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Introduction to Medical AssistingProcedure Guide

0203992SP01A-32

Introduction to

Medical AssistingProcedure Guide

No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the express written permission of U.S. Career Institute.

Copyright © 2012, Weston Distance Learning, Inc. All Rights Reserved. 0203992SP01A-32

AcknowledgmentsAuthors

Merry Perry

Paula Tripp

Editorial Staff Trish Bowen

Bridget Tisthammer

Lindsay Hansen

Jessica Tuttle

Design/Layout Connie 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

Table of ContentsVirtual Lab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Virtual Lab 7-1 Proper Hand Washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Virtual Lab 7-2 Proper Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Virtual Lab 8-1 Use an Autoclave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Virtual Lab 8-2 Use an Audiometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Virtual Lab 8-3 Electrocardiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Virtual Lab 8-4 Use a Nebulizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Virtual Lab 8-5 Use Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Virtual Lab 8-6 Use a Balance Beam Scale with a Measuring Bar . . . . . . . . . . . . . . . . . . . . . 11Virtual Lab 8-7 Use a Spirometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Virtual Lab 8-8 Use a Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Virtual Lab 11-1 Take Oral and Axillary Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Virtual Lab 11-2 Take a Pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Virtual Lab 11-3 Measure Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Virtual Lab 12-1 Proper Body Mechanics When Assisting Patients . . . . . . . . . . . . . . . . . . . . . 18Virtual Lab 12-2 PASS Technique to Handle a Fire Extinguisher . . . . . . . . . . . . . . . . . . . . . . . 19Virtual Lab 18-1 Determine Hemoglobin Levels Using HemoCue . . . . . . . . . . . . . . . . . . . . . 20Virtual Lab 18-2 Obtain Serum from Whole Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Virtual Lab 18-3 Screen Glucose Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Virtual Lab 22-1 Perform Routine Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Virtual Lab 22-2 Perform Pregnancy Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Virtual Lab 22-3 Obtain a Strep Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Virtual Lab 22-4 Perform a Hemoccult Sensa Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Virtual Lab 26-1 Set Up Minor Surgical Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Virtual Lab 26-2 Remove Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Virtual Lab 27-1 Obtain and Administer Oral Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Virtual Lab 27-2 Demonstrate Eye Drop Instillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Virtual Lab 27-3 Demonstrate Ear Drop Instillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Virtual Lab 27-4 Administer an Intradermal Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Virtual Lab 27-5 Administer a Subcutaneous Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Virtual Lab 27-6 Administer an Intramuscular Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Virtual Lab 27-7 Administer Intramuscular Injection by Z-track Method . . . . . . . . . . . . . . . . . 39

Steps to Take . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Steps to Take 7-1—Proper Surgical Hand Washing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Steps to Take 7-2—Proper Sterile Gloving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Steps to Take 7-3—Remove Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Steps to Take 7-4—Blocked Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Steps to Take 7-5—Heimlich Maneuver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Steps to Take 7-6—The Chest Thrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Steps to Take 7-7—Rescue Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Steps to Take 7-8—CPR for Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Steps to Take 7-9—CPR for Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Steps to Take 7-10—Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Steps to Take 7-11— Alerts of Hyperglycemia or Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . 54Steps to Take 7-12—Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Steps to Take 7-13—Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Steps to Take 7-14—Fainting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Steps to Take 7-15—General First Aid for Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Steps to Take 7-16—Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Steps to Take 7-17—Management of the Patient in Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Steps to Take 8-1—Proper Surgical Instrument Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Steps to Take 8-2—Ultrasonic Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Steps to Take 8-3—Daily and Weekly Cleaning of the Autoclave . . . . . . . . . . . . . . . . . . . . . . 62Steps to Take 8-4—Apply and Remove a Fiberglass Cast . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Steps to Take 8-5—Use a Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Steps to Take 8-6—Perform the Ishihara Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Steps to Take 8-7—Use an Otoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Steps to Take 8-8—Assist with a Sigmoidoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Steps to Take 8-9—Use a Sphygmomanometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Steps to Take 8-10—Use a Cane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Steps to Take 8-11—Use Crutches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Steps to Take 8-12—Use a Walker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Steps to Take 8-13—Use a Wheelchair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Steps to Take 8-14—Assisting Patient from Wheelchair to Examination Table . . . . . . . . . . . . . 76Steps to Take 8-15—Assisting Patient from Examination Table to Wheelchair . . . . . . . . . . . . . 78Steps to Take 11-1—Take a Tympanic Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Steps to Take 11-2—Take a Rectal Temperature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Steps to Take 11-3—Respiration Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Steps to Take 16-1—Perform the Snellen Chart Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Steps to Take 16-2—Perform the Weber and Rinne Hearing Tests . . . . . . . . . . . . . . . . . . . . . 83Steps to Take 16-3—Measure an Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84Steps to Take 16-4—Patient Positioning: Supine or Horizontal Recumbent Position . . . . . . . . . 86Steps to Take 16-5—Patient Positioning: Dorsal Recumbent Position . . . . . . . . . . . . . . . . . . . 87Steps to Take 16-6—Patient Positioning: Lithotomy Position . . . . . . . . . . . . . . . . . . . . . . . . . . 88Steps to Take 16-7—Patient Positioning: Fowler’s Position . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Steps to Take 16-8—Patient Positioning: Knee-Chest Position . . . . . . . . . . . . . . . . . . . . . . . . 90Steps to Take 16-9—Patient Positioning: Prone Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91Steps to Take 16-10—Patient Positioning: Sims’ Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Steps to Take 16-11—Patient Positioning: Trendelenburg or Shock Position . . . . . . . . . . . . . . 93Steps to Take 18-1— Obtain Venous Blood with a Sterile Needle . . . . . . . . . . . . . . . . . . . . . . 94Steps to Take 18-2— Obtain Venous Blood with a Vacuum Tube . . . . . . . . . . . . . . . . . . . . . . 96Steps to Take 18-3— Obtain Venous Blood Using the Butterfly Needle Method . . . . . . . . . . . . 98Steps to Take 18-4—Capillary Puncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Steps to Take 18-5—Capillary Puncture with a Heel Stick . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Steps to Take 18-6—Blood Smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102Steps to Take 18-7—Perform a Heel Stick for a PKU Test . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Steps to Take 21-1—Prepare a Dry Smear for Staining . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Steps to Take 22-1—Collect a Clean-catch Urine Specimen . . . . . . . . . . . . . . . . . . . . . . . . 105Steps to Take 22-2—Perform a Catheterization on a Female Patient . . . . . . . . . . . . . . . . . . 106Steps to Take 22-3—Perform a Catheterization on a Male Patient . . . . . . . . . . . . . . . . . . . . 108Steps to Take 22-4—Obtain the Specific Gravity of Urine Using a Refractometer . . . . . . . . . 110Steps to Take 25-1— Prepare a Female Patient for a Pap Test and Pelvic Exam . . . . . . . . . . . 111Steps to Take 25-2—Assist with a Sigmoidoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112Steps to Take 25-3—Conduct a Breast Self-exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Steps to Take 25-4— Determine Color Vision Using the Ishihara Method . . . . . . . . . . . . . . . 114Steps to Take 26-1—Prepare Treatment Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Steps to Take 26-2—Assist with Suturing a Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116Steps to Take 27-1— Obtain and Administer Liquid Oral Medication . . . . . . . . . . . . . . . . . . 118Steps to Take 27-2— Withdraw Medication from an Ampule . . . . . . . . . . . . . . . . . . . . . . . . 119Steps to Take 27-3—Withdraw Medication from a Vial . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120


0203992SP01A-32 1

Virtual LabVirtual Lab

Introduction to Medical Assisting Procedure Guide

2 0203992SP01A-32

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.


0203992SP01A-32 3

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.


4 0203992SP01A-32

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.


0203992SP01A-32 5

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.


6 0203992SP01A-32

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.


0203992SP01A-32 7

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.


8 0203992SP01A-32

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.



0203992SP01A-32 9

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.



10 0203992SP01A-32

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.


0203992SP01A-32 11

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.


12 0203992SP01A-32

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.


0203992SP01A-32 13

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.



14 0203992SP01A-32

Virtual Lab 11-1 Take Oral and Axillary Temperature

Procedure Objective: To measure the patient’s temperature through the mouth and under the arm

Equipment Needed: Digital thermometer, disposable covers, clean, non-sterile gloves, hand towel

Steps to Take:

Taking an oral temperature:

1. Wash hands.


3. Place a clean thermometer cover over the tip of the thermometer stylus. Push the power button. Do not take a patient’s temperature if within 15 minutes of eating, drinking or smoking, as this will alter the result.

4. Place thermometer under the patient’s tongue, in posterior sublingual cavity. Instruct patient to hold lips closed and breathe through nose.

5. When the thermometer beeps, remove the thermometer and drop probe cover off of tip into trash.

6. Document the procedure and communicate appropriate results to patient.

Taking an axillary temperature:

1. Wash hands.


3. Place a clean thermometer cover over the tip of the thermometer stylus. Push the power button.

4. Put on clean, non-sterile gloves. Pat the patient’s armpit dry with towel.

5. Place thermometer in center of armpit and instruct patient to hold arm snugly against body with other arm.

6. Remove after thermometer beeps.

7. Remove and discard gloves.

8. Wash hands.



0203992SP01A-32 15

Virtual Lab 11-2 Take a Pulse

Procedure Objective: To take the patient’s pulse at various pulse points

Equipment Needed: Stethoscope, clock or watch with a second hand

Steps to Take:

If obtaining a patient’s pulse for the fi rst time, measure a baseline pulse rate for one minute. Review the patient’s medical history and risk factors with him prior to assessment to determine factors impacting the pulse rate and previous baseline measurements. Assess whether the patient demonstrates any physical symptoms that could alter pulse rate such as edema, dyspnea or palpitations. Identify the most appropriate physical site to assess pulse.

Taking an apical pulse:

1. Wash hands.


3. Assist patient to a sitting or supine position and help remove upper body clothing.

4. Offer patient a gown.

5. Place stethoscope over the 5th intercostal space, left of the sternum, midclavicle to locate the apex of the heart.

6. Count heartbeats for one minute, noting any irregularities.

7. Help the patient get dressed, if needed.


Taking a radial pulse:

1. Wash hands.


3. Position patient with arm relaxed, palm facing down.

4. Locate pulse point on the thumb side of wrist, 1 inch above base of thumb. Use pads of fi rst three fi ngers, not thumb and apply slight pressure.

5. Count beats for one minute and note any irregularities or variations.


Taking a carotid pulse:

1. Wash hands.


3. Assist patient to supine position.


16 0203992SP01A-32

4. Locate pulse point on either side of larynx.

5. Place fi rst three fi ngers over artery with slight pressure.

6. Count for one minute, note rhythm and any irregularities.


Taking a femoral pulse:

1. Wash hands.


3. Have patient remove outer clothing on the lower half of his body. Assist patient to supine position.

4. Locate the femoral pulse by pressing deeply with your fi rst three fi ngers below the inguinal ligament.

5. Count beats for one minute and note rhythm and any irregularities.


Taking a popliteal pulse:

1. Wash hands.


3. Place patient in supine position with knee fl exed and skin exposed.

4. Place stethoscope on back of knee to hear pulse as palpation at this site is diffi cult.

5. Count pulse for one minute.



0203992SP01A-32 17

Virtual Lab 11-3 Measure Blood Pressure

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

Equipment Needed: Sphygmomanometer, stethoscope

Steps to Take:


2. Palpate the brachial pulse in both arms to determine the strongest rhythm. Use the side with the strongest rhythm.

3. Determine cuff size. Keep in mind that this can affect the reading.

4. Roll sleeve to 5 inches above elbow or remove sleeve from arm.

5. Place bladder of cuff 1 inch above crease of elbow. Support patient’s arm at heart level and instruct the patient to relax the arm.

6. Place stethoscope in ears, with earpiece facing forward and stethoscope bell on brachial artery.

7. Close valve and infl ate to 30 mmHg above the patient’s baseline systolic pressure or ~180 mmHg at a rapid, smooth rate.

8. Open valve slightly and defl ate at a rate of 2 mm per second while listening carefully for the heart beat. This fi rst sound may be a dull “lub dub.” This is the systolic pressure. When the sound stops or becomes faint, check the measurement again. This is the diastolic pulse.

9. Record these numbers.

10. The ausculatory gap is a loss of sound as the bladder defl ates and the sound reappears later. If uncertain, let all of the air out of the bladder, wait 1 to 2 minutes and repeat.



18 0203992SP01A-32

Virtual Lab 12-1 Proper Body Mechanics When Assisting Patients

Procedure Objective: To assist patient in moving from one location to another while using proper body mechanics

Equipment Needed: None

Steps to Take:

1. Keep the back straight and feet shoulder-width apart.

2. Bend from the hips and knees, not the waist.

3. Turn the entire body. Don’t twist.

4. Hold heavy objects close to the body.

5. Use your body weight to push or pull heavy objects.

6. Ask for help when needed.

7. Make sure the area is clear of clutter where you are working.


0203992SP01A-32 19

Virtual Lab 12-2 PASS Technique to Handle a Fire Extinguisher

Procedure Objective: To perform the PASS technique to handle a fi re extinguisher

Equipment Needed: Fire extinguisher

Steps to Take:

1. P: Pull the pin to break the seal.

2. A: Aim low pointing the nozzle at the base of the fi re.

3. S: Squeeze the handle to release the extinguishing agent.

4. S: Sweep from side to side at the base of the fi re until it appears to be out.

5. If you have any doubt about your ability to fi ght a fi re, evacuate immediately!


20 0203992SP01A-32

Virtual Lab 18-1 Determine Hemoglobin Levels Using HemoCue

Procedure Objective: To determine a patient’s hemoglobin levels using the HemoCue device

Equipment Needed: HemoCue, sterile lancet, capillary tubes, sealing clay, alcohol swab, dry cotton balls, gloves, safety glasses, mask or safety shield, sharps container, band aid

Steps to Take:

1. Wash your hands.


3. Put on gloves and safety glasses. Put on mask or place acrylic shield between yourself and the patient’s hand to prevent blood splatters.

4. Select the middle or ring fi nger for puncture site.

5. Cleanse and disinfect the site with an alcohol swab. Allow to air dry.

6. Pull the skin at the site taut. Do not squeeze the fi ngertip. If it is necessary to increase the blood fl ow, it is best to massage the whole hand, not just the fi nger.

7. Puncture the skin in one quick motion at the tip of the fl eshy pad and slightly to the side of the end of the fi nger.

8. The fi rst drop of blood is wiped away with a dry gauze or cotton ball because it contains tissue fl uid which dilutes the blood drop.

9. Holding the capillary tube nearly horizontal and slightly downward, touch the tip to the drop of blood. Fill two tubes two-thirds to three-quarters full. If the fl ow of blood begins to slow, rewipe the puncture site with a dry gauze pad.

10. As each tube is fi lled, wipe the outside of the fi lled tube with a cotton ball, if necessary, to remove excess blood. Stand it in the sealing clay which forms a plug in the end of the tube. Check to see that the clay appears level in the tubes.

11. Give the patient a gauze pad or cotton ball to press onto the puncture site. Offer a band aid. Dispose of the lancet in a nearby sharps container.

12. Place the tubes into the microhematocrit centrifuge with sealed ends against the gasket. Balance the centrifuge by placing the tubes opposite each other.

13. Fasten both lids securely. Set the timer and allow the centrifuge to run for the prescribed time.

14. Allow the centrifuge to come to a complete stop and unlock lid.


0203992SP01A-32 21

15. Determine the microhematocrit according to scale provided either in the machine or on the microhematocrit reader available.

16. Place tube on the reader card.

17. Average the values from the two tubes and record.

18. Discard the capillary tubes in a sharps container.

19. Clean the area with disinfectant.

20. Dispose of gloves in a biohazard container.

21. Wash your hands.

22. Document the results.


22 0203992SP01A-32

Virtual Lab 18-2 Obtain Serum from Whole Blood

Procedure Objective: To separate serum from whole blood using a centrifuge

Equipment Needed: Centrifuge, transport tube, clotted blood sample, gloves, safety glasses

Steps to Take:

1. Wash your hands.

2. After obtaining the blood sample, invert the red top tube of blood 5 times to activate clotting.

3. Allow the tube to clot upright in a rack for 30 to 60 minutes (no longer).

4. Place the tube in the centrifuge and spin at 2,500 rpm for 15 minutes.

5. Immediately transfer the serum that has risen to the top of the tube to a plastic transport vial for pickup by the laboratory.

6. Label the transfer tube. Complete a laboratory requisition.


8. Put tubes in a sharps container.

9. Wash your hands.



0203992SP01A-32 23

Virtual Lab 18-3 Screen Glucose Level

Procedure Objective: To screen a patient’s glucose level using a glucose analyzer

Equipment Needed: Glucose analyzer, control solution, test strips for analyzer, gloves, goggles, lancet, alcohol swab, dry cotton balls, paper towel, sharps container

Steps to Take:

1. Turn on the analyzer.

2. Wash your hands.

3. Identify the patient and explain the procedure. Verify that the patient has met the pre-testing requirements.

4. Put on gloves and protective goggles.

5. Record the control ranges, lot number and test strip lot number.

6. Perform the analyzer check test and control test. If both tests are within range, proceed to the glucose test.

7. Remove a test strip from the bottle.

8. Perform the capillary puncture. Place the used lancet in a sharps container immediately.

9. Apply a large drop of blood to the test strip.

10. Blot the test strip with a tissue after the time recommended by the manufacturer.

11. Insert the test strip into the test chamber.

12. Read the glucose results at the appropriate time interval.

13. Document the reading.

14. Dispose of all waste in a biohazard waste container.

15. Remove gloves and dispose of in a biohazard container.



24 0203992SP01A-32

Virtual Lab 22-1 Perform Routine Urinalysis

Procedure Objective: To conduct the urinalysis procedure

Equipment Needed: Gloves, biohazard waste container, urine specimen, sharps container, test tubes, pipette, centrifuge, reagent strips, microscope/slides, cover slips, refractometer, antiseptic cleaner, lab form

Steps to Take:

1. Wash your hands.

2. Put on the gloves.

3. Observe and record the color of the urine (amber, straw, yellow, etc.).

4. Observe and record the transparency of the urine (clear, cloudy, turbid, etc.).

5. Note unusual odor (not recorded).

6. Measure the specifi c gravity.

7. Dip the reagent strip into the specimen, moistening all pads.

8. Remove it immediately and tap it on container.

9. Observe the pads and compare colors to those on the chart of the dipstick container at the appropriate intervals. Dispose of the stick in the biohazard container.

10. Record the results on the lab report form.

11. Now carefully pour about 10-12 mL of urine into a centrifuge tube.

12. Centrifuge the specimen at 1,500 – 2,500 rpm for 5 minutes.

13. Carefully pour off the urine, preserving the sediment at the bottom of the tube.

14. Pipette one drop of the sediment onto a clean glass slide and place a cover slip over it.

15. Place the slide under the microscope.

16. Using low power (10X), scan the whole slide with low light, looking for casts. Refer to the urine atlas, usually on the wall, to refresh your memory of the appearance of a cast.

17. Turn the objective to high power to scan for any bacteria, blood cells, epithelial cells, yeast or parasites.

18. Identify any crystals or amorphous debris.

19. Record all results on the lab form.

20. Discard the slide in the sharps container.

21. Discard all biohazardous materials in the biohazardous waste container.


0203992SP01A-32 25

22. Clean the work area with disinfectant.

23. Discard the gloves in the biohazard container.



26 0203992SP01A-32

Virtual Lab 22-2 Perform Pregnancy Test

Procedure Objective: To test urine for hCG

Equipment Needed: Pregnancy test, gloves, urine specimen, watch, surface disinfectant, biohazard container

Steps to Take:

1. Wash your hands.


3. Put on sterile gloves.

4. Apply urine to the test unit using the dropper provider.

5. Begin timing immediately.

6. Compare the test unit to the control and determine the results.

7. Dispose of the specimen and testing materials in the biohazard container.

8. Disinfect the work area with chlorine solution.

9. Remove gloves and dispose of them appropriately.




0203992SP01A-32 27

Virtual Lab 22-3 Obtain a Strep Culture

Procedure Objective: To properly obtain a strep culture from a patient

Equipment Needed: Tongue depressor, sterile cotton tipped applicator, gloves, mask, biohazard waste container, culturette

Steps to Take:

1. Wash your hands.


3. Put on personal protective equipment (PPE).

4. Ask the patient to open her mouth wide and say “ahh.” Hold her tongue down with a tongue depressor.

5. Gently swab the back of the throat and tonsils with a sterile cotton-tipped applicator. Avoid swabbing the sides of the mouth or the tongue.

6. Place the swab into a culture tube with the culture media and label it for transport to the lab.

7. Dispose of PPE.

8. Wash your hands.



28 0203992SP01A-32

Virtual Lab 22-4 Perform a Hemoccult Sensa Test

Procedure Objective: To test the stool for blood

Equipment Needed: Gloves, hemoccult card, developer solution, biohazard waste container

Steps to Take:

1. Wash your hands.



4. Open the back fl ap of the hemoccult card that the patient has placed fecal occult samples on.

5. Place two drops of solution on the test area of the card.

6. Check your watch to time the development of the results.

7. Watch for the color blue to appear, which indicates hidden blood in the specimen.

8. Perform the same procedure on the control test positive and negative strips on the card. The positive strip should turn blue and the negative strip should remain neutral. Repeat the test if necessary.

9. Dispose of the hemoccult card in the biohazard container.

10. Remove your gloves.


12. Document the procedure. Enter positive or negative results in the patient’s chart.


0203992SP01A-32 29

Virtual Lab 26-1 Set Up Minor Surgical Tray

Procedure Objective: To prepare a minor surgical tray

Equipment Needed: Sterile laceration tray (wrapped), sterile drape (if not included in sterile pack), Mayo stand, sterile gloves for self and physician, sterile transfer forceps, injectable medications, syringe/needle, alcohol wipes, skin antiseptic

Steps to Take:

1. Wash hands.

2. Sanitize and disinfect Mayo stand.

3. Place wrapped surgical tray on Mayo stand.

4. Open outer wrapper, keeping your body away from the edges of the sterile fi eld.

5. Put on sterile gloves. Now you must keep your hands above waist level.

6. Continue to open inner wrap of instrument packs.

7. Arrange instruments and supplies in order of use.

8. Recheck for accuracy.

9. Remove gloves. Pour skin antiseptic into container on tray, if physician desires.

10. Cover with sterile drape.

11. Draw up local anesthetic or other medications as ordered by physician.


30 0203992SP01A-32

Virtual Lab 26-2 Remove Sutures

Procedure Objective: To remove sutures from a patient’s healed wound

Equipment Needed: Sterile gauze 4 × 4s/sterile cotton tipped applicators, bandage scissors, biohazard container, tape/dressing, sponge forceps, sterile gloves, Betadine solution/small bowl, sterile suture removal kit: suture scissors, thumb forceps, 4 × 4s, written wound care instructions

Steps to Take:

1. Wash hands.


3. Obtain physician’s approval that sutures are ready to be removed.

4. Open suture removal kit.


6. Using thumb forceps, carefully pick up one knot of a suture. Pull gently upward toward the suture line.

7. Use scissors to cut one side of the suture as close as possible to the skin.

8. Repeat procedure with each suture, noting the number of sutures removed. Place them on a sterile gauze sponge.

9. Examine the suture line to be certain all sutures have been removed.

10. Apply Betadine solution to the area with sterile applicator or gauze sponge.

11. Apply dry dressing, if ordered.

12. Remove gloves and dispose of all biohazardous materials.

13. Explain wound care and provide written instructions, if possible.

14. Wash hands.



0203992SP01A-32 31

Virtual Lab 27-1 Obtain and Administer Oral Medication

Procedure Objective: To measure a dosage and administer oral medication

Equipment Needed: Bottle of pills, med cup, glass of water, written order, PDR, patient’s chart

Steps to Take:

1. Wash hands.


3. If order is given to you verbally, repeat it back to the physician to verify.

4. Double check written orders. Clarify illegible writing.

5. Use reference book to look up any medication you are not familiar with.

6. Follow the six “rights.”

7. Compare medication label with doctor’s order. Check expiration date.

8. Calculate the dosage, as necessary.

9. Dispense the medication into med cup.

10. Explain the effects that the patient might experience.

11. Take vital signs prior to administration.

12. Provide suffi cient water.

13. Be certain that the patient actually takes the medication.

14. Wash hands.



32 0203992SP01A-32

Virtual Lab 27-2 Demonstrate Eye Drop Instillation

Procedure Objective: To properly administer eye drop medication

Equipment Needed: Eye medication bottle, dropper, sterile gauze pads/cotton balls, gloves

Steps to Take:

1. Wash hands.


3. Check medication label and expiration date. Make sure the medication is intended for ophthalmic use.

4. Compare the medication label with the physician’s order.


6. Instruct patient to tilt the head back and turn head toward the affected eye.


8. Use a sterile gauze pad and gently pull down the lower eyelid.

9. Ask the patient to look up at the ceiling.

10. Draw up the correct amount of medication.

11. Place the heel of the hand holding the dropper against the patient’s forehead and over the eye to be medicated.

12. Without touching any part of the eye with the dropper, gently drop the prescribed number of drops into the exposed conjunctival sac.

13. Do not instill drops directly onto the eyeball.

14. Ask the patient to close the eye and blink several times. You may apply gentle pressure to the inner canthus for 30 to 60 seconds at the same time.

15. Instruct the patient not to rub her eyes and to remain supine for fi ve minutes.

16. Remove gloves and dispose of them in a biohazard container along with any other used supplies.

17. Wash hands.



0203992SP01A-32 33

Virtual Lab 27-3 Demonstrate Ear Drop Instillation

Procedure Objective: To properly administer eardrop medication

Equipment Needed: Medication bottle with dropper, cotton balls, cotton tipped applicator, cup to hold bottle in warm water, gloves

Steps to Take:

1. Wash hands.


3. Compare medication label with doctor’s order.

4. Check the drug’s expiration date.

5. Recheck the label with physician’s order.

6. Make sure the medication is intended for use in ears.

7. Examine the ear canal for drainage, removing any present with a cotton-tipped applicator (external ear only).

8. Warm the medication to body temperature.

9. Assist patient into lateral position with affected ear positioned upward.

10. Put on gloves. Draw appropriate amount of medicine into the dropper.

11. Straighten the auditory canal: Adult-pull the auricle of the ear up and back. Child-pull the auricle of the ear down and back.

12. Place hand holding the dropper against the patient’s head.

13. Gently drop the correct number of drops into the ear canal. Do not touch any part of the ear with the dropper.

14. Ask the patient to stay in the lateral position for 5 to 10 minutes to allow the medication to run down into the ear.

15. Place a cotton ball in the outer ear, if ordered to do so.

16. Repeat procedure in other ear, if ordered.

17. Wash hands.



34 0203992SP01A-32

Virtual Lab 27-4 Administer an Intradermal Injection

Procedure Objective: To properly administer an intradermal injection

Equipment Needed: 1cc TB syringe, 25-27 gauge 1/2-5/8” needle, gloves, sharps container, alcohol swab, medication

Steps to Take:

1. Wash hands.


3. Open syringe package and remove cap from tip.

4. Open needle package. Remove cap from end of needle. Keep newly exposed hub sterile.

5. Attach needle fi rmly to syringe.

6. Read medication label. Calculate dosage, if necessary.

7. Disinfect top of medication vial with alcohol swab.

8. Check expiration date on medication.

9. Remove needle sheath.

10. Draw up medication from container. Replace needle sheath.

11. Compare medicine label with physician order again.

12. Place fi lled syringe on medicine tray and transport to patient.


14. Position patient comfortably, sitting or lying, as desired.

15. Put on disposable sterile gloves.

16. Select an appropriate injection site on the inside of the forearm.

17. Cleanse the site with an alcohol swab. Use a circular motion, working from the center out to about 2 inches beyond the site.

18. Allow the skin to dry. Pull skin around the site tight with your non-dominant hand.

19. With your dominant hand, hold the syringe-needle unit nearly parallel with the skin, (at a 10-15 degree angle), and with the bevel up. Quickly push the needle into the dermal layer of the skin and inject the medication. This will form a round wheal, or raised area in the skin. Do NOT massage the injection site.

20. Immediately dispose of the syringe/needle unit in a sharps container.

21. Dispose of gloves and other supplies in a biohazard container.




0203992SP01A-32 35

Virtual Lab 27-5 Administer a Subcutaneous Injection

Procedure Objective: To properly administer a subcutaneous injection

Equipment Needed: 3cc syringe, 25 gauge 5/8”needle, gloves, sharps container, alcohol swab, medication

Steps to Take:

1. Wash hands.












13. Position patient comfortably, sitting or lying, as desired.

14. Put on disposable gloves.

15. Select an appropriate injection site in subcutaneous tissue. The upper arms, the abdomen and the thighs are most common.

16. Cleanse the site with an alcohol swab. Use a circular motion, working from the center out to about two inches beyond the site.

17. Allow the skin to dry.

18. With your dominant hand, hold the syringe/needle unit like a pencil, at a 45 degree angle. Insert the needle into the skin with a dart-like motion and hold it there. With your non-dominant hand gently pull back on the plunger (aspirate) to ensure that the needle is not in a blood vessel.

Note: If blood appears in the syringe upon aspiration, remove the needle and discard the entire unit. Prepare another injection.

19. Slowly inject the medication.


36 0203992SP01A-32

20. Quickly remove the needle and discard the syringe/needle unit in a sharps container.

21. With a dry, sterile cotton swab gently massage the site.

22. Do not massage the site if the medication given is insulin, Imferon or heparin.

23. Apply band-aid, if needed. Observe patient for signs of hypersensitivity.

24. Dispose of gloves and other supplies in a biohazard container.




0203992SP01A-32 37

Virtual Lab 27-6 Administer an Intramuscular Injection

Procedure Objective: To administer an injection to a muscle.

Equipment Needed: 3cc syringe, 23 gauge 1” needle, gloves, sharps container, alcohol swab, medication

Steps to Take:

1. Wash hands.












13. Position patient comfortably, sitting or lying, as necessary.

14. Put on disposable sterile gloves.

15. Select an appropriate injection site in muscle tissue. The upper arms, the middle third of the thighs and the upper outer quadrant of the buttocks are most common.

16. Cleanse the site with an alcohol swab. Use a circular motion, working from the center out to about 2 inches beyond the site.

17. Allow the skin to dry. With your non-dominant hand above the site, pull the skin tight.

18. With your dominant hand, hold the syringe/needle unit at a 90 degree angle. Insert the needle into the skin with a dart-like motion and hold it there. With your non-dominant hand gently pull back on the plunger (aspirate) to ensure that the needle is not in a blood vessel.



38 0203992SP01A-32

19. Slowly inject the medication.

20. Quickly remove the needle and discard the syringe/needle unit in a sharps container.

21. With a dry, sterile cotton swab gently massage the site.






0203992SP01A-32 39

Virtual Lab 27-7 Administer Intramuscular Injection by Z-track Method

Procedure Objective: To administer an injection to a muscle using the Z-track method

Equipment Needed: 3cc syringe, 20 gauge 2”-3” needle, 22 gauge 1”needle, gloves, sharps container, alcohol swab, medication

Steps to Take:

1. Wash hands.








9. Draw up medication from container and add 0.3-0.5cc of air into the syringe. Replace needle sheath. Discard this needle and sheath.

10. Replace with new needle.




14. Position patient comfortably, sitting or lying, as necessary.

15. Put on disposable gloves.

16. Select an appropriate injection site in muscle tissue, in the middle third of the thighs or upper outer quadrant of the buttocks.

17. Cleanse the site with an alcohol swab. Use a circular motion, working from the center out to about two inches beyond the site.

18. Allow the skin to dry. With your non-dominant hand pull the skin laterally away from the intended injection site and hold it in place there.


40 0203992SP01A-32

19. With your dominant hand, hold the syringe/needle unit at a 90 degree angle. Insert the needle into the skin with a dart-like motion and hold it there. With the thumb of your dominant hand, pull back on the plunger (aspirate) to ensure that the needle is not in a blood vessel.


20. Slowly inject the medication. Wait 10 seconds before withdrawing the needle.

21. Quickly remove the needle and release the skin so that it returns to its normal position, sealing off the needle track.

22. Apply light, steady pressure to the site but do not massage.

23. Dispose of the syringe/needle unit in sharps container.






0203992SP01A-32 41

Steps to TakeSteps to Take


42 0203992SP01A-32

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 including wrists and forearms to the elbow. Scrub for 5-6 minutes duration.

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


0203992SP01A-32 43

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.


44 0203992SP01A-32

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 dragging 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.


0203992SP01A-32 45

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

10. Adjust gloves as needed without touching 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 surface of the glove. Keep hands above the waist.


46 0203992SP01A-32

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.


0203992SP01A-32 47

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 head 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.


48 0203992SP01A-32

Steps to Take 7-5—Heimlich Maneuver

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


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 mid-line 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


Steps to Take:

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

2. Using the abdominal clenched fi st techniques, 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.


0203992SP01A-32 49

Steps to Take 7-7—Rescue Breathing

Procedure Objective: To perform mouth-to-mouth resuscitation

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

Steps to Take:

1. Determine if the victim is awake by loudly speaking or shouting to them. 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 they’re 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, and 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.

A blocked airway must be cleared.

Use the chest thrust to clear a blocked airway.


50 0203992SP01A-32

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:

Based on 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care4

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—COMPRESSIONS4. 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 2 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—AIRWAY5. If you have been trained in CPR, continue CPR by opening the airway with a head

tilt-chin lift.B—BREATHING6. 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.

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


0203992SP01A-32 51

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: Please be sure to stay up-to-date with the 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.

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.


52 0203992SP01A-32

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.


0203992SP01A-32 53

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 wheelchair, 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.


54 0203992SP01A-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.


0203992SP01A-32 55

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.


56 0203992SP01A-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.


0203992SP01A-32 57

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.


58 0203992SP01A-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.


0203992SP01A-32 59

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.


60 0203992SP01A-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.


0203992SP01A-32 61

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.


62 0203992SP01A-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.


0203992SP01A-32 63

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.


64 0203992SP01A-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.


0203992SP01A-32 65

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.



66 0203992SP01A-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


0203992SP01A-32 67

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.


68 0203992SP01A-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.


0203992SP01A-32 69

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.


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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.


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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.


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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 any-thing 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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Steps to Take 11-1—Take a Tympanic Temperature

Procedure Objective: To measure the patient’s temperature through the ear

Equipment Needed: Electronic tympanic thermometer, disposable tympanic probe

Steps to Take:

1. Wash hands.


3. Remove tympanic thermometer from recharging base and attach disposable tympanic probe to sensor.

4. Insert probe into ear canal until probe fi ts snugly with tight seal. Do not force probe. Position the ear pinna appropriately for the patient’s age.

1-2 year old child: When placing the probe, the ear pinna is pulled down and back.

3 years and older: When placing the probe, the ear pinna is pulled up and back.

5. Activate the probe by pushing the read button.

6. Keep the thermometer in position until the probe beeps and a digital reading appears on the display screen.

7. Remove the thermometer and eject the probe cover into the trash.

8. Replace the thermometer into the recharging base.



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Steps to Take 11-2—Take a Rectal Temperature

Procedure Objective: To take the patient’s temperature rectally

Equipment Needed: Rectal electronic thermometer, privacy screen or door, non-sterile gloves, disposable thermometer covers, water-soluble lubricant

Steps to Take:

1. Wash hands.


3. Remove rectal electronic thermometer from battery pack and remove temperature probe from unit. The red probe is only used for rectal temperature to prevent cross contamination of blue oral probe.

4. Securely attach a clean cover on stylus.

5. Close privacy screen or door.

6. Put on clean, non-sterile gloves.

7. Assist patient to Sim’s position with upper leg fl exed. Expose anal area, keeping other patient areas covered.

8. Apply water-soluble lubricant to thermometer probe tip.

9. Separate patient’s buttocks with one hand.

10. Instruct patient to take a deep, slow breath, while slowly inserting the probe into the anus towards the umbilicus. If resistance is encountered, do not force probe.

11. Insert no more than .5 inch for infants, and 1.5 inches for adults.

12. Hold the probe in place until thermometer beeps.

13. Slowly remove the thermometer, drop the probe cover off of tip into trash.

14. Remove and discard gloves.

15. Wash hands.



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Steps to Take 11-3—Respiration Assessment

Procedure Objective: Measure the patient’s respiration

Equipment Needed: Clock or watch with a second hand

Steps to Take:

1. Wash hands and identify patient.

2. First determine the patient’s pulse.

3. When fi nished with pulse, while your fi ngers are still located at the pulse point, begin to count the patient’s respirations by watching the patient’s chest rise and fall with inspiration and expiration.

4. Count one respiration as the total of one inspiration and one expiration.

5. If unable to see the chest rise and fall, place your free hand on the patient’s chest to detect respiratory movement. Do not explain this hand placement to the patient.

6. Count respirations for the following intervals:

Adults with regular respiratory rate: 30 seconds and multiply by 2 to determine respirations per minute.

Children younger than 2 years or adults with irregular respiratory rate: one minute.

7. Document rate, rhythm and depth of respirations.


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Steps to Take 16-1—Perform the Snellen Chart Test

Procedure Objective: To measure distance vision

Equipment Needed: Snellen chart, pointer, occluder, alcohol wipes

Steps to Take:

1. Wash your hands.

2. Select the appropriate Snellen chart for the patient. For example, choose one with pictures for younger children and normal charts for children or adults who can read.

3. Explain the test to your patient.

4. The chart should be 20 feet away from the patient. If your patient normally wears glasses or contacts for distance vision, she can use them for the test.

5. Ask the patient to keep both eyes open, but cover her left eye with the occluder.

6. Point to the 20/40 line and have your patient read each letter in the row.

7. If the patient didn’t miss any letters, ask her to read the next line below the previously read line. Have your patient keep reading until she misses two or more letters in the same row.

8. If the patient misses two or more letters in the 20/40 row, have her read the row above that line. Continue moving up the chart until she can complete a row without missing two or more letters.

9. Have the patient cover her right eye and read the 20/40 line. Complete the same process as you did with the left eye until you fi nd a line that the patient can’t read without missing two or more letters.

10. Test both eyes by asking your patient to read the smallest line that she can read clearly.

11. Wipe the occluder with alcohol and allow to dry.


13. Record the number of the smallest line that the patient was able to read for each eye and also for both eyes. Use the abbreviations OD for right eye, OS for left eye and OU for both eyes.


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Steps to Take 16-2—Perform the Weber and Rinne Hearing Tests

Procedure Objective: To measure hearing

Equipment Needed: Quiet room, tuning fork

Steps to Take:

1. Wash your hands.

2. Explain the Weber test to the patient.

3. Strike a tuning fork and place it near the patient’s forehead. Ask her where she hears the sound the loudest—at the left, right or middle.

4. Record the results in the patient’s medical chart.

5. Explain the Rinne test to your patient.

6. Strike the tuning fork and place it next to the right mastoid and then in front of the right ear.

7. Ask the patient which is louder: –1 (near the mastoid) or 2 (near the ear).

8. Repeat the process with the left ear.

9. Record the result in your patient’s medical chart.


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Steps to Take 16-3—Measure an Infant

Procedure Objective: To properly measure an infant’s weight, length, head circumference and chest circumference

Equipment Needed: Infant scale, sanitation paper or paper towel, fl exible measuring tape, patient chart, growth chart and biohazard waste container

Steps to Take:

Infant Weight:

1. Wash your hands.

2. Explain the procedure to the parents or caregiver and have her undress the infant including the diaper.

3. Place a paper towel or sanitation paper on the scale and then check the scale’s balance if necessary.

4. Place the infant on his back on the scale and keep your hands near the infant.

5. Place the bottom weight as high as it will go before the balance drops.

6. Move the upper weight until the balance bar is in the center.

7. Read the weight while the infant is still.

8. Pick up the infant and have the caregiver or parent put the diaper on.

9. Throw the paper towel into the biohazard waste container.

10. Sanitize the scale and wash your hands.

11. Record the weight on the growth chart and the patient’s chart.

Infant Length:

1. Wash your hands.

2. Explain the procedure to the parents or caregiver. The infant should still be undressed from being weighed.

3. Place the infant on her back on the examination table. If you’re using an infant measuring board, place the head against the headboard. Feel free to have the parent or caregiver assist you in this procedure. Gently try to straighten the infant’s back and legs. Place the infant’s heels against the footboard. If you don’t have an infant measuring board, mark the exam table paper at the top of the child’s head with a pen mark or pin. Then try to straighten the infant’s back and legs and mark the heel location with a pen or pin. Ask the caregiver to pick up the infant. Use your measuring tape to measure the distance between the two marks.

4. Read the length and remember it so you can write it down.


0203992SP01A-32 85

5. Wash your hands.

6. Record the height on the growth chart and patient’s chart.

Head Circumference:

1. Wash your hands.

2. Explain the procedure to the parents or caregiver.

3. Ask the parent or caregiver to hold the child or see if the child will lie on the examination table. Older children can stand or sit if they stay still.

4. Place the measuring tape snugly at the largest part of the head, around the temples.

5. Read the measurement.

6. Wash your hands.

7. Record the head circumference on the growth chart and patient’s chart.

Chest Circumference:

1. Wash your hands.

2. Explain the procedure to the parents or caregiver.

3. Lie the infant on the examination table and ask the parents or caregiver to help hold the child.

4. Place the end of the tape measure against the middle front of the infant’s chest. Make sure the measuring tape is snug against the infant’s chest—just above the nipples—and measure around the infant’s chest.

5. Read the measurement in between the infant’s breaths.

6. Wash your hands.

7. Record the head circumference on the growth chart and patient’s chart.


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Steps to Take 16-4—Patient Positioning: Supine or Horizontal Recumbent Position

Procedure Objective: To properly position a patient in the supine or horizontal recumbent position

Equipment Needed: Drape and gown

Steps to Take:

1. Wash your hands.

2. Ask the patient to sit on the end of the table.

3. Ask the patient to lie back as you pull out the examination table extension. Make sure the patient’s back is supported as she lies back.

4. Unfold the drape and cover the patient from the shoulders to the ankles. Ensure that the patient has a pillow under her head.

5. Once the procedure or examination is complete, ask the patient to sit up. Assist her if necessary.

6. Support the patient’s feet as you slide the examination table extension back.

7. Make sure the patient is stable before moving her or proceeding to other instructions.


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Steps to Take 16-5—Patient Positioning: Dorsal Recumbent Position

Procedure Objective: To properly position a patient in the dorsal recumbent position


Steps to Take:

1. Wash your hands.

2. Ask the patient to sit on the end of the table.

3. Ask the patient to lie back as you pull out the examination table extension. Make sure the patient’s back is supported as she lies back.

4. Help the patient bend her knees and place her feet fl at on the table. Push in the table’s foot extension.

5. Unfold the drape and cover the patient from the shoulders to the ankles. Place the drape in a diamond shape so the corners are pointing to the patient’s face and feet.

6. Ensure that the patient has a pillow under her head.

7. Once the procedure or examination is complete, ask the patient to sit up. Assist her if necessary.



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Steps to Take 16-6—Patient Positioning: Lithotomy Position

Procedure Objective: To properly position a patient in the lithotomy position


Steps to Take:

1. Wash your hands.

2. Ask the patient to sit on the end of the examination table. Then cover her legs and lap with a drape.

3. Support the patient’s back as you have her lie back.

4. Adjust the stirrups so that they’re level with the table and one foot from the edge of the table.

5. Lock the stirrups in position.

6. Ask the patient to slide down on the table so her buttocks are close to the edge of the table.

7. Ask the patient to bend the knees and place the feet in the stirrups. Assist the patient if necessary.

8. Place the drape in a diamond shape. Ensure that the patient has a pillow under her head.

9. Once the procedure or examination is complete, pull out the foot extension of the table.

10. Remove the patient’s feet from the stirrups and place her on the table. Ask the patient to sit up. Assist her if necessary.



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Steps to Take 16-7—Patient Positioning: Fowler’s Position

Procedure Objective: To properly position a patient in the Fowler’s position


Steps to Take:

1. Wash your hands.

2. Give the patient a gown and assist her with changing if necessary.


4. Ask the patient to slide back on the table. Assist her if necessary.

5. Extend the foot of the table.

6. Change the position of the head of the table to either a 90-degree angle or a 45-degree angle for the semi-Fowler’s position.

7. Put a pillow under the patient’s knees for comfort.

8. Cover the patient with a drape from her shoulders to her ankles.

9. Once the procedure or examination is complete, extend the foot extension of the table.

10. Ask the patient to sit up. Assist her if necessary.



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Steps to Take 16-8—Patient Positioning: Knee-Chest Position

Procedure Objective: To properly position a patient in the knee-chest position


Steps to Take:

1. Wash your hands.


3. Ask the patient to lie back on the table while you extend the foot of the table. Assist her if necessary and make sure her back is supported.

4. Ask the patient to turn toward you. Assist her and make sure she stays in the center of the table. Make sure the drape is properly covering the patient.

5. Help the patient get onto her knees and bend at the hips so she can place her chest on the table.

6. Instruct the patient to keep her arms at the side of her head with her hands under her head. If she can’t do this, ask her to rest on her elbows.

7. Once the procedure or examination is complete, help the patient lie on her stomach and turn onto her back.




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Steps to Take 16-9—Patient Positioning: Prone Position

Procedure Objective: To properly position a patient in the prone position


Steps to Take:

1. Wash your hands.


3. Ask the patient to lie back as you extend the foot of the table. Make sure the patient’s back is supported.

4. Ask the patient to turn toward you and then onto her stomach. Make sure she stays in the center of the table.

5. Place pillows under the patient’s feet and head.

6. Make sure the patient is covered with a drape from her shoulders to her ankles.

7. Once the procedure or examination is complete, extend the foot extension of the table and help the patient turn toward you.




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Steps to Take 16-10—Patient Positioning: Sims’ Position

Procedure Objective: To properly position a patient in the Sims’ position


Steps to Take:

1. Wash your hands.



4. Stand on the patient’s left side and ask her to turn toward you. Have the patient place her left arm behind her and place her body weight on her chest. Make sure she stays in the center of the table.

5. Help the patient fl ex both knees with the right knee at a 90-degree angle. The right arm should be placed toward the head for support.

6. Make sure the patient is covered with a drape from her shoulders to her ankles. Put the drape in a diamond shape if necessary.

7. Once the procedure or examination is complete, have the patient turn toward you, then on her back.




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Steps to Take 16-11—Patient Positioning: Trendelenburg or Shock Position

Procedure Objective: To properly position a patient in the Trendelenburg or shock position


Steps to Take:

1. Wash your hands.



4. Place a pillow or folded blanket at the top of the bed.

5. Help the patient fl ex both knees.

6. Lower the head of the bed until it’s at a 30- to 40-degree decline.

7. Once the procedure or examination is complete, return the bed to a level position and ask the patient to sit up. Assist her if necessary.



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Steps to Take 18-1— Obtain Venous Blood with aSterile Needle

Procedure Objective: To collect a blood sample using a sterile needle

Equipment Needed: Safety glasses and mask as needed, tourniquet, alcohol swab, dry cotton balls/gauze, bandage or tape, sharps container, test tube rack, syringe/needle, tubes

Steps to Take:

1. Wash your hands.


3. Verify that the lab order matches the patient’s name. If a fasting specimen has been ordered, verify that the patient has fasted. Put required tubes in the test tube rack.

4. Seat the patient comfortably.

5. Put on gloves and protective gear.

6. Open the sterile needle and syringe and attach, as necessary.

7. Pump the plunger a time or two to prevent sticking.

8. Select the proper tube(s) to transfer the blood to after collecting it.

9. Apply the tourniquet 3 to 4 inches above the chosen venipuncture site.

10. Have the patient close her hand and angle the arm in a downward position. The patient should not pump her hand.

11. Palpate the upper area of the arm with your index fi nger. You are feeling for either the median cubital, basilica or cephalic vein.

12. Feel for a slight rebound and roundness of the vein. Feel for its center and see if it might roll to the side.

13. After locating an acceptable vein that does not roll, mentally mark the location and visualize the puncture site.

14. Clean the site with an alcohol swab in a circular motion, moving from the center outward. Do not touch the site.

15. Anchor the vein by pulling the patient’s skin tight with your thumb 1 to 2 inches above and below the puncture site.

16. Holding the syringe with the bevel of the needle up, line up the needle with the vein. Enter the vein 1/4 inch below the vein location. Push the needle into the skin. You will note a slight resistance at fi rst that will give way to easy penetration as the vein is entered. Stop movement at this point.

17. Using the opposite hand, pull the plunger back gently and slowly.


0203992SP01A-32 95

18. If the vein collapses, stop pulling on the plunger and let it refi ll with blood. Do not hold the tubes as you transfer blood. The tubes should remain in the rack.

19. Remember the evacuated tube rules: Fill sterile blood culture tubes fi rst, then blue, green, lavender, gray and red tops.

20. Ask the patient to open her hand.

21. Release the tourniquet.

22. Place a cotton ball or gauze square just above the site while removing the needle. Apply pressure to the site for 3 to 5 minutes. Encourage the patient to keep her arm extended while applying pressure.

23. Dispose of the syringe and needle in sharps container.

24. Gently mix any of the tubes that contain anticoagulant. Immediately label all tubes before leaving the exam room.

25. Apply a bandage or tape tightly over cotton ball or folded gauze at the site.

26. Discard waste, gloves and mask in a biohazard container.



29. Complete a laboratory requisition.


96 0203992SP01A-32

Steps to Take 18-2— Obtain Venous Blood with aVacuum Tube

Procedure Objective: To collect a blood sample using a vacuum tube

Equipment Needed: Safety glasses and mask as needed, tourniquet, alcohol swab, dry cotton balls/gauze, bandage or tape, sharps container, test tube rack, disposable needle for evacuated tube system (20, 21, 22 gauge), evacuated tubes

Steps to Take:

1. Wash your hands.


3. Verify that the lab order matches the patient’s name. If a fasting specimen has been ordered, verify that the patient has fasted. Put required tubes in rack.



6. Open the sterile needle and thread it into the holder.

7. Tap all tubes that contain additives.

8. Insert the tube into the holder and up to the stopper without going through it.

9. Apply the tourniquet 3 to 4 inches above the chosen venipuncture site.

10. Have the patient close the hand and angle the arm in a downward position. The patient should not pump his hand.

11. Palpate the upper area of the arm with your index fi nger. You are feeling for either the median cubital, basilica or cephalic vein.

12. Feel for a slight rebound and roundness of the vein. Feel for its center and see if it might roll to the side.

13. After locating an acceptable vein that does not roll, mentally mark the location and visualize the puncture site.

14. Clean the site with an alcohol swab in a circular motion, moving from the center outward. Do not touch the site.

15. Anchor the vein by pulling the patient’s skin tight with your thumb about 1 to 2 inches below and above the puncture site.

16. With the bevel of the needle up, line up the needle with the vein. Enter the vein about 1/4 inch below the vein location. Push the needle into the skin. You will note a slight resistance at fi rst that will give way to easy penetration as the vein is entered. Stop movement at this point.


0203992SP01A-32 97

17. Using the opposite hand, grasp the fl ange of the tube holder and push the tube forward till the stopper is punctured.

18. Fill the tube until the vacuum stops and blood fl ow ceases. Remove tube from holder. Use the opposite hand to change tubes, as needed. Gently invert and mix tubes as you remove them.

19. Remember the evacuated tube rules: Fill sterile blood culture tubes fi rst, then blue, green, lavender, gray and red tops.

20. Ask the patient to open his hand.

21. Release the tourniquet.

22. Place a cotton ball/gauze square just above the site while removing the needle. Apply pressure to the site for 3 to 5 minutes. Encourage the patient to keep his arm ex-tended while applying pressure.

23. Dispose of the syringe or needle in the sharps container.

24. Gently mix if any of the tubes contain anticoagulant. Immediately label all tubes before leaving the patient’s side.

25. Apply tape/bandage tightly over cotton ball or folded gauze at the site.

26. Discard waste and gloves and mask in a biohazard container.



29. Complete a laboratory requisition.


98 0203992SP01A-32

Steps to Take 18-3— Obtain Venous Blood Using theButterfl y Needle Method

Procedure Objective: To collect a blood sample using a butterfl y needle

Equipment Needed: Gloves, safety glasses and mask, as needed, tourniquet, alcohol swab, dry cotton balls/gauze, bandage or tape, sharps container, test tube rack, butterfl y needle system (21, 23 or 25 gauge), tubes

Steps to Take:

1. Wash your hands.


3. Verify that the lab order matches the patient’s name. If a fasting specimen has been ordered, verify that the patient has fasted.



6. Open the butterfl y needle system. Screw the luer into the holder.

7. Tap all tubes that contain additives before you start to be sure the chemical is dislodged from the stopper and wall of the tube.

8. Insert the tube into the holder up to but NOT through the stopper.

9. Apply the tourniquet. Have the patient close her hand but not pump it.

10. Select a vein, noting its location and the direction it is laying.

11. Cleanse the site with an alcohol swab. Do not touch the site.

12. Pull the patient’s skin tight with your thumb and index fi nger 1 to 2 inches on either side of the chosen site.

13. Hold the wings of the butterfl y with the bevel up. Line up the needle with the vein (bevel up) and proceed to puncture the skin.

14. Discontinue pulling the skin tight; grasp the far end of the tube holder and push the tube in until it punctures the stopper.

15. Fill the tube until the vacuum is gone and blood stops fl owing.

16. Remove the tube from the holder. Insert and puncture additional tubes, as needed.

17. Immediately invert and gently mix each tube that contains an additive (approximately 5 to 10 times).

18. Have the patient open her hand and release the tourniquet.

19. Place a sterile cotton ball over the puncture site as you withdraw the needle from the arm. Immediately put the butterfl y unit in the sharps container.


0203992SP01A-32 99

20. Have the patient apply pressure to the site for 3 to 5 minutes, keeping the arm extended and straight.

21. Label all tubes while still at the patient’s side.

22. Apply pressure bandage/tape to site.

23. Remove and discard protective gear in biohazard container.



26. Complete laboratory requisition.


100 0203992SP01A-32

Steps to Take 18-4—Capillary Puncture

Procedure Objective: To collect capillary blood for blood testing using capillary puncture

Equipment Needed: Safety glasses, mask, gloves, alcohol, cotton, gauze, lancet, capillary tubes, sharps container and sealing clay

Steps to Take:

1. Wash your hands.


3. Make sure supplies are nearby.

4. Massage the puncture site or apply a warm towel or heat compress.

5. Soak the gauze or cotton in alcohol and rub the patient’s puncture site. Either allow it to air dry or dry it with gauze.

6. Hold the patient’s fi ngertips taut without squeezing the fi nger. Use the lancet to puncture the side of fl eshy portion of the fi nger tip.

7. Discard the lancet into the sharps container.

8. Wipe the fi rst drop of blood with gauze.

9. Allow a drop of blood to form near the fi nger tip.

10. Hold a capillary tube horizontally and touch the end to the drop of blood. Fill the tube to 2/3 full. Do not scoop up the blood as this will break the RBCs. If you need more blood, massage the patient’s hand or fi ngers, but not the puncture site.

11. Wipe the blood from the outside of the tube.

12. Place the tube in the sealing clay.

13. Repeat the procedure with another capillary tube.

Proper locations for capillary puncture


0203992SP01A-32 101

Steps to Take 18-5—Capillary Puncture with a Heel Stick

Procedure Objective: To collect capillary blood from an infant using a heel stick

Equipment Needed: Safety glasses, mask, gloves, alcohol, cotton, gauze, warm compress pediatric lancet, capillary tubes, sharps container and sealing clay

Steps to Take:

1. Wash your hands.

2. Identify the patient and explain the procedure to the infant’s parents.


4. Apply a warm compress to the infant’s heel for fi ve minutes.

5. Clean the heel with alcohol-soaked cotton or gauze. Allow to air dry or wipe dry with gauze.

6. Hold the infant’s heel fi rmly and place the pediatric lancet against the heel. An automatic lancet will puncture the heel. Otherwise, activate the lancet to puncture the heel.

7. Put the lancet in the biohazard container.

8. Wipe the fi rst drop of blood away.

9. Collect the next few drops of blood in the capillary tube. Seal if necessary.

10. Apply pressure to the puncture site. Then apply a bandage.

11. Remove your gloves and place them in a biohazard container.



102 0203992SP01A-32

Steps to Take 18-6—Blood Smear

Procedure Objective: To prepare a blood smear

Equipment Needed: Gloves, alcohol, gauze, glass slides with a frosted end, disposable lancet, biohazard waste containers

Steps to Take:

1. Wash your hands.

2. Make sure supplies are nearby. Label two slides with the patient’s name and the date.


4. Perform a capillary puncture.

5. Wipe away the fi rst drop of blood and wait for a second drop to form. Touch the drop of blood to the slide, but don’t allow the fi nger to touch the slide. Position the fi nger so the blood drops 1/4” from the frosted end.

6. Pick up another slide, which will be your spreader slide. Hold it at a 30- to 35-degree angle and bring it against the slide with the blood.

7. Using a gliding motion, spread blood over 3/4 of the slide. Create a feathered edge.

8. Allow the slide to air dry.

9. Dispose of gloves in the biohazard container.




0203992SP01A-32 103

Steps to Take 18-7—Perform a Heel Stick for a PKU Test

Procedure Objective: To collect capillary blood using the heel stick method and to prepare the specimen for a PKU test

Equipment Needed: Safety glasses, mask, gloves, alcohol, cotton, gauze, pediatric lancet, PKU test card and mailing envelope

Steps to Take:

1. Wash your hands.

2. Explain the procedure to the infant’s parents.


4. Complete the PKU test card.

5. Apply a warm compress to the infant’s heel for fi ve minutes.

6. Soak gauze or cotton in alcohol and clean the infant’s heel. Either allow it to air dry or dry it with gauze.

7. Grasp the infant’s heel and press the pediatric lancet against it. Activate it to puncture the heel if it’s not an automatic device.

8. Place the lancet in the biohazard container.

9. Wipe away the fi rst drop of blood with some gauze.

10. Apply the infant’s heel to each circle on the PKU test card. Hold the heel fi rmly, but be careful not to squeeze it. Fill each circle with enough blood so that the blood can be seen on the other side of the card.

11. Apply pressure to the infant’s puncture site and then apply a bandage.

12. Remove your gloves and place them in a biohazard container.


14. Document the collection in the infant’s medical record.

15. Let the test card dry for two hours at room temperature. Place the card in a mailing envelope and mail within 48 hours.

Gray areas indicate proper locations for a heel stick.


104 0203992SP01A-32

Steps to Take 21-1—Prepare a Dry Smear for Staining

Procedure Objective: To prepare a dry smear for staining

Equipment Needed: Disposable gloves, clean glass slide, methanol, cotton swab, forceps

Steps to Take:

1. Wash your hands.

2. Label the slide with the patient’s name.

3. Put on gloves.

4. Cover two-thirds of the slide with a thin layer of specimen.

5. Hold the slide with forceps and dip into methanol, fi xing the specimen in place. Note: Safety concerns and effi ciency led to the common use of methanol fi xation, replacing the once popular heat-fi x technique that used Bunsen burners.

6. Let the slide air-dry, then proceed with staining procedure.

7 Sanitize your work area.


0203992SP01A-32 105

Steps to Take 22-1—Collect a Clean-catch Urine Specimen

Procedure Objective: To collect a clean-catch urine specimen

Equipment Needed: Sterile specimen container, two aseptic cleansing towels

Steps to Take:

1. Wash your hands.

2. Assemble the necessary supplies.

3. Identify the patient and explain the procedure, stressing the need for a mid-stream collection to ensure purity.

4. Give the patient the necessary supplies.

For Female Patients:

5. Wash your hands.

6. Open the container without touching inside.

7. Spread the labia and clean the genital area from front to back using both towels, once each.

8. Continuing to hold the labia apart, void a small amount of urine into the toilet. Then fi ll the specimen cup half full. Continue to void any remaining urine into the toilet.

9. Wash your hands and cap the container.

For Male Patients:

5. Wash your hands.

6. Open the container without touching inside.

7. Retract the foreskin of the penis and clean the glans using both towels, once each.

8. Continuing to hold the foreskin back, void a small amount of urine into the toilet. Then fi ll the specimen cup half full. Continue to void any remaining urine into the toilet.

9. Wash your hands and cap the container.


106 0203992SP01A-32

Steps to Take 22-2—Perform a Catheterization on a Female Patient

Procedure Objective: To catheterize a female patient for urine collection

Equipment Needed: Sterile catheter kit, including: sterile gloves, lubricant, sterile cotton balls, sterile urine container with label, sterile 2 x 2 sponges, forceps, sterile absorbent plastic pad, sterile catheter, biohazard waste container, waxed paper bag, Betadine

Steps to Take:

1. Wash your hands.

2. Assemble supplies on a Mayo stand.


4. Have the patient disrobe below the waist.

5. Position the patient in a dorsal recumbent position on an examining table.


7. Open the catheter kit on the Mayo stand. This is a sterile fi eld.

8. Place the sterile absorbent plastic pad under the patient’s buttocks. Ask the patient to keep her legs apart.

9. Pour Betadine over three cotton balls.

10. Open the urine specimen container.

11. Apply lubricant to a gauze sponge. Then, place the tip of the catheter in the lubricant.

12. Spread the labia with one hand. The other hand must remain sterile. Using forceps, use the cotton balls soaked in antiseptic to clean the genital area. One cotton ball for the right labia, one cotton ball for the left labia and one cotton ball for the center. Discard the forceps and continue holding the labia open with your unsterile hand.

13. With your sterile hand, grip the catheter three to four inches below the lubricated tip.

14. Gently insert the tip of the catheter into the urinary meatus six inches, until urine starts to fl ow.

15. Stop the fl ow by pinching the catheter.

16. Position the other end of the catheter in the urine specimen cup.

17. Allow the urine fl ow to continue, fi lling the cup with 60 mL of urine.

18. Allow the remaining urine to fl ow into a sterile kit pan.

19. Slowly remove the catheter.

20. Dry the area with remaining cotton balls.


0203992SP01A-32 107

21. Place the lid on the specimen container.

22. Remove the procedure supplies. Discard gloves and supplies in a biohazard waste container.

23. Help the patient sit up.




108 0203992SP01A-32

Steps to Take 22-3—Perform a Catheterization on a Male Patient

Procedure Objective: To catheterize a male patient for urine collection

Equipment Needed: Sterile catheter kit, including: sterile gloves, lubricant, sterile cotton balls, sterile urine container with label, sterile 2 x 2 sponges, forceps, sterile absorbent plastic pad, sterile catheter, biohazard waste container, waxed paper bag, Betadine

Steps to Take:

1. Wash your hands.

2. Assemble supplies on a Mayo stand.


4. Have the patient disrobe below the waist.

5. Position the patient in a dorsal recumbent position on an examining table.

6. Wash your hands. Put on sterile gloves.

7. Open the catheter kit on the Mayo stand. This is a sterile fi eld.

8. Place the sterile pad under the patient’s penis. Empty the contents of the kit onto the sterile fi eld.

9. Pour Betadine over three cotton balls.

10. Open the urine specimen container.

11. Apply lubricant to a gauze sponge. Then, place the tip of the catheter in the lubricant.

12. With one hand, hold the penis below the glans. The foreskin may be pulled back to expose the meatus. The free hand will remain sterile.

13. With the sterile hand, use sterile forceps to grip cotton balls soaked in antiseptic to clean around the meatus, using a circular motion from the center to the outside.

14. With the sterile hand, take the catheter in hand. Hold the penis upright and straight. Insert the catheter six inches in, until urine starts to fl ow. Do not force the catheter. If the catheter won’t go in, discontinue the procedure.

15. Position the other end of the catheter in a sterile kit pan. If a specimen is ordered, fi ll the cup.

16. Allow the remaining urine to fi ll the kit pan.

17. Slowly remove the catheter.

18. Dry the area with the remaining cotton balls.

19. Place the lid on the specimen container.


0203992SP01A-32 109

20. Remove the procedure supplies. Discard gloves and supplies in a biohazard waste container.

21. Help the patient sit up.




110 0203992SP01A-32

Steps to Take 22-4—Obtain the Specifi c Gravity of Urine Using a Refractometer

Procedure Objective: To use a refractometer to measure the specifi c gravity of urine

Equipment Needed: Gloves, urine specimen, refractometer, pipette, distilled water, 5% saline solution, lint free tissue, quality control sample, biohazard container, antiseptic cleaner

Steps to Take:

1. Wash your hands.



4. Calibrate the experiment by checking the value of distilled water, which should read 1.000.

5. Clean the cover and prism with a tissue moistened with distilled water. Wipe dry. Close the cover.

6. Apply a drop of distilled water to the notched part of the cover so that it spills over the prism.

7. Hold the instrument up and tilt it so that light enters.

8. Read the scale, which is the dividing line between the dark and light areas.

9. Wipe the prism.

10. Test a sample of 5% saline solution, which should read 1.023, +/- .0001.

11. Repeat the procedure with the urine specimen.

12. Clean the area with chlorine solution after fi nishing.

13. Dispose of all biohazardous waste in the biohazard container. Be sure the refractometer is thoroughly cleaned with distilled water and lint-free tissue.

14. Remove your gloves.




0203992SP01A-32 111

Steps to Take 25-1— Prepare a Female Patient for a Pap Test and Pelvic Exam

Procedure Objective: To assist a patient in preparing and completing a Pap test and pelvic exam

Equipment Needed: Speculum, lubricating gel, Thin Prep or glass slide for specimen, fi xative or hairspray, Texas swab, small cotton swab, gauze, tissues, gloves—a pair for physician and a pair for you, headlamp or gooseneck lamp

Steps to Take:

1. Wash hands.


3. Have patient empty her bladder prior to procedure.

4. Instruct patient to undress and put on gown with drape over lap.

5. Assist patient into the lithotomy position.

6. Explain the procedure and instruct her to breathe through her mouth to help her relax during the exam.


8. Assist physician during the pelvic exam and pass instruments as needed.

9. When the physician is ready to take a sample for the Pap test, label slide and/or wet prep with patient name, DOB and the date of the test.

10. Follow the doctor’s instructions to assist with the sample.

11. When the exam is completed, assist patient into sitting position and instruct her to get dressed, offering tissues.

12. Remove soiled instruments.

13. Complete preparation of the sample to be sent to the lab.

14. Clean room.

15. Wash hands.



112 0203992SP01A-32

Steps to Take 25-2—Assist with a Sigmoidoscopy

Procedure Objective: To assist the physician and the patient during a sigmoidoscopy

Equipment Needed: 10-12” sigmoidoscope, anoscope, headlamp or gooseneck lamp, suction pump, insuffl ator, rectal dressing forceps, fi nger cots, gloves, lubricating jelly, basin of water, patient gown and drape, towel, cotton balls, gauze, tissue, specimen container

Steps to Take:

1. Wash hands.



4. Assemble materials in order of use.

5. Make sure equipment functions properly.

6. Have patient empty bladder.

7. Instruct patient to undress from waist down and put on gown, open in back.

8. Assist patient into knee-chest position or on jack knife table.

9. Drape patient immediately to avoid unnecessary exposure.

10. Assist physician as needed, transferring instruments and equipment.

11. Lubricate end of scope.

12. Attach infl ation bulb to scope.

13. Attach light source.

14. Turn on suction machine.

15. Hand biopsy forceps to physician.

16. Label specimen bottle with patient’s name, DOB and the date of the exam.

17. Observe patient’s reactions such as fatigue and fainting and be ready to respond.

18. Wipe anal area with tissue at completion of exam.


20. Instruct patient to get dressed.

21. Clean room and equipment.

22. Send specimen to lab.

23. Wash hands.



0203992SP01A-32 113

Steps to Take 25-3—Conduct a Breast Self-exam

Procedure Objective: To teach the patient how to detect cancerous lumps in the breast tissue

Equipment Needed: Patient needs mirror, bed, shower

Steps to Take:

Instruct patient to:

1. Stand in front of a mirror with your hands on your hips. Examine your breasts visually. Be certain that both breasts are their usual size, shape and color. If you see any dimpling or puckering, or if the nipples have changed position or become inverted, call the doctor.

2. Repeat step one with your arms raised over your head.

3. While at the mirror, squeeze each nipple between fi nger and thumb, looking for discharge. The discharge could be milky, yellow or bloody.

4. Lie down on your back. Use your right hand to feel your left breast, and left hand to feel your right breast. Keep your fi ngers fl at and together. Cover the entire breast from top to bottom and side to side. Follow a pattern to ensure that each breast is checked entirely. Use a soft touch, followed by a fi rmer touch, looking for lumps.

5. Stand up in a running shower. Wet and slippery skin makes it easier to check for abnormalities. Repeat step four in the upright position.

6. Notify your doctor if you have any concerns, or if you notice any changes.


114 0203992SP01A-32

Steps to Take 25-4— Determine Color Vision Using the Ishihara Method

Procedure Objective: To test a patient’s color vision using the Ishihara test

Equipment Needed: Room with natural light, chair, Ishihara plates

Steps to Take:

1. Wash hands.


3. Have the patient sit comfortably in a room with natural light.

4. Hold each plate 30 inches from the patient.

5. Have patient state what number he sees and record the answer.

6. Record results on his chart. If 10 or more plates are read correctly (out of 24), color vision is considered normal.


0203992SP01A-32 115

Steps to Take 26-1—Prepare Treatment Room

Procedure Objective: To prepare a treatment room for minor surgery

Equipment Needed: Light bulbs, batteries, sutures, bandages, dressings, ointments, tape, pathology container with preservative for biopsy, lab requisition as needed

Steps to Take:

1. Check all treatment room supplies prior to procedure.

2. Adjust lighting. Replace bulbs and batteries as necessary.

3. Check function of all electrical instruments such as electrocautery unit, electric exam table, other electrical instruments.

4. Be sure physician stool is available.

5. Adjust Mayo stand height for appropriate doctor.

6. Arrange nonsterile supplies on side counter in order of use.

a. Sutures, bandages, dressings, ointments, tape

b. Pathology container with preservative for biopsy, as needed

c. Lab requisition, if needed

7. Waste receptacles should be nearby.


116 0203992SP01A-32

Steps to Take 26-2—Assist with Suturing a Laceration

Procedure Objective: To assist the physician in sealing a wound using sutures

Equipment Needed:

Sterile Tray: Syringe/needle for anesthetic, hemostats (curved), tissue forceps, iris scissors (curved), needle holder, suture material with needle, gauze sponges, sterile gloves

Nonsterile items: Anesthetic medication, as ordered, dressings, bandages, ointments, tape, gloves

Steps to Take:

1. Reassure and support patient. Explain the procedure.

2. Wash hands. Put on gloves.

3. Assess severity of wound and its cause.a. Ask about general health conditions.b. Ask about any known allergies, record.c. Inquire as to her last tetanus booster, record.d. Soak wound in antiseptic solution, as ordered.e. Clean and dry the wound. Apply pressure with sterile gauze if

bleeding continues.f. Position patient comfortably, lying or sitting on exam table.

4. Prepare sterile laceration repair tray. Notify physician.

5. Remove the sterile cover from the surgical tray while the doctor is putting on sterile gloves.

6. Assist with placement of the stool and spotlight adjustment. Position Mayo stand for physician convenience.

7. Assist as needed during the skin prep and draping.a. When pouring the antiseptic solution, fi rst pour a small amount into

waste receptacle to sterilize the edge of the bottle. Then pour a small amount into the sterile container on the surgical tray, being careful not to touch any part of the sterile fi eld.

8. Assist with drawing up local anesthetic, as needed.a. Hold the vial of medication upside down while physician withdraws

the appropriate dose.

9. Apply clean gloves to protect yourself or sterile gloves if physician wants you to assist with the procedure.


0203992SP01A-32 117

10. Provide emotional support to patient, as needed.

11. When physician selects appropriate suture material, open the chosen packet, dropping the inner suture pack onto sterile fi eld without touching any part of the sterile fi eld.

12. At end of suturing, cleanse wound, as ordered.

13. Apply dressing/bandage, as ordered.

14. Dispose of biohazardous waste materials appropriately.

15. Review postoperative instructions as provided by physician with the patient.

16. Remove gloves.

17. Wash hands.



118 0203992SP01A-32

Steps to Take 27-1— Obtain and Administer Liquid Oral Medication

Procedure Objective: To correctly pour and administer liquid oral medication

Equipment Needed: Bottle of liquid medicine, measuring cup or eyedropper, glass of water, doctor’s written order, PDR, patient’s chart

Steps to Take:

1. Wash hands.


3. If the doctor’s order is given to you verbally, repeat it back to the doctor to verify. Write down the order immediately.

4. Double check written orders. Clarify illegible writing.

5. Use the PDR to look up any medication you aren’t familiar with.

6. Follow the six “rights.”

7. Compare the medication with the doctor’s order. Check the expiration date. Check the medicine for discoloration.

8. Shake the liquid to ensure a homogenous dose.

9. Calculate the dosage, as necessary.

10. Open the bottle. Place the cap rim-up on a clean surface.

11. Pour medicine into measuring cup, or draw up with an eyedropper. If a cup is used, make certain that the cup is on a level surface. Measure liquid using the meniscus.

12. Take vital signs prior to administration.

13. Provide suffi cient water for the patient’s comfort.

14. Be certain that the patient takes the medication.

15. Wash hands.



0203992SP01A-32 119

Steps to Take 27-2— Withdraw Medication from an Ampule

Procedure Objective: To properly withdraw medication from an ampule using a syringe

Equipment Needed: Syringe and needle, ampule of medication, sterile gauze pad

Steps to Take:

1. Prepare a syringe and needle unit for use. Inspect the syringe. Make sure the needle is fi rmly attached.

2. Inspect the ampule to see if any medicine is trapped in the stem. If so, tap the stem gently to make the medicine return to the base of the ampule.

3. Cover the stem with sterile gauze.

4. Grasp fi rmly over the scored part of the stem and break off the stem, pushing it away from your body. Set the open ampule down.

5. Discard the gauze and stem in sharps container.

6. Place the syringe and needle in your dominant hand. Remove the needle cover. Do not pull air into the syringe.

7. Hold the open ampule between your thumb and index fi nger of the other hand.

8. Insert the needle into the medicine in the open ampule.

9. Fill the barrel of the syringe with the amount of medicine prescribed.

10. Remove the needle from the ampule. Hold the syringe toward the light and check for air bubbles. If necessary, remove air bubbles by tapping against the syringe and expelling the bubbles with the plunger as they rise to the top.

11. Recheck that the amount of medicine is correct.

12. Replace the sheath over the needle.

13. Dispose of ampule in sharps container.


120 0203992SP01A-32

Steps to Take 27-3—Withdraw Medication from a Vial

Procedure Objective: To properly use a syringe to withdraw medication from a vial

Equipment Needed: Vial of medication, syringe and needle unit, alcohol swab

Steps to Take:

1. Prepare a syringe and needle unit for use. Inspect the syringe. Make sure the needle is fi rmly attached.

2. Draw up an amount of air into the syringe that will be equal to the amount of medicine that you plan to withdraw from the vial.

3. Clean the rubber stopper on the top of the vial with an alcohol swab.

4. Place the syringe in your dominant hand and remove the cover from the needle.

5. Pick up the vial in the other hand and invert it. Hold it between your thumb and index fi nger.

6. With the bevel of the needle toward you, insert the needle straight through the rubber stopper at a 90-degree angle.

7. Slowly inject the air from the syringe into the vial.

8. Keeping the needle in the solution, fi ll the barrel of the syringe with the prescribed amount of medicine. Be careful not to have any dead air space left in the barrel before you remove the needle from the vial.

9. To remove air bubbles, hold the syringe vertically with the needle up. Tap the outside of the barrel with your fi nger next to the air bubble. When it moves to the top, use the syringe plunger to gently expel it from the unit into the vial.

10. Remove the vial from the tip of the needle.

11. Replace the sheath over the needle.

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