Nursing Ramblings

Introduction

2017-07-29T08:56:00.000-07:00

Hi! I am currently a nursing student in Singapore. This blog is mainly for me to remember things. Or if I can't, to store and retrieve nursing-related information when I need them: some nursing procedures, the common medications that are being used in Singapore and mostly importantly, my clinical life as a nursing student. IT IS NOT AN EDUCATIONAL WEBSITE. THUS, PLEASE TAKE EVERYTHING YOU READ HERE WITH A PINCH OF SALT AND CONSULT A PROFESSIONAL BEFORE YOU DO ANYTHING STUPID! I WILL NOT BE RESPONSIBLE!

Like I have mentioned above, this blog contains the steps of some common nursing procedures and medications that you may also be interested to know. You can read my experiences as a nursing student to learn more about this "helping profession" too. Hopefully, you gain a little knowledge about nursing and respect it more after reading my blog! If you find anything that is questionable, please bring it up to me too, so I can clarify them with my teachers in school before I graduate and IT'S TOO LATE! Lastly, thank you for taking your precious time to read my crazy ramblings! =)

Aged Care Posting

2012-01-01T20:05:00.000-08:00

When I first saw Mdm K, I realised, like Ah Gong (my grandfather), she had many bruises and skin breakdown on both her arms, in varying colours too! (ranging from red to different shades of purple). She looked old and frail.

I thought she was demented because when I asked her for her name, she told me a four-syllabus name. However, I couldn't make out the exact words and spelling of what she said but I thought it was a Japanese name and since she could really be a Japanese or demented, I thought she was the latter. Moreover, she told me her age was 35 when she obviously looked much older than that.

I realised my mistake when I turned around to look at the place and saw that the name outside Room 1 was exactly what she told me! Omg! I totally didn't expect that! First, she was still lucid enough to remember her name and second, I just assumed she wasn't and that a four-syllabus name could only be a Japanese!

I have a "natural inclination" to sayang the elderly especially when they have bruises on their arms and thus, I kept sayang-ing her while talking to her. I tried feeding her lunch too but she insisted on feeding herself with no assistance needed. Afraid that she would drop her food while bringing it from her plate to her mouth, like most elderly with dementia, I tried to use her plate to follow her spoon but she became irritated after that. She scolded me for grabbing her plate and for explaining to her my reasons. Lol. She insisted that she would not drip her food and refused to let me feed her or hold her plate. Elderly can be so stubborn. She even said I was "kpo". Haha. So fierce.

After I read her case notes, I learnt two important points about her. 1) her 2 sons "disowned" her 2) she had scabies =.= the first fact was saddening especially as it was written that she still misses one of them (if she forgets then at least it is less painful for her) the second fact was =.= omg! I just sayang-ed her everywhere sia. And how does scabies spread? Via direct contact. There are no difference whether you're a healthy young girl or a frail old lady with weaker immune system. Shit! This means my stronger immune system could not even protect me! Omg!!! I became sian after that. I should have read the case notes before touching any patient. However, the only consolation was that if she really had active scabies, the staff won't touch her too, without protecting themselves and they would inform us about her. The fact that they don't and the fact that the last report about her having scabies was in September this year probably meant that she was cured (?). I was still unconvinced and quite sian about touching or even going too near her.

The next day though, I still couldn't resist myself and kept going to her. This time round, I tried to keep my hands to myself and really did touch her LESS (instead of totally not touching her like what I should actually be doing=.=). I even told myself numerous times that if I get scabies, it's ooo..kkk.. la. If I do get it, I get it lo. Bo bian. She's worth it.

Sometimes, she felt so itchy that she asked the nurses to take out the board (in front of her chair) so that she could scratch herself properly. Of course, that wasn't attended to at all. Personally, I feel that the nurses there are quite free sometimes and they can actually just take out the board, sit with the residents and ensure that they do not fall out of their chair. However, I don't think they would ever be so nice to do this. Once, she signaled to me to help her remove the board; I explained my reasons for not being able to do so and she signaled Hui Ping to help her. When Hui Ping didn't understand her, she turned to the nurses who just brushed her aside and eventually, the resident beside her to ask for help! Sadly, that resident is slightly mentally unstable and didn't even respond to her. I think it's very sad that these people, having to live there for long periods of time, only talk to the nurses (who cannot even speak their tongue) rather than make friends with their neighbours. Just picture an old lady feeling itchy all over and failing to get help to allow her to scratch herself and relieve her itchiness. She must be feeling so terrible.. Haiz.. I tried to soothe her by talking and hoping to distracting her but to little success. I even wore gloves and helped her apply moisturizer. She also asked me to help her scratch. Lol.

I liked this lady so much that I actually went to re-read her case notes again and again to find out more about her. I specifically read the part about her skin condition because I could not bear to see her keep scratching herself and complaining about being itchy..</3 I wanted to find out what condition did she suffer from to give her so much pain (I didn't manage to figure that out). However, to my relief, I found out that she was cleared of scabies during her last dermatitis appointment! I was so happy! Mainly because I could now sayang her without fears! It is her other skin conditions (and the post-scabies) that are making her feel itchy. I feel so heart-pained for her. Poor lady.

After that, I became more willing to touch her again! I helped scratch her lightly when she complained of itchiness. She even told me not to do so because helping her scratch is dirty! Omg! Didn't expect that. Haha. I continued this on my third and last day there. I even sayang-ed her head and watched her sleep on the last day. I kind of hope all these elderly whom we interacted with would not remember us because they would then keep hoping that someone else would talk to them (?). They would then miss having us around to talk to them (?). *sigh*

Back to Reflections

Paedatrics Posting

2012-01-01T19:52:00.000-08:00

Even before I met H, I had already heard about him. My friends were "complaining" about him, saying he had a "bad record" with the other patients and their parents. His misdeeds were also recorded in his case notes. I also heard him using swear words freely. Though this is common, to hear it coming from a 12 year old is really quite shocking for me.

Thus, when he came over to my cubicle to find my patient, I was not too happy about it. Even when he tried to interact with me by asking me to play cards with him, I would find excuses to reject him. As I felt guilty, I agreed to play with him eventually. However, throughout the game, I was uneasy as he kept using swear words AND asking my patient to do the same. He even scolded other patients who were in the play area as well. I tried my best to steer clear of him and also hoped that he would leave my patients alone. I know I was wrong to be prejudiced against him and this is not how a nurse should behave.

Later, I found out that he is actually quite pitiful. His mother was non-existent and his father beat him frequently. This was what caused him to be hospitalized in the first place. I also heard his aunt intended to bring him overseas after he was discharged.

On my last day there, I realized that I actually cared about what happened to him. We would definitely never meet again but I hoped he would (and I told him this too) take care of himself. If no one cares for him, then all the more he should treat himself better and stay away from the "bad side"...

Back to Reflections

Cadiopulmonary Arrest (Hospital Settings)

2011-11-28T06:17:00.000-08:00

If you suspect a patient has collapsed,

1. Try to rouse the patient by calling his name and tapping him (eg. "Mr Tan, are you ok?" while tapping his shoulders)

2. If there is no response, take his pillow away and lie his head supine (ie. flat) on his bed.

3. Open airway by doing "head tilt, chin lift". If the patient has a cervical injury, perform jaw thrush instead. Inspect for any loose teeth, dentures or other foreign objects that may obstruct airway and remove these obstructions.

4. Check for presence of breathing by doing "look, listen & feel". Look for signs of breathing like chest rising; listen for breath sounds; feel for air exhaled from the patient.

5. Check for presence of circulation by feeling for the carotid pulse. If there is no pulse, activate "CODE BLUE" immediately.

If there is pulse, provide oxygen to the patient at a rate of 12 breaths/ min using a bag-valve-mask (BVM). ie. provide oxygen (by squeezing the bag), 2-a-thousand, 3-a-thousand, 4-a-thousand, 5-a-thousand, provide oxygen...

6. If the patient is pulseless, lock and pull the bed out a little before locking it back, set the height of the bed to the level of your thigh, remove the headboard and screen the patient for privacy.

7. Bring the cord side down, shift the patient more to his other side to allow more room for yourself and commence cardiopulmonary rescue (CPR).

8. When the e-trolley is pushed in by another nurse B, get her to attach the 3 leads electrocardiogram (ECG) and stop CPR to obtain the heart's rhythm. Once obtained, continue CPR. The doctor would prepare to "shock" the patient if it is a "shock-able" rhythm; either ventricular fibrillation (VF) or pulseless ventricular tachycardia (pulseless VT).

If sinus rhythm resumes after "shocking" the patient, continue CPR for a minute before checking for pulse unless patient shows signs of circulation eg. moving.

9. If patient's heart rhythm remains the same, nurse B would then insert oropharyngeal airway of suitable size (it should measure from the tragus of the ear to the tip of the mouth on the same side of the patient) to maintain patient's airway. Wear clean plastic gloves as there is a risk of contact with patient's body fluids (ie. saliva, in this case).

10. Nurse B would also assemble the BVM and provide 100% oxygen (15litres) to the patient at a rate of 30 compressions: 2 breaths if pulse is still absent. If pulse is present, continue providing 100% oxygen to the patient at a rate of 12 breaths/ min.

11. If the patient has an IV access, another nurse, C, would check for its patency by withdrawing any blood clots (if any) and then injecting 3-5ml of normal saline; "flushing". Maintain this IV access by running normal saline at a slow rate. If there is no IV plug in situ, prepare for the insertion of an IV plug.

12. Nurse C would also prepare for drugs to be administered when the doctor requests for it (usually, it is 1ml of adrenaline in 9ml of normal saline/ water for injection). If intubation is required, nurse C would prepare the requisites for intubation and suctioning equipment as well.

13. Once intubated, the patient's breathing would be taken over by the ventilator. If pulse returns, prepare to send patient to intensive care unit (ICU). Maintain therapeutic hypothermia for the patient. If pulse has not return, the doctor may administer more drugs/ shock the patient again, depending on the condition.

14. Nurse C should then document all the events/ procedures that happened during the resuscitation eg. the amount and type of drugs infused to the patient at ____ hours and the patient's response to that particular intervention etc.

Back to Procedures

Haloperidol

2011-08-10T03:32:00.000-07:00

Brand Name: Haldol

Class of Drug: Typical anti-psychotic

Mode of Action: For people with psychotic illnesses like acute psychosis, schizophrenia, there is an overactive / over-secretion of neurotransmitters in their brain. Thus, depending on which areas of nerves are constantly/ excessively triggered, they may see, hear, smell, feel or taste "excessive" things that others do not experience. Haloperidol blocks the receptors for the neurotransmitter, dopamine. Thus, excessive stimulation of the nerves are prevented, resulting in a decrease in the symptoms experienced by the patient.

Used For: Psychotic disorders, Controlling motor and verbal tics of those with Tourette's disorder

Side Effects: Extra-pyramidal side effects (various motor disturbances including inability to initiate movement, inability to stop movements, jerky and sudden movements etc), dizziness, dry mouth, lethargy, muscle stiffness or cramps, tremors, lactation, increased libido, decreased sexual functioning in males, difficulty urinating etc
Serious Side Effects: Neuroleptic Malignant Syndrome (muscle cramps, fever, unstable vital signs, tremors, change in cognition), difficulty breathing or swallowing, seizures, neck cramps etc

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

http://www.medicinenet.com/haloperidol/article.htm
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682180.html

Back to Medications

Amlodipine

2011-08-10T02:18:00.000-07:00

Brand Name: Norvasc

Class of Drug: Calcium channel blocker (CCB)

Mode of Action: A CCB prevents calcium from being transported into smooth muscle cells found along arteries, especially the coronary arteries. Without sufficient calcium, the smooth muscles cannot contract the artery muscles are relaxed. This dilates the arteries and lowers the blood pressure. The heart gets a larger supply of blood and this helps prevent chest pain (angina) which may result if there is insufficient blood flow to the heart and coronary artery spasm.

Used For: Preventing chest pain (angina) and for high blood pressure treatment

Side Effects: Swelling (edema of the lower extremities, headache, feeling faint, fatigue, drowsiness

Serious side effects: Palpitations (rapid, pounding heartbeats) or fainting

If you missed a dosage, just take it as soon as when you remember it. However, if it is almost time for the next dose, take only 1 dose and ignore the missed dose.

http://www.medicinenet.com/amlodipine-oral/article.htm

http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692044.html

Back to Medications

Rehabilitation Posting II

2011-08-07T23:39:00.000-07:00

When I first fed a real patient via a nasogastric tube (NGT), I was feeling a little nervous and I even dropped one of the connecting tubes right at the start! It was quite embarrassing especially with a nurse staring at a clumsy me. Other times during lab practices, I "fed" at most 50ml of plain water. However, this time round, I had to feed 200ml of thicker fluid which flowed much much slower. Thus, the entire process was quite draggy. I lost concentration and as a result, forgot to kink the tube immediately when needed. Luckily, the enrolled nurse (EN) and a fellow nursing student saw it and alerted me! Thankfully, Mr K., my patient, did not cough and appeared fine/ normal. I made a mental note never to lose focus on my task at hand again.

The second time I fed Mr K., I was constantly reminding myself to remember to kink the tube. This time, with the experience of my first NGT feeding, everything was much better and the process was smoother-- I did not drop anything and I kept my eyes constantly on Mr K., his tube and my equipment.

I learnt that besides aspiration of fluid from the NGT to test for its acidity, there are two other methods of testing the placement of the tube. They are auscultation, the pumping of air into the tube and hearing its sound in the stomach and putting the tube into a cup of water to check for presence of any air bubbles, which may mean that the tube is displaced into the lungs. However, the best method to check for tube placement is to send patient for an X-ray. Having said that though, it is not feasible to send patient for an X-ray everytime the patient is about to be fed as there are not only manpower and costs issues, exposing patient to constant radiation, no matter how low, is harmful for the patient too. Thus, the most practical and reliable method is the aspiration method.

Back to Reflections

Obstetrics Posting

2011-08-05T02:03:00.000-07:00

This is my most awaited posting! I love to interact with pregnant women who are anxiously waiting for the birth of their precious babies, new mothers and families who are basking in the joy of the arrival of the newborns and finally, BABIES!

However, on my first day in the obstetrics ward, what greeted my friends and I was a dismal sight. All the curtains were screened and the different patients were keeping to themselves. They certainly did not look welcoming and friendly, unlike the patients in my other postings. All my anticipation and looking forward towards this posting were dashed.

Over the next few days though, I realized drawn curtains did not mean unfriendly. It just meant that these tired women were exhausted either by their active foetus or by their crying newborns. Another reason was that many women breastfeed their babies and thus, it was more convenient to just leave the curtains drawn rather than screening and unscreening them every 2-3 hours. They were actually quite friendly and happy to share their joy with us; when they delivered, how many children they had, how pretty and handsome their newborn was, how well their child suckled when they breastfed or how much trouble they had when trying to breastfeed etc. Almost all of the mothers were very open too! They allowed us (the students) to be there with them while the breastfeeding nurse taught them breastfeeding. Without their generosity and open minds, we would not have been able to observe breastfeeding live and had to rely on watching videos. Watching the mothers breastfeed their child made me feel that breastfeeding is a natural and beautiful bonding process. THANK YOU to all the mothers who made me realize this!

The posting soon came to an end. Despite what my fellow students said about this obstetrics posting being a boring posting (as we did not have much opportunities to perform obstetrics-related skills), I felt happy and grateful for this posting. This is because I get to observe and learn stuffs too! *happy*

Back to Reflections

Subcutaneous Medications (Insulin)

2011-08-05T01:21:00.000-07:00

Insulin is basically available in two forms: 1) pen-like structure that stores a certain amount of insulin and can deliver a certain unit (depending on the order) each time its button is pushed or 2) bottled liquid form where you need syringe and needle to deliver the insulin. This post shall focus on the second form of insulin, where preparations are slightly more complicated.

Things Required:

IMR
Medications (this post shall explain how to serve a short-acting eg. Actrapid and a long-acting insulin simultaneously. If your order requires only one type of medication, just take that medication and ignore the second one)
Syringe
3 Needles (2 x 19G, 21G)
Gloves
Alcohol swabs
Kidney dish

Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. For example, if a patient is on sliding scale (ie. the amount of insulin needed is dependent on his hypocount), he may not need the insulin if his hypocount is of desirable value. Perform hand rub.

2. Get the correct medications out from the fridge (as insulin is usually stored there) and rub the bottles in your palms to warm them. Insulin, when injected cold, may be painful for the patient.

3. Swab the top of the bottles with alcohol swabs. Attach a 19G needle to the syringe and inject air equivalent to the unit of long-acting insulin needed into the long-acting (more cloudy appearance) insulin bottle and then inject air equivalent to the unit of short-acting insulin needed into the short-acting (clearer appearance) insulin bottle. Injecting air first will reduce the resistance when drawing the insulin.

That is, if I need 2 units of long-acting insulin and 3 units of short-acting insulin, I would inject 2 units of air into the bottle containing long-acting insulin first and then inject 3 units of air into the bottle containing short-acting insulin.

4. After injecting air, draw the required units of short-acting insulin. Change to another 19G needle and discard the first needle to avoid cross-contamination of the different insulin. Using the new 19G needle, draw the units of long-acting insulin needed. Discard the needle. Attach the 21G needle to the syringe.

5. Approach and identify patient with 2 patient identifiers again: patient’s name and IC by asking patient and verifying it with his wrist tag. Ensure that patient is not allergic to the medication by checking it with the IMR and by asking patient. Prepare the environment where necessary: adequate lighting, suitable working height, screening of the patient, who would have to expose himself)

6. Perform hand rub and wear gloves (wearing of gloves is dependable on hospital policy).

7. In Singapore, any subcutaneous injections are almost only performed in the abdomen area for adults. Thus, get patient to expose his abdomen and ask where was his last injection site (right or left side of the umbilicus) and avoid it. This is because injecting the same area over and over again with insulin will result in lipodystrophy, where the area would be slightly dented and insulin absorption diminished.

8. If patient's last injection site was to the right side of the umbilicus, measure two finger spacings away from the umbilicus on the left side and clean that area with alcohol swab.

9. Lightly pinch the area with your thumb and forefinger of your non-dominant hand. With your dominant hand holding the syringe like a dart, inject the needle fully, at 90 degrees to the skin and administer the insulin slowly.

10. Release the pinched area and take a piece of alcohol swab. Withdraw the needle and use the alcohol swab to apply pressure to the injection site for around 10 seconds. Do not rub the area as this would increase insulin absorption.

11. Inform patient that the procedure is completed and to inform you if he feels giddy. Remind him to have his meal or some food 30 minutes later. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

12. In the IMR, record that subcutaneous insulin had been given. Check for any adverse reactions/ patient's response to the medications and document in the relevant notes.

Back to Procedures

Rehabilitation Posting

2011-08-01T03:00:00.000-07:00

In this first ever posting of mine, I met the ever jovial Mr A, who had been hospitalized for quite some time already, due to a fall. As a result of that fall, Mr A had been in ICU (intensive care unit) for about a month and was recently discharged to this community hospital. He suffered a spinal injury and now only has movement neck up and some limited movement with his left finger, as a result of countless physiotherapy. Needless to say, all his ADLs (activities of daily living) had to be taken care of by the nurses and us, student nurses.

Yet, Mr A not only did not despair, he still has a positive outlook on life. One would expect someone in Mr A's condition to be sulking and withdrawn but Mr A was the exact opposite. He was very glad to still be alive and to be with his family. He taught us how to not focus on the small, unhappy details in life but to celebrate the living and be more forgiving. Every time if we had nothing to do, all we had to do was to look for Mr A and he would gladly entertain and cheer us when we should be the ones making his day. Even when I was not there, I would always hear laughter coming from his cubicle as he talked to his new friends (the other patients there) about the day's events. His wife would also come daily with homemade soups and food. Though I know this must be very tiring on her; having to look after their children, work and come visit Mr A everyday without fail, she never once complained or even sighed in front of us but supported her husband through this all. How noble love is..

Anyway, kudos to Mr A. Though it has been more than one year ago, I would never forget Mr A if I ever needed hope (?). I wish him success in his physiotherapy.

Back to Reflections

IV Medications (Addictives)

2011-07-31T08:01:00.000-07:00

The first seven steps here are exactly the same as IV Medications (Bolus). The two procedures are just slightly different.

Things Required:

IMR
Medications (usually powdered form)
Diluent (eg. H2O for injection)
Normal Saline
Syringes
Needle
Gloves
Alcohol swabs
Gauze
Kidney dish
IV set (if patient does not have an existing IV line running. If antibiotics are to be given, the IV should have a burette attached to it.)

IV Medications (Bolus)

2011-07-31T07:32:00.000-07:00

Things Required:

IMR
Medications (usually powdered form)
Diluent (eg. H₂O for injection)
Normal Saline
2 Syringes
2 Needles
Gloves
Alcohol swabs
Gauze
Kidney dish

Always check the items you take for expiry date and clarity (if applicable).

1. Check whether the order for that medication is a first dose for that patient. If it is the first dose, doctors are to administer them. Verify order and patient's need for this procedure.

2. Perform hand rub.

3. Withdraw an appropriate amount of diluent eg. 10ml (depends on what medications you are giving and the hospital policy/ guidelines) into a syringe. Ensure that there is no bubbles.

4. Swab the top of the medication bottle with an alcohol swab. Attach the needle to the syringe and inject the diluent into the medication. Dissolve the medication well by rolling the medication bottle in your palms, rather than shaking, which would introduce bubbles.

5. Withdraw the dissolved medication into the syringe and throw the needle into a sharp box.

6. Depending on hospital policy, withdraw 6-10ml of normal saline into another syringe. Place the IMR, syringes, alcohol swabs, gauze and gloves into the kidney dish before approaching patient.

7. Approach and identify patient with 2 patient identifiers again: patient’s name and IC by asking patient and verifying it with his wrist tag. Ensure that patient is not allergic to the medication by checking it with the IMR and by asking patient. Prepare the environment where necessary.

8. Wear gloves. Stop and detach any IV lines connected to the patient and swab the patient's IV plug with an alcohol swab. Place a gauze underneath it.

9. Occlude the vein just above the plug to prevent blood from flowing out when you disconnect the stopper. Connect the syringe containing normal saline to the plug. Attempt to withdraw any blood clots near the plug. If only blood is withdrawn, "flush" the plug to check for its patency by pushing 3-5ml of normal saline into it. If there is any blood clots withdrawn, great resistance when pushing the normal saline in or if patient complains of pain and tenderness around the plug, stop the procedure and report it.

10. If there is no blood clots, little resistance and no pain, slowly inject the whole medications in at a constant rate.

11. "Flush" with the remaining normal saline.

12. Swab the plug again before reattaching any IV lines back.

13. Inform patient that the procedure is complete and ask him to report if he is feeling uncomfortable/ malaise or if there is pain at the plug site. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving.

14. Document the procedure in the IMR. Check for any adverse reactions/ patient's response to the medications and document in the relevant notes.

Back to Procedures

Medical-Surgical Posting (Ortho)

2011-07-28T07:47:00.000-07:00

My impression of Mdm C was that she is a soft-spoken lady who cannot really express herself clearly. Every time when other nurses and I found her sliding or sleeping slanted, we would just inform her that we will be shifting her to an upright position and we would just shift her, sometimes even without waiting for her response, which would generally be lagged and inaudible.

Today, I was tasked with feeding Mdm C--our first "real" interaction. Throughout the whole process, she kept sliding to one side and kept her eyes closed. I thought she was just like one of the less responsive patients I sometimes see. Therefore, I did not even try to make small talk with her but just asked her to open her mouth when she stopped chewing and swallowing (ie. when she had already finished all the food in her mouth). However, from time to time, I would have to stop feeding just to drag and/or push her upright. Thus, the whole feeding process took up quite some time and became very draggy.

However, another student nurse who had been interacting with her for the past week came and talked to her. She asked Mdm C why she was eating with her eyes closed. Mdm C immediately responded by opening her eyes and smiled sheepishly! Furthermore, when that nurse asked her to sit up straight, she also responded and pushed herself upright! Oh my god! She is responsive! Had I known that or even try to talk to her in the first place, I could have saved myself all the trouble of dragging her upright by myself and that the both of us could have had a more enjoyable feeding time!

Moral of the story: Do not assume! I should talk to my patients instead of just focusing on my task. When I do that, I may just save myself some trouble and may even make my patients happier.

Back to Reflections

Simple Wound Dressing

2011-07-26T07:53:00.000-07:00

Things Required:

Septanol and tissue (to clean the wound trolley)
Gloves
Apron
IMR
Basic wound dressing pack
Normal saline solution
Micropore
Scissors and pen
Other wound dressing cleansing solutions or products like chlorhexidine, tegaderm, mepore

Always check the items you take for expiry date and clarity (if applicable).

1. Verify order and patient's need for this procedure. Perform hand rub.

2. Clean wound dressing trolley. Wear apron.

3. Approach and identify patient again with 2 patient identifiers: patient’s name and IC by asking patient and verifying it with his wrist tag. If patient is in pain, ask for pain score and offer interventions like ice packs or pain relief medications. If patient refuses the procedure, explain the importance of the procedure and get patient to rest and mentally prepare himself first.

4. Prepare the environment like switching on the lights, switching off the fans, screening the curtains and ensuring the correct working height. Always position your trolley and stand such that your dominant hand is nearer to the patient.

5. Perform hand rub. Open the sterile wound dressing pack without touching anything inside. Arrange the items inside and take out the plastic bag by maneuvering them from the outside of the dressing pack (the non-sterile side).

6. Pour normal saline and open other excess items, carefully touching only the packaging.

7. Expose wound with gloves. Palpate around/ along the wound site and note any Colour, Odour, Consistency and Amount of exudates (if applicable).

8. Perform surgical handwash. Dry with the tissue paper provided in the dressing pack, picking it up by taking only its corner.

9. Drape the area where you are cleaning the wound. Be careful not to touch anywhere else (especially the patient) except the drape.

10. Soak and squeeze out excess water from the cotton balls and arrange any items in the sterile field (where necessary) using the forceps provided.

11. Using one cotton ball at a time and one swipe per cotton ball, clean the wound from the least contaminated area (ie. the inner of the wound) to the most contaminated area. Lastly, clean the area surrounding the wound. The technique for cleaning the wound would be to take a clean cotton ball using your non-dominant hand and pass it over to your dominant hand outside the sterile field and use the dominant hand to clean the wound. If patient seems uncomfortable or in pain, stop and ask the patient if he needs you to stop the procedure for a while etc.

12. Tap the cleaned areas dry with gauze.

13. Cover with suitable/ prescribed wound products and label the “date changed”.

14. Explain to patient that the procedure has been completed and ask if patient has any questions for you like “how is their wound healing?”, “how long will their wound take to heal?” etc. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

15. Discard soiled requisites, clean trolley and wash hands.

16. Record the procedure in the relevant documents like the nursing notes and wound chart. Report any abnormalities.

Note: If patient seems uncomfortable or in pain during any part of the procedure, ask if he needs a break, any pain relief medications, or try blowing or soothing (sayang) the area surrounding the wound.

Back to Procedures

Psychiatric Posting

2011-07-26T07:14:00.000-07:00

Just as teachers would not approach students like me – quiet, do my own stuffs and never get into trouble, Mr W is someone whom I would never approach during this attachment had it not been for my clinical instructor, Mr A, who had requested an interview from him on my behalf, as part of my attachment requirements. He was a quiet person, never saying much to my questions besides the very basic. I guessed he may even be having trouble with sitting down with me and answering my endless questions. Nevertheless, he sat through the interview and did his best though he left abruptly after my interview, without even telling me.

Throughout my attachment, I tried to interact with him, firstly due to the need to write my report about his progress and gradually, just to talk to him, hoping to make his day less boring. However, not all days were smooth sailing. When he was in a good mood and not mentally disturbed, he would be able to play a few games of checkers and/or English chess. On the other hand, when his condition (schizophrenia) “striked”, mostly after dinner every day, he would feel the need to hum and pace up and down the whole ward for more than a few times. In this case, our interaction would be disrupted. Someone explained that humming may just be to block out the internal clatter (auditory hallucinations) -- Mr W's coping mechanism.

Throughout the attachment, I feel that Mr W has the potential to get well especially if his symptom of humming could be controlled. On his good days, he was willingly to play more than just a game of checkers only and answer with words, instead of sounds.

On the last day of my attachment however, his condition was bothering him and interfering with our interaction and thus, I didn’t have a chance to introduce new chess mates to him as planned (I had hoped to introduce one or two chess mates to him so that he could play and interact with more people and hone his social skills). Though all the patients in the ward would have known that day was our last day there, I still wanted to tell him personally that it was my last day and that I would not be there to disturb him anymore even if he wanted. However, I kept dragging having to tell him because I thought we would still have a lot of time for that later. I should have known that there isn’t much time actually because normally most of the patients would have been asleep by 8+pm. Mr W was no exception. He was already sleeping when I finally wanted to bade him goodbye for the last time. I wanted to leave without saying goodbye but after some internal reflection and debate, I realized I would not be able to live with not saying goodbye for at least a few days. Thus, wanting a proper closure, I went to wake him up and told him. He was half-asleep and I finally left with the feeling of not knowing whether he would wake up tomorrow thinking it was all a dream or whether he would even remember it at all.Oh well, I sincerely wish him all the best in reintegrating into our society.

Well, take-away point here is that never to leave things, especially leaving things unspoken, till the last minute because you never know how much time you are left with..?

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Urinary Catheterization for Females

2011-07-25T09:05:00.001-07:00

Things required:

Septanol and tissue (to clean the trolley)
IMR/ doctor's orders
Sterile gloves
Apron
Catheterization kit
2-way urinary catheter (usually French 10/12)
KY jelly/ aqua jelly
Urine bag
Chlorhexidine solution
Syringe
H₂O for injection
Blue sheet/ incontinence sheet
Micropore and scissors
Torchlight (if there is someone there to help you and where applicable)

Always check the items for expiry date and clarity (where applicable).

1. Verify order and patient's need for this procedure. Perform hand rub.

2. Clean trolley. Wear apron.

3. Approach and identify patient with 2 patient identifiers: patient’s name and IC again by asking patient and verifying it with his wrist tag. (Catheterization is usually ordered when patient is unable to void and there is a large volume of residual urine in the patient). Perform perineal care if needed.

4. Prepare the environment like switching on the lights, switching off the fans, screening the curtains and ensuring the correct working height. Stand on the patient's right side if you are right-handed.

5. Perform hand rub. Open the sterile urinary catheterization pack without touching anything inside. Arrange the items inside by maneuvering them from the outside of the catheterization pack.

6. Open items 6-11 into the catheterization pack. Remember to throw the first "non-sterile" part of the KY jelly and chlorhexidine solution away.

7. Assist patient to lie in the dorsal position with slightly-abducted legs, bent at the knees. Assist to remove patient's pants fully before covering them with a blanket. Place a blue sheet underneath the patient.

8. Perform surgical handwash. Dry with the tissue paper provided in the catheterization pack, picking it up by taking only its corner.

9. Don sterile gloves.

10. Test the catheter by filling its balloon up with the stated amount of water and observe for any leakage. Lubricate 3-5cm of the catheter tip with the KY jelly.

11. Close the urine bag drainage port.

12. Soak all cotton balls with chlorhexidine and squeeze out excess water, either with sterile gloves or using forceps.

13. Ask patient to remove the blanket and drape the perineum area to create a sterile field, exposing only the genitalia.

14. Take the plastic bag out and place it on the drape.

15. Place the two catheter trays on the sterile drape between the patient's legs. (The smaller tray should contain the cotton balls and a forceps while the other larger tray should contain the catheter and another forceps.)

16. With your dominant hand, use a forceps and the cotton balls to cleanse the genitalia in the following order: the labia majora, labia minora and lastly the urinary meatus. Use only one cotton ball at a time and one swipe per cotton ball. Use your non-dominant hand to separate the labia minora and expose the urethra until after insertion. Throw the forceps and the used cotton balls away.

17. Insert the urinary catheter into the urethra with another sterile forceps until urine first flows out of the catheter. Further advance the catheter around 2cm more and collect all the residual urine in the larger catheter tray by gently squeezing/ pushing down on the perineal area. The amount of residual urine should approximate the amount of residual urine shown by a bladder scan (which by right, would have been performed at least twice, depending on hospital policy, before catheterzation is ordered.)

18. Inflate the balloon with the recommended amount of water (the amount would be stated on the catheter packaging.) Gently tug the catheter to assure that it would not be displaced/ to ensure placement. When there is resistance (ie. the catheter can no longer be tugged out), push the catheter in by about 2cm.

19. Attach the urinary bag to the catheter and after tearing the drape, tape the catheter to the patient's thighs.

20. Place the urinary bag below the level of the patient's bladder to ensure there is no backflow of urine, without it touching the floor. Label "date changed" and "IDC-indwelling cathether" on the urinary bag.

21. Explain to patient that the procedure has been completed and ask if patient has any questions for you. Ensure patient’s safety and comfort levels and that the call bell is within reach before leaving the patient.

22. Discard gloves and soiled requisites. Clean the trolley and wash hands.

23. Record the procedure in the relevant documents like the nursing notes and I/O-intake/output chart (COCA-colour, odour, consistency and amount of urine). Report any abnormalities like heavily blood stained urine or other abnormal discharges present in the urine.

24. Empty the urinary bag and measure the urine at least once during every shift or when full and record COCA in the I/O chart as per order.

Note: Observe the patient throughout the whole procedure. Ask patient to take in deep breaths and relax while you insert the catheter.If patient seems uncomfortable or in pain, stop for a while to allow patient to collect and prepare herself.

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