Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

348

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 16-4

Removing Arterial and Femoral Lines (Continued)

Comments

13.Assess distal pulses every 3 to 5 minutes while pressure is

being applied.Note: dorsalis pedis and posterior tibial

pulses should be markedly weaker from baseline if

sufficient pressure is applied to the femoral artery.

14. Cover the site with an appropriate dressing and secure the
    dressing with tape. If stipulated by facility policy, make a
    pressure dressing for a femoral site by folding four sterile
    4 4 gauze pads in half, and then applying the dressing.


15. Cover the dressing with a tight adhesive bandage, per pol-
    icy, and then cover the femoral bandage with a sandbag.
    Remove gloves. Maintain the patient on bed rest, with the
    head of the bed elevated less than 30º, for 6 hours with
    the sandbag in place. Lower the bed height. Remind the
    patient not to lift his or her head while on bed rest.


16. Remove additional PPE. Perform hand hygiene. Send speci-
    mens to the laboratory immediately.


17. Observe the site for bleeding. Assess circulation in the
    extremity distal to the site by evaluating color, pulses, and
    sensation. Repeat this assessment every 15 minutes for the
    first 1 hour, every 30 minutes for the next 2 hours, hourly
    for the next 2 hours, then every 4 hours, or according to
    facility policy. Use log rolling to assist the patient in using
    the bedpan, if needed.

ExcellentSatisfactoryNeeds Practice