FINAL CHECK-OFFClinical ProceduresMedication AdministrationIntravenous ProceduresUrinary Catheterization

Wound CareGastrointestinal Tube

Traceostomy

MEDICATION ADMINISTRATION

IM or SQ injection1. Wash Hands2. Compare MAR with MD Orders: Client, Time, Drug, Dose, Route3. Check Patient chart for allergies to medications or latex drugs4. Take MAR to med cart5. I am going to perform my three checks:

As I am taking med out of med cartBefore withdrawing medAfter withdrawing med

6. Pull med from cart, checks with MAR7. Which needle size to use for

IM injection: 19-23 gauge, 1½ in.SQ injection: 25-27 gauge, 5/8 in.

8. Perform 2nd check before withdrawing med9. Withdraw med:

Take off vial capAlcohol swab the topMaintain sterile needleInject air into vialWith draw med w/ no bubblesRecap using sweep methodLabel needle

10. Perform the 3rd check after withdrawing medication11. Go into patient room and introduce self and id patient; ask about allergies12. Wash hands/Gloves13. Tell patient you are going to give him an IM injection, which puts the medication into the muscle. Explain what the med does and how it is useful.14. Put the patient in the correct position to relax muscle and minimize discomfort15. Checks one last time.

16. Select site and Perform assessment:InflammationErythemaMake sure rotating site from last injectionLesionsTendernessSwellingHardnessBruising

17. Alcohol swab the site18. Pull skin to the side for Z-track method19. Hold syringe like a dart, push in quickly20. Stabilize with non dominant hand, aspirate for 5 seconds and look for air If no air appears inject med slowly and pull needle out.21. Properly dispose of needle- do not recap

22. Document: On MAR: med and signaturePre-administration assessment findingsSite utilized normal Adverse effects

IM Injection sites1. Ventrogluteal:

Place heel of hand on greater trochanter(right hand for left hip)

Point fingers to the headMake a triangle with index finger on anterior superior iliac

spine and middle finger on iliac crestPosition: Side lying with knee bent towards chest

2. Vastus Lateralis:Middle third of the thighPosition: Back lying or sitting

3. Dorsogluteal:Palpate posterior superior iliac spineDraw imaginary line to greater trochanterSite lateral and superior to the linePosition: Prone with toes inward

4. Deltoid: 3 fingers below acromion processno more than 1 mL of solution

SQ Injection SitesAbdomen Lateral anterior armUpper thigh

ScapularGluteal

Seven Essential Parts to a Medication Order1. Client’s full name2. Date and Time order written3. Drug name4. Dose of drug5. Frequency6. Route7. Signature of person writing order

Ophthalmic Medication1. Assessment:

LesionsExudates ErythemaSwellingItchingBurningBlurred vision

OD: right OS: left OU: both2. Place client in a supine position with head slightly hyperextended3. Clean eyelids eyelashes with sterile cotton ball moistened with NS- wipe inner to outer4. Place tissue below eyelid5. Hold eyedropper ½ - ¾ in above eyeball6. Ointment- discard first bead7. Rest hand on client’s forehead8. Tell client to look up9. Drops into outer 1/3 of lower conjunctival sac10. Instruct patient to close eyes and move eyes11. Apply pressure to lacrimal ductsOtic Medication1. Assessment:

Signs of rednessAbrasionsDischarge

2. Side lying position with affected ear up3. Clean: use cotton tipped applicators to wipe pinna and auditory meatus4. Straighten ear canal: Up and out/back5. Hold dropper ½ in above ear6. Press firmly on tragus a few times7. Maintain position for 2-3 min8. Cotton ball on outermost part of ear

Topical Skin Medication1. Assessment:2. Remove old patch3. Clean site4. Apply medicationNasal Medication1. Position patient so they are sitting upright2. Ask pt to blow nose3. Inhaler, ask to inhale while spray is administered4. After- blot nose, but do not blowRectal1. Position client in side lying position on left side with upper leg drawn toward the chest2. Towel or pad under patient 3. Assess external anus4. Lubricate tip5. Tell client they will experience a cool sensation and pressure 6. Encourage slow deep breaths7. Separate buttocks and insert med8. Wipe anal areaVaginal1. Ask client to void and help into a back lying position with knees bent and hips rotated laterally2. Drape client and put towel or pad on bed3. Assess clean perineal area; Assessment:

InflammationAmount, character, and odor of dischargeComplaint of vaginal discomfort-burning, itching

4. Retract labia5. Insert applicator 2-3 in into the vagina

IV PROCEDURES

Primary Line1. Wash Hands2. Check MD order and MAR: date/time, med/fluid, route, dose/rate,

client name3. Check drug book for compatibility and adverse rexns4. Calculate drip rate5. Choose correct fluid and tubing – make sure bag is clear with no

precipitates, cloudiness or leaks and check exp date 6. Attach calculation strip to bag: Date, int, start amount, middle,

quarter, endMark how many mL will pass with each hour

7. Label tubing- Date, time, int8. Close clamp on tubing, Remove plastic stopper from IV bag, and

insert tubing9. Fill drip chamber ½ full10. Prime tubing- Take off cap, open clamp, hold over trash

can11. Prepare syringe with 3mL NS12. Go to client’s room, Introduce yourself, and Id patient,

check allergies13. Wash hands, gloves14. Check 5 rights15. Assess IV site for: Phlebitis, pain, infiltration, inflammation, irritation, edema, warmth, cool16. Hang bag17. Clean port with an alcohol swab18. Flush port with 3 mL NS (if nothing running) or

incompatible19. Connect new bag and tubing to port 20. Open clamp and regulate drip rate within 4 drops21. Check arm again22. Document date, time, type of solution, start and end time,

drip rate, condition of IV site, client response, signature

<100 mL/hr = Microdrip 60 gtts/mL >100 mL/hr = Macro drip 10, 12, 15, 20 gtts/mLGroshong style catheter- do not need to be heparinized because the prevents blood from entering

Complications from IV Therapy:1. Infiltration – Swelling, cool skin, blanching, discomfort, slowed

infusion rate2. Hematona – discoloration, swelling, tenderness3. Phlebitis – tenderness, redness, heat, edema4. Tissue Sloughing – tissue necrosis5. Infection – tenderness, swelling, erythema, induration, purulent

discharge

Peripheral IVAD: give IVPB1. Check MD orders with MAR: date/time, drug, strength/dose,

route, client2. Gather materials like med bag and tubing (need primary tubing),

tape, marker, alcohol, syringes3. Label bag and tubing – time, date, flow rate4. Prime tubing5. Get syringes ready – 2, 3mL saline syringes

6. 2nd check for medications7. Calculate flow rate by looking in IV med book and Look up signs

for adverse rexns8. Take into room – med bag w/ tubing, alcohol, 2 flushes, MAR9. Introduce self, id patient, check allergies to medication10. Wash hands/gloves11. Assessment of site12. Alcohol swab and flush13. Attach tubing and set flow rate14. Look at site again, any pain15. Come back when med is infused, give second flush,

assess for adverse rexnsCompatible Primary IV infusing: start IVPB

Same steps, the difference is in the priming of tubing/ secondary tubing1. Prime tubing when hooked to primary line on the upper Y port2. Open all the lines, let the med bag lower than the fluids3. Set the fluid on a hanger lower than the med bag4. Set drip rate with fluid bag drip chamber and let med bad wide

open5. Check site again

Incompatible Primary IV: start IVPBNeed Primary tubing for med bag

1. 3 NS syringes with 3 mL each2. Close off port by rolling down to lower Y clamp3. Flush4. Set up primary tubing at lower port5. Set flow rate6. Come back, flush, open clamp and roll back

Peripheral IVAD: IV Push1. Wash hands2. Check MAR with MD orders3. 3 checks- a) when taking from med cart

b) before withdrawing medc) after withdrawing med

4. Determine med action, SE, rate of administration5. Calculate med dosage6. Prepare 3mL NS syringe 7. Introduce self, id patient, determine allergies, explanation8. Wash hands, clean gloves, 9. Assess insertion site10. Take client VS11. Take off port cap12. Flush lock with 1mL of NS13. Push med14. Flush 1mL NS

15. Replace a new sterile cap over the lockCompatible Primary Line: Give IV Push

1. You don’t need flush because you have a flush running2. Use the port closest to the patient3. Alcohol swab it4. Clamp off the primary line5. Administer med at recommended rate6. Unclamp tubing

Incompatible Primary Line: Give IV Push1. Need two syringes for flushes and I syringe with medication2. Slide clamp down and close off3. Wash hands/glove4. Wipe port with alcohol swab5. Flush with 2-3cc NS6. Inject med7. Second flush8. Set clamp in previous position

Central LineTriple LumenBrown port used for blood withdrawsWith flush always use a 10cc syringeProtocols tell you how much flush to useFlushing a central catheter:

1. Wash hands, apply gloves2. Prep 2 syringes – 10cc NS, 5cc Heparin3. Swab injection cap/catheter hub with p-iodine and alcohol4. Clamp catheter and remove cap5. Check for patentcy6. Attach syringe of NS7. Release clamp8. Aspirate heparin solution from catheter9. Observe for blood return10. Flush quickly with NS11. Reclamp12. Remove empty syringe Attach 5cc heparin syringe13. Release clamp14. Flush quickly 15. Reclamp16. Place a new cap on catheter17. Tape all tubing connections18. Attach tubing to client’s clothing19. Wash hands20. Document: Condition of catheter, patentcy of

catheter(ability to draw blood), and report: occlusion, catheter damage, air embolus

Starting a Central Line Infusion1. If patient has no fluids running, flush with NS (10cc syringe)2. Look at protocols3. Slide clamp should be clamped off4. Wipe Port, and attach syringe5. Unclamp sliding clamp, aspirate blood**, infuse NS6. Before removing syringe, turn clamp off, then remove, and

attach tubing7. Turn fluids on

Central Line Dressing1. Wash hands/ clean gloves2. Remove old dressing3. Note drainage on dressing4. Inspect skin at insertion site for redness, tenderness, swelling5. Palpate catheter for Darcon cuff and document proper placement6. Inspect Catheter7. Remove gloves, wash hands, put on sterile gloves8. Clean exit site with P-iodine – begin at catheter and move out in

a circular motion9. Apply ointment to exit site10. Apply sterile gauze dressing with tape11. Label date and time of dressing change12. Secure tubing to clothing13. Document: date, time, type of ointment and dressing,

condition of skin, presence of exudates and bleeding

WOUND CARE & STERILE TECHNIQUE

Surgical Incision – wound created under sterile condition, center of the incision is cleanest

1. Clean down the middle first, go down one side then down the other with clean sponge each time

2. Drains should be cleaned last3. Closed drain – prevents pocket of blood and bacteria, neg

pressure(sanguinous – bloody drainage; serosanguinous – combination of serous and blood)4. Change every 2 hours, and record amount of drainage

Open wound – not surgically created; if it is not extremely dirty with much exudate it is not recommended to clean it bc you may destroy healing fiber

1. If it needs to be cleaned, irrigate or apply a wet-to-dry dressing2. Center is considered most contaminated

Wet-to-dry1. Physician does not want to surgically close incision so it is left

open2. Physician does not want to close fluid inside

Sterile Field1. Open away from you and set to side, 1in margin on all sides, You

can touch cloth underneath2. Pouring Solution – Open NS can be kept 24 hrs, if it is already

opened, then dump some in the trash, put bowl to the side so you do not have to reach over the sterile field, set cap down facing up

3. Adding ointment – pour some ointment in the field or put on a 4X4

4. Put on sterile gloves last after you set everything up5. You can use forceps to move things around

Sterile Gloving1. Touch folded area2. Make adjustments once gloves are on – watch where your fingers

are, hold over a sterile area, 3. Do not lower hands below waist4. Take glove off – dirty-to-dirty, clean-to-clean

Dressing Change1. Check MD orders for type of change, irrigation, or ointment2. Introduce Self, Id Patient, Explain what you are going to do and

why3. Wash hands/clean gloves/privacy4. Assessment of old dressing:

Appearance and size of woundAmount, character, and odor of exudatesComplaints of discomfortLocal Infection: Erythema, purulent drainage, swelling, pain, inflammationSigns of systemic infection: fever, diaphoresis, and malaise

5. Determine what supplies you need by assessing the wound – number of gauzes saturated and diameter of drainage, dressing change kit, Sterile NS, tape, Neosporin

6. Remove old dressing – pull tape gently but firmly toward wound7. Ready to set up sterile field8. Clean wound from clean to contaminated and clean drain last

(Penrose – half circle)9. Apply new dressing

Dry heat – apply 4X4 to the wound, place abd pad on topMoist heat – Wring NS out of 4X4 place on wound, dry external dressingDrain – cleanse area under drain, apply precut 4X4, top w/

4X4

10. Document: where the wound is, intact, kind of drainage, odor, how many gauze saturated, condition of surrounding skin, presence of drains, type of solutions used for cleaning, type old dressing reapplies, client tolerance

Principles of Sterile Field1. Tables about the waist2. Open package in sterile field3. Don’t put unsterile things in the field(ie. Tape)4. Don’t turn your back on the sterile field5. Hands above waist6. Make sure you open everything before you put your sterile

gloves onIrrigating a Wound

1. Check MD orders to determine type of irrigating solution, frequency of irrigation, and temp of the solution

2. Check irrigating solution is at proper temp3. Introduce self, ID Patient, Explain what you are going to do4. Wash hands/glove/privacy5. Position the client so solution will flow into the basin6. Place waterproof drape over client and bed7. Discard old dressing and assess wound drainage: Appearance

and size of the wound, character of exudates, signs of systemic infection, pain

8. Open sterile dressing set and supplies9. Position basin below the wound10. Instill a steady stream of irrigating solution into the

wound, all areas11. Continue irrigating until the solution becomes clear12. Dry area around the wound13. Use sterile technique to apply the dressing to the wound14. Document: Irrigating, Pt response, character of exudates,

appearance and size of wound

URINARY CATHETERIZATION

1. Check MD orders and size of catheter2. Gather catheter kit(ensure right size, exp date), drape for pt3. Introduce self, ID patient, Ask about allergies to latex or iodine,

Explain what you are going to do why necessary; Tell patient she it might feel like a voiding or urinating sensation

4. Wash hands/glove/privacy5. Perform Abdominal Assessment:

Inspect: Contour – distended; full bladderSymmetry – Shine light across, symmetrical

Umbilicus – midline, no discoloration, inflammation, or hernia(lift head)

Skin – smooth and even, no visible peristalsisPulsation – Pulsations from aortaDemeanor – comfortable, relaxedAuscutate – bowel sounds present in all four quadrantsPercuss – Tympany heard in all 4 quads with dullness noted

at two lower quads(urinary retention)

Palpate(light and deep) – no masses noted, ask for any tenderness

6. Place client in appropriate position and drape exposed areasMan – supine, legs abducted and laterally rotatedWoman – Supine, knees bents, legs laterally rotated

7. Stand on the client’s right if you are right-handed8. Bring bed to waist level9. Drape patient10. Open kit- first away, side-to-side, and then front11. Place waterproof drape under butt12. Apply sterile gloves13. Saturate cleaning balls with antiseptic solution14. Open lubricant15. Open specimen container and place it nearby with lid

loosely on top(if necessary)16. Test balloon by filling it with sterile water; leave syringe

attached 17. Open lubricant and pour in pocket in box18. Let pt know when you will expose them19. Place fenestrated drape over penis20. Clean meatus with nondominant handWoman: Use nondominant hand to spread labia

Pick up cleansing ball with forcepsClean one side of labia majora, then other side; anterior-posterior directionSame for labia minora and use last ball to go over meatus

Man: Grasp penis just below glans with nondominant hand Hold it firmly upright with slight tensionWipe center of meatus in a circular motion out

21. Grasp catheter firmly 2-3 in from tip, ask client to take a slow deep breath, and insert the catheter while pt exhaling

22. Advance catheter 2 in further after urine begins to flow23. Next move nondominant hand to catheter and inflate the

balloon with the clean dominant hand24. Pull gently on the catheter until resistance is felt25. Change gloves

26. Collect urine specimen(if required): Allow 20-30mL to flow into bottle with out touching the inside of the container

27. Secure catheter with enough slack to the thigh28. Make sure bag is hung below the level of the bladder29. Clean perineum and recover30. Documentation: date/time, name, amount and description

of urine, Catheter size and results, assessment findings, amount of water instilled into balloon

Obtain a Sterile Specimen1. Explain procedure2. Wash hands/ gloves3. Clamp foley until urine is seen4. Wipe port with alcohol swab 5. Remove lid from ua bottle6. insert needle, bevel up, and pull off 10cc7. Put urine into cup w/out touching sides of cup8. Discard sharps9. Put lid back on bottle10. Provide comfort11. Clean up/remove gloves/wash hands12. Documentation: Sterile specimen obtained, sent to lab,

side rails up, call light within reachDraping Woman:

1. Put drape in a triangle before you put legs up2. The point of the triangle between her legs3. Flex knees with feet flat on the bed and spread4. Wrap tails around legs and when you are ready, open them

Male:1. Lift gown until you see penis2. Use bottom cover or bath blanket in between their legs

GASTROINTESTINAL TUBES

NG Tube Insertion1. Check MD orders for type and size of tube2. Gather supplies:

TubeSolution basin filled with warm waterTapeLubricant TissueGlass of water w/ straw20-50mL syringe w/ adapter

pH stripsStethoscopeTowelPen lightTongue depressorSafety pin

3. Introduce self, id patient, explain what you are going to do: it is not painful, but it may be uncomfortable bc gag reflex is activated, ask if the client has any allergies or has dentures

4. Establish a method for the client to indicate distress5. Wash hand/ privacy6. Abdominal Assessment:

Inspect: Symmetrical, umbilicus midline without discoloration, skin smooth and even, warm to touchPulsation: Aortal pulsation, no visible peristaltic wavesAuscultate: bowel soundsX4Percuss: Tympanyx4Palpate: No masses, tenderness

7. Nose Assessment:Use pen light to check intactness of tissues-irritations, abrasionsExamine for obstruction or deformity by asking to breath through nostril while occluding the other

8. Determine how far to insert the tube – tip of nose to tip of ear lobe to tip of xiphoid

9. Tear the tapes, one for measurement, other as trousers10. Check patentcy of the tube11. Gloves12. Lubricate tip of tube well, insert tube with natural curve –

Ask client to hyperextend the neck13. Direct tube along floor of nostril14. As tube reached the throat ask client to lean head

forward and take sips of water, Which closes epiglottis

15. Ascertain correct placement by aspirating stomach contents and checking ph, auscultating air, or X-ray

16. Clamp tube, Tape tube to client’s nose and secure to gown

17. Document: Insertion of tube, means by which correct placement was checked and

client responseSalem slump used for suctioning and Levine for feedingIrrigation of NG Tube

1. Check MD orders2. Gather Supplies:

NSIrrigation SetTowelStethoscope

3. Emesis Basin4. Introduce self, ID patient, explain procedure5. Wash hands, privacy, gloves6. Abdominal Assessment7. Place towel under patient8. Semi-fowlers Position9. If on suction disconnect tube from suction10. Check Placement11. Inject 20-30 cc NS into tube12. Pull back on syringe and empty into basin13. Instill and withdraw until tube is patent14. Reestablish suction15. Document: Tube patent, any problems and pt rexn, how

many mLs irrigated with, and how much pulled back, color and consistency of drainage, amount and type of irrigating solution, time suction started and pressure established

Intermittent Tube Feeding1. Check MD order2. Gather supplies:

Feeding SolutionIrrigation setCup with waterEmesis basinPH strip

3. Introduce self, id patient, explain procedure, ask about allergies to any food

4. Wash hands, glove5. Abdominal Assessment6. Verify tube placement7. Check residual8. Attach syringe to NG tube and fill with a small amount of

contents and hold about 6 in about tube insertion9. Fill syringe with feeding and allow to slowly flow10. Flush with 30cc water11. Clamp NG tube12. Document: time of tube feeding, amount and what

feeding, tube placement verified, Assessment findings, Amount of residual

Continuous Feeding1. Check MD orders, Order is give for cc/hr, do not put more than 4

hours of feeding into the bag

2. Check placement and residual3. Prime tubing and connect to NG tube4. Turn on pump

Medication through NG tube1. Liquid med or crushable tab that dissolves in water2. Ensure 3 checks w/ 5 right3. Check placement4. Give med and follow with water

Connecting NG tube to suction1. Low-intermittent suction, watch for tube patentcy2. Do abdominal assessment3. Keep up with I&O

Initiating Suction:1. Semi-fowlers2. Check Placement3. Intermittent Suction set at 80-1004. Check suction level by occluding drainage tube

Salem sump tube(double lumen) – connect larger lumen to NG tube, smaller tube provides a continuous flow of atmospheric air to prevent excessive suction force, should always keep air vent tube higher than the stomach to prevent reflux of stomach contents and keep drainage collection chamber below the client’s stomachLevine – single lumen NG tube, smaller so it is usually for feedings

5. Coil and pin tubing so that is does not go below the suction bottle

6. Assess drainage – amount, color, odor, consistencyMaintaining suction:

1. After initiating suction assess client q30min until running regularly, then q2hr

2. Assess for complains of fullness, nausea, epigastric pain, and make sure there are flow of secretions

3. Inspect for patentcy or tightness of connections4. Relieve blockages, reposition client, rotate NG tube5. Irrigate NG tube6. Apply mouth care q2-4hr7. Empty drainage receptacle: clamp NG tube, turn off suction, note

amount, assess drainage, replace, turn on suction and unclamp tube

TRACHEOSTOMY

Trach Care1. Check MD orders2. Gather equipment: Stethoscope, sterile drape, sterile NS and HP,

sterile 4x4 gauze, dressing

3. Introduce self, ID patient, explain what you are going to do, Tell them to raise a hand or finger to signal distress

4. Wash hands5. Semi-fowlers position6. Chest assessment:Inspect: Color, condition, lesions, rate, rhythm, and depth of airwayPalpate: Symmetric chest expansionPercuss: Hear resonanceAuscultate: clear or crackles7. Place towel on chest8. Clean gloves/throw away old trach dressing9. Wash hands10. Establish sterile field; open and organize supplies, check

exp dates11. Pour NS and 2 HP into separate containers, 2 soaked

gauze with NS, 2 soaked gauze with HP12. Sterile gloves13. Unlock inner cannula with nondominant hand and pull it

towards you in line with curvature and place it in 14. HP solution for 2-3 min, clean with a brush and place in

NS, clean15. Insert inner cannula and lock it into place16. Clean insertion site/stoma and tube flange, wipe once

with NS gauze and discard17. Clean faceplate first with HP gauze, next w/ NS gauge,

next with dry18. Rinse and dry area thoroughly 19. Apply sterile dressing, use commertailly prepared or open

and refold 4x4 gauze to create V-shape20. Apply dressing under flange but make sure it is supported21. Change tracheostomy ties; enough to fit person’s neck

plus 6 in22. Discard equipment, client comfort, bed rails up, lower

bed, call light23. Wash hands24. Document: Describe color, amount, and odor of

secretions, size and type of tracheostomy in place, describe the condition of the stoma including presence of secretions, color, edema, skin breakdown

Trach SuctioningWhistle tip – less irritating to tissuesOpen tip – more effective at removing thick mucous plugsYankauer – Used to suction oral cavity

Symptoms that indicate need for suctioning: dyspnea, bubbling, rattling breath sounds, cyanosis, decreased Sa02, inability to move secretions

1. Check MD orders2. Gather equipment: Ambu bag, suctioning equipment, sterile

drape and gloves, stethoscope(assessment), 3. Introduce self, id patient, explain what you are going to do4. Wash hands/privacy5. Semifowlers position/analgesic before suctioning6. Assess patient, ant and post assessment:Inspect: skin color, conditions, and respirationsAuscultate: anterior and posterior respirationsPalpate: symmetric expansion of the chest, tenderness, lumps, massesPercuss: anterior/posterior7. Attach ambu bag to O2 source8. Open sterile supplies9. Place sterile drape across client’s chest10. 100-120 pressure for suction11. Pour sterile NS in sterile container12. Put on sterile gloves13. Hold catheter in dominant hand and connector in

nondominant hand attach suction catheter to suction tubing14. Flush and lubricate the catheter, place catheter tip in

sterile saline solution and with thumb of nondominant hand occlude the thumb control and suction a small amount of NS into the catheter

15. Hyperventilate lungs before suctioning, turn on 02 to 12-15L/min, compress ambu bag 3-5 times (adequacy of ventilation is assessed by rise and fall of the chest

16. Insert catheter (w/out suction) 5 in or until cough or resistance

17. Apply intermittent suction for 5-10s, rotate catheter by rolling it between the finger and thumb

18. Withdraw completely 19. Hyperventilate and suction again20. Encourage client to breath deeply and cough between

suctioning21. Allow 2-3 min between suctioning22. Documentation: time/date, Findings of respiratory

assessment(pre and post suctioning), description of secretions – color, amount, viscosity, odor, number of time suction catheter inserted