Sunday, 26 September 2010

HYPERTHERMIA-HYPOTHERMIA BLANKET

A blanket-sized aquathermia pad, the hyperthermia-hypothermia blanket raises, lowers, or maintains body temperature through conductive heat or cold transfer between the blanket and the patient. It can be operated manually or automatically.

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Hyperthermia-Hypothermia Blanket



In manual operation, the nurse or physician sets the temperature on the unit. The blanket reaches and maintains this temperature regardless of the patient's temperature. The temperature control must be adjusted manually to reach a different setting. The nurse monitors the patient's body temperature with a conventional thermometer.
In automatic operation, the unit directly and continually monitors the patient's temperature by means of a thermistor probe (rectal, skin, or esophageal) and alternates heating and cooling cycles as necessary to achieve and maintain the desired body temperature. The thermistor probe also may be used in conjunction with manual operation but isn't essential.
The unit is equipped with an alarm to warn of abnormal temperature fluctuations and a circuit breaker that protects against current overload.
The blanket is most commonly used to reduce high fever when more conservative measures—such as baths, ice packs, and antipyretics—are unsuccessful. Its other uses include maintaining normal temperature during surgery or shock; inducing hypothermia during surgery to decrease metabolic activity and thereby reduce oxygen requirements; reducing intracranial pressure; controlling bleeding and intractable pain in patients with amputations, burns, or cancer; and providing warmth in cases of severe hypothermia.
Equipment
Hyperthermia-hypothermia control unit • operation manual • fluid for the control unit (distilled water or distilled water and 20% ethyl alcohol) • thermistor probe (rectal, skin, or esophageal) • patient thermometer • one or two hyperthermia-hypothermia blankets • one or two disposable blanket covers (or one or two sheets or bath blankets) • lanolin or a mixture of lanolin and cold cream • adhesive tape • towel • sphygmomanometer • gloves, if necessary • optional: protective wraps for the patient's hands and feet.
Disposable hyperthermia-hypothermia blankets are available for single-patient use.
Preparation of equipment
First, read the operation manual. Inspect the control unit and each blanket for leaks and the plugs and connecting wires for broken prongs, kinks, and fraying. If you detect or suspect malfunction, don't use the equipment.
Review the physician's order, and prepare one or two blankets by covering them with disposable covers (or use a sheet or bath blanket when positioning the blanket on the patient). The cover absorbs perspiration and condensation, which could cause tissue breakdown if left on the skin. Connect the blanket to the control unit, and set the controls for manual or automatic operation and for the desired blanket or body temperature. Make sure the machine is properly grounded before plugging it in.
Turn on the machine and add liquid to the unit reservoir, if necessary, as fluid fills the blanket. Allow the blanket to preheat or precool so that the patient receives immediate thermal benefit. Place the control unit at the foot of the bed.
Implementation
  • Assess the patient's condition, and explain the procedure to him. Provide privacy, and make sure the room is warm and free of drafts. Check facility policy and, if necessary, make sure the patient or a responsible family member has signed a consent form.
  • Wash your hands thoroughly. If the patient isn't already wearing a patient gown, ask him to put one on. Use a gown with cloth ties rather than metal snaps or pins to prevent heat or cold injury.
  • Take the patient's temperature, pulse, respirations, and blood pressure to serve as a baseline, and assess his level of consciousness, pupil reaction, limb strength, and skin condition.
  • Keeping the bottom sheet in place and the patient recumbent, roll the patient to one side and slide the rolled blanket halfway underneath him, so that its top edge aligns with his neck. Then roll the patient back, and pull and flatten the blanket across the bed. Place a pillow under the patient's head. Make sure his head doesn't lie directly on the blanket because the blanket's rigid surface may be uncomfortable and the heat or cold may lead to tissue breakdown. Use a sheet or bath blanket as insulation between the patient and the blanket.
  • Apply lanolin or a mixture of lanolin and cold cream to the patient's skin where it touches the blanket to help protect the skin from heat or cold sensation.
  • In automatic operation, insert the thermistor probe in the patient's rectum and tape it in place to prevent accidental dislodgment. If rectal insertion is contraindicated, tuck a skin probe deep into the axilla, and secure it with tape. If the patient is comatose or anesthetized, insert an esophageal probe. Plug the other end of the probe into the correct jack on the unit's control panel.
  • Place a sheet or, if ordered, the second hyperthermia-hypothermia blanket over the patient. This increases the thermal benefit by trapping cooled or heated air.
  • Wrap the patient's hands and feet if he wishes to minimize chilling and promote comfort. Monitor vital signs and perform a neurologic assessment every 5 minutes until the desired body temperature is reached and then every 15 minutes until temperature is stable or as ordered.
  • Check fluid intake and output hourly or as ordered. Observe the patient regularly for color changes in skin, lips, and nail beds and for edema, induration, inflammation, pain, and sensory impairment. If they occur, discontinue the procedure and notify the physician.
  • Reposition the patient every 30 minutes to 1 hour, unless contraindicated, to prevent skin breakdown. Keep the patient's skin, bedclothes, and blanket cover free of perspiration and condensation, and reapply cream to exposed body parts as needed.
  • After turning off the machine, follow the manufacturer's directions. Some units must remain plugged in for at least 30 minutes to allow the condenser fan to remove water vapor
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    from the mechanism
    . Continue to monitor the patient's temperature until it stabilizes because body temperature can fall as much as 5° F (2.8° C) after this procedure.
  • Remove all equipment from the bed. Dry the patient and make him comfortable. Supply a fresh patient gown, if necessary. Cover him lightly.
  • Continue to perform neurologic checks and monitor vital signs, fluid intake and output, and general condition every 30 minutes for 2 hours and then hourly or as ordered.
  • Return the equipment to the central supply department for cleaning, servicing, and storage.
Special considerations
  • If the patient shivers excessively during hypothermia treatment, discontinue the procedure and notify the physician immediately. By increasing metabolism, shivering elevates body temperature.
  • Avoid lowering the temperature more than 1 degree every 15 minutes to prevent premature ventricular contractions.
  • Don't use pins to secure catheters, tubes, or blanket covers because an accidental puncture can result in fluid leakage and burns.
  • With hyperthermia or hypothermia therapy, the patient may experience a secondary defense reaction (vasoconstriction or vasodilation, respectively) that causes body temperature to rebound and thus defeat the treatment's purpose.
  • If the patient requires isolation, place the blanket, blanket cover, and probe in a plastic bag clearly marked with the type of isolation so that the central supply department can give it special handling. If the blanket is disposable, discard it, using appropriate precautions.
  • To avoid bacterial growth in the reservoir or blankets, always use sterile distilled water and change it monthly. Check to see if facility policy calls for adding a bacteriostatic agent to the water. Avoid using deionized water because it may corrode the system.
  • To gradually increase body temperature, especially in postoperative patients, the physician may order a disposable warming system. (See Using a warming system.)
Complications
Use of a hyperthermia-hypothermia blanket can cause shivering, marked changes in vital signs, increased intracranial pressure, respiratory distress or arrest, cardiac arrest, oliguria, and anuria.
Documentation
Record the patient's pulse, respirations, blood pressure, neurologic signs, fluid intake and output, skin condition, and position change. Record the patient's temperature and that of the blanket every 30 minutes while the blanket is in use. Also document the type of hyperthermia-hypothermia unit used; control settings (manual or automatic and temperature settings); date, time, duration, and the patient's tolerance of treatment; and signs of complications.

Friday, 24 September 2010

REDUCING PAIN WITH ICE MASSAGE

Normally, ice shouldn't be applied directly to a patient's skin because it can damage the skin surface and underlying tissues. However, when carefully performed, ice massage may help patients tolerate brief, painful procedures, such as bone-marrow aspiration, catheterization, chest-tube removal, injection into joints, lumbar puncture, and suture removal.
Prepare for ice massage by gathering the ice, a porous covering to hold it (if desired), and a cloth for wiping water from the patient as the ice melts. Water may be frozen in a cup ahead of time. The paper is removed from half of the cup exposing the ice to be used for the procedure.
Just before the procedure begins, rub the ice over the appropriate area to numb it. Assess the site frequently; stop rubbing immediately if you detect signs of tissue intolerance.
As the procedure begins, rub the ice over a point near but not at the site to distract the patient from the procedure itself and give him another stimulus on which to concentrate.
If the procedure lasts longer than 10 minutes or if you think tissue damage may occur, move the ice to a different site and continue massage.
If you know in advance that the procedure will probably last longer than 10 minutes, massage the site intermittently—2 minutes of massage alternating with a rest period until the skin regains its normal color. Alternatively, you can divide the area into several sites and apply ice to each one for several minutes at a time.

COLD APPLICATION

The application of cold constricts blood vessels; inhibits local circulation, suppuration, and tissue metabolism; relieves vascular congestion; slows bacterial activity in infections; reduces body temperature; and may act as a temporary anesthetic during brief, painful procedures. (See Reducing pain with ice massage.) Because treatment with cold also relieves inflammation, reduces edema, and slows bleeding, it may provide effective initial treatment after eye injuries, strains, sprains, bruises, muscle spasms, and burns. Cold doesn't reduce existing edema, however, because it inhibits reabsorption of excess fluid.
Cold may be applied in dry or moist forms, but ice shouldn't be placed directly on a patient's skin because it may further damage tissue. Moist application is more penetrating than dry because moisture facilitates conduction. Devices for applying cold include an ice bag or collar, aquathermia pad (which can produce cold or heat), and chemical cold packs and ice packs. Devices for applying moist cold include cold compresses for small body areas and cold packs for large areas.
Apply cold treatments cautiously on patients with impaired circulation, on children, and on elderly or arthritic patients because of the risk of ischemic tissue damage.
Equipment
Patient thermometer • towel • adhesive tape or roller gauze • gloves, if necessary.
For an ice bag or collar
Tap water • ice chips • absorbent, protective cloth covering.
For an aquathermia pad
Distilled water • temperature-adjustment key • absorbent, protective cloth covering.
For a chemical cold pack
Single-use packs are available for applying dry cold. These lightweight plastic packs contain a chemical that turns cold when activated. Reusable, sealed cold packs, filled with an alcohol-based solution, are also available. These packs may be stored frozen until use and, after exterior disinfection, may be refrozen and used again. Other chemical packs are activated by striking, squeezing, or kneading them.
For a cold compress or pack
Basin of ice chips • container of tap water • bath thermometer • compress material (4″ × 4″ gauze pads or washcloths) or pack material (towels or flannel) • linen-saver pad • waterproof covering.
Preparation of equipment
Ice bag or collar
Select a device of the correct size, fill it with cold tap water, and check for leaks. Then empty the device and fill it about halfway with crushed ice. Using small pieces of ice helps the device mold to the patient's body. Squeeze the device to expel air that might reduce conduction. Fasten the cap and wipe any moisture from the outside of the device. Wrap the bag or collar in a cloth covering, and secure the cover with tape or roller gauze. The protective cover prevents tissue trauma and absorbs condensation.
Aquathermia pad
Check the cord for frayed or damaged insulation. Then fill the control unit two-thirds full with distilled water. Don't use tap water because it leaves mineral deposits in the unit. Check for leaks, and then tilt the unit several times to clear the pad's tubing of air. Tighten the cap. After ensuring that the hoses between the control unit and pad are free of tangles, place the unit on the bedside table, slightly above the patient so that gravity can assist water flow. If the central supply department hasn't preset the temperature, use the temperature-adjustment key to adjust the control unit setting to the lowest temperature. Cover the pad with an absorbent, protective cloth, and secure the cover with tape or roller gauze. Plug in the unit and turn it on. Allow the pad to cool for 2 minutes before placing it on the patient.
Chemical cold pack
Select a pack of the appropriate size, and follow the manufacturer's directions (strike, squeeze, or knead) to activate the cold-producing chemicals. Make certain that the container hasn't been broken during activation. Wrap the pack in a cloth cover, and secure the cover with tape or roller gauze.
Cold compress or pack
Cool a container of tap water by placing it in a basin of ice or by adding ice to the water. Using a bath thermometer for guidance, adjust the water temperature to 59° F (15° C) or as ordered. Immerse the compress or pack material in the water.
Implementation
  • Check the physician's order and assess the patient's condition.
  • Explain the procedure to the patient, provide privacy, and make sure the room is warm and free of drafts. Wash your hands thoroughly.
  • Record the patient's temperature, pulse, and respirations to serve as a baseline.
  • Expose only the treatment site to avoid chilling the patient.
Applying an ice bag or collar, an aquathermia pad, or a chemical cold pack
  • Place the covered cold device on the treatment site and begin timing the application.
  • Observe the site frequently for signs of tissue intolerance, such as blanching, mottling, cyanosis, maceration, and blisters. Also be alert for shivering and complaints of burning or numbness. If these signs or symptoms develop, discontinue treatment and notify the physician.
  • Refill or replace the cold device as necessary to maintain the correct temperature. Change the protective cover if it becomes wet.
  • Remove the device after the prescribed treatment period (usually 30 minutes as reflex vasodilation begins to occur after that time).
Applying a cold compress or pack
  • Place a linen-saver pad under the site.
  • Remove the compress or pack from the water, and wring it out to prevent dripping. Apply it to the treatment site, and begin timing the application.
  • Cover the compress or pack with a waterproof covering to provide insulation and to keep the surrounding area dry. Secure the covering with tape or roller gauze to prevent it from slipping.
  • Check the application site frequently for signs of tissue intolerance, and note complaints of burning or numbness. If these symptoms develop, discontinue treatment and notify the physician.
  • Change the compress or pack as needed to maintain the correct temperature. Remove it after the prescribed treatment period (usually 20 minutes).
Concluding all cold applications
  • Dry the patient's skin and re-dress the treatment site according to the physician's orders. Then position the patient comfortably and take his temperature, pulse, and respirations for comparison with baseline.
  • Dispose of liquids and soiled materials properly. If the cold treatment will be repeated, clean and store the equipment in the patient's room, out of his reach; otherwise, return it to storage.
Special considerations
  • Apply cold immediately after an injury to minimize edema. (See Using cold for a muscle sprain.) Although colder temperatures can be tolerated for a longer time when the treatment site is small, don't continue any application for longer than 1 hour to avoid reflex vasodilation. The application of temperatures below 59° F (15° C) also causes local reflex vasodilation.
  • Use sterile technique when applying cold to an open wound or to a lesion that may open during treatment. Also maintain sterile technique during eye treatment, with separate sterile equipment for each eye to prevent cross-contamination.
  • Avoid securing cooling devices with pins because an accidental puncture could allow extremely cold fluids to leak out and burn the patient's skin.
  • If the patient is unconscious, anesthetized, neurologically impaired, irrational, or otherwise insensitive to cold, stay with him throughout the treatment, and check the application site frequently for complications.
  • Warn the patient against placing ice directly on his skin because the extreme cold can cause burns.
Complications
Hemoconcentration may cause thrombi. Intense cold may cause pain, burning, or numbness.
Documentation
Record the time, date, and duration of cold application; type of device used (ice bag or collar, aquathermia pad, or chemical cold pack); site of application; temperature or temperature setting; patient's temperature, pulse, and respirations before and after application; skin appearance before, during, and after application; signs of complications; and the patient's tolerance of treatment.


Thursday, 23 September 2010

USING MOIST HEAT TO RELIEVE MUSCLE SPASM

Then soak the compress or pack in the hot liquid. If necessary, prepare a hot-water bottle, aquathermia pad, or chemical hot pack to keep the compress or pack warm.

DIRECT HEAT APPLICATION

Heat applied directly to the patient's body raises tissue temperature and enhances the inflammatory process by causing vasodilation and increasing local circulation. This promotes leukocytosis, suppuration, drainage, and healing. Heat also increases tissue metabolism, reduces pain caused by muscle spasm, and decreases congestion in deep visceral organs.
Direct heat may be dry or moist. Dry heat can be delivered at a higher temperature and for a longer time. Devices for applying dry heat include the hot-water bottle, electric heating pad, aquathermia pad, and chemical hot pack.
Moist heat softens crusts and exudates, penetrates deeper than dry heat, doesn't dry the skin, produces less perspiration, and usually is more comfortable for the patient. Devices for applying moist heat include warm compresses for small body areas and warm packs for large areas.
Direct heat treatment can't be used on a patient at risk for hemorrhage. It also is contraindicated if the patient has a sprained limb in the acute stage (because vasodilation would increase pain and swelling) or if he has a condition associated with acute inflammation, such as appendicitis. Direct heat should be applied cautiously to pediatric and elderly patients and to patients with impaired renal, cardiac, or respiratory function; arteriosclerosis or atherosclerosis; or impaired sensation. It should be applied with extreme caution to heat-sensitive areas, such as scar tissue and stomas.

Equipment
Patient thermometer • towel • adhesive tape or roller gauze • absorbent, protective cloth covering • gloves, if the patient has an open lesion.
For a hot-water bottle
Hot tap water • pitcher • bath (utility) thermometer • absorbent, protective cloth covering.
For an electric heating pad
Absorbent, protective cloth covering.
For an aquathermia pad
Distilled water • temperature-adjustment key • absorbent, protective cloth covering.
For a chemical hot pack (disposable)
Absorbent, protective cloth covering.
For a warm compress or pack
Basin of hot tap water or container of sterile water, normal saline, or other solution, as ordered • hot-water bottle, aquathermia pad, or chemical hot pack • linen-saver pad.
The following items may be sterile or nonsterile as needed: compress material (flannel, 4″ × 4″ gauze pads) or pack material (absorbent towels, large absorbent pads) • cotton-tipped applicators • forceps • bowl or basin • bath (utility) thermometer • waterproof covering • towel • dressing.

Preparation of equipment
Hot-water bottle
Fill the bottle with hot tap water to detect leaks and warm the bottle; then empty it. Run hot tap water into a pitcher and measure the water temperature with the bath thermometer. Adjust the temperature as ordered, usually to 115° to 125° F (46.1° to 51.7° C) for adults.
  • PEDIATRIC ALERT Adjust the water temperature to 105° to 115° F (40.6° to 46.1° C) for children under age 2.
  • ELDER ALERT Adjust the water temperature to 105° to 115° F (40.6° to 46.1° C) for elderly patients.
Next, pour hot water into the bottle, filling it one-half to two-thirds full. Partially filling the bottle keeps it lightweight and flexible to mold to the treatment area. Squeeze the bottle until the water reaches the neck to expel any air that would make the bottle inflexible and reduce heat conduction. Fasten the top and cover the bag with an absorbent cloth. Secure the cover with tape or roller gauze.
Electric heating pad
Check the cord for frayed or damaged insulation. Then plug in the pad and adjust the control switch to the desired setting. Wrap the pad in a protective cloth covering, and secure the cover with tape or roller gauze.
Aquathermia pad
Check the cord for safety, as above, and fill the control unit two-thirds full with distilled water. Don't use tap water because it leaves mineral deposits in the unit. Check for leaks, and then tilt the unit in several directions to clear the pad's tubing of air. Tighten the cap, and then loosen it a quarter turn to allow heat expansion within the unit. After making sure the hoses between the control unit and the pad are free of tangles, place the unit on the bedside table, slightly above the patient so that gravity can assist water flow. If the central supply department hasn't preset the temperature, use the temperature-adjustment key provided to set the temperature on the control unit. The usual temperature is 105° F (40.6° C). Then place the pad in a protective cloth covering and secure the cover with tape or roller gauze. Plug in the unit, turn it on, and allow the pad to warm for 2 minutes.
Chemical hot pack
Select a pack of the correct size. Then follow the manufacturer's directions (strike, squeeze, or knead) to activate the heat-producing chemicals. Place the pack in a protective cloth covering, and secure the cover with tape or roller gauze.
Sterile warm compress or pack
Warm the container of sterile water or solution by setting it in a sink or basin of hot water. Measure its temperature with a sterile bath thermometer. If a sterile thermometer is unavailable, pour some heated sterile solution into a clean container, check the temperature with a regular bath thermometer, and then discard the tested solution. Adjust the temperature by adding hot or cold water to the sink or basin until the solution reaches 131° F (55° C) for adults.
  • PEDIATRIC ALERT Adjust the water temperature to 105° F (40.6° C) for children or for an eye compress.
  • ELDER ALERT Adjust the water temperature to 105° F (40.6° C) for elderly patients or for an eye compress.
Pour the heated solution into a sterile bowl or basin. Then, using sterile technique, soak the compress or pack in the heated solution. If necessary, prepare a hot-water bottle, aquathermia pad, or chemical hot pack to keep the compress or pack warm.
Nonsterile warm compress or pack
Fill a bowl or basin with hot tap water or other solution, and measure the temperature of the fluid with a bath thermometer. Adjust the temperature as ordered, usually to 131° F (55° C) for adults.
  • PEDIATRIC ALERT Adjust the water temperature to 105° F (40.6° C) for children or for an eye compress.
  • ELDER ALERT Adjust the water temperature to 105° F (40.6° C) for elderly patients or for an eye compress.

Implementation
  • Check the physician's order, and assess the patient's condition.
  • Explain the procedure to the patient, and tell him not to lean or lie directly on the heating device because this reduces air space and increases the risk of burns. Warn him against adjusting the temperature of the heating device or adding hot water to a hot-water bottle. Advise him to report pain immediately and to remove the device if necessary.
  • Provide privacy and make sure the room is warm and free of drafts. Wash your hands.
  • Take the patient's temperature, pulse, and respiration to serve as a baseline. If heat treatment is being applied to raise the patient's body temperature, monitor temperature, pulse, and respirations throughout the application.
  • Expose only the treatment area because vasodilation will make the patient feel chilly.
Applying a hot-water bottle, an electric heating pad, an aquathermia pad, or a chemical hot pack
  • Before applying the heating device, press it against your inner forearm to test its temperature and heat distribution. If it heats unevenly, obtain a new device.
  • Apply the device to the treatment area and, if necessary, secure it with tape or roller gauze. Begin timing the application.
  • Assess the patient's skin condition frequently, and remove the device if you observe increased swelling or excessive redness, blistering, maceration, or pallor or if the patient reports discomfort. Refill the hot-water bottle as necessary to maintain the correct temperature.
  • Remove the device after 20 to 30 minutes, or as ordered.
  • NURSING ALERT Tissue exposed to heat for more than 30 minutes begins to develop vasoconstriction.
  • Dry the patient's skin with a towel and re-dress the site, if necessary. Take the patient's temperature, pulse, and respiration
    P.167

    for comparison with the baseline. Position him comfortably in bed.
  • If the treatment is to be repeated, store the equipment in the patient's room, out of his reach; otherwise, return it to its proper place.
Applying a warm compress or pack
  • Place a linen-saver pad under the site.
  • Remove the warm compress or pack from the bowl or basin. (Use sterile forceps throughout the procedure if necessary.)
  • Wring excess solution from the compress or pack (using sterile forceps if needed). Excess moisture increases the risk of burns.
  • Apply the compress gently to the affected site (using forceps, if warranted). After a few seconds, lift the compress (with forceps, if needed) and check the skin for excessive redness, maceration, or blistering. When you're sure the compress isn't causing a burn, mold it firmly to the skin to keep air out, which reduces the temperature and effectiveness of the compress. Work quickly so the compress retains its heat.
  • Apply a waterproof covering (sterile, if necessary) to the compress. Secure it with tape or roller gauze to prevent it from slipping.
  • Place a hot-water bottle, aquathermia pad, or chemical hot pack over the compress and waterproof covering to maintain the correct temperature. Begin timing the application.
  • Check the patient's skin every 5 minutes for tissue tolerance. Remove the device if the skin shows excessive redness, maceration, or blistering or if the patient experiences pain or discomfort. Change the compress as needed to maintain the correct temperature.
  • After 15 to 20 minutes or as ordered, remove the compress. (Use forceps, if warranted.) Discard the compress into a waterproof trash bag.
  • Dry the patient's skin with a towel (sterile, if necessary). Note the condition of the skin and re-dress the area, if necessary. Take the patient's temperature, pulse, and respiration for comparison with baseline. Then make sure the patient is comfortable.

Special considerations
  • If the patient is unconscious, anesthetized, irrational, neurologically impaired, or insensitive to heat, stay with him throughout the treatment.
  • When direct heat is ordered to decrease congestion within internal organs, the application must cover a large enough area to increase blood volume at the skin's surface. For relief of pelvic organ congestion, for example, apply heat over the patient's lower abdomen, hips, and thighs. To achieve local relief, you may concentrate heat only over the specified area. (See Using moist heat to relieve muscle spasm.)
  • As an alternative method of applying sterile moist compresses, use a bedside sterilizer to sterilize the compresses. Saturate the compress with tap water or another solution and wring it dry. Then place it in the bedside sterilizer at 275° F (135° C) for 15 minutes. Remove the compress with sterile forceps or sterile gloves, and wring out the excess solution. Then place the compress in a sterile bowl and measure its temperature with a sterile thermometer.
  • Be sure to follow manufacturer's instructions for heating compresses and avoid over-heating.
Complications
Because tissue damage may result from direct heat application, monitor the temperature of the compress carefully. Assess frequently the condition of the patient's skin under the heat application device.
Documentation
Record the time and date of heat application; type, temperature or heat setting, duration, and site of application; patient's temperature, pulse, respirations, and skin condition before, during, and after treatment; signs of complications; and the patient's tolerance of treatment.


Monday, 20 September 2010

Physical Treatments

Used effectively for centuries, many physical treatments have become fundamental nursing procedures. The principles behind such treatments as application of heat and cold—and often the techniques for performing them—remain essentially unchanged. However, that doesn't make them any less important than more involved or specialized procedures created by new, high-technology medical treatments. In fact, physical treatments that many nurses might consider routine are those most responsible for maintaining patient comfort, decreasing anxiety, and reducing the risk of infection.
Proven effectiveness
Most physical treatments have endured procedurally intact because of their effectiveness. Some treatments stimulate or support normal physiologic processes. For example, the application of heat enhances healing because the warmth causes vasodilation, thereby increasing blood supply to the affected area and making more nutrients available for tissue growth. Antiembolism stockings support blood vessels, increasing venous return and thereby reducing the risk of deep vein thrombosis. Drains allow wound secretions to escape to the surface from underlying tissue, thus assisting the healing process.
Other physical treatments prevent a pathologic response or inhibit a full-blown response. For example, cold application produces vasoconstriction and increases blood viscosity, thereby reducing inflammation, bleeding, and localized tissue edema. Medicated baths relieve itching and reduce the irritation caused by various skin disorders. Wound irrigation performed with an antiseptic solution inhibits bacterial growth. Also, radiation therapy inhibits or destroys cancerous cells, offering patients palliation, control, or cure. In all these instances, nursing assessment and interventions are essential to the success of physical treatments.
Advances in equipment
Improvements in physical treatments have resulted in part from equipment advances. For example, single-use or single-patient disposable products have heightened efficiency and safety. Hot-water bottles and ice collars, sterile gauze dressings, presaturated sterile swabs, and aquathermia pads are all available for single use. The number and types of disposable items and the variety of prepackaged procedure setup trays available continue to expand. One of the latest such products is the single-patient hyperthermia-hypothermia blanket. This disposable, lightweight vinyl blanket connects to a conventional module for use both under and over the patient.
A portable Fiberglas tub makes it possible to bathe rather than sponge patients on bed rest. The full-sized tub stands as high as the bed, rolls easily on casters, and fills and empties at the bedside through a hose that attaches to any faucet.
Vinyl pressure cuffs improve on the well-known and effective antiembolism stockings. This portable system stimulates the normal pumping action of leg muscles by inflating progressively from the ankle to the thigh, assisting venous return and preventing blood backflow.
Hypoallergenic adhesive gauze dressings cover an entire wound site with a single sheet of air- and exudate-permeable adhesive gauze. This type of occlusive dressing is particularly well suited for large or curved body areas and holds dressings securely without tapes or straps. The gauze can be lifted off easily and painlessly for examination of the wound—even on sensitive or hairy skin—and then can be pressed back into place.
The silicone-foam dressing has improved the care of open, granulating wounds. Poured into the wound in liquid form, this new packing quickly congeals into an absorbent rubber pad with the exact contour of the wound, but it permits air circulation and doesn't cause irritation.
The new portable and disposable equipment saves nursing time because it's easier to use than the equipment it replaces. And nursing time saved means fewer delays in delivering patient care. What's more, disposables reduce the spread of nosocomial infection and enhance patient comfort.

SKIN BIOPSY

Skin biopsy is a diagnostic test in which a small piece of tissue is removed, under local anesthesia, from a lesion that is suspected of being malignant or from another dermatosis.
One of three techniques may be used: shave biopsy, punch biopsy, or excisional biopsy. Shave biopsy cuts the lesion above the skin line, which allows further biopsy of the site. Punch biopsy removes an oval core from the center of the lesion. Excisional biopsy removes the entire lesion and is indicated for rapidly expanding lesions; for sclerotic, bullous, or atrophic lesions; and for examination of the border of a lesion surrounding normal skin.
Lesions suspected of being malignant usually have changed color, size, or appearance or have failed to heal properly after injury. Fully developed lesions should be selected for biopsy whenever possible because they provide more diagnostic information than lesions that are resolving or in early stages of development. For example, if the skin shows blisters, the biopsy should include the most mature ones.
Normal skin consists of squamous epithelium (epidermis) and fibrous connective tissue (dermis). Histologic examination of the tissue specimen obtained during biopsy may reveal a benign or malignant lesion. Benign growths include cysts, seborrheic keratoses, warts, pigmented nevi (moles), keloids, dermatofibromas, and neurofibromas. Malignant tumors include basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.
Equipment
Gloves • #15 scalpel for shave or excisional biopsy • local anesthetic • specimen bottle containing 10% formaldehyde solution • 4-0 sutures for punch or excisional biopsy • adhesive bandage • forceps • laboratory specimen labels and laboratory biohazard transport bags.
Implementation
  • Explain to the patient that the biopsy provides a skin specimen for microscopic study. Describe the procedure and tell him who will perform it. Answer any questions he may have to ease anxiety and ensure cooperation.
  • Inform the patient that he need not restrict food or fluids.
  • Tell him that he'll receive a local anesthetic for pain.
  • Inform him that the biopsy will take about 15 minutes and that the test results are usually available in 1 day.
  • Have the patient or an appropriate family member sign a consent form.
  • Check the patient's history for hypersensitivity to the local anesthetic.
  • Position the patient comfortably, and clean the biopsy site before the local anesthetic is administered.
  • For a shave biopsy, the protruding growth is cut off at the skin line with a #15 scalpel. The tissue is placed immediately in a properly labeled specimen bottle containing 10% formaldehyde solution. Apply pressure to the area to stop the bleeding. Apply an adhesive bandage.
  • For a punch biopsy, the skin surrounding the lesion is pulled taut, and the punch is firmly introduced into the lesion and rotated to obtain a tissue specimen. The plug is lifted with forceps or a needle and is severed as deeply into the fat layer as possible. The specimen is placed in a properly labeled specimen bottle containing 10% formaldehyde solution or in a sterile container if indicated. Closing the wound depends on the size of the punch: A 3-mm punch requires only an adhesive bandage, a 4-mm punch requires one suture, and a 6-mm punch requires two sutures.
  • For an excisional biopsy, a #15 scalpel is used to excise the lesion; the incision is made as wide and as deep as necessary. The tissue specimen is removed and placed immediately in a properly labeled specimen bottle containing 10% formaldehyde solution. Apply pressure to the site to stop the bleeding. The wound is closed using a 4-0 suture. If the incision is large, a skin graft may be required.
  • Check the biopsy site for bleeding.
  • Label the specimen and send the specimen to the laboratory immediately in a laboratory biohazard transport bag.
  • If the patient experiences pain, administer analgesics.
Special considerations
  • Advise the patient going home with sutures to keep the area clean and as dry as possible. Tell him that facial sutures will be removed in 3 to 5 days and trunk sutures, in 7 to 14 days.
  • Instruct the patient with adhesive strips to leave them in place for 14 to 21 days.
Complications
Possible complications include bleeding and infection of the surrounding tissue.
Documentation
Document the time and location where the specimen was obtained, the appearance of the specimen and site, and whether bleeding occurred at the biopsy site.

BONE MARROW ASPIRATION AND BIOPSY

A specimen of bone marrow—the major site of blood cell formation—may be obtained by aspiration or needle biopsy. The procedure allows evaluation of overall blood composition by studying blood elements and precursor cells as well as abnormal or malignant cells. Aspiration removes cells through a needle inserted into the marrow cavity of the bone; a biopsy removes a small, solid core of marrow tissue through the needle. Both procedures are usually performed by a physician, but some facilities authorize specially trained chemotherapy nurses or nurse clinicians to perform them with an assistant.
Aspirates aid in diagnosing various disorders and cancers, such as oat cell carcinoma, leukemia, and such lymphomas as Hodgkin's disease. Biopsies are often performed simultaneously to stage the disease and monitor response to treatment.
Equipment
For aspiration:
Prepackaged bone marrow set, which includes povidone-iodine pads • two sterile drapes (one fenestrated, one plain) • ten 4″ × 4″ gauze pads • ten 2″ × 2″ gauze pads • two 12-ml syringes • 22G 1″ or 2″ needle • scalpel • sedative • specimen containers • bone marrow needle • 70% isopropyl alcohol • 1% lidocaine (unopened bottle) • 26G or 27G ½″ to 5/8″ needle • adhesive tape • sterile gloves • glass slides and coverglass • labels and laboratory biohazard transport bags.
For biopsy:
All equipment listed above • Biopsy needle, such as Vim-Silverman, Jamshidi, Illinois sternal, or Westerman-Jensen needle • Zenker's fixative.
Implementation
  • Tell the patient that the physician will collect a bone marrow specimen, and explain the procedure to ease his anxiety and ensure cooperation. Make sure the patient or a responsible family member understands the procedure and signs a consent form obtained by the physician.
  • Inform the patient that the procedure normally takes 5 to 10 minutes, that test results usually are available in 1 day, and that more than one marrow specimen may be required.
  • Check the patient's history for hypersensitivity to the local anesthetic. Tell him which bone—sternum or posterior superior or anterior iliac crest—will be sampled. Inform him that he will receive a local anesthetic and will feel heavy pressure from insertion of the biopsy or aspiration needle as well as a brief, pulling sensation. Tell him that the physician may make a small incision to avoid tearing the skin.
  • If the patient has osteoporosis, tell him that the needle pressure may be minimal; if he has osteopetrosis, inform him that a drill may be needed.
  • Provide a sedative, as ordered, before the test.
  • Position the patient according to the selected puncture site. (See Common sites for bone marrow aspiration and biopsy, page 160.)
  • Using sterile technique, the puncture site is cleaned with povidone-iodine pads and allowed to dry; then the area is draped.
    P.160

  • To anesthetize the site, the physician infiltrates it with 1% lidocaine, using a 26G or 27G ½″ to 5/8″ needle to inject a small amount intradermally and then a larger 22G 1″ to 2″ needle to anesthetize the tissue down to the bone.
  • When the needle tip reaches the bone, the physician anesthetizes the periosteum by injecting a small amount of lidocaine in a circular area about ¾″ (2 cm) in diameter. The needle should be withdrawn from the periosteum after each injection.
  • After allowing about 1 minute for the lidocaine to take effect, a scalpel may be used to make a small stab incision in the patient's skin to accommodate the bone marrow needle. This technique avoids pushing skin into the bone marrow and also helps avoid unnecessary skin tearing to help reduce the risk of infection.
Bone marrow aspiration
  • The physician inserts the bone marrow needle and lodges it firmly in the bone cortex. If the patient feels sharp pain instead of pressure when the needle first touches bone, the needle was probably inserted outside the anesthetized area. If this happens, the needle should be withdrawn slightly and moved to the anesthetized area.
  • The needle is advanced by applying an even, downward force with the heel of the hand or the palm, while twisting it back and forth slightly. A crackling sensation means that the needle has entered the marrow cavity.
  • Next, the physician removes the inner cannula, attaches the syringe to the needle, aspirates the required specimen, and withdraws the needle.
  • The nurse puts on gloves and applies pressure to the aspiration site with a gauze pad for 5 minutes to control bleeding while an assistant prepares the marrow slides. The area is then cleaned with alcohol to remove the povidone-iodine, the skin is dried thoroughly with a 4″ × 4″ gauze pad, and a sterile pressure dressing is applied. Specimens are labeled appropriately, placed in laboratory biohazard transport bags, and sent to the laboratory.
Bone marrow biopsy
  • The physician inserts the biopsy needle into the periosteum and advances it steadily until the outer needle passes into the marrow cavity.
    P.161

  • The biopsy needle is directed into the marrow cavity by alternately rotating the inner needle clockwise and counterclockwise. Then a plug of tissue is removed, the needle assembly is withdrawn, and the marrow specimen is expelled into a properly labeled specimen bottle containing Zenker's fixative or formaldehyde. It's then placed in the laboratory biohazard transport bag and sent to the laboratory.
  • The nurse puts on gloves, cleans the area around the biopsy site with alcohol to remove the povidone-iodine solution, firmly presses a sterile 2″ × 2″ gauze pad against the incision to control bleeding, and applies a sterile pressure dressing.
Special considerations
  • Faulty needle placement may yield too little aspirate. If no specimen is produced, the needle must be withdrawn from the bone (but not from the overlying soft tissue), the stylet replaced, and the needle inserted into a second site within the anesthetized field.
  • Bone marrow specimens shouldn't be collected from irradiated areas because radiation may have altered or destroyed the marrow.
Complications
Bleeding and infection are potentially life-threatening complications of aspiration or biopsy at any site. Complications of sternal needle puncture are uncommon but include puncture of the heart and major vessels, causing severe hemorrhage; puncture of the mediastinum, causing mediastinitis or pneumomediastinum; and puncture of the lung, causing pneumothorax.
If a hematoma occurs around the puncture site, apply warm soaks. Give analgesics for site pain or tenderness.
Documentation
Chart the time, date, location, and patient's tolerance of the procedure and the specimen obtained.

Saturday, 18 September 2010

Role of the nurse --Care for the patient after surgery

Care for the patient after surgery

Patients are usually taken to a regular ward or unit, once they are awake, with their reflexes working, and their breathing, pulse, bloodpressure and temperature stable. In cases of high risk or verycomplicated surgery, patients may remain in an intensive care unitto have special nursing care.
Once back from surgery, the nurse looks at the doctor's orders andchecks how the patient is.
  • First look at the patient's airway and breathing. Check the colour of the lips and nail beds. Check the skin colour and temperature. The skin, includingmucous membranes, lips and nail beds, should be pink.If it is bluish or the skin is cool and moist, the patient maybe having problems with breathing, blood pressure orcirculation.
  • Check the patient's level of consciousness. Thepatient should be fully awake though he or she willprobably feel sleepy.
  • Take the patient's vital signs. If they are not fullystable, take them every 15 minutes until they are stable.If the patient has a weak, rapid pulse, low blood pressure,pale, clammy skin and rapid breathing, there may beinternal bleeding. If you suspect that there is too muchbleeding or internal bleeding, make sure that the patienthas an intravenous drip and oxygen. Immediately notifythe nurse in charge or the doctor. Once the vital signsare stable, take them every hour for the first day after theoperation.
  • Check the patient's bandages and the sheets underthe patient. If there is a lot of blood on the bandages orbedclothes under the patient, he or she may behaemorrhaging. You should call the nurse in chargeimmediately. If for any reason you feel that the patient isnot completely stable or you are concerned about thebreathing, vital signs or possible blood loss, make surethat the patient is monitored continuously. Do nothesitate to ask the nurse in charge or the doctor to checkthe patient.
  • Carefully watch the amount of fluid the patient takesin and the fluid output. Most patients will continue tobe given fluids intravenously for a period after surgery.This makes sure that the fluids lost during surgery arereplaced. At the same time, however, take care that thepatient does not take in more fluid than the body canhandle. Look again at the doctor's order for the amountof fluid for the patient. Check the IV flow rate to makesure that the patient is getting the right amount of fluid.Many patients are thirsty when they wake up fromanaesthesia. Give them a wet cloth to wet their mouthuntil they are allowed to have water by mouth. Thenwhen the patients are allowed to drink, give them smallamounts of water until you are sure that they will notvomit.
  • Recheck the flow rate and operation of the IV lineevery hour. Also check the level of IV fluid in the bag orbottle, to make sure that the patient has had the rightamount of fluid each hour. Check any drainage tubes tobe sure they are working properly.
  • Write all your initial and ongoing assessments onthe patient's chart, including the patient’s vital signs,consciousness, skin colour, bloody drainage, and fluidintake.

Role of the nurse Immediately before surgery

Immediately before surgery

Patients should empty their bladder before surgery. They should take out false teeth, hairpins and clips, and take off glasses, rings, nail polish, lipstick, etc.
The patient may be given a narcotic before the surgery and atropine to dry the secretions of the mouth. Sometimes a tranquillizer is also given. Often, however, no medications are ordered until the patient is taken to the operating theatre.

Exercising legs and feet after surgery

Tell the patient why it is important to walk as soon as possible after surgery.

Wash the skin around the site of the incision and clean it with an antimicrobial agent. The clean area must be larger than theincision so that if the cut needs to be made bigger, the skin isproperly prepared. The area should not routinely be shavedbecause that can make the skin vulnerable to infection. If there is alot of hair and it absolutely must be removed, it is better to clip thehair. Only shave if it is essential.
Usually an intravenous line with saline solution is started before surgery. This may be done in the patient’s room, or in theoperating theatre. If there is a high risk of infection, usuallyantibiotics are given intravenously.
Prepare the family for the surgery. After the patient is taken to the operating theatre, tell the family how long the surgery is likely totake. Show them where they can wait comfortably. Promise to givethem information as soon as you can. It is very helpful for a nurse tocome out of the operating theatre from time to time to tell the familythat the surgery is progressing well. If there are serious problems,however, it is not useful to inform the family until you have a clearidea of what is going to happen. As soon as the surgery is finishedand the patient has been moved to the recovery room or to ahospital room, tell the family. Tell them when they will be able to seethe patient. Let them visit as soon as the patient is in a stablecondition.

Sunday, 5 September 2010

Staff Nurse (Outpatient/Wards/Home care Services – Paediatrics/ DRC)

St Andrew's Community Hospital

St. Andrew’s Community Hospital (SACH) is a community service of St. Andrew’s Mission Hospital. It is a voluntary welfare organisation which provides subsidised rehabilitative and sub-acute care for adult and child patients after the acute phase of treatment at a general hospital.

We invite you to join our team as:

Staff Nurse (Outpatient/Wards/Home care Services – Paediatrics/ DRC)

  • Registered with Singapore Nursing Board
  • Relevant post-basic qualification
  • Interested in rehabilitative and geriatric care and enjoys working with the elderly
  • At least 2 years working experience
  • Pleasant and cheerful disposition with good communication skills
  • Able to perform shift duties for Inpatient wards.

Interested applicants, please fax, e-mail or write in with full resume and supporting information, photograph, current and expected salaries, and notice period to:

The Human Resource Department
Address: 8 Simei Street 3 Singapore 529895
Fax: (65) 6586 1099
Email: applyto@sach.org.sg

ANAEROBIC SPECIMEN COLLECTION

Because most anaerobes die when exposed to oxygen, they must be transported in tubes filled with carbon dioxide or nitrogen. The anaerobic specimen collector shown here includes a rubber-stoppered tube filled with carbon dioxide, a small inner tube, and a swab attached to a plastic plunger.
Before specimen collection, the small inner tube containing the swab is held in place with the rubber stopper (as shown on the left). After collecting the specimen, quickly replace the swab in the inner tube and depress the plunger to separate the inner tube from the stopper (as shown on the right), forcing it into the larger tube and exposing the specimen to a carbon dioxide-rich environment.


before


after

Obtaining a nasopharyngeal specimen

After you've passed the swab into the nasopharynx, quickly but gently rotate the swab to collect the specimen. Then remove the swab, taking care not to injure the nasal mucous membrane.

Saturday, 4 September 2010

SWAB SPECIMENS

Correct collection and handling of swab specimens helps the laboratory staff identify pathogens accurately with a minimum of contamination from normal bacterial flora. Collection normally involves sampling inflamed tissues and exudates from the throat, nasopharynx, wounds, eye, ear, or rectum with sterile swabs of cotton or other absorbent material. The type of swab used depends on the part of the body affected. For example, collection of a nasopharyngeal specimen requires a cotton-tipped swab.
After the specimen has been collected, the swab is immediately placed in a sterile tube containing a transport medium and, in the case of sampling for anaerobes, an inert gas. Swab specimens are usually collected to identify pathogens and sometimes to identify asymptomatic carriers of certain easily transmitted disease organisms.
Equipment
For a throat specimen:
Gloves • tongue blade • penlight • sterile cotton-tipped swab • sterile culture tube with transport medium (or commercial collection kit) • label • laboratory request form and laboratory biohazard transport bag.
For a nasopharyngeal specimen:
Gloves • penlight • sterile, flexible cotton-tipped swab • tongue blade • sterile culture tube with transport medium • label • laboratory request form and laboratory biohazard transport bag • optional: small open-ended Pyrex tube or nasal speculum.
For a wound specimen:
Sterile gloves • sterile forceps • alcohol or povidone-iodine pads • sterile swabs • sterile 10-ml syringe • sterile 21G needle • sterile culture tube with transport medium (or commercial collection kit for aerobic culture) • labels • special anaerobic culture tube containing carbon dioxide or nitrogen • fresh dressings for the wound • laboratory request form and laboratory biohazard transport bag • optional: rubber stopper for needle.
For an ear specimen:
Gloves • normal saline solution • two 2″ × 2″ gauze pads • sterile swabs • sterile culture tube with transport medium • label • 10-ml syringe and 22G 1″ needle (for tympanocentesis) • label • laboratory request form and laboratory biohazard transport bag.
For an eye specimen:
Sterile gloves • sterile normal saline solution • two 2″ × 2″ gauze pads • sterile swabs • sterile wire culture loop (for corneal scraping) • sterile culture tube with transport medium • label • laboratory request form and laboratory biohazard transport bag.
For a rectal specimen:
Gloves • soap and water • washcloth • sterile swab • normal saline solution • sterile culture tube with transport medium • label • laboratory request form and laboratory biohazard transport bag.
Implementation
  • Explain the procedure to the patient to ease his anxiety and ensure cooperation.
Collecting a throat specimen
  • Tell the patient that he may gag during the swabbing but that the procedure will probably take less than 1 minute.
  • Instruct the patient to sit erect at the edge of the bed or in a chair, facing you. Then wash your hands and put on gloves.
  • Ask the patient to tilt his head back. Depress his tongue with the tongue blade, and illuminate his throat with the penlight to check for inflamed areas.
  • If the patient starts to gag, withdraw the tongue blade and tell him to breathe deeply. Once he's relaxed, reinsert the tongue blade but not as deeply as before.
  • Using the cotton-tipped swab, wipe the tonsillar areas from side to side, including any inflamed or purulent sites. Make sure you don't touch the tongue, cheeks, or teeth with the swab to avoid contaminating it with oral bacteria.
    P.157

  • Withdraw the swab and immediately place it in the culture tube. If you're using a commercial kit, crush the ampule of culture medium at the bottom of the tube, and then push the swab into the medium to keep the swab moist.
  • Remove and discard your gloves, and wash your hands.
  • Label the specimen with the patient's name and room number, the physician's name, and the date, time, and site of collection.
  • On the laboratory request form, indicate whether any organism is strongly suspected, especially Corynebacterium diphtheriae (requires two swabs and special growth medium), Bordetella pertussis (requires a nasopharyngeal culture and special growth medium), and Neisseria meningitidis (requires enriched selective media).
  • Place in a laboratory biohazard transport bag and send the specimen to the laboratory immediately to prevent growth or deterioration of microbes.
Collecting a nasopharyngeal specimen
  • Tell the patient that he may gag or feel the urge to sneeze during the swabbing but that the procedure takes less than 1 minute.
  • Have the patient sit erect at the edge of the bed or in a chair, facing you. Then wash your hands and put on gloves.
  • Ask the patient to blow his nose to clear his nasal passages. Then check his nostrils for patency with a penlight.
  • Tell the patient to occlude one nostril first and then the other as he exhales. Listen for the more patent nostril because you'll insert the swab through it.
  • Ask the patient to cough to bring organisms to the nasopharynx for a better specimen.
  • While it's still in the package, bend the sterile swab in a curve and then open the package without contaminating the swab.
  • Ask the patient to tilt his head back, and gently pass the swab through the more patent nostril about 3″ to 4″ (7.5 to 10 cm) into the nasopharynx, keeping the swab near the septum and floor of the nose. Rotate the swab quickly and remove it. (See Obtaining a nasopharyngeal specimen.)
  • Alternatively, depress the patient's tongue with a tongue blade, and pass the bent swab up behind the uvula. Rotate the swab and withdraw it.
  • Remove the cap from the culture tube, insert the swab, and break off the contaminated end. Then close the tube tightly.
  • Remove and discard your gloves and wash your hands.
  • Label the specimen for culture, complete a laboratory request form, and send the specimen to the laboratory immediately in a laboratory biohazard transport bag. If you're collecting a specimen to isolate a possible virus, check with the laboratory for the recommended collection technique.

Collecting a wound specimen
  • Wash your hands, prepare a sterile field, and put on sterile gloves. With sterile forceps, remove the dressing to expose the wound. Dispose of the soiled dressings properly.
  • Clean the area around the wound with an alcohol or a povidone-iodine pad to reduce the risk of contaminating the specimen with skin bacteria. Then allow the area to dry.
  • For an aerobic culture, use a sterile cotton-tipped swab to collect as much exudate as possible, or insert the swab deeply into the wound and gently rotate it. Remove the swab from the wound and immediately place it in the aerobic culture tube. Send the tube to the laboratory immediately with a completed laboratory request form. Never collect exudate from the skin and then insert the same swab into the wound; this could contaminate the wound with skin bacteria.
    P.158

  • For an anaerobic culture, insert the sterile cotton-tipped swab deeply into the wound, rotate it gently, remove it, and immediately place it in the anaerobic culture tube. (See Anaerobic specimen collection.) Or insert a sterile 10-ml syringe, without a needle, into the wound, and aspirate 1 to 5 ml of exudate into the syringe. Then attach the 21G needle to the syringe, and immediately inject the aspirate into the anaerobic culture tube. If an anaerobic culture tube is unavailable, obtain a rubber stopper, attach the needle to the syringe, and gently push all the air out of the syringe by pressing on the plunger. Stick the needle tip into the rubber stopper, remove and discard your gloves, and send the syringe of aspirate to the laboratory immediately with a completed laboratory request form in a laboratory biohazard transport bag.
  • Put on sterile gloves.
  • Apply a new dressing to the wound.
Collecting an ear specimen
  • Wash your hands and put on gloves.
  • Gently clean excess debris from the patient's ear with normal saline solution and gauze pads.
  • Insert the sterile swab into the ear canal, and rotate it gently along the walls of the canal to avoid damaging the eardrum.
  • Withdraw the swab, being careful not to touch other surfaces to avoid contaminating the specimen.
  • Place the swab in the sterile culture tube with transport medium.
  • Remove and discard your gloves and wash your hands.
    P.159

  • Label the specimen for culture, complete a laboratory request form, and send the specimen to the laboratory immediately in a laboratory biohazard transport bag.
Collecting a middle ear specimen
  • Put on gloves and clean the outer ear with normal saline solution and gauze pads. Remove and discard your gloves. After the physician punctures the eardrum with a needle and aspirates fluid into the syringe, label the container, complete a laboratory request form, and send the specimen to the laboratory immediately in a laboratory biohazard transport bag.
Collecting an eye specimen
  • Wash your hands and put on sterile gloves.
  • Gently clean excess debris from the outside of the eye with normal saline solution and gauze pads, wiping from the inner to the outer canthus.
  • Retract the lower eyelid to expose the conjunctival sac. Gently rub the sterile swab over the conjunctiva, being careful not to touch other surfaces. Hold the swab parallel to the eye, rather than pointed directly at it, to prevent corneal irritation or trauma due to sudden movement. (If a corneal scraping is required, this procedure is performed by a physician, using a wire culture loop.)
  • Immediately place the swab or wire loop in the culture tube with transport medium.
  • Remove and discard your gloves and wash your hands.
  • Label the specimen for culture, complete a laboratory request form, and send the specimen to the laboratory immediately in a laboratory biohazard transport bag.
Collecting a rectal specimen
  • Wash your hands and put on gloves.
  • Clean the area around the patient's anus using a washcloth and soap and water.
  • Insert the swab, moistened with normal saline solution or sterile broth medium, through the anus and advance it about 3/8″ (1 cm) for infants or 1½2″ (4 cm) for adults. While withdrawing the swab, gently rotate it against the walls of the lower rectum to sample a large area of the rectal mucosa.
  • Place the swab in a culture tube with transport medium.
  • Remove and discard your gloves and wash your hands.
  • Label the specimen for culture, complete a laboratory request form, and send the specimen to the laboratory immediately in a laboratory biohazard transport bag.
Special considerations
  • Note recent antibiotic therapy on the laboratory request form.
  • For a wound specimen: Although you would normally clean the area around a wound to prevent contamination by normal skin flora, don't clean a perineal wound with alcohol because this could irritate sensitive tissues. Also, make sure that antiseptic doesn't enter the wound.
  • For an eye specimen: Don't use an antiseptic before culturing to avoid irritating the eye and inhibiting growth of organisms in the culture. If the patient is a child or an uncooperative adult, ask a coworker to restrain the patient's head to prevent eye trauma resulting from sudden movement.
Documentation
Record the time, date, and site of specimen collection and any recent or current antibiotic therapy. Also note whether the specimen has an unusual appearance or odor.