Nursing Foundations · Nursing Care & Specific Procedures

Nursing Procedures & Emergencies

Modified Allen's Testdefinition

A test to assess ulnar artery patency and collateral circulation to the hand before radial artery puncture or cannulation.

in simple words: Checks if the ulnar artery can supply blood to the hand if the radial artery is damaged.

Why is it done?

The hand has dual blood supply from the radial and ulnar arteries via the palmar arches. The test confirms the ulnar artery can perfuse the hand if the radial artery is damaged or occluded. A negative Allen's test is an absolute contraindication to radial artery puncture or cannulation on that limb. High yield

Allen's Test Results – Positive vs Negative

Positive: return of palm colour within 5-15 seconds after releasing ulnar artery pressure. High yield
Negative: delayed or no return of colour; indicates inadequate ulnar collateral flow.
Negative test = absolute contraindication to radial puncture/cannulation on that limb. High yield

Procedure Steps

1. – Patient makes a fist; if unable, elevate the hand to allow passive blood drainage.
2. – Occlude both radial and ulnar arteries.
3. – Release ulnar artery pressure; observe palm colour return.
4. – Document finding; if negative, use other wrist or alternative site (brachial/femoral).

Nursing Procedures & Emergencies · Nursing Foundations

ABG Sampling & Arterial Lines

Arterial Line

An arterial line is used for continuous invasive blood pressure monitoring and for obtaining arterial blood samples such as ABGs. It is not used for infusing fluids or medications; arterial lines must be clearly labelled to prevent accidental arterial injection, which causes thrombosis, ischaemia and possible limb loss. High yield

Radial Artery – Most common site

Standard site for ABG sampling and arterial cannulation.
Located on the lateral side of the wrist.
Accessible with good collateral circulation to the hand.

Post-Puncture Care

Pressure: – Apply firm direct pressure with a sterile pad for at least 5 minutes. High yield
Anticoagulants: – Extend pressure to 10–15 minutes.
Monitor: – Watch for bleeding, swelling, or compromised circulation.
Distal assessment: – Check for pallor, coolness, numbness, or weak pulse after line insertion.

Nursing Procedures & Emergencies · Nursing Foundations

Sutures

Suturedefinition

A material used to close wounds or surgical incisions.

in simple words: Thread used to stitch tissues together.

Types of Sutures

Type	Examples	Properties
Absorbable	Catgut, Vicryl, Dexon, Monocryl	Broken down by body; no removal needed.
Non-absorbable	Silk, linen	Heat-stable; can be autoclaved.
Synthetic absorbable	Vicryl (polyglactin 910), Dexon (polyglycolic acid), Monocryl (poliglecaprone 25)	Used for deep, multi-layer lacerations; absorbed by hydrolysis.

Suture Removal

Technique: – Place curved tip of suture scissors under knot or at side close to skin; cut gently; pull out with forceps.
Rationale: – Cutting close to skin lets contaminated external portion be pulled out without dragging through tissue.
If dehiscence occurs: – Stop procedure, apply sterile strips, cover with sterile dressing, notify doctor.

Nursing Procedures & Emergencies · Nursing Foundations

Triage

Triagedefinition

The process of sorting patients based on urgency to prioritise care in mass casualty or emergency situations.

in simple words: Deciding who needs care first.

ABC Framework

The ABC (Airway, Breathing, Circulation) framework prioritises a patient with difficulty breathing after a road traffic accident. Compromised airway or breathing is the most immediate threat to life and requires immediate intervention to prevent respiratory or cardiac arrest. High yield

Triage Systems

START: – Simple Triage and Rapid Treatment; used in mass casualty incidents.
JumpSTART: – Paediatric modification of START; adjusts respiratory rate cutoffs and includes rescue breath trial.

Priority Examples

Condition	Priority
Cardiac arrest (ventricular fibrillation)	Highest priority; immediate CPR and defibrillation.
Pneumothorax with shortness of breath	Breathing emergency; seen first.
Congestive heart failure	High priority; risk of acute pulmonary edema.
Hand and foot syndrome (sickle cell)	Painful but not immediately life-threatening; lower priority.
Resolving pancreatitis	Clinical improvement; lower priority.

Nursing Procedures & Emergencies · Nursing Foundations

Standard Precautions

Standard Precautionsdefinition

Infection control practices required when a procedure risks contact with blood, body fluids, secretions, excretions, non-intact skin, or mucous membranes.

in simple words: Treat all patients' blood and body fluids as infectious.

Key Principles

Standard precautions are based on the task and anticipated exposure risk, not on the patient's diagnosis. Hand hygiene is the single most important practice in preventing the spread of infection. High yield

Types of Precautions

Precaution	Spread	Examples
Airborne	Droplets <5 microns	Tuberculosis, measles
Droplet	Droplets >5 microns	Influenza, rubella
Contact	Direct/indirect contact	MRSA, C. difficile

PPE Removal

Order: – Remove most contaminated item (gloves) first to prevent self-contamination.
Hand hygiene: – Perform immediately after removing PPE.

Nursing Procedures & Emergencies · Nursing Foundations

Blood Transfusion

IV Cannula Selection

The green IV cannula (18G) is the standard choice for routine adult blood transfusion. It provides a flow rate of about 90 mL/min, allowing transfusion within the safe 4-hour window while minimizing red cell damage. High yield

Cannula Sizes for Transfusion

Colour	Gauge	Flow Rate	Use
Green	18G	~90 mL/min	Standard for routine adult transfusion.
Pink	20G	~60 mL/min	Acceptable alternative if larger cannula cannot be inserted.
Gray	16G	Fastest	Rapid, high-volume administration in trauma/major surgery.
Blue	22G	~36 mL/min	Least used; risk of hemolysis.
Yellow	24G	~20 mL/min	Neonates and infants only.

Compatible IV Fluids

0.9% Normal Saline: – Only IV fluid compatible with blood transfusion. Isotonic, no calcium or dextrose.
Ringer's Lactate: – Incompatible; calcium clots blood.
Dextrose solutions: – Incompatible; cause red cell aggregation and hemolysis.
Distilled water: – Incompatible; hypotonic, causes hemolysis.

Nursing Procedures & Emergencies · Nursing Foundations

Bandages

Bandagedefinition

A material used to cover, support, and immobilise a wound or injured part.

in simple words: A strip of cloth used to wrap an injury.

Neurovascular Assessment

Neurovascular status (circulation, sensation and movement) distal to a bandage is assessed before, during and after application. High yield Improper bandaging can impair circulation, cause skin breakdown or produce a dressing that does not stay in place.

Bandaging Techniques

Technique	Use	Key Point
Circular	Anchor start/end; small cylindrical areas	Insufficient support over joints.
Spiral	Uniform circumference (upper arm, thigh, finger)	Bunches over joints.
Reverse spiral	Conical (tapering) parts (forearm, lower leg)	Lies flat without gaps.
Figure-of-eight	Joints (ankle, knee, elbow, wrist)	Standard for joints; controls oedema.
Spica	Joints at an angle (thumb, shoulder)	Specialized figure-of-eight.
Recurrent	End of body part (amputation stump, scalp)	Covers the end.

Knots & Bandage Types

Reef knot (square knot): – Standard knot for securing a bandage to control bleeding; lies flat, holds securely, easy to untie.
Triangular bandage: – Muslin cloth shaped as right-angled triangle; used as sling or folded into cravat.
Cravat: – Triangular bandage folded from apex to base into a long flat band; secures splints, applies pressure.
Tubular bandage: – Seamless elasticated tube; uniform compression; least versatile.

Nursing Procedures & Emergencies · Nursing Foundations

Airway Management

Guedel Airwaydefinition

An oropharyngeal airway (OPA) with a rigid C-shaped curve, a flange and a central air channel.

in simple words: A plastic tube inserted in the mouth to keep the airway open.

Airway Adjuncts

An endotracheal tube is a long tube passed through the mouth or nose past the vocal cords into the trachea, with an inflatable cuff and a 15 mm connector. A laryngeal mask airway is a supraglottic airway with a wide-bore tube ending in an elliptical inflatable mask that seals around the laryngeal inlet. High yield

Airway Devices

Device	Type	Key Feature
Oropharyngeal airway (OPA)	Supraglottic	Rigid, C-shaped; used only in unresponsive patients with no gag reflex.
Nasopharyngeal airway (NPA)	Supraglottic	Soft, flexible, uncuffed; inserted through nostril.
Laryngeal mask airway (LMA)	Supraglottic	Inflatable mask seals around laryngeal inlet; rescue airway.
Endotracheal tube (ETT)	Infraglottic	Passed through vocal cords; protects airway from gastric contents.
Tracheostomy tube	Surgical	Inserted into a surgical stoma in the neck.

OPA Sizing & Use

Sizing: – Measure from corner of mouth to angle of jaw.
Use: – Only in unresponsive patient with no gag reflex; remove if gag reflex returns.
Too large: – Can obstruct larynx or damage laryngeal structures.
Too small: – Pushes tongue back and worsens obstruction.

Nursing Procedures & Emergencies · Nursing Foundations

Choking & CPR

Heimlich Maneuver

The Heimlich maneuver (abdominal thrusts) relieves a foreign body airway obstruction in a conscious choking person. It creates a rapid increase in intrathoracic pressure, simulating a cough to expel the object. High yield Indicated when the person cannot speak, cough, or breathe.

Choking Response

Conscious, cannot speak/cough/breatheGive abdominal thrusts (Heimlich).
Becomes unconsciousLower to ground, call for help, start CPR with chest compressions.
Infant <1 year5 back blows alternating with 5 chest thrusts (not abdominal).
Pregnant or very large personChest thrusts instead of abdominal thrusts.

Key Points

Partial obstruction: – If patient can cough, speak, or breathe, encourage coughing; do not give thrusts.
Universal sign: – Clutching the throat.
CPR: – Chest compressions, not Heimlich, improve circulation during CPR.

Nursing Procedures & Emergencies · Nursing Foundations

Suctioning & Solutions

Suction Catheter Sizing

Suction catheter external diameter should not exceed 50% of the internal diameter of the artificial airway. This limit prevents airway occlusion, excessive negative pressure, hypoxia and tracheal mucosal trauma during suctioning. High yield

Suction Pressure – Adults

Oropharyngeal suctioning: 100–150 mmHg.
Apply suction only during withdrawal, not insertion.
Excessive negative pressure traumatises mucosa.

Oral Care Solutions

2% Chlorhexidine: – Recommended antiseptic mouth rinse; disrupts bacterial cell membranes.
Dettol (chloroxylenol): – Skin/surface disinfectant; toxic if ingested; never use as mouthwash.
Savlon (cetrimide + chlorhexidine): – Skin antiseptic for wounds; not for oral use.
10% Sodium hypochlorite: – Corrosive; for inanimate surfaces only; dangerous if ingested.

Nursing Procedures & Emergencies · Nursing Foundations

Invasive Lines Care

Air Embolism

Air embolism from a central venous line causes sudden dyspnea, chest pain, tachycardia, hypotension, and a mill-wheel murmur. Bradycardia with hypertension is not a sign of air embolism; it suggests raised intracranial pressure (Cushing's triad). High yield

Air Embolism Management

Clamp the catheterStops further air entry.
Left lateral TrendelenburgDurant's maneuver traps air in right ventricular apex.
Give 100% oxygenHelps resolve hypoxia.

Central Line Sites

Common veins: – Internal jugular, subclavian, femoral.
Femoral site: – Highest risk of infection.
Tibial vein: – Peripheral; not used for central line.

Nursing Procedures & Emergencies · Nursing Foundations

ICU Codes & Monitors

Hospital Emergency Codes

Code	Emergency
Code Pink	Infant and child abduction
Code Red	Fire
Code Black	Bomb threat
Code Yellow	Disastrous situation (mass casualty)

Monitor Colour Coding

Colour	Parameter
Green	ECG waveform and heart rate
Light blue (cyan)	SpO2 pulse oximetry
Yellow	Respiratory rate and capnography (EtCO2)
Red	Invasive blood pressure (including MAP)
White	Generic (NIBP, temperature)

Emergency Equipment

Electric needle destroyer: – Safe disposal of sharps; prevents needlestick injuries.
Suction collection canister: – Collects aspirated fluids; monitor level and connections.
Oxygen flow meter with regulator: – Controls and humidifies oxygen delivery.

Nursing Procedures & Emergencies · Nursing Foundations

Catheter & Tube Care

Urinary Catheter Securement

Secure an indwelling urinary catheter to the upper thigh to prevent tension and traction on the urethra and bladder neck. High yield In female patients, secure to the inner thigh; in male patients, secure to the lower abdomen to prevent pressure on the penoscrotal angle. High yield

Catheter Care

Drainage bag: – Keep below bladder level to prevent backflow and CAUTI.
Removal: – Clean procedure; deflate balloon through its own lumen; supine position.
Post-removal: – Monitor first void within 6-8 hours; bladder scan if not voided.

Nasogastric Tube

Chest radiograph is the gold standard for confirming initial placement of a nasogastric tube. Aspirating gastric fluid and testing pH is a recommended bedside method; pH ≤5.5 indicates gastric placement. If patient coughs or gasps during insertion, immediately withdraw the tube.

Nursing Procedures & Emergencies · Nursing Foundations

Lab Tests & Interventions

Vacutainer Colour Codes

Colour	Additive	Use
Red	None	Serum biochemistry, therapeutic drug monitoring (phenytoin).
Blue	Sodium citrate	Coagulation studies (PT, aPTT).
Grey	Sodium fluoride + potassium oxalate	Glucose and lactate.
Yellow	SPS	Blood cultures.

Phenytoin Monitoring

Red cap vacutainers are used for serum biochemistry tests, including therapeutic drug monitoring such as phenytoin levels. Serum separator gel tubes can falsely lower phenytoin levels because the gel absorbs the drug. Therapeutic range for phenytoin is 10-20 mcg/mL.

Nursing Interventions

Independent: – Elevating edematous limbs (uses gravity to reduce swelling).
Dependent: – Wound care (when dressing/solution prescribed), drug administration (requires prescription).
Physician-initiated: – Ordering diagnostic tests (nurses cannot order independently).