- Familiarise yourself with the procedure, including the indications, contraindications, technique with anatomical landmarks, and the potential complications.
- Never perform a procedure unless you have first observed. that procedure being performed, and then performed the procedure at least once under supervision.
- Never be afraid to ask for help. Do not bluff your way at the patient’s expense.
- Inform nursing staff that a procedure is to be performed.
- Adhere to aseptic practices for all procedures to prevent undue contamination of the patient, yourself or the area by microorganisms.
Prepare the patient (and relatives)
- Ensure that you have the correct patient for the correct procedure. Ask the patient’s name and date of birth and double check this with the patient’s name band.
- Introduce yourself: be polite, courteous and empathetic. Gaining the confidence and trust of the patient is invaluable, especially when faced with a painful or lengthy procedure, or should complications arise.
- Use simple language to explain what you are doing and why, and acquire verbal consent from the patient.
- Examine the patient, confirm anatomical landmarks and look for potential complicating factors such as local sepsis, deformities or scarring.
- Place the patient in the most appropriate position for the procedure and ensure that the patient is as comfortable as possible. Do not perform any potentially painful procedure with the patient standing up.
- Review requirements for pre-medication, sedation, analgesia and monitoring.
Prepare the equipment
Try to visualise the procedure and any potential complications in your mind. Locate all equipment required for the procedure and place on the lower shelf of a trolley. Commonly required equipment includes:
- Absorbent pad (‘bluey’): essential for all procedures. When placed correctly before commencing a procedure, the absorbent pad will protect the bed linen and the patient’s clothes from spilled blood or cleaning solution.
- Dressing pack: Contents are sterile and usually contain
- Folded plastic sheet (unfold and place sterile equipment onto it)
- Plastic tray to hold cleaning solution
- Gauze or cotton swabs
- Disposable forceps
- Simple sterile drape (green or blue paper).
- Skin cleaning solutions
- Alcohol swab: gamma-irradiated, individual, sterile swab impregnated with 70% isopropyl alcohol. Only for use as an antiseptic skin cleanser prior to an injection.
- Chlorhexidine: chemical antiseptic agent effective against Gram-positive and negative microbes, facultative aerobes, anaerobes and yeasts. Use for skin cleansing and wound irrigation, often in combination with cetrimide, another antiseptic agent. Both agents bind strongly to skin, mucosa and other tissues, but are poorly absorbed. Their activity is reduced by the presence of blood or body fluids.
- Povidone–iodine solution (Betadine): provides its antiseptic effect by slowly releasing iodine (iodophor). It is a skin cleanser for major and minor surgical procedures. Its action persists while the colour remains when in the presence of blood, serum, purulent exudate and necrotic (dead) tissue. Avoid in patients who have an allergy to iodine.
- Syringes: these vary in size from 1 mL to 60 mL. Common sizes required for procedures include 5, 10, 20 and 50 mL. The nozzle of the syringe may be a Luer-lock (locks the needle onto the tip of the syringe), slip tip (secures the needle by compressing the slightly tapered needle hub onto the nozzle) or a catheter tip (fitted to 50 mL syringes to access drains (e.g. NGT), sometimes using a spigot).
- Needles: the translucent hub to visualise fluid/blood flashback is colour-coded according to the gauge of the needle (Table 46.1). However, these colours are not standard across all manufacturers. The smaller the gauge, the larger the diameter of the needle. Needle length varies from 1.25 cm (e.g. for SC injections) to 4 cm (e.g. for deep IM injection or joint aspiration).
- Sharps bin: it is essential to have easy access to a sharps bin before performing any procedure because it reduces the risk of needle stick injury to yourself or other members of staff. Use a kidney dish as temporary store for unwanted sharps, if a sharps bin is not readily accessible. Never recap a used needle. Do not fill sharps bin above fill line.
Prepare for the procedure
- Gather all the equipment required for the procedure. Place on the bottom shelf of the trolley and put the dressing pack on the top of the trolley.
- Open the dressing pack onto the upper shelf of the trolley to create your sterile field. Remove the outer package or tape and open the dressing pack with the tips of your fingers, only touching the corners.
- Peel and open all needles and syringe required and drop them onto the dressing pack without touching them, so they remain sterile.
- Wash hands thoroughly, dry with sterile paper towel and put on sterile gloves.
- Use aseptic technique at all times.
- Post-procedural care
- Evaluate for signs of complications of procedure and the effectiveness of the procedure. This is your role as the proceduralist.
- Dispose of all contaminated material:
- Place all sharps in a sharps bin.
- Place contaminated rubbish in yellow plastic bag.
- Place contaminated linen in a clear bag, then in a linen bin.
- Remove gloves and wash hands.
- Record details of the procedure in the patient’s medical notes:
- Date, time and type of procedure performed
- Equipment used, size of catheter/cannulae/drain placed
- Report any complications or adverse side effects encountered
- Write appropriate aftercare management.
- Chart any medication given and prescribe further analgesia or fluids as required.
Associate Professor Curtin Medical School, Curtin University. Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM Sir Charles Gairdner Hospital. Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |