Avoid: side of mastectomy, AV fistula arm, oedematous limb, post-chemotherapy veins, infected/bruised sites
Anchoring & Needle Angle
Anchor vein 2–3 cm distal to puncture site with non-dominant thumb
Insert bevel-up at 15–30° to skin
Reduce angle once flashback seen; advance 2–3 mm
Release tourniquet before withdrawing needle
Blood Culture — Aseptic ANTT
2 sets (aerobic + anaerobic) from 2 separate sites at separate times where possible. Skin prep: 70% IPA then 2% chlorhexidine gluconate — allow 30 s dry time. Do not palpate again after prep. Inoculate anaerobic bottle first if using butterfly; aerobic first if syringe method.
Peripheral IV Cannulation
Gauge Colour Selection
Gauge
Colour
Flow Rate
Use
14G
Orange
~300 mL/min
Major trauma / rapid transfusion
16G
Grey
~180 mL/min
Surgery, blood products
18G
Green
~90 mL/min
Standard IV fluids, medications
20G
Pink
~60 mL/min
Most adult medications
22G
Blue
~35 mL/min
Elderly, paediatric, fragile veins
Failed Cannula Troubleshooting
Flashback then loss: vein rolled — re-anchor, adjust angle slightly
No flashback: needle too deep or too shallow — withdraw slowly
Cleanse skin with 70% isopropyl alcohol — wipe in concentric circles, allow 30 s to dry completely
Apply 2% chlorhexidine gluconate or povidone-iodine — allow 30–60 s to dry — DO NOT re-palpate
Decontaminate bottle tops with 70% IPA swab; allow to dry
Insert needle at 15–30°; collect 8–10 mL per bottle (adult)
Inoculate bottles: anaerobic first (butterfly) or aerobic first (syringe)
Label bottles at bedside with patient ID, time, date, site
Document in clinical notes: indication, site, time collected
Send to lab within 1 hour (do not refrigerate)
Two sets from two separate venepuncture sites increases sensitivity from ~80% to ~96% for bacteraemia detection.
Peak Flow Technique
Patient Instruction (PEFR)
Stand or sit upright; ensure reset to zero
Take a deep breath — fill lungs fully
Seal lips tightly around mouthpiece
Blast air out as fast and hard as possible (not long breath)
Record result; repeat 3 times — record the highest value
Compare to personal best / predicted value
Predicted PEFR Values (approximate)
Zone
% of Best
Action
Green
>80%
Well controlled, continue usual treatment
Amber
50–80%
Caution — increase bronchodilator, seek review
Red
<50%
Medical emergency — act immediately
Instruct patient to maintain a PEFR diary — twice daily (morning and evening), before and after bronchodilator, to identify diurnal variation (>20% variation suggests poorly controlled asthma).
Inhaler Technique
MDI (Metered Dose Inhaler)
Shake vigorously for 5 s; remove cap
Breathe out gently to functional residual capacity
Seal lips; actuate once at start of slow deep breath
Continue slow inhalation over 3–5 s
Hold breath 10 s; breathe out slowly
Wait 30–60 s before second dose
Spacer Device
Attach MDI to spacer; actuate once into spacer
Place mouthpiece in mouth; breathe in and out 5 times (tidal breathing) OR single deep breath + hold
Clean spacer monthly (warm water, air dry — do not towel dry)
DPI (Dry Powder Inhaler)
Load dose per device instructions; breathe out (away from device)
Fast, deep inhalation — do not block air holes
Hold breath 5–10 s; do not exhale into device
Nebuliser
Drug + diluent to 4–5 mL total volume (0.9% NaCl)
Flow rate: 6–8 L/min oxygen or air
Sit upright; mouthpiece preferred over mask
Duration: 10–15 min (until sputtering)
Monitor: SpO₂, RR, HR, wheeze, tolerability
Check inhaler technique at EVERY clinical encounter — poor technique is the most common cause of treatment failure.
Oxygen Therapy
Device
Flow Rate
Approx. FiO₂
Indication
Nasal Cannula
1 L/min
~24%
Mild hypoxia, comfort, COPD (low flow)
Nasal Cannula
4 L/min
~36%
Moderate supplemental O₂
Nasal Cannula
6 L/min
~44%
Upper limit of NC — consider simple mask
Simple Face Mask
5–6 L/min
~40%
Minimum 5 L/min to prevent CO₂ rebreathing
Simple Face Mask
10–15 L/min
~60%
Moderate hypoxia
Non-Rebreather Mask
15 L/min
~90–95%
Severe hypoxia, CO poisoning, acute resus
Venturi 24%
2 L/min
24% ± 2%
COPD — controlled O₂
Venturi 28%
4 L/min
28% ± 2%
COPD — controlled O₂
Venturi 35%
8 L/min
35% ± 2%
Controlled supplemental O₂
Venturi 60%
15 L/min
60% ± 2%
Higher FiO₂ with controlled delivery
For COPD patients: target SpO₂ 88–92%. Over-oxygenation can suppress hypoxic drive and cause type II respiratory failure (hypercapnia).
Sputum Collection
For MC&S (Microbiology)
Ideally early morning specimen (highest bacterial concentration)
Patient to rinse mouth with water first (reduce contamination)
Deep cough from lower airways — not saliva or postnasal drip
Collect into sterile container; minimum 1–2 mL
Label immediately; send within 2 hours (or refrigerate)
Insert anaesthetic gel (2% lidocaine gel) into urethra; wait 3–5 min
Hold penis at 90° (perpendicular) to reduce urethral angles
Advance catheter (12–14 Fr) full length to bifurcation before inflating balloon
Inflate balloon only once urine is draining freely
Return foreskin to normal position to prevent paraphimosis
Secure; connect to closed drainage system
Challenges
Prostatic enlargement Use larger bore (14–16 Fr), Coudé-tip catheter
Phimosis Cannot retract — use topical anaesthetic cream; urological referral may be needed
Resistance Never force — stop, escalate to urology
GCC Scope Note: In UAE (DHA/DOH), trained nurses of either gender may perform male catheterisation. In Saudi Arabia (SCFHS), traditionally restricted to male nurses — verify local policy.
Nasogastric Tube Insertion
Measurement (NEX Method)
Nose → Earlobe → Xiphoid process — measure and mark the tube at this point.
Procedure
Sit patient upright (45–90°); check for contraindications first
Lubricate tip with water-based lubricant
Insert through nostril, advance along floor of nasal cavity
Ask patient to sip water and swallow as tube passes pharynx (chin to chest)
Advance to marked length; secure with tape to nose
Confirm placement BEFORE use
Confirmation Methods
GOLD STANDARD CXR — tip below diaphragm, midline, left of midline in stomach
Contraindications: base of skull fracture, oesophageal varices/stricture, recent gastric/oesophageal surgery, coagulopathy (relative). NEVER confirm by air auscultation alone — this method is no longer recommended.
Suprapubic Catheter Care
Inspect insertion site daily — assess for redness, discharge, granulation
Clean with sterile normal saline; dry thoroughly
Change dressing per protocol (typically 48–72 h or when soiled)
First SPC change: performed by trained clinician (risk of tract closure)
Subsequent changes: per manufacturer interval (silicone ~12 weeks)
Bladder washout if blocked — use sterile technique
Ensure catheter is anchored to prevent accidental dislodgement
Educate patient on signs of infection, blockage, and leakage
General Catheter Care Principles
Daily meatal hygiene with soap and water
Maintain closed drainage system — do not disconnect unnecessarily
Empty bag when 2/3 full (or per shift); use individual draining receptacles
CAUTI prevention: hand hygiene, ANTT for all manipulations
Nitrites + leucocytes = highly suggestive UTI. Mid-stream urine (MSU) for MC&S to confirm before antibiotics in non-acute cases. Common GCC exam question!
12-Lead ECG Acquisition
Limb Lead Placement
Lead
Electrode
Position
RA (Red)
Right Arm
Right wrist/upper arm
LA (Yellow)
Left Arm
Left wrist/upper arm
LL (Green)
Left Leg
Left ankle/lower leg
RL (Black)
Right Leg
Right ankle (ground/neutral)
Derived Limb Leads
Lead I: LA(+) vs RA(−)
Lead II: LL(+) vs RA(−)
Lead III: LL(+) vs LA(−)
aVR, aVL, aVF: augmented unipolar leads
Chest (Precordial) Lead Placement
Lead
Position
V1
4th ICS, right sternal border
V2
4th ICS, left sternal border
V3
Between V2 and V4 (diagonal)
V4
5th ICS, midclavicular line
V5
Anterior axillary line (same level as V4)
V6
Midaxillary line (same level as V4/V5)
Patient Preparation & Artefact Prevention
Patient supine, relaxed, warm — shiver artefact is the most common cause of poor trace
Prepare skin: shave excess chest hair, use alcohol wipe, abrade with pad if necessary
Use fresh electrodes — avoid expired or dried gel electrodes
Ask patient to lie still and not talk during acquisition
Electrical interference: move away from pumps; ensure cables are not looped
Severe PAD — no compression; urgent vascular referral
Glasgow Coma Scale (GCS)
Component
Response
Score
Eye (E)
Spontaneous
4
To voice/sound
3
To pain/pressure
2
None
1
Verbal (V)
Oriented
5
Confused
4
Words (inappropriate)
3
Sounds (incomprehensible)
2
None
1
Motor (M)
Obeys commands
6
Localises to pain
5
Withdraws from pain
4
Abnormal flexion (decorticate)
3
Extension (decerebrate)
2
None
1
Total: 3–15. Document as E_V_M_ (e.g., E3V4M5=12). GCS ≤8: airway at risk — prepare for intubation support. Neurological obs frequency: every 30 min until stable, then per protocol.
Wound Swab Technique
Standard Culture Swab
Clean wound with normal saline; remove surface debris/slough
Identify the area of highest clinical concern (most inflamed, deep tissue)
Use Levine technique: rotate swab over 1 cm² area with sufficient pressure to express tissue fluid (not just surface exudate)
Place in transport medium immediately
Label and send within 4 hours (or refrigerate up to 24 h)
Biofilm & Levine Technique
The Levine technique targets deeper tissue colonisation including biofilm organisms — press firmly, rotate 5 rotations, 1 cm² area.
Swabbing wound exudate alone identifies surface colonisers, not infecting pathogens. Tissue biopsy is gold standard for wound infection diagnosis but swab is most practical.
Other Swab Types
Non-culture swab (cytology/MRSA screening): dry or flocked swab
Throat swab: depress tongue, swab tonsillar fossae and posterior pharynx
Nose swab (MRSA): rotate in both anterior nares
IV Drug Administration
IV Bolus vs Infusion
Method
Typical Rate
Examples
IV Push (bolus)
Per BNF/protocol (e.g., furosemide: max 4 mg/min)
Furosemide, morphine, metoclopramide
Short infusion
15–60 min
Antibiotics, antiemetics, potassium
Continuous infusion
Over hours/24 h
Insulin, heparin, amiodarone, vasopressors
Flush Protocol
Pre-flush: 5–10 mL 0.9% NaCl to confirm patency
Post-flush: 5–10 mL 0.9% NaCl with pulsatile technique (push-pause)
Check for compatibility before Y-site administration
Never mix medications in the same line without confirmed compatibility. Precipitate formation can cause fatal embolism. Use IV drug interaction resources (BNF/Micromedex/Trissel's).
Check drug compatibilities in the syringe (two-nurse check)
Draw up prescribed drugs + diluent (0.9% NaCl or water for injection) to correct volume
Label syringe: patient name, drugs, doses, diluent, total volume, rate, date/time, prepared by
Prime the syringe driver tubing; load syringe onto driver
Set rate (mL/hour or mm/hour depending on device)
Two-nurse check of pump settings before starting
Document start time, site, and observations
Check driver every 4 hours: volume remaining, site condition, patient comfort
Common palliative care combinations: Morphine + Midazolam + Haloperidol (check compatibility chart — not all combinations are compatible). Change syringe every 24 hours.
Epidural / Intrathecal Monitoring
Nursing Monitoring Parameters
Motor block: Bromage scale (0=no block, 3=unable to flex ankle/knee). Document hourly
Sensory level: Ice/cold test — document dermatomal level bilaterally
Haemodynamic: BP every 30 min for 2 h after insertion/dose change, then hourly
Sedation score ≥3 or RR <10: hold PCA, oxygen, consider naloxone, call doctor
Document: attempts vs deliveries ratio (excessive attempts = inadequate dose or lock out too long)
Only patient presses button — not family/staff (defeats safety mechanism)
Two-nurse check on drug load and pump settings
IM Injection Technique
Ventrogluteal Site (Preferred)
Locate with hand: heel on greater trochanter, point index finger to ASIS, spread middle finger toward iliac crest — inject in the V
Fewer nerves and blood vessels than dorsogluteal; accessible in most patients
Needle: 21–23G, 38–50 mm (depth depending on BMI)
Z-Track Technique
Pull skin 2–3 cm laterally with non-dominant hand
Inject at 90° — aspirate debate: current evidence does not support routine aspiration for IM in deltoid/ventrogluteal (vascularity low). Check local policy
Inject drug at 1 mL per 10 s; wait 10 s after injection
Release skin while withdrawing needle — seals track, prevents tracking
Maximum volumes: Deltoid 1 mL; Ventrogluteal 2–3 mL (up to 5 mL in large muscle); Vastus lateralis 2–3 mL.
Subcutaneous Insulin Injection
Rotation Sites
Abdomen (fastest absorption): avoid 5 cm around umbilicus
Outer thigh (slower absorption)
Upper outer arm (moderate absorption)
Rotate sites systematically — use body map/chart
Technique
Check insulin type, dose, expiry; two-nurse check for high-risk
Roll cloudy insulin gently 10× (do NOT shake)
Clean skin with wipe; allow 30 s to dry (alcohol can affect absorption)
Injecting into lipohypertrophic tissue causes unpredictable absorption. Assess all injection sites at each clinic visit. Systematic rotation prevents lipohypertrophy. Change needles with every injection.
GCC Regulatory Context
ANTT (Aseptic Non-Touch Technique)
Mandated in DHA (Dubai Health Authority) and DOH (Abu Dhabi Department of Health) infection control policies
Two levels: Standard ANTT (routine procedures) and Surgical ANTT (major invasive procedures)
Key Aseptic Field: the sterile zone containing key parts (catheter tip, needle, syringe tip) — must never be contaminated
Expected in all GCC nursing competency assessments
Cannulation Competency
Peripheral IV cannulation is a mandatory competency for GCC nurse registration
DHA/DOH/SCFHS licensing exams test gauge colours, indications, complications
Documented supervised practice hours required (varies by authority)
ECG Acquisition
12-lead ECG acquisition is a core nursing competency in DHA and MOH examination frameworks
Accurate lead placement (especially V1–V6) and artefact identification frequently tested
Focus on critical care, IV therapy, medication management
Clinical skills including ABG interpretation, ECG, ventilator care
High-Yield Exam Quick Reference
Order of Blood Draw (memorise)
Blood Cultures (Yellow/Orange)
Citrate — Coagulation (Light Blue)
Serum/SST (Red/Gold)
Haematology/FBC (Lavender/Purple)
Biochemistry (Green — heparin)
Glucose/Lactate (Grey — fluoride oxalate)
Cannula Gauge Colours
14G = Orange
16G = Grey
18G = Green
20G = Pink
22G = Blue
ECG Lead Placement (V leads)
V1 → 4th ICS, right sternal border
V2 → 4th ICS, left sternal border
V3 → Between V2 and V4
V4 → 5th ICS, midclavicular line
V5 → Anterior axillary line (V4 level)
V6 → Midaxillary line (V4 level)
GCS Quick Scores
Maximum: E4 V5 M6 = 15
Minimum: E1 V1 M1 = 3
Coma definition: ≤8
Mild brain injury: 13–15
Moderate: 9–12 | Severe: ≤8
Clinical Skills Competency Self-Checker
Select a skill category and specific skill to review the step-by-step procedure checklist. Track your competency and save progress.
Limb Leads
Colour (UK)
Position
Lead Views
Red (RA)
Right wrist
I, II, III, aVR, aVL, aVF
Yellow (LA)
Left wrist
Derived
Green (LL)
Left ankle
Derived
Black (RL)
Right ankle
Earth/ground
Territorial Groupings
Inferior wall: II, III, aVF (RCA territory)
Lateral wall: I, aVL, V5, V6 (LCx territory)
Anterior wall: V1–V4 (LAD territory)
Septal: V1, V2
Posterior (reciprocal): Tall R in V1–V2, ST depression
STEMI diagnosis: ST elevation ≥1 mm in 2 contiguous limb leads OR ≥2 mm in 2 contiguous chest leads — activate cath lab pathway immediately.
GCC Nursing Advanced Clinical Skills Guide — For educational purposes. Always follow local policies, protocols, and clinical guidelines. Verify information against current editions of BNF, NICE, and GCC regulatory authority guidelines.