introduction to medical assisting - u.s. career...

Introduction to Medical AssistingProcedure Guide 1

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© Copyright 2010-2012, Weston Distance Learning, Inc. All Rights Reserved. 0203902SP01A-32

Acknowledgments

AuthorsMerry Perry

Paula Tripp

Editorial StaffTrish Bowen

Bridget Tisthammer

Lindsay Hanson

Design/LayoutConnie Hunsader

D. Brent Hauseman

Sandy Petersen

FOR MORE INFORMATION CONTACT:

U.S. Career Institute

Fort Collins, CO 80525 • 1-800-347-7899

www.uscareerinstitute.edu

ContentsVirtual Lab 7-1 Proper Hand Washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Virtual Lab 7-2 Proper Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Virtual Lab 8-1 Use an Autoclave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Virtual Lab 8-2 Use an Audiometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Virtual Lab 8-3 Electrocardiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Virtual Lab 8-4 Use a Nebulizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Virtual Lab 8-5 Use Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Virtual Lab 8-6 Use a Balance Beam Scale with a Measuring Bar . . . . . . . . . . . . . . . . . . . . 10Virtual Lab 8-7 Use a Spirometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Virtual Lab 8-8 Use a Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Steps to Take 7-1—Proper Surgical Hand Washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Steps to Take 7-2—Proper Sterile Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Steps to Take 7-3—Remove Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Steps to Take 7-4—Blocked Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Steps to Take 7-5—Heimlich Maneuver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Steps to Take 7-6—The Chest Thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Steps to Take 7-7—Rescue Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Steps to Take 7-8—CPR for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Steps to Take 7-9—CPR for Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Steps to Take 7-10—Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Steps to Take 7-11— Alerts of Hyperglycemia or Hypoglycemia . . . . . . . . . . . . . . . . . . . . . 26Steps to Take 7-12—Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Steps to Take 7-13—Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Steps to Take 7-14—Fainting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Steps to Take 7-15—General First Aid for Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Steps to Take 7-16—Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Steps to Take 7-17—Management of the Patient in Shock . . . . . . . . . . . . . . . . . . . . . . . . . 31Steps to Take 8-1—Proper Surgical Instrument Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . 32Steps to Take 8-2—Ultrasonic Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Steps to Take 8-3—Daily and Weekly Cleaning of the Autoclave . . . . . . . . . . . . . . . . . . . . 34Steps to Take 8-4—Apply and Remove a Fiberglass Cast . . . . . . . . . . . . . . . . . . . . . . . . . . 35Steps to Take 8-5—Use a Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Steps to Take 8-6—Perform the Ishihara Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Steps to Take 8-7—Use an Otoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Steps to Take 8-8—Assist with a Sigmoidoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Steps to Take 8-9—Use a Sphygmomanometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Steps to Take 8-10—Use a Cane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Steps to Take 8-11—Use Crutches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Steps to Take 8-12—Use a Walker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Steps to Take 8-13—Use a Wheelchair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Steps to Take 8-14—Assisting Patient from Wheelchair to Examination Table . . . . . . . . . . . 48Steps to Take 8-15—Assisting Patient from Examination Table to Wheelchair . . . . . . . . . . . 50


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Virtual LabVirtual Lab

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Introduction to Medical Assisting Procedure Guide 1

Virtual Lab 7-1 Proper Hand Washing

Procedure Objective: To wash hands in the medical setting

Equipment Needed: Sink, soap (preferably liquid), antibacterial lotion, disposable paper towels, nail brush

Steps to Take:

1. Remove any jewelry other than a plain wedding band.

2. Prepare paper towel supply so it is readily available without touching any other surfaces.

3. Don’t allow your clothing to touch the sink. Never touch the inside of the sink with your hands.

4. Turn on faucet with dry paper towel, adjust temperature, then discard towel. Lukewarm water is best for your skin.

5. Wet hands and apply soap using a circular motion and friction.

6. Interlace fi ngers to clean between them. Also scrub up to and including the wrists. Scrub for 2 minutes at beginning of day, then for 30 seconds following each patient contact throughout the day.

7. Use brush on your nails at the beginning of each day.

8. Hold hands pointed downward under the water to rinse them.

9. Repeat hand washing for the fi rst hand washing of the day.

10. Blot hands and wrists dry with disposable paper towel; do not touch towel dispenser following hand washing.

11. Turn faucet off with clean paper towel.

12. Apply antibacterial lotion to prevent chapped skin.

Virtual Lab 7-2 Proper Gloving

Procedure Objective: To put gloves on in the medical setting

Equipment Needed: Sink; soap (preferably liquid); antibacterial lotion; disposable paper towels; nail brush; disposable, non-sterile latex or vinyl gloves

Steps to Take:

1. Wash hands.

2. Grasp gloves by cuff and slip on without any special technique.


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Virtual Lab 8-1 Use an Autoclave

Procedure Objective: To sanitize and then sterilize instruments using an autoclave

Equipment Needed: Autoclave, distilled water, various wrapping materials; these may be fabric, clear plastic or combo paper/plastic, indicator tape which has white stripes that turn black when sterilized, marker for labeling and dating the packages, brush and detergent for washing instruments/basin, gloves, sterilization indicator

Steps to Take:

Sanitizing contaminated instruments before autoclaving:

1. Take contaminated instruments to a designated work sink.

2. Wear gloves to protect yourself from blood and body fl uids.

3. Check the working condition of each instrument while you are cleaning it. Check alignment, serrations, ratchets and ease in opening and closing. Set aside any faulty or rusted instruments.

4. Use a brush to clean every surface of the instruments.

5. Rinse thoroughly. They are now ready to be wrapped for sterilization.

Preparing instruments for autoclaving:

1. Choose cloth, plastic or paper/plastic combination wrap.

A. Plastic/paper-plastic combo wrap:

i. Measure length of wrap to fi t instrument plus 1”.

ii. Place instrument inside wrap.

iii. Fold over ends and tape securely with autoclave tape across entire end of wrap.

iv. Use marker to identify the instrument, date of sterilization and your initials.

B. Cloth wrap:

i. Lay appropriate size wrap on counter.

ii. Center instrument diagonally on wrap. Place a sterilization indicator inside wrap beside the instrument.

iii. Bring up bottom corner to cover instrument, folding tip of wrap back down slightly.

iv. Bring side points of wrap in to center of package. Also fold back the tips so that they point outward.

v. Bring top point down to center of the pack and fold the tip upwards.

vi. Set entire package onto a 2nd wrap on the counter.

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vii. Repeat steps 3-5.

viii. Bring the top point down and wrap it around the entire package and put a piece of autoclave tape across it.

ix. Write instrument, date and your initials on the tape.

Loading the autoclave:

1. Open autoclave and check water level. Add more water as necessary.

2. Load cloth packages vertically onto autoclave tray allowing 3 inches between packages. Steam needs to be able to circulate freely in the autoclave.

3. Load unwrapped instruments fl at with their handles/ratchets open.

4. Close door and tighten seal.

5. Turn on autoclave and set temperature to 250-254 degrees and 15 pounds of pressure.

6. Do not set timer until the dial indicates it has reached those levels.

A. Wrapped instruments—30 minutes

B. Unwrapped instruments—15 minutes

C. Cloth wrapped packages—20 minutes

7. When timer sounds, exhaust steam pressure from the autoclave by following the manufacturer’s instructions.

8. When pressure gauge reaches zero and the temperature gauge has decreased to at least 212 degrees, you may open the door one inch.

9. Do not touch packs until completely dry (about 10-15 minutes) or you risk contaminating them.

10. Store sterilized packs in a clean, dry area designated for these items only.


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Virtual Lab 8-2 Use an Audiometer

Procedure Objective: Test a patient’s hearing with an audiometer

Equipment Needed: Audiometer with headphones, quiet room

Steps to Take:

1. Identify the patient and explain the procedure.

2. Position her in a comfortable sitting position.

3. Place headphones on the patient, noting right and left appropriately.

4. Audiometry is started at low frequency and each ear is tested separately. The patient will signal with her hand or a control button each time a sound is heard and you will mark the graph at that point.

5. The frequency range gradually increases until completed.

6. Repeat procedure on other ear.

7. Remove headphones.

8. Clean according to manufacturer’s instructions.

9. Document the procedure.

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Virtual Lab 8-3 Electrocardiograph

Procedure Objective: To obtain an electrocardiograph

Equipment Needed: EKG machine, disposable electrode tabs, EKG tracing paper, gauze squares, alcohol, mounting form, patient gown

Steps to Take:

1. Wash your hands.2. Identify the patient and explain the procedure.3. Have patient remove clothing from the waist up and uncover lower legs. Nylon

stockings must be removed. The gown should open in front.4. Explain that the procedure is painless and that it is important not to move or talk

during the procedure.5. Place the EKG machine with the power cord pointing away from the patient. Do not

let the cable go underneath the exam table.6. If patient’s skin is oily, wipe electrode areas with alcohol.7. Apply electrodes to fl eshy parts of arms and legs. Point arm tabs downward and leg

tabs upward. 8. Place the fi rst electrode for chest lead on the 4th intercostal space on the right of

sternum. You can count down starting from just under the collarbone to the 4th space.9. Place the 2nd electrode straight across the sternum on the left, also in the 4th

intercostal space.10. Place the 3rd electrode down 1 rib and just below the nipple, slightly to the left.11. Place the 4th electrode in the space directly below the left nipple.12. Place electrode 5 at the same level as4 but further to the side.13. Place electrode 6 directly under the axilla, fully on the side of the body.14. Connect lead wires to the electrodes.15. Provide a blanket or sheet to the patient for privacy and warmth.16. Be sure the cable is supported on the table or the patient’s abdomen. Do not let it

dangle over the side of the exam table.17. Turn on the EKG machine.18. Quickly press the standardization button. It should be 10mm or 10 small squares

high on the graph paper. This ensures a dependable, accurate tracing.19. Watch the recording throughout the procedure to be sure that the tracing remains in

the center of the paper. Use the position control knob as necessary to adjust it.20. Watch for artifacts (interferences) on the tracing and adjust accordingly. Sometimes

the patient’s wristwatch or even the overhead lights can cause interference in the tracings and may have to be removed or turned off.


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21. Continue with leads a VR, a VL and a VF.

22. When you get to the V leads record 6-8 complexes each.

23. Place another standardization at the end of the tracing.

24. Turn the EKG machine off. Tear off the tracing from the machine and immediately label it with the patient’s name, date and time of day. Sign your initials.

25. Do not disconnect the patient at this point.

26. Take the tracing to the physician for approval. Sometimes the physician requests further tracings from a particular lead before you disconnect the wires.

27. Return to patient. Disconnect the lead wires and remove the leads.

28. Assist the patient as needed.

29. Clean the equipment and return to storage.

30. Lay the EKG tracing out on counter.

31. Cut a few inches of the fi rst lead tracing from the strip and identify which lead it is.

32. Mount it in the appropriate box of the EKG form. Chest leads and limb leads each have a special section on the form.

33. Move on to each section separately and mount it before cutting another lead tracing from the EKG strip.

34. Continue until the entire EKG is properly attached to the form.

35. Write the patient’s name, age, gender, and date on the form. Some forms will also ask for blood pressure, height and weight.

36. Place in patient record.

37. Wash hands.


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Virtual Lab 8-4 Use a Nebulizer

Procedure Objective: To assist the patient when using a nebulizer

Equipment Needed: Handheld nebulizer, medication

Steps to Take:

1. Wash hands.


3. Instruct the patient to close her lips tightly around the mouthpiece. Tell her to inhale slowly, then to exhale fully.

4. Holding the nebulizer upside down, have the patient close her lips around the mouthpiece.

5. Have the patient tilt her head back and inhale deeply while the bottle is against the mouthpiece.

6. Tell the patient to continue inhaling until her lungs are full.

7. Pull the mouthpiece out and have the patient slowly exhale.

8. If the doctor has ordered more than one dose, repeat the steps as ordered.

9. Wash hands.

10. Teach the patient to clean the inhaler by rinsing the mouthpiece in warm water.

11. Impress upon the patient the importance of using only the prescribed amount and frequency of the medication.



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Virtual Lab 8-5 Use Oxygen

Procedure Objective: To administer oxygen and educate the patient

Equipment Needed: Portable oxygen tank, tubing, cannula, mask

Steps to Take:

Administering oxygen:

1. Place strap of the cannula or mask over the patient’s ears. Position the cannula prongs so they fi t in the nostrils or adjust the mask so it fi ts snugly.

2. Oxygen must be humidifi ed before delivery to the patient to prevent drying of the respiratory mucosa.

3. Be sure tank is placed on a stable platform or holder.

4. Attach tubing and open the valve at the top of the tank.

5. Watch gauge until prescribed oxygen level is reached. Oxygen prescriptions are based on individual needs. The patient’s physician will prescribe the fl ow rate, concentration, method of delivery and length of time for administration.

6. The physician may also stipulate whether to apply a cannula or mask.

Educating the patient:

1. Anything that has a fl ame, or that is smoking—such as cigarettes, lighters and candles—should not be in the same room where oxygen is being used.

2. Patient should be instructed to wear clothing that doesn’t produce static, such as cotton and other natural fi bers.

3. Oxygen toxicity may develop when 100 percent oxygen is breathed for a prolonged period. Symptoms are nausea, vomiting, malaise, fatigue, substernal pain and numbness and tingling of extremities.

4. Apnea (absence of breathing) can result if giving oxygen at a fl ow-rate of greater than 2 liters per minute to patients with chronic obstructive pulmonary disease, especially those with emphysema.

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Virtual Lab 8-6 Use a Balance Beam Scale with a Measuring Bar

Procedure Objective: To measure the patient’s weight and height

Equipment Needed: Balance Beam Scale with measuring bar, paper towel

Steps to Take:

Using a Balance Beam Scale:

1. The point of the balance beam must be fl oating in the center of its movement range when no weight is applied to the scale. Once it is centered, the scale is calibrated and ready for use.

2. The patient may wear normal indoor clothing for this measurement. Heavy coats and shoes should be removed.

3. Place a paper towel on the scale before asking the patient to stand on the scale.

4. Ask patient to stand with her back to the balance beam. Offer assistance to prevent falls.

5. Move weights across the balance beam until the end point fl oats without touching any part of the scale.

6. Record this weight on the chart.

7. Maintain the patient’s privacy in obtaining her weight. Don’t announce the results out loud. Comments or even encouragement for weight loss should be given in private.

8. To measure the height, slide the vertical measuring bar until the fold-out horizontal section on the top of the bar is resting on the patient’s head.

9. Note the reading where the solid bar and the sliding bar meet.

10. Record this height on the chart.


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Virtual Lab 8-7 Use a Spirometer

Procedure Objective: To measure the patient’s air capacity using a Spirometer

Equipment Needed: Spirometer, graph paper, disposable mouth piece

Steps to Take:

1. Wash hands.


3. Check to make sure that the patient has not used a bronchodilator within the last 24 hours prior to the procedure.

4. Have the patient loosen anything around her neck if it is constrictive.

5. The patient may sit or stand, but discourage bending forward during the test. Stress the importance of good posture during the procedure.

6. Inform the patient that her lips must seal tightly around the mouthpiece and that maximum effort should be exerted.

7. Turn the machine on. Be sure the graph paper is in place.

8. Allow patient to breathe into the spirometer to become comfortable with the equipment.

9. To begin the test, instruct the patient to inhale quickly and deeply, then exhale quickly and forcibly into the mouthpiece until no more air can be expelled.

10. Instruct her to keep blowing into the mouthpiece until she is told to stop, even if it doesn’t feel like she has any more air. This procedure is strenuous, so verbally coach and encourage her throughout the test.

11. Dispose of the mouthpiece in a biohazard container.

12. Wash hands.

13. Document the procedure. Take the graph off the machine and place it in the patient’s chart for the physician to review.

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Virtual Lab 8-8 Use a Stethoscope

Procedure Objective: To hear body sounds using a stethoscope

Equipment Needed: Stethoscope, alcohol wipes

Steps to Take:


2. Place the round diaphragm end of the stethoscope in your pocket or gently on the countertop so it isn’t damaged while you are adjusting the earpieces.

3. Hold the stethoscope up and twist the metal part that holds the earpieces so that they angle towards your face, not backwards.

4. Place the earpieces in your ears snugly.

5. Bring the diaphragm out of your pocket and place it on the arm or chest to be listened to. Take care that it doesn’t bang on any hard surfaces, which would create a very loud noise in your ears.

6. When you are done with the stethoscope, use alcohol wipes to clean the earpieces each time you use it.



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Steps to TakeSteps to Take

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Steps to Take 7-1—Proper Surgical Hand Washing

Procedure Objective: Proper surgical hand washing

Equipment Needed: Sink, soap (preferably liquid), disposable paper towels, watch or clock, nail brush, cuticle stick

Steps to Take:

1. Remove any jewelry other than a plain wedding band.

2. Prepare paper towel supply so it is readily available without touching any other surfaces.

3. Don’t allow your clothing to touch the sink. Never touch the inside of the sink with your hands.

4. Turn on faucet with dry paper towel, adjust temperature, then discard towel. Lukewarm water is best for your skin.

6. Interlace fi ngers to clean between them. Also scrub up to and includ-ing wrists and forearms to the elbow. Scrub for 5-6 minutes duration.

5. Wet hands and apply soap using a circular motion and friction.


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9. Blot hands and wrists dry with disposable paper towel; do not touch towel dispenser following hand washing.

10. Turn faucet off with clean paper towel.

11. Do NOT apply lotion.

8. Keep hands pointed upward under the water to rinse them.

7. Scrub nails with brush AND clean under each nail with a cuticle stick.

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Steps to Take 7-2—Proper Sterile Gloving

Procedure Objective: To maintain sterilization while gloving

Equipment Needed: Sink, soap (preferably liquid), disposable paper towels, watch or clock, nail brush, cuticle stick, packaged pair of sterile gloves

Steps to Take:

1. Perform surgical handwash.

2. Inspect glove package for tears or stains.

3. Place glove package on a clean, dry surface above waist level.

5. Grasp the inner cuff of one glove with index fi nger and thumb of the nondominant hand.

6. Pick the glove straight up without drag-ging it over any surface that is not sterile.

4. Peel open the package, pulling it fl at. Do not touch inner sterile surface. Be sure cuffs are toward you, palms up.


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9. Slip the second hand, palm up, into the glove.

10. Adjust gloves as needed without touch-ing the wrist area. Keep hands above the waist and away from the body.

8. With the newly gloved hand pick up the other glove by slipping fi ngers under the outside of the cuff. Lift it up, keeping it away from the body.

7. Slide dominant hand into glove, palm up and touching only the cuffed sur-face of the glove. Keep hands above the waist.

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Steps to Take 7-3—Remove Gloves

Procedure Objective: To remove contaminated gloves

Equipment Needed: Biohazard container

Steps to Take:

1. Grasp the palm of a used glove with one hand to begin removing the fi rst glove.

2. Keep hands away from the body and pointed downward.

3. Turn the used fi rst glove inside out and hold it in the other gloved hand.

4. Holding the removed glove in the palm of the still gloved hand, insert two fi ngers of the ungloved hand inside the glove on the hand.

5. Peel the dirty glove downward, turning it inside out over the balled glove in the palm. Note that one glove is inside the other with all contaminated surfaces inside.

6. Dispose of the gloves in a biohazard container.

7. Wash hands thoroughly.


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Steps to Take 7-4—Blocked Airway

Procedure Objective: To clear a blocked airway of an unconscious victim

Equipment Needed: Gloves or gauze

Steps to Take:

1. Place the victim in a supine position.

2. Use the tilt-chin lift maneuver to move the tongue from back of throat. Listen for air exchange at mouth and nose, and sense for exhaled air on rescuer’s cheek.

Airflow Tongue Trachea Airflow Tongue Trachea Airflow Tongue Trachea

3. Check for mouth obstruction. NOTE: Visible foreign matter and vomitus should be removed quickly. Liquids should be wiped out with covered middle and index fi ngers; solid material is swept out with a hooked index fi nger.

4. Check for air exchange. If none, then sit astride the victim’s thighs. With fi ngers pointed towards the head, place the heel of one hand fl at on the victim’s abdomen, slightly above the navel.

5. Place your other hand in a like position over the fi rst.

6. With your elbows straight, press inward and upward with quick thrusts to dislodge the block.

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Steps to Take 7-5—Heimlich Maneuver

Procedure Objective: To clear a blocked airway in a conscious person

Equipment Needed: None

Steps to Take:

1. While standing behind the victim, reach around the waist.

2. Clench one hand to make a fi st and grasp your fi st with the other hand.

3. Place the thumb side of the fi st against the midline of the victim’s abdomen between the waist and the rib cage.

4. Thrust fi st inward and upward in quick, fi rm movements to move air out of the lungs with enough force to dislodge the block.

5. A choking victim who is by herself may use the abdominal thrust with the fi st or may bend over a chair back or any hard object of appropriate height in order to simulate an abdominal thrust on herself.

Steps to Take 7-6—The Chest Thrust

Procedure Objective: To clear a blocked airway in a pregnant or obese person

Equipment Needed: None

Steps to Take:

1. Standing behind the victim, place arms around the victim directly under the underarms.

2. Using the abdominal clenched fi st technique, place the thumb over the sternum, place your hand over the fi st and give fi rm thrusts, pulling straight back toward yourself.

The Heimlich maneuver is used to clear foreign objects from blocked airways.


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Steps to Take 7-7—Rescue Breathing

Procedure Objective: To perform mouth-to-mouth resuscitation

Equipment Needed: Respirator if available, gauze squares, sanitizing material

Artifi cial breathing is a technique in which you blow air into the victim’s mouth in order to breathe for the victim until she can breathe on her own again. You provide the victim with enough oxygen to maintain life until she resumes breathing or until help arrives. You can perform artifi cial breathing in several ways. In a medical facility, you will have a respirator or oxygen tank and mask. Elsewhere, you will probably rely on mouth-to-mouth resuscitation.

Steps to Take:

1. Determine if the victim is awake by loudly speaking or shouting to him. If the victim is not awake, ensure you or someone else calls 911. If the victim is awake, but is unable to speak, determine if he is choking. If so, perform the Heimlich Maneuver. We’ll discuss this process further in a moment.

2. Determine if the victim has a blocked airway. Carefully tilt the head back with one hand on the forehead while lifting the jaw with the other hand. Do not move his head if you are concerned that the victim may have a spinal, neck or head injury. Instead use the jaw-thrust maneuver, in which you kneel near the victim’s head, grasp the angles of the victim’s lower jaw and lift with both hands. Next, swipe inside the victim’s mouth to fi nd the blockage. If you do not see a blockage, continue to the next step.

3. Determine if your victim is breathing. If not, immediately begin CPR using the C-A-B method outlined in the beginning of this chapter.

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Steps to Take 7-8—CPR for Adults

Procedure Objective: To perform CPR on an adult

Equipment Needed: Gauze squares, sanitizing material

Steps to Take:*

1. Make sure the victim is in a safe place.

2. Shake the victim’s shoulders and shout to see if he responds.

3. If the victim does not respond, and the victim is not breathing or not breathing normally, yell for someone to call 9-1-1 and get an automated electronic defi brillator (AED), if available. If you’re alone, call 9-1-1 and get an AED if

available. Follow the AED’s voice prompts.

If no AED is available, immediately start CPR, beginning with compressions

C—COMPRESSIONS

4. Push hard and fast on the center of the chest 30 times, at a rate of at least 100 compressions a minute. Push down as hard and as fast as you can, at least two inches with each compression. If you haven’t been trained in CPR, continue to give compressions until an AED arrives or trained help takes over.

A—AIRWAY

5. If you have been trained in CPR, continue CPR by opening the airway with a head tilt-chin lift.

B—BREATHING

6. Pinch the victim’s nose closed. Take a normal breath. Cover the victim’s mouth with your mouth, creating an airtight seal. Give two breaths (one second each). Watch for chest rise as you give each breath.

*Based on 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care


0203902SP01A-32 23

7. Keep giving sets of 30 compressions and two breaths until the AED arrives or trained help takes over.

Keep in mind that CPR is only intended for a person whose heart and breathing have stopped. If the victim moves or pushes you away, you should stop performing CPR. Remember to modify the techniques you’ll learn in this lesson with the new recommendations, and if you haven’t already, sign up for a CPR class. It may save a life.

Steps to Take 7-9—CPR for Infants and Children

Procedure Objective: To perform CPR on an infant or child

Equipment Needed: Respirator and gloves if available, gauze

NOTE: For CPR for infants and children, please be sure to keep up-to-date with the very latest guidelines from the American Heart Association. Recommendations change frequently.

Steps to Take:

1. Gently shake and call to a child, or fl ick the bottom of an infant’s foot to check for consciousness.

2. Tell another person to call 911.3. Place infant or child on back on fi rm surface.4. Use appropriate method to open the airway.5. Perform rescue breathing.6. Remove clothing from chest so you can

watch movement.7. Check pulse For infant: Check pulse over brachial artery by

putting your middle fi ngertips on inside of upper arm halfway between elbow and shoulder. At the same time keep airway open.

For child: Check carotid pulse on lower neck as for an adult. Check pulse in conjunction with assessment for signs of circulation, which includes evaluating victim for breathing, coughing or movement. This assessment should take no more than 10 seconds.

24 0203902SP01A-32


8. If pulse is present,

For infant: Continue rescue breathing until normal breathing occurs or help arrives.

For child: Continue rescue breathing until normal breathing occurs or help arrives.

9. If no pulse is present, start chest compressions.

For infant: Use the index and middle fi ngers

to compress just below the nipples in center of chest.

Press the chest down 1/3 to 1/2 of the chest depth.

Give 30 compressions at a rate of 100 per minute.

Count as one, two, three, four, fi ve. Give two rescue breaths after each set

of 30 compressions

For child: Place the heel of only one hand between

the child’s nipples, at the tip of the breastbone.

Press the chest down 1/3 to 1/2 of the chest depth.

Give 30 compressions at a rate of 100 times per minute.

Count as one and two and three and four and fi ve.

Give two rescue breaths after each set of 30 compressions.

10. Do 10 cycles of compressions and breaths, and then check for signs of circulation and pulse. NOTE: Do not take more than fi ve seconds for this check.

11. Continue cycle of 30 compressions and two breaths until the victim resumes breathing and pulse returns, or until help arrives.


0203902SP01A-32 25

Steps to Take 7-10—Cardiac Arrest

Procedure Objective: To assist a physician in treating a patient experiencing a heart attack

Equipment Needed: Wheelchair or chair with rollers; oxygen; BP cuff; EKG machine

Steps to Take if physician is present:

1. If the patient has medication such as nitroglycerine, it should be given immediately.

2. Depending upon severity of symptoms the physician may want to transfer the patient to an exam room. Never allow the patient to walk or carry objects such as a heavy purse or coat.

3. If you have a wheelchair, help the patient into the chair. In the absence of a wheel-chair, use any chair with rollers to move the patient.

4. Perform an electrocardiogram and administer oxygen per physician order. Monitor vital signs. Loosen the clothing and elevate head of the exam table as high as possible.

5. Contact emergency medical services at physician’s direction.

6. Treat for shock by maintaining body heat, covering with blanket.

7. If the patient stops breathing, lower head of exam table and start artifi cial respiration.

8. If there is no pulse, start CPR.

Steps to Take if physician is NOT present:

1. Call 911. You are NEVER wrong to call emergency services. Do not hesitate. Ask another staff member to call the physician.

2. If the patient has medication such as nitroglycerine, it should be given immediately, even in the reception room if necessary.

3. Administer oxygen while waiting for EMS. Provide reassurance.

4. Loosen patient’s clothing, position him sitting up as high as possible. A cool cloth to the forehead or around the neck is soothing while you wait for assistance. Cover the patient with a blanket to treat shock.

5. Monitor vital signs until paramedics arrive. Write these down to report to the paramedics and for your own documentation.

6. Do not waste time transferring the patient to an exam room. Keep him still.

26 0203902SP01A-32


Steps to Take 7-11— Alerts of Hyperglycemia or Hypoglycemia

Procedure Objective: To determine if a patient is hyperglycemic or hypoglycemic

Equipment Needed: Some form of sugar

Steps to Take:

1. Ask the patient questions. Can he talk? He may know his condition.

2. Ask the patient if insulin or food has been taken, and when.

3. Is the breath fruity or sweet-smelling?

4. Are respirations deep or shallow?

5. Fruity, sweet-smelling breath indicates hyperglycemia.

6. Deep breathing indicates hyperglycemia; shallow breathing indicates hypoglycemia.

If you cannot determine the condition:

1. Give the patient a little sugar regardless—hypoglycemia can cause irreversible brain damage.

Most diabetic people have a way to measure their blood sugar.


0203902SP01A-32 27

Honey can be a quickly absorbed source of sugar.

Steps to Take 7-12—Hyperglycemia

Procedure Objective: To assist a patient who is hyperglycemic

Equipment Needed: Telephone, some form of sugar, patient’s treatment and monitoring equipment, if avaiable, insulin

Steps to Take:

If the patient is conscious:1. Have the patient check his insulin/glucose level.2. Give the patient a little sugar and see if his condition improves.3. The patient should self-administer insulin if his personal readings indicate that his

blood sugar levels are too high.

If the patient is unconscious:1. Call 911 immediately.2. If a physician is present, she may administer insulin.3. The patient should be transported to the nearest hospital.4. The patient will be checked for positive diagnosis and reduction of blood sugar.

Steps to Take 7-13—Hypoglycemia

Procedure Objective: To assist a patient who is hypoglycemic

Equipment Needed: Some form of sugar and fat, IV fl uids or injectable glucose, telephone

Steps to Take:

If the patient is conscious:1. Give the patient a sugar, such as candy, and a fat such as

peanut butter, to stabilize glucose levels.

If the patient lapses into unconsciousness:1. Give the patient an intravenous form of glucose, either as an

IV fl uid or injectable.2. Stay with the patient until he becomes conscious.

If the patient doesn’t regain consciousness:1. Call 911.2. The patient must be transported at once to a hospital.

28 0203902SP01A-32


Steps to Take 7-14—Fainting

Procedure Objective: To assist a patient who has fainted

Equipment Needed: Cold compress, stethoscope, watch, thermometer

Steps to Take:

1. Gradually lower patient to a fl at surface.

2. Loosen any tight clothing.

3. Check breathing.

4. Check for any symptoms of a life-threatening emergency.

5. Elevate the legs if there is no back or head injury.

6. If vomiting occurs, place the patient on her side.

7. Apply a cold compress to the forehead.

8. Monitor vital signs to determine if she is stabilized before allowing her to leave.

Fainting is not serious, but 911 or EMS may need to be called if vital signs are abnormal—the fainting could be a symptom of a more complex medical condition.


0203902SP01A-32 29

Steps to Take 7-15—General First Aid for PoisoningProcedure Objective: To assist the patient with general poisoning

Equipment Needed: Wet washcloth, water and phone

Steps to Take:

1. Ask the patient what was taken, how much and when.

2. If the poison is an inhalant, take the patient to an area with fresh air. Call 911. The patient may require pulmonary resuscitation until help arrives and then will need 100% oxygen and immediate care in a hospital.

3. If the poison is affecting the skin, remove the clothing and wash the skin thoroughly unless you suspect that a dry powder is the cause of the poisoning.

4. If the poison is in the eye, fl ush the eye thoroughly for at least 15 minutes.

5. If the poisoning was ingested, dilute the poison with large amounts of warm water or milk.

6. Induce vomiting if the poison is: A strong alkali, acid or petroleum product Plants or mushrooms Bacterial poisoning from contaminated shellfi sh Give the patient syrup of ipecac or activated charcoal or press the back of the

patient’s tongue to induce vomiting.

7. Do not induce vomiting if the poison is: A corrosive substance such as a household cleaner

8. After you have performed this initial treatment, call the poison control center (1-800-222-1222) for further advice.

9. Keep the patient as quiet as possible.

30 0203902SP01A-32


Steps to Take 7-16—Seizure

Procedure Objective: To assist the patient during a seizure

Equipment Needed: Blanket

Steps to Take:

During the Convulsive Phase:

1. Do not restrain movement.

2. Move objects out of the way that might cause injury.

3. Do not force any object between the patient’s teeth or it could cause vomiting, aspiration or spasm of the larynx.

Following the Convulsion:

1. Turn the head to the side to prevent choking from profuse salivation.

2. Allow the patient to rest or sleep after the seizure is over.

3. Artifi cial respiration should be given if necessary.

4. Provide emotional support as the patient regains composure.

5. Try to alleviate any feelings of embarrassment.


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Steps to Take 7-17—Management of the Patient in ShockProcedure Objective: To assist the patient in shock

Equipment Needed: Telephone, emergency oxygen supply, blanket

Steps to Take:

Remember: Shock can be the result of many types of medical emergencies. The following should serve as a general guideline for managing a patient in shock.1. Call 911.2. Check your CABs and make sure the patient is breathing and has a pulse.3. Control any bleeding.4. Administer oxygen.5. Immobilize due to possible spinal injuries.6. Splint any fractures.7. Prevent loss of body heat by covering the victim with a blanket.8. Transport to the closest hospital as soon as possible.

32 0203902SP01A-32


Steps to Take 8-1—Proper Surgical Instrument Cleaning

Procedure Objective: To clean surgical instruments correctly

Equipment Needed: One or more plastic soak basins, soaking solution, heavy rubber gloves, soft bristle brush, running water, clean towels

Steps to Take:

1. Soak instruments immediately after they are used. This will soak away blood and soil before they dry on the instrument.

2. Make sure soaking solutions are at room temperature. Your soaking solution needs to have a pH neutral detergent with a protein and blood solvent to clean away blood. Also, this detergent will help keep instruments from corroding.

3. Make sure that your soak basin is plastic. If you have to use a metal basin, line the bottom with a towel. This padding will protect the instruments.

4. Wear heavy rubber gloves. The gloves will protect you from being poked or cut.

5. Separate delicate and fragile tools from heavy tools. This will protect the fragile tools from breaking or being damaged in other ways.

6. For your own safety, separate sharp instruments from blunt instruments. Sharp instruments can hurt you. Also, their pointy surfaces collect more germs that could infect you.

7. Use a soft bristle brush to scrub tight areas that are hard to get into. These include hinges, ratchets and serrations. You need to take apart any instruments that can be disassembled. Scrub the parts separately. Use a brush that is fi rm, but do not use a brush that will scratch the instruments.

8. Completely rinse and dry the instruments right after you sanitize them. This will protect them from being water damaged.

9. Inspect the instruments carefully, including the instrument handles. Make sure that there are no nicks, dulling or warping. The surface of the instrument should not be broken in any way. Check to make sure that blades that are supposed to be sharp are still sharp.

10. Repair or replace damaged instruments or ones that do not work anymore.


0203902SP01A-32 33

Steps to Take 8-2—Ultrasonic Cleaning

Procedure Objective: To clean instruments with an ultrasonic cleaner

Equipment Needed: Ultrasonic cleaner, ultrasonic cleaner solution

Steps to Take:

1. Put the instruments in the ultrasonic cleaner in an open position (that is, for example, so scissors blades are in the open position). Also, make sure that sharp blades and points of instruments do not touch other instruments. Instruments need to have room in between them.

2. Make sure all instruments are completely covered by solution.

3. Place like metals with like metals; do not mix metals in a single cycle. In other words, put stainless steel instruments with other stainless steel instruments. Do not place stainless steel instruments with copper instruments.

4. Change the solution often; follow the manufacturer’s instructions.

5. Rinse the instruments completely with water after they come out of the ultrasonic cleaning cycle. You should rinse off all of the ultrasonic cleaning fl uid.

6. Process instruments for the amount of time recommended by the manufacturer. This amount of time is usually 5 to 10 minutes.

34 0203902SP01A-32


Steps to Take 8-3—Daily and Weekly Cleaning of the Autoclave

Procedure Objective: To correctly clean the autoclave

Equipment Needed: Mild detergent and other cleaning products as recommended by the maker of the autoclave, soft clothes, distilled water

If you use the autoclave daily, you should clean it daily. At least once a week, clean the autoclave more thoroughly. The maker of the autoclave will give you recommendations for cleaning products.

Daily Cleaning of the Autoclave:

1. Wash the inner chamber with a mild detergent and a soft cloth.

2. Rinse and dry the autoclave.

3. Wipe the outside with a soft, damp cloth so it doesn’t collect dust that can get into the inner compartment.

Weekly Cleaning of the Autoclave:

Plan ahead to do the cleaning. You will need to clean the sterilizer when it will not be needed and when you have time to do the cleaning.

1. Begin by draining all of the water that is in the sterilizer.

2. Fill it with a cleaning solution and then run it through a 20-minute heated cycle.

3. Drain the solution.

4. Fill the autoclave with distilled water.

5. Run it through another 20-minute cycle.

6. Drain it again.

7. Fill with distilled water and run it through another cycle.

8. Remove the inner shelves and scrub them.

9. Wipe the inside of the autoclave.

10. Inspect the machine’s rubber seals to make sure they are not cracked or broken. Keep an extra seal to replace any seal that is damaged. You don’t want to need a seal and not have a replacement available. Even if the seal is not damaged, you will need to replace it at times. Old seals do not seal tightly.


0203902SP01A-32 35

Steps to Take 8-4—Apply and Remove a Fiberglass Cast

Procedure Objective: To apply and remove a fi berglass cast

Equipment Needed: Gloves, bandage scissors, stockinette, padding, also called webril, fi berglass casting material, lotion, basin and water, electric cast remover, lotion, large bandage scissors, cast splitter

Steps to Take:

Applying a short arm cast:

1. Wash hands.

2. Identify patient and explain the procedure.

3. Position patient so she is comfortable and is at a height comfortable for you to work. Remember to be gentle with her injured limb. Keep it upright as much as possible.

4. Pull a length of stockinette from the roll. Measure it against the patient’s arm.

5. Add about an inch for a cuff at each end of the cast.

6. Cut the appropriate length. Hold the stockinette against the arm again and note where to cut a hole for the thumb. Again, leave enough at the palm end to fold back a cuff.

7. Cut the opening.

8. Gently put the stockinette on the injured arm and smooth out any wrinkles.

9. Wrap padding over the stockinette and up the length of the forearm. You may tear or cut the padding in order to fi t it to the arm more easily. Be careful to keep it smooth. Any wrinkles or lumps will cause pressure points under the cast.

10. Put on gloves.

11. Remove fi berglass casting from package and submerge in water for 5-10 seconds.

12. Gently squeeze, but don’t wring. Warn the patient that she’ll feel a warm sensation from the fi berglass during application. It is self-limiting and will not get warm enough to burn.

13. Starting at the palm, fi rst wrap around the covered palm. Then fold stockinette over casting and wrap fi berglass over the cuff forming a smooth edge.

14. Next wrap in an upward direction and with a fi gure-eight confi guration around the wrist/thumb area.

15. Continue wrapping up the forearm. Overlapping about one half the width of the fi berglass. At the top of the cast, once again fold down the stockinette over the casting, then go over it with the end of the roll of fi berglass. Keep an even tension on the material and note any circulation problems by observing the color of their fi ngernails before, during, and after application of the cast.

36 0203902SP01A-32


16. Be careful during application to use the fl ats of your fi ngers so that you do not make indentations in the cast with your fi ngertips. This can create pressure points on the patient’s arm inside the cast.

17. Immediately put a generous amount of lotion into your gloved hands and spread it all over the newly-casted arm. This stops the chemical reaction in the fi berglass.

18. Remind the patient to keep the arm elevated to the level of the heart as much as possible.

19. Instruct the patient to report any of the following:

A. A bad odor coming from the cast

B. Temperature over 100ºF

C. Numbness, tingling, severe pain, diffi culty moving fi ngers or severe swelling

D. Changes in the color or temperature of fi ngers

E. A burning sensation over a bony area

F. Pink-to-red discoloration on the cast indicating there may be bleeding from a wound under the cast

20. Wash hands.


Cast care guidelines:

1. Keep the cast elevated. This will help reduce pain and swelling.

2. Do not stick objects into the cast to relieve itching. Do not put powder or creams inside cast.


0203902SP01A-32 37

3. Do not submerge cast. Use a hairdryer if it gets wet.

4. Do not cut or trim the cast.

Removing a fiberglass cast:

1. Explain the cast removal process to the patient. Do not use the term “cut” or “cast cutter.”

2. Show the patient how the cast remover vibrates and does not spin. Tell her that she will feel some pressure and warmth from the equipment during the process.

3. Touch the vibrating blade to the top of the cast at the inside of the arm. As it vibrates it will cut through the fi berglass and “drop” down onto the padding. Move the blade down the arm progressively, linking the series of “cuts” made in the fi berglass.

4. Once the cast is “cut” the entire length, it is time to split the cast.

5. Place the tip of the splitter into the crevice you made in the fi berglass at the top of the cast. Squeeze the instrument which will pry the sides of the cast open further.

6. Continue down the length of the cast.

7. At this point you should be able to gently slip the blunt tip of the bandage scissors under the padding and stockinette and cut through both layers all the way down to the hand.

8. Gently remove the entire cast. Be gentle with the patient’s arm.

9. As you smooth lotion onto the skin of the arm, observe for any open or reddened areas. Reassure the patient that the skin color and muscle tone will improve.

10. Wash hands.


38 0203902SP01A-32


Steps to Take 8-5—Use a Microscope

Procedure Objective: Use and care of a microscope

Equipment Needed: Microscope, microscope dust cover, slide, cover slip

Steps to Take:

How a microscope works:

1. The light source is a bulb in the base.

2. Light passes through a condenser and an iris diaphragm. The condenser controls the intensity of the light. The iris diaphragm controls the amount of light.

Eyepiece Lens

Fine Focus

Course Focus

Arm

Base

Revolving Nosepiece

Stage with Stage Clips

Illuminator

Objective Lenses

A compound microscope


0203902SP01A-32 39

3. The platform, also called the stage, is where the slide rests to be viewed.

4. The eyepiece may be single lens or binocular lens. Magnifi cation is usually 10×. Lenses are adjustable between low and high power and also have a setting for oil immersion view.

5. To make adjustments, you can use the coarse adjustment or the fi ne adjustment knobs. Coarse adjustment is used with the low power objective to bring the object into view. Then the fi ne adjustment is used to sharpen the image.

Caring for a microscope:

1. Avoid moving the microscope.

2. Carry it with one hand under the base and the other hand holding the arm.

3. Keep the microscope covered when it is not in use.

4. Use special lens cleaner and paper only.

5. Always focus away from the lens to prevent the lens from coming in contact with the slide.

Viewing a slide:

1. Place a cover slip over the specimen on the slide.

2. Use the coarse adjustment to raise the nosepiece unit.

3. Place the slide on the stage.

4. Turn on the microscope light.

5. Rotate the low-power (10×) objective into position.

6. Look at the stage from the side and turn the coarse adjustment until the objective is as close to the slide as it will go. Stop turning when the objective no longer moves.

7. Don’t lower the objective while looking through the oculars.

8. Look into the oculars and slowly turn the coarse adjustment to raise it until the object on the slide comes into view.

9. Turn the fi ne adjustment to sharpen the image.

10. If the stage is movable, use the knobs to survey the slide. If the stage is not movable, carefully move the slide while looking through the oculars.

40 0203902SP01A-32


Steps to Take 8-6—Perform the Ishihara TestProcedure Objective: To determine colorblindness in the patient

Equipment Needed: Ishihara book

Steps to Take:

1. Seat the patient and hold the book 14 to 16 inches away. 2. Ask the patient to tell you the numbers of the pages or to trace the lines in the

circles as you turn the book’s pages. If the patient cannot see the number of the page or trace the line, he may be colorblind.

3. You will then tell the physician what the patient could not see.

Steps to Take 8-7—Use an OtoscopeProcedure Objective: To examine the patient’s ears

Equipment Needed: Otoscope, variety of speculum sizes, light source

Steps to Take:

1. Wash hands.2. Identify the patient and explain the procedure. 3. Choose a speculum size that is appropriate for the patient’s ear canals and fi t it to

the otoscope. Children have narrower canals and will require a narrower speculum than adults. It is possible, though, that a small adult will have a smaller canal than a large child.

4. Hold the otoscope in the hand of the same side as the ear you are about to examine.5. Hold the otoscope like you would hold a pencil. The pencil grip feels natural and

gives you good control. Also, it lets you rest the side of your hand on the patient’s temple. This provides more stability if the patient moves suddenly, which is common with children.

6. If one ear is healthy, examine it fi rst to prevent possible spread of infection. It also provides a visual of what the patient’s “normal” ear looks like. This allows you to compare it with the other ear.

7. Provide a good light source with which to see.8. Adult ear canals can be crooked, so pull back the outer ear upwards and backwards.

This will straighten the ear canal so observation is easier.9. Rest your hand against the side of the patient’s temple while you slowly introduce

the otoscope into the canal.10. Look for redness, swelling, discharge and anything else that appears different from

the healthy ear.11. Record your fi ndings in the patient’s chart.


0203902SP01A-32 41

Steps to Take 8-8—Assist with a Sigmoidoscopy

Procedure Objective: To prepare the patient for a sigmoidoscopy and to assist the physician during the procedure

Equipment Needed: Sigmodoscope, enema, proctology table

Steps to Take:

The day before:

1. Prepare the patient on what to do the day before the procedure. If the patient does not follow the instructions, the test may be unsuccessful. This wastes time and money, and it is emotionally hard on the patient because he must become “psyched up” for a second procedure.

2. Give the patient both verbal and written instructions so that he can remember them.

3. Make sure the patient understands why he needs to follow your instructions. An enema, for example, will empty his colon, so the procedure will be more comfortable.

4. Tell the patient not to eat dairy products, raw fruits and vegetables, grains and cereals. Eat lightly. Drink large amounts of clear liquids, especially water.

On the day of the appointment:

1. The patient should give himself an enema two hours before the procedure. This will be in his written instructions. However, if the sigmoidoscopy must be performed before the patient had time to prepare or the patient did not do a thorough job at home, you may need to give him an enema in the offi ce.

2. The doctor may direct the patient to use laxatives. His instructions will vary somewhat according to the patient’s physical condition.

Before the procedure:

1. If you must perform the enema, do so in an examination room next to a bathroom.

2. Having an enema can be an uncomfortable and embarrassing situation; however, the longer the patient is able to retain the enema, the cleaner the colon will be of fecal matter.

3. Do everything you can to make your patient feel comfortable.

During the procedure:

1. Put the patient on a proctology table. The proctology table is designed to provide support for the patient’s chest and head during the sigmoidoscopy. The patient’s arm rests against a headboard. The table tilts so that the chest and knees are brought toward each other. This position places the patient’s posterior up.

42 0203902SP01A-32


2. If the patient cannot be in this position, place him into the Sim’s position or another position that the physician requests.

3. Position the patient so that he is comfortable and so that the doctor can see clearly.

4. During the procedure, tell the patient to breathe slowly and completely through the mouth and to relax his abdominal muscles. The patient may feel as though he needs to defecate during the procedure because the sigmoidoscope is stretching the wall of his intestine. Also, the air that goes into his intestine will increase this feeling.

5. Explain to the patient that if he breathes as you tell him to, he will have less discomfort. Help him breathe by breathing in rhythm with him.

6. Stay calm and relaxed. This will help your patient do the same.

7. Reassure the patient that the procedure will last only a few minutes.


0203902SP01A-32 43

Steps to Take 8-9—Use a Sphygmomanometer

Procedure Objective: Measure the patient’s blood pressure using a sphygmomanometer

Equipment Needed: Sphygmomanometer, blood pressure cuff, stethoscope

Steps to Take:


2. Be sure the patient has had a few moments to relax before taking her blood pressure. Offer her a chance to use the restroom.

3. Ask if she has smoked or had any caffeine in the previous 30 minutes. If so, wait until 30 minutes have passed. Nicotine and caffeine can raise blood pressure.

4. Wrap the appropriate size blood pressure cuff snugly on the patient’s arm with the arrow over the antecubital space.

5. The patient’s arm should be relaxed and held at about the level of her heart. The arm should never be extended in the air.

6. Place the earpieces of the stethoscope into your ears.

7. Place the diaphragm of the stethoscope in the antecubital space of the patient’s arm. Hold it in place by wrapping your fi ngers around it and the elbow.

8. Using your other hand, tighten the knob on the bulb of the cuff and pump it up to about 160-180. If your patient is known to have very high blood pressure, pump it up to a number higher than her normal range.

9. Carefully loosen the knob slightly and let the air slowly escape, keeping your eyes on the numbers of the sphygmomanometer as the mercury or dial drops.

10. Let the air slowly escape and concentrate on the sounds and the numbers on the gauge. While watching the dial, listen for the fi ve phases:

A. Phase 1—The fi rst sound you hear when defl ating the cuff should be a sharp, tapping sound. Note the corresponding number on the sphygmomanometer at that time. This is the systolic pressure. It is the top number of a blood pressure measurement.

B. Phase 2—The next sound is blood passing through the vessels as the cuff defl ates. This will be a soft, swishing sound.

C. Phase 3—Next, you’ll hear a rhythmic tapping as more blood continues to pass through the arm as the cuff defl ates. This can be mistaken for Phase 1 if you are not listening carefully.

D. Phase 4—The tapping sounds will begin to fade.

E. Phase 5—At this stage, blood is now fl owing freely and all sounds disappear. Note what number the arrow is pointing to when you hear the last sound. This is the diastolic pressure. It is the bottom number of a blood pressure measurement.

44 0203902SP01A-32


11. Loosen the knob all the way, let all the air escape and remove the cuff.

12. Record the upper and lower numbers on the patient’s chart.

13. Clean the ear pieces of the stethoscope.

14. If you aren’t sure of your measurements and need to repeat the blood pressure test, wait at least fi ve minutes between readings. Blood pressure readings will always be slightly different between the right and left arms.

Steps to Take 8-10—Use a Cane

Procedure Objective: To teach the patient how to use a cane

Equipment Needed: Cane

Steps to Take:

1. Explain and demonstrate to the patient how to use the cane. Give him both verbal and written instructions.

2. When he is ready to try it, tell the patient to hold the cane on the strong side of the body.

3. Measure the cane to make sure the top of it reaches the patient’s hip. If the cane is at the proper height, the patient will be able to bend his elbow slightly, about 20 to 30 degrees.

4. Tell the patient to move the cane forward 6 inches.

5. Tell the patient to move the weak leg forward to meet the cane.

6. Tell the patient to move the stronger leg about 6 inches in front of the cane.

7. Watch the patient to make sure he knows how to use it. If the patient still cannot use the cane properly, help him go through the above steps again.

8. Explain safety issues.

9. Document the procedure in the patient’s chart.


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Steps to Take 8-11—Use Crutches

Objective: To teach the patient how to use crutches

Equipment Needed: Crutches

Steps to Take:

1. Give the patient instructions both verbally and in writing on how to use the crutches and which gait to use.

2. Demonstrate how to use the crutches and the gait.

3. Check the height of the crutches; adjust the height if necessary.

4. Tell the patient to stand with the crutches spread about 4 inches to the side of his legs. The crutches should be 4 to 6 inches ahead of the foot. Make sure the patient is bearing weight appropriately on each leg. Follow the doctor’s instructions for how much weight the patient should be bearing.

5. Tell the patient how to walk in the gait that he is going to be using.

6. Show the patient how to walk this gait.

7. Watch the patient practice with the crutches, so you can correct any mistakes.

8. When the patient can walk properly, show him how to go up and down stairs.

9. If possible, watch him do this, so you can make corrections if necessary.

10. Document what you have told the patient, including the patient’s weight-bearing status, the gait you taught the patient and that the patient performed the gait correctly.

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Steps to Take 8-12—Use a Walker

Procedure Objective: To assist the patient with use of a walker

Equipment Needed: Comfortable, supportive shoes with rubber soles for patient; bathrobe if patient is not in street clothes; transfer/gait belt; walker; chart

Steps to Take:

1. Wash hands.


3. Confi rm order that patient is able to be up ambulating with use of walker.

4. Gather all equipment.

5. Confi rm patient’s identity. If in a hospital, check the patient’s armband. In other settings, ask the patient his fi rst and last name.

6. Provide for privacy by closing the door, or pulling the curtain closed around the bed. Drape the patient to avoid exposing him, if necessary.

7. Place the bed in its lowest position and raise the head of the bed if possible. The patient can sit up easier if the head of his bed is raised.

8. Place a transfer/gait belt around the patient’s waist. This belt allows you to guide the patient. It also offers support during transfer to a standing position.

9. Standing in front of the patient, grasp the transfer belt on both sides toward his back. When he is ready, assist him to a standing position by leaning slightly back and pulling upward on the belt until he is in a standing position.

10. Once he is stable in a standing position, place the walker between you and the patient and instruct him to place both hands on the walker.


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11. Confi rm that the walker is at the right height. The hand bar should be at a height just below the patient’s waist allowing the patient’s elbows to be slightly fl exed.

12. Step behind the patient and grasp the gait belt.

13. Teach the patient to lift the walker and move it 1 to 2 feet forward, depending upon his strength and comfort level. Change to a roller walker at this time if you observe that his strength in insuffi cient.

14. After the patient has moved the walker forward, ask him to take one or two small steps and assess his balance.

15. Repeat this procedure while walking with him several feet. Keep your grasp on the gait belt until you feel that he is strong enough to walk independently.


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Steps to Take 8-13—Use a Wheelchair

Procedure Objective: To safely transport the patient in a wheelchair

Equipment Needed: Wheelchair

Steps to Take:

1. Guide the wheelchair from behind and use your weight to help push it.

2. Always be sure the brakes are locked when transferring a patient into or out of a wheelchair.

3. Back down ramps. Back into and out of elevators.

4. Stay to the right in hallways.

5. Make sure patient’s feet are placed on the footrests.

Steps to Take 8-14—Assisting Patient from Wheelchair to Examination Table

Procedure Objective: To safely transfer the infi rm patient from wheelchair to exam table

Equipment Needed: Wheelchair, gait belt, stool with handrail

Steps to Take (one person transfer):

1. Place the wheelchair next to the exam table with the patient’s stronger side nearest the table.

2. Lock the brakes.

3. Adjust the exam table so that it is close to the same height as the wheelchair. Ensure that the exam table is solid and will not move, tilt or wiggle. Move anything that you might trip over while transferring the patient. Make sure that any equipment the patient is wearing, such as an IV cord or brace, is secure and will not get in the way.

4. Place gait belt snugly around the patient’s waist.

5. Move the footrests up and out of the way. Have patient put feet on fl oor. Remove footrests if possible.

6. Place the stool in front of the exam table, as close to the wheelchair as possible.

7. Have patient move forward to front of wheelchair.


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8. Stand in front of the patient with your feet slightly apart. Bending at the hips and knees, grasp gait belt and have patient place her hands on the armrests of the wheelchair so she can push up when you give the signal.

9. If she does not have the strength to push off, have her arms in front of her. Do not let the patient put her arms around your neck or shoulders. This will pull on you and injure you.

10. Pull the gait belt upwards, helping the patient to a standing position.

11. Keeping a hold on the gait belt, have patient step onto the stool and pivot so her back is to the exam table. Support the patient’s weaker, outer leg with your leg furthest from the exam table. Take small shuffl ing steps, so your feet are always in contact with the ground. Don’t cross your feet.

12. Have patient grasp the rail of the stool with one hand, placing other hand on the exam table.

13. Ease the patient to a sitting position on the exam table. Position as necessary.

14. Move the wheelchair and stool out of the way.

Steps to Take (two person transfer):

1. Place gait belt snugly around the patient’s waist.

2. Have one person stand in front of patient and the other to the side, next to the exam table.

3. Both persons should grasp gait belt from underneath. Have the patient place her hands on the armrests of the wheelchair.

4. On signal, both persons pull the patient straight up (forward to a standing position). The patient may push up with her arms if able.

5. The person nearest the exam table moves the wheelchair out of the way. The other person pivots the patient and has her place stronger leg on the stool. She may grasp the handrail if able.

6. On signal, both persons lift the patient onto the exam table and position her as necessary.

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Steps to Take 8-15—Assisting Patient from Examination Table to Wheelchair

Procedure Objective: To safely transfer the infi rm patient from exam table to wheelchair

Equipment Needed: Wheelchair, gait belt, stool with handrail

Steps to Take:

1. Place the wheelchair next to the exam table, on the patient’s stronger side and lock the brakes.

2. Position the stool next to the wheelchair.

3. Help patient into a sitting position and place gait belt snugly around his waist.

4. Pivot him so that his legs are dangling over the side of the table.

5. Always keeping a hand on the patient, move around so that you are in front of patient.

6. Grasp gait belt and stand with your feet shoulder width apart and bend your knees so you have a strong base of support.

7. On a signal, pull the patient slightly towards you so that her feet are on the stool. Have patient grasp the handrail for support.

8. Keeping grasp of the gait belt, have the patient step onto the fl oor with her strong leg, pivoting at the same time so her back is to the wheelchair.

9. Instruct the patient to hold the armrests of the wheelchair.

10. Bending from your hips and knees, gently lower the patient into the wheelchair.

11. Lower/replace the footrests and place her feet on them.

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