The procedures, and the reasoning underneath them
This is where a student stops caring for a patient with their hands alone and starts using equipment on them — oxygen, suction, tubes, drains, dressings, needles. Every one of those helps and every one can harm, and the difference is almost never dexterity. It is knowing what the device is for, what it does not do, and what to watch for while it is in place.
A cannula gives a route for fluids and opens a path into the bloodstream. A catheter empties a bladder and holds a door open into it. A feeding tube delivers nutrition and can deliver it into a lung. Oxygen corrects hypoxia and, in a small number of patients, suppresses the drive to breathe. There is no device in this manual that only helps. The competency being taught is holding both halves of the trade in mind at once, which is what turns a procedure into nursing.
Does this patient still need this device? A catheter removed on day two cannot cause an infection on day nine. A cannula taken out when the intravenous medicines stopped cannot become a site of phlebitis. A drain removed when it stops draining cannot be pulled out in the night. Asking this question of every device on every patient every day prevents more harm than any refinement of insertion technique, and it costs nothing but attention.
Students worry about their hands — whether they will get the cannula in, whether the dressing will look neat. Examiners and patients care far more about whether the right patient was identified, whether consent was taken, whether the field stayed clean, whether the waste went in the right container and whether the nurse noticed what the wound looked like. Technique can be practised in a week. Judgement about when not to proceed takes longer and matters more.
Nobody consents to something they have not understood, and a patient who does not know what is about to happen tenses, moves and makes the procedure harder and more painful. Say what you are going to do, why, what it will feel like, how long it will take, and what they should tell you about. Do not promise it will not hurt if it will — a patient lied to once does not believe the next thing anybody says.
Three words used loosely in speech and precisely in practice. Cleaning removes visible soil and most organisms and is the prerequisite for everything else — a dirty surface cannot be disinfected. Disinfection reduces organisms to a level considered safe but does not reliably destroy spores. Sterilisation destroys all microbial life. Which one a device needs follows from whether it touches intact skin, a mucous membrane, or sterile tissue and the bloodstream.
Aseptic technique becomes learnable when reduced to one discipline: name the parts that must not be contaminated, and protect only those. The key site is the patient's vulnerable point — the insertion site, the open wound. The key parts are the pieces of equipment that will touch it — the syringe tip, the needle hub, the inside surface of a dressing. Everything else can be handled normally. A student who identifies the key parts before starting will not contaminate them; one relying on concentration alone will fail the moment they are interrupted.
Almost every breach happens before the procedure begins. The trolley was not decontaminated. Something needed was not on it and had to be fetched mid-procedure. The pack was opened in a way that contaminated its contents. The patient had not been offered the toilet and had to move. Examiners score preparation first because it predicts everything after it.
A sterile field is sterile only at and above trolley level, only within its edges, only while it is in sight, and only while it is dry. Reaching across it contaminates it. Turning your back contaminates it. Fluid soaking through contaminates it. The commonest single error in practical assessment is a candidate who maintains perfect technique and then leans over the field to reach something.
Gloves reduce contamination of hands; they do not eliminate it, they can be perforated unnoticed, and hands are contaminated during removal. Hand hygiene is required after every removal. Worse, wearing gloves reliably reduces how often people decontaminate their hands, so gloves worn unnecessarily increase transmission. They are for anticipated contact with blood, body fluids, mucous membranes or non-intact skin — not for taking a blood pressure.
Oxygen is prescribed, has indications, has a target, and has an endpoint. It is not something to turn up because a patient looks anxious or turn on because they are unwell. A nurse who treats it as a comfort measure will leave it running unmonitored on a patient who no longer needs it, and in a small group of patients with chronic respiratory disease sustained high concentrations carry their own risk — which is why targets are set and reviewed rather than left at maximum.
Oxygen saturation is useful and it is not the assessment. A patient can hold a reasonable saturation through enormous work of breathing that they cannot sustain, and the number says nothing about how long they can keep it up. Respiratory rate, work of breathing, the ability to speak in sentences, colour, and level of alertness all reach a nurse before the saturation falls. Reading the monitor without looking at the person is the characteristic failure of monitored care.
Different devices deliver different and differently reliable concentrations, and some depend heavily on how the patient is breathing. What matters for a student is knowing that the device is chosen for the target and the patient, that swapping one for another is a clinical decision and not a convenience, and that a mask sitting on somebody's forehead is delivering nothing. Check that the device is actually on the patient every time you pass.
Tubing kinked or disconnected. The cylinder empty, or the flowmeter at zero. Humidification absent, leaving the nose and mouth raw. Pressure damage behind the ears and across the bridge of the nose from the elastic and the mask edge — a common and entirely preventable injury. And the patient who has quietly removed the mask because it frightens them, which is a conversation rather than a battle.
Suction is for secretions the patient cannot clear themselves, indicated by the sound of their breathing, their work of breathing, visible secretions or a fall in saturation — not by the clock. Routine suctioning on a schedule causes trauma, hypoxia and distress for no benefit. The assessment decides, every time.
Suctioning removes air as well as secretions, so it lowers oxygen. It stimulates the airway, which can slow the heart. It damages the lining if done too long, too often, or too deeply. The mitigations are consistent everywhere: keep each pass brief, allow recovery between passes, use the lowest effective pressure, and stop if the patient deteriorates. Knowing that this procedure can harm is what makes a nurse use it only when indicated.
The mouth of a patient who is not eating, drinking or breathing normally through their nose deteriorates within hours, and a dirty mouth seeds the lungs. Mouth care is most needed in exactly the patients least able to ask for it — unconscious, ventilated, tube-fed, dying — and is one of the most neglected tasks in hospital nursing with one of the most direct links to pneumonia.
A patient who is unresponsive but breathing goes into the recovery position so the tongue falls forward and vomit drains out rather than in. A patient at risk of aspiration sits upright to eat and stays upright afterwards. A patient with secretions is positioned to let gravity help. None of this needs equipment and all of it prevents the thing suction is used to treat.
It protects the wound from contamination and trauma, manages fluid, and maintains the conditions in which tissue repairs. Wounds heal better moist than dry — a wound allowed to dry out forms a scab over tissue that then has to work underneath it. The dressing is chosen for what the wound is doing, which is why assessing the wound is the part that matters and choosing the product is the part that follows.
Size, depth, what the wound bed looks like, how much fluid and what kind, the smell, the state of the skin around it, pain, and whether any of that has changed since last time. A dressing changed without the wound being looked at properly is a missed assessment wrapped in gauze. Record what you saw in words the next nurse can compare against — and where your service photographs wounds, that is better still.
Increasing pain, spreading redness, heat, swelling, fluid that has become thicker or discoloured, an offensive smell, a wound that had been improving and has stopped, and the patient feeling generally unwell or feverish. Any of these is escalated rather than dressed over. A patient can be taught this list before discharge, which turns them into somebody who returns at the right time instead of two weeks late.
Clean hands, clean field, only the key parts touched. Remove the old dressing without dragging new tissue with it. Do not swab a healing wound vigorously — cleaning removes debris, it does not scrub a wound clean. Work from the cleanest area outward. Dispose of the old dressing as contaminated waste before touching anything clean. And decontaminate your hands again before the new dressing goes anywhere near the patient.
Debriding tissue, packing a cavity, deciding a wound needs an antimicrobial, or judging that a deteriorating wound can wait. These are decisions with training and scope attached, and they differ by country. Recognising and escalating a wound that is not healing is a nursing competency everywhere; treating it is not.
Do not recap needles. Dispose of every sharp at the point of use, yourself, into a container that is there before you start. Never pass an uncovered sharp hand to hand. Never fill a container past its line and never push anything down into one. The World Health Organization treats unsafe injection practice as a significant source of preventable harm worldwide, and most sharps injuries happen at disposal rather than during the procedure.
A syringe or needle used on one person is never used on another, and a single-use device is not made safe by rinsing it. This is stated flatly because reuse still happens where supplies are short, and it transmits bloodborne infection on a scale that has caused documented outbreaks. Where supplies are inadequate that is an urgent thing to escalate and document, not a situation to work around.
Encourage bleeding, wash with running water without scrubbing, and report it immediately. Occupational health can only act within a window, and a report made at the end of the shift may be too late to matter. Students routinely delay reporting out of embarrassment; knowing in advance that the delay is the dangerous part is what changes the behaviour.
The minutes after an injection are part of the procedure. Reactions — local swelling, a rash, breathlessness, faintness, a patient who says something feels wrong — appear in that window, and a nurse who has already moved on will hear about it late or not at all. Where an injection carries a recognised risk of a serious reaction, the observation period is defined by policy and is not optional, however well the patient looks at the moment the needle comes out.
Choosing an appropriate site, rotating sites where injections are repeated, checking the site before and after, and watching for a reaction. What is injected and how much is prescribed and appears nowhere in this manual. What belongs to nursing is the identification of the patient, the checking, the technique, the observation afterwards, and the record.
Peripheral cannulas are treated casually and should not be. They sit in a vein and they are a direct route into the bloodstream, and bloodstream infection is among the most serious healthcare-associated infections there is. Skin antisepsis at insertion, decontamination of the access port before every single use, a secure dressing that lets the site be seen, and daily review of whether it is still needed. The port step is the one most often skipped, because it takes seconds and happens many times a day — which is the exact profile of a habit that decays.
Pain, redness, swelling, hardness along the vein, coolness, leaking, or a patient saying it feels wrong. Any of these means stop the infusion and look. Fluid escaping into tissue rather than vein causes swelling and, with some substances, serious tissue damage — which is why a site is checked at every observation round and not only when an alarm sounds.
The rate, the volume given, what is in the bag, whether it matches the prescription, and how the patient is responding. Giving too much fluid too fast causes breathlessness and overload, particularly in the old, the very young and anyone with a struggling heart or kidneys — and the signs reach a nurse before any chart does. No rate or volume appears in this manual; both are prescribed and patient-specific.
Do not silence an alarm you have not understood. Do not restart an infusion that has stopped without finding out why it stopped. Do not run a line dry and assume it is harmless. And where a service has no pumps and infusions run by gravity and counting, the nursing attention required goes up rather than down, because the device is no longer doing any of the watching.
A feeding tube that has moved delivers feed into a lung, and that is one of the most serious avoidable harms in ward nursing. Whatever method your service uses to confirm position, it is used before every feed, every medicine and every flush — not only after insertion. A tube that was in the right place yesterday is not evidence about today. A patient who has coughed, vomited or pulled at it is a reason to check again.
The closed drainage system is not broken. The bag stays below bladder level and off the floor. No routine irrigation. The need for it is reviewed daily, and the most effective prevention of infection is removing it — or never inserting it. Almost every catheter-associated infection traces back to a break in the closed system or a catheter that outlived its indication.
Know what this drain is draining, how much is expected, what the fluid should look like, and what a change would mean. Secure it so it cannot be pulled, keep the tubing free of kinks and loops, measure and record output accurately, and report a sudden increase, a sudden stop, or a change in the character of the fluid. A drain that suddenly stops is not necessarily good news.
Every tube and line is secured so its weight is not taken by the insertion site, and every securing device is itself a pressure point. Tubing under a limb, a catheter strap too tight, oxygen tubing over an ear — device-related pressure damage is a large and rising share of the total, and it happens in places nobody thinks to look.
Collected correctly, labelled at the bedside in front of the patient, and sent promptly, a specimen guides treatment. Collected carelessly it produces an answer about something else entirely and the patient is treated for it. The commonest failures are contamination during collection, labelling away from the bedside, and delay in transport — all of which produce confident wrong results rather than obviously bad ones.
The container and any preservative are part of the test. A specimen in the wrong container may be rejected, or worse, processed and reported. Labelling is done at the bedside with two identifiers, never in the treatment room afterwards, because that is where specimens get swapped. And a specimen sitting in a rack for hours is a different specimen from the one that was collected.
Know what the procedure is, prepare the patient and the equipment, position them, stay where they can see you, watch them rather than the operator, and say when something is wrong. The nurse in an assisting role is usually the only person whose whole job is the patient rather than the task, and noticing that somebody has gone pale or stopped responding is that role's entire point.
The nurse assisting is frequently the only person in the room whose attention is on the patient rather than on the task, and that makes them the person most likely to notice that something has changed. Saying stop to somebody more senior, mid-procedure, is difficult and it is exactly what the role is for. A prepared form of words helps: I need you to stop, the patient has changed. Nobody has ever regretted pausing a procedure for thirty seconds; a great many people have regretted staying quiet.
Observations on whatever schedule the procedure warrants, the site checked, pain assessed, the patient told what was done and what happens next, the specimen sent, the record written, and the equipment and waste dealt with. The period after a procedure is when complications appear and when attention has usually moved on, which is precisely why it is written into every protocol.
Airway position, mouth care, eye care because the blink reflex has gone and corneas dry and ulcerate, skin and pressure relief, joint position to prevent contracture, bladder and bowel care, nutrition and hydration, and temperature. Nothing here is optional and all of it is invisible in the sense that the patient cannot ask for any of it. The standard of nursing an unconscious patient receives is a reasonably good measure of the standard of a ward.
Awareness is not all or nothing and people recovering from unconsciousness frequently report having heard conversations. Speak to the patient, say who you are and what you are about to do, and do not discuss them over their bed as though they were furniture. It costs nothing, it is what you would want, and occasionally it turns out to have mattered a great deal.
Level of consciousness described with a scale rather than a word, because drowsy means different things to different nurses while a recorded score does not. Pupils, limb movement, breathing pattern, and the observations. A change in the score between two nurses only means something if both measured the same way, which is why the scale is taught rather than assumed.
A limb left unsupported in a poor position stiffens faster than students expect, and a contracture that took two weeks to form can take months of therapy to undo or may never fully resolve. Joints are positioned in a neutral, supported alignment, moved through their range as often as the plan allows, and supported so that gravity is not slowly pulling a foot or a wrist into a position it will keep. This is one of the clearest cases in nursing where routine, unremarkable work quietly determines what somebody's arm will do for the rest of their life.
Relatives sitting with an unconscious patient need to be told what is happening in plain words, repeatedly, and to be given something to do if they want it — hand holding, mouth care, reading aloud. Being useful is what most families ask for and are least often offered, and it is good for the patient as well.
When treatment aimed at cure ends, the care does not end — it becomes almost entirely nursing. Mouth care, position, cleanliness, symptom relief, quiet, company, and care of the family. Students should know in advance that there is no such thing as nothing more can be done, only a change in what is being done, and that this is skilled work rather than what remains when the skilled work stops.
Pain, breathlessness, noisy breathing from secretions, restlessness, dry mouth and nausea are the common ones. Some are relieved by prescribed treatment, and several respond to positioning, mouth care, a fan, a quiet room and fewer interventions. Noisy breathing distresses the family far more than the patient, and explaining that plainly is itself a nursing act.
Carried out with the same dignity as care before it: the body handled gently, washed and positioned according to the family's wishes and the customs of their faith, devices removed or left according to policy, identification correct, the family given time and not hurried. Practices differ enormously between communities and asking is always better than assuming.
People who care for the dying carry it. Services that acknowledge this keep their nurses; services that expect them to carry on as though nothing happened lose them. Know what support exists where you work before the day you need it, and understand that being affected is evidence of engagement rather than unsuitability.
A patient goes home to be cared for by themselves or by a relative who must know what to watch for, what to do, and when to come back. Teaching that consists of handing over a leaflet has not happened. Asking the person to say back, in their own words, what they will do is the check that it has, and it takes one minute.
Whatever else there is time for, the person should leave knowing what would mean come back now. For a wound that is spreading redness, increasing pain, discharge and fever. For a device it is what a blockage or a dislodgement looks like. For a new condition it is the two or three changes that matter. Where the nearest facility is hours away, what the family knows determines when the patient arrives.
Short sentences, one idea at a time, in their language, with demonstration rather than description where a skill is involved, and repetition across more than one occasion. Written material helps people who read; pictures and demonstration help everybody. Assess what they already believe about their condition before correcting it, because teaching over the top of a belief rarely displaces it.
In most of the world the person who will actually do the dressing, give the feed or turn the patient is a relative with no training and no pay. Teaching them properly, checking they can do it rather than that they said yes, and telling them who to call, is among the highest-value things a nurse does and is almost never counted as work.
A bandage applied too tightly restricts circulation, and the damage happens under a covering where nobody can see it. Swelling after an injury or a procedure increases with time, so a bandage that was comfortable when applied can become constricting hours later without anybody touching it. This is why what is checked after applying a bandage matters more than the neatness of the applying: colour, warmth, swelling, sensation, movement and the patient's own report of pain or tightness, reassessed on a schedule rather than once.
Pain out of proportion to the injury, pain on passive movement, numbness or pins and needles, a limb that is cold or pale or dusky, swelling beyond the bandage edge, or a capillary refill that has slowed. Any of these means release the bandage and reassess, then escalate. Students hesitate here because undoing somebody else's careful work feels presumptuous; a limb is worth more than a dressing, and nobody has ever been criticised for taking a bandage off a compromised leg.
Holding a joint still lets tissue heal and prevents further damage, and it also stiffens joints, wastes muscle, damages skin at the edges of casts and splints, and predisposes to clots. Both halves are true at once. The nursing work is keeping the immobilised part correctly positioned and supported, watching the skin at every edge and pressure point, maintaining movement everywhere that is not immobilised, and asking regularly whether the immobilisation is still required.
An injured limb is elevated to reduce swelling and supported so its weight does not hang on the injury. A patient with a limb in a sling still needs the shoulder moved. A leg in a cast still needs the foot looked at. These are small, unglamorous things, and the complications they prevent — pressure damage under a cast, a frozen shoulder, a missed compartment problem — are large and slow to undo.
Heat and cold change blood flow, muscle tone and the perception of pain, and they are available in every setting including those with almost nothing else. They are also capable of causing burns and cold injury, particularly in the people most likely to be given them: the old, the very young, the unconscious, anyone with reduced sensation, and anyone with poor circulation — precisely the patients who cannot tell you it is too hot.
Never apply either directly to skin. Never apply to an area with reduced sensation or poor circulation without checking whether it is safe to. Check the skin frequently rather than at the end. Keep applications time-limited. And never leave a heat source with a patient who cannot move away from it or report discomfort. Burns from hot water bottles and improvised heat sources in patients who could not feel them are a recurring and entirely preventable injury.
Position and support. Emptying a bladder. Loosening something that is pulling. A fan or moving air for breathlessness. A quiet, darkened room. An explanation, because fear measurably amplifies pain. Company. Distraction. These are not what a nurse does when there is nothing else; they are effective, they are available everywhere, and they are the things most often skipped while waiting for medication to be due.
A great deal of this manual assumes sterile packs, disposable everything, working suction and oxygen on the wall. Many readers will have some of that some of the time. The professional response is not to pretend the standard is met, and not to abandon the patient either: it is to use risk assessment to direct what exists towards the exposures that most warrant it, to follow whatever local policy covers reuse or extended use, and to document the shortfall every time so it becomes visible to somebody who can act on it.
Clean hands, with soap and clean water, prevent an enormous amount. Physical friction and detergent remove organisms even without a disinfectant. Boiling, sunlight and ventilation are real interventions. Position, elevation, gravity and pressure relief need no equipment. Teaching a family to recognise danger signs costs two minutes. None of this is a reason to accept a badly supplied service, and all of it is better than doing nothing while waiting for something better.
Improvisation guided by the principle is nursing; improvisation guided by hope is not. If you cannot confirm a tube's position by the method your policy requires, you do not feed through it and guess — you escalate. If you have no sterile pack, you do the cleanest thing available and you record what you actually did. A record that says what was genuinely possible is worth more than one that describes a procedure that did not happen.
A gap that is worked around silently is a gap that will still be there in ten years. Written records of unmet need are what eventually move budgets and staffing; quiet heroism is what allows a shortage to persist. This is a professional act rather than a complaint, and it protects you as much as it protects the next patient.
What was done, when, by whom, and what happened afterwards. Most procedure records answer the first two and stop, which is how a complication ends up with no baseline to compare against. The site looked like this before and like this after. The patient tolerated it, or did not, and here is what they said. This much was drained, and it was this colour. A record written that way lets the next nurse notice a change; a record that says dressing done does not.
That the procedure was explained, that the patient agreed, and that they were competent to agree. Where a patient refused, that is recorded too, along with what was explained and what alternative was offered — a refusal recorded properly protects the patient's right and the nurse's position at the same time. A signature on a form is evidence that a conversation happened; the note is where the conversation is described.
Where a device, implant, blood product or sterile item carries an identifying number, it is recorded. This looks like bureaucracy until a product is recalled or an infection cluster is investigated, at which point it is the only way to find out which patients are affected. Nurses are almost always the people who record it, and it is almost always the field left blank.
If a procedure was abandoned, if it took three attempts, if the equipment failed, if the patient became distressed — that belongs in the record. It reads as an admission and it is actually the opposite: it is the information that lets somebody else avoid the same thing, and a record that describes only successful procedures is a record nobody can learn from. Services where this is written down honestly are services where fewer patients are harmed twice.
Identification and consent. Hand hygiene at the right moments. Preparation before starting. Maintaining the field. Correct sequence. Observing and reporting what you saw. Safe disposal. Leaving the patient comfortable, informed and safe. Candidates rarely fail on the core technique; they fail on consent, hand hygiene, contaminating a field by reaching across it, and disposal.
Almost always what the nurse does first or next when something changes — a cannula site that has swollen, a feeding tube whose position cannot be confirmed, a drain that has suddenly stopped, a saturation that has fallen. The safe answer stops the thing that could be causing harm, assesses, and escalates. Options that continue the procedure, adjust a prescribed rate, or reassure instead of assessing are the distractors.
Every device is a trade. Ask daily whether it is still needed. Confirm tube position before every use, not only after insertion. Check the cannula site at every round. Never recap a needle. Never silence an alarm you have not understood. Assess the wound rather than the dressing. And assume the unconscious patient can hear you. Six sentences, none of them difficult to understand, and between them they prevent most of the harm that devices do to patients on ordinary wards in ordinary weeks.
None of these procedures can be learned from a page, and this manual has deliberately not written any of them as a checklist. What it gives you is the reason behind each step, so that when you are taught the procedure your service uses you understand why it is that way — and so that you notice when something is about to go wrong rather than only when it has. A student who arrives at a practical session already knowing what each step is protecting learns the procedure in half the time and forgets it far more slowly, because they are learning one idea rather than eleven unrelated movements.