A hard surface on which to place the patient ♦ protective equipment, such as a disposable airway device (optional)

♦ These instructions provide a step-by-step guide for CPR as currently recommended by the American Heart Association (AHA).

♦ Acquired immunodeficiency syndrome (AIDS) isn’t known to be transmitted in saliva, but some health care professionals may hesitate to give rescue breaths if the patient has AIDS. AHA recommends health care professionals learn how to use disposable airway equipment.

♦ Note why you initiated CPR; report whether the patient suffered cardiac or respiratory arrest.

♦ Record when you found the patient and started CPR and how long the patient received CPR.

♦ Note the patient’s response and complications.

♦ Document if the patient was moved to the intensive care area.

♦ Document health care personnel participating in the resuscitation.

No specific equipment needed

♦ Determine the patient’s level of consciousness by shouting, “Are you choking? Can you speak?”

♦ Assess for airway obstruction.

♦ Don’t intervene if the person is coughing forcefully and able to speak; a strong cough can dislodge the object.

♦ Give each individual thrust with the intent of relieving the obstructing object. It may be necessary to repeat thrusts to dislodge the obstruction and clear the airway.

♦ If the patient vomits, wipe out his mouth to prevent additional obstruction.

♦ Even if efforts to clear the airway don’t seem to be effective, keep trying.

♦ Explain what you’re doing to gain the patient’s cooperation, as needed.

♦ Record the date and time of the event.

♦ Note the patient’s actions before the obstruction.

♦ Document the approximate length of time it took to clear the airway.

♦ Record the type and size of object removed.

♦ Note vital signs after the event.

♦ Document complications and nursing actions taken.

One 4,000-ml container or two 2,000-ml containers of irrigating solution (usually normal saline solution) or the prescribed amount of medicated solution ♦ Y-type tubing made specifically for bladder irrigation ♦ alcohol ♦ I.V. pole or bedside pole attachment ♦ drainage bag and tubing

♦ Double-check the irrigating solution against the physician’s order. Usually, normal saline solution is prescribed for bladder irrigation after prostate or bladder surgery. The patient will need large volumes of solution for the first 24 to 48 hours after surgery. Make sure the solution is at room temperature or slightly warmed for patient comfort.

♦ If the solution contains an antibiotic, check the patient’s chart to make sure he isn’t allergic to the drug.

♦ Wash your hands. Assemble all equipment at the patient’s bedside. Explain the procedure and provide privacy.

♦ Hang the irrigating solution on the I.V. pole.

♦ Insert one spike of the Y-type tubing into each container of irrigating solution.

♦ Unclamp the tubing clamp on one container of irrigation solution. Squeeze the drip chamber on the tubing.

♦ Open the flow clamp and flush the tubing to remove air, which could cause bladder distention. Then close the clamp.

♦ Clean the opening to the inflow lumen (third port) of the catheter with alcohol.

♦ Insert the distal end of the Y-type tubing securely into the inflow lumen of the catheter.

♦ Make sure that the outflow lumen is securely attached to the tubing of the drainage bag.

♦ Open the flow clamp and set the drip rate as ordered.

♦ To prevent air from entering the system, replace the primary container before it empties completely.

♦ If you have a two-container system, simultaneously close the clamp under the nearly empty container and open the clamp under the reserve container. This prevents reflux of irrigating solution from the reserve container into the nearly empty one. Hang a new reserve container on the I.V. pole and insert the tubing, maintaining asepsis.

♦ Empty the drainage bag about every 4 hours or as often as needed. Use sterile technique to avoid the risk of contamination.

♦ Monitor the patient’s vital signs at least every 4 hours during irrigation. Increase the frequency of monitoring if the patient’s condition becomes unstable.

♦ Unless specified otherwise, the patient should remain on bed rest while receiving continuous bladder irrigation.

♦ Check the inflow and outflow lines periodically for kinks to make sure the solution is running freely. If the solution flows rapidly, check the lines often.

♦ Measure the outflow volume accurately. It should, allowing for urine production, exceed inflow volume.

If the inflow volume exceeds the outflow volume postoperatively, suspect bladder rupture at the suture lines or renal damage, and notify the physician immediately.

♦ Check outflow for changes in appearance and for blood clots, especially if irrigation is ordered postoperatively to control bleeding.

– If the drainage is bright red, irrigating solution is usually infused rapidly, with the clamp wide open, until the drainage clears. Notify the physician at once if you suspect hemorrhage.

– If the drainage is clear, the solution is usually given at a rate of 40 to 60 gtt/minute. The physician typically specifies the rate for antibiotic solutions.

♦ Encourage oral fluid intake of 2 to 3 qt/day (2 to 3 L/day), unless contraindicated by another medical condition.

♦ Watch for interruptions in the continuous irrigation system; these can predispose the patient to infection.

♦ Check often for obstruction in the outflow lumen of the catheter. Obstruction can lead to bladder distention and rupture.

♦ Record the date, time, and amount of fluid given (on the intake and output record) each time you finish a container of solution.

♦ Record the time and amount of fluid each time you empty the drainage bag.

♦ Note the appearance of drainage.

♦ Note any patient complaints.

Reagent strips ♦ gloves ♦ portable blood glucose meter ♦ alcohol pads ♦ gauze pads ♦ disposable lancets or mechanical blood-letting device ♦ small adhesive bandage ♦ watch or clock with a second hand, if meter is unavailable

♦ Verify the patient’s identity using two patient identifiers. Explain the procedure to the patient. If the patient is a child, explain the procedure to the parents and child. Provide privacy.

♦ Select the puncture site; this is usually the lateral side of a fingertip but may also be the arm or leg, depending on the machine used.

Select the heel or great toe for an infant.

♦ Wash your hands and put on gloves.

♦ If needed, dilate the capillaries by applying warm, moist compresses to the area for about 10 minutes or place the limb in a dependent position below the heart.

♦ Wipe the puncture site with an alcohol pad, and dry it thoroughly with a gauze pad.

♦ To collect a sample from the fingertip with a disposable lancet (smaller than 2 mm) or an Autolet (which uses a spring-loaded lancet), position the lancet on the side of the patient’s fingertip, perpendicular to the fingerprint lines. Pierce the skin sharply and quickly to minimize the patient’s pain and anxiety and to increase blood flow.

♦ After puncturing the fingertip, don’t squeeze the puncture site to avoid diluting the sample with tissue fluid.

♦ Touch a drop of blood to the reagent patch or membrane on the strip; make sure you cover the entire area.

♦ After collecting the blood sample, briefly apply pressure to the puncture site to prevent painful extravasation of blood into subcutaneous tissues. Ask an adult patient to hold a gauze pad firmly over the puncture site until bleeding stops.

♦ If reading the test without a meter, leave the blood on the reagent strip for exactly 60 seconds. Compare the color change on the strip with the standardized color chart on the product container.

♦ If you’re using a blood glucose meter, follow the manufacturer’s instructions and read the result on the digital display.

♦ After bleeding has stopped, you may apply a small adhesive bandage to the puncture site, if needed.

♦ Before using reagent strips, check the expiration date on the package, and replace outdated strips. Check for special instructions related to the specific reagent. The reagent area of a fresh strip should match the color of the “0” block on the color chart. Protect the strips from light, heat, and moisture.

♦ Before using a blood glucose meter, calibrate it and run it with a control sample to ensure accurate test results. Follow the manufacturer’s instructions for calibration.

♦ Avoid selecting cold, cyanotic, or swollen puncture sites to ensure an adequate blood sample. If you can’t obtain a capillary sample, perform venipuncture and place a large drop of venous blood on the reagent strip. If you
want to test blood from a refrigerated sample, allow the blood to return to room temperature before testing it.

♦ To help detect abnormal glucose metabolism and diagnose diabetes mellitus, the physician may order other blood glucose tests.

♦ Record the reading from the reagent strip or blood glucose meter (in your notes or on a special flowchart, if available).

♦ Document the time and date of the test.

♦ Record how the patient tolerated the procedure and any teaching done.

Stethoscope ♦ emesis basin ♦ facial tissues ♦ suction equipment as needed ♦ equipment for oral care ♦ trash bag

♦ Gather the equipment at the bedside. Set up suction equipment, if needed, and test its function.

♦ Explain the procedure to the patient, provide privacy, and wash your hands.

♦ Auscultate the patient’s lungs with a stethoscope to evaluate the patient’s baseline respiratory status.

♦ Position the patient as needed using pillows.

– For patients with generalized disease, drainage usually starts with the lower lobes, continues with the middle lobes, and ends with the upper lobes.

– For patients with localized disease, drainage starts with the affected lobes and proceeds to the other lobes to avoid spreading the disease to uninvolved areas.

♦ Instruct the patient to remain in each position for 10 to 15 minutes. During this time, perform percussion and vibration as ordered. (See Performing percussion and vibration.)

♦ After you perform postural drainage, percussion, or vibration, instruct the patient to cough to remove loosened secretions.

– Tell him to inhale deeply through his nose and then to exhale in three short huffs.

– Instruct him to inhale deeply again and then to cough through a slightly open mouth.

– Three consecutive coughs are highly effective.

– An effective cough sounds deep, low, and hollow; an ineffective one, high-pitched.

♦ Have the patient exercise for about 1 minute, then have him rest for 2 minutes. Gradually progress to 10-minute exercise periods done four times daily.

♦ Provide oral hygiene because secretions may have a foul taste or a stale odor.

♦ Dispose of secretions with suction equipment or tissues and a trash bag.

♦ Provide an emesis basin if needed.

♦ Auscultate the patient’s lungs to evaluate the effectiveness of therapy.

♦ For optimal effectiveness and safety, modify chest PT according to the patient’s condition.

– For example, start or increase the flow of supplemental oxygen, if indicated.

– Also, suction a patient who has an ineffective cough reflex.

– If the patient tires quickly during therapy, shorten the sessions. Fatigue leads to shallow respirations and increased hypoxia.

♦ Chest PT should be limited to 30 minutes or less, as tolerated. Drainage of different lobes may need to be done during separate PT sessions.

♦ If the patient is receiving chest PT to prevent dehydration of mucus and promote easier mobilization, make sure he takes in plenty of fluids.

♦ Avoid performing postural drainage immediately before or within 1½ hours after meals to avoid nausea and aspiration of food or vomitus.

♦ Because chest percussion can induce bronchospasm, adjunct treatment (for example, intermittent positivepressure breathing, aerosol, or nebulizer therapy) should precede chest PT.

♦ To avoid injuring the spine or internal organs, don’t percuss over the spine, liver, kidneys, or spleen. Also, don’t percuss over bare skin or a woman’s breasts. Percuss over soft clothing (but not over buttons, snaps, or zippers), or place a thin towel over the chest wall. Remove jewelry that might scratch or bruise the patient.

♦ Observe the patient for complications.

– During postural drainage in headdown positions, pressure on the diaphragm by abdominal contents can impair respiratory excursion and lead to hypoxia or orthostatic hypotension.

– The head-down position may also lead to increased intracranial pressure, which precludes the use of chest PT in a patient with acute neurologic impairment.

– Vigorous percussion or vibration can cause rib fracture, especially if the patient has osteoporosis.

– In a patient with emphysema and blebs, coughing can lead to pneumothorax.

Preoperatively, explain coughing and deep-breathing exercises so the patient can practice them when he’s pain-free. Postoperatively, splint the patient’s incision using your hands or, if possible, teach the patient to splint it himself to minimize pain during coughing.

♦ Record the date and time of chest PT.

♦ Note positions used to drain secretions.

♦ Record the length of time each position maintained.

♦ Note the chest segments percussed or vibrated.

♦ Record color, amount, odor, and viscosity of secretions produced.

♦ Note any presence of blood.

♦ Note complications and nursing actions taken.

♦ Note patient’s tolerance of treatment.

Pouching system ♦ stoma measuring guide ♦ stoma paste (if drainage is watery to pasty or stoma secretes excess mucus) ♦ scissors ♦ water ♦ closure clamp ♦ toilet or bedpan ♦ gloves ♦ facial tissue ♦ prepared skin barrier ♦ gauze pad ♦ optional: ostomy belt, paper tape, mild nonmoisturizing soap, skin shaving equipment

♦ Explain the procedure to the patient.

♦ Provide privacy and emotional support.

♦ Gather the equipment and take it to the patient’s bedside.

♦ After you perform the procedure and explain it to the patient, encourage the patient’s increasing involvement in self-care.

♦ Use adhesive solvents and removers only after patch testing the patient’s skin. Some products may irritate skin or produce hypersensitivity reactions.

♦ Consider using a liquid skin sealant to give the skin added protection from drainage and adhesive irritants.

♦ Remove the pouching system if the patient reports burning or itching beneath it or purulent drainage around the stoma.

♦ Notify the physician or therapist of skin irritation, breakdown, rash, or unusual appearance of the stoma or peristomal area.

♦ Use commercial pouch deodorants, if desired. However, most pouches are odor-free, and odor should be evident only when you empty the pouch or if it leaks.

♦ Before the patient is discharged, suggest that he avoid odor-causing foods, such as fish, eggs, onions, and garlic.

♦ If the patient wears a reusable pouching system, suggest that he obtain two or more systems so that he can wear one while the other dries after it’s cleaned with soap and water or a commercially prepared cleaning solution.

♦ Failure to fit the pouch properly over the stoma or improper use of a belt can injure the stoma.

♦ Be alert for a possible allergic reaction to adhesives or other ostomy products.

♦ Record date and time of the pouching system change. Note how the patient tolerated the procedure.

♦ Note character of drainage, including color, amount, type, and consistency.

♦ Note the appearance of the stoma and the peristomal skin.

♦ Document patient teaching content.

♦ Record patient’s response to selfcare instruction.

♦ Record your evaluation of the patient’s learning progress.

Colostomy irrigation set (contains an irrigation drain or sleeve, an ostomy belt [if needed] to secure the drain or sleeve, water-soluble lubricant, drainage pouch clamp, and irrigation bag with clamp, tubing, and cone tip) ♦ 1 L of tap water irrigant warmed to about 100° F (37.8° C) ♦ warmed normal saline solution (for cleansing enemas) ♦ I.V. pole or wall hook ♦ washcloth and towel ♦ water ♦ ostomy pouching system ♦ linen-saver pad ♦ gloves ♦ optional: bedpan or chair, mild nonmoisturizing soap, rubber band or clip, and small dressing, bandage, or commercial stoma cap

♦ Gather equipment at the bedside or help the patient get to the bathroom. Provide privacy. Wash your hands and put on gloves.

♦ Explain each step of the procedure to the patient because he’ll probably be irrigating the colostomy himself.

♦ Depending on the patient’s condition, colostomy irrigation may be performed in bed using a bedpan or in the bathroom using the toilet or a chair.

– For irrigation with the patient in bed, place the bedpan beside the bed and elevate the head of the bed to between 45 and 90 degrees, if allowed.

– For irrigation in the bathroom, have the patient sit on the toilet or on a chair facing the toilet, whichever he finds more comfortable.

♦ Set up the irrigation bag with tubing and a cone tip.

♦ Fill the irrigation bag with warmed tap water (or normal saline solution, if the irrigation is to clean the bowel).

♦ Hang the bag on the I.V. pole or a wall hook. The bottom of the bag should be at the patient’s shoulder level to prevent fluid from entering the bowel too quickly. Most irrigation sets also have a clamp that regulates the flow rate.

♦ Prime the tubing with irrigant to prevent air from entering the colon and possibly causing cramps and gas pains.

♦ If the patient is in bed, place a linen-saver pad under him to protect the sheets from getting soiled.

♦ If the patient uses an ostomy pouch, remove it.

♦ Place the irrigation sleeve over the stoma. If the sleeve doesn’t have an adhesive backing, secure the sleeve with an ostomy belt. If the patient has a two-piece pouching system with flanges, snap off the pouch and save it. Snap on the irrigation sleeve.

♦ Place the open-ended bottom of the irrigation sleeve in the bedpan or toilet to promote drainage by gravity. If needed, cut the sleeve so that it meets the water level inside the bedpan or toilet. Effluent may splash from a short sleeve or may not drain from a long one.

♦ Lubricate your gloved small finger with water-soluble lubricant, and insert the gloved finger into the stoma. If you’re teaching the patient, have him do this to determine the bowel angle at which to insert the cone safely. Expect the stoma to tighten when the finger enters the bowel and then to relax in a few seconds.

♦ Lubricate the cone with watersoluble lubricant to prevent it from irritating the mucosa.

♦ Angle the cone to match the bowel angle, and insert it into the top opening of the irrigation sleeve and then
into the stoma. Insert the cone gently but snugly; never force it into place.

♦ Unclamp the irrigation tubing, and let the water flow slowly.

– If you don’t have a clamp to control the flow rate of the irrigant, pinch the tubing to control the flow.

– The water should enter the colon over a period of 10 to 15 minutes.

– If the patient reports cramping, slow or stop the flow, keep the cone in place, and have the patient take a few deep breaths until the cramping stops.

– Cramping during irrigation may result from a bowel that’s ready to empty, water that’s too cold, a rapid flow rate, or air in the tubing.

♦ Have the patient remain stationary for 15 to 20 minutes to let the initial effluent drain.

♦ If the patient is ambulatory, he can stay in the bathroom until all effluent empties, or he can clamp the bottom of the drainage sleeve with a rubber band or clip and return to bed. Explain that ambulation and activity stimulate elimination.

♦ Suggest that a nonambulatory patient lean forward or massage his abdomen to stimulate elimination.

♦ Wait about 45 minutes for the bowel to finish eliminating the irrigant and effluent. Then remove the irrigation sleeve.

♦ If the irrigation was intended to clean the bowel, repeat the procedure with warmed normal saline solution until the return solution appears clear.

♦ Using a washcloth, mild nonmoisturizing soap, and water, clean the area around the stoma. Rinse and dry the area thoroughly with a clean towel.

♦ Inspect the skin and stoma for changes in appearance.

– Although it’s usually dark pink to red, the color of the stoma may change with the patient’s status.

– Notify the physician of marked changes in stoma color.

– A pale hue may result from anemia.

– Substantial darkening suggests a change in blood flow to the stoma.

♦ Apply a clean pouch. If the patient has a regular pattern of bowel elimination, he may prefer a small dressing, bandage, or commercial stoma cap.

♦ If the irrigation sleeve is disposable, discard it. If it’s reusable, rinse it and hang it to dry along with the irrigation bag, tubing, and cone.

♦ Irrigating a colostomy to establish a regular bowel elimination pattern isn’t successful in all patients.

– Keep a record of results.

– If the bowel continues to move between irrigations, try decreasing the volume of irrigant.

– Increasing the volume of irrigant won’t help, because it only stimulates peristalsis.

– Also consider irrigating every other day.

♦ Irrigation may help regulate bowel function in patients with a descending or sigmoid colostomy because this is the bowel’s stool storage area. However, a patient with an ascending or transverse colostomy won’t benefit from irrigation. A patient with a descending or sigmoid colostomy who’s missing part of the ascending or transverse colon may not be able to irrigate successfully, because his ostomy may function as an ascending or transverse colostomy.

♦ If diarrhea develops, stop irrigations until stools form again.

♦ Irrigation alone won’t achieve regularity for the patient. He must also observe a complementary diet and exercise regimen.

♦ If the patient has a strictured stoma that prohibits cone insertion, remove the cone from the irrigation tubing and replace it with a soft silicone catheter.

– Angle the catheter gently 2″ to 4″ (5 to 10 cm) into the bowel to instill the irrigant.

– Don’t force the catheter into the stoma, and don’t insert it farther than the recommended length because you may perforate the bowel.

♦ Observe the patient for complications.

– Bowel perforation may occur if a catheter is incorrectly inserted into the stoma.

– Fluid and electrolyte imbalances may result from using too much irrigant.

♦ Record the date and time of irrigation. Note the patient’s tolerance of the procedure.

♦ Note type and amount of irrigant used.

♦ Note the color of the stoma.

♦ Note the character of drainage, including color, consistency, and amount.

♦ Record patient teaching content.

♦ Note patient’s response to self-care instruction.

♦ Record your evaluation of the patient’s learning progress.

AED ♦ two prepackaged electrodes ♦ electrode connector cables

♦ After you discover that your patient is unresponsive to your questions,
pulseless, and apneic, follow BLS and ACLS protocols.

♦ Ask a colleague to bring the AED into the patient’s room and set it up before the code team arrives.

♦ Open the foil packets that contain the two electrode pads.

♦ Attach the white electrode cable connector to one pad and the red electrode cable connector to the other. The electrode pads aren’t site-specific.

♦ Expose the patient’s chest.

♦ Remove the plastic backing film from the electrode pads, and place the electrode pad that’s attached to the white cable connector on the right upper portion of the patient’s chest, just beneath his clavicle.

♦ Place the pad that’s attached to the red cable connector to the left of the apex of the heart. To remember where to place the pads, think “white—right, red—ribs.” (Placement for the electrode pads is the same for both manual defibrillation and cardioversion.)

♦ Firmly press the ON button, and wait while the machine performs a brief self-test. Most AEDs indicate their readiness by sounding a computerized voice that says “Stand clear” or by emitting a series of loud beeps.

♦ If the AED isn’t functioning properly, it conveys the message “Don’t use the AED. Remove and continue cardiopulmonary resuscitation [CPR].”

♦ Remember to report any AED malfunctions according to facility procedure.

♦ Now the machine is ready to analyze the patient’s heart rhythm. Ask everyone to stand clear, and press the ANALYZE button when you are prompted by the machine.

– Be careful not to touch or move the patient while the AED is in analysis mode.

– If you get the message “Check electrodes,” make sure that the electrodes are correctly placed and that the patient cable is securely attached; then press the ANALYZE button again.

– In 15 to 30 seconds, the AED will analyze the patient’s rhythm.

♦ If a shock isn’t needed, the AED displays a “No shock indicated” message and prompts you to “Check patient.”

♦ If the patient needs a shock, the AED will display a “Stand clear” message and emit a beep that changes into a steady tone as it’s charging.

♦ When an AED is fully charged and ready to deliver a shock, it prompts you to press the SHOCK button. (Some fully automatic AED models automatically deliver a shock within 15 seconds after analyzing the patient’s rhythm.)

♦ Make sure that no one is touching the patient or his bed, and call out “Stand clear.” Then press the SHOCK button on the AED. Most AEDs are ready to deliver a shock within 15 seconds.

♦ After the first shock, the AED automatically reanalyzes the patient’s heart rhythm. If no additional shock is needed, the machine prompts you to check the patient. However, if he’s still in ventricular fibrillation, perform CPR for 2 minutes and then press the analyze button on the AED to identify the heart rhythm.

♦ If the patient is still in ventricular fibrillation, the AED will prompt you to press the shock button. A second shock at 360 joules will be delivered.

♦ If the patient is still in ventricular fibrillation, continue the algorithm sequence until the code team leader arrives.

♦ After the code, remove and transcribe the computer memory module or tape, or prompt the AED to print a rhythm strip with the code data. Follow facility policy for analyzing and storing the code data.

♦ AEDs vary from one manufacturer to another, so familiarize yourself with the equipment at your facility.

♦ The operation of the AED should be checked every shift and after each use.

♦ Because defibrillation can accidentally shock those providing care, emergency responders should be alerted when a shock is being discharged.

♦ Record all information required by the appropriate code form.

♦ Record the patient’s name, age, medical history, and chief complaint, if available.

♦ Note the time you found the patient in arrest.

♦ Note the time CPR began.

♦ Note the time when the AED was applied.

♦ Record the number of shocks the patient received.

♦ Note the time that the patient’s pulse was regained.

♦ Record all postarrest care given.

♦ Note findings of physical examination.

Doppler ultrasound blood flow detector ♦ coupling or transmission gel ♦ soft cloth ♦ antiseptic solution or soapy water

♦ Apply a small amount of coupling or transmission gel (not water-soluble lubricant) to the ultrasound probe.

♦ Position the probe on the skin directly over the selected artery.

♦ If the device you’re using has a speaker, turn the instrument on. Moving counterclockwise, set the volume control to the lowest setting.

♦ If your model doesn’t have a speaker, plug in the earphones and slowly raise the volume. This device is basically a stethoscope fitted with an audio unit, a volume control, and a transducer, which amplifies the movement of RBCs.

♦ To obtain the best signals with either device, tilt the probe 45 degrees from the artery and apply gel between the skin and the probe. Slowly move the probe in a circular motion to locate the center of the artery and the Doppler signal—a hissing noise at the heartbeat. If needed for future use, mark the location with a permanent marker.

♦ Avoid moving the probe rapidly because it distorts the signal.

♦ Count the signals for 60 seconds to determine the pulse rate.

♦ After you’ve measured the pulse rate, clean the probe with an antiseptic solution.

♦ Don’t immerse the probe in water or bump it against a hard surface.

♦ Note the location and quality of the pulse.

♦ Record the patient’s pulse rate.

♦ Note the time of measurement.

ECG machine ♦ recording paper ♦ disposable pregelled electrodes ♦ 4″ × 4″ gauze pads ♦ optional: clippers, marking pen

♦ Verify the patient’s identity using two patient identifiers.

♦ Place the ECG machine close to the patient’s bed, and plug the power cord into the wall outlet.

♦ Keep the patient away from objects that might cause electrical interference, such as equipment, fixtures, and power cords.

♦ As you set up the machine to record a 12-lead ECG, explain the procedure to the patient and provide privacy.

– Tell him that the test records the heart’s electrical activity and it may be repeated at certain intervals.

– Emphasize that no electrical current will enter his body and that the test is painless.

– Also, tell him that the test typically takes about 5 minutes.

♦ Wash your hands.

♦ Have the patient lie in a supine position in the center of the bed with his arms at his sides. You may raise the head of the bed to promote his comfort.

♦ Expose his arms and legs, and drape him appropriately.

– His arms and legs should be relaxed to minimize muscle trembling, which can cause electrical interference.

– If the bed is too narrow, place the patient’s hands under his buttocks to prevent muscle tension.

– Also use this technique if the patient is shivering or trembling.

– Make sure his feet aren’t touching the bed board.

♦ Select flat, fleshy areas to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the residual limb.

♦ Clean excess oil or other substances from the skin to enhance electrode contact.

♦ Apply the disposable electrodes. Peel off the contact paper and apply them directly to the prepared site, as recommended by the manufacturer’s instructions.

♦ To guarantee the best connection to the leadwire, position disposable electrodes on the legs with the lead connection pointing superiorly.

♦ Connect the limb leadwires to the electrodes.

♦ You’ll see that the tip of each leadwire is lettered and color-coded for easy identification.

– The white or RA leadwire goes to the right arm.

– The green or RL leadwire goes to the right leg.

– The red or LL leadwire goes to the left leg.

– The black or LA leadwire goes to the left arm.

– The V₁ to V₆ leadwires go to the chest.

♦ Expose the patient’s chest. Apply a disposable electrode at each electrode position.

♦ If your patient is female, place the chest electrodes below the breast tissue. In a large-breasted woman, you may need to displace the breast tissue laterally.

♦ Check to see that the paper speed selector is set to the standard 25 mm/second and that the machine is set to full voltage. The machine will record a normal standardization mark—a square that’s the height of two large squares or 10 small squares on the recording paper.

♦ If needed, enter the appropriate patient identification data.

♦ If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization to half-standardization. Note this adjustment on the ECG strip because this will need to be considered in interpreting the results.

♦ Now you’re ready to start recording.

– Ask the patient to relax and breathe normally.

– Tell him to lie still and not to talk when you record his ECG.

♦ Then press the AUTO button.

– Observe the tracing quality.

– The machine will record all 12 leads automatically, recording three consecutive leads simultaneously.

– Some machines have a display screen so you can preview waveforms before the machine records them on paper.

♦ When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the patient’s skin.

♦ Small areas of hair on the patient’s chest or extremities may be clipped, but this usually isn’t needed.

♦ If the patient’s skin is exceptionally oily, scaly, or diaphoretic, rub the electrode site with a dry 4″ × 4″ gauze or alcohol pad before applying the electrode to help reduce interference in the tracing.

♦ If the patient’s respirations distort the recording, ask him to hold his breath briefly to reduce baseline wander in the tracing.

♦ If the patient has a pacemaker, you can perform an ECG with or without a magnet, according to the physician’s orders. Be sure to note the presence of a pacemaker and the use of the magnet on the ECG printout.

♦ Record the patient’s name, identification number, facility name, date, and time on the ECG recording.

♦ Note any appropriate clinical information on the ECG.

♦ Record the date and time of test in your notes.

♦ Note significant responses by the patient in your notes.