Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition was adapted by Renée Anderson, Thompson Rivers University from Glynda Rees Doyle & Anita McCutcheon, British Columbia Institute of Technology’s textbook Clinical Procedures for Safer Patient Care. The original textbook content was produced by Glynda Rees Doyle & Anita McCutcheon and is licensed under a Creative Commons Attribution 4.0 International license. The changes and additions noted below are © by Renée Anderson and are licensed under a  Creative Commons Attribution 4.0 International license

BCcampus Open Education began in 2012 as the B.C. Open Textbook Project with the goal of making post-secondary education in British Columbia more accessible by reducing students’ costs through the use of open textbooks and other OER. BCcampus supports the post-secondary institutions of British Columbia as they adapt and evolve their teaching and learning practices to enable powerful learning opportunities for the students of B.C. BCcampus Open Education is funded by the British Columbia Ministry of Advanced Education, Skills & Training, and the Hewlett Foundation.

Open educational resources (OER) are teaching, learning, and research resources that, through permissions granted by the copyright holder, allow others to use, distribute, keep, or make changes to them. Our open textbooks are openly licensed using a Creative Commons licence, and are offered in various e-book formats free of charge, or as printed books that are available at cost.

For more information about open education in British Columbia, please visit the BCcampus Open Education website. If you are an instructor who is using this book for a course, please fill out our Adoption of an Open Textbook form and let Renée  know.

The 2018 adaptation (TRU edition) includes the following changes: all learning objectives have been modified and are titled learning outcomes. All broken video links have been deleted. ‘Physician orders’ has been changed to ‘prescriber’s orders’. ‘Hospital’ has been changed to ‘agency’. All new figures that have been added have been attributed. Figures without attribution are present from the first edition. All critical thinking exercises have been modified. Where possible reference lists have been added to, some links have been updated. ‘Perform point of care risk assessment for PPE’ has been added to each appropriate checklist. In addition:

Chapter 1: Infection Control

• Section 1.4 added video ‘Donning and Doffing of PPE’
• Section 1.5 changed ‘principles of sterile technique’ to ‘principles of asepsis’ and added two principles; added video ‘Principles of asepsis’
• Section 1.7 now called ‘Surgical Hand Scrub, Applying Sterile Gloves and Preparing a Sterile Field’; added video  ‘Applying Sterile Gloves’ and ‘Simple sterile dressing change’

Chapter 2: Patient Assessment

• Reorganization of the entire chapter into short chapters reflecting each body system
• Section 2.1 new learning outcomes
• Section 2.2 minor wordsmithing
• Section 2.3 added figure 2.2; added table 2.1
• Section 2.4 Added information about choosing the correct cuff size. Added information about vital signs normal ranges; Added figure 2.3; new critical thinking exercises
• Section 2.5 expanded discussion on head to toe versus systems approach to assessment; new critical thinking exercises
• Section 2.6 – 2.12 new content, critical thinking exercises, figures, links to resources, videos
• Section 2.13 Now called Quick Priority Assessment (formerly chapter 2.5 initial and emergency assessment); critical thinking questions
• Section 2.14 added references Alberta Health Services, 2009; BCGuidelines.ca., 2014; Braden, B. & Bergstrom, N., 1989; British Columbia College of Nursing Professionals (BCCNP), 2018; Brodovicz, K., et al. 2009; Christensen, B., & Kockrow, E., 1999; Critical Care Services Ontario, 2014; Davis, C., Chrisman, J., & Walden, P.,  2012;  Heart and Stroke Foundation, 2019; Hill, D., & Smith, R., 1990, Lapum, J. et al. 2018; Lloyd H., & Craig, S., 2007; Our Lady Children’s Hospital, Crumlin (OLCHC), 2016Pasero, C. 2009; Perry, A., Potter, P., & Ostendorf, W., 2018; Potter, P., Perry, A., et al.,  2019; Registered Nurses Association of Ontario (RNAO), n.d.; Registered Nurses Association of Ontario (RNAO), 2013. Registered Nurses Association of Ontario (RNAO), 2016; Royal Children’s Hospital Melbourne (RCH),  2015; Royal  Children’s Hospital Melbourne (RCH), 2017; Safer Health Care Now. 2015; Taylor, T. n.d..

Chapter 3 now called Safer Patient Handling, Positioning, Transfers and Ambulation

• Section 3.2 added to Table 3.1 Factors that contribute to an MSI (force, repetition, work posture, local contact stress); added Figure 3.2 Pivot transfer.
• Section 3.3 now called Risk Assessment for Safer Patient Handling; added to Checklist 24 Risk assessment: risk assessment also involves knowing any activity restrictions associated with recent surgery/ injury; added link to Safe Patient Handling Assessment for from Winnipeg Region Health Authority
• Section 3.4 now called  ‘Levels of Assistance’; included expanded discussion about this. Table 3.4 clarified to include general levels of assistance. Types of transfers moved to a  table in Section 3.6.
• Section 3.5 now called ‘Assistive Devices’;  added air transfer mattress, slider sheets, monkey bar, sit to stand lift, transfer board added. Added figures 3.3 – 3.6.
• Section 3.6 now called Types of Patient Transfers; Table 3.6  expanded to include sit to stand, mechanical/ ceiling track and information about appropriateness of each type of transfer.
• Section 3.7 now called ‘Types of Patient Transfers: Transfers without Mechanical Assistive Devices’; provided clarity in Checklist 26 ‘moving a patient from bed to stretcher’ in relation to the role of individual care giver during a transfer; Checklist 27 now called ‘Bed to wheelchair transfer – 1 person assist’; added video ‘Assisting from Bed to Chair with a Gait Belt or Transfer Belt’.
• Section 3.8 now called ‘Types of Patient Transfers: Transfers using Mechanical Aids’; Added videos ‘Sit to stand mechanical assist’,’How to use a ceiling lift’, ‘How to use a hammock sling’, ‘How to use a hygiene sling’; added Table 3.6 Choosing a Sling to be used with the Ceiling Lift; added special considerations.
• Section 3.9 now called ‘Positioning Patients in Bed; added figure 3.7.
• Section 3.10 now called ‘Assisting a Patient to Ambulate using Assistive Devices’; Checklist 29 Assisting a Patient to a sitting position’ moved here; modified Checklist 31 ‘Assisting to ambulate using a gait belt/ transfer belt’; added video ‘How to ambulate with or without a gait belt or transfer belt’; modified checklist 32 ‘Ambulating with a walker’; Added figure 3.8 – 3.14; added checklist 33 ‘Ambulating with Crutches’; added video ‘How to Ambulate with Crutches’; added checklist 34 ‘Ambulating with a cane’; added video ‘How to Ambulate with a Cane’.
• Section 3.11 added video ‘Assisted Fall’
• Section 3.12 added references Clevelandclinic.org (3 references); Handicare, 2018; Hovertech International, 2016; Perry et al., 2018; Potter et al., 2017; Salience Health, n.d.; WHO, 2018; WRHA, 2008

Chapter 4: Wound Care

• Added Section 4.3 Wound Infection and Risk of Infection
• Added Section 4.4 Wound Management
• Section 4.5 Checklist 33: included note about principles of asepsis; added sample charting & video ‘Simple sterile dressing change’
• Section 4.6 changed the title of section to ‘Advanced wound care: Wet to moist dressing and wound irrigation and packing’; Introduction changed; Checklist 36 now ‘Wet to moist dressing changes’; Adjusted some procedural steps; added sample charting. Added Table 4.7 Wound Care Products; added video ‘Wound irrigation and wound packing’
• Section 4.7 added Figure 4.2 suture technique and Figure 4.3 simple interrupted sutures; added sample charting; added videos ‘Intermittent suture removal’ and ‘Removal of continuous blanket sutures’
• Section 4.8 added Figure 4.4 Surgical staples after total hip replacement; added video ‘Staple removal’
• Section 4.9 added sample charting; added video ‘JP Drain Removal’
• Section 4.10 added references: Alavi & Archibald, 2015; British Columbia College of Nursing Professinals, 2019; British Columbia Provincial Skin and Wound Committee, 2011; Ebberlein & Assadian, 2010; Harris et al., 2018; Healthwise, 2017; International Wound Infection Institute, 2016; Munteanu et al., 2016; Norton et al., 2018; Perry et al., 2018; Wiegand et al., 2015

Chapter 5: Oxygen Therapy

• Section 5.2 changed to oxygenation.   Info added regarding four functional components of the respiratory system and health conditions that might present challenges in terms of increasing risk of impaired oxygenation
• Section 5.5 note added to simple face mask in Table 5.3; added Figure 5.2 Non re-breather mask; deleted Partial re-breather mask; added Figure 5.3 Oxygen concentrator / nubulizer / humidifier; added Figure 5.4 High flow therapy; Checklist 41 added Professional practice considerations when choosing O₂ delivery system and sample charting
• Section 5.8 added video ‘Oral suctioning’
• Section 5.9 added Strickland et al., 2013; and Perry, Potter, & Ostendorf, 2018 references to intro; added Figure 5.6 Structures of the mouth and pharynx; added Figure 5.7 Suction regulator & canister; Checklist 43 added Risks associated with oral and nasal route; added information about recovery time between suction passes; added sample charting; added videos ‘Oropharyngeal Suctioning’ and ‘Tracheal Suctioning Closed (in line) Method’
• Section 5.10 added references Astle & Duggleby, 2019; BTS, 2017; Considine, 2007; BCCNP, 2018; Fisher & Paykel, 2018; Fournier, 2014; McCance et al., 2014; Perry et al., 2018; Strickland et al., 2014; WHO, 2011

Chapter 6: Non Parenteral Medication Administration

• All checklists updated with clarity around bringing MARs to bedside whenever possible; clarity about when 3 checks should happen; labelling medications prepared away from the bedside; all checklists direct reader to Table 6.2
• Section 6.1 rearranged introduction
• Section 6.2 revised Table 6.2 Principles for Safer Medication Administration: added ‘assessment comes before, during, and after medication administration’; ‘strive to give medications on time’; ‘when possible take MARs to the bedside’, ‘open medication packages at the bedside’; ‘label medications prepared away from the bedside’; ‘use a system to help you keep track of which meds you’ve prepared’; ‘Follow seven rights….’; ‘complete 3 checks…’; Added Table 6.2 Acute care guidelines for timely administration of scheduled medications (ISMP); added Medication Reconciliation paragraph; deleted Checklist 43 (info integrated into Table 6.2)
• Section 6.3 Checklist 45 now includes specific oral medication safety considerations; added Figures 6.1 – 6.6; expanded paragraph discussing administering medication via a gastric tube; Checklist 46 now includes specific G tube medication safety considerations.
• Section 6.4 added Figures 6.9 – 6.10. Checklist 47 now includes specific rectal medication safety considerations; Checklist 48 now includes specific vaginal medication safety considerations
• Section 6.5 added Figures 6.13 – 6.19; Checklist 98 now includes specific opthalmic medication safety considerations; Checklist 50 now includes specific otic medication safety considerations; Checklist 51 now includes specific nasal medication safety considerations
• Section 6.6 added Figure 6.21 – 6.28; Checklist 52 now includes specific small volume nebulizer safety considerations; expanded paragraph discussing MDIs; Checklist 53 now includes specific MDI safety considerations; Added paragraph ‘Medication by Dry Powder Inhaler (DPI)’; added Checklist 54 ‘Medication by Dry Powder Inhaler (DPI)’
• Section 6.7 added Figures 6.29 – 6.31; Checklist 55 now includes specific transdermal patch safety considerations; Checklist 56 now includes specific topical safety considerations; deleted Checklist 55 ‘Applying Topical Powder’
• Section 6.8 added references Baker et al., 2004; Bell et al., 2011; Boullata, 2009; ISMP, 2011; ISMP 2017a; ISMP 2017b; ISMP 2018; Lilley et al., 2016; Lung Association of Saskatchewan, 2018; Martindate Pharma, nd; Nursing, 2007; Perry et al., 2018; Ramadin & Sarkis, 2017; Royal Children’s Hospital Melbourne, 2017; Saskatoon Health Region, 2017;  Zed et al., 2008

Chapter 7: Parenteral Medication Administration

• Section 7.2 now called ‘Preparing Medications From Ampules and Vials’; added Figures 7.3 – 7.13. Added videos ‘Preparing Medications from a Vial’; ‘Preparing Medications from an Ampule’; ‘Reconstitution of Powdered IV Medication and Administration via a MiniBag’
• Section 7.3 now titled ‘Intradermal Injections’
• Section 7.4 now Subcutaneous Injections; Added Figure 7.15-7.21; added videos ‘Administering a Subcutaneous Injection’, ‘Insertion of an Indwelling Subcutaneous Device aka ‘subcutaneous butterfly”
• Section 7.5 added Figure 7.23 & 7.25; caution about meds that are incompatible or whose compatibility cannot be verified cannot be given simultaneously from the same syringe; information about independent double checks; labelling syringes for injectables prepared away from the bedside; STAB, GRAB, ASPIRATE, INJECT; added videos ‘Preparing medication from a vial’; ‘Preparing medication from an ampule’; ‘Landmarking deltoid’; ‘Administering IM injection Z track method / Landmarking ventrogluteal’; ‘Administering IM injection Z track method / Landmarking vastus lateralus’; ‘Administering IM injection Z track’
• Section 7.6 added information about the nurse must consult their agency parenteral practices manual and / or drug monographs for specific information about IV direct administration times for individual medications. Administering a medication intravenously virtually eliminates the process of first pass by directly depositing it into the blood; all references to ‘Posi flow valve’ and ‘MaxPLus’  changed to ‘needleless cap’; added ‘IV access devices such as PICCS and central lines which remain insitu for long periods have the potential for medication residue to build up in the lumen of the catheter posing a risk for occlusion and reaction with non compatible medications’; Checklist 60: now titled ‘Administering Medications IV Direct into a Locked / Capped IV; (PVAD Short, Midline, PICC, Percutaneous Non-Hemodialysis CVC)’; rewrote steps; added ‘Attempt to have half of the syringe emptied in half of the recommended infusion time’; added ‘use 10ml syringes for flushing reduces risk of fracturing IV cannula’; deleted ‘Use a push-pause method to inject the medication’ and replaced with ‘Administer the medication slow and steady. Attempt to have half of the syringe emptied in half of the recommended infusion time’; added ‘Never administer an IV medication into an IV line that isn’t patent’; added ‘Aspirating on a PICC, midline and percutaneous non hemodialysis CVAD should reveal blood flash back. If you suspect the line is not patent, or partially occluded, follow agency guidelines (this usually involves consulting the IV team / PICC nurse)’;  Checklist 61 new title: ‘Administering medications IV direct into an infusing IV – with compatible solution: (PVAD short, midline, PICC, percutaneous non hemodialysis CVC)’. Rewrote steps; deleted step ‘If IV solution is on an IV pump, pause the device. Pinch IV tubing above the lowest access port or use blue slider clamp’; deleted ‘removes used medication syringe….flush 3-5 ml at the SAME rate… unpinch / unclamp the IV tubing’ (formerly steps 10,12 & 13) ; deleted ‘restart IV on opposite arm’. Checklist 62 new title: ‘Administering medications IV Direct  into an infusing IV with Incompatible IV Solution: (PVAD short, midline, PICC, percutaneous non hemodialysis CVC)’; rewrote steps; deleted ‘clamp or pinch the IV line…’ and changed to ‘stop the infusion’; deleted ‘clamp IV tubing above the lowest port…’; deleted ‘Use a push-pause method to inject the medication’ and replaced with ‘Administer the medication slow and steady. Attempt to have half of the syringe emptied in half of the recommended infusion time’; ‘watch’ changed to ‘clock’. Table 7.9 added ‘Correctly identify the VAD and use agency flushing and locking protocols for correct administration’; added ‘Check patency of the line (PICCs and percutaneous non-hemodialysis CVAD lines aspirate for blood return)’; added ‘Aspirating on a PVAD short often does not reveal blood flash back despite the site being patent. Assess for patency of PVAD short during the flush’; added video ‘Administering Medications: Direct IV – Into a Locked IV (PVAD short)’ and ‘Administering medications: Direct IV – into an IV with an infusion’
• Section 7.7 deleted ‘A piggyback medication is given through an established IV line that is kept patent by a continuous IV solution or by flushing a short venous access device (saline lock)’; Checklist 63: now titled ‘Administering an intermittent IV medication by a minibag  (initial dose)’; added ‘Set the infusion rate according to PDTM’; added ‘Ensure the medication to be hung is compatible with the medication in the previous minibag…If they are compatible simply hang the new bag…If they aren’t compatible, either change the secondary line or back flush / back fill. Close the clamp on the secondary IV line. Empty the drip chamber into the minibag. Remove the old mini bag from the secondary IV tubing. Hang the new minibag onto the IV pole. Remove sterile blue cover on new medication bag, and insert the spike of the secondary IV tubing into it.’; Checklist 64: now titled ‘Administering an intermittent IV medication by a minibag – Using Existing Secondary Line’; deleted ‘Prime the secondary IV line by “back filling” using the empty IV mini bag attached to the secondary IV line’; added ‘Set the infusion rate according to PDTM’; added ‘Ensure the medication to be hung is compatible with the medication in the previous minibag…If they are compatible simply hang the new bag…If they aren’t compatible, either change the secondary line or back flush / back fill. Close the clamp on the secondary IV line. Empty the drip chamber into the minibag. Remove the old mini bag from the secondary IV tubing. Hang the new minibag onto the IV pole. Remove sterile blue cover on new medication bag, and insert the spike of the secondary IV tubing into it.’; added ‘An electronic infusion device …MUST be used for specific medications like IV insulin and high dose KCL’; added video ‘Reconstitutingof Powdered IV Medication and Administration via a Mini-bag’ ; added Figure 7.33
• Section 7.8 added ‘heparin given IM instead of SC’ as example of wrong location for medication; ‘total parenteral nutrition’ changed to ‘parenteral nutrition’; differentiated references ISMP 2014 into 2014a and 2014b; Table 7.10 added ‘if precipitates are noted in the tubing, stop the infusion. Prime a new IV line and change at the cannula site. Flush IV catheter with normal saline’; added information about infiltration and extravasation; added ‘Document and notify prescriber. Report incident as per agency policy’
• Section 7. 9 added references Astle & Duggleby, 2019; Children’s Hospitals and Clinics of Minnesota, 2018.Dawkins, et al., 2000; Goossens, 2015; Perry et al., 2018, 2014; Shah et al., 2016

Chapter 8: Intravenous Therapy

• Chapter 8.2 title changed to ‘IV therapy: Guidelines and Potential Complications’; added ‘IV sites must be assessed regularly.  Check your agency for specific guidelines. Some guidelines may suggest every 5 minutes, others hourly, others every 12 hours’;  In the absence of guidelines exercise some clinical judgement and consider that sites requiring more frequent assessment include those that have an infusion versus those that are locked; in an acute care environment versus a home environment; patient conditions where cognitive and sensory changes inhibit their ability to voice concerns; types of solutions – vesicants require more frequent site assessment than solutions with less potential for harm if infiltrated; location and type of catheter – areas of flexion have higher risk of infiltration; central venous access have higher risk of air emboli if equipment fails ; Table 8.1 now called Potential Local Complications of IV Therapy; Table 8.3 now called  Potential Systemic Complications of IV Therapy; included preventative strategies; added references Gorski et al., 2015; RCH 2014; RNAO 2005, Singh et al., 2015
• Section 8.3 now called ‘Types of Venous Access’; added Figure 8.1, 8.2, 8.4, 8.6-8.14;  PVAD short – with infusion; regarding PVAD short site changes; added ‘Some literature challenges this firm timeline and suggests that sites should be assessed individually for decisions about removal’; added ‘Midline Catheters’; added specific information about CVAD dwell times – Non tunneled percutaneous CVAD – several days – weeks / IVADs can remain in place and function for many years / PICCs can remain in place as long as there is no evidence of complications;  added Table 8.4 Potential Complications associated with CVADs specifically; added info about Mulitlumen CVCs; added info about Valve Technology: Open ended versus closed ended lumens; added Table 8.5 Characteristics of open versus closed eneded CVC lumens;
• Section 8.5 now called  ‘IV Administration Equipment’; deleted A peripherally inserted catheter is usually replaced every 72 to 96 hours, depending on agency policy; added As of 2017, the CDC is saying no recommendation can be made regarding the frequency for replacing intermittently used administration sets; deleted ‘Ideally, the IV solution should be 90 cm above patient heart level’; added Table 8.6 Common IV equipment including Figures 8.13 – 8.16
• Section 8.7 now called Priming IV Tubing / Changing IV Fluids / Changing IV Tubing; Checklist 66: Priming IV Tubing-  added ‘Hang IV bag on hook or IV pole in a way that will allow gravity to help you’; added ‘Only if absolutely necessary, remove protective cover on the end of the tubing and keep sterile’; Checklist 68: now called ‘ Changing IV Tubing’; deleted let it dry for 30 seconds. Now says ‘let it dry’; deleted ‘check for signs and symptoms of phlebitis’. Now says ‘check for evidence of complications’; added ‘If the extension isn’t present and / or you are changing the extension set – Loosen the IV tubing from the IV cannula; PVAD short occlude the vein / CVAD – open ended … use clamps / CVAD – closed ended …lumens have valves to prevent reflux’; ‘IV fluid administration set’ changed to ‘IV administration set’; added ‘Understanding the structure and function of different IV access devices helps to determine risk of air emboli / exposure to BBF and subsequent safety considerations and need for clamping’; added videos ‘Priming IV lines’, ‘Changing IV bags’, ‘Converting an IV to a saline lock – Extension Present’, ‘Converting an IV to a saline lock – No Extension Present’
• Section 8.8 now called Flushing and Locking – PVAD short, midlines, CVCs (PICC, non hemodialysis lines); added Table 8.11 Sample flushing and Locking Protocol;  Checklist 69 now called ‘Flushing a PVAD short saline Lock’;  Checklist 70 now called ‘Flushing a CVAD (PICC and percutaneous CVC non hemodialysis)’ with corresponding steps and additional information and figures added; added videos ‘Converting an IV to a saline lock (PVAD short) – extension present’; added video ‘Converting an IV to a saline lock (PVAD short) – no extension present’; added video ‘CVAD care and maintenance – lumens with valves’; added video ‘CVAD care and maintenance – lumens without valves’; Added figures 8.21-8.23.
• Section 8.9 now called ‘Removal of a PVAD short, midline catheter, percutaneous non hemodialysis CVC and PICC’; added ‘before IV access is discontinued…added ‘Is the patient using an epidural/PCA and need IV access as part of safety protocols?’; added ‘Do you have an order from the prescriber or are you doing this under your independent scope of practice? If the later, is this in agreement with agency policy?’; deleted Checklist 72: ‘converting IV to a saline lock’ and replaced with ‘Removing a PVAD short cannula / peripheral midline catheter’; Checklist 72 now called ‘Removing a percutaneous non hemodialysis CVC / PICC’ with corresponding steps, additional information and figures; added ‘If purulent drainage is present consider a swab for C&S. Report using  the agency’s patient safety learning system (incident report)’; added ‘This provides follow-up data for potential infection. Reporting of events contributes to the culture of patient safety’; added video ‘Removing PVAD short cannula’; added Figures 8.24 – 8.26.
• Section 8.10 new section IV Site Dressing Changes; Checklist 73 now called changing an IV site dressing  – no additional securement devices with accompanying steps and additional information; added videos ‘PVAD short dressing’, ‘PICC dressing change’; Checklist 74 now called Changing an IV site dressing – involving a securement device including steps, additional information and Figures 8.27-8.30
• Section 8.11: Jehovah Witnesses changed to Jehovah’s Witnesses. Checklist 75 added clarity around having a primed IV line ready in the event of transfusion reaction; differentiated allergic reaction actions versus other actions; Checklist 75 now called ‘pretransfusion preparation’; added ‘Some blood products require refrigeration. Complete the preparation BEFORE calling for delivery of the blood / blood product’; added ‘If the product does require refrigeration and cannot be administered immediately, return it to TMS (transfusion medical services) for safe storage’; added ‘Medications given prior to transfusion are only considered for persons with documented moderate to sever reactions. Typically medications are administered 30 minutes prior to the transfusion. Examples of meds include diphenhydramine, acetaminophen, furosemide. Remember these medications can also mask a potential reaction’; added ‘Check that the patient identification and TMS identification band are correct’; ‘if no identification band, apply one. If no TMS (aka blood band) present, STOP, notify TMS. Only TMS can apply blood bands. If any discrepancies STOP, do not proceed until the discrepancy is resolved’; added ‘Group, screen and cross match must be completed within 96 hours of the transfusion to establish any new antibody formation and to ensure current compatibility. If group and screen are outdated, initiate processes for new testing.’; added ‘step 6 verify correct infusion equipment’; added ‘Packed RBCs require filter tubing to remove clots, debris, and coagulated protein. Glass bottles containing  albumin and IVIG require vented tubing’; added step 8 ‘Ensure prescriber has obtained consent. Nurses verify consent and ensure the patient is informed about the rationale, possible risks. Nurses to document confirmation of consent; Blood products require consent prior to administration. Consent is obtained by the prescriber. If unable to verify consent, notify the prescriber’; ‘in addition assess for other symptoms that may be confused with transfusion reaction’; added Figures 8.31-8.32
• Section 8.12 TPN changed to PN; Tables retitled; altered Table 8.8 to include referencing of other tables earlier in the text
• Section 8.13 Added references: British Columbia College of Nursing Professionals (BCCNP), 2018; Canadian Blood Services, 2017a; Canadian Blood Services, 2017b; Canadian Blood Services,2017c; Center for Disease Control, 2017;   Ferroni, A. et al, 2014; Fraser Health Authority, 2014; Goossens, 2015; Gorski, L. et al., 2016 ; Gorski, L. et al., 2012; Ho, C. & Spry, C., 2017; Interior Health, 2012; Interior Health, 2018; Perry, A. G., Potter, P. A., & Ostendorf, W. R., 2018; Registered Nurses’ Association of Ontario (RNAO), 2005; Rosenthal, K., 2007; Royal Children’s Hospital Melbourne (RCH),  (n.d.);  Singh, A., et al.,  2015.

Chapter 9: Blood Glucose Monitoring

• Section 9.4 added references: Accu-Chek, n.d.; Canadian Diabetes Association, 2018; Kaiser Permanente, n.d.

Chapter 10: Tubes and Devices

• Section 10.2 reorganized existing text information into Table 10.1’Guidelines for Caring for Patients with Tubes and Attachments’
• Section 10.3 clarified naso gastric tubes used for feeding versus naso gastric tubes used for gastric decompression; added reference  Stewart, 2014; Checklist 78 insertion a nasogastric tube simplified procedure; added videos ‘Insertion of an NG tube’, ‘Nasogastric tube removal’; added reference Lilley et al., (2016)
• Section 10.5 rewrote introduction; added Figure 10.1- 10.5 , 10.7; added Table 10.2 Parts of a Tracheostomy Tube; modified Checklist 82 Tracheal suctioning – open method; added videos ‘Tracheal Suctioning – Closed Method’, ‘Replacing and Cleaning an Inner Tracheal Cannula’, ‘Changing a Tracheostomy Site Dressing’, ‘Replacing Tracheotomy Ties’; added references BTS, 2014; RCH, n.d.; St George’s University Hospital, n.d.; Lewarski, 2005
• Section 10.6 added Figures 10.8-10.10; enlarged 10.11, added Figure 10.12, 10.15; added Table 10.4 The differences between a Dry suction Chest Drainage System and a Wet Suction Chest Drainage System; added ‘accidental chest tube removal kit’ including a description of contents; Table 10.5 added complication ‘The drainage unit has tipped over’; modified Checklist 86 Care and Management of a Closed Chest Tube Drainage System; Checklist 86 added sample documentation; added references Atrium, 2009; Perry et al., 2018; RNAO, 2019; Teleflex, 2018; Zisis et al., 2015
• Section 10.7 added images 10.16 – 10.17; added clarity around retracted stomas and use of a convex flange; added references: Oxford University Hospital, 2013; Birmingham Bowl Clinic, 2011; deleted Checklist 88 ‘changing an ostomy appliance (urostomy)’ and incorporated information into Checklist 87 ‘Changing an Ostomy Appliance (flange and pouch)’; slight modifications to Checklist 87 by combining 2 steps; added sample documentation; added resources Convatec Ostomy Care Video Library  and Hollister Ostomy Care Resources ; added  Table 10. 6  ‘How changing a urostomy pouch is different than a colostomy/ ileostomy’