Minimum: Nursing care checklist portion of the PFC flowsheet (Appendix A)

Best: PFC nursing care plan (Appendix B)

Flush Saline Locks

At least every 8 hours, flush saline locks with 10mL of NS.

  1. Gather equipment.
  2. Clean access port with alcohol pad.
  3. Take prefilled 10mL syringe of NS and needle (if applicable) or attach syringe to port.
  4. With constant pressure, inject NS into port to flush catheter to ensure line remains open.
  5. If resistance is met, gently use pulsating pressure on end of syringe until NS flows freely.
  6. Carefully observe the IV site for swelling or pain. Start a new IV if swelling or pain occurs.
  7. Detach syringe and dispose; place needle in sharps container (if applicable).

If prefilled syringes are unavailable, draw up NS into unused, empty syringe from a bag of NS, then follow steps above.

Suction Advanced Airway

Perform airway suction only when needed, using sterile technique for advanced airways or clean technique for the mouth and throat. Humidify the air using a humidifier, moist gauze, or by boiling a pot of water.

  1. Gather necessary equipment.
  2. Ensure patient’s head is elevated.
  3. Perform hand hygiene.
  4. Place a clean towel under patient’s chin.
  5. Don eye protection.
  6. Hyperventilate patient for 10 seconds.
  7. Perform appropriate suctioning with available equipment (ensuring suction is performed while withdrawing the catheter for no longer than 10 seconds at a time).
  8. Allow at least 30 seconds before repeating suctioning, if needed.
  9. Perform oral care as needed but at least every 4 hours.

Reposition and Check Padding

Identify patients who cannot reposition themselves. Reposition patient and check padding at least every 2 hours. To prevent ischemic tissue injury and the formation of pressure sores, frequent movement of the patient is necessary. Relieving pressure from superficial capillaries allows the skin to recover from the temporary ischemia.

  1. Roll the patient onto one side (if concerned about spine injury, carefully log roll while maintaining spine stabilization).
  2. Have an assistant remove pillows, blankets, or soft items being used for positioning and gently guide the patient down onto their back.
  3. Using the same procedure, have assistant gently roll patient in the opposite direction.
  4. Place pillows, blankets, or soft items under patient for positioning and have assistant guide patient back down.
  5. Ensure the patient’s ankles, knees, and elbows are not resting on top of each other and arms are not resting on the abdomen, by placing padding between them.
  6. Ensure the patient’s head and neck are in line with the spine.
  7. Use additional padding items for bony prominences on hard surfaces.
  8. Ensure creases and bumps in clothing, sheets, and blankets are smoothed out under the patient.
  9. Be aware of the location of external equipment such as Foley catheter, IV tubing, and ventilator tubing to prevent dislodging during repositioning.
  10. If any areas of nonblanchable erythema are noted, outline area with marker and prevent placing patient on the affected area until it recovers.
  11. Burned and injured extremities should be slightly elevated and slightly flexed to optimize venous return and maintain adequate peripheral pulses.

Oral Care

Good oral hygiene reduces oropharyngeal colonization, which is associated with ventilator-acquired pneumonia. Patients who are conscious and able should brush their teeth a minimum of every 12 hours. For unconscious patients, perform oral care at least every 4 hours. Ensure some type of suction is available (e.g., manual suction device, syringe with IV tubing).

Foley Catheter Care

Minimum: Basin, warm water, nonirritating soap, linen saver pad, towels

Perform Foley care once a day or as needed for excessive drainage.

  1. Wash hands thoroughly with soap and water, apply gloves, and place linen-saver pad or dry towels under patient.
  2. Using mild soap and water, clean genital area.
  3. For male patient: retract the foreskin, if needed, and clean the area, including the penis.
  4. For female patient: separate the labia, and clean the area from front to back.
  5. Clean urethra (urinary opening), where the catheter enters the body.
  6. Clean the catheter from where it enters the body and then down, away from urethra. Hold the catheter at the point it enters the patient so that tension is not placed on it.
  7. Rinse the area well, dry gently, and replace linen-saver pad under patient.

Wash and Dry Skin, Apply Lotion

At least once per day or as needed, wash, dry, and apply lotion to skin. Cleaning the skin is an opportunity to evaluate additional injuries and visualize any new areas of erythema.

  1. Prepare basin or bowl with warm water and a small amount of baby wash.
  2. Obtain multiple 4×4 gauze pads or clean washcloths and place in water
  3. Expose body part to be washed, keeping the rest of the patient covered, and place linen-saver pad under the area to absorb water.
  4. Take one gauze or washcloth out of the basin and wring out excess water. Wash skin a little bit at a time, throwing away used gauze or washcloths until clean. DO NOT place contaminated gauze or washcloths back into basin or bowl.
  5. Wash face first and genitalia last. (Cleaning genitalia is detailed under Foley care.)
  6. Ensure the skin is thoroughly dried, including all skin folds, and apply lotion.

Caution: If baby wipes or skin wipes are used to wash the skin, the wipes should be thoroughly rinsed with water first, because most contain alcohol and residues that can irritate the skin.

Change Intravenous Bag and Tubing

Every 72 hours if possible, replace infusing bag of fluids and tubing with new equipment. If fluids infusing at a to-keep-open rate and a bag has been up for 72 hours, ensure a fresh bag and tubing are hung and marked with new time and date.

Check Blood Glucose Level

If available, check blood glucose level (BGL) every 8 hours or more frequently as dictated by patient status. A low BGL (less than 80 mg/dL) must be treated immediately with oral sugar or juice or IV glucose. A high BGL (greater than 200 mg/dL) is less dangerous than low glucose, but may be treated if the capability is available.

Change  Tape

  1. Once a day, change tape on patient’s skin (except for peripheral IV sites, which can be changed every 72 hours to avoid exposing puncture site to contaminants). Daily tape changes decrease the potential for skin breakdown. This intervention may be accomplished after patient’s daily wash.
  2. For ETT or cricothyroid tube, gently remove tape. If tape is strongly adhered, use an alcohol swab to moisten the top of the tape. As the tape is lifted back, use the alcohol swab and gently rub across the skin at the junction with tape to loosen, ensuring not to dislodge tube placement.
  3. For ETT, after tape is removed, gently move the tube to the opposite side of the mouth, again ensuring not to dislodge it or rest on lip.
  4. Apply new tape to a section of skin next to where tape was previously removed. To give skin a break, do not place over the same area.

Lower Extremity Massage, DVT Prevention

If available, compression stockings, or elastic bandages (wrapped starting from the toes upward) should be placed on immobile or unconscious patients, ensuring toes remain exposed for capillary refill assessment. Patients who are conscious and able may perform the following exercises, completing 10 repetitions of each exercise every hour while awake. This may be done in burned extremities or in the presence of open wounds, but should be avoided when fractures or severe extremity injuries are present.

Perform DVT prevention for unconscious patients at least every 2 hours.

Range of Motion Exercises

At least every 8 hours, perform range of motion exercises on all movable joints such as ankles, knees, hips, wrists, fingers, elbows, and shoulders, except where joint mobility is restricted by injury.

Turn, Cough, Deep Breathe

  1. For a conscious patient, encourage them to turn, cough, and take deep breaths to prevent atelectasis.
  2. Instruct the patient to breathe in deeply and slowly through their nose, expanding lower rib cage, and letting abdomen move forward.
  3. Hold for a count of 3 to 5.
  4. Instruct patient to breathe out slowly and completely through pursed lips.
  5. Have patient rest and repeat 10 times every hour.
  6. Code Brown: Unconscious Patient Bowel Movement Recommend leaving unconscious patients unclothed from the waist down and covered with a sheet or blanket, with linen-saver pad or towel under the buttocks for easy bowel movement clean up. During assessment, check if the unconscious patient has had a bowel movement and clean if needed.
  7. Gather a basin with warm, soapy water; rolled linen-saver pad or towel; gloves; and washcloths.
  8. Have assistant log roll the patient toward them.
  9. Start cleaning from top of patient toward soiled linen-saver pad or towel, obtain a new washcloth when current one is completely used.
  10. When patient is cleaned as far as can be reached on that side, roll soiled pad or towel on itself to contain fecal matter and start to unroll new linen-saver pad, keeping clean one under dirty one.
  11. Gently log roll patient to the other side and have assistant finish cleaning soiled area; dry completely.
  12. Discard soiled pad or towel and finish unrolling clean pad, ensuring there are no folds under patient.
  13. Gently roll patient to previous position of comfort and cover.
  14. For nursing assessment and intervention packing list, see Appendix D.
  15. Hospital clinical rotations are an excellent opportunity to learn and practice nursing assessments and interventions. The recommended nursing skills checklist for clinical rotations is included in Appendix E.