital Corps School Lesson 3.17 Storage of Medications Worksheet
Handbook III
NOTES/COMMENTS
261
Lesson 3.20 Sublingual, Topical, and Rectal Basic Hospital Corps School
Medication Administration Handbook III
Lesson 3.20

Sublingual, Topical, and Rectal
Medication Administration

Terminal Objective:

3.20 List concepts and principles of administering sublingual, topical, and rectal medications.

Enabling Objectives:

3.20.01 Define terms related to medication administration.

3.20.02 List patient safety, privacy, education, and comfort considerations when administering
medications.

3.20.03 List the procedure for administering sublingual medications.

3.20.04 List the procedure for administering topical medications.

3.20.05 List the procedure for administering rectal medications.

3.20.06 List the procedure for documenting the administration of medications.


Non-parenteral medications are those
that are given by routes other than by injection
(intravenous, intramuscular, or subcutaneous).
Medications given by mouth are the most
common group of non-parenteral medication.
The other routes of medication administration,
sublingual, topical, and rectal, will be
discussed in this lesson.

Sublingual route -- placing the
medication under the tongue. The medication
will be absorbed through the blood vessels
under the tongue.

The sublingual route uses the thin
epithelium and the rich network of capillaries
on the underside of the tongue to gain rapid
absorption and drug action. Drugs absorbed
from the sublingual route have increased
potency since they enter the bloodstream
directly without being metabolized by the liver
or being affected by gastric and intestinal
enzymes. The most common drug
administered by this method is Glyceryl
Trinitrate, also known as Nitroglycerin. The
effects of medications administered
sublingually are usually felt in one to five
minutes. Patients are not allowed to eat, chew,
drink, or smoke until the medication is
dissolved and absorbed.

Topical route -- placing the medication
on the skin or mucous membranes. Topical
medications can have a local and/or a systemic
effect, however, most are given for direct
effect on the tissue to which the medication is
applied. Ointments, lotions, oils, creams, and
solutions are examples of topical medications.

Rectal route -- insertion of medication
into the rectum. These medications are used
primarily for their local effect(s) and include
suppositories, creams, and solutions (enemas).
Rectal medications are used as an alternative
262
Basic Hospital Corps School Lesson 3.20 Sublingual, Topical, and Rectal
Handbook III Medication Administration
to the intramuscular and intravenous routes.
Due to an abundant surface blood supply, this
route is particularly useful for children with
fever or patients with nausea or vomiting.

A suppository is an oval or cone shaped
solid substance designed for easy insertion
into a body cavity. A suppository is designed
to melt a body temperature. The most common
indication for use is to promote the expulsion
of feces and flatus.

An enema is the introduction of a
solution into the large intestines. The most
common type is a cleansing enema that is used
to empty feces from the lower intestinal tract.
An enema may also be used to relieve
distention, for destruction of internal parasites,
or to supply the body with fluids or nutrients.

PATIENT PRIVACY, SAFETY,
EDUCATION, AND COMFORT

Patient care, always involves education,
privacy, safety, and comfort. A full
explanation of what is going to happen and
why the procedure is necessary will help you
obtain cooperation and ensure proper
administration of the medication. Patients
should know the purpose of the medication
and the potential side effects. Always close the
door and/or pull the curtains around the
patient's bed for privacy. Expose only the
areas necessary for the procedure. Remember
to lock the bed wheels and to raise the
opposite side rail to ensure the safety of the
patient. Prior to administering any medication,
ask if the patient has any allergies. Proper
patient positioning will assist in accomplishing
the procedure. For your (and the patient's)
comfort and safety raise the bed to a
comfortable working level.

Refer to Oral Medications lesson for
detailed instructions regarding medication
administration. The five drug rights and
identification checks for patients apply to all
medication administration.

ADMINISTERING SUBLINGUAL
MEDICATION

Preparation of sublingual medication is
done essentially the same as oral medication
using the unit dose or floor stock system.
When administering a sublingual medication
you must have the patient's cooperation.
He/she must be conscious and able to
understand instructions. Never give sublingual
medications to an unconscious patient. Help
the patient into a sitting position (unless
contraindicated) and instruct the patient to
place the medication under the tongue. The
patient should not eat, chew, or smoke until
the medication is dissolved and absorbed.
Remain with the patient, watching for possible
side effects, until the medication is absorbed.

APPLYING TOPICAL
MEDICATION TO THE SKIN

Wash your hands and don clean gloves to
prevent absorption through your skin.. Cleanse
the patients skin prior to application of a
topical medication.

Topical medications are applied and
absorbed through the skin in two ways. Oils,
lotions, and ointments, are rubbed into the
skin. This procedure is called inunction.

Transdermal topical medications are
applied via a patch and are absorbed through
the hair follicles and sweat glands. Place the
patch on a non-hairy skin surface. The two
best locations are on the chest wall or the
upper arm of the patient. Since transdermal
patches stay on the skin for extended periods
of time, rotate application sites to avoid skin
irritation. After administering the medication
remove your gloves and wash your hands.

APPLYING TOPICAL
MEDICATION TO THE EYES

Wash your hands. Cleanse the patients
eyelid and lashes from inner to outer canthus
using normal saline (NS) or water. Place the
patient in a supine or sitting position with the
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Lesson 3.20 Sublingual, Topical, and Rectal Basic Hospital Corps School
Medication Administration Handbook III
head tilted back and to the side on which
administration will take place. Have the
patient look away from you when the solution
is administered so it will not enter the tear
duct. Place a thumb or two fingers below the
margin of the eyelashes under the lower lid
and gently pull the lower lid down exposing
the conjunctiva. Tell the patient to look up
during administration of the medication. Instill
drops into the center of the lower conjunctiva.
Instill ointment by applying a ribbon of
medication from the inner to the outer canthus
of the lower eyelid. Do not allow the
applicator to touch the eye at any time during
administration of medication. If both drops
and ointment are ordered, instill drops first
and ointment last.

Following instillation, instruct the patient
to gently close both eyes and move the eyes
around. Instruct the patient not to rub his/her
eyes. Wipe or sponge any excess medication
from the patient's skin and wash your hands.

APPLYING TOPICAL
MEDICATION TO THE EARS

Wash your hands and position patient with
the affected ear up. Straighten the auditory
canal of an adult patient by gently pulling the
ear up and back. Straighten the auditory canal
of a child patient by gently pulling the ear
down and back. Instill the correct number of
drops by directing the medication along the
side of the ear canal, not directly on the
eardrum. If ordered, place cotton loosely in the
ear and instruct patient to remain in position
for five minutes. Wash your hands.

Eye and ear instillation should be done
with the medication at room temperature to
avoid discomfort to the patient. Never return
unused medication to the bottle, to prevent
contamination of the remaining solution.

APPLYING TOPICAL
MEDICATION TO THE NOSE

Wash your hands and position patient with
his/her head tilted backwards. Unless
contraindicated have the patient blow his/her
nose before administering the medication.
Instruct the patient to breathe through his/her
mouth during administration of the
medication. Draw enough solution into the
dropper for both nares. Do not return unused
solution to the bottle to avoid contamination of
the remaining solution. Instill the correct
number of drops by holding the dropper
slightly above the nostril then carefully
inserting the tip of the dropper into the nares.
Instruct patient to remain in position and not
to blow nose for five minutes. Wash your
hands.

ADMINISTERING
SUPPOSITORIES

Wash your hands and don clean gloves.
Position the patient in the left Sim's position
exposing only the buttocks. Remove the
wrapper and lubricate the suppository and
your gloved finger. Separate the buttocks so
the anus is in plain view. Instruct the patient to
take deep breaths to help relax the anal
sphincters. Insert the suppository beyond the
internal sphincter, about a finger length. The
suppository should be in contact with the
mucous membrane and should not be
embedded in stool. Instruct the patient to
retain the suppository until he/she has the urge
to defecate, normally 15 to 45 minutes.
Remove your gloves and wash your hands.

ADMINISTERING ENEMAS

The most common solutions for enemas
are soap and water, normal saline, and a
highly concentrated hypertonic solution. A
hypertonic solution is commonly used to
cleanse the lower intestinal tract for several
reasons. Hypertonic solution draws fluid from
body tissues into the bowel, so only a small
amount of solution is needed (120 ml). These
solutions are available in commercially
prepared, disposable containers. Hypertonic
solutions minimize patient distress and
fatigue. Patients can easily self-administer
hypertonic enemas.

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Basic Hospital Corps School Lesson 3.20 Sublingual, Topical, and Rectal
Handbook III Medication Administration
RECORDING THE
ADMINISTRATION OF
MEDICATIONS
Wash your hands and don clean gloves.
Position the patient in a knee-chest position, if
not contraindicated. Otherwise position the
patient lying in bed on his/her back or on
either side. Insert the prelubricated tip
completely within the rectum. While applying
gentle, steady pressure on the solution
container, instill the solution. Instillation
should take one to two minutes, with results
expected in two to eight minutes. Remove the
gloves and wash your hands.

Medication administration is recorded
after the medication has been administered.
Routine medications are recorded on the front
of the Medication Administration Record
(MAR). On the back, top portion of the MAR,
record single order, pre-op, and STAT
medications. On the back, bottom portion of
the MAR, record PRN medications. A Nursing
Note is required for single order, pre-op,
STAT, and PRN medications.








265
Lesson 3.20 Sublingual, Topical and Rectal Basic Hospital Corps School
Medication Administration Worksheet Handbook III
Lesson 3.20

Sublingual, Topical, and Rectal
Medication Administration Worksheet

1. Match each definition in column B with the correct term in column A.

A B


a. Sublingual Route ______________


b. Topical Route ______________


c. Rectal Route ______________


d. Suppository ______________


e. Enema ______________

1. An oval or cone shaped solid substance that
melts at body temperature.

2. Medication placed on the skin or mucous
membrane

3. Introduction of a solution into large
intestines.

4. Medication is placed under the tongue.


5. Insertion of medication into rectum.

2. Circle each method for providing patient privacy.

a. Close the door to the patient's room.

b. Pull the curtain around the bed.

c. Expose only the area necessary.

3. Sublingual medications are administered:

a. orally.

b. intramuscularly.

c. subcutaneously.

d. by placing medication under the patient's tongue.

4. The epithelium and the rich network of capillaries of the underside of the tongue provide
__________________ absorption of drugs and __________________ drug action.


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Basic Hospital Corps School Lesson 3.20 Sublingual, Topical and Rectal
Handbook III Medication Administration Worksheet
5. Sublingual medication gain access to the general circulation:

a. by going through the liver.

b. after being affected by gastric and intestinal enzymes.

c. by direct absorption of the drug.

d. after being absorbed by the muscles.

6. Circle each reason medication may be administered sublingually.

a. The medication gains access to general circulation without going through the liver or
intestines

b. The medication is absorbed through the thin epithelium and the rich network of capillaries on
the underside of the tongue.

c. The medication is rapidly absorbed.

d. The medication increases potency by interaction with gastric and intestinal enzymes.

7. For the administration of sublingual medications the patient should be placed in the
____________________ position.

8. Sublingual medication should not be administered to __________________________ patients.

9. Water should be offered to the patient after administration of a sublingual medication to help with
swallowing.

a. True b. False

10. List the ways topical medications are absorbed through the skin.

a. ________________________________

b. ________________________________

11. Transdermal absorption means absorption:

a. through hair follicles and sweat glands.

b. through the skin glands.

c. by inunction.

d. through mucus membranes




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Lesson 3.20 Sublingual, Topical and Rectal Basic Hospital Corps School
Medication Administration Worksheet Handbook III
12. The best patient position for instillation of eye drops is:

a. supine with the patient's head tilted back.

b. prone with the head looking toward the floor.

c. head back, looking away from the person administering medication.

d. patient on his/her side, head looking toward the ceiling.

13. Eye drops or ointments are instilled into the ________________________________ of the lower
conjunctival sac.

14. How do you straighten the auditory canal for an adult? __________________________________

15. When instilling topical medications to the ear the patient should be positioned with the

______________________________________________________________________________

16. Eardrops should be placed directly on the eardrum.

a. True b. False

17. Eardrops are administered at room temperature to:

a. avoid discomfort to the patient.

b. ensure maximum effectiveness of the medication.

c. promote ease of administration.

d. to avoid damage to the medication with temperature changes.

18. When instilling topical medications to the nose, position the patient:

a. with head tilted forward and to the side.

b. with head tilted backwards.

c. supine, looking at the feet.

d. with head tilted backwards and to the side.

19. After instillation of nose drops, the patient should remain in position for 10 minutes.

a. True b. False

20. When administering suppositories how is the patient positioned?

______________________________________________________________________________

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Basic Hospital Corps School Lesson 3.20 Sublingual, Topical and Rectal
Handbook III Medication Administration Worksheet
21. A suppository is inserted:

a. about two inches.

b. to the internal sphincter.

c. three to five inches.

d. beyond the internal sphincter, about a finger length.

22. After insertion of a suppository, instruct the patient to retain it for 15 to 45 minutes.

a. True b. False




269
Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School
Medication Administration Handbook III
Lesson 3.21

Intramuscular and Subcutaneous
Medication Administration

Terminal Objective:


3.21 Administer medications using the intramuscular and subcutaneous routes.

Enabling Objectives:

3.21.01 List equipment for administering medications using the intramuscular and subcutaneous
routes.

3.21.02 List common intramuscular and subcutaneous injection sites.

3.21.03 List basic concepts and guidelines for administering medications using the intramuscular and
subcutaneous routes.

3.21.04 List documentation requirements for administering medications using the intramuscular and
subcutaneous routes.

3.21.05 Prepare and administer a medication using the intramuscular route.

3.21.06 Prepare and administer a medication using the subcutaneous route.



The term parenteral refers to all routes of
medication administration except oral.
However, parenteral is used most commonly
to indicate intravenous and injection routes.
Drugs injected intramuscularly or
subcutaneously are absorbed from the
injection site into the blood capillaries and the
lymphatic system. Absorption from an
injection is more rapid and complete than
absorption from the gastrointestinal tract
because destruction and inactivation of drugs
by digestive juices is avoided. The effects of
medications administered by injection are
prompt and predictable, and a more accurate
dosage can be attained. However, injury to the
patient and complications may arise due to
faulty injection technique. Drugs that are
administered by parenteral methods must be
prepared and given using principles of surgical
asepsis. Using sterile technique minimizes the
danger of injecting pathogens into the patient.

EQUIPMENT

Parenteral medications are usually
administered by needles and syringes. Both
are available in various sizes and each has
individual parts that must always remain
sterile and other parts that may be touched.

A needle consists of the: shaft, hub,
lumen, hilt, bevel, and needle guard, Figure
3.21.01. The shaft is the long, cylindrical
hollow tube. This portion is usually made of
stainless steel and must remain sterile. The
hollow inside diameter of the shaft is called
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Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous
Handbook III Medication Administration
the lumen. The hub is the wide base portion
of the needle that fits over the syringe tip. This
area is frequently plastic and is color-coded
with the specific gauge size of the needle. The
hilt is the junction between the hub and shaft,
and must remain sterile. The bevel is the
distal, tapered open end of the shaft that must
remain sterile. For subcutaneous injections,
the position for insertion is bevel up. In this
position, the sharpened or pointed end of the
bevel enters the skin first, which will create an
incision, making it possible for the rest of the
needle to enter the body tissue. The final part
is the needle guard. This is a cap that protects
the needle and helps maintain sterility.

Needles are available in different lengths
and gauges. The gauge is the diameter of the
needle lumen. The size of the needle to be
used will depend upon the tissue of the
injection site. Needle length can vary from 1/2
to 2 1/2 inches, Figure 3.21.02.

The syringe is a graduated tubular outer
portion (the barrel) and a solid inner portion
(the plunger). The barrel is hollow. The outer
wall of the barrel has a scale calibrated in cc's
or minims and cc's. (CAUTION: Ensure cc's
are used to prevent medication error.) The
outer portion of the syringe wall is unsterile
and will be handled when administering and
preparing the medication. At the end of the
barrel is the tip. The tip is the small end that
fits into the needle hub when assembling the
needle and syringe together. The final part of
the syringe is the plunger that is the inner
movable section. On its end, is the knob. The
knob is the only part of the plunger which can
be touched in order to maintain sterility,
Figure 3.21.03. Syringes are available in sizes
from 1 cc to 50 cc.

Medication may be packaged in a variety
of containers. A vial, which is a glass or
plastic container that has a self-sealing rubber
stopper, may be single dose, containing one
dose, or multi-dose, containing many doses,
Figure 3.21.04. A multi-dose container must
be dated when opened and may require
refrigeration after opening. Medication may be
premixed or in powder form, which means a
liquid must be added to reconstitute the
medication before use. Air equal to the
amount of medication to be withdrawn must
be injected into a vial before withdrawing the
drug. An ampule is a sealed glass container
that must be broken in order to withdraw the
liquid medication. Any unused medication in
an ampule must be discarded after the dosage
is withdrawn.

A prefilled medication cartridge is a
commercially prepared single dose medication
that has a needle permanently attached to a
calibrated barrel. There is no plunger, so a
cartridge holder is used to administer the
medication. A cartridge holder is a reusable
metal or plastic holder that fits the prefilled
medication cartridge.

Additional equipment needed to
administer an injection includes: antiseptic
swabs, sterile gauze pads, clean gloves, and
Band-Aids.

SITE SELECTION

Selecting the appropriate site for
subcutaneous and intramuscular injections
ensures that the medication solution will be
most readily absorbed by the body and also
ensures the safety of the patient.

An intramuscular (IM) injection is the
administration of a solution containing
medication into a muscle or muscle group.
Deep muscles contain very few nerve endings,
so irritating drugs are commonly given by
intramuscular injection. Medication injected
intramuscularly is absorbed more rapidly than
any other route, except intravenously. Various
muscles may be used as IM injection sites. In
order to select an injection site, the corpsman
must know how to identify certain landmarks
to avoid injuring large nerves, striking bones,
or entering blood vessels. Muscles commonly
used for the intramuscular administration of
medications are located in the upper arm,
thigh, and buttock. There are advantages and
disadvantages associated with the muscles in
each of these particular injection sites.

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Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School
Medication Administration Handbook III
A site for an IM injection in the upper arm
is the deltoid muscle, Figure 3.21.05.
However, caution must be taken since this is a
small and shallow muscle. Only small
amounts of medication (1 cc or less) can be
injected here. A one-inch or shorter needle
must be used to avoid hitting the humerus. Do
not use this site for infants or children due to
inadequate muscle development.

Another favored site is the thigh,
particularly the vastus lateralis muscle
located on the lateral thigh. This injection site
contains no major nerves or vessels. This site
is an excellent choice for use in children or
thin, debilitated adults. The rectus femoris
muscle is located on the anterior aspect of the
thigh. This site is commonly used in infants
since it is highly visible and easily located,
Figure 3.21.06.

The dorsogluteal muscle is located on the
back of the hip and is the outer aspect of the
upper outer quadrant, Figure 3.21.07. Proper
identification of the dorsogluteal site is
essential to avoid entry into major nerves such
as the sciatic nerve and blood vessels. This
site is commonly used for IM injections
because it can receive large volumes of fluid
with minimal pain. Do not use for children
under three years old, due to inadequate
muscle development.

The final IM site is the ventrogluteal that
is located on the side of the hip, just below the
iliac crest, Figure 3.21.08. There are no large
nerves or blood vessels in this area.

A subcutaneous (SC) injection involves
the administration of a medication into the
tissues and blood vessels that lie between the
epidermis and the muscle. The medication is
absorbed fairly rapidly and begins acting
within one-half hour after being administered,
figure 3.21.09.

There are two preferred sites for a
subcutaneous injection: the lateral aspect of
the upper arm, specifically the middle third of
the arm, Figure 3.21.10 and the abdomen,
specifically the anterior and lateral aspect,
Figure 3.21.11.

INJECTION GUIDELINES

There are important factors that affect the
proper site selection. 1) Amount and type of
solution. Use large muscles for amounts
greater than 2 cc. Type and characteristic of
medication is an important consideration. Any
thick (viscous) or irritating solution should be
given in a large muscle (avoid the deltoid). 2)
The general condition of the patient.
Overall, the patient's general nutritional status
will be reflected in the muscular development
and fatty deposits present. Note any
restrictions of movement the patient exhibits.
Note the general appearance of the injection
site. It should be free of skin lesions,
inflammation, rashes, or moles. Try to avoid
extremely hairy sites, as this may set up local
tissue reactions. 3) Frequency of injections in
specific sites indicates the need for rotation of
sites. Signs of irritation (puncture marks,
redness, and swelling) indicate the need for
rotation of sites. The MAR NAVMED 6550/8
has a list of injection site codes to assist the
health care provider with site selection. This,
along with the corpsman's knowledge of
anatomical location of large nerves and blood
vessels is imperative to avoid damage to these
areas.

Be sure to acquire and administer the
correct medication to the correct patient. This
process starts with verifying the MAR
NAVMED 6550/8 with the Patient Profile
NAVMED 6550/12 at the beginning of the
shift. If there is a discrepancy, compare the
MAR with the original Doctor's Orders SF
508 to identify the transcription error.

Perform three medication checks to ensure
the correct dose of the correct medication is
prepared. The first medication check is
performed when locating the medication in the
drawer or on the shelf. The second
medication check occurs after the needle and
syringe are assembled. Next, the medication
dose is calculated. The third medication
check occurs after the medication has been
272
Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous
Handbook III Medication Administration
prepared in the syringe. The repetition of the
medication checks helps to guard against
errors. When performing the medication
checks, verbally state, I need... when
reading the MAR and I have... when looking
at the vial or syringe.

PATIENT CONSIDERATIONS

The primary considerations include
explaining the procedure to the patient and
ensuring privacy, safety, and comfort at all
times during the procedure.

Always explain the procedure you will be
performing and its rationale to the patient prior
to beginning any action. This information will
eliminate any misunderstandings and will
elicit better patient cooperation.

It is important, as well as common
courtesy, to provide for the patient's privacy.
Accomplish this by using bed drapes or
screens prior to beginning the procedure.
Ensure safety of the patient by locking the bed
wheels and raising the side rail on the opposite
side so the patient won't fall out of bed.
Finally, be certain of the patient's comfort
during the procedure. Position the patient so
that the injection can be given safely and as
comfortably as possible. After administrating
the injection, massage the area to aid
absorption, unless contraindicated.

INJECTION COMPLICATIONS

The corpsman should be constantly on
alert for signs of complications when a patient
is receiving medication by means of injection.
The best safeguards against complications are
maintaining aseptic technique during
preparation and administration and utilizing
proper injection technique. Always check
equipment (needle and syringe) for possible
contamination and check the medication for
particles floating in the solution before use.

Tissue trauma can be minimized by
selecting the proper injection site as well as
the proper needle length and gauge.
Supporting of the flesh during needle insertion
will also help decrease tissue trauma. When
administering an IM injection, spread the
flesh taut. Use 20-23 gauge needles that are 1-
1 1/2 to 2 inches in length for adults or 1 inch
length for children. To administer a SC
injection, pinch the flesh into a cushion. Use
23-25 gauge needles that are 1/2 to 5/8 inches
in length.

Insert the needle rapidly and without
hesitation. Always aspirate to avoid
inadvertent injection into a blood vessel. To
aspirate: pull back on the plunger of the
syringe before injecting the solution into the
tissue. While aspirating, observe for blood in
the hub of the needle or tip of the syringe. If
none is present, continue with the injection. If
blood is present, withdraw the needle, apply
direct pressure to injection site, and discard
the medication. Prepare a new injection and
select a new injection site.

Hold the syringe steady and inject the
drug slowly. Then withdraw the needle rapidly
at the same angle as insertion Finally, rotate
injection sites to diminish tissue trauma of
repeated injection in the same site.

EQUIPMENT DISPOSAL

To prevent injury, proper disposal of
contaminated equipment is essential. NEVER
RECAP A USED OR CONTAMINATED
NEEDLE. The used medication cartridge is
disassembled from the cartridge holder and the
cartridge is discarded in a puncture resistant
Sharps container. The cartridge holder is not
discarded since it is reusable. If the cartridge
holder becomes soiled, follow the local policy
for cleaning. The syringe and needle that was
assembled to administer the SC injection is
discarded together in a puncture resistant
Sharps container. Never dispose of used
injection equipment in the general trash.





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Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School
Medication Administration Handbook III
RECORDING MEDICATION
ADMINISTRATION
c. Medication refusals are indicated with
an asterisk in the medication
time/dose box.

Administration of all medications is
recorded on the MAR NAVMED 6550/8.
Administration of PRN medications or a
refusal of medication are also recorded in the
Nursing Notes SF 510. Use the following
guidelines:
5. Enter initials, full signature, and rate in
Initial Code Box Section if not already
done.

6. Nursing Notes SF 510 entries are also
needed for:

1. Ensure MAR is stamped with the patient's
correct addressograph.
a. Patient refusal of medication.

b. PRN medications
2. Record only after administration of the
medication.

(1) Enter reason for medicating.

3. Locate medication on MAR.
(2) Enter administration of
medication.
4. Record your initials in appropriate square
on MAR

(3) Enter effectiveness of medication.

a. Utilize an injection site code to help
with rotation of sites, located on lower
right front of MAR.
c. Side effects and adverse reactions.

7. Some medications, such as
immunizations, also require a Health
Record entry.

b. Enter the circled site code number in
initial code square with your initials.



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Handbook III Medication Administration











FIGURE 3.21.01
Parts of a Needle




























FIGURE 3.21.02
Needle Gauges
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Medication Administration Handbook III





















FIGURE 3.21.03
Various Size Syringes and Their Parts

















FIGURE 3.21.04
Medication Containers
A. Ampule B. Vial
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Handbook III Medication Administration




















FIGURE 3.21.05
Intramuscular Injection Site
(Deltoid Muscle)

FIGURE 3.21.06
Intramuscular Injection Sites
(Vastus Lateralies & Rectus Fermoris)
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Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School
Medication Administration Handbook III




















FIGURE 3.21.07
Intramuscular Injection Site
(Dorsal Gluteal)

















FIGURE 3.21.08
Intramuscular Injection Site
(Ventrogluteal)
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Handbook III Medication Administration
















FIGURE 3.21.09
Tissue Penetration






















FIGURE 3.21.10
Site of Subcutaneous Injection
(Side View)
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FIGURE 3.21.11
Subcutaneous Injection Sites
(Abdomen)
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Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous
Handbook III Medication Administration
NOTES/COMMENTS
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Basic Hospital Corps School Lesson 3.21 Intramuscular and Subcutaneous
Handbook III Medication Administration Worksheet
Lesson 3.21

Intramuscular and Subcutaneous
Medication Administration Worksheet

1. What is the correct gauge and length needle for an intramuscular injection?

a. 21 gauge, 1 1/2 inch length

b. 22 gauge, 3/4 inch length

c. 23 gauge, 1 1/4 inch length

d. 25 gauge, 1/2 inch length

2. The proper gauge and needle length for a subcutaneous injection is 22 gauge with one-inch
length.

a. True b. False

3. Which of the following is not part of a needle?

a. Tip

b. Hub

c. Bevel

d. Lumen

4. The dorsogluteal injection site should be avoided in patients 6 years of age or older.

a. True b. False

5. When withdrawing medication from an ampule, first draw in air equal to the dose of medication
to be withdrawn.

a. True b. False

6. What syringe part fits into the hub of the needle?

a. Tip

b. Knob

c. Bevel

d. Barrel
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Medication Administration Worksheet Handbook III

7. Circle the preferred sites for subcutaneous injections.

a. Thigh - rectus femoris

b. Upper arm - deltoid

c. Upper arm - middle 1/3 outer lateral surface

8. List three factors that affect injection site selection.

a. _________________________________________

b. _________________________________________

c. _________________________________________

9. Which preferred site for intramuscular injections requires the use of a short needle to avoid injury
to the patient?

a. Dorsogluteal

b. Upper arm - middle 1/3 outer lateral surface

c. Upper arm - deltoid

d. Ventrogluteal

10. When withdrawing medication from a vial, it is necessary to inject air from the syringe into the
vial.

a. True b. False

11. To dispose of equipment after administration of an injection:

a. discard cartridge and holder in the sharps container.

b. discard needle and syringe in the sharps container.

c. re-cap needle and discard in the sharps container.

d. discard syringe only in trash.

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Handbook III Medication Administration Worksheet
12. Which position is considered best for administering an intramuscular injection into the
dorsogluteal muscle?

a. Prone

b. Supine

c. Sim's

13. During an injection, blood is noted upon aspiration. What should be the next step?

a. Change to a different site and continue to inject the medication.

b. Discard medication and record as wasted.

c. Continue to inject the medication and report the occurrence to the nurse.

d. Discard the medication and prepare a new injection.

14. When is the administration of medication recorded?

a. At the time the medication is ordered

b. After administration of the medication

c. Right after shift change

d. J ust before going to the patient's room/bedside

15. If a patient refuses a medication, how is it recorded?

a. Leave the medication square on the MAR blank since no medication was given

b. Initial the appropriate square on the MAR

c. Place an asterisk in the appropriate square on the MAR

d. Only on the Nursing Notes SF 510

16. Immunizations for active duty members admitted to the hospital are recorded where?

a. Nursing Notes SF 510 only

b. Health record

c. MAR

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Lesson 3.21 Intramuscular and Subcutaneous Basic Hospital Corps School
Medication Administration Worksheet Handbook III
17. A Nursing Notes SF 510 entry is not required for:

a. PRN medications.

b. medication refusal.

c. routine medications.

d. adverse reactions.
285
Lesson 3.24 Venipuncture Basic Hospital Corps School
Handbook III
Lesson 3.24

Venipuncture

Terminal Objective:

3.24 Perform venipuncture.

Enabling Objectives:

3.24.01 List basic concepts and guidelines for venipuncture.

3.24.02 List the supplies needed to perform venipuncture.

3.24.03 Define common complications of venipuncture.

3.24.04 List documentation requirements for venipuncture.

3.24.05 Perform venipuncture to collect a laboratory specimen.


The laboratory analysis of blood and its
components is a common process used to aid
in making an accurate clinical diagnosis. The
most common method of obtaining blood
specimens is by venipuncture, the therapeutic
act of puncturing a vein. The purposes of
venipuncture are to:

1. obtain blood specimens.

2. infuse fluids and blood.

3. administer medication.

4. draw blood for diagnostic testing.

In order for venipuncture to be completed
successfully the vein must be:

1. large enough to receive the shaft of the
needle

2. visible and palpable after the tourniquet is
correctly placed

3. intact (without lacerations).

Veins should be chosen that are located in
uninjured extremities since scar tissue may
interfere with correct location of the vein and
successful insertion of the needle. Veins
chosen for venipuncture should not be
proximal to a site where fluids are being
infused as this will result in abnormal lab
results. Thrombosed (clotted), tortuous
(crooked), or rolling veins should not be used
for venipuncture. A straight and stable vein
affords the best opportunity for successful
venipuncture.

The veins in the bend of the elbow
(antecubital space) are the preferred
venipuncture location, Figure 3.24.01.
However, variables such as patient choice,
age, medical conditions, and other treatments
may necessitate the use of other sites for
venipuncture. As in any procedure where you
may have contact with a patient's blood or
body fluids, protect yourself by using
Universal Precautions. If no vein is
immediately visible after placement of a
tourniquet, you can promote vein distention
by:

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Basic Hospital Corps School Lesson 3.24 Venipuncture
Handbook III
1. patient clenching and unclenching the fist

2. tapping the area lightly.

3. patient lowering the arm

4. applying warm compress over the
intended venipuncture site ten to twenty
minutes. Be sure to release the tourniquet
while the compress is in place.

SUPPLIES

Performing venipuncture can be easy with
the proper equipment and a good knowledge
of the procedure. Start by determining the lab
test to be performed and fill out the laboratory
request form (chit) correctly. It must include
the patient's name, social security number, rate
or dependency status, branch of service, and
duty status (active or retired). The laboratory
chit must include the date and time the
specimen was drawn, the source and the
specific test requested. Fill in the requesting
physician's name and your initials. Enter any
pertinent remarks in remarks section such as
the patient's diagnosis, or anything that might
affect the test in any way.

Additional equipment required includes a
specimen label, protective pad (Chux),
tourniquet, vacutainer holder, multidraw or
single draw vacutainer needles, the proper
vacutainer tube, antiseptic swabs, sterile 2x2,
Band-Aid, and clean gloves.

The specimen label must include the
patient's full name, Social Security Number of
Family Member Prefix, rate/rank, or
dependency status, branch of service, and
active duty or retired.

The tourniquet is used to restrict venous
blood flow distal to where the tourniquet is
applied. The vacutainer holder is a disposable
plastic barrel or sleeve that connects the
vacutainer needle to the selected vacutainer
tube. The vacutainer needle is a sterile needle
that is used to collect one vacutainer tube of
blood (single draw) or can remain in the vein
while numerous blood specimens are obtained
(multidraw needle). Vacutainer tubes are a
vacuum test tube sealed with a colored rubber
stopper, Figure 3.24.02. The tubes come in
various sizes with the color of the rubber
stopper top depending on the preservatives or
anticoagulants in the tube. If unsure as to the
type of vacutainer tube to use for a particular
test, consult the laboratory manual, ask
laboratory personnel, or contact a nurse or
physician. Two commonly used tubes are the
red topped tube for evaluation of serum
contents and the lavender topped tube for
evaluation of different blood cells.

COMPLICATIONS OF
VENIPUNCTURE

As with any procedure the patient will
need to be monitored for complications after
venipuncture. The following are commonly
seen complications:

Hematoma -- collection of blood usually
clotted, in an organ, space or tissue that
develops after a break in a vessel wall or due.
A hematoma may develop if insufficient direct
pressure is applied to the puncture site after
the needle is removed. Commonly called a
bruise.

Phlebitis -- inflammation of a vein. It may
result from repeated puncture of a vein, and/or
use of improper venipuncture technique.

Septicemia -- systemic disease caused by
the presence of pathogenic microorganisms or
their toxins in the blood. It may result from
improper technique or the use of contaminated
equipment.

Trauma -- Injury to underlying tissues
usually caused by probing with the needle
during venipuncture in attempts to locate the
vein.

DOCUMENTING
VENIPUNCTURE

Venipuncture needs to be documented on
the Patient Profile NAVMED 6550/12. Note
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Lesson 3.24 Venipuncture Basic Hospital Corps School
Handbook III
aseptically clean. Remove the needle guard,
grasp the patients extremity with you non-
dominate hand so the thumb rests on the skin 2
inches distal to the site of venipuncture and
exert tension pulling the skin toward the
patients hand, Figure 3.24.04 and 3.24.05.
Holding the vacutainer at a 15-degree angle
with the bevel up, insert the needle into the
vein, Figure 3.24.06. Steady your hand
against the patient's arm. Release the skin and
advance the tube, puncturing the rubber
stopper (using your non-dominate hand).
Blood flow should start immediately if the
needle is in the vein. Release the tourniquet.
Once the tube is full, you may discontinue the
venipuncture.
the date the test sample was sent to the lab.
The Nursing Notes SF 510 entry should
include the date and time the specimen was
drawn, the specific test ordered, disposition of
the specimen, the patients tolerance of the
procedure, and the location the specimen was
drawn from.

INITIATING VENIPUNCTURE

This section explains the step by step
process for performing venipuncture for
obtaining a blood specimen in a safe, effective
manner.

Many wards or clinics have all the
equipment in a specific tray used for
venipuncture. After gathering the equipment,
wash your hands and assemble the needle and
holder. Insert blood tube until edge of stopper
meets the guideline on the vacutainer holder.
Next, take the equipment into the patient's
room. Check patient identification comparing
it to the lab chit; ask about allergies. Explain
the procedure and provide for patient privacy
and safety. Place the Chux pad under the
patient's arm. Place a tourniquet about three
inches above the selected site (usually a fairly
large, convenient vein in the antecubital
space), Figure 3.24.03. Evaluate the site and
don clean gloves. If necessary, promote vein
distention. Once a suitable vein has been
located, cleanse the area with an antiseptic
swab by using a circular motion from center of
site outward. The selected site is now

DISCONTINUING
VENIPUNCTURE

To discontinue, ensure the tourniquet is
released. Remove tube from the holder. Place
a sterile 2x2 lightly over the puncture site, and
withdraw the needle quickly. Apply pressure
to the puncture site or until bleeding stops. Do
not recap needle. Carefully dispose of needle
and vacutainer holder (without disassembling)
in a puncture resistant container. Apply a
Band-Aid over the venipunture site. Dispose
of remaining equipment. Attach the lab chit
and the specimen label with the patient's
addressograph to the vacutainer tube of blood.
Remove gloves and wash hands. Transport
specimen to the laboratory. Document the
procedure. Wash hands and document the
procedure.



FIGURE 3.24.01
Common Venipuncture Sites
FIGURE 3.24.02
Vacutainer
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Basic Hospital Corps School Lesson 3.24 Venipuncture
Handbook III

FIGURE 3.24.03
Tourniquet Placement
FIGURE 3.24.04
Venipuncture
FIGURE 3.24.05
Venipuncture
FIGURE 3.24.06
Needle Insertion
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Lesson 3.24 Venipuncture Worksheet Basic Hospital Corps School
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Lesson 3.24

Venipuncture Worksheet

1. Venipuncture is defined as _________________________________________________.

2. List the purposes of venipuncture.

a. ___________________________________________

b. ___________________________________________

c. ___________________________________________

d. ___________________________________________

3. Characteristics of a vein suitable for use in venipuncture is one that is:

a. tortuous and thrombosed.

b. visible and palpable after tourniquet placement.

c. located on an injured extremity.

d. smaller than the shaft of the venipuncture needle.

4. Circle each way to promote venous distention.

a. Raise patients arm

b. Tap lightly on selected vein

c. Apply cool compresses

d. Have patient clench and unclench fist

5. The purpose of a tourniquet in performing a venipuncture is _____________________________.

6. If you are unsure of the type or color of vacutainer tube to use, what reference sources are
available to assist you?

a. Patient

b. Ward nurse

c. Laboratory manual

d. Pharmacy personnel

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Basic Hospital Corps School Lesson 3.24 Venipuncture Worksheet
Handbook III
7. Which of the following best describes hematoma?

a. Inflammation of a vein

b. Collection of blood, usually clotted, in an organ, space or tissue

c. The therapeutic act of puncturing a vein

d. Restriction of venous flow to obtain blood

8. Trauma to underlying tissues is caused by ___________________________.

9. Venipuncture of a patient is recorded on the:

a. __________________________________________

b. __________________________________________

10. When performing a venipuncture, where is the tourniquet applied in relation to the selected site
for venipuncture?

a. 3 inches below the selected site

b. 3 inches above the selected site

c. 1 inch below the selected site

d. 1 inch above the selected site

11. When performing venipuncture, at what angle is the needle inserted into the vein?

a. 15 degrees

b. 30 degrees

c. 45 degrees

d. 90 degrees
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Lesson 3.24 Venipuncture Worksheet Basic Hospital Corps School
Handbook III
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Handbook III
Basic Hospital Corps School Lesson 3.24 Venipuncture Worksheet
Handbook III
293

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Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School
Handbook III
Lesson 3.25

Introduction to Intravenous Therapy

Terminal Objective:

3.25 List concepts and principles of intravenous therapy.

Enabling Objectives:

3.25.01 List the purposes of intravenous therapy.

3.25.02 List common intravenous fluids and their specific indications.

3.25.03 List complications of intravenous therapy and measures to prevent their occurrence.

3.25.04 List principles and guidelines of blood transfusion.

3.25.05 List the signs and symptoms of adverse transfusion reactions.

3.25.06 List basic emergency care for adverse transfusion reactions.

3.25.07 State the purpose for monitoring intake and output.

3.25.08 State methods of assessing fluid balance.

3.25.09 List sources of intake fluids and output fluids.

3.25.10 State the procedure for initiating the measurement of intake and output.

3.25.11 State the procedures for measuring and recording intake and output.

3.25.12 Distinguish between intake fluids and output fluids.

3.25.13 Demonstrate documentation of intake and output.


PURPOSES OF INTRAVENOUS
THERAPY

Intravenous (IV) infusions are started for
three primary reasons. First, to provide a route
for replacement of fluids, electrolytes, or
blood products that may have been lost
through diarrhea and vomiting, diseases such
as cancer, or burns. Second, to administer
drugs to assure their prompt access into the
circulatory system. The IV route is the fastest
and most efficient way for medications to
reach all parts of the body. The third reason
for IV therapy is to provide blood expansion
in case of severe hemorrhage. Their role is to
replace a depleted intravascular volume.

TYPES OF IV FLUIDS

There are several types of intravenous fluids
and blood volume expanders. Normal Saline
(0.9% NS) and Lactated Ringers (LR) are
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Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy
Handbook III
the most common fluid and electrolyte
solutions. Electrolytes are substances capable
of breaking into ions and developing an
electrical charge when in solution. IV's of NS
and LR help to correct losses due to vomiting,
diarrhea, and severe diaphoresis. They can
also be used as a medium to infuse drugs. LR
solutions contain the electrolytes sodium,
potassium, calcium, and chloride.

Solutions containing 5% Dextrose in Water
(D5W) are most commonly used as a medium
to infuse drugs. The dextrose is easily
metabolized and the water is distributed to all
body fluid compartments.

Whole blood is used when blood
replacement is required, such as with
hemorrhage, severe burn, surgery,
hemodialysis, and to treat peripheral vascular
collapse or shock. In some cases, the patient
does not need all of the components of whole
blood. Packed Red Blood Cells (PRBC's)
may be given to restore a low red blood cell
(RBC) count or to treat low hemoglobin. The
added serum of whole blood may cause
circulatory overload and left--sided heart
failure so only PRBC's may be indicated.

After the RBC's are separated from whole
blood the remaining liquid portion is plasma.
Plasma is commonly used to treat clotting
deficiencies and can also be used as a blood
volume expander. Plasma Protein Fraction
(PPF) and Albumin are the proteins found in
plasma. They are frequently used a blood
volume expanders.

COMPLICATIONS OF
INTRAVENOUS THERAPY

While intravenous therapy is a common
procedure, there are some complications that
may occur. Some of these complications
include:

Air embolism -- a bubble of air circulating
in the blood. Symptoms of an air embolism are
cyanosis, hypotension, and a weak and rapid
pulse. Prevention of an air embolism consists
of ensuring that all air has been removed from
the IV tubing before connecting it to the
patient. It is also important to monitor the
tubing during administration to ensure that the
solution does not completely drain from the
bag before a new bag has been hung.

Circulatory overload -- administering too
much IV fluid too quickly. Symptoms include
headache, dyspnea, flushed skin, rapid pulse,
and pulmonary edema. Prevention of
circulatory overload includes frequent
monitoring of the infusion and careful control
of the flow rate. NEVER try to catch up an IV
in case it gets behind, as the increased flow
rate may cause circulatory overload.

Infiltration -- IV solution going into tissue,
NOT the vein. It occurs when the
needle/catheter has dislodged from the vein
and the solution escapes into the surrounding
tissue. Symptoms include edema, localized
pain, and coolness at the insertion site. A slow
flow rate or flow stopping completely also
indicates that the IV has infiltrated. Prevention
of infiltration includes carefully securing the
needle or catheter and limiting the movement
of the arm by applying an armboard.

Nerve damage -- can result from a tight
armboard that compresses the nerves.
Symptoms are numbness and tingling of the
extremity. Prevention of nerve damage
includes padding armboards before use and
making neurological checks during rounds.
Completely encircling the arm with tape when
applying the armboard can also lead to nerve
damage.

Phlebitis -- inflammation of a vein is called
phlebitis. Phlebitis is caused by IV fluids that
are particularly irritating to the vein or if the
needle/catheter is left in the same site for a
prolonged period of time. Symptoms include
pain, redness, and edema with warmth along
the vein. Phlebitis can be prevented by
changing the infusion site every 72 hours and
by changing the IV site dressing every 24
hours (or as indicated by local policy). Proper
documentation on the IV site dressing label
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Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School
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and in the Nursing Notes SF 510 will help
ensure that these changes are made.

Pyrogenic contamination -- bacterial
contamination of the IV tubing, fluid, or site.
Symptoms are restlessness, fever, chills, and
headache. Prevention consists of using aseptic
technique whenever working with IV's,
changing the tubing every 48 hours (in
accordance with local policy), and performing
IV site dressing changes every 24 hours (or
per local policy). The IV fluid container needs
to be changed at least every 24 hours even
when the infusion rate is slow and there is still
fluid in the bag at the end of the 24 hour
period.

BLOOD TRANSFUSION

Blood transfusion means the transfer of
human blood or its components from a donor
to a recipient. The purpose of a blood
transfusion is to restore the quantity and
quality of a patient's circulating blood.

Blood transfusion plays an important role in
treating battlefield casualties who have lost
significant amounts of blood from wounds,
surgery, or burns. An example of the
effectivess of blood transfusions can be cited
in the Falkland Island conflict. The battlefield
hospital on the island saved every wounded
soldier that was brought in alive. Many of the
hundreds they treated required blood
transfusion.

Prior to a blood transfusion, it must be
determined that the blood of the donor and the
recipient are compatible. Incompatible blood
types react with each other and can cause
severe reactions and even death of the
recipient. Blood is categorized into four main
groups - A, B, AB, and O, depending on the
type of protein on the red blood cells. The
blood type of the donor and the blood type of
the recipient are tested (cross-matched) to
determine compatibility.

Blood transfusions areonly administered by
authorized personnel (usually Nurses).
Hospital Corpsmen may be involved in
obtaining the necessary supplies and
monitoring the patient during the transfusion.

There are some special considerations to
remember when handling blood products. The
unit of blood should not be obtained from the
blood bank until it is needed and there is
someone available to administer the
transfusion. Blood must not remain on the
ward for more than 30 minutes prior to
administration. It cannot be stored in the ward
refrigerator prior to administration as the
temperature is not sufficiently well controlled
for blood storage. If the transfusion is not
started within 30 minutes after obtaining it
from the blood bank, the blood product must
be returned to the blood bank.

The special equipment needed for a
transfusion includes: blood administration Y
tubing with microfilter, Normal Saline
solution for IV administration, and an IV
catheter that is an 18 gauge needle or larger.

The patient requires very close monitoring
during administration of a blood transfusion.
Immediately prior to starting the transfusion,
take and record baseline vital signs. The
patient must be observed constantly during the
first 15 minutes of the transfusion to monitor
for signs and symptoms of transfusion
reactions. Vital signs are taken every 5
minutes during the first 15 minutes of the
transfusion. After the initial 15 minutes, vital
signs are taken and recorded as per local
policy.

TRANSFUSION REACTIONS

Transfusion reactions are potentially life
threatening. There are different reasons a
patient may have a reaction. While the
reasons for a transfusion reaction may vary,
the signs and symptoms are similar. It is
important to recognize them and to respond
quickly. Signs of a transfusion reaction
include: fever, anaphylaxis, hematuria (blood
in the urine), facial flushing, and hives.
Symptoms include: discomfort and anxiety,
shortness of breath, chills, pain in neck, chest
or flank area, headache, and itching. When
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Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy
Handbook III
these signs and symptoms are evident, the
transfusion must be stopped immediately by
closing the flow clamp on the blood tubing.
Do not remove the IV catheter. Disconnect
blood IV tubing. Access to the vascular
system is maintained by infusing the Normal
Saline solution at a very rapid rate, using new
tubing. Notify the nurse, physician and
laboratory personnel immediately. Take and
record the patients vital signs every five
minutes until otherwise directed. A urine
specimen and a blood specimen will also be
obtained from the recipient. The partially used
blood bag and blood tubing will be sent to the
blood bank for further analysis.

MONITORING INTAKE AND
OUTPUT

Water is essential to life. An individual
can survive only a few days without water.
Human bodies are approximately 45-75%
water. The exact amount depends upon the
age, gender, and body composition (lean or
fat) of the individual. All water in the human
body contains dissolved chemicals. The term
body fluid is used to discuss this mixture of
chemicals and water.

The purpose for monitoring a patient's
intake and output is to maintain an accurate
account of fluid balance. Fluid balance is the
state in which water remains in normal
amounts and percentages within various
locations of the body. Healthy people maintain
fluid balance automatically; the amount of
fluid in each area tends to remain fixed.
During an illness, body fluids may become
unbalanced.

Intracellular fluid is fluid within cells.
Most body fluid is intracellular.

Extracellular fluid is all fluid not in cells:

1) intravascular all the fluid within the
blood, also known as plasma or serum

2) interstitial - fluid between cells.

ASSESSING FLUID BALANCE

Assessing a patient's fluid balance can be
vital in providing proper care. The simplest
method to assess fluid balance is to compare
the amount of fluid taken in with fluid
eliminated by the body. In particular, look for
fluid loss or fluid retention.

Fluid loss is a warning sign that the patient
is at risk for fluid imbalance. Typical reasons
for loss include: Diaphoresis due to fever or
exercise. Patients with a fever may lose more
water than one whose temperature is normal.
Nausea and a poorly balance diet may precede
vomiting or diarrhea. Increased urination (over
2,000 ml per day) can be measured easily.
Wound or body drainage (such as chest tube
drainage or nasogastric tube drainage) adds to
fluid loss. Blood loss from surgery, trauma, or
an ulcer is considered fluid loss as well.

Fluid retention indicates a fluid imbalance,
and is usually associated with kidney disease
or failure. Retention also occurs with heart
disease and liver failure.

INTAKE AND OUTPUT FLUIDS

Fluid Intake is determined by measuring
the amount of fluid taken into the body. Intake
can be oral (PO), by gastric tube feeding,
intravenous (IV), or by irrigation or
instillation. Oral intake is liquid taken by
mouth, including solid foods which would be
liquid if kept at room temperature (ice cream,
gelatin, sherbet, and ice.) When a patients
medical condition prevents oral food/fluid
intake, a specially prepared infant formula-like
liquid is administered via a gastrostomy or
nasogastric tube.

Intravenous fluids includes all intake
administered through a vein. IV solutions,
blood, and blood derivatives are sources of IV
intake. IV solutions are usually a combination
of water, sugar, and salt(s). Irrigations or
instillations wash or rinse parts of the body or
tubes, as in nasogastric, bladder, or bowel
irrigations. The solution is usually water or
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Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School
Handbook III
water with salt. In many cases, the solution
will return from the body quickly. After being
counted as intake, irrigation fluid that returns
will become counted as output.

Fluid output is the total of all liquids
eliminated from the body. The primary source
of fluid output is urine. Fluid lost through
tubes such as a Foley catheter, chest tube,
Penrose drain, J ackson-Pratt (J P) drain, or
nasogastric tube is output.

Emesis, diarrhea (liquid feces or stool),
wound drainage, and irrigations or aspirations
are also sources of output. In some cases, you
will be required to measure liquid lost in
dressings, linen, and diapers. To do so, weigh
the linen or dressing before and after
absorption of liquid, or use an average dry
weight to compare against the soaking wet
weight.

Water lost from the lungs and skin during
expiration and rapidly evaporating sweat is
referred to as insensible loss of fluid.

MEASUREMENT OF INTAKE
AND OUTPUT (I & O)

Initiate I&O by verifying the Doctor's
Orders SF 508 for intake and output. This can
also be found on the Patient Profile NAVMED
6550/12. Stamp the Twenty-Four Intake and
Output Worksheet DD 792 with the patient's
addressograph card, or write in standard
patient identification information. Record the
date and starting/stopping time on the I&O
Worksheet.

Begin documenting I&O when you
receive the order. Time and date the Twenty-
Four Intake and Output Worksheet DD 792
each day the patient remains on I&O. Place
the dated worksheet at the patient's bedside.
The patient may be actively involved in
his/her care by recording intake and output on
a piece of paper. Educate the patient on the
importance of accurate I&O.

RECORDING INTAKE AND
OUTPUT

The Twenty-Four Hour Intake and Output
Worksheet DD 792 is the primary tool for
measurement of I&O, but a local form may be
used. A list of intake equivalents is at the
bottom of the DD 792. It documents how
many cc/mls are in a serving of ice cream or a
cup of coffee. Liquid intake and output is
recorded in cc/ml's. Unless ordered to do so,
or unless a specimen is needed, after noting
the amount, discard any output, using blood
and body fluid precautions.

Record the time, type, and amount of fluid
intake and fluid output on Twenty-Four Hour
Intake and Output Worksheet DD 792.
Remember to record irrigations as both intake
and output. Some conditions require aspirating
fluid from a tube or body cavity. This fluid is
also output. For example: when instilling 50
ml of water into a nasogastric tube, and
aspirating 40 ml using a syringe, record 50 ml
intake and 40 ml output.

A running total of all fluid consumed is
kept in the accumulated total column.
Maintain a cumulative total in the grand total
column and record the result at the end of 24
hours. When each DD 792 is completed place
it in the back of the patient's inpatient clinical
record (unless local policy directs otherwise.)
Every 24 hours, a new DD 792 is started as
long as the patient remains on I&O. Following
discharge, follow local policy regarding
disposition of DD 792 forms.

At the bottom of Vital Signs Record SF
511, record I&O as special data in the space
provided. On the SF 511, record the 24 hour
grand total and the cumulative total for each
type of fluid (PO, IV, tube drainage, tube
feeding, etc.)
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Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy
Handbook III






















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299
Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.25

Introduction to Intravenous Therapy
Worksheet

1. Match each use in column B to the correct IV fluid in column A.

A B


a. Normal Saline _________

b. Dextrose in water _________

c. Whole Blood _________

d. Packed Red Blood Cells _________

e. Plasma _________

1. To treat low hemoglobin

2. To correct losses due to dehydration

3. To treat clotting deficiencies

4. As a medium to infuse drugs

5. To treat severe hemorrhage

2. Match each definition in column B to the correct term in column A.


A

B


a. Infiltration _______


b. Circulatory overload _______


c. Air embolism _______


d. Pyrogenic contamination _______

e. Phlebitis _______

f. Nerve damage _______

1. Prevented by clearing all the air from the IV
tubing prior to connecting

2. Needle/catheter dislodges from vein and fluid
or a catheter left in one place too long.

3. Inflammation of a vein by irritating IV fluid
or a catheter left in one place to long

4. Armboard too tight, compressing on nerve

5. Administering too much fluid too quickly

6. Prevented by maintaining strict aseptic
technique whenever working with IVs


3. Blood for a transfusion must not be kept on the ward for longer than _____________ minutes.

4. An IV catheter used to administer blood should be no smaller than _________________ gauge.

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Basic Hospital Corps School Lesson 3.25 Introduction to Intravenous Therapy
Handbook III Worksheet
5. List the purposes of intravenous therapy.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

6. What is plasma?_____________________________________________________

7. Symptoms of phlebitis include:

a. edema.

b. coolness at site.

c. pain.

d. redness.

8. Circle each sign/symptom that indicates an air embolism.

a. Weak and rapid pulse

b. Hypotension

c. Numbness and tingling in fingers

d. Cyanosis

9. At what interval are vital signs taken during a blood transfusion?

a. ____________________________________________________________________________

b. ____________________________________________________________________________

10. List six signs/symptoms of a transfusion reaction.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

e. ____________________________________________________________________________

f. ____________________________________________________________________________


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Lesson 3.25 Introduction to Intravenous Therapy Basic Hospital Corps School
Worksheet Handbook III
11. What is the initial treatment for a patient with signs or symptoms of a transfusion reaction?

_________________________________________________________________________

12. What is the purpose for monitoring intake and output?

_________________________________________________________________________

13. Tube feedings are considered both intake and output.

a. True b. False

14. Urine is the primary form of fluid output.

a. True b. False

15. Which form is used to record intake and output each 24 hours?

_________________________________________________________________________

16. Irrigation is both intake and output.

a. True b. False

17. Match each definition in Column B with the correct term in column A.

A B


a. Intracellular Fluid _______


b. Extracellular Fluid _______


c. Intravascular Fluid _______

1. Water located in the blood, also known as
plasma or serum.

2. Body fluid located outside the cells.


3. Water that is contained within cells.

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Handbook III Worksheet
NOTES/COMMENTS







303
Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Handbook III
Lesson 3.26

Maintenance of Intravenous Therapy

Terminal Objective:

3.26 Perform selected intravenous therapy procedures.

Enabling Objectives:

3.26.01 List equipment for changing intravenous tubing, solution container and performing IV site
care.

3.26.02 List guidelines for preparing equipment used to change intravenous tubing and IV solution
container.

3.26.03 Calculate intravenous flow rate within "plus or minus" one drop per minute.

3.26.04 List guidelines for changing intravenous solution container and tubing.

3.26.05 List guidelines for performing intravenous site care.

3.26.06 List guidelines for documenting intravenous tubing change, solution container change, and
site care.

3.26.07 Change an intravenous bag and tubing.

3.26.08 Perform intravenous site care while providing patient safety, privacy, education, and
comfort.

3.26.09 Record intravenous tubing and bag changes, and intravenous site care.



EQUIPMENT FOR
MAINTAINING IV THERAPY

Routine care of existing IV therapy
includes monitoring for correct rate of
infusion, caring for the insertion site, changing
solution containers, and changing infusion
tubing. The following is a list of equipment
needed for routine care of existing IVs.

IV administration set -- allows the flow
of solution to be regulated from the IV
container to the patient's arm. The IV set
consists of the drip chamber, tubing and flow
regulator clamp, Figure 3.26.01

IV solution -- physician uses the Doctor's
Order to specify the type of solution desired
for a patient. Obtain and prepare the ordered
solution.

Antiseptic swabs -- Betadine sponges or
alcohol swabs are used to cleanse around the
insertion site.

Tape -- various widths of tape are used to
anchor the catheter, secure the IV tubing, time
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Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III
tape the IV solution container, label the IV
container, label the IV tubing, and label the
site dressing.

Sterile dressing -- placed after routine site
care/cleaning or when the old dressing
becomes contaminated or damaged. The
principle of asepsis is very important when
placing the sterile dressing over the insertion
site. The site is a direct line to the bloodstream
and pathogens may circulate easily to other
parts of the body.

Chux pad -- used during routine IV
therapy to provide patient comfort and prevent
the need for unnecessary linen changes.

Gloves -- barrier against blood borne
pathogens and are to be worn when working
around the IV insertion site or when changing
IV tubing at the catheter hub connection.
(Local policy will determine if sterile or clean
gloves are to be used.)

IV Pole -- IV solution container is
suspended on a pole above the level of the
puncture site to allow the fluid to infuse by
gravity.

Infusion Pump -- electronic device that
infuse IV solutions at a preset rate.

PREPARATION OF IV
EQUIPMENT

Verify order -- To complete a routine
tubing change and solution container
replacement, verify the Doctor's Orders SF
508 for the correct IV solution, amount, and
rate of infusion. Select the appropriate
container from storage. IV solutions are
dispensed in bottles or in collapsible plastic
bags and come in volumes of 1,000 ml, 500
ml, 100 ml, and 50 ml.

Examine container -- Remove the IV
solution container from the protective plastic
covering. Inspect the container and its contents
for physical damage such as cracks, breaks, or
holes. Observe for the expiration date and any
evidence of contamination. There should be no
cloudiness, discoloration or particles floating
in the solution. Ensure the ports are sealed. If
discrepancies are noted, discard and obtain
another container.

Time tape and label container -- The
time tape is a marker strip that is placed on the
container of solution so the flow rate can be
easily monitored. It allows staff personnel to
tell at a glance whether the solution is being
infused at the proper rate. A commercially
made time tape or a long strip of adhesive tape
is attached length--wise to the IV container,
Figure 3.26.02. The entire time tape is
prepared by marking lines or points to denote
the start time, hourly IV rate (ml/hr) ordered
by the physician, and time the IV container is
expected to run out. (The actual times are
placed on these lines immediately after the
infusion has been started.)

The container label is placed across the
top of the IV container, to identify the
prepared container and its contents. The label
must include the date, patient's name, type of
IV fluid and total volume in container,
container number, any medications added, the
rate of infusion (ml/hr), and the initials of the
person preparing the container.

Prepare administration set -- Check for
the drop factor (gtts/ml) on the package. The
rate, or speed, that the solution drops into the
drip chamber IV set is called the tubing's drop
factor and is based on the internal diameter of
the IV tubing. It is measured by drops per
milliliter (gtts/ml). This means the number of
drops released into the administration set drip
chamber to make one ml, or cc, of IV solution.

The drop factor varies according to the
manufacturer of the product. To determine the
drop factor of an administration set, look at the
package it came in. Examples of drop factors
are 10 gtts/ml, 15 gtts/ml, 20 gtts/ml and 60
gtts/ml. A macro drip administration set is one
that allows larger amounts of IV solution to
flow through its chamber and is mainly used
for adult patients requiring a high fluid
volume. A micro drip administration set is
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Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Handbook III
mainly used for pediatric patients or patients
who can only tolerate a slower rate and small
amounts of fluid.
Remove the IV administration set from the
package and uncoil the tubing. Do NOT allow
the tubing to touch the floor. Slide the flow
regulator clamp along the tubing to position it
directly under the drip chamber and ensure the
clamp is in the closed position. Inspect the
tubing and drip chamber for cracks or breaks.

Attach and prime tubing -- The adapter
spike on the tubing will be inserted into the
port of the IV container. Aseptically remove
and discard the cover from the adapter spike
and the cover on the port. The spike and the
port must remain sterile. To ensure these
parts are not contaminated, do NOT touch the
tubing adapter spike to the outside of the IV
container port. Carefully insert the adapter
spike into the port of the IV container using a
slight twisting motion.

Hang the IV container on an IV pole.
Squeeze and release the drip chamber of the
IV administration set to fill the chamber half
full with IV solution, Figure 3.26.03. If fluid
does not readily enter the drip chamber, check
to ensure the adapter spike has punctured the
seal of the IV container. Bubbles will rise in
the IV solution container as air from the drip
chamber enters the container.

The distal end of the administration set
(IV tubing) will connect into the IV catheter
hub. The distal end of the IV tubing must
remain sterile. Aseptically remove the cover
protecting the distal tip of tubing and set it
aside, ensuring the cover is NOT
contaminated. Hold the distal end of the IV
tubing over a sink or wastebasket and open the
regulator clamp to allow IV solution to clear
the tubing of air. Once the air is purged from
the IV tubing, reclamp the flow regulator,
replace the cover aseptically, and inspect to
ensure no air bubbles remain in the tubing.

Label IV tubing -- Use a commercially
made tubing label or a length of adhesive tape
to document the time and date the tubing was
prepared or changed, and the initials of the
person preparing the tubing.

IV pole or infusion pump -- IV solutions
generally infuse by gravity. The IV container
is hung on an IV pole attached to the bed or on
a portable pole. Since the pressure in a
patient's vein is greater than atmospheric
pressures, the container must be maintained
18-24 inches above the puncture site for the
fluid to infuse properly. If the container is
lowered, the flow of solution will decrease.
When the container is raised, the solution will
infuse more rapidly.

An infusion pump is a machine that
accurately regulates the volume and rate of
infusion. When used properly, an infusion
pump can increase patient safety. Audible and
visual alarms indicate when IV flow is not
progressing as ordered. Since there are
numerous types of pumps produced, the
manufacturer's operating directions should be
followed for the particular model. However,
when in use, never assume the infusion pump
is accurate. IV flow rate checks need to be
continued as directed by local policy.

CALCULATION OF IV FLOW
RATE

To carry out a Doctor's Order for IV
therapy, calculations are needed to determine
correct flow rate. The physician will order the
type, amount, and rate of solution to be
infused. The rate will be ordered in one of two
ways:

1. Number of hours to infuse total volume.
Example: 1,000 ml LR over 10 hours.

2. Hourly rate desired. Example: LR at 100
cc/hour.

Calculate the drops per minute in order to
maintain the IV flow at the ordered rate. The
flow rate is calculated to within plus or minus
one drop per minute.


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Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III
FORMULA TO CALCULATE
FLOW RATE:


gtts/minute =

# of ml/hr X Drop Factor
60 minutes


STEPS TO PERFORM FLOW
RATE CALCULATION:

1. Find manufacturer's drop factor on
package of administration set.

2. Determine ml (cc) /hr. If the order is
written for #of ml/hr use it in the formula.
Example #1: LR at 100 ml/hr. Use
formula:

gtts/minute =

100 ml/hr x Drop Factor
60 minutes


Example #2: 1,000 ml LR over 10 hours.
Before you can enter a value into the flow rate
formula you must find the amount of ml to be
administered in one hour. This is done by
dividing total volume by total time to infuse
1,000 by 10 (1,000/10 = 100 ml/hr), Enter
value into formula as:

gtts/minute =

100 ml/hr x Drop Factor
60 minutes

3. Enter the value for manufacturer's drop
factor. If package states drop factor is 20
gtts/ml, then:

100 ml/hr x 20 gtts/ml
60 minutes = gtts/minute

4. Complete the calculations:

a) Cancel like terms:

100 ml 20 gtts 2,000 gtts
hr x ml = hr

b) divide by 60 minutes per hour

__________
60 min )2,000 gtts/hr =33.3 or 33 gtts/min

This value is used to set the flow rate after
the IV solution has been initiated and to
maintain an ongoing infusion rate. In the
above example, 33 gtts of solution will
enter the drip chamber every minute. It is
acceptable to count the number of drips
for 30 seconds and multiply by 2 to obtain
the 60-second rate.

Another problem:

5. Drop factor on package =15 gtts / ml

6. IV order =1,000 ml of D5W over 8 hours
______
8 ) 1,000 = 125 ml / hr

7. Enter values into formula:

#ml/hr x drop factor
60 minutes =gtts/minute

125 ml/hr x 15 gtts/ml
60 minutes

8. Complete the calculation

a. 125 ml 15 gtts 1,875 gtts
hr x ml = hr
___________
b. 60 min) 1,875 gtts/hr = 31.25 or

31gtts / min





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Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Handbook III
CHANGING THE IV SOLUTION
CONTAINER AND TUBING

Use universal precautions whenever there
is the potential to contact a patient's blood or
body fluids. Through hand washing should be
done before and after applying gloves. Gloves
are a barrier against blood borne pathogens
and are to be worn when working around the
IV insertion site or when changing IV tubing
at the catheter hub connection.

Gather all equipment needed to change IV
container and tubing and prepare equipment
away from the patient's bedside. Entering the
room with all supplies ready helps decrease
patient apprehension about the procedure.
Identify the patient by comparing bed tag,
wrist bracelet and patient's stated name with
labeled IV container. Provide for patient
safety, privacy, education, comfort.
Explaining the procedure to the patient will
help him/her cooperate during and after the
procedure. Since the tubing will be
disconnected from the hub of the IV catheter,
reassure the patient that the catheter will not
be removed. Remind the patient to NOT move
suddenly during the procedure as it may
dislodge the catheter. A Chux pad placed
under the IV site will prevent soiling of the
bed linen.

The IV catheter will need a continuous
flow of IV solution in order to keep the
catheter patent. Blood will clot at the tip of the
catheter in the vein when the solution flow is
stopped. Close the flow regulator clamp
immediately before removing old IV tubing.
Hold new IV tubing in place and open clamp
to allow for minimal IV fluid flow to keep
vein open (KVO) as soon as the new IV tubing
is connected to the catheter hub.

Support the hub securely with the thumb
and forefinger when removing the old IV
tubing. If the tubing is difficult to remove, a
hemostat may be used to hold catheter hub
while the tubing is removed using a twisting
motion. Occlude the vein at the end of the
catheter with the ring finger to prevent blood
from escaping from the hub when the tubing is
disconnected.

Use aseptic technique whenever
connecting the distal end of IV tubing to hub
of the IV catheter. The catheter is a direct line
to the bloodstream and pathogens may
circulate easily to other parts of the body.

Secure IV tubing to patient's skin with
tape. The weight of the tubing may cause the
catheter to dislodge if the tubing is not well
secured. A loop of tubing over the patient's
hand or lower arm allows slack to prevent
dislodging of the catheter from tension on the
IV line.

Adjust the flow regulator clamp to
establish ordered flow rate, Figure 3.26.04.
Count the number of drops for 30 seconds and
multiply by 2 to determine the rate per minute.
Adjust as needed to maintain flow at ordered
rate. Monitor the flow rate at least hourly.
Many factors can influence the flow rate of an
IV including the height of the IV fluid
container in relation to the patient, the position
of the patient's arm, total or partial occlusion
of the tubing by the patient's body weight,
kinks in the tubing and parts of the bed as they
move and operate. Cold IV fluid may cause
the blood vessels to constrict and thus slow the
rate of infusion.

IV solution containers are not left in place
more than 24 hours, to reduce the potential for
bacteria growth in the solution. Tubing should
be changed every 48 hours for the same
reason, per guidelines from the Centers for
Disease Control (CDC).

If the patient is receiving continuous IV
fluids, the solution container should be
replaced when it becomes nearly empty.
Prepare the new IV container about one hour
before it is needed and apply time strip. To
prevent air from entering the IV tubing,
change container when there is still fluid in the
drip chamber. Prior to changing IV containers,
decrease the flow rate by tightening the flow
regulator. Remove the almost empty container
from the IV pole and hold on a slant when
308
Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III
Use tape to secure the catheter hub to the
patient's skin. Do NOT cover the hub or
tubing connection site. Different techniques
of taping (chevron or goal-post) may be used
to minimize catheter movement. Cover the
insertion site with a sterile dressing to protect
the wound. Label the dressing with time and
date of dressing change, your initials, and
gauge of catheter. This information near the
catheter entry site provides a quick reminder
when the dressing change needs to be
performed next.
removing adapter spike from container. Do
NOT touch the adapter spike. Remove seal
from new IV container and immediately insert
adapter spike into new container. Hang new
container on IV pole and regulate IV flow rate
by adjusting flow regulator clamp. Fill in
times on time tape.

IV SITE CARE

Routine IV site care should be performed
every 24 hours unless a transparent dressing is
used. A transparent dressing allows the site to
be seen without removing the dressing. Follow
local policy for changing transparent dressing.
A non-transparent dressing (Band-Aid or 2x2)
must be removed daily to examine the IV site.
Since there is a potential for contact with the
patient's blood, use universal precautions
when performing IV site care.

RECORDING OF TUBING
CHANGE, SOLUTION
CONTAINER CHANGE, AND
SITE CARE

An entry is made on the Nursing Notes SF
510, after the procedures are completed. The
following should be included: the bottle
number of the IV container removed with type
and amount of fluid that the patient received;
the amount, type of solution, and bottle
number of the IV container started; rate of
flow in ml (cc's) per hour; location and
appearance of insertion site; completion of site
care, completion of tubing change; and how
the patient tolerated the procedure.

Use aseptic technique when performing
IV site care. The puncture site is a type of
open wound. The wound and catheter provides
a direct line to the bloodstream and pathogens
may circulate easily to other parts of the body.
It is important to inspect, dress the wound, and
document its condition at routine intervals.

Supporting the hub of the catheter, remove
all dressing from the IV insertion site and tape
from the catheter hub. The tape securing the
tubing may be left in place if it does not
interfere with the dressing change. Observe
the insertion site and surrounding tissue for
complications such as phlebitis, infiltration,
infection, and edema. Cleanse around the
insertion site with Betadine or alcohol swabs.
Do NOT contaminate the site. Wipe outward
from the insertion site, using a new swab for
each outward wipe.

Patients on IV therapy may also need
intake/output monitoring. This may be
directed by Doctor's Orders or local policy.
Documentation completed on the Twenty-
Four Hour Intake and Output Worksheet DD
792 includes: the time current IV container
taken down, amount of solution received, and
cumulative total, time the new IV container
started, initial amount in the container, type of
solution, and bottle number, Figure 3.26.05

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Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Worksheet Handbook III
Lesson 3.26

Maintenance of Intravenous Therapy
Worksheet

1. The IV administration set allows regulation of fluid flow from an IV container into a patient's
vein.

a. True b. False

2. Asepsis is not a concern when working with IVs.

a. True b. False

3. List the four checks of an IV container prior to use.

a. ___________________________________________________

b. ___________________________________________________

c. ___________________________________________________

d. ___________________________________________________

4. List eight items to include on the IV container label.

a. ___________________________________________________

b. ___________________________________________________

c. ___________________________________________________

d. ___________________________________________________

e. ___________________________________________________

f. ___________________________________________________

g. ___________________________________________________

h. ___________________________________________________

5. Where is the drop factor for the IV tubing found? _____________________________________

6. What is the purpose of priming the IV tubing? _______________________________________



310
Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III Worksheet
7. An IV infusion pump is used to:

a. remove the need for frequent monitoring of the IV.

b. accurately regulate the amount and rate of IV fluid infused.

c. eliminate the need to change IV tubing.

d. increase patient safety when administering IV fluids.

8. Using the order given, calculate the flow rate within plus or minus one drop per minute.

a. Order: 1000 cc RL at 150 cc/hr (drop factor =10 gtts/ml) Flow rate ___________

b. Order: 500 cc D5 1/2 NS q 10 hours (drop factor =60 gtts/ml) Flow rate ___________

c. Order: 1000 cc NS at 50 cc/hr (drop factor =20 gtts/ml) Flow rate ___________

d. Order: 250 cc D5RL q 5 hrs (drop factor =60 gtts/ml) Flow rate ___________

e. Order: 1000 cc D5W at 200 cc/hr (drop factor =10 gtts/ml) Flow rate ___________

9. When changing IV tubing the flow regulator clamp may be closed for extended periods of time
without harm to the site and the patient.

a. True b. False

10. KVO means ___________________________________________.

11. Circle each factor that can influence the rate of flow of an IV.

a. Height of the IV fluid container

b. Position of the patient's arm

c. Occluded or twisted tubing

d. Temperature of the IV fluid

12. The maximum time a single container of IV fluid can hang is _____________.

13. Circle each item listed on the IV site dressing label.

a. Gauge of the IV catheter

b. Drop factor of the tubing being used

c. Time and date of dressing change

d. Your initials

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Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Worksheet Handbook III
14. How frequently should IV site care be performed when using a non-transparent dressing?
______________________________

15. List the items to include in a Nursing Notes when documenting an IV tubing and container
change, and IV site care.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

e. _______________________________________________________________________
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Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III Worksheet
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Lesson 3.26 Maintenance of Intravenous Therapy Basic Hospital Corps School
Worksheet Handbook III
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Basic Hospital Corps School Lesson 3.26 Maintenance of Intravenous Therapy
Handbook III Worksheet


315
Lesson 3.27 Intravenous Insertion Basic Hospital Corps School
Handbook III
Lesson 3.27

Intravenous Insertion

Terminal Objective:

3.27 Perform an intravenous insertion.

Enabling Objectives:

3.27.01 List the equipment needed to perform intravenous insertion.

3.27.02 List common peripheral intravenous insertion sites.

3.27.03 List factors for selecting an intravenous insertion site.

3.27.04 List guidelines for intravenous insertion.

3.27.05 List guidelines for documenting intravenous insertion.

3.27.06 List guidelines for discontinuing intravenous therapy.

3.27.07 List guidelines for documenting discontinuation of intravenous therapy.

3.27.08 Perform an intravenous insertion using principles of patient safety, privacy, education,
and comfort.

3.27.09 Discontinue intravenous insertion.

3.27.10 Document discontinuation of intravenous therapy on appropriate forms.


Initiation of intravenous therapy involves
venipuncture, an invasive procedure in which
the skin is punctured by a hollow needle and
the needle or a catheter is inserted into a vein.
The over-the-needle catheter, butterfly needle,
through-the-needle catheter and hypodermic
needle are all types of venipuncture devices
used for IV therapy. The solution to be
administered and the condition of the patient
will determine which type of device will be
used.






INTRAVENOUS INSERTION
EQUIPMENT



To initiate IV therapy the following items
are needed:

IV administration set, IV solution as
ordered, tourniquet, antiseptic swabs, tape,
sterile dressing, Chux pads, IV pole, gloves
and IV catheter.

The over-the-needle catheter, also called
an Angiocath or J elco, is used for most routine
patient care situations and is the best choice
316
Basic Hospital Corps School Lesson 3.27 Intravenous Insertion
Handbook III
for most patients, Figure 3.27.01. This type of
catheter is a plastic tube that is threaded into
the vein over a metal needle. The metal needle
extends beyond the tip of the catheter to
provide a sharp bevel to puncture the skin and
vein. Once the vein has been entered, the
catheter is advanced into the vein and the
needle is withdrawn. The use of a blunt,
flexible catheter reduces the incidence of
infiltration with prolonged therapy.

A butterfly needle, also called a winged-
tip or scalp vein needle, is a short metal needle
with plastic wings or tabs, Figure 3.27.02. The
tabs allow ease of handling during insertion
and lay flat to the skin for ease in securing.
This type of needle is used for short-term
administration of IV fluids since there is a
high risk of damage to the vein with prolonged
use. A butterfly needle is good choice for use
in adults with small or fragile veins, children,
and infants.

A through-the-needle catheter, also
called an intracath, is a flexible plastic tube
that is inserted into the vein through a metal
needle. A needle is used to enter the skin and
the vein and then withdrawn. The needle
remains attached to the tubing with the tip of
the needle covered to prevent puncturing the
patient or the tubing. A through-the-needle
catheter is generally inserted in a large vein,
e.g., internal jugular or subclavian veins.
Large volumes of fluid can be infused through
an intracath in a critical care or trauma
situation. Doctors or specially trained
personnel usually insert a through-the-needle
catheter.

In an emergency situation where proper
equipment may not be available, such as in the
field, a hypodermic needle may be used to
infuse fluids or blood components. Infiltration
is common due to the sharp metal edges and
the inflexibility of the needle. The hypodermic
needle is the least desirable device to use for
IV fluid administration.




PURPOSES FOR DIFFERENT
GAUGE SIZES:
The gauge of the needle is the
measurement of the internal diameter of the
lumen, the space within the needle shaft,
sometimes called the needle bore. A needle
with a large lumen will have a low gauge
number (16g, 18g). A small lumen will have a
high gauge number (22g, 24g).

1. 16 gauge - used for patients receiving
treatment for acute trauma, undergoing
major surgery, or receiving multiple blood
transfusions.

2. 18 - 20 gauge - for general use in patients
receiving IV fluids or blood transfusions.
An 18 gauge catheter is preferred for use
with blood transfusions.

3. 22 gauge - used to minimize discomfort
during venipuncture procedure. The
smaller size also reduces the risk of
complications.

4. 24 gauge - used for infants, children and
adults with small veins or fragile skin..

Select the largest gauge number
needle/catheter (small lumen) to accomplish
the intended purpose. The effects of
needle/catheter size include:


High Gauge Number

Low Gauge Number

Less trauma to vein

More trauma to vein

More blood flow
through vein

Less blood flow
through vein

Less infusion of
solution

More infusion of
solution

More potential for
catheter clotting

Less potential for
catheter clotting
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Lesson 3.27 Intravenous Insertion Basic Hospital Corps School
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PERIPHERAL INSERTION SITES

Placement and selection of IV insertion
site will vary with each patient. The most
common sites for IV insertion are found on the
back of the hand, forearm, and antecubital
area. The antecubital site is very accessible
and it is fairly easy to insert a needle or
catheter at this site. A disadvantage is that an
IV at this site severely limits the mobility of
the extremity and may be uncomfortable to the
patient.

Avoid using foot and leg veins as IV
insertion sites unless other sites are not
accessible. Circulation is often reduced in the
lower extremities and there is a greater risk of
thrombus and embolus formation when
placing a catheter in these veins. Although the
foot and legs are common IV insertion sites
for infants and small children, they should be
used only when other sites are not accessible.

FACTORS INFLUENCING SITE
SELECTION

Selecting the best possible venipuncture
site is influenced by numerous factors. The
age of the patient is one consideration. Infants
and children will not protect an IV site. A
peripheral site must be well secured to prevent
it from being dislodged. Peripheral veins are
often difficult to locate in an infant. Scalp
veins are commonly used as IV sites in
infants.

The health and physical status of the
patient will influence site selection. Infusions
should NOT be administered on the same side
as recent extensive breast surgery due to
possible circulation problems in the area. A
patient with burns on both arms will not have
accessible forearm vessels. A normal vein is
smooth, pliable, and resilient. A straight vein
facilitates threading of the catheter. Do NOT
use sclerotic veins or scarred veins.

The ordered flow rate may also influence
the site selection. A larger bore catheter (16g -
18g) will allow fluid to be infused more
quickly. In order to place a large bore catheter,
a vein large enough to permit the passage of
the catheter needs to be selected. Peripheral
sites in the antecubital area can accommodate
a large bore catheter (low gauge number),
while smaller hand sites generally cannot.
Certain types of fluids that are thick or
irritating solutions require the use of a larger
vein to decrease irritation to the vessel.
Because the blood flow is greater in larger
veins, the vessel is less likely to become
irritated. Certain types of medications in
solution can cause tissue damage if infiltration
occurs, therefore a large bore catheter (low
gauge number) is used for these medications.

In an emergency situation, IV insertion
will take place any where a site can be located.
A large lumen catheter is desirable to replace
fluids and blood quickly. When an IV catheter
is inserted preoperatively, a large lumen
catheter (low gauge number) is desirable due
to the potential for an emergency situation to
develop. Do NOT place an IV in the same
extremity where surgery will occur.

If possible, avoid using the patient's
dominant hand or arm. The nondominant
side will be used infrequently during daily
activities and the potential for displacing the
catheter will be less. The patient will be less
likely to feel inconvenienced or restricted if
the catheter is placed in his/her nondominant
hand or arm. Try to place the catheter in a
distal branch of a large vein. If the patient
remains on IV therapy for a prolonged period
of time, proximal sites can be used for
subsequent IV insertion sites.

GUIDELINES FOR
INTRAVENOUS INSERTION

During intravenous insertion, there is the
possibility that you may come into contact
with the patient's blood. To protect yourself,
use universal precautions. Wash your hands
before and after the procedure and wear gloves
when performing the venipuncture.

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Basic Hospital Corps School Lesson 3.27 Intravenous Insertion
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Aseptic technique is required when
inserting an IV catheter. If the site is not
cleansed properly prior to inserting the
catheter or contaminated while performing the
procedure, pathogens can be introduced into
the bloodstream. Local policy will dictate
whether clean or sterile gloves are worn when
starting IVs.

After verifying the Doctor's Orders SF
508, select and prepare the equipment away
from the patient's bedside. Entering the room
prepared helps to decrease patient anxiety
about the procedure. Collecting all the
supplies prior to starting ensures that the
procedure will not be interrupted once it is
started. Obtain the correct IV solution, insert
adapter spike into container, and purge the
tubing of air. Apply the time tape, container
label, and tubing label.

Take all prepared equipment to the
patient's room. Identify the patient using the
labeled IV container. Ask about allergies,
particularly noting sensitivity to latex, tape, or
Betadine. Provide for patient safety, privacy,
and comfort. Explain the procedure; patients
will cooperate more easily if they understand
what is about to happen. Place a protective
(Chux) pad under the patient's arm to protect
the bed linen.

Hang the primed IV container and tubing
within easy reach. Prepare and inspect all
needed supplies, then place them so they are
accessible during the procedure. Tear the
pieces of tape that will be used to secure the
IV catheter and tubing in place. Having the
tape pieces prepared allows the catheter to be
secured when insertion is completed and is
easier to accomplish when ungloved. Remove
the protective covering from the
catheter/needle without contaminating the
catheter and check the catheter tip for tears or
splitting prior to inserting.

To select an appropriate insertion site,
apply a tourniquet on the arm about 2-4 inches
above the intended site. Observe and palpate
to determine general condition and suitability
of veins. Feel and look for an area in the vein
that is fairly straight and approximately the
length of the catheter or needle. If unable to
locate a vein, promote venous distention by
having the patient open and close the fist or
lower arm below the level of the heart. The
skin over the vein can also be stroked distally
or a warm compress can be applied to the
intended site for 10-15 minutes. Be sure to that
the tourniquet is not applied to the arm during
this 10-15 minute period.

Don clean gloves and cleanse the intended
site with antiseptic swabs, using a circular
motion, moving outward from the site. (Sterile
gloves may be used depending on local
policy.) Thorough cleansing of the skin prior
to insertion of the needle will reduce the
possibility of pathogens entering the blood
stream. The antiseptic needs time to dry to
reach its maximum antimicrobial effect. Once
the site is cleansed, do NOT touch the area.
The site will require recleansing if the area is
touched.

When inserting an over-the-needle
catheter, anchor the vein about 2 inches below
the intended site. Apply tension in the
opposite direction to which the needle will be
inserted, using the thumb of the non-dominant
hand. This anchoring will stabilize the vein
and minimize rolling. Insert the
catheter/needle at a 45 degree angle with the
bevel up. Decrease the angle of the catheter to
10-15 degrees once the skin is penetrated. A
lower angle will reduce the potential of
puncturing the posterior wall of the vein after
the needle has entered the vein. You may feel
a pop when the blood vessel wall is punctured.
Once the needle is in the vein, a backflow of
blood will appear in the needle hub. Securely
hold the needle and continue to advance only
the catheter into the vein until the hub rests on
the skin.

Release the tourniquet. Immediately apply
pressure with your fingers on the patient's skin
proximal to the internal tip of the catheter to
prevent blood flow from the catheter hub until
the tubing is applied. Dispose of the
contaminated needle in the Sharps container.
Hold tubing in place at catheter hub and open
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Lesson 3.27 Intravenous Insertion Basic Hospital Corps School
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flow regulator clamp on IV tubing to allow a
keep vein open (KVO) rate to infuse through
the catheter. Observe the site for signs and
symptoms of infiltration once fluid is flowing.

Wipe excess blood from skin using a
sterile 2x2. Secure the hub of the catheter to
the patient's skin using tape. Do NOT
contaminate the insertion site when applying
the tape to the catheter hub. Adjust the flow
regulator clamp to obtain the correct flow rate.

Cover the site with a sterile dressing using
a Band-Aid, sterile 2x2, or transparent
dressing according to local policy. Secure IV
tubing to the patient's arm to prevent tension
on the tubing during patient movement. Do
NOT apply the tape so it completely encircles
the arm as it may act as a tourniquet if the arm
becomes edematous. A loop of tubing below
the IV insertion site will prevent dislodging of
the catheter if the tubing is accidentally pulled.

DOCUMENTING INTRAVENOUS
INSERTION

Insertion of an IV and the initiation of IV
therapy are documented on the Nursing Notes
SF 510 when it is completed on the hospital
ward patient. When an IV is inserted on an
outpatient in the Emergency Room or the
clinic, the procedure is documented on either
the Emergency Medical Treatment Record SF
558 or on the Chronological Record of
Medical Care SF 600. Narrative
documentation includes:

1. Time and date inserted.

2. Type and gauge of catheter.

3. Location and condition of site.

4. Type and amount of fluid being infused.

5. Infusion rate.

6. Patient tolerance of the procedure.

7. Signature and rate.
Documentation on the Twenty-Four Hour
Intake and Output Worksheet DD 792 for a
inpatient includes:

1. Time container hung.

2. Amount of solution in container.

3. Type of solution and container number.

DISCONTINUING INTRAVENOUS
THERAPY

An IV catheter may need to be removed if
the current site shows signs of infiltration,
infection, or phlebitis. To prevent the vein
from becoming irritated with prolonged use,
the site is changed every 72 hours (follow
local policy). Once IV therapy is no longer
required, the infusion is discontinued and the
catheter removed.

Gather the equipment needed to
discontinue the infusion, including: gloves,
protective (Chux) pad, sterile 2x2, Band-Aid,
puncture resistant Sharps container, and a
biohazard waste bag for disposal of the IV
tubing.

When discontinuing intravenous therapy,
there is the possibility that you may come into
contact with the patient's blood. To protect
yourself, use universal precautions. Wash your
hands before and after the procedure and wear
gloves when performing the procedure.

After verifying the Doctor's Orders that
the infusion is to be discontinued, proceed to
the patient's room. Identify the patient, explain
the procedure and provide for safety, privacy,
and comfort. Close the flow regulator clamp to
stop the flow of solution through the catheter.
The lack of IV fluid flow will cause blood to
clot at the tip of the catheter.

After removing all the tape and the
dressing, place a sterile 2x2 lightly over the
insertion site. Smoothly and quickly remove
the catheter from the vein, following the
course of the vein. Do NOT raise, lower, or
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Basic Hospital Corps School Lesson 3.27 Intravenous Insertion
Handbook III
twist catheter when removing as this action
may cause damage to the posterior wall of the
vessel. Apply pressure to the insertion site
until the bleeding stops and then cover site
with a sterile dressing.

Place contaminated catheter in a puncture
resistant Sharps container. The empty
container is discarded in the garbage. Local
policy may dictate the procedure for disposal
of IV tubing. It may be discarded in regular
garbage or in biohazard garbage if the tubing
contains blood.

DOCUMENTING
DISCONTINUATION OF
INTRAVENOUS
THERAPY

Removal of an IV and the discontinuation
of IV therapy are documented on the Nursing
Notes SF 510 when it is completed on the
hospital ward patient. When an IV is removed
on an outpatient in the Emergency Room or
the clinic, the procedure is documented on
either the Emergency Medical Treatment
Record SF 558 or on the Chronological
Record of Medical Care SF 600. Narrative
documentation includes:

1. Time and date removed.

2. Type and amount of fluid infused.

3. Location and condition of site.

4. Condition of catheter upon removal.

5. Signature and rate.

Documentation on the Twenty-Four Hour
Intake and Output Worksheet DD 792 for a
inpatient includes:

1. Amount of solution infused.

2. Time container removed.

3. Cumulative amount of today's IV fluids.
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Lesson 3.27 Intravenous Insertion Basic Hospital Corps School
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FIGURE 3.27.01
Over-the-needle Catheter


























FIGURE 3.27.02
Butterfly Needle
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Basic Hospital Corps School Lesson 3.27 Intravenous Insertion
Handbook III
NOTES/COMMENTS
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Lesson 3.27 Intravenous Insertion Worksheet Basic Hospital Corps School
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Lesson 3.27

Intravenous Insertion Worksheet

1. Match the IV catheters in column B with their use in column A.
(Catheters in column B may be used more than once.)

A B


a. Short term administration ________
of fluids

b. Best choice for acute trauma ________

c. Best choice for most patients ________

d. Good choice for infants ________

e. Usually inserted into jugular ________
vein, subclavian vein or
cephalic vein.

f. Routine situations ________

g. Field use ________

1. Butterfly needle

2. Through-the-needle catheter

3. Over-the-needle catheter

4. Hypodermic needles



2. The larger the gauge number of a catheter, the larger the lumen.

a. True b. False

3. The IV site that offers the patient the greatest mobility will be veins found in the antecubital
space.

a. True b. False

4. Small veins are used for thick or irritating solutions.

a. True b. False

5. Placement of the initial IV catheter in the non-dominant hand is preferred in a patient expecting
to be on long-term IV therapy.

a. True b. False



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Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Worksheet
Handbook III
6. Circle the procedures that are methods to promote venous distention.

a. Patient opening and closing hand.

b. Patient waving arm.

c. Patient dangling arm over side of bed.

d. Patient holding the arm above the head,

e. Corpsman gently slapping site.

f. Corpsman applying heat to selected site.

7. An IV catheter is inserted into the skin at a 15 to 30 degree angle.

a. True b. False

8. What information is required on the Twenty-Four Hour Intake and Output Worksheet DD 792
when recording intravenous insertion?

a. _____________________________________________________________________

b. _____________________________________________________________________

c. _____________________________________________________________________

9. List the equipment needed to discontinue an IV.

____________________________________________________________________

____________________________________________________________________

10. When discontinuing an IV, the flow regulator clamp is:

a. regulated to maintain a KVO rate.

b. closed after the IV catheter is removed.

c. closed before the IV catheter is removed.

d. not used during the discontinuation process.

11. List the components of the narrative documentation when an IV is discontinued.

____________________________________________________________________

____________________________________________________________________



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Basic Hospital Corps School Lesson 3.27 Intravenous Insertion Worksheet
Handbook III
329

329
Lesson 3.22 Pain Management Basic Hospital Corps School
Handbook III
Lesson 3.22

Pain Management

Terminal Objective:

3.22 List concepts and principles of pain management.

Enabling Objectives:

3.22.01 Define terms related to pain.

3.22.02 List influencing factors related to pain.

3.22.03 List the physical and psychological symptoms of pain.

3.22.04 State how to assess pain.

3.22.05 List methods to control pain.

3.22.06 List requirements to record pain, related pain control methods, and their effectiveness.


Patients come for medical treatment with a
variety of medical conditions. Whether illness,
injury, surgical condition, or depression, most
patients are in pain. It is imperative that they
be treated appropriately, both psychologically
and physically.

PAIN TERMINOLOGY

Asking a patient to describe the pain that
is being experienced is very important for an
accurate assessment. Assessment involves
gathering information/data about the quality,
intensity, duration, and location of the pain.
Each of these terms is further subdivided into
categories or classifications.

Location of pain is where the patient feels
the pain. Diffuse pain is discomfort that
covers a large area of the body, such as the
entire back or abdomen. Shifting pain moves
from one area of the body to another, such as
from the lower abdomen to the chest.
Referred pain describes discomfort
experienced at a location other than the
diseased area. A common example is a patient
experiencing a heart attack complaining of
pain in his/her jaw or arm.

Quality refers to the patient's description
of how the pain feels. Adjectives used to
describe the quality of pain are interpreted by
their common meaning. Words that describe
pain quality include: cutting, dull, jabbing,
knife-like, pounding, sharp, throbbing,
cramping, crushing, and burning.

Intensity is the extent, degree of strength,
or force of the pain. Slight or mild pain is
noticeable but interferes little with activity.
Moderate pain is definitely noticeable and
interferes with activity. Severe pain is
persistent and makes it impossible to carry out
activities.

Duration is the length of time patient
experiences the pain. Acute pain is discomfort
of short duration from which relief is
expected. Chronic pain is always present.
Intermittent pain comes and goes.
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Basic Hospital Corps School Lesson 3.22 Pain Management
Handbook III
Phantom pain occurs after amputation of
a body part. The patient experiences pain from
that part as if the limb were still present. The
physiological transmission of the pain impulse
is similar to normal physical pain.

INFLUENCING FACTORS

No matter how slight the condition or
trivial the cause, pain is very real to the
patient. There are no signs or symptoms that
always demonstrate the severity of a patient's
pain. Pain is subjective in nature. It can only
be described by the person who is feeling it
and knows how much it hurts. Every person
reacts differently to pain. The ability of an
individual to endure the discomfort from pain
is called pain tolerance.

Feelings of pain are not necessarily
proportionate to the amount of damage or
severity of the injury. A patient with minor
hemorrhoids may be in more pain than a
patient with cancer. Consciousness and
attention are necessary to experience pain. An
unconscious patient is unaware of pain and
will have no memory of it. A conscious
patient may be aware of trauma suffered
during activity but not notice it until later,
often when he/she ceases the activity. Once a
person becomes aware of pain, its intensity
increases.

The cultural background of the patient is
another consideration in the management of
pain. Different cultures have different ways of
dealing with and expressing pain. In some
cultures, bearing pain is a means of learning
sturdiness and bravery, thus a patient may not
complain even though severe pain is being
experienced. Other cultures openly express
pain and a patient may show great concern for
even slight pain. (Also refer to Lesson Topic:
Interpersonal Communications and
Relationships.)




PHYSICAL AND
PSYCHOLOGICAL SYMPTOMS
OF PAIN

Patients in pain exhibit various signs and
symptoms. Symptoms of pain include:

1. Elevated pulse, blood pressure, and
respiration.

2. Dilated pupils.

3. Perspiration.

4. Muscle tension.

5. Nonverbal communications such as:

a. crying.

b. moaning.

c. frowning.

d. rubbing the painful area.

A patient in pain may exhibit symptoms in
combination with or separate from physical
signs. Symptoms include:

1. Verbal complaint.

2. Constant focus on pain.

3. Agitation or depression.

4. Refusal of treatment which causes pain,
e.g., deep breathing, coughing.

5. Change in normal activities of daily
living.

ASSESSMENT OF PAIN

In order to control pain, it must be
assessed. A battery of tests is not needed to
make a baseline assessment. For example: In
an accident, the patient may have slammed
his/her head and chest into a steering wheel.
He/she complains of a headache and appears
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Lesson 3.22 Pain Management Basic Hospital Corps School
Handbook III
to have difficulty during inspiration. It is safe
to deduce head and chest trauma, render
appropriate emergency care, and transport the
patient. If the mechanism of injury is not
apparent on examination, knowing what is not
causing the pain is helpful. For example: A
50 year-old patient is complaining of pain in
his/her left arm and jaw. There is no history
of trauma. It is safe to assume that the patient
is not suffering from an injury. The patient
may be experiencing a hear attack.

It is important to assess the features of
pain: its quality, intensity, duration, and
location. Watching for the signs and
symptoms of pain will assist in assessing pain.
Verbal and nonverbal responses must be
considered. A patient with elevated vital signs,
who rubs his/her leg and complains that it
hurts has most likely injured that leg. Once
pain relief measures have been initiated, it is
important to evaluate the patient's response to
all efforts.

CONTROLLING PAIN

Once the pain has been assessed, it can be
controlled. The prime consideration for
control of pain is management of the cause.
Non-pharmaceutical management techniques
should be used to the greatest extent possible
before using pharmaceutical management.

Non-pharmaceutical management includes:

1. Immobilizing/splinting of
fractures/suspected fractures.

2. Immobilizing impaled/imbedded foreign
objects.

3. Bandaging wounds.

4. Relieving a full bladder.

Non-pharmaceutical comfort measures:

1. Change patient's position, unless
contraindicated.

2. Change soiled linens and dressings as
indicated. This comfort measure is
normally performed when patient is in
inpatient status. In the field, dressings are
NOT removed.

3. Use distractions to take patient's attention
away from the pain. In the field, talking
with the patient or playing music helps
take attention away from the pain. In an
inpatient setting, music, television,
books/magazines, visitors, or back rubs
provide distraction from pain.

4. Stay and talk with patient, as time permits.
In multiple casualties situations this may
not be possible.

5. Instruct patient in relaxation techniques
such as deep breathing or focusing
attention on something else.

In the event that non-pharmaceutical
management does not provide enough relief,
medications may be employed as an adjunct.
When using medication for pain relief, always
use the mildest, most effective agent! The
intensity of the patient's pain will be a guide to
the appropriate medication.

1. Mild pain -- Use mild analgesics such as
Aspirin or Acetaminophen (Tylenol).

2. Moderate pain -- An opiate such as
Codeine Sulfate or Non-Steroidal Anti-
Inflammatory Drugs may be used.

3. Severe pain -- Opiates such as Morphine
Sulfate or Demoral (a synthetic opiate) are
used.

Injectable medications begin to take effect
approximately 15 minutes after injection. Oral
medications begin to take effect approximately
30 minutes after administration.






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Basic Hospital Corps School Lesson 3.22 Pain Management
Handbook III
RECORDING OF PAIN,
CONTROL MEASURES, AND
EFFECTIVENESS OF CONTROL
MEASURES
Finally, document the effectiveness of
control measures. Even if the measure did not
help the patient or if it caused increased pain,
the control measure and its results must be
documented. This may provide clues for
additional conditions. When documenting the
effectiveness of medications, evaluation
should be made after 15 minutes for
medication injected intramuscularly or 30
minutes for medication administered orally.
Description of pain, control measures, and
effectiveness are recorded on:

All aspects of patient care are documented
in order to monitor the patient's progress,
determine which treatments are effective, and
provide medico-legal documentation. First,
describe the pain. Note the patient's complaint
of pain, its quality, intensity, duration, and
location. Next, relate steps taken to manage
the pain. List treatments used to manage the
cause of the pain, e.g., bandaging, splinting,
and the use of medication.

1. Medications Administration Record
NAVMED 6550/8 and Nursing Notes SF
510 - for inpatients


If the medications were used to control the
pain, the type, dosage, route, date, and time
the medication was received must be noted.
This prevents accidentally overdosing the
patient by giving medications too close
together.
2. Chronological Record of Medical Care,
SF 600 or Emergency Treatment Record
(ETR) SF 558 - for outpatients.

3. Field Medical Card DD 1380 - for patients
treated in the field or in mass casualty
situations.


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Lesson 3.22 Pain Management Worksheet Basic Hospital Corps School
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Lesson 3.22

Pain Management Worksheet

1. What classification is given to pain that is noticeable, but interferes little with activity?

a. Severe

b. Unbearable

c. Moderate

d. Slight

2. What classification is given to pain which is persistent, making it impossible to carry out
activities?

a. Moderate

b. Severe

c. Slight

d. Excruciating

3. Pain that comes and goes is called __________________ pain.

a. chronic

b. acute

c. intermittent

d. transitory

4. Diffuse pain is best described as pain that:

a. covers a large area of the body.

b. is removed from the disease or injury.

c. moves from one area to another.

d. is always present.

5. Pain is objective in nature.

a. True b. False

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Basic Hospital Corps School Lesson 3.22 Pain Management Worksheet
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6. A pain that moves from the chest to the abdomen is called _______________ pain.

a. shifting

b. diffuse

c. referred

7. Circle each statement that is correct.

a. Regardless of its cause, pain is real to the patient.

b. Pain is proportionate to the damage within the body.

c. Consciousness and attention are necessary to experience pain.

d. An unconscious person is not aware of pain.

8. Awareness of pain ____________________ the intensity of pain.

a. decreases

b. minimizes

c. increases

d. neutralizes

9. The eyes of a person in pain will usually exhibit:

a. edematous conjunctival.

b. detached retinas.

c. constricted pupils.

d. dilated pupils.

10. Circle each nonverbal communication that may indicate that a patient is in pain.

a. Crying.

b. Rubbing the painful part.

c. Frowning.






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Lesson 3.22 Pain Management Worksheet Basic Hospital Corps School
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11. What is the primary consideration for controlling pain?

a. Immobilizing fractures

b. Treating for shock

c. Managing the cause

d. Maintaining an open airway

12. Codeine sulfate may be prescribed for the management of which type of pain?

a. Mild

b. Moderate

c. Severe

d. Intermittent

13. Which form is used to record pain management in the field?

a. Nursing Notes SF 510

b. Chronological Record of Medical Care SF 600

c. Field Medical Card DD 1380

d. Medication Administration Record NAVMED 6550/8

14. Which form is used to record pain management during outpatient treatment?

a. Nursing Notes SF 510

b. Chronological Record of Medical Care SF 600

c. Field Medical Card DD 1380

d. Medication Administration Record NAVMED 6550/8

15. The effect of oral pain medication administration is noted and recorded after _________ minutes.

a. 15

b. 30

c. 50

d. 60

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Basic Hospital Corps School Lesson 3.22 Pain Management Worksheet
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16. The effect of intramuscular morphine administration is noted and recorded after _______
minutes.

a. 15

b. 20

c. 30

d. 45


337
Lesson 3.29 Cast Care Basic Hospital Corps School
Handbook III
Lesson 3.29

Cast Care

Terminal Objective:

3.29 List concepts and principles for cast care.

Enabling Objectives:

3.29.01 Define terms related to cast care.

3.29.02 State the purposes for applying a cast.

3.29.03 State the purpose and procedure of cast care.


A cast is a stiff dressing made of bandage
soaked with a hardening material. Originally
casts were made from plaster of paris. Now,
materials such as polyurethane and fiberglass
are also used. These materials dry more
rapidly, but are more expensive.

Before a cast is applied, a fracture must be
reduced. Reduction is the procedure used to
reposition the broken ends of a bone. There
are two types of reduction, closed and open.
Closed reduction is the realigning of bone by
manual manipulation without making
incisions in the skin. Open reduction
realigns the broken ends through surgery, with
incisions.

Casts are used to immobilize injured
structures. A fracture, sprain, or damaged
ligaments may be immobilized with a cast so
proper healing may occur.

The purpose of cast care is to promote
patient comfort and to give the care provider
an opportunity to recognize any
complications, including:

1. Excessive bleeding

2. Skin breakdown

3. Infection

4. Circulatory compromise

5. Nerve damage

Decreased blood circulation in an affected
limb could result in permanent nerve damage.
Constriction of the cast can slow blood flow
through an extremity or put pressure on blood
vessels and nerves.

A newly applied (wet) cast requires
special care. The wet cast should be elevated
to prevent edema of the injured extremity.
Elevation helps promote circulation and
prevents problems of pressure from swelling.

An important aspect of wet cast care is to
protect the contour of the cast. Wet plaster is
easily dented, which may create pressure
points. Placing the cast on a hard surface or
lifting a cast with your fingertips could cause
denting. Decubitus ulcers can result from such
pressure. When lifting a cast, use the palms of
your hands to support the cast. Ensure that the
mattress does not sag. Support the full length
of the cast using soft objects, such as pillows,
to elevate the cast. Plastic covered pillows are
used to prevent patient to patient
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Basic Hospital Corps School Lesson 3.29 Cast Care
Handbook III
contamination. Do not cover the cast itself,
allow it to air dry.

Encourage patient cooperation by
explaining cast care thoroughly. Inform the
patient that the plaster of paris will become
very warm during the drying process. Identify
precautions such as care in supporting and
lifting a wet cast to ensure that the cast is
allowed to dry without complications.

Circulation and neurovascular checks
must be performed at regular intervals for a
patient with a newly applied cast. Observe the
fingers or toes of the affected extremity for
signs of circulatory compromise or nerve
damage, such as:

1. cool temperature

2. cyanosis or pallor

3. numbness, tingling, or burning sensation

4 edema

5. poor blanching and inadequate capillary
refill (more than 3 seconds)

6. pain

7. variance of pulse between like extremities

8. decreasing movement

In addition, observe the newly applied cast
for drainage or bleeding. Check the cast every
hour for the first 24 hours, then every 4 hours
for the next 2 to 3 days, then every shift, as
ordered.

If a stain appears on the cast draw a ring
around it to help in noting any increase in size.
The first time you observe any drainage, note
the date and time, and initial the site. Check
for enlargement of the bleeding area at least
every 1 to 3 hours.

Allow the cast to dry. Plaster will be wet
for 24 to 48 hours. Fiberglass and
polyurethane casts will dry in 5 to 15 minutes.
Keep the cast uncovered, and turn the patient,
so that all sides of the cast can air-dry. In
some instances, a cast dryer may be used,
usually in the cast room by an orthopedic
technician. Extreme care should be taken to
avoid exposing the cast to intense heat.
Intense heat could burn the patient, crack the
cast, or dry the outside of the cast while the
inside stays wet and becomes moldy.

The inner lining of stockinette should be
pulled to the outside of the cast and taped
securely.

After the cast has dried, there is a need to
continue general principles of care. The
patient should be turned as ordered,
maintaining the proper body alignment at all
times. Skin care should be performed every
shift. Cast edges and body should be checked
frequently for pressure points. Muscle tone
and joint mobility are maintained by
performing ROM to unaffected extremities
every two hours.

When in bed, or sitting up in a chair, the
cast should be elevated on plastic covered
pillows to provide support. If a patient is
confined to bed, a trapeze should be placed on
the bed frame to help the patient lift his/her
body off the bed.

Patients should be instructed not to insert
foreign objects underneath the cast.
Scratching under the cast can cause lacerations
that easily become infected. Pediatric patients
may need frequent reinforcement of this
instruction.

Encourage good nutritional intake to
promote bone healing.

As always, safety is an important
consideration in good patient care. The
patient with a cast must have the side rails up
and should be assisted with ambulation aids
such as crutches and walkers.

The cast must be protected from moisture,
which can destroy the cast and contribute to
skin break down. Waterproof material should
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Lesson 3.29 Cast Care Basic Hospital Corps School
Handbook III
be used around edges near the buttocks and
the perineal area. An orthopedic bedpan,
designed for easier insertion, is extremely
helpful for a patient with a cast who is on bed
rest. A patient who is allowed to shower
needs to have the cast protected from moisture
by covering it with plastic.

Evidence of the following complications
should be monitored every shift, and reported
to the nurse:

1. Sharp edges of plaster

2. Wrinkles

3. Odors that may indicate

a. moisture

b. mold

c. skin breakdown

d. infection

4. Neurological or circulatory problems

Instruct the patient on cast care.
Concentrate on giving information that will
allow the patient to recognize problems that
require follow up care. (Edema, pain,
drainage, foul odor, etc.)

Cast care should be recorded following
standard procedures for documentation. Other
pertinent observations to be recorded on
Nursing Notes SF 510:

1. Drainage or bleeding

a. color

b. odor

c. consistency

d. amount (size of stain on cast)

2. Time of observation

3. Unusual symptoms or observations

a. Pain

b. Pressure areas

c. Change in neurovascular circulation
checks

The Neurological Circulation Check Sheet
is used to record the following information:

1. Skin temperature of distal fingers or toes

2. Presence and quality of distal pulse

3. Movement

4. Sensation in fingers and toes

5. Color of fingers and toes

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Basic Hospital Corps School Lesson 3.29 Cast Care
Handbook III
NOTES/COMMENTS
341
Lesson 3.29 Cast Care Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.29

Cast Care Worksheet


1. What is a cast? ________________________________________________________________

2. A cast is used to:

a. seal a fracture.

b. stop bleeding.

c. immobilize a fracture.

d. reduce a dislocation.

3. Open reduction is used to align a broken bone:

a. without incisions.

b. through surgery.

c. before surgery.

d. after surgery.

4. List three complications that may be avoided by proper cast care.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

5. Circulatory compromise can result in nerve damage.

a. True b. False

6. If a stain is noted on a cast, draw a ring an inch larger than the stain on the cast.

a. True b. False

7. Skin care for a patient with a cast should be performed every shift.

a. True b. False



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Basic Hospital Corps School Lesson 3.29 Cast Care Worksheet
Handbook III
8. List four signs to note during a circulation check.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

9. During the first 24 hours after application, a cast is to be checked _____________ for drainage or
bleeding?

a. hourly

b. every two hours

c. every three hours

d. every four hours

10. A plaster cast should dry within ________ hours and a fiberglass cast should dry within
____________ minutes.

11. To protect a cast from moisture:

a. do not bathe the patient.

b. do not allow the patient to shower.

c. use waterproof material around the edges.

d. use waterproof paint to seal the plaster.

12. Record on the Nursing Notes SF 510 the size of any drainage or stain on a cast.

a. True b. False

13. Record on the Neurovascular Circulation Check Sheet:

a. drainage noted.

b. pain in affected extremity.

c. presence of central pulses.

d. sensation in toes and fingers.


343
Lesson 3.30 Chest Tubes Basic Hospital Corps School
Handbook III
Lesson 3.30

Chest Tubes

Terminal Objective:

3.30 List concepts and principles for using chest tubes.

Enabling Objectives:

3.30.01 State the purpose of chest tubes.

3.30.02 Describe the anatomy and physiology of the respiratory system.

3.30.03 List the equipment used for chest tube insertion.

3.30.04 State medical, surgical, and traumatic non-surgical conditions requiring a chest tube.

3.30.05 List the nursing care procedure for a patient with a chest tube.

3.30.06 State the common complications and nursing interventions for a patient with a chest tube.


A chest tube is a firm, flexible plastic
drain with several openings at the distal end
inserted into the pleural space to drain fluid or
blood, or to remove air. Removal of fluid, air,
and blood permits reexpansion of a collapsed
lung. Once inserted, a chest tube is sutured to
the skin and securely taped to prevent
accidental removal. A chest tube is attached to
a drainage system that collects drainage from
the pleural cavity. Chest drainage systems are
closed systems, meaning they are not open to
the air. Water is used as a seal to prevent air
from entering the pleural space. The drainage
system acts as one-way valve, preventing back
flow into the pleural space by means of
gravity or suction. Chest drainage re-
establishes or maintains the negative pressure
normally present in the pleural cavity. The
system assists in re-expansion of lungs by
draining fluid, blood, or air.

THE RESPIRATORY SYSTEM

The respiratory system is composed of
upper and lower airway structures, Figure
3.30.01. The upper airway consists of the
nasopharynx and the oropharynx where air
enters the respiratory system from the
atmosphere, and the trachea, which lets air
travel to the lower airway. The lower airway
consists of the bronchi, bronchioles, and
alveoli. Bronchi branch from the trachea into
the right and left lungs, then further divide into
the smaller elements called bronchioles before
ending at the alveoli, Figure 3.30.02.

Gas exchange takes place in the lungs. In
the alveoli, carbon dioxide created by
metabolism in the cells is given up and oxygen
from atmospheric air diffuses into the blood
stream. This process is referred to as 02-CO2
exchange. It is this exchange that provides
oxygen to the body's cells so that they may
carry out the functions of reproduction and
growth.

The lungs have a total of five lobes; three
in the right lung and two in the left lung. They
are located in the pleural cavity inside the
chest wall (the rib cage and associated
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Basic Hospital Corps School Lesson 3.30 Chest Tubes
Handbook III
muscles) and are separated from the
abdominal cavity by the diaphragm. The
diaphragm is the main muscle of respiration.
During inspiration, the diaphragm contracts,
increasing the size of the chest cavity, which
allows the lungs to fill with atmospheric air.
During exhalation the diaphragm relaxes,
decreasing the space in the chest cavity,
forcing air and C02 out of the lungs. Normal,
quiet breathing is accomplished almost
entirely with the diaphragm.

Lungs are surrounded by two membrane
linings (the pleurae) that assist the respiratory
muscles (diaphragm, intercostal and
abdominal) in breathing. The visceral pleura
covers the external surface of the lungs. The
parietal pleura lines the internal surface of the
thorax (chest wall). Between these two layers,
a suction-like seal exists, similar to placing
two pieces of plastic wrap together. This seal
is maintained by a minimal amount of fluid
(about 4 ml) that fills the pleural space
between the visceral and parietal pleura.

The pleural space is called a potential
space because when the lungs are functioning
normally, the space is barely noticeable. The
fluid in the pleural space reduces friction
between the two linings during movement that
occurs upon inspiration and expiration. The
potential space becomes an actual space if
there is a break in the seal between the pleural
linings, and the normal function of the lung is
altered.

The pleural space can fill with air, blood
or other secretions created by disease or
trauma to the lungs. As the pleural space fills,
lung capacity is decreased. The lungs can
totally collapse if a significant amount of air
or fluid fills the pleural space. Chest tubes are
inserted into the pleural space to drain the air
or fluid that is compressing the lung.

PHYSIOLOGY OF RESPIRATION

Respiration includes not only the
exchange of oxygen and carbon dioxide in the
lungs (external respiration), but also the
exchange that takes place between the
capillaries and the peripheral tissues of the
body (internal respiration.) Oxygen needs at
the peripheral tissues are communicated by
chemical and nerve signals.

The rhythmical movements of breathing
are controlled by the respiratory center in the
medulla of the brain. Receptors in the carotid
arteries and the aorta react to small changes in
CO2 concentration, and send signals to the
medulla. Nerves from the medulla pass down
through the neck to the chest wall and the
diaphragm. The nerve to the diaphragm is
called the phrenic nerve. The nerve to the
larynx is the vagus nerve, and the nerves to the
muscles of the thorax are called the intercostal
nerves.

As the respiratory center of the brain is
stimulated by chemical changes in the blood,
the respiratory center responds by stimulating
the nerves controlling respiratory movements.
The respiratory rate is increased, and the body
rids itself of the excessive carbon dioxide.

The muscles of respiration normally act
automatically. The respiratory cycle consists
of:

1. Ventilation -- movement of air into and
out of the lungs.

2. Inspiration -- diaphragm contracts and the
ribs are elevated, producing negative
pressure in the chest, along with increased
pressure in the abdomen (the chest cavity
increases in size.) This change in pressure
causes air to be drawn into the lungs.

3. Exhalation -- the diaphragm relaxes and
the elasticity of the chest wall and pleura
causes the chest to return to its original
size. Gasses are expelled from the lungs as
the size of the chest cavity decreases.

4. Rest is an interval between breaths.

5. Normal adult respiration is 12 to 20
breaths per minute.

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Lesson 3.30 Chest Tubes Basic Hospital Corps School
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When the chest wall expands during
inspiration, the pleurae are stretched and lung
volume increases. Elastic recoil begins after
the pleurae are stretched, starting the
expulsion of gas through exhalation. An
interruption in the continuity of either pleural
layer will allow air or fluid to enter the pleural
space and cause the lung to collapse.

EQUIPMENT FOR CHEST TUBE
INSERTION

Hospital Corpsmen are primarily
responsible for assisting the physician with
insertion of chest tubes. Maintaining the
patency of the tubes and assisting the patient
in respiratory exercises are additional tasks
performed by corpsmen. Prior to the insertion
of the chest tube, the corpsman should
assemble the following equipment at the
patient's bedside: sterile chest tube insertion
tray (usually obtained from the Central Supply
Department), sterile gloves, sterile 4x4 gauze
pads, sterile antiseptic swabs, sterile distilled
water, petroleum jelly gauze, an occlusive
dressing (usually done with tape), and suturing
material. Tubing of several kinds is also
needed: chest tubes appropriate sized, (for an
adult usually a 26 - 36 French), straight
connecting tubing (a rigid, short tube), flexible
(rubber) suction tubing, are required, and
tubing clamps (used only in emergencies). An
appropriate suction apparatus should be set up.
Wall suction units are present on most wards,
but you may need to get a portable suction unit
from Central Supply.

A Pleur-evac or other three chamber
portable suction unit must be set up before
chest tube insertion. The drainage system for
closed chest drainage is a collection of bottles
and a water seal to prevent air from returning
to the pleural space through the chest tube.
Water seal drainage acts as a one-way valve
that allows air and fluid out of the pleural
space but not back into the pleural space. The
simplest drainage system is a single bottle
with one long tube attached to the chest tube
with the opposite end at least 3 - 5 cm below
the level of the water, Figure 3.30.04. A
second shorter tube is placed next to the long
tube and is above the water level and open to
the atmosphere. This second tube acts as an air
vent allowing air to escape as the drainage or
air from the pleural cavity collects in the
drainage system.

Because bottles must be changed as fluid
accumulates, it is customary to use a three-
bottle system where the tubing of the first
bottle is attached to the chest tube from the
patient and acts as a collection bottle. The
other two bottles are used as the water seal, air
vent, and for additional fluid collection.

A third type of drainage system commonly
used is called a Pleur-evac, Figure 3.30.05. It
is a portable system that functions using the
same principle as the three-bottle water seal.
In addition, this systems acts as a suction
control. Major advantages of the Pleur-evac
system are the ability to control suction levels,
portability, and they are disposable.

When it is not possible to attach the chest tube
to a drainage system (such as in the field), a
Heimlich valve can be utilized to prevent air
that has left the pleural space through the chest
tube from re-entering. A Heimlich valve
provides a temporary seal for a chest tube.
Exhaled air escapes through the valve so that
accumulation of air in the pleural space is
prevented.

Miscellaneous equipment that will be
needed includes: a stethoscope for
auscultation of the lungs (pre and post-chest
tube insertion), 1% Lidocaine solution for
numbing the insertion site, benzoin ointment
to facilitate adhesion of the occlusive dressing,
waterproof tape, antiseptic solution, and a
completed x-ray request chit SF 519 for a
post-insertion chest x-ray.

CONDITIONS REQUIRING
CHEST TUBE PLACEMENT

Several conditions can cause an
interruption in the pleural lining. These
conditions are grouped into medical, surgical,
346
Basic Hospital Corps School Lesson 3.30 Chest Tubes
Handbook III
and traumatic non-surgical causes. All of these
conditions require placement of a chest tube
by the physician to assist in re-expansion of
the lung.

Medical conditions that require chest
tube placement include:

Spontaneous pneumothorax occurs
when air enters the pleural space from a
ruptured alveolus. This can occur in
adolescents during sudden growth spurts or in
adults with sudden changes in atmospheric
pressures. In rare cases it occurs without a
definite cause.

Empyema is purulent fluid in the pleural
cavity from infection. Conditions that create
empyema are chronic respiratory infections
such as fibrosis or fluid-secreting tumors.
Trauma from a penetrating chest wound, the
spread of infection from other structures, such
as the lungs, mediastinum, or chest wall, can
also lead to empyema, Figure 3.30.03. In cases
of chronic empyema, resistant to antibiotic
therapy, closed chest drainage may be used to
drain the cavity and allow the lung to re-
expand. The exudate must be thin enough to
drain through a chest tube, for this treatment to
be effective.

Tuberculosis is a communicable,
infectious disease caused by mycobacterium
bovis. It can occur in many places in the body,
but commonly affects the pulmonary system.
It may be acquired by drinking unpasteurized
milk from infected cattle or by living in close
proximity to other individuals with an active
infection. When the bacteria attach to the lung
wall, the tissue of the lung and white blood
cells encapsulate them. The tissue under the
encapsulated bacteria then becomes necrotic.
As the process continues, lesions may form
cavities that require drainage.
Fluid secreting tumors may encapsulate
and create an empyema or they may simply
secrete fluid into the pleural space, causing
compression of the lung.

Surgical conditions that require chest
tube placement include:
Lobectomy or pneumonectomy - the
surgical or invasive removal of a lobe or an
entire lung. When a disease such as
tuberculosis, a pulmonary abscess, a cyst or
cancer, has damaged the lung tissue the lobe
(lobectomy) or the entire lung
(pneumonectomy) can be removed and the
remaining bronchus sutured. During surgery,
air may enter the pleural space. A closed chest
drainage system is used to drain air and blood
from the pleural space post-operatively to
keep the lung from collapsing.

Pleural abrasion is a surgical procedure
where a caustic substance, (usually an
antibiotic such as tetracycline), is injected into
the pleural space through a chest tube. This
causes scarring of the tissue to seal the
visceral and parietal pleura. Pleural abrasion
may be used in cases of recurrent spontaneous
pneumothorax.

Any surgical procedure that interrupts the
pleural lining will allow air and blood to enter
the pleural space, requiring initiation of a
chest drainage system.

Traumatic nonsurgical conditions
requiring chest tube placement include:

Tension pneumothorax pressure builds
up in the pleural space, causing the lung to
collapse and push against the mediastinum.

Hemothorax blood in the pleural space.

Open pneumothorax air entering from an
opening in the chest wall.

These conditions can result from a variety
of causes, including diagnostic and therapeutic
measures such as biopsy or subclavian vein
catheterization. Either procedure can create a
tension pneumothorax, which requires chest
tube placement.






347
Lesson 3.30 Chest Tubes Basic Hospital Corps School
Handbook III
ASSISTING WITH CHEST TUBE
INSERTION

The insertion of a chest tube is a highly
specialized skill that requires rapid, efficient
movements to avoid further trauma to the
lung. Hospital Corpsmen are in a position to
assure patient privacy, comfort, and safety
throughout the procedure. This procedure
requires strict surgical asepsis. To insert the
tube, the physician makes a small lateral
incision in the chest wall, between the ribs that
lie just below the affected area of the lung.
Positioning the patient prior to the procedure
eases insertion, Figure 3.30.06. After the
physician makes the incision, the pleural
cavity is punctured with a sharp object (scalpel
or hemostats), Figure 3.30.07. A sudden rush
of expelled air or fluid, whichever has been
filling the pleural space is expected. Speed is
essential. The chest tube and equipment
should be readily available to the physician.
Once the tube has been inserted into the
pleural space it will be attached to the
drainage collection and suction system. The
physician will suture the chest tube to the skin
of the exterior chest wall and apply an
occlusive dressing. Securing the tube with
sutures and tape prevents accidental removal.
Once the tube has been secured, the x-ray
department should be notified of the need for a
chest x-ray.

At all times during the insertion
procedure, the corpsman should be observing
the patient for signs of respiratory distress. If
the patient appears to be in distress (becomes
extremely dyspneic, cyanotic or faints), alert
the physician immediately and prepare to
administer supplemental oxygen (if the patient
is awake) or initiate airway resuscitation.

CARE OF PATIENTS WITH
CHEST TUBES

Nursing care of the patient with a chest
tube centers on the maintenance of an intact
drainage system and facilitating adequate
respiratory function. An occlusive dressing is
used to prevent air from entering the pleural
cavity. The chest tube dressing should be
changed only when ordered by the physician.
It is critical to observe the dressing site at least
every shift for signs of infection such as
purulent drainage, foul odor, edema or redness
around the site. In addition, the corpsman
should listen for sucking noises that would
indicate that there is air leaking from the
pleural space.

The patient should be observed for any
signs and symptoms of respiratory distress
such as sudden onset of dyspnea, rapid,
shallow breathing, or cyanosis. Complaints of
chest pressure should be assessed
immediately. Air that leaks into the
subcutaneous tissue around the chest tube site
results in a condition called subcutaneous
emphysema. Subcutaneous emphysema can be
recognized by skin that appears slightly lumpy
and may crackle when palpated. Any of these
symptoms should be promptly reported to the
nurse. A functioning closed chest drainage
system will have continual fluctuation in the
water seal chamber. This indicates that air is
draining from the pleural space. Bubbling in
the water seal chamber indicates that there is
an air leak in the system and the nurse should
be notified.

When assessing the patency of a chest
tube and closed drainage system, work in a
systematic and organized fashion, starting
with the patient and ending at the drainage
system. Observe the patient for any signs of
respiratory distress. Observe the dressing,
ensuring that it remains occlusive. Observe the
area around the insertion site for signs of
infection or subcutaneous emphysema. Follow
the tubing toward the collection bottles.
Ensure that all connections are tightly sealed
with waterproof tape. Look at the drainage
system and the water seal to ensure proper
functioning. If the drainage system is attached
to a wall or portable suction unit make certain
that the suction is set at the appropriate level.
Make certain that there are no kinks or twists
in the tubing. Excess tubing should be coiled
next to the patient on the bed to avoid kinking
and prevent loops that might interfere with
drainage.
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Basic Hospital Corps School Lesson 3.30 Chest Tubes
Handbook III
If the tubing appears to be clogged with a
blood clot or viscous drainage, the doctor may
order it to be milked to ensure patency.
Milking requires a Doctor's Order. Proceed by
applying lotion to the hand used to milk the
tubing. Secure and occlude the tubing with the
other hand just below the connection to the
chest tube. With the lubricated hand about two
inches below the other hand, occlude and milk
the tubing by sliding your hand down the
drainage tube. Release the tubing slowly to
avoid a snap of air back into the patient's
chest.

Measurement and recording of chest tube
drainage is essential to assist the physician in
making decisions about when to discontinue
suction. Noting the amount and characteristics
of drainage can be an important indicator of
possible complications. Drainage should be
measured and recorded, a minimum of once
per shift. Mark the level of fluid on the
collection chamber (note the date and time.) It
is important for the bottle to be at eye level
when marking the fluid level. The output for
the shift is calculated by subtracting the
current level from the amount of the previous
mark. This amount should be recorded on the
Twenty-Four Hour Intake and Output
Worksheet DD 792 and in the Nursing Notes
SF 510, Figures 3.30.08 and 3.30.09. When
documenting chest tube drainage on the
Nursing Notes, record the at of the previous
mark. This amount should be recorded on the
Twenty-Four Hour Intake and Output
Worksheet DD 792 and in the Nursing Notes
SF 510, Figures 3.30.08 and 3.30.09. When
documenting chest tube drainage on the
Nursing Notes, record the amount, type and
color of the drainage. If drainage output
exceeds 60 ml per hour, notify the nurse and
begin measuring and recording the drainage
hourly. 60 ml per hour is a large amount of
output at any time other than the first few
post-operative hours.

If there is a sudden change in the color or
type of drainage, such as previously
serosanguinous drainage becoming sanguinous
or a chest tube that had no output for the
previous shift suddenly drains 60 - 100 ml, the
nurse should be notified immediately. These
changes are indicative of serious
complications and may necessitate immediate
action. If the drainage suddenly stops, check
for blockage and milk the tube (if there is a
Doctor's Order to do so.)

Although chest tube clamps should always be
available at the bedside, clamp the tubing
close to the chest and notify the nurse
immediately. A clamped chest tube can result
in a tension pneumothorax. Observe the
patient carefully for signs of tension
pneumothorax. Keep the tubing free of kinks
and twists and maintain the drainage apparatus
below the level of insertion at all times.

Respiratory care of a patient with a chest
tube includes breathing exercises as well as
maintaining normal activity levels. The patient
should be instructed on appropriate coughing
and deep breathing techniques. It is usually
beneficial to have the patient use an incentive
spirometer prior to coughing and deep
breathing. (Instruct the patient in the use of the
incentive spirometer if necessary.) The
incentive spirometer provides forced lung
expansion that will aid in getting oxygen to
the alveoli, thereby increasing the
effectiveness of coughing and deep breathing.

Whenever possible, instruct the patient
about breathing exercises prior to chest tube
insertion. Have the patient demonstrate
breathing exercises to make certain he/she has
a clear understanding of the purpose and
technique. Exercises are usually performed
every two hours. Post insertion pain may
interfere with the patient's ability to perform
respiratory exercises.

Maintenance of normal activity level will
facilitate respiratory function and promote a
sense of well being. Assist the patient with
ambulation when it is ordered. Patients may be
afraid to get up to walk, due to the pain during
movement and fear of pulling out the tube. If
pain medication is ordered, pre-medicate the
patient approximately 15 - 30 minutes prior to
exercise. This will decrease pain and facilitate
lung expansion and ventilation.
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Lesson 3.30 Chest Tubes Basic Hospital Corps School
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If the closed chest drainage system is
attached to a suction apparatus, there must be
a written Doctors Order for ambulation
because the suction will be off while the
patient is ambulating. Before ambulating,
instruct the patient on the purpose of
ambulation and the technique for getting out
of bed. Education will alleviate some of the
patient's fear about pulling out the tube.

To assist the patient in getting out of bed,
elevate the head of the bed approximately 45
degrees. Have the patient roll onto his/her
side, then swing the legs over the edge of the
bed while you assist him/her into a sitting
position. Have the patient sit at the edge of the
bed for a few minutes before standing to
lessen dizziness or light-headedness. Once the
patient is sitting, unplug the suction apparatus.
Keep the drainage apparatus below the
level of insertion at all times. Inadvertently
allowing the drainage system to be above the
level of insertion can allow drainage to flow
back into the chest cavity. The patient can
support the tube by holding it in his/her hand
while ambulating.

While ambulating, observe the patient for
signs of respiratory distress. If the patient
appears to be in distress, allow him/her to sit
and rest for short periods. Document in the
Nursing Notes SF 510, the length of time the
patient tolerated the activity, if he/she was pre-
medicated, and any complications that the
patient experienced during the exercise.
Record findings from auscultation of the
lungs. Auscultation should be done at least
Q4H to assess air exchange in the affected
lungs.

Because a chest tube may be in place for a
number of days, provide range of motion
exercises (ROM) to the arm on the affected
side to maintain muscle function and avoid
discomfort from the tube. Range of motion
exercises should be performed at least once
per shift. Active-assistive exercises for
patients with chest tubes includes ROM of the
shoulder girdle, flexion-extension exercises of
the upper arm and forearm and hand grasp
exercises. As with ambulation, premedication
with an analgesic should be done 15 - 30
minutes before the ROM exercises.

To maintain patient comfort, it is often
beneficial to have the patient lie on the
operative side. In addition to promoting
comfort, lying on the operative side will
facilitate expansion of the unaffected lung and
drainage of fluids from the affected lung.
When assisting the patient with coughing,
deep breathing and incentive spirometer
exercises, encourage your patient to splint the
chest wall on the affected side. It is best to
plan procedures so that the patient will have
the benefit of pain medications. Expect to
premedicate patients before insertion or
removal of chest tubes.

A patient with a chest tube may have
many fears related to the insertion of the tube
itself, unfamiliar equipment, coughing out the
tube, accidentally pulling out the tube, or
issues related to the diagnosis (cancer, death,
disability). Encouraging the patient to
verbalize these fears can help lessen the fears
and promote a sense of well being. Patient
education about the purpose and procedure of
chest tube insertion and removal, tube care,
respiratory exercises and activity limitations
can be extremely beneficial in helping the
patient adjust to this invasive procedure.

A knowledgeable patient is often a
cooperative patient. By having the patient
verbalize understanding of instructions and
procedures, the corpsman can assess the
patient's comprehension. You can then be
confident that the patient knows what to do in
the event of damage to the closed system
(clamping the chest tube and calling for help),
that he/she knows to help maintain a closed
system, and that he/she will be ready to
ambulate when allowed.

COMPLICATIONS OF CHEST
TUBES

Complications can arise after the insertion
of a chest tube.

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Basic Hospital Corps School Lesson 3.30 Chest Tubes
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Traumatic removal of the chest tube can
occur any time there is excessive force applied
to the tube, for example if the tube gets caught
on a bed rail and the side rail is pulled. Since
the tube is sutured in place, traumatic removal
may be quite painful. A pneumothorax or
hemothorax may occur if the pleural space
becomes filled with air or blood when the tube
is pulled out. In the event of a traumatic
removal, apply an occlusive dressing (using
petroleum gauze) to prevent air from entering
the pleural cavity. If significant bleeding is
present, apply a pressure dressing to control
hemorrhage. Notify the nurse or medical
officer immediately.

Infection can be recognized by the
presence of purulent drainage, erythema or
swelling at the dressing site. (The drainage
from the tube may be purulent as well.) An
elevated temperature is another sign of
infection. If the patient's temperature is
elevated but there are no signs of infection at
the insertion site, it is possible that the patient
has an atelectasis (or collapsed lung.)

A clamped or occluded tube can cause
tension pneumothorax. A clamped tube
allows a buildup of pressure in the contents of
the pleural space without an exit. This is a life-
threatening situation and requires prompt
treatment. If the tubing is clamped, release the
clamp and reclamp it at the end of exhalation.
If you suspect a tension pneumothorax, notify
the nurse immediately. If ordered, milk the
tubing to maintain patency.

Hypoxia, a condition where there is by
poor oxygenation of body tissues, can result
from poor ventilation or a decrease in lung
capacity (perhaps due to surgery). The patient
should be encouraged to perform respiratory
exercises as directed. Administer oxygen, if
ordered.

Occlusion of the chest tube can occur
from clots or viscous (thick) drainage in the
tubing. Milk the tube, if ordered, to maintain
patency. If the tubing is occluded, the patient
should be observed for signs and symptoms of
respiratory distress and the nurse should be
notified.

Disconnection of the tubing can occur at
any connection in the closed chest drainage
system. Clamp the tubing close to the patient's
chest and notify the nurse immediately.

The care of a patient with a chest tube can
be very complex. Application of the principles
of good respiratory care and surgical asepsis
can minimize the potential complications of
this invasive procedure.




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Lesson 3.30 Chest Tubes Basic Hospital Corps School
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FIGURE 3.30.01
Structure of the Respiratory System



















FIGURE 3.30.02
Lower Airway
FIGURE 3.30.03
Empyema
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Basic Hospital Corps School Lesson 3.30 Chest Tubes
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FIGURE 3.30.04
Lower Airway
FIGURE 3.30.05
Pleu-Evac
FIGURE 3.30.06
Position for Chest Tube Insertion
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Lesson 3.30 Chest Tubes Basic Hospital Corps School
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354
FIGURE 3.30.08
Nursing Notes SF 510 Entry
FIGURE 3.30.07
Chest Tube in Pleural Space
Basic Hospital Corps School Lesson 3.30 Chest Tubes
Handbook III
































FIGURE 3.30.09
Twenty-Four Hour Intake & Output Worksheet DD 792 Entry


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Lesson 3.30 Chest Tubes Worksheet Basic Hospital Corps School
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Lesson 3.30

Chest Tubes Worksheet


1. A tube that assists in the re-expansion of the lungs is called a ___________________________.

2. List three things drained using a chest tube.

a. ______________________________________________________________________

b. ______________________________________________________________________

c. ______________________________________________________________________

3. The muscle that aids in respiration and divides the chest cavity from the abdominal cavity is the:

a. deltoid.

b. masseter.

c. diaphragm.

d. gluteus.

4. The right lung has __________ lobes.

5. The left lung has ___________ lobes.

6. The visceral pleura lines the surface of the _______________.

7. The parietal pleura lines the surface of the _______________.

8. The potential space between the visceral and parietal pleura is called the _________________.

9. The mechanism of breathing is controlled by the:

a. brain.

b. heart.

c. lungs.

d. diaphragm.

10. The movement of air into and out of the lungs is called: _________________________________.



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Basic Hospital Corps School Lesson 3.30 Chest Tubes Worksheet
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11. An interruption in the continuity of the pleura may allow air or fluid to enter the pleural space and
cause the lungs to collapse.

a. True b. False

12. Which of the following medical department personnel may insert chest tubes?

a. Hospital Corpsman

b. Nurse

c. Physician

d. Medical student

13. Mark the two types of suction units used for thoracic suction.

a. Wall unit

b. Portable unit

c. Floor unit

d. Bed unit

14. Chest tube placement must be verified by a CAT scan after insertion.

a. True b. False

15. A portable, disposable thoracic suction system with three chambers is called a ______________.

16. A one-way valve used in the field that provides a temporary seal for chest tubes by allowing
exhaled air to escape through the valve, but prevents the return of air into the pleural space is a:

________________________________

17. Circle the equipment necessary to maintain a chest tube.

a. Sterile occlusive dressing

b. Drainage system

c. Suction unit

d. Airway

18. The surgical removal of a lobe of the lung is called ________________________________.

19. Injection of a caustic substance into the pleural space through a chest tube to cause scarring and
sealing of the lung surface is called: ______________________________________.

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Lesson 3.30 Chest Tubes Worksheet Basic Hospital Corps School
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20. Circle each traumatic non-surgical condition that would require chest tube placement.

a. Tension pneumothorax

b. Open heart surgery

c. Puncture wounds

d. Open pneumothorax

21. When maintaining a chest tube, a/an ______________ dressing should always be used.

22. List three signs/symptoms of chest tube insertion complication.

a. _______________________________________________

b. _______________________________________________

c. _______________________________________________

23. Bubbling in the water seal chamber indicates a/an ________________________________ .

24. The technique of cleaning the tubing to maintain chest tube patency is called declotting.

a. True b. False

25. Chest tube drainage is recorded on the:

a. _________________________________________________________

b. _________________________________________________________

26. If there is a sudden change in the color or type of drainage from a chest tube:

a. tell the patient.

b. immediately notify the nurse.

c. immediately note it on the Nursing Notes SF 510.

d. ignore it, because it is normal.

27. Chest tube drainage output that exceeds 60 ml per hour should be measured hourly.

a. True b. False

28. A chest tube should be clamped if the drainage system is destroyed.

a. True b. False


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Basic Hospital Corps School Lesson 3.30 Chest Tubes Worksheet
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29. List three techniques that aid the respiratory care of the patient with a chest tube.

a. _____________________________________________________________

b. _____________________________________________________________

c. _____________________________________________________________

30. When ambulating a patient with a chest tube, the drainage apparatus should be kept above the
level of insertion at all times.

a. True b. False

31. Administration of pain medication 15-30 minutes prior to ambulation will increase patient
comfort.

a. True b. False

32. Traumatic removal of a chest tube may result in what complications?

_________________________________________________________________

33. In the event of traumatic chest tube removal what kind of dressing should be applied to prevent
air from exiting?

_________________________________________________________________

34. Purulent drainage, erythema, and swelling at the insertion site and fever are signs of:

a. tension pneumothorax.

b. infection.

c. hypoxia.

d. occlusion.

35. Poor ventilation or a decreased lung capacity may result in a/an:

a. tension pneumothorax.

b. infection.

c. hypoxia.

d. occlusion.

36. A disconnected chest tube should be clamped as close as possible to the suction apparatus.

a. True b. False
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Lesson 3.34 Respiratory Care Basic Hospital Corps School
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Lesson 3.28

RESPIRATORY CARE

Terminal Objective:

3.28 List concepts and principles of respiratory care.

Enabling Objectives:

3.28.01 Define medical terms related to respiratory care.

3.28.02 State the purposes and procedures for assisting a patient with effective coughing, deep
breathing and an incentive spirometer.

3.28.03 State the purpose and describe the procedure for postural drainage, chest percussion and
vibration.

3.28.04 State the purpose and procedure to collect an arterial blood gas.

3.28.05 State the purpose, procedure, and special considerations related to tracheostomy tube
care.


Respiratory care is important to all
patients in the hospital because they have a
decreased level of activity. Less activity leads
to less chest and lung expansion. Secretions
can accumulate, providing an opportunity for
bacteria to multiply. Some patients are
admitted for care related to the respiratory
system. Others will have surgery, and need
respiratory care to prevent post-operative
complications. Basic terminology and
respiratory care will be covered in this lesson.

TERMS

Apnea - cessation of breathing; also called
respiratory arrest.

Atelectasis - the collapse of alveoli in the
lungs. It may be caused by poor ventilation or
poor chest expansion.

Bradypnea - abnormal slowness of
breathing.

Bronchial - refers to the sound of air
rushing through the larger airways.

Dyspnea - difficult or labored breathing.

Expectorant - substance which aids in
loosening and removal of secretions.

Expectorate - to cough up and spit out
mucus or sputum.

Hyperventilation - increase in the rate
and/or depth of respiration, which alters CO2
exchange.

Hypoxemia - decreased oxygen
concentration in the blood.

Hypoxia - reduction of oxygen in the
body tissues.

Incentive Spirometer - mechanical
device that provides a means of lung volume
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Basic Hospital Corps School Lesson 3.28 Respiratory Care
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measurement when performing deep breathing
exercises.

Orthopnea - condition in which breathing
is easier when the patient is in a sitting or
standing position.

Pneumonia - inflammation of the lungs,
usually caused by an infectious agent.

Rales (or crackles) - crackling, rattling, or
bubbling sounds that occur when air enters
smaller, fluid filled airways during inspiration.

Rhonchi - rumbling or gurgling sounds
heard on expiration as air moves through
larger airways containing fluid or secretions.
Rhonchi are often described as snoring
sounds.

Tachypnea - respiration rate that is
excessively rapid.

Tracheostomy - an artificial hole or
opening (stoma) made into the trachea to
allow air passage into and out of the lungs.

Tracheostomy tube - cannula inserted
into an artificial opening in the trachea.

Vesicular sounds - normal inspiratory
sounds with little or no noise heard throughout
exhalation.

Wheezing - high pitched whistling sounds
that occur in a partial airway obstruction
during inspiration or expiration.

COUGHING AND DEEP
BREATHING

Coughing and deep breathing are used to
prevent respiratory complications such as
atelectasis and pneumonia, and to move
secretions to the large airways to be coughed
out. Patients need to be well hydrated to thin
secretions for easier removal. Often, patients
will be taught how to cough and deep breathe
effectively as part of preoperative care.
Atelectasis and pneumonia occur post-
operatively due to decreased ventilation from
anesthesia and pain. For example, an incision
can be painful when moved or stretched,
which happens when taking a deep breath.

To assist a patient with effective coughing
and deep breathing, use this procedure:

1. Medicate the patient 30 minutes before
deep breathing, if necessary.

2. Wash hands. Gather equipment - emesis
basin, tissues, and stethoscope.

3. Explain all procedures, including the
importance of deep breathing and
coughing.

4. Auscultate the lungs before the procedure.

5. Assist the patient into a sitting position,
with his/her feet on the floor. (If
necessary, the patient can lie in bed on the
back or side with the knees flexed.) This
position allows the patient to use
abdominal muscles that help to deliver a
forceful expiration. The feet give stability
and aid in pushing during forceful
expiration.

6. Splint painful areas to decrease pain and
permit a more forceful expiration. A
folded sheet, a pillow, a sandbag, or hands
(yours or the patient's) are used to support
tissue, especially incisions or chest tube
insertion sites. Decreased movement of
these structures means less pain for the
patient.

7. Instruct the patient to take a deep breath
through his/her mouth while counting to
five or seven, at one second per count.
Encourage him/her to use the diaphragm.

8. Have the patient hold his/her breath for
three seconds, then exhale through pursed
lips for twelve to fifteen seconds.
(Exhaling through pursed lips causes back
pressure which keeps the alveoli
expanded.) As the patient exhales, tell
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Lesson 3.28 Respiratory Care Basic Hospital Corps School
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him/her to contract the abdomen toward
the spine.

9. Repeat this procedure three or four times,
resting for a few seconds between each
breath.

10. Have patient cough. Ask him/her to inhale
deeply, splint the abdomen, and give two
or three (deep) coughs while exhaling. If
sputum is expectorated, hand the patient a
tissue.

11. Auscultate the lungs to reassess the
patient's breath sounds.

12. Repeat the exercise Q2H.

13. After the procedure, provide comfort
measures as needed.

14. Document the procedure on the Nursing
Notes SF 510. Note the number of deep
breathing exercises performed, the quality
of the cough, breath sounds before and
after the procedure, whether sputum was
produced (if so, describe it in terms of
color, odor, consistency, and amount), and
the patient's tolerance of the procedure.

INCENTIVE SPIROMETER

An incentive spirometer may be used to
prevent atelectasis and to move secretions to
the large airways to be coughed out. The
device allows the staff and the patient a means
of seeing his/her current respiratory volume at
work. Patients can follow their own progress,
and reach for realistic higher levels. The
procedure for using the incentive spirometer
is:

1. Medicate the patient, if ordered, 30
minutes before the procedure.

2. Wash hands. Gather equipment - Incentive
spirometer, tissues, emesis basin, and a
stethoscope. (Incentive spirometers are
disposable items used for one patient only.
The spirometer stays at the bedside
between uses.)

3. Explain the procedure and its purpose to
the patient. Set the spirometer to the initial
desired goal (usually 500-ml.)

4. Auscultate lungs to establish a baseline for
later evaluation.

5. Position the patient sitting at the bedside
or in high Fowler's position.

6. Instruct the patient to exhale, emptying the
lungs as much as possible.

7. Have the patient seal his/her lips around
the mouthpiece of the spirometer and
immediately inhale. Encourage the patient
to take a deep breath, maintaining a seal
around the mouthpiece.

8. The patient holds the inspiration for three
to five seconds.

9. After holding the inspiration, the patient
may relax and exhale. Have him/her take
several breaths before repeating the
incentive spirometer exercise. (A typical
exercise set is ten repetitions, each taking
about one minute.)

10. Increase the patient's goal level when
he/she can easily reach the current level.

11. Encourage the patient to cough after a
deep breath, using the basic principals of
effective coughing and deep breathing.
Splint the abdomen as necessary.

12. Auscultate the lungs to reassess the
patient's breath sounds.

13. Record the procedure in the Nursing Notes
SF 510. Note the procedure done, how
many times done and the average volume
attained with each maximal inspiration.
Describe the quality of the cough, and
characteristics of any sputum produced
(color, odor, consistency, and amount.)
Document the breath sounds before and
after the procedure and the patient's
tolerance of the exercise.
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Basic Hospital Corps School Lesson 3.28 Respiratory Care
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POSTURAL DRAINAGE

Postural drainage is a technique for
clearing secretions from air passageways by
placing the patient in various positions.
Gravity is used to promote drainage. The
procedure for postural drainage is:

1. Verify the Doctor's Orders for area(s) to
be drained.

2. Wash your hands. Gather the equipment -
emesis basin, tissues, towel, and
stethoscope.

3. Explain the procedure and its purpose to
the patient.

4. Assess the patient's breath sounds to
establish a baseline for later evaluation.

5. Position patient in the desired or
prescribed drainage position. Incorrect
positioning will let secretions drain deeper
into the lungs. Common areas to be
drained include the posterior basilar
segments, the right middle lobe and
lingular (nipple line) segment of the left
lung, and the apical segments of the upper
lobes. Prepare the patient for comfort,
since postural drainage positions may be
held for up to 45 minutes (as tolerated.)
Assess for respiratory distress when the
patient is in a drainage position.

6. Have the emesis basin and tissues ready to
catch secretions, within easy reach of the
patient.

7. Protect any exposed skin area with a
towel.

8. Encourage the patient to cough.

9. Discontinue the procedure if any of the
following complications occur:
Tachycardia, palpitations, dyspnea, chest
pain, fatigue, or lightheadedness. Be alert
for nausea.

10. Auscultate the lungs to reassess the
patient's breath sounds.

11. Perform oral hygiene and reposition the
patient for comfort after the procedure.

12. Record the procedure on the Nursing
Notes SF 510. Note the type of treatment
performed, the lobes of the lung which
were drained, the length of the treatment,
and the quality of the cough. Describe the
sputum produced, document the breath
sounds before and after the procedure, and
the patient's tolerance of the procedure.

CHEST PERCUSSION AND
VIBRATION

Chest percussion and vibration (also
called chest physiotherapy) should be done in
conjunction with postural drainage to aid in
breaking up respiratory secretions so that they
can be coughed up. The procedure for chest
percussion and vibration is:

1. Verify the Doctor's Orders for the area(s)
to be percussed and vibrated. (Plan to do
percussion and vibration in conjunction
with postural drainage.)

2. Wash your hands. Gather the equipment -
emesis basin, tissues, towel, and
stethoscope.

3. Auscultate the lungs anteriorly and
posteriorly prior to beginning the
treatment to establish a baseline for later
evaluation.

4. Position the patient in the desired or
prescribed postural drainage position.

5. Protect any exposed skin area with a
towel.

6. Percuss over the desired segments and/or
lobes with your hands held in a cupped
fashion. Never percuss over the kidneys,
soft tissue (like the breast), the sternum or
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Lesson 3.28 Respiratory Care Basic Hospital Corps School
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the spine. Instruct the patient to inhale
slowly and deeply, then exhale passively
through pursed lips while percussing.
(Exhaling through pursed lips causes back
pressure which keeps the alveoli
expanded.) Vibrate the chest wall while
the patient is exhaling. Place one hand on
top of the other over the affected segment
of the chest. Apply gentle vibration over
the affected segment. Ask the patient to
breathe deeply four to six times with
prolonged expiration. Encourage the
patient to cough, using abdominal
muscles, after three or four vibrations.

7. Continue percussion and vibration for at
least three to five minutes per lobe.

8. Position the patient to allow secretions to
drain from the lower areas of the lungs to
the large air passages, promoting more
efficient removal of secretions.

9. Discontinue chest physiotherapy if any of
these adverse changes occur: Fatigue,
tachycardia, palpitations, dyspnea,
lightheadedness, or chest pain.

10. Auscultate the lungs anteriorly and
posteriorly, reevaluating the breath sounds
after percussion and vibration.

11. After the procedure, perform oral hygiene
and reposition the patient in a comfortable
position.

12. Record the procedure on the Nursing
Notes SF 510. Indicate the lobes drained,
the type of treatment performed, the
length of the treatment, and the quality of
the cough. Describe the character of the
sputum produced, the breath sounds
before and after the treatment, and the
patient's tolerance of the procedure.

ARTERIAL BLOOD GAS
SPECIMENS

Arterial blood gas (ABG) specimens are
collected to provide information about a
patient's acid/base balance and oxygen and
carbon dioxide levels. Critical information for
clinical decisions is obtained from ABG
results. ABG specimens are collected by
physicians, certified technicians, or registered
nurses. This is a potentially dangerous
procedure because an artery must be
punctured to obtain the specimen. Corpsmen
often assist with ABG collection. The
following procedure is:

1. Wash hands and gather the equipment - a
blood gas chit, blood gas syringe, needle,
clean gloves, sterile gauze, and container
of ice.

2. Explain the procedure and its purpose to
the patient.

3. After the specimen is drawn, apply firm,
direct pressure to the puncture site.
Manual pressure is maintained for 5-10
minutes until the bleeding stops. A
pressure dressing is applied after the
manual pressure.

4. Immediately after the ABG specimen is
drawn, the specimen is placed in a
container of ice to reduce the continued
metabolism of oxygen and production of
carbon dioxide. (Blood cells are living,
and will continue metabolic processes.)
Any air bubbles are removed to prevent
contamination of the specimen with
atmospheric oxygen before the sample is
placed on ice. ABG samples are sent to
the lab as soon as possible.

5. Observe the puncture site every 15-30
minutes for bleeding. If bleeding or
swelling starts, reapply pressure and notify
the nurse.

6. Clean and dispose of all equipment.

7. Record the procedure on the Patient
Profile NAVMED 6550/12 on the
backside, right hand column, in the Lab
test section. (Enter the date the specimen
was sent to the lab.) On the Nursing Notes
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Basic Hospital Corps School Lesson 3.28 Respiratory Care
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SF 510 record the procedure and the
patient's tolerance to the procedure.

TRACHEOSTOMY TUBE CARE

A tracheostomy is an artificial hole or
opening (stoma) into the trachea to allow air
passage in and out of the lungs. The
tracheostomy cannula is inserted into the
opening to maintain the patency of the
artificial airway and to prevent infection of the
lungs. Patients with tracheostomy tubes cannot
filter air through the mouth and nose. Sputum
is coughed out through the tube, which can
become plugged with secretions. Suctioning is
done to prevent the accumulation of
secretions, or to clear a clogged tracheostomy
tube. At times, a doctor may order collection
of a sputum specimen from a tracheostomy.

Most tracheostomy tubes are made of
plastic and have two pieces, an inner cannula
and an outer cannula. The inner cannula must
be cleaned periodically to prevent infection.
Most facilities require tracheostomy care Q8H
(and PRN.) Inner cannulas may be reusable or
disposable. Disposable inner cannulas are
removed (wear clean gloves) and discarded,
then a new, sterile inner cannula is inserted
quickly but gently. Reusable inner cannulas
are replaced by using this procedure:

1. Check the Patient Profile NAVMED
6550/12 for the procedure to be
performed.

2. Wash hands and gather equipment - clean
and sterile gloves, tracheostomy care kit,
sterile suction set, sterile water, oxygen
delivery device (bag-valve-mask device),
suction device, and when needed, a sterile
specimen container.

3. Place the patient in high Fowler's position
if possible. Assess breath sounds.

4. Wipe away any secretions that have
accumulated at the tracheostomy opening.
Use a lint free wipe, since the patient may
inhale lint directly into the lungs.

5. Open the suction set and the tracheostomy
care kit aseptically.

6. Don clean gloves.

7. Preoxygenate the patient before suctioning
by hyperventilating him/her with 100%
oxygen connected to the bag-valve-mask
unit. (Suctioning the patient will remove
oxygen from the lungs.)

8. Discard clean gloves and don sterile
gloves. Open the water cup, and have an
assistant pour sterile water into the cup. (If
the kit allows you may pour the water
before donning the sterile gloves.)

9. Use aseptic technique during the
procedure to prevent infection.

10. Attach the sterile suction catheter to the
suction tubing. One hand will become
contaminated, so be sure to keep the
sterile hand sterile.

11. Lubricate the first few inches of the
suction catheter with sterile water to ease
its passage into the cannula.

12. Test the suction by covering the hole near
the distal end of the catheter with the
contaminated (now considered a clean
glove) hand.

13. Insert the catheter slowly and carefully
about six to ten inches into the
tracheostomy. Stop if you meet resistance.
(Do not suction while inserting the
catheter.)

14. Apply suction for no longer than 15
seconds, as the catheter is withdrawn.

15. Flush the catheter with sterile water.
Allow the patient to rest between passes.
Repeat the procedure until the tube is
clear.



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Lesson 3.28 Respiratory Care Basic Hospital Corps School
Handbook III
16. To collect a sputum specimen, use a sterile
sputum trap attached to the suction tubing.
Keep the trap upright or the contents will
be sucked into the drainage tubing.

17. After suctioning, remove the inner cannula
and replace with another reusable inner
cannula. Most patients will have one clean
cannula ready. When a spare inner
cannula is not available, clean and replace
the inner cannula within five minutes of
removal.

18. Replace the tracheostomy ties PRN, and
always be sure that the ties in place are
securely fastened.

19. Reassess breath sounds. Provide comfort
measures.

20. Clean and dispose of all equipment.

21. Document the care provided on the
Nursing Notes SF 510. Note the type of
treatment performed, the character of the
sputum produced, the breath sounds
before and after the treatment, and the
patient's tolerance of the procedure
Tracheostomy tubes require special
considerations:

1. Always use sterile suctioning technique
because the tracheostomy leads directly to
the trachea and lungs.

2. Prior to obtaining a specimen,
hyperventilate patient with 100% oxygen,
because suctioning will remove oxygen
from the airway.

3. Ensure you know how to use the special
suction trap to obtain the specimen.

4. The inner cannula should be cleaned at
least every eight hours. Once the inner
tube has been removed, it must be
replaced within five minutes.

5. Ensure the tracheostomy tube is securely
fastened before leaving the patient.


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Basic Hospital Corps School Lesson 3.28 Respiratory Care
Handbook III
NOTES/COMMENTS
367
Lesson 3.28 Respiratory Care Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.28

Respiratory Care Worksheet


1. Match each definition in column B to the correct term in column A.

A B


a. Apnea _______


b. Dyspnea _______

c. Hypoxia _______

d. Hypoxemia _______

e. Rales _______

f. Rhonchi _______

g. Vesicular _______

1. Rumbling or gurgling sounds heard as air
moves through larger airways.

2. Difficult or labored breathing.

3. Exhalation which has little or no noise.

4. Cessation of breathing

5. Reduction in oxygen in body tissues.

6. Crackling sounds heard during inspiration.

7. Decreased oxygen concentration in the blood.

2. Coughing and deep breathing is used to:

a. explain pre-operative respiratory care.

b. prevent post-operative atelectasis.

c. move secretions to smaller airways.

d. increase ventilation during anesthesia.

3. Patients should be in a sitting position for coughing and deep breathing.

a. True b. False

4. An expectorant aids in loosening and removal of secretions.

a. True b. False

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Basic Hospital Corps School Lesson 3.28 Respiratory Care Worksheet
Handbook III
5. Splint painful areas during coughing and deep breathing to:

a. prevent wound dehiscence.

b. prevent pathological fractures.

c. decrease pain during coughing.

d. immobilize strained muscles.

6. List three items that may be used to splint painful areas during coughing and deep breathing.

a. ________________________________________________________________

b. ________________________________________________________________

c. ________________________________________________________________

7. An incentive spirometer is a mechanical device that forces air in and out of the lungs.

a. True b. False

8. The patient should exhale as much as possible just before using the incentive spirometer.

a. True b. False

9. List three areas that commonly need postural drainage.

a. __________________________________________________________________

b. __________________________________________________________________

c. __________________________________________________________________

10. List four reasons to discontinue postural drainage.

a. __________________________________________________________________

b. __________________________________________________________________

c. __________________________________________________________________

d. __________________________________________________________________

11. Chest percussion and vibration should be done in conjunction with postural drainage.

a. True b. False




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Lesson 3.28 Respiratory Care Worksheet Basic Hospital Corps School
Handbook III
12. Percussion may be performed over:

a. lung lobes or segments.

b. either kidney.

c. soft tissue, like the breast.

d. the sternum or spine.

13. Vibration is done while the patient is exhaling.

a. True b. False

14. Arterial blood gas specimens are collected:

a. when the doctor asks for a fresh blood sample.

b. routinely during admission to the hospital.

c. only on pediatric patients.

d. to get information on a patients oxygen/carbon dioxide levels.

15. ABG may be collected by any corpsman.

a. True b. False

16. The ABG sample must be kept warm until delivered to the lab.

a. True b. False

17. A tracheostomy tube must:

a. be suctioned periodically to prevent infection.

b. be removed every hour for cleaning.

c. never be touched because it keeps the airway open.

d. be sutured to the patient's skin for security.

18. Most local protocols require that a tracheostomy tube be suctioned at least every ______ hours.

a. 2

b. 4

c. 8

d. 12
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Basic Hospital Corps School Lesson 3.28 Respiratory Care Worksheet
Handbook III

19. Before suctioning a tracheostomy:

a. place the patient in the Trendelenburg position.

b. always perform chest percussion and vibration.

c. hyperventilate the patient with 100% oxygen.

d. make sure that the breath sounds are clear.

20. During tracheostomy cleaning, suction is applied for no longer than 15 seconds, and only
when withdrawing the catheter.

a. True b. False

371
Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III
Lesson 3.23

Preoperative and Postoperative Care

Terminal Objective:

3.23 List concepts and principles of preoperative and postoperative medical care.

Enabling Objectives:

3.23.01 Define the types of anesthesia used in surgery.

3.23.02 List guidelines for preparing the patient for surgery.

3.23.03 List guidelines for meeting the psychological needs of a preoperative patient.

3.23.04 List guidelines for documenting preoperative nursing care.

3.23.05 List supplies and equipment used for postoperative nursing care.

3.23.06 State nursing care measures performed upon arrival of the postoperative patient to the
ward.

3.23.07 State observations of postoperative patients that should be reported or recorded.

3.23.08 State nursing interventions for treatment of postoperative complications or symptoms.

3.23.09 State guidelines for patient safety, privacy, education, and comfort for postoperative
patients.

3.23.10 Report and record pertinent observations on postoperative patients.


Skilled nursing care given during the
preoperative time will aid in preparing the
patient for surgery, both physically and
emotionally. All members of the health care
team will focus on the needs of the patient in
administering care.

ANESTHESIA

During physical preparation of the patient,
or during preoperative teaching, staff may be
questioned about the types and effects of
anesthesia. Honest and simple answers may do
much to prepare the patient mentally for
surgery. The anticipated sensation of pain and
the unavoidable feeling of loss of control are
prominent fears of many patients.

Anesthesia refers to the loss of sensation
to an area and is desired to eliminate the
uncomfortable sensations associated with an
invasive procedure such as surgery. The
following are the major types of anesthesia
that are usually used during surgical
procedures.

General anesthesia is administered by
inhalation or intravenous injections and
produces a state of unconsciousness. It causes
a lack of sensation throughout the body.
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Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
Regional anesthesia is a lack of sensation
due to an interruption of the nerve sensation in
any region of the body. Does not result in loss
of unconsciousness. Field block is a type of
regional anesthesia. The blocking of nerve
impulses in the particular field or area results
when local anesthetics are injected into
surrounding tissues of an area to be operated
on, such as an arm, a leg, a finger, etc.

Spinal anesthesia is another type of
regional anesthesia. The anesthetic agent is
injected in the subarachnoid space of the
spinal cord. Sensations the body will be lost
distal to the injected area. This anesthesia is
not used for surgery above the diaphragm as it
could cause breathing difficulties.

PREOPERATIVE PREPARATION

Essential to preparing the patient for
surgery is to ensure adequate rest, nutrition
and hydration, and to complete preoperative
teaching. Teaching should include instructions
on events that will occur before surgery and
those that will be occurring after surgery. Pre-
op events to be explained include:

1. skin preparation -- shower, scrub, and
shave of surgical area

2. pre-op medication

3. equipment -- IVs, NG tube, Foley catheter

4. procedures -- lab tests, x-rays, enemas

5. NPO from 2400 until surgery

Teaching about postoperative events will
facilitate patient compliance and decrease
postoperative complications. Postoperative
events include

1. respiratory care

2. foot and leg exercises

3. pain control

4. wound care
Preoperative teaching is documented in the
Nursing Notes SF 510.

Numerous procedures assist in preparing
the patient for surgery. Physical preparations
include skin preparation such as a bath or
shower with an antibacterial soap. A shave of
the operative site may also be ordered, Figure
3.23.01. A cleansing enema may be ordered to
reduce postoperative abdominal distention and
constipation. Explain to the patient that he/she
will be NPO from 2400 until the surgery is
completed. The lack of food in the stomach at
the time of surgery prevents aspiration in the
event the patient vomits. Place an NPO sign at
the bedside to remind the patient and all staff
members that the patient is NPO.

The morning of surgery, the final
preparations for the patient's trip to the
operating room takes place. Vital signs are
taken prior to the patient leaving the ward and
recorded on the Vital Signs Record SF 511
and on the preoperative checklist. During
surgery, the preoperative vital signs will be
used as the baseline to determine high and low
values. The patient needs to remove all
jewelry. If the patient objects to having the
wedding band removed, it may be secured to
the finger with tape or gauze. If the jewelry is
not sent home with a family member, it must
be inventoried using the Valuables Envelope
NAVMED 6010/8 and secured per local
policy.

All prosthetic devices will be removed -
dentures, eyeglasses, contact lenses, artificial
limbs. Local policy will indicate that hearing
aids may be worn to the operating room so the
patient can follow instructions prior to
receiving anesthesia. Hairpieces, combs,
bobby pins, barrettes are all removed. Nail
polish is removed from fingers and toes.

When the operating room staff notify the
ward that they are ready to receive the patient,
the final On-Call preparations are made. Re-
confirm the patient's identity and ensure that
the correct identification bracelet is secured to
his/her wrist. Instruct the patient to void prior
to receiving the preoperative medication. After
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Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III
the preoperative medication is given instruct
the patient to remain in bed. To ensure patient
safety, raise the bed rails and place the call bell
within reach. Document administration of the
medication of the Medication Administration
Record (MAR) NAVMED 6550/8, the
Nursing Notes SF 510, and on the preoperative
checklist.

The patient may go to the operating room
wearing only a hospital gown or be sent
without any clothes. Provide for patient
privacy when transferring to the gurney and
when being transported in the hallway.

The ward staff must review the entire
preoperative clinical record and check for
completeness. The chart should contain a pre-
op pack of clinical forms. The staff should
ensure that all forms are properly
addressographed and that the front hard cover
of the clinical record has the following
attached:

1. Patient's Addressograph card,

2. Allergy label, if applicable,

3. Pre-op checklist, with check marks and
initials to indicated completed orders and
procedures in preparation for surgery.

PSYCHOLOGICAL NEEDS OF
PREOPERATIVE PATIENTS

The need for psychological support will
vary greatly according to the patient's age,
diagnosis, cultural and educational
background, family, and occupations. There
are numerous ways the staff can help meet the
psychological needs of a pre-op patient. To
help reduce apprehension, use laymen's terms
when explaining pre-op and postoperative
activities. Try to empathize with the patient to
anticipate their concerns and need for
emotional support. Since family members
have many of the same concerns as the patient,
every effort should be made to include family
members during patient teaching. Answer
questions as completely as you can, but
remember to refer to someone more qualified
if you do not know the answer. Be aware of
the importance of providing spiritual support.
Individual religious differences should be
recognized. Listen carefully for patients who
indicate a need or desire for spiritual support.
Contact a chaplain for the patient when
requested.

DOCUMENTATION

Documentation of preoperative nursing
care is done in the preoperative checklist and
in the Nursing Notes SF 510. The various
procedures on the preoperative checklist
should be checked and initialed as they are
completed. While the checklist format may
vary between hospitals, the items on the
preoperative checklist will include:

1. Physical preparation of the patient:

a. skin preparation (shower, scrub, and
shave)

b. NPO status

c. enema

d. urinary tract preparation (voiding/catheter
placed)

e. bath/shower

f. oral hygiene - dentures removed

g. jewelry removed or secured

h. prosthesis, eyeglasses removed

i. hairpins and hairpieces removed

j. nail polish removed

2. Most recent vital signs

3. Correct ID band on patient

4. Consent forms signed

5. Pre-op medications given
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Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
6. Lab test results in chart

A Nursing Notes SF 510 entry should include
the physical preparation of the patient (shower,
shave, and medications), emotional
preparation, education and patient
comprehension, and safety measures provided.
An entry is also made when the patient leaves
the ward and should include mode of transport
to the operating room and the name of the
person accompanying the patient.

POSTOPERATIVE NURSING
CARE EQUIPMENT

Equipment that will be needed for the
immediate care of the postoperative patient
includes:

1. Postoperative bed with linen fan-folded
back and side rails attached.

2. IV pole

3. Emesis basin

4. Respiratory aids:

a. Artificial airway

b. Suction equipment

c. Oxygen equipment

d. Pillow/folded sheet for abdominal
support

e. Incentive spirometer

f. Tissues

5. Vital signs equipment:

a. Sphygmomanometer

b. Stethoscope

c. Thermometer


6. Forms

a. Nursing Notes SF 510 to record post-
op observations.

b. Plotting Chart SF 512 to record post-
op vital signs.

c. Twenty-Four Hour Intake & Output
Worksheet DD 792 to record intake
and output.

d. Completed Recovery Room Record.

e. Anesthesia Report SF 517.

f. Post-op Doctor's Orders SF 508.

NURSING CARE MEASURES

Prior to the patient's arrival on the nursing
care ward, the Recovery Room personnel will
have called a report to the ward nursing staff.
It should be a nurse to nurse report. The report
generally includes a brief synopsis of the
surgical procedure, any complication
encountered during surgery and recovery from
anesthesia, condition of the dressing, IV
solution and intake, any tubes or drains in
place and the amount of drainage from them,
condition of the dressing, urinary output, and
any medication given along with time of
administration.

Quickly read the recovery room report,
Anesthesia Report SF 517, and post-op
Doctor's Order SF 508. The post-op orders
should be reviewed with particular attention to
the following information: IV solution, vital
signs regime, N2O administration, any
medications needed, intake and output, food
and fluids to be given, activity level, wound
care, and any laboratory work needing to be
completed. In addition the Anesthesia Report
should be reviewed for the agent used, any
complications, and time extubated. The
Recovery Room Record should also be briefly
reviewed for the patient's general condition,
intake and output during the recovery phase,
medications given during this period, and level
of consciousness.
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Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III

Upon the patient's arrival to the ward,
assist with transferring the patient from the
gurney to the bed, while supporting and
protecting the head, extremities, drainage
tubes, and all IVs. Make sure the patient is
adequately covered during the transfer
procedure.

A patent airway must be maintained at all
times. Keep the patient's chin up and pull the
jaw forwarded if it is necessary to maintain the
airway. (Similar to the modified jaw thrust
used in BLS.) The patient should be positioned
on one side, or have the head turned to one
side to facilitate mouth drainage if the patient's
condition permits. If necessary, or if ordered,
the patient should be suctioned. Most patients
return to the ward without an airway in place,
since it usually is removed in the operating
room, or the recovery room. If the patient still
has an artificial airway, do not remove it until
the gag reflex has returned.

Vital signs should be monitored according
to the patient's condition and the physician's
postoperative Doctors Orders, generally every
15 minutes until stable. A common
postoperative routine is vital signs every 15
minutes for an hour, every 30 minutes for two,
every hour for 4 hours, then every four hours.
Vital signs taken in the postoperative period
should be compared to the baseline
preoperative vital signs.

The patient should be observed for
recovery from anesthesia. Two types of
anesthesia are used in surgery, general
anesthesia or regional anesthesia. General
anesthesia causes a completed loss of
sensation and consciousness, and is
administered via gas or as an intravenous
medication. The patient is fully recovered
from general anesthesia when he/she is alert
and oriented. Regional anesthesia is
administered by injection, which causes a loss
of sensation to a particular area. With regional
anesthesia the patient does not lose
consciousness. Recovery from this anesthesia
is complete when full sensation and voluntary
movement returns to the anesthetized area.

The general condition of the patient should
be closely monitored. Cardiovascular function
should be assessed by observing skin color,
body temperature, capillary refill, and color of
mucus membranes. Take a few minutes to
closely observe the patient's skin to ensure
there are no abrasions or bruises that may have
inadvertently occurred during the transfer from
bed to gurney, and from restraining straps
utilized in the operating room.

Most importantly, observe the site of the
operation. Check the location and size of the
dressing frequently (with vital signs.) All
drainage (type and amount) should be noted
and recorded. If a dressing becomes heavily
saturated, reinforce it and notify the nurse. Do
not change the dressing unless ordered to do
so. The first dressing change is usually done
by the physician. In addition, check under the
patient for any drainage. The dressing may be
dry and intact, but the patient may actually be
lying in a pool of blood. Gravity will cause the
drainage to pool under the patient.

All tubes and drains should be located
early in the postoperative phase of nursing
care. If you are unsure of the presence of
drainage tubes, refer to the Anesthesia Record
or the Recovery Room Record for
documentation of their presence. A Penrose
drain may be underneath the dressing. If it is
present, you can expect more drainage.

A Hemovac, or a J ackson-Pratt drain may
be in place. A drain removes fluid to collapse
skin flaps against underlying tissue through
the use of constant, gentle suction. Drains are
inserted by the surgeon during the operation
and sutured in place, with collection devices
that are exterior to the dressing. The patient
may also have a chest tube. the tubing and
collection device should be monitored for type
and amount of drainage. In addition, output
from NG tubes and Foley catheters should be
closely monitored.

All IV intake must be closely monitored
and documented. Check the rate and type of
infusion ordered. Frequently the patient will
376
Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
arrive on the ward with a different IV solution
hanging than what is specified in the Doctor's
Orders SF 508. (Fluids are managed by the
anesthesiologist during surgery.) Check the
postoperative Doctors Orders to verify type
and rate of infusion. Note the amount of fluid
received in the Operating Room and Recovery
Room (RR or PACU.) These need to be
recorded on the Twenty-Four Hour Intake and
Output Worksheet DD 792. The IV site should
be monitored for infiltration, phlebitis, edema,
inflammation, and tubing obstruction/patency
as discussed in the IV therapy lesson. Record
IV intake on the DD 792.

Basic nursing care is imperative to ensure
full recovery of the postoperative patient.
Position the patient on one side until he/she is
fully conscious and has an adequate gag
reflex. If the patient has not fully recovered
from anesthesia, stay with the patient.
Respiratory exercises should be initiated as
quickly as the patient's condition permits.
Refer to the Doctor's Orders SF508 for
appropriate respiratory care. The patient
should be instructed to turn, cough, and deep
breathe at least every two hours. This should
have been taught during the preoperative
period. The Hospital Corpsman needs to
reinforce this teaching, and assist the patient as
necessary. If incentive spirometry is ordered,
ensure that the patient completes the exercises.

All safety precautions must be closely
observed. Ensure all side rails are up, even if
you are nearby. A groggy patient with a side
rail down presents a dangerous situation.
Remember, the patient's safety is your
responsibility. Instruct the patient not to
ambulate or sit on the side of the bed unless
you are there. Ensure the call bell is within the
patient's reach at all times.

Family members should be incorporated
into the patient's postoperative care as soon as
feasible. As soon as the patient has been
returned to bed and assessed, family members
should be allowed to visit briefly. The
attending physician should contact the family
and provide current information concerning
the patient's condition as soon as possible after
surgery. Patient and family anxiety can be
alleviated by a brief visit. Provide
spiritual/emotional support as needed.
Reinforce preoperative teaching as needed,
and as the patient recovers.

All pertinent observations should be
documented on the Nursing Notes SF 510 as
soon as possible. Notify the nurse immediately
of any unusual observations. Record the
following on the SF 510:

1. Time patient was received from the
Recovery Room or Operating Room.

2. Vital signs on arrival to the ward.

3. Assessment of the airway.

4. Level of Consciousness/Recovery from
anesthesia.

5. Color and condition of the skin.

6. Condition and location of dressing, drains,
tubes, and catheters.

7. IV solution, flow rate, bag number, and
site.

8. Pain location and type.

9. Complications.

10. Diet and toleration of the diet.

11. Elimination and any problems.

12. Activity level.

13. Other pertinent observations.

14. Presence of family/significant others.

Vital signs are recorded on the Plotting
Chart SF 512. All oral and IV intake should
be documented on the Twenty-Four Hour
Input & Output Worksheet DD 792.



377
Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III

CIRCULATORY
COMPLICATIONS

The most life threatening circulatory
complications are hemorrhage and shock.
Hemorrhage may be internal, external, or both.
A change in vital signs or level of
consciousness may be the only external
indication of internal bleeding. While
observing the dressing for drainage, monitor
external bleeding.

Hemorrhage and shock should be
suspected when there is excessive sanguineous
drainage, cool, moist skin, and/or cyanosis, a
falling blood pressure, and an increased heart
rate.

Treatment includes:

1. Keep the patient warm and in the
Trendelenburg position.

2. Reinforce the dressing, applying
pressure if necessary.

3. Monitor temperature, pulse,
respiration, and blood pressure.

4. Notify the nurse immediately.

Thrombophlebitis of the lower
extremities may occur as a result of several
factors: injury to the vein, slowed circulation
postoperatively, and dehydration. Signs and
symptoms include: pain, redness, swelling, a
positive Homan's sign, and heat.

As with most post-op complication,
prevention is the key to success.
Thrombophlebitis can be prevented in part by
early ambulation and patient education.

Treatment includes:

1. The physician may order
antiembolism stockings to prevent the
condition.

2. Restrict the patient's activity and
elevate the affected leg in straight
alignment.

3. Do not massage legs or restrict
circulation in any way.

4. Hot moist packs may be ordered by
the doctor for the affected leg.

An embolus is a blood clot that dislodges
and moves through the circulatory system. It
may lodge in a vital organ, resulting in an
embolism that could cause severe disability or
death. Again, the best treatment of this
condition is prevention. If the patient develops
an embolism, he/she will be placed on strict
bed rest to reduce the possibility of the clot
dislodging. Symptoms may vary depending on
where the embolism lodges. Signs and
symptoms include: Chest pain (pulmonary or
cardiac), difficulty breathing (pulmonary), and
neurological manifestations (cerebral).

Treatment includes:

1. Notify the nurse immediately, if signs
and symptoms are present. Treatment
will be directed at the affected system.

RESPIRATORY
COMPLICATIONS

Respiratory complications are fairly
common, yet easy to prevent. Vigorous
pulmonary exercises will aid tremendously in
preventing these potentially life threatening
complications. The signs and symptoms
include: restlessness, anxiety, dyspnea, and
cyanosis.

Treatment includes:

1. Check airway for obstruction and
reposition the head as necessary.

2. Suction the oropharynx as needed.

3. Administer oxygen.

378
Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
4. Administer medications ordered by d
doctor.

5. Aids for lung expansion:

a. Turn, cough, deep breath (T, C, D
B) Q2H.

b. Incentive spirometer Q2H.

c. Postural drainage as ordered by
doctor.

6. Notify the nurse.

Postoperative Pneumonia is a relatively
common postoperative respiratory
complication that results from stasis of
secretions. Signs and symptoms include: a
productive cough, shallow respirations,
elevated temperature, rhonchi, rales, and
diminished breath sounds (especially in the
lower lobes). Treatment measures are aimed at
prevention.

Treatment includes:

1. Early and daily ambulation. (This is
more a preventive measure than a
treatment.)

2. Turning, coughing, deep breathing (T,
C, DB) Q2H.

3. Incentive spirometer Q2H.

4. Provide respiratory therapy as ordered:

a. Oxygen therapy.

b. Chest percussion/vibration and
postural drainage.

5. Notify nurse/doctor.

Atelectasis is often caused by mucus that
has plugged a bronchiole. Signs and symptoms
include: tachypnea, decreased breath sounds
on the affected side, cough, and fever.

Treatment includes prevention by:
1. Turning, coughing, deep breathing (T,
C, DB) Q2H.

2. Incentive spirometer use Q2H

3. Early ambulation.

4. Maintaining hydration, push fluids if
not contraindicated.

WOUND COMPLICATIONS

Wound complications may also occur,
depending upon the underlying disease
condition, physical and nutritional state of the
patient, and the type of incision.

Wound dehiscence is a separation of the
wound edges. It generally occurs 7-10 days
postoperatively. Causes of dehiscence may
include wound infections, straining during
coughing, poor nutrition leading to slow
wound healing, and premature suture removal.
Dehiscence may include all layers of the
wound, or merely the superficial layers. Signs
and symptoms include: pain, swelling and
redness, drainage, odor, separation of wound
edges, and elevated vital signs - temperature,
pulse, and respirations.

Treatment includes:

1. Notify nurse.

2. Cover wound with sterile gauze.

Signs and symptoms of a wound infection
include: pain, heat, swelling, redness,
drainage, foul odor, and elevated vital signs -
temperature, pulse, respirations and blood
pressure.

Treatment includes:

1. Notify the nurse or doctor.

2. Change dressings as ordered by
doctor.

3. Give medications as ordered by
doctor.
379
Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III
4. Irrigate wounds as ordered by doctor.

5. Maintain sterile technique when
indicated.

Pain is expected after surgery. It is a
subjective symptom that can be felt only by
the patient. Signs and symptoms include:
restlessness, anxiety, crying, increased pulse
and increased blood pressure.

Treatment includes:

1. Determine the location, type, and
intensity of the pain to assist in
treatment of the cause.

2. Reassurance:

a. Stay with patient, as time permits.

b. Use a calm, supportive touch.

3. Activities that assist in the relief of
pain, anxiety, and general discomfort
include:

a. Change position (unless
contraindicated).

b. Splinting the incision.

c. Application of an abdominal
binder if available and ordered by
doctor.

4. Use techniques to distract patient:

a. Visit and talk with the patient.

b. Music could be used to relax the
patient.

5. Encourage the patient to relax through
rhythmic breathing.

6. Medicate as necessary per Doctor's
Order.

a. 30 minutes prior to painful
dressing changes or T, C, & DB.
URINARY TRACT PROBLEMS

Postoperative patients may encounter
urinary problems. Prompt identification and
treatment are essential. Check the recovery
room record to assess whether or not the
patient voided before returning to the ward,
and if a catheter was used during the surgical
procedure and immediate postoperative period.
Assess the urine for color, odor, consistency,
and amount. Signs and symptoms of urinary
tract difficulties include: retention, dysuria,
and incontinence.

Treatment includes:

1. Ensure patient voids within 8 - 12
hours postoperatively.

2. Observe for any signs and symptoms
of bladder distention and urinary tract
infections. Notify the nurse or doctor,
if present.

3. Catheterization may be ordered by the
doctor.

4. Medication may be ordered by the
doctor.

GASTROINTESTINAL
COMPLICATIONS

General anesthesia and pain medications
often cause discomfort to the postoperative
patient. Signs and symptoms of upper
gastrointestinal complications include:
anorexia, nausea, and vomiting.

Treatment includes:

1. Place patient in Sim's position to
prevent aspiration of vomitus. Suction
as needed.

2. Start slowly with sips of liquid once
oral fluids are allowed, per Doctor's
Orders.

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Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
DISORIENTATION
3. If the patient has anorexia, encourage
a slow increase in dietary ingestion,
per Doctor's Orders, which will assist
in the healing process.

Disorientation may occur postoperatively
and is generally due to anesthesia and
medication. It is essential to complete a
baseline mental status on the postoperative
patient so that changes can be promptly noted.
Some disorientation is normal upon return to
the ward. Signs and symptoms include:
speaking incoherently, bizarre statements, or
attempting to get out of bed (especially when
reminded not to).

Signs and symptoms of lower
gastrointestinal complications include:
abdominal distention, constipation,
absent/hypoactive bowel sounds, and the
patient's complaint of gastrointestinal
cramping/discomfort.

Treatment includes:


Treatment includes:
1. Ambulation when tolerated.


1. Notify the nurse immediately if the
disorientation progresses.
2. The doctor may order an NG tube to
relieve distention.


2. Maintain patient safety by:
3. Laxatives or cathartics may be ordered
to assist bowel movements.

a. Maintaining a continuous presence
at the bedside.
4. NPO as ordered by doctor.


b. Restrain patient as necessary.

c. Re-orientation to reality (time,
place, person).



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Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III
FIGURE 3.23.01 FIGURE 3.23.01
Lesson 3.23 Preoperative & Basic Hospital Corps School
Postoperative Care Handbook III
382
Sites for Pre-Operative Shave Preps
382
Basic Hospital Corps School Lesson 3.23 Preoperative &
Handbook III Postoperative Care
NOTES/COMMENTS
383
Lesson 3.23 Preoperative and Postoperative Basic Hospital Corps School
Care Worksheet Handbook III
Lesson 3.23

Preoperative and Postoperative
Care Worksheet


1. Circle the steps for checking the completeness of a chart.

a. Ensure the operative permit has been filled out and signed by the patient or legal guardian.

b. Give preoperative medication before consent is signed.

c. Ensure the laboratory reports are displayed on chart prior to going to the operating room.

d. Ensure the preoperative checklist, Addressograph, and allergy label are displayed on the
front of chart.

2. What type of anesthesia produces unconsciousness?

______________________________________________________________________________

3. What are the types of anesthesia that do not produce unconsciousness?
______________________________________________________________________________

______________________________________________________________________________



4. Circle the steps that are part of the physical preparation of a patient for surgery.

a. Ensure adequate rest and nutrition.

b. Shave of operative site.

c. Shower with an anti-bacterial soap.

d. Applying nail polish to fingers and toes.

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Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative
Handbook III Care Worksheet
5. List six items or events that need to be included in the preoperative teaching of a patient.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________

e. ________________________________________________________________________

f. ________________________________________________________________________

6. Why is a patient NPO prior to surgery? _______________________________________.

7. List three items on the front of the chart when the patient goes to surgery.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

8. List three factors that may affect a patient's need for psychological support.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

9. List three ways to meet the psychological needs for a preoperative patient.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________


10. List two forms where pre-op nursing care is documented.

a. ________________________________________________________________________

b. ________________________________________________________________________

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Lesson 3.23 Preoperative and Postoperative Basic Hospital Corps School
Care Worksheet Handbook III
11. List respiratory equipment needed to care for a postoperative patient.

____________________________________________________________________________

____________________________________________________________________________

12. Post-op vital signs are recorded on what form? ______________________________________

13. A postoperative patient should be transferred from the gurney to the bed while supporting the

__________________________ and __________________________.

14. What is the difference between general and regional anesthesia?

___________________________________________________________________________

___________________________________________________________________________

15. During initial postoperative care, the operative dressing should be observed for location and size.

a. True b. False

16. List two assessments that should be made for all drains and tubes.

__________________________________________________________________________

__________________________________________________________________________

17. List five observations that should be recorded for the post-op patient.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

e. _______________________________________________________________________

18. The most life threatening circulatory complications during post-op recovery are dehiscence and
pulmonary emboli.

a. True b. False

19. A blood clot that moves through the circulatory system is known as a/an ______________.

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Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative
Handbook III Care Worksheet
20. List three aids for lung expansion when a patient experiences respiratory complications.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

21. List the signs and symptoms of atelectasis.

a. _______________________________________________________________________

b. _______________________________________________________________________

c. _______________________________________________________________________

d. _______________________________________________________________________

22. A patient should be medicated _______ minutes before painful dressing changes or T, C, & DB.

a. 5

b. 15

c. 30

d. 60

23. Ensure that the patient has voided 8 - 12 hours postoperatively.

a. True b. False
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Lesson 3.23 Patient Care Documentation Basic Hospital Corps School
Scenarios Handbook III
Lesson 3.23

Postoperative Scenario




1400 TM3 J ones has just returned from an
emergency appendectomy. Recovery room
personnel report he has RLQ incision and dressing.
Dressing is heavily saturated with serosanguineous
drainage and was reinforced X1. Oral airway is
out, gag reflex is present and patient is awake and
moving all four extremities, but remains groggy.
Foley catheter removed at 1200 and patient has not
voided. NG tube removed at 1230, no nausea or
vomiting since that time. During exam, you note
the following: TM3 J ones moves all four
extremities and answers you appropriately. He
drifts off to sleep frequently. Respirations are
even and unlabored. Skin is warm and dry,
abdomen is tense, and he is complaining of lower
abdominal pain. He is unable to turn without
assistance. He is complaining of nausea and feels
as though he may vomit. There is an IV of LR of
150 cc/hr in the right forearm.
























POST-OP DOCTOR'S ORDERS.

1. Return to 5E S/P appendectomy.

2. VS Q15" x 4, Q 30" x 4, Q 1H x 4, then Q 4H.

3. NPO until 1800, then clear liquid diet.

4. Advance diet as tolerated.

5. IV D5W 125 cc/hr x 2 liters, then DC if taking
fluids.

6. Ambulate tonight.

7. TC & DB Q1H.

8. Incentive spirometry Q2H.

9. Phenergan 25 mg IM Q6H PRN nausea.

10. Demerol 50 mg IM Q4H PRN pain.

11. I & O.

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Basic Hospital Corps School Lesson 3.23 Preoperative and Postoperative
Handbook III Care Scenario
NOTES/COMMENTS
389
Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School
Nursing Care Forms Handbook III
390
Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative
Handbook III Nursing Care Forms
391
Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School
Nursing Care Forms Handbook III
392
Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative
Handbook III Nursing Care Forms
393
Lesson 3.23 Pre-operative and Postoperative Basic Hospital Corps School
Nursing Care Forms Handbook III
394
Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative
Handbook III Nursing Care Forms
Basic Hospital Corps School Lesson 3.23 Pre-operative and Postoperative
Handbook III Nursing Care Forms
395

395
Lesson 3.31 Death and Dying Basic Hospital Corps School
Handbook III
Lesson 3.31

Death and Dying

Terminal Objective:

3.31 List concepts and principles for physical, psychological, and spiritual care for death and
dying.

Enabling Objectives:

3.31.01 State the five stages of coping with a terminal illness or death.

3.31.02 State the fears of the terminal patient and their significant others.

3.31.03 State measures that support physical, emotional, and spiritual needs of a dying patient.

3.31.04 List feelings and attitudes of health care providers concerning death and post-mortem
care.

3.31.05 State the procedure for preparing a body for viewing.

3.31.06 State the procedure for preparing a body for discharge.


FIVE STAGES OF COPING

Modern society often seems to be focused
on youth and the future. In the early years of
our lives, it is rare that we are exposed to a
terminal illness or death.

Generally, the terminally ill are taken out
of the home and cared for in a high tech
institution where miracles happen every day.
Life is given through new hearts, lungs, and
kidneys. Again and again, life triumphs over
death. In the United States, due to continued
advances in technology, life expectancy
continues to increase for both men and
women. But we have not yet achieved
immortality. Even though life spans are
longer, death is inevitable.

Rarely do we think about death, at least
not until we must face our death or that of a
significant other. Reactions to death vary
greatly from person to person and culture to
culture. Individual reactions are based on a
variety of factors such as age, the value we
attach to the dying individual, past experiences
with death, religious beliefs, and cultural
heritage. The quality of care given to a
terminally ill patient depends on the attitudes
and values of the health care personnel
involved.

Take a few minutes to think about the
following: If I had a choice, when would I die?
How would I choose to die? How do I react to
a young person's death? Is my reaction to the
death of senior citizen different? What do I
want to accomplish before I die?

Now that you have thought about death on
a personal level, change your focus to a
professional level. A terminal illness is one in
which there is no realistic hope of recovery.
Patients faced with a terminal illness, and their
own mortality, go through several
psychological stages. Not all people go
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Basic Hospital Corps School Lesson 3.31 Death and Dying
Handbook III
through the stages in the same order. A person
may skip a stage or fall back a stage. Stages
may overlap. The length of a stage may range
from a few hours to a few months. Significant
others and health care staff also may go
through these stages and may need help. The
stages of coping with death are:

1. Denial - a psychological technique in
which the individual believes that certain
information may not be true. The patient
may say, No, not me, and think that there
has been a mistake.

2. Anger -- hostility is projected onto the
patient's environment, involving people
and situations at random. The patient may
ask, Why me?, with hostility directed
towards family members, friends, or
health care providers.

3. Bargaining -- trying to make some sort of
arrangement to postpone the inevitable.
The patient may say, Yes, me, but..., often
bargaining with God or other higher
power.

4. Depression -- characterized by mourning
for self and loss of life in general. A
downward or inward displacement, a
hollowness. The patient feels sadness and
often cries, as though mourning his/her
own death.

5. Acceptance -- Coming to terms with
illness or outcome. This is the final stage
of coping and is not always achieved. The
patient at this stage says, I am ready. This
is characterized by a positive feeling and a
readiness for death. This stage is usually
peaceful and tranquil.

As a health care provider, you are caring
not only for the patient, but for the entire
family group as they move through these
stages. Each stage is preparation for the next.
Some individuals reach the acceptance stage
very early and others never reach it. In
addition to patients and family, staff members
involved in the care of dying patients often go
through these stages. Everyone will experience
grief in some form. Grieving is generally the
emotional and physical feelings dealing with
separation and loss.

Emotional responses such as fear are
typical for a terminally ill patient and family
members. Fears are as varied as people's
attitudes towards death. Fears and the attitude
toward death may change over time. Most
people fear death because it represents a force
over which we have no control. Common fears
associated with dying are:

1. Fear of Abandonment -- Many dying
patients feel isolated and alone. Such fear
may be reduced when shared with others.

2. Fear of suffering and extreme pain --
Discomfort that cannot be relieved and is
both physically and emotionally
exhausting.

3. Fear of loss of control -- Fear related to
the inability to control bodily functions,
diminished intellectual capacity, or the
inability to maintain a previously held
role.

4. Fear of dependence -- Most adults resent
having to rely on others for measures that
once were performed independently.

5. Fear of body alterations -- Some
terminal illnesses involve surgical removal
of body structures. Drug therapy may
cause hair loss or other changes in
appearance. Patients may feel they repulse
others.

6. Fear of loss of dignity -- The hospital
setting and use of highly technical
equipment may cause a patient to fear
being treated as an object rather than as a
person.

7. Financial ruin -- Medical expenses
accumulate during lengthy illness,
potentially leaving a family financially
devastated.

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Lesson 3.31 Death and Dying Basic Hospital Corps School
Handbook III
8. Fear of the unknown -- Threatening and
unknown experiences produce fear. Such
fear may be reduced when shared with
others.

SUPPORT MEASURES

In addition to the emotional components
involved in the grieving process, the
terminally ill patient may require complete
physical care. At this point, the primary goal
of nursing care is to provide for physical needs
and patient comfort:

1. Nutritional support.

2. Physical care and hygiene.

3. Pain relief.

4. Comfort and safety measures.

5. Adequate rest and sleep.

Since emotional needs are very important
during the dying process, help the patient and
family to separate those things that can be
known from those that cannot, while
sustaining realistic hope. Provide and
encourage human (social) contact. Set aside
time to be with the patient. Be a good listener.
Establish rapport with the patient and his/her
family.

1. Provide consistency in patient care
assignments.

2. Be flexible in enforcing visiting hours and
age restrictions.

3. Support the patient in his/her grief over
losses and encourage him/her to continue
activities in to the extent possible.

4. Encourage significant others to participate
in patient care.

Allow the patient and family to talk about
the illness and dying. Maintain the self-respect
and dignity of the patient and family members
at all times.

1. Help the patient to look beyond the body
distortions that the illness has caused.

2. Assist and support efforts to conceal or
lessen the impact of disfigurement, such as
using a wig, prosthesis, make-up, etc.

3. Allow the patient as much control over
his/her life as possible.

Allow for individuality of the experience.
During the final stages of death, organize staff
and family support so someone is with the
patient.

Attitudes toward death are influenced by
various cultural factors, including religion.
During the process of dying, there is often a
difference between the patient's stated
religious beliefs, and the patient's feelings
expressed during this time. Do not assume that
involvement in a specific religion means
acceptance of the beliefs or practices of the
religion. Use a variety of ways to meet the
patient's spiritual needs.

1. Contact the chaplain or clergy if the
patient or family desires.

2. Respect the patient's religious beliefs.

FEELING AND ATTITUDES

Your own attitude and values will affect
the care that you give. At this point in your
career, discussing and thinking about the
concept of death will help prepare you to care
for a terminally ill patient.

Post-mortem care is a solemn experience
requiring the utmost respect for the deceased.
Care of the deceased includes preparing the
body for viewing, preparing the body for
discharge from the ward, and completing ward
forms. The terms family member and next of
kin are intended to include significant others,
as applicable.

Death is a part of life, but may be an
experience that you have not faced. Corpsmen
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Basic Hospital Corps School Lesson 3.31 Death and Dying
Handbook III
may experience fear or uneasiness when
preparing the body. These are normal feelings.
At times, corpsmen feel anger, especially if the
death was unexpected or a child. You may fear
your own death. A feeling of peace can follow
the death of a patient who had suffered a
chronic illness, e.g., cancer. Family members
may need support or may be angry. Allow
yourself, other staff members, and family
members to discuss any feelings that result
from a patient's death. Chaplains and
experienced staff members can be a source of
support.

PREPARING A BODY FOR
VIEWING

After a death, move any roommates out of
the room, when possible. Roommates should
be moved out before a death, if possible.
Preparation of a body for viewing is the last
privacy you can give the individual. The goal
is for the body to present a natural appearance.

Do not remove tubes and drains unless
directed by local policy. In most cases, tubes
and lines are tied off. (You may cut off excess
lengths of tubing.) Close the patient's eyes.
Bathe the body, and change any soiled linen.
Replace dentures and other prosthetic devices.
These items are important for embalming
purposes. Place the body in a supine position,
with the head slightly elevated. Remove all
excess and used equipment from the room,
e.g., IV poles, suction machines.

Provide empathy and support to the
family. (A statement such as, I'm so sorry that
your relative died may be consoling to a
grieving family.) Allow the next of kin to view
the body, giving them as much privacy as
possible. Viewing the body helps the family
work through the grief process.

PREPARING A BODY FOR
DISCHARGE

When the family has viewed the body and
left the hospital, prepare the body for
discharge to the morgue. Local policy will
indicate the equipment used to wrap a body for
discharge. Often, a commercially
manufactured post-mortem pack is used.
Obtain the post-mortem pack, which contains
identification tags, absorbent padding, and a
shroud or plastic sheet. Complete three
identification tags with the patient's name,
social security number, grade, rank, or status,
diagnosis, ward, date and time of death, and
the name of the physician certifying the death.

Place the tags on the right wrist, the right
great toe of an adult (use the right ankle for an
infant or very small child), and on the outside
of the wrapping sheet at chest level. Mummy
wrap the body in the sheet. Follow local policy
regarding placement of padding and ties. Some
morticians prefer that extremities not be tied to
prevent damaging the skin. Notify the morgue
when the body is ready and transport the body
to the morgue on a gurney. Some facilities
have a special gurney to carry bodies to the
morgue. It masks the fact a deceased patient is
being transported through the hospital. Upon
return from the morgue, clean the unit,
complete the paperwork, and send the Clinical
Record to the Patient Affairs Office. Return
the roommates to the room if applicable.

ADMINISTRATIVE
PROCEDURES

Documentation of a death must be
completed along with the care of the body.
Several administrative forms are required

The Seriously or Very Seriously III List
NAVMED 6320/5 is used to inform
commands (hospital and patient's) and notify
the next of kin of the seriousness of the
patient's condition. The physician completes
this form and the patient is removed from the
list upon death. The galley and pharmacy
must be notified of the patient's death and the
patient's name should be removed from the
bed and room.

An inventory of the patient's valuables and
personal effects is conducted to safeguard the
patient's belongings when he/she is placed on
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Lesson 3.31 Death and Dying Basic Hospital Corps School
Handbook III
the SL/VSL or if deceased. The Patient's
Valuables Envelope NAVMED 6010/8 is used
for money, credit cards, jewelry, etc., and the
inventory of personal effects (local form)
is used to safeguard items such as clothing,
toiletry items, etc.

Until you experience the death of a
patient, it is hard to understand the feelings
and attitudes that corpsmen experience while
caring for the deceased. Care of the deceased
should be carried out solemnly and with the
utmost respect for the deceased and the family
of the deceased. Staff members will work
together to deal with the feelings brought on
by the death of a patient.
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Basic Hospital Corps School Lesson 3.31 Death and Dying
Handbook III
SCENARIO A

J im is a 55-year-old laborer with a
diagnosis of terminal cancer. He has been a
patient for the last two months. The charge
nurse has taken care to assign the same staff
members to care for him to ensure his trust and
cooperation in his treatment regime. He has
just finished his last chemotherapy treatment
and is failing rapidly. Generally, J im is an
even-tempered man and his family is
extremely cooperative in his care. Family
members have always been included in his
daily care. It is not unusual for his wife or son
to assist with his bed bath and daily hygiene.
You took time to teach the family about his
physical needs and allowed the family to ask
questions or discuss concerns they had.

You have just returned from a one-week
leave period. During morning routine, as you
enter J im's room, you notice that he glares at
you. He then turns and faces the window,
refusing to look at you or communicate in any
way. All your attempts at conversation fail, at
the end of your shift, you go into his room to
attempt to find out what is troubling him. You
find him lying face down on the floor. As you
turn him over, you note his skin is cold, and he
is not breathing.

SCENARIO B

Leann is 6 year old female with a
diagnosis of terminal cancer. She is the darling
of the ward, everyone's favorite patient. She
has been home on a weekend pass. When she
returns to the hospital, Leann doesn't look
well. You are unable to determine the
problem. Vital signs are stable, skin is warm
and dry. There are no physical symptoms. The
child's physicians are also unable to determine
any physical abnormalities. Leann, states that
she is going to die today and refuses to drink
or eat anything, even though you offer all of
her favorites. Leann refuses to talk to you and
only wants her mother. Leann's mother cannot
be reached.

During the course of the afternoon, the
child's behavior becomes more and more
withdrawn. You note that her B/P is dropping
and her pulse is rising steadily. All physicians
are notified and are in attendance at her
bedside. Leann is placed on a cardiac monitor
at 1400. At 1430 the curtains are drawn around
her bed. As the junior medical student leaves,
he tells you, Leann just died. Call her parents
and tell them. I can't do it. The medical student
leaves the room in tears.

SCENARIO C

J ohn Doe arrives in the Emergency
Department at approximately 0215. He is 24
years old and has been in a hit and run
accident. J ohn Doe was a pedestrian struck by
a drunk driver. On arrival, J ohn Doe had no
pulse, and was in respiratory arrest. You note
his pupils are fixed and dilated. There is a
depression on his left temporal lobe, with bone
fragments protruding inward. A full code is in
progress with no results. After approximately
30 minutes of resuscitation there is no return
of vital signs. J ohn Doe is pronounced dead at
0245.

SCENARIO D

Mrs. Mary J ones is 82 years old and has
been suffering from heart disease for twenty
years. She is in the end stage of Congestive
Heart Failure and must be maintained on a
ventilator to survive. The physician writes a
NO CODE order. Twenty-four hours later,
Mrs. J ones, who has been in pain all day, goes
into cardiac arrest. No member of the medical
staff makes any intervention, her primary
physician is at the bedside during this time. He
is talking to Mrs. J ones, generally trying to
make her comfortable. You cannot understand
why no attempt was made to save this
woman's life. After all, isn't that our job?

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Lesson 3.31 Death and Dying Worksheet Basic Hospital Corps School
Handbook III
Lesson 3.31

Death and Dying Worksheet

1. List the five stages of coping with a terminal illness.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

e. ____________________________________________________________________________

2. All stages of coping are demonstrated by every individual during a terminal illness.

a. True b. False

3. When a patient asks Why me?, he/she is in which stage of coping with death? ______________

4. List eight fears that are common to patients and family members during a terminal illness.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

e. ____________________________________________________________________________

f. ____________________________________________________________________________

g. ____________________________________________________________________________

h. ____________________________________________________________________________

5. Establishing a rapport with the terminally ill patient and his/her family is not necessary.

a. True b. False

6. Fear and uneasiness are normal when providing post-mortem care.

a. True b. False


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Basic Hospital Corps School Lesson 3.31 Death and Dying Worksheet
Handbook III
7. List the types of nursing care support you can render to a terminally ill patient.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

c. ____________________________________________________________________________

d. ____________________________________________________________________________

e. ____________________________________________________________________________

8. List two ways can you help to meet the spiritual needs of a terminally ill patient.

a. ____________________________________________________________________________

b. ____________________________________________________________________________

9. Your _________________ and _________________ will affect the care you give to terminally ill
patients.

10. Post-mortem care is a solemn experience requiring the utmost respect for the deceased.

a. True b. False

11. List three feelings that a corpsman may experience following the death of a patient.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

12. List five steps to prepare a body for viewing.

a. ________________________________________________________________________

b. ________________________________________________________________________

c. ________________________________________________________________________

d. ________________________________________________________________________

e. ________________________________________________________________________

13. All tubes and drains are removed from a deceased body prior to viewing by family members.

a. True b. False



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Lesson 3.31 Death and Dying Worksheet Basic Hospital Corps School
Handbook III
14. How many tags are prepared and placed on a deceased body?

a. 1

b. 2

c. 3

d. 4

15. Circle each item recorded on the identification tags attached to a deceased patient.

a. Patient's name

b. Patient's age

c. Patient's social security number

d. Patient's address

e. Date and time of death

f. Name of the physician certifying the death

16. List two areas in the hospital that must be notified when a patient dies.

a. ___________________________________________________________________________

b. ___________________________________________________________________________






















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Basic Hospital Corps School Lesson 3.31 Death and Dying Worksheet
Handbook III

405
Lesson 3.32 Transferring Basic Hospital Corps School
and Ambulating a Patient Handbook III

Lesson 3.32

Transferring and Ambulating a Patient

Terminal Objective:

3.32 Transfer and ambulate a patient.

Enabling objectives:

3.32.01 State the location and proper use of safety devices on a wheelchair, gurney, and bed.

3.32.02 List the procedure for transferring a patient from a bed to a wheelchair.

3.32.03 List the procedure for transferring a patient from a bed to a gurney.

3.32.04 State considerations for patient safety, privacy, education, compliance, and comfort when assisting
with ambulation.

3.32.05 State considerations for assisting a patient to ambulate without ambulation aids.

3.32.06 List the procedure for assisting a patient to ambulate with a cane.

3.32.07 List the procedure for assisting a patient to ambulate with crutches

3.32.08 List the procedure for assisting a patient to ambulate with a walker.

3.32.09 Transfer and ambulate a patient using various devices.

3.32.10 Record ambulation assistance on Nursing Notes SF 510

HOMEWORK

1. Reading Assignment: Read Transferring, and Ambulating Information Sheet


2. Written Assignment: Complete Worksheet 3.32.

LABORATORY:

1. The laboratory for this lesson is Performance Checklist 3.32.

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Basic Hospital Corps School Lesson 3.32 Transferring and Ambulating a Patient
Handbook III



TRANSFERRING AND AMBULATING INFORMATION SHEET

Introduction

Before transferring a patient (moving a patient
from one place to another), the move needs to be
planned. Planning will decrease the chance of
injury to the patient and corpsman, and make the
move go smoother. Before moving a patient, you
should know the patient's diagnosis, capabilities,
and weaknesses. Be familiar with the equipment
and follow safety guidelines.

SAFETY DEVICES

Wheeled equipment (wheelchairs, gurneys,
and beds) is normally equipped with lockable
wheels. Wheelchairs commonly have removable
and/or adjustable sides and foot pieces. These
make it easier for a patient to be seated in the
chair. Be sure that pieces are locked in place
during use. Seat belts are not standard equipment
on most wheelchairs, but can be very useful for
some patients.

Many types of side rails are available on
gurneys. Most gurneys have built-in safety straps.
Beds also have a variety of side rails. Some beds
have safety straps, but most do not. Bed safety
straps would only for a patient who needs specific
protection from falling.

TRANSFERRING FROM BED TO
WHEELCHAIR

Provide patient safety, education, and privacy
before the transfer. Explain the destination and
procedures to the patient. State the reasons for
safety precautions. Use good body mechanics to
prevent injury. Lock the wheels on the bed, check
I.V. tubing for free movement, and be sure that
dressings are secure. Remove any obstacles that
may make the transfer more difficult, such as
chairs and bed side tables. Place adjustable beds in
low position or level with the wheelchair. Adjust
the bed to the High Fowler's position and fan fold
the top sheet towards the foot of the bed.

Place the wheelchair on the patient's strongest
side, parallel to the bed. The foot pieces should be
moved to the side or removed for safer and easier
access. Lock the wheels.

Assist the patient to sit on the edge of the bed
with legs over the side. Have patient place
stronger leg slightly in front of other leg. Place
one arm around the patient's shoulder or waist, and
the other arm over or under the knees. Pivot your
body to assist the patient to a sitting position.
Watch for signs of weakness or fainting. Sudden
position changes can cause postural hypotension.
Let the patient rest as needed.

Assist the patient into a bathrobe and place
slippers or shoes on his/her feet.

Help the patient stand and get in the
wheelchair. Face the patient and place your arms
under the patient's arms with his/her hands on your
shoulders. Assume a forward-backward stance
(one foot forward, the other backward). Support,
but do not lift, the patient under the axilla to avoid
injury to major nerves and blood vessels.

Assist the patient to lean forward from the
waist. On your signal, the patient will assist with
standing as you lift. Support the patient's knees by
using your knee as a brace. Pivot the patient so
that his/her back is toward the wheelchair. Have
the patient place one hand on the wheelchair arm
and then bend the knees. Smoothly lower the
patient into the chair. Adjust the foot and leg rests
(replace them PRN) and secure all tubing and
drainage systems.

Patients who cannot stand require modification
of the procedure. Usually, an additional person is
required to transfer such a patient.

407
Lesson 3.32 Transferring Basic Hospital Corps School
and Ambulating a Patient Handbook III
As the patient's condition warrants, secure a
seat belt around the patient. Cover the patient's
legs with a blanket (or sheet), unlock the wheel
locks, and transport. Return patients to bed by
reversing the steps of the procedure. Document
pertinent information on Nursing Notes SF 510.

TRANSFERRING FROM BED TO GURNEY

Provide patient safety, education, and privacy
before the transfer. Explain the destination and
procedures to the patient. State the reasons for
safety precautions. Use good body mechanics to
prevent injury. Lock the wheels on the bed, check
I.V. tubing for free movement, and be sure that
dressings are secure. Remove any obstacles that
may make the transfer more difficult, such as
chairs and bed side tables. Adjust the height of the
bed to a position level with the gurney. Depending
on the size of the patient, up to six people may
assist with the transfer. Two corpsmen of small
stature cannot safely lift and carry a large patient.
Harm could come to the patient or the staff
member.

Lower the side rails on the bed, making sure
that someone is positioned on each side of the bed
for safety. Loosen the draw sheet on both sides of
the bed. For best results, the draw sheet should be
beneath the patient from the shoulders to the
thighs. When there is no draw sheet on the bed,
use the bottom sheet. Place the gurney next to the
bed and lock the wheels. Stand at the side of the
gurney, with the second person on the opposite
side of the bed. When more assistants are
necessary, divide them equally beside the bed and
the gurney.

Ask the patient to position his/her arms across
the abdomen or chest. This prevents injury to the
upper extremities and interference from the arms
during the transfer. Ensure that tubing is free of
tangles and that tubing moves with the patient
during the transfer. Foley catheters, I.V.s, and NG
tubes can pull out during a transfer if they get
caught between the bed and the gurney.

Roll the sides of the draw sheet or bottom
sheet close to the patient's body. On signal (usually
the person at the head gives the signal) gently slide
the patient to the edge of the bed. Again on signal,
lift the patient from the bed to the gurney. Lift the
patient only high enough to clear the mattress. Use
movements that are as smooth as possible during
lifting. The patient will feel more secure during a
smooth transfer. Some patients will be able to
assist fully or partially in the transfer from bed to
gurney. In such cases, the corpsman provides for
safety by keeping the gurney secure as the patient
moves from the bed.

Cover the patient with a sheet or blanket,
secure the gurney straps, and raise the side rails on
the gurney. Transport the patient by standing at the
head of the gurney and push the gurney foot first.
Return the patient to bed by following the same
procedure in reverse. Document patient
instructions and use of the gurney for
transportation on Nursing Notes SF 510.

USING AMBULATION AIDS

Provide for privacy, education, compliance,
comfort, and safety. Explain and/or demonstrate
the correct procedure for ambulation with a cane,
crutches, or a walker. Discuss the rationale for the
use of assistive devices. Close doors or pull the
curtains when transferring the patient from the
bed. Keep the patient appropriately clothed or
covered.

Ensure that the floors are dry and litter free.
Remove any obstacles that may make ambulation
more difficult such as chairs, and bed side tables.
Have the patient wear well fitting shoes with firm
soles. Slippers should be evaluated to be sure that
they do not increase the chance that a patient will
trip.

Inspect the ambulation aid. Look at the rubber
pads on top of crutches and on the crutch hand
pieces. Inspect the rubber tips on the bottom of
crutches, canes, and walkers. Replace any worn or
missing parts.

If the patient is unable to walk independently,
have him/her wear a walking belt, which is a web
belt worn around the patient's waist which the
corpsman can hold to provide assistance. Explain
the safety guidelines to the patient. Do not allow
the patient to use ambulation equipment alone
until he/she has mastered the technique.
408
Basic Hospital Corps School Lesson 3.32 Transferring
Handbook III and Ambulating a Patient

To increase comfort, keep all movements slow
and smooth. Periodically ask the patient about
his/her level of comfort. Be alert for fatigue,
especially the first few times a patient is
ambulatory.

ASSISTING WITH A CANE

Canes are used for balance and support, Figure
3.32.01. Patients with musculoskeletal
deficiencies can compensate for functions
normally performed by the skeletal system by
using a cane. Pressure placed on weight-bearing
joints can be relieved through use of a cane.

A cane may be wood or aluminum.
Aluminum canes have the advantage of being
adjustable. Some aluminum canes have four feet
instead of one, and are called quad cantes. Wooden
canes come in various lengths.

The top of the cane should reach the level of
the great trochanter. This will prevent leaning on
the cane and poor posture. The cane is positioned
about four inches to the side of the body on the
unaffected side.

When walking with a cane, the patient
advances the cane at the same time as the affected
leg is moved. When a corpsman needs to walk
with the patient, stay on the opposite side from the
cane to protect your patient from falling.

ASSISTING WITH CRUTCHES

Crutches are artificial supports used to assist
patients who need help with walking because of
injury, birth defect, or disease, Figure 3.32.02. The
upper extremities bear body weight in crutch
walking.

Like canes, wood and aluminum crutches are
available. Unlike canes, both types of crutches are
adjustable. To measure a patient for crutches, have
the patient stand in a relaxed position. Adjust the
crutches so they are two inches from the axilla (the
top of the crutch should come to two inches below
the arm pit), when the rubber tip is on the floor
four inches in front of the patient and six inches to
the side of the toes. Measure and adjust the hand
pieces to allow the elbows 20 degrees of flexion.

Instruct the patient to support his/her weight
on the hand pieces not the under arm pieces.
Prolonged pressure on the axilla can result in
damage to the nerves of the brachial plexus,
producing crutch paralysis.
A patient can be measured in bed horizontally

from the anterior fold of the axilla to the sole of
the foot. Add two inches to this distance for an
approximation of the proper crutch length.

Crutch walking requires balance, coordination,
strength, and endurance. Practice will result in
improved skill. Different gaits are used to meet the
variety of needs placed on crutch walking patients.

The three-point gait is used when weight
bearing is permitted on one foot. The three-point
gate is used when a cast or other condition
prevents or limits one foot from bearing weight.
To use the three-point gait, the patient will bear
weight on the unaffected leg and advance the
weaker (or affected) leg and the crutches at the
same time. The stronger leg is then moved forward
while putting most body weight on the crutch hand
pieces.

The swing-through gait is a quick gait used
when the patient is able to bear weight on both feet
(or one foot if an amputee). Have the patient lift
both feet off the ground simultaneously. Swing the
body forward through the crutches while pushing
up on the crutches, bearing body weight on both
hands.

Two-point and four-point gaits are also used.
These gaits constantly shift the weight between
crutch and legs.

ASSISTING WITH A WALKER

A walker provides a patient who does not have
good balance more support than a cane or
crutches, Figure3.32.03. Walkers are often used by
patients who are weakened following prolonged
bed rest. A walker provides stability, but does not
allow a normal walking pattern.

409
Lesson 3.32 Transferring Basic Hospital Corps School
and Ambulating a Patient Handbook III
When teaching a patient to use a walker,
instruct him/her to stand behind the walker. Be
ready to give assistance to ensure patient safety.
The patient should not put his/her entire weight on
the walker. Have him/her hold the hand grips at
the sides of the walker. Adjust the height to permit
20-30 degrees of flexion in elbows. Instruct
patient to move one foot and place it in front of
himself/herself, then step into the walker and
repeat the process. The corpsman should walk on
the side and slightly behind the patient's affected
extremity. Encourage independent ambulation,
after observing that the patient is walking safely.

AMBULATION WITHOUT
AMBULATION AIDS

Provide for privacy, education, compliance,
comfort, and safety. Instruct the patient on
ambulation without the use of ambulation aids,
including safety guidelines. Close doors or pull the
curtains when transferring the patient from the
bed. Keep the patient appropriately clothed or
covered.

Ensure that the floors are dry and litter free.
Remove any obstacles that may make ambulation
more difficult such as chairs and bed side tables.
Have the patient wear well fitting shoes with firm
soles. Slippers should be evaluated to be sure that
they do not increase the chance that a patient will
trip. Use a walking belt PRN.

Walk alongside the patient, keeping your arm
under the patient's arm. Be alert for weakness or
fainting. If the patient begins to feel faint, the
corpsman should slide an arm or both arms up into
the patient's axillary area. Place one foot to the
side to form a wide base of support. Lower the
patient to the floor by sliding him/her down your
hip and thigh as smoothly as possible. Some
patients will go down to the floor. Your job is to
be aware of the patient's condition, prevent falls if
possible, and to provide a safe transfer to the floor
if necessary.


Recording Ambulation Assistance

Nursing Notes SF 510 are used to document
ambulation assistance. Record any patient
instruction or education related to ambulation with
or without aids. Document your observation of
patient difficulties and/or progress with
ambulation.
410
Basic Hospital Corps School Lesson 2.02 Lifting and Moving Patients
Handbook II

FIGURE 3.32.01
Ambulating With A Cane
FIGURE 3.32.02
Standing With Crutches
FIGURE 3.32.03
Ambulating With A Walker
411
Lesson 3.32 Transferring and Basic Hospital Corps School
Ambulating a Patient Worksheet Handbook III

Lesson 3.32

Transferring and Ambulating a Patient
Worksheet




1. The__________is a method of transferring a patient from the bed to the stretcher by grasping and
pulling the loosened bottom sheet of the bed.

2. Unresponsive patients without suspected spinal injury should be placed in the ______ position.

3. List three safety devices used on beds, gurneys, and wheelchairs.

a. _______________________________________________________________

b. _______________________________________________________________

c. _______________________________________________________________


4. A gurney should be pushed from the head of the gurney, moving the patient feet first.

a. True b. False


5. When transferring a patient from bed to a wheelchair, place the wheelchair on the:

a. left side of the bed.

b. patient's strongest side.

c. right side of the bed.

d. patient's weakest side.

6. When transferring a patient from a bed to a wheelchair, be alert for signs of:

a. weakness and fainting.

b. bleeding and hemorrhage.

c. abdominal evisceration.


d. Alzheimer's disease.
412
Basic Hospital Corps School Lesson 3.32 Transferring and Ambulating a
Handbook III Patient Worksheet

7. Before transferring a patient from a bed:

a. clamp the Foley catheter.

b. discontinue all I.V. lines.

c. sedate the patient.

d. secure all tubing.

8. When ambulating a patient, have the patient walk three steps ahead of the corpsman.

a. True b. False

9. When walking with a cane, the patient should hold a cane on the affected side.

a. True b. False

10. Crutches should be adjusted so the top is 2" below the axilla.

a. True b. False

11. The three-point gait is used when a patient using crutches can bear weight on either foot.

a. True b. False


12. When using the swing-through gait, a patient with crutches should lift:

a. both feet off the ground at the same time.

b. the crutches one at a time.

c. one foot, and swing the other through the crutches.

d. the crutches off the ground as much as possible.

13. A correctly adjusted walker permits _____ degrees of elbow flexion.

a. 10-20

b. 20-30

c. 30-40

d. 40-50



413
APPENDIX 1


WEIGHTS AND MEASURES CONVERSION TABLE


METRIC WEIGHT MEASURE

1 Kilogram (Kg) =1000 grams (Gm)1 Gram (Gm)
1 Gram (Gm) =.001 kilograms (Kg)
1 Gram =1000 milligrams (mg)
1 Milligram (mg) =.001 gram (Gm)
1 Milligram =1000 Micrograms (mcg)
1 Microgram (mcg) =.001 Milligram (mg)

METRIC FLUID MEASURE

1 Liter (L) =1000 milliters (ml)
1 Milliliter (ml) =.001 liter (L)
1 Milliliter (ml) =1 cubic centimeter

US LIQUID MEASUREMENTS AND METRIC FLUID MEASURES

U.S. Liquid Metric
1 drop (gtt) =.06 milliliter (ml)
15 drops (gtts) =1 milliliter (ml)
1 teaspoonful (tsp) =4 milliliters (ml)
1 tablespoonful (Tbsp) =15 milliliters (ml)
1 ounce (oz) =30 milliliters (ml)
1 cup (c) =240 milliliters (ml)
1 pint =480 milliliters (ml)
1 quart =960 milliliters (ml)
4 cups (c) =960 milliliters (ml)

APOTHECARY WEIGHT TO METRIC SYSTEM
1 grain (gr) =.065 gra
=65 milligrams (sometimes considered
to be 60 to 64 milligrams)

WEIGHT CONVERSION
1 kg =2.2 lbs

A-1-1

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