Emergency access only — requires senior nurse / physician
Emergency
Cannula Gauge Selection
Gauge
Colour
Indication
14G
Orange
Trauma, rapid fluid/blood transfusion
16G
Grey
Blood transfusion, theatre, surgery
18G
Green
Standard adult — IV fluids, antibiotics
20G
Pink
Standard adult — elderly/difficult veins
22G
Blue
Paediatrics, elderly with thin fragile veins
24G
Yellow
Neonates, very fragile veins
Equipment Required
Tourniquet
70% isopropyl alcohol swab
Appropriate gauge cannula
Transparent semi-permeable dressing
10 mL 0.9% NaCl flush (pre-drawn)
10 mL syringe
Non-sterile gloves
Sharps bin (at point of care)
Date/time label for documentation
Insertion Technique — Step by Step
Explain procedure and gain verbal consent. Position patient comfortably with arm supported.
Apply tourniquet 5–10 cm above chosen site. Ask patient to clench fist if needed.
Palpate and visualise vein — assess direction, depth, and mobility.
Clean skin with 70% isopropyl alcohol swab — 30 seconds friction, allow 30 seconds to dry completely (do not fan or blow).
Apply skin traction distally with non-dominant hand to stabilise vein.
Insert cannula bevel up at 15–30° to skin in the direction of blood flow.
Observe for blood flashback in the chamber — advance needle 2–3 mm further into vessel.
Lower angle slightly, advance cannula off needle into vein (slide plastic cannula only).
Release tourniquet. Occlude vein proximally. Remove needle and discard directly into sharps bin.
Connect bung/port. Flush with 10 mL 0.9% NaCl using push-pause technique — check for patency, no swelling, no pain.
Apply transparent dressing. Secure with tape if needed. Label with date, time, gauge, and name.
Document fully in patient record.
Push-pause flush technique: Creates turbulence that clears the cannula lumen and prevents fibrin build-up. Always end on positive pressure (clamp while still flushing).
Difficult IV Access Strategies
Apply warm towels or warm packs to limb for 5–10 minutes to dilate veins
Allow gravity — dangle arm dependent for 1–2 minutes
Document: Date & time of insertion | Site (right/left, specific vein) | Gauge | Number of attempts | Who inserted | Flush confirmed patent | Next review date. Record VIP score at each assessment shift.
Base of skull fracture — use orogastric tube (OGT) only
Raised intracranial pressure — use OGT; avoid nasal stimulation
Coagulopathy — proceed with caution; gel liberally
Oesophageal varices / recent oesophageal surgery — senior-led decision
NEX Measurement
Estimate insertion length before insertion using the NEX method:
Nose → Earlobe → Xiphisternum Measure this distance on the tube and mark it with tape or note the marking. Advance a further 10 cm past the NEX measurement to ensure gastric placement.
Typical adult insertion length: 50–60 cm (varies by patient height).
Tube Sizing
Fine-bore feeding tube: 8–12 Fr (preferred for nutrition — less discomfort)
Wide-bore (Ryles): 12–16 Fr (decompression, lavage, large volumes)
Insertion Technique
Explain procedure and gain consent. Position patient upright at 45–90° (high Fowler's). Have tissues and emesis basin available.
Check nostrils — select most patent side. Assess for obstruction, previous trauma, or surgery.
Measure NEX distance on the tube and mark/note the measurement. Add 10 cm.
Apply water-soluble lubricant / anaesthetic gel (lignocaine gel if prescribed) to tip of tube.
Insert tube horizontally into nostril (not upward) — advance along floor of nasal cavity.
As tube reaches posterior pharynx (~15 cm), ask patient to flex chin to chest and swallow water through a straw if able — this opens the oesophagus and closes the trachea.
Advance tube with each swallow. If resistance, coughing, or gagging persists — withdraw slightly and retry. Do NOT force.
Continue advancing to marked measurement (NEX + 10 cm).
Temporarily secure tube to nose with tape. Confirm position before proceeding.
Position Confirmation — Safety Critical
NEVER use the whoosh/auscultation test ("air bubbling" test) — this method is unreliable and has caused fatal misplacements. It is banned in evidence-based practice and must not be used as a sole confirmation method.
pH Testing — Gold Standard (1st Line)
Aspirate gastric contents using a syringe. Test aspirate with CE-marked pH indicator paper.
pH ≤5.5 = gastric position confirmed — safe to use. pH 5.5–6 = inconclusive — proceed to X-ray. pH >6 = do NOT use — X-ray required.
Check placement before every feed and every medication dose
If unable to aspirate: reposition patient (roll to side), advance 5 cm, try again
pH may be falsely elevated if patient on PPI/H2 antagonist — X-ray if doubt
Long-term, urethral obstruction, post-pelvic surgery — inserted by physician
Intermittent
Neurogenic bladder, CISC programme
Sizing
Male standard: 12–14 Fr (haematuria: 16–18 Fr, 3-way 20–22 Fr)
Female standard: 10–14 Fr
Balloon volume: 10 mL sterile water (standard adult); 30 mL for traction post-TURP
Male Catheterisation — Anatomy & Technique
Urethra length ~18–20 cm. Key anatomical points: navicular fossa, penile urethra, bulbomembranous urethra (external sphincter — point of resistance), prostatic urethra, internal sphincter (smooth muscle), bladder neck.
ANTT throughout. Open sterile field. Prepare equipment.
Retract foreskin (if present) — must be restored after procedure to prevent paraphimosis.
Clean glans/meatus with 0.9% NaCl using non-touch technique.
Insert 2% lignocaine gel (instillagel) into urethra — wait minimum 5 minutes for anaesthetic effect.
Apply gentle upward traction (perpendicular to body) to straighten penile urethra.
Advance catheter slowly — do not force. At bulbomembranous urethra (resistance point), ask patient to breathe deeply / bear down gently.
At prostatic urethra — angle catheter downward toward patient's feet.
Advance until urine drains (advance further 2–3 cm before inflating balloon).
Inflate balloon with 10 mL sterile water. Withdraw catheter until resistance felt.
Connect to closed drainage bag. Restore foreskin. Secure catheter to thigh.
Female Catheterisation
Female urethra: ~4 cm long. Urethral meatus located anterior to vaginal opening (posterior to clitoris). Identification can be difficult — use adequate lighting, consider patient positioning (frog-leg / lithotomy).
Technique
Position patient supine with knees bent and abducted (frog-leg).
ANTT. Open sterile field.
Clean labia minora and urethral meatus with 0.9% NaCl — always front to back.
Apply lignocaine gel if indicated / per local policy.
Identify urethral meatus — if unsure, use a gloved finger to gently separate labia. Do not insert into vagina.
Advance catheter ~5–6 cm until urine drains. Advance 2–3 cm further.
Inflate balloon with 10 mL sterile water. Connect drainage. Secure.
Identification Tips
Urethral meatus is smaller, round, anterior
Vaginal opening is larger, posterior — if catheter enters vagina, leave it in place as a landmark and insert new catheter anteriorly
Elderly/post-menopausal: atrophic changes may obscure anatomy — use extra lighting
If insertion into vagina is suspected — no urine drainage; check positioning
If catheter accidentally placed in vagina: leave in place as anatomical landmark, insert new sterile catheter into urethra, then remove vaginal catheter.
Difficult Catheterisation
If unable to advance catheter — STOP. Do not force. Forced catheterisation causes urethral trauma, false passages, and bleeding.
Call for experienced help immediately — senior nurse or urology team
Consider Tiemann-tip catheter for BPH/stricture
Urology referral for flexible cystoscopy-guided catheterisation
Suprapubic catheterisation by physician if urethral route impossible
CAUTI Prevention
Daily Indication Review
Ask every day: Is this catheter still clinically necessary? Remove as soon as indication is resolved.
Maintain closed drainage system — never break circuit unnecessarily
Hand hygiene before and after any handling of catheter/bag
Keep drainage bag below bladder level at all times (prevent backflow)
Catheter care BD: clean perineum/meatus with soap and water
Avoid unnecessary sampling — use needle-free port with ANTT
Document output, catheter size, balloon volume, insertion date every shift
Catheter Removal & TWOC
Deflate balloon fully using 10 mL syringe before removal
Remove gently — do not cut drainage bag tubing
TWOC (Trial Without Catheter): document time of removal, first void time and volume
Post-void residual (PVR): bladder scan 30 min after first void — PVR >300 mL (or per policy) may indicate need for re-catheterisation
Encourage fluids post-removal
Catheter Maintenance Solutions
Optiflo G (Suby G solution): Citric acid 3.23% — pH 4. Used for catheter encrustation (crystalline blockage). Dissolves struvite/phosphate crystals. Use per policy — typically 50 mL instilled, retained 30 min, then drain.
Optiflo R (Solution R): 6% citric acid — for more resistant encrustations. Consult urology before use.
Not for routine flushing — only indicated when catheter is blocked or encrusted.
Blood Glucose Monitoring & Insulin Administration
Capillary Blood Glucose (BM) Monitoring
Check glucometer QC is current (within range). Check strip expiry date and calibration code matches meter.
Wash and dry patient's hand — do not use alcohol swab (falsely elevated result).
Use lancet on the lateral side of fingertip (less painful) or palm — avoid index finger/thumb (used for grip).
Obtain a free-flowing drop — do not squeeze excessively (dilutes sample with tissue fluid).
Apply blood to test strip per manufacturer instructions. Read result.
Apply gentle pressure to puncture site.
Document result with time, site, patient ID, and any action taken.
POCT (Point-of-Care Testing) Requirements (JCI/HAAD/DHA): Daily QC documentation, external QC reagents (high and low), competency records for all staff performing POCT, calibration records, equipment maintenance log.
Check insulin type, dose, expiry, appearance (clear or cloudy as expected). Roll intermediate/premixed gently (do not shake).
Attach new pen needle (4 mm preferred — reduces intramuscular risk).
Prime 2 units with needle pointing up — confirms needle patency, removes air.
Dial required dose. Double-check with second nurse (high-alert medication).
Select injection site — abdomen preferred (fastest absorption), thigh, upper arm, or buttock.
Pinch skin if patient is thin or using short needle. Insert needle at 90° (45° if very thin).
Depress plunger fully. Hold for 10 seconds before removing needle — prevents dose loss.
Remove needle. Do not recap — discard in sharps bin.
Apply gentle pressure — do not rub (may accelerate absorption).
Document dose, site, time, BM result.
Site Rotation
Rotate injection sites systematically to prevent lipohypertrophy (fatty lumps from repeated injections at same site). Lipohypertrophic tissue has erratic/reduced absorption — can cause glycaemic variability.
Absorption Rate by Site
Abdomen: fastest (preferred for mealtime insulin)
Upper arm: intermediate
Thigh: slower (good for basal insulin)
Buttock: slowest
IV Insulin Infusion
Only regular/soluble insulin (e.g. Actrapid, Humulin R) may be given intravenously. Insulin analogues (NovoRapid, Lantus, etc.) must NOT be given IV — not licensed for IV use.
Dedicated IV line for insulin infusion — do not piggyback other medications
Standard concentration: 1 unit/mL (50 units in 50 mL 0.9% NaCl via syringe driver)
Flush line with insulin solution before starting — insulin adsorbs to plastic tubing
Hourly BM monitoring (or as per VRIII/sliding scale protocol)
VRIII (Variable Rate Intravenous Insulin Infusion): used peri-operatively and for DKA/HHS management alongside glucose/potassium infusion
150–200 mL fruit juice or regular (non-diet) fizzy drink
5–6 glucose tablets (GlucoTabs)
3–4 teaspoons of sugar dissolved in water
Glucogel (40% glucose gel) — 1–2 tubes buccally
Recheck BG after 15 minutes. If still <4 mmol/L — repeat. Once BG ≥4, give long-acting carbohydrate (biscuits, bread).
Unconscious / Unable to Swallow
IV: 75–80 mL of 20% glucose (or 150 mL 10% glucose) — IV access required
IM/SC: Glucagon 1 mg — if no IV access available
Recheck BG 10–15 minutes after IV treatment
Identify and treat cause — missed meal, excess insulin, renal impairment
Insulin — High-Alert Medication Rules
Insulin is a HIGH-ALERT medication — errors have caused patient deaths. The following safeguards are mandatory in GCC hospitals (JCI/HAAD/DHA standards):
Double-Check Required
Two registered nurses must independently check: drug name, type, dose, device, route, patient ID
Verify against medication chart — both sign
Never abbreviate "units" as "U" (confused with zero) — write "units" in full
Storage & Labelling
Store unopened vials/pens in refrigerator (2–8°C)
In-use pens: room temperature for up to 28 days (product-specific)
Label all insulin syringes prepared for IV use — "INSULIN" in capitals
Never transfer between insulin pens
Administration Errors Prevention
Use insulin-specific syringes (units marked) — never standard syringe
Confirm patient has eaten (or will eat) before mealtime insulin
Hold insulin if patient NBM — contact prescriber
Report all insulin errors immediately — patient safety incident
Wound Care & Dressing Competencies
ANTT — Aseptic Non-Touch Technique
ANTT Principle: Identify KEY PARTS (parts that must remain sterile — e.g. wound surface, sterile field, needle tip, syringe tip, catheter tip) and KEY SITES (patient's wound/access point). Never touch these directly.
Standard ANTT (Ward Procedures)
Non-sterile gloves acceptable for wound dressings with a critical micro aseptic field
Sterile field maintained within a general aseptic field
Non-touch technique used throughout
Applicable to: cannulation, simple wound dressings, urinary catheterisation
Surgical ANTT (Theatre/Complex Procedures)
Sterile gloves required
Larger critical aseptic field
Used for: CVC insertion, complex wound management, chest drain insertion
Key ANTT exam point: The critical concept is "non-touch of key parts" — this is what differentiates ANTT from general clean technique.
WHO 5 Moments of Hand Hygiene
#
Moment
1
Before patient contact
2
Before aseptic procedure / clean/aseptic task
3
After body fluid exposure risk
4
After patient contact
5
After contact with patient environment/surroundings
Moment 2 is the most critical for wound care and any aseptic procedure. Hand hygiene with ABHR (alcohol-based hand rub) takes 20–30 seconds. Hand washing with soap and water: 40–60 seconds — required for C. diff, norovirus (alcohol-resistant spores).
Emergency equipment at bedside at ALL TIMES: Spare tracheostomy tube (same size + one size smaller), tracheal dilators, 10 mL syringe, suction equipment, bag-valve-mask.
Inner Tube Management
Non-disposable inner tube: Remove, clean with 0.9% NaCl and brush, dry, reinsert — minimum q4h or as per secretion levels
Disposable inner tube: Remove and replace with new tube — q4h or per protocol
Never leave tracheostomy without inner tube for more than 10–15 seconds
Tie Change — Two-Person Technique
Two nurses always required for tie change — one holds tube while second changes ties
Check ties are secure: one finger breadth space under ties
Assess stoma site for skin breakdown, granulation, infection
CVC Dressing Care & PEG Site Care
CVC Dressing Change
Transparent semi-permeable dressing: change every 7 days or when soiled/loose/lifting
Chlorhexidine-impregnated dressing (e.g. Biopatch/Tegaderm CHG): preferred at insertion site
"Scrub the hub": Before any access — clean needleless connector with 70% isopropyl alcohol for 15 seconds; allow to dry before accessing
Document dressing date, insertion site condition, any signs of infection
PEG Site Care
Clean site daily with soap and water — dry thoroughly
Rotate external disc/bumper 360° daily to prevent buried bumper syndrome
Check tube length/external position at each use
Assess for overgranulation (hypergranulation tissue) — manage with silver nitrate sticks or corticosteroid cream per specialist advice
Ensure tube moves freely 1–2 cm within stoma — if fixed, report
GCC Exam Focus & Quick Reference
High-Yield Exam Topics
These topics appear frequently in DHA, DOH, HAAD, SCFHS, and QCHP nursing examinations. Review each section carefully — safety-critical items are exam priorities.
VIP Score — Complete Scale (0–5) ▼
Score
Observation
Action
0
IV site appears healthy — no signs
Continue monitoring
1
One of: slight pain near site OR slight redness
Observe — document
2
Two of: pain, erythema, swelling
Re-site cannula
3
All of: pain, erythema, swelling; IV site streaking
Never touch key parts — this is the defining rule of ANTT
Standard ANTT: non-sterile gloves + critical micro aseptic field
Surgical ANTT: sterile gloves + full sterile field
Common exam question: A nurse is about to do a wound dressing. She touches the sterile gauze with an ungloved hand. This is a failure of which principle?
Answer: Non-touch of key parts (ANTT breach)
ANTT does NOT mean the nurse is sterile — it means the KEY PARTS remain uncontaminated through non-touch technique.
Rate your self-assessed competency level for each skill. 1 = Never done | 2 = Observed only | 3 = Assisted | 4 = Done with supervision | 5 = Independent practice
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Overall Competency Progress
0% average competency
0
Skills ready for independent practice
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