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Nursing Skill Procedures

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Nursing Skills Procedure Manual

Lahore School of Nursing The University of Lahore

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Contributor: Farzana Iqbal Hina Adeel Kousar Parveen (Instructor) (Instructor) (Instructor)

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Principal:

Muhammad Afzal

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Table of Contents
Sr. No 1 Contents Vital Signs 1.Body Temperature a. Taking oral Temperature b. Taking axillary Temperature c. Taking rectal Temperature 2.Pulse a. Taking radial pulse 3.Respiration 4.Blood pressure Bed making Performing Oral Care Administration of Medicine Simple Enema Inserting a Flatus Tube Care for Nasal-gastric Tube 1. Inserting a Nasal-Gastric Tube 2. Removal a Nasal-Gastric Tube 3. Administering a Nasal-Gastric tube feeding Colostomy Care 1.Feeding via a Gastrostomy and Jejunostomy feeding tube 2.Administering Bolus Feeds 2.Colostomy Irrigation Urinary catheterization 1.Female Urinary Catheterization 2.Male Urinary Catheterization 3.Supra-pubic Urinary Catheterization Performing Surgical Dressing 1. Cleaning a wound and applying surgical dressing I V Cannulation Starting an Intravenous Infusions 1.Maintenence of IV system 2. Changing of IV system Specimen Collection 1. Collecting blood specimen a. Performing Venipuncture b. Assisting in obtaining blood for culture 2. Collecting urine specimen a. Collecting a single voided specimen b. Collecting a 24-hour urine specimen c. Collecting a urine specimen from a retention catheter d. Collecting a urine culture 3. Collecting a stool specimen Application of Restrains Monitoring blood Glucose level Mixing insulin in one syringe Administering Oxygen Assisting a client in ambulation Page No. 06 06 06 09 11 14 17 19 24 27 30 34 37 39 39 47 49 54 54 58 61 66 66 73 79 85 85 91 95 102 105 109 110 110 115 119 119 122 125 128 131 134 137 140 144 152

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Using an Inhaler Using a Nebulizer Performing Nasopharyngeal and Orophsaryngeal Suctioning Performing Adult Cardiopulmonary Resuscitation Assisting with a Lumber Puncture Teaching patient to use an Incentive Spirometer Obtaining an arterial blood specimen for blood gas analysis Eye Care a. Contact lens removal b. Artificial eye removal Performing range of motion exercises

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I. Basic Nursing Care/ Skill

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Taking Vital Signs Temperature, Pulse, Respiration, Blood pressure
Definition: Taking vital signs are defined as the procedure that takes the sign of basic physiology that includes temperature, pulse, respiration and blood pressure. If any abnormality occurs in the body, vital signs change immediately. Purpose: 1) To assess the client‘s condition 2) To determine the baseline values for future comparisons 3) To detect changes and abnormalities in the condition of the client Equipments required: 1 2 3 4 5 6 7 8 9 Oral/ axilla / rectal thermometer Stethoscope Sphygmomanometer with appropriate cuff size Watch with a second hand Spirit swab or cotton Sponge towel Paper bag Record form Ball- point pen: blue black red 10 Steel tray: to set all materials 1 1 1 1 1 1 1 3 1 1 1 1

a. Taking Oral Temperature by Glass Thermometer
Definition: Measuring/monitoring patient‘s body temperature using clinical thermometer Purpose: 1) To determine body temperature 2) To assist in diagnosis 3) To evaluate patient‘s recovery from illness 4) To determine if immediate measures should be implemented to reduce dangerous elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patient‘s response once heat conserving or heal reducing measures have been implemented No. Procedure Rationale 1 Place the patient in a comfortable To ensure comfort and accuracy of position temperature reading 2 Wash hands To reduces transmission of micro organisms 3 Hold the stem end of the glass To reduce contamination of thermometer thermometer with finger tips bulb

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Rinse the thermometer in cold water if it is in a disinfectant solution Take wet swabs and wipe thermometer toward fingers in rotating fashion. Dispose of the swab Read mercury level while holding thermometer at eye level and gently rotating it If mercury is above the desired level, securely grasp tip and stand away from solid objects. Sharply flick wrist downward as through cracking a whip. Continue shaking until reading is below 35.5°C or 96°F Ask the patient to open mouth, and gently place thermometer under tongue in posterior or sublingual pocket, lateral to the centre of the lower jaw Ask the patient to hold thermometer under tongue with lips closed. Caution against biting it. Leave the thermometer inside for 2-3 minutes Carefully remove the thermometer and read at eye level. Inform the patient about this temperature reading Wipe the thermometer with wet cotton swab. Wipe in rotating fashion from fingers, toward bulb Wash the thermometer in cold water, dry and put it , after disinfection , in storage container Wash hands Remove and replace the other articles, after use, in their proper places Record the temperature in the TPR chart and inform the abnormalities to ward sister

To remove solution irritating to oral mucosa To reduce contamination of bulb end

Thermometer reading must be below body temperature before use

Heat from blood vessels in sublingual pocket produces temperature reading

To ensure safety. Breaking of thermometer causes mercury poisoning To allow time for expansion of mercury To ensure accuracy To promote patient participation From the least area of contamination to the most contaminated area To prevent infection. To prevent breakage To reduce transmission of infection For easy availability for next use To detect disease condition earlier

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Procedure Checklist: a. Taking Oral Temperature by Glass Thermometer
Check () Yes or No No 1 2 3 4 5 6 7 Procedure Yes Place the patient in a comfortable position Wash hands Hold the stem end of the glass thermometer with finger tips Rinse the thermometer in cold water if it is in a disinfectant solution Take wet swabs and wipe thermometer toward fingers in rotating fashion. Dispose of the swab Read mercury level while holding thermometer at eye level and gently rotating it If mercury is above the desired level, securely grasp tip and stand away from solid objects. Sharply flick wrist downward as through cracking a whip. Continue shaking until reading is below 35.5°C or 96°F Ask the patient to open mouth, and gently place thermometer under tongue in posterior or sublingual pocket, lateral to the centre of the lower jaw Ask the patient to hold thermometer under tongue with lips closed. Caution against biting it. Leave the thermometer inside for 2-3 minutes Carefully remove the thermometer and read at eye level. Inform the patient about this temperature reading Wipe the thermometer with wet cotton swab. Wipe in rotating fashion from fingers, toward bulb Wash the thermometer in cold water, dry and put it , after disinfection , in storage container Wash hands Remove and replace the other articles, after use, in their proper places Record the temperature in the TPR chart and inform the abnormalities to ward sister No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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b. Taking Axillary Temperature by Glass Thermometer
Definition:
Measuring/monitoring patient‘s body temperature using clinical thermometer

Purpose:
1) 2) 3) 4) To determine body temperature To assist in diagnosis To evaluate patient‘s recovery from illness To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patient‘s response once heat conserving or heat reducing measures have been implemented

No. 1

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Procedure Bring the articles to the bed side. These are the same as the ones used for oral temperature Screen the bed or close the door Make the patient lying in supine position or sitting Move clothing away from shoulder or arm Repeat steps 2 to 6 used in taking oral temperature Insert thermometer into the center of axilla, lower arm over thermometer and place it across patient‘s chest Hold the thermometer for 5 minutes in axilla Remove the thermometer and swab it with a wet swab, from fingers towards bulb. Dispose of the swab in paper bag Read the thermometer at eye level Inform the patient about this temperature reading Wash the thermometer with soap or soapy swab and rinse it in cold water Disinfect , dry and keep it in storage container Assist the patient in putting on his clothes and put him in a comfortable position Record it in the chart and report, if any abnormality is noticed, to ward sister Wash hands

Rationale For easy availability

To provide privacy. Embarrassment is minimized To provide easy access to axilla For easy exposure of axilla

Maintains proper position

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To ensure accuracy of reading To avoid contact with microorganisms

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To ensure accuracy To give him awareness about his condition To assure cleanliness To prevent breakage To ensure comfort

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For early detection of disease condition and for prompt treatment To prevent transmission of micro organisms

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Procedure Checklist: b. Taking Axillary Temperature by Glass Thermometer
Check () Yes or No No 1 Steps of procedure Bring the articles to the bed side. These are the same as the ones used for oral temperature Screen the bed or close the door Make the patient lying in supine position or sitting Move clothing away from shoulder or arm Repeat steps 2 to 6 used in taking oral temperature Insert thermometer into the center of axilla, lower arm over thermometer and place it across patient‘s chest Hold the thermometer for 5 minutes in axilla Remove the thermometer and swab it with a wet swab, from fingers towards bulb. Dispose of the swab in paper bag Read the thermometer at eye level Inform the patient about this temperature reading Wash the thermometer with soap or soapy swab and rinse it in cold water Disinfect , dry and keep it in storage container Assist the patient in putting on his clothes and put him in a comfortable position Record it in the chart and report, if any abnormality is noticed, to ward sister Wash hands Yes No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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c. Taking Rectal Temperature by Glass Thermometer
Definition:
Measuring/monitoring patient‘s body temperature using clinical thermometer

Purpose:
1) 2) 3) 4) To determine body temperature To assist in diagnosis To evaluate patient‘s recovery from illness To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patient‘s response once heat conserving or heal reducing measures have been implemented

No. 1 2 3 4 5 6 7 8

Procedure Screen the patient Upper body and lower extremities should be covered with a sheet Put the patient in left lateral-position. It exposes only anal area Repeat steps 2-6 of oral temperature measurement Separate buttocks to expose anus and clean it if needed Ask the patient to breathe slowly and relax Lubricate the rectal thermometer Insert thermometer bulb 0.5 inch for infant and 1.5 inch for adults into rectum Keep the thermometer inside for two minutes

Rationale To provide privacy To prevent unnecessary exposure To expose area for placing rectal thermometer To have minimum exposure To ensure proper exposure of anus To relax anal sphincter For easy insertion and to prevent trauma to rectal mucosa Ensures adequate exposure against blood vessels in rectal wall To ensure accuracy of reading

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Carefully remove thermometer and wipe it with wet cotton swabs to remove faecal matter and Vaseline Put the swabs into paper bag Read temperature, holding the thermometer at the eye level Record the temperature in the chart and report to ward sister if any abnormalities are detected Take the articles to the utility room, clean and keep them in their respective storage containers and places Make the patient comfortable and let him know about this temperature

To ensure cleanliness

To prevent transmission of micro organisms To ensure accuracy in reading For easy management of patient

For easy availability at any time. To prevent breakage To ensure comfort To gain patient‘s cooperation

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Procedure Checklist c. Taking Rectal Temperature by Glass Thermometer
Check () Yes or No No Steps of Procedure Yes 1 Screen the patient 2 Upper body and lower extremities should be covered with a sheet 3 Put the patient in left lateral-position. It exposes only anal area 4 Repeat steps 2-6 of oral temperature measurement 5 Separate buttocks to expose anus and clean it if needed 6 Ask the patient to breathe slowly and relax 7 Lubricate the rectal thermometer 8 Insert thermometer bulb 0.5 inch for infant and 1.5 inch for adults into rectum 9 Keep the thermometer inside for two minutes 10 Carefully remove thermometer and wipe it with wet cotton swabs to remove faecal matter and Vaseline 11 Put the swabs into paper bag 12 Read temperature, holding the thermometer at the eye level 13 Record the temperature in the chart and report to ward sister if any abnormalities are detected 14 Take the articles to the utility room, clean and keep them in their respective storage containers and places 15 Make the patient comfortable and let him know about this temperature No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: ____________________________________

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d. Measuring a Radial Pulse
Definition:
Checking presence, rate, rhythm and volume of throbbing of artery

Purpose:
1) 2) 3) 4) To determine number of heart beats occurring per minute (rate) To gather information about heart rhythm and pattern of beats To evaluate strength of pulse To assess heart's ability to deliver blood to distant areas of the blood viz. fingers and lower extremities 5) To assess response of heart to cardiac medications, activity, blood volume and gas exchange 6) To assess vascular status of limbs

General instructions for taking pulse: 1) Pulse should not be taken immediately after exercise, in emotional stress or during or after a painful treatment. 2) Count pulse for one full minute, especially when there is irregularity. 3) Observe rate, rhythm, volume and tension of pulse 4) Record pulse immediately 5) Choose suitable site for taking pulse

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Procedure Before taking pulse, consider factors that normally influence pulse character, e.g., age, exercise Explain the procedure to the patient and courage him to relax. Prepare the needed articles pen, pencil, wrist watch with seconds hand, chart Wash hands Place the patient in supine position. Place forearm across the chest, with wrist extended and palm down Place tips of first two fingers of your hand over groove, along radial or thumb side of patient‘s inner wrist Lightly compress against radius After pulse is felt regularly, look at watch‘s seconds hand and begin to count rate. Start counting with zero, one and so on. Count pulse for full one minute, if irregular, otherwise, 30 seconds, and multiply total by 2. Determine strength of pulse, note thrust of vessel against finger tips Palpate with two fingers, along course of artery, to ward wrist, to determine elasticity of arterial wall Put the patient in a comfortable position Write down the result immediately Remove the articles and keep them their respective places

Rationale To have accurate assessment of pulse

To reduce anxiety and activity To avoid delay To prevent transmission of micro organisms To have proper exposure of artery for palpation Finger tips are more sensitive for palpation. Thumb has pulsation that may interfere with accuracy To count only after timing

To ensure accuracy 30 seconds check is most accurate Strength reflects volume To have an idea about peripheral vascular system To ensure a sense of well-being To avoid errors For easy availability next time

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Procedure Checklist d. Measuring a Radial Pulse
Check () Yes or No No 1 Step of procedure Yes Before taking pulse, consider factors that normally influence pulse character, e.g., age, exercise Explain the procedure to the patient and courage him to relax. Prepare the needed articles pen, pencil, wrist watch with seconds hand, chart Wash hands Place the patient in supine position. Place forearm across the chest, with wrist extended and palm down Place tips of first two fingers of your hand over groove, along radial or thumb side of patient‘s inner wrist Lightly compress against radius After pulse is felt regularly, look at watch‘s seconds hand and begin to count rate. Start counting with zero, one and so on. Count pulse for full one minute, if irregular, otherwise, 30 seconds, and multiply total by 2. Determine strength of pulse, note thrust of vessel against finger tips Palpate with two fingers, along course of artery, to ward wrist, to determine elasticity of arterial wall Put the patient in a comfortable position Write down the result immediately Remove the articles and keep them their respective places No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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e. Counting Respiration
Definition:
Monitoring the involuntary process of inspiration and expiration in a patient

Purposes:
1) To determine number of respiration occurring per minute 2) To gather information about rhythm and depth 3) To assess response of patient to any related therapy/medication

No. 1 2 3 4 5 6

Procedure If the patient has been active, wait 510 mints. Make the patient comfortable in the bed in fowlers or sitting position Prepare the articles; watch having seconds hand, pen and chart. Provide privacy and wash hands Expose the chest of patient Place the patient‘s arm across lower chest and your hand over his upper abdomen Observe completely, one inspiration and expiration Then, look at the watch and count the respiration for one full minute. Note the depth of respiration by observing chest wall movement while counting rate. Note rhythm of inspiration and expiration Redress the patient and cover him with bed linen Wash hands Inform the patient against his respiration Record it in the chart and report to the ward sister if any abnormalities are detected

Rationale Activity increases respiratory rate and depth An erect, sitting position promotes easy respiration

To prevent transmission of micro organisms To ensure proper exposure to observe the movements of the chest and abdominal wall Hand rises and falls during respiration

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To ensure rate To ensure accuracy To assess disease condition

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Alteration shows disease condition To provide comfort Reduces transmission of micro organisms To ensure understanding of his health- status To ensure accuracy and to give proper treatment

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Procedure Checklist e. Counting Respiration
Check () Yes or No No 1 2 3 4 5 6 Procedure Yes If the patient has been active, wait 5-10 mints. Make the patient comfortable in the bed in fowlers or sitting position Prepare the articles; watch having seconds hand, pen and chart. Provide privacy and wash hands Expose the chest of patient Place the patient‘s arm across lower chest and your hand over his upper abdomen Observe completely, one inspiration and expiration Then, look at the watch and count the respiration for one full minute. Note the depth of respiration by observing chest wall movement while counting rate. Note rhythm of inspiration and expiration Redress the patient and cover him with bed linen Wash hands Inform the patient against his respiration Record it in the chart and report to the ward sister if any abnormalities are detected No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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f. Measuring Blood Pressure
Definition:
Monitoring blood pressure using palpation and/or sphygmomanometer

Purpose:
1) 2) 3) 4) To obtain baseline data for diagnosis and treatment To compare with subsequent changes that may occur during care of patient To assist in evaluating status of patient‘s blood volume, cardiac output and vascular system To evaluate patient‘s response to changes in physical condition as a result of treatment with fluids or medications

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Procedure Explain the procedure to the patient and put him in a comfortable position, either lying down with the arm resting on the bed or sitting with the arm supported on the table at heart-level. Determine the best site for applying the cuff. Don‘t use bandaged arm or arm with I.V. infusion or an injured arm Bladder and cuff bladder should completely encircle arm without overlapping Place the patient in a sitting or lying position Wash hands Place the patient‘s base upper arm at heart level with palm turned up. Expose the upper arm by removing clothing Palpate brachial artery, place the central bladder above the artery

Rationale To ensure comfort To ensure accurate reading To gain cooperation

Inappropriate selection will not give accurate reading and will cause pain and discomfort to patient To ensure proper reading of blood pressure

To ensure comfort To reduce transmission of micro-organisms To ensure proper reading To ensure proper application of cuff To ensure application of pressure

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Wrap the cuff evenly around upper arm; see step 3.

Loose filling cuff shows false readings

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Place the manometer vertically at eye level

To ensure accurate reading

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Close the valve, deflate the cuff and palpate the radial artery. Pump up air in the cuff until the sphygmomanometer at which the radial pulsation Place the stethoscope earpieces in ears and place its bell over brachial artery in cubital fossa Close valve of pressure bulb clockwise until tight Slowly release valve and allow mercury to fall. Note the point on manometer when first clear sound is heard Continue to deflate the cuff gradually when the sound becomes the muffled and disappears Deflate the cuff rapidly and completely

To identify approximate systolic pressure

To ensure proper hearing

To prevent air leak during inflation First sound indicates systolic pressure

It indicates diastolic pressure

Continuous inflation causes arterial occlusion

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Place the patient in a comfortable position Tell him about his blood pressure Wash hands Record blood pressure in nurse‘s notes and, if any abnormalities are there, report them to ward sister. Keep the stethoscope Sphygmomanometer at proper place in the box

To ensure comfort To give him information about his condition To reduce transmission of micro-organisms To ensure accuracy and proper treatment

To ensure safety of the instrument

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Procedure Checklist f. Measuring Blood Pressure
Check () Yes or No No 1 Steps of Procedure Explain the procedure to the patient and put him in a comfortable position, either lying down with the arm resting on the bed or sitting with the arm supported on the table at heart-level. Determine the best site for applying the cuff. Don‘t use bandaged arm or arm with I.V. infusion or an injured arm Bladder and cuff bladder should completely encircle arm without overlapping Place the patient in a sitting or lying position Wash hands Place the patient‘s base upper arm at heart level with palm turned up. Expose the upper arm by removing clothing Palpate brachial artery, place the central bladder above the artery Wrap the cuff evenly around upper arm; see step 3 Place the manometer vertically at eye level Close the valve, deflate the cuff and palpate the radial artery. Pump up air in the cuff until the sphygmomanometer at which the radial pulsation Place the stethoscope earpieces in ears and place its bell over brachial artery in cubital fossa Close valve of pressure bulb clockwise until tight Slowly release valve and allow mercury to fall. Note the point on manometer when first clear sound is heard Continue to deflate the cuff gradually when the sound becomes the muffled and disappears Deflate the cuff rapidly and completely Yes No Comments

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Place the patient in a comfortable position Tell him about his blood pressure Wash hands Record blood pressure in nurse‘s notes and, if any abnormalities are there, report them to ward sister. Keep the stethoscope Sphygmomanometer at proper place in the box

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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Bed Making
Definition: It is a technique which provides enough area to patient on which he can be comfortable and perform his activities of daily living and also to facilitate therapeutic care. Purpose: 1) 2) 3) 4) To provide, rest, comfort and safety to the patient To help him have a good relaxed sleep To give the room a neat and tidy appearance To provide an opportunity to the nurse for observation and assessment of the nursing needs of the patient 5) To give active and passive exercises to the patient and to promote cleanliness 6) To keep it ready for an emergency in order to economize time and energy. 7) To establish a good nurse patient relationship and to teach the relatives bed-making to take care of the patient in home situations

Equipments: For an ambulatory patient 1 2 3 4 5 6 7 8 9 10 11 Chair / stool / trolley – hamper Duster 2 Basin with water/lotion savlon, 1:100 Mattress protector Mattress with cover Long mackintosh Bed sheets 2 Pillow with covers 2 Draw sheet with mackintosh Blankets (if required) Bed spread (counter pane)

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No. 1 2 3 4

Procedure The nurse should wash her hands Collect all needed articles on a chair, stool or trolley Explain to the patient the entire procedure Take off bed clothes, by folding one by one, and place them on a stool/chair/trolley. Shake them gently Discard the soiled linen into the hamper or bucket. Clean and draw the mackintosh, roll it and take it off Take pillows off, shake and change covers Discard dirty linen into the hamper Clean the long mackintosh, roll and keep it on the chair/trolley Dust mattress and Dari with a dry duster Clean bed with wet duster Replace the long mackintosh on the mattress Spread bed sheet (bottom) and make box corners on your side of the bed Spread and draw mackintosh, drawsheet and tuck them on your side Go to the other side of the bed Make the box corner of the sheet at the head –end and the foot-end of the bed. Tuck draw-mackintosh and draw-sheet neatly without wrinkles on the side Spread top sheet to the full length of the mattress Spread blankets over the top sheet Tuck at the foot end by making corners Spread counter pane to the full length by making corners Put the pillow case and place the pillow at the head-end, the open end away from entrance

Rationale To reduce infection by reducing microorganisms

To establish a good nurse patient relationship To prevent the spread of micro-organisms

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To prevent the spread of micro-organisms Folding causes creases

To prevent infection

Damp dusting will stain the mattress To prevent cross infection To protect it from soiling Saves many steps Draw sheets protect the bottom sheet from soiling To have a neat appearance and for the comfort of the patients

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To have a neat appearance and also for fixing the sheet in bed

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Procedure Checklist Bed Making
Check () Yes or No No Steps of Procedure Yes 1 The nurse should wash her hands 2 Collect all needed articles on a chair, stool or trolley 3 Explain to the patient the entire procedure 4 Take off bed clothes, by folding one by one, and place them on a stool/chair/trolley. Shake them gently 5 Discard the soiled linen into the hamper or bucket. 6 Clean and draw the mackintosh, roll it and take it off 7 Take pillows off, shake and change covers 8 Discard dirty linen into the hamper 9 Clean the long mackintosh, roll and keep it on the chair/trolley 10 Dust mattress and Dari with a dry duster 11 Clean bed with wet duster 12 Replace the long mackintosh on the mattress 13 Spread bed sheet (bottom) and make box corners on your side of the bed 14 Spread and draw mackintosh, draw-sheet and tuck them on your side 15 Go to the other side of the bed 16 Make the box corner of the sheet at the head –end and the foot-end of the bed. Tuck drawmackintosh and draw-sheet neatly without wrinkles on the side 17 Spread top sheet to the full length of the mattress 18 Spread blankets over the top sheet 19 Tuck at the foot end by making corners 20 Spread counter pane to the full length by making corners 21 Put the pillow case and place the pillow at the head-end, the open end away from entrance No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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Performing Oral Care
Oral Hygiene: Oral hygiene is important because mouth is the portal of entry of food and digestion starts from mouth. So, the condition of mouth directly affects health. Purpose: 1) 2) 3) 4) 5) To prevent dental carries and tooth decay To feel fresh, clean and socially acceptable To stimulate salivation To prevent inflammation of gums and salivary glands To prevent complications such as stomatitis, glossitis, pyorrhea, parotitis, etc.

Equipments Required: 1 2 3 4 5 6 7 8 9 10 11 12 A tray containing Artery forceps Dissecting forceps Small mackintosh Cotton swabs in a bowl Tongue depressor – solution as ordered Feeding cup Gauge pieces in a bowl Paper beg kidney tray Face towel A bowl with clean water

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Solutions used for oral care: 1) 2) 3) 4) No 1 2 3 4 5 6 7 8 Potassium permanganate 1: 5000 solution Hydrogen peroxide 1:8 Sodium chloride 1 teaspoon to 500ml of water Sodium chloride and lime juice mixture Procedure Explain the procedure to the patient Provide Privacy Position the patient in side-lying position toward the dependent side Arrange the articles conveniently Wash hands Place the mackintosh and towel beneath the patient‘s chin Place the kidney tray close to the cheek Use any dentifrice to clean teeth Rational To allay anxiety if not unconscious To give security To prevent aspiration of secretions and to help in drainage To save time and energy To prevent cross infection To prevent soiling bed linen To prevent soiling bed linen To ensure through Cleanliness

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Do not pour water into mouth if the patient is unconscious Wrap a swab around the forceps, covering the tips completely, and clean the mouth systematically. Clean the mouth in the following order: Inside cheeks Gums Teeth Roof of mouth Lips Use tongue depressor, if needed, and wipe the tongue from side to side For a conscious patient, tooth brush and paste can be used; the patient can spit, and water can be poured for washing his mouth Use as many swabs as required till the mouth is clean Repeat the entire procedure with swabs dipped in fresh water When the teeth and tongue are cleaned well, stop the procedure, wipe the lips and face with towel Apply glycerin borax on the cracked lips

Due to poor gag reflex, the fluid will go into lungs It removes secretions and encrustations

It helps in proper visualization of tongue, gums Ensure proper cleanliness

To give a sense of freshness

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Procedure Checklist Giving Mouth Care
Check () Yes or No No Steps of procedure Yes 1 Explain the procedure to the patient 2 Provide Privacy 3 Position the patient in side-lying position toward the dependent side 4 Arrange the articles conveniently 5 Wash hands 6 Place the mackintosh and towel beneath the patient‘s chin 7 Place the kidney tray close to the cheek 8 Use any dentifrice to clean teeth 9 Do not pour water into mouth if the patient is unconscious 10 Wrap a swab around the forceps, covering the tips completely, and clean the mouth systematically. Clean the mouth in the following order: Inside cheeks Gums Teeth Roof of mouth Lips 11 Use tongue depressor, if needed, and wipe the tongue from side to side 12 For a conscious patient, tooth brush and paste can be used; the patient can spit, and water can be poured for washing his mouth 13 Use as many swabs as required till the mouth is clean 14 Repeat the entire procedure with swabs dipped in fresh water 15 When the teeth and tongue are cleaned well, stop the procedure, wipe the lips and face with towel 16 Apply glycerin borax on the cracked lips No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: ____________________________________

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Administration of Medicine
Definition: A drug medication is a substance used for diagnosis, treatment, cure, relief or prevention of disease. Every drug has got a chemical or pharmacological name and trade name or different trade names by different drug companies. Equipments required: A clean trolley A tray containing 1 2 3 4 5 6 7 8 9 No 1 A bowl of clean water Ounce glass, dropper Teaspoon Drinking water in a feeding cup or glass Mortar and pestle Duster Kidney tray and paper bags Medicine cards Towel to protect patient‘s bed Procedure Assess for contraindication of oral medications such as, dysphagea, nausea, vomiting, bowel inflammation, gastrointestinal surgery, etc. Explain the procedure to the patient Assist the patient to a sitting position Check the medicine card with doctor, s order Wash hands Take appropriate medicine from shelf. Compare the label with the medicine card. Read the expiry date With the medicine card in sight, pour the medication into the ounce glass. Read the lower meniscus Calculate correct drug dose. Take time. Double check calculation Take out tablets in required number into bottle cap; transfer them to medicine cup or paper. Do not touch with fingers. Extra tablets may be returned to the bottle. Rationale Contraindicated conditions will not produce expected effect of the drug due to poor absorption To allay anxiety To ensure comfort To ensure accuracy To reduce transmission of micro-organisms To ensure correctness and accuracy

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To ensure safety second time

8 9

To ensure safety second time To maintain cleanliness of drugs

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10

11

12 13 14 15

While using liquid medicine, pour it from the side of the bottle, away from the label. Hold the ounce glass at the eye level, place the thumb nail at the correct measurement mark and pour the medicine with care. Read the lower meniscus. Excess medicine should be poured into sink. Do not pour it back into the bottle. Place all tablets or capsules given at the same time in one cup or container except liquids. Keep the medicine also in the tray Liquid medicines should not be mixed Take medication to bed side at the correct time Identify the patient by calling his name and recognizing him Verify the identification of the patient with the patient and also with other staff If blood pressure or pulse is to be assessed, assess it before giving medicine. Pulse in case of tab digoxin B.P, in the case of Hypertensive‘s. Give a little water to moisten mouth Give medication one at a time. Give water. Stay with the patient until he takes all the medicines. Check the mouth and ensure that the medicine is swallowed. Lozenges should not be chewed or swallowed Give liquid medicines after giving tablets Place the ounce glass in a bowl of water Help the patient to a comfortable position Wipe the patient, s face and lips, and remove the towel Wash hands Record actual time that each drug was administrated Observe for side effects Wash and place all the articles in their respective places

To ensure correct dosage. To prevent contamination

It is easy for administration

Mixing is hazardous. It will not produce proper result To ensure proper effect To avoid error To identify correctly

16

To ensure safety

17 18

To help swallowing To ensure accuracy and safety

19 20 21 22 23 24 25 26 27

It will not give desired effect

For easy washing To ensure comfort To ensure cleanliness To reduce transmission of micro-organisms

To ensure safety To ensure proper placement

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Procedure Checklist: Administering Oral Medication
Check () Yes or No No Steps of Procedure Yes 1 Assess for contraindication of oral medications such as, dysphagea, nausea, vomiting, bowel inflammation, gastrointestinal surgery, etc. 2 Explain the procedure to the patient 3 Assist the patient to a sitting position 4 Check the medicine card with doctor, s order 5 Wash hands 6 Take appropriate medicine from shelf. Compare the label with the medicine card. Read the expiry date 7 With the medicine card in sight, pour the medication into the ounce glass. Read the lower meniscus 8 Calculate correct drug dose. Take time. Double check calculation 9 Take out tablets in required number into bottle cap; transfer them to medicine cup or paper. Do not touch with fingers. Extra tablets may be returned to the bottle. 10 While using liquid medicine, pour it from the side of the bottle, away from the label. Hold the ounce glass at the eye level, place the thumb nail at the correct measurement mark and pour the medicine with care. Read the lower meniscus. Excess medicine should be poured into sink. Do not pour it back into the bottle. 11 Place all tablets or capsules given at the same time in one cup or container except liquids. Keep the medicine also in the tray 12 Liquid medicines should not be mixed 13 Take medication to bed side at the correct time 14 Identify the patient by calling his name and recognizing him 15 Verify the identification of the patient with the patient and also with other staff No Comments

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33

16

17 18

19 20 21 22 23 24 25 26 27

If blood pressure or pulse is to be assessed, assess it before giving medicine. Pulse in case of tab digoxin B.P, in the case of Hypertensive‘s. Give a little water to moisten mouth Give medication one at a time. Give water. Stay with the patient until he takes all the medicines. Check the mouth and ensure that the medicine is swallowed. Lozenges should not be chewed or swallowed Give liquid medicines after giving tablets Place the ounce glass in a bowl of water Help the patient to a comfortable position Wipe the patient, s face and lips, and remove the towel Wash hands Record actual time that each drug was administrated Observe for side effects Wash and place all the articles in their respective places

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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34

Giving Simple Enema
Definition: An Enema is an introduction of fluid into the bowel through the rectum for the purpose of cleansing or to introduce nourishment. Purpose: 1) 2) 3) 4) 5) 6) To stimulate defecation and treat constipation To cleanse bowel before operations, x – ray studies To stimulate uterine contraction to hasten child birth To relive retention of urine by stimulating reflex action of bladder To relive gaseous distention by stimulating peristalsis To cleanse bowel prior to retention enema

Equipments required: 1 2 3 4 5 6 7 8 9 10 Enemas can, rubber tubing, glass connection, screw clamp Mackintosh and towel Rectal tube or catheter no. 12 in a kidney tray Vaseline Hot water in a jug Pint measure Soap jelly in a bottle I.V. stand Toilet tray Bed pan - 2

Solution used Soap water – soap jelly 50 ml to 1 liter of water Amount of solution Infants Children Adults Temperature of solution Children Adults‘ 100°F 105-110°F 250 ml or less 250 – 500 ml 500 – 1000 ml

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No 1 2 3

Procedure Explain the procedure to the patient Screen the patient Cover the patient with or top sheet or bath blanket. Place the mackintosh and draw sheet under patient‘s buttocks. Assist the patient to turn to left lateral position Keep articles ready on bed side locker Place the bed pan under the bed over a news paper Wash hands Prepare the soap solution at 105°F, by adding 30ml of soap jelly to 600ml of water Attach the rubber tubing to enema can and clamp the tube Hang the - can with the solution on the stand. The height of the can should not be more than 45cms or 18 inch from the anus Attach a catheter to the tubing. Allow a small amount of solution to flow into the kidney tray. Pinch of tubing with fingers Lubricate 2 inch – 4 inch of catheter Separate the buttocks Instruct patient to breathe deeply through his mouth Gently insert rectal tube 2 – 4 inches. Release tubing to allow solution to flow. Allow solution to run slowly with interruptions Give about 500 – 1000ml of solution Clamp the tubing before emptying the can completely Slowly withdraw the catheter. Cover it with gauge pieces or rags and place it in the kidney tray Encourage the patient to retain solution for a few minutes if possible Give the patient bed pan or take him to bath room Collect specimens if required

Rationale To win his confidence and to get his cooperation To provide privacy To protect bed and linen

4 5 6 7 8

To enhance the flow of solution For easy availability For easy availability To reduce transmission of micro-organisms High temperature solution more than 105°F will burn the mucous membrane To ensure safety To enhance and regulate

9 10

11

To expel air

12 13 14 15

To avoid friction To visualize anus To help in relaxation

16 17 18 19

Interruptions of the fluid will relax the bowl

To prevent air entry into the tube To cleanse the tube

20 21 22

To help in proper evacuation

For diagnostic purpose

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36

Procedure Checklist Giving Simple Enema
Check () Yes or No No Steps of procedure Yes No Comments 1 Explain the procedure to the patient 2 Screen the patient 3 Cover the patient with or top sheet or bath blanket. Place the mackintosh and draw sheet under patient‘s buttocks. 4 Assist the patient to turn to left lateral position 5 Keep articles ready on bed side locker 6 Place the bed pan under the bed over a news paper 7 Wash hands 8 Prepare the soap solution at 105°F, by adding 30ml of soap jelly to 600ml of water 9 Attach the rubber tubing to enema - can and clamp the tube 10 Hang the - can with the solution on the stand. The height of the can should not be more than 45cms or 18 inch from the anus 11 Attach a catheter to the tubing. Allow a small amount of solution to flow into the kidney tray. Pinch of tubing with fingers 12 Lubricate 2 inch – 4 inch of catheter 13 Separate the buttocks 14 Instruct patient to breathe deeply through his mouth 15 Gently insert rectal tube 2 – 4 inches. Release tubing to allow solution to flow. 16 Allow solution to run slowly with interruptions 17 Give about 500 – 100ml of solution 18 Clamp the tubing before emptying the can completely 19 Slowly withdraw the catheter. Cover it with gauge pieces or rags and place it in the kidney tray 20 Encourage the patient to retain solution for a few minutes if possible 21 Give the patient bed pan or take him to bath room 22 Collect specimens if required Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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37

Insertion of a flatus tube
Definition: It is insertion of tube in the lower bowel for the removal of gases Purpose: 1) To remove flatus from the lower bowel Equipment Required: 1 2 3 4 5 6 7 8 No 1 2 3 Screen A tray containing Flatus tube Vaseline Wet swabs in a bowl Paper or mackintosh or towel Paper bag Long artery forceps Procedure Prepare the patient as for enema Place the patient in the left lateral position Lubricate the flatus tube and insert 4inch-6inch into the anal canal, the free end of the tube is kept in water in a kidney tray Keep the tube in place for 20 minutes The presence of air bubbles in the water indicates that flatus is being expelled The tube may be reinserted 4 hourly if required Clean the anal region with swabs Replace the articles after cleaning Rationale To reduce anxiety and save times For easily visualization For easy insertion

4 5

For complete removal of flatus To identify any leakage

6 7 8

For complete removal of flatus To reduce the contamination of other things Foe easy availability for next time

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38

Procedure Checklists For insertion of flatus tube
Check () Yes or No No Steps of procedure 1 Prepare the patient as for enema 2 Place the patient in the left lateral position 3 Lubricate the flatus tube and insert 4inch-6inch into the anal canal, the free end of the tube is kept in water in a kidney tray 4 Keep the tube in place for 20 minutes 5 The presence of air bubbles in the water indicates that flatus is being expelled 6 The tube may be reinserted 4 hourly if required 7 Clean the anal region with swabs 8 Replace the articles after cleaning 9 Record the procedure in the patient‘s chart Yes No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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39

Care for Nasal-Gastric Tube a. Inserting a Nasal-Gastric Tube
Definition: Method of introducing a tube through nose into stomach Purpose: 1) To feed client with fluids when oral intake is not possible 2) To dilute and remove consumed poison 3) To instill ice cold solution to control gastric bleeding 4) To prevent stress on operated site by decompressing stomach of secretions and gas 5) To relieve vomiting and distention Equipments: 1 2 3 4 5 6 Nonsterile gloves Ice chips in an emesis basin Towel and tissues Tongue blade Hypoallergenic tape, rubber band, safety pin Wall mount or portable suction equipment as available Procedure Review client‘s medical record 7 8 9 10 11 12 Cup of ice or water and straw Water-soluble lubricant Flashlight or penlight pH chemstrip 20-ml syringe or asepto syringe, 30 ml or larger with small bore tube Administration set with pump or controller for feeding tube Rationale Confirms physician‘s prescription for inserting a nasogastric tube; history of nasal or sinus problems. Promotes efficiency. Reduces transfer of microorganisms. Verifies correct client; reduces anxiety and increases client cooperation. Facilitates passage of the tube into the esophagus and swallowing.

No 1

2 3

Gather equipment. Wash hands. Check client‘s armband; explain procedure, showing items. Place client in Fowler‘s position, at least a 45° angle or higher, with a pillow behind client‘s shoulders; provide for privacy. Place comatose clients in semi-Fowler’s position. Place towel over chest, put tissues in reach. Don gloves Examine nostrils and assess as client breathes through each nostril. Measure length of tubing needed by using tube as a tape measure: Measure from bridge of client‘s nose to earlobe to xiphoid process of sternum (Figure A).If tube is to go below stomach (nasoduodenal or nasojejunal),

4

5

6 7

Prevents soiling of gown and bedding and protects nurse from contamination with bodily fluids; lacrimation can occur during insertion through nasal passages Determines the most patent nostril to facilitate insertion. Approximates length of tube needed to reach stomach.

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40

add an additional 15 to 20 cm (Figure B). Place a small piece of tape on tube to mark length.

8

9 10

(Figure A) Measuring the Length of Nasogastric Tubing. Have client blow nose and encourage swallowing of water if level of consciousness and treatment plan permit. Lubricate first 4 inches of tube with water soluble lubricant a) Insert tube as follows: b) Gently pass tube into nostril to back of throat (client may gag); aim tube toward back of throat and down. c) When client feels tube in back of throat, use flashlight or penlight to locate tip of tube. d) Instruct client to flex head toward chest.

(Figure B) Measuring Length of Nasoduodenal or Nasojejunal Tubing. Clears nasal passage without pushing microorganisms into inner ear; facilitates passage of tube. Facilitates passage into the nares.

Promotes passage of tube with minimal trauma to mucosa. Ensures tip‘s placement.

11 12

e) Instruct client to swallow, offer ice chips or water, and advance tube as client swallows. f) If resistance is met, rotate tube slowly with downward advancement toward client‘s closest ear; do not force tube. Withdraw tube immediately if changes occur in respiratory status. Advance tube, giving client sips of water, until taped mark is reached.

Opens esophagus and assists in tube insertion after tube has passed through nasopharynx and reduces risk of tube entering trachea. Assists in pushing tube past oropharynx.

Tube may be coiled or kinked or in the oropharynx or trachea.

Indicates placement of tube in the bronchus or lung. Assists with tube insertion.

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41

13

Check placement of tube:  Attach syringe to free end of tube and aspirate sample of gastric contents and measure with chemstrip pH (Figure C).

Ensures proper placement in the stomach; pH below 3, tube is in stomach; a pH range of 6 to 7 indicates intestinal sites.

14

(Figure C) For Measuring the pH of Aspirate  Leave syringe attached to free end of tube.  If prescribed, obtain x-ray; keep client on right side until x-ray is taken. Secure tube with tape as shown in Figure D or use a commercially prepared tube holder.

• Prevents leakage of gastric contents. • Confirms correct placement; if nasoduodenal or nasojejunal feedings are required, passage through pylorus may require several days. Prevents tube from becoming dislodged.

(Figure D) Securing Tube to the Client‘s Nose with Tape  Split a 4-inch piece of tape to a length of 2 inches and secure tube with tape by placing the intact end of the tape over the bridge of the nose. Wrap split ends around the tube as it exits the nose.

Prevents trauma to nasal mucosa by reducing pressure on nares.

Allows client movement without causing friction nares; metal devices are removed for x-rays to prevent artifacts.

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42

Place a rubber band, using a slip knot, around the exposed tube (12–18 inches from nose toward chest); after x-ray, pin rubber band to client‘s gown. Reduces anxiety and teaches client how to prevent tugging on tube with head movement. Provides for decompression as prescribed by physician; intermittent or continuous suctioning is determined by type of tube inserted.

15

Instruct client about movements that can dislodge the tube. a) Gastric decompression: b) Remove syringe from free end of tube and connect tube to suction tubing; set machine on type of suction and pressure as prescribed. c) Levine tubes are connected to intermittent low pressure. d) Salem sump or Anderson‘s tube is connected to continuous low suction. e) Observe nature and amount of gastric tube drainage. f) Assess client for nausea, vomiting, and abdominal distention. Provide oral hygiene and cleanse nares with a tissue. Remove gloves, dispose of contaminated materials in proper container, and wash hands. Position client for comfort, and place call light in easy reach. Document: a) The reason for the tube insertion b) The type of tube inserted c) The type (intermittent or continuous) of suctioning and pressure setting d) The nature and amount of aspirate and e) drainage f) The client‘s tolerance of the procedure g) The effectiveness of the intervention, such as nausea relieved

16

Provides information about patency of tube and gastric contents. Indicates effectiveness of intervention.

17 18

Promotes comfort. Reduces transmission of microorganisms; protects other workers from coming into contact with objects contaminated with body fluids Promotes comfort and safety. Promotes continuity of care and shows implementation of intervention.

19 20

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43

Procedure Checklist Inserting a Nasal-Gastric Tube
Check () Yes or No No 1 2 3 4 Procedure Review client‘s medical record Gather equipment. Wash hands. Check client‘s armband; explain procedure, showing items. Place client in Fowler‘s position, at least a 45° angle or higher, with a pillow behind client‘s shoulders; provide for privacy. Place comatose clients in semi-Fowler’s position. Place towel over chest, put tissues in reach. Don gloves Examine nostrils and assess as client breathes through each nostril. Measure length of tubing needed by using tube as a tape measure: Measure from bridge of client‘s nose to earlobe to xiphoid process of sternum (Figure A).If tube is to go below stomach (nasoduodenal or nasojejunal), add an additional 15 to 20 cm (Figure B). Place a small piece of tape on tube to mark length. Yes No Comments

5

6 7

8

(Figure A) Measuring the Length of Nasogastric Tubing. Have client blow nose and encourage swallowing of water if level of consciousness and treatment plan permit.

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44

9 10

11 12 13

Lubricate first 4 inches of tube with water soluble lubricant g) Insert tube as follows: h) Gently pass tube into nostril to back of throat (client may gag); aim tube toward back of throat and down. i) When client feels tube in back of throat, use flashlight or penlight to locate tip of tube. j) Instruct client to flex head toward chest. k) Instruct client to swallow, offer ice chips or water, and advance tube as client swallows. l) If resistance is met, rotate tube slowly with downward advancement toward client‘s closest ear; do not force tube. Withdraw tube immediately if changes occur in respiratory status. Advance tube, giving client sips of water, until taped mark is reached. Check placement of tube:  Attach syringe to free end of tube and aspirate sample of gastric contents and measure with chemstrip pH (Figure C).

14

(Figure C) For Measuring the pH of Aspirate  Leave syringe attached to free end of tube.  If prescribed, obtain x-ray; keep client on right side until x-ray is taken. Secure tube with tape as shown in Figure D or use a commercially prepared tube holder.

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(Figure D) Securing Tube to the Client‘s Nose with Tape  Split a 4-inch piece of tape to a length of 2 inches and secure tube with tape by placing the intact end of the tape over the bridge of the nose. Wrap split ends around the tube as it exits the nose.  Place a rubber band, using a slip knot, around the exposed tube (12–18 inches from nose toward chest); after x-ray, pin rubber band to client‘s gown. 15 16 Instruct client about movements that can dislodge the tube. g) Gastric decompression: h) Remove syringe from free end of tube and connect tube to suction tubing; set machine on type of suction and pressure as prescribed. i) Levine tubes are connected to intermittent low pressure. j) Salem sump or Anderson‘s tube is connected to continuous low suction. k) Observe nature and amount of gastric tube drainage. l) Assess client for nausea, vomiting, and abdominal distention. Provide oral hygiene and cleanse nares with a tissue.

17

Nursing Skill Procedures

46

18

19 20

Remove gloves, dispose of contaminated materials in proper container, and wash hands. Position client for comfort, and place call light in easy reach. Document: h) The reason for the tube insertion i) The type of tube inserted j) The type (intermittent or continuous) of suctioning and pressure setting k) The nature and amount of aspirate and l) drainage m) The client‘s tolerance of the procedure n) The effectiveness of the intervention, such as nausea relieved

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________

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b. Removal a Nasal-Gastric Tube
No 1 Procedure: Assemble the appropriate equipment, such as kidney tray, tissues or gauze and disposable gloves, at the client‘s bedside. 2 Explain the client what you are going do. 3 Put on the gloves 4 Remove the tube a) Take out the adhesive tape which holding the nasal-gastric tube to the client‘s nose b) Remove the tube by deflating any balloons Rationale Organization facilitates accurate skill performance

Providing explanation fosters cooperation To prevent spread of infection

Do not remove the tube if you encounter any resistance not to harm any membranes or organs. Do another attempt in an hour. Continuous slow pulling it out can lead coughing or discomfort

c) Simply pulling it out, slowly at first and then rapidly when the client begins to cough. d) Conceal the tube. 5 Be sure to remove any tapes from the client‘s face. Acetone may be necessary. Provide mouth care if needed. Put off gloves and perform hand hygiene. Record the date, time and the client‘s condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal. Sign the signature. Dispose the equipments and replace them. Report to the senior staff.

6 7 8

Acetone helps any adhesive substances from the face. You should also wipe acetone out after removed tapes because acetone remained on the skin may irritate. To provide comfort To prevent the spread of infection Documentation provides coordination of care Giving signature maintains professional accountability

9 10

To prepare for the next procedure To provide continuity of care

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48

Procedure Checklist Removal a Nasal-Gastric Tube
Check () Yes or No No 1 Procedure: Yes Assemble the appropriate equipment, such as kidney tray, tissues or gauze and disposable gloves, at the client‘s bedside. Explain the client what you are going do. Put on the gloves Remove the tube Take out the adhesive tape which holding the nasal-gastric tube to the client‘s nose Remove the tube by deflating any balloons Simply pulling it out, slowly at first and then rapidly when the client begins to cough. Conceal the tube. Be sure to remove any tapes from the client‘s face. Acetone may be necessary. Provide mouth care if needed. Put off gloves and perform hand hygiene. Record the date, time and the client‘s condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal. Sign the signature. Dispose the equipments and replace them. Report to the senior staff. No Comments

2 3 4 e)

f) g)

h) 5

6 7 8

9 10

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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49

Administering Enteral Tube Feedings
Definition: A nasal-gastric tube feeding is a means of providing liquid nourishment through a tube into the intestinal tract, when client is unable to take food or any nutrients orally Purpose: 1) To provide adequate nutrition 2) To give large amounts of fluids for therapeutic purpose 3) To provide alternative manner to some specific clients who has potential or acquired swallowing difficulties Equipment: 1. Asepto syringe or 20- to 50-ml syringe 2. Emesis basin 3. Formula 4. Infusion pump for feeding tube No 1 2 3 4 5 Procedure Review client‘s medical record. Gather equipment. Check client‘s armband. Explain procedure to client. Assemble equipment. If using a bag, fill with prescribed amount of formula

5. 6. 7. 8.

Clean towel Disposable gavage bag and tubing Water to follow feeding Nonsterile gloves Rationale Verifies physician‘s prescription for appropriate formula and amount. Promotes efficiency during procedure. Verifies correct client. Reduces anxiety and increases client cooperation. Ensures efficiency when initiating feeding.

6 7 8

(Figure A) Preparing Formula Place client on right side in high Fowler‘s position. Wash hands and don nonsterile gloves. Provide for privacy.

Reduces risk of pulmonary aspiration in event client vomits or regurgitates formula. Reduces transmission of pathogens from gastric contents Places client at ease.

Nursing Skill Procedures

50

9

Observe for abdominal distention; auscultate for bowel sounds. Check feeding tube: Insert syringe into adapter port, aspirate stomach contents, and determine amount of gastric residual.  If residual is greater than 50 to 100 ml (or in accordance with agency protocol), hold feeding until residual diminishes.  Instill aspirated contents back into feeding tube. Administer tube feeding: Intermittent—Bolus  Pinch the tubing.  Remove plunger from barrel of syringe and attach to adapter.  Fill syringe with formula  Allow formula to infuse slowly; continue adding formula to syringe until prescribed amount has been administered.  Flush tubing with 30 to 60 ml or prescribed amount of water. Intermittent—Gavage Feeding  Hang bag on IV pole so that it is 18 inches above the client‘s head.  Remove air from bag‘s tubing.  Attach distal end of tubing to feeding tube adapter and adjust drip to infuse over prescribed time.  When bag empties of formula, add 30 to 60 ml or prescribed amount of water; close clamp.  Change gavage bag every 24 hours or wash reusable gavage bag with soap and hot water every 24 hours. Continuous Gavage Check tube placement at least every 4 hours.  Check residual at least every 8 hours.  If residual is above 100 ml, stop feeding.

Assesses for delayed gastric emptying; indicates presence of peristalsis and ability of GI tract to digest nutrients. Indicates whether gastric emptying is delayed.

Reduces risk of regurgitation and pulmonary aspiration related to gastric distention.

Prevents electrolyte imbalance. Provides nutrients as prescribed. Prevents air from entering tubing. Provides system to delivery feeding.

Allows gravity to control flow rate, reducing risk of diarrhea from bolus feeding. Prevents air from entering stomach and reduces risk for gas accumulation. Maintains patency of feeding tube.

Allows gravity to promote infusion of formula. Prevents air from entering stomach. Decreases risk of diarrhea

Ensures that remaining formula in tubing is administered and maintains patency of tube; prevents air from entering the stomach. Decreases risk of multiplication of microorganisms in bag and tubing.

Ensures that feeding tube remains in stomach. Indicates ability of GI tract to digest and absorb nutrients. Reduces risk of regurgitation and pulmonary aspiration related to gastric distention.

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51

  

     

12 13 14 15

Provides comfort and maintains the integrity of buccal cavity. Administer water as prescribed with and Ensures adequate hydration. between feedings. Clamp proximal end of feeding tube Prevents air from entering the tube. after formula has been administered. Remove gloves and wash hands. Reduces risk of transmission of microorganisms. Record total amount of formula and Documents administration of feeding and water administered on I & O form and achievement of expected outcome; for client‘s response to feeding. example, client tolerates feeding and weight is maintained or increased.

Add prescribed amount of formula to bag for a 4-hour period; dilute with water if prescribed. Hang gavage bag on IV pole. Prime tubing. Thread tubing through feeding pump and attach distal end of tubing to feeding tube adapter; keep tubing straight between bag and pump. Adjust drip rate. Monitor infusion rate and signs of respiratory distress or diarrhea. Flush tube with water every 4 hours as prescribed or following administration of medications. Replace disposable feeding bag at least every 24 hours, in accord with agency‘s protocol. Turn client every 2 hours. Provide oral hygiene every 2 to 4 hours.

Provides client with prescribed nutrients and prevents bacterial growth (formula is easily contaminated). Removes air from tubing. Provides for controlled flow rate; prevents loops in tubing.

Infuses formula over prescribed time. Prevents complications associated with continuous gavage. Maintains patency of tube. Decreases risks of microorganisms. Promotes digestion and reduces skin breakdown.

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52

Procedure Checklist Administering Enteral Tube Feedings
Check () Yes or No No 1 2 3 4 5 6 7 8 9 Procedure Review client‘s medical record. Gather equipment. Check client‘s armband. Explain procedure to client. Assemble equipment. If using a bag, fill with prescribed amount of formula Place client on right side in high Fowler‘s position. Wash hands and don nonsterile gloves. Provide for privacy. Observe for abdominal distention; auscultate for bowel sounds. Check feeding tube: Insert syringe into adapter port, aspirate stomach contents, and determine amount of gastric residual.  If residual is greater than 50 to 100 ml (or in accordance with agency protocol), hold feeding until residual diminishes.  Instill aspirated contents back into feeding tube. Administer tube feeding: Intermittent—Bolus  Pinch the tubing.  Remove plunger from barrel of syringe and attach to adapter.  Fill syringe with formula  Allow formula to infuse slowly; continue adding formula to syringe until prescribed amount has been administered.  Flush tubing with 30 to 60 ml or prescribed amount of water. Intermittent—Gavage Feeding  Hang bag on IV pole so that it is 18 inches above the client‘s head.  Remove air from bag‘s tubing.  Attach distal end of tubing to feeding tube adapter and adjust drip to infuse over prescribed time.  When bag empties of formula, add 30 to 60 ml or prescribed amount of water; close clamp. Yes No Comments

Nursing Skill Procedures

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12 13 14 15

Change gavage bag every 24 hours or wash reusable gavage bag with soap and hot water every 24 hours. Continuous Gavage Check tube placement at least every 4 hours.  Check residual at least every 8 hours.  If residual is above 100 ml, stop feeding.  Add prescribed amount of formula to bag for a 4-hour period; dilute with water if prescribed.  Hang gavage bag on IV pole.  Prime tubing.  Thread tubing through feeding pump and attach distal end of tubing to feeding tube adapter; keep tubing straight between bag and pump.  Adjust drip rate.  Monitor infusion rate and signs of respiratory distress or diarrhea.  Flush tube with water every 4 hours as prescribed or following administration of medications.  Replace disposable feeding bag at least every 24 hours, in accord with agency‘s protocol.  Turn client every 2 hours.  Provide oral hygiene every 2 to 4 hours. Administer water as prescribed with and between feedings. Clamp proximal end of feeding tube after formula has been administered. Remove gloves and wash hands. Record total amount of formula and water administered on I & O form and client‘s response to feeding.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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54

Feeding via a Gastrostomy and Jejunostomy Feeding Tube
Definition: Jejunostomy is a surgical procedure by which a tube is situated in the lumen of the proximal jejunum, primarily to administer nutrition. Purpose: To provide an alternative to oral and parenteral nutrition Equipments: 1 2 3 4 5 6 7 8 9 10 Sterile dressing pack Sterile gloves Disposable apron Enteral Feeding pump and stand Enteral Feeding system device, labeled ‗enteral‘ color coded purple. Dietetic feeding regimen Record of administration Prescribed feed as per dietetic feeding regimen Freshly drawn tap water unless sterile water specified by managing dietitian Female Luer Lock syringes. Syringe size and quantity will depend on dietetic regimen and size of feeding tube, and will be directed by managing dietitian

No 1

2 3

Procedure Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent Wash and dry hands and apply sterile gloves Apply single use disposable apron

Rationale To reduce potential error of giving feed to wrong patient To enable patient to make an informed decision about their own health care To protect clothing and prevent transfer of transient organisms to a susceptible site To reduce the risk of transfer of transient organisms on the healthcare workers hands To minimize reflux and risk of aspiration

4

5

Position the patient in an upright position (30 - 45°) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water from a kitchen sink to ensure the water is fit to drink (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube

To prevent air being in the giving set and causing pump to alarm

To maintain patency of tube

Nursing Skill Procedures

55

6

7

8

9 10

11

Administration:A `no touch` aseptic technique should be used to connect the enteral feeding system device to the enteral feeding tube. If administering feed via a pump, place feed container on a stand. Attach feeding system to prescribed feed and prime system Set feeding pump at prescribed flow rate (as per dietetic regimen) release clamp on feeding tube and start pump Ensure the type of feed and volume given is recorded in the patients health records On completion of feeding, advise carer to switch off feeding pump and close clamp on enteral feeding system and disconnect the feeding system from the feeding tube. If no carer, nurse to re-visit to close enteral feeding system. Post feed:Flush enteral feeding tube with prescribed amount of tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding system and disconnect feeding system from feeding tube– this may be done by the nurse or advice appropriate carer. When the feeding tube is not in use the clamp should always remain open. Dispose of feeding equipment in general household waste, remove disposable apron and gloves, wash and dry hands. Document treatment in patient‘s health records.

Aseptic technique is to prevent any contamination of site Feed should be administered at room temperature and stored following manufacturers‘ instructions To allow feed to be administered correctly

To maintain tube patency and ensure fluid requirements are met To close system

To maintain patency of tube

To prevent damage to tube To prevent cross infection Enteral feed administration sets are for single use only and must be discarded after each feeding session To comply with PCT health records policy and to maintain accurate records

Nursing Skill Procedures

56

Procedure Checklist Feeding via a Gastrostomy and Jejunostomy feeding tube
Check () Yes or No No 1 Procedure Yes Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent Wash and dry hands and apply sterile gloves Apply single use disposable apron Position the patient in an upright position (30 - 45°) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water from a kitchen sink to ensure the water is fit to drink (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Administration:A `no touch` aseptic technique should be used to connect the enteral feeding system device to the enteral feeding tube. If administering feed via a pump, place feed container on a stand. Attach feeding system to prescribed feed and prime system Set feeding pump at prescribed flow rate (as per dietetic regimen) release clamp on feeding tube and start pump Ensure the type of feed and volume given is recorded in the patients health records On completion of feeding, advise carer to switch off feeding pump and close clamp on enteral feeding system and disconnect the feeding system from the feeding tube. If no carer, nurse to re-visit to close enteral feeding system. No Comments

2 3

4

5

6

7

8

Nursing Skill Procedures

57

9

10

11

Post feed:Flush enteral feeding tube with prescribed amount of tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding system and disconnect feeding system from feeding tube– this may be done by the nurse or advice appropriate carer. When the feeding tube is not in use the clamp should always remain open. Dispose of feeding equipment in general household waste, remove disposable apron and gloves, wash and dry hands. Document treatment in patient‘s health records.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

58

Administering Bolus Feeds
Equipments: 1 2 3 4 5 6 7 8 9 Sterile dressing pack Sterile gloves Single use disposable apron Enteral Feeding system device, labelled ‗enteral‘ colour coded purple. Dietetic feeding regimen Record of administration Prescribed feed as per dietetic feeding regimen Freshly drawn tap water (or sterile water as per dietetic regime) Female Luer Lock syringes. Syringe size and quantity will depend on dietetic regimen and make of feeding tube, and will be directed by managing dietitian Procedure Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent. Wash hands and apply sterile gloves Apply single use disposable apron Rationale To reduce potential error of giving feed to wrong patient To enable patient to make an informed decision about their own health care To reduce the risk of transfer of transient organisms on the healthcare workers hands To protect clothing and prevent transfer of transient organisms to a susceptible site To minimize reflux and risk of aspiration

No 1

2 3

4

5

6 7

Position the patient in an upright position (30- 45°) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:To maintain patency of tube Flush enteral feeding tube with prescribed amount of freshly drawn tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Attach an enteral syringe without the To allow feed to be administered plunger to the feeding tube Slowly pour the prescribed quantity of To allow feed to be administered feed into the syringe. If the feed is running too quickly or slowly altering the height of the syringe slightly may help. The plunger can be used to apply gentle pressure if the feed is running too slowly. Do not apply pressure with force.

Nursing Skill Procedures

59

8

9

10

11

When the prescribed feed has been delivered, flush tube with freshly drawn tap water, (or sterile water as per dietetic regime) remove the syringe. Ensure type of feed and volume given is recorded in the patients health records Dispose of feeding equipment in general household waste, remove gloves, wash and dry hands Document all care in patients records

To maintain patency of tube

To maintain accurate records

To prevent cross infection

To promote safe continuity of health care

Nursing Skill Procedures

60

Procedure Checklist Procedure for Administering Bolus Feeds
Check () Yes or No No 1 Procedure Yes Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent. Wash hands and apply sterile gloves Apply single use disposable apron Position the patient in an upright position (30- 45°) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Attach an enteral syringe without the plunger to the feeding tube Slowly pour the prescribed quantity of feed into the syringe. If the feed is running too quickly or slowly altering the height of the syringe slightly may help. The plunger can be used to apply gentle pressure if the feed is running too slowly. When the prescribed feed has been delivered, flush tube with freshly drawn tap water, remove the syringe. Ensure type of feed and volume given is recorded in the patients health records Dispose of feeding equipment in general household waste, remove gloves, wash and dry hands Document all care in patients records No Comments

2 3 4

5

6 7

8

9

10

11

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

61

Colostomy Irrigation
Definition: Colostomy irrigation is ―a way to regulate the intestinal activity of colostomized patients, followed by emptying the colon‖ Purpose: 1) To promote the emptying of the fecal content 2) To reduce the formation of gas since, by removing the residues 3) To maintain normal bowel function 4) To avoid constipation Equipments: A trolley [which is cleansed with an appropriate solution] with the following: 1 Irrigation container 2 Irrigation fluid 500 to 1,000 ml lukewarm water or other solution 3 Soft rubber catheter No. 22 or No. 24 4 New colostomy appliance 5 Irrigation sleeve 6 Disposable gloves 7 Apron 8 Lubricant 9 Receiver / plastic bag for the disposal of old colostomy pouch / dressing 10 Cotton wool swabs 11 Protector / plastic sheet [if patient is confined to bed] 12 Bedpan

No 1

2

3

Procedure Verify physician‘s order, progress notes, and nursing care plan for colostomy. Assess patient‘s condition to determine if procedure should be done in bed or in the bathroom Ensure privacy.

Rationale To obtain specific instructions and / or information. To facilitate the patient in comfortable position

4 5 6 7 8

To avoid unnecessary embarrassment to the patient during the procedure. Respect for patient‘s privacy is an essential aspect of the holistic care of a patient. Wash hands and dry hands.(refer Hand To reduce nosocomial infection. washing procedure) Don gloves. To reduce nosocomial infection. Assemble equipment correctly It ensures the procedure is carried out smoothly. Explain procedure to patient. To allay fears and gain patient‘s confidence and cooperation. Position patient. Lie patient on the side To facilitate the patient closest to the stoma or in supine position if patient is confined to bed. Sit the patient on toilet if ambulatory

Nursing Skill Procedures

62

9

10 11 12

13 14

15

16

Remove regular ostomy pouch by unsnapping the pouch from the skin barrier with flange Cleanse stoma and surrounding skin area. Apply irrigator sleeve by snapping it onto the skin barrier with flange. Connect irrigation bag to tubing. The two pieces slide apart and push together. If stoma protrudes, use the cone tip. Put on glove, lubricate small finger and gently insert into colostomy Fill irrigating bag with 1000 mL lukewarm water. If new ostomy, begin with 250 mL lukewarm water, or as ordered by physician. Hang bag so that bottom of bag is at patient‘s shoulder level, (Figure 3) or if patient is on bed rest, 18 inches ( 45 cm ) above stoma.. Allow small amount of water to run through tubing to clear it of air.

Proper disposal of the colostomy to avoid contamination. Ist promotes comfort and hygiene.

To determine the direction of the lumen.

It ensures the irrigation fluid will flow by gravity

17

19 20

21

22

23

Air will not be introduced into the colon that could cause discomfort to the patient If using a catheter, lubricate and gently Ensures a smooth entry into the stoma and insert about two inches avoids friction. If any resistance is felt, change direction of catheter and/or allow small amount of water to flow through catheter before attempting to insert it further. If using cone tip, hold snugly into stoma. Open clamp and allow water to enter bowl. Patient may complain of cramping if irrigation flows too rapidly. If cramping occurs, clamp off tubing until cramps subside. Remove catheter and fold over top of To prevent return from splashing drain sleeve and fasten closed with clamp provided Allow about 15-20 minutes for most of drainage to return, then rinse sleeve with lukewarm water through top of sleeve Fold end of irrigating sleeve up twice and clip to top, thus making a temporary catch bag. Patient may now go out into room for remaining 45 minutes.

Nursing Skill Procedures

63

24

25

26 27

28

After 1-hour, rinse irrigating sleeve and remove by unsnapping it from skin barrier with flange. Apply clean pouch by snapping it onto skin barrier with flange. May apply Banish deodorant into pouch. Wash and dry hands. Wash irrigating equipment and allow to dry. Place patient‘s name and room number on a piece of tape and attach to equipment hanging in the bathroom Complete Documentation (type and amount of irrigant, whether cone tip or cath use, description of stoma, amount and type of returns, If wafer and pouch changed, description of peristomal skin).

To reduce the risk of nosocomial infection. The clean equipment will be ready for re-use.

To determine skin / stoma integrity and to detect early signs of infection and any possible problems.

Nursing Skill Procedures

64

Procedure Checklist Colostomy irrigation
Check () Yes or No No 1 Procedure Yes Verify physician‘s order, progress notes, and nursing care plan for colostomy. Assess patient‘s condition to determine if procedure should be done in bed or in the bathroom Ensure privacy. Wash hands and dry hands.(refer Hand washing procedure) Don gloves. Assemble equipment correctly Explain procedure to patient. Position patient. Lie patient on the side closest to the stoma or in supine position if patient is confined to bed. Sit the patient on toilet if ambulatory Remove regular ostomy pouch by unsnapping the pouch from the skin barrier with flange Cleanse stoma and surrounding skin area. Apply irrigator sleeve by snapping it onto the skin barrier with flange. Connect irrigation bag to tubing. The two pieces slide apart and push together. If stoma protrudes, use the cone tip. Put on glove, lubricate small finger and gently insert into colostomy Fill irrigating bag with 1000 mL lukewarm water. If new ostomy, begin with 250 mL lukewarm water, or as ordered by physician. Hang bag so that bottom of bag is at patient‘s shoulder level, (Figure 3) or if patient is on bed rest, 18 inches ( 45 cm ) above stoma.. Allow small amount of water to run through tubing to clear it of air. If using a catheter, lubricate and gently insert about two inches If using cone tip, hold snugly into stoma. No Comments

2

3 4 5 6 7 8

9

10 11 12

13 14

15

16 17 19

Nursing Skill Procedures

65

20

21

22

23

24

25

26 27

28

Open clamp and allow water to enter bowl. Patient may complain of cramping if irrigation flows too rapidly. If cramping occurs, clamp off tubing until cramps subside. Remove catheter and fold over top of drain sleeve and fasten closed with clamp provided Allow about 15-20 minutes for most of drainage to return, then rinse sleeve with lukewarm water through top of sleeve Fold end of irrigating sleeve up twice and clip to top, thus making a temporary catch bag. Patient may now go out into room for remaining 45 minutes. After 1-hour, rinse irrigating sleeve and remove by unsnapping it from skin barrier with flange. Apply clean pouch by snapping it onto skin barrier with flange. May apply Banish deodorant into pouch. Wash and dry hands. Wash irrigating equipment and allow to dry. Place patient‘s name and room number on a piece of tape and attach to equipment hanging in the bathroom Complete Documentation (type and amount of irrigant, whether cone tip or cath use, description of stoma, amount and type of returns, If wafer and pouch changed, description of peristomal skin).

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

66

Urinary Catheterization
Definition: Urinary catheterization is the insertion of a catheter into a patient's bladder. The catheter is used as a conduit to drain urine from the bladder into an attached bag or container. Purpose: 1) To relieve urinary retention and 2) To promote the comfort and dignity in palliative patients Equipments: 1 Single use disposable apron 2 Catheter: 3 Sterile dressing pack 4 Additional pair of single use disposable sterile gloves 5 One pair of single use disposable non-sterile gloves 6 Prescribed single use anesthetic gel/ lubricant gel - written on Patients Medication administration Chart 7 Drainage bag 8 10 ml Syringe x 2 9 Single use sachet normal saline 0.9% 10 If catheter is not prefilled - 10mls sterile water for injection and green needle 11 Disposable Non-sterile Kidney dish Catheter Size The system of measurement to express catheter diameter is the Charriere (ch). For routine drainage in an adult select the smallest charriere size that will ensure adequate drainage, to minimize urethral trauma and irritation of the bladder mucosa (Pellowe 2009). Female 10-14ch Male 12-16ch Suprapubic 14-16ch Female Urinary Catheterization Procedure Rationale Introduce yourself and any colleagues To gain co-operation involved at the contact. Verbally confirm the identity of the To avoid mistaken identity patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Explain procedure to patient including To ensure client understands procedure risks and benefits and gain informed Use consent form 4 if appropriate consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document It is the patients‘ choice to have a chaperone decision in health records if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment

No 1 2

3

4

Nursing Skill Procedures

67

5

Ensure all equipment is gathered before commencing the procedure

6

7 8 9

10

11

12

13

14

15 16

17

18

19

Check the catheter size and type against the written instructions in the patient‘s health records If not first catheterization ask the patient To avoid spillages of urine during procedure to empty their drainage bag. Check for any allergies e.g. latex or To reduce risk of anaphylaxis anesthetic gels Decontaminate hands prior to procedure To reduce the risk of transfer of transient micro - organisms on the health care workers hands Open sterile dressing pack onto a clean To maintain asepsis and prevent field and place all sterile single use contamination of sterile equipment equipment required within sterile field Use aseptic principle to ensure that only To prevent contamination of a susceptible sterile single use items are used to keep site by organisms that could cause infection exposure of the susceptible site to a minimum In the event the patient requires To prevent cross infection assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient to position To maintain dignity and comfort themselves in a supine position, with knees bent and hips flexed and feet comfortably apart.(If able) Decontaminate hands prior to procedure To reduce the risk of transfer of transient micro - organisms on the health care workers hands Apply single use disposable apron and To prevent cross infection and environmental gloves contamination. If not first catheterization remove To avoid vacuuming of the bladder mucosa existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Place a piece of gauze around the catheter and slowly withdraw the catheter Using sterile gauze, separate the labia Inadequate preparation of the urethral orifice and identify urethral meatus, clean is a major cause of infection following around the urethral orifice with normal catheterization. To reduce risk of cross saline 0.9% using downward strokes infection (DH 2005) Insert prescribed single use anaesthetic / To ensure full effectiveness of lubricating gel with dominant hand to anaesthetic/lubricant gel, to minimise urethra and leave for recommended discomfort and help prevent urethral trauma manufacturer‘s time/ 5 minutes (Woodward 2005) Remove and dispose of PPE to comply To prevent cross infection and environmental with waste management policy contamination

To prevent contamination of sterile equipment and to ensure the procedure is not commenced without all necessary equipment To reduce risk of using the incorrect device

Nursing Skill Procedures

68

20 21

22

23

24 25

Arrange sterile towel to cover the surrounding area and maintain dignity Apply single use disposable sterile apron and gloves in a manner which prevents the outer surface of the sterile glove being touched by a non-sterile item Insert the catheter approximately 56cms. Once urine has started draining insert a further 3-5cms. If at any time the patient experiences any undue pain or there is resistance when passing the catheter, stop and seek advice. If Prefilled balloon: Release clamp of balloon and allow slow release of water. If not prefilled balloon: Slowly inflate the balloon with 10mls of sterile water according to manufacture‘s instructions. Balloon inflation should be pain free. If the patient is experiencing any pain or discomfort during balloon inflation, the balloon might be positioned in the urethra. Deflate the balloon and advance the catheter a few more centimeters before trying again. Attach the catheter to a previously selected drainage system or catheter valve. Attach sterile drainage bag. Measure the amount of urine

To create sterile field and help prevent contamination To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection

To ensure the balloon is in the bladder

To retain catheter in bladder (Over inflation of the balloon may cause irritation of the bladder trigone inducing bladder spasm which in turn causes ―by passing‖ of urine around the urethral orifice)

26 27

28

Ensure the patient is comfortable and the genital area is dry On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE

To maintain closed circuit system To be aware of bladder capacity for patients who have presented with urinary retention. To monitor renal function and fluid balance If the area is left wet or moist, secondary infection and skin irritation may occur To prevent cross infection and environmental contamination To remove any accumulation of transient skin flora that may have built up under gloves and possible contamination following removal of PPE To document event and have a permanent record for reference and monitoring of future care planning.

29

Record information in patients health records • Catheter material/ expiry date • Charrière size and length Balloon size • Batch number • Cleansing and anesthetic agents • Urine drainage system • Planned date for the next catheter change

Date of catheter change essential for safety of patient

Nursing Skill Procedures

69

30

31

Reinforce management of catheter and ongoing care, document patient catheter booklet explained and given to patient/carer contact details given Fully document all intervention and any follow up care required in the patients care plan Record patients/carers comments or any concerns following the procedure

Promotes independence and reduces incidence of problems/infections Promoting self-care To record patients perspective.

To provide safe and effective continuity of care

Nursing Skill Procedures

70

Procedure Checklist Female Urinary Catheterization
Check () Yes or No No 1 2 Procedure Yes Introduce yourself and any colleagues involved at the contact. Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Explain procedure to patient including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document decision in health records Ensure all equipment is gathered before commencing the procedure Check the catheter size and type against the written instructions in the patient‘s health records If not first catheterization ask the patient to empty their drainage bag. Check for any allergies e.g. latex or anesthetic gels Decontaminate hands prior to procedure Open sterile dressing pack onto a clean field and place all sterile single use equipment required within sterile field Use aseptic principle to ensure that only sterile single use items are used to keep exposure of the susceptible site to a minimum In the event the patient requires assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient to position themselves in a supine position, with knees bent and hips flexed and feet comfortably apart.(If able) Decontaminate hands prior to procedure No Comments

3

4 5 6

7 8 9 10

11

12

13

14

Nursing Skill Procedures

71

15 16

17

18

19 20 21

22

23

24 25

Apply single use disposable apron and gloves If not first catheterization remove existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Place a piece of gauze around the catheter and slowly withdraw the catheter Using sterile gauze, separate the labia and identify urethral meatus, clean around the urethral orifice with normal saline 0.9% using downward strokes Insert prescribed single use anaesthetic / lubricating gel with dominant hand to urethra and leave for recommended manufacturer‘s time/ 5 minutes Remove and dispose of PPE to comply with waste management policy Arrange sterile towel to cover the surrounding area and maintain dignity Apply single use disposable sterile apron and gloves in a manner which prevents the outer surface of the sterile glove being touched by a non-sterile item Insert the catheter approximately 56cms. Once urine has started draining insert a further 3-5cms. If at any time the patient experiences any undue pain or there is resistance when passing the catheter, stop and seek advice. If Prefilled balloon: Release clamp of balloon and allow slow release of water. If not prefilled balloon: Slowly inflate the balloon with 10mls of sterile water according to manufacture‘s instructions. Balloon inflation should be pain free. If the patient is experiencing any pain or discomfort during balloon inflation, the balloon might be positioned in the urethra. Deflate the balloon and advance the catheter a few more centimeters before trying again. Attach the catheter to a previously selected drainage system or catheter valve. Attach sterile drainage bag. Measure the amount of urine

Nursing Skill Procedures

72

26 27

28 29

30

31

Ensure the patient is comfortable and the genital area is dry On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Record information in patients health records • Catheter material/ expiry date • Charrière size and length Balloon size • Batch number • Cleansing and anesthetic agents • Urine drainage system • Planned date for the next catheter change Reinforce management of catheter and ongoing care, document patient catheter booklet explained and given to patient/carer contact details given Fully document all intervention and any follow up care required in the patients care plan Record patients/carers comments or any concerns following the procedure

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

73

Male Urinary Catheterization
No 1 2 Procedure Introduce yourself and any colleagues involved at the contact. Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Explain procedure to patient, including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document decision in health records Rationale To gain co-operation To avoid mistaken identity

3

To ensure client understands procedure and enable patient to make informed decisions Use consent form 4 if appropriate It is the patients‘ choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment To prevent contamination of sterile equipment and to ensure the procedure is not commenced without all necessary equipment To reduce risk of using the incorrect device.

4

5

Ensure all equipment is gathered before commencing the procedure

6

7 8 9

10

11

12

13 14

Check the catheter size and type against the written instructions in the patient‘s health records Check for any allergies e.g. latex or To reduce risk of anaphylaxis anaesthetic gels If not first catheterisation ask the patient To avoid spillages of urine during procedure to empty their drainage bag. Decontaminate hands prior to procedure To reduce the risk of transfer of transient micro - organisms on the health care workers hands Open sterile dressing pack onto a clean To maintain asepsis and prevent field and place all sterile single use contamination of sterile equipment equipment required within sterile field including catheter and drainage system Use aseptic principle to ensure that only To prevent contamination of a susceptible sterile single use items are used to keep site by organisms that could cause infection exposure of the susceptible site to a minimum In the event the patient requires To prevent cross infection assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient into a supine To ensure abdominal muscles relaxed position Decontaminate hands To reduce the risk of transfer of transient micro - organisms on the health care workers hands

Nursing Skill Procedures

74

15 16

17

Apply sterile single use disposable apron and gloves If not first catheterization, remove existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Place a piece of sterile gauze around the catheter and slowly withdraw the catheter, whilst supporting the penis Retract foreskin (if not circumcised), clean around the Glans and urethral orifice with normal saline 0.9% Insert prescribed single use anesthetic / lubricating gel slowly into urethra and leave for recommended manufacturer‘s time/ 5 minutes Remove and dispose of PPE to comply with waste management policy Decontaminate hands and apply new sterile single use disposable apron and gloves Arrange sterile towel to cover the surrounding area and maintain dignity Wrap sterile folded gauze around the penis and use to support the penis at a 90 degree angle Whilst maintaining an angle of 90 degrees, insert the catheter slowly into urethra. There may be a slight resistance at the external sphincter, asks the patient to cough or try to pass water and the catheter should pass easily. If resistance felt and unable to progress the catheter, stop and seek help, do not force. Insert catheter until urine has started to drain, then insert a further 5cm or almost up to the bifurcation. If Prefilled balloon: Release clamp of balloon and allow slow release of water.

To prevent cross infection and environmental contamination. To avoid vacuuming of bladder mucosa

18

19 20

21 22

23

Inadequate preparation of the urethral orifice is a major cause of infection following catheterization. To reduce risk of cross infection (DH 2005) To ensure full effectiveness of anesthetic/lubricant gel, to minimize discomfort and help prevent urethral trauma (Woodward 2005) To prevent cross infection and environment contamination To reduce the risk of transfer of transient micro - organisms on the health care workers hands To create sterile field and help prevent contamination This straightens out the first curve of the urethra; the gauze will contain any excess gel. To aid insertion This will help relax the pelvic floor and sphincters to aid insertion of the catheter.

24

To prevent trauma as there could be an obstruction. Ensures the catheter is within the bladder.

25

26

To retain catheter in bladder (Over inflation of the balloon may cause irritation of the bladder trigone inducing bladder spasm which in turn causes ―by passing‖ of urine around the urethral orifice)

Nursing Skill Procedures

75

27

28 29 30

10ml balloon catheters are now If not prefilled balloon: Slowly inflate the balloon with 10mls of recommended for urine routine use. sterile water according to manufacturer‘s instructions. Balloon inflation should be pain free. If the patient is experiencing any pain or discomfort during balloon inflation, the balloon might be positioned in the urethra. Deflate the balloon and advance the catheter a few more centimetres before trying again. Attach the catheter to a previously selected sterile drainage system or catheter valve. Measure the amount of urine To be aware of bladder capacity for patients who have presented with urinary retention. To monitor renal function and fluid balance Attach sterile drainage bag. To maintain closed circuit system Ensure the patient is comfortable and the genital area is dry On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE If the area is left wet or moist, secondary infection and skin irritation may occur To prevent cross infection and environmental contamination To remove any accumulation of transient skin flora that may have built up under gloves and possible contamination following removal of PPE To document event and have a permanent record for reference and monitoring of future care planning. Date of catheter change essential for safety of patient

31

32

33

34

Record information in patients health records • Catheter material/ expiry date • Charrière size and length • Balloon size • Batch number • Cleansing and anesthetic agents • Urine drainage system • Planned date for the next catheter change Reinforce management and ongoing care of catheter and contact details should any problems arise. Patient catheter booklet explained and updated with date of change Fully document all intervention and any follow up care required in the patients care plan Record patients/carers comments or any concerns following the procedure

Promotes independence and reduces incidence of problems/infections Promoting self-care

To record patients perspective. To provide safe and effective continuity of care

Nursing Skill Procedures

76

Procedure Checklist Male Urinary Catheterization
Check () Yes or No No 1 2 Procedure Introduce yourself and any colleagues involved at the contact. Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Explain procedure to patient, including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document decision in health records Ensure all equipment is gathered before commencing the procedure Check the catheter size and type against the written instructions in the patient‘s health records Check for any allergies e.g. latex or anaesthetic gels If not first catheterization ask the patient to empty their drainage bag. Decontaminate hands prior to procedure Open sterile dressing pack onto a clean field and place all sterile single use equipment required within sterile field including catheter and drainage system Use aseptic principle to ensure that only sterile single use items are used to keep exposure of the susceptible site to a minimum In the event the patient requires assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient into a supine position Decontaminate hands Apply sterile single use disposable apron and gloves Yes No Comments

3

4 5 6

7 8 9 10

11

12

13 14 15

Nursing Skill Procedures

77

16

17 18

19 20 21 22 23

24 25 26

If not first catheterization, remove existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Place a piece of sterile gauze around the catheter and slowly withdraw the catheter, whilst supporting the penis Retract foreskin (if not circumcised), clean around the Glans and urethral orifice with normal saline 0.9% Insert prescribed single use anesthetic / lubricating gel slowly into urethra and leave for recommended manufacturer‘s time/ 5 minutes Remove and dispose of PPE to comply with waste management policy Decontaminate hands and apply new sterile single use disposable apron and gloves Arrange sterile towel to cover the surrounding area and maintain dignity Wrap sterile folded gauze around the penis and use to support the penis at a 90 degree angle Whilst maintaining an angle of 90 degrees, insert the catheter slowly into urethra. There may be a slight resistance at the external sphincter, asks the patient to cough or try to pass water and the catheter should pass easily. If resistance felt and unable to progress the catheter, stop and seek help, do not force. Insert catheter until urine has started to drain, then insert a further 5cm or almost up to the bifurcation. If Prefilled balloon: Release clamp of balloon and allow slow release of water. If not prefilled balloon: Slowly inflate the balloon with 10mls of sterile water according to manufacturer‘s instructions. Balloon inflation should be pain free. If the patient is experiencing any pain or discomfort during balloon inflation, the balloon might be positioned in the urethra. Deflate the balloon and advance the catheter a few more centimetres before trying again. Attach the catheter to a previously selected sterile drainage system or catheter valve.

Nursing Skill Procedures

78

27 28 29 30

Measure the amount of urine Attach sterile drainage bag. Ensure the patient is comfortable and the genital area is dry On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Record information in patients health records • Catheter material/ expiry date • Charrière size and length • Balloon size • Batch number • Cleansing and anesthetic agents • Urine drainage system • Planned date for the next catheter change Reinforce management and ongoing care of catheter and contact details should any problems arise. Patient catheter booklet explained and updated with date of change Fully document all intervention and any follow up care required in the patients care plan Record patients/carers comments or any concerns following the procedure

31 32

33

34

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

79

Supra - Pubic Urinary Catheterization
No 1 Procedure Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Introduce yourself and any colleagues involved at the contact. Explain procedure to patient including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document decision in health records Rationale To avoid mistaken identity

2 3

To gain co-operation To ensure client understands procedure and enable patient to make informed decisions Use consent form 4 if appropriate It is the patients‘ choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment To prevent contamination of sterile equipment and to ensure the procedure is not commenced without all necessary equipment To reduce risk of using the incorrect device

4

5

Ensure all equipment is gathered before commencing the procedure

6

7 8 9

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Check the catheter size and type against the written instructions in the patient‘s health records Check for any allergies e.g. latex or To reduce risk of anaphylaxis anesthetic gels If not first catheterization ask the patient To avoid spillages of urine during procedure to empty their drainage bag. Decontaminate hands prior to procedure To reduce the risk of transfer of transient micro - organisms on the health care workers hands Open sterile dressing pack onto a clean To maintain asepsis and prevent field and place all sterile single use contamination of sterile equipment equipment required within sterile field including catheter and drainage system Use aseptic principle to ensure that only To prevent contamination of a susceptible sterile single use items are used to keep site by organisms that could cause infection exposure of the susceptible site to a minimum In the event the patient requires To prevent cross infection assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient into a supine To relax abdominal muscles position Decontaminate hands prior to procedure To reduce the risk of transfer of transient micro - organisms on the health care workers hands

Nursing Skill Procedures

80

15

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26 27

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Apply single use disposable apron and gloves Using dominant hand wrap a piece of sterile gauze around existing catheter at the point it enters the cystostomy To remove existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Slowly remove, noting length and angle of removed catheter. Place old catheter into non-sterile kidney dish Cleanse around the cystostomy site using normal saline 0.9% Observe the cystostomy site for discharge, inflammation or over granulation Insert prescribed single use anesthetic lubricating gel and wait for three to five minutes Remove and dispose of PPE to comply with waste management policy Decontaminate hands prior to procedure and apply new single use disposable sterile apron and gloves Visually compare length of new catheter with length of old catheter (the inner wrapper can be used to mark the length of catheter to be inserted) Gently insert new catheter to same length and angle as previous catheter (this should be done as soon as possible after removal of old catheter to maintain patency of the cystostomy). Wait for urine to appear Inflate balloon slowly with the volume of sterile water recommended for balloon size, observing the patient for signs of pain or discomfort. Attach sterile drainage bag. Apply keyhole dressing if required to catheter site Inspect the removed catheter, checking that it is intact, check for encrustation and its extent.

To prevent cross infection and environmental contamination The gauze will act as a marker to ensure correct length of new catheter inserted To avoid vacuuming of bladder mucosa

. For later comparison and inspection of the catheter To reduce risk of cross infection May indicate signs of infection that require intervention To ensure area is lubricated and anaesthetized To prevent cross infection and environmental contamination To reduce the risk of transfer of transient micro - organisms on the health care workers hands To ensure catheter inserted to the correct length Ensures catheter is inserted to client‘s own requirements

Confirms intravesical positioning Ensures intravesical inflation of balloon

30

To maintain closed circuit system Dressings should only be used if discharge present or patient finds it more comfortable with a dressing in place Encrustation is a sign of infection

Nursing Skill Procedures

81

31

On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands prior to procedure and apply new single use disposable sterile gloves Record information in patients health records • Catheter material/ expiry date • Charrière size and length • Balloon size • Batch number • Cleansing and anaesthetic agents • Urine drainage system • Planned date for the next catheter change Reinforce management and ongoing care of catheter and contact details should any problems arise. Patient catheter booklet explained and updated with date of change Fully document all intervention and any follow up care required in the patients care plan. Record patients/carers comments or any concerns following the procedure

To prevent cross infection and environmental contamination.

32

33

To reduce the risk of transfer of transient micro - organisms on the health care workers hands To document event and have a permanent record for reference and monitoring of future care planning.

34

Promotes independence and reduces incidence of problems/infections Promoting self-care

35

To record patients perspective. To provide safe and effective continuity of care

Nursing Skill Procedures

82

Procedure Checklist Supra - Pubic Urinary Catheterization
Check () Yes or No No 1 Procedure Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer Introduce yourself and any colleagues involved at the contact. Explain procedure to patient including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy Offer patient a chaperone and document decision in health records Ensure all equipment is gathered before commencing the procedure Check the catheter size and type against the written instructions in the patient‘s health records Check for any allergies e.g. latex or anesthetic gels If not first catheterization ask the patient to empty their drainage bag. Decontaminate hands prior to procedure Open sterile dressing pack onto a clean field and place all sterile single use equipment required within sterile field including catheter and drainage system Use aseptic principle to ensure that only sterile single use items are used to keep exposure of the susceptible site to a minimum In the event the patient requires assistance with personal hygiene apply single use disposable non-sterile apron and gloves Ask or assist the patient into a supine position Decontaminate hands prior to procedure Yes No Comments

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Nursing Skill Procedures

83

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28 29 30

Apply single use disposable apron and gloves Using dominant hand wrap a piece of sterile gauze around existing catheter at the point it enters the cystostomy To remove existing catheter attach empty syringe to catheter port. Do not draw back on the syringe; allow the catheter balloon to deflate using gravity. Slowly remove, noting length and angle of removed catheter. Place old catheter into non-sterile kidney dish Cleanse around the cystostomy site using normal saline 0.9% Observe the cystostomy site for discharge, inflammation or over granulation Insert prescribed single use anesthetic lubricating gel and wait for three to five minutes Remove and dispose of PPE to comply with waste management policy Decontaminate hands prior to procedure and apply new single use disposable sterile apron and gloves Visually compare length of new catheter with length of old catheter (the inner wrapper can be used to mark the length of catheter to be inserted) Gently insert new catheter to same length and angle as previous catheter (this should be done as soon as possible after removal of old catheter to maintain patency of the cystostomy). Wait for urine to appear Inflate balloon slowly with the volume of sterile water recommended for balloon size, observing the patient for signs of pain or discomfort. Attach sterile drainage bag. Apply keyhole dressing if required to catheter site Inspect the removed catheter, checking that it is intact, check for encrustation and its extent.

Nursing Skill Procedures

84

31

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34

35

On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands prior to procedure and apply new single use disposable sterile gloves Record information in patients health records • Catheter material/ expiry date • Charrière size and length • Balloon size • Batch number • Cleansing and anaesthetic agents • Urine drainage system • Planned date for the next catheter change Reinforce management and ongoing care of catheter and contact details should any problems arise. Patient catheter booklet explained and updated with date of change Fully document all intervention and any follow up care required in the patients care plan. Record patients/carers comments or any concerns following the procedure

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

85

Performing Surgical Dressing: Cleaning a Wound and Applying a Sterile Dressing
Definition: Sterile protective covering applied to a wound/incision, using aseptic technique with or without medication Purpose: 1) 2) 3) 4) 5) 6) 7) 8) To promote wound granulation and healing To prevent micro-organisms from entering wound To decrease purulent wound drainage To absorb fluid and provide dry environment To immobilize and support wound To assist in removal of necrotic tissue To apply medication to wound To provide comfort

Equipments: 1 2 3 4 5 6 7 8 9 10 11 No 1 2 3 4 5 6 7 8 Sterile gloves Gauze dressing set containing scissors and forceps Cleaning disposable gloves if available Cleaning basin (optional) as required Plastic bag for soiled dressings or bucket Waterproof pad or mackintosh Tape Surgical pads as required Additional dressing supplies as ordered, e.g. antiseptic ointments, extra dressings Acetone or adhesive remover (optional) Sterile normal saline (Optional) Procedure Explain the procedure to the client Assemble equipments Perform hand hygiene Check Dr‘s order for dressing change. Note whether drain is present. Close door and put screen or pull curtains. Position waterproof pad or mackintosh under the client if desired Assist client to comfortable position that provides easy access to wound area. Place opened, cuffed plastic bag near working area. Rationale Providing information fosters his/her cooperation and allays anxiety. Organization facilitates accurate skill performance To prevent the spread of infection The order clarifies type of dressing To provide privacy To prevent bed sheets from wetting body substances and disinfectant Proper positioning provides for comfort. Soiled dressings may be placed in disposal bag without contamination outside surfaces of bag. 1 1 1 1 1 1 1

Nursing Skill Procedures

86

9

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Loosen tape on dressing. Use adhesive remover if necessary. If tape is soiled, put on gloves. 1) Put on disposable gloves 2) Removed soiled dressings carefully in a clean to less clean direction. 3) Do not reach over wound. 4) If dressing is adhering to skin surface, it may be moistened by pouring a small amount of sterile saline or NS onto it. 5) Keep soiled side of dressing away from client‘s view. Assess amount, type, and odor of drainage. 1) Discard dressings in plastic disposable bag. 2) Pull off gloves inside out and drop it in the bag when your gloves were contaminated extremely by drainage. Cleaning wound: a. When you clean wearing sterile gloves: 1) Open sterile dressings and supplies on work area using aseptic technique. 2)Open sterile cleaning solution 3) Pour over gauze sponges in place container or over sponges placed in sterile basin. 4) Put on gloves. 5) Clean wound or surgical incision ① Clean from top to bottom or from center Outward ②Use one gauze square for each wipe, discarding each square by dropping into plastic bag. Do not touch bag with gloves. ③ Clean around drain if present, moving from center outward in a circular motion. ④ Use one gauze square for each circular motion. b. When you clean using sterile forceps: 1) Open sterile dressings and supplies on work area using aseptic technique. 2)Open sterile cleaning solution

It is easier to loosen tape before putting in gloves. 1. Using clean gloves protect the nurse when handling contaminated dressings. 2. Cautious removal of dressing(s) is more comfortable for client and ensures that drain is not removed if it is present. 3. Sterile saline provides for easier removal of dressing.

11 12

Wound healing process or presence of infection should be documented. Proper disposal dressings prevent the spread of microorganisms by contaminated dressings.

13

1. Supplies are within easy reach, and sterility is maintained. 2. Sterility of dressings and solution is maintained. 3. Cleaning is done from least to most contaminated area. 4. Previously cleaned area is re contaminated.

Nursing Skill Procedures

87

14 15 16 17

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3) Pour over gauze sponges or cottons in place container or over sponges or cottons placed in sterile basin. 4) Clean wound or surgical incision: Follow the former procedure using sterile gloves. Dry wound or surgical incision using gauze sponge and same motion. Apply antiseptic ointment by forceps if ordered. Apply a layer of dry, sterile dressing over wound using sterile forceps. If drainage is present: Use sterile scissors to cut sterile 4 X 4 gauze square to place under and around drain. Apply second gauze layer to wound site. Place surgical pad over wound as outer most layer if available. Remove gloves from inside out and discard the min plastic bag if you worn. Apply tape or existing tape to secure dressings 1) Perform hand hygiene. 2) Remove all equipments and disinfect them as needed. Make him/her comfortable. Document the following: 1) Record the dressing change 2) Note appearance of wound or surgical incision including drainage, odor, redness, and presence of pus and any complication. 3) Sign the chart Check dressing and wound site every shift.

Do not touch bag with sterile forceps to prevent contamination Moisture provides medium for growth of Micro organisms. Growth of microorganisms may be retarded and healing process improved. Primary dressing serves as a wick for drainage. Drainage is absorbed, and surrounding skin area is protected.

Additional layers provide for increased absorption of drainage. Wound is protected from microorganisms in environment. To prevent cross-infection Tape is easier to apply after gloves have been removed. To prevent the spread of infection

Documentation provides coordination of care.

Giving signature maintains professional accountability Close observation can find any complication as soon as possible.

Nursing Skill Procedures

88

Procedure Checklist Cleaning a Wound and Applying a Sterile Dressing
Check () Yes or No No 1 2 3 4 5 6 7 8 9 Procedure Yes Explain the procedure to the client Assemble equipments Perform hand hygiene Check Dr‘s order for dressing change. Note whether drain is present. Close door and put screen or pull curtains. Position waterproof pad or mackintosh under the client if desired Assist client to comfortable position that provides easy access to wound area. Place opened, cuffed plastic bag near working area. Loosen tape on dressing. Use adhesive remover if necessary. If tape is soiled, put on gloves. 1) Put on disposable gloves 2) Removed soiled dressings carefully in a clean to less clean direction. 3) Do not reach over wound. 4) If dressing is adhering to skin surface, it may be moistened by pouring a small amount of sterile saline or NS onto it. 5) Keep soiled side of dressing away from client‘s view. Assess amount, type, and odor of drainage. 1) Discard dressings in plastic disposable bag. 2) Pull off gloves inside out and drop it in the bag when your gloves were contaminated extremely by drainage. Cleaning wound: a. When you clean wearing sterile gloves: 1) Open sterile dressings and supplies on work area using aseptic technique. 2)Open sterile cleaning solution 3) Pour over gauze sponges in place container or over sponges placed in sterile basin. 4) Put on gloves. No Comments

10

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13

Nursing Skill Procedures

89

14 15 16 17

18 20 21 22 23

5) Clean wound or surgical incision ① Clean from top to bottom or from center Outward ②Use one gauze square for each wipe, discarding each square by dropping into plastic bag. Do not touch bag with gloves. ③ Clean around drain if present, moving from center outward in a circular motion. ④ Use one gauze square for each circular motion. b. When you clean using sterile forceps: 1) Open sterile dressings and supplies on work area using aseptic technique. 2)Open sterile cleaning solution 3) Pour over gauze sponges or cottons in place container or over sponges or cottons placed in sterile basin. 4) Clean wound or surgical incision: Follow the former procedure using sterile gloves. Dry wound or surgical incision using gauze sponge and same motion. Apply antiseptic ointment by forceps if ordered. Apply a layer of dry, sterile dressing over wound using sterile forceps. If drainage is present: Use sterile scissors to cut sterile 4 X 4 gauze square to place under and around drain. Apply second gauze layer to wound site. Place surgical pad over wound as outer most layer if available. Remove gloves from inside out and discard the min plastic bag if you worn. Apply tape or existing tape to secure dressings 1) Perform hand hygiene. 2) Remove all equipments and disinfect them as needed. Make him/her comfortable.

Nursing Skill Procedures

90

24

25

Document the following: 1) Record the dressing change 2) Note appearance of wound or surgical incision including drainage, odor, redness, and presence of pus and any complication. 3) Sign the chart Check dressing and wound site every shift.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

91

IV Cannulation
Definition: A venous cannula is inserted into a vein, primarily for the administration of intravenous fluids, for obtaining blood samples and for administering medicines Purpose: 1) To examine the condition of client and assess the present treatment Equipments: 1 Sterilized syringe 2 Sterilized needles 3 Tourniquet (1) 4 Blood collection tubes or specimen vials as ordered 5 Spirit swabs 6 Dry gauze 7 Disposable Gloves if available (1) 8 Adhesive tape or bandages 9 Sharps Disposal Container (1) 10 Steel Tray (1) 11 Ball point pen (1) No 1 2 Procedure Identify the patient. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure. Perform hand hygiene and put on gloves if available. Positioning 1)Make the client to be seated comfortably or supine position 2) Assist the client with the arm extended to form a straight-line from shoulder to wrist 3) Place a protective sheet under the arm.

1

1 1 1 1

Rationale This information must match the requisition. To perform once properly without any unnecessary venipuncture Organization facilitates accurate skill performance Providing explanation fosters his/her cooperation and allays anxiety To prevent the infection of spreading.

3

4 5 6

7

To make the position safe and comfortable is helpful to success venipuncture at one try. To prevent the spread of blood Check the client‘s requisition form, To assure the Dr‘s order with the correct blood collection tubes or vials and make client and to make the procedure smoothed the syringe-needle ready.

Nursing Skill Procedures

92

8

Select the appropriate vein for venipuncture.

The larger median cubital, basilica and cephalic veins are most frequently used, but other may be necessary and will become more prominent if the client closes his/her fist tightly.

9

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Applying the tourniquet: 1) Apply the tourniquet 3-4 inches ( 8 10 cm)above the collection site. Never leave the tourniquet on for over 1minute. 2) If a tourniquet is used for preliminary To prevent the venipunctue site from vein selection, release it and reapply touching the tourniquet and keep clear vision after two minutes. Tightening of more than 1 minute may bring erroneous results due to the change of some blood composition. Selection of the vein: 1) Feel the vein using the tip of the finger and detect the direction, depth and size of vein. 2) Massage the arm from wrist to To assure venipuncture at one try. elbow. If the vein is not prominent, try the other arm. Disinfect the selected site: To prevent the infection from venipuncture 1) Clean the puncture site by making a site smooth circular pass over the site with Disinfectant has the effect on drying the spirit swab, moving in an outward To prevent the site from contaminating spiral from the zone of penetration. 2) Allow the skin to dry before proceeding. 3) Do not touch the puncture site after cleaning. Inset the needle gently. Observe for To ensure that the needle is in the right place backflow of blood before pushing further into the vein If not successful try again for second To lesson pain on the punctured site time. Do not do it for the third time. If successful, attached the IV and flush. To avoid blood clot on the IV site Observe for the smooth flow of the solution Secure the site with tape. Make sure that To avoid moving the needle that can cause the exit point of the needle is clearly injury and to observe infection that may seen. occur Discard all used equipments in a proper bin. Clean tray and keep it for next use Put off gloves and perform hand To prevent the spread of infection hygiene.

Nursing Skill Procedures

93

Procedure Checklist IV Cannulation
Check () Yes or No No 1 2 Procedure Yes No Identify the patient. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure. Perform hand hygiene and put on gloves if available. Positioning 1)Make the client to be seated comfortably or supine position 2) Assist the client with the arm extended to form a straight-line from shoulder to wrist 3) Place a protective sheet under the arm. Check the client‘s requisition form, blood collection tubes or vials and make the syringe-needle ready. Select the appropriate vein for venipuncture. Applying the tourniquet: 1) Apply the tourniquet 3-4 inches ( 8 10 cm)above the collection site. Never leave the tourniquet on for over 1minute. 2) If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes. Selection of the vein: 1) Feel the vein using the tip of the finger and detect the direction, depth and size of vein. 2) Massage the arm from wrist to elbow. If the vein is not prominent, try the other arm. Disinfect the selected site: 1) Clean the puncture site by making a smooth circular pass over the site with the spirit swab, moving in an outward spiral from the zone of penetration. Comments

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Nursing Skill Procedures

94

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2) Allow the skin to dry before proceeding. 3) Do not touch the puncture site after cleaning. Inset the needle gently. Observe for backflow of blood before pushing further into the vein If not successful try again for second time. Do not do it for the third time. If successful, attached the IV and flush. Observe for the smooth flow of the solution Secure the site with tape. Make sure that the exit point of the needle is clearly seen. Discard all used equipments in a proper bin. Clean tray and keep it for next use Put off gloves and perform hand hygiene.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

95

Starting an Intra-Venous Infusion
Definition: Starting intra-venous infusion is a process that gives insertion of Intra-venous catheter for IV therapy Purpose: 1) To give nutrient instead of oral route 2) To provide medication by vein continuously Equipments required: 1 I.V. solution prescribed 2 I.V. infusion set/ IV. Tubing 3 IV. Catheter or butterfly needle in appropriate size 4 Spirit swabs 5 Adhesive tape 6 Disposable gloves if available 7 IV. Stand 8 Arm board, if needed, especially for infant 9 Steel Tray 10 Kidney tray

1 1

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1 1

No 1 2

Care Action Assemble all equipments and bring to bedside. Check I.V. solution and medication additives with Dr.‘s order. Explain procedure to the client

3 4 5

Perform hand hygiene Prepare I.V. solution and tubing: 1)Maintain aseptic technique when opening sterile packages and I.V. solution 2) Clamp tubing, uncap spike, and insert This punctures the seal in the I.V. bag. into entry site on bag as manufacturer directs 3) Squeeze drip chamber and allow it to Suction effects cause to move into drip fill at least one-third to halfway. chamber. Also prevents air from moving down the tubing 4) Remove cap at end of tubing, release This removes air from tubing that can, in clamp, allow fluid to move through larger amounts, act as an air embolus tubing. Allow fluid to flow until all air bubbles have disappeared. 5) Close clamp and recap end of tubing, To maintain sterility maintaining sterility of set up.

Rationale Having equipment available saves time and facilitates accurate skill performance Ensures that the client receives the correct I.V. solution and medication as ordered by Dr. Explanation allays his/her anxiety and fosters his/her cooperation To prevent the spread of infection This prevents spread of microorganisms

Nursing Skill Procedures

96

6) If an electric device is to be used, follow manufacturer‘s instructions for inserting tubing and setting infusion rate. 7)Apply label if medication was added to container

This ensures correct flow rate and proper use of equipment

6

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8) Place time-tape (or adhesive tape) on container as necessary and hang on I.V. stand Preparation the position: 1) Have the client in supine position or comfortable position in bed. 2) Place protective pad under the client‘s arm. Selection the site for venipuncture: 1) Select an appropriate site and palpate accessible veins 2) Apply a tourniquet 5-6 inches above the venipuncture site to obstruct venous blood flow and distend the vein. 3) Direct the ends of the tourniquet away from the site of injection. 4) Check to be sure that the radial pulse is still present

This provides for administration of correct Solution with prescribed medication or additive. Pharmacy may have added medication and applied label This permits immediate evaluation of I.V. according to schedule Mostly the supine position permits either arm to be used and allows for good body alignment

The selection of an appropriate site decreases discomfort for the client and possible damage to body tissues Interrupting the blood flow to the heart causes the vein to distend. Distended veins are easy to see The end of the tourniquet could contaminate the area of injection if directed toward the site of injection. Too much tight the arm makes the client discomfort. Interruption of the arterial flow impedes venous filling. Contraction of the muscle of the forearm forces blood into the veins, thereby distending them further. To reduce several puncturing Lowering the arm below the level of the heart, tapping the vein, and applying warmth help distend veins by filling them with blood.

8

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Palpation the vein 1) Ask the client to open and close his/her fist. 2)Observe and palpate for a suitable vein 3) If a vein cannot be felt and seen, do the following: a. Release the tourniquet and have the client lower his/her arm below the level of the heart to fill the veins. Reapply tourniquet and gently over the intended vein to help distend it b. Tap the vein gently c. Remove tourniquet and place warmed-moist compress over the intended vein for 10-15 minutes. Put on clean gloves if available.

Care must be used when handling any blood or body fluids to prevent transmission of HIV and other blood-born infectious disease

Nursing Skill Procedures

97

10

Cleanse the entry site with an antiseptic solution (such as spirit) according to hospital policy. a. Use a circular motion to move from the center to outward for several inches b. Use several motions with same direction as from the upward to the downward around injection site approximate 5-6 inches Holding the arm with un-dominant hand a. Place an un-dominant hand about 1 or 2 inches below entry site to hold the skin taut against the vein. b. Place an un-dominant hand to support the forearm from the back side ❖ Nursing Alert❖ Avoid touching the prepared site.

Cleansing that begins at the site of entry and moves outward in a circular motion carries organisms away from the site of entry. Organisms on the skin can be introduced into the tissues or blood stream with the needle.

11

Pressure on the vein and surrounding tissues helps prevent movement of the vein as the needle or catheter is being inserted.

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Puncturing the vein and withdrawing blood: 1) Enter the skin gently with the catheter held by the hub in the dominant hand, bevel side up, at a 15-30 degree angle. 2) The catheter may be inserted from directly over the vein or the side of the vein. 3) While following the course of the vein, advance the needle or catheter into the vein. 4) A sensation can be felt when the needle enters the vein. 5)When the blood returns through the lumen of the needle or the flashback chamber of the catheter, advance either device 1/8 to 1/4 inch farther into the vein. 6) A catheter needs to be advanced until hub is at the venipuncture site Connecting to the tube and stabilizing the catheter on the skin: 1) Release the tourniquet. 2) Quickly remove protective cap from the I.V. tubing 3)Attach the tubing to the catheter or needle 4) Stabilize the catheter or needle with non dominant hand

The needle entry site and catheter must remain free of contamination from un-sterile hands This technique allows needle or catheter to enter the vein with minimum trauma and deters passage of the needle through the vein

The tourniquet causes increased venous pressure resulting in automatic backflow.

Having the catheter placed well into the vein helps to prevent dislodgement

The catheter which immediately is connected to the tube causes minimum bleeding and patency of the vein is maintained

Nursing Skill Procedures

98

14

Starting flow 1) Release the clamp on the tubing 2) Start flow of solution promptly 3) Examine the drip of solution and the issue around the entry site for sign of infiltration Fasten the catheter and applying the dressing: 1) Secure the catheter with narrow nonallergenic tape 2) Place strictly sided-up under the hub and crossed over the top of the hub

Blood clots readily if I.V. flow is not maintained. If catheter accidentally slips out of vein, solution will accumulate and infiltrate into surrounding tissue Non-allergenic tape is less likely to tear fragile skin

15

3) Loop the tubing near the site of entry 16 17 Bring back all equipments and dispose in proper manner. If necessary, anchor arm to an arm board for support

The weight of tubing is enough to pull it out of the vein if it is not well anchored. There is various ways to anchor the hub. You should follow agency /hospital policy. To prevent the catheter from removing accidentally To prepare for the next procedure. An arm board helps to prevent change in the position of the catheter in the vein. Site protectors also will be used to protect the I.V. site. Dr. prescribed the rate of flow or the amount of solution in day as required to the client‘s condition Some medications are given very less amount. You may use infusion pump to maintain the flow rate This ensures continuity of care

18

Adjust the rate of I.V. solution flow according to Dr.‘s order

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Document the procedure including the time, site , catheter size, and the client‘s response Return to check the flow rate and observe for infiltration

To find any abnormalities immediately

❖ Nursing Alert❖ You should have special consideration for the elderly and infant. To Older adults Avoid vigorous friction at the insertion site and using too much alcohol.(Rationale: Both can traumatize fragile skin and veins in the elderly) To Infant and Children Hand insertion sites should not be the first choice for children. (Rationale: Nerve endings are more very close to the surface of the skin and it is more painful)

Nursing Skill Procedures

99

Procedure Checklist Starting an Intra-Venous Infusion
Check () Yes or No No 1 2 3 4 5 Care Action Yes No Assemble all equipments and bring to bedside. Check I.V. solution and medication additives with Dr.‘s order. Explain procedure to the client Perform hand hygiene Prepare I.V. solution and tubing: 1)Maintain aseptic technique when opening sterile packages and I.V. solution 2) Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs 3) Squeeze drip chamber and allow it to fill at least one-third to halfway. 4) Remove cap at end of tubing, release clamp, allow fluid to move through tubing. Allow fluid to flow until all air bubbles have disappeared. 5) Close clamp and recap end of tubing, maintaining sterility of set up. 6) If an electric device is to be used, follow Manufacturer‘s instructions for inserting tubing and setting infusion rate. 7)Apply label if medication was added to container 8) Place time-tape (or adhesive tape) on container as necessary and hang on I.V. stand Preparation the position: 1) Have the client in supine position or comfortable position in bed. 2) Place protective pad under the client‘s arm. Selection the site for venipuncture: 1) Select an appropriate site and palpate accessible veins 2) Apply a tourniquet 5-6 inches above the venipuncture site to obstruct venous blood flow and distend the vein. 3) Direct the ends of the tourniquet away from the site of injection. 4) Check to be sure that the radial pulse is still present Comments

6

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Nursing Skill Procedures

100

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Palpation the vein 1) Ask the client to open and close his/her fist. 2)Observe and palpate for a suitable vein 3) If a vein cannot be felt and seen, do the following: a. Release the tourniquet and have the client lower his/her arm below the level of the heart to fill the veins. Reapply tourniquet and gently over the intended vein to help distend it b. Tap the vein gently c. Remove tourniquet and place warmed-moist compress over the intended vein for 10-15 minutes. Put on clean gloves if available. Cleanse the entry site with an antiseptic solution (such as spirit) according to hospital policy. a. Use a circular motion to move from the center to outward for several inches b. Use several motions with same direction as from the upward to the downward around injection site approximate 5-6 inches Holding the arm with un-dominant hand a. Place an un-dominant hand about 1 or 2 inches below entry site to hold the skin taut against the vein. b. Place an un-dominant hand to support the forearm from the back side ❖ Nursing Alert❖ Avoid touching the prepared site. Puncturing the vein and withdrawing blood: 1) Enter the skin gently with the catheter held by the hub in the dominant hand, bevel side up, at a 15-30 degree angle. 2) The catheter may be inserted from directly over the vein or the side of the vein. 3) While following the course of the vein, advance the needle or catheter into the vein. 4) A sensation can be felt when the needle enters the vein.

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5)When the blood returns through the lumen of the needle or the flashback chamber of the catheter, advance either device 1/8 to 1/4 inch farther into the vein. 6) A catheter needs to be advanced until hub is at the venipuncture site Connecting to the tube and stabilizing the catheter on the skin: 1) Release the tourniquet. 2) Quickly remove protective cap from the I.V. tubing 3)Attach the tubing to the catheter or needle 4) Stabilize the catheter or needle with non dominant hand Starting flow 1) Release the clamp on the tubing 2) Start flow of solution promptly 3) Examine the drip of solution and the issue around the entry site for sign of infiltration Fasten the catheter and applying the dressing: 1) Secure the catheter with narrow nonallergenic tape 2) Place strictly sided-up under the hub and crossed over the top of the hub 3) Loop the tubing near the site of entry

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Bring back all equipments and dispose in proper manner. If necessary, anchor arm to an arm board for support Adjust the rate of I.V. solution flow according to Dr.‘s order Document the procedure including the time, site , catheter size, and the client‘s response Return to check the flow rate and observe for infiltration

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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Maintenance of I.V. System
Definition: Maintenance of I.V. system is defined as routine care to keep well condition of I.V. therapy Purpose: 1) To protect injection site from infection 2) To provide safe IV therapy 3) To make the client comfort with IV therapy 4) To distinguish any complications as soon as possible Equipments: 1 Steel Tray 2 Spirit swab 3 Dry gauze or cotton 4 Adhesive tape 5 IV infusion set if required 6 Chart, client‘s record 7 Kidney tray No Procedure 1 Make at least hourly checks of the rate, tubing connections, and amount and type of solution present. If using an electronic infusion device (pump or controller), check that all settings are correct. 2 Watch for adverse reactions. One such problem is infiltration, in which the I.V. solution infuses into tissues instead of the vein. Check the insertion site for redness, swelling, or tenderness hourly. Document that you have checked the site. 3 Report any difficulty at once. The doctor may order the I.V. line to be discontinued or to be irrigated. 4 Safeguard the site and be aware of tubing and pump during transfers, ambulation, or other activities. Rationale Regular checking give proper amount

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Keen observation prevent any complications with I.V.

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Change the I.V. dressing every 72 hours and if it Becomes wet or contaminated with drainage. Wear gloves when changing dressings or tubing.

If a controllers is being used, remember this System works on the principle of gravity. If the bag of solution is too low, blood will flow up the tubing and may cause complications. Change of the dressing with wet or contamination of drainage prevents infection in the I.V. insertion site. Wear gloves prevents from infection. The few times that nurse handle dressings, the lower the client's risk of infection.

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Be sure to double-check all clamps when changing tubing, adding medications, or removing I.V. tubing (from a pump or controller). If the rate of flow is not regulated properly, it could result in the client receiving a bolus of mediation. Always check to make sure medications, solutions, or additives are compatible before adding them to existing solutions. Protect the I.V. site from getting wet or soiled. If the client will be away from the nursing unit for tests or procedures, be sure there is adequate solution to be infused while he/she is gone.

Double -check system prevents from medical error.

The rate of flow regulated prevent the client From overdose. Checking before adding avoids having incompatibility.

Protection of the I.V. site reduces the possibility of infection. It will avoid having shortage of IV. or making Coagulation while having tests or procedures.

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Procedure Checklist Maintenance of I.V. System
Check () Yes or No No 1 Procedure Yes No Comments Make at least hourly checks of the rate, tubing connections, and amount and type of solution present. If using an electronic infusion device (pump or controller), check that all settings are correct. 2 Watch for adverse reactions. One such problem is infiltration, in which the I.V. solution infuses into tissues instead of the vein. Check the insertion site for redness, swelling, or tenderness hourly. 3 Report any difficulty at once. The doctor may order the I.V. line to be discontinued or to be irrigated. 4 Safeguard the site and be aware of tubing and pump during transfers, ambulation, or other activities. 5 Change the I.V. dressing every 72 hours and if it Becomes wet or contaminated with drainage. 6 Wear gloves when changing dressings or tubing. 7 Be sure to double-check all clamps when changing tubing, adding medications, or removing I.V. tubing (from a pump or controller). 8 If the rate of flow is not regulated properly, it could result in the client receiving a bolus of mediation. 9 Always check to make sure medications, solutions, or additives are compatible before adding them to existing solutions. 10 Protect the I.V. site from getting wet or soiled. 11 If the client will be away from the nursing unit for tests or procedures, be sure there is adequate solution to be infused while he/she is gone. Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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Maintenance of I.V. System: Changing of I.V. system
No 1 2 Procedure Check I.V. solution Determine the compatibility of all I.V. fluids and additives by consulting appropriate literature. Determine client's understanding of need for continued I.V. therapy. Assess patency of current I.V. access site. Have next solution prepared and accessible (at least 1 hour) before needed. Check that solution is correct and properly labeled. Check solution expiration date and for presence of precipitate and discoloration. Prepare client and family be explaining the procedure, its purpose, and what is expected of client. Be sure drip chamber is at least half full. From old to new solution. Perform hand hygiene Prepare new solution for changing. If using plastic bag, remove protective cover from I.V. tubing port. If using glass bottle, remove metal cap. Move roller clam to stop flow rate. Remove old I.V. fluid container from I.V. stand. Quickly remove spike from old solution bag or bottle and, without touching tip, insert spike into new bag or bottle. Hang new bag or bottle of solution on I.V. stand. Check for air in tubing. If bubbles form, they can be removed by closing the roller clamp, stretching the tubing downward, and tapping the tubing with the finger. Make sure drip chamber is one-third to one-half full. If the drip chamber is too full, pinch off tubing below the drip chamber, invert the container, squeeze the drip chamber, hang, hang up the bottle, and replace the tubing. Rationale Ensure that correct solution will be used. Incompatibilities may lead to precipitate formation and can cause physical, chemical, and therapeutic client changes. Reveals need for client instruction. If patency is occluded, a new I.V. access site may be needed. Notify a doctor. Adequate planning reduces risk of clot formation in vein caused by empty I.V. bag. Checking prevents medication error.

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Appropriate explanation decreases his/her anxiety and promote cooperation Half full in Chamber provides fluids to vein while bag is changed. Hand hygiene reduces transmission of microorganisms. It permits quick, smooth and organized change

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It Prevents solution removing in drip chamber from emptying while changing solutions Brings work to nurse's eye level. Reduces risk of solution in drip chamber running dry and maintains sterility.

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Gravity assists delivery of fluid into drip chamber. Reduces risk of air embolus.

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Reduces risk of air entering tubing.

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Regulate flow to prescribed rate. Place on bag. (Mark time on label tape or on glass bottle). Observe client for signs of over hydration or dehydration to determine response to I.V. fluid therapy. Observe I.V. system for patency and development of complications.

Deliver I.V. fluid as ordered. Ink from markers may leach through polyvinyl chloride containers. Provides ongoing evaluation of client's fluid and electrolyte status. Provides ongoing evaluation of I.V. system.

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Procedure Checklist Maintenance of I.V. system: Changing of I.V. system
Check () Yes or No No 1 2 Procedure Check I.V. solution Determine the compatibility of all I.V. fluids and additives by consulting appropriate literature. Determine client's understanding of need for continued I.V. therapy. Assess patency of current I.V. access site. Have next solution prepared and accessible (at least 1 hour) before needed. Check that solution is correct and properly labeled. Check solution expiration date and for presence of precipitate and discoloration. Prepare client and family be explaining the procedure, its purpose, and what is expected of client. Be sure drip chamber is at least half full. From old to new solution. Perform hand hygiene Prepare new solution for changing. If using plastic bag, remove protective cover from I.V. tubing port. If using glass bottle, remove metal cap. Move roller clam to stop flow rate. Remove old I.V. fluid container from I.V. stand. Quickly remove spike from old solution bag or bottle and, without touching tip, insert spike into new bag or bottle. Hang new bag or bottle of solution on I.V. stand. Check for air in tubing. If bubbles form, they can be removed by closing the roller clamp, stretching the tubing downward, and tapping the tubing with the finger. Make sure drip chamber is one-third to one-half full. If the drip chamber is too full, pinch off tubing below the drip chamber, invert the container, squeeze the drip chamber, hang, hang up the bottle, and replace the tubing. Regulate flow to prescribed rate. Yes No Comments

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Place on bag. (Mark time on label tape or on glass bottle). Observe client for signs of over hydration or dehydration to determine response to I.V. fluid therapy. Observe I.V. system for patency and development of complications.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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Collecting Specimen
You always should follow the principle steps as the following: 1) Label specimen tubes or bottles with the client‘s name, age, sex, date, time, inpatient no. and other data if needed before collecting the specimen. 2) Always perform hand hygiene before and after collecting any specimen. 3) Always observe body substance precautions when collecting specimens 4) Collect the sample according your hospital/agent policy and procedure. 5) Clean the area involved for sample collection 6) Maintain the sterile technique if needed for sample or culture. 7) Transport the specimen to laboratory immediately 8) Be sure specimen is accompanied by specimen form or appropriate order form 9) Record the collection and forwarding of the sample to laboratory on the client‘s record

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Collecting Blood Specimen a. Performing Venipuncture
Definition: Venipuncture is using a needle to withdraw blood from a vein, often from the inside surface of the forearm near the elbow. Purpose: 1) To examine the condition of client and assess the present treatment 2) To diagnose disease Equipments: 1 Laboratory form 2 Sterilized syringe 3 Sterilized needles 4 Tourniquet 5 Blood collection tubes or specimen vials as ordered 6 Spirit swabs 7 Dry gauze 8 Disposable Gloves if available 9 Adhesive tape or bandages 10 Sharps Disposal Container 11 Steel Tray 12 Ball point pen No 1 Procedure Identify the patient. Outpatient are called into the phlebotomy area and asked their name and date of birth. In patient are identified by asking their name and date of birth. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure. Perform hand hygiene and put on gloves if available. Positioning 1)Make the client to be seated comfortably or supine position 2) Assist the client with the arm extended to form a straight-line from shoulder to wrist 3) Place a protective sheet under the arm. Rationale This information must match the requisition.

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To perform once properly without any unnecessary venipuncture Organization facilitates accurate skill performance Providing explanation fosters his/her cooperation and allays anxiety To prevent the infection of spreading.

To make the position safe and comfortable is helpful to success venipuncture at one try. To prevent the spread of blood

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Check the client‘s requisition form, blood collection tubes or vials and make the syringe-needle ready. Select the appropriate vein for venipuncture.

To assure the Dr‘s order with the correct client and to make the procedure smoothed The larger median cubital, basilica and cephalic veins are most frequently used, but other may be necessary and will become more prominent if the client closes his/her fist tightly.

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Applying the tourniquet: 1) Apply the tourniquet 3-4 inches ( 8 10 cm)above the collection site. Never leave the tourniquet on for over 1minute. 2) If a tourniquet is used for preliminary To prevent the venipunctue site from vein selection, release it and reapply touching the tourniquet and keep clear after two minutes. vision.Tightening of more than 1 minute may bring erroneous results due to the change of some blood composition. Selection of the vein: 1) Feel the vein using the tip of the finger and detect the direction, depth and size of vein. 2) Massage the arm from wrist to To assure venipuncture at one try. elbow. If the vein is not prominent, try the other arm. Disinfect the selected site: To prevent the infection from venipuncture 1) Clean the puncture site by making a site smooth circular pass over the site with Disinfectant has the effect on drying the spirit swab, moving in an outward To prevent the site from contaminating spiral from the zone of penetration. 2) Allow the skin to dry before proceeding. 3) Do not touch the puncture site after cleaning. 4) After blood is drawn the desired To avoid making ecchymoma amount, release the tourniquet and ask The normal coagulation time is 2the client to open his/her fist. 5minutes. 5) Place dry gauze over the puncture site and remove the needle. 6) Immediately apply slight pressure. Ask the client to apply pressure for at least 2minutes. 7) When bleeding stops, apply a fresh bandage or gauze with tape. 1) Transfer blood drawn into A delay could cause improper coagulation appropriate blood specimen bottles or tubes as soon as possible using a needless syringe. 2) The container or tube containing an Do not shake or mix vigorously. additive should be gently inverted 5-8 times or shaking the specimen container by making figure of 8.

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Dispose of the syringe and needle as a unit into an appropriate sharps container. Label all tubes or specimen bottles with client name, age, sex, inpatient no., date and time. Send the blood specimen to the laboratory immediately along with the laboratory order form. Replace equipments and disinfects materials if needed. Put off gloves and perform hand hygiene.

To prevent the spread of infection

To prevent the blood tubes or bottles from misdealing. To avoid misdealing and taking erroneous results To prepare for the next procedure and prevent the spread of infection To prevent the spread of infection

❖ NURSINGALERT❖ Factors to consider in site selection:  Extensive scarring or healed burn areas should be avoided.  Specimens should not be obtained from the arm on the same side as a mastectomy.  Avoid areas of hematoma  If an I.V. is in place, samples may be obtained below but NEVER above the I.V. site.  Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.  Allow10-15minutes after a transfusion is completed before obtaining a blood sample.  Safety  Observe universal (standard) precaution safety precautions. Observe all applicable isolation procedures.  Needle are never recapped, removed, broken or bent after phlebotomy procedure.  Gloves are to be discarded in the appropriate container immediately after the procedure.  Contaminated surfaces must be cleaned with freshly prepared 10%bleach solution. All surfaces are cleaned daily with bleach.  In the case of an accidental needle-stick, immediately wash the area with an antibacterial soap  I f a blood sample is not available, Reposition the needle.  Loosen the tourniquet  Probing is not recommended.  A patient should never be stuck more than twice unsuccessfully by a same staff. The supervisor or a senior staff should be called to assess the client.

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Procedure Checklist a. Performing Venipuncture
Check () Yes or No No 1 Procedure Identify the patient. Outpatient are called into the phlebotomy area and asked their name and date of birth. In patient are identified by asking their name and date of birth. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure. Perform hand hygiene and put on gloves if available. Positioning 1)Make the client to be seated comfortably or supine position 2) Assist the client with the arm extended to form a straight-line from shoulder to wrist 3) Place a protective sheet under the arm. Check the client‘s requisition form, blood collection tubes or vials and make the syringe-needle ready. Select the appropriate vein for venipuncture. Applying the tourniquet: 1) Apply the tourniquet 3-4 inches ( 8 10 cm)above the collection site. Never leave the tourniquet on for over 1minute. 2) If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes. Selection of the vein: 1) Feel the vein using the tip of the finger and detect the direction, depth and size of vein. 2) Massage the arm from wrist to elbow. If the vein is not prominent, try the other arm. Yes No Comments

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Disinfect the selected site: 1) Clean the puncture site by making a smooth circular pass over the site with the spirit swab, moving in an outward spiral from the zone of penetration. 2) Allow the skin to dry before proceeding. 3) Do not touch the puncture site after cleaning. 4) After blood is drawn the desired amount, release the tourniquet and ask the client to open his/her fist. 5) Place dry gauze over the puncture site and remove the needle. 6) Immediately apply slight pressure. Ask the client to apply pressure for at least 2minutes. 7) When bleeding stops, apply a fresh bandage or gauze with tape. 1) Transfer blood drawn into appropriate blood specimen bottles or tubes as soon as possible using a needless syringe. 2) The container or tube containing an additive should be gently inverted 5-8 times or shaking the specimen container by making figure of 8. Dispose of the syringe and needle as a unit into an appropriate sharps container. Label all tubes or specimen bottles with client name, age, sex, inpatient no., date and time. Send the blood specimen to the laboratory immediately along with the laboratory order form. Replace equipments and disinfects materials if needed. Put off gloves and perform hand hygiene.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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b. Assisting in Obtaining Blood for Culture
Definition: Collecting of blood specimen for culture is a sterile procedure to obtain blood specimen. Sterile technique is used in whole of the procedure. Purpose: 1) To identify s disease-causing organisms 2) To detect the right antibiotics to kill the particular microorganisms Equipments: 1 Laboratory form 2 Sterilized syringes (10mL) 3 Sterilized needles 4 Tourniquet 5 Blood culture bottles or sterile tubes containing a sterile anticoagulant solution as required 6 Disinfectant: Povidon-iodine or spirit swabs 7 Dry gauze 8 Disposable gloves if available 9 Adhesive tape or bandages 10 Sharps Disposal Container 11 Steel Tray 12 Ball point pen

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❖ Nursing Alert❖ Your role is that of assistant. You are responsible to notify the proper client when the culture is to be done. Use the following actions in assisting with blood cultures: No 1 2 Procedure Identify the patient. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure Label all tubes or specimen bottles with client name, age, sex, inpatient no., date and time. Perform hand hygiene and put on gloves Protect the bed with a pad under the client‘s arm. Place the arm with proper position and disinfect around the injection site approximate 2-3 inches Rationale This information must match the requisition. To perform once properly without any unnecessary collecting of blood Organization facilitates accurate skill performance Providing explanation fosters his/her cooperation and allays anxiety To prevent the blood tubes or bottles from misdealing. To prevent the infection of spreading. To prevent the bed of escaping or wetting the disinfectant and blood. To prevent unnecessary injury and protect of entering organisms from the skin surfaces

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While puncturing: 1)Assist the person who is drawing blood 2) Confirm the amount 3) After obtaining sufficient blood specimen, receive and place the specimen into the specimen container with strict sterile technique. 4) Close the container promptly and tightly After puncturing: 1) Place a sterile gauze pad and folded into a compress tightly over the site 2) Secure firmly with tape 3) Check the stop of bleeding a few minutes later Dispose of the syringe and needle as a unit into an appropriate sharps container. Send the specimen to the laboratory immediately along with the laboratory order form. Replace equipments and disinfects materials if needed. Put off gloves and perform hand hygiene. Document the procedure in the designated place and mark it off on the Kardex.

Sometimes the blood may be placed into two or more tubes or bottles. To secure the sterilized condition of container

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To make sure all bleeding has stopped

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To prevent the spread of infection

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To avoid misdealing and taking erroneous results To prepare for the next procedure and prevent the spread of infection and To prevent the spread of infection To avoid duplication Documentation provides coordination of care

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Procedure Checklist b. Assisting in Obtaining Blood for Culture
Check () Yes or No No 1 2 Procedure Identify the patient. Reassure the client that the minimum amount of blood required for testing will be drawn. Assemble the necessary equipment appropriate to the client's physical characteristics. Explain to the client about the purpose and the procedure Label all tubes or specimen bottles with client name, age, sex, inpatient no., date and time. Perform hand hygiene and put on gloves Protect the bed with a pad under the client‘s arm. Place the arm with proper position and disinfect around the injection site approximate 2-3 inches While puncturing: 1)Assist the person who is drawing blood 2) Confirm the amount 3) After obtaining sufficient blood specimen, receive and place the specimen into the specimen container with strict sterile technique. 4) Close the container promptly and tightly After puncturing: 1) Place a sterile gauze pad and folded into a compress tightly over the site 2) Secure firmly with tape 3) Check the stop of bleeding a few minutes later Dispose of the syringe and needle as a unit into an appropriate sharps container. Send the specimen to the laboratory immediately along with the laboratory order form. Yes No Comments

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Replace equipments and disinfects materials if needed. Put off gloves and perform hand hygiene. Document the procedure in the designated place and mark it off on the Kardex.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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Collecting Urine Specimen
Definition: Urinalysis, in which the components of urine are identified, is part of every client assessment at the beginning and during an illness. Purpose: 1) To diagnose illness 2) To monitor the disease process 3) To evaluate the efficacy of treatment ❖Nursing Alert  Label specimen containers or bottles before the client voids (Rationale: Reduce handling after the container or bottle is contaminated.)  Note on the specimen label if the female client is menstruating at that time (Rationale: One of the tests routinely performed is a test for blood in the urine. If the female client is menstruating at the time a urine specimen is taken, a false-positive reading for blood will be obtained. )  To avoid contamination and necessity of collecting another specimen, soap and water cleansing of the genitals immediately preceding the collection of the specimen is supported.(Rationale: Bacteria are normally present on the labia or penis and the perineum and in the anal area.)  Maintain body substances precautions when collecting all types of urine specimen.(Rationale: To maintain safety.)  Wake a client in the morning to obtain a routine specimen.(Rationale: If all specimen are collected at the same time, the laboratory can establish a baseline. And also this voided specimen usually represents that was collecting in the bladder all night. )  Be sure to document the procedure in the designated place and mark it off on the Kardex.(Rationale: To avoid duplication.)

a. Collecting a single voided specimen
Equipments required: 1 Laboratory form 2 Clean container with lid or cover: wide-mouthed container is recommended 3 Bedpan or urinal : as required 4 Disposable gloves : if available 5 Toilet paper as required No 1 2 Procedure Explain the procedure

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Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Perform hand hygiene and put on gloves To prevent the spread of infection

Rationale Providing information fosters his/her cooperation Organization facilitates accurate skill performance Ensure that the specimen collecting is correct Ensure correct identification and avoid mistakes

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Instruct the client to void in a clean To prevent cross-contamination receptacle Remove the specimen immediately after Substances in urine decompose when the client has voided exposed to air. Decomposition may alter the test results Pour about 10-20 mL of urine into the Ensure the client voids enough amount of the labeled specimen bottle or container and urine for the required tests cover the bottle or container Covering the bottle retards decomposition and it prevents added contamination. Dispose of used equipment or clean To prevent the spread of infection them. Remove gloves and perform hand hygiene. Send the specimen bottle or container to Organisms grow quickly at room temperature the laboratory immediately with the specimen form. Document the procedure in the To avoid duplication designated place And mark it off on the Kardex Documentation provides coordination of care

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Procedure Checklist a. Collecting a single voided specimen
Check () Yes or No No 1 2 Procedure Yes Explain the procedure Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Perform hand hygiene and put on gloves Instruct the client to void in a clean receptacle Remove the specimen immediately after the client has voided Pour about 10-20 mL of urine into the labeled specimen bottle or container and cover the bottle or container Dispose of used equipment or clean them. Remove gloves and perform hand hygiene. Send the specimen bottle or container to the laboratory immediately with the specimen form. Document the procedure in the designated place And mark it off on the Kardex No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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b. Collecting a 24-hour Urine Specimen
Definition: Collection of a 24-hour urine specimen is defined as the collection of all the urine voided in 24 hours, without any spillage of wastage. Purpose: 1) To detect kidney and cardiac diseases or conditions 2) To measure total urine component Equipments required: 1 Laboratory form 2 Bedpan or urinal 3 24 hours collection bottle with lid or cover 4 Clean measuring jar 5 Disposable gloves if available 6 Paper issues if available 7 Ballpoint pen No 1 2 Procedure Explain the procedure Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Instruct the client: 1) Before beginning a 24 hour urine collection, ask the client to void completely. 2) Document the starting time of a-24 hour urine collection on the specimen form and nursing record. 3) Instruct the client to collect all the urine into a large container for the next 24 hours. 4) In the exact 24 hours later, ask the client to void And pour into the large container. 5) Measure total amount of urine and record it on the specimen form and nursing record. 6)Document the time when finished the collection

1 1 1 1 Rationale Providing information fosters his/her cooperation Organization facilitates accurate skill performance Ensure that the specimen collecting is correct Ensure correct identification and avoid mistakes To measure urinal component and assess the function of kidney and cardiac function accuracy The entire collected urine should be stored in a covered container in a cool place.

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Sending the specimen: 1) Perform hand hygiene and put on gloves if available. 2)Mix the urine thoroughly 3) Collect some urine as required or all the urine in a clean bottle with lid. 4) Transfer it to the laboratory with the specimen form immediately.

To prevent the contamination

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Dispose of used equipment or clean them. Remove gloves and perform hand hygiene. Document the procedure in the designated place and mark it off on the Kardex.

Ensure the client voids enough amount of the urine for the required tests Covering the bottle retards decomposition and it prevents added contamination. Substances in urine decompose when exposed to air. Decomposition may alter the test results To prevent the spread of infection

To avoid duplication Documentation provides coordination of care

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Procedure Checklist b. Collecting a 24-hour Urine Specimen
Check () Yes or No No 1 2 Procedure Yes Explain the procedure Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Instruct the client: 1) Before beginning a 24 hour urine collection, ask the client to void completely. 2) Document the starting time of a-24 hour urine collection on the specimen form and nursing record. 3) Instruct the client to collect all the urine into a large container for the next 24 hours. 4) In the exact 24 hours later, ask the client to void And pour into the large container. 5) Measure total amount of urine and record it on the specimen form and nursing record. 6)Document the time when finished the collection Sending the specimen: 1) Perform hand hygiene and put on gloves if available. 2)Mix the urine thoroughly 3) Collect some urine as required or all the urine in a clean bottle with lid. 4) Transfer it to the laboratory with the specimen form immediately. Dispose of used equipment or clean them. Remove gloves and perform hand hygiene. Document the procedure in the designated place and mark it off on the Kardex. No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

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c. Collecting a Urine Specimen from a Retention Catheter
Equipments: 1 2 3 4 5 6 7 Laboratory form Disposable gloves if available Container with label as required Spirit swabs or disinfectant swabs 10-20-mLsyringewith 21-25-gauge needle Clamp or rubber band Ballpoint pen

1

1 1

No Procedure 1 Assemble equipments. Label the container. 2 Explain the procedure to the client 3 4 Perform hand hygiene and put on gloves if available. Clamp the tubing: 1) Clamp the drainage tubing or bend the tubing 2)Allow adequate time for urine collection ❖ Nursing Alert❖ You should not clamp longer than 15minutes Cleanse the aspiration port with a spirit swab or another disinfectant swab (e.g., Beta dine swab) Withdrawing the urine: 1) Insert the needle into the aspiration port 2) Withdraw sufficient amount of urine gently into the syringe Transfer the urine to the labeled specimen container ❖ Nursing Alert❖ The container should be clean for a routine urinalysis and be sterile for a culture Unclamp the catheter

Rationale Organization facilitates accurate skill performance Providing information fosters his/her cooperation To prevent the spread of infection Collecting urine from the tubing guarantees fresh urine. Long-time clamp can lead back flow of urine and is able to cause urinary tract infection

5

Disinfecting the port prevents organisms from entering the catheter. This technique for uncontaminated urine specimen, preventing contamination of the client‘s bladder

6

7

Careful labeling and transfer prevents contamination or confusion of the urine specimen Appropriate container brings accurate results of urinalysis

8

9

Prepare and pour urine to the container for transport

The catheter must be unclamped to allow free urinary flow and to prevent urinary stasis. Proper packaging ensures that the specimen is not an infection risk

Nursing Skill Procedures

126

10

11 12

Dispose of used equipments and disinfect if needed. Remove gloves and perform hand hygiene Send the container to the laboratory Immediately Document the procedure in the designated place and mark it off on the Kardex.

To prevent the spread of infection

Organisms grow quickly at room temperature To avoid duplication Documentation provides coordination of care

Nursing Skill Procedures

127

Procedure Checklist c. Collecting a Urine Specimen From a Retention Catheter
Check () Yes or No No 1 Procedure Yes No Comments Assemble equipments. Label the container. 2 Explain the procedure to the client 3 Perform hand hygiene and put on gloves if available. 4 Clamp the tubing: 1) Clamp the drainage tubing or bend the tubing 2)Allow adequate time for urine collection ❖ Nursing Alert❖ You should not clamp longer than 15minutes 5 Cleanse the aspiration port with a spirit swab or another disinfectant swab (e.g., Beta dine swab) 6 Withdrawing the urine: 1) Insert the needle into the aspiration port 2) Withdraw sufficient amount of urine gently into the syringe 7 Transfer the urine to the labeled specimen container ❖ Nursing Alert❖ The container should be clean for a routine urinalysis and be sterile for a culture 8 Unclamp the catheter 9 Prepare and pour urine to the container for transport 10 Dispose of used equipments and disinfect if needed. Remove gloves and perform hand hygiene 11 Send the container to the laboratory Immediately 12 Document the procedure in the designated place and mark it off on the Kardex. Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: ____________________________________

Nursing Skill Procedures

128

d. Collecting a Urine Culture
Definition: Collecting a urine culture is a process that it obtains specimen urine with sterile technique Purpose: 1) To collect uncontaminated urine specimen for culture and sensitivity test 2) To detect the microorganisms causes urinary tract infection (; UTI) 3) To diagnose and treat with specific antibiotic Equipments: 1 2 3 4 5 6 7 Laboratory form Sterile gloves Sterile culture bottle with label as required Sterile kidney tray or sterile container with wide mouthed if needed Bed pan if needed Paper tissues if needed Ballpoint pen

1

1 1

No 1

2

3 4

Procedure Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Explain the procedure to the client Instruct the client: 1) Instruct the client to clean perineum with soap and water 2) Open sterilized container and leave the cover facing inside up 3) Instruct the client to void into sterile kidney tray or sterilized container with wide mouth 4) If the client is needed bed-rest and needs to pass urine more, put bed pan after you collected sufficient amount of sterile specimen Remove the specimen immediately after the client has voided. Obtain 30-50mL at midstream point of voiding

Rationale Organization facilitates accurate skill performance Ensure that the specimen collecting is correct Ensure correct identification and avoid mistakes Providing information fosters his/her cooperation To prevent the contamination of specimen from perineum area The cover should be kept the state sterilized To secure the specimen kept in sterilized container surely

5

Substances in urine decompose when exposed to air. Decomposition may alter the test results Ensure the client voids enough amount of the urine for the required tests Emphasize first and last portions of voiding to be discarded

Nursing Skill Procedures

129

6

Close the container securely without touching inside of cover or cap. Dispose of used equipment or clean them. Remove gloves and perform hand hygiene. Send the specimen bottle or container to the laboratory immediately with the specimen form. Document the procedure in the designated place and mark it off on the Kardex.

Covering the bottle retards decomposition and it prevents added contamination. To prevent the spread of infection

7

8

Organisms grow quickly at room temperature

9

To avoid duplication Documentation provides coordination of care

Nursing Skill Procedures

130

Procedure Checklist d. Collecting a urine culture
Check () Yes or No No 1 Procedure Assemble equipments and check the specimen form with client‘s name, date and content of urinalysis Label the bottle or container with the date, client‘s name, department identification, and Dr‘s name. Explain the procedure to the client Instruct the client: 1) Instruct the client to clean perineum with soap and water 2) Open sterilized container and leave the cover facing inside up 3) Instruct the client to void into sterile kidney tray or sterilized container with wide mouth 4) If the client is needed bed-rest and needs to pass urine more, put bed pan after you collected sufficient amount of sterile specimen Remove the specimen immediately after the client has voided. Obtain 3050mL at midstream point of voiding Close the container securely without touching inside of cover or cap. Dispose of used equipment or clean them. Remove gloves and perform hand hygiene. Send the specimen bottle or container to the laboratory immediately with the specimen form. Document the procedure in the designated place and mark it off on the Kardex. Yes No Comments

2

3 4

5

6 7

8

9

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

131

Collecting a Stool Specimen
Definition: Collection of stool specimen deters a process which is aimed at doing chemical bacteriological or parasitological analysis of fecal specimen Purpose: 1) To identify specific pathogens 2) To determine presence of ova and parasites 3) To determine presence of blood and fat 4) To examine for stool characteristics such as color, consistency and odor Equipments: 1 2 3 4 5 6 7 Laboratory form Disposable gloves if available Clean bed pan with cover Closed specimen container as ordered Label as required Wooden tongue depressor Kidney tray or plastic bag for dirt

1

1-2 1

No 1

Procedure Assemble equipments. Label the container

2

3 4

Rationale Organization facilitates accurate skill performance Careful labeling ensures accuracy of the report and alerts the laboratory personnel to the presence of a contaminated specimen Explanation: Providing information fosters his/her 1) Explain the procedure to the client cooperation 2) Ask the client to tell you when he/she Most of clients cannot pass on command feels the urge to have a bowel movement Perform hand hygiene and put on gloves To prevent the spread of infection if available. Placing bedpan: To provide privacy 1) Close door and put curtains/ a screen. You are most likely to obtain a usable 2) Give the bed pan when the client is specimen at this time. ready. To gain accurate results 3) Allow the client to pass feces 4) Instruct not to contaminate specimen with urine

Nursing Skill Procedures

132

5

6

7

Collecting a stool specimen: 1) Remove the bedpan and assist the client to clean if needed 2) Use the tongue depressor to transfer a portion of the feces to the container without any touching 3) Take a portion of feces from three different areas of the stool specimen 4) Cover the container Remove and discard gloves. Perform hand hygiene Send the container immediately to the laboratory

It is grossly contaminated To gain accurate results It prevents the spread of odor

To prevent the spread of infection

8

Document the procedure in the designated place and mark it off on the Kardex.

Stools should be examined when fresh. Examinations for parasites, ova, and organisms must be made when the stool is warm. To avoid duplication Documentation provides coordination of care

Nursing Skill Procedures

133

Procedure Checklist Collecting a Stool Specimen
Check () Yes or No No 1 2 Procedure Yes Assemble equipments. Label the container Explanation: 1) Explain the procedure to the client 2) Ask the client to tell you when he/she feels the urge to have a bowel movement Perform hand hygiene and put on gloves if available. Placing bedpan: 1) Close door and put curtains/ a screen. 2) Give the bed pan when the client is ready. 3) Allow the client to pass feces 4) Instruct not to contaminate specimen with urine Collecting a stool specimen: 1) Remove the bedpan and assist the client to clean if needed 2) Use the tongue depressor to transfer a portion of the feces to the container without any touching 3) Take a portion of feces from three different areas of the stool specimen 4) Cover the container Remove and discard gloves. Perform hand hygiene Send the container immediately to the laboratory Document the procedure in the designated place and mark it off on the Kardex. No Comments

3 4

5

6

7 8

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

134

Application of Restraints
Definition Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. Purpose: 1) Restraints are used to protect the client. 2) Allow for treatment in a safe environment. 3) Reduce the risk of injury to others. Equipment: Restraint Types of Physical Restraints

A. Jacket

B. Belt

C. Mitten or Hand

E. Limb or Extremity

D. Elbow

F. Mummy

Nursing Skill Procedures

135

No 1

2

Action Explain rationale for application of restraint. Repeatedly reinforce rationale. Select the proper type of restraint.

Rationale Explanations facilitate cooperation.

3 4

5

Assess skin for irritation. Apply restraint to client assuring some movement of body part. One to two fingers should slide between restraint and client‘s skin. Tie straps securely with clove hitch knot To make a clove hitch: make a figure-eight; pick up the loops; put the limb through the loops and secure. Pad bony Prominences. Secure restraint to bed frame; do not tie the straps to the side rail. Assess restraints and skin integrity every 30 minutes. Release restraints at least every 2 hours. Continually assess the need for restraints (at least every 8 hours).

Least restrictive restraint that does not interfere with client‘s health status but provides safety should be selected. Provides baseline skin assessment. Maintains adequate circulation and mobility. Prevents skin breakdown. Restraint should be easy to release.

6

Prevents accidental injury to client from moving side rails and decreases client‘s ability to untie restraints. Permits muscle exercise. Promotes circulation. Assist in evaluating client‘s progress and response to restraints.

7

Making a Clove Hitch Knot: A. Make a figure-eight; B. Pick up the loops; and C. Put the limb through the loops and secure.

Nursing Skill Procedures

136

Procedure Checklist Application of Restraints
Check () Yes or No No Action 1 Explain rationale for application of restraint. Repeatedly reinforce rationale. 2 Select the proper type of restraint. 3 Assess skin for irritation. 4 Apply restraint to client assuring some movement of body part. One to two fingers should slide between restraint and client‘s skin. Tie straps securely with clove hitch knot To make a clove hitch: make a figure-eight; pick up the loops; put the limb through the loops and secure. Pad bony Prominences. 5 Secure restraint to bed frame; do not tie the straps to the side rail. 6 Assess restraints and skin integrity every 30 minutes. Release restraints at least every 2 hours. 7 Continually assess the need for restraints (at least every 8 hours).Making a Clove Hitch Knot: A. Make a figure-eight; B. Pick up the loops; and C. Put the limb through the loops and secure. Yes No Comments

Recommendation: Pass ____________ Need more practice ___________________________ Student: ________________________Date: ______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

137

Monitoring Blood Glucose Level
Definition: It is defined as monitoring the presence of glucose in a person. Purpose: 1) To determine or monitor blood glucose levels of clients at risk for hyperglycemia or hypoglycemia. 2) To promote blood glucose regulation by the client. 3) To evaluate the effectiveness of insulin administration. Equipments: 1 Glucometer 2 Testing strips 3 Sterile lancet 4 Disposable gloves 5 Alcohol swabs 6 Cotton balls

No 1 2 3 4 5 6

7

8

9 10

Procedure Check physicians order for monitoring schedule. Gather equipments. Explain to the client what you are going to do. Wash hands.don disposable gloves. Prepare lancet. Turn monitor on and check that the code number on strip matches the code number on the monitor screen. Massage side for finger for the adult (or heel for child) toward puncture site. Have patient wash hands with soap and water or cleanse the area with alcohol. Dry it. Hold lancet perpendicular to skin and prick site with the lancet. Wipe away the first drop of blood with cotton ball. Lightly squeeze or milk the puncture site until a hanging drop of blood to pad on test strip without smearing it. Gently touch the drop of blood to pad on test strip without smearing it.

Rationale

Providing explanation fosters his/her cooperation and allays anxiety. Aseptic technique maintains sterility. Matching code numbers on the strip and glucose monitor ensure that machine is calibrated correctly. Massage encourages the blood flow to the area. To prevent the spread of infection

11

Holding the lancet in proper position facilitates proper skin penetration. Some feel that the first drop of blood may be contaminated by serum or cleansing product and may produce inaccurate reading. To provide continuity of care

12

Smearing blood on the strip may result in inaccurate results.

Nursing Skill Procedures

138

13 14 15 16

17

18 19 20

Insert strip into the meter according to directions for the specific device. Press timer if directed by the puncture. Apply pressure to the puncture site. Read the blood glucose results and document appropriately at bedside. Inform patient of the test results. Turn meter off, dispose of the used supplies and place lancet in sharp container. Remove gloves. Wash hands. Record blood glucose on chart or medication record. Inform the doctor

Correcting insert the strip allows the meter to read the blood glucose level accurately. Pressure causes homeostasis.

Proper disposal prevents exposure to blood and accidental needle sticks injury.

Nursing Skill Procedures

139

Procedure Checklist Monitoring Blood Glucose Level
Check () Yes or No No 1 Procedure Yes No Comments Check physicians order for monitoring schedule. 2 Gather equipments. 3 Explain to the client what you are going to do. 4 Wash hands.don disposable gloves. 5 Prepare lancet. 6 Turn monitor on and check that the code number on strip matches the code number on the monitor screen. 7 Massage side for finger for the adult (or heel for child) toward puncture site. 8 Have patient wash hands with soap and water or cleanse the area with alcohol. Dry it. 9 Hold lancet perpendicular to skin and prick site with the lancet. 10 Wipe away the first drop of blood with cotton ball. 11 Lightly squeeze or milk the puncture site until a hanging drop of blood to pad on test strip without smearing it. 12 Gently touch the drop of blood to pad on test strip without smearing it. 13 Insert strip into the meter according to directions for the specific device. 14 Press timer if directed by the puncture. 15 Apply pressure to the puncture site. 16 Read the blood glucose results and document appropriately at bedside. Inform patient of the test results. 17 Turn meter off, dispose of the used supplies and place lancet in sharp container. 18 Remove gloves. 19 Wash hands. 20 Record blood glucose on chart Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

140

Mixing Insulins in One Syringe
Purpose: 1) To control the blood glucose level of the patient suffering with hyperglycemia. Equipments: 1 Medication administration record (MAR) 2 Alcohol swabs 3 Insulin vials 4 Insulin syringe

No 1

2 3 4 5 6 7

8 9

10

Procedure Check with the client and the chart for known allergies or medical conditions that would contraindicate the use of the drug. Gather necessary equipment. Check the MAR against written health care orders. Wash your hands. Follow the five rights of medication administration. Check the client‘s identification band. Remove caps from insulin vials Slowly rotate each bottle of insulin. Never shake. Make sure suspensions are thoroughly mixed. (Cloudy insulin such as NPH should be completely mixed.) Clean the rubber stoppers of the vials with an alcohol swab. Remove cap from the needle. Draw air into the syringe equal to the dose of insulin to be given. Insert needle into vial of the suspension, being careful not to touch the needle to the medication in the vial. Inject the air into the vial and remove the needle. Do not withdraw any insulin yet. Fill syringe with air equal to dose of regular insulin. Insert needle into bottle and inject air into vial. Invert bottle and pull plunger down to withdraw the appropriate dose of insulin. With needle in the bottle, hold it up to the light and look for air bubbles. To remove air bubbles, tap or flick the syringe with your finger to cause air to rise. Push plunger to push air and some insulin back into the vial. Pull back to get the appropriate dose of insulin free of air. Remove the needle.

Rationale Prevents occurrence of adverse reactions.

Promotes efficiency. Ensures accuracy in identification of medication. Reduces transmission of microorganisms. Ensures correct client. Permits access to solution. Ensures complete mixture of suspension. Make sure there are no crystals on the bottom of the vial. Helps remove surface contaminants Injected air will displace the insulin to be removed.

Injected air displaces insulin and facilitates withdrawal. Inverting the vial allows the air to rise and the solution to settle on the bottom of the Vial. Air displaces the medication in the syringe and can cause errors in dosage. Air bubbles must be removed to ensure that an accurate dose of insulin is in the syringe.

Nursing Skill Procedures

141

12

13 14

Insert needle into the vial of longeracting insulin; be sure the tip of the needle is below the surface of the fluid level. Invert the bottle, and slowly drawback to dose of insulin required. Remove needle. • Have another nurse check the prescribed dose. Store insulin vials according to your agency policy. Wash your hands.

Drawing back slowly helps prevent air from being drawn into the syringe. • Ensures accuracy.

To prevent from the medication waste. Reduces transmission of microorganisms.

Nursing Skill Procedures

142

Procedure Checklist Mixing Insulins in One Syringe
Check () Yes or No No 1 Procedure Check with the client and the chart for known allergies or medical conditions that would contraindicate the use of the drug. Gather necessary equipment. Check the MAR against written health care orders. Wash your hands. Follow the five rights of medication administration. Check the client‘s identification band. Remove caps from insulin vials (if not already off). Slowly rotate each bottle of insulin. Never shake. Make sure suspensions are thoroughly mixed. (Cloudy insulin such as NPH should be completely mixed.) Clean the rubber stoppers of the vials with an alcohol swab. Remove cap from the needle. Draw air into the syringe equal to the dose of insulin to be given. Insert needle into vial of the suspension, being careful not to touch the needle to the medication in the vial. Inject the air into the vial and remove the needle. Do not withdraw any insulin yet. Fill syringe with air equal to dose of regular insulin. Insert needle into bottle and inject air into vial. Invert bottle and pull plunger down to withdraw the appropriate dose of insulin. Yes No

2 3 4 5

6 7

8 9

10

Nursing Skill Procedures

143

11

12

13 14

With needle in the bottle, hold it up to the light and look for air bubbles. To remove air bubbles, tap or flick the syringe with your finger to cause air to rise. Push plunger to push air and some insulin back into the vial. Pull back to get the appropriate dose of insulin free of air. Remove the needle. Insert needle into the vial of longer-acting insulin; be sure the tip of the needle is below the surface of the fluid level. Invert the bottle, and slowly drawback to dose of insulin required. Remove needle. • Have another nurse check the prescribed dose. Store insulin vials according to your agency policy. Wash your hands.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

144

Administering Oxygen
Definition: Method by which oxygen is supplemented at higher percentages thanwhat is available in atmospheric air. Purpose: 1) To relieve dyspnea 2) To reduce or prevent hypoxemia and hypoxia 3) To alleviate associated with struggle to breathe Equipments: 1 2 3 4 5 6 Oxygen source (wall outlet or tank) Oxygen regulator or flow meter Humidifier bottle, if used Nipple adapter for flow meter, if humidification is not used Nasal cannula of appropriate size or oxygen mask Oxygen connecting tube

a. Nasal Cannula Method
No 1 Procedure Verify written order for oxygen therapy, including methods of delivery and flow rate. Wash hands. Explain procedure to client. If oxygen is being given in a facility where smoking is permitted, instruct the patient and any other persons in the room to refrain from smoking or lighting matches while oxygen is in use. Check that all electrical equipment in use in the room has been inspected for electrical safety. Post appropriate signs in the room and on the door. Assess the client for obstruction of the nasal passages by observing of breathing patterns and, if indicated, inspecting of nasal passages with a pen light. If using a wall outlet as oxygen source, plug flow meter into outlet by pushing until it snaps into place. If a lock-release button is present, depress it as you insert the flow meter. Rationale Oxygen is a drug, and its use must be ordered by a physician. Oxygen delivered by nasal cannula is prescribed in flow rates expressed as Liters per minute (L/min). Prevents transmission of pathogens. Explanation reduces anxiety. Oxygen, while not itself flammable, makes fires burn more readily than they otherwise would, so strict fire safety must be observed. Faulty electrical equipment may produce sparks that could ignite materials nearby.

2 3

4

If nasal passages are obstructed, oxygen delivery by nasal cannula will be ineffective and another route should be chosen.

5

Wall outlets are sealed by heavy steel valves that prevent the escape of oxygen from the system. If you hear hissing from the valve, the flow meter is not fully engaged.

Nursing Skill Procedures

145

6

7

If a tank is used as the oxygen source, the flow meter should already be attached If humidification is used, remove the cover from the humidifier bottle to expose the adapter that connects the bottle to the flow meter. Attach the bottle to the flow meter by screwing the plastic nut on the adapter to the threaded outlet of the flow meter. If no humidification is used, attach the nipple adapter to the flow meter by screwing it onto the threaded outlet of the flow meter. Attach oxygen tubing to the port on the humidifier bottle or the pointed end of the nipple adapter. Turn on oxygen flow by turning the thumbscrew (wall outlet) or knob (tank). Adjust flow rate to the prescribed amount. Gently position nasal prongs into client‘s nares, with curves of prongs pointing toward the floor of the nostrils.

Special tools are used to attach valves to oxygen tanks. If long-term oxygen therapy is anticipated, if flow is 6 L/min or higher, or if drying of the respiratory mucosa and/or thick secretions are present, humidification of oxygen is indicated. Short-term and/or low-flow oxygen use, such as during a medical procedure, may not require humidification. This adapter allows the oxygen tubing to be connected directly to the flow meter.

8

9

10

11

Establishes proper functioning of equipment. If humidifier bottle is used, bubbling of oxygen through the bottle will be noted. In addition, verify flow by feeling for the flow of air from the cannula‘s nasal prongs. As for any drug, correct dosing of oxygen is essential. Both insufficient and excessive amounts can be harmful to the client. Directs the flow of oxygen into the nasal cavity, where it will mix with inspired room air.

Nursing Skill Procedures

146

12

Loop the cannula tubing over the client‘s ears; adjust the fit of the tubing by sliding the adjuster upward to hold the cannula in place.

The fit of the cannula should be secure but not tight. A too-tight fit is uncomfortable, may cause skin breakdown (especially above the ears), and can occlude oxygen flow.

13

Assess the client‘s nares, face, and ears every 4 hours for signs of skin irritation or breakdown and document your findings. At the same time, inspect the nasal prongs for the presence of nasal secretions or crusts. If needed, wipe the prongs clean with a gauze pad.

Pressure from the tubing or cannula may cause skin breakdown. Accumulated secretions can impair the flow of oxygen.

Nursing Skill Procedures

147

Procedure Checklist a. Nasal Cannula Method
Check () Yes or No No 1 Procedure Verify written order for oxygen therapy, including methods of delivery and flow rate. Wash hands. Explain procedure to client. If oxygen is being given in a facility where smoking is permitted, instruct the patient and any other persons in the room to refrain from smoking or lighting matches while oxygen is in use. Check that all electrical equipment in use in the room has been inspected for electrical safety. Assess the client for obstruction of the nasal passages by observing of breathing patterns and, if indicated, inspecting of nasal passages with a pen light. If using a wall outlet as oxygen source, plug flow meter into outlet by pushing until it snaps into place. If a lock-release button is present, depress it as you insert the flow meter. If a tank is used as the oxygen source, the flow meter should already be attached If humidification is used, remove the cover from the humidifier bottle to expose the adapter that connects the bottle to the flow meter. Attach the bottle to the flow meter by screwing the plastic nut on the adapter to the threaded outlet of the flow meter. If no humidification is used, attach the nipple adapter to the flow meter by screwing it onto the threaded outlet of the flow meter. Attach oxygen tubing to the port on the humidifier bottle or the pointed end of the nipple adapter. Turn on oxygen flow by turning the thumbscrew (wall outlet) or knob (tank). Yes No Comments

2 3

4

5

6

7

8

9

Nursing Skill Procedures

148

10 11

12

13

Adjust flow rate to the prescribed amount. Gently position nasal prongs into client‘s nares, with curves of prongs pointing toward the floor of the nostrils. Loop the cannula tubing over the client‘s ears; adjust the fit of the tubing by sliding the adjuster upward to hold the cannula in place. Assess the client‘s nares, face, and ears every 4 hours for signs of skin irritation or breakdown and document your findings. At the same time, inspect the nasal prongs for the presence of nasal secretions or crusts. If needed, wipe the prongs clean with a gauze pad.

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

149

b. Oxygen Mask Method; Simple Facemask

A

B

C Oxygen Delivery Systems: A. Single face mask B. Open face tent C. Reservior mask D. Venturi mask No 1 Procedure Verify written order for oxygen therapy, including methods of delivery and flow rate. Wash hands. Prepare the oxygen equipment: 1) Attach the humidifier to the threaded outlet of the flow meter or regulator. 2)Connect the tubing from the simple mask to the nipple outlet on the humidifier 3) Set the oxygen at the prescribed flow rate.

D

2 3

Rationale Oxygen is a drug, and its use must be ordered by a physician. Oxygen delivered by nasal cannula is prescribed in flow rates expressed as Liters per minute (L/min). Prevents transmission of pathogens. To maintain the proper setting The oxygen must be flowing before you apply the mask to the client

Nursing Skill Procedures

150

4

5

6 7 8 9 10 11

To apply the mask, guide the elastic strap over the top of the client's head. Bring the strap down to just below the client‘s ears. Gently, but firmly, pull the strap extensions to center the mask on the client‘s face with a tight seal. Make sure that the client is comfortable. Remove and properly dispose of gloves. Wash your hands. Document the procedure and record the client‘s reactions. Sign the chart and report the senior staffs Check periodically for depresses respirations or increased pulse. Check for reddened pressure areas under the straps

This position will hold the mask most firmly

The seal prevents leaks as much as possible

Comfort helps relieve apprehension, and lowers oxygen need. Respiratory secretions are considered contaminated. Documentation provides for coordination of care. To maintain professional accountability To assess the respiratory condition and find out any abnormalities as soon as possible The straps, when snug, place pressure on the underlying skin areas

Nursing Skill Procedures

151

Procedure Checklist b.Oxygen Mask Method; Simple Facemask
Check () Yes or No No 1 Procedure Verify written order for oxygen therapy, including methods of delivery and flow rate. Wash hands. Prepare the oxygen equipment: 1) Attach the humidifier to the threaded outlet of the flow meter or regulator. 2)Connect the tubing from the simple mask to the nipple outlet on the humidifier 3) Set the oxygen at the prescribed flow rate. To apply the mask, guide the elastic strap over the top of the client's head. Bring the strap down to just below the client‘s ears. Gently, but firmly, pull the strap extensions to center the mask on the client‘s face with a tight seal. Make sure that the client is comfortable. Remove and properly dispose of gloves. Wash your hands. Document the procedure and record the client‘s reactions. Sign the chart and report the senior staffs Check periodically for depresses respirations or increased pulse. Check for reddened pressure areas under the straps Yes No Comments

2 3

4

5

6 7 8 9 10 11

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________

Nursing Skill Procedures

152

Assisting a Client with Ambulation
Definition: It is defined as assisting the client to move, depending on the client‘s activity level and tolerance for physical exertion Purpose: 1) To prevent the complications of immobility 2) To assess the client‘s blood pressure, respiratory rate, pulse, skin color and moisture, and subjective responses from the activity. Equipments: None required No 1 2 3 4 Procedure Inform client of the purposes and distance of the walking exercise. Elevate the head of the bed and wait several minutes. Lower the bed height. With one arm under the client‘s back and one arm under the client‘s upper legs, move the client into the dangling position. Rationale Reduces client anxiety and increases cooperation Prevents orthostatic hypotension. Reduces distance client has to step down, thus decreasing risk of injury. Provides client support and reduces risk of fall.

Nursing Skill Procedures

153

5 6

7 8 9

Encourage client to dangle at side of bed for several minutes. Stand in front of client with your knees touching Client‘s knees. Place arms under client‘s axillae. Assist client to a standing position, allowing client time to balance Help client ambulate desired distance or distance of tolerance by placing your hand under the client‘s forearm and ambulating close to the client.

Prevents orthostatic hypotension. Allows for assessing tolerance for the sitting position. Prevents client from sliding forward if dizziness or faintness occurs. Supports client‘s trunk Reduces risk of fall Provides assistance in achieving ambulatory goals.

Nursing Skill Procedures

154

Procedure Checklist Assisting a Client with Ambulation
Check () Yes or No No Procedure Yes 1 Inform client of the purposes and distance of the walking exercise. 2 Elevate the head of the bed and wait several minutes. 3 Lower the bed height. 4 With one arm under the client‘s back and one arm under the client‘s upper legs, move the client into the dangling position. 5 Encourage client to dangle at side of bed for several minutes. 6 Stand in front of client with your knees touching Client‘s knees. 7 Place arms under client‘s axillae. 8 Assist client to a standing position, allowing client time to balance 9 Help client ambulate desired distance or distance of tolerance by placing your hand under the client‘s forearm and ambulating close to the client. No Comments

Recommendation: Pass ___________ Need more practice ___________________________ Student: _________________________Date: ____________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

155

Inhaler
Definition:
A device that produces a vapor to ease breathing or is used to medicate by inhalation, especially a small nasal applicator containing a volatile medicament

Purpose:
1) To relieve respiratory related symptoms

Inhalers can be helpful in the relief of many symptoms dealing with a broad range of health issues such as the following:
a) b) c) d) e) f) g) h) i) j)

Asthma flare-ups Chest congestion Cough Nasal congestion Nausea Parched throat Shortness of breath Sinus congestion Tightness of chest Wheezing

Equipments:
1 2 3 4 Dr.‘s order card, client‘s chart and kardex Inhaler Tissue paper Water, lip cream as required 1

No 1 2

3 4

5 6

Procedure Perform hand hygiene. Prepare the medication following the Five rights of medication administration: ①Right drug ②Right dose ③Right route ④Right time ⑤Right client. Explain to the client what you are going to do. Assist the client to make comfortable position in sitting or semi-Fowler position. Shake the inhaler well immediately prior to use. Spray once into the air.

Rationale To prevent the spread of infection. Strictly observe safety precautions to decrease the possibility of a medication error

Providing explanation fosters his/her cooperation and allays anxiety. Upright position can help expanding the chest. Shaking aerosolizes the fine particles. To fill the mouthpiece

Nursing Skill Procedures

156

7

Instruction to the client: 1) Instruct the client to take a deep breath and exhale completely through the nose 2) The client should grip the mouthpiece with the lips, push down on the bottle, and inhale as slowly and deeply as possible through the mouth. 3) Instruct the client to hold his/her breath for adult 10 seconds and then to slowly exhale with pursed lips 4) Repeat the above steps for each ordered ― puffs‖, waiting 5-10 seconds or as prescribed between puffs. 5) Instruct the client to gargle and wipe the face if needed. Replace equipments used properly and discard dirt. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

The procedure is designed to allow the medication to come into contact with the lungs for the maximum amount of time

This method achieve maximum benefits

8 9 10

11

Gargling cleanse the mouth. When steroid remains inside the mouth, infection of fungus may occur. To prepare for the next procedure prevent the spread of infection To prevent the spread of infection Documentation provides continuity of care Giving signature maintains professional accountability To provide continuity of care

Nursing Skill Procedures

157

Procedure Checklist Inhaler
Check () Yes or No No 1 2 3 4 Procedure Perform hand hygiene. Prepare the medication Explain to the client what you are going to do. Assist the client to make comfortable position in sitting or semi-Fowler position. Shake the inhaler well immediately prior to use. Spray once into the air. Instruction to the client: 1) Instruct the client to take a deep breath and exhale completely through the nose 2) The client should grip the mouthpiece with the lips, push down on the bottle, and inhale as slowly and deeply as possible through the mouth. 3) Instruct the client to hold his/her breath for adult 10 seconds and then to slowly exhale with pursed lips 4) Repeat the above steps for each ordered ― puffs‖, waiting 5-10 seconds or as prescribed between puffs. 5) Instruct the client to gargle and wipe the face if needed. Replace equipments used properly and discard dirt. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff. Yes No Comments

5 6 7

8 9 10

11

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

158

Using a Nebulizer
Definition Nebulizer deliver medications administered through the inhaled route. A nebulizer is used to deliver a fine spray of medication through a nose piece or mouth piece. Purpose: a) Medication to be administered directly to the lungs b) Inhaled aerosol droplets can only penetrate into the narrow branches of the lower airways if they have a small diameter of 1–5 micrometers. Equipments: 1 Dr.‘s order card, client‘s chart and kardex 2 Ultrasonic nebulizer 3 Circulating set-up 4 Sterile water 5 Mouthpiece or oxygen mask 6 Prescribed medication 7 Sputum mug if available 8 Tissue paper 9 Water, lip cream as required

1 1 1 1

No 1 2 3

4 5

6

Procedure Check the medication order against the original Dr‘s order Perform hand hygiene Prepare the medication following the Five rights of medication administration: ①Right drug ②Right dose ③Right route ④Right time ⑤Right client. Explain to the client what you are going to do. Assist the client to make comfortable position in sitting or semi-Fowler position. Setting the nebulizer: 1) Plug the cord into an electrical outlet 2) Fill the nebulizer cup with the ordered amount of medication 3) Turn on the nebulizer at the prescribed time

Rationale To ensure that you give the correct medication to the correct client To prevent the spread of infection Strictly observe safety precautions to decrease the possibility of a medication error

Providing explanation fosters his/her cooperation and allays anxiety. Upright position can help expanding the chest. To ensure that you give the correct amount of medication

Nursing Skill Procedures

159

7

8

Instructing the client during nebulization 1) Instruct the client to close the lips around the Mouth piece and to breathe through the mouth. 2) Instructing the client to continue the  treatment until he/she can no longer see a mist on exhalation from the  opposite end of the mouthpiece or vent holes in the mask Nursing Alert Discontinue when the client feel ill and you find side effects. You should take vital signs, check respiration sound and report to the Dr. 3) Encourage the client to partially cough and expectorate any secretions loosed during the treatment After nebulization finished, 1) Turn off the nebulizer and take off the cord from the electrical outlet. 2) Instruct the client to gargle and wipe the face if needed. Apply lip cream if needed 3) Soak the nebulizer cup and mouthpiece or Oxygen mask in warm salvon water for an hour. Disinfect the nebulizer by spirit swab. 4) Rinse and dry it after each use 5) Replace equipments used properly and discard dirt. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

If the client is using a mask, he/she may breathe normally

To ensure that the client inhales the entire dose Side effect includes nausea, vomiting, palpitation, difficult breathing, cyanosis and cold sweat.

Gargling cleanse the mouth. When steroid remains inside the mouth, infection of fungus may occur. To prepare for the next procedure prevent the spread of infection Gargling cleanse the mouth. When steroid Remains inside the mouth, infection of fungus may occur. Applying lip cream provides moisten on lips. To avoid contamination

9 10

11

To prepare for the next procedure To prepare for the next procedure and prevent the spread of infection To prevent the spread of infection Documentation provides continuity of care Giving signature maintains professional accountability To provide continuity of care

Nursing Skill Procedures

160

Procedure Checklist Nebulizer
Check () Yes or No No 1 2 3 Procedure Yes Check the medication order against the original Dr‘s order Perform hand hygiene Prepare the medication following the Five rights of medication administration: ①Right drug ②Right dose ③Right route ④Right time ⑤Right client. Explain to the client what you are going to do. Assist the client to make comfortable position in sitting or semi-Fowler position. Setting the nebulizer: 1) Plug the cord into an electrical outlet 2) Fill the nebulizer cup with the ordered amount of medication 3) Turn on the nebulizer at the prescribed time Instructing the client during nebulization 1) Instruct the client to close the lips around the Mouth piece and to breathe through the mouth. 2) Instructing the client to continue the treatment until he/she can no longer see a mist on exhalation from the opposite end of the mouthpiece or vent holes in the mask Nursing Alert Discontinue when the client feel ill and you find side effects. You should take vital signs, check respiration sound and report to the Dr. 3) Encourage the client to partially cough and expectorate any secretions loosed during the treatment No Comments

4 5

6

7

Nursing Skill Procedures

161

8

9 10

11

After nebulization finished, 1) Turn off the nebulizer and take off the cord from the electrical outlet. 2) Instruct the client to gargle and wipe the face if needed. Apply lip cream if needed 3) Soak the nebulizer cup and mouthpiece or Oxygen mask in warm salvon water for an hour. Disinfect the nebulizer by spirit swab. 4) Rinse and dry it after each use 5) Replace equipments used properly and discard dirt. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

Recommendation: Pass ___________ Need more practice ____________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

162

Performing Nasopharyngeal and Oropharyngeal Suctioning
Definition: Nasopharyngeal suctioning involves passing a suction catheter or nasal trumpet through the nare, down the pharynx; through the larynx and Oropharyngeal suctioning involves passing the catheter through the mouth down to the pharynx. Purpose: 1) Clear the secretions the client cannot remove by coughing. 2) To improve the breathing patterns of the client Equipments: 1 Suction source (wall suction regulator with collection bottle or portable suction machine) 2 Extension tubing connected to suction device 3 Small bottle of sterile water or normal saline if not included in kit 4 Sterile suction kit (contains suction catheter, sterile gloves, sterile solution container; may contain a small container of sterile normal saline) 5 Sterile water-soluble lubricant 6 Personal protective devices: gown, mask and goggles or face shield if splattering is likely (e.g., a client with a vigorous productive cough)

No 1

2

Procedure Assess the client‘s need for suctioning: inability to effectively clear the airway by coughing and Expectoration; coarse bubbling or gurgling noises with respiration. Choose the most appropriate route (nasopharyngeal or Oropharyngeal) for your client. If nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency. Alternatively, you may assess patency by occluding each nare in turn with finger pressure while asking the client to breathe through the remaining nare. Explain the procedure to the client. Advice that suctioning may cause coughing or gagging but emphasize the importance of clearing the airway. Wash the hands Position the client in a high Fowler‘s or semi- Fowler‘s position.

Rationale Suctioning is an uncomfortable and traumatic procedure and should be used only when needed.

3

The oropharyngeal approach is easier but requires that the client cooperate; it may also produce gagging more readily in some persons. The nasopharyngeal route is more effective for reaching the posterior oropharynx but is contraindicated in clients with a deviated nasal septum, nasal polyps, or any tendency toward excessive bleeding (low platelet count, use of anticoagulants, and recent history of epistaxis or nasal trauma). Promotes cooperation and reduces anxiety

4 5

Reduces the transmission of pathogens. Maximizes lung expansion and effective coughing.

Nursing Skill Procedures

163

6

7

If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying Position. Adjust suction control to between 110 and 120 mm Hg. Put on gown and mask and goggles or face Shield if indicated. Using sterile technique, open the suction kit. Consider the inside wrapper of the kit to be sterile, and spread the wrapper out carefully to create a small sterile field. Carefully lift the wrapped gloves from the kit without touching the inside of the kit or the Gloves themselves. Lay the wrapped gloves down Next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique.

Protects the client from aspiration in the event of vomiting.

8 9

Excessive negative pressure can cause tissue trauma, whereas insufficient pressure will be ineffective. Protects you from splattering with body fluids. Produces an area in which to place sterile items without contaminating them.

10

Lubricant will be used to further lubricate the Catheter tip if the nasopharyngeal route is used.

11

12

13

If sterile solution (water or saline) is not included in the kit, pour about 100 ml of solution into the sterile container provided in the kit. Carefully lift the wrapped gloves from the kit without touching the inside of the kit or the gloves themselves. Lay the wrapped gloves down next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique If a cup of sterile solution is included in the suction kit, open it. Designate one hand as sterile (able to touch only sterile items) and the other as clean (able to touch only nonsterile items).

This solution will be used to lubricate the catheter and to rinse the inside of the catheter to clear secretions. The gloves should be kept sterile for handling the sterile suction catheter to avoid introducing pathogens into the client‘s airway.

14

This solution will be used to lubricate the catheter and to rinse the inside of the catheter to clear secretions. Usually, the dominant hand is the sterile hand, while the nondominant hand is clean. This prevents contamination of sterile supplies while allowing you to handle unsterile items.

Nursing Skill Procedures

164

11

12

13

Using your sterile hand, pick up the suction catheter. Grasp the plastic connector end between your thumb and forefinger and coil the tip around your remaining fingers Pick up the extension tubing with your clean Hand. Connect the suction catheter to the extension tubing, taking care not to contaminate the catheter Position clean hand with the thumb over the catheter‘s suction port. Dip the catheter tip into the sterile solution, and activate the suction. Observe as the solution is drawn into the catheter.

Prevents accidental contamination of the catheter tip.

The extension tubing is not sterile.

14

Suction is activated by occluding this port with the thumb. Releasing the port deactivates the suction. Tests the suction device as well as lubricates the interior of the catheter to enhance clearance of secretions.

15

16

17

18

For oropharyngeal suctioning, ask the client to open his or her mouth. Without activating the suction, gently insert the catheter and advance it until you reach the pool of secretions or until the client coughs. For nasopharyngeal suctioning, estimate the distance from the tip of the client‘s nose to the earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance from the catheter‘s tip. Dip the tip of the suction catheter into the water soluble lubricant to coat catheter tip liberally Insert the catheter tip into the nare with the suction control port uncovered. Advance the catheter gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion. Advance the catheter to the point marked by your thumb and forefinger

To minimize trauma, do not apply suction while the catheter is being advanced.

Ensures placement of the catheter tip in the oropharynx and not in the trachea.

Promotes the client‘s comfort and minimizes trauma to nasal mucosa. Guides the catheter toward the posterior oropharynx along the floor of the nasal cavity.

Nursing Skill Procedures

165

19

20

21

22 23 24

25 26 27

If resistance is met, do not force the catheter. Withdraw it and attempt insertion via the opposite nare. Apply suction intermittently by occluding the suction control port with your thumb; at the same time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly withdrawing it. Apply suction for no longer than 15 seconds at a time. Repeat step 24 until all secretions have been cleared, allowing brief rest periods between suctioning episodes Withdraw the catheter by looping it around your fingers as you pull it out. Dip the catheter tip into the sterile solution and apply suction. Disconnect the catheter from the extension tubing. Holding the coiled catheter in your gloved hand, remove the glove by pulling it over the catheter. Discard catheter and gloves in an appropriate container. Wash the hands. Provide the client with oral hygiene if indicated or desired. Document the procedure, noting the amount, color, and odor of secretions and the client‘s response to the procedure

Forceful insertion may cause tissue damage and bleeding. Prolonged suction applied to a single area of tissue can cause tissue damage.

Promotes complete clearance of the airway.

Allows you to maintain control over the catheter tip as it is withdrawn. Clears the extension tubing of secretions that would promote bacterial growth. Contains the catheter and secretions in the glove for disposal

Prevents the transmission of pathogens. Suctioning and coughing may produce an unpleasant taste. Changes in the amount, color, or odor of pulmonary secretions may indicate infection.

Nursing Skill Procedures

166

Procedure Checklist Performing Nasopharyngeal and Oropharyngeal Suctioning
Check () Yes or No No 1 Procedure Assess the client‘s need for suctioning: inability to effectively clear the airway by coughing and Expectoration; coarse bubbling or gurgling noises with respiration. Choose the most appropriate route (nasopharyngeal or Oropharyngeal) for your client. If nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency. Alternatively, you may assess patency by occluding each nare in turn with finger pressure while asking the client to breathe through the remaining nare. Explain the procedure to the client. Advice that suctioning may cause coughing or gagging but emphasize the importance of clearing the airway. Wash the hands Position the client in a high Fowler‘s or semi- Fowler‘s position. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying Position. Adjust suction control to between 110 and 120 mm Hg. Put on gown and mask and goggles or face Shield if indicated. Using sterile technique, open the suction kit. Consider the inside wrapper of the kit to be sterile, and spread the wrapper out carefully to create a small sterile field. Carefully lift the wrapped gloves from the kit without touching the inside of the kit or the Gloves themselves. Lay the wrapped gloves down Next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique. Yes No Comments

2

3

4 5 6

7 8 9

10

Nursing Skill Procedures

167

11

12

13 14

11

12

13 14

15

16

17

If sterile solution (water or saline) is not included in the kit, pour about 100 ml of solution into the sterile container provided in the kit. Carefully lift the wrapped gloves from the kit without touching the inside of the kit or the gloves themselves. Lay the wrapped gloves down next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique If a cup of sterile solution is included in the suction kit, open it. Designate one hand as sterile (able to touch only sterile items) and the other as clean (able to touch only nonsterile items). Using your sterile hand, pick up the suction catheter. Grasp the plastic connector end between your thumb and forefinger and coil the tip around your remaining fingers Pick up the extension tubing with your clean Hand. Connect the suction catheter to the extension tubing, taking care not to contaminate the catheter Position clean hand with the thumb over the catheter‘s suction port. Dip the catheter tip into the sterile solution, and activate the suction. Observe as the solution is drawn into the catheter. For oropharyngeal suctioning, ask the client to open his or her mouth. Without activating the suction, gently insert the catheter and advance it until you reach the pool of secretions or until the client coughs. For nasopharyngeal suctioning, estimate the distance from the tip of the client‘s nose to the earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance from the catheter‘s tip. Dip the tip of the suction catheter into the water soluble lubricant to coat catheter tip liberally

Nursing Skill Procedures

168

18

19

20

21

22 23 24

25 26 27

Insert the catheter tip into the nare with the suction control port uncovered. Advance the catheter gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion. Advance the catheter to the point marked by your thumb and forefinger If resistance is met, do not force the catheter. Withdraw it and attempt insertion via the opposite nare. Apply suction intermittently by occluding the suction control port with your thumb; at the same time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly withdrawing it. Apply suction for no longer than 15 seconds at a time. Repeat step 24 until all secretions have been cleared, allowing brief rest periods between suctioning episodes Withdraw the catheter by looping it around your fingers as you pull it out. Dip the catheter tip into the sterile solution and apply suction. Disconnect the catheter from the extension tubing. Holding the coiled catheter in your gloved hand, remove the glove by pulling it over the catheter. Discard catheter and gloves in an appropriate container. Wash the hands. Provide the client with oral hygiene if indicated or desired. Document the procedure, noting the amount, color, and odor of secretions and the client‘s response to the procedure

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

169

Performing Adult Cardiopulmonary Resuscitation
Definition Cardiopulmonary resuscitation (CPR) is the accepted technique of basic life support. Purpose: 1) To restore partial flow of oxygenated blood to the brain and heart 2) CPR combines breathing and chest compressions to circulate a small amount blood and oxygen in victims whose heart has stopped Equipment: Backboard (optional) Resuscitation masks or face shield (optional)

No Procedure 1 Determine unresponsiveness in the victim by tapping or gently shaking and shouting, ―Are you OK?‖

2

3

4

If the victim is unresponsive, call out for help and activate the EMS if outside the hospital or the internal emergency paging system if inside the hospital. Position the victim for CPR: Place supine on a firm surface. If in a bed, roll the victim onto his or her side and place firm backboard under the torso, then roll back into a supine position. Open the victim‘s airway using the head tilt–chin lift method .Once the airway is open, place your cheek very close to the victim‘s mouth; look, listen, and feel for breathing.

Rationale Quickly determines whether an emergency Exists. Note: If the victim has sustained an injury to the head or neck, to avoid furthering a spinal cord injury, move the victim only if absolutely necessary. Rapid initiation of Advanced Life Support techniques, particularly defibrillation, is associated with increased success of resuscitation. Facilitates airway opening and chest compressions, and the firm surface increases the effectiveness of chest compressions.

Removal of the tongue from the posterior oropharynx may restore breathing in the unconscious adult victim. Note: If this maneuver restores breathing, place the victim in a sidelying position or continue to hold the airway open and monitor breathing until help arrives.

5

If neck injury is present or suspected, open the airway by placing the fingertips of both hands under the angle of the victim‘s jaw and pulling the jaw forward.

Minimizes neck movement but is more difficult to perform.

Nursing Skill Procedures

170

6

7

If the victim is not breathing, position your mouth over the victim‘s mouth, forming an airtight seal. If a resuscitation mask or face shield is available, position it over the victim‘s mouth according to the product directions. Give two slow, full breaths. Uncover the victim‘s mouth completely after each breath. Watch the chest rise as the breath is given, and feel for exhalation after the breath is given

A mask or shield can be used to reduce the exposure of the rescuer to the oral secretions, blood, vomitus of the victim

8

9

Locate the carotid artery in the victim‘s neck Palpate for at least 5 seconds to determine whether a pulse is present. If a pulse is present, continue to deliver breaths at a rate of 10 to 12 per minute, or a breath every 5 to 6 seconds. If no pulse is present, begin chest compressions: Position yourself over the victim with your shoulders directly over the victim‘s chest. Place the heel of one hand over the lower half of the sternum, avoiding the xyphoid process. Place the second hand directly on top of the first, keeping the fingers up and off of the chest wall. Lock your elbows. Compress the sternum 1 1/2 to 2 inches; then release fully while maintaining correct hand position. Repeat the compression and release sequence 15 times at a rate equivalent to 80 to 100 compressions per minute. After 15 chest compressions, return to the victim‘s head and open the airway as in step 4. Deliver two slow, full breaths as in steps 6 and 7. Repeat the sequence of 15 compressions to two breaths until help arrives or pulse and breathing are restored.

Slow breath delivery improves the distribution of air in the victim‘s lungs and decreases the risk that air will enter the stomach. Uncovering mouth after breath delivery permits passive exhalation. Watching the chest rising and feeling exhalation verify successful delivery of breaths. Too-rapid pulse assessment may cause the rescuer to miss a slow or weak pulse. If a pulse is present, chest compression should not be performed.

10

Correct hand position maximizes the effectiveness of compressions while minimizing the risk of injuries such as fractured ribs, pneumothorax, and lacerations of internal structures. Correct hand position may be achieved by running the middle finger along the bottom rib toward the sternum until the xyphoid process is felt. Place the opposite hand on the sternum two finger widths above this point. Compression of the sternum forces blood to be ejected from the heart, mimicking normal ventricular systole. Release of the pressure moves blood into the heart, mimicking diastole Repeated cycles of breaths and compressions are necessary to deliver oxygenated blood to the vital organs.

11

Nursing Skill Procedures

171

12

Reassess for the return of breathing and pulse every few minutes; then resume CPR.

In rare instances, breathing and circulation may be restored with CPR; in most circumstances, CPR sustains minimal tissue oxygenation until advanced Life Support measures are available.

Nursing Skill Procedures

172

Procedure Checklist Performing Adult Cardiopulmonary Resuscitation
Check () Yes or No No 1 Procedure Determine unresponsiveness in the victim by tapping or gently shaking and shouting, ―Are you OK?‖ If the victim is unresponsive, call out for help and activate the EMS if outside the hospital or the internal emergency paging system if inside the hospital. Position the victim for CPR: Place supine on a firm surface. If in a bed, roll the victim onto his or her side and place firm backboard under the torso, then roll back into a supine position. Open the victim‘s airway using the head tilt–chin lift method .Once the airway is open, place your cheek very close to the victim‘s mouth; look, listen, and feel for breathing. If neck injury is present or suspected, open the airway by placing the fingertips of both hands under the angle of the victim‘s jaw and pulling the jaw forward. If the victim is not breathing, position your mouth over the victim‘s mouth, forming an airtight seal. If a resuscitation mask or face shield is available, position it over the victim‘s mouth according to the product directions. Give two slow, full breaths. Uncover the victim‘s mouth completely after each breath. Watch the chest rise as the breath is given, and feel for exhalation after the breath is given Locate the carotid artery in the victim‘s neck Palpate for at least 5 seconds to determine whether a pulse is present. If a pulse is present, continue to deliver breaths at a rate of 10 to 12 per minute, or a breath every 5 to 6 seconds. Yes No Comments

2

3

4

5

6

7

8

Nursing Skill Procedures

173

9

10

11

If no pulse is present, begin chest compressions: Position yourself over the victim with your shoulders directly over the victim‘s chest. Place the heel of one hand over the lower half of the sternum, avoiding the xyphoid process. Place the second hand directly on top of the first, keeping the fingers up and off of the chest wall. Lock your elbows. Compress the sternum 1 1/2 to 2 inches; then release fully while maintaining correct hand position. Repeat the compression and release sequence 15 times at a rate equivalent to 80 to 100 compressions per minute. After 15 chest compressions, return to the victim‘s head and open the airway as in step 4. Deliver two slow, full breaths as in steps 6 and 7. Repeat the sequence of 15 compressions to two breaths until help arrives or pulse and breathing are restored. 12. Reassess for the return of breathing and pulse every few minutes; then resume CPR.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

174

Assisting with a Lumbar Puncture
Definition: A lumbar puncture (spinal tap) is carried out by inserting a needle into the lumbar subarachnoid space to withdraw CSF. Purpose: 1) 2) 3) 4) 5) The test may be performed to obtain CSF for examination, To measure and reduce CSF pressure, To determine the presence or absence of blood in the CSF, To detect spinal subarachnoid block, and To administer antibiotics intrathecally (into the spinal canal) in certain cases of infection

Equipments: At the side 1 Adhesive bandages 2 Sterile gloves 3 Lumbar needle with a stylet 4 Gauze piece 5 Sterile drape 6 Antiseptic 7 Specimen tubes 8 Completed laboratory slips for CSF On the field 1 Local anesthetic and syringe (Note: these should be on the field if the physician prefers to administer the anaesthesia from the sterile field) 2 Lumbar needle with a stylet 3 Sterile gloves for the physician. 4 Gauze sponges 5 Specimen tubes for the transport. 6 Sterile drape 7 Antiseptic

No 1 2 3

4 5 6

Procedure Perform hand hygiene. Greet and identify the patient. Explain the procedure. Warn the patient not to move during the procedure. Tell the patient that pressure may be felt. Check the consent form is signed and posted on the chart. Have the patient void.

Rationale To prevent the spread of infection. Providing explanation fosters his/her cooperation and allays anxiety. To prevent a traumatic (bloody) tap. Contamination of the sample and pain.

Adhere the legal requirement for written consent for invasive procedures. Prevents one source of discomfort during procedure. Direct the patient to disrobe and put on Exposes site for the procedure. a gown with the opening in the back.

Nursing Skill Procedures

175

7 8

9

10

Determine and record the vital signs/. When the physician is ready, open the field(follow the steps for opening sterile surgical packs and assist with the initial preparations) A).place the package, with the label facing up, on a clean, dry, flat surface. B). carefully remove the sealing tape. If the package is commercially prepared, carefully remove the outer protective wrapper. Prepare the skin as part of sterile preparation. Many physicians prefer to prepare the skin using a sterile forcep after gloving. If this is the preferred procedure you may add sterile solutions to the field. Assist as needed with the administration of the anesthesia. Assist the patient into the appropriate position. a). For the side-lying position :The patient is positioned on one side at the edge of the bed or examining table with back toward the physician; the thighs and legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae, for easier entry into the subarachnoid space. A small pillow may be placed under the patient‘s head to maintain the spine in a horizontal position; a pillow may be placed between the legs to prevent the upper leg from rolling forward.

Provides baseline vital signs. A). Provides convenient area maximally free of microorganisms. b). avoids contaminating package contents.

To prevent the entry of the microorganisms.

Positions patient to widen space between vertebrae to allow entrance of needle; helps prevent movement during procedure.

b).For the forward-leaning, supported position: stand in front and rest your hands on the patients shoulder as a reminder to remain still. Have the patient to breath slowly and deeply.

Nursing Skill Procedures

176

11

12

13

14

15

16 17 18

19

Throughout the procedure observe the patient closely for signs such as dyspnea or cyanosis. Monitor the pulse at intervals. When the physician has the needle securely in place, help the patient to straighten slightly At the completion of the procedure, cover the site with an adhesive bandage and assist the patient to a supine position for 2 to 3 hours. If specimens are to be taken, put on gloves to receive the potentially hazardous body fluid. Label the tubes in sequence as you received them. Also label them with the patient‘s identification and place them in biohazard bags. Record the vital signs after the procedure. Note: note mental alertness, any leakage at the site, nausea and vomiting. Assess the lower limb mobility. The physician determines when the patient is ready to leave the examining room and the office. Clean the room and care for or dispose of the equipments as needed. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

To observe the patient for shock complications.

To ease the tension and allow a more normal CSF flow. To separate the alignment of the dural and arachnoid needle punctures in the meninges, to reduce leakage of CSF. To prevent from the mixing of the different samples.

Observes for complication during recovery.

To prevent the spread of infection Documentation provides continuity of care Giving signature maintains professional accountability To provide continuity of care

Nursing Skill Procedures

177

Procedure Checklist Assisting with a Lumbar Puncture
Check () Yes or No No Procedure Yes 1 Perform hand hygiene. 2 Greet and identify the patient. Explain the procedure. 3 Warn the patient not to move during the procedure. Tell the patient that pressure may be felt. 4 Check the consent form is signed and posted on the chart. 5 Have the patient void. 6 Direct the patient to disrobe and put on a gown with the opening in the back. 7 Determine and record the vital signs/. 8 When the physician is ready, open the field(follow the steps for opening sterile surgical packs and assist with the initial preparations) A).place the package, with the label facing up, on a clean, dry, flat surface. B). carefully remove the sealing tape. If the package is commercially prepared, carefully remove the outer protective wrapper. 9 Prepare the skin as part of sterile preparation. Many physicians prefer to prepare the skin using a sterile forcep after gloving. If this is the preferred procedure you may add sterile solutions to the field.Assist as needed with the administration of the anesthesia. 10 Assist the patient into the appropriate position. a). For the side-lying position :The patient is positioned on one side at the edge of the bed or examining table with back toward the physician; the thighs and legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae, for easier entry into the subarachnoid space. A small pillow may be placed under the patient‘s head to maintain the spine in a horizontal position; a pillow may be placed between the legs to prevent the upper leg from rolling forward. b).For the forward-leaning, supported position: stand in front and rest your hands on the patients shoulder as a reminder to remain still. Have the patient to breath slowly and deeply. No Comments

Nursing Skill Procedures

178

11

12

13

14

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Throughout the procedure observe the patient closely for signs such as dyspnea or cyanosis. Monitor the pulse at intervals. When the physician has the needle securely in place, help the patient to straighten slightly At the completion of the procedure, cover the site with an adhesive bandage and assist the patient to a supine position for 2 to 3 hours. If specimens are to be taken, put on gloves to receive the potentially hazardous body fluid. Label the tubes in sequence as you received them. Also label them with the patient‘s identification and place them in biohazard bags. Record the vital signs after the procedure. Note: note mental alertness, any leakage at the site, nausea and vomiting. Assess the lower limb mobility. The physician determines when the patient is ready to leave the examining room and the office. Clean the room and care for or dispose of the equipments as needed. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

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179

Teaching Patient to Use an Incentive Spirometer
Definition Incentive spirometer provides visual reinforcement for deep breathing by the patient and providing immediate positive reinforcement. Purpose: 1) It assists the patient to breathe slowly and deeply 2) To sustain maximal inspiration 3) To maximize lung inflation and prevent or reduce atelectasis 4) Optimal gas exchange is supported and secretions can be cleared and expectorated. Equipments: 1 Incentive spirometer 2 Stethoscope 3 Folded blanket and pillow for splinting of chest or abdominal incision if appropriate

No 1

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Procedure Review Chart for any health problem that would affect the patient‘s oxygenation status. Bring necessary equipments to the bedside stand or over bed table. Perform hand hygiene. Greet and identify the patient.

Rationale Identifying influencing factors aids in interpretation of results.

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Bringing everything to the bed conserves time and energy. To prevent the spread of infection. Providing explanation fosters his/her cooperation and allays anxiety. Close the curtains around the bed and This ensures the patients privacy. close the room, if possible. Explain Explanation relieves anxiety and facilitates what you are going to and why you are cooperation. going to do it on the patient. Assist patient to an upright or semiUpright position facilitates the lung fowler‘s position. Remove dentures if expansion. Dentures may inhibit the patients they fit poorly. Assess the patient‘s from taking deep breaths if he or she is level of pain. concerned that dentures fall out. Administer pain medication as Pain may decrease the patient‘s ability to prescribed, if needed. take deep breaths. Wait for the appropriate time for the Splinting the incision supports the area and medication to take effect. If the patient helps reduce pain from the incision. has recently undergone abdominal or chest surgery, place a pillow or folded blanket over the chest or abdominal incision for splinting. Demonstrate how to steady the This allows the patient to remain upright, spirometer with one hand and the visualize the volume of each breath, nad mouthpiece with the other hand. If the stabilize the device. patient cannot use hands than assists the patient.

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Instruct the patient to exhale normally and then place lips securely around the mouthpiece. Instruct the Patient to inhale slowly and as deeply as possible through the mouthpiece without using nose. When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of the gauge to determine progress and level attained. If patient begins to cough, splint an abdominal or chest incision. Instruct the patient to remove lips from the mouthpiece and exhale normally. If the patient becomes lightheaded during the process, tell him or her to stop and take few normal breaths before resuming incentive spirometry. Encourage the patient to perform incentive spirometry 5 to 10 times every 1 to 2 hours. At the completion of the procedure, cover the site with an adhesive bandage and assist the patient to a supine position for 2 to 3 hours. Clean the mouth piece with water and shake to dry. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

Patient should fully empty lungs so that maximal volume may be inhaled. A tight seal allows for maximal use of the device. Inhaling through the nose will provide an inaccurate measurement of inhalation volume. Holding breath for 3 seconds help the alveoli to re-expand. Volume on incentive spirometry should increase with practice.

Deep breaths may change the CO2 level, leading to light-headedness.

This helps to inflate the alveoli and prevent atelectasis due to hypoventilation. To separate the alignment of the dural and arachnoid needle punctures in the meninges, to reduce leakage of CSF. Cleaning equipments deters the spread of infection. To prevent the spread of infection Documentation provides continuity of care Giving signature maintains professional accountability To provide continuity of care

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181

Procedure Checklist Teaching Patient to Use an Incentive Spirometer
Check () Yes or No No 1 Procedure Yes Review Chart for any health problem that would affect the patient‘s oxygenation status. Bring necessary equipments to the bedside stand or over bed table. Perform hand hygiene. Greet and identify the patient. Close the curtains around the bed and close the room, if possible. Explain what you are going to and why you are going to do it on the patient. Assist patient to an upright or semifowler‘s position. Remove dentures if they fit poorly. Assess the patient‘s level of pain. Administer pain medication as prescribed, if needed. Wait for the appropriate time for the medication to take effect. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over the chest or abdominal incision for splinting. Demonstrate how to steady the spirometer with one hand and the mouthpiece with the other hand. If the patient cannot use hands than assists the patient. Instruct the patient to exhale normally and then place lips securely around the mouthpiece. Instruct the Patient to inhale slowly and as deeply as possible through the mouthpiece without using nose. When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of the gauge to determine progress and level attained. If patient begins to cough, splint an abdominal or chest incision. No Comments

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Instruct the patient to remove lips from the mouthpiece and exhale normally. If the patient becomes lightheaded during the process, tell him or her to stop and take few normal breaths before resuming incentive spirometry. Encourage the patient to perform incentive spirometry 5 to 10 times every 1 to 2 hours. At the completion of the procedure, cover the site with an adhesive bandage and assist the patient to a supine position for 2 to 3 hours. Clean the mouth piece with water and shake to dry. Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

183

Obtaining an Arterial Blood Specimen for Blood Gas Analysis
Definition The common site for sampling arterial blood is the radial artery.ABG sample can be used to analyze for oxygen content, saturation and blood PH Purpose: 1) To evaluate ventilation by measuring blood PH and the partial pressure of arterial oxygen (Pao2) and the partial pressure of carbon dioxide (Paco2). 2) To reveal the acid-base balance Equipments: 1 ABG kit, or heprainized, self filling 10ml syringe with 22-G, 1-inch needle attached. 2 Airtight cap for hub of syringe. 3 2*2 gauze pad 4 Band-Aid 5 Antimicrobial swab, such as chlohexidine 6 Biohazard bag 7 Appropriate label for specimen 8 Cup or bag of ice 9 Non-sterile gloves 10 Rolled towel

No 1

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Procedure Gather the necessary supplies. Check product expiration dates. Identify ordered arterial blood gases analysis. Check the chart to make sure the patient has not been suctioned within the past 15 minutes. Perform hand hygiene. Greet and identify the patient. Close the curtains around the bed and close the room, if possible. Explain what you are going to and why you are going to do it on the patient. Check specimen label with patient identification bracelet. Label should include patient name and identification number, time of the specimen collected, route of collection, amount of the oxygen the patient is receiving and any other information required by the agency.

Rationale Ensure proper function of the equipments.

Suctioning can change the oxygen saturation and is a temporary change. To prevent the spread of infection. Providing explanation fosters his/her cooperation and allays anxiety. This ensures the patients privacy. Explanation relieves anxiety and facilitates cooperation. Confirmation of the patients identification information ensures specimen is labeled correctly for the right patient.

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Provide for good light artificial light is recommended. Place a trash receptacle within easy reach.

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Good light is necessary to perform the procedure properly. Having the trash receptacle in easy reach allows the safe disposal of contaminated material. If the patient is on bed rest, ask him or Positioning the patient comfortably helps her to lie in the supine position, with the minimize the anxiety. head slightly elevated and the arms on Using a rolled towel under the wrist provides the sides. for the easy access to the insertion site. Ask the ambulatory patient to sit on the chair and support the arm securely on an armrest or a table. Place a rolled towel under the wrist. Perform Allen‘s test before obtaining a Allen‘s testing assesses patency of the ulnar sample from the radial artery. and radial arteries. a). Have the patient clench the wrist to minimize blood flow into the hand. b). Using your index and middle finger, press on the radial and ulnar arteries. Hold this position for a few seconds. c) Without removing your fingers from the arteries, ask the patient to unclench the fist and hold the hand in a relaxed position. The palm will be blanched because pressure from your fingers has impaired the normal blood flow. d) Release pressure on the ulnar artery. If the hand is flushed which indicates that the blood is filling it is safe to proceed with the radial artery puncture. This is considered a positive test if the hand does not flush. Put on non sterile gloves. Locate the Gloves reduce the transmission of infection. radial artery and lightly palpate it for a If you push too hard during palpation, the strong pulse. radial artery will be obliterated and hard to palpate. Clean the site with the antimicrobial Site cleansing prevents potentially infectious swab. Allow the site to dry. After skin flora from introduced into the vessel disinfection, do not palpate the site during the procedure palpation after unless sterile gloves are worn. cleansing contaminates the area. Hold the needle bevel up at a 45-degree The proper angle of insertion ensures correct angle at the site of maximum pulse access to the artery. The artery is shallow do impulse, with the shaft parallel to the not require the deeper angle to penetrate. path of the artery. (When puncturing the brachial artery, hold the needle at 60degree angle). Puncture the skin and arterial wall in The blood should enter the syringe one motion. Watch for blood backflow automatically due to arterial pressure. in the syringe. Do not pull back on the plunger. Fill the syringe to the 5ml mark.

Nursing Skill Procedures

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After collecting the sample, withdraw the syringe while your non-dominant hand is beginning to place pressure proximal to the insertion site with the 2*2 gauze. Press a gauze pad firmly over the puncture site until the bleeding stops atleast 5 minutes. Note: If the patient is receiving anticoagulant therapy or has a blood dyscrasia, apply pressure for 10 to 15 min if necessary ask the coworker to hold the gauze piece while you prepare the sample to transport to the laboratory, but do not ask the patient to hold the pad. When the bleeding stops and the appropriate time are lapsed, apply a small adhesive bandage or small pressure dressing. Once the sample is obtained check the syringe for air bubbles. If any appear, remove them by holding the syringe upright and slowly ejecting some of the blood onto the gauze. Engage the needle guard and remove the needle. Place the airtight cap on the syringe.  Gently rotate the syringe to ensure that the heparin is well distributed.  Do not shake.  Insert the syringe into the bag of ice. Place label on the syringe per policy. Place iced syringe in the plastic sealable biohazard bag.

If sufficient pressure is applied, a large, painful hematoma may form, hindering future arterial puncture.

Applying a dressing also prevents from the hemorrhage and extravasation into the surrounding tissues, which can cause hematoma. Air bubbles can affect the laboratory values.

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Discard needle in sharps container. Remove gloves Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

This prevents the sample from leaking and keeps air out of the syringe, because blood will continue absorbing oxygen and will give false reading if allowed to have contact with air.  Heparin prevents the blood from clotting.  Vigorous shaking may cause hemolysis.  Ice prevents the blood from degrading. Labeling ensures the specimen is the correct one for the right patient. Packing the specimen in a biohazard bag prevents the person transporting the samples from coming in contact with blood. Proper disposal of equipments prevent from accidental injury. To prevent the spread of infection Documentation provides continuity of care giving signature maintains professional accountability To provide continuity of care

Nursing Skill Procedures

186

Procedure Checklist Obtaining an Arterial Blood Specimen for Blood Gas Analysis
Check () Yes or No No 1 Procedure Yes Gather the necessary supplies. Check product expiration dates. Identify ordered arterial blood gases analysis. Check the chart to make sure the patient has not been suctioned within the past 15 minutes. Perform hand hygiene. Greet and identify the patient. Close the curtains around the bed and close the room, if possible. Explain what you are going to and why you are going to do it on the patient. Check specimen label with patient identification bracelet. Label should include patient name and identification number, time of the specimen collected, route of collection, amount of the oxygen the patient is receiving and any other information required by the agency. Provide for good light artificial light is recommended. Place a trash receptacle within easy reach. If the patient is on bed rest, ask him or her to lie in the supine position, with the head slightly elevated and the arms on the sides. Ask the ambulatory patient to sit on the chair and support the arm securely on an armrest or a table. Place a rolled towel under the wrist. Perform Allen‘s test before obtaining a sample from the radial artery. a). Have the patient clench the wrist to minimize blood flow into the hand. b). Using your index and middle finger, press on the radial and ulnar arteries. Hold this position for a few seconds. No Comments

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c) Without removing your fingers from the arteries, ask the patient to unclench the fist and hold the hand in a relaxed position. The palm will be blanched because pressure from your fingers has impaired the normal blood flow. d) Release pressure on the ulnar artery. If the hand is flushed which indicates that the blood is filling it is safe to proceed with the radial artery puncture. This is considered a positive test if the hand does not flush. Put on non sterile gloves. Locate the radial artery and lightly palpate it for a strong pulse. Clean the site with the antimicrobial swab. Allow the site to dry. After disinfection, do not palpate the site unless sterile gloves are worn. Hold the needle bevel up at a 45degree angle at the site of maximum pulse impulse, with the shaft parallel to the path of the artery. (When puncturing the brachial artery, hold the needle at 60-degree angle). Puncture the skin and arterial wall in one motion. Watch for blood backflow in the syringe. Do not pull back on the plunger. Fill the syringe to the 5ml mark. After collecting the sample, withdraw the syringe while your non-dominant hand is beginning to place pressure proximal to the insertion site with the 2*2 gauze. Press a gauze pad firmly over the puncture site until the bleeding stops atleast 5 minutes. Note: If the patient is receiving anticoagulant therapy or has a blood dyscrasia, apply pressure for 10 to 15 min if necessary ask the coworker to hold the gauze piece while you prepare the sample to transport to the laboratory, but do not ask the patient to hold the pad. When the bleeding stops and the appropriate time are lapsed, apply a small adhesive bandage or small pressure dressing.

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Once the sample is obtained check the syringe for air bubbles. If any appear, remove them by holding the syringe upright and slowly ejecting some of the blood onto the gauze. Engage the needle guard and remove the needle. Place the airtight cap on the syringe.  Gently rotate the syringe to ensure that the heparin is well distributed.  Do not shake.  Insert the syringe into the bag of ice. Place label on the syringe per policy. Place iced syringe in the plastic sealable biohazard bag. Discard needle in sharps container. Remove gloves Perform hand hygiene. Document the date, time, amount of puffs, and response. Sign on the documentation Report any findings to a senior staff.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

189

Eye Care: Contact Lens Removal
Purpose: 1) To prevent the clients eye from infection 2) During any emergency situations Equipments: Contact Lenses 1 Lens container 2 Soaking solution (type used by client) 3 Towel 4 Suction cup (optional) 5 Scotch tape (optional) 6 Nonsterile gloves

No 1 2

Procedure Assemble equipment for lens removal. Assess level of assistance needed, provide privacy, and explain the procedure to the client. Wash hands and don gloves. Assist the client to a semi-Fowler‘s position Drape a clean towel over the client‘s chest. Prepare the lens storage case with the prescribed solution. Instruct the client to look straight ahead. Assess the location of the lens. If it is not on the cornea, either you or the client should gently move the lens toward the cornea with pad of index finger Remove the lens. a. Hard lens:  Cup nondominant hand under the eye  Gently place index finger on the outside corner of the eye and pull toward the temple and ask client to blink b. Soft lens:  With nondominant hand, separate the eyelid with your thumb and middle finger.

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Rationale Promotes efficiency. Level of assistance determines level of intervention. Privacy reduces anxiety. Explanation of procedure promotes cooperation. Reduces transfer of microorganisms. Facilitates removal of lens. Provides a clean surface and facilitates the location of a lens if it falls during removal. Hard lenses can be stored dry or in a special soaking solution. Soft lenses are stored in sterile normal saline without a preservative. Client‘s position promotes easy removal of lens. Positioning lens on the cornea aids removal. Use of the finger pad of the index finger prevents damage to cornea and lens. Cupping the hand under eye helps to catch the lens and prevent breakage. Pulling corner of the eye tightens eyelid against eyeball. Pressure on upper edge of lens causes lens to tip forward.  Separating the eyelid exposes the lower edge of lens.  Positions lens for easy grasping with the pad of the index finger, which prevents injury to the cornea and lens. Squeezing the lens allows air to enter and release the suction.

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With the index finger of the dominant hand gently placed on the lower edge of the lens, slide the lens downward onto the sclera and gently squeeze the lens.  Release the top eyelid (continue holding the lower lid down) and remove the lens with your index finger and thumb Note: If step 8 is unsuccessful, secure a suction cup to remove the contact lens. If you are unable to remove the lens, notify. Store the lens in the correct compartment of the case (―right‖ or ―left‖). Label with the client‘s name.. Remove the other lens by repeating steps 8 and 9.

 Suction cup is used to remove a lens from an unconscious or dependent client.

Storage prevents damage to the lenses and ensures that each lens will be reinserted into the correct eye. Refer to steps 8 and 9.

11 12

Assess eyes for irritation or redness. Store the lens case in a safe place.

Signs of corneal irritation. Prevents damage or loss.

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Dispose of soiled articles and clean and return reusable articles to proper location. Reposition the client, raise side rails, and place call light in reach. Remove gloves and wash hands.

Reduces transmission of infection.

Promotes client comfort, safety, and communication Prevents transmission of infection.

Document procedure, client‘s response Documents the removal of lenses, condition and assessment findings, and the of the cornea, and where the lenses are storage place of the lenses. stored.

Nursing Skill Procedures

192

Procedure Checklist Eye care: Contact Lens Removal
Check () Yes or No No 1 2 Procedure Assemble equipment for lens removal. Assess level of assistance needed, provide privacy, and explain the procedure to the client. Wash hands and don gloves. Assist the client to a semi-Fowler‘s position Drape a clean towel over the client‘s chest. Prepare the lens storage case with the prescribed solution. Instruct the client to look straight ahead. Assess the location of the lens. If it is not on the cornea, either you or the client should gently move the lens toward the cornea with pad of index finger Remove the lens. a. Hard lens:  Cup nondominant hand under the eye  Gently place index finger on the outside corner of the eye and pull toward the temple and ask client to blink b. Soft lens:  With nondominant hand, separate the eyelid with your thumb and middle finger.  With the index finger of the dominant hand gently placed on the lower edge of the lens, slide the lens downward onto the sclera and gently squeeze the lens.  Release the top eyelid (continue holding the lower lid down) and remove the lens with your index finger and thumb Note: If step 8 is unsuccessful, secure a suction cup to remove the contact lens. If you are unable to remove the lens, notify. Yes No Comments

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Store the lens in the correct compartment of the case (―right‖ or ―left‖). Label with the client‘s name.. Remove the other lens by repeating steps 8 and 9. Assess eyes for irritation or redness. Store the lens case in a safe place. Dispose of soiled articles and clean and return reusable articles to proper location. Reposition the client, raise side rails, and place call light in reach. Remove gloves and wash hands. Document procedure, client‘s response and assessment findings, and the storage place of the lenses.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

194

Eye care: Artificial Eye Removal
Purpose: 1) To prevent the eye from infection 2) During any emergency situations Equipments: Artifical Eye 1 Storage container 2 Mild soap 3 3 × 3 gauze sponges 4 Cotton balls 5 Towel 6 Emesis basins 7 Eye irrigation syringe (optional) 8 Running water 9 Nonsterile gloves 10 Biohazardous bag 11 Saline solution

No 1 2 3 4 5 6

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Procedure Inquire about client‘s care regimen and gather equipment accordingly. Provide privacy Wash hands; don gloves. Place client in a semi-Fowler‘s position. Place the cotton balls in emesis basin and half fill with warm tap water. Place 3 × 3 gauze sponges in bottom of second emesis basin, and half-fill with mild soap and tepid water. Grasp and squeeze excess water from a cotton ball. Cleanse the eyelid with the moistened cotton ball, starting at the inner canthus and moving outward toward the outer canthus. After each use, dispose of cotton ball in biohazard bag. Remove the artificial eye: a. Using dominant hand, raise the client‘s upper eyelid with index finger and depress the lower eyelid with thumb b. Cup nondominant hand under the client‘s lower eyelid. c. Apply slight pressure with index finger between the brow and the artificial eye and remove it.

Rationale Promotes continuity of care. Relaxes the client. Prevents transmission of microorganisms. Facilitates procedure and client participation. Dry cotton balls could cause irritation. Gauze serves as padding to prevent breakage of the prosthesis. Eliminating the excess water prevents water from running down the client‘s face. Cleansing the eyelid prevents contamination of the lacrimal system (inner canthus area). Disposal of cotton balls prevents transmission of microorganisms to other health care workers. Promotes removal of artificial eye. Cupping prevents dropping and possible breaking of the eye. Applying pressure will help the prosthesis to slip out.

Nursing Skill Procedures

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Place the artificial eye in the emesis basin that has soap and water. Removal of an Artificial Eye

Prevents secretions from adhering to the prosthesis.

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Grasp a moistened cotton ball and cleanse around the edge of the eye socket. Dispose of the soiled cotton ball into biohazard bag. Replace the prosthesis in the soap-and-water solution. Inspect the eye socket for any signs of irritation, drainage, or crusting. Note: If the client‘s usual care regimen or physician order requires irrigation of the socket, proceed with step 12; otherwise, go to step 13. Eye socket irrigation: a. Lower the head of the bed and place the client in a supine position. Place protector pad on bed; turn head toward socket side and slightly extend neck. b. Fill the irrigation syringe with the prescribed amount and type of irrigating solution (warm tap water or normal saline). c. With nondominant hand, separate the eyelids with your forefinger and thumb, resting fingers on the brow and cheekbone. d. Hold the irrigating syringe in dominant hand several inches above the inner canthus; with thumb, gently apply pressure on the plunger, directing the flow of solution from the inner canthus along the conjunctival sac.

Cleanses the eye socket. Disposal of cotton ball prevents transmission of microorganisms to other health care workers. Keeping eye in solution during cleaning decreases risk of damage. Indicates an infection.

Cleanses the eye socket and removes secretions.  Positioning of client facilitates ease in performing the procedure and client comfort.  Assures compliance with client‘s regimen or prescribed orders.  Keeps the eyelid open and the socket visible.  Prevents injury to the client.  Prevents transmission of microorganisms to prosthesis.

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e. Irrigate until the prescribed amount of solution has been used. f. Wipe the eyelids with a moistened cotton ball after irrigating. Dispose of soiled cotton ball in biohazard bag. g. Pat the skin dry with the towel. h. Return the client to a semi-Fowler‘s position. I. Remove gloves, wash hands, and don clean gloves. Rub the artificial eye between index finger and thumb in the basin of warm soapy water. Rinse the prosthesis under running water or place in the clean basin of tepid water. Do not dry the prosthesis. Note: Either reinsert the prosthesis (step 15) or store in a properly labeled container (step 16). Reinsert the prosthesis: a. With the thumb of the nondominant hand, raise and hold the upper eyelid open. b. With the dominant hand, grasp the artificial eye so that the indented part is facing toward the client‘s nose and slide it under the upper eyelid as far as possible. c. Depress the lower lid. d. Pull the lower lid forward to cover the edge of the prosthesis. Place the cleaned artificial eye in a labeled container with saline or tap water solution. Grasp a moistened cotton ball and squeeze out excessive moisture. Wipe the eyelid from the inner to the outer canthus. Dispose of the soiled cotton ball in a biohazard bag. Clean, dry, and replace equipment. Reposition the client, raise side rails, and place call light in reach. Dispose of biohazard bag according to institutional policy. Remove gloves and wash hands. Document procedure, client‘s response and participation, and client teaching and level of understanding.

Creates cleaning with friction and prevents breakage of the prosthesis. Removes soap and secretions. Keeping the artificial eye wet prevents irritation from lint or other particles that might adhere to it and facilitates reinsertion.

Facilitates reinsertion of the prosthesis without discomfort to the client.

Protects the prosthesis from scratches and keeps it clean. Squeezing the cotton ball removes moisture. Cleansing the eyelid prevents contamination of lacrimal system. Disposal of cotton ball prevents the transmission of microorganisms to other health care workers. Promotes a clean environment Promotes client‘s comfort, safety, and communication. Prevents the transmission of microorganisms to other health care workers. Same as step 20. Demonstrates that the procedure was done and the level of client participation and learning.

Nursing Skill Procedures

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Procedure Checklist Eye care: Artificial Eye Removal
Check () Yes or No No 1 2 3 4 5 6 Procedure Yes Inquire about client‘s care regimen and gather equipment accordingly. Provide privacy Wash hands; don gloves. Place client in a semi-Fowler‘s position. Place the cotton balls in emesis basin and half fill with warm tap water. Place 3 × 3 gauze sponges in bottom of second emesis basin, and half-fill with mild soap and tepid water. Grasp and squeeze excess water from a cotton ball. Cleanse the eyelid with the moistened cotton ball, starting at the inner canthus and moving outward toward the outer canthus. After each use, dispose of cotton ball in biohazard bag. Remove the artificial eye: a. Using dominant hand, raise the client‘s upper eyelid with index finger and depress the lower eyelid with thumb b. Cup nondominant hand under the client‘s lower eyelid. c. Apply slight pressure with index finger between the brow and the artificial eye and remove it. Place the artificial eye in the emesis basin that has soap and water. Removal of an Artificial Eye Grasp a moistened cotton ball and cleanse around the edge of the eye socket. Dispose of the soiled cotton ball into biohazard bag. Replace the prosthesis in the soap-and-water solution. Inspect the eye socket for any signs of irritation, drainage, or crusting. Note: If the client‘s usual care regimen or physician order requires irrigation of the socket, proceed with step 12; otherwise, go to step 13. No Comments

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Eye socket irrigation: a. Lower the head of the bed and place the client in a supine position. Place protector pad on bed; turn head toward socket side and slightly extend neck. b. Fill the irrigation syringe with the prescribed amount and type of irrigating solution (warm tap water or normal saline). c. With nondominant hand, separate the eyelids with your forefinger and thumb, resting fingers on the brow and cheekbone. d. Hold the irrigating syringe in dominant hand several inches above the inner canthus; with thumb, gently apply pressure on the plunger, directing the flow of solution from the inner canthus along the conjunctival sac. e. Irrigate until the prescribed amount of solution has been used. f. Wipe the eyelids with a moistened cotton ball after irrigating. Dispose of soiled cotton ball in biohazard bag. g. Pat the skin dry with the towel. h. Return the client to a semi-Fowler‘s position. I. Remove gloves, wash hands, and don clean gloves. Rub the artificial eye between index finger and thumb in the basin of warm soapy water. Rinse the prosthesis under running water or place in the clean basin of tepid water. Do not dry the prosthesis. Reinsert the prosthesis: a. With the thumb of the nondominant hand, raise and hold the upper eyelid open. b. With the dominant hand, grasp the artificial eye so that the indented part is facing toward the client‘s nose and slide it under the upper eyelid as far as possible. c. Depress the lower lid. d. Pull the lower lid forward to cover the edge of the prosthesis.

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Place the cleaned artificial eye in a labeled container with saline or tap water solution. Grasp a moistened cotton ball and squeeze out excessive moisture. Wipe the eyelid from the inner to the outer canthus. Dispose of the soiled cotton ball in a biohazard bag. Clean, dry, and replace equipment. Reposition the client, raise side rails, and place call light in reach. Dispose of biohazard bag according to institutional policy. Remove gloves and wash hands. Document procedure, client‘s response and participation, and client teaching and level of understanding.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

Nursing Skill Procedures

200

Performing Range-of-Motion Exercises
Definition Range-of-motion exercises are performed by placing each joint through its full functional motion. Purpose: 1) To maintain full flexibility, maintain muscle tone and strength, prevent contractures, and improve circulation Equipments:  Bed with side rails No Procedure 1 Explain the purposes of range-ofmotion (ROM) exercises 2 Elevate the bed. 3 Assist client to supine position in a warm, comfortable environment. 4 Start at head of client and perform ROM exercises down each side of the body. 5 Repeat each range-of-motion exercise 5 times in a slow, firm manner.. 6 Cradle client‘s head with palms of hand while holding the extremities by the long bone areas. 7 Head: Rotation—Turn the head from side to side. Flexion and extension— Tilt the head toward the chest and then tilt slightly upward. Lateral flexion— Tilt the head on each side so as to almost touch the ear to the shoulder. Rationale Reduces client anxiety and increases cooperation. Decreases nurse‘s muscle strain. Promotes client‘s comfort level. Provides a systematic method to ensure that all body parts are exercised.

Provides support to each body part, thus reducing strain on muscles and joints.

A. Flexion of Neck

B. Extension of Neck

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Neck: Rotation—Place the client in a sitting position and rotate the neck in a semicircle while supporting the head. Trunk: Flexion and extension—Bend the trunk forward, straighten the trunk, and then extend slightly backward. Rotation—Turn the shoulders forward and return to normal position. Lateral flexion—Tip trunk to left side, straighten trunk, tip to right side. Have the client resume a supine position. Arm: Flexion and extension—Extend the arm in a straight position upward toward the head, then downward along the side. Adduction and abduction— Extend the arm in a straight position toward the midline (adduction) and away from the midline (abduction). Shoulder: Internal and external rotation—Bend the elbow at a 90° angle with the upper arm parallel to the shoulder; rotate the shoulder by moving the lower arm upward and downward. Elbow: Flexion and extension— Supporting the arm, flex and extend the elbow. Pronation and supination—Flex elbow, move the hand in palm-up and palm-down position.

A. Flexion of Elbow

B. Extension of Elbow

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Wrist: Flexion and extension— Supporting the wrist, flex and extend the wrist. Adduction and Abduction—Supporting the lower arm, turn wrist right to left, left to right, then rotate the wrist in a circular motion. Hand: Flexion and extension— Supporting the wrist, flex and extend the fingers. Adduction and abduction— Supporting the wrist, spread fingers apart and then bring them close together. Opposition—Supporting the wrist, touch each finger with the tip of the thumb. Thumb: Rotation—Supporting the wrist, rotate the thumb in a circular manner. Hip and Leg: Flexion and extension— Supporting the lower leg, flex the leg toward the chest and then extend the leg Internal and external rotation— Supporting the lower leg, angle the foot inward and outward. Knee: Flexion and extension— Supporting the lower leg, flex and extend the knee. Ankle: Flexion and extension— Supporting the lower leg, flex and extend the ankle. Foot: Adduction and abduction— Supporting the ankle, spread the toes apart and then bring them close together. Flexion and extension— Supporting the ankle, extend the toes upward and then flex the toes downward.

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Procedure Checklist Performing Range-of-Motion Exercises
Check () Yes or No No Procedure Yes Explain the purposes of range-of-motion 1 (ROM) exercises Elevate the bed. 2 Assist client to supine position in a 3 warm, comfortable environment. Start at head of client and perform ROM 4 exercises down each side of the body. Repeat each range-of-motion exercise 5 5 times in a slow, firm manner.. Cradle client‘s head with palms of hand 6 while holding the extremities by the long bone areas. Head: Rotation—Turn the head from 7 side to side. Flexion and extension—Tilt the head toward the chest and then tilt slightly upward. Lateral flexion—Tilt the head on each side so as to almost touch the ear to the shoulder 8 Neck: Rotation—Place the client in a sitting position and rotate the neck in a semicircle while supporting the head. Trunk: Flexion and extension—Bend the trunk forward, straighten the trunk, and then extend slightly backward. Rotation—Turn the shoulders forward and return to normal position. Lateral flexion—Tip trunk to left side, straighten trunk, tip to right side. Have the client resume a supine position. Arm: Flexion and extension—Extend the arm in a straight position upward toward the head, then downward along the side. Adduction and abduction— Extend the arm in a straight position toward the midline (adduction) and away from the midline (abduction). Shoulder: Internal and external rotation—Bend the elbow at a 90° angle with the upper arm parallel to the shoulder; rotate the shoulder by moving the lower arm upward and downward. Elbow: Flexion and extension— Supporting the arm, flex and extend the elbow. Pronation and supination—Flex elbow, move the hand in palm-up and palm-down position. No Comments

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Wrist: Flexion and extension— Supporting the wrist, flex and extend the wrist. Adduction and Abduction—Supporting the lower arm, turn wrist right to left, left to right, then rotate the wrist in a circular motion. Hand: Flexion and extension— Supporting the wrist, flex and extend the fingers. Adduction and abduction— Supporting the wrist, spread fingers apart and then bring them close together. Opposition—Supporting the wrist, touch each finger with the tip of the thumb. Thumb: Rotation—Supporting the wrist, rotate the thumb in a circular manner. Hip and Leg: Flexion and extension— Supporting the lower leg, flex the leg toward the chest and then extend the leg Internal and external rotation— Supporting the lower leg, angle the foot inward and outward. Knee: Flexion and extension— Supporting the lower leg, flex and extend the knee. Ankle: Flexion and extension— Supporting the lower leg, flex and extend the ankle. Foot: Adduction and abduction— Supporting the ankle, spread the toes apart and then bring them close together. Flexion and extension— Supporting the ankle, extend the toes upward and then flex the toes downward.

Recommendation: Pass ______ Need more practice _________________________________ Student: _______________________Date: _______________________________________ Instructor: _______________________ Date: _____________________________________

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