Heart valve closure sequence:

Try Pulling My Aorta

Tricuspid

Pulmonic

Mitral

Aortic

Heart valve blood flow sequence:

TRIPS BIAS

Tricuspid

Pulmonary

Semilunar

Bicuspid

Aortic

Semilunar

Other memory tools:

TRI before you BI

Blood flows through the TRIcuspid before BIcuspid.
First learn a TRIcycle, then learn a BIcycle
Tricuspid valve in the Right heart - you always "tri" to do the "right"
thing

Blood Product Administration (Blood Transfusion)

Purpose: Blood products including whole blood or packed red blood cells,
plasma, or platelets may be administered to a patient via the venous
circulation, depending on their needs. Red blood cells may be administered
to treat hemorrhage, symptomatic anemia, or sickle cell crisis, and will
improve oxygen delivery to the tissues. Fresh frozen plasma can help
reverse the effect of anticoagulants. Platelets transfusions may prevent
bleeding with thrombocytopenia. Compatibility must be checked by two
qualified personnel before a blood product is administered to prevent a life
threatening transfusion reaction.

Most blood products are frozen and require time to thaw in the lab. Prior to
thawing, the lab performs blood typing and compatibility testing - including
antibody screening (ABO Rh and cross match). Blood bank personnel use
special equipment to prepare the blood for transfusion only after orders are
received to transfuse. Once thawed, blood products must be hung within 30
minutes after obtaining the unit from blood bank; otherwise it is to be
returned to the lab to avoid spoiling. Typically, one unit is dispensed at a
time except in cases where rapid replacement is needed for gross
hemorrhage or in the OR).

Note: When emergent transfusion is required, the blood bank needs

notification as early as possible in order to prepare Type O-Negative
blood. In these cases, cross matching is not always done, but blood banks
have special procedures for these situations.

Blood Warmers: Even after thawing, blood arrives from the lab cold. Blood
warming devices aid in preventing hypothermia by warming blood as it is
being administered to the patient. Although a warmer is not required for
routine transfusions, they are preferred when time permits because they
enhance patient comfort and tolerance. Special tubing is usually
required. Blood warmers are typically used in intensive care, operating
rooms, post anesthesia care, and emergency departments, where larger
amounts of blood are often administered. Once blood is warmed it can
never be returned to the blood bank.

NEVER warm blood in hot water or a microwave.

Nursing Considerations

Assessment:

Check the provider order for type of blood product to be

administered.

Check if the patient is wearing a blood ID bracelet. It is usually

applied to the wrist. The patient MUST have a blood ID bracelet. A
phlebotomist applies the bracelet when blood is drawn for the
purpose of screening. Most facilities have strict policies that guide
the use of blood ID bracelets.
 Ensure that a recent type and cross-match is available for review.
The patients blood must be ABO-typed and cross-matched for
compatibility.

Evaluate the patients labs, including the CBC.

Ask if patient has received a transfusion or organ or tissue transplant

in the past and whether they had any reaction. Note the type of
reaction. Check if the patient requires irradiated blood products due
to immunosuppression.

Send the order for the blood product to the blood bank immediately.
Call the blood bank to confirm.

Assess IV access site for patency; catheter will ideally be size 18

gauge or larger. While it is safe to administer some products through
20 gauge catheters, hospital policy will govern what is acceptable.

Assess heart and lung sounds and recent urinary output. Baseline
vitals including temperature and respirations will be taken just prior to
administration of blood product and every 15-30 minutes during
administration, therefore, it is advisable to dedicate equipment for
serial measurements at the bedside.

Contraindications:

Patients at risk for graft vs host disease or with immunocompromised

conditions may require irradiated blood components.

Platelet infusions are contraindicated as a prophylactic measure in

most cases of HIT and TTP: Heparin-induced thrombocytopenia
(HIT) and thrombotic thrombocytopenic purpura (TTP) are disorders
in which thrombocytopenia leads to a risk of bleeding due to platelet
consumption and activation. Platelet transfusions may help in cases
where there is active or anticipated bleeding due to an invasive
procedure, and platelet transfusion should not be withheld in these
case. However, platelet transfusions may cause an increased risk of
arterial thrombosis in patients with TTP or HIT due to the same
pathophysiology causing the initial thrombocytopenia.

Members of some faith such as Jehovah's Witnesses may refuse

blood products, but individual patients make their own decisions.
Some may allow albumin or immunoglobulin but will not accept whole
blood products. Informed consent must be obtained and
documented.
Risks:

There is a risk of transmission of blood borne pathogens such as

Hepatitis B, Hepatitis C, HIV and others from donated blood. All
donated blood products are carefully screened for these diseases,
but a very small risk remains.

Transfusion reactions occur when blood is mismatched according to

blood type, but can occur due to undetected incompatibilities,
regardless of proper screening procedures. Common signs of
reactions include fever, hives or rash, and breathing problems. Fever
and chills are the earliest and most common complaint. This can be
quite pronounced, inducing rigors in minutes, often resembling
anaphylaxis. The patient may turn bright red with body-wide flushing.
Note: Reactions may begin at any time during transfusions, however,
most reactions occur within the first few minutes of administration.

Patient Teaching:

Instruct patient to report any sensation of flushing, itching, shortness

of breath, or back/flank pain immediately, as these may be signs of a
transfusion reaction.

Procedure

Supplies:

0.9% normal saline, 250 mL bag

blood administration set with in-line filter and a Y set for saline
administration

IV pole

clean gloves

blood product

IV pump (most facilities)

blood warmer, if indicated

Steps:

ALWAYS ensure patency of IV line prior to obtaining blood from the

lab.

Obtain blood product from the blood bank promptly.

Visually inspect the blood for clots, sediment, or bubbles.

Confirm the patients ID with two identifiers and ensure that the
consent is signed, if required by your facility.

Perform hand hygiene and put on clean gloves.

Obtain baseline vital signs. Pre-existing fever should be reported to

the provider prior to proceeding with transfusion.

Two RNs (one of whom will administer the blood product, though this
policy may vary) must confirm the following on the blood unit, lab
paperwork, and the blood ID band at the bedside: blood unit ID
number, blood ABO and Rh type, unit expiration date, unit
unique identifier (a code), and patients name and DOB
confirmed with the ID band.

Close ALL clamps on Y set tubing. Hang 0.9 % NS. Note: Only
isotonic electrolyte solutions are approved from blood administration.
Dextrose will hemolyze RBCs and the calcium in Lactated Ringers
will cause clotting.

Prime Up: Spike the normal saline with one short end of the Y tubing
and open the clamps on both of the shorter Y ends set to prime them.
The descending tubing clamp remains closed.

Prime Down: With NS clamp still open, now close the clamp on the
other short end of the Y set and open main (descending tubing)
clamp to prime the rest of tubing with NS.

Close all clamps.

Gently agitate blood bag (suspends the blood cells). Pull back the
tabs on blood bag ports to expose them.

Prime Blood: Main tubing and NS Y arm clamps remain closed.

Spike the blood bag with the free short end of the Y tubing and open
the corresponding clamp to allow blood to flow down and prime the
filter with blood.
 Note: The filter is housed in a large round or cylindrical drip chamber
that lies below the Y set connection. It is necessary to allow blood
into this drip chamber until the filter is completely submerged in the
blood. It is best to allow a little air to remain at the very top of the drip
chamber to allow you to observe the drip rate.

Load tubing into the infusion pump, if used.

Prep injection port per facility policy, and connect the tubing to
patient.

Open main clamp and begin infusion via pump or gravity. Begin the
transfusion slowly, rate of 2 mL/minute for the first 15 minutes (100
mL/hour). In most cases, the rate should not exceed 2-4 mL/kg/hr.

Stay with the patient for the first 15 minutes and assess vital
signs at 15 minutes and again at 30 minutes. Follow institutional
guidelines for monitoring vital signs for the remainder of the
transfusion. Most severe reactions occur in the first 15 minutes or 50
mL of the transfusion. Watch for pain near the insertion site,
backache, fever, chills, itching, hives, dyspnea, or unusual
complaints from the patient.

Administer blood at prescribed rate but continue to monitor for signs

of hemolytic reaction or fluid overload. A rise of 1 degree C (2
degrees F) warrants reporting to the provider.

From the time a unit of blood is spiked, the infusion should take
a maximum of four hours. Each unit of plasma or platelets
should be administered over 30-60 minutes.

In addition, the tubing/administration set should be changed with

each unit of blood, or at the end of 4 hours. This reduces the risk
for bacterial contamination.

Once complete, all transfusion-related items should be discarded in a

biohazard waste receptacle according to facility policy.

If a reaction is suspected, stop the blood immediately, replace the

tubing, and run 0.9% normal saline. Report this to the health care
provider and the blood bank immediately. The entire unit with tubing
still connected if often retrieved by the blood bank.
Tracheostomy Care: Cleaning the Inner Cannula and Dressing Change

Purpose: Routine tracheostomy and stoma care is provided to aid in

healing and prevent infection and skin breakdown. Frequent soiling and
moisture from secretions leads to skin maceration and discomfort. The
tracheostomy site should be kept clean and dry with dressing changes daily
or whenever soiled or wet. Dressings should be sterile and non-woven to
avoid fraying fibers from entering the trach tube. Accumulated secretions
also contribute to occlusion and provide an environment for bacterial
growth, so care also includes removal and cleaning of the inner cannula, if
present.

Nursing Considerations

Assessment:

Review provider orders and patient care plan.

Review trach care policies. Evidence-based practice

recommends two-persontechnique for trach care when possible to
avoid dislodging tube.

Assess whether patient has an inner cannula. Many patients have

disposable inner cannulas, which eliminate the need for cleaning.

Assess secretions and pulmonary status and perform trach suction, if

indicated.

Assess skin integrity and look for signs of infection near stoma and
along the neck where trach ties lie.

Ensure that suction equipment, additional trach tubes, and an

obturator is available at the bedside.

Check for an inner cannula. It is important to remove the inner

cannula and clean it to prevent mucus buildup. The inner cannula
locks into place.

Assess the type of tracheostomy: Many trachs are

uncuffed. Some trachs have inflated cuffs (balloons) to decrease the
risk for aspiration and facilitate ventilator use. These are generally
used for patients with swallowing difficulties, pediatric patients, or
ventilated patients. Routine trach care is essential whether cuffed or
uncuffed. Cuff pressures are routinely checked and documented per
facility policy to avoid damage to airway tissue over time and this can
be done at the same time as cleaning if desired. Cuffs are inflated or
 deflated per provider orders only, so it is important to assess each
patients tracheostomy and orders.

Contraindications

none

Risks:

When performing tracheostomy care, emergency supplies should be

available at all times in case the tube is inadvertently dislodged.

Patient Teaching:

Explain the procedure. Patients should verbalize understanding of

proper care.

Procedure

Supplies:

trach cleaning tray (includes sterile gloves, sterile basins, pipe

cleaners, brush, cotton-tipped applicator, gauze)

presplit non-fraying 4x4 or split drain sponge

replacement inner cannula, if applicable

sterile normal saline

clean cotton trach ties or Velcro tube holder

Steps:

Confirm the patients ID using two identifiers.

Explain procedure to patient.

Open trach tray and put on one sterile glove in order to set up two
basins.

With an un-gloved (non-sterile) hand, pour saline into each basin.

 Don the second sterile glove - both hands are now sterile.

Remove inner cannula, if applicable: Secure outer cannula neck

plate with index finger and thumb. Unlock inner cannula - usually by
turning LEFT 90 degrees. Gently pull cannula up and out - it should
withdraw easily.

Soak and clean the inner cannula in sterile normal saline or discard if
disposable. Remove any secretions by cleansing and wiping the
lumen with moistened brush.

Place cleaned inner cannula on sterile gauze and dry thoroughly.

Replace inner cannula with care, stabilizing outer flange with

opposite hand. Lock into place (turn RIGHT).

Cleanse skin around stoma with gauze or applicator soaked in sterile

saline from the clean basin (the basin that was not used to clean
inner cannula). Use a separate gauze/applicator to clean the outer
cannula.

Apply new dressing: Apply presplit non-fraying gauze/split drain

sponge around stoma/trach tube with flaps pointing up. (See picture
of how to make folded 4x4 dressing if a presplit is not available.)

Change trach ties/tube holder if needed. (See: Changing

tracheostomy tube ties)

Tracheostomy Suctioning

Purpose: Tracheostomy suctioning, or deep suctioning, is done to

improve ventilation by removal of airway secretions using a sterile catheter.
The catheter must remain sterile when inserted into a tracheostomy either
by the use of sterile gloves and sterile technique or a by using a catheter-
in-sleeve to prevent bacterial contamination and reduce the risk for
nosocomial infections.

A closed catheter system is preferred when suctioning ventilator-dependent

patients to allow vent pressure to be maintained during suctioning.
Ventilated patients will not be discussed here.
Nursing Considerations

Assessment:

Review medical history and indication for tracheostomy. Many

patients have long-standing tracheostomies and consider suctioning
routine, while post op patients may require additional measures to
address fears and concerns for pain.

Assess for airway patency, effective vs. ineffective airway clearance

(ability to cough), and for presence of abnormal breath sounds. Also
assess heart rate, oxygen saturation, and respiratory rate.

If applicable, clean the inner cannula (see: Cleansing Inner Cannula

and Ostomy procedure). Many times secretions collect along the
cannula and may cause occlusion. Suctioning may be avoided by
cleaning the inner cannula and by encouraging the patient to cough.

Review whether patient is on droplet precautions or is at risk for

infectious disease related to droplet or airborne transmission
(influenza, MRSA). The CDC advises caution while performing
aerosol-generating procedures (AGP).. Procedures that induce
coughing with tracheal intubation have been associated with
transmission of smaller droplet particles and may require use of N-95
mask according to the World Health Organization.

Calculate catheter size: The diameter should be less than or up to

half the internal diameter of the trach tube. If it is too large it will
occlude the airway or cause injury. Estimated size: Adults: 12-18 Fr,
Children: 14 Fr, Infant: 6-10 Fr.

Sizing formula: INNER trach diameter divided by 2, then multiplied

by 3 = French size.

Contraindications

Scheduled suctioning is inappropriate. Frequency of suctioning

should be guided by clinical indications based on patients respiratory
status, consistency of secretions, and ability to mobilize secretions
independently with coughing.

Routine instillation of saline prior to suctioning in order to loosen

secretions has not been shown to be effective and is no longer
recommended. The best approach to manage secretions and
 enhance pulmonary function is by adequate hydration and
humidification of oxygen when ordered.

Suctioning should not be performed if resistance is met when

attempting to pass the tube into the tracheostomy or if the tube is
dislodged. This may cause injury.

Risks:

Suctioning temporarily depletes oxygen, and can lead to hypoxia and

atelectasis. A vagal response including arrhythmias can also occur;
however, proper technique and catheter size can mitigate these
problems. Note: Suctioning causes coughing and tachycardia. This
is an expected response.

Suctioning can cause damage to the mucosal lining. Appropriate

suction pressure and technique can reduce this risk.

Measures must be taken in case of inadvertent dislodging of the

trach tube during any care for a patient with tracheostomy. An
obturator should be present at the bedside as well as a self-inflating
resuscitator bag (AMBU) for emergency use.

Patient Teaching:

Patients should be instructed to breath normally. Inform him or her

that the procedure will likely induce coughing. Suctioning should not
be painful.

Patients should be given a hand signal to use if they experience

discomfort or wish to pause the procedure, since they cannot speak
during suctioning.

Procedure

Supplies:

suction tubing

trach suctioning kit or individually wrapped sterile gloves and suction

catheter

bottle sterile water or normal saline (250mL)

sterile container to hold water

 clean gloves

PPE including gown and mask with face shield (CDC recommends
N-95 mask for suspected pathogen)

suction machine (portable or wall connection with Y connector)

oxygen source with tubing

obturator (kept at bedside for emergencies)

self-inflating resuscitator bag (AMBU) with trach tube adapter (for

emergencies)

Steps:

Confirm the patients ID using two identifiers and explain the

procedure to the patient.

Prepare equipment: Wall suction should have tubing connected and

be set between -80 mmHg and -120 mmHg. Higher pressures
increase the risk of trauma to the mucosa. Depending on method of
delivery, the oxygen source should be set to maximum (10-12 LPM)
with the tubing connected. An AMBU bag should have a trach tube
adapter connected and should be checked for function - this can be
done by squeezing the bag. It should re-inflate spontaneously.

Perform hand hygiene; don clean gloves and PPE.

Position client for comfort. Semi-fowlers or upright is optimal for

pulmonary hygiene, but not required.

Hyperoxygenate: Instruct patient to take a few deep breaths while

oxygen is at maximum, then disconnect oxygen source from the trach
tube.

Remove and the clean inner cannula if the patient has one. While
suctioning, this can be placed on the sterile field or in sterile
water. (see: Tracheostomy Care: Removing and Cleaning Inner
Cannula)

Open new suction catheter package, and ready sterile container for
water.

Remove cap from sterile water, and pour into open sterile container.
 Don sterile gloves. Keeping dominant hand sterile and the other hand
clean, grasp suction tubing with clean hand and sterile catheter with
sterile hand. Estimate the depth catheter will be advanced: 0.5 to 1
cm past the end of trach tube - and grasp the catheter at that point.

Move your clean hand near the chimney valve at base of catheter
(this end will not touch the tracheostomy). The chimney valve
initiates suction when it is occluded with your thumb.

Insert the catheter: Without applying suction, move your sterile

hand toward the end/tip of catheter and guide the catheter into trach
tube just until resistance is felt. If patient begins coughing, withdraw
catheter slightly. (Suction during insertion may cause discomfort and
injury.)

Suction: Using your clean thumb, occlude the chimney valve to

produce intermittent suction as catheter is rotated gently while
withdrawing from the trach. Suction for no more than 10 seconds.

Rinse the catheter with sterile water from the tray until the lumen is
clear by using intermittent suction. Do this between each pass with
the suction.

Repeat the suction steps, inserting without suction and removing with
intermittent suction for no more than 10 seconds.

Turn off suction and replace oxygen to patient as ordered.

Discard catheter into appropriate receptacle after disconnecting from

suction tubing.

Empty suction bowl with sterile water and discard.

Auscultate lungs and assess heart rate and breathing effort.

Remove (doff) all PPE before exiting room and place in appropriate
receptacle.

Urinary Catheter Insertion, Indwelling - Male

Purpose: An indwelling Foley (or retention catheter) is used to remove

urine from the bladder in situations when there is a mechanical obstruction
in the urethra or retention of urine due to a nerve block (i.e. after surgery,
with epidural administration), due to benign prostatic hypertrophy (BPH), or
in cases where urine needs to be carefully measured. A catheter may also
be used when a patient must be immobilized (such as with skeletal traction)
and during many surgical procedures.

Nursing Considerations

Assessment:

Determine the indication for the indwelling catheter (Foley or

retention catheter) and confirm the order.

Ask the patient if he has a history of urinary issues or has been

catheterized before and for how long it may have been in place. If the
patient has urethral strictures or an enlarged prostate (BPH), this can
make catheterization more difficult.

Assess for latex allergy, depending on the catheter being used.

Consider the use of a silicone catheter.

Assess for adhesive allergies.

Assess for shellfish allergy or iodine sensitivity.

Contraindications

Catheterization is contraindicated if there is suspected urethral

trauma/tearing.

Risks:

The main risk is infection. Catheter-associated urinary tract infections

are the most common nosocomial infections. 10-30% of patients
develop bacteriuria and become symptomatic within 2-4 days after
insertion of an indwelling catheter. Though catheters may be used for
comfort at end of life, indwelling catheters are not indicated to
manage incontinence or for convenience at any other time, and
should always be removed as soon as possible.

Indwelling catheters may also lead to renal inflammation and

pyelonephritis with prolonged use.
Patient Teaching:

Explain the procedure and what the patient can expect to feel during
insertion (pressure, some temporary discomfort if there is an
enlarged prostate, then relief as urine is released).

Due to expected concerns for modesty, offer to provide a bath

blanket to cover the legs and close the curtain to provide privacy.

Procedure

Supplies:

Note: Catheters come in different sizes and materials. Catheters are

sized in units called French, ranging from 12 FR (small) for pediatrics
to 48 FR (extra large), and are usually silicone but may be latex or
another material.

clean gloves

washcloth and warm water for perineal hygiene

waterproof pad

sterile Foley catheter kit

If you are not using a kit, also assemble the following supplies:

sterile catheter in the appropriate size

sterile gloves

sterile drapes, one with a fenestration (window)

antiseptic solution such as betadine (use castile soap or Hibiclens if

the patient reported an iodine sensitivity)

sterile basin (the catheter kit tray may act as the basin)

sterile cotton balls

sterile forceps

prefilled syringe with WATER

 lubricant (sterile)

disposable urine collection bag and tubing

paper tape or a leg strap

Steps:

Confirm the patients ID using two identifiers.

Close the curtain to provide for patient privacy and stand on the
patients right side if you are right-handed or the left side of the bed if
you are left-handed.

Ask the patient to lay back in the dorsal recumbent position; legs
straight and slightly apart. Slip the waterproof pad under the patients
penis and/or scrotum. Keep the patient covered while you set up your
sterile field.

Set up the urine collection bag if a separate system is to be used,

and attach it to the bed frame.

Open the sterile catheterization kit on the patients legs using

sterile technique. If no kit is used, open a sterile drape and prepare
sterile field with necessary supplies.

Don the sterile gloves included in the kit.

Apply the drapes: Lift the first sterile drape (with no window) and,
using part of the drape to protect the sterile gloves, drape the thighs.
If the gloves become contaminated, replace them with new gloves.

The second drape is fenestrated, and is placed over the patients

groin area to expose the genitals through the window.

Open all the sterile supplies in the tray.Remove the plastic sheath
covering the catheter, squirt the lubricant in the tray, and lay the
catheter in the tray with the tip in the lubricant. Pour the antiseptic
over the cotton balls, unwrap and attach the 10 mL syringe of water
to the balloon port. (If no kit is used, ensure that the drainage end of
the catheter is in the basin and this is within reach for urine
drainage.)

Testing the balloon prior to insertion is not recommended. All

catheters are tested during the manufacturing process. Also, inflation
creates stress on the balloon that creates ridges and increases the
 surface area, causing higher incidences of urinary tract infections and
more irritation upon insertion.

Clean the penis glans and urinary meatus: Using your

nondominant hand as your working/nonsterile hand, pull back the
foreskin, if applicable. Hold the penile shaft and glans and prepare to
keep this hand in place until the catheter is in and urine is flowing.

Using your dominant hand and keeping it sterile, use the included
sterile forceps to pick up an antiseptic-soaked cotton ball and clean
the meatus and the surrounding penis glans in a circular motion
starting at the tip, discarding the cotton ball after one pass. Pick up
another cotton ball and repeat the process at least two more times.

Insert the catheter: Using your sterile, dominant hand, pick up the
catheter a few inches from the tip ensure it is coated in the lubricant.
Then insert the tip slowly into the urethra and advance it until you see
the flow of urine, and then advance another 3 inches. Note: If you
encounter pressure before you see any urinary flow, this may be due
to a narrowing of the urethra from the prostate. Turn the catheter a
little and advance further and it will slip past and into the bladder. Do
NOT force the catheter if there is great resistance.

Inflate the balloon with the entire volume of sterile water (usually 10
mL). Do not inflate against great resistance. Try moving the catheter
a little further before attempting to inflate again to avoid damage to
the urethra.

Attach the urine drainage bag if no kit was used. Otherwise, attach
the urine drainage bag to the bed frame now. Clean up supplies.

Use tape or a velcro leg strap to attach drainage tubing to leg,

leaving some slack to allow for movement.

Remove gloves and perform hand hygiene.

Assist patient to a comfortable position.

Urinary Catheter Insertion, Indwelling - Female

Purpose: (Foley or retention catheter) A catheter is used to remove urine

from the bladder in situations when there is a mechanical obstruction in the
urethra or retention of urine due to a nerve block (after surgery or childbirth,
for example), or in cases where urine needs to be carefully measured. A
catheter may also be used when a patient must be immobilized (such as
with skeletal traction) and during many surgical procedures.

Nursing Considerations

Assessment:

Determine the indication for the indwelling catheter (Foley or

retention catheter) and confirm the order.

Ask the patient if she has a history of urinary issues or has been
catheterized before and for how long it may have been in place. If the
patient has urethral strictures, this can make catheterization more
difficult.

Assess for latex allergy, depending on catheter being used.

Assess for adhesive allergies.

Assess for shellfish allergy or iodine sensitivity.

Contraindications

Catheterization is contraindicated if there is suspected urethral

trauma/tearing.

Risks:

The main risk is infection. Catheter-associated urinary tract infections

are the most common nosocomial infections. 10-30% of patients
develop bacteriuria and become symptomatic within 2-4 days after
insertion of an indwelling catheter. Though catheters may be used for
comfort at end of life, indwelling catheters are not indicated to
manage incontinence or for convenience at any other time, and
should always be removed as soon as possible.

Indwelling catheters may also lead to renal inflammation and

pyelonephritis with prolonged use.
Patient Teaching:

Explain the procedure and what the patient can expect to feel during
insertion (pressure, then relief as urine is released).

Due to the expected concerns for modesty, offer to provide a bath

blanket to cover the legs and close the curtain to provide privacy.

Procedure

Supplies:

Note: Catheters come in different sizes and materials. Catheters are

sized in units called French, ranging from 12 FR (small) for pediatrics
to 48 FR (extra large), and are usually silicone but may be latex or
another material.

clean gloves

washcloth and warm water for perineal hygiene

waterproof pad

sterile Foley catheter kit

If you are not using a kit, also assemble the following supplies:

sterile catheter in the appropriate size

sterile gloves

sterile drapes, one with a fenestration (window)

antiseptic solution such as betadine (use castile soap or Hibiclens if

the patient reported an iodine sensitivity)

sterile basin (the catheter kit tray may act as the basin)

sterile cotton balls

sterile forceps

prefilled syringe with WATER

 lubricant

disposable urine collection bag and tubing

paper tape or a leg strap

Steps:

Confirm the patients ID using two identifiers.

Close the curtain to provide for patient privacy and stand on the
patients right if you are right-handed or the left side of the bed if you
are left-handed.

Ask the patient to lay back in the dorsal recumbent position; knees
flexed and legs about two feet apart with legs abducted. Slip the
waterproof pad under the patients buttocks. Keep the patient
covered while you set up your sterile field.

Set up the urine collection bag if a separate system is to be used,

and attach it to the bed frame.

Open the sterile catheterization kitbetween the patients legs using

sterile technique. If no kit is used, open a sterile drape and prepare
sterile field with necessary supplies.

Don the sterile gloves included in the kit.

Lift the first sterile drape (with no window) and, using part of the
drape to cover the gloves, tuck the drape just under the patients
buttocks while she lifts up. If the gloves become contaminated,
replace them with new gloves.

The second drape is fenestrated, and is placed over the patient to

expose the genital area.

Open all the sterile supplies in the tray. Remove the plastic sheath
covering the catheter, squirt the lubricant in the tray, pour the
antiseptic over the cotton balls, and attach the syringe to the port. (If
no kit is used, ensure that one end of the catheter tube is in the basin
and this is within reach for urine drainage.)

Testing the balloon prior to insertion is not recommended. All

catheters are tested during the manufacturing process. Also, inflation
creates stress on the balloon that creates ridges and increases the
 surface area, causing higher incidences of urinary tract infections and
more irritation upon insertion.

Clean the labia and urinary meatus: Using your nondominant hand
as your working/nonsterile hand, spread the labia open and prepare
to keep this hand there until the catheter is in and urine is flowing.

Using your dominant hand and keeping it sterile, use the included
sterile forceps to pick up an antiseptic-soaked cotton ball and clean
one labial fold front to back, discarding the cotton ball afterward. Pick
up another cotton ball and clean the other labial fold front to back and
discard. Then use another cotton ball to clean the meatus and down
the middle toward the rectum.

Using your sterile, dominant hand, pick up the catheter a few inches
from the tip and dip it in the lubricant. Then insert the tip slowly into
the urethra and advance it until you see the flow of urine, and then
another 3 inches.

Inflate the balloon with the entire volume of sterile water (usually 10
mL). Do not inflate against great resistance. Try moving the catheter
in a little before attempting again.

Attach the urine drainage bag if no kit was used. Otherwise, attach
the urine drainage bag to the bed frame now. Clean up supplies.

Use tape or velcro leg strap to attach drainage tubing to leg, leaving
some slack to allow for movement.

Remove gloves and perform hand hygiene.

Assist patient to comfortable position.

Ostomy Bag and Appliance; Emptying and Changing

Supplies:

For emptying the pouch:

bedpan, graduated container, and access to a toilet

clean gloves
 toilet tissue

For changing an appliance:

clean gloves

washcloth

towel

basin with warm water

waterproof pad

clean gloves

gauze

skin protectant

stoma measuring guide

ostomy appliance and bag (1 or 2 piece system)

ostomy pouch clamp

trash bag

Steps:

Emptying an ostomy pouch:

Confirm the patients ID using two identifiers.

Close the curtain to provide patient privacy.

Perform hand hygiene and don clean gloves.

Help the patient to a sitting position, if possible, to make it easier for

them to assist and to watch the procedure. The patient may choose
to sit in the bathroom.

Place the bedpan or graduated container (for measuring output)

under the pouch and remove the clamp. Cuff the bottom two inches,
 turning the end of the pouch inside out, and allow the contents to
empty into the bedpan, container, or directly into the toilet. It may be
necessary to squeeze the pouch if the feces is more formed.

Wipe the cuffed end of the pouch with toilet tissue and un-cuff it.
Squeeze the air out and reapply the clamp.

If appliance is not to be changed, remove gloves and perform hand

hygiene.

Changing an ostomy appliance:

Confirm the patients ID using two identifiers if not already done.

Set up a work area over a waterproof pad with a basin and warm
water the other supplies including a trash bag.

Perform hand hygiene and don gloves.

Place a waterproof pad or towel over the patients lap.

Empty the pouch if not already done.

Starting at the top and moving around edge, push the skin away from
the appliance gently but firmly. Dont peel the appliance up, which
can cause skin tears. Use adhesive remover or warm water if
necessary. Discard the appliance or set aside to wash, if reusable.

Use tissue or gauze to remove any stool from the stoma, and then
cover the stoma with gauze. Clean the surrounding skin gently with a
washcloth using mild soap and water. Use adhesive remover, if
necessary. Do not apply lotion.

Pat the skin dry and apply skin protectant to the area, but no
closer than two inches from the stoma edge. Let it dry completely for
30 seconds.

Remove the gauze from the stoma and use the stoma measuring
guide. The guide will have several holes with which to match the size
of the stoma. Then replace the gauze and trace the correct size on
the back of the new appliance.
 Using scissors, cut a hole in the appliance that is 1/8 inch larger than
the selected stoma size.

Peel away the backing from the appliance, remove the gauze from
the stoma, and carefully lay the new appliance over the stoma, lining
up the opening. Smooth out any trapped air and maintain even
pressure to the appliance for five minutes.

Apply the clamp to the bottom of the new pouch.

* Labs marked with asterisks are those that students are responsible for
knowing for the NCLEX, as indicated on the NCSBN Educator Test
Blueprint.

Detailed information follows chart.

For simplicity, the table above refers to values as either US or SI, referring
to U.S. Conventional Units or Le Systme international d'units
(abbreviated SI from French). SI is most widely used system of
measurement, the metric form of measurement for labs. In some instances,
the values expressed in the right hand column may not be in the SI, but are
the units which are most familiar to Canadian nurses in practice. In the
International System of Units (SI), the base unit for molar concentration
is mol/m3.

NCLEX Mastery provides lab reference ranges from Mosbys, 5th Edition
(2013) and Canadian (2012). The units in the US Conventional Units and
the SI are different, but the quantities have a fixed relationship to each
other. US Conventional units can be converted into SI Units or vice versa.
In a few instances, when Canadian reference ranges have not been
provided by Mosbys, they have been sourced from Stedmans Online or
conversions made from the Mosbys US conventional values and
calculated using the AMA Manual of Style SI Conversion Calculator.

Laboratory reference values and units may vary among individual reference
sources and are highly dependent on the analytic methods used. Since
there is no one accepted lab resource for the NCLEX, we recommend you
use the lab values you learned in school.

TERMINOLOGY:

Gram: common measurement of weight. Used in this table are: pg

(picograms), g (grams), and mg (milligrams) per liter.

Micrometer (m): a unit of length. Mean Corpuscular Volume is expressed

in cubic micrometers

Mole or Gram Molecular Weight: a quantity based on the atomic weight of

the substance. Many test results in the Systme Internationale are
expressed as the number of moles per liter. In US units, these
measurements are usually in grams per liter. Used in this table: mmol
(millimoles), mol (micromoles), nmol (nanomoles), and pmol (picomoles)
per liter. In the International System of Units (SI), the base unit for molar
concentration is mol/m3.

Some units of measurement include the following fractions and multipliers:

mega (M) : 10 6 or x1,000,000

kilo (k) : 10 3 or x1,000
deca or deka : 10 1 or x10
deci (d) : 10 -1 or 10
milli (m) : 10 -3 or 1,000
micro () : 10 -6 or 1,000,000
nano (n) : 10 -9 or 1,000,000,000
pico (p) : 10 -12 or 1,000,000,000,000

Sources:

AMA Manual of Style SI Conversion Calculator. Accessed Feb. 1, 2016. si -

conversion - calculator

Pagana KD. Mosby's Manual of Diagnostic and Laboratory Tests. Elsevier

Health Sciences; 2013.

Pagana KD, Pagana TJ, Pike - MacDonald SA. Mosby's Canadian Manual
of Diagnostic and Laboratory Tests. Mosby Canada; 2012.

Duh and Cook. Stedmans Online Laboratory Reference Range Values;

2005. Available at: www.stedmansonline.com - Stedmans28/APP17.
Accessed February 11, 2016.

Complete Blood Count (CBC)

RBC
Male: 4.7-6.6 million
Female: 4.2-5.4 million
WBC* 5,000-10,000 cells/ml
Critical WBC* <2,000 or >40000/ml
Neutrophils 55-70%
Lymphocytes 20-40%
Monocytes 2-8%
Eosinophils 1-4%
Basophils 0.5-1%
Hemoglobin*
Male: 14-18 g/dl
Female: 12-16 g/dl
Pregnant Female: > 11 g/dl
Hematocrit*
Male: 42-52%
Female: 37-47%
Pregnant Female: > 33%
Platelets*
Adults and elderly 150,000-400,000
Critical PLTs*
 Critical Value: <20,000 or >1 million

Comprehensive Metabolic Panel (CMP)

Sodium (Na)* 136-145 mEq/L

Critical Sodium*
Critical Value: <120 or > 160 mEq/L
Potassium (K)* 3.5-5.0 mEq/L
Critical Potassium*
Critical Value: <3 or >6.1mEq/L
Chloride 98-106 mEq/L
Calcium 9-10.5 mg/dl
Magnesium 1.3-2.1 mEq/L
Phosphorus 3-4.5 mg/dl
Glucose*
Fasting: 70-110 mg/dl
Casual: 200 mg/dl
Critical Glucose*
Male: <50 and >450 mg/dl
Female: <40 and >450 mg/dl
BUN* 10-20 mg/dl
Critical BUN* >100 mg/dl
Creatinine*
Male: 0.6-1.3 mg/dl
Female: 0.5-1.1 mg/dl
Critical Creatinine*
Adults: >4 mg/dl
Total Protein 6.4-8.3 g/dl
Albumin 3.5-5.0 g/dl
Bilirubin 0.3-1 mg/dl
Alkaline Phosphatase 30-120 units/L
ALT 4-36 international units/L
AST 0-35 units/L

Arterial Blood Gas (ABG)

pH* 7.35-7.45
Critical pH* <7.25 or >7.6
pCO2* 35-45 mmHg
Critical pCO2* < 20 or >60 mmHg
pO2* 80-100 mmHg
Critical pO2* (arterial) <40 mmHg
HCO3* 21-28 mEq/L
Critical HCO3* <10 or >40 mEq/L
SaO2* 95%-100%
Critical SaO2* 75% or lower

Coagulation

PT* 11-12.5 seconds

Full anticoagulant therapy
> 1.5-2 times control value
INR*
0.8-1.1
2-3 (A-fib)
3-4 (Prosthetic valve prophylaxis)
aPTT* 30-40 seconds
With anticoagulant therapy
1.5-2.5 times control value (in seconds)
Critical aPTT* > 70 seconds
D-Dimer <0.4 mg/L

Cardiac

Troponin-I <0.03 ng/ml

BNP <100 pg/ml
CK (Creatine Kinase)
Male: 50-150 U/L
Female: 50-150 U/L
C-reactive protein
<1.0 mg/dl (low cardiac risk)
>3.0 mg/dl (high cardiac risk)
Lactate dehydrogenase (LDH) 100-190 U/L

Urinalysis

Glucose:
Fresh specimen: should not be detected. 24-hr specimen: 50-300 mg/24 hr is
WNL.
Protein:
0-8 mg/dL or 50-80 mg/24 hr (at rest) is WNL. Over this indicates proteinurea.
pH:
4.6-8.0 is WNL. Average is 6
Ketones:
 Should not be detected. Low pH may cause a color change resulting in a false
positive.
Specific gravity:
1.005 - 1.030
Blood:
Blood may be present during menstruation or with external skin damage, neither of
which is indicative of hematuria.
Bilirubin:
Should be negative, but OTC selenium and pyridium can cause false positives
All others:
Should be negative

Other

Triglycerides*
Male: 40-160 mg/dl
Female: 35-135 mg/dl
Total cholesterol* <200 mg/dl
HDL*
Male: >45 mg/dl
( 60 = low risk for heart disease)
Female: >60 mg/dl
( 70 = low risk for heart disease)
LDL*
Male and Female: <130 mg/dl
Lactate
0.6-2.2 mmol/L or
5-20 mg/dl (venous blood)
HgB A1C*
Non-diabetic 4-5.9%
Good Diabetic control <7%
Poor Diabetic control >9%
TSH 0.3-5 /L
Free T4 0.8-2.8 ng/dl
Total T4 4.5-12 ng/dl
Critical Total T4
<2 mcg/dL if myxedema coma possible;
>20 mcg/dL if thyroid storm possible
Free T3 1.7-3.7 pg/ml
Uric Acid
Male: 4.0-8.5 mg/dl
Female: 2.7-7.3 mg/dl
Erythrocyte sedimentation rate Westergen Method
Male: up to 15 mm/hour
Female: up to 20 mm/hour
Amylase
60-120 Somogyi units/dL
or 30-220 units/L (SI units)
Lipase 0-160 units/L
Myoglobin <90 mcg/L
Ammonia 10-80mcg/dl
Iron
Male: 80-180 mcg/dl
Female: 60-160 mcg/dl

What Labs Do I Have to Know for the Exam?

* Labs marked with asterisks are those that students are responsible for
knowing for the NCLEX, as indicated on the NCSBN Educator Test
Blueprint:

* ABGs (pH, PO2, SaO2, HCO3)

* BUN

* cholesterol (total)

* glucose

* hematocrit

* hemoglobin

* HgbA1C

* platelets

* potassium

* sodium

* WBC

* creatinine

* PT, PTT & APTT, and INR

Lab values do vary slightly, depending on the resource. Since there is no
one accepted lab resource for the NCLEX, we recommend you use the lab
values you learned in school.

NCLEX Mastery provides reference ranges from Mosby's (Pagana and

Pagana, 2015).

These prefixes, roots, and suffixes apply only to

generic names.
prefix, root, examples (generic names) drug class or drug category
suffix

-afil avanafil; sildenafil; tadalafil; vardenafil phospho- diesterase (PDE)

inhibitor

-asone betamethasone; dexamethasone; diflorasone; corticosteroid

fluticasone; mometasone

-bicin doxorubicin; epirubicin; idarubicin; antineoplastic; cytotoxic agent

valrubicin

-bital butabarbital; butalbital; phenobarbital; barbiturate (sedative)

secobarbital

-caine bupivacaine; lidocaine; mepivacaine; local anesthetic

prilocaine; proparacaine

cef-, ceph- cefaclor; cefdinir; cefixime; cefprozil; cephalosporin antibiotic

cephalexin

-cillin amoxicillin; ampicillin; dicloxacillin; penicillin antibiotic

nafcillin; oxacillin

cort clocortolone; fludrocortisone; corticosteroid

hydrocortisone

-cycline demeclocycline; doxycycline; minocycline; tetracycline antibiotic

tetracycline

-dazole albendazole; mebendazole; metronidazole; anthelmintic; antibiotic;

tinidazole antibacterial

-dipine amlodipine; felodipine; nifedipine; calcium channel blocker

nimodipine; nisoldipine

-dronate alendronate; etidronate; ibandronate; bisphosphonate; bone

risedronate resorption inhibitor

-eprazole esomeprazole; omeprazole; rabeprazole proton pump inhibitor (PPI)

-fenac bromfenac; diclofenac; nepafenac NSAID

-floxacin besifloxacin; ciprofloxacin; levofloxacin; quinolone antibiotic

moxifloxacin; ofloxacin

-gliptin saxagliptin; sitagliptin; linagliptin antidiabetic; inhibitor of the

DPP-4 enzyme

-glitazone pioglitazone; rosiglitazone; troglitazone antidiabetic; thiazolidine-

dione

-iramine brompheniramine; chlorpheniramine; antihistamine

pheniramine

-lamide acetazolamide; brinzolamide; dorzolamide; carbonic anhydrase inhibitor

methazolamide

-mab adalimumab; daclizumab; infliximab; monoclonal antibody

omalizumab; trastuzumab

-mustine carmustine; estramustine; lomustine; alkylating agent

bendamustine (antineoplastic)

-mycin azithromycin; clarithromycin; clindamycin; antibiotic; antibacterial

erythromycin

-nacin darifenacin; solifenacin muscarinic antagonist

(anticholinergic)

-nazole fluconazole; ketoconazole; miconazole; antifungal

terconazole; tioconazole

-olol atenolol; metoprolol; nadolol; pindolol; beta blocker

propranolol; timolol

-olone fluocinolone; fluorometholone; corticosteroid

prednisolone; triamcinolone

-olone nandrolone; oxandrolone; oxymetholone anabolic steroid

-onide budesonide; ciclesonide; desonide; corticosteroid

fluocinonide; halcinonide

-oprazole dexlansoprazole; lansoprazole; pantoprazole proton pump inhibitor (PPI)

parin; -parin dalteparin; enoxaparin; fondaparinux; antithrombotic; anticoagulant

heparin; tinzaparin (blood thinner)

-phylline aminophylline; dyphylline; oxtriphylline; xanthine derivative

theophylline (bronchodilator)

-pramine clomipramine; desipramine; imipramine; tricyclic antidepressant (TCA)

trimipramine
pred; pred- loteprednol; prednicarbate; prednisolone; corticosteroid
prednisone

-pril benazepril; captopril; enalapril; lisinopril; ACE inhibitor

moexipril; ramipril

-profen fenoprofen; flurbiprofen; ibuprofen; NSAID

ketoprofen

-ridone iloperidone; paliperidone; risperidone atypical antipsychotic

-sartan candesartan; irbesartan; losartan; angiotensin II receptor

olmesartan; valsartan antagonist; ARB

-semide furosemide; torsemide loop diuretic (water pill)

-setron alosetron; dolasetron; granisetron; serotonin 5-HT3 receptor

ondansetron; palonosetron antagonist

-setron dolasetron; granisetron; ondansetron; antiemetic and antinauseant

palonosetron

-statin atorvastatin; lovastatin; pitavastatin; HMG-CoA reductase inhibitor;

pravastatin; rosuvastatin; simvastatin statins

sulfa- sulfacetamide; sulfadiazine; antibiotic; anti-infective; anti-

sulfamethoxazole; sulfasalazine inflammatory

-tadine cyproheptadine; desloratadine; loratadine; antihistamine

olopatadine

-tadine amantadine; rimantadine antiviral; anti-influenza-A

-terol albuterol; arformoterol; formoterol; beta agonist; bronchodilator

levalbuterol; salmeterol

-thiazide chlorothiazide; hydrochloro- thiazide; thiazide diuretic (water pill)

methyclothiazide

-tinib crizotinib; dasatinib; erlotinib; gefitinib; antineoplastic (kinase

imatinib inhibitor)

-trel desogestrel; etonogestrel; levonorgestrel; female hormone (progestin)

norgestrel

tretin-; tretin; acitretin; alitretinoin; isotretinoin; tretinoin retinoid; dermatologic agent;

-tretin form of vitamin A

-triptan almotriptan; eletriptan; rizatriptan; antimigraine; selective 5-HT

sumatriptan; zolmitriptan receptor agonist

-tyline amitriptyline; nortriptyline; protriptyline tricyclic antidepressant (TCA)

 vir; -vir abacavir; efavirenz; enfuvirtide; nevirapine; antiviral; anti-HIV
ritonavir; tenofovir

vir; -vir adefovir; entecavir; ribavirin (along with antiviral; anti-hepatitis

interferon)

-vir acyclovir; famciclovir; penciclovir; antiviral; anti-herpes

valacyclovir

-vir cidofovir; ganciclovir; valganciclovir antiviral; anti-CMV

-vir oseltamivir; zanamivir antiviral; anti-flu

-vudine lamivudine; stavudine; telbivudine; antiviral; nucleoside analogues

zidovudine

-zepam clonazepam; diazepam; flurazepam; benzodiazepine

lorazepam; temazepam

-zodone nefazodone, trazodone, vilazodone antidepressant

-zolam alprazolam; estazolam; midazolam; benzodiazepine

triazolam

-zosin aFDAlfuzosin; doxazosin; prazosin; alpha blocker

terazosin
Source: U.S. Food and Drug Administration (FDA)