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STANDARD PRACTICE FOR ALL PROCEDURES


BEFORE THE PROCEDURE

Check the patients chart both to identify the patient and to


understand why procedure was ordered.

Evaluate if the patients condition or history will affect how the


procedure is performed.

Wash your hands.

Introduce yourself if the patient does not know you. Verify patients
identity.

Explain procedure to the patient and answer any questions.

Close curtains or door to ensure privacy.

Obtain and arrange supplies and equipment.

Raise the bed to the appropriate height, raise side rails, and obtain
assistance if necessary.

DURING THE PROCEDURE

Wash your hands.

Don gloves following standard precautions. Don eye protection and


gown, if necessary.

Execute procedure in accordance with standard practices.

AFTER THE PROCEDURE

Dispose of sharps in appropriate container.

Remove protective equipment.

Wash your hands.

Help the patient to a comfortable position.

Lower the bed height.

Wash your hands again before leaving the room.

Document the procedure and report signicant variations or results.

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Page i

Daviss Guide to

Clinical
Nursing
Skills
Jacqueline Rhoads, PhD, ACNP-BC, ANP-C, GNP, CCRN
Professor
Director of Primary Care in Community Health Public Health Nursing
Louisiana State University Health Sciences Center School of Nursing
New Orleans, Louisiana

Bonnie Juv Meeker, DNS, RN


Professor of Nursing
Southeastern Louisiana University
School of NursingBaton Rouge Center
Baton Rouge, Louisiana

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Page ii

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright 2008 by F. A. Davis Company
Copyright 2008 by F. A. Davis Company. All rights reserved.This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor: Robert G. Martone
Content Development Manager: Darlene D. Pedersen
Project Editor: Padraic J. Maroney
As new scientic information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher
have done everything possible to make this book accurate, up to date, and in accord with
accepted standards at the time of publication. The author(s), editors, and publisher are not
responsible for errors or omissions or for consequences from application of the book, and
make no warranty, expressed or implied, in regard to the contents of the book. Any practice
described in this book should be applied by the reader in accordance with professional
standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering
any drug. Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Rhoads, Jacqueline, 1948
Daviss guide to clinical nursing skills / Jacqueline Rhoads, Bonnie
Juv Meeker.
p. ; cm.
ISBN-13: 9780803611641
ISBN-10: 08036-11641
1. NursingHandbooks, manuals, etc. I. Meeker, Bonnie Juv.
II. Title. III. Title: Guide to clinical nursing skills.
[DNLM: 1. Nursing CaremethodsHandbooks. WY 49 R474d
2007]
RT41.D3844 2007
610.73dc22
2006034029
Authorization to photocopy items for internal or personal use, or the internal or personal
use of specic clients, is granted by F. A. Davis Company for users registered with the
Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of
$.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those
organizations that have been granted a photocopy license by CCC, a separate system of
payment has been arranged. The fee code for users of the Transactional Reporting Service
is: 8036-1164-1/07 1 $.10.

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Page iii

Contributors
Michael Adams, RN, MN, CRNA
Louisiana State University Health Sciences Center
Lake Chartes, Louisiana

Jennifer Eileen Badeaux, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Marie Billings, RN, MN


Southeastern Louisiana University
Hammond, Louisiana

Suzanne Robbins Blumer, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Daniel M. Castell, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Chris Davis, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

William Davis, MN, APRN, CRNA, CCRN


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Claudine Dufrene, RN, C, APRN, BC, MSN


University of Texas Medical Branch
Galveston, Texas

Carol Foster, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Deborah Delaney Garbee, PhD, APRN, BC


Louisiana State University Health Sciences Center
New Orleans, Louisiana

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iv Contributors

Kathleen Harris, RN, CWOCN


Wound, Ostomy, Continence Society
Baton Rouge, Louisiana

Denise Hart, MSN, APRN, BC, CWOCN


Southeastern Louisana University
Baton Rouge, Louisiana

Alison Hepting, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Barbara Hyde, EdD, APRN, FNPBC


Southeastern Louisiana University
Baton Rouge, Louisiana

Scott Larson, PT, OCS


BRPT Lake Rehabilitation Centers
Baton Rouge, Louisiana

Cynthia Logan, PhD, APRN


Southeastern Louisiana University
Baton Rouge, Louisiana

Jamie May, MN, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Karen B. Moody, PhD, RNC


Southeastern Louisiana University
Baton Rouge, Louisiana

Harold S. Mustin III, MN, APRN, CRNA

Judith L. Mysing RN, APRN, CRNA


Ochsner
New Orleans, Louisiana

Lynn Pennington, FNP-C, BC-ADM, CWOCN


Stanacola Medical Center
Baton Rouge, Louisiana

Demetrius Porche, DNS, APRN


Louisiana State University Health Sciences Center
New Orleans, Louisiana

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Contributors v

Susan Pryor, DNS, RN


Southeastern Louisiana University
Baton Rouge, Louisiana

Marcy Ruello, APRN, CRNA


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Ruth Rolling, RN, MSN


Southeastern Louisiana University
Baton Rouge, Louisiana

Jerilyn Schaller, MN, APRN


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Karen Silady, RN, MN, CEN, APRN


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Wanda Spurlock, DNS, RN, BC, CNS


Southern University and A&M College
Baton Rouge, Louisiana

Francise Thomas, MN, CCRN


Louisiana State University Health Sciences Center
New Orleans, Louisiana

Yolanda Jean Urick, MN, RN


Southeastern Louisiana University
Hammond, Louisiana

Sonja Washington, MN, CNS


Louisiana State University Health Sciences Center
New Orleans, Louisiana

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Page vi

Contents

U N I T

Basic Care
C H A P T E R

1.1
1.2
1.3
1.4

C H A P T E R

2.1
2.2
2.3
2.4
2.5

C H A P T E R

Vital Signs

Assessing Body Temperature,


30
Assessing Heart Rate,
38
Assessing Respiratory Rate,
44
Assessing Blood Pressure,
47

C H A P T E R

vi

20

Assessment
3

4.1
4.2
4.3
4.4

Infection Control

Handwashing,
18
Donning Isolation Gown and Gloves,
Droplet Precautions,
22
Contact Precautions,
24
Airborne Precautions,
26
U N I T

3.1
3.2
3.3
3.4

Hygiene

Giving a Complete Bed Bath,


2
Providing Mouth Care,
5
Performing Foot Care,
10
Making an Occupied Bed,
12

Physical Assessment

Assessing the Eyes,


54
Assessing the Ears,
61
Assessing the Nose and Sinuses,
Assessing the Mouth and Pharynx,

67
71

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4.5
4.6
4.7
4.8
4.9
4.10
4.11

Assessing the Neck,


75
Assessing the Thorax and Lungs,
78
Assessing the Heart and Vascular System,
86
Assessing the Musculoskeletal System,
96
Assessing the Abdomen,
100
Assessing the Neurologic System,
105
Assessing the Skin, Hair and Scalp, and Nails,
115

U N I T

Medication Administration
5 Oral and Topical Medications
C H A P T E R

5.1
5.2
5.3
5.4
5.5
5.6
5.7

Administering Oral Medications,


120
Helping Patients with Self-Medication,
126
Applying Medications to the Skin,
130
Administering Eye Drops and Ointments,
134
Instilling Medications into the Ear,
139
Administering Medications via Metered-Dose
Inhaler,
142
Administering Medications via Rectal
Suppositories,
145

C H A P T E R

6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9

Parenteral Medications

Administering Subcutaneous Injections,


150
Administering Intramuscular Injections,
155
Administering Intramuscular Injections by the
Z-Track Method,
161
Administering Intradermal Injections,
164
Administering Intravenous Medications by
Intermittent Infusion Sets or Mini-Infusion Pumps,
Administering Medications by Intravenous Bolus,
Teaching Patients How to Administer
Self-Injections,
183
Mixing Two Types of Insulin,
188
Using Patient-Controlled Analgesia (PCA) Infusion
Devices,
191

169
178

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viii Contents

U N I T

Respiratory
7
C H A P T E R

7.1
7.2

Performing Postural Drainage,


198
Teaching Controlled Coughing Techniques,

C H A P T E R

8.1
8.2

9.2
9.3
9.4
9.5
9.6
9.7

203

Oxygen Therapy

Administering Oxygen Therapy,


208
Administering Oxygen Therapy to the Patient with an
Articial Airway,
213

C H A P T E R

9.1

Noninvasive Pulmonary Hygiene

Ventilation Support

Managing Continuous Positive Airway


Pressure (CPAP),
220
Managing Intermittent Positive Pressure
Ventilation,
223
Managing Mechanical Ventilation (MV),
225
Using an Ambu Manual Ventilator,
229
Performing Endotracheal Tube Care,
232
Performing Tracheostomy Care,
235
Managing a Cuffed Endotracheal or Tracheostomy
Tube,
240

C H A P T E R

10

Airway Suctioning

10.1 Inserting an Oral or Nasal Airway,


244
10.2 Performing Oropharyngeal (Yankauer)
Suctioning,
249
10.3 Performing Nasopharyngeal and Nasotracheal
Suctioning,
252
10.4 Performing Endotracheal or Tracheostomy Tube
Suctioning,
257
C H A P T E R

11

Lung Re-Expansion or Chest


Drainage

11.1 Managing Chest Tube and Drainage Systems,


11.2 Assisting with Chest Tube Removal,
271

264

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U N I T

Cardiovascular
12 Intravenous Fluid Therapy
C H A P T E R

12.1 Inserting a Short-Term Intravenous Catheter,


276
12.2 Inserting Peripheral Midline and Central
Catheters (PICC),
285
12.3 Calculating and Regulating Intavenous Flow Rate,
293
12.4 Changing Intravenous Site Dressings
(Peripheral and Central),
296
12.5 Assisting with Percutaneous Central Line
Placement,
299
C H A P T E R

13.1
13.2
13.3
13.4

13

Circulatory Maintenance

Caring for Vascular Access Devices,


308
Applying Sequential Compression Devices,
311
Applying Antiembolic Hose,
313
Teaching Postoperative Leg Exercises,
315

C H A P T E R

14

Blood Transfusion Therapy

14.1 Transfusing Blood Products,


320
14.2 Assisting with Autotransfusion,
324
U N I T

Nutritional and Digestive


15 Oral and Enteric Nutrition
C H A P T E R

15.1 Administering Nasogastric, Nasoenteric, and Enteric


Tube Feedings,
330
15.2 Administering Medications Through a Feeding
Tube,
335
C H A P T E R

16

Parenteral Nutrition

16.1 Administering Total Parenteral Nutrition (TPN),


340
16.2 Administering Peripheral Partial Nutrition,
343
16.3 Administering a Fat Emulsion (Lipids),
346

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C H A P T E R

17

Gastrointestinal Intubation

17.1 Inserting a Nasogastric Tube,


352
17.2 Advancing a Nasoenteric Decompression Tube,
C H A P T E R

18

Bowel Elimination

18.1 Administering an Enema,


18.2 Managing a Rectal Tube,
18.3 Managing Ostomy Care,
U N I T

356

360
366
370

Renal and Urinary


19 Urinary Elimination
C H A P T E R

19.1 Inserting a Straight or Indwelling Catheter


(Male and Female),
378
19.2 Performing Catheter Care,
385
19.3 Applying a Urinary Incontinence Collection
Device,
388
19.4 Teaching Clean Intermittent Self-Catheterization,
C H A P T E R

20

Bladder Irrigation and Function

20.1 Performing and Managing Bladder Irrigation


Through a Three-Way Foley Catheter,
396
20.2 Obtaining a Post-Void Residual Urine Volume,
U N I T

391

400

Musculoskeletal
21 Body Alignment and Mechanics
C H A P T E R

21.1 Maintaining Proper Body Alignment,


21.2 Performing Correct Lifting Techniques,
C H A P T E R

22

406
411

Exercise and Ambulation

22.1 Performing Passive Range-of-Motion (ROM)


Exercises,
418
22.2 Teaching Isometric Exercises,
422

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22.3 Teaching the Patient to Crutch Walk or Use


a Walker,
425
C H A P T E R

23

Transfer and Positioning

23.1 Moving and Positioning the Patient in Bed,


432
23.2 Transferring a Patient from Bed to Wheelchair,
437
23.3 Teaching Hip Precautions,
439
C H A P T E R

24.1
24.2
24.3
24.4
24.5

24

Orthopedic Interventions

Providing Cast Care,


444
Applying Skin Traction,
448
Managing Skeletal Traction,
453
Applying a Moist Compress,
456
Applying an Ice Bag, Ice Pack, or Collar,

C H A P T E R

25

459

Beds, Frames, and Mattresses

25.1 Placing the Patient on a Specialty Surface,


25.2 Placing the Patient on an Air-Suspension or
Air-Fluidized Bed,
467
U N I T

464

Integumentary System and Wound Care


26 Pressure Ulcers
C H A P T E R

26.1 Assessing Pressure Ulcer Risk,


472
26.2 Implementing Pressure-Ulcer Prevention
Strategies,
477
26.3 Assessing Wounds and Staging Pressure Ulcers,
C H A P T E R

27

480

Wound Care

27.1
27.2
27.3
27.4
27.5

Applying a Pressure Bandage,


488
Administering a Sitz Bath,
490
Performing Wound Irrigation,
493
Managing Wound Drainage,
495
Teaching Self-Management of Wound-Drainage
Devices,
498
27.6 Applying Wound Dressings,
501
27.7 Applying and Managing a V.A.C. ATS System,

506

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U N I T

10

Specimen Collection
28 Collecting Blood Samples
C H A P T E R

28.1 Performing Venipuncture,


512
28.2 Obtaining a Blood Glucose Level by Finger Stick,
28.3 Obtaining a Specimen for Arterial Blood Gas
Analysis,
520
C H A P T E R

29

517

Collecting Urine Samples

29.1 Collecting a Midstream Urine Specimen,


526
29.2 Collecting a Timed (24-Hour) Urine Specimen,
528
29.3 Collecting a Sterile Urine Specimen from an
Indwelling Catheter,
531
29.4 Measuring Specic Gravity of Urine,
533
C H A P T E R

30

Collecting Other Specimens

30.1 Collecting a Nose or Throat Specimen for Culture,


30.2 Collecting a Sputum Specimen,
541
30.3 Obtaining a Wound Drainage Specimen,
545

References,

549

Illustration Credits,
Index,

555

552

538

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Page 1

U N I T

C H A P T E R

Basic Care

1
Hygiene
1.1
1.2
1.3
1.4

Giving a Complete Bed Bath, 2


Providing Mouth Care, 5
Performing Foot Care, 10
Making an Occupied Bed, 12

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2 C h a p t e r 1 Hygiene

PROCEDURE 1.1
Giving a Complete Bed Bath
OVERVIEW

Ensures cleanliness of patients who cannot bathe themselves.


Promotes circulation.
Provides comfort.
Maintains muscle tone and joint mobility through active and passive
movement.
Provides an opportunity for thorough assessment.

P R E PA R AT I O N

Assess patients ability to perform his or her own care.


Discuss patient preferences for bathing.
Provide privacy.
Avoid chilling the patient.
Wash your hands; wear gloves if you will come in contact with body
uids or handle a bedpan.
Gather all supplies in room before you begin.
Ask patient if he or she needs to use the bedpan
Check to see if patient is allergic or sensitive to soap.

Special Considerations
Patients who need a complete bed bath are usually dependent in
other ways also. They may need to be fed, be incontinent, or have
devices such as IVs, feeding tubes, or multiple dressings in place.
The nurse needs to be comfortable manipulating these devices
when giving the bath and ensuring patency and cleanliness of
these devices.
It is always preferable to have the patient assist with the bath as
much as possible, particularly with perineal care.
The bed bath is a good time to establish rapport and expand the
nursepatient relationship.
During and after the bath, the bed linen is changed, and the two
activities are usually combined.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired bed mobility


Bathing/hygiene self-care decit
Risk for disuse syndrome

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P r o c e d u r e 1 . 1 Giving a Complete Bed Bath 3


EXPECTED OUTCOMES

Patient expresses comfort and relaxation


Skin is clean and dry
Patient participates in the procedure as much as possible

E Q U I P M E N T/S U P P L I E S

Basin of warm water


Soap and soap dish
Towels and washcloths (two or three of each, if possible)
Laundry bag or hamper
Clean gown
Clean gloves

I M P L E M E N TAT I O N
Discuss procedure with patient and ensure privacy.
Promotes cooperation and decreases anxiety.
Place all supplies within reach.
Organizes task and prevents unnecessary steps.
Wash hands.
Reduces transmission of microorganisms.
Position bed at comfortable height.
Reduces nurses back strain.
Fill basin with warm water, and test temperature on wrist.
Testing temperature helps prevent accidental scalding.
Help patient to side of bed closest to you, and lower side rail.
Provides access to patient, and reduces back strain of nurse.
Remove patients clothes while providing warmth and privacy with

a covering such as a bed blanket.


Provides access to body parts; provides modesty and warmth.
Take washcloth and wrap the cloth around your hand tightly, form-

ing a mitt.
Prevents splashing water on patient and bedclothes.
Be careful of the patients eyes. Use clear water to clean them, start-

ing from the inner canthus to the outer canthus. If patient is not sensitive to soap, lather washcloth and gently wash the patients face,
starting from the forehead down.
Some patients are sensitive to soap or have very dry skin, and soap could
increase dryness and lead to irritation and skin breakdown. Bathe from

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4 C h a p t e r 1 Hygiene
cleanest area and work downward toward feet, going from areas of cleanest
to dirtiest.
Attention to the eyes prevents eye irritation and infection.
Bathe ears and front and back of neck.
Perspiration accumulates on the back of the neck when patients lie in bed for
long periods.
Bathe upper body and extremities, stroking arms from wrist to

shoulder. Include axillary area.


Stimulates circulation.
Soak hands in basin if indicated.
Dirt accumulates under ngernails, especially in incontinent patients.
Keep chest covered with towel and wash under breasts on female

patients. Apply powder if patient desires.


This area stays moist on many females and can lead to skin excoriation.
Bathe abdomen using side-to-side strokes on skin folds.
Moisture and debris can accumulate in skin folds leading to irritation.
Bathe legs and feet, being sure perineal area is draped.
Prevents unnecessary exposure.
Soak feet in basin if indicated, and if patient is able to hold leg in

position.
Soaking will soften rough skin and facilitate cleaning toenails.
Change bath water if necessary.
Bath water may be cool or dirty.
Assist patient to side-lying position and wash back. Give backrub.
Side-lying position gives access to patients back for backrub.
Put on clean gloves and bathe perineal area. Dry thoroughly.
Prevents cross contamination of organisms. Excess moisture contributes to
skin breakdown.
Remove gloves and assist patient to put on clean gown.
Promotes dignity and reduces exposure.
Conduct other personal hygiene activities as needed.
Promotes patients body image.
Lower bed, raise side rails, put call bell in reach, and dispose of used

equipment and linen.


Provides safety.
Wash your hands.
Reduces transmission of microorganisms.

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P r o c e d u r e 1 . 2 Providing Mouth Care 5


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Ask if patient is comfortable and feels refreshed


Make sure bed is in low position, side rails are up, and call bell is
within reach
Replace all supplies, and put equipment where it belongs

KEY POINTS

FOR

REPORTING

AND

RECORDING

Level of assistance the patient required.


Condition of skin and any signicant ndings, such as
decreased skin turgor, or areas of redness, swelling, or
breakdown.

PROCEDURE 1.2
Providing Mouth Care
OVERVIEW

Removes plaque and bacteria-producing agents from the oral cavity,


and removes unpleasant tastes and odors.
Teaches proper oral hygiene.
Assesses oral mucosa, teeth and throat at this time.
Procedure includes:
Brushing the teeth.
Flossing.
If the patient wears dentures, brushing dentures.
If patient is unconscious, providing complete mouth care.

P R E PA R AT I O N

Determine if the patient wears dentures.


Assess whether the patient can perform his or her own mouth care.
Inquire about oral hygiene practices.

Special Considerations
Patients who will need frequent oral hygiene are those with an oral
airway, NG tube, or tube feeding, and patients who are receiving
oxygen.

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6 C h a p t e r 1 Hygiene

Anyone who has not eaten for 12 hours or more should receive oral
care.
Check for personal preference prior to providing mouth care even
if the patient is unconsciousasking the patients family will allow
you to give the type of oral care most acceptable to the patient.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired dentition
Impaired oral mucous membrane
EXPECTED OUTCOMES

Oral mucosa, teeth, and throat have been inspected by the nurse
Food particles and plaque are removed without complication
Unpleasant odors and tastes are removed
Patient expresses comfort and satisfaction

E Q U I P M E N T/S U P P L I E S

Toothbrush
Dental oss
Cup of water
Emesis basin
Towel
Clean gloves
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Gather all equipment.
Promotes efficiency.
Discuss procedure with patient.
Discover hygiene preferences.
Put on clean gloves.
Prevents contact with microorganisms or body uids.
Assess oral mucosa, teeth, and throat.
Determines status of oral cavity and patients need for care and teaching.
Hold emesis basin beneath chin.
Catches spilled water and irrigation water.

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P r o c e d u r e 1 . 2 Providing Mouth Care 7


Taking the soft toothbrush in hand, brush the teeth starting from the

top front and moving to the back molars. Do not brush in a circular
motion, but begin at the gum line and sweep toward teeth. Brush
gently.
Stimulates gums and removes food particles from gum line.
With various disease states, gums become sensitive and easily fragile making
them more susceptible to micro tears.
Lightly brush the tongue.
Improves the breath, cleans the tongue of coated food particles and sputum.
Allow patient to rinse his or her mouth and expectorate into emesis

basin.
Irrigation removes food particles.
Ask the patient if he or she uses dental oss. If acceptable to

the patient, oss between each tooth, using approximately


1215 inches of easy-glide oss, taking care not to get oss
lodged between teeth.
Removes particles caught between teeth that was not removed by brushing.
Allow patient to rinse his or her mouth and expectorate into emesis

basin.
Removes food particles.
Remove equipment.
Proper disposal of equipment prevents spread of infection.
Remove gloves and wash hands.
Reduces spread of microorganisms.
Check to see if patient is comfortable.
Veries comfort status.
EQUIPMENT/SUPPLIES FOR PROVIDING DENTURE CARE

Toothbrush
Denture cup
Denture cleanser
Clean gloves
I M P L E M E N TAT I O N F O R P R O V I D I N G D E N T U R E C A R E
Wash hands, and put on clean gloves.
Reduces transmission of microorganisms, and prevents contact with body
uids.

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8 C h a p t e r 1 Hygiene
Help patient remove dentures or remove them by placing your

nger on the upper denture and gently pressing downward.


Breaks the seal at the roof of the mouth and allows the upper denture to
slide out. Lowers usually lift out easily.
Place a washcloth on the bottom of the sink, if washing dentures

over the sink.


Prevents dentures from breaking in case they are dropped in sink.
Take the patients soft toothbrush and gently brush the dentures

with toothpaste and rinse under running water.


Removes food particles and bacteria.
Replace dentures in patients mouth or store in denture cup full

of water.
Dentures need to be kept in a wet area to avoid warping.
Remove gloves and wash hands.
Reduces transmission of microorganisms.
E Q U I P M E N T/S U P P L I E S F O R P R O V I D I N G M O U T H
C A R E F O R U N C O N S C I O U S PAT I E N T S

Lemon-Glycerin or other mouth swabs (optional)


Toothbrush or sponge toothettes
Tongue blade
Emesis basin
Towel
Clean gloves
20-mL syringe
I M P L E M E N TAT I O N F O R P R O V I D I N G M O U T H C A R E F O R
U N C O N S C I O U S PAT I E N T S
Gather equipment listed above.
Promotes efficiency.
Wash hands, and put on clean gloves.
Reduces transmission of microorganisms and prevents contact with body
uids.
Place the patient in a side-lying position or, if patient does not have

any head or neck injury, turn the head to the side.


Allows uid to drain from mouth and prevents aspiration.
Place clean towel under the patients mouth.
Keeps bedclothes dry and free from debris.

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P r o c e d u r e 1 . 2 Providing Mouth Care 9


Brush teeth and tongue with brush or sponge toothettes, using

tongue blade to move cheek and lips to allow visibility of area.


Removes food particles and bacteria.
Rinse with very small amount of water using a 20-mL syringe and

gently irrigating the teeth and sides of the mouth, catching water
in emesis basin.
Large amounts of water can increase the patients chances for aspiration.
Repeat this step if patients mouth has dried sputum/saliva to loosen

dried debris gently.


Repeated gentle irrigation will loosen dried debris and prevent mucosal
breakdown.
Lubricate lips and tongue with lip protector lubricant.
Provides moisture and helps with control of halitosis.
Remove emesis basin and towel from under patients chin, ensuring

that the patient is dry and free from wetness.


Reduces transmission of microorganisms.
Reposition patient as necessary.
Frequent checks ensure correct body alignment.
Remove gloves and wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Condition of oral mucosa, teeth, and throat have been assessed by


nurse
Unpleasant odors and tastes have been eliminated
Excess secretions have been removed

KEY POINTS

FOR

REPORTING

AND

RECORDING

Findings of assessment of oral mucosa, teeth, and throat.


Oral care given.
Patients comfort level during the procedure.
Any abnormalities noted on assessment.

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10 C h a p t e r 1 Hygiene

PROCEDURE 1.3
Performing Foot Care
OVERVIEW

Prevents infection and injury to soft tissues.


Patients with peripheral vascular disease or diabetes mellitus need
to be referred to a specialist, such as a podiatrist.
Many institutions do not allow staff to perform foot care especially
with diabetic patientstoenail clipping should be referred to a
podiatrist but check with institutions policy before doing so.

P R E PA R AT I O N

Assess the ability of the patient to perform his or her own nail care
before intervening.
Assess condition of feet, toes, and toenails.
Inspect all surfaces of the nails.
Assess color, pulses, and temperature of toes and feet.
Check water temperature.

Special Considerations
Patients with Diabetes or Circulatory Disorders
Many diabetic patients lack sensation in their feet, which can allow
abrasions of the skin to go unnoticed and become infected.
Diabetic patients have an altered ability to ght infection.
It is usually permissible to le the nails of diabetic patients or those
with circulatory disorders. Check your institutions policy rst.
Teach patients the importance of proper foot care:
Inspect feet daily, including soles, heels, and areas between toes.
If necessary, use a mirror to inspect the soles and toes.
Always wear clean socks or stockings daily.
Check for holes or lumps in stockings or socks, which can contribute to skin breakdown.
Do not walk barefoot.
Wear properly-tting shoes.
Dry feet completely, especially between toes.
Check inside of shoes for stones, tears, or foreign objects before
putting them on.
Apply lotion if feet are exceptionally dry and aky.
Do not cut corns or calluses. Instead, alert the health-care provider.

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P r o c e d u r e 1 . 3 Performing Foot Care 11


R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to impaired blood ow


Risk for impaired skin integrity
EXPECTED OUTCOMES

Clean, manicured nails


Patient is able to verbalize correct nail care
E Q U I P M E N T/S U P P L I E S

Basin
Nail clippers
Emery board or nail le
Disposable gloves
Towel
Orange stick
I M P L E M E N TAT I O N
Inspect all surfaces of each foot. Check in between toes and around

nail bed to detect early skin breakdown. Check pulse, skin color, and
temperature, and compare to other foot.
Early detection of break in skin integrity. Identify circulatory problems.
Soak feet in basin lled with warm, soapy water before trimming the

toenails. Gently wash each foot, between nails, and all surfaces.
Soaking softens the nails and allows them to be trimmed and cleaned easily.
Washing removes dirt.
Thoroughly dry each foot. Be careful to dry in between toes.
Excess moisture leads to skin breakdown, possible fungal infections.
Perform nail care if allowed given facility policy and patient risks.
Improperly performed nail care can lead to nonhealing injuries, including the
potential for amputation in patients with impaired circulation.
Push cuticle gently back with orange stick.
Reduces incidence of irritated, cracked, loose fragmented cuticles.
After soaking the nails and if appropriate (if nails are not thick), use a

toenail clipper and clip nail straight across. Take care not to trim the
nail too short.
Cutting straight across prevents formation of sharp nail spikes that can
irritate nail margins.

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12 C h a p t e r 1 Hygiene
Slowly trim all toenails as previously described.
Take time to trim slowly, avoiding cutting toenails at corners, which may
damage tissues.
After all nails have been trimmed, lightly apply lotion to feet.
To lubricate dry skin and retain moisture.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess color, pulses, and temperature of toes, feet, and/or ngers


Assess condition of cuticles and surrounding skin after nail care
EXPECTED OUTCOMES

Patient verbalizes comfort and satisfaction with nail care


Nails are smooth, no breaks in skin integrity

KEY POINTS

FOR

REPORTING

AND

RECORDING

Procedure performed and any abnormalities seen.


of color, pulses, and temperature of toes, feet,
and/or ngers.
Any skin breaks or ulcerations observed.
Color, pulses, and temperature of toes, feet, and/or ngers.
Assessment

PROCEDURE 1.4
Making an Occupied Bed
OVERVIEW

Promotes patient comfort.


P R E PA R AT I O N

Determine need for assistance in rolling the patient from side to


side.
Determine if the patient is incontinent or has drainage from any
source, and obtain absorbent linen protectors, if necessary.

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P r o c e d u r e 1 . 4 Making an Occupied Bed 13

Special Considerations
Determine patients need for pain medication to make the process
of changing the bed easier.
Refusal to have bed changed: Nurse needs to determine the
reason that the patient refuses to have the bed changed. If, for
example, the patient is in pain, providing pain medication
15 minutes before assisting the patient out of bed may help
the patient move easier. Explain to the patient the importance
of moving.
Elderly Patient
Determine elderly patients skin condition during each linen change.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired bed mobility


Risk for Impaired Skin Integrity
EXPECTED OUTCOMES

Bed linens will be clean, dry, wrinkle free


Patient will verbalize comfort after the bed has been changed
Patient will experience minimal discomfort while the bed is being
made

E Q U I P M E N T/S U P P L I E S

Bottom sheet (tted if available)


Mattress cover
Draw sheet
Top sheet
Gloves and gown if there is presence of bodily uids or wet bed
clothes or if patient is in isolation
Pillowcases for each pillow
I M P L E M E N TAT I O N
Explain to the patient how you plan to change the bed.
Patient will know what to expect and can assist as much as possible.
Put on gloves and gown if there will be contact with body uids or if

the patient has been placed on contact isolation.


Reduces transmission of infectious organisms.

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14 C h a p t e r 1 Hygiene
Roll the patient to one side, opposite you. Make sure that if the

patient is not able to assist in turning, assistance is available to


help turn the patient safely and efficiently.
Prevents injury to the health-care provider and unnecessary strain and
pressure on the patient.
Once the patient is safely on his side, loosen the old linen from that

side closest to you.


Roll the dirty linen up close to the patients back.
Tuck the old linen close to the patients body.
If the mattress is wet from bodily excretions, wash the mattress with

a germicidal agent.
Reduces transmission of infectious organisms.
If the bottom sheet is tted, apply it smoothly and evenly to that

side.
If the bottom sheet is a at sheet, apply it as evenly as possible, leav-

ing at least 2 in. or less hanging over the top and bottom edge.
Place a bed protector 2 feet down from the top of the bed, and

place a draw sheet over the bed protector, if needed for patient
positioning.
Helps protect bottom sheet.
Allows moving the patient up in bed.
Roll the clean linen lengthwise, and tuck it under the rolled dirty

linen.
Protect the new linen from the old linen by adding a barrier such as

a Chucks pad between the soiled and new linen.


Prevents soiling clean sheets.
Raise side rail and move to opposite side of bed if making the bed

unassisted.
Roll the patient back over the roll of linen to the opposite side.
Loosen the old linen, gather, and place in pillowcase or linen bag,

keeping the soiled linen away from your body.

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P r o c e d u r e 1 . 4 Making an Occupied Bed 15


If the mattress is wet from bodily excretions, wash the mattress with

a germicidal agent.
Reduces transmission of infectious organisms.
Remove gown and gloves, and wash your hands.
Reduces transmission of infectious organisms.
Pull clean sheets, and tuck smoothly.
Ensures tight t of bottom sheet, thereby preventing skin wrinkling and skin
breakdown.
Tuck the sheet at the top, and square the corners.
Keeps the sheets and blankets secure and in place for patient comfort and
safety.
Move along each side of the bed and tuck in the sheet, pulling it

securely so the sheet is tight tting and there are no wrinkles.


Ensures smooth base free of wrinkles that could cause patient discomfort
and possible skin irritation
Once the bottom sheet is secure, place the draw sheet or pull sheet

on the bed 2 feet from the top of the mattress. Tuck the draw sheet
in securely and tightly.
Assists in repositioning the patient.
The top sheet should be placed over the bed making sure the top

of the sheet is at least 2 in. over the top of the mattress.


The top sheet can be tucked in or left loose, depending on patient
or nursing preference.
A blanket can be placed on top of the top sheet if the patient
desires.
Tuck in the bottom of the top sheet and blanket, if used. Square the

corners. Allow a 2-in. fold or pleat at the bottom of the top sheet so
patient can move feet freely.
Prevents too-tight sheets, which can contribute to foot drop and impaired
skin integrity.
Place a clean pillowcase on each pillow in the room, whether the

patient is using them or not.


Allows the easy use of clean pillows for positioning if needed.

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16 C h a p t e r 1 Hygiene
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Bed linens are clean, dry, wrinkle free


Patient verbalizes comfort in the clean bed

KEY POINTS

FOR

REPORTING

AND

RECODING

Document linen change and note if linens were wet secondary to perspiration or episodes of incontinence.

C H A P T E R

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2
Infection Control
2.1
2.2
2.3
2.4
2.5

Handwashing, 18
Donning Isolation Gown and Gloves, 20
Droplet Precautions, 22
Contact Precautions, 24
Airborne Precautions, 26

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18 C h a p t e r 2 Infection Control

PROCEDURE 2.1
Handwashing
OVERVIEW

Promotes asepsis.
Prevents the transmission of infections.
Removes transient organisms.
Handwashing is recommended:
After contact with blood and/or body uids, mucous membranes,
soiled linen, waste or contaminated equipment.
Immediately after removing gloves.
Before and after aseptic and sterile procedures.
Between tasks at different body sites.
Between patient contacts.
Before and after eating, drinking, smoking, applying cosmetics, or
preparing food.
Upon arrival at work and prior to departing the work setting.
Alcohol-based hand rinses are not a substitute for handwashing.

P R E PA R AT I O N

Remove jewelry and watches.

Special Considerations
Alcohol-based rinses can be used when soap is not readily available,
but hands should be washed as soon as possible after using alcoholbased rinses.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection


EXPECTED OUTCOMES

Organisms are not transmitted to other patients or health-care


workers
EQUIPMENT/SUPPLIES

Running water
Antimicrobial soap

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P r o c e d u r e 2 . 1 Handwashing 19
I M P L E M E N TAT I O N
Remove jewelry and watch.
Provides access to skin surfaces for cleaning. Permits thorough cleansing
of skin.
Rinse hands and wrist with running water.
Running water removes microorganisms. Provides effective soap
distribution.
Apply soap.
Detergents promote degradation of organisms. Lather facilitates removal of
microorganisms.
Use friction to wash hands for at least 10 to 15 seconds. Clean

between ngers, palms, back of hands, wrist, forearms, and skin


creases (knuckles). More time may be required for visibly soiled
hands.
Friction physically removes any transient organisms and soil.
Rinse with hands in a down position with elbows straight. Rinse in

direction of forearm to wrist to ngers.


Downward ow of water rinses away dirt and microorganisms.
Blot hand and forearms; dry thoroughly. Dry in direction of ngers to

wrist to forearms.
Blotting reduces chapping of skin. Dry in an upward direction from most
clean to least clean area.
Turn off water faucet with clean, dry paper towel.
Prevents contamination of clean hands.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

No evidence of soil or contaminants on hands


Hands are free of soap and dry

KEY POINTS

FOR

REPORTING

AND

RECORDING

Handwashing should be documented for aseptic and sterile


procedures.

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20 C h a p t e r 2 Infection Control

PROCEDURE 2.2
Donning Isolation Gown and Gloves
OVERVIEW

To protect patient from organisms or to prevent transmission of


infectious organisms to other patients or staff.
Isolation gown and gloves create a physical barrier between the
patient and health-care professional or visitor that reduces the risk
for infectious exposure.

P R E PA R AT I O N

Gown and gloves should be impermeable.

Special Considerations
Isolation equipment should be discarded upon exiting patients
room to prevent transmission of microorganisms.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection


EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted


to other patients or health-care workers
Health-care professionals do not transmit infections to patients
Gown and gloves are donned correctly

EQUIPMENT/SUPPLIES

Isolation sign
Disposable gown, gloves, and masks
Impermeable bags

I M P L E M E N TAT I O N
Remove jewelry, lab coat, and other items not necessary during

patient care.
Decreases spread of resident and transient microorganisms.
Wash hands.
Removes transient microorganisms.
Apply cap to cover hair and ears completely.
Cap protects hair from contamination and prevents transmission of microorganisms from hair to patient.

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P r o c e d u r e 2 . 2 Donning Isolation Gown and Gloves 21


Don gown.

Hold gown in front of the body while placing arms through sleeves.
Pull sleeves to wrist level.
Tie gown securely around neck and waist.

Disposable gown acts as a barrier between the health-care professional


and patient.
Don gloves. Pull gloves to cover gowns cuff.
Gloves act as a barrier between the health-care professional and patient
Apply mask.

Place the top of the mask over the nasal bridge and pinch the
metal strip to t snugly against your nose.
Tie mask in place.

Mask acts as a barrier between the health-care professional and patient for
any potential splashes or airborne/droplet precautions.
Exiting isolation room.

Untie gown at waist.


Remove one glove by grasping the cuff and pulling down so that
the glove turns inside out. Dispose of glove.
With ungloved hand, slip your nger inside the cuff of the other
glove, pull the glove off, inside out, and dispose of it.
Grasp and release the ties of the mask, dispose of mask.
Release neck ties of the gown allowing the gown to fall forward.
Place ngers of dominant hand inside cuff of other hand, and pull
gown sleeve over other hand.
With gowned covered hand, pull gown down over the dominant
hand, folding the gown together as it is pulled down, remove entire
gown and dispose of gown.
Remove cap by slipping ngers under the cap and removing from
the back and dispose of cap.

Gloves are removed inside out to avoid contact with skin. Gown is removed
and folded with hands touching only outer edge of gown to reduce contamination.
Wash hands.
Removes resident and transient microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Health-care professionals and visitors wear gloves upon entering


patients room

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22 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient diagnosis, infecting microorganisms, antimicrobial


therapy.
Isolation precautions implemented.
Maintenance of proper technique for donning gown and
gloves.
Date, time, and precautions implemented.

PROCEDURE 2.3
Droplet Precautions
OVERVIEW

To prevent the transmission of microorganisms transmitted by


droplets that are larger than 5 microns in size generated by patient
coughing, sneezing, or talking.
P R E PA R AT I O N

Place patient in private room. If private room is not available,


infected patients can be roomed with patients having the same
infection.
Contact precautions should be used with standard precautions.
Maintain at least 3 feet spatial separation between infected patient
and health-care professional or visitors.
Door may remain open.

Special Considerations
Isolation signs are a method for communicating isolation precautions to other health-care professionals and visitors.
Patient diagnosis should not be included on the isolation signs.
Patient transportation should be limited.
If a patient must be transported within the health-care environment,
the patient should wear a mask during transport.
Isolation precautions can be discontinued if the microorganism is
determined not to be communicable.

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P r o c e d u r e 2 . 3 Droplet Precautions 23
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection


Social isolation related to isolation
EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted


to other patients or health-care workers
Health-care professionals do not transmit infections to patients

EQUIPMENT/SUPPLIES

Masks
Droplet isolation sign
I M P L E M E N TAT I O N
Instruct patient on droplet precautions.
Patient education about droplet precautions may decrease feelings of anxiety, fear, stigma, and loneliness.
Place patient in private room or with another patient with the same

infection.
Decreases exposure of other patients to infectious microorganisms.
Don a mask when entering the room. Masks should be worn when

within 3 feet of the patient. Maintain standard precautions.


Microorganisms of 5 microns or larger are heavy and do not remain dispersed in the air, nor do these microorganisms travel more than 3 feet in
the air when dispersed.
Remove masks and other personal protective equipment prior to

leaving patients room.


Prevents further contamination and spread of infectious microorganisms.
Keeps any potential microorganisms in the patients environment.
Wash hands.
Removes any potential contamination and glove powder. Removes transient
organisms. Promotes asepsis.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Health-care professionals and visitors wear masks when within 3 feet


of patient

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24 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient diagnosis, infecting microorganism, antimicrobial


therapy.
Isolation precautions implemented.
Maintenance of droplet precautions.
Date, time, and precautions implemented when patient
transported.

PROCEDURE 2.4
Contact Precautions
OVERVIEW

To prevent the transmission of microorganisms transmitted via


direct contact (hand-to-skin contact) or indirect contact (touching
inanimate objects or contaminated environmental surfaces).
P R E PA R AT I O N

Place patient in private room. If a private room is not available,


infected patients can be roomed together.
Dedicate the use of noncritical patient care equipment to a single
patient. Avoid sharing between patients. If sharing of equipment is
unavoidable, the equipment must be thoroughly cleaned between
patient use

Special Considerations
Isolation signs are a method of communicating isolation precautions
to other health-care professionals and visitors.
Patient diagnosis should not be included on the isolation signs.
Patient transportation should be limited.
If a patient must be transported within the health-care environment,
the patient should wear gloves or site of infection must be concealed
with an impermeable barrier during transport.
Isolation precautions can be discontinued when the offending
microorganism is determined not to be communicable.

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P r o c e d u r e 2 . 4 Contact Precautions 25
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection


Social isolation related to isolation
EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted


to other patients or health-care workers
Health-care professionals do not transmit infections to patients

EQUIPMENT/SUPPLIES

Gloves
Contact isolation sign
I M P L E M E N TAT I O N
Instruct patient on contact precautions.
Patient education about contact precautions may decrease feelings of anxiety, fear, stigma, and loneliness.
Place patient in a private room. Keep door closed.
Decreases exposure of other patients to infectious microorganisms. Closed
door assists with maintaining negative pressure room.
Don gloves (clean, nonsterile gloves are adequate) when entering

the room. Change gloves during patient contact if gloves become


soiled or contaminated.
Gloves provide a barrier between health-care professional and infected
patient. Avoids skin contact with infected patient.
Remove gloves immediately upon exiting the room.
Prevents further contamination and spread of infectious microorganisms.
Keeps any potential microorganisms in the patients environment.
Wash hands.
Removes any potential contamination and glove powder. Removes transient
organisms. Promotes asepsis.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Health-care professionals and visitors wear gloves upon entering


patients room

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26 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient diagnosis, infecting microorganisms, antimicrobial


therapy.
Isolation precautions implemented.
Maintenance of contact precautions.
Date, time, and precautions implemented when patient transported.

PROCEDURE 2.5
Airborne Precautions
OVERVIEW

To prevent the transmission of microorganisms transmitted by


droplets with nuclei smaller than 5 microns in size. These microorganisms are lighter and remain suspended in the air with the potential of wide air dispersion.
P R E PA R AT I O N

Place patient in private room. If a private room is not available,


infected patients can be cohorts.
Keep door to room closed.
Monitor negative air pressure in room.
Ensure that room has 6 to 12 air exchanges per hour.
Ensure appropriate discharge of air outdoors or ensure that a highefficiency lter is in place for room air that is recirculated.

Special Considerations
Isolation signs are a method of communicating isolation precautions
to other health-care professionals and visitors.
Patient diagnosis should not be included on the isolation signs.
Patient transportation should be limited.
If a patient must be transported within the health-care environment,
he or she should wear a mask during transport.
Isolation precautions can be discontinued when the offending
microorganism is determined not to be communicable.

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P r o c e d u r e 2 . 5 Airborne Precautions 27
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection


Social isolation related to isolation
EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted


to other patients or health-care workers
Health-care professionals do not transmit infections to patients
Nosocomial infections do not occur
Masks worn upon entrance to patients room

EQUIPMENT/SUPPLIES

Masks
Airborne isolation sign
I M P L E M E N TAT I O N
Instruct patient on airborne precautions.
Patient education about airborne precautions may decrease feelings of anxiety, fear, stigma, and loneliness.
Place patient in a private room or cohort. Keep door closed.
Decreases exposure of other patients to infectious microorganisms. Closed
door assists with maintaining negative pressure room.
Don mask prior to entering patients room.
Microorganisms of 5 microns or smaller are light and are considered to be
dispersed throughout the patients room.
Remove masks and other personal protective equipment prior to

leaving patients room.


Prevents further contamination and spread of infectious microorganisms.
Keeps any potential microorganisms in the patients environment.
Wash hands.
Removes any potential contamination and glove powder. Removes transient
organisms. Promotes asepsis.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Health-care professionals and visitors wear a mask upon entering


patients room

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28 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient diagnosis, infecting microorganism, antimicrobial


therapy.
Isolation precautions implemented.
Maintenance of airborne precautions.
Date, time, and precautions implemented when patient
transported.

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U N I T

C H A P T E R

Assessment

3
Vital Signs
3.1
3.2
3.3
3.4

Assessing Body Temperature, 30


Assessing Heart Rate, 38
Assessing Respiratory Rate, 44
Assessing Blood Pressure, 47

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30 C h a p t e r 3 Vital Signs

PROCEDURE 3.1
Assessing Body Temperature
OVERVIEW

Establish baseline data.


Determine if core temperature is within normal range.
Determine changes in core temperature in response to specic
therapies (e.g., antipyretic medication, immunosuppressive therapy,
invasive procedures).
Monitor patients who are at risk for temperature alterations (those
exposed to extreme temperatures; patients at risk for or with a diagnosis of infection; patients with a leukocyte count below 5000 or
above 12,000).
Most common sites for measuring body temperature are sublingual,
rectal, axillary, and tympanic.
Site most often used for body temperature measurement is
sublingual.

P R E PA R AT I O N

Assess patient to determine appropriate method to obtain body


temperature.
For an oral temperature, obtain reading 15 to 30 minutes after ingestion of hot or cold food or uids or smoking.
Oral route is contraindicated if patient is unable to hold thermometer properly or if there is a risk that patient may bite thermometer.
Rectal thermometer must be held securely in place and never left
unattended.

TABLE 3.1 Comparing Fahrenheit and Centigrade Temperatures


FAHRENHEIT (F)

CENTIGRADE (C)

96.8
97.7
98.6
99.5
100.4
101.0
102.2
103.1
104.0
To convert degrees F to degrees C subtract 32, then multiply by 5/9.
To convert degrees C to degrees F multiply by 9/5, then add 32.

36.0
36.5
37.0
37.5
38.0
38.3
39.0
39.5
40.0

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P r o c e d u r e 3 . 1 Assessing Body Temperature 31

Special Considerations
Pediatric Patients
Oral temperature measurement is not used on infants or small
children.
Rectal temperature measurement is contraindicated in newborns.
Prevent infants and young children from kicking their legs or rolling
to their side while the thermometer is in place.
Tympanic membrane thermometers quickly obtain a childs temperature and may provide less of a threat to the child.
Elderly Patients
Disturbances in temperature regulation that normally occur with
aging can cause the older adult to have a lower-than-normal body
temperature.
R E L E VA N T N U R S I N G D I A G N O S E S

Ineffective thermoregulation
Risk for altered body temperature
EXPECTED OUTCOMES

Correct method for temperature assessment is performed


Accurate temperature data is obtained
E Q U I P M E N T/S U P P L I E S

Oral, rectal, axillary, or tympanic thermometer


Probe covers if electronic thermometer is used
Lubricant and tissue if rectal site is used
Towel if axillary site is used
Disposable gloves

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32 C h a p t e r 3 Vital Signs

FIGURE 3.1 Types of thermometers. (A) Glass thermometer.

(B) Electronic thermometer. (C) Tympanic-membrane thermometer (infrared). (D) Tape or other chemical/paper thermometer.
I M P L E M E N TAT I O N
Wash hands and apply disposable gloves.
Reduces transmission of microorganisms.
Explain procedure to patient.
Reduces anxiety and promotes cooperation.

Variation 1: Oral Temperature Assessment


Sublingual Temperature Using a Glass Thermometer
Hold color-coded end of glass thermometer between ngertips.
Prevents contamination of bulb to be inserted into patients mouth.
Slowly rotate thermometer at eye level to read mercury level.
Mercury is to be below 96F (35.5C). Thermometer reading must be below
patients actual temperature before use.
If mercury is higher than desired level, shake thermometer down-

ward. Hold upper end of thermometer securely between thumb


and forenger and stand away from solid objects. Sharply ick
wrist downward until mercury is at appropriate level.
Brisk shaking lowers mercury level in the glass tube. Standing in an open
area away from objects prevents the breakage of the thermometer.
Place thermometer in a plastic sheath according to agency policy.
Prevents spread of microorganisms.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 33


Ask patient to open mouth and gently place thermometer at the

base of the tongue to the right or left of the frenulum, in the posterior sublingual pocket.
Reects the core temperature of the blood in the larger blood vessels.
Ask patient to close the lips, not the teeth, around the thermometer.
Maintains the proper position of the thermometer. Biting could cause the
thermometer to break and can injure the oral mucosa and cause mercury
poisoning.
Leave the thermometer in place for 3 minutes or according to

agency policy.
Minimum amount of time recommended obtaining an accurate reading
with this type of thermometer.
Carefully remove thermometer, discard plastic sheath, and read

results at eye level.


Gentle handling prevents discomfort to patient and ensures an accurate
reading.

Variation 2: Rectal Temperature Assessment


Rectal Temperature
Draw curtains around the patients bed and/or close the door. Keep

the patients upper body and lower extremities covered.


This maintains privacy for the patient and minimizes patient embarrassment.
Assist patient into Sims position, with the upper leg exed to expose

anal area.
Children may be placed in a prone position.
This provides for optimal exposure of the anal area for correct placement of
the thermometer.
Squeeze a liberal amount of water-soluble lubricant onto a tissue.

Apply lubricant to the thermometer.


Insertion of the thermometer into the lubricant container would contaminate contents of the container. Use of lubrication minimizes trauma to the
rectal mucosa during insertion.
With the nondominant hand, raise the patients upper buttock to

expose the anus.


Full retraction of the buttocks completely exposes anus.
Gently insert the thermometer into the anus in the direction of the

umbilicus.
Insert the thermometer 11/2 in. (3.5 cm) for adults and 1/2 in. (1.2 cm)
for infants or children. Do not force the thermometer. Ask the patient
to take a deep breath and blow out. Insert the thermometer as the

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34 C h a p t e r 3 Vital Signs

patient takes in a breath. If resistance is felt, immediately remove the


thermometer.
Proper insertion of the thermometer ensures adequate exposure to the blood
vessels in the rectal wall. Gentle insertion prevents trauma to the mucosa or
the breakage of the thermometer. Having the patient take a deep breath
helps to relax the anal sphincter.
Hold the thermometer in place for a minimum of 2 minutes or

according to agency policy. It may be necessary to hold patients legs.


Holding the thermometer in place prevents injury to the patient.

Variation 3: Axillary Temperature


Axillary Temperature
Draw curtains around the bed and/or close the door.
Provides privacy and minimizes embarrassment for the patient.
Assist the patient into a supine or sitting position. Move clothing away

from the patients shoulder and arm. Be sure the axillary area is dry.
Provides optimal exposure of the patients axilla.
Place the thermometer into the center of the patients axilla, lower

the arm over the thermometer, and place the patients forearm
across the chest.
Maintains the proper position of the thermometer against the blood vessels
in the axilla.
Hold the thermometer in place for; 5 to 10 minutes or according to

agency policy.
The recommended time varies among agencies; 5 minutes is the time most
often recommended for children.
Remain with the patient and hold the thermometer in place if the

patient is unable to do so.


Prevents injury to the patient.
Remove the thermometer, remove plastic sheath, and read results

at eye level. Wash the thermometer in tepid, soapy water, rinse in


cold water, and dry. Shake down the thermometer and return it to
its container.
Cleaning the thermometer after use reduces the spread of infection.

Variation 4 : Electronic Oral Temperature Assessment


Electronic Thermometer: Oral Temperature
Attach the oral probe (blue tip) to the electronic display unit. Grasp

the top of the stem, using caution not to apply pressure to the eject
button.
Ejection button releases the plastic cover from the probe.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 35


Slide a clean disposable plastic cover over the temperature probe

until it locks in place.


The soft plastic cover will not break in the patients mouth and it prevents
transmission of microorganisms between patients.
Ask the patient to open mouth and gently place the probe under

the tongue, on either side of the frenulum.


This ensures accurate reading. Use of correct techniques prevents injury to
the patient.
Have patient keep the probe in place until the alarm on the elec-

tronic thermometer sounds and the temperature reading appears


on the digital display.
Electronic units register the body temperature within seconds.
Remove the probe from under the patients tongue, then push the

eject button on the thermometer probe to discard the plastic probe


cover into the proper receptacle.
This reduces the spread of infection.
Replace probe in electronic unit.
The battery unit is rechargeable.

Electronic Thermometer : Rectal Temperature


Attach the rectal probe (red tip) to the electronic display unit, using

care not to apply pressure to the eject button.


The ejection button releases the plastic cover from the probe.
Slide the clean disposable plastic cover over the temperature probe

until it locks into place.


This prevents the transmission of microorganisms.
With the nondominant hand, raise the patients upper buttock to

expose the anus.


This fully retracts the buttocks to expose the anus.
Apply lubricant to the probe end of the thermometer.
Lubricant minimizes trauma to the rectal mucosa during insertion of the
thermometer.
Gently insert the lubricated thermometer as previously described.
Proper insertion of the thermometer ensures adequate exposure to blood
vessels in the rectal wall. Gentle insertion prevents trauma to the mucosa,
while deep breaths help to relax the anal sphincter.
Hold the electronic probe in place until the electronic units alarm

sounds and the temperature reading appears on the digital display.


Electronic units register body temperature within seconds.

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36 C h a p t e r 3 Vital Signs
Carefully remove the probe from the patients rectum.
This avoids trauma to the rectal mucosa.
Push eject button on the thermometer probe and discard the plastic

probe cover into the proper receptacle.


This reduces the spread of infection.
Replace the probe in the electronic unit.
The battery unit is rechargeable.

Electronic Thermometer: Axillary Temperature


Attach the rectal probe (red tip) to the electronic display unit as

instructed in the rectal thermometer.


The ejection button releases the plastic cover from the probe.
Slide the clean disposable plastic cover over the temperature probe

until it locks in place.


This prevents transmission of microorganisms.
Insert the probe into the center of the axilla, lower the patients arm

over the thermometer, and place the arm across the patients chest.
Maintains the proper position of the thermometer against the blood vessels
in the axilla.
Hold the electronic probe in place until the electronic unit alarm

sounds and the temperature reading appears on the digital display.


Electronic units measure the body temperature within seconds.
Carefully remove the probe from the patients axilla and push the

eject button on the thermometer probe to discard the plastic probe


cover into the proper receptacle.
This reduces the spread of microorganisms between patients.
Replace the probe in the electronic unit.
The battery unit is rechargeable.

Electronic Thermometer: Tympanic Temperature


Attach a disposable probe cover to the thermometer unit.

Different size sheaths t adults and children.


This reduces the spread of microorganisms.
Select the ear opposite the side on which the patient has been lying.
The ear lying against a surface can build up heat.
Use the right hand to hold the thermometer when using the

patients right ear, the left hand for the left ear.
This helps to achieve the proper angle for a good seal.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 37


Gently pull the pinna upward and back for children older than age 3

and adults; straight back for children younger than age 3.


This straightens the ear canal.
Center the probe and gently advance into the ear canal to make a

rm seal, directing the probe toward the tympanic membrane.


The pressure close to the tympanic membrane seals the ear canal and allows
an accurate reading.
Press and hold the temperature switch until the green light ashes

and the temperature reading is displayed.


This method records core body temperature.
Remove the thermometer and discard the probe cover.
This reduces the spread of infection.
Return the thermometer to its home base or storage unit for

recharge.
The unit is rechargeable.
Assist the patient to return to a comfortable position.
This will restore the patients comfort.
Record the patients temperature in the proper chart or ow sheet.

Signify rectal reading by a capital R and an axillary reading by a


lower case a.
Vital signs should be recorded immediately after measurement.
R and a prevents later confusion with oral measurements.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare body temperature measurement with previous and baseline data


Determine if measurement is within normal range for the patient
Determine relationship to other vital signs
Notify physician of abnormal ndings

KEY POINTS

FOR

REPORTING

AND

RECORDING

Note the method of temperature measurement.


Report abnormal temperature variations to the physician.

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38 C h a p t e r 3 Vital Signs

PROCEDURE 3.2
Assessing Heart Rate
OVERVIEW

Provides valuable data regarding the integrity of the cardiovascular


system.
The most common sites of heart rate measurement are the apical
and radial pulses.
Other sites include temporal, carotid, brachial, femoral, popliteal, posterior tibial, and pedal pulses.
The pulse is assessed for rate, rhythm, strength, and equality.

Temporal

Carotid

Brachial

Radial
Ulnar

Femoral

Popliteal

Posterior tibial
Dorsalis pedis

FIGURE 3.2A Sites commonly used for

assessing radial pulse.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 39


P R E PA R AT I O N

Patient should be resting for measurement.


Factors such as exercise, anxiety, pain, and postural change should
be controlled to obtain an accurate measurement of heart rate.
Heart rate is affected by certain medications and disease processes.

Special Considerations
Pediatric Patients
The most accurate site for pulse assessment in infants and small
children is the apical site.
Manubrium
of sternum

Clavicle
Angle of
Louis

Midsternal line

Midclavicular line

Anterior
axillary
line
Apical
pulse
before
age 4
Apical
pulse
at ages
4 to 6

Body of
sternum

Apical pulse
in adult

FIGURE 3.2B Location of apical pulses for adults and children.

Resting heart range for newborns ranges from 80 to 180 beats per
minute.
Children 1 to 3 years of age have a resting heart rate that ranges
from 80 to 140 beats per minute. Children 6 to 8 year olds have a
resting heart rate that ranges from 75 to 120 beats per minute.
By 10 years of age, children have a resting heart rate that ranges
from 50 to 90 beats per minute.

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40 C h a p t e r 3 Vital Signs

Elderly Patients
The resting heart rate should range between 60 and 100 beats per
minute in the healthy older adult.
The healthy older adult has a normal cardiac rate and rhythm.
Older adults with cardiovascular, pulmonary, or other chronic illnesses are at risk for rapid, slow, or irregular heart rate and rhythms,
and their heart rates should be assessed with an apical pulse.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to cardiovascular disease


EXPECTED OUTCOMES

Accurate assessment of heart rate


Circulatory status is determined
EQUIPMENT/SUPPLIES

Wristwatch with second hand or digital display


Stethoscope (for apical heart rate)
Pen, pencil, and ow sheet or record form
I M P L E M E N TAT I O N

Assessing Radial Pulse


Wash hands.
Reduces transmission of microorganisms.
Explain purpose and method of assessment to the patient. If the

patient was recently active, wait 5 to 10 minutes.


This relieves patient anxiety and promotes cooperation. Activity and anxiety
may increase patients heart rate.
Have the patient get into a sitting or supine position. If in a

supine position, place the patients arm across lower chest with
the wrist extended and palm down. If sitting, bend patients
elbow 90 degrees and support the lower arm on a chair or
your arm. Extend the patients wrist with the palm down.
Proper positioning of the arm fully exposes the radial artery for palpation.
Place the tips of the rst two or three ngers of your hand over the

groove along the radial or thumb side of the patients inner wrist.
The ngertips are the most sensitive parts of the hand to palpate arterial pulsations. Avoid use of the thumb because it has pulsation and may interfere
with accuracy.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 41


Lightly compress your ngers against the radius, initially obliterate

pulse, and then relax the pressure so that the pulse becomes easily
palpable.
The pulse is assessed more accurately with moderate pressure. Too much
pressure occludes the pulse and impairs the blood ow.
When the pulse can be felt regularly, use a watchs second hand or

seconds elapsed display and begin to count the rate, starting with 0,
then 1, etc.
The rate is accurately determined only after the assessor is certain that a
pulse can be palpated. Timing should begin with 0 and the count of 1 is the
rst beat that is felt after the timing begins.
If the pulse is regular, count for 30 seconds and multiply by 2.
A 30-second pulse check is the most accurate for rapid pulse rates.
If the pulse is irregular, count for 1 full minute.
Counting for a full minute ensures an accurate count.
Assess regularity and frequency of any dysrhythmia.
Inefficient contraction of the heart fails to transmit a pulse wave and can
interfere with cardiac output.
Determine the strength of the pulse. Note whether the thrust of the

pulse against the ngertips is bounding, strong, weak, or thready.


The strength of the pulse reects the volume of the blood that is ejected
against the arterial wall with each contraction of the heart.
Assist patient to return to a comfortable position.
Promotes comfort.
Record characteristics of the pulse in the medical record or the ow

sheet. Report any abnormalities to the physician.


This provides data for monitoring of changes in the patients condition.
Detection of abnormalities may determine the need for medical intervention.

Assessing Apical Pulse


Clean the earpieces and the diaphragm of the stethoscope with an

alcohol swab.
This controls the transmission of microorganisms when nurses share a
stethoscope.
Wash hands.
This reduces the spread of microorganisms.
Explain procedure to patient. If patient was recently active, wait 10 to

15 minutes before obtaining measurement.

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42 C h a p t e r 3 Vital Signs
This relieves anxiety and promotes patient cooperation. Activity and anxiety
may increase the patients heart rate.
Close the room door and/or draw curtains around the patients bed.
This maintains patient privacy.
With the patient in a supine or sitting position, remove patients

upper garments to expose the sternum and left side of the chest.
This exposes the portion of the chest for selection of the auscultatory site.
Palpate the point of maximal impulse (PMI), located at the fth inter-

costal space to the left of the sternum at the midclavicular line.


The use of anatomic landmarks allows the correct placement of the stethoscope over the apex of the heart. This position enhances the ability to hear
heart sounds clearly. The PMI is located over the apex of the heart.
Place the diaphragm of the stethoscope in the palm of your hand

for 5 to 10 seconds.
This warms the diaphragm and reduces the risk for startling the patient.
Place the diaphragm of the stethoscope over the PMI, and auscultate

for normal S1 and S2 (lub, dub) heart sounds.


Heart sounds are the result of blood moving through the valves of the heart.
When S1 and S2 sounds are heard with regularity, observe the

watchs second hand and count one sound (lub) for 30 seconds,
then multiply the number by 2.
An accurate rate is determined only after the nurse is able to clearly auscultate the sounds.
If the heart rate is irregular or the patient is on cardiovascular med-

ications, count for 1 full minute.


The rate is determined more accurately when heard over a longer period.
Replace patients garments.
Provides comfort and privacy to the patient.
Record characteristics of the pulse on the ow sheet. Report any

abnormalities to the physician.


This provides data to monitor changes in the patients condition.
Abnormalities may require medical intervention.

Assessing an Apical-Radial Pulse: Two-Nurse Technique


Explain the procedure to the patient.
This decreases the patients anxiety.
Assist the patient into a supine position, and expose the chest area.
This exposes the portion of the chest wall for the site of the apical pulse.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 43


Place a watch where it will be seen by both nurses.
This facilitates accuracy in the beginning and the ending.
Position one nurse to take the radial pulse.
Locates the radial pulse.
The second nurse places the stethoscope on the patients chest at

the fth intercostal space to the left of the sternum at the midclavicular line.
Locates the apical pulse.
The nurse taking the radial pulse states Start when ready to begin

and Stop when completed.


This ensures that both counts are done simultaneously.
Both nurses count the pulse for 1 full minute at the same time.
Counting for 1 full minute is necessary for an accurate assessment of any
discrepancies that may exist between the two sites.
Compare the rates obtained. If a difference is noted between the

rates, subtract the radial rate from the apical rate.


This determines if a pulse decit exists. A pulse decit represents the number
of ineffective or nonperfused heartbeats.
Replace the patients clothing, and place patient in position of

comfort.
This restores patients privacy.
Notify the physician if a pulse decit was noted.
Provides prompt medical intervention.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Monitor patients response to activity, and note any abnormalities


Determine if external factors such as exercise, anxiety, pain, and postural change may have affected measurements
Report any abnormal ndings to physician

KEY POINTS

FOR

REPORTING

Pulse rate, rhythm, and strength.


Patients condition.
Any change in patients condition.

AND

RECORDING

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44 C h a p t e r 3 Vital Signs

PROCEDURE 3.3
Assessing Respiratory Rate
OVERVIEW

Establish baseline data.


Monitor respiratory rate, depth, and rhythm.
Assess patient for presence of dyspnea or cyanosis.
Assess for abnormal lung sounds, such as rales, rhonchi, or wheezes.
Note respiratory rate, rhythm, and depth.
Note labored, difficult, or noisy respirations or cyanosis.
Identify alterations in respiratory pattern resulting from disease
conditions.
Assess if accessory muscles are used for breathing.

P R E PA R AT I O N

Assess rate when patient is at rest.


Special Considerations
Pediatric Patients
Respirations range from 30 to 80 per minute in newborns. Children 1
to 3 years of age have a normal respiratory range of 20 to 40 breaths
per minute. Children 6 to 8 years olds have respiratory rates that
range from 15 to 25 breaths per minute, as do 10-year-old children.
Elderly Patients
Chronic illness in the older population can affect respiratory patterns.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange


Ineffective breathing pattern
EXPECTED OUTCOMES

Accurate respiratory data are obtained


Patient exhibits regular rate, depth, and rhythm of respirations
EQUIPMENT/SUPPLIES

A watch with a second hand

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P r o c e d u r e 3 . 3 Assessing Respiratory Rate 45


I M P L E M E N TAT I O N
Place the patient in a position of comfort, preferably sitting.
Discomfort can cause the patient to breathe more rapidly.
Place the patients arm in a relaxed position across the abdomen or

lower chest, or place your hand directly over the patients upper
abdomen.
This is the same position used during the assessment of the pulse. Both the
patients and the nurses hands rise and fall during the respiratory cycle.
Measurement of the respirations is done immediately after the pulse assessment and is not perceived by the patient.
Observe the complete respiratory cycle (consists of one inspiration

and one expiration).


This ensures that the count will begin with a normal respiratory cycle.
Once a cycle is observed, monitor the watchs second hand and

begin to count the rate of respirations. When the second hand


reaches a number on the dial, count one to begin the rst
cycle.
Timing of the respirations begins with a count of 1. Respirations occur more
slowly than the pulse; therefore, the count begins with 1.
For adults, count the number of respirations in 30 seconds, then

multiply by 2. For infants or young children, count the respirations


for 1 full minute.
The respiratory rate is equivalent to the number of respirations
per minute.
If an adults respirations have an irregular rhythm or they are

abnormally fast or slow, count for 1 full minute.


This ensures an accurate measurement.
While counting, note whether the depth of respirations is shallow,

normal, or deep and whether the rhythm is regular or altered.


The character of ventilatory movements may indicate specic alterations in
respirations or disease states.
Record the results in the chart or the ow sheet. Report any signs

of respiratory alterations to the physician.


This provides data to monitor for changes in the patients condition.
Abnormalities require medical intervention.

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46 C h a p t e r 3 Vital Signs

TABLE 3.3 Respiratory Rates and Rhythms


TYPE

DESCRIPTION

ILLUSTRATION

Respirations that are


regular but abnormally deep and
increase in rate
Biots respira- Periods of respiration of
equal depth, altertion
nating with periods
of apnea (absence of
breathing)
Cheyne-Stokes Gradual increase in
depth of respirations,
respiration
followed by gradual
decrease and then a
period of apnea
Absence of breathing
Apnea
Kussmauls
respiration

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the patients respiratory status, and compare to baseline


Compare the respiratory rate with the pulse and blood pressure
measurements

KEY POINTS

FOR

REPORTING

AND

RECORDING

Respiratory rate, depth, and rhythm.


Use of accessory muscles.
Abnormal breath sounds.
Respiratory status.
Alterations from baseline respiratory patterns.

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 47

PROCEDURE 3.4
Assessing Blood Pressure
OVERVIEW

Establish a baseline measurement of arterial blood pressure for


subsequent evaluation.
Determine the patients hemodynamic status (e.g., stroke volume
of the heart and blood vessel resistance).
Identify and monitor changes in blood pressure resulting from a
disease process and medical therapy (e.g., presence or history of
cardiovascular disease, renal disease, circulatory shock, or acute
pain; rapid infusion of uids of blood products).

P R E PA R AT I O N

Readings reecting a 20-mm Hg change in blood pressure should be


reported.
Although a diastolic pressure can be obtained by palpation, frequent
errors occur in obtaining results.
If the patient has had a mastectomy or has a hemodialysis shunt or
IV infusion, avoid taking blood pressure in the affected extremity.

Special Considerations
Pediatric Patients
Newborns have a mean systolic pressure of about 75 mm Hg.
The pressure rises with age, reaching a peak at the onset of puberty,
and then tends to decline somewhat.
One quick way to determine the normal systolic blood pressure of a
child is to use the following formula:
Normal systolic BP 80 (2 childs age in years).
Elderly Patients
In older people, elasticity of the arteries is decreasedthe arteries
are more rigid and less yielding to the pressure of the blood.
This produces an elevated systolic pressure.
Because the walls no longer retract as exibly with decreased pressure, the diastolic pressure is also higher.
R E L E VA N T N U R S I N G D I A G N O S E S

Decreased cardiac output related to low blood pressure


Excess uid volume

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48 C h a p t e r 3 Vital Signs
EXPECTED OUTCOMES

Blood pressure is accurately assessed within normal range for the


individual patient.
Severely altered blood pressure readings are rechecked with different equipment or validated by another nurse.
Alterations in blood pressure are identied early, and appropriate
treatment is initiated.

E Q U I P M E N T/S U P P L I E S

Sphygmomanometer with proper-size cuff


Stethoscope
I M P L E M E N TAT I O N
Check to determine if patient smoked or had caffeine prior to blood

pressure assessment.
This allows the nurse to assess blood pressure accurately and to identify signicant changes.
Instruct patient to refrain from both prior to measurement.
Determine the proper cuff size for the patient. The bladder should

completely encircle the arm without overlapping. The cuff should be


long enough to encircle the arm several times.
Proper cuff size is required for the correct amount of pressure to be applied
over the artery.
Determine the best site for the

cuff placement.
Application of pressure from an
inated cuff can temporarily
impair blood ow and compromise patients circulation.

FIGURE 3.4 Site for blood

pressure cuff placement.

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 49


Explain the purpose of the procedure to the patient.
This reduces anxiety.
Wash hands.
Reduces spread of microorganisms.
Assist the patient to a comfortable sitting position, with the upper

arm slightly exed, the forearm supported at heart level, and the
palm turned up.
Placing the arm above the level of the heart produces false-low readings.
This position facilitates cuff application.
Fully expose the patients upper arm.
This ensures proper cuff placement.
Palpate the brachial artery (on the lower medial side of the biceps

muscle) and position the cuff 1 in. (2.5 cm) above the pulsations.
The stethoscope will be placed over the artery without touching the cuff.
Center the arrows marked on the cuff over the brachial artery.
Inating the bladder directly over the brachial artery ensures that proper
pressure is applied during ination of the cuff.
With the cuff fully deated, wrap it evenly and snugly around the

upper arm.
A loose-tting cuff will cause a false elevation in the blood pressure
measurement.
Keep manometer at eye level.

The nurse should be no more than approximately 1 yard away.


This ensures accurate reading of the mercury level.
Palpate the brachial or radial artery while rapidly inating the cuff.

Inate to a pressure 30 mm Hg above the point at which the pulse


disappears. Slowly deate the cuff, and notice when the pulse reappears.
This identies the patients approximate systolic pressure and determines
the maximal ination point for an accurate reading. It also prevents an
auscultatory gap.
Place the stethoscope earpieces in the ears, and be sure that sounds

are clear, not muffled.


Each earpiece should follow the angle of the ear canal to facilitate hearing.

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50 C h a p t e r 3 Vital Signs
Deate the cuff, and wait 30 seconds.
Prevents venous congestion and false-high readings.
Relocate the brachial artery, and place the diaphragm of the stetho-

scope over it.


Ensures optimal reception of sound.
Close the valve of the pressure bulb by turning it clockwise until

tight.
Prevents air leaking during ination.
Inate the cuff to 30 mm Hg above the patients palpated systolic

level.
This ensures an accurate pressure measurement.
Slowly open the valve and allow the mercury to fall at a rate of 2 to

3 mm Hg per second.
A decline in mercury that is too fast or too slow may lead to an inaccurate
measurement.
Note the point on the manometer when the rst clear sound is

heard.
The rst Korotkoff sound indicates the systolic pressure.
Continue to deate the cuff gradually making note when the muf-

ed or dampened sound appears, and the point on the manometer


when the sound disappears in adults. (Note the pressure to the nearest 2 mm Hg.)
A fourth Korotkoff sound may be detected as a diastolic pressure in adults
with hypertension.
Continue to deate the cuff, noticing the point to the nearest 2 mm

Hg when the sound disappears.


The fth Korotkoff sound is recommended as the diastolic reading in an
adult.
Deate the cuff rapidly and remove from the patients arm, unless

the measurement needs to be repeated.


Continuous ination causes arterial occlusion, which will result in numbness
and tingling of the patients arm.
If the procedure needs to be repeated, wait 30 seconds.
This prevents venous congestion and a false-high reading.
Fold the cuff and store it in its proper place.
Proper maintenance of the equipment contributes to the accuracy of the
instrument.

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 51


Assist the patient to a comfortable position and cover upper arm.
Promotes comfort.
Record ndings on the medical record or the ow sheet.
This documents the procedure and the patients status.

Blood Pressure by Palpation


Explain the procedure to the patient
This decreases anxiety and promotes patient cooperation.
Wash hands.
Prevents transmission of microorganisms.
Locate the patients brachial or radial pulse.
This locates the pulse that offers the best palpable volume for the procedure.
Place the cuff on the patients arm.
This will position the cuff for ination.
Palpate again for the pulse. When the pulse is felt, continue to

palpate.
This relocates the pulse for the procedure.
Inate the cuff until unable to palpate the pulse.
This occludes the arterial blood ow.
Inate the cuff until the measurement gauge is 20 mm Hg past the

point at which the pulse was lost on palpation.


This identies the point of pulse return.
Slowly deate the cuff at a rate of 2 to 3 mm Hg per second.
This prevents the nurse from missing the rst palpable beat.
Note the reading on the measurement gauge when the pulse

returns. Remove cuff from the patients arm.


This identies the systolic blood pressure reading.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare blood pressure measurement to baseline


Note if blood pressure measurement is appropriate for age and
health status
Note the relationship of the blood pressure measurement to pulse
and respirations

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52 C h a p t e r 3 Vital Signs

KEY POINTS

FOR

REPORTING

AND

RECORDING

Document blood pressure measurement on appropriate form.


Report signicant change in the patients blood pressure to
physician.
Method of blood pressure measurement.
Patients condition.

C H A P T E R

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4
Physical Assessment
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11

Assessing the Eyes, 54


Assessing the Ears, 61
Assessing the Nose and Sinuses, 67
Assessing the Mouth and Pharynx, 71
Assessing the Neck, 75
Assessing the Thorax and Lungs, 78
Assessing the Heart and Vascular
System, 86
Assessing the Musculoskeletal System, 96
Assessing the Abdomen, 100
Assessing the Neurologic System, 105
Assessing the Skin, Hair and Scalp,
and Nails, 115

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54 C h a p t e r 4 Physical Assessment

PROCEDURE 4.1
Assessing the Eyes
OVERVIEW

The eyes are the sensory organ of vision. They allow humans to be
an integral part of the world.
Careful assessment of the eyes and vision is essential for promoting
health and well-being.

P R E PA R AT I O N

Review related history including


Vision difficulty, photophobia.
Eye pain; external eye problems, such as excessive tearing;
discharge; entropion; and ectropion.
Glaucoma.
Use of glasses or contact lenses.

Special Considerations
Pediatric Patient
Special accommodations must be made for the evaluation of visual
acuity in children, adults who cannot read, and those patients who
do not speak English. Often, the Snellen E chart can be used, and the
patient can point a nger in the direction that the legs are facing.
Picture cards can also be used. A translator or family member can
translate directions.
In examining the eyes of infants and children, it is important to
remember that a child does not achieve 20/20 vision until the age of
6 or 7. Color vision should be tested once between the ages of 4 and
8. Testing for strabismus is an important screening to perform in
early childhood, to receive the best prognosis. A funduscopic examination is difficult to perform on infants, but the red reex and pupillary response to light should be checked. School-age childrens
funduscopic examinations can be performed using the same procedure as that for adults.
Elderly Patient
The loss of elasticity in the skin may make the lids appear heavier
and the eyes appear sunken.
Decreased tear production causes the eye to look and feel dry.
Central acuity and peripheral vision may decrease as well.
Cataract formation, glaucoma, and macular degeneration are more
prevalent in the aging population.
Careful assessment is imperative to maintain adequate vision in
these populations.

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P r o c e d u r e 4 . 1 Assessing the Eyes 55


EXPECTED OUTCOMES

Completion of the eye examination while maintaining the patients


comfort
Examination adjusted for age, and developmental and educational
levels

R E L E VA N T N U R S I N G D I A G N O S E S

Possible disturbed sensory perception: visual


EQUIPMENT/SUPPLIES

Snellen eye chart


Near-vision card (Jaeger card)
or newsprint
Opaque cover card
Penlight
Ophthalmoscope

FIGURE 4.1 Ophthalmoscope.

I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Explain procedure to patient.
Careful explanation reduces the patients anxiety.
To test visual acuity.

Check distance vision using the Snellen eye chart.

Position the patient exactly 20 feet from the chart.

If patient wears corrective lenses, conduct the test with them on.

This is the most common and accurate measure of visual acuity.


Ensures accurate measurement of visual acuity.

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56 C h a p t e r 4 Physical Assessment
Only remove reading glasses because they will blur the patients far vision.
Record results and make sure to state the results were with corrective lenses
in place.

Direct patient to cover one eye with the opaque card and read the
smallest line possible.
Record the result as 20 (distance from the chart) over the number beside the
smallest line of print the patient can read with at least half the numbers correct.

Repeat for opposite eye.

Check near vision in patients who are older than 40 years or in


those complaining of reading difficulty.

Evaluates each eye separately.

Near vision is most commonly impaired in people who are older than 40
years. Use near vision card or newsprint to evaluate near-vision acuity.

Place the Jaeger card 14 inches in front of the patients face.

If patient wears corrective lenses, conduct the test with them on.

Direct patient to cover one eye with the opaque card and read the
smallest line possible.

Repeat for opposite eye.

Have patient hold and read from newsprint at a comfortable


distance.

Ensures accurate measurement of visual acuity.


Allows evaluation of corrected vision.

Record the results as J1 through J12 as indicated on the chart.


Evaluates each eye separately.

Record the type of reading material and the distance held from the face.
Test visual elds by performing the confrontation test.
This test is a gross measure of peripheral vision. It compares the patients
peripheral with the examiners.

Position yourself at eye level and about 2 feet away from the patient.

Direct the patient to cover one eye with the opaque card and to
look straight at you with his or her left eye. Cover your eye opposite
to the patients covered one.

Hold a raised nger or pen midline between you and the patient
and slowly advance it from the periphery in several directions
(temporal, nasal, superior, and inferior).

Allows the patient and examiner to have the same eld of vision.

Allows the patient and examiner to have the same eld of vision.

Provides a focus target; tests all peripheral vision elds except the temporal in
which the object should come from slightly behind the patients head.

Have the patient say now as the target is rst seen; this should be
just about the time that you see the object also.
Compares the patients peripheral vision to your own.

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P r o c e d u r e 4 . 1 Assessing the Eyes 57

Repeat the entire procedure for the opposite eye.


Tests peripheral vision of both eyes.

Test extraocular muscle function.


Check corneal light reex.
Assesses the parallel alignment of the eyes.

Instruct the patient to stare straight ahead while you shine a light
into his or her eyes from 30 cm (12 inches) away.
Note the location of the light reection on the corneas; it should be
in exactly the same spot in each eye.

Allows detection of any deviation in alignment due to eye muscle weakness


or paralysis.
Check for coordinated movement of the eyes.
Elicits any eye muscle weakness during movement.

Direct patient to hold head still and follow your nger only with his
or her eyes as it moves.

Hold your nger about 30 cm (12 inches) in front of the patient.

Slowly move your nger from the center out to each of the six cardinal elds of gaze, hold it momentarily, and then move it back to
center.

Encourages eye movement only.


Allows the patient to focus comfortably on the object.

Allows detection of any eye movement that is not parallel. Also detects nystagmus and lid lag.

Observe for a normal response, which is parallel tracking of the nger with both eyes.
An abnormal response indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

Check for convergence.


Elicits any eye muscle weakness during movement.

Have the patient watch your nger as it is moved from in front of


the eyes to the bridge of the nose.

Observe for medial movement of both eyes.

Encourages a focal point of vision.


Elicits an asymmetric response if abnormal.
Inspect the external eye structures.

Note eyelids and lashes.


Note any visible sclera above the iris, closure, or lesions. Note distribution and
direction of lashes.

Note the position of the globe.


Protrusion may be indicative of thyroid disorder; sunken eyes may be indicative of dehydration or wasting illness.

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58 C h a p t e r 4 Physical Assessment

Note the conjunctiva and sclera.

Note the lacrimal gland.

Indicative of local infection, hemorrhage, or jaundice.


Redness, swelling or excessive tearing may indicate blockage of the nasolacrimal duct.
Inspect the anterior eye structures.
Provides an evaluation of the anatomic structures involved in sight.

Check the clarity of the cornea by shining a light from the side
onto each eye.
This oblique view allows detection of any irregularities in the corneal surface
such as opacities or irregular ridges in the reected light.These ndings may be
indicative of uid accumulation or a corneal abrasion, respectively.

Note the shape and coloration of the irises. Compare the irises
bilaterally.
May indicate infection, glaucoma, or abnormalities in the pupils.

Inspect the pupils for color, size, and equality.


Abnormalities may indicate cataracts or neurologic problems.
Test the pupillary response to light.
Abnormalities may indicate neurologic problems.

Have the patient look into the distance, then shine a light on each
pupil in turn. Make sure to advance the light from the side to
directly in front of the pupil.
Bringing the light in from the side will elicit a true light reex. If the light is
advanced from the front, the eyes will constrict to accommodate for near
vision.

Observe for constriction of the pupil into which the light was
shown (direct response) and for the simultaneous constriction
of the other pupil (consensual response).
These responses provide information on the central nervous system and the
effect of certain drugs, including narcotics and anticholinergics.

Test for accommodation.


Elicits vision problems or eye muscle weakness.

Direct the patient to focus on an object in the distance, then have


the person focus on your nger held 8 to 10 cm (34 inches) from
the nose.
Focusing on distant objects dilates the pupils, whereas focusing on near
objects constricts the pupils.

Observe the patient for pupillary constriction and convergence.


Absence of constriction or convergence indicates a problem with vision
and/or eye muscle weakness.

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P r o c e d u r e 4 . 1 Assessing the Eyes 59


Examine the ocular fundus (retina, optic disk, macula, and retinal

vessels) in a darkened room using an ophthalmoscope.


Perform this examination to view the inner structures of the eye. This is the
only place in the body where you can directly view the blood vessels that are
affected in systemic diseases, namely hypertension.

Remove eyeglasses worn by either the patient or you.


Eyeglasses obstruct close movement, and you can adjust the diopter setting
to correct your vision.

Select a large, round aperture with white light for routine


examination.
The light used should have maximum brightness to facilitate an
adequate examination.

Hold the ophthalmoscope in your right hand up to your right eye


to examine the patients right eye while placing your free hand on
the patients forehead.
This position allows you to gain close proximity to your patient while your
free hand helps to orient you and secure the patients upper lid to help prevent blinking.

Have the patient focus on a distant xed object.


Staring at a distant object helps to dilate the pupils and hold the retinal
structures still.

Begin the examination about 10 inches from the patient slightly


lateral to the patients eld of vision; note the red reex and
steadily move closer to the eye.
The red reex is caused by the reection of the light of the ophthalmoscope
off the retina; any variations such as dark or black spots may indicate
cataracts.

Continue moving in along a 15-degree lateral line to locate the


optic disk, which is to the nasal side of the retina; it can also be
found by following a blood vessel as it enlarges.

Focus on the optic disk, and note its color, shape, margins, and cupdisk ratio.

The larger retinal vessels converge at the optic disk.

The disk should be creamy yellow-orange to pink, round or oval, with distinct
margins. The cup-disk ratio may vary, but is normally not greater than one
half the disk diameter. Variations in color and margins may indicate pallor or
differences in pigmentation.

Note the retinal arterioles and veins (darker and larger than arterioles). Observe their branching pattern, contour, and integrity.
Many systemic diseases that affect the vascular system show signs in the retinal vessels. Narrowed, discolored, and/or nicked vessels are some of the most
signicant evidence of hypertension and arteriosclerosis.

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60 C h a p t e r 4 Physical Assessment

Examine the general background of the fundus.


Color should be consistent with the patients skin color; look for lesions, exudates, or microaneurysms.

Last, locate the macula, which should be 2 disc diameters (DD)


temporal to the disc.
Examine this structure last, because it may cause watering and discomfort.
Clumped pigment in the macula may indicate trauma or retinal detachment.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Refer patient to optometrist or ophthalmologist as needed for evaluation of abnormal ndings

KEY POINTS
Visual

FOR

REPORTING

AND

RECORDING

acuity results for the left eye (O.S.) and right eye (O.D.)
separately. For Snellen chart, record the result as 20 over the
number beside the smallest line of print the patient can read
with at least half the numbers correct. For the Jaeger chart,
record the results as J1 through J12 as indicated.
Results of visual confrontation test, extraocular movements,
normal or abnormal ndings.
Symmetry of corneal light reex, eyelids.
Color of conjunctiva and sclera, and any abnormal ndings
during the external eye examination.
Pupillary ndings: if normal, may chart PERRLA (pupils equal,
round, reactive to light, and accommodation); if abnormal,
chart ndings.
Fundi ndingsshape, margins, vessels, ability to see macula.
Document any abnormal ndings in the fundus by noting the
clock position and relation to the optic disk in terms of size
and distance. Example: Noted at 2 oclock 3 DD from the disk.
Visual acuity results.
Patients use of corrective lenses or glasses and vision with
corrected noted.

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P r o c e d u r e 4 . 2 Assessing the Ears 61

PROCEDURE 4.2
Assessing the Ears
OVERVIEW

Plays an important role in the function of the ear as the sensory


organ for hearing and maintaining equilibrium.
Can help determine if hearing, equilibrium, or even speech problems
stem from the ear, or if the neurologic system may be involved.

P R E PA R AT I O N

Review related history that would give the examiner information


(past and present) regarding patients hearing and general ear condition, including earaches, infections, tinnitus, vertigo, and speechdevelopment problems.
Ask about the intake of ototoxic drugs such as aspirin, furosemide,
quinine, and aminoglycosides (gentamycin, vancomycin).
Observe for signs of hearing loss during all interactions with the
patient.
Adjust your examination for the developmental and cultural needs
of the patient.

Special Considerations
Never insert a speculum if a foreign object is seen in the external
auditory canal.
Pediatric Patient
In infants and children, otoscopic examination is best done at the end
of the complete assessment, because children tend to protest. Make
sure the child is securely restrained, preferably in the caretakers lap,
to prevent head movement during the examination. Remember to
pull the pinna straight down and back in children younger than 3
years old to match the direction of the ear canal. The tympanic membranes of a child may appear reddened and swollen, especially after
crying. A pneumatic bulb may be used in children to introduce air
into the canal and examine the mobility of the tympanic membrane.
Use developmental milestones to assess hearing in an infant. Loud,
sudden sound should produce:
Newbornstartle reex, acoustic blink reex
34 monthsacoustic blink reex, infant stops movement
68 monthsturns head toward sound, responds to own name
Delayed speech development can indicate a hearing problem in
children.

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62 C h a p t e r 4 Physical Assessment

Elderly Patient
Elderly patients may have more pendulous earlobes; men may have
coarse hairs present at the opening of the ear canal; the eardrum
may appear whiter, thicker, and more opaque than in younger
patients.
Presbycusis, the hearing loss that occurs with aging, affects the highfrequency tones.
This condition may become apparent in the whispered test and in
difficulty hearing consonants during conversation.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible disturbed sensory perception: auditory


EXPECTED OUTCOMES

Completion of the assessment, including examination of the external


ear, internal ear, hearing, and equilibrium while maintaining patient
comfort and safety
Examination performed appropriately for age, and developmental
and educational levels

EQUIPMENT/SUPPLIES

Otoscope with bright white light


Pneumatic bulb attachment
(optional)
Tuning fork (512 or 1024 Hz)

FIGURE 4.2A Otoscope.

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P r o c e d u r e 4 . 2 Assessing the Ears 63

FIGURE 4.2B Tuning fork.

I M P L E M E N TAT I O N
Inspect the external ear.
Provides information and evidence of infection, deformities, trauma, or systemic problems.

Note placement, size, shape, symmetry of placement, and skin color.


Abnormal size or placement of ears is associated with some genetic disorders; reddened ears may indicate inammation, whereas red-blue color indicates frostbite. Ecchymosis behind the ear (Battles sign) may indicate basilar
skull fracture.

Observe for drainage, swelling, lumps, and lesions.


These signs are often found in infection, dermatitis, or carcinoma.

Palpate the external ear for nodules and tenderness.


Uncovers abnormalities that cannot be seen.

Move the pinna, push on the tragus, and press on the mastoid
process.
These maneuvers elicit pain and tenderness with otitis externa, mastoiditis,
or trauma.

Inspect the external auditory meatus noting the size of the opening,

any redness, swelling, or discharge


Cerumen may be present, but other discharge may indicate infection.
Examine the ear canal and eardrum using the otoscope.
Provides a thorough examination of the ear that cannot be examined with
the naked eye

Choose the largest speculum that will t comfortably in the ear


canal. Slightly tilt the patients head to the opposite shoulder of
the ear that is being examined
This will provide the best view of the eardrum.

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64 C h a p t e r 4 Physical Assessment

Pull the pinna up and back in


an adult using your nondominant hand. Maintain this
position until the otoscope
is removed.
Pulling the pinna up and back
in the adult helps to straighten
the ear canal.

Hold the otoscope in your


dominant hand in an upsidedown position with the back
of your hand braced on the
patients cheek.
This position helps to prevent
forceful insertion and also
stabilizes your hand in case
the patients head moves.

FIGURE 4.2C Otoscope in sertion.


Insert the speculum slowly,
avoiding the medial wall, which is sensitive to pain. Observe the
canal for redness, swelling, discharge, foreign bodies, and lesions.

Redness, swelling, and purulent discharge suggests otitis externa or otitis


media with a ruptured eardrum. Frank blood or clear, watery uid following
trauma is associated with basal skull fracture.

Inspect the eardrum, noting the color, contour, and integrity of the
eardrum.
Normally the eardrum is shiny, translucent, pearl-gray. Other colors indicate
infection, or the accumulation of serous uid behind the eardrum. A perforated eardrum presents as a dark oval area or a larger opening on the drum.

Observe the umbo, the handle of the malleus, and the cone of light
(noted at 5 oclock in the right drum and at 7 oclock in the left
drum.
Absent or distorted landmarks indicate uid accumulation or a ruptured
eardrum.

pars
flaccida
malleous
umbo
pars
tensa

cone of
light
FIGURE 4.2D Eardrum.

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P r o c e d u r e 4 . 2 Assessing the Ears 65


Clean off any discharge or change the speculum, and repeat the

procedure for the other ear.


Helps to prevent contamination of the other ear with possibly infectious
material.
Test hearing acuity.
Tests conductive hearing as well as cranial nerve VIII.
Voice Test (Whisper Test)
Tests gross acuity of hearing.

Direct patient to occlude one ear by placing his or her nger on


the tragus and rapidly push it in and out of the auditory meatus.

Have the patient repeat each word after you say it.

Repeat for the other ear.

This will mask the hearing in that ear while hearing is tested in the other ear.
Veries that the patient correctly heard the whispered word.
Tests gross acuity in both ears.
Weber Test
Tests lateralization of sound.

Gently strike the tines of a


tuning fork against your
other hand.

Place the vibrating tuning


fork on the midline of the
patients skull. Ask the patient
where the tone is heard: left
ear, right ear, or both.

Sets the tuning fork vibrating.

Tests bone conduction through


the skull; it should sound equally
loud in both ears.

FIGURE 4.2E Weber test.

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66 C h a p t e r 4 Physical Assessment
Rinne Test
Compares air conduction
and bone conduction of sound.

Place the base of a vibrating


tuning fork on the patients
mastoid process; have the
person signal when the
sound is no longer heard.
Determines the length of
bone conduction.

When the tone is no longer


FIGURE 4.2F Rinne test.
heard, quickly move the fork
so that the tines are near the ear canal. Ask the patient if the
tone is heard, and direct him or her to signal when it ends.

Compare the time of bone conduction to the time of air


conduction.

Determines the length of air conduction.

Normally, air conduction is twice as long as bone conduction; variations


from normal may indicate a conductive or sensorineural hearing loss.
Perform the Romberg test.
Tests the ability of the vestibular apparatus in the inner ear to help maintain
standing balance.

Direct the patient to stand with feet together and arms at the
sides, then have the person close his or her eyes and hold the
position.
Normally, the patient is able to maintain this position without swaying or falling for at least 20 seconds. A positive Romberg test (loss
of balance) may indicate inner-ear problems or a problem with the
cerebellum.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Refer patient to an audiologist or physician for further testing and
evaluation of abnormal ndings if needed

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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 67

KEY POINTS

FOR

REPORTING

AND

RECORDING

Abnormal

ndings in assessment, including the use of a hearing aid.


Symmetry of external ears; redness, scaling, discharge, masses,
or tenderness noted on examination of the external ear and
canals.
Characteristics of the tympanic membrane, such as color, ability to see landmarks, integrity of the membrane.
Whispered words repeated correctly or incorrectly.
Results of Weber testnormally tone heard midline without
lateralization
Results of Rinne testnormally AC (air conduction) BC
(bone conduction) 2:1.
Results of Romberg testnormally negative (no swaying).
Use of hearing-aid device.
Any consultations recommended.

PROCEDURE 4.3
Assessing the Nose and Sinuses
OVERVIEW

The nose is the rst segment of the respiratory system and is multifunctional.
As inspired air passes through the nasal mucosa, nasal turbinates,
and nasal hairs, it is heated, humidied, and ltered.
The nose is also the sensory organ for smell.
The sinuses lighten the skull, serve as resonators for sound, and provide mucus, which drains into the nasal cavity.
Assessment of these areas offers insight to respiratory complaints as
well as problems involving the ears, throat, and even headaches.

P R E PA R AT I O N

Review related history that would give the examiner information


(past and present) regarding patients sense of smell and general
information regarding the nose and sinuses, including allergies,
epistaxis, nasal discharge, frequent colds, trauma or surgery, and
sinus pain.

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68 C h a p t e r 4 Physical Assessment

Ask about the use of nasal sprays and intranasal use of cocaine or
amphetamines.
Cranial nerve I is usually not tested in a routine examination. If the
sense of smell is tested, it can be performed while assessing the nose
or while assessing the neurologic system.

Special Considerations
Pediatric Patient
Most newborns are obligate nose breathers, and, therefore, special
attention must be given to the patency of the nares. Often, nasal aring is a sign of respiratory distress.
Avoid the nasal speculum in infants and young children; simply push
the tip of the nose up and shine the light into the nares.
Only palpate the sinuses in children 8 and older; in younger children
the sinuses are too small for palpation.
In toddlers, pay special attention to the possibility of foreign bodies
lodged in the nasal cavity.
Pregnant Patient
Nasal stuffiness and epistaxis may occur during pregnancy because
of the increased vascularity in the upper respiratory tract.
Elderly Patient
In older patients, the nose may appear larger, with the growth of
especially coarse nasal hairs. The sense of smell may be diminished,
and the nasal mucosa may become drier, making these patients
more prone to nosebleeds.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible disturbed sensory perception: olfactory


Possible ineffective airway clearance
EXPECTED OUTCOMES

Completion of the examination while maintaining the patients


comfort
Examination performed appropriately for age, and developmental
and educational level

EQUIPMENT/SUPPLIES

Otoscope with short, wide nasal tip or nasal speculum and penlight
Small samples of familiar odors

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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 69


I M P L E M E N TAT I O N
Inspect the external aspect of the nose.
Exposes any asymmetry, deformity, inammation, or skin lesions.
Palpate the nose gently.
Uncovers pain, any breaks in the contour of the nose, or minute masses.
Test the patency of each nostril by having the patient close the

mouth, then occlude one nostril and sniff inward through the
other naris.
Reveals any obstruction of the nares, such as nasal polyps or rhinitis.
Inspect the nasal cavity using

either the otoscope with the


nasal tip or a nasal speculum
and penlight.
This allows a more thorough
examination of the nasal cavity.

Tilt the patients head back,


stabilize the instrument, and
gently insert the speculum
approximately 1 cm while
avoiding the nasal septum.

FIGURE 4.3A Inspect nasal cavity.

Provides maximum exposure while maintaining patient safety and


comfort; the nasal septum is highly vascular and may bleed if irritated
by the speculum.

Note the color and characteristics of the mucosa.


Exposes any swelling, discharge, or bogginess, which are indicative
of rhinitis, sinusitis, or chronic allergies.

Note the inferior and middle turbinates (the superior will not be in
your view).

Note any deviation of the nasal septum.

Exposes nasal polyps or foreign bodies.


A deviated septum is common and does not present a problem unless airow
is obstructed (if found in a hospitalized patient, document the ndings in
case the person requires a nasogastric tube or nasal suctioning).

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70 C h a p t e r 4 Physical Assessment
Palpate the sinuses.
Tenderness is elicited by palpation
of sinuses in persons with chronic
allergies and sinusitis.

Frontal sinuses by pressing


with your thumbs up from
under the medial aspect of
the eyebrows.
Pressure but not pain should be
felt; be careful not to press on
the eyeballs.

Maxillary sinuses by pressing


up and in from under the
cheekbones.
Pressure but not pain should
be felt.
FIGURE 4.3B Palpate sinuses.

Test cranial nerve I: olfactory.


Evaluates the patients sense of smell; abnormalities can indicate a neurologic or a local problem.

Direct the patient to close eyes and occlude one naris.


Ensures that the patient is not identifying the substance by sight and that he
or she is not compensating by using the other naris.

Hold a substance with a familiar odor under the other naris and
have the patient identify the odor.

Repeat for the other side.

Allows easy detection if the sense of smell is intact.


Tests the sense of smell in each naris.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Inspect and ensure that if any bleeding occurred during the examination, it has stopped
Compare assessment ndings to normal
Refer patient to an ear, nose, and throat specialist for further testing
and evaluation of abnormal ndings, if necessary

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P r o c e d u r e 4 . 4 Assessing the Mouth and Pharynx 71

KEY POINTS

FOR

REPORTING

AND

RECORDING

Abnormal

ndings noted in the assessment.


Deformities or tenderness noted as well as location and
description.
Patency of nares.
Color, character of mucosa, including any lesions and their
location.
Position of septum (midline or side of deviation).
Results of palpation of sinuses (note tenderness/no tenderness and which sinus).
Sinus tenderness.

PROCEDURE 4.4
Assessing the Mouth and Pharynx
OVERVIEW

The mouth and pharynx are the rst segments of the respiratory
and digestive systems.
The structures included in this region are important for speech
formation and the sense of taste, and contain a large amount of
lymphatic tissue.
Assessment of this area provides clues to local and systemic
problems, such as nutritional status, hydration, and infection.

P R E PA R AT I O N

Review related history that would give the examiner information


(past and present) regarding the general state of the patients mouth
and pharynx, including sore throat, lesions, toothache, voice changes,
difficulty swallowing, and self-care behaviors.
Observe the patient with dentures to inspect the t, but have the
patient remove the dentures during the examination.
Note the use and type of tobacco products (how much, how often,
how long).
Cranial nerve X and XII are usually tested during the assessment
of the neurologic system, but such testing can be performed while
assessing the mouth and pharynx as well.

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72 C h a p t e r 4 Physical Assessment

Special Considerations
Pediatric Patient
In the infant or young child, save the oral examination until near the
end of the complete examination; but, if a crying episode occurs
before, take that opportunity to examine the mouth while it is open;
Have the caretaker hold and restrain the child if necessary.
Only use the tongue blade when necessary because many people
have an active gag reex; have a child roar like lion or pant like a
dog to encourage him or her to open the mouth wide.
Normal variations in infants include Epsteins pearls, sucking tubercle,
no tonsillar tissue, and a slightly large tongue.
In children 10 years and under, the tonsils are normally large (1
or 2).
Eruption of teeth varies widely. As a general guide: for children under
2 years, the childs age in months minus 6 should equal the number
of teeth; normally all 20 deciduous teeth are present by 21/2 years.
Elderly Patient
In elderly patients, the teeth may appear yellow, gum margins may
recede, teeth may become looser, and the tongue may appear
smoother. Check for proper t of dentures if worn (no rough spots
or ulcerations caused by the dentures); tonsils will normally shrink
with age.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible disturbed sensory perception: gustatory


Possible ineffective airway clearance
EXPECTED OUTCOMES

Completion of the examination while maintaining the patients


comfort
Examination performed appropriately for age, and developmental
and educational level

EQUIPMENT/SUPPLIES

Light
Tongue blade
Gauze square
Clean gloves

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P r o c e d u r e 4 . 4 Assessing the Mouth and Pharynx 73


I M P L E M E N TAT I O N
Inspect the outer and inner surface of the lips noting color, moisture,

lesions, and cracking.


Variations from the normally pink, moist lips such as cyanosis, pallor, and
cracking may indicate poor nutrition, dehydration, or hypoxia. Lesions may
indicate herpes simplex.
Inspect the buccal mucosa; ask patient to remove dentures if worn.

Use a tongue blade and good light.


Careful inspection can reveal nodules, lesions, and the rst signs of mumps
(red Stensens ducts) and measles (Kopliks spots).
Inspect the teeth and gums for discoloration and diseased or miss-

ing teeth. Check gums for pink color, swelling, bleeding, or lesions.
Teeth can be used as an index of a persons general health. Abnormalities
may indicate tobacco use, dental caries, or gingivitis.
Inspect the roof of the mouth for color and structure.
Reveals any deformities in the hard/ soft palate, jaundice, or pallor.
Inspect all surfaces of the

tongue and the oor of the


mouth.
Reveals lesions, color, texture,
size of the tongue. Normally
the tongue is pink, the dorsal
surface is roughened from
the papillae, and a white
coating may be present.
Abnormalities may indicate
poor nutrition, neurologic
problems, or dehydration

FIGURE 4.4 Inspecting the pharynx.

Direct the patient to touch the tongue to the roof of the mouth
and examine the ventral surface and the oor of the mouth carefully.
Normally this surface should appear pink, smooth. Veins and saliva should be
present. Oral malignancies are likely to develop in the area under the tongue;
look for lesions, patches, or nodules.

Palpate the area under the tongue.

Have the patient stick out the tongue, and grasp it using a gloved
hand and a piece of gauze. Pull the tongue to the left and examine
it, then do the same to the other side.

Elicits tenderness and/or nodules not revealed by inspection alone.

Reveals lesions or patches on the sides and under the tongue where malignancies are common.

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74 C h a p t e r 4 Physical Assessment
Inspect the throat by depressing the middle of the tongue with a

tongue blade and using a light. Note color, ulcerations, exudate, and
enlargement of the tonsils.
Tonsils that are swollen, bright red, or have exudate may have infection.
Test cranial nerve X (vagus).
Provides motor innervation to the palate, pharynx, and larynx.

Have the patient say ah, and watch for the rise of the soft palate
and the uvula (it should be in the midline).
Any deviation to the side or absence of movement indicates nerve
damage.

Test cranial nerve XII (hypoglossal).


Provides motor innervation to the tongue.

Ask the person to stick out the tongue; observe for symmetry.
Deviation will be toward the paralyzed side; tremors may be associated with
conditions such as hyperthyroidism or cerebral palsy.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Refer patient to a dentist or an ear, nose, and throat specialist for
evaluation of abnormal ndings if necessary

KEY POINTS
Abnormal

FOR

REPORTING

AND

RECORDING

ndings noted in the assessment.


Color and character of lips, mucosa and gingivae, including
any lesions, bleeding, cracking, and the location; color of pharynx, lesions noted and location.
Any abnormalities noted on the teeth or gums.
Symmetry of tongue, tongue midline, or deviated when protruded, any tremors noted.
Tonsillar size (graded 1 thru 4), exudate on tonsils.
Midline rise or deviation of uvula on phonation.
Dental abnormalities, especially loose teeth.

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P r o c e d u r e 4 . 5 Assessing the Neck 75

PROCEDURE 4.5
Assessing the Neck
OVERVIEW

The neck is a channel for the passage of many structures including


vessels, muscles, nerves, lymphatics, and viscera of the respiratory
and digestive system.
It is also the home of the thyroid gland.
By assessing the structures in the neck, information concerning all of
these systems is gained.

P R E PA R AT I O N

Review related history that would give the examiner information


(past and present) regarding the neck, thyroid, and lymphatic system
including pain, injury, difficulty swallowing, change in voice, lumps or
swelling, thyroid disease or surgery, weight change, temperature
intolerance, or change in activity tolerance.

Special Considerations
Pediatric Patient
Infants have a short neck that can be more easily assessed by supporting the infants shoulders and tilting the head back slightly. The
cervical lymph nodes and thyroid gland of an infant are not usually
palpable.
Children can be assessed in the same manner as adults; their lymph
nodes will feel more prominent until puberty when the lymphoid
tissue begins to atrophy.
Pregnant Patient
During pregnancy, the thyroid gland enlarges slightly due to hyperplasia of the tissue and increased vascularity.
Elderly Patient
In elderly patients, the neck may show signs of kyphosis; ask them
to perform range of motion slowly. Older patients may also have
prolapse of the submandibular glands, which can be mistaken for
a tumor. However, prolapsed glands will feel soft and symmetric.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible impaired neck mobility


Possible Impaired swallowing

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76 C h a p t e r 4 Physical Assessment
EXPECTED OUTCOMES

Completion of the examination while maintaining the patients


comfort
Exam performed appropriately for age, developmental, and
educational level

EQUIPMENT/SUPPLIES

Stethoscope
Glass of drinking water
I M P L E M E N TAT I O N
Inspect the neck for appearance and position while the patient is

sitting upright.
The head should be erect and still; the neck and accessory neck muscles
should be symmetric.
Check the range of motion of the neck, note any pain or limited

movement.
Stiffness or pain with movement may indicate arthritis or inammation of
the neck muscles.

Have the patient ex, extend neck, turn neck to the right and left,
and touch each ear to the corresponding shoulder.
Examines range of motion of the neck.

Inspect the carotid artery and the jugular vein; note any obvious

pulsations.
Normally there are no pulsations; if pulsations are present, the person may
have an elevated blood pressure or uid volume overload.
Palpate for cervical lymph nodes using a gentle circular motion of

your ngerpads with light pressure; palpate both sides of the neck
simultaneously.
Use gentle pressure because strong pressure could push the nodes into the
muscle; by palpating both sides simultaneously, the two sides can be compared.

Begin in front of the ear, and work systematically.

When palpating the submental node, palpate with only one hand,
and use the other to position the head.

Establishes a sequence so that no nodes are missed.

This gland is easier to explore with only one hand.


Inspect and palpate the trachea for deviation from the midline

position.
Abnormalities may indicate cardiac, vascular, or pulmonary problems.

Place your index nger along one side of the trachea. Note the
space between it and the sternocleidomastoid muscle.

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P r o c e d u r e 4 . 5 Assessing the Neck 77


Provides a method of measurement of the space between the trachea and
the sternocleidomastoid muscle.

Repeat the procedure on the opposite side and compare the


spaces.
The two sides should be symmetric if the trachea is midline.

Inspect the neck for the thyroid gland while the patient extends the

neck; have the patient swallow a sip of water in this position.


Ability to view the thyroid gland is difficult; thyroid tissue moves up with a
swallow. If thyroid tissue is seen, look for symmetry.
Palpate the thyroid (the pos-

terior approach is described


because it is easier for beginning practitioners).
An enlarged thyroid is a good
indication of hyperthyroidism.

Stand behind the patient and


have the person bend the
head slightly forward and to
the right.

Using the ngers of your left


hand, push the trachea slightly
to the right while curving your
right ngers between the
trachea and the sternocleidomastoid muscle pulling
back slightly.

This will relax the neck muscles.

The left hand pushes the boarder


of the thyroid gland over while
FIGURE 4.5 Palpating the
the right hand retracts the sternthyroid.
ocleidomastoid muscle slightly.
This makes the thyroid gland easier to feel.

Direct the patient to take a sip of water and feel for the rise of the
thyroid as the person swallows.
Water facilitates swallowing for the patient, and swallowing facilitates
palpation of the thyroid. Usually the normal thyroid gland cannot be
palpated; abnormalities include enlarged lobes that are easily palpated
before swallowing.

Reverse the procedure for the left side.


Evaluates both sides of the thyroid gland.

Auscultate any enlarged thyroid with the bell of the stethoscope.


A bruit will be heard with accelerated or turbulent blood ow indicating
hyperplasia of the thyroid.

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78 C h a p t e r 4 Physical Assessment
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Refer patient to an internist or endocrinologist for evaluation of
abnormal ndings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

Abnormal

observations of the neck including lesions, nodules,


swelling, asymmetry, or tenderness.
If nodes are palpated, note their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and
tenderness.
Position of the trachea (midline or direction of deviation) and
direction of tracheal deviation if present.
Ability to palpate thyroid, tenderness; if enlarged, which lobes
are palpable, auscultation of a bruit.
Presence of jugular-vein distention noting the degree of elevation of the head.
Limitation of range of motion and in which position.

PROCEDURE 4.6
Assessing the Thorax and Lungs
OVERVIEW

To determine functional status and to detect any alteration in physiologic process.


A complete physical assessment of the chest and lungs, together
with the history, will provide the examiner with important clues to
diagnose and treat various pathologic conditions.

P R E PA R AT I O N

Provide privacy during assessment.


Interview patient prior to assessment focusing on any history of
cough, sputum production, allergies, dyspnea at rest or on exertion,
chest pain, asthma, bronchitis, emphysema, tuberculosis, cyanosis,
pallor, exposure to environmental irritants, or smoking.
A specic sequence should be used when assessing the chest and
lungsinspection, palpation, percussion, and auscultation.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 79

Special Considerations
Pediatric Patient
There are special considerations when assessing the thorax and
lungs of an infant. The anterior-posterior diameter noted on inspection of an infant is equal to the lateral or transverse diameter (1:1).
The lateral diameter increases in proportion to the anteroposterior
diameter.
The chest wall is thin, and the rib cage is soft and pliant.
Respiratory rate will vary with age.
Hyperresonance will be demonstrated upon auscultation throughout
the lungs owing to the thin chest wall.
The bell of the stethoscope or small diaphragm should be used to
localize ndings.
Wheezes and rhonchi occur more frequently in infants and young
children.
See Table 4.6A for respiratory rates for children.
TABLE 4.6 Respiratory Rates for Children
AGE

RATE

Newborn5 months
523 months
24 months12 years
12 years19 years

3050
2030
2030
1220

Elderly Patient
Chest expansion is often decreased owing to muscle weakness,
physical disability, or calcication of the rib articulations.
Bony prominences are marked, and there is a loss of subcutaneous
tissue.
The dorsal curve of the thoracic spine may be pronounced (kyphosis), along with attening of the lumbar curve.
The anterior-posterior diameter is increased in relation to the lateral
diameter.
The pace of the physical examination should be adapted to the individual need.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible impaired tissue perfusion due to disease


Impaired gas exchange related to infection

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80 C h a p t e r 4 Physical Assessment
EXPECTED OUTCOMES

The outcome of assessing the thorax and lungs will include the
following:
Inspection of symmetry of movement on expansion, anteriorposterior to lateral diameter, and the use of accessory muscles
Palpation of tactile fremitus
Percussion for diaphragmatic excursion, resonance notes
Auscultation of vesicular, bronchovesicular, bronchial, and adventitious breath sounds
EQUIPMENT/SUPPLIES

Stethoscope
Tape measure
Drapes
Marking pencil
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning an assessment enhances efficiency.
Explain assessment to patient.
Careful explanation reduces the patients anxiety.
Expose anterior, posterior, and lateral chest with patient in sitting

position.
Exposure of the chest in the sitting position facilitates easy access for inspection, palpation, percussion, and auscultation of the area.

Inspection
Inspect anterior, posterior, and lateral thorax for the following:
Inspection will enable the examiner to assess the general appearance of the
thorax. Inspection is important before palpation, percussion, and auscultation as the latter are more invasive.

Color
Color should be pink without pallor or cyanosis.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 81

Intercostal spaces
The intercostal spaces should be even and relaxed, without bulging or
retracting.

Chest symmetry

Costal angle

Both sides of the chest should be equal.


The costal angle is formed by the blending together of the costal margins at
the sternum. It is usually no more than 90 degrees, with the ribs inserted at
approximately 45-degree angles.

Respirations

Anterior-posterior to lateral diameter

Respirations should be even, 1220/min, unlabored.


Normal is a 1:2 ratio (anterior-posterior diameter is approximately one half
the lateral diameter). This information will provide the examiner with shape
and symmetry of the chest. A barrel chest, which results from compromised
respiration, chronic obstructive pulmonary disease (COPD), for example, will
demonstrate an increase in the anteroposterior diameter.

Shape and position of sternum


Sternum should be level with the ribs. Two structural variations of the sternum are pigeon chest (pectus carinatum), a prominent sternal protrusion,
and funnel chest (pectus excavatum), which is an indentation of the lower
sternum above the xiphoid process.

Position of trachea

Chest expansion

Trachea should be midline without deviation to either side.


Chest should expand approximately 3 inches upon inspiration.

Palpation
Drape anterior chest. Use nger pads or palm of hands to palpate

posterior chest. Have patient lean forward and fold arms across chest.
Palpation of the chest will enable the examiner to assess the thoracic muscles and skeleton, and to feel for pulsations, areas of tenderness, bulges,
depressions, and unusual movements. The anterior chest should be draped
while you are assessing the posterior chest to ensure privacy. Leaning forward increases the area of the lungs. Palpation, percussion, and auscultation
of the posterior lungs will be done while the patient remains in the sitting
position.

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82 C h a p t e r 4 Physical Assessment
Palpate upper, middle, and lower thorax for sensation.
No pain or tenderness should be present.

Palpating anterior chest excursion


at apex

Palpating anterior chest excursion


at base

FIGURE 4.6A Example of chest palpation.

Palpate upper, middle, and lower thorax for vocal fremitus. Have the

patient say 99 while palpating.


Vibration should be decreased over the periphery of the lungs and increased
over the major airways. Vibration will be increased over areas of consolidation and decreased over airway with obstruction.
Palpate the thorax for expansion. Place hands at level of 10th rib on

the posterior thorax, and have patient take a deep breath. Observe
thumb movement.
2- to 3-inch symmetric expansion should be noted upon inspiration.
Place hands on the lower sternum anteriorly and have patient take

a deep breath. Observe thumb movement.


Symmetric expansion of 2 to 3 inches should be noted.

Percussion
Percuss over shoulder apices and at posterior, anterior, and lateral

intercostal spaces moving from apex to base of lungs.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 83


Percussion will provide the examiner with information concerning areas of
the thorax and lungs that are air-lled or that may have consolidation (uidlled). The impact of the examiners nger produces a vibration against the
underlying tissue, and percussion tones can be heard (resonance). Resonance,
a loud, low-pitched, hollow sound is percussed in healthy lungs. The more
dense the medium, as in uid or masses, for example, the quieter (dullness)
the percussion tone. The percussion tone over air-lled lungs is loud, lowpitched, and has a boomlike quality (hyperresonance), as in emphysema.

FIGURE 4.6B Percussion sequence.

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84 C h a p t e r 4 Physical Assessment
Percuss for diaphragmatic excursions bilaterally.

Ask patient to inhale deeply and hold.


Percuss along the scapular line until you locate the lower border
(noted by a change from resonance to dullness).
Mark the point with a pencil and have the patient breathe.
Ask the patient to exhale as much as possible and hold.
Percuss up from the marked point and mark where the change
from dullness to resonance occurred. Have the patient breathe.
Measure and record the distance in centimeters.

The excursion distance of the diaphragm is usually 3 to 5 cm. The descent


of the diaphragm may be limited by emphysema, ascites, tumor, or pain.

Auscultation
Instruct patient to take slow, deep breaths through his mouth while

you auscultate the intercostal spaces with the diaphragm of the


stethoscope. Auscultate over the following areas:

FIGURE 4.6C Auscultation sequence.

Auscultation of the chest provides the examiner with important clues to the
condition of the lungs. Listen for two full breaths while comparing each side
of the thorax moving the stethoscope from the apex of the lungs to the base.

Trachea
Bronchial (tubular)/ tracheal breath sounds are heard over the trachea.
They are high-pitched, loud, with the expiratory phase of respiration often
longer than the inspiratory phase.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 85

Bronchial airway, including below clavicles and between scapulae


Bronchovesicular breath sounds, medium in pitch, are heard over the main
bronchus area and over the upper-right posterior lung eld. The inspiratory
phase should equal expiratory phase.

Lung periphery
Vesicular (soft, breezy) breath sounds, low in pitch, are heard over lung
periphery. The inspiratory phase should be longer than the expiratory
phase.

Auscultate breath sounds for adventitious sounds, including

wheezes, rales, and rhonchi.


Lungs should be clear to auscultation on inspiration and expiration. If abnormal sounds are heard, ask patient to cough and note if adventitious sound is
still present.
Auscultate for altered voice sounds over lung periphery where any

previous lung abnormality was noted.


Bronchophony patient says 99 while examiner auscultates.
Whispered pectoriloquy patient whispers one, two, three while
examiner auscultates.
Egophony patient says eee while examiner auscultates.
Auscultation for altered voice sounds will provide the examiner with clues
regarding the presence of consolidation in the lung tissue. The voice
vibrates and transmits sounds through the lung elds. The sounds should
be muffled in healthy lungs, but may be loud and clear in any condition
that consolidates lung tissue.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal ndings


Record and report normal and abnormal ndings

KEY POINTS
A

FOR

REPORTING

AND

RECORDING

history of any condition reported in the interview (subjective data) such as a history of cough, sputum production, allergies, dyspnea at rest or on exertion, chest pain, asthma,
bronchitis, emphysema, tuberculosis, cyanosis, pallor, exposure
to environmental irritants, or smoking.
Assessment ndings (objective data) to include
Size and shape of chest, anteroposterior versus lateral diameter, symmetry of movement with respiration
Presence of retractions or use of accessory muscles

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86 C h a p t e r 4 Physical Assessment

Diaphragmatic excursion
Respiratory rate, depth, regularity, and ease of respiration
Symmetry and quality of tactile fremitus
Symmetry and quality of percussion notes
Characteristics of breath sounds including location and
phase of respiration where abnormal sounds are auscultated
Characteristics of cough
Presence of vocal resonance

PROCEDURE 4.7
Assessing the Heart and Vascular System
OVERVIEW

The heart and the blood vessels are complex, integrated systems.
Findings from examinations of other systems, besides the cardiovascular, have a signicant impact on judgments that will be made
about the cardiovascular system.
Performing a successful examination requires an ability to integrate
and interpret ndings in relation to the cardiac events they reect.

P R E PA R AT I O N

The parts of the physical examination should be performed in a


sequence that is comfortable for the examiner, with assessment of
the heart following the traditional inspection, palpation, percussion,
and then auscultation.
These systems cannot be appropriately evaluated unless a complete
examination is performed.
Interview the patient for any history of the following: chest pain,
irregular heartbeats, hypertension, diabetes, rheumatic fever, stroke,
or smoking. Ask about pain in calves, feet, buttocks, or legs, including
the type of pain and what aggravates or relieves the pain. Is there a
history of coldness, cyanosis, edema, varicosities, paresthesia, or tingling in the extremities?

Special Considerations
Pediatric Patient
There are a few variations that occur normally in children.
The presence of an S3 and S4 in children and young adults is common, but an increase in the intensity should be suspect.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 87

Sinus arrhythmia is a physiologic event during childhood because


the heart rate varies in a cyclic pattern, usually faster on inspiration
and slower on expiration.
The heart rates in children vary from those of adults. The location of
the apex of the heart also varies in infants and young children, as
compared to adults.
Elderly Patient
Variations that are usually noted in the assessment of elderly patients
include the following:
Occasional ectopic beats and the presence of an S4, which may
indicate decreased left ventricular compliance.
Early, soft, physiologic murmurs may be heard due to aortic lengthening, tortuosity, and sclerotic changes.
The dorsalis pedis and posterior tibial pulses may be difficult to
detect without a Doppler.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired tissue perfusion related to injury


Airway clearance, ineffective related to infection
EXPECTED OUTCOMES

The outcome of assessing the cardiovascular system will include the


following:
Thorough observation and palpation of the pulses, as compared
with the contralateral pulse and comparing pulses in the upper
extremities with those in the lower extremities
Complete inspection of the veins, especially the jugular venous veins
Accurate measurement of blood pressure in both upper extremities
with the patient sitting, standing, and supine
Complete inspection, palpation, percussion, and auscultation of the
heart
EQUIPMENT/SUPPLIES

Stethoscope with a bell and diaphragm


The bell of the stethoscope transmits low-pitched sounds when
very light pressure is applied.
The diaphragm of the stethoscope screens out low-pitched sounds
and best transmits high-pitched sounds with rm pressure
applied.

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88 C h a p t e r 4 Physical Assessment

Sphygmomanometer with appropriately sized cuff


Cuffs are available in a number of sizes; the appropriate size is
determined by the size of the patients limb. For adults, choose a
width that is one third to one half the circumference of the limb.
The length of the bladder should be twice the width (about 80%
of the limb circumference), not quite enough to completely encircle the limb. For children, the cuff width should cover approximately two thirds of the upper arm or thigh. A cuff that is too
wide will underestimate blood pressure, and those that are too
narrow will give an articially high measurement. Using the correct size cuff ensures that equal pressure is exerted on the artery,
resulting in an accurate measurement.
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning the assessment enhances efficiency.
Explain the process of heart and vascular assessment to patient.
Careful explanation reduces the patients anxiety.
Have the patient assume the supine position, and expose the ante-

rior chest providing privacy with drapes.


A thorough examination of the heart requires the patient to assume several
positionssupine, sitting erect, and leaning forward, and being in the left
lateral recumbent position.

Inspection
Inspect the chest for landmarks, including point of maximal impulse

(PMI) and any abnormal pulsations.


Identifying the landmarks will aid in assessment of the heart. The point at
which the apical pulse is most readily seen or felt is called the point of maximal impulse (PMI). It should be visible at the midclavicular line in the fth
intercostal space (ICS). The PMI is most visible when the patient is in the
supine position because the heart is brought closer to the chest.

Palpation
(Examiner should stand on the patients right side with the patient in

the supine position.) Palpate using the ngertips and palmar surfaces of the hands gently in an organized fashion, beginning in the
aortic area and moving down the chest toward the tricuspid area.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 89


Palpation allows the examiner to feel the apical pulse and identify its location by intercostal space and distance from the midsternal line. Palpation
over each valvular area will assist the examiner in detecting abnormal pulsations or vibrations. It is always best to be methodical in your examination. A
suggested sequence is to begin at the apex, move to the left sternal border
and then to the base, going down to the right sternal border. Touch gently
and let movements rise to your hand, because sensation will decrease as you
increase pressure.

BASE
Base right (aortic)
Base left (pulmonic)
Erbs point
Left lateral sternal
border (tricuspid)
Apex (mitral)
Xiphoid
APEX

1
2

FIGURE 4.7A (1) Sites for cardiac assessment; (2) Palpating the mitral

valve area; (3) Palpating the pulmonic area.

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90 C h a p t e r 4 Physical Assessment
A. Aortic area

Palpate second ICS at right sternal border.


A. Palpation in the aortic area will allow the examiner to detect abnormal
pulsations or vibrations. No vibrations or pulsations should be palpated.
A pulsation or vibration generally indicates a disruption of the expected
blood ow.
B. Pulmonic area

Palpate second ICS at left sternal border.


B. Palpation at the pulmonic valve area will allow the examiner to detect
abnormal pulsations or vibrations.
No vibrations or pulsations should be palpated.
C. Erbs point

Palpate third ICS at left sternal border.


C. Palpation at Erbs point will disclose possible dysfunction of the aortic
valve during diastole (when the ventricles are lling).
No vibrations or pulsations should be palpated.
D. Tricuspid area

Palpate fth ICS at lower left sternal border.


D. Palpation at the tricuspid valve area will allow the examiner to detect
abnormal pulsations or vibrations.
No vibrations or pulsations should be palpated.
E. Mitral area

Palpate fth ICS at the left midclavicular line. This is also called the
PMI.
E. Palpation at the mitral valve area will allow the examiner to feel the
PMI and determine if there are any vibrations present.
A pulsation about the size of a nickel should be felt.
No vibration should be present.

Percussion
Percussion is an unreliable method in determining the borders of

the heart or determining its size.


Percussion allows the examiner to determine borders of the heart and its
approximate size, but has been found to be an unreliable method because
the shape of the chest is relatively rigid and can make the more malleable
heart conform. Size of the heart can be more accurately determined by
chest radiograph.

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Auscultation
A. With the patient in the supine position, auscultate in an orderly,

systematic fashion beginning in the aortic area and moving across


and down the chest through the pulmonic, tricuspid, and mitral
areas. Auscultate each area with the diaphragm of the stethoscope
applied rmly to the chest and then repeat the sequence with the
bell of the stethoscope applied lightly to the chest. Auscultate each
sound and pause individually, focusing on one sound at a time.
Identify the rst heart sound (S1) or lub with the diaphragm of the
stethoscope. Identify the second heart sound (S2) or dub with the
diaphragm of the stethoscope.
A. Auscultation allows the examiner to assess the heart sounds. Heart sounds
are of relatively low frequency and are transmitted in the direction of blood
ow. Specic heart sounds are best heard over areas where blood ows after
it passes through a valve. Take the time to isolate each sound and each
pause in the cycle listening separately for as many beats as necessary to
evaluate the sounds. Avoid jumping the stethoscope from one point to
another; instead, inch the endpiece along the route. This prevents missing
important sounds, especially more widely transmitted abnormal sounds.
S1 is a crisp, distinct sound that follows the long diastolic pause (lling of the
right and left ventricles) and corresponds with ejection of the blood from the
ventricles. Its sound is caused by the closure of the tricuspid and mitral valves
(atrioventricular valves). S1 should also correlate with the carotid pulse
because blood that is ejected from the left ventricle into the aorta travels to
the carotid artery causing a pulsation. It should be heard in each area (aortic, pulmonic, tricuspid, and mitral), but should be loudest at the mitral and
tricuspid areas. S1 may become louder with inspiration. S2 is a crisp, distinct
sound heard loudest at the aortic and pulmonic areas and is caused by closure of the aortic and pulmonic valves (semilunar valves). It follows the short
systolic pause (ejection of the blood from the ventricles into pulmonic and
systemic circulation) of the cardiac cycle and corresponds with lling of the
ventricles after the closure of the aortic and pulmonic valves.
B. Assist the patient to the left lateral position and auscultate over

the apex (mitral area) with the bell of the stethoscope for a third
heart sound (S3).
B. Auscultation over the mitral area will allow the examiner to assess normal
heart sounds (S1 and S2 or lub and dub) and also to detect extra heart
sounds. A third heart sound is caused by rapid ventricular lling that occurs
in the diastole phase of the cardiac cycle, or the ventricular lling phase.
External inuences that may cause a third heart sound are exercise, fast
heart rates, elevation of the legs, and in increase in the venous return to the

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92 C h a p t e r 4 Physical Assessment
heart. If a third heart sound is detected, it should be relatively quiet and difficult to hear. The left lateral position is the best position for detecting these
low-pitched lling sounds.
C. Assist the patient to a sitting position and auscultate each area

(aortic, pulmonic, tricuspid, and mitral) with the diaphragm of the


stethoscope.
C. Auscultation over each of the valvular areas of the heart will allow the
examiner to assess for S1 and S2 and extra heart sounds. The supine position
is the best position to hear relatively high-pitched murmurs (abnormal
sounds).
D. Auscultate systolic pause phase:

Heard between S1 and S2.


D. Should hear a silent pause; distinct end of S1 and beginning of S2 with
nothing heard in between. A murmur is an abnormal swishing sound heard
at the beginning, middle, or end of systolic phase. (Note intensity, pitch, and
quality.) A click is an abnormal sharp, high-pitched snapping sound heard
immediately after S1 or in the middle of the systolic pause.
E. Auscultate diastolic pause phase:

Space heard between S2 and the next S1.


E. Should hear a silent pause; distinct end of S2 and distinct beginning of S2.
Note the presence of murmurs or clicks during the beginning, middle, or end
of the diastolic phase.
F. Auscultate for rate and rhythm.
F. Normal heart rate is between 60 and 100 beats per minute with a regular
rhythm. Bradycardia is a heart rate 60, and tachycardia is a heart rate
100. An irregular rhythm should be noted as abnormal.
G. Auscultate for S4.
G. During diastole, the ventricles ll in two steps: an early passive ow of
blood from the atria followed by a more vigorous atrial ejection. S4 is caused
by the second phase of ventricle lling, which causes vibration in the valves,
papillae, and ventricular walls. S4 is a soft, low-pitched sound that occurs
late in diastole (ventricular lling) and should be quiet and difficult to hear.
H. Have the patient lean forward and exhale while you listen over the

aortic area with the diaphragm of the stethescope.


H. Auscultation over the aortic area, while the patient is leaning forward, will
enable the examiner to assess the normal S1 and S2 heart sounds and detect
extra high-pitched sounds, which may be associated with disruptions in the
blood ow at the aortic valve. This is the best position to hear relatively highpitched murmurs (abnormal sounds).

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Inspection, palpation, and auscultation of circulation to arms and

neck are performed together while the patient remains in the sitting
position.
A systematic assessment of circulation provides a thorough, organized
approach to ensure efficiency.
A. Palpate brachial artery and auscultate blood pressure in both arms

(patient remains in the sitting position).


A. Normal systolic pressure is between 95 to 140 mm Hg with a diastolic pressure between 60 and 90. May be a difference of 5 to 10 mm Hg between the
two arms. Deviations from normal are systolic 95 mm Hg or 140 mm
Hg, a diastolic 60 mm Hg or 90 mm Hg, or more than a 10mm Hg difference in pressure between the two arms.
B. Palpate brachial artery and auscultate blood pressure in both arms

while the patient is standing.


B. The difference between systolic pressure in both arms should be 15 mm Hg
or less and a diastolic difference of 5 mm Hg or less.
C. Palpate each carotid artery alternately for rate, rhythm, symmetry,

strength, and elasticity. NEVER palpate both sides simultaneously.


C. Rate should correlate with apical pulse consisting of a regular rhythm,
equal, strong, and elastic bilaterally. Palpating both sides simultaneously
may stimulate the carotid sinus reex and slow the pulse, drop the blood
pressure, and compromise blood ow to the brain.
D. Auscultate the carotid arteries with the bell of the stethoscope

while the patient holds breath.


D. No sound should be heard. A bruit (murmur or unexpected sound) over
an artery is a swishing, low-pitched sound that is relatively hard to hear.
Holding the breath aids in detecting the abnormal sound.
E. Inspect and palpate the upper extremities for the following.
E. A continuous, systematic approach during the assessment ensures
efficiency.

Color

Temperature

Mobility

Radial and ulnar pulses

Color should be pink.


Should be warm to touch.
Should be mobile.
Bilateral pulses should be strong and equal.

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94 C h a p t e r 4 Physical Assessment
Allens test

This is performed if the patient has weak radial or ulnar pulses.


Procedure:
Ask patient to make a st.
Compress radial and ulnar arteries.
Ask patient to open hand.
Release ulnar artery.
Repeat with release of radial artery.
The entire palm of hand should return to pink with the release of radial or
ulnar artery. An abnormal nding is when only one half of the palm returns
to pink with the release of the ulnar or radial artery and the other half
remains whitish.

F. Inspect jugular veins with the patient in the supine position and

the head elevated 45 degrees. Identify the highest point of venous


wave in relation to the sternal angle and measure in centimeters.
F. The pulsation height should be 3 cm.

External jugular vein


Internal jugular vein
Carotid Artery
Angle of Louis
(sternal
angle)
Level of right atrium

FIGURE 4.7B Location of jugular veins.

G. Inspect and palpate the legs for the following.

Color

Temperature

Mobility

Color should be pink (white skin) and dark brown (black skin).
Temperature should be warm.
Legs should be mobile.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 95

Supercial veins
There should be slight venous distention with standing or lowering the extremity below the level of the heart and collapse with
elevation.

Edema

Femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

Capillary rell

No edema should be present.


Pulses should be strong and equal bilaterally.
Compress nail beds of ngers and toes, and observe return of blood to
capillaries.
Color should return to pink in 2 seconds.
H. Check for deep phlebitis by quickly squeezing calf muscle against

the tibia.
H. No calf pain should be present.
I. Check for Homans sign by extending leg and dorsiexing

foot.
I. No calf soreness or pain should be present.
J. Check for arterial deciency if leg pulses are weak.

Support patients legs 12 inches above the level of the heart


while the patient remains in the supine position.
Ask patient to sit up and dangle legs in a dependent
position.

J. Feet should be pink to slight pale with elevation of the legs, and
pink color should return to tips of toes in 10 seconds with lowering
of the legs.
K. Auscultate over the following arteries: aorta, renal, iliac, and

femoral.
K. No sound should be heard. Note the presence of a bruit if auscultated.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal ndings


Report and record normal and abnormal ndings

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96 C h a p t e r 4 Physical Assessment

KEY POINTS

FOR

REPORTING

AND

RECORDING

history of any condition reported in the interview (subjective data) such as chest pain, irregular heartbeats, hypertension, diabetes, rheumatic fever, stroke, or smoking. Also
include a history of pain in the calves, feet, buttocks, or legs,
including the type of pain, what aggravates the pain, and what
relieves the pain. Note a history of coldness, cyanosis, edema,
varicosities, parethesis, or tingling in the extremities.
Heart
Assessment ndings (objective data) to include
Anatomic location of apical impulse.
Heart rate, rhythm, and symmetry of apical pulse and pulse
in extremities.
Palpation ndings: pulsations, thrills.
Auscultation ndings: characteristics of S1 and S2 (location,
intensity, pitch, timing, systole, and diastole).
Presence of murmurs, clicks, S3 or S4 (description by timing, location, radiation, intensity, pitch, quality, variation with
respiration).
Blood Vessels
Assessment ndings (objective data) to include
Amplitude, symmetry of pulses in extremities.
Jugular vein pulsations and distention, pressure measurement.
Presence of bruits over carotid, renal, iliac, femoral arteries,
and aorta.
Temperature, color nail beds of lower extremities.
Presence of edema, swelling, vein distention, varicosities,
Homans sign, tenderness of lower extremities.

PROCEDURE 4.8
Assessing the Musculoskeletal System
OVERVIEW

The assessment of the musculoskeletal function focuses on determining range of motion, muscle strength and tone, and joint and
muscle condition.

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P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 97


P R E PA R AT I O N

Depending on the muscle or joint group assessed, the patient may


be standing, sitting, supine, or prone.
Joints vary in degrees of movement.

Special Considerations
When assessing range of motion, do not force a joint into a painful
position. It is good practice to know the joints normal range and the
extent to which it can be moved.
Elderly Patient
Note: in older adults, a loss of muscle mass may cause bilateral
weakness.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for injury due to immobility


Self-care decit due to injury
EXPECTED OUTCOMES

Assessment completed while maintaining patients privacy and


comfort
Awareness of cultural and traditional health practices

EQUIPMENT/SUPPLIES

Marking pen or pencil


Goniometer
Tape measure
Reex hammer
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Explain each procedure to patient.
Careful explanation reduces the patients anxiety.
Fully expose area and be able to freely move body parts.
Adequate exposure is necessary for a thorough examination.

General Inspection
General inspection.
The nurse inspects patients body and observes physical features and gait
and posture.

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98 C h a p t e r 4 Physical Assessment

Observe gait and posture as the patient walks into the room. Note
any foot dragging, limping, shuffling, and note the position of the
trunk in relation to the legs.
The patient is unaware of your assessment and is likely to walk
naturally.

Note standing posture. Note the normal cervical, thoracic, and


lumbar curves.
Normal standing posture is upright with parallel alignment of the hips and
shoulders, and the head is erect. Abnormalities include:
Kyphosishunchback
Lordosisswayback
Scoliosislateral spinal curvature
Osteoporosisheight loss occurring in trunk

Note symmetry of joints, muscles, and extremity length, and look


for obvious deformities.
Asymmetric joints, muscles, and extremity lengths are abnormal and should
be reported.

Palpation
Palpation.
The nurse uses the hands and sense of touch to gather data. Palpation is
used to detect tenderness, temperature, texture, pulsations, and masses, and
other changes in structural integrity.

Palpate all muscles, joints, bones while noting any tenderness,


swelling, crepitus, and resistance to pressure.
Provides information regarding any abnormalities in joints, muscles, and
bones.

Range of Motion
Range of joint motion.
Assessment of patient mobility and range of joint motion allows the nurse
to determine the amount of work or exercise tolerance a person is able to
perform.
Measure the precise degree of motion in a joint with the goniometer.
This is usually done only when you suspect a reduction in joint movement.

Ask the patient to put each joint through its full range of motion
while you gently support the extremity.
The same body parts are compared for equality in movement.
If patient is weak or ill, nurse may do passive ROM by gently supporting and
moving the extremities through their range of movement.

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P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 99


Note:
Swelling
Stiffness
Instability
Deformity
Tenderness
Crepitus (a crackling sensation and noise caused by rubbing of bone fragments)
Normal joints are nontender and move freely; in the elderly you may see
stiffness with reduced ROM.

Muscle Tone and Strength


Muscle tone and strength.
The muscle tone and strength are assessed bilaterally to compare to opposite muscle. Differences in bilateral muscle tone or strength may indicate a
pathologic diagnosis.

The nurse may assess muscle strength and tone during range of
motion. Note: tone is the muscular resistance felt.
You must know each joints normal range.
Do not force a joint into a painful position.

Hypertonicity and movement will be met with resistance.


Hypotonicity feels abby and may hang loosely in a position determined by
gravity.

Apply gradual increase in pressure to a muscle group, and have the


patient resist the pressure to measure strength of the muscle.
Neck: Place hand rmly against patients upper jaw and ask patient
to turn head laterally against resistance.
Shoulder: Place hand over midline of patients shoulder, exerting
pressure. Have patient raise shoulders against resistance.
Elbow: Pull down on forearm as patient attempts to ex arm, as
patients arm is exed, apply pressure against forearm. Ask patient
to straighten arm.
Hip: With patient in sitting position, apply downward pressure to
thigh. Ask patient to raise leg up from table.
Gastrocnemius: With patient sitting, hold shin of exed leg. Ask
patient to straighten leg against resistance.

If weakness is identied, the muscle size is compared to opposite muscle with


a measuring tape.

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100 C h a p t e r 4 Physical Assessment


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to the normal


Pursue more specic tests and assessments regarding abnormal
ndings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

Gait and posture and symmetry of joints, muscles, and extremity length.
Note the joints range of motion and the extent to which it
can be moved. Record and report any abnormalities found.
Note in the patients record the muscle tone and strength
that were observed and report any abnormalities found.

PROCEDURE 4.9
Assessing the Abdomen
OVERVIEW

The abdominal assessment is routine in a physical examination and


is performed on patients of all ages.
The abdominal cavity contains several of the bodys vital organs and
can provide valuable clues as to the patients diagnosis and condition.

P R E PA R AT I O N

Landmarks help the nurse map out the abdominal region.


Assessment involves examination of organs and tissues anteriorly
and posteriorly.
Patients must be relaxed, warm, and provided privacy for the examination.
Adequate light is essential for inspection and visualization during
examination.
Nurse must begin with inspection then follow with auscultation.

Special Considerations
The nurse must begin with inspection and then follow with
auscultation.

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Palpation and percussion may alter the frequency and character of


bowel sounds.
During auscultation, the nurse asks the patient to refrain from talking. If the patient has a nasogastric tube or an orogastric tube connected to suction, it should be turned off so that the sound from
the suction will not obscure the bowel sounds.
R E L E VA N T N U R S I N G D I A G N O S E S

Nutrition, altered related to infection


Pain related to injury
EXPECTED OUTCOMES

Assessment completed while maintaining patients privacy and


comfort
Awareness of cultural and traditional health practices

EQUIPMENT/SUPPLIES

Stethoscope
Ruler or nonstretchable measuring tape
Marking pen
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Explain procedure to patient.
Explanation reduces the patients anxiety.
Position the patient supine with arms down at sides, and place a

small pillow beneath the knees.


Supine position facilitates the examination of the entire abdomen. Pillow
supports the patients back.
Provide adequate cover for the patient.
This helps to reserve the patients privacy and provide warmth before proceeding with rest of the assessment.
The nurse must stand on the patients right side and sit in a position

to look across the abdomens surface.


Standing helps detect abnormal shadows and movement. Sitting position
provides horizontal view that allows detection of abnormal protuberances
and contours.
Divide the abdomen into four quadrants.
Landmarks help the nurse map out the abdominal regions.

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102 C h a p t e r 4 Physical Assessment

Inspection
Inspection.
Examiner needs to make sure the patient is disrobed and provide privacy
with adequate covers and warmth of the examination room.
Inspection of skin.
The location of scars, venous patterns, rashes, lesions, pigmentation
changes, and stretch marks are noted. This can help identify previous
surgeries or trauma and show if skin has been stretched from obesity
or pregnancy. Striations can also signal possible adrenal problems.
Inspection of umbilicus.
Normally the umbilicus is at. You may notice a different shape or color,
which could indicate pathology.
Underlying masses may displace the umbilicus, and an everted umbilicus
indicates distention.
Watch for umbilical discharge; this is an abnormal sign.
Inspect contour and symmetry.
The presence of a mass or masses on one side may indicate a problem.
Intestinal gas, tumor, or uid in the abdomen may cause distention.
Do not confuse distention with obesity.

Observe the abdomen while asking the patient to take a deep


breath.
This moves the diaphragm downward and decreases the size of the abdominal cavity; any enlarged organs may cause a bulge.

Observe the abdomen while the patient raises his or her hands
over the head.
This helps to evaluate the abdominal musculature. Any hernias, masses,
and muscle separation will become more apparent.

Inspect for movement and pulsations.


With pain, respiratory movement is diminished, and the patient may guard
against the pain by tightening the abdominal muscles. (Women breathe
costally, and men breath more abdominally.)
Looking across the abdomen, the nurse may see peristaltic movement and
aortic pulsations (midline, above the umbilicus).

Auscultation
Auscultation.
Auscultation comes next in the physical examination.
The examiner should listen to bowel sounds before palpating or percussing.
These actions will stimulate bowel action and provide unreliable data for the
examiner.

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P r o c e d u r e 4 . 9 Assessing the Abdomen 103


Warm the diaphragm of the stethoscope, and with light pressure

auscultate in all four quadrants to detect normal, high-pitched


bowel sounds.
Sounds are normally described as
Normal
Audible
Absentabsence of gastrointestinal motility and a late stage of bowel
obstruction
Hyperactive or hypoactiveHyperactive sounds indicate hypermotility
caused by inammation of the bowel, anxiety, diarrhea, bleeding, excess
ingestion of laxatives, and reaction of the intestine to certain foods.
You must listen 5 to 15 seconds in each quadrant.
Place the bell of the stethoscope diaphragm over the epigastrium

to auscultate for bruits, which manifests as a whooshing or blowing


sound. Renal-artery bruits can be heard by placing the stethoscope
over each upper quadrant anteriorly or over the costovertebral angle
posteriorly.
If a bruit is heard, it is not normal and should be reported to a physician
immediately.
Place bell of the stethoscope above the liver and spleen and listen

for a friction rub.


An inamed liver or spleen may rub against the peritoneum during inspiration, creating a grating sound.

Percussion
Percussion.
Percussion allows the examiner to determine borders of the spleen, liver, and
other major organs in the abdomen. It also provides information regarding
presence of uid in the abdominal cavity.
Systematically percuss each quadrant to assess areas of tympany

and dullness.
Tympany is percussed when there is air in the stomach or intestine. Dull
percussion is heard over solid masses as in an enlarged liver, spleen, tumor,
or a full bladder.
Percuss to identify the liver border by starting at the iliac crest and

proceeding upward on the right midclavicular line. As you percuss


upward, the percussion note changes from tympanic to dull at the
livers lower border. (Mark the point.) The upper border is found by
percussing downward from the nipple along the midclavicular line.
When the note changes from resonance to dull, make a mark. The
distance between the points should be 6 to 12 cm.

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104 C h a p t e r 4 Physical Assessment


Percussion allows the nurse to identify borders of the liver and to detect any
organ enlargement. Diseases such as cirrhosis, cancer, and hepatitis can
cause this liver enlargement.
Percuss for the gastric air bubble in the left lower anterior rib cage

and left epigastric area.


Note: The tympany heard when percussing the gastric bubble is lower in
pitch than the tympany of the intestines.
Have the patient sit or stand erect to assess for kidney inammation.

With the ulnar surface of a partially closed st, percuss the costovertebral angle at the scapular line.
If the kidneys are inamed, the patient will feel tenderness during percussion.

Palpation
Palpation.
Palpation is the last process of the abdominal examination and provides the
examiner with data concerning areas of tenderness and presence of uid,
masses.
Hold the palm of your hand and forearm horizontally and lightly

palpate each quadrant.

FIGURE 4.9 Light palpation.

Supercial palpation (1 cm)


Deep palpation (2.5 to 7.5 cm). If you are experienced, you may
do this.
You are palpating for muscular resistance, distention, tenderness, and
supercial organs or masses.

Wash hands.
Reduces transmission of microorganisms, which could cause infection.

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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 105


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Pursue more specic tests and assessment regarding abnormal
ndings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

If patient has abdominal or lower back pain, record the pain


in detail (location, onset, frequency, severity, precipitating factors, aggravating factors).
Assess normal bowel habits and any history of changes.
Determine if patient has had abdominal surgery or trauma to
the abdomen in the past.
Assess for difficulty swallowing, heartburn, black or tarry
stools, diarrhea, or constipation.
Determine if patient is pregnant, and note last menstrual
period.
Ask patient about history of alcohol or aspirin intake.

PROCEDURE 4.10
Assessing the Neurologic System
OVERVIEW

To determine alteration in neurologic functions such as initiation


and coordination of movement, reception and perception of sensory
stimuli, organization of thought processes, control of speech, and
storage of memory.
To determine a cause for level of consciousness (LOC), mental/emotional status, and to determine if there are any alterations in central
or peripheral nervous system. Identication of specic patterns may
aid in the diagnosis of a pathologic condition.

P R E PA R AT I O N

Neurologic assessment can be time consuming, and the examiner


must not rush through the assessment process.
An efficient nurse can integrate neurologic measurements with
other parts of a physical examination. Example: While taking the history, the nurse can note the patients mental and emotional status.

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Special Considerations
A patients level of consciousness inuences the ability to follow
directions.
General physical well-being may inuence tolerance to assessment.
Chief complaint helps determine the need for a more thorough
examination.
Complaint of headache or recent loss of function in an extremity
may warrant a complete neurologic examination.
R E L E VA N T N U R S I N G D I A G N O S E S

Confusion related to uid volume decit


Self-care decit due to immobility
EXPECTED OUTCOMES

Assessment completed while maintaining the patients privacy and


comfort
Awareness of patients cultural and traditional health practices

EQUIPMENT/SUPPLIES

Reading materials
Safety pin
Penlight
Tongue blade
Hot and cold water
Cotton balls
Tuning fork
Reex hammer
I M P L E M E N TAT I O N

Mental and Emotional Status


Mental and emotional status.
An observation made by the nurse to assess the appropriateness of emotions
and mental status.

Levels of Consciousness
Level of consciousness.
Assess whether the patient will be able to follow with you during the examination. If a patient is not fully awake and alert, the neurologic assessment
may be difficult.

Note LOC from fully awake, alertness, and cooperation to unresponsiveness to any form of stimuli.

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Note if patient is oriented to person, time, and place.


A fully conscious patient responds to questions spontaneously. As patients
LOC lowers, you may see irritability, shorter attention span, and uncooperativeness.

Exert pressure on supraorbital ridge of nailbed.

Pinch Achilles tendon.

Normally, patient will try to stop or pull away from painful stimuli.
If not responding properly, the patient may assume
Decorticate posturing (legs extended; feet extended with plantar exion;
arms internally rotated and exed on chest) may be due to lesion of corticospinal tract near cerebral hemisphere.
A. Decorticate posturing
Wrists and fingers flexed

Feet plantar flexed

Legs internally rotated

Elbows flexed

Arms adducted

B. Decerebrate posturing

Feet plantar flexed

Wrists and fingers flexed


Forearms pronated

Arms adducted
Elbows extended

FIGURE 4.10 Decorticate (A) and decerebrate (B) posturing.

Decerebrate posturing (arms stiffly extended and hands turned outward


and exed; legs extended with plantar exion) may be due to lesion in diencephalons, pons, or midbrain.
Flaccid posturing (no motor response) may be due to extreme brain
injury to motor area of brain.
Abnormal involuntary movements
Choreiform(jerky and quick).
Athetoid(twisting and slow) present in cerebral palsy.

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Tremorshyperthyroidism, cerebellar ataxia, parkinsonism.
Spasmscord injury.
Seizuresbrain injury, heat stroke, electrolyte imbalance.
Asterixismetabolic encephalopathy due to liver or kidney failure.

Behavior and Appearance


Behavior and appearance.
Patients behavior and appearance initially show how they view themselves.
This will often alert the nurse to a more thorough examination.

Note the patients behavior, mood, hygiene, and choice of dress.


Appearance reects how one feels about oneself. An unkempt appearance
can mean a variety of things, such as:
Poor self-image.
Inability to keep clothes clean.
Inability to perform grooming.

Language
Language.
When communication is altered, the assessment may be difficult, but also
may indicate a pathologic diagnosis.
Assess language when communication with the patient is

ineffective.
Have the patient name an object you point to.
Have the patient follow simple written commands like sit down.
Have the patient read simple sentences aloud.
If the patient is unable to understand spoken words or written words and to
express the self through writing or gestures, there may be an injury to the
cerebral cortex, which is called aphasia:
Receptivecannot understand written or verbal speech.
Motorcan understand written and verbal speech but cannot return
communication.
Globalunable to understand speech or express the self.

Intellectual Function
Intellectual function.
Alerts the nurse of possible pathologic diagnosis.

Memory
Memory.
Many conditions can alter a patients memory.

Test for memory by assessing immediate recall and recent remote


memory.
Have patient repeat a series of numbers.

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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 109

Have patient recall events occurring during the same day.


Have patient recall medical history or family history or ask about
birthdays or anniversaries.
Sudden confusion may be caused by acute conditions such as dehydration,
infection, drug toxicity, or hypoglycemia.
In elderly, confusion and forgetfulness are common, but gradual, progressive
deterioration in mental function may indicate Alzheimers disease.

Abstract Thinking
Abstract thinking.
Any type of altered mentation may prevent the patient from explaining an
abstract idea.
Test by asking the patient to explain a stitch in time saves nine.
If the explanations are relevant and concrete, altered mentation is not suspected.
A patient with altered mentation may interpret the phrase literally or just
repeat the phrase.

Pupil Assessment
Pupil assessment.
When a beam of light is shone through the pupil and onto the retina, the
third cranial nerve is stimulated and innervates the muscles of the iris to
contract. Any abnormality along the nerve pathway from the retina to
the iris alters the ability of the pupil to react to light.
Size of pupil (holding eyelids open).

Shape of pupil.
Unilateral dilationthird cranial nerve involvement.
Bilateral dilationupper brainstem damage.
Unilateral and nonreactiveincreased ICP or CNIII compression.
Fixed and dilatedmidbrain involvement.
Pinpoint and xeda sign of pontine involvement or opiate effects.
Equality of pupil.
Unequal denotes that parasympathetic and sympathetic nervous systems
are not synchronized.
Reaction to lightIn darkened room, open eyelid being tested

(cover opposite eye) and move penlight toward patients eye from
side position.
Sluggish reaction is an early warning of deteriorating condition.
If pupil does not constrict, the connection between the brainstem and pupil
is not intact.

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Light reexhold both eyes open and shine light into one eye while

observing the reaction of the opposite pupil.


Note light reex is the most important sign differentiating structural (cranial involvement) from metabolic coma due to extracranial cause (diabetic
coma), which does not alter light reex.

Motor Function
Motor function.
An assessment of motor function includes the same measurements made
during the musculoskeletal examination. In addition, cerebellar function is
assessed.

Muscle Strength
Have patient squeeze your ngers bilaterally.

Test arm strength by having patient close eyes and hold arms out in
front with palm side up.
Lack of or diminished muscle function on one side may be a sign of:
Hemiplegia (paralysis on one side of the body).
Hemiparesis (weakness on one side of the body).
Paraplegia (paralysis of the legs or lower body) .
Tetraplegia or quadriplegia (paralysis of arms and legs).

Flexion and Extension


Stand in front of patient and ask patient to push your hands away.

Have patient pull upward after placing your hand on patients


forearm.
Place patients knee in exed position and ask patient to keep foot
down while you extend the leg.
Have patient straighten leg as you apply resistant force to knee and
ankle with each hand.
1. Increased resistance is a sign of increased muscle rigidity or spasticity, and
decreased resistance to leg extension and arm exion may be assign of
cerebrovascular accident (CVA).
2. Weakness may indicate cerebellar lesion.

Muscle Tone
Flex and extend patients upper extremities to assess how well

patient resists your movements.


Flex and extend patients lower extremities to assess resistance.

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Coordination
Coordination.
The nurse must observe the smoothness and balance of movements.
Uncoordinated movements may be from cerebellar involvement or basal
ganglia involvement.

Hand
Hand.

While patient is seated, have the patient pat both thighs as rapidly
as possible.
Have the patient turn hands over in rapid succession.
Ask the patient to touch thumb with each nger in rapid
successionrepeat with other hand.
Foot

Foot.

Place your hands close to patients feet and ask the patient to tap
your hands alternately with the balls of the feet.
Hand Positioning

Hand positioning.

Ask the patient to alternately touch his own nose and your index
nger of one hand.
Repeat test with patients eyes closed.

Inability to perform task with eyes closed: may be due to loss of positioning
sense.

Leg Positioning
Leg positioning.

Have patient run the heel of one foot down the shin or tibia of the
other leg.

Reexes
Reexes.
Eliciting reex reactions allows the nurse to assess the integrity of sensory
and motor pathways of the reex arc and specic spinal cord segments.

Blink
Blink.

Have patient look up and away from you, as you approach from the
side. Lightly touch the cornea with a cotton wisp.
Absence of a blink response may indicate fth or seventh cranial nerve
involvement.

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Gag and Swallow


Gag and swallow.

Open patients mouth and hold tongue down with tongue blade.
Touch back of pharynx on each side with cotton applicator stick.
Absence of gag and swallow may indicate ninth or tenth cranial nerve
involvement.

Plantar Response
Plantar response.

Run a pointed object on the lateral side of foot, from heel to ball,
then curve medially across the ball of the foot.
Babinski responsegreat toe dorsiexes; others fan on foot of paralyzed
side (CVA), and bilaterally in spinal cord injury (SCI).

Deep Tendon
Deep tendon.

Patient must be relaxed. Position the limb with slight tension on


the tendon to be tapped. Briskly tap tendon.
Bicepsex at elbow and contract bicep
Tricepsextend at elbow and contract triceps
Kneeextend knee and contract quadriceps
Absent or diminished bicep reexC5 or C6 involvement.
Absent, diminished tricepsC7 or C8 involvement.
Absent or diminished kneeL23 or L34 involvement.

Sensory Function
Sensory function.
The sensory pathways of the central nervous system conduct sensations
of pain, temperature, touch, and position.

Pain
Pain.

Stroke or touch skin with safety pin, alternate dull and sharp
endask patient to distinguish the two.
Alteration in pain or temperature sensations may indicate a lesion in posterior horn or spinal cord.
Analgesia absence of sense of pain.
Hypoalgesia decrease pain sensation.
Hyperalgesia exaggerated sensitivity to pain.

Temperature
Temperature.

With patients eyes closed, have patient distinguish between a hot


and cold item.

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Touch
Touch.

Have patient close eyes. Touch skin lightly and have patient point
or tell you the area when sensation is felt.
Anesthesia loss of light touch.

Positioning
Positioning.

Have patient close eyes; grasp nger with your thumb and index
nger.
Move patients nger up and down.
Have patient identify direction of movement.

Inability to identify correct direction of movement may indicate injury to


posterior column or peripheral nerve disease.

Vital Signs
Respirations
Respirations.

Assess rate and pattern of breathing.


If respiratory imbalance noted, monitor arterial blood gases.
Cheyne-Stokesrhythmic increase in depth of breathing followed by
a period of apnea may indicate a cerebellar lesion or condition altering
cerebral profusion.
Hyperventilationupper brain stem involvement.
Ataxicirregular, unpredictable breathing due to lower brain stem involvement.
Alterations in pH and Pco2 values indicate respiratory imbalance.
Normal: pH: 7.357.45.
Pco2: 3545 mm Hg.
HCO3: 2226 mEq/L.
pH 7.35 and Pco2 45 Respiratory acidosis (hypoventilation).
pH 7.45 and Pco2 35 Respiratory alkalosis (hyperventilation).
HCO3 26 indicates metabolic compensation for chronic respiratory acidosis
(hypoventilation).

Apical and Radial Pulse


Apical and radial pulse.

Note character of pulses.


Count heart rate.
Count radial pulse rate.

Fast heart ratedecreased blood volume, arrhythmia, heart failure.


Irregular rhythm with premature beatshypoxia, cardiac irritability,
or electrolyte imbalance.

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Temperature
Temperature.

Take rectal or tympanic temperature if patient is semiresponsive.


Inability to maintain normal temperature may indicate damage to hypothalamus.

Blood Pressure
Blood pressure.

Position neurologic patients in low to semi-Fowlers position.


Systolic pressure rise without a rise in diastolic (widening pulse pressure)
may indicate increased ICP.
B/P 140/90 mm Hg hypertension.
B/P 95/60 mm Hg hypotension.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal


Pursue more specic tests and assessment regarding abnormal ndings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

Mental and emotional status.


Intellectual function.
Pupil size and reaction.
Motor coordination.
Reexes.
Use grading scale:
4 Hyperactive or exaggerated
3 More brisk than usual but not indicative of disease state
2 Average or normal
1 Slightly diminished, low normal
0 No response
Sensory.
Vital signs.

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PROCEDURE 4.11
Assessing the Skin, Hair and Scalp, and Nails
OVERVIEW

Skin, hair, and nails provide a self-regenerating protective covering


for the body.
Assessment of the skin not only provides information about the
integumentary system but also provides data on the bodys circulation, nutritional status, and signs of systemic disease.

P R E PA R AT I O N

Review related history that would give the examiner information


(past and present) regarding patients skin, hair, scalp, and nail conditions (i.e., skin cancer, eczema, change in mole, hair or nails, excessive
bruising, rash or lesion).
Integrate this assessment throughout the examination as each body
part is examined.
Observe symmetry of skin markings and pigmentation.
Separate all skin folds and inspect thoroughlyfront and back.

Special Considerations
Pediatric Patient
Several pigmentation differences are found in the assessment of
infants. The mongolian spot, a blue-black macular area at the sacrum
or buttocks is more commonly found in Asian, Native American, and
Hispanic newborns, as are caf au lait spots.
Newborns may also have acrocyanosis, a bluish color around the lips,
hands, and feet as well as transient mottling when exposed to cool
temperatures. Physiologic jaundice is also seen in approximately half
of all newborns. Lanugo, a covering of ne hair over the body is often
found, especially in premature infants.
Turgor is tested over the abdomen in an infant.
Pregnant Patient
In the assessment of a pregnant woman, striae or stretch marks are
often found as well as the linea nigra, a brownish black line down the
midline of the abdomen. Chloasma, the mask of pregnancy, is an
irregular patch of hyperpigmentation on the face. Vascular spiders
are found in about two thirds of pregnancies in white women.
Elderly Patient
Elderly patients have special considerations as well.

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The skin is thin and dry, with decreased turgor, and the nails become
more brittle and yellowed.
Hair growth decreases, although in men, the hair becomes thick and
coarse at the eyebrows, nose, and ears.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired tissue integrity related to infection


Risk for infection related to injury
EXPECTED OUTCOMES

Assessment completed while maintaining patients privacy and


comfort
Awareness of cultural and traditional health practices

EQUIPMENT/SUPPLIES

Strong, direct lighting


Clear, exible centimeter ruler
Penlight
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Explain procedure to patient.
Careful explanation reduces the patients anxiety.
Fully expose area to be examined.
Adequate exposure is necessary for a thorough examination.
Inspect and palpate under strong, direct light.
Weak, indirect lighting can distort colors and mask jaundice.

Skin
Note general color as well as local variations.
Color should be consistent with genetic background; look for pallor,
cyanosis, jaundice.
Note temperature using backs of hands, and compare bilaterally.
Provides insight to circulatory status, infection, or trauma.
Note moisture and texture using pads of ngers.
Provides information regarding metabolic activity and fever.

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Note mobility and turgor using skin under the clavicle.
Provides data on uid status, weight gain/loss.
Check for edema by pressing rmly over bony area of tibia or ankle.
Provides information on uid status, indicative of possible congestive heart
failure, kidney failure, or local problem (especially if unilateral).
Note lesions; identify color, shape, size, location, distribution, eleva-

tion, and any exudate (color/odor).


May be indicative of traumatic or pathologic changes.

Hair and Scalp


Note color of hair.
Consistent with genetic background and signs of premature gray.
Note texture of hair.
Indicative of nutritional and endocrine status.
Note distribution of hair.
Indicative of endocrine and nutritional status.
Note scalp abnormalities by parting and lifting hairpay special

attention to occipital area and behind the ears.


Provides information of presence of ringworm, lice, dandruff, lesions, or
trauma.

Nails
Note color.
Provides information on perfusion and oxygenation status (pallor/cyanosis).
Note capillary rell timenormal 12 seconds.
Cyanotic or sluggish color return may suggest cardiovascular or respiratory
dysfunction.
Note consistencysmoothness, thickness, adherence to nail bed.
Indicative of nutritional, cardiovascular, or respiratory condition.
Note shape and contour.
Angle at nail base 160 degrees with spongy nail base indicative of chronic
cyanotic condition such as emphysema or chronic bronchitis.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare assessment ndings to normal ndings


Pursue more specic tests and assessment regarding abnormal
ndings if warranted

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KEY POINTS

FOR

REPORTING

AND

RECORDING

Skin color, integrity, texture, temperature, turgor, hygiene, scars


(location).
Edema.
Location.
Degree: 1 Mild, 2 Moderate, 3 Deep pitting, 4 Very
deep pitting.
Unilateral/bilateral.
Excessive perspiration, unusual odor.
Presence and description of lesions.
Size, shape, location, distribution.
Color, blanching, tenderness, elevation.
Exudatecolor/odor.
Presence and description of decubitus.
Stage IReddened area of intact skin that will not blanch.
Stage IIPartial thickness wound involving the epidermis
and/or dermis. Presents as a blister, abrasion, or shallow
crater.
Stage IIIFull-thickness wound extending into the subcutaneous tissue. Presents as a deep crater.
Stage IVFull-thickness wound with extensive destruction
of tissue, necrosis, and/or damage to muscle or bone.
Traumalocation and description.
Hair texture, distribution, parasites.
Nail color, capillary rell time, nail base angle, adherence to
nail bed.

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U N I T

C H A P T E R

Medication
Administration

5
Oral and Topical
Medications
5.1
5.2
5.3
5.4

Administering Oral Medications, 120


Helping Patients with Self-Medication, 126
Applying Medications to the Skin, 130
Administering Eye Drops and
Ointments, 134
5.5 Instilling Medications into the Ear, 139
5.6 Administering Medications via
Metered-Dose Inhaler, 142
5.7 Administering Medications via Rectal
Suppository, 145

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PROCEDURE 5.1
Administering Oral Medications
OVERVIEW

Safe medication administration involves accurate dose calculation,


of the correct medication, given to the intended recipient, by the
appropriate route, at the right time (the 5 rights).
P R E PA R AT I O N

Calculation of Medications
There are numerous methods for calculating medications. A few
examples are listed.
Desired Dose (mg) Available Vehicle (mL, tab, etc.)
Correct Dose

(mL, tab)
Available Dose (mg)
Available Vehicle Amount (mL, tab) Desired Dose (mg) Correct
Dose
Available Dose (mg)
(mL, tab)
Special Considerations
A medication order must include the patients full name, the date
and time the order was written, the name of the medication, the
dose, the route, the frequency, and the signature of the person writing the order.
Medications must be checked for the five rights with each administration: right patient, right medication, right dose, right route, and
right time.
Allergies should be checked prior to each medication administration.
The timing of the medication can affect the speed with which it is
absorbed and acts.
In general, oral medications are absorbed better on an empty stomach if the patient can tolerate the medication. Many medications
cause gastrointestinal distress.
Circadian rhythm also will affect absorption.
Check with references or the pharmacy before crushing any medication. Alert the prescriber if a liquid form is needed.
Do not crush an enteric-coated tablet, as they are not designed to be
absorbed immediately.
Do not crush sustained-release tablets, as the delay in release of the
drug will be lost, and more of the drug will be absorbed immediately.
Some medications, such as liquid iron preparations, will stain the
teeth.

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P r o c e d u r e 5 . 1 Administering Oral Medications 121

Some medications have special administration instructions, such as


the patient must remain upright after administration.
If a medication falls on the oor, discard it and replace it to prevent
contamination.
If the patient is scheduled for a test or procedure, check with the
prescriber regarding medication administration, especially if the
patient is ordered to have nothing by mouth.
Many medications have similar names. If an order is unclear, check
with the prescriber before administration.
Many medications are made by more than one company.
The nurse needs to know the trade as well as the generic name of
the medications being administered.
Pediatric Patient
Do not refer to medications as candy.
In administering liquid medications to children, use a calibrated
syringe or spoon readily available at drug stores and supermarkets
to ensure correct dosing.
For infants, a syringe or dropper is best.
Place syringe alongside the tongue to prevent gagging and expulsion of medication.
To prevent choking, position the infant in a semi-reclining position
and administer in small aliquots.
If using a spoon, collect and re-feed any expelled medication.
Do not mix medication into a large volume, as the child may not be
able to drink the entire amount.
Play techniques may help elicit the childs cooperation.
For children taking sweetened medications, especially on a longterm basis, follow medication administration with oral hygiene to
assist in decreasing dental caries.
Elderly Patient
The elderly are often on multiple medications from various physicians.
Look for possible drug interactions as well as prescriptions for more
than one drug from the same class (such as beta-blockers).
At home, memory aides such as charts, daily-pill dispensers, and calendars can assist in ensuring that medications are taken correctly,
especially for those on complex regimens.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible Knowledge Decit related to safe medication administration

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122 C h a p t e r 5 Oral and Topical Medications


EXPECTED OUTCOMES

The correct person will receive the correct medication and the correct dose, by the correct route, at the correct time, without injury or
incident
EQUIPMENT/SUPPLIES

Order Sheet
Medication Administration Record (MAR)
Medication Cart/Automated medication-dispensing system
Medication to be administered (pills, capsules, liquids)
Disposable medication cups or syringes as indicated
Glass of water or other liquid and drinking straw
Pill-crushing devise, if indicated
I M P L E M E N TAT I O N
Check MAR against order sheet, including checking for patient aller-

gies and order-expiry dates. Notify prescriber/supervisor of discrepancies and correct as necessary.
Promotes safety, prevents errors, and prevents patient injury and unnecessary allergic reactions.
Wash hands.
Reduces transfer of infections.
Assemble equipment.
Improves efficiency.
Obtain appropriate medications. Pour correct amount. Begin at the

top of the MAR. Check each against bottle label and MAR when
pulled from the shelf or machine, as it is poured, and as bottle is
replaced or drawer closed. Calculations should be made using standard formulas according to institutional policy when required.
To ensure no medications are missed and the correct medication and dose
are poured.
For tablets or capsules: pour into cap of bottle then into medication

cup without touching the tablets/capsules.


To prevent contamination.
Unit dose: leave in packages until at the bedside.
Keeps the medication clean and facilitates identication at the bedside
Breaking tablets: Only scored tablets should be broken. Use a cutting

device as needed. The rest of the unused tablet should be discarded


according to agency policy.
To ensure correct amount is given and that safety is maintained.

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P r o c e d u r e 5 . 1 Administering Oral Medications 123


Crushing tablets: Place tablet between two medicine cups then

crush with pill crusher until a ne powder. Mix at bedside with small
amount soft food or liquid.
Fine powders mix better. To assist patients who have difficulty swallowing
whole pills.
Pouring liquids: Gently mix liquid by inverting bottle a few times.
Many liquids settle while on the shelf.
Set the cap upside down on the counter.
To avoid contamination.
Pour liquid away from label.
To prevent destruction of label.
Pour liquid medication into cup set on a rm surface, and read at the

lowest level of the meniscus.


Ensures the most accurate dose.
Wipe bottle before replacing cap.
To keep cap from sticking.
Controlled substances: The dose must be signed out on the narcotics

sheet with the patients name, medication, dose, date, time, and your
name as the administering nurse. For those with automated dispensing machines, this is done automatically when the medication is
removed.
To comply with federal regulations.
Obtain assessment data.
To determine whether any medications need to be withheld for safety
Take medication to bedside with liquid for swallowing.
In preparation for administration.
Assist the patient into a semi-Fowlers position.
To decrease risk for aspiration.
Don gloves if exposure to saliva is possible.
Protects nurse from infection.
Recheck patients identity using armband and bar code, and asking

patients name. Explain procedure and medications.


To ensure correct medication is being given to the correct patient. To enlist
cooperation.
If patient questions any medication, hold the medication and

recheck order.
To ensure safety. Unfamiliar medications may signal a previously unidentied discrepancy.

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124 C h a p t e r 5 Oral and Topical Medications


If a medication has a bad taste, sucking on ice before taking the

medication, giving it in a small amount of juice, or following it with


a small amount of juice is permitted.
Facilitate compliance by decreasing the bad taste.
Open unit dose packets and place one at a time into a medication

cup.
Give tablet or capsule medications to patient. Ask patient to take

one medication at a time and drink plenty of water.


To ensure medication is swallowed and not lodged in throat or esophagus.
Liquid medications should be taken after capsules and tablets are

taken. Ask the patient to nish the liquid medication. Follow with a
small amount of water.
Some liquids should not be further diluted.
Stay with the patient until all medications are taken. Check patients

mouth if there is any question that the medication has been swallowed.
Ensures all of the medications are taken and not retained in mouth or cheek.
Reposition patient, lift side rails if lowered, and place call light within

reach.
Instruct patient to call nurse for any deleterious side effects or symptoms of allergic reaction.
Facilitates comfort. Ensures safety.
Discard trash and remove any medications not ingested.
Maintain safe environment.
If patient refused medication or wishes to take it later, do not leave

at bedside.
Maintain a safe environment.
Remove medication and restore to shelf or machine only if in

unopened unit-dose packet.


Allows nurse to administer later.
All open pills and open unit-dose packets must be discarded accord-

ing to facility policy. Witness is needed for controlled substances.


To comply with federal regulations.
Wash hands
Prevent spread of infection.
Document administration.
Serves as legal record of medication administration, and prevents inadvertent double dosing.

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P r o c e d u r e 5 . 1 Administering Oral Medications 125


Check patient 30 to 60 minutes later.
To detect effectiveness of medication and/or any adverse or side effects.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Many medications have side effects; the patient should be carefully


assessed for side effects and adverse reactions

KEY POINTS

FOR

REPORTING

AND

RECORDING

Routine medications are documented on the MAR.


record should be clearly labeled with the persons name.
It should include the medication name, dose, route, frequency,
and the time medication was administered.
Any assessment data pertinent to the medication should be
easily accessible, such as blood pressure measurement and
heart rate for certain cardiovascular agents.
For controlled substances, the dose must be signed out on the
narcotics sheet with the patients name, medication, dose,
date, time, and name of the administering nurse to comply
with federal regulations.
In automated dispensing machines, this is done automatically
when the medication is removed.
If the patient refuses a medication, document which medication is being refused and the reason and that the medication
was withheld.
Also document the notication of the prescriber.
For medications administered on an as-needed basis (PRN),
the assessment data pertinent to the medication, the reason
the medication was given, the effects of the medication (Did
it help?), and any teaching done should be recorded in the
patient care record.
Side effects from medications should be documented in the
patient record.
In shift report, it is assumed that all routine medications were
given on time unless otherwise specied.
Any problems, such as with swallowing, gastric distress,
refused medications, or any changes in the routine should be
reported.
Any PRN medications, including results, should be reported.
The

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126 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.2
Helping Patients with Self-Medication
OVERVIEW

To assist the patient in managing home medication regimens.


P R E PA R AT I O N

When teaching about medications, the essential nature and reason


for that particular medication must be stressed. Perception of the
helpfulness of treatment will affect the patients understanding and
thus help promote understanding and compliance.
Return demonstration for more difficult psychomotor skills such as
inhalers, nebulizers, eye drops, ear drops, and insulin injections allows
the nurse the best opportunity to assess patient performance.
Common errors made include forgetting a medication, refusing to
take a medication because of side effects, taking out-of-date medications, failing to understand instructions, taking medications prescribed for someone else, failing to obtain needed lab work to
monitor medication dosing, and being unable to afford the medication prescribed.
Addiction to prescription medications can occur. Assessment for
signs of possible addiction and concomitant alcohol use should be
assessed during routine visits using standardized formats, especially
when patient is taking controlled substances.
Especially in complex medicine regimens and when working with
the elderly, it is helpful to use a daily medication chart upon which
marks can be made or stickers placed as medications are taken.

TABLE 5.2 Medication Chart

MEDICATION

MON

Aspirin
325 mg
Digoxin
0.125 mg
Labetalol
200 mg

TUES

WED

THURS

FRI

SAT

SUN

AM
PM

AM
PM

AM
PM

AM
PM

AM
PM

AM
PM

X
AM X
PM

For those with poor reading skills, pictures or sketches can be used.
A clock face, picture of a meal, or picture of a bed for nighttime

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P r o c e d u r e 5 . 2 Helping Patients with Self-Medication 127

medications can be placed on the chart for time. A picture of the


medication can be placed in the medication list.
The medication bottles can be color-coded corresponding to a line
on the chart to ensure medications are taken correctly. Pill cases with
sections for days and/or times can be used.
If the pocket is empty, the patient knows the medication was taken
for that day. These pill minders can be lled by part-time caretakers to increase the patients independence and sense of self-esteem.
Some drug companies have special programs for low-income
patients to assist in obtaining needed medications.
Special Considerations
Pediatric Patient
The parent or child care provider needs to be an integral part of the
teaching/learning process. Children are generally quick learners;
however, they have little life experience in which to couch new
learning.
The consequences of their actions may not be understood. Simple
developmental levelappropriate language must be used in teaching
to facilitate understanding. Using a game format often facilitates
learning in children.
Even very young children can be taught to use various medical
equipment, such as nebulizers; however, usually an adult is required
to supervise treatments and medication administration, especially
for time management.
Children fear needles because of the pain. Teaching needs to include
the sensations involved as well as the reason for the medication.
Elderly Patient
In the elderly, anxiety and distraction decrease learning. The time
needed to learn is increased. Sensory-perceptual and motor decits
require modied teaching techniques and make it more difficult to
read labels and perform motor skills involved with self-medication
administration.
Age-related physiologic changes alter the absorption and effects
of medications. Many dosing regimens need to be decreased. Many
elderly patients are on multiple medications, which increases the
likelihood of interactions and side effects.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible knowledge decit related to complex medication schedules


and administration

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128 C h a p t e r 5 Oral and Topical Medications


EXPECTED OUTCOMES

The patient will correctly and safely administer own medications


according to schedule on a routine basis at home
EQUIPMENT/SUPPLIES

Medications and administration equipment needed


Chart for medication administration, calendar, list of medications
Pill-minder boxes
Clock, timer
Pens, markers, stickers
I M P L E M E N TAT I O N
Assess patients ability to read, write, and any cognitive or psychomo-

tor impairment. Identify any other barriers to self-medication.


To design a plan that is appropriate for that patient. If the patient cannot
read or write, another avenue should be considered or adaptations made
(see special considerations section). Many medications are very expensive,
and patients cannot afford them.
Gather all necessary equipment to be used by this patient. Obtain

placebo equipment, if needed, such as inhalers or saline for injection


to teach insulin self-administration.
For organization and to facilitate return demonstration for learning.
Set up a mutually agreeable date and time to meet with the patient

and family or others involved in care.


If the date and time is not agreeable, the patient will not be able to attend.
Have patient bring all medications to teaching/learning session.
To identify all medications the patient is taking, including over-the-counter
and herbal medications, for possible interactions, double or incorrect dosing,
missed medications, and expired medications.
Review each medication with the patientits purpose, effect, and

common side effects along with any special instructions.


This will help the patient understand correct administration, and help prevent the patient from taking a medication for too long or not long enough;
allows home assessment of effectiveness of treatment and opportunity to
notify the health-care provider of problems.
Encourage the use of one pharmacy for all medications.
Using the same pharmacy will help ensure oversight of multiple medication
regimens for possible drug interactions or other problems.

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P r o c e d u r e 5 . 2 Helping Patients with Self-Medication 129


Develop with the patient the chart or pill-minder system to be used.
Improves compliance, and ensures that the patient can perform the plan.
Teach psychomotor skill, then have the patient perform return

demonstrations until the patient is able to perform the skill correctly.


Ask patient to verbally explain and to demonstrate steps of skill.
To ensure correct performance and understanding of step.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Having the patient bring medications and charts or pill minders to


routine visits helps reinforce learning and identify specic problems
the patient may be having
Return demonstrations for skills should be assessed periodically to
correct poor habits that may have developed and to positively reinforce correct performance and previous learning
Alternative plans can be made if needed to better meet the patients
needs

KEY POINTS

FOR

REPORTING

AND

RECORDING

In the patients chart, a note should be made regarding persons taught, content taught, the plan developed, any tools
used (such as a chart), the patients response, and any return
demonstration performed.
Any problems identied (such as the patient cannot see without his glasses, which are at home) should be documented
with actions taken in attempting to solve the problem.
Plans for follow-up care should be recorded.
In report, persons taught, content taught, the plan developed,
any tools used (such as a chart), the patients response, and
any return demonstration performed should be discussed
with those involved in the patients care (such as other
nurses, physicians, and social workers).
Plans for follow-up care should also be discussed.

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130 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.3
Applying Medications to the Skin
OVERVIEW

To create systemic and/or local effects when absorbed through the


skin.
These applications, such as lotions, powders, aerosol sprays, patches,
pastes, and ointments, can be used to
Maintain skin hydration.
Protect skin surfaces.
Reduce local skin irritation.
Create local anesthesia.
Treat infections or medical conditions.

P R E PA R AT I O N

Topical medications should not be administered if skin integrity is


altered, unless otherwise indicated.
The skin must be cleaned thoroughly before applying topical medication to allow proper assessment of the skin surface and to ensure
benecial therapeutic outcomes (skin encrustations can harbor
microorganisms and cause local infections as well as impede contact
of medication to treatment area).

Special Considerations
Pediatric Patient
A dry dressing to cover the affected area is usually necessary when
applying topical agents to young children to prevent them from
rubbing the medication off.
Elderly Patient
Carefully apply topical agents and use tape sparingly when caring
for an elderly patient.
Their skin can be thin and fragile.
Tape can cause bruising of the skin.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for impaired skin integrity related to topical medication


Risk for noncompliance related to misunderstanding topical
regimen

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P r o c e d u r e 5 . 3 Applying Medications to the Skin 131


EXPECTED OUTCOMES

Skin surfaces protected and hydrated


Medication is properly administered
Therapeutic effect is achieved

EQUIPMENT/SUPPLIES

Medication Administration Record (MAR) or chart (see Chapter 8)


Ordered topical agent
Clean and/or sterile disposable gloves (if required)
Cotton-tipped applicators or tongue blades
Sterile or nonsterile dressing, tape (if required)
Cleaning solution to wash area if indicated
I M P L E M E N TAT I O N
Review physicians order for drug name, strength, time of adminis-

tration, and site of application. Compare the label on the medication container with the MAR and check the expiration. (See
Procedure 5.1)
Ensures drug will be administered accurately and safely.
Wash hands, observe appropriate infection control technique, and

organize the patients supplies at bedside. Prepare clean (intact skin)


or sterile gloves (open noninfectious skin).
Reduces transmission of microorganisms. Ensures an efficient, methodical
procedure. Topical skin applications are usually not measured in the medication room.
Close door to room or pull room curtain around bed; check patients

identication by asking patients name and checking it against ID


bracelet; explain procedure, and position the patient comfortably.
Provides privacy for patient, promotes comfort, and ensures that the right
patient receives the right medication. Decreases anxiety and promotes
patient cooperation.
Expose area to be treated, inspect the condition of the skin and wash

affected area with a mild, nondrying soap, if indicated.


Provides easy access to treatment area; provides a baseline to determine skin
changes following therapy. Skin should be clean to conduct a proper assessment. Cleaning removes encrustations and debris and enhances penetration
of the topical agent through the skin.
Gently pat skin dry or let air dry. If skin is excessively dry and aking,

apply topical agent to damp skin.


Excessive moisture can prevent even application of topical agent. Applying
agent over damp skin retains moisture within the skin layers.

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132 C h a p t e r 5 Oral and Topical Medications


Don gloves, and apply topical agent.
Disposable gloves prevent cross-contamination of infected lesions and protect the nurse from medication effects.

Applying Creams, Pastes, Ointments, and Oil-Based Lotions


Using gloved hands, warm and soften medication by rubbing briskly

between hands or place a small amount of cream on tongue blade.


Softening a topical agent makes it easy to spread on skin.
Spread medication evenly over skin following the direction of hair

growth.
Ensures even distribution of medication and prevents irritation of hair
follicles.
Explain to the patient that the skin may feel greasy after application.
Ointments often contain oils.

Applying Nitroglycerin (in Antianginal) Ointment


Remove previous dose paper. Wipe off residual medication with

tissue. Apply desired number of inches of ointment over papermeasuring guide.


Removal of previous dose paper prevents overdose. Ensures correct dose
of medication. Antianginal ointments are usually ordered in inches.
Rotate site with each application. Apply ointment to skin surface

by holding edge or back of paper wrapper, and place ointment and


wrapper directly on skin. Do not rub or massage ointment into skin
Prevents skin irritation. Decreases the chance of ointment touching nurses
hands. Massaging may increase absorption of medication.
Date, time, and initial paper.
Prevents missed doses.
Secure ointment and paper with plastic wrap and tape (optional).
Prevents medication from being removed and clothing from being stained.

Applying a Transdermal Patch


Choose a clean, dry, hairless area recommended by the manufac-

turer.
Placing the patch over hair or scar tissue may decrease the absorption.
Carefully remove the patch from its protective covering. Holding

the patch without touching the adhesive edges, apply the patch
by pressing rmly with the palm of one hand for approximately
10 seconds. Make sure edges stick well.

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P r o c e d u r e 5 . 3 Applying Medications to the Skin 133


Touching the adhesive edges may interfere with adherence of patch and
medication dose.
Date, time, and initial patch.
Prevents missed doses.
When the next dose is due, remove the patch and fold it so that the

medication side is covered before disposal. Choose a different site


with each change. Wait at least 1 week before applying the patch
to a previously used site.
Proper disposal protects against accidental exposure of medication to
others. Rotation of patch decreases skin irritations from medication and
adhesive.

Applying Aerosolized Medication (Spray)


Shake container vigorously, and hold the container at the recom-

mended distance (usually 612 inches).


A mixture of contents and propellant ensures distribution of ne, even spray.
Holding container too close results in thin, watery distribution.
Spray medication evenly over affected area. If neck or upper chest

areas are to be sprayed, have patient turn face away from spray or
briey cover face with towel.
Entire affected area should be covered with a ne, thin spray. Avoiding facial
area prevents inhalation of spray.

Applying a Powder
Dry the skin surface thoroughly. Spread apart any skin folds and dust

skin lightly with dispenser until area is covered with a ne, thin layer
of powder.
Decreases caking and crusting of powder. Skin is fully exposed for application. Slight lubricating properties are achieved in a thin layer of powder,
reducing friction and promoting drying.

Applying Suspension-Based Lotion


Shake container vigorously, and apply a small amount of lotion to

gauze dressing or pad. Apply to the skin by evenly stroking the


lotion in the direction of hair growth. Explain to the patient that the
skin may feel cool and dry.
Mixture of powder and liquid forms well-mixed suspension. After water base
of suspension dries, a protective lm of powder is left on the skin. Technique
prevents irritation of hair follicles. Water evaporates, leaving a thin layer of
powder.

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134 C h a p t e r 5 Oral and Topical Medications


Cover skin with dressing if ordered by physician; assist patient to

comfortable position and cover exposed area.


May prevent agent from being rubbed off and staining clothing. Provides
sense of well-being for patient.
Remove gloves, dispose of supplies in proper receptacle, and wash

hands.
Reduces transmission of microorganisms and/or residual medication to
others.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients response to medication


Rotate sites for application of transdermal medications
Assess skin around wound or lesions, if applicable, for maceration
from medications and moisture

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

ndings before and after application of medication.


Description of lesion and/or secretions.
Patients tolerance of the procedure.
Time medication was applied; site used.
Cardiac status.
Healing process of affected area.

PROCEDURE 5.4
Administering Eye Drops and Ointments
OVERVIEW

To treat medical conditions (e.g., glaucoma) and infectious and


inammatory processes, dilate or vasoconstrict pupils for eye
examinations, relieve pain, and prevent drying of delicate eye
structures.

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P r o c e d u r e 5 . 4 Administering Eye Drops and Ointments 135


P R E PA R AT I O N

Avoid instilling medication directly onto the cornea.


The wrong concentration of an ophthalmic drug may cause local irritation and systemic effects, and can prolong adverse side effects,
such as blurred vision.
Instill eye drops at room temperature to decrease irritation due to
cold solution.
When drops and ointment are ordered, place drops in rst and wait
3 minutes before administering the ointment to allow time for the
drops to be absorbed.

Special Considerations
Pediatric Patient
Infants and young children may require immobilization of head and
distraction.
Older children will only need explanation and direction.
If an infant clenches the eyes tight, place drops at the nasal corner
where the lids meet.
The eye medication will ow into the childs eye when it opens.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for injury related to impaired visual acuity


EXPECTED OUTCOMES

Desired effect is achieved


Patient denies discomfort
Patient experiences no side effects, and symptoms are relieved

EQUIPMENT/SUPPLIES

MAR (Medication Administration Record)


Medication bottle, ointment tube, or medicated intraocular disk
Cotton balls and absorbent sponge (use sterile products if indicated)
Wash basin lled with warm water or sterile solution
Eye patch and tape (if indicated)
Clean gloves

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136 C h a p t e r 5 Oral and Topical Medications


I M P L E M E N TAT I O N
Review physicians order for correct drug name, drug concentration,

time of administration, and eye (right, O.D.; left O.S.; both O.U.).
Compare the label on the medication container with the MAR, and
check the expiration.
Ensures drug will be administered accurately and safely.
Wash hands, observe appropriate infection control technique, and

organize the patients supplies at bedside.


Reduces transmission of microorganisms. Ensures an efficient, methodical
procedure.
Check patients identication by asking patients name and checking

it against ID bracelet. Explain procedure and purpose of medication.


Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation.
Position patient in a supine or a sitting position with the head ex-

tended. (Do not hyperextend the neck if there is cervical spine injury.)
Positioning facilitates correct placement of medication and reduction of
medication drainage through tear duct.
Clean eyelids and eyelashes
Removes microorganisms, and facilitates medication absorption through
mucous membranes.

Don clean gloves


Inhibits exposure to eye secretions.

Using moistened cotton balls, wipe eye from inner to outer canthus.
Prevents cross-contamination and entrance of microorganisms into lacrimal
duct.

Let moistened cotton balls remain over eye for a few minutes to
remove crust. (Do not use the same cotton ball for both eyes.)
Soaking allows easy removal of crust and prevents direct eye pressure.
Prevents cross-contamination.
Administer eye medications:

Hold or give patient a dry cotton ball or absorbent sponge.


Rationales for eye medications:
Absorbs medication that may run off.

Instruct patient to look toward the ceiling.

Place thumb or ngers of nondominant hand on the patients cheekbone just below the eye, and gently draw the skin down on the
cheek to expose the conjunctival sac.

Reduces the likelihood that the patient will blink if looking upward.

Reduces the risk for touching the cornea and putting pressure on the eyeball.
Prevents the patient from blinking or squinting.

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P r o c e d u r e 5 . 4 Administering Eye Drops and Ointments 137

Eye Drops
Rest the dominant hand on

the forehead. Approaching


the eye from the side, instill
the correct number of drops
onto the outer third of the
lower conjunctival sac. The
dropper should be held about
1 to 2 cm above the sac.
The side approach minimizes
the blink response. Instilling
drops into the conjunctival sac
will eliminate harm to the
cornea. The cornea may be
FIGURE 5.4A Instilling eye drops.
harmed if drops fall directly on
the cornea. Do not let dropper touch sac or cornea.
Instruct patient to gently close eyelids.
Allows the medication to spread over eyeball. Squeezing the eye could cause
harm to the eye and force the medication out.
Press rmly or instruct patient to press rmly on the nasolacrimal

duct for approximately 30 to 60 seconds.


Prevents drainage of medication out of the eye and to the nasopharynx.
Prevents bad taste of drug.

Eye Ointment
Discard the rst bead.
The rst bead is considered
to be contaminated.

FIGURE 5.4B Instilling eye ointment.

Hold the tube above the lower conjunctival sac; apply a thin ribbon

of ointment from tube onto the inner edge of the lower lid from
inner to outer canthus. Instruct patient to gently close eyelid, and,
using a circular motion, lightly rub lid with absorbent sponge.
Allows for medication to be evenly distributed across the eye and lid margin
without causing harm to the eye.

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138 C h a p t e r 5 Oral and Topical Medications

Intraocular Disk Procedure


Remove disk from packaging. Adhere disk to nger by lightly pressing your ngertip against disk. (Note: You may have to moisten your
gloved nger with sterile saline.) Position the convex side of disk on
ngertip.
Ensures that there is no damage or deformity to disk. Prepares disk for correct administration.
Gently pull the patients lower eyelid away from eye using the non-

dominant hand. Instruct patient to look toward the ceiling. Place


the disk in the conjunctival sac; the disk should oat on the sclera
between the iris and lower eyelid.
Exposes conjunctival sac to receive medicated disk.
Pull the patients lower lid out and over the disk.
Ensures medication delivery.
To remove the disk, lightly pull the patients lower eyelid to expose

disk using your nondominant hand. Pinch the disk and lift it out of
the patients eye using the forenger and thumb of your opposite
hand.
Exposes the disk for removal without causing harm to the eye.
Gently remove excess medication by wiping the eye from the inner

to outer canthus.
Prevents cross-contamination.
If patient requires an eye patch, apply clean patch by placing it over

the affected eye, covering the eye completely. Tape patch securely
without applying pressure to eye.
A clean patch minimizes the opportunity for infection.
Remove gloves, dispose of dirty supplies in the appropriate recepta-

cle, and wash hands.


Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe patients response to instillation


Note if any discomfort is felt
Assess visual changes, and note any side effects; if blurring of vision
occurs, assist patient to bed if in chair, and instruct patient to remain
in bed until clear vision returns; raise side rails and place call button
within reach.

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P r o c e d u r e 5 . 5 Instilling Medications Into the Ear 139

KEY POINTS

FOR

REPORTING

AND

RECORDING

Drug name, concentration, and time administered.


Patients response to instillation.
Any discomfort or side effects.
Patients visual status.
Whether pain medication was required.

PROCEDURE 5.5
Instilling Medications Into the Ear
OVERVIEW

To treat inammation and infection and soften cerumen for easy


removal.
P R E PA R AT I O N

Solution must be at room temperature to avoid vertigo or nausea.


Do not force solution into ear.
Do not occlude ear canal with dropper; pressure can rise during
instillation causing injury to ear drum.

Special Considerations
Pediatric patients may require a second person (preferably a caretaker) to assist by holding the child in a position as to avoid causing
damage to the ear during administration of ear drops.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible disturbed sensory perception (hearing) related to infection


or disease process
EXPECTED OUTCOMES

Patient states there is no discomfort or pain during procedure


Patient reports that pain is relieved or eliminated
Affected ear shows no evidence of wax buildup, redness, swelling,
or drainage
Patient shows improvement in hearing acuity

EQUIPMENT/SUPPLIES

Medication Administration Record (MAR) (See Procedure 5.1)


Medication to be administered

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140 C h a p t e r 5 Oral and Topical Medications

Clean gloves
Small basin of warm water
Soap
Washcloth
Small, dry towel
I M P L E M E N TAT I O N
Review physicians order for correct drug name, number of drops

to instill, time of administration, and ear (right, A.D.; left A.S.; both
A.U.). Compare the label on the medication container with the MAR,
and check the expiration.
Ensures drug will be administered accurately and safely.
Wash hands, observe appropriate infection control technique, and

organize the patients supplies at bedside.


Reduces transmission of microorganisms. Ensures an efficient, methodical
procedure.
Check patients identication by asking patients name and checking

it against ID bracelet. Explain procedure and purpose of medication,


and close room curtain or door for patient privacy.
Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation.
Don gloves and wash ear if excess wax or drainage is observed.
Reduces the risk for exposure to ear secretions. Cerumen and drainage can
harbor microorganisms and inhibit the distribution of medication.
Position patient in a side-lying, sitting, or high Fowlers position with

affected ear facing up (if in a sitting position, patient will have to tilt
head toward the opposite side).
Helps to channel medication into ear canal.
Gently pull the auricle of the

ear up and back using the


nondominant hand (in
children younger than
3 years old, pull the auricle
down and back).
This technique straightens
the ear canal for proper
channeling of medication.

FIGURE 5.5A (1) Method for instill-

ing ear medications in an adult.

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P r o c e d u r e 5 . 5 Instilling Medications Into the Ear 141

FIGURE 5.5A (2) Method for instill-

ing ear medications in a child.


Instill drops as ordered holding the dropper about 1/2 inch above

ear canal.
Accidental injury of eardrum is prevented; medication is delivered; and
contamination of remaining solution in bottle is reduced.
Request that patient remain in position for 510 minutes. Use

gentle massage or pressure to tragus of ear.


Allows complete distribution and absorption. Helps to move medication
toward the inside of ear.
Remove gloves, dispose of dirty supplies in the appropriate recep-

tacle, and wash hands.


Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients comfort level during procedure


Assess amount, color, character, and odor of drainage if indicated
Assess patients pain level using a pain scale; determine if pain
medication is indicated

KEY POINTS

FOR

REPORTING

AND

RECORDING

Medication name and time administered.


Patients tolerance to procedure.
Amount, color, character, and odor of drainage if indicated.
Swelling or redness in ear canal.
Type of test used to assess patients auditory acuity.
Irrigation solution used.

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142 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.6
Administering Medications via Metered-Dose Inhaler (MDI)
OVERVIEW

Metered-dose inhalers (MDI) are used for medications administered


by means of the inhaled route and are usually intended to produce
local effects.
Because inhaled medications are absorbed rapidly through pulmonary circulation, systemic effects may occur.

P R E PA R AT I O N

The canister must be pressed at the same time the breath is taken.
The inhaler must be shaken prior to delivering the medication.
Wait 1 minute between inhalations.
Clean the valve frequently.
Observe a test spray before administering medication.
Overuse may result in tolerance to medication and serious side
effects.

Special Considerations
Pediatric Patient
Infants and young children requiring inhaled medications use a
nebulizer machine to deliver medications.
School-aged children through adolescence and elderly patients
usually require a spacer device.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible impaired gas exchange related to disease process


EXPECTED OUTCOMES

Medication is administered correctly


Patient experiences improved breathing patterns and less restricted
airways
Patient has adequate gas exchange

EQUIPMENT/SUPPLIES

MAR (see Procedure 5.1)


MDI with medication canister
Stethoscope
Spacer device (if indicated)

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P r o c e d u r e 5 . 6 Administering Medication via MDI 143

Drug canister
Spacer

Metered-dose
inhaler

FIGURE 5.6 Metered-dose inhaler.

I M P L E M E N TAT I O N
Review physicians order for correct drug name, drug concentration,

time of administration, and route (mouth or naris). Compare the label


on the medication container with the MAR and check the expiration.
Ensures drug will be administered accurately and safely.
Wash hands, observe appropriate infection-control technique, and

organize the patients supplies at bedside.


Reduces transmission of microorganisms. Ensures an efficient, methodical
procedure.
Check patients identication by asking patients name and check-

ing it against ID bracelet. Explain procedure and purpose of medication.


Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation.
Explain and demonstrate steps for administering medications via

an MDI:
Remove cover from the MDI mouthpiece.
Using simple step-by-step explanations along with demonstration facilitates
patient participation.

Shake inhaler effectively for about 25 seconds.


Ensures mixture of medication and propellant.

Maintain inhaler in an upside-down position.


Prepares patients airway to accept medication.

Instruct patient to take several slow deep breaths exhaling deeply


through the nose.
Guides aerosol spray toward airway. Holding the mouthpiece 12 inches from
mouth opening is the preferred delivery position without use of spacer device.

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144 C h a p t e r 5 Oral and Topical Medications

Place the mouthpiece of the inhaler into the mouth with the opening pointed at the throat, or hold the mouthpiece 12 inches from
the opening of the mouth.
Hold one naris closed, and place the nosepiece at the entrance of
the other naris for nasal instillation. Repeat for other naris.
Allows medication to be effectively distributed to airways during inhalation.

With head slightly tilted back, inhale slowly and deeply through the
mouth (or naris for nasal instillation) while pressing down on the
medication canister to release the medication dose.
Allows aerosol spray to get into deeper airways. Controlling exhalation
allows the small airways to remain open during exhalation.

Hold the breath for a count of 10 (approximately 10 seconds), and


slowly exhale through pursed lips or nose.
Waiting allows the rst dose to begin working so that the following dose can
reach deeper into the airways.

If a second dose is ordered, wait 1 minute between puffs.


Explain and demonstrate use of MDI with spacer device:
Using simple step-by-step explanations along with demonstration facilitates
patient participation.

Remove mouthpiece covers from MDI and spacer device. MDI is


inserted into the end of the spacer device.
MDI ts into the end of spacer device.

Shake inhaler effectively for 25 minutes.


Ensures mixture of medication and propellant.

Close lips around the spacer device mouthpiece and breathe normally. Do not cover exhalation slots with lips.
Medication should not seep from mouth. Normal breathing allows patient to
relax prior to medication delivery.

Spray one puff into spacer device.


Medication from MDI is trapped in spacer device.

Inhale slowly and completely for about 5 seconds; hold breath for a
count of 510 seconds.
Prepares patients airway to accept medication. Allows aerosol spray to get
into deeper airways.
Rinse the mouth following delivery of medication.
Medication from MDI has an unpleasant taste.
Explain to patient that medication droplets on the pharynx or

tongue may elicit a gag response.


Incorrectly inhaled medication produces a gag response.
Remove medication canister, and clean inhaler with warm water.
Medication can accumulate around mouthpiece and prevent correct distribution during use.

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P r o c e d u r e 5 . 7 Administrating Medications via Rectal Suppository 145


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe patients breathing patterns


Assess patients respiratory status, and compare to pretreatment
status
Assess patients oxygen saturation
If respiratory status shows no improvement, or if serious side effects
develop, contact physician

KEY POINTS

FOR

REPORTING

AND

RECORDING

Drug name, concentration, and time administered.


signs before and after treatment including oxygen
saturation.
Respiratory status.
Need for oxygen.
Cardiac monitor (if indicated).
Vital

PROCEDURE 5.7
Administrating Medications via Rectal Suppository
OVERVIEW

Various medications are delivered via rectum and absorbed through


mucous membranes of rectum.
This approach is convenient and safe.
Medications delivered rectally are used to produce systemic effects
or a local effect on gastrointestinal mucosa.

P R E PA R AT I O N

Improper placement can cause the suppository to be released prior


to the medication being absorbed into the mucosa.
The suppository should never be forced into a mass of fecal matter.
Do not divide suppository into smaller sections; incorrect dosing
may occur.
Rectal suppositories should not be administered to patients with
rectal surgery or active rectal bleeding.

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146 C h a p t e r 5 Oral and Topical Medications

Special Considerations
Pediatric Patient
In pediatric patients, it may be necessary to gently hold the buttocks
for 5 to 10 minutes.
Pressure on the anal sphincter is relieved until the urge to expel the
suppository has ended.
Elderly Patient
Elderly patients may have difficulty retaining suppository due to
poor sphincter control.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for constipation or diarrhea related to suppository use


EXPECTED OUTCOMES

Patients symptoms for which medication is ordered are relieved or


reduced
Patient experiences no discomfort during procedure

EQUIPMENT/SUPPLIES

Medication administration record (MAR) (see Procedure 5.1)


Rectal suppository
Water-soluble lubrication jelly
Clean gloves
Tissues
Drape
I M P L E M E N TAT I O N
Review physicians order for correct drug name, drug strength, and

time of administration. Compare the label on the medication container with the MAR, and check the expiration.
Ensures drug will be administered accurately and safely.
Wash hands, observe appropriate infection control technique, and

organize the patients supplies at bedside.


Reduces transmission of microorganisms. Ensures an efficient, methodical
procedure
Check patients identication by asking patients name and checking

it against ID bracelet. Explain procedure and purpose of medication,


and close room curtain or door for patient privacy.
Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation.

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P r o c e d u r e 5 . 7 Administrating Medications via Rectal Suppository 147


Position patient prone or in the left side-lying Sims position. Flex

upper right leg. Keep patient covered with drape, and expose only
the anal area.
Sims position aids in relaxing the external anal sphincter. Lying on the left
side reduces the likelihood that the suppository or feces will be released.
Don gloves and examine the condition of the anus.
Inhibits exposure to feces. Allows observation of hemorrhoids, active bleeding, or rectal irritation.
Remove the suppository from foil wrapper, and apply lubricant to

gloved index nger of dominant hand and to the smooth, rounded


end of suppository. (Gently rub tip of suppository until smooth and
slightly rounded if edge is sharp.)
Water-soluble lubrication decreases friction as suppository is introduced into
the rectal canal.
Using the nondominant hand, spread the buttocks and instruct

patient to breathe slowly and deeply through mouth.


Relaxes anal sphincter. Pushing a suppository through a constricted sphincter produces pain.
Ask patient to bear down to identify anal opening (if indicated) and

insert suppository using your gloved dominant hand into the rectum beyond internal sphincter and against the rectal wall, approximately 4 inches.
Absorption and therapeutic effects are achieved when the suppository is
placed against the rectal mucosa.

FIGURE 5.7 Inserting a rectal suppository.

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148 C h a p t e r 5 Oral and Topical Medications


Remove nger and wipe patients anal area.
Maintains patient comfort.
Ask patient to squeeze buttocks together for 35 minutes and

remain at or on side for about 1520 minutes. Raise side rails and
place call light and bedpan within reach (if laxative is administered).
Decreases the likelihood of expulsion of suppository. Allows time for medication to be distributed and absorbed.
Remove gloves, dispose of dirty supplies in the appropriate recepta-

cle, and wash hands.


Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Determine if suppository was released; reinsertion may be required


Assess patients comfort level during insertion
Assess for therapeutic effects
Assess for rectal pain using a pain scale; determine if pain medication is required

KEY POINTS

FOR

REPORTING

AND

RECORDING

Medication name and time administered.


Rectal pain.
Unrelieved symptoms or therapeutic effects.

C H A P T E R

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6
Parenteral Medications
6.1 Administering Subcutaneous Injections, 150
6.2 Administering Intramuscular Injections, 155
6.3 Administering Intramuscular Injections by
Z-Track Method, 161
6.4 Administering Intradermal Injections, 164
6.5 Administering Intravenous Medications by
Intermittent Infusion Sets or Mini-Infusion
Pumps, 169
6.6 Administering Medications by
Intravenous Bolus, 178
6.7 Teaching Patients How to Administer
Self-Injections, 183
6.8 Mixing Two Types of Insulin, 188
6.9 Using Patient-Controlled Analgesia (PCA)
Infusion Devices, 191

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150 C h a p t e r 6 Parenteral Medications

PROCEDURE 6.1
Administering Subcutaneous Injections
OVERVIEW

To deposit medication into the subcutaneous tissue layers safely,


avoiding injury to the patient, while ensuring proper drug absorption after injection.
Reasons medications are given parenterally are
To prevent irritation to the gastrointestinal tract.
To prevent destruction of the medication by rst-pass hepatic
effect or gastric juices.
To anesthetize specic areas of the body.
To achieve a rapid effect.
When the physical or mental state of the patient prohibits the use
of other routes.

P R E PA R AT I O N

Review the medication order for patients name, drug name, dosage,
and time and route of administration.
Know information specic to drug that is ordered: action, purpose,
time of onset and peak action, dosage, side effects, and nursing
implications.
Review patients allergy, medical, and medication history.
Know reasons for giving medication by this route and if subcutaneous injection is contraindicated (circulatory shock or reduced local
tissue perfusion).

Special Considerations
Subcutaneous injection is an effective method of drug delivery that
is used quite frequently in nursing.
However, some rules of thumb must be kept in mind for the nurse
using this method.
First, a well-lighted area should be used to assess the site of
injection.
Second, when giving repeated doses on a regular basis, the use of a
site rotation chart should be instituted and kept on the Medication
Administration Record (MAR).
Third, avoiding exposing the needle in the patients line of vision
decreases level of anxiety.
Additionally, keep in mind the anatomy of the patients receiving
the medication: obesity requires the use of a longer needle, and

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P r o c e d u r e 6 . 1 Administering Subcutaneous Injections 151

elderly people have less subcutaneous tissue stores and less skin
elasticity.
Insulin is routinely delivered by the subcutaneous injection route.
Reference should be made to the section on insulin for added information.
Efficient teaching to diabetic patients is benecial because most of
these patients will be self-administering these medications at home.
Heparin is another medication that is commonly administered by
subcutaneous injection.
Some special considerations for heparin, owing to its anticoagulant
effects, are
Site of choice is the abdomen, because the layer of subcutaneous
tissue here does not lie over any major muscles, leading to
decreased chance of hematoma formation and movement.
Use of a 1/2-inch, 25- to 27-gauge needle is a common choice.
Changing the needle once the medication is drawn up to prevent
heparin from remaining in needle, which could lead to inadvertent
delivering of the medication into the intradermal tissue.
Controversial views on aspirating prior to injection (review agency
policy on this issue).
Massaging the site after injection can increase incidence of bruising.
Rotation of sites around abdomen to decrease irritation to tissue.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for impaired skin integrity


EXPECTED OUTCOMES

Mild burning/stinging sensation at site of injection


Patient explains purpose and effects of medication
No allergies or unwanted effects from medication

EQUIPMENT/SUPPLIES

MAR
Alcohol swabs
Gloves (nonsterile)
Adhesive bandage
1- to 2-mL syringe (insulin syringe may be appropriate)
Needle (1/2- to 1-inch, 25- to 27-gauge; dependent on patients size)
Medication to be administered

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152 C h a p t e r 6 Parenteral Medications


I M P L E M E N TAT I O N
Wash hands.
Decreases transfer of microorganisms.
Preparation of medication following the ve rights of drug adminis-

tration.
Decreases the chance of making a drug error.
Properly identify the patient from the identication bracelet and by

asking his name.


Ensures that medication not given to wrong patient.
Give explanation of procedure and reason for giving drug in a calm,

condent manner.
Decreases patient anxiety level.
Explanation helps patient to anticipate nurses actions.
Verify allergies on MAR with patient.
Reduces chance of adverse reactions.
Provide privacy.
Lessens embarrassment.
Don gloves.
Prevents direct contact with body uids.
Perform or teach patient on the following steps of procedure.
If patient is to self-administration at home.
Selection of injection site.

FIGURE 6.1A Subcutaneous injection sites.

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P r o c e d u r e 6 . 1 Administering Subcutaneous Injections 153

Common sites are abdomen and upper arm.

Heparin should be injected into abdomen.

Easy for self-administration.


Recommended site.

Use alternative site if scarring, tissue irritation, or bulky dressings


present.
Rotation of sites, note on chart.

Prevents repeated and permanent damage to tissue.


Position patient; cleanse site with alcohol swabs.
Provides access to site.
Decreases microorganism transmission.
With needle exposed, hold

approximately 1 inch of fatty


tissue between thumb and
forenger of nondominant
hand.
Elevates subcutaneous tissue.

(NOTE: Grab skin gently


with minimal manipulation
if giving heparin injection.)

Skinfold thickness

2 inches: Use a 90 angle


1 inch: Use a 45 angle

Prevents tissue trauma.

FIGURE 6.1B Pinch tissue between


thumb and forenger.

With dominant hand, insert needle at a 45-degree angle in one

quick, smooth motion while holding syringe between thumb and


forenger. Use a 90-degree angle on a larger person.
Quick, smooth insertion decreases discomfort.
Angle prevents insertion into muscle layer.
Obese people have larger layer of subcutaneous tissue.

90

45
Skin
Subcutaneous
tissue
Muscle

FIGURE 6.1C Insert needle at a 45-degree


or 90-degree angle.

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154 C h a p t e r 6 Parenteral Medications


On release of skinfold, aspirate plunger, looking for blood return in

the syringe.
Presence of blood return indicates intravenous placement.
If no blood return is noted, give drug slowly.
Slow administration of drug reduces discomfort and trauma.
If blood return is present:

Withdraw needle.
Apply pressure until bleeding stops.
Assess for presence of hematoma/bruising.
Apply bandage, if needed.
Begin again from step 1.

Prevents injection of drug intravenously.


Subcutaneous medications are usually not indicated for intravenous
absorption.
Withdraw needle at the same angle as insertion,
Prevents additional trauma to tissue.
Wipe site with another alcohol swab while lightly massag-

ing site.
DO NOT massage after heparin injection.
Massage stimulates circulation, improving distribution and
absorption of drug.
Massage after heparin injection may cause bruising.
Place bandage, if needed.
Decreases amount of bleeding from site.
Discard all equipment in proper manner.
Prevents accidental needle sticks, and keeps work environment
clean.
Wash hands.
Reduces transmission of infection.
Document administration on MAR.
Required for legal purposes, and makes others aware that drug has been
administered.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 155


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

After a short period of time, ask patient if there is acute pain, burning
sensation, tingling, and/or numbness at site of injection
Check for a response to the medication approximately 30 minutes
after injection
Assess that patient has an understanding for the purpose of the
drug administered

KEY POINTS

FOR

REPORTING

AND

RECORDING

Name, dose, injection site, and administration route of drug,


as well as date and signature in MAR.
Any teaching that was done with patient during task.
Any adverse reactions from drug administration.
Any as-needed (PRN) or one-time orders for medications
should be charted in nurses notesonce at time of administration and another entry within 1 hour of patients response
to medication.
Report any unwanted side effects of medication to physician
and charge nurse.

PROCEDURE 6.2
Administering Intramuscular Injections
OVERVIEW

To administer ordered medication to the patient.


This method provides rapid drug absorption because muscle tissue
is highly vascular.
Muscle is less sensitive to irritating and viscous medications.

P R E PA R AT I O N

Identify anatomic landmarks for injection


Ventrogluteal Muscle
Situated away from all major nerves and blood vessels.
Safe for all patients and the preferred site for anyone older than
7 months old.

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156 C h a p t e r 6 Parenteral Medications

Locate muscle by placing heal of hand over the greater trochanter


of the patients hip with wrist perpendicular to femur. Use right
hand for the left hip and left hand for the right hip. The index nger, middle nger, and the iliac crest form a V-shaped triangle.
Inject into the center of the triangle.
Anterior
superior
iliac
spine

Iliac
crest

Injection
site

FIGURE 6.2A Locating the ventrogluteal

site.

Vastus Lateralis Muscle


Well-developed muscle.
Preferred site for infants.
Located on the anteriorlateral aspect of thigh, one
hand-breadth below the
trochanter and above the
knee.
Injection should be into the
middle third of the muscle.

FIGURE 6.2B Locating the vastus


lateralis injection site.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 157

Dorsogluteal Muscle
Traditional site for intramuscular (IM) injections but
should be last choice because of risk for striking
the sciatic nerve or major
Inject
here
blood vessels.
Avoid this site in small children until they are walking;
adequate musculature may
FIGURE 6.2C Locating the
not have developed.
dorsogluteal
injection site.
Have the patient assume a
prone position with toes
inward. This produces inward rotation of the hips, which relaxes the
muscle, making injection less painful.
Locate posterior superior iliac spine and the greater trochanter of
the femur. Draw an imaginary line between the two landmarks, and
inject above and lateral to the line. Avoid the sciatic nerve that runs
parallel and below the line.
Deltoid Muscle
Easily accessible but not well
developed in many adults.
Use only for small volumes
of medication (0.51.0 mL).
Locate the acromion process.
The injection site is 2 inches
below the acromion process
in the center of the muscle.
Correct needle length is
important to avoid subcutaneous injection.
FIGURE 6.2D Locating the deltoid
11/2-inch is usually long
injection
site.
enough to penetrate the
muscle in an adult.
2- to 3-inch will be needed in the obese patient to avoid subcutaneous injection.
1 inch is usually long enough to penetrate muscle in a child or
emaciated adult.
A tuberculin syringe is usually adequate for injections in a small

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158 C h a p t e r 6 Parenteral Medications

child or infant.
Gauge (diameter) of the needle should be based on the viscosity
of the uid that is injected.
If the medication is irritating to the tissues, change to a new needle
before injection.
If medication has been ordered in multiple routes (oral, parenteral,
or rectal), determine the patients preference before medication
preparation.
If medication has been ordered for pain, ask the patient to rate the
pain using an approved pain scale.
Special Considerations
Consider the volume of medication to be delivered to the patient;
if volume exceeds 5 mL in an adult or 3 mL in a child, two separate
injections should be given at different sites.
The deltoid muscles are limited to a volume of 1 mL.
If the medication is irritating to the tissues, use the Z-track method.
(See Procedure 6.3.)

R E L E VA N T N U R S I N G D I A G N O S E S

Risk for injury related to intramuscular injection


EXPECTED OUTCOMES

Atraumatic delivery of medication to a muscle mass via appropriate


injection site
EQUIPMENT/SUPPLIES

Alcohol swabs
Syringe
Needles 1- to 11/2-gauge (2)
Band-Aid
Gauze
MAR
I M P L E M E N TAT I O N
Prepare medication adhering to the ve rights of administration.
Decreases chance of drug error.
Identify patient by name and identication bracelet.
Conrms identify of patient.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 159


Explain procedure and purpose of drug to patient/family.
Reduces patient anxiety, and promotes cooperation.
Verify allergies listed in medical record.
Avoids possibility of drug reaction.
Don gloves.
Prevents contact with body uids.
Position patient according to selected injection site appropriate for

age and size located by anatomical landmarks.


Facilitates visualization and access to muscle mass of selected injection site.
(See Figs. 6.2A, B, C, and D.)
Ask patient to relax the extremity planned for injection.
Minimizes trauma and discomfort upon injection.
Clean Injection site with alcohol, and remove needle cap. Provide air

lock.
Maintains asepsis.
Pull skin taut at insertion area.
Facilitates complete needle insertion into muscle.
Place thumb and index nger of nondominant hand over injection

site (avoid cleaned area) to form a V.


Pull thumb and index nger in opposite directions, about 3 inches

apart.
Rapidly insert needle at a 90-degree angle with dominant hand

using a darting motion.


Reduces pain from needle insertion.
This angle facilitates the medication reaching the muscle.
Move thumb and index nger of nondominant hand to support bar-

rel of syringe (avoid obstructing view of barrel with ngers; you will
need to visualize contents upon aspiration).
Prevents needle movement and tearing injury to tissues.
Pull back on plunger observing for blood return in barrel of syringe.
Establishes if the needle is in a blood vessel or in a muscle.
If blood present: remove needle, apply pressure to site, and repeat

steps 7 to 13.
Prevents unintentional intravenous injection.

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160 C h a p t e r 6 Parenteral Medications


If no blood present, slowly and steadily push the plunger down;

encourage patient to talk.


Medication delivery that allows time for dispersal through the tissues.
Reduces patient anxiety.
Remove needle using the same angle as that of insertion.
Prevents unnecessary tearing of tissues.
Clean and massage insertion area with a second alcohol pad (if con-

traindicated for drug use rm pressure). Apply Band-Aid if needed.


Prevents seepage of drug into subcutaneous tissues.
Do not recap needle; place in sharps container; remove gloves.
Averts accidental needle stick and spread of infection.
Reposition patient; raise side rails, and position with call bell within

reach.
Maintains safety, comfort, and communication.
Wash hands.
Prevents spread of microorganisms.
Document administration on medication record.
Serves as a legal record, and avoids inadvertent re-medication.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess infection site for bleeding, hematoma, and local reactions


Assess for medication effects (i.e., allergic reactions and/or relief of
pain/nausea)

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients tolerance to injection.


Location and condition of injection site.
Effect of medication.
Time of injection.
Status of side rail.
Pain score (if appropriate).
Adverse reactions to medication should be reported to physician and charge nurse.

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P r o c e d u r e 6 . 3 Administering Intramuscular Injections 161

PROCEDURE 6.3
Administering Intramuscular Injections
by the Z-Track Method
OVERVIEW

To contain irritating medication in the muscle and prevent seepage


to the surrounding subcutaneous tissues.
P R E PA R AT I O N

Appropriate injection sites for this method of medication administration include dorsogluteal, ventrogluteal, and vastus lateralis areas.
Needle length should be 2 inches to prevent medication delivery to
subcutaneous tissue.
Viscosity of the solution should be considered when selecting gauge
of needle.
Consider consulting physician to obtain an alternative route in the
patient who is emaciated or has muscle atrophy

Special Considerations
Incorrect administration of iron preparations can cause skin staining.
Incorrect administration of other medications may cause irritation to
subcutaneous tissue.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for injury related to IM injection and irritating medications


EXPECTED OUTCOMES

Patient is without extreme pain after medication delivery via Z- track


method
Skin surrounding injection site should be intact without bruising or
hematoma
Mild burning or irritation upon injection; extreme pain is an unexpected outcome

EQUIPMENT/SUPPLIES

Syringe
2 needles (one 2-inch needle)
Alcohol pads
Medication

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162 C h a p t e r 6 Parenteral Medications


I M P L E M E N TAT I O N
Wash hands.
Prevents transmission of microorganisms.
Prepare syringe with ordered medication adhering to the ve rights

of drug administration.
Reduces risk of drug error.
Proper preparation of drug.
Change needle after medication has been drawn up, and pull

plunger back 0.3 mL.


Prevents irritation and staining of skin and subcutaneous tissues when needle is inserted into skin; airlock prevents back seepage of medication through
the tissues.
Identify patient by reading identication bracelet and addressing

patient by name.
Conrms identity of the patient.
Explain procedure and purpose of medication to be given.
Decreases anxiety and promotes cooperation.
Verify allergies listed on medication record.
Alerts nurse to possible allergic reactions.
Provide privacy.
Reduces embarrassment.
Don gloves.
Prevents contact with body uids.
Assist patient into the prone position.
Prone position facilitates identication of anatomic landmarks and promotes relaxation of gluteal muscles.
Outline injection site by identication of anatomical landmarks of

dorsogluteal site (see Fig. 6.2C for important factors for acceptable
sites), and information on locating anatomical landmarks).
Prevents nerve injury.
Clean skin with alcohol, and remove needle cap.
Prevents transfer of microorganisms.
Pull skin 1 to 1/2 inches laterally away from midline with nondomi-

nant hand, and rest the heel of the hand on the skin while maintaining traction.
Retracts the skin and subcutaneous tissue from muscle, forming a tract that
prevents back seepage of medication into subcutaneous tissues.

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P r o c e d u r e 6 . 3 Administering Intramuscular Injections 163


Allows ngers to support syringe barrel to provide stability of needle while
aspirating.

Skin
Subcutaneous
tissue
Muscle
Medication
FIGURE 6.3A Applying traction.

Observe for the rise of the air bubble to the top of syringe and

quickly insert needle at 90-degree angle.


Minimizes pain upon needle insertion, facilitates needle entering muscle
mass, and ensures that air clears the needle to seal drug in muscle tissue.
Pull plunger back to aspirate for blood return.
Determines if inadvertent insertion into blood vessel has occurred.
If blood returns, remove the needle, assess and clean site with alco-

hol pad, apply Band-Aid, and discard medication. Repeat steps 114.
If no blood, return slowly inject medication, and hold needle in place
for 10 seconds.
Blood return indicates intravascular injection.
Medication contaminated with blood must be discarded.
Provides adequate absorption time, and prevents leakage of medication
back into subcutaneous tissues.
Release the skin while removing needle at the same angle of

insertion.
Avoids a direct track between muscle and subcutaneous tissue and skin that
would allow the drug to be displaced causing irritation and pain.
Skin
Subcutaneous
tissue
Muscle
Medication
FIGURE 6.3B Medication is sealed

in the muscle.

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164 C h a p t e r 6 Parenteral Medications


Dispose of needle in sharps container; do not recap.
Prevents accidental needle stick.
Do not massage the insertion area; may place alcohol pad or Band-

Aid over the site.


Massage will increase the possibility of drug displacement into the tissues.
Reposition patient, raise side rails, and lower bed. Place call bell

within reach.
Maintains safety, comfort, and communication.
Wash hands
Prevents transfer of microorganisms.
Document administration on medication record.
Prevents accidental re-medication, and serves as a legal record.
Re-check site in 15 to 30 minutes.
Veries that no seepage of drug has occurred.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Reassessment of site after injection is important to ascertain


whether seepage has occurred
Notify physician if subcutaneous seepage is suspected

KEY POINTS

FOR

REPORTING

AND

RECORDING

Reporting should include all the information under IM injections with the following additions: method (Z-track), pain after
injection, and presence of skin stain.
Extreme pain upon injection.
Skin stain.
Physician notication.

PROCEDURE 6.4
Administering Intradermal Injections
OVERVIEW

Serves as a method of diagnostic testing for exposure to specic


diseases or as a method of diagnostic testing for allergens.

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P r o c e d u r e 6 . 4 Administering Intradermal Injections 165


P R E PA R AT I O N

Caution patient to avoid use of new products on skin (i.e., soap or


perfumes) or covering injection site with a bandage as these actions
may produce false-positive test results.
Assess the patients skin before administration, and note presence of
redness, swelling, lesions, abrasions, excoriations, and excessive hair.
If present, avoid administration in these areas.

Special Considerations
The patient is at risk for injury related to allergen sensitivity.
Have appropriate antidotal medications (usually epinephrine
hydrochloride, a bronchodilator, and an antihistamine) available
on the unit before the start of the procedure.
Know the location of resuscitation equipment (articial airway,
Ambu-bag, and code cart); reactions can be fatal. Should reaction
occur:
Maintain airway.
Notify physician immediately.
Administer medications as ordered or per protocol.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for tissue damage related to intradermal injection


EXPECTED OUTCOMES

The patient will be free of local or systemic reactions


Small bleb forms at the site of injection that gradually disappears
Minimal bruising may develop at the site of injection

EQUIPMENT/SUPPLIES

Medication record
Two alcohol pads
Pen (ink or felt)
Gloves (nonsterile)
Medication and tray
1-mL syringe with 26- to 28-gauge needle

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I M P L E M E N TAT I O N
Wash hands.
Decreases microorganism transfer.
Prepare medication according to the ve rights of administration.
Reduces possibility of drug error.
Identify patient by reading identication bracelet and addressing

the patient by name.


Veries identity of the patient.
Explain the purpose of medication and the administration

procedure.
Lessens anxiety, and encourages cooperation.
Verify allergies listed on the medical record.
Alerts the nurse to possibility of allergic reactions.
Don gloves.
Prevents direct contact with body uids.
Select injection site on the forearm if no other site is required by

doctors order or agency policy.


Sites for intradermal administration are determined via areas where subcutaneous fat is less likely to interfere with administration and absorption.

If forearm unsuitable for use, select an alternative site.


Forearm is the standard initial starting point and has the least amount of
subcutaneous tissue.

FIGURE 6.4A Locations for intradermal injections.

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P r o c e d u r e 6 . 4 Administering Intradermal Injections 167


Position patient with forearm supinated.
Allows assessment of injection area.
Clean site area with alcohol and remove needle cap.
Decreases microorganism transfer.
Place nondominant thumb approximately 1 inch below insertion

site, and pull skin toward the hand.


Taut skin facilitates needle entry.
Insert needle just below the skin at a 10- to 15-degree angle with

dominant hand.
Facilitates needle placement just below epidermis.

Epidermis
Dermis

Subcutaneous
tissue

FIGURE 6.4B Angle of needle for insertion.

Advance needle another 1/8 inch after entering skin surface.


Prevents back leakage of medication.
Inject medication slowly and steadily while observing for bleb (a

raised welt) formation.


Slow administration allows time to terminate injection should systemic
reaction occur.
Bleb formation conrms proper drug administration.

FIGURE 6.4C Bleb formation.

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168 C h a p t e r 6 Parenteral Medications


Remove needle at the same angle of insertion.
Prevents tissue trauma.
If blood is present remove by dabbing with a second alcohol swab.

Do not rub area.


Rubbing causes the drug to leak out.
Observe skin for local redness and swelling.

If an allergy test was performed, observe patient for signs of systemic


reaction (i.e., respiratory distress, hypotension, diaphoresis, nausea,
vomiting, and cyanosis).
Provides a visual assessment of local or systemic reaction.
Place needle in sharps container.
Prevents accidental needle sticks.
Draw a 1-inch circle around the bleb.
Aids in reassessment of site.
Reposition patient; instruct not to rub, cover or apply new products

to area.
Prevents inaccurate test results.
Discard equipment, and wash hands.
Promotes clean environment, and reduces microorganism transmission.
Document administration on patients medication record.
Prevents accidental re-medication, and serves as a legal record.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Reassess patient at 5 and 15 minutes after administration as


subsequent reactions may occur
Read site within 48 to 72 hours of injection

KEY POINTS

FOR

REPORTING

AND

RECORDING

Documentation of patients response to administration.


Date and time medication given.
Site of administration.
Reassessment of ndings.
Documentation of lot numbers (check with agency).
Undesirable side effects to the medication effects to physician
or charge nurse.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 169

PROCEDURE 6.5
Administering Intravenous Medications by Intermittent
Infusion Sets or Mini-Infusion Pumps
OVERVIEW

To lessen the risk for sudden drug side effects caused by rapid
administration of medications.
This method also avoids infusing large uid volumes in patients
with uid restrictions.

P R E PA R AT I O N

Maintenance intravenous (IV) line must be functioning properly to:


Ensure proper drug administration.
Prevent drug extravasation.
Medication may be delivered via intravenous piggyback (IVPB),
Buretrol (plastic graduated container that is part of the main line
that separates the IV uid bag from the infusion tubing; also called
a vulture) or mini-infusion pump (a battery powered, portable, automated delivery device).
If the medication is to be given through a secondary line or vulture,
the primary infusion rate may have to be changed to administer the
medication over the proper amount of time (usually 3060 minutes).
Expiration dates of tubing should be monitored to decrease the possibility of contamination and infection.
Know the drop factor (drops per milliliter [gtts/mL]) of the infusion
sets in use by your agency.
Microdrip: 60 gtts/mL
Macrodrip: 10 or 15 gtts/mL
Know the conversion formula to calculate drops per minute: mL/hr
drop factor/60 minutes drops/minute.
Infusion pumps use positive pressure rather than gravity to control
ow; inltration is more likely when using a pump because ow will
continue even in the presence of increased resistance. Although
pumps have pressure limits that activate an alarm, tissue damage
may occur before the alarm will sound.

Special Considerations
Pediatric Patient
When administering intermittent infusion medications to pediatric
patients, always use a volume-controlled chamber such as a Buretrol,

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Buretrol, Volutrol or an electronic infusion device such as an IV pump


or controller to prevent accidental uid overload and increased infusion rates.
Pediatric patients receive smaller doses with less volume than adults;
therefore, it is important when using Buretrol or Volutrol to make
sure that the patient receives all of the medication contained within
the chamber and tubing.
Elderly Patient
Elderly patients often have fragile veins that may easily rupture and
cause inltration of IV uids inltrate.
Periodic assessment of the infusion site should be done with any
intermittent drug infusion.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for impaired skin integrity related to invasive line


EXPECTED OUTCOMES

Medication will be delivered at a continual, steady rate over a


specied period of time
Medication will be delivered without contamination, adverse
reaction, discomfort, or irritation to site

EQUIPMENT/SUPPLIES

Gloves
Alcohol swabs
Needleless connection device
Medication record
Watch with second hand
IVPB Method:
Medication prepared in a 50 to 100 mL infusion bag
Main IV uid line
Short secondary tubing set
Buretrol Method:
Syringe with prepared medication
Volutrol
Infusion-Pump Method:
Infusion pump
Compatible IV tubing

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 171

Mini-infusionPump Method:
Medication
Syringe to draw up medication
Syringe (360 mL) large enough to hold medication and
diluents
Diluent (if needed) to form desired concentration of
medication
Extension tubing
Needleless adapter (See Fig. 6.5A)
I M P L E M E N TAT I O N
Wash hands.
Reduces microorganism transfer.
Prepare medication adhering to the ve rights of administration.
Decreases the possibility of drug error.
Calculate the infusion ow rate.
Determines the accuracy of the infusion rate.
Identify the patient by reading the identication bracelet and

addressing the patient by name.


Veries identity of patient.
Explain the purpose of medication and the administration proce-

dure.
Reduces anxiety and promotes cooperation.
Verify allergies listed on the medication record.
Reduces the possibility of an allergic reaction.
Don gloves
Decreases exposure to body uids.
Assess patency of IV catheter.
Veries the IV access is viable.
Clean rubber port with alcohol.
Decreases microorganisms.

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172 C h a p t e r 6 Parenteral Medications


Hold the port with the thumb and rst nger of nondominant hand

while inserting the needle, or, if using a needleless system, needleless


adapter of a sterile saline syringe into the port.
Stabilizes catheter and prevents accidental removal.

FIGURE 6.5A Needleless adapter con-

nection with saline ush.

FIGURE 6.5B Insertion of needle/


needleless adapter into heparin lock.

Pull back on the plunger, and observe for blood return.


Aspiration of blood determines if catheter is functional.

If no blood return, reposition that extremity, and reassess site for


redness, edema, and/or pain.

Discontinue IV lock and restart if unable to see blood return.

If positive blood return, insert saline.

Veries if the problem is related to positioning, inltration, or phlebitis.


Removes nonfunctional catheter and reestablishes a functional IV site.
Flushes catheter.

The medication may be administered IVPB, by a mini-infusion pump,


or in a Volutrol.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 173

Primary Line and Secondary Line


Clean rubber port with alcohol.
Decreases microorganism transmission.
Insert needle/needleless

adapter of syringe containing sterile saline into port


nearest the catheter
insertion site.

Primary

Secondary

Port nearest the insertion


site allows easy visualization of blood return upon
aspiration.
Clamp

Piggyback
port
Primary
line
Secondary
line

Secondary
port

To patient

FIGURE 6.5C Use port closer


to insertion site.

Clamp or pinch IV tubing just above the port.


Permits one-way ow during aspiration.
Observe for blood return in the tubing by pulling back on syringe

plunger or by lowering the IV uid bag and tubing below the level
of the extremity for 1 to 2 minutes:
Aspiration of blood return indicates a functional IV line.

If no blood returns, reposition the arm and reassess for redness,


edema or pain.

If positive blood return, instill saline.


Determines catheter placement and checks for problems associated with
positioning, phlebitis, and inltration.

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174 C h a p t e r 6 Parenteral Medications

Use of the Volutrol


Verify infusion rate of IV line.

Fill chamber (Volutrol) with 50 to 100 mL or desired amount of mL


by opening up the clamp between the Volutrol and the main IV bag;
clamp off IV bag with roller clamp above Volutrol.
Determines patency of system.
Maintains volume status.
Dilutes medication with small amount of uid, and reduces the risk of rapid
dose infusion.
Avoids accidental excess uid infusion, and prevents inaccurate drug
dosage.

Medication
bag

Primary
bag
Clamp

Fluid

Clamp

To
patient

FIGURE 6.5D Intravenous medication administration using a Buretrol-type setup.

Clean injection port on Volutrol, and unclamp vent.


Decreases infection, and unclamping of vent prevents a negative pressure
buildup within the Volutrol.
Insert syringe/adapter into port on Volutrol, and inject medication.

Gently rotate the Volutrol between hands.


Mixes medication within the Volutrol for even distribution.

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Infusion Pumps/Controllers
Close regulating clamp; spike and prime the tubing, lling the drip

chamber halfway full.


This allows the medication or uid to be sensed.
Allows visualization of ow.
Hang the bag on the IV pole approximately 36 inches from infusion

site (for controller).


This height provides enough gravity for ow of solution.
Turn machine on, and insert tubing into pump following manufac-

turers directions.
Failure to follow the manufacturers directions may lead to mechanical failure and incorrect dosing.
Place the drip sensor on the drip chamber (if required).
Allows certain machines to determine ow.
Set the pump at the prescribed rate and mode (mL/hr, mg/hr, g/kg/

hr or g/kg/min; intermittent or continuous, and set the volume to


be infused.

Determines the proper amount of medication to be delivered to the patient.


Press the start button and observe the drip chamber for ow;

recheck settings 15 minutes after the start of the infusion.


Permits visualization of proper machine function.

Mini-Infusion (Syringe) Pumps


Select the proper size syringe according to manufacturers directions

and draw up uid appropriate for dilution.


Certain medications are caustic to veins and need further dilution.
Attach the extension tubing to the Luer-Lok end of the syringe

(for administration via syringe pump through a Hep-Lock, a longer


extension tubing will be necessary). Hold the syringe upside down
and prime the tubing.
Holding the syringe upside down allows expulsion of air without creating
an air.
Insert the syringe into the cradle of the pump, and squeeze clamp

to seat the plunger of syringe.


Syringe must be seated correctly in the cradle of the pump in for proper
mechanical function.
Set the pump to the desired rate, mode, and volume to be infused

(follow manufacturers instructions).


Delivers the correct amount of medication.

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176 C h a p t e r 6 Parenteral Medications


Start the syringe pump, and check the infusion indicator.
Veries that pump is infusing.
Clean the rubber stopper to be used for instillation with alcohol.
Decreases microorganisms.

Administering the Medication


Insert the needle or needleless adapter connected to the medication

tubing into the IV lock port; for IVPB, insert the port closest to top of
primary tubing and secure with tape if needle used.
Prevents needle dislodgment.
For IVPB method, lower the

primary IV uids about


6 inches lower than the
secondary (medication) bag.
Increased height creates more
gravitational pull on secondary
bag rather than on the primary
infusion.

Secondary
"Piggyback"
Extension
hook

Primary

Clamp

Piggyback line
Primary line
Primary Y port

Clamp

Secondary
port
To patient

FIGURE 6.5E For IVPB, use extender


so primary IV bag hangs lower than
secondary bag.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 177


Open the roller clamp on the secondary tubing slowly to adjust drip

rate.
Prevents excessive infusion rate and associated drug reactions.
Periodically assess patient during infusion.
Allows monitoring of infusion and adverse drug reactions.
For heparin lock and multiple IVPB medications with a primary line:

when infusion is complete and tubing is not expired, disconnect and


recap needle/adapter. Otherwise leave tubing in port.
Discard expired tubing.
Allows greater mobility for the patient with a heparin lock. (Recapping
needle or adaptor reduces microorganisms and prevents infection.)
Reduces damage to primary tubing port.
Prevents contamination of primary system.
Insert needle/adapter of a second sterile saline syringe and Inject

into heparin lock; then ush with heparin if ordered.


Clears medication and/or blood from catheter and conrms IV patency.
Discard equipment and sharps appropriately.
Promotes a clean and organized environment.
Prevents accidental needle sticks.
Wash hands.
Decreases the spread of microorganisms.
Document administration in medical record.
Prevents accidental re-medication; serves as a legal record.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Readjust to previous IV ow rate (if needed)


Reassess IV site every 2 hours if infusion controlled by gravity;
reassess site every hour if infusion controlled by a pump
Periodically assess rate of infusion, especially if medication is infusing
via gravity; rates are altered by position changes of the extremity in
which the IV is placed
Report any drug reaction
Compare the IV site pre- and post-infusion
Assess IV patency post-infusion

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178 C h a p t e r 6 Parenteral Medications

KEY POINTS

FOR

REPORTING

AND

RECORDING

Dose of medication.
Route of administration.
Method of administration (IVP, IVPB, or infusion pump).
Amount of diluent given.
Time of administration.
Adverse reactions.
Condition of IV site.
One-time medications
Last dose (most important if medication levels need to be
obtained).

PROCEDURE 6.6
Administering Medication by Intravenous Bolus
OVERVIEW

To deliver a concentrated dose of medication directly into the systemic circulation (directly into vein or existing IV catheter), thus
bypassing the absorption phase.
IV bolus administration is used during emergencies, with critically
unstable patients, and as a route when rapid and predictable
responses are required.

P R E PA R AT I O N

Verify physicians order for the type of medication, dosage, time, and
route of administration.
To increase safety, be aware of information about drug before
administering it:
Drugs action
Purpose
Side effects
Normal dosage
Time of peak onset
Nursing implications
Drug expiration date
Verify allergies from MAR and patient.
Assess IV catheter site for inltration. Observe for redness, pain,
swelling, patency of vein, and blood return.

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Check compatibility if other uids are infusing at intended site for


IV bolus.

Special Considerations
Giving IV bolus medications delivers a greater concentration of medication in a shorter period of time. This is benecial when a rapid
effect is desired.
By entering directly into the bloodstream, adverse reactions may be
evident within seconds.
Of great importance is that the nurse must be aware not to administer the drug too quickly.
Knowing pertinent information about the drug beforehand allows
the nurse to be better prepared if an adverse reaction occurs.
Elderly and pediatric patients veins are generally more fragile than
other populations. Because of this, rapid or forceful administration of
a drug can cause inltration.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential for injury related to medication administration


EXPECTED OUTCOMES

No adverse reactions occur after drug infusion


IV site remains clear, absent of swelling
No precipitation or clouding of medication during IV bolus

EQUIPMENT/SUPPLIES

IV existing line
Medication in vial or ampule
Syringe (35 mL)
Sterile needles (21- and 25-gauge)
Alcohol swabs
A watch with ability to read seconds
MAR
IV intravenous lock (Hep-Lock)
Medication in vial or ampule
Syringe (35 mL)
Syringes (13 mL)
Vial of heparin ush solution (1 mL 100 units, check agency policy,
may be optional) or vial of normal saline
Sterile needles (21- and 25-gauge)
Alcohol swabs
A watch with ability to read seconds

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180 C h a p t e r 6 Parenteral Medications


I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Don gloves.
Prepare ordered medication (aseptic technique) in adequate sized

syringe with small gauge needle, comparing dose to MAR, and reading package insert for correct IV dilution (reconstitute if necessary).
Ensures medication is sterile.
Ensures proper dose is drawn up.
Ensures medication is administered correctly.

IV Push
Existing line:

Explain procedure to patient while comparing identication with


armband, MAR, and asking patient his name. (May look on MAR, if
not done already, as well as asking patient).
Decreases patient anxiety.
Decreases chance of giving medication to wrong patient.
Reactions from drug allergies may be fatal.
The nurse is responsible for all medications given to the patient.
Clean closest injection port to patient with alcohol swab. (Some

ports have a circle to indicate where to insert needle.)


Decreases introduction of microorganisms during needle insertion.
Using closest port permits easier aspiration to check for blood return.
Insert the prepared syringe

with medication into center


of port while clamping or
pinching IV tubing just above
port.
Pull gently on plunger to
check for blood return.
(Assess IV site for inltration.)
Ports are self-sealing and
designed for needle insertion
in center.
Ensures that medication is
delivered to patient and not
FIGURE 6.6A Clamp or pinch IV
backward into IV tubing.
tubing just above port.
Blood return indicative of
properly functioning IV catheter.
Ensures safe drug administration.

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After noting blood return, inject medication slowly in accordance

with directions on package. (Use watch to keep track of time.)


Rapid administration of some drugs can be fatal.
Infusion rates may be altered after IV bolus.
Once medication has been delivered, release IV tubing, withdraw

syringe (dispose into sharps container), and recheck the infusion rate
on existing uid.
Proper disposal reduces unwanted needle sticks.
Checking for proper infusion rate decreases chance for circulatory overload.

Intravenous lock:
Explain procedure to patient while verifying identication by com-

paring armband, MAR, and asking patient his name. (Check for drug
allergies by checking MAR and asking patient.)
Decreases patient anxiety.
Ensures medication not given to wrong patient.
Reactions from drug allergies may be fatal.

Using heparin ush method:


Syringe and small gauge needle with 1 mL of heparin ush solution.

(*Note concentration is in accordance with agency policy.)


Syringe and needle (25-gauge) with 1 mL of normal saline ush.
The nurse is responsible for all medications given to the patient.
Flush solution helps keep IV lock open after drug administration.
Heparin comes in several different doses.
Used to assess for blood return.

Using saline ush method:


Two syringes with needles (25-gauge) each with 2 mL of normal

saline.
Saline alone has been found effective in maintaining the patency of IV locks.

To administer medication:
Wipe port with alcohol swab.
Prevents introduction of microorganisms.
Insert needle with syringe of normal saline into center of port,

pulling syringe plunger back gently checking for blood return.


(Refer to Fig 6.6A.)
Blood return indicates that IV catheter is within the vein. (Blood return is not
always present with heparin lock even though IV lock is patent.)

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182 C h a p t e r 6 Parenteral Medications


Flush with 1 mL of saline via syringe, and then remove syringe.
Cleans needle and reservoir of blood.
Wipe port again with alcohol swab.
Prevents introduction of microorganisms.
After inserting needle and

syringe with medication


through the center of the
port, slowly depress plunger
over period of time according
to recommendation on drug
package insert. (Use watch to
monitor time.)
Using center of port eliminates
leakage.
Rapid IV bolus of a medication
can prove to be fatal.

FIGURE 6.6B Administer medication


in increments according to rate of
infusion.

Once IV push is complete, withdraw and dispose of needle properly

and wipe port once more with alcohol swab.


Proper disposal decreases chance of needle stick and reduces incidence of
microorganism transmission.

If using heparin ush:


Insert needle connected to syringe with heparin ush into center of
port.
Maintains patency by inhibiting clots.
Diluted heparin decreases chance of inadvertent anticoagulation.
Instill 1 mL of heparin slowly while slowly removing needle. (Dispose

of needle properly.)
Injecting while removing ensures catheter and hub contain heparin.
Prevents accidental needle stick.

If using saline ush:


Insert needle connected to saline syringe, inject 2 mL of saline, withdraw, and discard needle and syringe properly.
Flushes medication out of IV catheter.
Prevents needle stick.
Wash hands.
Decreases transmission of microorganisms.

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 183


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Orders should be checked for medication to be administered, dose,


time, and route of administration
Important to know about drug prior to giving: action, type of drug,
onset, peak, duration, dose, side effects, and nursing considerations
Observe IV insertion site for patency or inltration
Know patient medical, medication, and allergy history
Review compatibility if giving with existing uid infusion

KEY POINTS

FOR

REPORTING

AND

RECORDING

Documentation of drug, time, date, dose, route, and signature


on MAR.
If PRN or one-time order medication, document in nurses
narrative at time medication is given and 1 hour later on
patients response to medication.
Report any adverse reactions to physician and charge nurse.

PROCEDURE 6.7
Teaching Patients How to Administer Self-Injections
OVERVIEW

To facilitate self-care.
The patient with knowledge of the disease process and treatment
plan is more likely to comply with his or her health-care regimen.
P R E PA R AT I O N

Assessment of the patients ability to learn


Language barriers
Cognitive barriers
Physical barriers
Develop individual objectives for each patients teaching plan.

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184 C h a p t e r 6 Parenteral Medications

Special Considerations
Sensory changes related to diseases such as diabetes may cause
decreases in tactile and visual acuity that could impede the learning
process.
Alternative aids may be required to assist the patient with handling
the syringe and medications.
Family members may be required to learn technique.
A family member or caretaker should be taught to care for the
patient in times of illness when self-care is difficult.
If the patient wears glasses, instruct him or her to put them on
before drawing up medication.
If visual acuity is reduced, consider a syringe magnier.
If the patient is diabetic, make sure he or she can distinguish
between a 0.5-mL syringe, which is marked off in 1-unit increments,
and a 1.0-mL syringe that is marked off in 2-unit increments.
If the medication is heparin, the preferred site is the abdomen; this
area has fewer capillaries and will bruise less easily.
R E L E VA N T N U R S I N G D I A G N O S E S

Readiness for enhanced therapeutic regimen


Risk for injury related to inappropriate technique
EXPECTED OUTCOMES

Patient and/or caregiver should recognize the medication label and


have increasing knowledge of medication and injection method via
aseptic technique with each practice session
State the importance of site rotation
Ability to state the signs and symptoms of hypoglycemia and hyperglycemia (if the medication is insulin)
Ability to recognize and manipulate syringe, draw up the ordered
amount and type of medication, and to correctly inject it at the
proper site while maintaining aseptic technique

EQUIPMENT/SUPPLIES

2 to 3 syringes (2 for practice and 1 to draw up medication)


Alcohol swabs
Bottle of normal saline (for practice)
Chart of injection sites

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 185


I M P L E M E N TAT I O N
Identify patient and verify the 5 rights of medication administration
Conrms patient identity.
Assemble equipment and teaching material and place orderly on a

table within easy reach in a quiet, comfortable environment.


Organization and easy access to materials facilitate the learning process.
Have patient wash hands.
Prevents transfer of microorganisms and maintains aseptic technique.
Have patient manipulate syringe and explain the parts that need to

remain sterile and those that can be touched.


Familiarity with parts of the syringe increases safe administration.
Discuss the ordered dose of the medication.
Facilitates administration of correct dosage.
Have the patient check the label and the expiration date on the

medication vial, and compare the dose of ordered medication to the


markings on the syringe.
Avoids delivery of precipitated or expired medication.
If the medication is insulin, have the patient inspect the vial for

clumping or color change and allow to warm to room temperature.


Reduces tissue trauma upon injection.
Demonstrate the steps necessary to draw up the medication:
Wipe off the top of the vial with alcohol.
Prevents spread of microorganisms.
Pull the plunger back to the same number of units to be removed

from the vial.


This facilitates accurate medication withdrawal from vial.
Push the plunger back into the vial.
This prevents a vacuum.
Hold the vial and the syringe together and turn both upside down.

With the other hand pull the plunger back to the number of units to
be given making sure the needle stays under the uid level of the
vial. Do not touch the inside of the plunger.
Facilitates the withdrawal of the correct amount of medication, and prevents
withdrawing air in the syringe.

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186 C h a p t e r 6 Parenteral Medications


Check for presence of air bubbles inside the syringe; if bubbles are

seen, re-inject the medication back into the syringe and slowly pull
back to the correct dose. Repeat until no bubbles are seen.
Maintains aseptic technique. Inclusion of air alters the dose of medication to
be delivered to the patient.
Remove syringe from vial and, without touching, recap the needle.
Avoids unintentional needle stick.
Show chart of injection sites and have patient nd accessible sites

on his/her own body.


Allows assessment of patients ability to recognize acceptable injection sites.
Discuss importance of systematically rotating sites, using all of the

sites in one area before altering site location. Have the patient
choose a site in the abdomen or thigh where demonstration is easily
visible.
Prevents the development of scar tissue that decreases drug absorption.
Visualization of procedure enhances learning.
Administer the injection concurrently, explaining each step in simple

terms; have the patient:


Visualization and verbal explanation facilitate retention.
Clean injection site with alcohol.
Reduces microorganism transmission.
Remove cover/sheath off of needle.
Hold the syringe as if it were a pencil.
Holding the barrel provides stability of the syringe upon injection.
Grasp skin of injection site between thumb and ngers of nondomi-

nant hand to fold up skin. To inject posterior upper arm, press back
of upper arm against wall or back of chair and rotate inward to push
up the skin.
Grasping the skin ensures that the injection is given into subcutaneous
tissue.
Insert needle at a 90-degree angle (45 degrees for children or thin

adults).
A 90-degree angle may be too deep for thin or small individuals, and the
medication could unintentionally be delivered intramuscularly.

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 187


Insert needle while holding onto skin, then let skin go and use free

hand to push the plunger. (Routine aspiration is no longer recommended for subcutaneous injections.) Be sure that all of the medication is administered.
Routine aspiration may cause tissue damage.
Administer the correct dose of medication.
Place alcohol pad over injection site and quickly remove needle at

the same angle of insertion. Assess for leakage of medication.


Leakage decreases the amount of medication delivered to the patient and
can also cause tissue irritation.
Discard uncapped needle in a sharps container.
Prevents accidental needle sticks.
Have patient indicate on record chart where injection was given.
Documentation will assist the patient to correctly rotate injection sites.
Give opportunity for patient to ask questions regarding procedure.
Clarication and reinforcement enhance the patients knowledge base.
Provide guidelines to patient with written literature and visual aids.
Guidelines and aids reinforce the teaching plan.
Document evaluation of the learning process: the ability of the

patient to correctly prepare and self-administer injections.


Documentation provides continuity of the teaching plan and enables the
nurse to determine if more instruction is needed.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

May need several practice sessions before independent insulin


administration
Assess the need for further teaching sessions

KEY POINTS

FOR

REPORTING

AND

RECORDING

Describe the content and/or skills taught with each session


and the ability of the patient to perform (this provides continuity of the teaching plan and avoids needless repetition).

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188 C h a p t e r 6 Parenteral Medications

PROCEDURE 6.8
Mixing Two Types of Insulin
OVERVIEW

To deliver the prescribed combination of insulin to the patient to


control the blood glucose level without cross-contamination of
medication.
P R E PA R AT I O N

Regular insulin (unmodied insulin) is a rapid-acting, clear solution.


Most other types of insulin are cloudy (modied) because of the
addition of proteins, which slow the absorption of the drug, giving
them an intermediate-to-long duration of action.
Newer, long-acting insulins such as Lantus are clear but cannot be
mixed with other insulins.
Mixing guidelines:
Regular insulin can be mixed with any other type of insulin and
should always be drawn up in the syringe rst.
NPH (Neutral Protamine Hagedorn) insulin can only be mixed with
regular insulin.
Different types of Lente insulin can be mixed together, and with
regular insulin, but not with any other type of insulin.
Insulin syringes are calibrated in 50 or 100 units per milliliter. Care
must be taken not to confuse the two, as each marking represents
one unit on a 50-unit syringe and 2 units on a 100-unit syringe; that
could lead to medication error.
Insulin can be kept at room temperature for approximately
1 month. Refrigeration is required for longer periods of time.
Insulin should not be given cold, but should be allowed to warm
to room temperature.

Special Considerations
Have D50W, sugar, orange juice, and glucagon available on unit.
If lispro (rapid acting) insulin is used, make sure meals are on unit;
onset of action within 15 minutes.
Do not use insulin that has changed color or has become clumped
or granular in appearance.

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P r o c e d u r e 6 . 8 Mixing Two Types of Insulin 189

Regular and short-acting insulin should be clear; other types should


be uniformly cloudy.
Store unused insulin in a cool area; use room temperature insulin for
injection to limit irritation at injection site.
Mix insulin by gently rotating between palms. Do not shake; this creates air bubbles in the mixture and syringe thereby altering the dose
delivered to the patient.
Commercial insulin concentrations of 100 or 500 U/mL are available.
500 U/mL preparations are useful for the patient with insulin resistance who requires large doses, but should be stored separately to
avoid an accidental overdose.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential for injury related to medication error


EXPECTED OUTCOMES

The appropriate, prescribed combination of insulin will be drawn up


in a single syringe without cross-contamination of insulin vials
EQUIPMENT/SUPPLIES

Medication vials
2 alcohol pads
Insulin syringe
2 needles (if applicable)
I M P L E M E N TAT I O N
Wash hands, rotate insulins in palms of hands for 1 minute (do not

shake); clean vial stoppers with alcohol.


Decreases microorganism transmission.
Rotating insulin resuspends the modied insulin and warms the medications.
Shaking creates air bubbles that can alter dose.
Aspirate volume of air equivalent to the dosage of the modied

(cloudy) insulin.
Creates pressure to withdraw solution; avoids a vacuum that can cause
cross-contamination.

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190 C h a p t e r 6 Parenteral Medications


Inject the air into the modied (cloudy) vial; do not touch the med-

ication with the needle. [See Fig. 6-8A (1).]


Prevents cross-contamination.

Regular

Lente

(1) Inject
air

Lente

Regular

(2) Inject
air

(3) Withdraw
regular
insulin

(4) Withdraw
lente insulin;
total dose now
a mixture

FIGURE 6.8A (14) Mixing two kinds of insulin

in one syringe.
Remove needle and syringe from vial and aspirate the amount of air

equivalent with the unmodied, regular (clear) insulin dosage.


Creates pressure to withdraw the desired amount of medication in syringe.
Insert the needle into the vial of unmodied, regular (clear) insulin

and inject the air; then pull back on plunger to ll syringe with prescribed insulin dosage. Remove needle from vial by the barrel and
not the plunger. Verify the dosage. [See Fig. 6.8A (2) and (3).]
Preparation of the rst portion of insulin dosage.
Prevents manipulation of plunger that may cause excess or loss of medication; ensures proper dosage prepared.
Calculate the amount on the syringe what the combined units of

insulin should measure.


Prevents inadvertent withdrawal of excess insulin from the second (cloudy)
vial.

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P r o c e d u r e 6 . 9 Using Patient-Controlled Analgesia 191


Insert needle into the modied (cloudy) insulin vial. Use care not to

manipulate plunger and expel medication. Invert vial to withdraw


desired amount of insulin in the syringe. [See Fig. 6.8A (4).]
Syringe will ll, owing to positive pressure in the vial; no need to aspirate.
Remove needle; expel excess air or uid from the syringe.
Air or insulin excess will incorrectly dose the patient.
Discard needle in sharps container and wash hands.
Reduces transfer of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

It is important to administer insulin mixture within 5 minutes of


preparation. The action of regular insulin is reduced by its binding
with NPH insulin

KEY POINTS
Verication

FOR

REPORTING

AND

RECORDING

of dosage witnessed with a second nurse.

PROCEDURE 6.9
Using Patient-Controlled Analgesia (PCA) Infusion Devices
OVERVIEW

To provide relief from acute or severe pain while providing a steadier drug serum level than that of IM and subcutaneous methods.
PCA allows patients more self-control in their management of pain.

P R E PA R AT I O N

Most often used with postoperative patient population, although


uses also include patients with advanced stages of cancer.
Terms associated with PCA are:
Loading dosethe rst dose of pain medication infused, normally
more than doses that follow.
PCA doseamount (mL) of drug to be administered with each
infusion.
Lock-out intervalminimum ordered time in minutes in which
the pain medication cannot be delivered.

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Basal rateordered dose per hour that can be infused at a continuous rate.
Maximum hourly limittotal amount of drug that can be infused
over a certain time (usually 14 hours).
Bolus doseloading dose can fall in this classication. An additional amount of drug other than PCA dose. An example is giving
a bolus dose prior to a dressing change.
Attemptsthe number of times a patient presses the button.
Injectionsthe number of times the drug is actually delivered.
Total doseamount of drug delivered over a certain period of time
Special Considerations
PCA can be a very effective tool in the prevention of pain for a large
number of patients.
Not all patients are candidates for PCA use.
Patients who are mentally impaired, with a history of chronic
obstructive pulmonary disease, a history of narcotic abuse, who are
allergic to narcotics, or have septic proles should not be prescribed
PCA infusions.
R E L E VA N T N U R S I N G D I A G N O S E S

Pain, acute related to injury


Ineffective coping related to fear of unknown
Risk for poisoning due to knowledge decit

EXPECTED OUTCOMES

The patient is pain free and well rested


Patient is able to move without excessive pain
Patient is able to cough, turn, and deep breathe
The patient does not excessively press the button more than actual
delivery of medication
The need for pain medication decreases over time

EQUIPMENT/SUPPLIES

PCA infusion device (including IV tubing, key, and IV pole) with manual
on operation
IV or epidural line that is patent
Correct medication that is ordered
Narcan 0.4 mg at bedside for patients with epidural infusion

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I M P L E M E N TAT I O N
Review doctors order for drug, dose, route, bolus, lock-out interval,

and maximum dose to be administered.


PCA infusions require a doctors order.
Assess patients mental status, knowledge of PCA, and reason for

infusion before administering medication


Allows the nurse to see if the patient is coherent/competent to participate
in PCA operation.
Observe IV for patency/inltration.
Inltration can lead to serious tissue damage from medication.
Set the primary uid infusion rate specied in PCA orders.
Primary uid at a continuous rate ensures that the IV system will remain
patent.
Verify patient identication by comparing name on order sheet with

ID bracelet and asking patient his name.


Avoids giving wrong medication.
Compare medication in syringe to that on order sheet before prop-

erly inserting syringe into PCA device.


Safety check to decrease risk for drug error.
Connect plunger unit and medication vial by screwing together.
Must be connected to deliver medication to patient.
Prime the plunger unit by holding in vertical alignment with vial

below plunger. Push down gently to advance medication and expel


air.
This will decrease the risk for advancing air bubbles through tubing once
infusion starts.
Connect plunger unit (male end) to PCA tubing (female end).
PCA tubing will deliver medication from the vial to the patient.
Prime PCA tubing with medication up to the Y-branch in the tubing,

then clamp. This can be done manually before placing vial into PCA
infusion pump OR by using the priming feature of the pump after
the vial is loaded in place.
Not priming past the Y-branch avoids giving too much medication or wasting medication when priming the rest of tubing.
Load the vial/plunger unit into the PCA pump:

Unlock and open the door using the PCA key.


Door must be unlocked to put medication vial in place.

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194 C h a p t e r 6 Parenteral Medications

Squeeze the two release levers on the top of the drive mechanism
and slide it in an upward motion.
This will allow the placement of a full medication vial. The plunger sticks out
further when connected to a full vial.

Place the medication vial into the drive mechanism (should snap
rmly into place).

Once in place, squeeze the release lever and slide in a downward


motion until the ange on the plunger snaps rmly into the holder.

Assures proper placement.

Ensures proper placement of system.


Connect PCA tubing and maintenance tubing to patient IV

connection.
If maintenance uid is not already infusing at this time, connect the
maintenance tubing to the Y-tubing. Maintenance uid that is
infusing prior to setup must be turned off. Clamp the patients IV
connection tubing and maintenance tubing and disconnect in a
sterile fashion before connecting the two tubings
(maintenance/PCA) together.
Maintenance uid is needed to keep IV patent since medication is delivered
intermittently and in small quantities.
Clamping will avoid bleeding from IV and maintenance uid from
leaking out.
To prevent introduction of microorganisms into the patients bloodstream.

Use the roller clamp to nish priming the PCA tubing to the distal
end, then clamp.

Connect distal PCA tubing to IV connection; release all clamps.

Adjust as needed to slowly prime tubing to keep from making a mess.


Releasing clamps will allow uids to be delivered to patient.
Set the limits (loading dose, PCA dose, lockout interval, maximum

dose) specied in the PCA order. If unfamiliar with use of PCA, ask
coworker to verify that settings are correct. Use instructions that
come with PCA device.
Ensures that PCA is used in a safe manner.
Following the loading dose, provide patient with the injection but-

ton, making sure patient understands how to use PCA.


The patient will take control of pain medication administration.
Initially, the patient may be unable to press the button, in which a con-

tinuous dose may be administered. Keep reinforcing PCA instructions,


assessing when patient will be able to participate in PCA delivery.
Patients may be groggy following surgery due to anesthesia and other medications received. Patient must be alert enough to understand how to use PCA.

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Assess patients level of consciousness, pain level, and vital signs fre-

quently.
Good indicators that patient is over- or undermedicated.
Routinely check patency of IV line and that PCA is functioning prop-

erly.
Ensures that patient is receiving medication in a safe manner.
Document use of PCA on patients record and on controlled sub-

stance record.
Documenting that nursing care is being provided as well as serving as a legal
record.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare pain levels periodically on an institution-approved pain


scale to determine if PCA infusion is effective
Monitor for adverse reactions
Routinely assess patency of IV line and proper functioning of PCA
pump
Observe for empty syringe and patients use of PCA (reinforce
instructions as needed)

KEY POINTS

FOR

REPORTING

AND

RECORDING

Specics about drug dose, beginning time, and delivery settings should be documented on proper record.
Intermittent observations on patient should be documented
and include:
Vital signs (BP, HR, RR, and pain level)
Patients level of consciousness
Patency of IV
Amount of solution infused and remaining
Amount of drug that patient received
Report any adverse reactions to physician and charge nurse.
Report to oncoming nurse should touch on PCA settings,
drug,VS, LOC of patient, total dose, and patency of IV.

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U N I T

C H A P T E R

Respiratory

7
Noninvasive Pulmonary
Hygiene
7.1 Performing Postural Drainage, 198
7.2 Teaching Controlled Coughing
Techniques, 203

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198 C h a p t e r 7 Noninvasive Pulmonary Hygiene

PROCEDURE 7.1
Performing Postural Drainage
OVERVIEW

To use the principles of gravity to assist in bronchial drainage whenever excessive uid or mucus in the bronchi is not being removed by
normal ciliary action and cough.
There are 18 positions to facilitate drainage, each corresponding
with one of the 18 segments of the lungs.
The purpose of the various positions is to drain each segment
toward the larger airways.
This procedure is usually indicated in people with
Excessive bronchial secretions who have difficulty clearing secretions, with sputum production greater than 25 to 30 mL per day.
Evidence or suggestion of retained secretions in the presence of an
articial airway.
Lobar atelectasis caused by or suspected of being caused by mucus
plugging.
Loosens airway secretions.
Uses gravity to drain and remove excessive secretions.
Decreases accumulation of secretions in unconscious or weakened
patients.

P R E PA R AT I O N

Positions are determined by areas of involved lung, which are


assessed by chest radiograph, percussion, palpation, and auscultation.
Chosen position is maintained for 5 to 15 minutes, although variations can be made if patient has trouble assuming various positions.
Usually done 2 to 4 times per day.

Special Considerations
Aerosolized bronchodilators and hydration therapy are frequently
administered before postural drainage.
It is important to remember to perform this procedure 1 hour before
meals or 1 to 3 hours after meals.
Remember that the frequency and choice of positions depend on
the location of retained secretions and patient tolerance to dependent positions.
The patient with chest trauma, hemoptysis, heart disease, or head
injury should not be placed into Trendelenburgs position.

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R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to excessive secretions


EXPECTED OUTCOMES

Respirations, 14 to 20 per minute, of normal depth, smooth, and symmetric


Breath sounds clear in target areas; chest radiograph reveals clear
lung elds
Arterial blood gases within normal limits for patient
Sputum specimen within 1 hour after treatment

EQUIPMENT/SUPPLIES

Hospital bed or tilt board to place patient in Trendelenburgs position


(pillows, blocks, or books can also be used to help position patients)
Tissues
Container for sputum
Mouthwash and emesis basin
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient and family.
Careful explanation reduces the patients and familys anxiety and facilitates
cooperation.
Administer bronchodilators, expectorants, or warm liquids if ordered.
Loosens and liquees secretions and facilitates drainage.
Encourage patient to void.
Prevents interruption of therapy.
Loosen any tight clothing and auscultate breath sounds.
Allows assessment of pulmonary to perform therapy in the correct anatomical place and assesses breath sounds prior to procedure.
Position patient to drain upper lung segments/lobes:

Sitting upright in bed or chairtargets right and left chest.

Leaning forward in sitting positiontargets back.

Drains anterior right and left apical segments.


Drains posterior right and left apical segments.

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200 C h a p t e r 7 Noninvasive Pulmonary Hygiene

Lying at on backtargets right and left chest.

Lying on abdomen, tilted to right or left sidetargets right or


left back.

Drains anterior segments.

Drains posterior segments.

FIGURE 7.1A Correct position to drain right

posterior segment.
Position patient to drain middle lobe:

Lying on back, tilted to left side in Trendelenburgs position


targets right chest.
Drains middle posterior lobe.

FIGURE 7.1B Correct position to drain right

middle lobe.

Lying on abdomen, tilted to left side with hips elevatedtargets


right back.
Drains middle posterior lobe.

Position patient to drain basal/lower lobes:

Lying in Trendelenburgs position on backtargets right and


left chest.
Drains anterior basal lobes.

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P r o c e d u r e 7 . 1 Performing Postural Drainage 201

Lying in Trendelenburgs position on abdomentargets right and


left back
Drains posterior basal lobes.

FIGURE 7.1C Correct position to drain lower right

and left lobes.

On right or left side in Trendelenburgs positiontargets back.

Lying on abdomentargets right and left back

Drains lateral basal lobes.


Drains superior basal lobes.

FIGURE 7.1D Correct position to drain right

and left back.


Maintain patient in position until chest percussion and vibration are

completed (approximately 5 minutes).


Loosens secretions in target area and facilitates removal.
Assist patient into position for coughing or for suctioning of trachea.
Removes secretions from lungs that accumulate in the trachea.
Auscultate chest areas for breath sounds.
If breath sounds are clear, secretions are cleared; however, if crackles are
present, secretions may not be cleared, and nurse may need to repeat
process.

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202 C h a p t e r 7 Noninvasive Pulmonary Hygiene


Continue until identied target areas have been drained.
Completes drainage of congested lung elds.
Auscultate breath sounds, and assist patient with mouth care.
Assesses breath sounds after procedure, removes residual secretions from
oral cavity, and freshens mouth.
Position patient in bed with head of bed elevated 45 degrees or

more.
Facilitates lung expansion and deep breathing.
Turn patient to side with pillow at back.
Facilitates movement of secretions.
Raise side rails, and place call light within reach.
Facilitates patient safety and communication with nurse.
Wash hands.
Reduces transmission of infection.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory status, and compare to baseline


Note sputum characteristics and send to lab if ordered
Assess how patient tolerated procedure, and write in nurses notes

KEY POINTS
Vital

FOR

REPORTING

AND

RECORDING

signs.
Rate and character of breath sounds, pulse.
Which areas produced the most secretions.
What areas sound the same before and after drainage upon
auscultation.
Description and amount of secretions.
Patients tolerance of the procedure (which positions tolerated best).
Patients acceptance and willingness to participate in procedure.
Any unusual symptoms following procedure and what was
done about symptoms.
Replacement of oxygen source (if applicable).
Time therapy was performed.
Patients tolerance.
Amount and characteristics of sputum.
Respiratory status.

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P r o c e d u r e 7 . 2 Teaching Controlled Coughing Techniques 203

PROCEDURE 7.2
Teaching Controlled Coughing Techniques
OVERVIEW

To clear the airways of sputum.


It is important to teach the patient how to cough effectively after
CPT.
Removes secretions from large airways.

P R E PA R AT I O N

Have patient conserve as much energy as possible by teaching


proper technique.
Reduce patient fatigue by teaching proper technique.
The patient with a surgical incision may need to be premedicated
with pain medications and use a pillow as a splint over the incision.

Special Considerations
Effective coughing is the best means of removing secretions from
the airways.
It is contraindicated for the patient who has had eye, ear, brain, or
neck surgery.
The frequency of coughing should be determined based on need
and patient tolerance of procedure.
Following abdominal or chest surgery, coughing could be performed
hourly.
If the patient is unable to sit upright, positioning the patient in a
side-lying position with hips and knees exed or in a semi-Fowlers
position with the head and arms supported with pillows and knees
exed decreases abdominal tension and allows maximal movement
of the diaphragm, thereby improving effectiveness of the cough.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to retained secretions


EXPECTED OUTCOMES

Cleared airway secretions


Patient states understanding of effective coughing techniques
Arterial blood gases within normal limits for patient

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204 C h a p t e r 7 Noninvasive Pulmonary Hygiene


EQUIPMENT/SUPPLIES

Straight chair or hospital bed in upright position


Pillows for positioning and incisional support
Tissues or emesis basin for secretions
Protective gear: gloves, gown, goggles, and mask
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Premedicate patient if indicated.
Reduces pain.
Organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient and family.
Careful explanation reduces the patients and familys anxiety and facilitates
cooperation.
Put on protective gear.
To protect self from bodily secretion.
Place patient in upright position with upper body slightly forward,

and auscultate breath sounds.


Assists patient to cough more effectively, and assesses breath sounds before
procedure.
Ask patient to take 2 to 3 slow, deep breaths, inhaling through the

nose and exhaling through the mouth.


Adequately oxygenates patients and relaxes them.
Instruct patient to inhale deeply and hold for 5 seconds, then lean

forward and cough rapidly using abdominal, thigh, and buttock muscles.
Promotes forceful, effective cough.
Instruct patients with pulmonary disease to exhale through pursed

lips and to cough early in exhalation.


Helps prevent collapse of airways.
Remember to support any incision with a pillow held tightly on top

of it.
Supports incision and prevents strain. May encourage patient to take deeper
breaths.

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P r o c e d u r e 7 . 2 Teaching Controlled Coughing Techniques 205


Encourage patient to keep coughing if cough is productive.
Secretions left in airways promote bacterial growth and interfere with
ventilation.
Auscultate breath sounds, and ask if patient has any questions.

Be sure that he or she understands the importance of coughing


effectively.
Assesses breath sounds after coughing, facilitates rapport with patient, and
educates patient.
Reposition patient if in hospital bed (if indicated), raise side rails, and

place call light within reach.


Promotes patient comfort, facilitates safety and communication with nurse.
Discard protective gear.
Reduces transmission of infection.
Wash hands.
Reduces transmission of infection.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory status, and compare to baseline


Note sputum characteristics, and send to lab if ordered
Assess how patient tolerated procedure, and write in nurses notes

KEY POINTS
Vital

FOR

REPORTING

AND

RECORDING

signs.
Rate and character of breath sounds, pulse.
What areas sound like before and after coughing upon
auscultation.
Description and amount of secretions.
Patients tolerance of the procedure.
Patients acceptance and willingness to participate in
coughing.
Any unusual symptoms following procedure and what was
done about symptoms.
Replacement of oxygen source (if applicable).
Time therapy was performed.
Patients tolerance.
Amount and characteristics of sputum.
Respiratory status.

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C H A P T E R

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8
Oxygen Therapy
8.1 Administering Oxygen Therapy, 208
8.2 Administering Oxygen Therapy to the
Patient with an Articial Airway, 213

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208 C h a p t e r 8 Oxygen Therapy

PROCEDURE 8.1
Administering Oxygen Therapy
OVERVIEW

Improves tissue oxygenation.


There are several indications for oxygen therapy:
Hypoxia/hypoxemia.
Decreased cardiac output.
Increased oxygen demand.
Decreased oxygen carrying capacity.
Increased myocardial workload.
Procedures that may cause hypoxemia.
P R E PA R AT I O N

The device for delivery of oxygen should be chosen based on the


oxygen delivery needs of the patient.

FIGURE 8.1A Oxygen-delivery systems.

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P r o c e d u r e 8 . 1 Administering Oxygen Therapy 209

Low-ow devices do not provide the total inspired gas; the remainder of the inspired volume is from the surrounding room air. Lowow devices include
Nasal cannula.
Simple face mask.
Partial rebreather mask.
Trach collar (used with tracheostomy).
T-piece (used with tracheostomy and endotracheal tube).
High-ow devices provide the entire total inspired gas to the
patient. High-ow devices include
Nonrebreather mask (used with nasal or oral airway).
Venturi mask (used with nasal or oral airway).
Mechanical ventilator (used with tracheostomy, endotracheal tube,
nasotracheal tube).

Special Considerations
Nasal Cannula
16 L/min delivers 24% to 44% oxygen.
May cause pressure sores on earsplace gauze pads under cannula
at tops of ears.
May cause dryness and pressure sores in naresgive nasal care
every 8 hours, and check position of cannula to ensure that continuous pressure is not concentrated on one spot.
Simple Face Mask
610 L/min delivers 40% to 60% oxygen.
Hot, conning, and uncomfortableclean face mask and wipe face
every 48 hours.
Places pressure on bridge of nose and earspad with gauze pads
to prevent pressure sores and necrosis.
Interferes with eating and drinking.
Partial Rebreather Mask
610 L/min delivers 35% to 60% oxygen.
Never let bag totally deate because this may cause CO2 retention.
Places pressure on bridge of nose and earspad with gauze pads
to prevent pressure sores and necrosis.
Interferes with eating and drinking.
Nonrebreather Mask
610 L/min delivers 60% to 100% oxygen.
Places pressure on bridge of nose and earspad with gauze pads
to prevent pressure sores and necrosis.
Interferes with eating and drinking.

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210 C h a p t e r 8 Oxygen Therapy

Venturi Mask
4 L/min delivers 24% to28% oxygen.
8 L/min deliver 35% to 40% oxygen.
Places pressure on bridge of nose and earspad with gauze pads
to prevent pressure sores and necrosis.
Interferes with eating and drinking.
Safety and Toxicity Considerations
Some special safety considerations pertain to all types of oxygen
therapy including keeping oxygen away from open ames and
smoking, and using only water-soluble lubricants and creams with
those receiving oxygen therapy.
Also make sure to observe patient for signs of oxygen toxicity such
as substernal retractions, paresthesias in extremities, dry cough, dyspnea, anorexia, nausea, vomiting, fatigue, lethargy, malaise, restlessness, and progressive ventilatory difficulty.
Hypoxic Patient
Patients who are hypoxic often become combative and may need to
have constant supervision and alternative methods, including the
possibility of restraints, to facilitate the continuation of oxygen therapy via an articial airway.
Elderly Patient
Older adults are at greater risk for skin breakdown; therefore, more
frequent skin assessment may be necessary in these individuals.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to disease process


EXPECTED OUTCOMES

Oxygenation saturation improves


Tissue oxygenation improves
Patients hemodynamics improve

EQUIPMENT/SUPPLIES

For all types of oxygen delivery, the following are needed:


Oxygen source
Oxygen owmeter
Humidier (if ordered)
Specic type of oxygen delivery system (nasal cannula, simple face
mask, partial rebreather mask, nonrebreather mask, Venturi mask)

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P r o c e d u r e 8 . 1 Administering Oxygen Therapy 211


I M P L E M E N TAT I O N

Nasal Cannula
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning procedure enhances efficiency
and patient safety.
Explain procedure to patient.
Ensures that patient is informed, and decreases patient anxiety.
Prepare humidier: Add distilled water if needed or remove prelled

humidier from package and screw enclosed spike cap to bottle.


Delivers humidied oxygen to mucous membranes of airway.
Connect humidier to ow meter, and connect humidier to tubing

attached to cannula.
Controls ow of oxygen and connects humidication to oxygen delivery
system.
Turn oxygen owmeter on until bubbling is noted in humidier.
Ensures connections are intact and that oxygen delivered will be humidied.
Check order.
Adjust ow of oxygen via owmeter.
Regulates oxygen ow delivery.
Put on gloves.
Reduces transmission of microorganisms.
Place tips of cannula in patients nares; t tubing over ears, tighten

tubing under chin, and adjust to proper t.


Ensures proper t of nasal cannula.
Position patient for comfort and ease of breathing with head of bed

elevated.
Facilitates lung expansion for adequate gas exchange.
Evaluate patients respirations and oxygen saturation.
Determines adequacy of oxygen delivery system for patient.

Simple Face Mask, Partial Rebreather Mask,


Nonrebreather Mask, Venturi Mask
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning procedure enhances efficiency
and patient safety.

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212 C h a p t e r 8 Oxygen Therapy


Explain procedure to patient.
Ensures that patient is informed and decreases patient anxiety.
Prepare humidier: Add distilled water if needed or remove prelled

humidier from package and screw enclosed spike cap to bottle.


Delivers humidied oxygen to mucous membranes of airway.
Connect humidier to owmeter, and then connect humidier to

mask tubing.
Controls ow of oxygen and connects humidication to oxygen delivery
system.
Turn oxygen ow meter on until bubbling is noted in humidier.
Ensures connections are intact and that oxygen delivered will be humidied.
Adjust ow of oxygen via ow-

Adjustable
nose clip

meter (with Venturi mask, attach


oxygen percentage regulator to
oxygen mask and regulate ow
as indicated).

30%
28% L3M
26%
24%

Regulates oxygen ow delivery.


Oxygen
regulator
Venturi
barrel

FIGURE 8.1B Oxygen percentage

regular.
Put on gloves.
Reduces transmission of microorganisms.
Place mask over nose, mouth, and chin; adjust metal strip over

bridge of nose to t securely; and pull elastic band around back


of head and tighten to t.
Ensures proper t of mask.
Position patient for comfort and ease of breathing with head of

bed elevated.
Facilitates lung expansion for adequate gas exchange.
Evaluate patients respirations and oxygen saturation.
Determines adequacy of oxygen-delivery system for patient.

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P r o c e d u r e 8 . 2 Administering Oxygen: Articial Airway


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the patients:


Oxygen saturation, and compare to baseline
Quality of and rate of respirations, and compare to baseline
Vital signs, and compare to baseline
Comfort level

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

of the patients respiratory status prior to initiation of oxygen therapy, including oxygen saturation and a
description of respirations including rate.
Type of oxygen-delivery method initiated.
Time of initiation of oxygen-delivery method.
Percentage of oxygen currently being given.
Assessment of patients respiratory status after initiation of
oxygen therapy to include oxygen saturation and a description of respirations, including rate.

PROCEDURE 8.2
Administering Oxygen Therapy to the Patient
with an Articial Airway
OVERVIEW

Improves tissue oxygenation.


There are several indications for oxygen therapy:
Hypoxia/hypoxemia.
Decreased cardiac output.
Increased oxygen demand.
Decreased oxygen carrying capacity.
Increased myocardial workload.
Procedures that may cause hypoxemia.

213

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214 C h a p t e r 8 Oxygen Therapy


P R E PA R AT I O N
The device for delivery of oxygen should be chosen based the oxygen-delivery needs
of the patient.

Trach Collar
21% to 70% oxygen delivery.
Possibility for condensation to collect
in tubing and drain into patients airway
upon turningtherefore, empty
tubing frequently.
Does not pull on tracheostomy.
Elastic ties allow movement of collar
away from trach without
removing it.

FIGURE 8.2

Trach collar.

T-piece
21% to 100% oxygen.
Possibility for condensation to collect
in tubing and drain into patients
airway upon turningtherefore,
empty tubing frequently.
Possibility that weight of T-piece
can pull on tracheostomy
T-piece.

Mechanical ventilator
21% to100% oxygen delivery.
Requires skilled personnel to manage (usually respiratory therapy).
Possibility that condensation could collect in the tubing and drain
into the patients airway, especially during turningtherefore, frequent emptying of tubing condensation is indicated.

Special Considerations
High-ow systems that use heated humidiers or aerosols are a common source of infection, particularly for the patient with an articial
airway.
Tubing should be changed every 48 hours in the hospital.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to disease process

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P r o c e d u r e 8 . 2 Administering Oxygen: Articial Airway 215


EXPECTED OUTCOMES

Oxygenation saturation improves


Tissue oxygenation improves
Patients hemodynamics improve

EQUIPMENT/SUPPLIES

Oxygen source
Oxygen owmeter
Humidier (if ordered)
Specic type of oxygen delivery system (trach collar, T-piece and tubing with reservoir bag, mechanical ventilator and circuit)
I M P L E M E N TAT I O N

Trach Collar
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning procedure enhances efficiency and
patient safety.
Explain procedure to patient.
Ensures that patient is informed and decreases patient anxiety.
Prepare humidier: Add distilled water if needed or remove prelled

humidier from package and screw enclosed spike cap to bottle.


Delivers humidied oxygen to mucous membranes of airway.
Connect humidier.
Controls ow of oxygen and connects humidication to oxygen delivery
system.
Turn oxygen owmeter on until bubbling is noted in humidier.
Ensures connections are intact and that oxygen delivered will be humidied.
Check order.
Adjust ow of oxygen via ow meter.
Regulates oxygen ow delivery.
Put on gloves.
Reduces transmission of microorganisms.
Place collar around tracheostomy; adjust elastic band behind neck

and tighten to t.
Ensures proper t of trach collar.

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216 C h a p t e r 8 Oxygen Therapy


Position patient for comfort and ease of breathing with head of bed

elevated.
Facilitates lung expansion for adequate gas exchange.
Evaluate patients respirations and oxygen saturation.
Determines adequacy of oxygen-delivery system for patient.

T-piece
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Organizing equipment before beginning procedure enhances efficiency and
patient safety.
Explain procedure to patient.
Ensures that patient is informed, and decreases patient anxiety.
Prepare humidier: Add distilled water if needed or remove prelled

humidier from package and screw enclosed spike cap to bottle.


Delivers humidied oxygen to mucous membranes of airway.
Connect humidier to owmeter and connect humidier to tubing

attached to T-piece.
Controls ow of oxygen and connects humidication to oxygen delivery
system.
Turn oxygen owmeter on until bubbling is noted in humidier.
Ensures connections are intact and that oxygen delivered will be humidied.
Check order.
Adjust ow of oxygen via owmeter.
Regulates oxygen ow delivery.
Put on gloves.
Reduces transmission of microorganisms.
Place T-piece on end of tracheostomy or endotracheal tube.
Ensures proper t of T-piece.
Place condensation tubing and reservoir bag dependently (lower

than the patient) to allow adequate collection of uid within


drainage bag, which is periodically emptied.
Allows collection of uid in drainage bag away from patients airway.
Position patient for comfort and ease of breathing with head of bed

elevated.
Facilitates lung expansion for adequate gas exchange.

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P r o c e d u r e 8 . 2 Administering Oxygen: Articial Airway 217


Evaluate patients respirations and oxygen saturation.
Determines adequacy of oxygen-delivery system for patient.

Mechanical Ventilator
Wash hands.
Reduces transmission of microorganisms.
Equipment.
Organizing equipment before beginning procedure enhances efficiency and
patient safety.
Explain procedure to patient.
Ensures that patient is informed and decreases patient anxiety.
Put on gloves.
Reduces transmission of microorganisms.
Attach ventilator circuit to tracheostomy, endotracheal tube, or naso-

tracheal tube, and ensure adequate seal.


Ensures adequate attachment for the delivery of oxygen.
Ventilator will be set by respiratory therapy. Monitor settings and

patients response.
Ensures appropriate settings for the delivery of oxygen.
Secure tubing to allow turning of patients head without

disconnection.
Provides continuous oxygen delivery and guards against disconnection.
Position patient for comfort and ease of breathing with head of bed

elevated.
Facilitates lung expansion for adequate gas exchange.
Evaluate patients respirations and oxygen saturation.
Determines adequacy of oxygen delivery system for patient.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the patients:


Oxygen saturation, and compare to baseline
Quality and rate of respirations, and compare to baseline
Vital signs, and compare to baseline
Comfort level

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218 C h a p t e r 8 Oxygen Therapy

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

of the patients respiratory status before initiation


of oxygen therapy, including oxygen saturation and a description of respirations including rate.
Type of oxygen-delivery method initiated.
Time of initiation of oxygen-delivery method.
Percentage of oxygen currently being given.
Assessment of patients respiratory status after initiation of
oxygen therapy to include oxygen saturation and a description of respirations including rate.

C H A P T E R

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9
Ventilation Support
9.1 Managing Continuous Positive Airway
Pressure, 220
9.2 Managing Intermittent Positive Pressure
Ventilation, 223
9.3 Managing Mechanical Ventilation, 225
9.4 Using an Ambu Manual Ventilator, 229
9.5 Performing Endotracheal Tube Care, 232
9.6 Performing Tracheostomy Care, 235
9.7 Managing a Cuffed Endotracheal or
Tracheostomy Tube, 240

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220 C h a p t e r 9 Ventilation Support

PROCEDURE 9.1
Managing Continuous Positive Airway Pressure (CPAP)
OVERVIEW

To treat oxygen deciency to maintain airway patency and prevent


obstruction.
CPAP mask maintains alveolar patency during expiration to prevent
alveolar collapse.

P R E PA R AT I O N

Indicated for severely hypoxic patients such as those in early acute


respiratory distress syndrome (ARDS).
Proper seal of mask is of utmost importance in the delivery of CPAP.
Contraindicated in hypovolemic patients and chronic obstructive
pulmonary disease (COPD) patients because CPAP can increase
intrathoracic pressure causing a further decrease in blood pressure,
for COPD patients CPAP increases the work of breathing during the
exhalation phase.
Potential side effects include uid retention, decreased cardiac output, pneumothorax, and gastric distention due to increased intrathoracic pressure and air entering the stomach.

Special Considerations
Patients are at increased risk for aspiration due to gastric distention
caused by high pressure air entering the esophagus. CPAP should not
be used with confused, agitated, or semicomatose patients.
In certain pathologies, alveolar collapse will occur within 1 hour of
discontinuation.
Do not discontinue CPAP therapy unless urgent.
Patients require meticulous assessment of face every 2 hours for skin
breakdown due to the increased pressure from the mask.
R E L E VA N T N U R S I N G D I A G N O S E S

Ineffective breathing pattern


Risk for aspiration

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P r o c e d u r e 9 . 1 Managing Continuous Positive Airway Pressure 221


EXPECTED OUTCOMES

Patient achieves target tidal volumes, promoting optimal lung


expansion
Absence of adventitious breath sounds
Absence of copious secretions and pneumonia
Achieves optimal oxygenation status as evidenced by PaO 60100
2
mm Hg, capillary rell 3 seconds, and pink nail beds
Absence of atelectasis

EQUIPMENT/SUPPLIES

Appropriately sized CPAP mask (small, medium, and large) appropriate


size mask must t securely for therapy to be effective

FIGURE 9.1A CPAP mask.

Head strap
Oxygen tubing, humidier, and oxygen source
Prescribed pressure adaptor
Suctioning equipment
I M P L E M E N TAT I O N
Explain and give rationale for the use of CPAP.
Reduces anxiety.
Apply face mask and head strap to make an adequate seal. Adjust

head strap making sure no unnecessary pressure is applied to ear.


Effective continuous positive pressure treatment is dependent on good seal.
However, preventing skin breakdown is of utmost importance.
Adjust oxygen concentration to ordered settings.
Provides optimal oxygenation to patient.

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222 C h a p t e r 9 Ventilation Support


Monitor patient for nausea caused by air entering the stomach

at frequent intervals and have suction equipment available.


Patients risk for aspiration is markedly increased should vomiting occur with
this type of mask.
Provide communication devices, i.e., writing slates and call light.
Enables patient to communicate needs without disruption of therapy.
Evaluate ABGs and pulse oximetry as ordered every 47 hours.
Establishes need for alternative interventions such as endotracheal tube
intubation and mechanical ventilation.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess bilateral breath for decreased or absent breath sounds indicating the possibility of pneumothorax
Evaluate pulse oximetry; make sure it is within the normal range
ordered by the physician
Evaluate patients ability to cough
Evaluate patients tolerance to treatment
Evaluate arterial blood gas analysis before, during, and after

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

oxygenation (skin color, capillary rell, and oxygen saturation) before and after treatment.
FiO concentration used.
2
Color, consistency, and odor of secretions.
Vital sign alterations before, during, and after therapy.
Patients tolerance of treatment.
Time of last treatment.
Frequency of treatments ordered by the physician to ensure
continuity of care.
Results of treatment, i.e., improved respiratory status.
Associated nausea and vomiting.
Amount of pressure of CPAP mask ordered by physician.
Episodes of hypotension because excessive CPAP pressure
can decrease cardiac output.
Episodes of hypotension may be an indication or reduction in
CPAP pressure or change in therapy.

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P r o c e d u r e 9 . 2 Managing Intermittent Positive Pressure Ventilation 223

PROCEDURE 9.2
Managing Intermittent Positive Pressure Ventilation
OVERVIEW

To improve oxygenation, lung expansion, and promote clearing


of bronchial secretions.
To prevent or relieve atelectasis.

P R E PA R AT I O N

Hyperination of the lungs is dependent on compliance of the chest


wall and amount of positive pressure applied.
Decreased compliance requires higher pressures to inate the lungs.
Intermittent positive pressure ventilation is useful in treating
patients with respiratory weakness, chest wall deformity, and thoracic or abdominal incisions who are unable to deep breathe.
Potential complications include nosocomial pneumonia, barotraumas, respiratory alkalosis, and psychological dependence in COPD
patients.

Special Considerations
Intermittent positive pressure ventilation should not be used with
confused, agitated, or semicomatose patients.
Because these patients are not able to cooperate, they are likely to
swallow large volumes of air that leads to gastric distention and possible vomiting.
Elderly Client
There is a great chance for barotraumas due to fragility of lung space.
Pediatric Client
There is a tendency to overinate pediatric clients, thereby increasing
risk for barotraumas.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential impaired gas exchange


EXPECTED OUTCOMES

Patient achieves target tidal volumes, promoting optimal lung


expansion
Absences of adventitious breath sounds
Absences of copious secretions and pneumonia
Achieved optimal oxygenation status

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224 C h a p t e r 9 Ventilation Support


EQUIPMENT/SUPPLIES

Pressure controlled ventilator


Appropriate-sized mouth piece
Saline or prescribed medications
Oxygen source

FIGURE 9.2A Pressurecontrolled noninvasive ventilator.

I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Assist patient into semi-Fowlers or high Fowlers position.
These positions enhance intermittent positive pressure ventilation therapy
and promote lung expansion.
Demonstrate proper mouthpiece position, and emphasize that the

lips must completely cover mouthpiece.


Demonstration is a reliable teaching technique to ensure proper technique.
Ensure sensitivity setting is 1 or 2 cm H2O to trigger intermittent

positive pressure breathing (IPPB) cycling.


Allows small respiratory effort to trigger ventilator cycle to assist patient with
inspiration and adequate delivery of tidal volume and medication.
Instruct patient to breathe with the machine until it cycles off, at

which time the patient should hold his or her breath for 35 seconds
and exhale passively.
Ensures adequate chest expansion with each inhalation and prevents forced
exhalation, which can increase small airway obstruction.
Encourage patient to cough and deep breathe during and after

treatment.
Enhances removal of airway secretions.
Wash hands.
Reduces transmission of microorganisms.

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P r o c e d u r e 9 . 3 Managing Mechanical Ventilation (MV) 225


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess bilateral breath sounds for decreased or absent breath


sounds indicating the possibility of pneumothorax
Evaluate pulse oximetry if improvement with therapy
Evaluate patients ability to clear secretions after postural drainage,
controlled cough techniques and percussion by assessing bilateral
breath sounds for adventitious or diminished breath
Patients tolerance to treatment

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

of bilateral breath sounds before and after


treatment.
Type of ventilator and medication used to provide therapy,
i.e., Bird Mark 1 ventilator or the Bennett Pressure Breathing
Therapy Unit.
Color, consistency, and odor of secretions suctioned or expectorated.
Vital sign alterations before, during, and after therapy.
Patients tolerance of treatment.
Time of last treatment.
Frequency of treatments to ensure continuity of care and primary care providers orders.
Results of treatment, i.e., improved respiratory status.

PROCEDURE 9.3
Managing Mechanical Ventilation (MV)
OVERVIEW

To maintain the patients arterial blood gas, which is achieved


through keeping the PaO2, pH, and PaCO2 as close to normal limits
as possible.
Indicated for patients who cannot maintain adequate ventilation
and/or unable to protect ones own airway.

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P R E PA R AT I O N

Ensure patient on a ventilator is carefully monitored and that the


alarms are always on.
Monitor the system at regular intervals to detect problems early.
Anticipate problems and anticipate your response to the problems.
Remember that machines fail and have a manual system in place,
i.e., oxygen tank and Ambu bag.

FIGURE 9.3A Ambu bags, infant to

adult sizes.

Special Considerations
The psychosocial needs of the patient must be addressed.
The nutritional needs of the patient who is on an MV are of utmost
importance.
Cardiac output may be decreased, which will affect end-organ
perfusion.
Patients on MV are at high risk for the development of pneumothorax.
Repositioning of patient at least every 2 hours facilitates removal
of pulmonary secretions and prevention of atelectasis.
Age of patient.
Coexistence of different pathologies.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired spontaneous ventilation


Ineffective breathing pattern

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P r o c e d u r e 9 . 3 Managing Mechanical Ventilation (MV) 227


EXPECTED OUTCOMES

Improved patient oxygenation status


Able to maintain airway reexes
Absence of adventitious breath sounds
Normal respiratory rate
Negative inspiratory ow of greater than20 cm
Vital capacity greater than 10 mL/kg
PaO greater than 60 on FiO of less than 50%
2
2
Patient achieves target tidal volumes, promoting optimal lung
expansion

EQUIPMENT/SUPPLIES

Oxygen and air source at 50 psi


Spirometer
Ventilator
Humidier
Oxygen analyzer
Distilled water
Ambu bag
Two endotracheal tubes and emergency equipment (sizes appropriate
for patient). For women use 6.5 mm to 7.5 mm ETT and for men use
7.0 mm to 8.0 mm
Connectors, adaptors, and ventilator circuit
Monitors (blood pressure cuff, pulse oximetry, electrocardiogram)
Stethoscope
Suction equipment
Communication device, i.e., magic slate, pen and paper
Emergency airway equipment, such as oral airway, laryngoscope handle, and blades
I M P L E M E N TAT I O N
Wash hands.
Reduces the transmission of microorganisms.
Explain the rationale for therapy to patient and family.
Establishes rapport, reduces anxiety, and promotes autonomy.
Develop communication plan if time and condition permit.
Enables patient to communicate needs.
Address physical and psychological comfort measures.
Reduces discomfort, and improves patient outcomes.

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228 C h a p t e r 9 Ventilation Support


Administer pain and anxiety medication as prescribed.
Reduces discomfort and anxiety related to therapy.
Adjust alarm setting.
Provides early detection of potential problems. Mechanical alarms are useful
but patient assessment is vital.
Provide client opportunity for position changes and mouth and

endotracheal tube care frequently.


Promotes mobilization of secretions, and prevents oral cavity erosion.
Preoxygenate by providing 100% oxygen and suction when indi-

cated.
Promotes removal of pulmonary secretions and improved pulmonary function.
Continuously evaluate ventilator settings, arterial blood gases

(ABGs), goals for therapy, and patient response.


Improvement or deterioration in patient condition often requires changes in
ventilator setting.
Monitor patients ventilator pressure readings and breath sounds for

presence and quality.


Barotrauma and pneumothorax associated with MV often present in an
abrupt rise in peak inspiratory pressure or decreased breath sounds.
Perform oral care and avoid triggers for gag reex, such as deep

oropharyngeal suctioning.
Contaminated oral secretions are often associated with nosocomial pneumonia. Gagging causes discomfort and increases intrathoracic and intracranial pressure.
Elevate head of bed at least 30 degrees.
Reduces the risk for aspiration and promotes lung expansion.
Change ventilator tubing according to hospital policy to prevent

colonization of microorganisms.
Warm, moist nature of ventilator equipment is a medium for bacterial
growth, which makes patient prone to nosocomial infections.
Make appropriate ventilator changes such as increasing or decreas-

ing rate and/or tidal volume and monitor for patients ability to be
weaned from ventilator.
Changes in ventilator setting facilitate spontaneous ventilation and selfsustained ventilation.
Make referrals to dietitian to provide optimal nutrition.
Provides holistic care to meet the individual needs of the patient.
Wash hands.
Reduces the transmission of microorganisms.

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P r o c e d u r e 9 . 4 Using an Ambu Manual Ventilator 229


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the initial reason for MV, and evaluate goals for therapy
Anticipate duration of MV
Know successful criteria for achievement of goals
Detect patient problems early
Evaluate arterial blood gas analysis
Patients tolerance to treatment

KEY POINTS

FOR

REPORTING

AND

RECORDING

Size and depth of endotracheal tube used.


Date of MV initiation.
Ventilator settings at time of report.
Patients response to ventilatory changes.
Arterial blood gas analysis for the shift.
Vital signs.
Frequency of additional therapy, i.e., nebulizer treatments,
chest postural treatment, suctioning.
Amount, color, and consistency of secretions.
Alarm limits.
Ventilator settings
Vital signs.
Last treatments and suctioning.
Patients tolerance.
Neurological status of patient.
Breath sounds.

PROCEDURE 9.4
Using an Ambu Manual Ventilator
OVERVIEW

To hyperinate the lung and increase minute ventilation.


Useful in resuscitation efforts in which patients are unable to
breathe adequately or ventilate.
Used as a temporary means of assisting or total ventilation.

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P R E PA R AT I O N

Designed primarily to be used in emergency situations.


Useful in transporting mechanically ventilated patients.
Useful in hyperventilation of the lungs to promote removal of
secretions.
Can deliver from 240 to 2000 mL.

Special Considerations
Hyperination of the lungs using an Ambu bag can result in gastric
distention and increase the risk for aspiration.
Proper mask seal often requires an additional resuscitator assigned
to mask placement.
Assisted ventilation should be timed and sequenced with patients
inspiratory effort.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange


Impaired spontaneous ventilation
EXPECTED OUTCOMES

Secretions are loosened and easily removable


Removable of mucus plugs by suctioning
Normalizes respiratory rate and volumes
Improved oxygen status and arterial blood gas analysis
Restore articial respirations

EQUIPMENT/SUPPLIES

Ambu bag with mask (see gure in Procedure 9.3)


15 mm adapter for endotracheal tube connection
Endotracheal tube CO2 adapter
Oxygen source and supply tubing
Suction equipment
I M P L E M E N TAT I O N
Connect oxygen supply, and ll reservoir with 100% oxygen.
Provides supplement oxygen.
Prepare suction equipment.
Suctioning is necessary to provide pulmonary toileting and prevent
aspiration.

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P r o c e d u r e 9 . 4 Using an Ambu Manual Ventilator 231


If patient is intubated and you suspect mucus plugs, perform saline

lavage without preservative.


Aids removal and loosening of secretions.
Connect Ambu bag to endotracheal tube or place mask in proper

position on mouth and nose and create a good seal.


Ensures supplemental ventilator support.

FIGURE 9.4A Create a good seal.

Assess patients oxygen status, and, if necessary, perform suctioning.


Removal of secretions improves oxygenation.
Repeat steps if necessary, and monitor patient throughout procedure.
Provides information about improvement or deterioration in patients status.
If patients status improves, discontinue Ambu ventilation. If patients

respiratory status does not improve, place on mechanical ventilator


and develop appropriate plan of care.
Ambu ventilation is only for emergencies and temporary use; alternative
ventilatory methods are often needed.
Reposition patient.
Different pathologies affect ventilator status; repositioning may improve
ventilatory status and promote comfort.
Wash hands.
Reduces the transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient before and after use of Ambu bag


Patients tolerance

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KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

before and after bagging.


Rate and duration of ventilation.
Percentage of oxygen used.
Color, consistency, and amount of secretions obtained during
suctioning procedure.
Patients tolerance and outcome.
Last time of suctioning.
Duration of apnea.

PROCEDURE 9.5
Performing Endotracheal Tube Care
OVERVIEW

To provide oral hygiene.


To prevent tracheal damage.
To promote ventilation.
To prevent endotracheal tube (ETT) complications.

P R E PA R AT I O N S

Important to maintain proper position of tube.


Promote oral hygiene.
Maintain tube patency.

Special Considerations
All patients with ETT require meticulous mouth care every 2 hours.
Repositioning and manipulation of ETT should only be done by
experienced nurses or respiratory therapist to prevent accidental displacement of ETT.
Breath sounds should be assessed before, after, and during ETT care.
Confused patients who require ETT care will require more than one
nursing professional to perform ETT care to prevent inadvertent displacement while tube is not secure.
Male patients may require shaving of beard and mustache to adequately secure ETT.
The risk for accidental extubation exists during ETT care; therefore,
reintubation equipment should be readily available.

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P r o c e d u r e 9 . 5 Performing Endotracheal Tube Care 233


R E L E VA N T N U R S I N G D I A G N O S E S

Ineffective airway clearance


Potential impaired tissue integrity
EXPECTED OUTCOMES

ETT is positioned on opposite side of mouth after tube care and


retaping
ETT depth is the same as when care started
Tape is clean and secured to ETT and cheeks
ETT patency is maintained, as evidenced by absences of high peak
airway pressures, adequate oxygen saturation

EQUIPMENT/SUPPLIES

Bedside table
Towel
Wet washcloth
Tincture of benzoin swab
Peroxide/mouthwash swabs with suction adapter
11.5 inch tape
Two pair of nonsterile gloves
Endotracheal and oropharyngeal suction equipment
Tongue depressor
I M P L E M E N TAT I O N
Wash hands and apply gloves.
Prevents transmission of microorganisms.
Perform oropharyngeal suctioning
Removes secretions and decreases patients need to cough during the
procedure.
Prepare tape. Have an available assistant hold ETT tube securely.
Allows nurse to have one hand secure to the ETT throughout the procedure.
Prevents accidental extubation and maintains correct ETT position and depth.
Carefully remove tape from endotracheal tube and patients face.

Use adhesive remover to remove extra adhesive; discard tape into


proper receptacles.
Promotes access to skin beneath tape for visualization and hygiene.
Clean mouth, gums, and teeth on opposite side of tube with mouth-

wash swabs and solution. Move tube to opposite side and repeat
cleaning.
Allows access and complete visualization of the oral cavity. Promotes
hygiene, and reduces oral cavity infections.

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Clean face with soapy washcloth and towel dry. Use tincture of

benzoin swab on cheeks and chin. Allow to dry completely.


Protects skin, and makes skin more receptive to skin taping.
Pass tape under patients neck with adhesive side up. Careful not to

twist tape. Center tape. On one side of face, secure tape across cheek.
Tear remaining tape in half lengthwise. Secure top half of tape above
upper lip and bottom half around ETT. On other side of face rmly
remove slack, and secure to face. Tear tape lengthwise. Secure bottom half to lip and top half to ETT.
Secures tube to face, and positions tube at proper place and depth.
Wash oral airway with hydrogen peroxide, and rinse with normal

saline.
Prevents transmissions of microorganisms.
Reinsert oral airway using tongue depressor to displace tongue inferi-

orly, allow proper positioning of oral airway, and prevent oral trauma.
Prevents trauma to oral cavity and allows access for oropharyngeal airway.
Prohibits patient from biting ETT.
Check ETT cuff pressure.
Discard soiled items, and wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for unequal breath sounds


Assess for endotracheal tube depth (2021 cm for the average adult
female and 2224 cm for the average adult male)
Make sure tape is secure to cheek bone and jaw
Check ETT cuff pressure using minimal leak technique

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

before and after ETT care.


Supplies used to complete process.
Patients tolerance to procedure.
Frequency and extent of ETT care needed.
Size and depth of ETT tube.
Frequency of ETT care.
The presence of ulceration.
Type, consistency, color of secretions obtained.

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 235

PROCEDURE 9.6
Performing Tracheostomy Care
OVERVIEW

To maintain airway patency, prevent infection, promote cleanliness,


and prevent skin breakdown.
P R E PA R AT I O N

One-way patency is achieved and maintained by suctioning and


cleaning the inner cannula.
Long-term tracheostomy patients and their family members should
be taught proper tracheostomy care.
Have extra tracheostomy tube of equal size at bedside in case of displacement and contamination.

Special Considerations
Patients with tracheal stomatitis, pneumonia, bronchitis, tracheitis,
and short, fat neck may require more frequent tracheostomy care due
to increased production and pooling of secretions with these disorders.
In addition, hydration and nutrition affect consistency of secretions
and risk for infection. Adequate hydration promotes easily mobilized
secretions. Adequate nutrition is necessary to maintain proper
immune function to ght off infection.
Patients with tracheotomy may have decreased ability to cough and
clear secretions, which may impede airway patency, thus requiring
more suctioning and tracheostomy care. Meticulous attention to
individualize a plan of care is important.
If long-term placement of tracheostomy tube is anticipated, the
patient and family members should be educated and evaluated on
performing tracheostomy care.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to infection


Impaired gas exchange related to impaired tissue integrity

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EXPECTED OUTCOMES

Maintenance of patent airway


Device appropriate for patient, i.e., fenestrated for patients who can
vocalize
Inner cannula free of secretions
Tracheostomy ties are clean and secure
Stoma site is free of redness, mucoid secretions, and foul smelling
and/or colored secretions

EQUIPMENT/SUPPLIES

Bedside table
Tracheotomy suction supplies
Sterile gloves
Hydrogen peroxide
Normal saline
Sterile cotton-tipped swabs
Tracheostomy ties
Sterile basin
Towel
Sterile 44 gauze
Small sterile brush
Scissors
Sterile tracheostomy care kit (if available)
I M P L E M E N TAT I O N
Wash hands.
Prevents transmission of microorganisms.
Perform tracheotomy suction.
Removes secretion to prevent occlusion of outer cannula by secretions.
Allow patient to reoxygenate by breathing 100% oxygen, and pour

the hydrogen peroxide and normal saline into sterile bowls. Place tracheotomy O2 collar over tracheotomy to ensure oxygen saturation.
Allows efficient and organized completion of tracheotomy care.
Don sterile gloves; remove soiled dressing with forceps and discard

in trash receptacle.
Prevents transmission of microorganisms.
Keeping dominant hand sterile, remove oxygen source and inner

cannula with nondominant hand; place cannula in hydrogen peroxide basin.


Hydrogen peroxide loosens the secretions.

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 237


Place tracheotomy oxygen collar over outer cannula.
Maintains oxygenation of patient.
Clean inner cannula using small brush.
Brush provides mechanical force to remove thick secretions.

FIGURE 9.6A Clean inner cannula


with hydrogen peroxide and small
brush.

Rinse inner cannula with normal saline using nondominant non-

sterile hand to pour saline.


Cleanses secretions and hydrogen peroxide from inner cannula.
Replace inner cannula and secure locking mechanism. Reapply oxy-

gen source.
Secures inner cannula and re-establishes oxygen supply. (Note: some tracheotomy devices do not have an inner cannula.)
Cleanse outer cannula with a sterile cotton swab moistened with

hydrogen peroxide.
Aseptically removes secretions from stoma site.
Rinse stoma with cotton swab soaked in normal saline and dried

with sterile 44s.

FIGURE 9.6B Clean stoma with


cotton-tipped swab.

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238 C h a p t e r 9 Ventilation Support


Rinses hydrogen peroxide from surface and dries surface, prohibiting a moist
medium for microorganisms.
Do not release all tracheotomy ties at the same time.
To prevent dislodgement of tracheotomy.
Cut length adequate enough to wrap around the patients neck

twice and cut ends on diagonal. Insert end of tie through eye of
faceplate and pull through ipsilateral eye. Slide tie around neck to
other eyelet and insert through second eyelet. Bring one tie around
back of neck until ends meet. Tie ends securely allowing one nger
breath between neck and tie.
Cutting ends on diagonal aids in insertion of tie through eyelet. One nger
breath between neck and ties prevents ties from being too tight.

FIGURE 9.6C Securing face plate

with ties.
Insert fresh tracheotomy dressing under clean ties and faceplate.
Absorbs drainage.

FIGURE 9.6D Insert clean dressing


under ties and face plate.

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 239


Position patient comfortably and assess respiratory status.
Promotes comfort. Reassessment of airway patency and respiratory status
ensures good patient outcomes and provides clues to whether further interventions are needed.
Wash hands.
Prevents transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the patients respiratory status after procedure and compare


to baseline
Make sure tracheotomy is secure and ties are tight but not tight
enough to constrict circulation
Assess for stomatitis and pressure sores

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

ndings such as airway patency, stoma condition


before and after tracheostomy care.
Size and type of tracheostomy tube.
Description of secretions.
Patients tolerance of the procedure.
Supplies used.
Special care of stoma.
Frequency of tracheotomy care.
Time tracheotomy care was completed to ensure continuity
of care.
Patients tolerance to tracheotomy care.
Whether or not suctioning was needed to provide the caregiver with information on the frequency of suctioning.
Respiratory status such as breath sounds, ease of respirations,
and respiratory rate.

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PROCEDURE 9.7
Managing a Cuffed Endotracheal or Tracheostomy Tube
OVERVIEW

To prevent cuff-related injuries such as tracheal stenosis, tracheal


esophageal stula, erosion of blood vessels, and tracheal malacia.
To prevent accumulation of secretions above the cuff.

P R E PA R AT I O N

Detailed assessment to prevent complication.


Three important techniques: Inating the cuff; monitoring cuff
pressure; and preventing pooling of secretions above the cuff.
All complications of cuffed endotracheal tube and tracheostomy
tube are preventable with proper cuff care.

Special Considerations
Patients who have cuffed endotracheal tube and tracheostomy tube
require cuff care at least every 4 hours.
Patients who require frequent suctioning will require more frequent
cuff care.
Patients who are not mechanically ventilated and are eating may
only require cuff ination during meals.
Measurement should be taken at end of expiration.
Patients who have undergone general anesthesia with N2O must
have their cuff pressure measured immediately postoperatively
because N2O diffuses readily into endotracheal cuffs.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential for tracheal injury related to ET tube


Ineffective airway clearance
EXPECTED OUTCOMES

Proper cuff ination is equal to or less than 2025 cm H2O or 1417


mm Hg
Absence of tracheal or blood vessel erosion
Secretions above cuff are suctioned and removed

EQUIPMENT/SUPPLIES

Suction equipment
12- or 20-mL syringe
Pressure manometer

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P r o c e d u r e 9 . 7 Managing a Cuffed Endotracheal 241


I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Attach pressure manometer to pilot balloon cuff, and measure cuff

pressure.
Records cuff pressure, cuff pressure above 20 cm H2O may cause tracheal
necrosis.
If cuff pressure is greater than 2025 cm H2O or 1417 mm Hg, aspi-

rate air using syringe to appropriate pressure.


High pressures obstruct tracheal capillary blood ow, which can cause
necrotic injuries.
If cuff pressure is less than 2025 cm H2O or 1417 mm Hg, inject air

using syringe to appropriate pressure.


Pressures less than these values allow air to leak around cuff and prevent
adequate ventilation of the lung.
Perform endotracheal tube or tracheostomy tube suctioning.
Removes secretions.
Deate cuff.
Allows secretions above cuff to drain into a lower trachea to be suctioned.
Repeat suctioning technique.
Removes secretions.
Reinate cuff.
Maintains integrity of airway and allows adequate ventilation of the lungs.
Wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for excessive cuff pressure as evidenced by cuff manometer


pressure greater than 25 cm H2O and remove excess air
Assess for cuff rupture and leaking of air around the tube by monitoring pilot balloon pressure
Assess for intratracheal bleeding as evidenced by blood-tinged sputum noted when suctioning endotracheal tube and oral pharynx

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KEY POINTS
Amount

FOR

REPORTING

AND

RECORDING

of cuff pressure used.


If excessive or low cuff pressure noted, record amount of air
injected or removed, time and frequency of intervention.
Color, consistency, and amount of secretions above the cuff
that were removed when suctioning the oropharynx. (Oral
secretions that leak around the cuff can frequently cause aspiration pneumonia.)
Frequency and last time of cuff care performed.
Patients tolerance of process.
Technique used (i.e., measuring of cuff pressure and minimal
leak technique).
Amount of pressure in cuff after cuff care performed.

C H A P T E R

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10
Airway Suctioning
10.1 Inserting an Oral or Nasal Airway, 244
10.2 Performing Oropharyngeal (Yankauer)
Suctioning, 249
10.3 Performing Nasopharyngeal and
Nasotracheal Suctioning, 252
10.4 Performing Endotracheal or Tracheostomy
Tube Suctioning, 257

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PROCEDURE 10.1
Inserting an Oral or Nasal Airway
OVERVIEW

To facilitate easy removal of secretions.


To hold tongue forward and maintain open airway.
To prevent biting of endotracheal or nasogastric tubes.

P R E PA R AT I O N

Oral Airway

Minimal exibility of the airway.


Airway extends from exterior mouth, over the tongue, to the
pharynx.

FIGURE 10.1A Oropharyngeal airway

in place.

Proper size is needed for proper function. Sizes range from


pediatric #000 to adult #9. Measure from mouth to meatus of
the ear.

Nasal Airway

Correct size is important for proper t and function.


Extends from the naris and the back of the throat, to the
pharynx in patients who need an airway but have a gag
reex or in whom an oropharyngeal airway cannot be
placed or tolerated.

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P r o c e d u r e 1 0 . 1 Inserting an Oral or Nasal Airway 245

FIGURE 10.1B A nasopharyngeal airway


in proper position.

Provides airway maintenance.


Clearance of secretions.
Nasal airways are exible.

Special Considerations
The airway should be removed by gently pulling downward and
outward following the normal curve of the nose/mouth.
This should be done at least every 4 hours.
Good nasal and mouth care should be administered before
reinsertion.
Water-soluble lubricant should be applied to the lips to prevent
cracking and breakdown from the pressure of the airway.
After lips and mouth are cleaned, reinsert the oral airway.
Before discontinuing the airway, ensure that the patient can follow
commands and can swallow, and has regained gag and cough
reexes to prevent aspiration of airway secretions into the lungs.
If nasal airway cannot be inserted, consider the following:
Changing size of the tube.
Relubricating airway and attempt to reinsert.
Hyperextending the patients neck.
Inserting the tube at a different angle.
Inserting the oropharyngeal rather than nasopharyngeal airway.
Patients with nasal airways need to be assessed for suctioning, especially the elderly and children.
Keep materials for cleaning the nares and moisturizing the nasal
mucosa close to the patients bedside.
Assess the patients nares and face around the nasal tube for skin
breakdown, especially in elderly patients.

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246 C h a p t e r 1 0 Airway Suctioning

Prior to removal, suction airway to remove secretions.


Rotate the airway to the other naris every 8 hours to prevent breakdown of nasal mucosa.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential impaired gas exchange related to retained respiratory


secretions
EXPECTED OUTCOMES

Airway placed atraumatically without damage to the nasal or oral


airway or mucous membranes
Airway properly secured
Airway protected from obstruction

EQUIPMENT/SUPPLIES

Oral or exible nasopharyngeal airway


Equipment for suctioning
Tape strips (one approximately 20 inches, one 16 inches)
Tongue depressor
Petroleum jelly
Mouth moistener or swab with mouthwash
Gloves, nonsterile
I M P L E M E N TAT I O N
Explain procedure to patient/family.
Decreases anxiety and facilitates cooperation.
Wash hands.
Reduces transmission of microorganisms.
Gather equipment to the bedside, including an oral or nasal airway.
Enhances efficiency and patient safety.
Prepare and test suction system.
To ensure prompt removal of secretions that increase risk for aspiration.
Don nonsterile gloves.
Reduces transmission of microorganisms.
Rinse airway with cool water.
Facilitates insertion; acts as a lubricant.
Position patient in semi-Fowlers or Fowlers position; place a pillow

or shoulder roll under the shoulders to hyperextend the neck.

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P r o c e d u r e 1 0 . 1 Inserting an Oral or Nasal Airway 247


The semi-Fowlers/Fowlers position can facilitate removal of secretions,
should patient vomit.
Hyperextension of the neck opens the airway and helps keep the tongue
from the pharynx.
Determine if the patient needs an oral or a nasopharyngeal airway.
An oral airway should only be placed on an unconscious or unresponsive
patient or when nares are occluded.

Nasal Airway
Select the naris that looks most patent by examining each side of

the nares with a ashlight to observe for occlusion.


To facilitate easy insertion of nasal tube without trauma to the patient with
multiple attempts of insertion.
Select appropriate size nasal airway (should extend from tip of nares

to earlobe). For optimal t, the lumen of airway should be narrower


than patients nares airway.
Choosing correct airway size will ensure adequate patency and facilitate
easy removal of secretions.
Wash hands, and don nonsterile gloves.
Reduces transmission of microorganisms which could cause infection.
Lubricate entire length of tube with water-soluble jelly or anesthetic

jelly. Check with patients physician to determine if anesthetic lubricant can be used.
To prevent trauma to the airway and facilitate insertion.
Insert the entire tube gently through the naris. Follow the anatomic

line of the nasal passage.


If you feel resistance, the naris may be deviated or obstructed. Attempt placement via the other naris.
Validate proper positioning by:

Feeling exhaled air with your hand through tube opening.


Inspecting, with patients mouth open, for the tip of tube behind
uvula.
To ensure that the nasal tube is in the correct position and promoting
respiratory function.

Suction mouth and throat if needed.


Removes accumulated or loosened secretions pooled in mouth and throat.
Discard dirty gloves.
Reduces transmission of infection.
Wash hands.
To prevent the spread of microorganisms.

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248 C h a p t e r 1 0 Airway Suctioning

Oral Airway
Choose the correct size oral airway based on patients age, size, and

condition.
To ensure adequate airway patency and ease of removal of secretions.

TABLE 10.1A Oral Airway Size in Children and Adults

Age
Wt (kg)

PREMA- NEOTURE
NATE INFANT

TODDLER

SMALL LARGE SMALL MEDIUM LARGE


CHILD CHILD ADULT ADULT
ADULT

0-1
mo
0.53

Oral
000Airway 00
(mm)

01
mo
35

112
mo
410

13
yr
816

38
yr
1430

812
yr
2550

00

0
(40)

1
(50)

2
(70)

3
(80)

1318
yr
above
50
3
(80)

Above
18 yr

Above
18 yr

4
(90)

5
(100)

Hold oral airway with the curved end up.


Makes insertion of airway easier.
Slide oral airway in until tip is at the lower half of tongue.
Ensure accurate placement.
Tape airway securely to prevent injury to lips, teeth, tongue, and pos-

terior pharynx.
Prevents expulsion of nasal airway.

Tape
Nasal
airway

Tape
Airway

FIGURE 10.1C Taping the airway.

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P r o c e d u r e 1 0 . 2 Performing Oropharyngeal (Yankauer) Suctioning 249


Suction mouth and throat if needed.
Removes accumulated or loosened secretions pooled in mouth and throat.
Discard dirty gloves.
Reduces transmission of infection.
Wash hands.
Prevents the spread of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory status, and compare to pre-insertion respiratory status


If patient is attempting to remove or push airway out, consider that
the airway may no longer be needed
Assess for trauma to lips, teeth, tongue, and pharynx
If the patient is gagging, consider a smaller airway

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

before/after insertion of airway.


Size of airway used.
Patients tolerance of procedure.
If patient needed to be suctioned and what secretions looked
like (bloody, clear, etc.).
Any trauma from procedure.
Time of insertion of airway.
Patients tolerance of procedure.
Respiratory status pre- and post-insertion.
If suctioning was required, and what secretions looked like
(bloody, clear, etc.).
Any trauma from procedure.

PROCEDURE 10.2
Performing Oropharyngeal (Yankauer) Suctioning
OVERVIEW

To clean oral airway of secretions.


To facilitate breathing.

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250 C h a p t e r 1 0 Airway Suctioning


P R E PA R AT I O N

Indications for suctioning include ineffective cough; thick, tenacious


mucus; impaired pulmonary function; and pooled secretions in
mouth and throat.
Smaller Yankauer suctions are designed for pediatric patients.

Special Considerations
If adult or child is capable and wishes to manage suctioning
independently, provide instruction in the use of the Yankauer
catheter.
Suctioning of infants may require two people; parents may be
helpful in assisting and allaying the infants fears.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential impaired gas exchange related to retained secretions


EXPECTED OUTCOMES

Respirations of 14 to 20 breaths per minute


Oral airway clear and free of secretions
Easy respirations

EQUIPMENT/SUPPLIES

Portable or wall suction unit with connection tubing and Yankauer


connector
Large towel
Yankauer (oral suction) catheter
Nonsterile gloves
Oral moisturizer swabs
Sterile saline
Mouthwash (optional)
I M P L E M E N TAT I O N
Explain procedure to the patient.
Reduces anxiety, and increases cooperation.
Wash hands.
Reduces transmission of microorganisms.

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P r o c e d u r e 1 0 . 2 Performing Oropharyngeal (Yankauer) Suctioning 251


Gather equipment, including Yankauer and suction tubing.
Enhances efficiency and patient safety.

FIGURE 10.2A Yankauer suction tube.

Prepare and test suction system.


Removes secretions during suctioning.
Don nonsterile gloves.
Reduces transmissions of microorganisms.
Position patient in semi-Fowlers or Fowlers position.
Facilitates forward draining of secretions in mouth.
Place towel on pillow or under patients chin.
Prevents soiling of bed linens or cloths from secretions.
Select proper suction pressure and type of suction unit.
Ensures safe negative pressure for patients age to prevent precipitate
injury to mucosa.

TABLE 10.2A Vacuum and Suction Settings


VACUUM SETTINGS
Wall

Portable

Infants

60100 mm Hg

35 inches Hg

Children

100120 mm Hg

710 inches Hg

Adult

120150 mm Hg

715 inches Hg

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252 C h a p t e r 1 0 Airway Suctioning


Gently insert Yankauer catheter into one side of patients mouth, and

guide it to the oropharynx.


Reduces stimulation of the gag reex.
Gently extract Yankauer catheter from mouth without excessive

force.
Reduces injury to the mouth and the teeth.
Flush Yankauer with sterile solution by placing it in solution and

applying suction.
Removes secretions from Yankauer.
Repeat step 9 (insert Yankauer) if all secretions are not cleared from

patients mouth.
Ensures removal of all secretions from patients mouth.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory status


Assess for trauma to mucous membrane of mouth

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

before/after suctioning.
Patient tolerance.
Trauma during procedure.
Color, amount, and consistency of secretions.
Time of last suctioning.
If patient is suctioning self or nurse is suctioning.
Patients tolerance to procedure.
Any trauma from procedure.
Respiratory status.

PROCEDURE 10.3
Performing Nasopharyngeal and Nasotracheal Suctioning
OVERVIEW

To clean airway of secretions.


To facilitate breathing and improve gas exchange.

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P r o c e d u r e 1 0 . 3 Nasopharyngeal & Nasotracheal Suctioning 253


P R E PA R AT I O N

Suction catheter sizes are adult, sizes 12 to 16 French; and pediatric,


sizes 6 to 12 French.
Limit suctioning to no more than 12 seconds to prevent hypoxia.

TABLE 10.3A Suction Catheter Sizes


AGE
Newborn
Infant to 18 mo
18 mo
24 mo
24 yr
47 yr
712 yr
Adults

CATHETER SIZE (FRENCH)


68
68
810
10
1012
12
1214
1216

Special Considerations
Some patients may require more frequent but shorter-duration suctioning to hypoxia. Assess pulse oximetry readings during suctioning
to determine patients level of tolerance.
Pediatric Patient
Two people may be required to suction infants and children, one to
calm and hold the childs hands and one to suction.
Determine correct length of suction catheter by measuring from the
tip of the childs nose to the ear lobe, then to the midsternum.
The premeasured length should be used to prevent tracheal trauma
instead of waiting for a cough to be induced.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to retained secretions


EXPECTED OUTCOMES

Respirations of 14 to 20 breaths per minute, normal depth, easy


and symmetrical
Upper lung elds clear on auscultation

EQUIPMENT/SUPPLIES

Portable or wall suction unit with connecting tubing


Large towel or linen saver
Sterile irrigation saline or water
Sterile gloves

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254 C h a p t e r 1 0 Airway Suctioning

Suction catheter
Cotton-tip swabs
Moist tissue/cotton swab
Goggles and mask (optional) or face shield
I M P L E M E N TAT I O N

General Procedure
Explain the procedure to the patient.
Reduces anxiety and increases cooperation.
Wash hands.
Reduces transmission of microorganisms.
Position patient in semi-Fowlers during procedure.
Facilitates maximal breathing during procedure.
Don nonsterile gloves.
Reduces transmission of microorganisms.
Turn suction on. Place nger over end of tubing attached to suction

machine. Observe meter on suction head to make sure suction is


working properly. Set suction to 60 mm Hg for children and 120 mm
Hg for adults.
Tests suction function.
Open sterile irrigation solution, and pour solution into sterile cup.
Allows sterile rinsing of catheter.
Place towel under patients chin.
Prevents soiling of sheets and clothes.
Ask patient to breathe through one naris while the other is

occluded, then repeat with other naris.


Determines patency of nasal passage.
Provide skin care to nares if indicated. Remove and discard nonsterile

gloves.
Clears nasal passage.
Open sterile gloves, and suction package.
Maintains aseptic procedure.
Don sterile glove on dominant hand.
Maintains sterile technique.
Hold the suction catheter in sterile hand. Grasp the suction end and

the length of the tubing with the sterile hand. Attach suction control
port end of the suction catheter to the tubing coming from the wall
suction, which is held in the nonsterile hand.
Maintains sterility while establishing suction.

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P r o c e d u r e 1 0 . 3 Nasopharyngeal & Nasotracheal Suctioning 255


Remove plastic sleeve from suction catheter if there is one. Using

sterile hand, grasp the suction catheter tubing closer to the fenestrated end. You can wrap tubing partially around hand. Hold suction
control port end with nonsterile hand.
Facilitates control of tubing.
Lubricate 3 to 4 inches of catheter tip with irrigating solution.
Prevents mucosal trauma when catheter is inserted.
Ask patient to take several deep breaths with oxygen source before

suctioning.
Provides additional oxygen to body tissues before suctioning.

Nasopharyngeal Suctioning
Insert catheter into an unobstructed naris, using a slanted downward

motion.
Facilitates unrestricted insertion of catheter.
Observe the back of the throat to see if catheter is properly posi-

tioned or coiled in the mouth. If properly positioned, place thumb


over suction port to apply suction.
Assess position.
Applies suction to the catheter for suctioning secretions.
Withdraw catheter in circular motion, rotating it between thumb and

nger. Release suction every few seconds so that suction is on no


more than a total of 10 seconds in the patients trachea.
Removes secretions without removing oxygen. Protects mucosa from force
of suction.
Place tip of suction catheter in sterile solution, and apply suction for

1 to 2 seconds.
Clears secretions from tubing.
Have patient take several deep breaths. Assess lung sounds, espe-

cially over bronchi, and determine if secretions are still obstructing


the airway.
Determines if repeat suctioning is needed.
Repeat one more time if secretions are still present when assessed.
Promotes adequate clearing of airway.
Disconnect suction catheter from suction tubing, and turn off suc-

tion machine. Properly dispose of suction catheter, gloves, and other


supplies.
Prevents spread of microorganisms.

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256 C h a p t e r 1 0 Airway Suctioning


Wash hands.
Removes microorganisms.

Nasotracheal Suctioning
Ask patient to open mouth wide as catheter is inserted.
Allows visibility of tip of catheter.
Insert the catheter deeper when the patient pants or coughs.
Decreases resistance to catheter insertion.
Place thumb over suction port.
Provides a suction to remove secretions.
Encourage patient to cough.
Facilitates loosening and removal of secretions.
Withdraw catheter in circular motion, rotating it between thumb and

nger. Release suction every few seconds so that suction is on no


more than a total of 10 seconds in the patients trachea.
Removes secretions without depleting oxygen supply.
Place tip of suction catheter in sterile solution, and apply suction for

1 to 2 seconds.
Clears clogged tubing after suctioning.
Have patient take several deep breaths. Auscultate bronchial area,

and assess if patients airway is clear.


Determines if repeated suctioning is needed.
Repeat if secretions are still present when assessed.
Promotes adequate clearing of airway.
Suction the mouth and pharynx.
Clears secretions from oral airway.
Disconnect suction catheter from suction tubing, and turn off suc-

tion machine. Properly dispose of or store equipment.


Prevents spread of microorganisms.
Wash hands.
Removes microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory status


Assess for trauma, including bleeding or cuts to mucous membranes
of nares and mouth

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 257

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

before and after suctioning. Include work of


breathing, frequency of cough, subjective feelings, if possible.
Patient tolerance. Oximetry readings before and after
suctioning.
Trauma, including bleeding or tears in the mouth or nares
during procedure
Color, amount, and consistency of secretions
Time of last suctioning
Respiratory status

PROCEDURE 10.4
Performing Endotracheal or Tracheostomy Tube Suctioning
OVERVIEW

To maintain a patent airway and prevent airway obstruction.


To promote optimal respiratory exchange of oxygen and carbon
dioxide into and out of the lungs.
To prevent pneumonia that may result from accumulated secretions.

P R E PA R AT I O N

Indications for endotracheal or tracheostomy tube suctioning: ineffective cough; depressed level of consciousness; thick, tenacious
mucus; impaired pulmonary function.
To determine suction catheter size, multiply the articial airways
diameter times 2 (e.g., for 8-mm tube, use a 16 F suction catheter).
Assess patients need for suctioning every 2 hours and as needed.
Limit suctioning to no more than 10 seconds to prevent removal of
excessive oxygen.

Special Considerations
Discontinue suction immediately if any of the following adverse
reactions occur:
Hypoxia.
Cardiac arrhythmias (bradyarrhythmias).
Hypotension/hypertension.
Mucosal trauma.

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258 C h a p t e r 1 0 Airway Suctioning

Laryngospasm/bronchospasm.
Cardiac/respiratory arrest.
Extreme anxiety/agitation.
Pediatric Patient
Suction pressure should range from 80 to 100 mm Hg.
The suction catheter is inserted to 0.5 cm beyond or just to the end
of the endotracheal or tracheostomy tube. Advancing the suction
catheter until resistance is met may cause trauma to the tracheobronchial wall in children.
Elderly Patient
Elderly patients have a decreased PaO2, resulting in increased oxygen
demands between suctioning.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential impaired gas exchange related to retained secretions


EXPECTED OUTCOMES

Decreased or cleared secretions


Improved breath sounds
Improved oxygen saturation

EQUIPMENT/SUPPLIES

Ambu bag connected to


100% O2

FIGURE 10.4A Ambu bag connected

to 100% oxygen.

Sterile suction catheter kit (includes sterile catheter, gloves, and cup)
Sterile normal saline
Personal protective equipmentgoggles, mask, and gown (if examiner will be exposed to any bodily secretions).
Continuous suction source

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 259


I M P L E M E N TAT I O N
Assess patients vital signs, breath sounds, and appearance prior to

suctioning.
Establishes a baseline for comparison after suctioning.
Obtain and organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient or signicant other.
Reduces anxiety, and promotes patient cooperation.
Wash hands.
Reduces transmission of microorganisms.
Put on personal protective equipment.
Reduces transmission of microorganisms.
Turn suction on between 80 mm Hg and 120 mm Hg.
Adequate suction is needed to ensure clearance of the airway.
Open suction catheter set.
Don sterile gloves.
Prevents contamination of eld.
Open sterile saline irrigation, and pour into sterile cup.
Allows sterile rinsing of catheter after examiner has suctioned.
Hold suction catheter

with dominant (sterile) hand


while connecting suction
source to suction catheter
with nondominant
(nonsterile) hand.
Prevents contamination of
sterile eld and transmission
of microorganisms.

Note: Throughout procedure


continue to hold sterile suction catheter with dominant
(sterile) hand.

FIGURE 10.4B

Suction small amount of sterile saline by placing nondominant

(nonsterile) thumb over suction port.


Determines that the suction equipment is working properly and lubricates
the outside and the lumen of the catheter. Lubrication eases insertion and
reduces tissue trauma during insertion.

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260 C h a p t e r 1 0 Airway Suctioning


Connect Ambu bag to endotracheal tube or tracheostomy tube

adapter. Hyperoxygenate patient with 100% oxygen using Ambu


bag or mechanical ventilator.
Provides additional oxygen to body tissues before suctioning, preventing
hypoxemia. Hyperventilation with Ambu bag is used to break up secretions
and to hyperoxygenate patient.
Insert suction catheter into endotracheal tube or tracheostomy tube

using a slanted, downward motion until resistance is felt or cough is


elicited.
Prevents trauma to membranes due to suction from catheter.

Note: Do not apply suction while inserting catheter.

Apply intermittent suction with nonsterile (nondominant) thumb

while withdrawing catheter in a circular motion, rotating between


thumb and nger of sterile (dominant) hand.
Intermittent suction and catheter rotation prevents damage to mucosal lining during suctioning.

Note: Suction time is limited to 10 seconds or less.


Minimizes oxygen loss.

Replace oxygen delivery system between suctioning by reconnect-

ing to ventilator or connecting to oxygen source.


Prevents hypoxemia.

Note: After catheter insertion, allow patient to return to baseline O2


saturation level or better before resuctioning.

Place tip of suction catheter into sterile saline, and apply suction.
Rinses suction catheter and removes secretions.
Repeat suctioning procedure 2 or 3 times as necessary to remove

secretions.
Promotes adequate clearing of airway.
Reattach oxygen source to endotracheal tube or tracheostomy tube.
Prevents hypoxemia.
Disconnect suction catheter, wrap catheter around nger, and

remove glove over catheter. Discard suction equipment appropriately.


Reassess patients vital signs, breath sounds, and oxygen saturation.
Assesses patient status in comparison with patients baseline.
Remove gloves and wash hands.
Reduces transmission of infection.

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 261

If Specimen Is Needed
Connect suction catheter to

rubber tubing of specimen


container and tubing from
suction source to suction
adaptor on lid of specimen
container.
Places specimen container in
the suction pathway so
specimen collects in cup.

FIGURE 10.4C

Suction patient per procedure.


Secretions will collect in the specimen cup.
When secretions are visible (about 23 mL) in Luki tube, stop suc-

tioning. Be careful to avoid suctioning for greater than 10 seconds.


23 mL of sputum is necessary for a sputum culture or Gram stain.
Disconnect Luki tube, seal

the specimen container,


reconnect suctioning tubing
to suction catheter.
Allows continuation of
suctioning to clear airway and
safe handling of body uids.

FIGURE 10.4D Seal the speci-

men cup.
Complete suctioning procedure as needed.

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262 C h a p t e r 1 0 Airway Suctioning


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess breath sounds


Assess vital signs, oxygen saturation
Assess patient comfort

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date, time and procedure.


Reason for suctioning.
Patients tolerance, changes in breath sounds, etc.
Color, consistency, and amount of secretions removed.
Current MD suctioning orders.
Time suctioned.
Patients tolerance.
Color, consistency, and amount of secretions removed.

C H A P T E R

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11
Lung Re-Expansion
or Chest Drainage
11.1 Managing Chest Tube and
Drainage Systems, 264
11.2 Assisting with Chest Tube Removal, 271

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264 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage

PROCEDURE 11.1
Managing Chest Tube and Drainage Systems
OVERVIEW

To remove air, blood, or uid from the intrapleural space.


To facilitate removal of air and uids while reestablishing normal
intrapleural pressure and lung expansion.
To remove air, chest tubes are placed through the second intercostal
space (ICS) anteriorly.
To remove blood or uid, chest tubes are placed posteriorly through
the eighth or ninth ICS.

P R E PA R AT I O N

36 French (F) is the most common adult size.


Trocar chest tubes are available for emergency insertion and require
a minimal number of instruments.
Heimlich valves can be used for emergency transport until a chest
drainage system is available.
Chest tubes are connected to bottle systems or disposable chest
drainage systems.
Bottle systems have one, two, or three bottles, whereas disposable
chest drainage systems have three chambers.
Three-bottle or disposable chest drainage systems are used most
often.
The three bottles/chambers are: collection chamber, water seal
chamber, and suction chamber.

Special Considerations
Milking and stripping of chest tubes is controversial and only
performed with a physicians order. Research shows that milking and stripping causes increased negative pressure. Always
follow specic policy and procedures for these techniques
and milk/strip away from the patient toward the drainage
system.
If a chest tube becomes disconnected, instruct the patient to exhale
fully, clamp the chest tube with two rubber-shod Kelly clamps
closest to the patient; cleanse the ends with antiseptic; reconnect to
drainage system; remove clamps; tape the connections; and assess
the patient.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 265

If a chest tube is accidentally removed, apply pressure with Vaseline


gauze and a 44, tape the dressing, notify the physician, and continue to assess the patient for respiratory distress.
Other situations with potential risk for closed pneumothorax requiring a chest tube include injury from mechanical ventilation, insertion
of a central venous catheter, perforation of the esophagus, and blunt
trauma from motor vehicle accidents.
Tension pneumothorax is life threatening and requires immediate
intervention. Intrathoracic pressure increases, the mediastinum shifts
to the unaffected side, cardiac output is decreased, and jugular vein
distention occurs.
Patients at risk for tension pneumothorax are those on mechanical ventilation, after resuscitation, or with an obstructed chest
tube.
Elderly Patient
Elderly patients may be at risk for pneumothorax following blunt
trauma from falls or from ruptured blebs or bullae associated with
chronic obstructive pulmonary disease (COPD).
Pediatric Patient
Pediatric patients are also at increased risk for accidental injury.
Although their bones are more exible, internal injuries may exist
without apparent external injuries.
Pediatric patients are more sensitive to changes in respiratory status.
Hypoxia and respiratory arrest are the primary causes of cardiac
arrest in children.
Drainage greater than 3 mL/kg/hr in a pediatric patient for 3 hours or
more indicates possible hemorrhage. Whenever possible, use sedation for chest tube insertion and removal, such as local anesthetics,
conscious sedation, or EMLA cream.
To reduce anxiety in children, show them pictures or an actual setup
of equipment.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to pneumothorax or


hemothorax
Pain related to presence of chest tube

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266 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage


EXPECTED OUTCOMES

Air, uid, and blood are removed from the intrapleural space
Lungs re-expand producing improved breath sounds in all lobes,
oxygen saturation between 95% and 100%, pink color, and stable
vital signs
Intrapleural pressure returns to normal
No air leaks detected

EQUIPMENT/SUPPLIES

36 French chest tube (for adult)


Chest drainage system (disposable or three-bottle)
Sterile water
5 in 1 connector or Y connector (for 2 chest tubes)
Sterile gloves and masks
Dressing (Vaseline gauze, split drain sponge, 44s, 3-inch tape)
Rubber shod Kelly clamps
Chest tubeinsertion tray (povidone-iodine, local anesthetic, syringe,
needles, drapes, scalpel, suture)
I M P L E M E N TAT I O N
Assess patient; vital signs, respiratory and cardiac status, anxiety,

pain.
Obtain baseline data.
Explain procedure to patient/family.
Reduce anxiety.
Wash hands.
Reduce transmission of microorganisms.
Organize equipment.
Enhance efficiency and patient safety.
Prepare a chest drainage system, per physician preference,

using sterile technique to open packages, handle contents,


and pour solutions. Don sterile gloves; recap connectors when
nished.
Facilitate rapid attachment of chest tube to water seal and suction.
Maintain sterility of system and connections.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 267


One-bottle system: add sterile water to submerge water seal tube.
Maintains water seal and uid collection in one bottle.

Suction
chamber

Water seal
chamber

Drainage
collection
chamber

FIGURE 11.1A Bottle and disposable

chest drainage systems.


Two-bottle system: add sterile water to submerge water-seal tube;

connect water-seal bottle to collection bottle.


Provides separate bottles for uid collection and water seal.
Three-bottle system: add sterile water to submerge water-seal tube,

connect water-seal bottle to collection bottle, add sterile water to


the suction bottle, ensure that long tube is submerged, connect
suction bottle to water seal bottle then to suction regulator.
Depth of long-tube submersion determines amount of negative pressure.
Disposable system: swivel base of unit to stand upright, remove cap

on suction control chamber and add sterile water to 20-cm level,


replace cap, remove cap on water-seal chamber tubing and use
catheter tip syringe to add sterile water to 2-cm level, replace cap
on tubing, inspect system for leaks or cracks.
System is ready to provide water seal, suction, and uid collection. Water seal
prevents room air from entering pleural cavity.
Assist physician as needed with chest tube insertion, maintain sterile

technique, don sterile gloves and mask. Monitor patients physical


and emotional response to procedure.
Assessment facilitates prompt interventions.
Once chest tube is inserted, connect it to the long tube of collection

chamber of chest drainage system and remove rubber-shod Kelly. If

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268 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage

suction is ordered, attach short water-seal tubing to suction tubing


and regulator. Keep unclamped if no suction has been ordered.
Rubber-shod Kelly clamp prevents or reduces air entering chest during
insertion.
Apply dressing: Vaseline gauze, drain sponge, 44s, and tape. Tape

all connections.
Reduces risk for air leak at insertion site and all connections.

FIGURE 11.1B(1) Apply occlusive

dressing.

FIGURE 11.1B(2) Tape connections.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 269


Adjust suction until gentle bubbling occurs in suction control

chamber.
Unit is functioning properly.
Ensure tubing is free of kinks and is loosely coiled or forms a straight

line to drainage system.


Prevents obstruction and pooling of uids in dependent loops.

FIGURE 11.1C

Observe for air bubbles in water-seal chamber and uctuations,

tidaling, with respiration.


Continuous, constant bubbling in water-seal chamber indicates an air leak;
intermittent bubbling is normal. Fluctuations, tidaling with respiration are
normalabsence indicates lungs re-expanded or a blockage.
Position chest drainage system upright and below level of chest.

Secure bottles in stand or disposable system to bed frame.


Prevents uid from draining back into chest. Secure position prevents overturning and loss of water seal.

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270 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage


Order chest x-ray.
Conrms chest tube placement and lung expansion.
Mark uid level on collection chamber and time of measurement.

Use tape if needed to write on.


Accuracy of output.
Encourage patient to breathe deeply, cough, and change positions.
Facilitate drainage and lung expansion.
Assess drainage and vital signs, notify physician for changes in

drainage quantity or character, especially change from serous to


bloody.
Identify and intervene based on changes in patient status.
Keep rubber-shod Kelly clamps at bedside.
Rapid availability in event of disconnection or break of drainage system.
Document.
Validates procedure and patient response.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients respiratory and cardiac status, vital signs, skin color,
and compare to baseline. Assess for symmetric chest wall movement
and subcutaneous emphysema
Monitor water level in water seal and suction chambers; replace sterile water as needed
Rule out suspected air leaks by rst retaping connections, checking
dressing, and/or momentarily clamping tubing with rubber-shod
Kelly clamp, starting nearest patient and moving distal until bubbling
ceases
Report bleeding or drainage greater than 100 mL/hr

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

ndings before, during, and after chest tube


insertion.
Physician performing procedure.
Size of chest tube and placement.
Local anesthetic injected and amount.
Pre-medication or conscious sedation.
Drainage system used and amount of suction.

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Description of drainage.
Patients tolerance of procedure.
Dressings applied.
Time chest tube inserted.
Patients tolerance.
Respiratory status and vital signs.
Amount and characteristics of drainage.
Type of drainage system and amount of suction.

PROCEDURE 11.2
Assisting with Chest Tube Removal
OVERVIEW

When lungs are re-expanded and uid drainage ceases, the chest
tube is removed.
Serial chest x-rays document progression of improvement, lung reexpansion.

P R E PA R AT I O N

Pain medication is given prior to chest tube removal.


Sterile technique is used for removal.
Respiratory distress or recurrent pneumothorax are possible.

Special Considerations
Some references recommend chest tube removal on full inspiration
whereas others recommend removal on full expiration.
Check your facilitys policy and your physicians preference.
If a purse-string suture is used at the time of chest tube placement, it
is pulled tight after removal of the chest tube for closure.
Elderly Patient
Elderly patients need encouragement to cough and deep breathe
following chest tube removal. They may be reluctant to take pain
medications, which would make these tasks easier.
Pediatric Patient
Pediatric patients should be sedated to reduce their pain and fear.
Intravenous medication or EMLA cream applied 1 hour prior to
removal and covered with an occlusive dressing, are effective to
decrease pain of chest tube removal.

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272 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage


R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to decreased oxygenation


Impaired gas exchange related to infection
EXPECTED OUTCOMES

Pleura will close


Skin at chest tube site heals
Intrapleural pressure remains normal
No air leaks detected
Lungs remain re-expanded
Bilateral breath sounds clear, all lobes

EQUIPMENT/SUPPLIES

Sterile gloves
Suture removal set
Vaseline gauze
44 gauze
Tape
I M P L E M E N TAT I O N
Medicate patient for pain 30 minutes before chest tube removal.
Enhances comfort.
Assemble equipment.
Enhances efficiency.
Explain procedure to patient/family.
Reduces anxiety.
Don gloves, remove dressing, discard in red biohazard bag.
Reduces transmission of microorganisms.
Assist physician as needed, don sterile gloves, cut suture on chest

tube, instruct patient to take a deep breath and hold, clamp chest
tube, remove tube, tie purse-string suture (if present), apply sterile
Vaseline gauze and 44, tape dressing.
Facilitates airtight seal.
Assess patients response; vital signs, breath sounds, anxiety, and

pain.
Provides data for prompt interventions.

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Assess breath sounds every hour for 4 hours.
Veries lung ination.
Discard chest tube and drainage system in biohazard containers.
Prevents spread of microorganisms.
Document procedure.
Validates procedure and patient response.
Order chest x-ray.
Veries lung re-expansion.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe dressing for wound drainage


Reinforce dressing if needed
Assess for signs and symptoms of respiratory distress, diminished or
absent breath sounds, or tension pneumothorax
Call for chest x-ray report

KEY POINTS

FOR

REPORTING

AND

RECORDING

Pain medication administered; type, dose, and route.


Date and time of removal.
Physician removing chest tube.
Quantity and characteristic of drainage in collection chamber.
Patient response, vital signs, breath sounds, anxiety and pain
rating.
Dressing applied, condition of dressing.
Chest x-ray report and physician reading x-ray.
Time chest tube removed.
Patients tolerance.
Assessment data since removal; vital signs, breath sounds,
color, oxygen saturation.

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U N I T

C H A P T E R

Cardiovascular

12
Intravenous Fluid
Therapy
12.1 Inserting a Short-Term Peripheral
Intravenous Catheter, 276
12.2 Inserting Peripheral Midline and Central
Catheters (PICC), 285
12.3 Calculating and Regulating Intravenous
Flow Rate, 293
12.4 Changing Intravenous Dressings
(Peripheral and Central), 296
12.5 Assisting with Central-Line
Placement, 299

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276 C h a p t e r 1 2 Intravenous Fluid Therapy

PROCEDURE 12.1
Inserting a Short-Term Peripheral Intravenous Catheter
OVERVIEW

To provide venous access for administration of uids, electrolytes,


blood, medications, or nutrients.
Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic functions.
Types of catheters used
Scalp or buttery vein needles.
Over-the-needle catheters.
Through- or inside-the-needle catheters.
Neonates26- to 24-gauge needles; children24- to 22-gauge
needles.
Short peripheral catheters are not used to infuse vesicants, parenteral
nutrition exceeding 10% dextrose, and/or 5% protein solutions.
Site selection should be in accordance with diagnosis, age, condition
of veins, previous venipuncture, and type and length of therapy
required.
All IV therapy should be accompanied by a physicians order.
IV therapy requires frequent monitoring.
Documentation should include site, type of catheter, needle gauge
and length, date and time of insertion, IV uids or ush solution,
absence of signs and symptoms of complications.
All IV sites require care at least every 48 to 72 hours.
Tubing change is usually every 48 to 72 hours.
Avoid drawing blood from short catheters.
Site should be carefully inspected at least every 2 hours while
therapy is in progress.

P R E PA R AT I O N

Choose needle length and gauge appropriate for the solution.


TABLE 12.1A Catheter Sizes and Uses
SIZE

USED FOR

Small diameter (2224 gauge)

Fluids and medications


Pediatric patients
Fragile veins (as in the elderly)
Blood products
Hypertonic solutions
Large amounts of uid
Blood administration during surgery

Medium diameter (1820 gauge)


Large diameter (1416 gauge)

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Choose smallest gauge that will meet the patients specic need.
Use lower distal veins rst to avoid leakage if same vein is used
later.
Veins in the lower extremities should not be used routinely to avoid
the increased risk for embolism and thrombophlebitis.
Vein should be large enough for needle insertion and advancement.
Avoid areas of exion.
Do not shave venipuncture site; clip hairy sites with scissors. Shaving
increases chances of contamination.
IV solution should be clear and outer wrap dry.
Do not use felt tip pens to mark IV solution bagit may migrate
through plastic into solution.
Cannulas must be maintained by ushing if IV uids are not
ordered.
Protocol for use of local anesthetic should be in accordance with
Nurse Practice Act and the institutions policies.

Special Considerations
Patients with mastectomies need physicians approval and written
order to access veins in the extremity.
Elderly
Elderly patients veins are often fragile; insertion may be done without tourniquet if vein is clearly visible.
Pediatric
Scalp vein needles, and veins in the dorsum of the hand, forearm, and
foot, are usually used in infants and children or for single-dose therapy, IVP medications, or blood drawing.
Candidates for infant peripheral IV therapy include those with diarrhea, dehydration, or serious infection.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for injury and infection related to invasive venous access device
Risk for excess uid volume related to IV uid therapy
EXPECTED OUTCOMES

Vein is cannulated successfully


IV insertion site is clean, dry, and free of redness, swelling, or pain
Catheter is secured safely
Catheter aspirates blood and ushes easily
Cannulation and IV intake are consistent with physicians order

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278 C h a p t e r 1 2 Intravenous Fluid Therapy


EQUIPMENT/SUPPLIES

Clean gloves
Select catheter (over-the-needle, through-the-needle, or buttery) that
is appropriate for the patient, considering type of infusion and vein
fragility
IV uid or IV lock, injection caps, IV tubing (vented or nonvented), IV
pole, IV pump 0.9% sodium chloride (normal saline) ush (at least
23 mL)
IV kit (if available) or
Tourniquet
Tape 1 or 2 inch (if patient has tape allergy, use paper tape)
70% alcohol wipes, 10% povidone-iodine swabs or wipes, tincture
of iodine 2%, and chlorhexidine
Dressing22-inch gauze, transparent semipermeable occlusive
dressing (Tegaderm, Opsite)
Labels
Plastic pad or towel
I M P L E M E N TAT I O N

Prepare IV Fluids
Verify physicians order for IV therapy.
A physicians order is needed to initiate therapy. Order should include type of
infusion, route, dosage of administration, volume to be infused, rate, and
duration.
Gather equipment: IV tubing, injection caps/needleless systems; type

of IV solution.
Enhances efficiency.
Wash hands.
Reduces microorganisms and chances of cross-contamination.
Remove container from outer wrap; inspect uid, and check

expiration.
Assess sterility of contents.
Remove IV tubing and uncoil; do not let end become contaminated.
Prevents contamination.
Close roller clamp or ow regulator.
Prevents accidental spillage of IV uids.
Remove protective cap from uid container.
Allows sterile tubing entry into container.

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Remove covering from spike of IV tubing.
Permits entry of tubing into IV container.
Insert spike into port of IV container with a quick twist.
Prevents contamination from insertion.
Hang uid container on IV pole.

Squeeze drip chamber once or twice.

Open clamp or regulator slowly, allowing tubing to ll slowly.

Invert lters and medication ports/Y-sites to clear air.

Close clamp.

Creates suction effect; uid enters drip chamber and prevents air entry.
Starts uid ow.
Clears air.
Prevents loss of uid.

Insert Peripheral Catheter


Check physicians order.
A physicians order is needed to initiate therapy.
Assemble and organize equipment.
Enhances efficiency.
Wash hands.
Reduces microorganisms and chances of cross-contamination.
Explain procedure.
Decreases anxiety and evaluates patients psychological preparedness for
the procedure.
Tie tourniquet on arm 3 to 5 inches above projected insertion site.
Promotes vein distention or dilation.
Ask patient to open and close hand; use warm compress if the vein is

difficult to palpate, or ask the patient to let his or her arm hang
down below the level of the heart.
Increases blood ow to veins below tourniquet.
Select vein. Use vein with few curves and largest diameter. Use non-

dominant hand/extremity or patients preference, if possible.


Selecting the best and largest vein with few curves allows more chance at
successful cannulation and toleration of IV therapy.
Release tourniquet.
Reestablishes blood ow; allows patient comfort while preparing for
venipuncture.

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280 C h a p t e r 1 2 Intravenous Fluid Therapy


Select appropriate catheter, and open IV kit or supplies.
Selecting appropriate catheter size prevents irritation of vein lining, decreasing inltration and phlebitis problems; opening supplies prevents interruption during insertion.
Place patients extremity on top of pad or towel.
Protects linen.
Prime IV tubing and hang on pole or prepare saline ush for IV lock.
Enhances efficiency and avoids delay after vein is cannulated.
Tear tape 3 strips of 1/2 inch tape.
Have tape ready for immediate stabilization of cannula after insertion.
Don gloves and prep site.
Reduces potential for infection and cross contamination.

Remove hair with scissors.


Clip hair instead of shaving because of potential abrasive effect of a razor,
which increases risk of infection.

Can use prep agents as single agent or in combination; 70% alcohol wipes can be used to defat skin prior to application of other
antimicrobial agents.

Vigorously use circular motion at site from center outward for at


least 30 seconds using povidone-iodine 10% or chlorhexidine.

Adhesive on tape sticks better if skin is defatted.

If patient is ALLERGIC to iodine or shellsh, use 70% alcohol for at least


30 seconds.
Friction needed to remove microbes.

Alcohol should NOT be used after povidone.

Allow agent to completely air-dry.

Alcohol negates the effect of povidone.


Fanning the area may transmit microorganisms.

Venipuncture
Pull skin taut below puncture area (continuously).
Stabilizes skin and prevents vein rolling.

FIGURE 12.1A Pulling skin taut.

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With bevel up, insert needle at a 30- to 45-degree angle into skin.
Allows backow of blood.

30
15

FIGURE 12.1B Insert needle at correct

angle.

For winged-tip (buttery or scalp) catheter, pinch wings together to


insert needle.

For fragile or rolling veins, puncture directly over the vein.

Provides stabilization, and decreases pain during insertion.


Greater chance for success if catheter is inserted and directed over a rolling
vein.

For all other veins, insert alongside the vein distal to the selected
puncture site.
Allows full insertion of catheter.

Gently insert into vein and advance tip into vein lumen (about 1/4

inch). Maintain alignment with vein, relocate vein, and reduce angle,
if necessary.
Reduces risk for going through vein, which causes a hematoma and immediate swelling at site.
Observe for blood ashback in plastic hub of catheter.
Indicates you are in vein.
After catheter tip is in vein, advance plastic over-the-needle catheter

(not needle) forward off the needle into vein while maintaining skin
taut.

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282 C h a p t e r 1 2 Intravenous Fluid Therapy


Prevents accidental puncture of both walls of vein wall causing swelling or
hematoma.

FIGURE 12.1C Advance the catheter.

*DO NOT ATTEMPT to reinsert needle if backow of blood subsides.


Catheter tip may shear off, causing an embolus.
*IF UNABLE to insert fully, DO NOT force: Attach catheter to IV uid and

open clamp.
Fluid may facilitate insertion by dilating and straightening small curves in
veins.
When catheter is in place, carefully place one 22 gauze under

catheter and needle.


Absorbs blood.
Release tourniquet.
Prevents vein rupture from uid owing against closed vessel and restores
circulation.
Remove needle by holding hub with one hand and placing pressure

with ngertip above tip to occlude site.


To slow blood ow.

FIGURE 12.1D Removing the needle.

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P r o c e d u r e 1 2 . 1 Inserting a Short-Term Peripheral Intravenous 283


Connect IV uids or injector cap. For IV lock, ush with 1 to 2 mL of

normal saline.
Prevents clot formation; clears tubing of blood.
Open clamp on IV uids, and observe ow at site.
Check for patency and ease of ow.
Clean site of moisture and blood.
Removes medium for bacteria growth.
Stabilize catheter by taping main hub or buttery wings using

one of the methods below. Make sure insertion site can always
be visualized.
Maintains catheters position for long-term use. Allows site assessment for
swelling, redness, or drainage.

U Method
Place one piece of 1/2-inch tape below hub, adhesive side up.
Bring tape ends over the wings of the catheter
and secure to skin in a U-shape (both ends
U Method
parallel to the catheter).
Place a sterile, occlusive, transparent dressing
over site and partially over hub.

Stabilizes and secures catheter. Allows visualization


of site.

FIGURE 12.1E

U Method.

Chevron Method
Place one piece of 1/2-inch tape under the hub
and criss-cross over each wing, forming an x
over the hub, but not over insertion site.
Place another small piece over the crossed tape
at the hub to stabilize further, if necessary.
Place a sterile, occlusive transparent, dressing
over site and partially over hub.

Stabilizes and secures catheter. Allows visualization


of site.

Chevron Method

FIGURE 12.1F

Chevron Method.

Transparent Film

The transparent lm may also be used alone, without the adhesive


tape.

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284 C h a p t e r 1 2 Intravenous Fluid Therapy

Place lm over insertion site and up to catheter hub. Pinch the lm


around the catheter hub to secure.
Stabilizes and secures catheter. Allows visualization of site.

FIGURE 12.1G Cover site with transpar-

ent lm.
Loop IV tubing and tape to arm or hand a short distance from site.
*DO NOT loop so as to cause a kink in tubing.
Keeps tubing from dangling.
Label site with date, needle gauge, and initials on side of dressing or

across hub.
Alerts others when inserted and type of needle used.
Label tubing according to agency policy. Label all uids with date,

time hung, medication additives, and initials.


Alerts caregivers when tubing and uid change is due.
Dispose of all equipment.
*DO NOT recap needle; dispose in needle container.
Prevents accidental needle puncture.
Document in nurses notes procedure and patient response.
Contains information to identify infusion procedures and provides patient
and caregiver protection.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Note skin above insertion site for swelling or redness. If present,


discontinue IV and remove cannula
If uid does not infuse, try to ush again and hang bag higher. If
catheter is determined to be clotted, remove peripheral short
catheters
Follow agencys policy for site change, tubing change, and site/
dressing care
For all peripherally placed catheters, do not use blood pressure
cuffs or tourniquets on the same extremity as the catheter

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 285

If bright red blood is seen immediately in the tubing and IV bag, you
may be in an artery. Stop the ow, remove the catheter, and place
pressure on the site for 5 minutes
Infusion therapy should be discontinued upon order of authorized
prescriber or when complications of therapy are evident.
Complications can include
Phlebitis or inltration
Circulatory overload, especially in the elderly and very young
Infection at site
Extravasation
Thrombosis

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of insertion.


Catheter device with gauge and length.
Location of insertion site.
Fluid infusing and rate or if catheter is IV locked (heparin or
saline lock).
Infusion controlled by pump or gravity.
Patients response to procedure and therapy including what
instructions were given to patient.
Condition of site and last time assessed.
Any specic changes in therapy owing to, for example, volume, type of uid, or rate change.
Time current IV container was hung and how much is left to
be infused.

PROCEDURE 12.2
Inserting Peripheral Midline and Central Catheters (PICC)
OVERVIEW

To provide venous access for long-term administration of uids,


electrolytes, blood, medications, or nutrients.
Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic
functions.

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Peripherally Inserted Midline (short- to medium-term


use: 2 to 4 weeks
Do not use midlines for continuous vesicant chemotherapy,
parenteral nutrition exceeding 10% dextrose, and/or 5% protein
solutions.
Avoid routine blood drawing.
Midline catheters are 3 to 8 inches in length.

FIGURE 12.2A Midline catheter.

About 2 hours after insertion, the catheter becomes softer and will
increase approximately 2 gauges in size.
Peripherally inserted with tip in the proximal axillary vein.
Need physicians order to place catheter in arm of a patient with
mastectomy or axillary node dissection.
X-ray conrmation of placement necessary.

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 287

Peripherally Inserted Central Catheter (PICC)


(long-term use: weeks to months)

PICCs are 20 to 24 inches in length, gauges range from 16 to 26 g.

B
FIGURE 12.2B Peripheral intravenous central catheters (PICCs).

Select site in antecubital fossa.


Distal tip should dwell in vena cava or subclavian vein.
Previously damaged or sclerotic veins should be avoided.
Need physicians order to place catheter in arm of a patient with
mastectomy or node dissection.
Can deliver all types of therapy and be used for blood draws.
X-ray conrmation of placement necessary.
Most institutions require certication in IV therapy for insertion of
PICC and midline catheters.
Consent may be required for PICC and midline catheter insertion.
Know and follow your agencys policy.

P R E PA R AT I O N

Examine the package carefully before opening to conrm integrity


and identify expiration date. Do not use if package is damaged,
opened, or the expiration date has passed.
Inspect kit for inclusion of all components.
Flush the catheter with sterile normal saline prior to use.

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Identify the vein and insertion site; select site in region of antecubital
fossa.

Special Considerations
Geriatric
Veins in older adults may be sclerotic and/or very mobile, meaning
that the vein has a tendency to be pushed away by the catheter needle rather than pierced by it. Warm compresses can help dilate veins,
especially if the patient is cold.
Tourniquet pressure can damage the vein, especially if the patient is
on an anticoagulant or a corticosteroid. Do not tie tourniquet too
tightly.
Avoid overtaping the catheter or dressing; removing the tape can
easily tear an elderly patients fragile skin.
Pediatric
Small vessel size makes midline and PICC placement challenging in
the pediatric population.
Palpation of vessels may be difficult, and ultrasound guidance is
often not helpful because the child cannot remain still throughout
the procedure.
Risk for piercing nerve bundles or arteries is higher in children due to
stages of anatomic development.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection related to placement of invasive IV


Risk for injury related to placement of invasive IV
EXPECTED OUTCOMES

Line is placed atraumatically


Correct placement is veried
EQUIPMENT/SUPPLIES

Sterile gloves (2 pair), masks, sterile gown, and goggles


PICC insertion kit if provided or
Sterile gauze 22, and transparent semipermeable occlusive
dressing
Tape 1 or 2 inch and steri-strips
IV uid, one vial of 100 U/mL heparin ush, at least two 10-mL
syringes of 0.9% normal saline, injection caps, IV tubing (vented
or nonvented), IV pole, IV pump

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70% alcohol wipes, 10% povidone-iodine swabs or wipes, tincture of


iodine 2%, and chlorhexidine
2 drapes
Tourniquet, sterile forceps, and scissors
2 tape measures
PICC or midline catheter (size depends on patients vein and type
of infusion needed)
Labels
I M P L E M E N TAT I O N
Verify physicians order.
A physicians order is needed to initiate therapy.
Gather equipment.
Enhances efficiency.
Wash hands.
Reduces microorganisms and chances of cross-contamination.
Apply tourniquet above projected insertion site. Assess antecubital

veins (basilic, cephalic median cubital veins); basilic vein is preferred.


These veins are large and usually straight.
Select a vein, and release tourniquet.
Measure arm with tape measure from a ngerbreadth below antecu-

bital fossa to shoulder and across the shoulder to midclavicular line


for subclavian placement (PICC only).
For vena cava placement, continue to the sternal notch and down to
the third intercostal space (PICC only).
Determines length of catheter needed for insertion.
Select a catheter insertion kit with smallest gauge and shortest

length that will coincide with therapy.


Write down lot number and expiration date from PICC or midline

insertion kit.
Needed for defects or returns.
Wash hands with antibacterial agent for 60 seconds.
Decreases chance of contamination.
Set up supplies on sterile eld.
Decreases chance of contamination.
Put on mask, and don sterile gloves.
Prevents contamination of site and subsequent infection.

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Flush catheter with 0.9% normal saline.
Ensures patency, removes air, and detects leaks.
Prepare site with 70% alcohol starting at insertion site cleaning in

a circular motion at least 8 to 10 inches in diameter. Repeat three


times allow to dry.
Decreases transmission of microorganisms.
Repeat cleansing using povidone-iodine.
Decreases transmission of microorganisms.
Remove gloves.
Gloves are contaminated; sterile gloves must be worn for insertion.
Reapply tourniquet.
Promotes venous distention.
Tourniquet is no longer sterile, and, therefore, it should be put on before
donning sterile garb.
Put on second pair of sterile gloves and sterile gown according to

agency policies.
Decreases chance of contamination.
Drape patients arm with sterile towels or sheet, making sure a sterile

eld is created.
Provides a sterile eld around site.
Anesthetize the site using intradermal or topical lidocaine without

epinephrine (topical must be done before site prep).* Eliminate this


step if local anesthesia is NOT used. Anesthesia should be used in accordance with agency policies and state standards of care.
Anesthetic reduces pain.
Perform venipuncture with dominant hand while holding the skin

taut with other hand.


Stabilizes skin and prevents vein rolling.
Verify blood return through the introducer/stylet or aspirate with

syringe.
Ensures cannulation.
Decrease the angle, and advance introducer 1/4 to 1/2 inch further into

vein.
Allows further catheter advancement and prevents contamination.
Different manufacturers have different designs. For kit with

guidewire, thread wire through needle and remove needle. Then


thread catheter over guidewire and remove wire.
Wire adds rmness to catheters and enhances advancement.

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 291


Using sterile gauze to maintain your sterility, remove tourniquet.

(Midline catheter may be advanced slowly with tourniquet on while


intermittently ushing with normal saline and aspirating for blood).
Removal will decrease chance of catheter puncture.
Remove stylet or needle.
*Remove breakaway introducer if kit and catheter has this type.
Slowly advance catheter about halfway of desired length through

the introducer (PICC).


Have patient turn head toward insertion site with chin placed
tucked down toward clavicle or chest (PICC).
Position change will facilitate entry into vena cava or subclavian vein.

Use forceps to stabilize catheter or apply light pressure and then


remove the introducer.

Continue to slowly advance catheter to desired length.

Ensures that catheter will not be removed with introducer.


*If resistance is met, stop advancement.
Never force catheter.
*Attempt to ush or ush while continuing to thread catheter

If unsuccessful, you may need to use another vein.


May enhance advancement if blood return is still good.
*Do not force; guidewire could puncture catheter.
Avoids puncture of catheter and vein wall.
*Never withdraw catheter through introducer.
May puncture vein or kink catheter.
Prime and attach extension tubing and injection cap.
Clears air from tubing.
Flush with 0.5 mL of normal saline and then aspirate to check blood

return; note blood ow, color, and consistency.


Helps verify patency and placement.
Vigorously ush catheter with remaining normal saline followed by

heparinized saline.
Clears catheter of blood, preventing clotting.
Secure catheter with sterile tape, Steri-Strips, sutures, or stabilization

device.
Maintains catheters position, and prevents catheter migration.
Cover site with 22 gauze dressing and transparent dressing.
Provides pressure on site for 24 hours to control oozing caused by large bore
needle.

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Obtain chest x-ray to assess for catheter tip placement.
Veries correct placement.
Document procedure and patient response in the patient record.
Communicates information about infusion procedure. Provides patient and
caregiver protection and is a part of quality and risk management.
After verication of placement, begin IV uids if ordered.
Avoids complications. Do not start IV uids until placement is veried.
Dispose of equipment appropriately.
Avoids accidental needle sticks.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for bleeding, oozing, ecchymosis, or pain around site. May


apply pressure or use a pressure dressing for the rst 24 hours for
oozing. Change dressing if saturated. Notify nurse practitioner or
physician if oozing does not stop
Assess for tenderness, warmth, redness, cord-like feeling of vein. May
treat with moist heat and arm elevation. Notify nurse practitioner or
physician
Monitor for infection or sepsis (fever, chills, drainage at site), cellulitis
(diffuse redness at site, or thrombophlebitis (pain in arm, shoulder,
and neck; edema of arm/shoulder)
Flush catheter per protocol, and prepare for thrombolytic declotting
Assess for air embolism (chest pain, confusion, lightheadedness,
tachycardia, and hypotension)

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of insertion.


Catheter device with gauge and length.
Location of insertion.
Fluid infusing and rate or if catheter is IV locked (heparin or
saline lock).
Infusion controlled by pump or gravity.
Patients response to procedure and therapy, including the
instructions that were given to patient.
Condition of site and last time assessed.

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P r o c e d u r e 1 2 . 3 Calculating and Regulating Intravenous Flow Rate 293

PROCEDURE 12.3
Calculating and Regulating Intravenous Flow Rate
OVERVIEW

Veries correct drug dosage or uid rate for the patient.


Infusions must be checked and regulated frequently, especially in
the elderly and very young.
P R E PA R AT I O N

Calculations should be done twice for accuracy.


All IV solutions with additives should be calculated for rate and
amount of drug administered either per minute or per hour.
A check of pharmacy calculation of IV solutions containing additives
should be done prior to administration.
Pay careful attention to tubing package to determine correct drop
factor.

Special Considerations
Nurses should select one preferred method of calculation and consistently use that method.
Infusion controllers can malfunction. Compare amount of infused
uids to programmed rate to verify accuracy.
Double-check all machine ow rates for accuracy by calculating rates
manually.
Pediatric Patient
Pediatric patients should have precise volumes administered.
Large volumes and fast rates are not safe for children.
Use of an infusion pump is advised.
Elderly Patient
Elderly patients are at risk for heart failure if IV uids infuse too
rapidly.
Careful intake and output documentation helps the nurse monitor
uid balance.
Use of an infusion pump is advised.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for imbalanced uid volume related to rate/ow of IV uids


EXPECTED OUTCOMES

Correct uid and/or medication are infused within designated time


as ordered

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294 C h a p t e r 1 2 Intravenous Fluid Therapy


EQUIPMENT/SUPPLIES

IV pole
Primed IV uid system
IV pump, if indicated
Calculator, pen or pencil, scratch pad
Watch with second hand
I M P L E M E N TAT I O N
Obtain physicians order.
A physicians order is needed to initiate therapy.
Gather equipment.
Enhances efficiency.
Choose tubing and observe drop factor on package.
Indicates drops per milliliter for drip rate calculation.

Drop factor is drops/mL.


Microdrip 60 gtt/mL.
Macrodrip 10, 15, or 20 gtt/mL.

Used for pediatric or very precise volumes.


Used for all other infusions.
Calculate mL per hour.

Example: Order is for 1000 mL over 24 hours.


Total volume administration time.

1000 mL 24 hours 41.6 (round) 42 mL/hr.


Determines volume that should be infused hourly.

Calculate rate per minute.


mL/hour 60 minutes
42 mL/hr 60 min 0.7 mL/min.
Determines volume that should be infused per minute.
Calculate drops per minute.

Determine tubing drop factor, in this example, 10 gtt/mL.


Total volume multiplied by drop factor ( total hour multiplied by
60 minutes.
1000 mL 10 gtt/mL
24 hours 60 minutes
1000
144
6.9 or 7 gtt/min

or use hourly rate of 42 mL/hr


42 mL 10 gtt/mL
1hour 60 minutes
6.9 or 7 gtt/min
Determines volume that should be infused in drops per minute.

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P r o c e d u r e 1 2 . 3 Calculating and Regulating Intravenous Flow Rate 295


If IV pump is used, enter rate in mL/hr

Insert tubing into pump according to manufacturers directions.

Set volumes in rate/hour.

Enter volume to be absorbed.

Start infusion.

Can regulate IV rate if properly used.


Determines amount of uid pump will deliver.
Pump will let nurse know when volume has infused.
If manually regulating IV, use second-hand watch, and count drops

over one minute.


Determines correct drip rate.

Adjust roller clamp to increase or decrease speed.


Check the rate hourly.

To detect changes in rate.

Calculating and Regulating Secondary IV Rates (IVPB)


Obtain correct IVPB noting medication, date prepared, and patient

name.
Decreases chance of medication error.
Obtain secondary tubing.
Tubing is for intermittent secondary infusion (IVPB).
If using IV pump, enter mL/hour.
Ensures accurate rate of delivery.

IVPB of 50 mL to be infused over 1 hour.


Set pump on 50; the pump will deliver 50 mL over 1 hour.

If manually regulating IVPB, calculate gtt/min.

IVPB 50 mL to be infused over 30 minutes


total uids
drop factor
minutes
50 mL
10 gtt/mL
30 min
1.66 10
16.6 or 17 gtt/min

Regulate IV rate using second-hand watch and counting drops

over 1 minute. Adjust roller clamp to increase or decrease


speed.
Place time tape or IV label on bag.
Time taping gives visual cue to whether IV is infusing at set rate.

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E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess site for signs of inltration if IV is sluggish


If an infusion pump is used, nurse should still monitor rate for at
least 15 seconds and multiply by 4 to check rate
Recheck manually regulated drips after 5 minutes and again in
15 minutes

KEY POINTS

FOR

REPORTING

AND

RECORDING

Time

of initiation of infusion.
and volume of infusion.
Manual control or pump controlled.
Additives.
Rate in mL/hr or mL/minute.
Type

PROCEDURE 12.4
Changing Intravenous Site Dressings (Peripheral
and Central)
OVERVIEW

Reduces colonization of bacteria.


Soiled, wet, or poorly taped dressings should be changed immediately.
Cumulative incidence of infection rises with time.
Direct observation of site should be done often for evidence of
infection.
Protects the site from contamination.
Sites with gauze dressings require change every 24 to 48 hours on
central lines and every 72 hours for peripheral sites.
Transparent dressings allow direct visualization of site.
The risk for infection increases if the site was not prepared well upon
initial insertion.
All patients require meticulous site care along with observing and
assessing the site often.
The dressing should be observed to ensure that it is intact, dry, and
clean.
If the dressing is damp, its integrity has been compromised and
needs replacing.

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P r o c e d u r e 1 2 . 4 Changing Intravenous Site Dressings 297


P R E PA R AT I O N

Sites with transparent semi-permeable dressing: site care and dressing change should be done 72 hours.
Antimicrobial ointments are of no proven benet and should not be
used.
Care should be taken to maintain tape sterility; do not stick tape to
contaminated bed rails or over bed tables.
Anchor tape should be applied to cannula hub distal to insertion
site.

Special Considerations
The elderly, very young, and immunosuppressed patients are at
greatest risk for infection; systemic infections for these populations
can be fatal.
Any complaint from the patient concerning burning, pain, or tenderness should be investigated immediately.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection related to invasive IV line


EXPECTED OUTCOMES

Dressing clean and dry


Gauze or transparent dressing is secure on all sides
Skin integrity maintained
Site free of swelling, redness, and drainage

EQUIPMENT/SUPPLIES

Nonsterile gloves
Dressing change kit or
Sterile gloves
Povidone swabs or wipes
Alcohol wipes or swabs
Skin barrier
Transparent dressing
Tape
22 gauze
Sterile barrier
Mask(s) (central lines, percutaneous, PICCs, midlines, tunneled)
Sterile Steri-Strips (PICCs)

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I M P L E M E N TAT I O N
Wash hands.
Reduces microorganisms and chances of cross-contamination.
Set up sterile eld on sterile barrier; arrange and open supplies.
Enhances efficiency and reduces chance of contamination.
Check patient allergy to iodine/shellsh.
May need to use just alcohol or other antimicrobial agent.
Explain procedure.
Reduces anxiety.
Put on mask (central, PICCs, midlines, and tunneled catheters ONLY).

Second mask can be placed on patient (optional).


If mask not used, have patient turn head in opposite direction from
site.
Protects IV site from airborne microbes.

Don nonsterile gloves.


Protects from potential contamination.
Stabilize catheter while removing old dressing.
Prevents accidental catheter dislodgement or migration.
Assess site for redness, swelling, or drainage, and remove old gloves.
Close observation for signs of infection.
Don sterile gloves.
Reduces chance of contamination of site.
Cleanse site with alcohol swabs or pads using circular motion from

inside outward. Repeat this process again with new swab.


Removes organisms away from the site.
Cleanse hub, sutures (if applied), and catheter with new swab.
Removes debris, old blood, and organisms from equipment.
Cleanse insertion site with povidone swabs, repeating circular

motion as with alcohol. Repeat this process again.


Removes organisms from the site.
Allow to air dry without fanning.
Fanning may transmit microorganisms.
Apply skin barrier or skin prep (optional).
Protects skin, and adhesive on dressings will stick better.

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 299


Tape catheter under hub or use Steri-Strips (PICCs).
Secures catheter.
Apply gauze or just transparent dressing over site, securing all edges.
Protects site from contamination. Stabilizes and secures site.
Label dressing with date, time, and nurses initials.
Determines when next care is due.
Document in record.
Legal protection for nurse and patient.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient tolerance of procedure


Dressing is intact and secure on all sides
Catheter is stabilized

KEY POINTS

FOR

REPORTING

AND

RECORDING

Condition of site.
site care done.
Stabilization of catheter.
Patient tolerance of procedure.
Actual

PROCEDURE 12.5
Assisting with Percutaneous Central Line Placement
OVERVIEW

Used when a patient needs support that a peripheral IV cannot give;


for example, vesicant therapy, nutritional support, and high-volume
hydration.
Central venous catheter placement at the bedside is associated with
serious complications including pneumothorax, hemothorax, cardiac
tamponade, and air emboli.
There are several types of central venous access devices, which have
somewhat different uses.

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300 C h a p t e r 1 2 Intravenous Fluid Therapy

Percutaneous catheters or central


venous catheters (CVC) are placed
in the subclavian or jugular vein
(sometimes femoral vein).
They are:
Secured by suturing.
May be single, double, or triple
lumen.
Require x-ray conrmation of
placement.

Slide clamp

Proximal
lumen port
(18-gauge
lumen)
Distal
lumen port
(16-gauge
lumen)

Medial
lumen port
(18-gauge
lumen)

FIGURE 12.5A Injection

ports of a triple lumen


catheter.

Tunneled catheters (Hickman, Broviac, and Groshong) are soft silicone catheters with a Dacron cuff for securing the device. They are
tunneled under the skin to help prevent infection. The small
Dacron cuff on the distal end of the catheter will be located just
under the skin after insertion. Skin grows over this cuff, which helps
keep the catheter in place. Tunneled catheters
Can be single, dual, triple, or quadruple lumen.
Are 20 to 30 inches long and have 22 to 17 gauge lumens.
Have an insertion site and an exit site.
Cephalic vein
Entrance site

Superior vena cava


Right atrium

Basilic vein

Dacron cuff
Subcutaneous tunnel

Exit site

FIGURE 12.5B Tunneled catheter.

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 301

Ports are permanent vascular access devices implanted beneath the


skin in the arm or chest. Ports are completely closed systems consisting of a catheter attached to a small drug reservoir. They are used
when IV access is required intermittently over a long period of time.
Ports are:
Surgically implanted.
Can deliver all types of therapy and be used for blood draws.
Must be accessed with a noncoring needle called a Huber needle
(sizes from 1924 gauge, 12 inches in length, curved or straight).
Can withstand up to 2000 needle punctures.

Hickman Titanium Port

MRI Port

Dome Port

MRI Dual Port

FIGURE 12.5C Ports.

See Table 12.5A for a discussion of catheter types, their uses, advantages, and disadvantages
TABLE 12.5A Types, Use, Advantages and Disadvantages
of Central Catheters
TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

Percutaneous
Single, double or
triple lumen
catheter

Any type of uid


Short-term use
up to a few
weeks (follow
agencys
guidelines for
replacement)
Blood sampling
insertion sites
Subclavian
Jugular
Femoral

Access can be
done at bedside
Can change
catheter over a
guidewire when
needed

Requires sterile
dressing
maintenance and
heparin ushes at
least daily or
more if IV
medications or
blood sampling
done
Mobility and
comfort altered

(table continued on page 302)

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TABLE 12.5A Types, Use, Advantages and Disadvantages of Central


Catheters (continued)
TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

Inserted at
bedside by a
trained nurse
Little chance of
pneumothorax
Repair kits
available for
external tear in
catheter

Femoral sites are


for short-term use
only
Hard to maintain
sterility of jugular
site
Activity restriction
Risk of
pneumothorax
and cardiac
tamponade from
puncture of lungs
or heart
Requires sterile
dressing
maintenance and
routine heparin
ushes or more if
IV medications or
blood sampling
done via catheter
Activity restriction

Can only be
inserted by a
physician
Requires consent

PICC
Discussed in
previous
section

Any type of uid


Long-term use
up to several
months
May require
consent

Tunneled
Hickman
Broviac

Any type of uid Patient can be


Long-term use
taught site care
Blood sampling Once site healed
requires consent
can use clean
Can only be
dressings instead
inserted by a
of sterile
physician
Routine heparin
ushes except
catheter with
Groshong valve
No activity
restriction
Can be repaired
externally

Catheters can
break and need
repair or
discontinuation
May need daily up
to weekly site
care
Catheter is visible
under clothes and
may be at least 6
to 8 inches long
Requires surgery
for insertion

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 303

TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

Implanted
Ports

Any type of uid


Long-term use
Blood sampling
requires consent
Can only be
inserted by a
physician

Monthly heparin Minor surgery


Requires a
ushes
noncoring needle
No activity
for access called
restriction
Huber needle
No dressing
changes required Must have special
training for
Monthly heparin
accessing ports
ushes
Much less risk
for infection

P R E PA R AT I O N

Keep transparent dressing occluded at all edges.


Clamp all lumens, and cap them when not in use.
Patients with central lines require meticulous site care maintenance.

Special Considerations
Central line lumens also need to be maintained by ushing regularly
with saline and heparinized saline.
Assess central line sites for signs of infection at least every shift or
more often if warranted.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for complications related to placement and ongoing presence


of invasive central intravenous catheter
Impaired skin integrity related to catheter insertion

EXPECTED OUTCOMES

Central catheter is placed atraumatically


Catheter is properly secured
No adverse effects such as pneumothorax or cardiac tamponade

EQUIPMENT/SUPPLIES

The following Equipment and Implementation sections are for percutaneous central line placement ONLY. See Procedure 12.2 for PICCs; all
other central catheters require surgery.
Sterile gloves (23 pair), face masks (at least two), and sterile gowns

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3 to 4 10-mL syringes lled with normal saline


3-mL syringes with heparinized saline (34)
2 to 3 syringes with 1 inch needle
2 to 35/8 inch , 1 inch, and 11/2 inch needles
Central line introducer kit with:
Introducer
Betadine swabs
Sterile drapes
10-mL syringe
Xylocaine 1% or 2% without epinephrine
Suture
Sterile scissors and needle holder
Single-lumen or multilumen kit
I M P L E M E N TAT I O N
Explain procedure, and assist with consent.
Allays patient anxiety.
Gather equipment, and arrange supplies on a clean tray.
Enhances efficiency.
Wash hands.
Reduces risk of contamination.
Position patient in Trendelenburg position with a towel rolled

between shoulders.
Dilates neck vessels.
Don mask, and prepare area opening trays.
Reduces risk for contamination of equipment by air droplets.
Offer physician mask, gown, and then sterile gloves after washing of

hands.
Maximum barrier precautions required for central line placement.
Nurse dons sterile gloves and mask.
Reduces risk for contamination.
Prepare site with 70% alcohol starting at insertion site cleaning in a

circular motion at least 8 to 10 inches in diameter.


Repeat three times, then do the same with povidone detergent
scrub for 2 minutes.
Allow to air dry.
Reduces microbes on skin. Removes organisms away from the site.

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Drape insertion site, creating a wide sterile eld, and have patient

turn head in opposite direction of insertion.


Creates sterile eld to decrease chance of contamination.
Physician will:

Anesthetize area with lidocaine.


Decreases pain and anxiety.

Perform venipuncture with insertion needle either in jugular site or


subclavian site.
*Femoral site used in emergency situations.

Allows accessing of site.

Attach syringe to needle, and aspirate for blood.


Indicates that needle is in the vein.

Once there is good blood return, remove syringe from needle.


Insert the guidewire through the needle.

Provides guide for catheter into the vein.

Remove needle slowly, and use dilator to enlarge hole, if needed.

Flush catheter and introducer with normal saline.

May need larger hole to accommodate catheter.


Removes air and tests for leaks.

Thread catheter over wire.


Insert introducer over wire, which can be left in as another access.

Adds another access site.

Insert catheter through introducer.


Aspirate all air out of lumens and then ush with normal saline.

Decreases chance of air embolism

Place injection caps on each lumen.

Suture catheter.

Prevents blood loss and protects sterility of lumens.


Stabilizes catheter.
Nurse will:

Apply sterile transparent dressing over site.


Maintains sterility, and site can be observed.

Assist with equipment disposal.


Make patient comfortable.
Auscultate lungs, and assess for respiratory distress.

Checks for pneumothorax or tamponade.

Obtain vital signs.


Assess for complications.

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Obtain chest x-ray.

Document in record.

Veries placement and absence of thorax and cardiac puncture.


Records procedure done.
Legal protection for nurse and patient.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Asses patient comfort


Assess site for bleeding and other complications, including signs and
symptoms of pneumothorax (shortness of breath, light-headedness,
fainting, chest pain, feeling unable to take a deep breath)
Assess for signs and symptoms of infection (fever, shaking chills,
vomiting, lethargy, change in mental status)
Assess line for mechanical problems (failure of uids to infuse, difficulty injecting lumen(s), absence of blood return, pain with injection
into lumen(s)
After x-ray verication, ush with heparinized saline or hang IV if
ordered

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of catheter insertion.


Insertion site location and catheter size.
Care and maintenance procedures performed at the times of
insertion and immediately after.
Patient tolerance of procedure.
X-ray verication.

C H A P T E R

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13
Circulatory
Maintenance
13.1 Caring for Vascular Access Devices, 308
13.2 Applying Sequential Compression
Devices, 311
13.3 Applying Antiembolic Hose, 313
13.4 Teaching Postoperative Leg Exercises, 315

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308 C h a p t e r 1 3 Circulatory Maintenance

PROCEDURE 13.1
Caring for Vascular Access Devices
OVERVIEW

To obtain a blood specimen from a vascular access device because


there is no other peripheral venous access available and diagnostic
studies requiring a blood sample are ordered.
To change the port cap(s) at regular intervals prevents leakage from
the catheter and creates a secure seal which prevents air from
entering.
To ush the catheter(s) of vascular access devices every shift or
according to facility protocol ensures patency of the catheter.

P R E PA R AT I O N

Sterility must be maintained when obtaining a blood specimen,


ushing, and changing port caps.
Lumen should be clamped before withdrawing syringe from port to
prevent aspiration of blood or air into lumen.
Flushing lumen with positive pressure decreases catheter complications.
Proximal lumen should be utilized to obtain blood sample.

Special Considerations
Wear protective equipment, (i.e., gloves, mask, gown, and goggles)
when drawing blood from a patient who is in isolation, HIV positive,
on neutropenic precautions, and so on.
Flush various catheters according to facility protocol.
Monitor for any adverse reactions during and after procedures,
(e.g., air embolism).
Monitor for signs and symptoms of infection at the insertion site and
sepsis.
Newborn and Pediatric Patient
Insertion sites may vary from adult and geriatric according to age
and physical development
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection related to altered tissue


Impaired skin integrity related to an invasive surgical procedure of
inserting a vascular access device
Altered nutrition, less than body requirements related to anorexia or
surgery
Fluid volume decit related to nausea and vomiting

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P r o c e d u r e 1 3 . 1 Caring for Vascular Access Devices 309


EXPECTED OUTCOMES

Procedure will be accomplished without untoward effects to patient


Sterility will be maintained while procedures are done
Patient remains free of air embolism and infection at the catheter
site and systemically
Patient maintains optimum body weight

EQUIPMENT/SUPPLIES

Mask and gown (if required per agency protocol)


Clean gloves
Gown (depending on patient diagnosis)
Goggles (depending on patient diagnosis)
44 sponges
Povidone-iodine
Three 10-mL syringes with needleless tip (for blood draws)
0.9% sterile sodium chloride solution in 10-mL syringe for ushing
and blood draws
Heparin 100 units/mL in 10-mL syringe for ushing and blood draws
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure and how patient can

assist.
Decreases anxiety; meets patients right to be informed; encourages cooperation and participation.
Wash hands and don clean gloves. (Wear gown and goggles as

indicated.)
Reduces transmission of infectious microorganisms.
Prep cap of proximal lumen with povidone-iodine solution and allow

to dry.
Reduces introduction of infectious microorganisms into blood stream.
Insert needleless cannula of a 10-mL syringe containing 10 mL of

0.9% sodium chloride into proximal lumen port.


Using proximal port decreases contamination of specimen from solutions
infusing into other lumens of catheter.
Unclamp lumen and briey aspirate for blood. Return.
Veries patency of lumen.
Attach an empty sterile 10-mL syringe to port.
Empty syringe needed to withdraw blood.

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310 C h a p t e r 1 3 Circulatory Maintenance


Aspirate 3 mL of blood and discard blood and syringe.
Avoids infusion of clotted blood.
Attach an empty sterile 20-mL syringe to port and aspirate blood

needed for sample; place in appropriate laboratory tubes.


Minimizes transmission of organisms by using one syringe to obtain blood
sample.
Flush catheter with 10 mL of 0.9% sodium chloride solution.
Clears lumen and port of blood.
Use 2 mL of heparin 100 units/mL to ush heparin lock, or according

to agency protocol.
Decreases clotting of lumen.
Continue pressure on plunger as syringe is withdrawn.
Maintains positive pressure in line.
Clamp lumen before withdrawing syringe.
Prevents aspiration of blood into lumen.
Change the port cap(s):

Open sterile cap package.

Place patient in supine or modied Trendelenburg position.

Prime cap with sodium chloride solution with syringe with needleless cannula.

Make sure catheter is clamped.

Using aseptic technique, remove existing cap and insert new one.

Maintains aseptic technique.


Prevents air entering catheter.

Prevents air in cap.


Prevents air in cap.
Prevents transmission of infectious microorganisms.

Continue with same procedure until all ports are changed.


Discard contaminated equipment, remove gloves, and wash hands.

Reposition patient, if necessary.


Patient comfort.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood specimen was drawn, ushing was done, and port caps were
changed correctly on the central venous catheter
Patient did not experience discomfort or adverse reactions during or
after procedures

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P r o c e d u r e 1 3 . 2 Applying Sequential Compression Devices 311

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of collection of blood sample, ushing, and/or


changing port caps as per protocol.
Any problems with the catheter.
Assessment of insertion site.

PROCEDURE 13.2
Applying Sequential Compression Devices
OVERVIEW

To prevent postoperative complications, (i.e., thrombophlebitis).


To promote comfort in lower extremities.
P R E PA R AT I O N

Review history related to recent surgical procedure, peripheral vascular disease, and thrombophlebitis.
Determine patients ability to understand, cooperate, and participate
in the procedure.

Special Considerations
Any patient may need additional assistance, support, and teaching to
understand the importance of using SCDs and keeping them on as
prescribed.
Elderly, Physically, and Mentally Challenged Patients
May require more assistance to apply SCDs.
R E L E VA N T N U R S I N G D I A G N O S E S

At risk for altered peripheral tissue perfusion related to immobility


Impaired gas exchange related to pulmonary embolus
Impaired physical mobility related to injury and/or surgery
Pain/discomfort related to injury and/or surgery

EXPECTED OUTCOMES

Patient will have improved circulation in lower extremities postoperatively and without developing thrombophlebitis
Patient expresses increased comfort

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EQUIPMENT/SUPPLIES

Sequential compression stockings/hose and equipment


Clean gloves
Tape measure
I M P L E M E N TAT I O N
Check doctors order; identify patient; explain purpose, procedure,

and how patient can assist if indicated. Assess patients or family


members ability to participate.
Conrms order; meets patients right to be informed; encourages cooperation and participation.
Wash hands and don clean gloves.
Reduces transmission of infectious microorganisms.
Measure around the largest part of the thigh.
Ensures correct sizing of stockings/hose.
Obtain equipment from central supply.
It is not usually on the supply cart on the nursing unit.
Gather equipment and place at bedside and adjust lighting.
Enhances organization; ensures good visualization to apply stockings/hose.
Position patient in bed in Fowlers position.
Patient comfort and easy access to lower extremities.
Wrap stockings/hose around the leg, starting at the ankle, with the

opening over the patella.


For correct positioning and optimal compression to promote circulation by
sequentially compressing the legs from the ankle upward.
Attach the stockings/hose to the insufflator, and make sure the inter-

mittent pressure is between 35 to 40 mm Hg.


Ensures stockings/hose are correctly placed and a constant intermittent pressure is maintained for optimal circulation.
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.
Check stockings/hose and compressor equipment periodically.
Ensures proper functioning of stockings/hose and equipment.
Conduct patient and/or family teaching about removal and applica-

tion of stockings/hose as indicated.


Promotes participation from patient and/or family in the use of these
stockings/hose.

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P r o c e d u r e 1 3 . 3 Applying Antiembolic Hose 313


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate


Sequential compression devices (SCDs) are applied correctly.
Patients circulation is improved and without postoperative thrombophlebitis

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time SCDs were applied (as required).


Patient/family participation and any teaching that was done
(as required).
Any problems patient has with SCDs.

PROCEDURE 13.3
Applying Antiembolic Hose
OVERVIEW

To prevent postoperative complications, (i.e., thrombophlebitis).


To promote comfort in lower extremities.
P R E PA R AT I O N

Review history related to recent surgical procedure, peripheral vascular disease, and thrombophlebitis.
Determine patients ability to understand, cooperate, and participate
in the procedure.

Special Considerations
Any patient may need additional assistance, support, and teaching to
understand importance of using TED hose and keeping them on as
prescribed.
Elderly, Physically, and Mentally Challenged Patients
May require more assistance to apply hose.

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314 C h a p t e r 1 3 Circulatory Maintenance


R E L E VA N T N U R S I N G D I A G N O S E S

At risk for altered peripheral tissue perfusion related to immobility


Impaired gas exchange related to pulmonary embolus
Impaired physical mobility related to injury and/or surgery
Pain/discomfort related to injury and/or surgery

EXPECTED OUTCOMES

Patient will have improved circulation in lower extremities postoperatively and without developing thrombophlebitis
Patient expresses increased comfort

EQUIPMENT/SUPPLIES

A pair of TED hose


Clean gloves
Tape measure
I M P L E M E N TAT I O N
Check doctors order; identify patient; explain purpose, procedure

and how patient can assist if indicated. Assess patients or family


members ability to participate.
Conrms order; meets patients right to be informed; encourages cooperation and participation.
Wash hands and don clean gloves.
Reduces transmission of infectious microorganisms.
After determining patients ability to stand with or without assis-

tance, measure while standing, from gluteal fold to the oor, circumference of largest part of the calf. If patient is unable to stand,
measure patient in bed.
Ensures correct sizing of stockings/hose.
Obtain equipment from central supply.
It is not usually on the supply cart on the nursing unit.
Gather equipment and place at bedside and adjust lighting.
Enhances organization; ensures good visualization to apply stockings/hose.
Position patient in bed in Fowlers position.
Patient comfort and easy access to lower extremities.
With patient lying in bed, invert the stocking and slip it over the foot.
For correct positioning of stocking/hose.

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P r o c e d u r e 1 3 . 4 Teaching Postoperative Leg Exercises 315


With the foot raised, ease the stocking/hose snugly over entire the

leg and then apply the other one in the same way.
Ensures stockings/hose are correctly placed and that compression of these
snugly tting stockings/hose promotes proper circulation during periods of
immobilization.
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.
Check stockings/hose and periodically.
Ensures proper functioning of stockings/hose and equipment.
Conduct patient and/or family teaching about removal and applica-

tion of stockings/hose as indicated.


Promotes participation from patient and/or family in the use of these stockings/hose.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate


Antiembolic hose (TED hose) are applied correctly
Patients circulation is improved and without postoperative thrombophlebitis

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time TED hose were applied and removed (as
required).
Patient/family participation and any teaching that was done
(as required).
Any problems patient has with TED hose.

PROCEDURE 13.4
Teaching Postoperative Leg Exercises
OVERVIEW

To prevent postoperative complications, (i.e., thrombophlebitis).


To promote optimal circulation in lower extremities.

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P R E PA R AT I O N

Review history related to recent surgical procedure(s), peripheral


vascular disease, and/or thrombophlebitis.
Assess for pain/discomfort before and during exercises.
Determine patients ability to understand, cooperate, and participate
in the procedure.
Determine patients ability to perform exercises independently after
initial instructions.

Special Considerations:
Pediatric, Elderly, and Physically and Mentally Challenged Patients
May need additional assistance, support, and follow-up teaching to
learn to perform the exercises independently and following a prescribed schedule.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for altered tissue perfusion related to immobility


Risk for impaired gas exchange related to pulmonary embolus
EXPECTED OUTCOMES

Patient will have optimal circulation in lower extremities postoperatively and without developing thrombophlebitis
EQUIPMENT/SUPPLIES

Clean gloves
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist in learning these exercises. Assess patients or family members


ability to participate.
Meets patients right to be informed that these exercises will prevent pooling
of blood in the lower extremities after surgery and will prevent clot formation; encourages cooperation and participation.
Wash hands and don clean gloves.
Reduces transmission of infectious microorganisms.
Place patient in supine or semi-Fowlers position.
Patient comfort.
Instruct patient to bend knee, raise foot in air, and hold in this posi-

tion for 23 seconds.


Circulates blood from lower extremities back to body.

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Have patient extend leg and lower it to bed.
Extends muscles and circulates blood from lower extremities to upper body.
Repeat procedure with other leg.
Ensures consistency of exercising both lower extremities.
Complete sequence 510 times each hour while awake.
Ensures consistent and constant optimal circulation to lower extremities.
Instruct patient to extend toes (plantar exion) toward bottom of

bed, then ex (dorsiexion) toward head of bed.


Optimizes blood circulation from feet to legs.
Repeat foot extension and exion with the other side.
To be consistent for both lower extremities.
Repeat sequence 5 times each hour while awake.
Ensures consistent and optimal blood circulation to lower extremities.
Instruct patient to make circles with the ankle moving rst to the left

and then to the right.


Promotes optimal blood circulation to the foot.
Repeat sequence 5 times each hour while awake.
Ensures consistent optimal blood circulation to lower extremities.
If you used gloves to assist patient with leg exercises, remove them

and wash hands.


Prevents transmission of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate/perform


exercises
Patient performed exercises correctly and consistently as instructed
Patients circulation is improved and without postoperative thrombophlebitis

KEY POINTS

FOR

REPORTING

AND

RECORDING

Frequency of exercises as done by patient (as required).


Family participation and any teaching that was done (as
required).
Any problems patient has with understanding or performing
the exercises.

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C H A P T E R

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14
Blood Transfusion
Therapy
14.1 Transfusing Blood Products, 320
14.2 Assisting with Autotransfusion, 324

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320 C h a p t e r 1 4 Blood Transfusion Therapy

PROCEDURE 14.1
Transfusing Blood Products
OVERVIEW

To safely transfuse whole blood, packed erythrocytes (RBCs),


platelets, fresh frozen plasma so that special deciencies such
as anemia and bleeding disorders can be corrected.
P R E PA R AT I O N

An informed consent must be obtained before transfusing blood.


Baseline vital signs must be obtained.
The nurse should remain with patient during the rst 15 minutes
of blood transfusion to assess for adverse reaction.
Blood must be veried by two nurses or a nurse and a physician
prior to transfusion.
Medications should never be administered via blood transfusion tubing. A separate IV site should be used to administer
medications.
Monitor for uid overload and transfusion reactions.
No more than two units of blood should be administered via
one blood administration set and/or ltersee protocol.
Stop transfusion if reaction occurschange tubing and keep
IV patent with 0.9% sodium chloride.
Return blood container and tubing to blood bank if reaction
occurs.
Obtain rst voided urine specimen after a transfusion reaction
and send to lab.

Special Considerations
Elderly Patient
Infuse blood at a slower rate for better tolerance and prevention
of complications (i.e., circulatory overload, pulmonary edema, and
congestive heart failure).
Pediatric, Confused, Comatose, and Mentally Challenged Patients
Monitor closely and often for adverse reactions since they often
cannot communicate effectively if problems occur.
Home Health Patient
The registered nurse should stay with the patient throughout the
entire process of blood transfusion and 12 hours post-transfusion
to monitor for adverse reactions. An additional RN would be indi-

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P r o c e d u r e 1 4 . 1 Transfusing Blood Products 321

cated for this procedure to check blood and patient information


prior to administration.
Cultural Considerations
Some religious groups do not receive blood transfusions and blood
products, (e.g., Jehovahs Witness).
R E L E VA N T N U R S I N G D I A G N O S E S

Fluid volume decit related to hemorrhage from trauma, GI bleeding, and/or surgery
Fluid volume excess related to rapid infusion of blood
At risk for decreased cardiac output related to circulatory overload
and/or transfusion reaction

EXPECTED OUTCOMES

Transfusion will be completed for time frame ordered and no longer


than 4 hours
Symptoms of an allergic reaction to blood will be recognized early
and prompt intervention initiated
Improvement in serum hemoglobin and hematocrit will be noted
following transfusion

EQUIPMENT/SUPPLIES

Blood unit or other blood product


Bag of 0.9% sodium chloride IV solution
Y-set blood tubing with lter
Antimicrobial swabs
Clean gloves
Infusion pump, if needed
Blood warmer, if needed
Protective clothing, if needed
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure and how patient can

assist.
Decreases anxiety; meets patients right to be informed; encourages cooperation and participation.
Obtain informed consent.
An informed consent is an INS standardthe patient should be aware of
what is involved in the procedure and his or her role in the procedure and
should be made aware of symptoms indicating a reaction to the transfusion.

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322 C h a p t e r 1 4 Blood Transfusion Therapy


Establish that patient has a patent large-bore IV catheter.
Blood should be transfused via a minimum of a 20-gauge IV catheter to provide adequate ow rate and prevent lysis of RBCs.
Prime blood administration tubing with 0.9 % sodium chloride

solution.
IV solutions other than 0.9 % sodium chloride may result in damage to RBCs
or precipitate clots.
Obtain blood from agency blood bank.
Blood should remain at properly stored temperature until time of transfusion. Blood should be returned to blood bank if the unit will not be given
within 2030 minutessee protocol of agency.
Wash hands.
Reduces transmission of infectious microorganisms.
Verify the following information with another nurse or a physician:

Patients name and identication number.


Blood component blood type and Rh factor.
Crossmatching numbers.
Expiration date of blood.

Any blood product must be veried as to correct blood component, correct


type, expiration date, and correct patient to receive this blood.
Obtain vital signstemperature, pulse, respiration, blood pressure

and record on transfusion ow form.


Provides baseline of vital parameters.
Spike the blood container on the blood administration tubing Y

opposite of the 0.9% sodium chloride solution container, pushing tip


of tubing straight up into the blood bag entry portmake sure the
Y leading to the sodium chloride solution is turned OFF prior to
spiking the blood bag.
Spiking the blood container in a straight motion prevents puncture to blood
bag.
Priming the blood set is an INS standardsee fourth item of this procedure.
Prime the blood administration tubing with blood and then initiate

transfusion at 5 mL/min. for the rst 15 minutes of the transfusion.


Blood transfusion reactions are more common during the rst 15 minutes of
the transfusion thus the transfusion rate is slower initially.
Monitor and record the temperature, pulse, respiration, and blood

pressure at 5-minute intervals for the rst 15 minutes of transfusion.


Diligent monitoring of the patient during blood transfusion is necessary to
ascertain adverse effects of the transfusion and institute early intervention.

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P r o c e d u r e 1 4 . 1 Transfusing Blood Products 323


The patient is more susceptible to an adverse reaction within the rst
15 minutes of transfusion.
Monitor patient for any signs or symptoms of an adverse reaction to

the transfusion (itching, hives, rash, urticaria, pain in lumbar-sacral


region, chest pain, or decreased blood pressure, increased pulse or
respiratory distress) at 5-minute intervals and record on transfusion
ow form.
Diligent monitoring of the patient during blood transfusion is necessary to
ascertain adverse effects of the transfusion and institute early intervention.
If a reaction occurs, stop the transfusion, notify physician, and

change IV tubing and keep vein open with 0.9% sodium chloride
solution.
Prepare to administer medications, return blood and tubing to blood
bank, and obtain blood and urine specimens.
Continuing the transfusion may result in more severe reaction. An IV access
must be maintained in the event that patient requires IV medicationnot
changing tubing will result in furthering transfusion reaction.
Treat reaction and identify type of reaction.
After the initial 15 minutes of transfusion, as long as there are no

signs of transfusion reaction, the rate of ow can be increased to


complete the transfusion during the time indicated by the physician
or agency policy.
Rate of infusion is based on the blood volume, hemodynamic and cardiac
status of the patient. The total transfusion must not exceed 4 hours (this
includes the initial 15 minutes transfusion).
The T, P, R, and BP and clinical status of the patient should continue

to be assessed and recorded every 15 minutes for the rst hour and
then every 30 minutes until completion of the transfusion.
A transfusion reaction may occur at any time during the transfusion.
At completion of the blood transfusion, turn off ow control on

Y section leading to blood bag and open the ow control to the


0.9% sodium chloride solution. Flush the blood administration tubing until a light pink uid is noted.
Flushing blood tubing with sodium chloride solution ensures that patient
receives all of blood.
If no further blood is to be transfused, change tubing or cap IV line

with prn adaptor.


IV site can be maintained for further use. Blood tubing should be utilized only
for transfusion of blood.

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324 C h a p t e r 1 4 Blood Transfusion Therapy


Dispose of blood container and tubing according to agency protocol.
Blood container should be returned to blood bank if transfusion reaction
occurs, otherwise can be discarded in contaminated waste (check protocol
of agency).
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.
Reposition patient as needed.
Promotes patient comfort.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood was transfused correctly


Patient did not experience any adverse reactions
Patients blood count has improved

KEY POINTS

FOR

REPORTING

AND

RECORDING

Notication of adverse reactions, if occurred, and report to


physician and orders indicated
Date and time of completion of transfusion

PROCEDURE 14.2
Assisting with Autotransfusion
OVERVIEW

To collect, lter, and reinfuse the patients own blood.


Indications for autologous transfusion include:
Elective surgery (blood donated by the recipient over time). Patient
works with hospital or outpatient blood bank facility to donate
blood as needed and follows that facilitys established protocol and
will receive his own blood when indicated.
Nonelective surgery (blood drawn immediately before surgery).
Perioperative and emergency blood salvage during and after thoracic, cardiovascular, hip, or knee surgery.
Perioperative and emergency blood salvage for traumatic injury to
major organs (i.e., lungs, liver, heart, and major blood vessels).

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P r o c e d u r e 1 4 . 2 Assisting with Autotransfusion 325


P R E PA R AT I O N

Autologous blood transfusion eliminates allergic reactions and


eliminates the risk of exposure to blood-borne infectious agents.
This type of transfusion provides more viable RBCs and has
increased oxygen-carrying capacity than banked blood.
Approval from the recipients physician/prescriber as well as the
medical administrator of the blood bank is needed prior to autologous blood collection.
Medications should never be administered via blood reinfusion tubing. A separate IV site should be used to administer.
Each unit of blood should be administered with one blood administration set that is discarded when nished.
Before reinfusion, identify the patient and make sure that the collection bag is clearly labeled with name, ID number, and an autologous
blood label.
Check patients appropriate lab data before reinfusion and compare
to beginning baselinethat is, coagulation prole, hemoglobin,
hematocrit, and so on.

Special Considerations
Contraindicated in patients:
Taking antibiotics.
When blood becomes contaminated by bowel contents.
When the hemoglobin is less than 11g/dL.
With a bacterial infection.
With unstable vital signs.
With unstable angina, severe aortic stenosis, and/or severe coronary
artery disease.
With recent weight loss due to illness or malnutrition.
Cultural Considerations
This type of transfusion provides and option for patients whose religious beliefs prohibit homologous transfusion.
Elderly Patients
Infuse blood at a slower rate for better tolerance and prevention of
complications (i.e., circulatory overload, pulmonary edema, and congestive heart failure).
R E L E VA N T N U R S I N G D I A G N O S E S

Fluid volume decit related to surgery


Fluid volume excess related to rapid infusion
Risk for decreased cardiac output related to circulatory overload

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326 C h a p t e r 1 4 Blood Transfusion Therapy


EXPECTED OUTCOMES

Blood will be available when needed and the transfusion will be


completed in a timely manner
Symptoms of an allergic reaction to blood will not occur
Improvement in serum hemoglobin and hematocrit will be noted
following transfusion

EQUIPMENT/SUPPLIES

Autologous transfusion system, such as the Davol or Pleur-evac system


ACD or CPD
Collection bags
Vacuum source regulator
Suction tubing
18-gauge needle
Blood administration set with in-line lter
500 mL of normal saline solution
Optional: Hemovac and another autologous transfusion system
I M P L E M E N TAT I O N

Perioperative Blood Donation


Identify patient; explain purpose and procedure. If you know that the

patient will leave surgery with a drain to the autologous device, tell
him this beforehand.
Decreases anxiety; meets patients right to be informed; encourages cooperation and participation.

Perioperative Blood Donation Using a Davol System


Open the transfusion unit onto the sterile eld. The physician/

prescriber inserts the drain tube from the patient to the connecting
tube of the unit.
Follows protocol.
The physician/prescriber injects 25 to 35 mL of ACD or CPD into the

injection port on top of the lter and wets the lter with anticoagulant.
To prime tubing and keep the blood from clotting.
Label the collection bag with the patients name and the time the

infusion was started.


Ensures the reinfusion time is within standardized guidelines.

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P r o c e d u r e 1 4 . 2 Assisting with Autotransfusion 327


After the patient arrives on the nursing unit, note the amount of blood

in the bag on the appropriate document.


Establishes and maintains an accurate record of blood collection.
Attach the tube from the suction source to the port on the suction

control module and adjust to between 80 and 100 mm Hg on the


wall regulator.
Higher suction can cause problems, such as the collection bag to collapse,
causing lysis of blood cells and unsafe to reinfuse. Lower than 80 mm Hg
suction results in no blood collection.
If less than 200 mL is collected in 4 hours, record on the appropriate

document, discard, and switch from the collection container to a


closed-wound suction unit, such as a Hemovac.
Because only 200 mL was collected within the 4-hour period, the proportion of
anticoagulant (inserted in the operating room) to blood is too great to infuse.
If 500 or more mL of blood is collected in the rst 4 hours, connect a

new autologous transfusion unit to the patient, then reconnect to


suction, monitor patient, and record.
Enough blood is collected within 4 hours to reinfuse to the patient, if ordered
by the doctor.

Blood Reinfusion
Prime the blood lter with 500 mL of normal saline solution.
Priming the blood set is an INS standard procedure.
Twist the suction control module to remove it.
It is not needed for blood reinfusion.
Remove the hanger assembly from the collection bag; pull the clear

cap from the top of the bag and discard the cap and lter.
Removing unnecessary equipment to prepare for reinfusion.
Insert a spike adapter into the large port on top of the bottle.
To prepare for reinfusion.
Remove the protective seal to expose the ltered vent.
To follow protocol.
Attach the blood to the Y-connector of the blood lter; invert the

bag and hang it


Ensures correct equipment is used to reinfuse blood.
Obtain vital signs and document them.
Establishes a baseline to compare to later.
Begin the infusion, following your facilitys policy and procedure. This

will include that the T, P, R, and BP and clinical status of the patient

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328 C h a p t e r 1 4 Blood Transfusion Therapy

should continue to be assessed and recorded every 15 minutes for


the rst hour and then every 30 minutes until completion of the
transfusion
To compare to baseline vital signs and pre-infusion clinical status.
Be sure to complete the infusion within 2 hours. At completion of

the blood transfusion, turn off ow control on Y section leading to


blood bag and open the ow control to the 0.9% sodium chloride
solution. Flush the blood administration tubing until a light pink
uid is noted.
Follows standard time for blood reinfusion. Flushing blood tubing with
sodium chloride solution ensures that patient receives all of blood.
If no further blood is to be transfused, change tubing or cap IV line

with prn adaptor.


IV site can be maintained for further use. Blood tubing should be utilized only
for transfusion of blood.
Dispose of blood container and tubing according to agency protocol.
Blood container can be discarded in contaminated waste (check protocol of
agency).
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.
Reposition patient as needed.
Patient comfort.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood was reinfused correctly


Patient did not experience any adverse reactions
Patients blood count has improved

KEY POINTS

FOR

REPORTING

AND

RECORDING

Baseline vital signs prior to initiating reinfusion.


Informed consent was obtained.
Date and time of initiating blood reinfusion and time
completed.
Any adverse reactions experienced by the patient,
notication to physician/prescriber, and actions taken.

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U N I T

C H A P T E R

Nutritional and
Digestive

15
Oral and Enteric
Nutrition
15.1 Administering Nasogastric, Nasoenteric,
and Enteric Tube Feedings, 330
15.2 Administering Medications Through
a Feeding Tube, 335

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330 C h a p t e r 1 5 Oral and Enteric Nutrition

PROCEDURE 15.1
Administering Nasogastric, Nasoenteric, and
Enteric Tube Feedings
OVERVIEW

To provide an alternative route for the administration of liquid nutrients to the patient who cannot take anything by mouth and has a
nasogastric, nasoenteric, or gastrostomy (PEG) tube in place.
To restore and/or maintain the patients nutritional status.

P R E PA R AT I O N

Assess for nasogastric or gastric tube placement (see Chapter 17).


If the equipment, such as the catheter tip syringe, is to be reused,
clean it thoroughly after each use.
Do not allow feeding formula to hang more than 8 hours, and
change reservoir bag and administration set with addition of feeding according to protocol.
Gastrostomy or PEG tube site care and dressings should be done at
least once per shift or as needed if soiled and according to facility
protocol.
Assess the site for signs of tube migration, dislodgment, infection, or
skin breakdown at least every 8 hours, prn, and according to facility
protocol.
Follow prescriber and facility protocol related the use of blue tinting
of the formula for detection of aspiration.
Review appropriate blood work that may be critical for optimum
nutritional replacement and management (i.e., complete blood
count [CBC] and renal function studies).

Special Considerations
Monitor patient often for coughing, movement, or attempts to
remove the nasogastric (NG) tube, which can cause tracheobronchial
aspiration during enteral feedings.
If the patient is on a pump, monitor often and do not exceed 40 psi
because excessive pressure can cause the tubing to rupture.
In patients with endotracheal or tracheostomy tubes, check cuff ination. If deated, inate and maintain at least 30 to 60 minutes after
feeding to prevent aspiration.
Elderly Patient
Check level of consciousness.
Check for aspiration.

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P r o c e d u r e 1 5 . 1 Administering Nasogastric, Nasoenteric, & Enteric 331

Place in Fowlers position (3045 degrees) before and after feeding,


to prevent aspiration.
Pediatric Patient
Make sure children are in high Fowlers or upright position during
and after feeding to prevent aspiration.
Hold and rock the infants and children if possible during the feeding.
Give a pacier to an infant during the feeding to meet developmental needs.
Burp or bubble infants at intervals during the feeding and after.
Position an infant in a prone or side-lying position for at least an
hour following the feeding to prevent aspiration.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to anorexia,


failure to thrive, or surgery
Ineffective infant feeding pattern related to premature birth and
underdevelopment of major body systems
Self-care decit related to dysphagia and impaired physical mobility
Risk for aspiration related to impaired swallowing

EXPECTED OUTCOMES

Tube feeding is administered safely


Desired uid volume achieved without signs of uid volume excess
or decit
Patients pre- and post-therapy nutrition status (e.g., blood urea
nitrogen [BUN], creatinine, serum albumin, and blood sugar) is within
normal range

EQUIPMENT/SUPPLIES

Prescribed amount of nutrition formula/product


Graduated container for measuring the feeding
Irrigating syringe (60 mL) with catheter tip for bolus feeding or calibrated plastic feeding bag with tubing
Feeding pump if required
Calibrated container of water for ushing
Water for diluting and ushing
Clean gloves
Alcohol swabs

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332 C h a p t e r 1 5 Oral and Enteric Nutrition


I M P L E M E N TAT I O N
Check the expiration date, and swab unopened formula container

top with alcohol.


Reduces transmission of microorganisms.
Date and refrigerate opened formula can.
Discard unused formula after 24 hours and change formula delivery syringe
daily to reduce the transmission of microorganisms.
Warm refrigerated formula to room temperature.
Excessively cold feedings may cause cramping.
Prepare the patient for the feeding.
This process of feeding should not cause discomfort, but the patient may
have a sensation of fullness.
Don nonsterile gloves.
Reduces transmission of microorganisms.
Elevate the head of the bed to a Fowlers position in bed or a sitting

position in a chair.
These positions facilitate gravitational ow of the feeding and prevent
aspiration of feeding in the lungs.
Assess patients abdomen, and verify the presence of bowel

sounds.
Absence of bowel sounds indicates lack of peristalsis; gastric feeding
should not be given in the case.
Check tube placement by two methods: aspiration of gastric con-

tents, checking pH of gastric contents, air insufflation with 20 to


30 mL of air, or radiographic conrmation.
Gastric contents may vary from clear to yellow or green. Medical diagnosis
may also affect color. Usually pH of 0 to 4 ensures that tube is correctly
placed in the stomach. Air insufflation while auscultating over the epigastrium assists in determining proper placement. NOTE: Radiographic
determination of placement is most accurate but is costly and may not
be feasible in all situations.
If the feeding is being given through a gastrostomy tube, assess the

migration or change of length of the exposed tube, which is usually


1/2 inch.
Changes in the length of the exposed tube may indicate tube displacement.

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P r o c e d u r e 1 5 . 1 Administering Nasogastric, Nasoenteric, & Enteric 333


Aspirate and measure gastric contents to determine residual

volume.
If residual volume is greater than half the volume previously delivered
or greater than 100 mL, hold feeding and recheck in 1 hour.
Return aspirated contents to stomach.
Secretions contain electrolytes that, if removed, may cause an electrolyte
imbalance.
For continuous tube feed-

ings, connect administration


tubing to formula bag, thread
tubing through pump per
manufacturers instructions,
connect the feeding tube
to the nasoenteric tube or
the jejunostomy tube, and
start feeding at a slow,
constant infusion rate
(25 to 50 mL/hr).
Priming the tube according
to manufacturers instructions prevents administration
difficulties, and incremental
increases in rate may be better
tolerated (maximum rate is
usually 100 to 150 mL/hr).

FIGURE 15.1A Continuous

tube feeding administered by


enteral pump.
For intermittent tube feedings, remove the plunger from the

syringe and connect the empty syringe barrel to a pinched or


clamped NG tube.
Pinching or clamping the NG tube prevents excess air from entering the
stomach.
Holding the syringe no higher than 18 inches above the patients

stomach, administer 30 mL of water to ush the tubing; clamp tubing by folding before syringe empties.
Prevents administering air into the patients stomach.

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334 C h a p t e r 1 5 Oral and Enteric Nutrition


Pour feeding into the syringe

barrel and allow to ow


slowly by gravity over
15 minutes.
Rapid or forced delivery of
feeding increases the risk
for cramping, nausea, or
vomiting.

FIGURE 15.1B Intermittent feeding

by gravity.
Clamp tubing before the syringe empties, and continuously ll

syringe before it completely empties.


If the syringe empties and lls with air, the additional formula will move this
air into the patients stomach and increase the risk for vomiting.
Flush the tubing with 30 mL of water following the intermittent

feeding or every 4 hours during a continuous feeding.


Prevents the tube from clogging.
Clamp the feeding tube before all the water is instilled.
Clamping prevents leakage and air from entering the tube.
Keep the head of the bed elevated for 2 hours following intermittent

feeding or at all times during a continuous feeding.


This position facilitates digestion and movement of the feeding from the
stomach along the alimentary tract and prevents potential aspiration of the
feeding into the lungs.

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P r o c e d u r e 1 5 . 2 Administering Medications Through a Feeding 335


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate the patients tolerance of the feeding such as regurgitation,


abdominal distention, or feelings of fullness, gagging, coughing, or
verbal expressions of gastric discomfort
Evaluate weight gain or loss daily
Evaluate fecal elimination changes such as diarrhea, atulence, or
constipation
Evaluate post-therapy nutrition status (e.g., BUN, creatinine, serum
albumin, and blood sugar) to determine it is within normal range

KEY POINTS

FOR

REPORTING

AND

RECORDING

The

date, time, type, rate, and amount of feeding administered


and the next scheduled feeding.
Quantity and character of the residual volumes obtained.
Abdominal assessment ndings.
Type of infusion pump if applicable.
Patients elevated position post bolus feeding or patients continuous elevated positioning for continuous feeding.
Patients response to feeding and tolerance.
Assessment characteristics of tube insertion site.
Type and frequency of tube site dressing changes, if
appropriate.
Type and frequency of oral hygiene provided.
The patients residual volumes prior to feedings.
Any changes in the insertion site.
Any obstructive issues occurring during the administration.
Any signs of aspiration.
Record intake and output as indicated.

PROCEDURE 15.2
Administering Medications Through a Feeding Tube
OVERVIEW

To provide an alternative route for administration of medications to


the patient who cannot take anything by mouth and has a nasogastric, nasoenteric, or gastrostomy tube in place.

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336 C h a p t e r 1 5 Oral and Enteric Nutrition


P R E PA R AT I O N

Check prescribers order to verify medication orders.


Use the ve rights of drug administration.
Check with the pharmacist to see if the patients medication comes
in a liquid form, because these are less likely to cause tube obstruction.
Determine if the nasogastric tube or gastric tube is in place (see
Chapter 17).

Special Considerations
Elderly Patient
Check level of consciousness.
Check for aspiration.
Place in Fowlers position (30 to 45 degrees) before and after feeding
to prevent aspiration.
Pediatric Patient
Because of the small size of the feeding tube, use only medications
that come in a liquid preparation to prevent occlusion.
Be sure children are in a high Fowlers or upright position to prevent
aspiration during administration.
Position an infant in a prone or side-lying position for 30 minutes to
1 hour following medication administration.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to anorexia


and/or failure to thrive
Self-care decit related to impaired swallowing and physical mobility
Ineffective infant feeding pattern related to premature birth and
underdeveloped sucking reex

EXPECTED OUTCOMES

Medications will be administered safely and on time according to


physicians order
Desired effects from the medication (e.g., relief or pain or decrease in
body temperature) will occur
The feeding tube will remain patent

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P r o c e d u r e 1 5 . 2 Administering Medications Through a Feeding 337


EQUIPMENT/SUPPLIES

Medication prepared and ready for insertion through the feeding tube
according to physicians orders
Water for diluting and ushing the feeding tube
60-mL catheter-tip syringe
Clean gloves
I M P L E M E N TAT I O N
Review prescribers orders.
Determine medications and route to be administered to patient.
Gather all equipment before administering the medications.
Saves time and allows efficiency in the medication administration.
Stop the tube feeding if medication is to be given on an empty

stomach.
Some medications are not absorbed if taken with food or other medications.
Prepare each medication separately.
Maintains discrete identity of each medication. If, for some reason, a medication must be withheld, it can be easily identied.
Check to determine if medications can be crushed.
Enteric-coated, sustained-action, buccal, and sublingual medications should
never be crushed, as doing so alters the absorbability of the medication or
yields a toxic dose of the medication.
Dilute crushed tablet or powder from a capsule in 30-mL warm

water.
Facilitates easier ow of medications through the tube, and cold water may
cause patient discomfort.
Don nonsterile gloves.
Reduces transmission of microorganisms.
Always check and conrm NG tube placement before administering

the medications.
Tube must be placed in the correct position to avoid aspiration.
Check residual volume, return residual, and ush NG tube.
Validates gastric capacity for receiving medications and ush solution.
Flush the tube with 15 to 30 mL of water before administering med-

ications.
Determines tube patency and reduces the risk for obstructing the feeding
tube.

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338 C h a p t e r 1 5 Oral and Enteric Nutrition


Disconnect NG tube from the feeding tube, maintaining asepsis of

the connecting adapter.


Reduces transmission of infectious organisms.
If several medications are being given, administer each one

separately using gravity.


Allows identication of each medication given.
Flush tube with 15 to 30 mL water after each medication.
Reduces risk for tube obstruction.
Restart tube feeding.
Continues nutrition feeding.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Note if patient gags or coughs


Patient verbalizes no gastric discomfort
Patient will exhibit desired effects from the medication
The NG tube remains patent

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date, time, medication, dosage, and route of administration for


each medication given.
Documentation of the patients pre-administration and postadministration assessment data for medication administration.
Reason for patients refusal or nurses decision not to administer medication.
Any difficulty with the administration of medications through
the feeding tube.
Any PRN medications received and the evaluation of their
effectiveness.

C H A P T E R

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16
Parenteral Nutrition
16.1 Administering Total Parenteral
Nutrition (TPN), 340
16.2 Administering Peripheral
Partial Nutrition, 343
16.3 Administering a Fat Emulsion
(Lipids), 346

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340 C h a p t e r 1 6 Parenteral Nutrition

PROCEDURE 16.1
Administering Total Parenteral Nutrition (TPN)
OVERVIEW

To provide a nutrition source for patients who are unable to process


nutrients normally; nutrients for patients requiring bypass of the
gastrointestinal tract; and increased calories for patients in a catabolic state.
To prevent or correct a deciency of essential fatty acids.

P R E PA R AT I O N

Determine patients ability to understand purpose of TPN therapy.


Assess patients nutrition status.
Assess nutrition needs of patients who are unable to process nutrients normally (gastrointestinally).
Check prescribers orders for correct additives in each hyperalimentation bottle, bag, or other type of container.
Check rate of infusion according to prescribers orders, and monitor
closely.
Check facility policy and procedure. Many require tubing and lter
change with every bottle/bag.
Monitor patients blood glucose level regularly.
Keep family informed of therapy procedure, possible complications, and patient tolerance if patient has difficulty understanding
information.
Store TPN solution in the refrigerator until 30 minutes before use.
(Some pharmacies deliver the solution before each infusion. Make
sure TPN was mixed within 24 hours of infusion.)

Special Considerations
Elderly and Pediatric Patients
Monitor elderly patients and children closely for signs of overload
and hyperglycemia, and notify prescriber.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to nausea,


vomiting, anorexia, and/or surgery

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P r o c e d u r e 1 6 . 1 Administering Total Parenteral Nutrition (TPN) 341


EXPECTED OUTCOMES

TPN is infused at prescribed ow rate and tolerated by patient


Dressing at catheter insertion site remains dry and intact
Catheter insertion site remains free of infection and inammation
Patient receives nutrients necessary for tissue repair
Patients blood glucose level is maintained within normal
parameters

EQUIPMENT/SUPPLIES

Hyperalimentation solution (TPN) (refrigerated)


Clean gloves (optional)
Intravenous tubing, lter, and infusion pump
Extension tubing
Blood glucose testing monitor (e.g., Accucheck)
Intake and output (I & O) record
I M P L E M E N TAT I O N
Identify patient; explain procedure and its purpose.
Meets patients right to be informed, and encourages cooperation.
Gather equipment, and place at bedside.
Enhances organization and provides optimal lighting environment.
Wash hands, and don clean gloves
Reduces transmission of infectious microorganisms.
Position in bed in supine position.
Provides patient comfort.
Obtain TPN bag after allowing it to warm to room temperature.
Solution is refrigerated to prevent growth of organisms, but should be left
at room temperature for 30 minutes to 1 hour before use.
Check the bag for leaks, cloudiness, or oating particles. Do not use

if any of these are present.


Reduces chances of adverse events and contamination.
Check bag for patients name, correct bag number, expiration date,

and any additives. Compare with original order.


Ensures that correct infusion is administered.

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342 C h a p t e r 1 6 Parenteral Nutrition


Connect IV tubing and lter to TPN solution container.
Ensure tubing and container are properly connected; changing lter and
tubing every 24 hours or with each bottle/bag prevents growth of microorganisms that can cause infection.
Prime IV tubing to clear air.
Prevents air from entering patients bloodstream, which will cause air
embolism.
Place IV tubing through infusion pump. Set pump to correct rate.
Infusion pump controls rate and prevents complications associated with
too-rapid infusion.
Using sterile technique, connect IV tubing to lumen of

central catheter. Make sure the lumen is dedicated to TPN


administration.
Reduces risk from contamination and line sepsis.
After TPN and tubing are changed and infusion pump is started

at prescribed rate, remove gloves and discard, then wash hands.


Ensures solution has begun without complications; prevents transmission
of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance


Assess vital signs; notify prescriber if temperature is elevated
Assess blood glucose every 6 hours. Administer regular insulin
according to sliding scale, if indicated
Monitor serum electrolytes for potential imbalances
Monitor and maintain an accurate intake and output record
Weigh patient daily or at least three times per week to assess for
uid overload
Assess for TPN therapy complicationsthat is, air embolus, hyperglycemia, osmotic diuresis, inltration, or sepsis
Change lter daily
Change TPN tubing and needleless access cap every 24 hours for
TPN with lipids and every 48 hours for TPN without lipids. Check
facility policy
Monitor and change dressing using sterile technique at IV (central
line) catheter insertion site every 72 hours

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P r o c e d u r e 1 6 . 2 Administering Peripheral Partial Nutrition 343

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date and time of TPN bottle/bag hung, ow rate, and


tubing change.A special TPN form may be used for documentation for this procedure.
Results of nger-stick blood glucose checks.
If insulin is required, type, amount, and site administered.
Condition of catheter (central line) insertion site; status of
dressing and if changed.
Patients weight.
I & O.
Any problems the patient has with TPN therapy.

PROCEDURE 16.2
Administering Peripheral Partial Nutrition
OVERVIEW

To provide a nutrition source for patients who are unable to process


nutrients normally, such as patients requiring bypass of the gastrointestinal tract.
Provides increased calories for patients in a catabolic state.
These solutions/medications will often include: potassium or magnesium supplements and amino acids.
To prevent or correct a deciency of essential electrolytes.

P R E PA R AT I O N

Determine patients ability to understand the purpose of peripheral


partial nutrition therapy.
Assess patients current diet (nothing by mouth [NPO] or diet type,
percutaneous endoscopic gastrostomy [PEG], or feeding tube).
Assess nutrition needs of patient related to electrolyte imbalance or
amino acid deciency.
Check prescribers orders for correct additives for each bottle or bag.
Check rate of infusion according to physicians orders, and monitor
closely.
Monitor patients electrolyte, blood glucose, and amino acid blood
values.

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344 C h a p t e r 1 6 Parenteral Nutrition

Keep family informed of therapy procedure, possible complications,


and patients tolerance of IV solution.

Special Considerations
Elderly and Pediatric Patients
Monitor closely for signs of circulatory overload and hyperglycemia.
Notify prescriber as needed.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to nausea,


vomiting, anorexia, and/or surgery
Risk for decreased cardiac output related to circulatory overload
Risk for electrolyte imbalance related to intolerance of IV solution
mixture

EXPECTED OUTCOMES

Peripheral partial nutrition therapy is infused at prescribed ow rate


and tolerated by patient
IV site remains dry, intact, and free of infection and inammation
Patients electrolytes are maintained within normal parameters

EQUIPMENT/SUPPLIES

Solution and/or medication to be administered IV (may be refrigerated or not, depending upon the solution/medication)
Clean gloves (optional)
IV tubing, lter (if indicated), and infusion pump
Extension tubing
I & O record
I M P L E M E N TAT I O N
Identify patient; explain purpose, and procedure.
Prevents administration error. Meets patients right to be informed and
encourages cooperation.
Gather equipment and place at bedside.
Enhances organization and provides optimal lighting environment.
Wash hands, and don clean gloves.
Reduces transmission of infectious microorganisms.

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P r o c e d u r e 1 6 . 2 Administering Peripheral Partial Nutrition 345


Position in bed in supine position or sitting up in a chair at the bed-

side, depending on patients activity status.


Patient comfort.
Obtain the prescribed IV solution/medication. Allow bag to warm

to room temperature by removing it from the refrigerator approximately 30 minutes before use.
Solution is refrigerated to prevent growth of organisms, but should be left
at room temperature for 30 minutes to 1 hour prior to use.
Connect IV tubing and solution container. Check facility policy and

procedure manual for frequency of changing tubing.


Ensures that tubing and container are properly connected; ensures adherence to policy and procedure of changing tubing.
Prime IV tubing to clear air.
Prevents air entering patients blood stream and causing an air embolism.
Place IV tubing through infusion pump and connect to primary

IV line.
Controls rate of infusion and prevents uid overload from too-rapid
administration.
Remove gloves and discard, then wash hands.
Ensures solution has begun without complications; prevents transmission
of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance


Monitor appropriate blood studiesthat is, electrolytes and amino
acids
Monitor and maintain an accurate intake and record
Assess IV for complications (air embolus, inltration)

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date and time that solution is hung and ow rate.


Results of appropriate blood studiesthat is, electrolytes.
Condition of IV site; status of dressing, and if changed.
Patients tolerance of procedure and any problems that
occurred.
Patients most recent body weight.
I & O.

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346 C h a p t e r 1 6 Parenteral Nutrition

PROCEDURE 16.3
Administering a Fat Emulsion (Lipids)
OVERVIEW

To spare protein in the critically ill patient.


To provide a contamination-free mode of delivering lipids.
To prevent or correct a deciency of essential fatty acids.
To provide a source of energy for patients with decient protein
intake.

P R E PA R AT I O N

Determine patients ability to understand purpose of receiving lipids.


Assess patient for signs of essential fatty acid decits; rash; eczema;
dry, scaly skin; poor wound healing; and sparse hair.
Assess patient for predisposing factors that could promote fat
emboli, such as anemia, coagulation disorders, abnormal liver, pancreatic, or respiratory function.
Check IV site of vascular access device for patency, erythema, and
edema before infusing solution.
Check rate of infusion according to prescribers orders, and monitor
closely.
Take patients vital signs to establish baseline.
Keep family informed of therapy procedure, possible complications,
and any problems related to patient understanding the procedure.

Special Considerations
Elderly and Pediatric Patients
Monitor closely for adverse reactions, and notify prescriber as needed.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to a deciency


in protein and essential fatty acid intake
EXPECTED OUTCOMES

Lipids are infused at the prescribed ow rate and tolerated by patient


Dressing at the IV or vascular access catheter insertion site remains
dry and intact
IV site remains free of infection and inammation
Adequate calories, protein, and essential fatty acids are provided
to patients who are unable to ingest them

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P r o c e d u r e 1 6 . 3 Administering a Fat Emulsion (Lipids) 347


EQUIPMENT/SUPPLIES

IV fat solution (lipids) (not refrigerated)


Special IV tubing infusion set for lipids (to prevent pooling of fat in IV
tubing) and infusion pump
Needleless cannula
Iodophor sponges
Alcohol swabs
Clean gloves (optional)
I M P L E M E N TAT I O N
Review prescribers orders; identify patient; explain purpose and pro-

cedure.
Conrms that lipids have been ordered; meets patients right to be informed
and encourages cooperation.
Gather equipment and place at bedside; adjust lighting as needed.
Enhances organization and provides optimal lighting environment.
Wash hands, and don clean gloves.
Reduces transmission of infectious microorganisms.
Position in bed in supine position.
Patient comfort.
Make sure lipids are room temperature.
Prevents discomfort when infusing.
Examine bottle for separation of emulsion into layers or fat globules

or for accumulation of froth.


Prevents infusion of lipids that are contaminated.
Label bottle with patients name, room number, date, time, ow rate,

and start and stop times.


Ensures proper identication.
Take vital signs for baseline assessment.
Baseline vital signs are needed because an immediate reaction to the lipid
solution can occur.
Swab stopper on IV bottle with iodophor sponge or alcohol swab

and allow to dry.


Cleans stopper and prepares for spiking bottle.
Connect special IV tubing to bottle, twisting the spike to prevent

particles from the stopper falling into the lipids. New tubing is

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348 C h a p t e r 1 6 Parenteral Nutrition

changed with each bottle. Because lipid particles are large, a lter is
not used with infusion.
Ensures that tubing and container are properly connected; changing tubing
with each bottle prevents growth of microorganisms that can cause infection.
Hang IV bottle at least 30 inches above IV site.
Because of the solution viscosity, lipids need to be at a height to prevent
backing up into infusion tubing.
Fill drip chamber two-thirds full, gradually open clamp on the tub-

ing, and prime the tubing slowly.


Reduces the chance of air bubble formation in the solution by priming the
tubing slowly, and removes air in the tubing, preventing air from entering
the patient.
Attach the primed tubing to the IV site.
Allows the start of infusion.
If piggybacking lipids into hyperalimentation (TPN), use the port

closest to the patient, below tubing lter.


Lipids are compatible with TPN and can be piggybacked into the same tubing as long as it is below the lter because the particles are large and will not
go through a lter.
Ideally, infuse lipids slowly at rst; 1.0 mL/minute for adults and

0.1 mL/minute for children.


Allows time to see if the body is going to have an adverse reaction to the
solution.
Monitor vital signs every 10 minutes for the rst 30 minutes and

observe for side effects, such as chills, fever, ushing, dyspnea, nausea/vomiting, and allergic reaction. If any of these occurs, stop the
infusion, follow protocol, and notify the prescriber.
Alerts nurse to patient tolerating or not tolerating the lipid solution and
allows decisions concerning emergency measures.
If no reactions occur, adjust to prescribed ow rate and continue to

monitor according to protocol.


Patient is tolerating the solution without complications, and monitoring follows facility protocol for administering lipids.
If ordered by prescriber, monitor serum lipids 4 hours after discontin-

uing the infusion.


Incorrect blood values will result if a blood sample is drawn too soon after
the infusion is discontinued.

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P r o c e d u r e 1 6 . 3 Administering a Fat Emulsion (Lipids) 349


Discard partially used bottles.
Prevents contamination.
Discard bottle and used IV administration set after each use in the

proper trash receptacle.


Prevents transmission of infectious microorganisms.
Remove gloves (if used), and wash hands before leaving the room.
Prevents transmission of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance


Assess nutrition status
Monitor for adverse events and complications
Monitor IV site for inltration and inammation

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date and time lipids were hung and ow rate.


Results of post-infusion blood tests, if ordered.
Condition of IV site; status of dressing and if changed.
Patients tolerance of procedure and any problems encountered and reported.
Most recent body weight, if ordered.
I & O.

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Page 350

C H A P T E R

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17
Gastrointestinal
Intubation
17.1 Inserting a Nasogastric Tube, 352
17.2 Advancing a Nasoenteric
Decompression Tube, 356

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PROCEDURE 17.1
Inserting a Nasogastric Tube
OVERVIEW

To remove stomach contents and/or decompress the bowel when


peristalsis is absent or malfunctioning.
To introduce uids into the stomach to provide nutrition.
Patients who require insertion of a nasogastric (NG) tube may:
Be unable to swallow or eat normally.
Be bleeding from the gastrointestinal (GI) tract.
Have ingested poison or other dangerous substances, requiring
evacuation of stomach contents.

P R E PA R AT I O N

The right naris is usually larger and facilitates easier insertion.


Assessment prior to insertion of an NG tube should include careful
history of any nasal injuries or anatomy-related problems.
Severe coughing or cyanosis during the procedure may mean that
the tube has slid into the trachea. Remove at once, allow the patient
time to recover, and attempt again.

Special Considerations
Pediatric Patient
Often requires a smaller bore tube.
Parents should be allowed to comfort infants and children and participate in care.
May require restraints to prevent dislodging of the tube because
they are too young to understand explanations of procedure.
Elderly, Disoriented, or Confused Patient
May require restraints to prevent dislodging of the tube and may
require more frequent monitoring for complications, such as aspiration, because they are unable to communicate problems with the
tube.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to nausea,


vomiting, anorexia, and/or surgery
Risk for uid volume decit related to vomiting and/or surgery

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EXPECTED OUTCOMES

Nasogastric tube is placed atraumatically


Tube is properly secured
Proper placement is conrmed

EQUIPMENT/SUPPLIES

Correct size NG tube: Usually a #16 or #18 for adults and size varies
with infants and children
Feeding tubes may be smaller and may have a weighted end
Nonsterile gloves
Ice or water, if patient can swallow voluntarily
Water-soluble lubricant
Tape or device for securing tube
Large syringe (catheter tip or needle tip, depending on type of tube)
for aspirating stomach contents
pH paper
Towel
Emesis basin
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient/family.
Reduces anxiety.
Place patient in semi-Fowlers position with neck slightly exed.
Facilitates insertion of the tube into the esophagus. Flexion narrows upper
airway slightly.
Don nonsterile gloves.
Reduces transmission of microorganisms.

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354 C h a p t e r 1 7 Gastrointestinal Intubation


Estimate the required length

by holding the distal end at


the end of the nose, curving
toward the ear, and then to a
point approximately one
quarter to one half the distance between the lower
end of the sternum and the
umbilicus. Mark this point
with a marker or tape.
Proper length and diameter
of the tube facilitates insertion of the nasogastric tube.
FIGURE 17.1A Measuring tube

for placement.
Determine patency of nares before choosing an acceptable naris.
Facilitates identication of obstruction.
Lubricate the tube.
Facilitates advancing the tube, and decreases patient discomfort.
Insert tube into the more

patent nostril, and advance


with gentle pressure.
Anatomic problems, such as
deviated septum, can interfere with insertion.

FIGURE 17.1B

Rotate the tube when resistance felt.


Resistance as the tube is advanced can be overcome usually by changing
the direction of the tip of the tube slightly.

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Ask the patient to swallow sip of water, if able, and continue to

advance the tube until it reaches the marked point.


Facilitates advancing the tube through the esophagus, avoiding advancing
into the trachea.
Secure the tube.
Prevents displacement of tube.

FIGURE 17.1C Secure tube

with tape.
Check tube placement by at least two of the following methods:

Aspiration of gastric contents.


Checking pH of aspirate (usually pH of 0 to 4 ensures that tube is
correctly placed in the stomach).
Auscultate with insufflation of 20 to 30 mL of air.
Radiographic conrmation.

Ensure that tube is in the stomach and not in trachea. NOTE: Radiographic
determination of placement is most accurate but is costly and may not be
feasible in all situations.
Connect to suction or feeding, if required.
Suction facilitates removal of gastric contents. An NG feeding tube allows
introduction of nutrition into the stomach.
Assess patients comfort status, and answer any questions.
Reinforces nursepatient relationship and allows patient time to voice
concerns or problems.

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E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess characteristics of gastric drainage


Assess respiratory status and comfort level
Answer any questions from patient and/or family
Determine effectiveness of connected equipment

KEY POINTS

FOR

REPORTING

AND

RECORDING

Assessment

ndings before and after insertion of NG tube.


Size of NG tube.
Characteristics of drainage.
Method for checking placement and ndings.
Patients tolerance of procedure.
Time NG tube was inserted.
Respiratory status.

PROCEDURE 17.2
Advancing a Nasoenteric Decompression Tube
OVERVIEW

To remove uids from the small intestine.


To relieve abdominal distention.
To allow the return of intestinal peristalsis.

P R E PA R AT I O N

A nasoenteric tube is inserted following the same steps used in


nasogastric tube insertion. (Refer to Procedure 17.1 on Inserting a
Nasogastric Tube for a detailed explanation.)
Approximately 3 to 4 cm of additional tubing are inserted to allow
adequate length for passage of the tube through the pylorus into
the small intestine.
Passage of the tube from the stomach through the pylorus may take
up to 24 hours.
Surgery may be required if this treatment is ineffective.

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Special Considerations
Pediatric Patient
Parents should be allowed to comfort infants and children and
participate in care.
Use age-appropriate explanations.
May require restraints to prevent dislodging of the tube.
May require adaptation of play activities to remain in proper
position.
Elderly, Disoriented, or Confused Patient
May require restraints to prevent dislodging of the tube and may
require more frequent monitoring for complications, such as aspiration because they may be unable to communicate problems with
the tube.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to nausea,


vomiting, anorexia, and/or surgery
Risk for trauma to intestinal mucosa related to migration of the
advanced tube

EXPECTED OUTCOMES

Nasoenteric tube is placed and advanced atraumatically


Tube is secured properly
Proper placement is conrmed

EQUIPMENT/SUPPLIES

Tape or permanent pen


Nonsterile gloves
Large syringe for aspirating intestinal contents
pH paper
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Mark the tube with tape or permanent pen at a point 3 to 4 cm

past the point of insertion of an NG tube.


Allows adequate tubing to reach and move through the pylorus.

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358 C h a p t e r 1 7 Gastrointestinal Intubation


Following insertion of the tube, place the patient on his or her

right side.
Facilitates movement of the tube through the pylorus.
Check the pH of the aspirate.
pH of intestinal contents is 6 or above.
Conrm tube placement by x-ray.
Most accurate method for determining placement.
Secure the tube once placement has been conrmed.
Maintains proper placement.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess characteristics of gastric/intestinal drainage


Assess respiratory and comfort level
Note progress of the nasoenteric tube
Answer any questions from patient and/or family
Determine effectiveness of connected equipment

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

ndings during the advancement of the tube.


Characteristics of the drainage.
Method for checking placement and ndings.
Progress of advancement.
Patients tolerance of procedure.
Respiratory status.

C H A P T E R

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18
Bowel Elimination
18.1 Administering an Enema, 360
18.2 Managing a Rectal Tube, 366
18.3 Managing Ostomy Care, 370

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PROCEDURE 18.1
Administering an Enema
OVERVIEW

To evacuate the bowel of stool caused by constipation.


To cleanse the bowel prior to surgery or other procedures for
which the bowel, colon, and rectum are visualized.
P R E PA R AT I O N

Determine patients ability to understand procedure.


Assess patients ability to participate in procedure, such as holding
contents when administered.

Special Considerations
Patients who have had recent surgery, or who have arthritis,
a cast, lower limb amputations, or fractured pelvis may need
additional time for the procedure, owing to limited physical
mobility.
Patients with cardiac history or spinal cord injury may be at risk
for complications from vagal stimulation.
Elderly and Physically and Mentally Challenged Patients
May need more time and instruction of the procedure for optimal
participation and results.
Pediatric Patient
Care should be taken in insertion of the enema tube and instillation of the solution to prevent injury to anus and colon during the
procedure.
Parents should be allowed to comfort infants and children and participate in the procedure.
R E L E VA N T N U R S I N G D I A G N O S E S

Constipation related to decreased peristalsis


Chronic pain related to abdominal discomfort and distention from
bowel malfunction
Potential for injury related to abdominal distention and trauma to
the anus and colon during the procedure

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EXPECTED OUTCOMES

Patient will return to an optimal bowel elimination pattern


Patient is able to assist/participate
Patient will be able to evacuate feces from rectum and colon after
the enema
Patient experiences minimal discomfort during procedure and no
injury to the colon and/or anus
Patient experiences relief and comfort after procedure

EQUIPMENT/SUPPLIES

Regular bedpan, fracture pan, or bedside commode


Water-soluble lubricant
Clean gloves
Toilet paper
Disposable, absorbent bed pads
Skin care items (i.e., soap or skin cleanser, water, towels)
IV pole
Enema container with tubing, normal saline, tap water, soap solution,
or commercially prepared enema.
I M P L E M E N TAT I O N
Check prescribers order; identify patient; explain purpose, pro-

cedure, and how patient can assist. Assess patients ability to


participate.
Conrms order; meets patients right to be informed; encourages cooperation and participation.
Gather all equipment and place in an easy to access area in patients

room; adjust lighting as needed.


Promotes organization of equipment; saves time; and adjusted lighting
enhances visualization for procedure.
Explain to the patient the benets of relaxing and taking periodic

deep breaths.
Reduces anxiety and promotes comfort.
Wash hands, and don clean gloves.
Reduces transmission of infectious microorganisms, and prevents contact
with urine and/or feces.

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After determining patients ability to assist, place disposable

waterproof pad under patient. Have patient lift hips or roll from
side to side.
Bed pad protects against soiling of linens.
Place patient in a left side-lying position with knees exed.
To facilitate ow of solution using contour of the bowel.
Place bedpan next to patient.
For easy access in case patient cannot hold enema solution.

Enema Bag (For Cleansing Enemas Using


Soap Suds, Tap Water, or Saline)
Fill enema container with 750 mL to 1000 mL of warm solution

and check temperature by dripping some solution on inner


wrist. If too warm, empty container and rell. Add soap solution
if ordered.
This amount of solution is the standard volume unless a specic amount is
ordered by the physician. This amount is normally what is tolerated; solutions that are too hot or too cold can cause cramping, damage to the
rectal mucosa, or extreme shock.
Allow the solution to run through the tubing to clear out the air;

clamp tubing and hang on an IV pole approximately 12 to 18 inches


above the patients buttocks.
Aids in removing air from the tubing that could cause abdominal cramping
if instilled into the colon during the procedure; 18 inches is considered a high
height, and 12 inches is considered a low height. The higher the pole, the
faster the solution will enter the colon.
Lubricate tip of tubing with generous amount of water-soluble

lubricant.
Facilitates easier insertion of tubing into the rectum.
Spread the buttocks, and gently insert the tip of the tubing 3

to 4 inches while the patient is instructed to take slow deep


breaths.
3 to 4 inches is the correct placement of tubing in the rectum to allow solution to enter the colon without leakage; slow, deep breaths aids in relaxation
of the rectal sphincter.

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FIGURE 18.1A

Open the regulating clamp and allow the solution to ow slowly.


When the solution is instilled slowly, less cramping is experienced by the
patient, and the patient will be able to tolerate more volume of the solution.
Hold the tubing in place in the patients rectum at all times, and

keep the bedpan nearby.


The tubing will slip out easily if not held in place; the patient may need to
expel contents before expected.
Lower the solution container or clamp tubing if the patient com-

plains of cramping, then resume after a few minutes.


Lowering the container will slow down the ow of solution and aid in
decreasing cramps.
After solution is instill, clamp tubing and gently remove.
Prevents siphoning out enema solution as tube is removed.

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Instruct the patient to hold the solution about 10 to 15 minutes or

longer as tolerated.
The longer the solution is retained, the more effective the results.
Provide bedpan or assist to commode as needed.
Aids in evacuation of solution and feces.
Instruct patients with cardiovascular disease not to strain when

expelling contents.
Avoids creating the Valsalva maneuver, which can lead to sudden cardiac
arrest.
Assist patient with personal hygiene as needed.
Provides patient comfort, and reduces transmission of infectious microorganisms.
Assist patient back to bed as needed and into a comfortable position.
Patient comfort.
Dispose of enema equipment and clean bedpan or bedside com-

mode as needed.
Prevents transmission of infectious microorganisms.
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.

Commercially Prepared Enema (Fleets, Oil, or Medicated)


Prepare patient and environment as described in rst section.

Lubricate tip of enema container as needed (most are prelubricated).


Facilitates easier insertion into the rectum.
Spread buttocks and insert

the tip into the rectum.


Gently squeeze entire contents of the container.
Aids in optimal results if all
solution is instilled.

FIGURE 18.1B

Remove the tip while continuing to squeeze the container.


To prevent the solution from being siphoned back into the container.

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Instruct the patient to hold the solution at least 5 to 7 minutes.
To ensure optimal results.
Provide bedpan or assist to commode as needed.
Aids in evacuation of solution and feces.
Instruct patients with cardiovascular disease not to strain when

expelling contents.
Avoids creating the Valsalva maneuver, which can lead to sudden cardiac
arrest.
Assist patient with personal hygiene as needed.
Provides patient comfort, and reduces transmission of infectious microorganisms.
Assist patient back to bed as needed and into a comfortable position.
Patient comfort.
Dispose of enema equipment, and clean bedpan or bedside com-

mode as needed.
Prevents transmission of infectious microorganisms.
Remove gloves and wash hands.
Prevents transmission of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to tolerate procedure


Administration of an enema is done correctly, safely, and successfully
An optimal pattern of elimination is maintained or restored

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date, time, type, and results of enema administration,


as well as amount and other important characteristics of stool
(as required in the designated area on the patient record).
Record patients tolerance of procedure and any complications that occurred.
Report patient teaching about prevention of constipation,
such as, adequate hydration and dietary adjustments.

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PROCEDURE 18.2
Managing a Rectal Tube
OVERVIEW

To alleviate abdominal distention and discomfort from atus.


P R E PA R AT I O N

Determine patients ability to understand procedure.


Assess patients history of cardiac disease, because insertion of a
rectal tube can cause vagal stimulation, which causes bradycardia.
Determine degree of abdominal distention by palpating the
patients abdomen.
Assess discomfort caused by atulence.
Assess quality and rate of pulse and respirations.
Assess condition of perianal tissues.

Special Considerations
Patients who have had recent surgery, or have arthritis, a cast, lower
limb amputations, or a fractured pelvis may need additional time for
the procedure, owing to limited physical mobility.
Patients with cardiac history or spinal cord injury may be at risk for
complications from vagal stimulation.
If the patient experiences seepage of liquid fecal material after this
procedure, contact the prescriber, because an enema may be needed
to remove stool in the rectum and dietary adjustments may be indicated, such as increased uid and ber.
Elderly and Physically and Mentally Challenged Patients
May need more time and instruction of the procedure for optimal
participation and learning about preventing constipation.
Pediatric Patient
Extra care must be taken when inserting the rectal tube to prevent
injury to anal sphincters and/or rectum.
Parents should be allowed to comfort infants and children and participate in the procedure.
R E L E VA N T N U R S I N G D I A G N O S E S

Constipation related to decreased peristalsis


Pain related to abdominal discomfort and distention from bowel
malfunction
Potential for injury related to abdominal distention and trauma to
the anal sphincters and/or rectum during the procedure

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EXPECTED OUTCOMES

Patient will experience greater comfort from relief of abdominal


distention
Patient experiences minimal discomfort
Respirations remain within normal limits after procedure if atulence
has caused respiratory distress
Flatulence is removed from lower gastrointestinal tract

EQUIPMENT/SUPPLIES

Rectal tube: size 22 to 30 straight French for adults, and size 12 to 18


French for children
Water-soluble lubricant
Clean gloves
Toilet paper
Disposable, absorbent bed pad
Skin care items (i.e., soap or skin cleanser, water, towels)
Small plastic bag or stool specimen container
Hypoallergenic paper tape
I M P L E M E N TAT I O N
Check prescribers order; identify patient; explain purpose, proce-

dure, and how patient can assist. Assess patients or family members
ability to participate in education of prevention.
Conrms order; meets patients right to be informed; encourages cooperation and participation.
Gather all equipment, place in an easy-to-access area in patients

room, and adjust lighting as needed.


Promotes organization of equipment; saves time; and adjusted lighting
enhances visualization for procedure.
Obtain baseline vital signs and record.
This procedure can cause bradycardia and hypotension due to vagus nerve
stimulation. Therefore, baseline vital signs are necessary for comparison
post-procedure or if the patient develops abnormal vital signs during the
procedure.
Wash hands, and don clean gloves.
Reduces transmission of infectious microorganisms and prevents contact
with urine and/or feces.
After determining patients ability to assist, place disposable water-

proof pad under patient. Have patient lift hips or roll from side to
side.
Bed pad protects against soiling of linens

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368 C h a p t e r 1 8 Bowel Elimination


Place patient in a left side-lying position.
Facilitates insertion of tube following the normal curve of rectum and
sigmoid colon.
Tape the plastic bag around the distal end of the rectal tube or insert

the tube into the stool specimen container.


To collect tiny pieces of stool if expelled with atus.
Vent the upper side of the plastic bag.
Prevents ination of atus and bursting of the bag.
Lubricate the proximal end of the rectal tube with water-soluble

lubricant.
Aids in easier insertion of rectal tube.
While separating the buttocks, ask the patient to take a deep

breath. Gently insert the tube into the rectum, past the external
and internal anal sphincters (46 inches in adults and 24 inches
in children).
Taking deep breaths relaxes the anal sphincter and prevents tissue trauma
during tube insertion.
With adults, tape the tube in place, using hypoallergenic paper tape.

With children, hold the tube in place manually.


Keeps the tube securely in place in order to function properly.
Assess patients tolerance of procedure by checking heart rate

and respirations. If any untoward symptoms occur, stop procedure,


notify physician immediately, and take appropriate actions, including
monitoring vital signs.
To monitor for adverse reactions caused by vagus nerve stimulation.
Leave the tube in place no longer than 20 minutes.
Prolonged presence of the catheter may cause pressure necrosis of the
mucosa, and prolonged stimulation of the anal sphincter may result in loss
of the neuromuscular response.
After removal of the tube, wipe buttocks with tissue and assist with

cleaning of rectal area as needed.


Prevents transmission of infectious microorganisms from feces and promotes
patient comfort.
Help the patient to resume a comfortable position in bed.
Promotes comfort.

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P r o c e d u r e 1 8 . 2 Managing a Rectal Tube 369


Clean equipment if it is to be reused, and discard equipment not

being reused.
Prevents transmission of infectious microorganisms, and provides clean
equipment for next use.
Instruct patient that chewing gum, sucking on candy, using a

straw, drinking carbonated beverages, and smoking should be


avoided.
This increases the chance of swallowing air and increases abdominal
distention.
Remove your gloves and wash hands.
Prevents transmission of infectious microorganisms.
Discuss with patient and/or family factors that promote normal

bowel functioningfor example, activity, increased uid intake as


tolerated, and dietary habits.
Promotes patient/family understanding and cooperation of preventing
future problems of constipation and fecal impaction.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patients compliance and ability to tolerate procedure


Assess degree of abdominal distention
Assess for complications

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date, time, and size of tube inserted and characteristics of feces collected.
Change or no change of abdominal distention.
Pulse and respiratory rates before, during, and after procedure.
Record patients tolerance of procedure and any complications that occurred.
Report patient/family teaching about prevention of constipation and fecal impaction, such as, adequate hydration and
dietary adjustments.

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PROCEDURE 18.3
Managing Ostomy Care
OVERVIEW

To provide the skills necessary to manage an ostomy including:


The application of an ostomy pouch.
Emptying a pouch and preventing skin breakdown associated with
pouch leakage or an ill-tting pouch.
Teaching the patient and/or caregiver to perform ostomy care.
Instructing the patient and/or caregiver about potential problems,
such as skin irritation, pouch leakage, stomal irritation, stomal
necrosis, or stenosis.
Giving useful tips to promote optimal adjustment and rehabilitation for the patient with an ostomy.
P R E PA R AT I O N

Assess patients and/or caregivers knowledge about care of the


ostomy.
Assess the colostomy or ileostomy opening or stoma for a moist,
pink appearance and notify the prescriber immediately if the stoma
has any change in color. Deep purple or black coloring is a sign of
necrosis and usually will require surgical intervention to revise the
stoma.
Assess ostomy for atus as the rst output after surgery and soft
or liquid stool, until a regular diet is resumed.
Assess for bleeding from the stoma, because it is never a normal
nding, and notify the prescriber immediately, because this may
represent gastrointestinal hemorrhage.
Assess the stoma for retraction or separation, and notify the prescriber as needed.
Assess the stoma for pain, which should be absent unless there is
skin irritation from stool leakage.
Assess the stoma location and shape, amount of output, patient
dexterity, and personal preference. This and cost will determine
the type of pouch used (a one-piece or two-piece).

Special Considerations
Provide simple instructions, and answer every question.
Allow the patient time to adjust to the change in body image.

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 371

The patient may suffer depression and may need to work through
the loss of a body part and normal bowel function.
Reinforce all learning, and remind the patient that adjustment and
learning are individual.
Brief, frequent teaching sessions are helpful and less overwhelming
for the patient and caregiver.
Provide age-appropriate teaching to the patient and/or caregiver
about diet, medications, and activity specic to the type of ostomy.
Provide resource numbers, including the United Ostomy Association
(UOA) and the local Ostomy Support meetings for additional information and patient/family support
TABLE 18.3A Support Groups for People with Ostomies
American Cancer Society (ACS)
1599 Clifton Road NE
Atlanta, GA 30329
1-800-ACS-2345
www.cancer.org
Crohns & Colitis Foundation of
America, Inc. (CCFA)
386 Park Avenue South
New York, NY 10016-8804
1-800-343-3637
1-212-685-3440 for NY
www.ccfa.org
National Family Caregivers
Association
10605 Concord Street, Suite 501
Kensington, MD 20895-2504
1-800-896-3650
www.nfcacares.org

Great Comebacks Awards Program


P. O. Box 9922
Rancho Santa Fe, CA 92067
www.greatcombacks.com
United Ostomy Association (UOA)
19772 MacArthur Blvd., Suite 200
Irvine, CA 92612-2405
1-800-826-0826
www.uoa.org

Wound, Ostomy and Continence


Nurses Society (WOCN)
1550 S. Coast Highway, Suite 201
Laguna Beach, CA 92651
1-888-224-WOCN or
1-888-4-WOCNCB
www.wocn.org

Pediatric, Elderly, or Physically Challenged Patient


May have difficulty learning to manage the ostomy and need additional training.
Home Health Patient
Arrange for a home health nurse if additional instruction or supervision is needed. Provide ostomy supplies, and arrange for the patient
to get necessary supplies for home use.

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R E L E VA N T N U R S I N G D I A G N O S E S

Body image disturbance related to the ostomy


Ineffective individual coping related to a change in bowel elimination and lifestyle
Risk for impaired skin integrity related to increased contact of fecal
matter around stoma
Risk for knowledge decit related to lack of understanding about
ostomy care
Risk for caregiver role strain related to added responsibility of caring
for an ostomy

EXPECTED OUTCOMES

The ostomy stoma remains viable and begins normal function as


expected postoperatively
The stoma remains intact, without necrosis or retraction
The patient and/or caregiver is taught to manage the ostomy at
home by performing these skills independently and gives return
demonstration before discharge to home
Supplies are accessible to the patient
The patient achieves a satisfactory adjustment to the ostomy, evidenced by achieving self-care and resumption of everyday activities

EQUIPMENT/SUPPLIES

Gloves
Washcloths, moistened with cool tap water (never hot water to avoid
trauma to the stoma)
Towel or waterproof pad
Adhesive remover wipes
Skin prep wipes
Colostomy pouch (one-piece adhesive pouch with cut-to-t starter
hole)
Pouch clamp
Scissors
Measuring template for sizing the stoma
Deodorizing liquid (Banish)*
Liquid detergent cleanser (Uniwash)*
Plastic squeeze bottle for pouch rinsing
Toilet tissue
Plastic bag to dispose of used equipment
Hy-tape (pink waterproof tape) (optional)
Stomahesive powder (optional)
Stomahesive paste (optional)

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 373


I M P L E M E N TAT I O N
Gather supplies and explain the procedure to the patient. Ask if

there is anyone else that the patient would prefer to have included
in learning to perform the procedure (e.g., spouse).
Reduces anxiety. Supplies at hand promote a relaxed learning environment.
Respect the patients privacy.
Position the patient comfortably in bed or chair; drape a towel or

waterproof pad under the colostomy pouch.


Provides clear vision of the abdomen so that the patient can begin to learn
self-care. A mirror may be helpful as well. Padding the bed avoids unpleasant
leakage.
Gently remove the ostomy

pouch using the adhesive


remover wipes. Have the moist
washcloth handy, once the
pouch is removed. Gently
cleanse the stoma and the
skin with the washcloth. Use
only cool tap water. Discard
the pouch, unless there is a
two-piece system in place;
the pouch may be rinsed and
FIGURE 18.3A Remove old wafer
snapped back on the ange
from the skin.
if using a two-piece system.
Remember to save the pouch
clamp for reuse.
Adhesive remover protects the skin from stripping and promotes patient
comfort. Plain, cool tap water is used to clean the stoma and peristomal skin.
Hot or warm water may stimulate the bowel to act. Hot water could burn the
stoma also. Soap is not advisable. It may leave a residue and interfere with
pouch adhesion.
Leave the moist washcloth in place over the stoma while preparing

the new pouch.


The colostomy may expel atus or stool; the skin must be protected from
stool.

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374 C h a p t e r 1 8 Bowel Elimination


Use the stoma measuring

guide that is with the box of


pouches to cut the opening
in the pouch. Trace the pattern on the pouch barrier, and
cut the hole. Save the pattern
for the next pouch change.
Expect some shrinkage in the
stoma size over several weeks
postoperatively. Note: Pouches
FIGURE 18.3B
with pre-cut holes also available for later when stoma reaches mature size.
The pouch should t with no more than 1/8 inch of skin around the stoma
exposed; the stoma expands when expelling stool; a tight pouch could traumatize the stomal mucosa; a large opening causes skin irritation.
Apply Skin Prep wipe to peristomal skin, and allow to air-dry for a

few seconds.
Skin Prep degreases the skin and prepares the skin for the pouch.
Close end of pouch with pouch clamp; use a few drops of Banish

deodorizer or mouthwash into the pouch. Put a few drops of


Uniwash into the pouch or a tiny drop of dishwashing liquid to help
with cleansing and emptying the pouch.
Deodorizer and detergent help prevent odor and allow ease in rinsing and
emptying the pouch. A small squirt bottle is useful for rinsing the pouch. A
few drops of cooking oil or Pam cooking spray also allow ease in emptying
the pouch.
Place one edge of the pouch

on the skin, rolling it up and


over the stoma, while pressing all around the stoma. Use
one hand to gently stretch
the skin as the other hand
places the pouch. If using a
two-piece system, center the
wafer over the stoma and
press down gently. Angle
the pouch to the side if the
FIGURE 18.3C Center the wafer over
patient is inactive or bedridthe stoma.
den. If the patient is ambulatory, the pouch should be placed with the clamped end pointing
down, toward the feet. Frame the pouch with waterproof tape
(optional).

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 375


Good adhesion prevents leakage and skin irritation and promotes overall
well-being for the patient.
Angling the pouch downward allows ease of rinsing and emptying the
pouch.
Waterproof tape provides added security.
Chart the procedure, and notify the prescriber of any unusual

ndings.
Documentation is essential. Bleeding from the stoma, stomal separation, or
retraction is an unusual nding.
Advise the patient to sit quietly for a few minutes after the pouch

change to ensure good pouch adhesion.


Decreases the chance of leakage.
Teach the patient and/or caregiver to practice rinsing and emptying

the pouch while the patient is wearing it; this will be done 34 times
a day or when the pouch is about one-third full. The pouch change is
done every 3 to 5 days.
An empty pouch is lighter; the patient will develop an emptying routine once
usual bowel function resumes. Pouch wear time is dependent on adherence
of the pouch and patient comfort and preference.
Apply Skin-Prep wipe to the skin around the stoma, and wait

about 10 seconds for this to dry. Stretch the skin with one hand
while applying the wafer to the skin. Press gently to adhere to
the skin. Place the pouch clamp on the bottom of the pouch
and add a drop of deodorizer and liquid detergent to the pouch.
Snap the pouch onto the ange. Run a ngertip around the rim
to ensure a tight seal. Picture-frame the wafer with waterproof
tape (optional).
Skin-Prep degreases the skin and prepares the skin for the wafer. Deodorizer
and detergent reduce odors and allow ease in emptying the pouch. Checking
the ange or rim for a tight seal prevents leakage.
Waterproof tape provides added security.
Record the pouch change procedure, how the patient toler-

ated the procedure, and notify the prescriber of any unusual


ndings.
Documentation is essential for proper care of the ostomy.

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376 C h a p t e r 1 8 Bowel Elimination


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess periostomal skin for breakdown or irritation


Assess stoma for change in color, which can indicate lack of blood
supply
Assess that bag remains secure
Teach patient about ostomy supplies and community resources
Teach the patient to empty the pouch either by removing the clamp
and squirting water into the pouch or by snapping the pouch off of
the ange for rinsing and emptying
Change the adhesive wafer every 5 to 7 days or sooner if there is
leakage

KEY POINTS

FOR

REPORTING

AND

RECORDING

Condition of stoma and skin; characteristics of output.


Complications such as bleeding, stomal necrosis, retraction, or
stomal separation, and that prescriber was notied.
Time and date of ostomy change.
Patients response to altered anatomy.
Patients ability to participate in care of ostomy.
Patient and family teaching.
Discharge plans, including obtaining supplies and community
resources are initiated.

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U N I T

C H A P T E R

Renal and Urinary

19
Urinary Elimination
19.1 Inserting a Straight or Indwelling Catheter
(Male and Female), 378
19.2 Performing Catheter Care, 385
19.3 Applying a Urinary Incontinence
Collection Device, 388
19.4 Teaching Clean Intermittent SelfCatheterization, 391

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378 C h a p t e r 1 9 Urinary Elimination

PROCEDURE 19.1
Inserting a Straight or Indwelling Catheter
(Male and Female)
OVERVIEW

To drain the bladder of urine due to an obstruction or incontinence.


A straight or in-and-out catheter facilitates intermittent bladder
drainage.
An indwelling catheter allows continuous ow of urine in patients
with poor or absent bladder control.
P R E PA R AT I O N

Check prescribers order to ensure that the procedure species a


straight or indwelling catheter.
Determine if the patient is unconscious, hard of hearing, blind, or if
there are any restrictive devices attached, such as restraints, traction,
or casts.
Note on lab form if patient is having a menstrual period if specimen
is obtained for diagnostic study.

Special Considerations
Female Patient
Because the urethra is close to the anus in female patients, thorough
and careful cleaning of the perineum is very important before
catheter insertion to reduce the incidence of infection.
For postpartum or post-gynecologic surgery, the perineum and labia
may be swollen and tender; therefore, handle gently to minimize discomfort.
Elderly and Physically Challenged Patients
Will require additional time and careful handling, especially if lower
extremities are contracted, to prevent damage to muscle and bone.
Pediatric Patient
Provide age-appropriate instructions to decrease anxiety and facilitate cooperation.
For infants and children, allow parents to participate in comforting
patient.
Home Health Patient
Patients may need careful monitoring and additional education
about catheter care for indwelling and straight catheterization to
prevent urinary tract infection.

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 379


EXPECTED OUTCOMES

Patient will experience increased comfort related to decreased bladder distention or urinary incontinence
Bed linen and patients clothing will remain clean and dry for a
longer period of time
Ensures more accurate measurement of urinary output

R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery,


and/or neuromuscular dysfunction
Pain related to bladder distention or edema in perineum
Potential for infection related to possible introduction of microorganisms in urethra from repeated catheterizations with in-and-out
or poor catheter care with indwelling

EQUIPMENT/SUPPLIES

Appropriate disposable sterile catheterization tray for straight or


indwelling procedure
Additional sterile catheter if the physician orders a special type or size
(age appropriate)
Closed drainage set, if for an indwelling catheter and not included in
kit
Additional lighting as needed
Towels and washcloths for cleaning and drying perineum
Clean gloves
Tape or catheter secure device if indwelling catheter, as per facility
policy
Completed specimen identication label and laboratory requisition
form if specimen is ordered
I M P L E M E N TAT I O N
Review prescribers order; identify patient; explain purpose, proce-

dure, and how patient can assist, depending upon patients mental
status.
Conrms type and size of catheter to be inserted; meets patients right to be
informed; encourages cooperation and participation.
Gather all equipment and place on bedside table.
Provides organization and saves time.
Wash hands, and don clean gloves.
Reduces transmission of infectious microorganisms.

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380 C h a p t e r 1 9 Urinary Elimination


Adjust bed to a workable height, and lower side rail.
Creates a comfortable working position while decreasing strain on back
and arms.
Assist/place patient to a supine position with knees exed. (Use

assistance from other personnel as necessary.)


Provides good access to and visualization of perineum.
Drape patient with blanket or sheet covering abdomen and lower

legs.
For male: Cover patients upper body with a blanket, and fold bed
sheets down to expose penis.
For female: Cover patients body with a blanket or sheet. Cover
each leg with separate sheet crisscrossing sheets over the patients
abdomen. When it is time to examine the female genitalia, only the
perineum is exposed affording the patient the privacy necessary
for the exam.
Provides comfort and privacy.

FIGURE 19.1A

Cleanse perineal area with appropriate antibacterial solution, rinse

well, and dry.


Reduces presence of microorganisms near urethra.

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 381


Remove clean gloves, discard, and wash hands.
Reduces transmission of infectious microorganisms.
Open sterile package, and place plastic package container at the foot

of the bed.
Facilitates for waste disposal.
Place catheter tray on the bed between the patients legs.
Allows easy access to equipment.
Fold back blanket/sheet to expose perineum.
Helps to clearly identify urinary meatus.
Open white outer wrapping away from sterile package with last turn

toward patient.
To maintain sterile eld.
Position white package wrap under patients buttocks.
To protect bed linens.
Remove sterile absorbent pad and place under patients buttocks.

If he or she is able, have patient lift buttocks.


Maintains clean area.
Don sterile gloves, remove sterile equipment from catheter tray, and

arrange for use.


Provides easy access to equipment during procedure.
Pour antiseptic or Betadine solution over cotton balls (use a different

solution if patient is allergic to Betadine).


Cleanses.
Uncap syringe lled with lubricant, or tear open package; lubricate

catheter tip generously. Leave catheter tip in sterile lubricant on sterile eld until used.
Provides easier catheter insertion.
If specimen is ordered, uncap sterile container and place nearby on

the sterile eld.


Saves time and provides easier access when needed.
If a straight/in-and-out catheterization is being done, place the urine

collection container close to the patient.


Prevents urine from spilling onto working surface and bed.
If an indwelling catheterization is being done, place drainage bag on

sterile eld.
Provides easier access after catheter is inserted and in place.
For Male: Place the fenestrated drape (with the hole in the middle)

over the penis, exposing the urinary meatus.

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382 C h a p t e r 1 9 Urinary Elimination

For Female: Place the fenestrated drape (with the hole in the
middle) over the perineum exposing the urinary meatus.
Provides a clean working area near the catheter insertion site.
For Male: Hold the penis upright with your nondominant hand. If

uncircumcised, retract foreskin. Hold glans of penis to prevent closing of urethra.


Allows easy access when catheter is inserted.
To cleanse urinary meatus and insert catheter:

With dominant, sterile, gloved hand, use forceps to pick up a cotton


ball saturated with antiseptic or Betadine solution.
Move in a circular motion from the meatus down to base of glans.

Reduces microorganisms at meatus and moves from least contaminated


to most contaminated area.

FIGURE 19.1B

Discard each cotton ball after use.


Prevents contamination after cleaning meatus.

Repeat cleaning at least 2 to 3 more times.


Discard forceps, and with dominant, sterile, gloved hand, pick up
lubricated catheter about 3 to 4 inches from the tip.
Lift penis to a 90-degree angle (perpendicular to body) and exert
slight traction by pulling upward.

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 383

Insert catheter into urinary


meatus about 7 to 9 inches
in an adult (less in an infant
or child) or until urine begins
to ow. When urine appears,
advance the catheter another
12 inches. Hold in place.
Straightens the urethra for easier
insertion of the catheter. Also, further
advancement of the catheter ensures
proper placement.

FIGURE 19.1C

For Female: Carefully retract labia to fully expose urinary meatus

with nondominant hand.


Allows easier access when catheter is inserted.
To cleanse urinary meatus and insert catheter:

With dominant, sterile, gloved hand, use forceps to pick up a cotton


ball saturated with antiseptic or Betadine solution and cleanse the
urinary meatus with one downward stroke each time, one on each
side and then down the middle.
Reduces microorganisms at meatus and moves from least contaminated to
most contaminated area.

FIGURE 19.1D

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384 C h a p t e r 1 9 Urinary Elimination

Discard each cotton ball after use.


Prevents contamination after cleaning meatus.

Repeat cleaning at least 2 to 3 times.


With dominant hand, continue to hold labia apart.
Discard forceps and with dominant, sterile, gloved hand, pick up
lubricated catheter about 3 to 4 inches from tip.
Insert the catheter into the urinary meatus about 2 to 3 inches
(less with infants and children) or until urine begins to ow. Hold
in place.

Ensures catheter is in the bladder.

FIGURE 19.1E

If a straight/in-and-out catheterization is being done, and a urine

specimen is needed, collect about 30 mL of urine in the sterile specimen container by placing the container under the drainage end of
the catheter.
To collect a urine specimen and drain bladder without spillage of urine.
If an indwelling catheter is being inserted, follow steps for insertion;

then, with the dominant hand, ll the 10-mL balloon with approximately 8 mL of water. Gently pull back the catheter to make sure it is
in place.
Ensures catheter is in place and balloon is intact and adequately inated.
Decreases the incidence of catheter dislodging.
For an indwelling catheter, after the balloon is lled with water and

catheter is intact in the bladder, secure catheter to patients upper


leg with tape or a Catheter Secure Device, unless contraindicated by
facility policy. Secure bag to bed rail.
To ensure catheter is securely attached to patient and to reduce risk for dislodging with normal movement.

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P r o c e d u r e 1 9 . 2 Performing Catheter Care 385


Remove drapes, used catheter equipment, and dry perineum.
Patient comfort.
Position patient for comfort, side rails up, and in low position,

depending on patients activity status.


Patient comfort and safety.
Measure and record urine as indicated/ordered.
To maintain an accurate I & O record.
Discard gloves and used equipment in the proper waste disposal

and wash hands.


To prevent transfer of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance; assess level of comfort


Observe characteristics of urine and signs of urinary infection
Inform prescriber of abnormal ndings, and discuss any need for
additional or change in therapy

KEY POINTS

FOR

REPORTING

AND

RECORDING

Document and report date and time of catheterization and


specimen collected if ordered.
Characteristics of urine and signs of possible urinary infection.
Disposition of specimen if ordered.

PROCEDURE 19.2
Performing Catheter Care
OVERVIEW

To prevent the introduction of infectious microorganisms into the


urethra and bladder to cause bladder and kidney infections.
P R E PA R AT I O N

Determine patients ability to understand and cooperate in the


procedure.
Assess for signs and symptoms of urinary infection.
Determine an appropriate time for catheter care.

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386 C h a p t e r 1 9 Urinary Elimination

Special Considerations
Catheter care is most benecial if performed after defecation if
patient is incontinent.
Female Patient
In females, note if patient is having menstrual period or vaginal
discharge and, because the urethra is close to the anus, thorough
and careful cleaning of the perineum is very important.
For postpartum or postgynecologic surgery, the perineum and
labia may be swollen and tender, therefore, handle gently to minimize discomfort.
Pediatric Patient
Provide age-appropriate instructions to decrease anxiety and facilitate cooperation.
For infants and children, allow parents to participate by comforting
patient.
Home Health and Physically and/or Mentally Challenged Patients
Patients and/or caregivers may need careful monitoring and additional education about catheter care to prevent the occurrence of
urinary tract infection.
R E L E VA N T N U R S I N G D I A G N O S E S

At risk for infection related to bacterial invasion into urinary meatus


from indwelling catheter
At risk for injury related to possible renal involvement from urinary
tract infection
Pain related to urinary and/or renal infection

EXPECTED OUTCOMES

Patient will not develop a urinary tract infection


Patency of catheter will be maintained
EQUIPMENT/SUPPLIES

Wash cloth, soap, and towels


Sterile catheter care kit or
Sterile cotton balls or 22 gauze pads
Antiseptic solution
Clean gloves
Plastic bag for garbage

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P r o c e d u r e 1 9 . 2 Performing Catheter Care 387


I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist.
Decreases anxiety; meets patients right to be informed; encourages cooperation and participation.
Wash hands.
Reduces transmission of infectious microorganisms.
Provide privacy.
Encourage patients participation as appropriate.
Raise bed and lower side rail on working side.
Provides a comfortable working level.
Place patient in supine position, and expose perineal area.
To easily visualize urinary meatus.
Don clean gloves and wash the urinary meatus and the proximal

catheter with soap and water; rinse, and gently dry with towel.
Reduces transmission of infectious microorganisms.
After removing contaminated gloves and washing hands, open

catheter care kit or assemble equipment on over-bed table and


remove tape if used to secure catheter to patients upper thigh.
Reduces transmission of infectious microorganisms and organizes equipment within easy reach while maintaining a clean working area.
Don clean gloves and cleanse urinary meatus using a circular motion

moving from middle toward outside with antiseptic-soaked cotton


ball or swab. Dispose of cotton ball/swab in trash bag.
This motion prevents bacteria from entering the urinary meatus. Also, proper
disposal of contaminated materials prevents the transmission of infectious
microorganisms.
Gently pull catheter taut and cleanse with a new cotton ball/swab

from catheter insertion site down catheter tubing about 4 to 5


inches toward drainage bag. Dispose of used cotton ball/swab.
Cleans catheter and prevents bacterial growth.
Dispose of all cleaning materials in proper waste container.
Prevents transmission of infectious microorganisms.
Remove gloves and re-tape catheter (as per facility policy).
Prevents additional pull/strain on catheter by securing it to upper leg.
Position patient for comfort, lower bed, and raise side rail.
Provides comfort and safety measures.
Wash hands
Prevents transmission of infectious microorganisms.

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E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient comfort


Observe characteristics of urine and signs of urinary infection
Check test results and inform physician of abnormal ndings
Discuss appropriate therapy with prescriber

KEY POINTS

FOR

REPORTING

AND

RECORDING

Characteristics of urine and signs of urinary infection.


Document date and time catheter care was done and participation of patient and/or caregiver.

PROCEDURE 19.3
Applying a Urinary Incontinence Collection Device
OVERVIEW

To allow the patient to be able to collect urine for diagnostic studies


and I & O.
To prevent skin breakdown from urinary incontinence.
To follow prescribers orders to apply collection device.

P R E PA R AT I O N

Determine patients ability to understand and cooperate in the procedure.


Assess for signs and symptoms of urinary infection.

Special Considerations
Determine if the patient is unconscious, hard of hearing, blind, or if
there are any restrictive devices attached, such as restraints, traction,
and casts.
For postpartum or post-gynecologic surgery, the perineum and labia
may be swollen and tender; therefore, handle gently to minimize discomfort.
If contaminated during defecation, remove device and reapply.

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P r o c e d u r e 1 9 . 3 Applying a Urinary Incontinence Collection Device 389

Pediatric Patient
Provide age-appropriate instructions to decrease anxiety and facilitate cooperation.
For infants and children, allow parents to participate by comforting
patient.
Elderly and Physically Challenged Patients
Will require additional time and careful handling, especially if lower
extremities are contracted, to prevent damage to muscle and bone.
Home-Health Patient
Patients and/or caregivers may need careful monitoring and additional education about application and maintenance of this type of
catheter to prevent urinary tract infection.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery,


and/or neuromuscular dysfunction.
Pain related to bladder distention, edema in perineum, or infection.
At risk for infection related to bacterial invasion into urinary meatus
from this type of catheter and length of time applied.

EXPECTED OUTCOMES

Urine output can be monitored, and a specimen can be collected for


diagnostic studies as needed.
Bed linens will remain dry for longer periods of time and patient will
be more comfortable.
Patient will not develop a urinary-tract infection.
Patency of catheter will be maintained.

EQUIPMENT/SUPPLIES

Clean gloves
Soap, water, towels, and washcloth
Gender- and age-specic commercial urinary incontinence collection
device
Container for urine to be measured (keep in the patients bathroom)
I M P L E M E N TAT I O N
Check providers orders; identify patient; explain purpose, procedure,

and how patient can assist.


Conrms order for urinary incontinence collection device; meets patients
right to be informed; encourages cooperation and participation.

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390 C h a p t e r 1 9 Urinary Elimination


Gather equipment and wash hands.
Promotes organization; reduces transmission of infectious microorganisms.
Provide privacy.
Encourage patients participation.
Raise bed and lower side rail on working side.
Provides a comfortable working level.
Don clean gloves, wash genital area with soap and water, and dry

thoroughly.
Prevents transmission of infectious microorganisms.
Peel off paper from both sides of the adhesive liner that accompa-

nies the commercial product.


So device will adhere securely to the skin surface.
In males, place penis inside

urinary incontinence collection device, unroll the


condom along the shaft
and secure.
Ensures device will stay in place.

FIGURE 19.3A

In females, secure device over urethra area, which may extend over

the vaginal area.


Ensures device will stay in place.
Lower bed, and raise side rail as indicated by patients activity regi-

men.
Promotes patient safety.
Instruct patient and/or caregiver about application and maintenance

of this device.
Decreases anxiety and promotes cooperation by patient and/or caregiver.
Remove gloves and wash hands.
Prevents transmission of infectious organisms.
Check catheter in 15 to 30 minutes to ensure it is in place, and moni-

tor periodically.
Prevents complications and dislodging of device.

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P r o c e d u r e 1 9 . 4 Teaching Clean Intermittent Self-Catheterization 391


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and/or participation


Observe characteristics of urine
Inform provider of abnormal ndings, and discuss any need for
additional or change in therapy

KEY POINTS

FOR

REPORTING

AND

RECORDING

Document date and time of application of collection device.


Specimen collected and disposition if ordered.
Characteristics of urine and signs of possible urinary infection.
Absence/presence of complications.

PROCEDURE 19.4
Teaching Clean Intermittent Self-Catheterization
OVERVIEW

To provide the patient and/or caregiver with means of intermittently


draining the bladder due to urinary retention.
To prevent complications of bladder distention and urinary-tract
infection.

P R E PA R AT I O N

Determine patients and/or caregivers ability to understand and perform the procedure.
Determine patients mobility and independence in performing the
procedure.

Special Considerations
Note any physical or mental decits that may prevent this procedure
being preformed by patient.
Teach caregiver to perform procedure as needed.
If specimen is ordered for a diagnostic test, note and document on
container/lab form if patient is having menstrual period.
Home Health Patient
Patients and/or caregivers may need careful monitoring and additional education regarding performing this procedure.

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392 C h a p t e r 1 9 Urinary Elimination


R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery,


and/or neuromuscular dysfunction
Pain related to bladder distention
Potential for infection related to possible introduction of microorganisms in urethra from repeated catheterizations and irritation to
urethral mucosa

EXPECTED OUTCOMES

Patient will experience increased comfort related to decreased bladder distention and/or urinary-tract infections
EQUIPMENT/SUPPLIES

Appropriate disposable sterile catheterization tray


Cleansing towelette
Povidone-iodine solution (if patient is not allergic)
Sterile container for specimen, if ordered
Clean gloves
Bedpan, urinal, or commode
Specimen hat if all urine must be measured
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient will

proceed. If a caregiver will be performing this procedure, explain


procedure and assess ability to perform.
Meets patients or caregivers right to be informed; encourages cooperation
and participation.
Wash hands.
Reduces transmission of microorganisms.
Provide privacy.
Encourage patients participation.
Instruct patient to open disposable catheterization tray and put at a

convenient and close location.


Convenience of equipment for patient use.
(Refer to Procedure 19.1 Inserting a Straight or Indwelling

Catheter [Male and Female]).


Instruct female patient to put on clean gloves. Wash and dry genital
and perineal areas with soap and water. Remove soiled gloves; wash

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P r o c e d u r e 1 9 . 4 Teaching Clean Intermittent Self-Catheterization 393

hands, put on sterile gloves, and prepare equipment in a sterile tray


for catheterization.
Reduces transmission of microorganisms and reduces contamination of
specimen with transient bacteria.
Female patient: Spread the labia with ngers of nondominant hand.
Cleanse each side of labia with cotton ball/swab with antiseptic solu-

tion on it and down the middle over urinary meatus using one
stroke and one swab.
Clean from area of least contamination to greatest contamination; decreases
bacterial levels on the area.
Discard towelette.

Male patient: Instruct male patient to put on sterile gloves, retract


foreskin if not circumcised, use a clean towelette in a circular motion
from the urinary meatus and several inches on the shaft of the penis.
Show patient how to use sterile cotton ball/swab soaked with anti-

septic/Betadine solution, in a circular motion from urinary meatus


and several inches on the shaft of the penis.
Clean from least contaminated to greatest contamination to reduce bacteria
on the area.
Instruct patient to discard cotton balls/swabs and with the dominant

sterile gloved hand, pick up the lubricated catheter about 3 to 4


inches from tip and insert into the urinary meatus until urine begins
to ow. (The male urethra is longer than that of the femaleinstruct
on depth of insertion.).
Reduces transmission of infectious microorganisms.
Instruct patient to place open end of catheter in drainage container.

If specimen is needed, instruct patient to drain urine into the sterile


urine specimen container.
Prevent spillage of urine.
After bladder is emptied and urine ow stops, instruct patient to

slowly remove catheter.


Provides patient comfort.
Instruct patient to remove and dispose of all equipment.
Prevents the transmission of infectious microorganisms.
Instruct patient to wash and dry perineal area, remove and discard

gloves, and wash hands.


Prevents transmission of infectious microorganisms.

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394 C h a p t e r 1 9 Urinary Elimination


If a specimen is collected, instruct patient to tightly close the con-

tainer, touching only the outside of container and cap.


Prevents contamination of the specimen.
Instruct patient to clean outside of the container if contaminated

with urine.
Prevents transfer of microorganisms to others.
Instruct patient to label container with name, etc.
Ensures accurate patient identication.
Refrigerate specimen if it cannot be transported immediately.
Prevents deterioration of urine from bacterial contamination when left at
room temperature.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient or caregiver (if indicated) compliance and ability to


perform procedure
Instruct patient to observe characteristics of urine and signs of urinary infection, and report to prescriber
If a specimen was collected and sent to a lab for analysis, instruct the
patient to contact the prescriber for the results

KEY POINTS

FOR

REPORTING

AND

RECORDING

Note date and time of specimen collection, if applicable.


Characteristics of urine and signs of urinary infection.
Disposition of specimen, if ordered.
Teaching procedure to patient or caregiver if indicated.

C H A P T E R

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20
Bladder Irrigation
and Function
20.1 Performing and Managing Bladder
Irrigation Through a Three-Way Foley
Catheter, 396
20.2 Obtaining a Post-Void Residual Urine
Volume, 400

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396 C h a p t e r 2 0 Bladder Irrigation and Function

PROCEDURE 20.1
Performing and Managing Bladder Irrigation Through
a Three-Way Foley Catheter
OVERVIEW

To ush or wash out the bladder (intermittent or continuous) using


a closed system.
To maintain or restore catheter patency.

P R E PA R AT I O N

Use strict aseptic technique if intermittent irrigation is ordered.


Medications may be added to irrigation solution.
Isotonic irrigation solutions are used.
Check prescribers order to determine if it is a continuous or intermittent irrigation.

Special Considerations
Assess bladder for distention, because clots can occur.
Assess patient for lower abdominal pain and/or cramping.
Perform manual irrigation as needed to remove clots and reestablish
irrigation ow.
If resistance is met during manual irrigation, do not force irrigation
uid, notify prescriber.
Pediatric, Elderly, and Mentally Challenged Patients
May need closer monitoring because they may not be able to communicate problems.
R E L E VA N T N U R S I N G D I A G N O S E S

Pain or discomfort related to blood clots obstructing normal


irrigation ow
Potential for injury related to blood clots in bladder and/or urethra
and causing distention

EXPECTED OUTCOMES

All irrigation solution and debris from bladder drains into catheter
drainage bag
Continuous: Flow rate of irrigant remains constant at prescribed rate,
and bags of irrigation solution are added as needed
Catheter and drainage bag tubing remain patent
Urinary output is accurately assessed
Patient experiences no discomfort during or following procedure
Patients questions and concerns are adequately addressed

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P r o c e d u r e 2 0 . 1 Performing and Managing Bladder Irrigation 397


EQUIPMENT/SUPPLIES

Clean gloves
Three-way Foley catheter with
drainage bag in place
Warmed or room temperature
sterile irrigation solution
Sterile infusion tubing
IV pole
tel

n d
01 o
0

e ti
c

FIGURE 20.1A Triple lumen catheter.

Irrigation bag

Drip chamber
Clamp
Tubing to
irrigate port
Bladder

Inflation Triple
port
lumen
catheter
Drainage tubing
Drainage bag
FIGURE 20.1B Setup for continuous
bladder irrigation.

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398 C h a p t e r 2 0 Bladder Irrigation and Function


I M P L E M E N TAT I O N
Review prescribers orders and obtain prescribed irrigation solution

from pharmacy (unless solution is already in place at bedside).


Determines type, strength, and amount of irrigation solution, as well as frequency and timing of procedure.
Place label on irrigation bag if not labeled; include patients initials,

date, time, room number, type of solution, and any additives.


Provides safety and continuity of care.
Gather all equipment.
Enhances efficiency and patient safety.
Check patients identication band.
Ensures patient safety.
Explain procedure and its purpose to patient, and provide privacy.
Clear explanations reduce patients anxiety and increase cooperation with
procedure.
Maintains patients dignity.
Organize equipment within easy reach and drape patient, exposing

access to irrigation port on catheter only.


Enhances efficiency and patient safety.
Don clean gloves, and empty and measure urine present in drainage

bag; discard urine and gloves in appropriate receptacles.


Decreases transmission of microorganisms, provides pertinent data regarding patients urine output, and provides empty drainage bag for accurate
measurements following procedure.
Wash hands.
Decreases transmission of microorganisms.

Infusion Tubing and Irrigation Solution


Already in Place
Continuous Irrigation
Ascertain that solution is correct as prescribed.
Ensures that the irrigation solution already hanging and connected to infusion tubing is the prescribed solution.
Open ow clamp on urinary drainage tubing and on infusion tubing.
Opening drainage bag ow clamp allows infused irrigation solution to ow
from bladder into drainage bag.
Adjust ow rate to prescribed hourly rate.
Ensures that ow rate is continuous.

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P r o c e d u r e 2 0 . 1 Performing and Managing Bladder Irrigation 399

Intermittent Irrigation
Ascertain that solution is correct as prescribed.
Ensures that prescribed solution is in place.
Open ow clamp to urinary drainage bag and to infusion tubing.
Allows irrigation solution to ow into bladder, then into drainage bag.
Allow prescribed amount of irrigation solution to infuse into bladder

and then clamp infusion tubing.


Ensures that only prescribed amount is instilled into bladder.

Irrigation Solution and Infusion Tubing Not in Place


Hang irrigation solution bag on IV pole 24 to 36 inches above

bladder.
Ensures correct height for effective ow.
Connect infusion tubing to irrigation solution, prime drip chamber,

and ush tubing with solution.


Flushing infusion tubing with irrigation solution prevents air from entering
patients bladder and causing discomfort.
Close infusion tube clamp and connect infusion tubing to irrigation

port on three-way Foley.


Closing infusion clamp allows only prescribed amount of irrigant to be
infused.
Open ow clamp on urinary drainage bag.
Opening drainage bag ow clamp allows instilled irrigation solution to ow
from bladder into drainage bag.
Intermittent: Open ow clamp on infusion tubing, allowing pre-

scribed amount of irrigation solution to infuse into bladder; clamp


tubing.
Opening infusion ow clamp allows prescribed volume of irrigant to be
infused. Clamping infusion tubing ensures that only prescribed amount of
solution is instilled.
Continuous: Open ow clamp on infusion tubing and adjust the

prescribed hourly rate. Change or add irrigation solution as needed,


maintaining aseptic technique.
Ensures continuous ow of solution. Ensures continuous irrigation and
change in solution when prescribed.
Change infusion tubing every 24 to 48 hours or per facility protocol.
Reduces incidence of urinary tract infection.

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400 C h a p t e r 2 0 Bladder Irrigation and Function


Monitor urine output hourly or as ordered, subtracting the amount

of irrigant from the total output from drainage bag.


Provides pertinent information about bladder and kidney function and need
for additional or change in plan of care.
Assess drainage bag frequently and empty as needed.
Bag can ll more quickly with irrigation and often needs more frequent
emptying.
Assess color, clarity, odor, and other characteristics of urinary output

during irrigation process and each time drainage bag is emptied.


Provides pertinent information about bladder and kidney function and need
for intervention.
Discard gloves and urine in appropriate receptacles.
Reduces transmission of organisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess amount, color, clarity, odor, and character of uid in drainage


bag, noting clots, tissue prior to and following irrigation
Assess accurately urine volume and irrigant volume
Assess patients comfort level during and after procedure
Address patients questions and concerns

KEY POINTS

FOR

REPORTING

AND

RECORDING

Time

of procedure.
Irrigation solution type and amount.
Amount, color, clarity, odor, and character of contents of urinary bag (including urine and irrigant volumes) pre- and postprocedure.
Patients tolerance of procedure.

PROCEDURE 20.2
Obtaining a Post-Void Residual Urine Volume
OVERVIEW

To assess bladder function related to urine retained after voiding.

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P r o c e d u r e 2 0 . 2 Obtaining a Post-Void Residual Urine Volume 401


P R E PA R AT I O N

Assess patients and/or caregivers understanding and ability to


participate in the procedure.
Make sure patient understands that catheterization occurs immediately post-void and bladder will be drained.
Determine if specimen is needed.
Voided and residual urine volumes are attained.

Special Considerations
Patients who have had recent gynecologic surgery need careful
handling because the perineum may still be in the healing process.
Elderly, Physically, or Mentally Challenged Patients
May need more assistance for procedure.
Pediatric Patient
Explanation of procedure should be appropriate for age/developmental level and involve parents as much as possible.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery,


and/or neuromuscular dysfunction
Pain related to bladder distention or edema in perineum
Potential for Infection related to increased microorganism growth
due to urinary retention

EXPECTED OUTCOMES

Obtained residual urine volume is accurate


Patient expresses minimal discomfort during and following procedure
Patient will not develop a urinary tract infection
Patients concerns and questions are adequately addressed

EQUIPMENT/SUPPLIES

Clean gloves
Bedside commode or bedpan as needed
Toilet collection pan (hat)
Straight catheterization kit
Exam light or lamp
Bladder scanner (if used by facility)

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402 C h a p t e r 2 0 Bladder Irrigation and Function


I M P L E M E N TAT I O N
Review prescribers orders.
Determines if patient can ambulate, and frequency of residual urine volume
measurement.
Explain procedure and its purpose to patient; provide privacy.

Include caregiver when indicated.


Clear explanations reduce patient anxiety and facilitate patient/caregiver
cooperation and understanding of procedure.
Maintains patients dignity.
Gather all equipment.
Enhances organization and patient safety.
Wash hands and don clean gloves.
Reduces transmission of organisms.
Insert hat into toilet or bedside commode and assist patient to

bathroom or bedside commode, or with bedpan/urinal if needed,


and have patient void.
To collect voided urine for measurement.
Facilitates voiding in manner most comfortable or necessary for patient.
Have patient lay at and use the bladder scanner to check for

residual urine (if indicated by facility protocol).


Facilitates performance of procedure and justies bladder is not empty.
If there is a signicant residual, prepare to catheterize the patient.
Empty bladder and determine amount of residual urine.
Wash hands.
Reduces transmission of organisms.
Perform straight catheterization, maintaining aseptic technique and

being careful to completely empty bladder.


Reduces transmission of organisms.
Ensures accurate residual urine volume measurement.
Clean and dry perineum and assist patient to a comfortable position.
Reduces transmission of organisms and promotes patient comfort.
Measure voided and residual urine.
Provides pertinent information regarding bladder status.
Obtain a specimen, if ordered, and then dispose of urine. Dispose of

contaminated equipment in appropriate receptacles.


A specimen may be ordered to monitor for urinary-tract infection.
Reduces transmission of organisms.

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P r o c e d u r e 2 0 . 2 Obtaining a Post-Void Residual Urine Volume 403


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess accurately both voided and residual urine volumes


Assess color, clarity, odor, and character of both voided and residual
urine
Assess patients comfort level during and following procedure
Address patients questions and concerns

KEY POINTS
Time

FOR

REPORTING

AND

RECORDING

of procedure and patients tolerance.


Report any unusual ndings to prescriber that may need
additional follow-up and change in therapy.

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U N I T

C H A P T E R

Musculoskeletal

21
Body Alignment
and Mechanics
21.1 Maintaining Proper Body Alignment, 406
21.2 Performing Correct Lifting
Techniques, 411

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406 C h a p t e r 2 1 Body Alignment and Mechanics

PROCEDURE 21.1
Maintaining Proper Body Alignment
OVERVIEW

To provide the patient with proper body alignment, thus promoting


comfort and preventing bone, joint, muscular, skin, neural, lymphatic,
circulatory, or tissue damage.
P R E PA R AT I O N

Check prescribers order to ensure that patient can be moved to various positions.
Determine need to assist the patient to various positions.
Determine presence of IV equipment, surgical wounds, drains, or
mechanical equipment.
Determine need for extra pillows and covers, level and position
of bed.
Before beginning, assess skin surfaces for signs of pressure areas,
such as blanched or reddened areas.
Assess patients diet (e.g., high protein, high calorie, diabetic, cardiac)
Avoid serving foods that cause alkaline ash and residue, such as
tomato or grapefruit juices. Encourage an adequate amount of vitamin C foods that acidify patients urine.
Monitor patients urine for sediment.

Special Considerations
Most patients require frequent repositioning, but this will vary with
each patient and situation.
Repositioning will require a complete and thorough assessment of
the patient to optimize patient comfort and proper alignment.
Provide intellectual stimulation. Suggest receiving visitors; working
crossword puzzles; reading newspapers, books, magazines; and playing computer games.
Elderly and Physically and/or Mentally Challenged Patients
Will often require more time for communication and understanding
of positioning techniques.
Provide more time for moving and exercising activities.
Pediatric Patient
Involve parents in procedure and mobility activities to reduce anxiety and enhance cooperation of infants and children.

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P r o c e d u r e 2 1 . 1 Maintaining Proper Body Alignment 407


R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or growth


decit
Pain/discomfort related to inability to cope with body movements
and prescribed alignment plan

EXPECTED OUTCOMES

Proper body alignment will be maintained at all times


Patient will verbalize comfort in prescribed positions
Patient will experience minimal discomfort in attaining proper body
alignment for proper body posture

EQUIPMENT/SUPPLIES

Pillows
Blankets
Sheets
Foot-drop stop
Splints
Heel and elbow protectors
Floating mattress
Air or water mattress
Egg crates
Trochanter rolls
Lumbar roll
Chair or positional bed
I M P L E M E N TAT I O N
Review prescribers order.
Determine what is to be done and ability of patient to move.
Gather all equipment before moving the patient.
Saves time and allows patient to prepare for movement in/out of bed.
Explain procedure and purpose to the patient/caregiver.
Knowledge of procedure allows the patient to prepare for the procedure.
Decreases dependency, disorientation, decreased motivation, and insomnia.
Promotes relaxation.
Don gloves and gown as necessary.
Reduces transmission of infectious organisms.
Assist patient to desired position for proper body alignment (use

assistance of another health-care provider if patient is unable to


assist).
Allows the position of comfort with correct alignment for the patient.

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408 C h a p t e r 2 1 Body Alignment and Mechanics


Use the draw sheet or pull sheet to assist the patient in movement in

bed (use assistance of another health-care provider if patient is


unable to assist). Another health-care provider may be needed to
assist the patient to a chair or to stand.
Assists in repositioning the patient.
Place pillows, foot-drop stops,

splints, trochanter (sheet roll


or blanket) between legs,
under legs, or behind back
as appropriate for comfort
and positioning.
Maintains position of comfort with correct alignment
of the patient. Decreases
back pain and/or discomfort.
Ensures that joints and muscles are properly supported.

FIGURE 21.1A A footboard is placed

at the end of the bed to prevent foot


drop.

Greater
trochanter
FIGURE 21.1B Trochanter roll prevents external rota-

tion.
Assess all skin surfaces for pressure signs, such as blanched or red-

dened areas.
Prevents tissue damage in areas of bony prominences, heavy tissue, or
surgical-site areas.

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P r o c e d u r e 2 1 . 1 Maintaining Proper Body Alignment 409


Gently massage around (never on) pressure areas.
Massage increases circulation to the area to prevent painful, reddened areas
and decubitus ulcers. Prevents venous stasis, thrombus formation, and
orthostatic hypotension.
Perform complete range of motion at least three times per day.
Maintains or increases muscle tone and prevents muscle atrophy. Prevents
contractures; promotes relaxation and enhances exibility.
Turn and position patient frequently according to individual needs.

Elevate areas as needed.


Prevents contractures, pressure points, thrombus formation, and decubitus
ulcers. Prevents backaches and osteoporosis from disuse. Reduces edema.

FIGURE 21.1C The oblique position.

Alternate use of chair, bed, or

standing as appropriate for


individual patient.
Promotes independence in
choices of care. Eliminates
the feeling of loss of control
and decient state of wellness.

FIGURE 21.1D Assisting patient


to chair using a transfer belt.

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410 C h a p t e r 2 1 Body Alignment and Mechanics


Provide instructions for and encourage coughing and deep

breathing in all positions.


Prevents pooling of respiratory secretions thus restricting respiratory
infections, hypostatic pneumonia, atelectasis, respiratory acidosis,
and pulmonary emboli.
When positioning is complete, return patient to comfortable

position.
Patient comfort.
Remove gloves (if used), discard, and wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient comfort and body alignment position


Assess for complications such as contractures, decreased muscle
tone, muscle atrophy, backaches, or osteoporosis
Make sure supportive devices are correctly positioned and maintained
Assess patients skin for signs of pressure, such as blanched or
reddened areas
Assess status of the respiratory and circulatory systems for venous
stasis, thrombus formation, orthostatic hypotension, pooling of
secretions, respiratory infections, atelectasis, respiratory acidosis,
or pulmonary emboli
Assess complications associated with immobility such as anorexia,
constipation, renal calculi, urinary retention, or urinary tract
infections

KEY POINTS

FOR

REPORTING

Position of patient.
Patients response to change.
Any tissue deviation or damage.

AND

RECORDING

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 411

PROCEDURE 21.2
Performing Correct Lifting Techniques
OVERVIEW

To provide the patient and health-care provider with knowledge to


perform correct lifting techniques, thus preventing stress, fatigue,
trauma, and injury to promote comfort and prevent bone, joint, muscular, skin, or neural damage.
P R E PA R AT I O N

Check prescribers order to appraise the amount of lifting the patient


can perform.
Determine need to assist the patient in the process of lifting.
Assess the knowledge the patient has about the process of lifting.
Determine need for any equipment to assist patient in the lifting
process, proper body alignment, and correct body mechanics.

Special Considerations
Some patients require frequent re-educating about correct lifting
positions.
The ability to perform lifting procedures may vary with each
situation.
Elderly and Physically Challenged Patients
May take longer to perform techniques due to limited mobility.
R E L E VA N T N U R S I N G D I A G N O S E S

Pain/discomfort related to inability to perform correct lifting techniques due to limited mobility from poor muscle tone
Risk for injury related to improper lifting techniques

EXPECTED OUTCOMES

Position will be comfortable and enhance proper body alignment


at all times while performing the lifting process
Patient will experience minimal discomfort in attaining proper
body posture for lifting
Patient will demonstrate proper lifting techniques in all
performances
Patient will express the value to his present and future health
from the utilization of proper body alignment during the lifting
process

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412 C h a p t e r 2 1 Body Alignment and Mechanics


EQUIPMENT/SUPPLIES

Any positional aids such as pillows or blankets


I M P L E M E N TAT I O N
Review prescribers order.
Determine ability of patient to lift.
Gather all materials/equipment before approaching the patient.
Saves time and allows patient to prepare for learning the lifting
maneuvers.
Explain procedures and purposes to the patient and/or caregiver.
Knowledge of procedure allows the patient to prepare for the procedure.
Decreases dependency, disorientation, decreased motivation, and
trauma from improper techniques.
Don gloves and gown if necessary.
Reduces transmission of infectious organisms.
Assist patient to desired position for proper body alignment (use

assistance of another health-care provider if patient is unable to


assist). Teach patient to use proper body mechanics.
Allows the position of comfort with correct alignment for the patient. Proper
body mechanics can prevent back injury, help speed up recovery if injured,
and prevent further injury after back is healed.
Begin teaching the various lifting techniques. Use assistance of

another health-care provider if patient has difficulty in standing


alone.
Knowledge of the actual techniques will increase the patients selfcondence and ensure future health.
Have the patient test the weight of the load. Ascertain that the

patient can lift the weight safely. If not, use an assistive device.
Safety at a task reduces trauma, pain, discomfort, and future injury.
Ensures that joints and muscles are properly positioned.
Keep the back in its natural curve by bending at the hips and/or

knees with the low back erect.


Position allows for safe distribution of the forces.
Maintain a wide base of support with feet.
A solid and wide base of support reduces the possibility of slipping.

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 413

FIGURE 21.2 Wide stance lowers the center of gravity and


is more stable.

Hold objects as close to the body as possible.


A wide base of support reduces stress to the muscles, ligaments, skeletal
structure, and tissue of the back.
Avoid twisting motion when lifting and carrying the object.
Moving or changing the direction with the feet decreases the stress
and load on the structures of the back.
Tighten stomach muscles when lifting.
Assisting with the abdomen reduces strain on the back during the lifting
process.
Plan the lift before beginning the process.
Previous planning decreases the chance of damage to the body.
Lift with the large muscle group of the legs.
Use of the large muscle groups of the legs diminishes the forces on the low
back.
Make certain that the pathway is clear prior to beginning the move.
A clear pathway eliminates slipping or falling.
To squat-lift something of moderate size and weight:

Stand close to the object to be lifted.

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414 C h a p t e r 2 1 Body Alignment and Mechanics

Squat down, keeping the back straight, and rmly grasp the
container.
Pick up the container and hold it close to the body.
Tighten the abdominal muscles and stand up slowly and smoothly
letting the large leg muscles do the work.

Firm abdominal muscles strengthen the back. Use of the large muscle groups
of the legs reduces the strain on the structures of the back.
The half-kneel lift may be helpful with things that have an irregular

shape or may tend to move when lifted (e.g., pets, children).


Stand close to the object, and squat down onto one knee.
Keep the back straight; pick up the object and slide it up onto thigh
and then cradle the object against the body.
Tighten stomach muscles and slowly stand, using the strong leg
muscles.

Use of the large muscle groups of the legs reduces the strain on the structures
of the back. Proper body mechanics reduces trauma to the various body
parts.
The overhead lift is used when lifting objects down from a high sur-

face. A stepstool should be used when the object is higher than the
head.
Move close to the object.
Place one leg in front of the other.
Shift weight slightly to the front leg.
Reach up and rmly grasp the object in both hands while keeping
the back straight.
Slowly lift the object off the shelf and shift equal weight back onto
both feet.
Carefully lower the object down to the chest.
Maintaining proper body mechanics ensures stress and trauma reduction.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient comfort and body alignment position


Teach patient about all aspects of lifting
Assess for complications such as contractures, decreased muscle
tone, muscle atrophy, backaches, or osteoporosis
Supportive devices, if needed, are correctly positioned and
maintained
Monitor that patient assumes correct body mechanics for each
lifting procedure
Assess for injury in the lifting procedure

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 415

KEY POINTS

FOR

REPORTING

AND

RECORDING

Position of patient when lifting.


Patients responses to lifting procedures.
Any injury or damage the patient might experience.

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C H A P T E R

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22
Exercise and
Ambulation
22.1 Performing Passive Range-of-Motion
(ROM) Exercises, 418
22.2 Teaching Isometric Exercises, 422
22.3 Teaching the Patient to Crutch Walk
or Use a Walker, 425

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418 C h a p t e r 2 2 Exercise and Ambulation

PROCEDURE 22.1
Performing Passive Range-of-Motion (ROM) Exercises
OVERVIEW

To enhance/maintain joint ROM and soft tissue integrity, assist


circulation and synovial nutrition, decrease formation of contractures, reduce or inhibit pain, and facilitate active ROM.
P R E PA R AT I O N

Check prescribers orders to ensure passive ROM can be performed.


Passive ROM is not the same as stretching.
Movements should be performed in a pain-free ROM.
Passive motion does not take the place of active motion.
Will not prevent muscle atrophy.
Will not increase strength or endurance.

Special Considerations
Careful handling needs to be done any time there is a surgical site,
and this includes ROM restrictions or contraindications.
Elderly, Pediatric, Unconscious, or Confused Patient
May take more time and communication to complete correctly.
Assess skin condition before beginning, and use gentle handling.
Include caregiver as much as possible because they may be participating when the patient goes home.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to cope with extremity movements
Potential for injury related to improper ROM techniques
used, such as extra force on a joint

EXPECTED OUTCOMES

Patient will experience comfort


Maintenance or enhancement of ROM
Assist in circulation and healing

EQUIPMENT/SUPPLIES

Gloves

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P r o c e d u r e 2 2 . 1 Performing Passive Range-of-Motion (ROM) 419


I M P L E M E N TAT I O N
Review prescribers order.
Determine if patient can be moved and any limitation of movement.
Explain procedure to patient and/or caregiver.
Enhances relaxation, understanding, and cooperation.
Don gloves and gown.
Reduces transmission of infectious organisms.
Adjust bed to appropriate height for provider.
Ensures proper mechanics and decreases strain.
Assess placement of IVs, catheters, etc.
Determine if any device will restrict motion.
Lower side rails.
Allows easier access to patient and allows good mechanics.
Expose body part/extremity where ROM exercises will be performed,

and drape patient appropriately.


Allows free motion of patient while providing privacy.
Hold area to be moved close to joint (hand and wrist, hip, knee).
Supports affected joint.
Provide support of remaining extremity or injured site.
Provides patient comfort and encourages relaxation.
Move extremity through pain-free ROM (PROM) 5 to 10 times.

Follow anatomical planes or line of muscle.


Accomplishes goals of PROM.

Neck

FIGURE 22.1

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420 C h a p t e r 2 2 Exercise and Ambulation

Wrist/hand

Shoulder

Hip

Elbow

Knee

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P r o c e d u r e 2 2 . 1 Performing Passive Range-of-Motion (ROM) 421

Foot

FIGURE 22.1 (continued)

Monitor patients response to treatment, including facial

reactions, subjective reports, tissue response, vital signs,


and ROM.
Provides information regarding accomplishment of treatment
and adjustments in speed and ROM if necessary.
Reposition patients extremity and cover appropriately.
Promotes comfort.
Raise and secure side rails and other protective devices

in use.
Patient safety.
Document treatment.
As required by facility.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient appears relaxed and correctly positioned


Patient verbalizes comfort after treatment

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients response to treatment, including subjective and body


response.
Procedure performed, including direction and repetitions.
Any limitations felt during motions.
Report and discuss with prescriber any unusual ndings, such
as skin breakdown, increased pain after therapy.

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422 C h a p t e r 2 2 Exercise and Ambulation

PROCEDURE 22.2
Teaching Isometric Exercises
OVERVIEW

To assist the patient to decrease pain, increase circulation when


little resistance is applied, and increase strength, endurance, and
circulation when adequate resistance (60%80% maximum
capacity) is applied.
P R E PA R AT I O N

Check prescribers orders to ensure that isometric exercises can be


initiated.
Multiple angles may need to be performed, because strength
gains are accomplished at the position performed.
Site of application of resistance is usually distal to the segment
desired to be strengthened.
Force is applied opposite the desired direction of movement.
There is no change in joint position during application.

Special Considerations
Gentle handling may be necessary for a patient with a surgical
site, including ROM, muscle contraction, healing restrictions, and
contraindications to prevent injury.
Determine need to educate caregivers about procedure.
Elderly and Physically Challenged Patients
Determine and give consideration to patients physical conditioning and cognitive status.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to cope with body movements
At risk for injury related to improper use of isometric exercises

EXPECTED OUTCOMES

Patient will increase strength in extremities


Increase circulation to applied area
Patient will experience an increase in comfort and healing time

EQUIPMENT/SUPPLIES

Gloves

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P r o c e d u r e 2 2 . 2 Teaching Isometric Exercises 423


I M P L E M E N TAT I O N
Review prescribers orders.
Determine if patient can be moved and any limitation or contraindication to
treatment.
Explain procedure to patient and caregiver as indicated.
Enhances patient/caregiver understanding, participation, and relaxation.
Don clean gloves.
Reduces transmission of infectious organisms.
Evaluate patients motion and strength.
Determines how much resistance and ROM for isometric contraction to be
performed.
Place patient in comfortable position.
Promotes relaxation.
Position yourself so that you can use good body mechanics.
Ensures provider safety.
Assess placement of IVs, and catheters.
Determine if devices will restrict techniques.
Expose body part to be exercised.
Ensures no restriction from clothing.
Drape patient appropriately.
Promotes patient privacy.
Place extremity in desired position.
To prevent possible injury.
Stabilize extremity by holding in place.
Helps prevent substitution from other muscle groups.
Demonstrate movement by taking extremity through passive

ROM.
Enhances patients understanding of motions.
At desired angle, instruct patient to hold against resistance.
Allows proper and safe movements.
Advance slowly to movements that are maximum and pain-free

that the patient can tolerate.


Provides maximum effect of exercise without pain and/or injury.
Allow resistance to build from minimum to maximum.
Allows patient understanding of movements and optimal muscle
contraction.

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424 C h a p t e r 2 2 Exercise and Ambulation


Hold contraction 10 seconds.
Allows physiological changes to occur.
Reassess patients status related to strength, pain, and

substitution.
Allows adjustments in resistance, joint angle, and patient
position.
Repeat 10 times and then consider different angles for strengthen-

ing entire muscle.


Allows treatment effects to entire muscle length.
Adjust resistance, ROM, patient position.
Ensures pain-free but maximum performance.
Monitor patients response to treatment, including facial reactions,

subjective reports, tissue response, vital signs, and ROM.


Provides information regarding accomplishment of treatment
and adjustments in speed and ROM if necessary.
Reposition patients extremity and cover/drape appropriately.
Promotes patient comfort.
Raise side rails and replace any other protective devices in use.
Patient safety.
Document treatment.
As required by facility.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients ability to perform exercises


Assess patients compliance with exercise schedule
Assess muscle tone
Assess for complications of bedrest, including thrombophlebitis,
atelectasis, renal calculi, pressure ulcers, joint deformity

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients response to treatment, including subjective and


body response.
Procedure performed, including body part, direction, resistance, and repetitions.
Any limitations/restrictions to treatment.
Patient response/tolerance to treatment.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 425

PROCEDURE 22.3
Teaching the Patient to Crutch Walk or Use a Walker
OVERVIEW

To allow patients to resume daily transfers, improve self ADLs,


and increase household and community ambulation following
deconditioning and/or surgery.
P R E PA R AT I O N

Always use gait belt for patient safety.


For safety considerations, ensure patient understands procedures.
Check prescribers orders regarding teaching crutch walking
and/or using a walker.

Special Considerations
For post-op patients, consideration has to be given to weightbearing precautions, contraindications, and deconditioning
Determine need to educate caregivers about the procedure
and importance of safety measures
Elderly Patient
Most often will require instruction on a walker versus crutches
due to decreased physical tness.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, and/or


neuromuscular dysfunction
Pain/discomfort related to inability to cope with extremity
movements
Potential for injury related to improper movements with crutches
or a walker

EXPECTED OUTCOMES

Patient will be able perform self ADLs with minimal or no assistance or discomfort
Patient will be able to ambulate independently while following
precautions
Patient will be able to assist in self-reconditioning

EQUIPMENT/SUPPLIES

Axillary crutches/walker
Gait belt

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426 C h a p t e r 2 2 Exercise and Ambulation


I M P L E M E N TAT I O N
Review prescribers orders regarding the use of crutches or a walker.
Determine if patient can be ambulated, and note any precautions or weightbearing restrictions.
Don clean gloves.
Reduces transmission of infectious organisms.
Assess patients mental status.
Determines if patient can follow explanations to ensure safety.
Assess patients upper-extremity and lower-extremity strength.
Ensures strength is adequate for gait training.
Assess patients balance.
Helps in selection of assistive device.
Determine appropriate gait pattern and assistive device based on

physical and mental assessment, and record review.


Ensures safety for patient.
Follow surgical precautions.

TABLE 22.3A Different Types of Gait Patterns


Four-point
pattern

Most stable pattern.


Requires bilateral ambulation device (crutches, cane).
Alternate pattern (i.e., left crutch advances and then right foot
advances, right crutch advances and then left foot advances, etc.).
Slow gait pattern.

Two-point
pattern

Requires bilateral ambulation device (crutches, canes)


Faster than four-point.
Requires increased balance and coordination.
Reciprocal motion (i.e., right foot and left crutch together, then left
foot and right crutch, etc.).

Three-point Used with crutches or walkers.


pattern
Used when patient requires nonweight-bearing status
Less stable pattern.
Requires good upper-extremity strength and coordination.
Assistive device and nonweight-bearing extremity advanced and
then patient steps up to or through with full weight-bearing extremity.
Crutches or walker.
Modied
three-point Use when allowed only partial weight-bearing.
Progress assistive device and partial weight-bearing extremity simulpattern
taneously, and then progress full weight-bearing lower extremity.
More stable, than three-point gait pattern.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 427

2-Point Gait

3-Point Gait

4-Point Gait

Partial weight bearing,


both feet: faster, but
less support than a
4-point gait.

Non-weight bearing;
faster than a 4-point
gait; can be used with
walker

Partial weight bearing,


both feet; patient must
shift weight constantly

4. Advance right foot


and left crutch

4. Advance right foot

4. Advance right foot

3. Advance left foot


and right crutch

3. Advance left foot


and both crutches

3. Advance left crutch

2. Advance right foot


and left crutch

2. Advance right foot

2. Advance left foot

1. Advance left foot


and right crutch

1. Advance left foot


and both crutches

1. Advance right crutch

Tripod postition

Tripod postition

Tripod postition

FIGURE 22.3

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428 C h a p t e r 2 2 Exercise and Ambulation


Assess for IVs, catheters, etc.
Determine if any device will restrict and/or interfere with selected gait
pattern.
Assess walking area for hazards and/or barriers.
Ensure safe walking environment.
Check crutches/walker for safety (i.e., bolts tight, rubber caps not

worn).
Ensure equipment safety.
If necessary, transfer patient to seated position.
Allow patient to watch demonstration of gait pattern.
Apply gait belt.
Ensure patients safety.
Demonstrate selected gait pattern.
Educate patient on correct procedure.
Have patient explain procedure to you.
Ensures patient understanding of techniques.
If performing four-point pattern:

Instruct patient to move one crutch, then opposite foot.


Maintain grip on gait belt.
Continue with opposite crutch, then opposite foot.
Repeat.

For use with unstable patient.


If performing two-point pattern:

Instruct patient to move one crutch and opposite foot


simultaneously.
Repeat with other side.

For use when safety remains a concern.


If performing three-point pattern:

Instruct patient to move crutches/walker forward, advance


nonweight-bearing lower extremity.
Instruct patient to advance uninvolved extremity placing weight
through upper extremity.
Maintain grip on gait belt.

For use with nonweight-bearing lower extremity, a walker is more stable.


Patient safety.
If performing modied three-point pattern:

Instruct patient to progress assistive device and partial weightbearing lower extremity.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 429

Instruct patient to advance uninvolved lower extremity to or


through placing weight through upper extremity and partial
weight-bearing lower extremity.
Maintain grip on gait belt.

Patient safety.
Walk at least 20 feet.
Ensures patient performance safety and understanding.

Ascending (if nonweight-bearing lower extremity)


With crutches: Patient pushes through crutches to raise unin-

volved lower extremity to next step.


With walker: Place up onto curb rst and then raise uninvolved

lower extremity by pushing through walker.


To allow clearance to step.
With crutches and walker:

Hold nonweight-bearing knee in exion.


Step up and advance crutches or walker.
Repeat.

Descending
When full weight-bearing allowed with crutches:

Lower crutches/walker and weak lower extremity down to


next surface while bending/controlling with strong lower
extremity.
Step down with strong lower extremity placing weight through
walker or crutches.

Allows control of weak lower extremity with strong lower extremity.


When nonweight-bearing on lower extremity:

Place nonweight-bearing lower extremity in front of body.


Place crutches/walker on surface below.
Allows control with weight-bearing lower extremity and protects
nonweight-bearing extremity.

Lower down to next level by bending strong leg and placing


weight through crutches/walker.

Maintain grip on gait belt.

Ensures patient safety.

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430 C h a p t e r 2 2 Exercise and Ambulation

All Patients
Monitor patients response to treatment including difficulties, safety

concerns, subjective reports, and visual signs.


Provides information regarding appropriateness of device selection and
modication, if needed.
Return patient to sitting or lying position with call button.
Provides patient comfort.
Document treatment including any equipment needs for discharge.
Communication and facilitation of patient care.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients ability to ambulate with assistive device


Assess patients tolerance of activity, distance he or she can ambulate, proper technique

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients response to treatment including subjective, body


response, and safety.
Assistive device, gait pattern, assistance required, and for what
length/time of ambulation.
Any safety concerns for patient and other caregivers.

C H A P T E R

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23
Transfer and
Positioning
23.1 Moving and Positioning the Patient
in Bed, 432
23.2 Transferring a Patient from Bed
to Wheelchair, 437
23.3 Teaching Hip Precautions, 439

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432 C h a p t e r 2 3 Transfer and Positioning

PROCEDURE 23.1
Moving and Positioning the Patient in Bed
OVERVIEW

To facilitate and maintain correct body alignment, reduce discomfort, and promote normal tissue integrity.
P R E PA R AT I O N

Check prescribers orders for specic restrictions.


Assess patients ability to assist with moving.
Determine patients and/or caregivers ability to understand and
follow instructions.
Assess patients activity tolerance.
Determine comfort level of patient.

Special Considerations
Be sure that IV and/or drainage tubing is positioned to prevent
tension or tangling during procedure.
If the patient is in isolation or if there is presence of body uids
or wet bed/clothing, wear gloves, gown, and any other personal
protective equipment as indicated.
Elderly and Physically Challenged Patients
Often have fragile skin; be careful not to drag the patient across
the sheets, because it could cause skin sheering or tearing.
May take more time due to contractures and fragile bones.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to tolerate body movements
Impaired skin integrity related to limited mobility and prolonged
pressure on bony prominences
Self-care decit related to mental and/or physical impairment

EXPECTED OUTCOMES

Patient will be moved and positioned in bed without injury or


discomfort
Patient will maintain proper skin integrity with positioning
regimen

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P r o c e d u r e 2 3 . 1 Moving and Positioning the Patient in Bed 433


EQUIPMENT/SUPPLIES

Hospital bed with side rails


Pillows
Trapeze if indicated
Turn sheet or draw sheet
Clean gloves
Personal protective equipment (if indicated)
I M P L E M E N TAT I O N

Moving Patient Up in Bed (One Nurse)


Wash hands and don gloves and any other personal protective

equipment, if indicated.
Reduces transmission of microorganisms.
Explain procedure to patient and/or caregiver as indicated, and

how to assist if able.


Reduces anxiety. Increases comprehension and cooperation. Promotes
patient autonomy.
Raise bed to your thigh level. Place patient on back with head of

bed in at position. Lower side rails on side nearest you. Lock bed
wheels.
Lessens strain on nurses back muscles. Reduces gravitys pull on patients
upper body. Promotes patient safety.
Remove pillow and place against the headboard.
Prevents striking patients head against head of bed.
Have patient fold arms across chest.
Prevents injuring the patients arms during the move.
If available, have patient hold on to overhead trapeze.
Allows patient to assist with move, thus promoting patients autonomy.
Have patient ex knees, and place feet at on bed.
Allows patient to assist with move.
Stand at an angle to the head of the bed, feet apart, knees bent,

and feet toward the head of bed.


Promotes good body mechanics.
Place one hand and arm under patients shoulder, and the other

under patients thigh.


Distributes patients weight more evenly. Supports shoulder and hip joints.

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434 C h a p t e r 2 3 Transfer and Positioning


Rock forward toward the head of the bed, lifting patient with

you while having patient push with his/her legs. Note: If trapeze
available, have patient pull up holding onto trapeze as you move
patient upward in bed.
Allows a smooth motion to lift patient. Assistance from patient reduces
strain on nurses back muscles. Promotes patient autonomy.
Replace patients pillow under the head. Elevate head of bed to

position tolerated by patient.


Promotes patient comfort. Facilitates activities such as eating and
drinking.
Repeat steps if necessary until patient is high enough in bed.
Heavy or immobile patients are often not moved far enough in one
step.
Raise side rails. Lower bed.
Promotes patient safety.
Wash hands.
Reduces transmission of microorganisms.

Moving Patient Up in Bed (Two Nurses)


With two nurses on opposite sides of bed, lower side rails. Lock

the wheels on the bed.


Promotes patient safety.
Remove pillow and place against headboard.
Prevents striking patients head against top of bed.
Place draw sheet on bed under patients midsection.
Supports patients weight and reduces friction during move.
Roll or bunch sheet so edges are close to patients body and

grasp rmly next to patients shoulders and hips.


Provides support under heavy parts of the body and places the nurses
hands close to the weight to be moved.
If able to assist, have patient ex knees and place feet at on

bed.
Allows patient to assist with move.

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P r o c e d u r e 2 3 . 1 Moving and Positioning the Patient in Bed 435


Facing head of bed, the nurses stand on either side of the

patients center with knees exed and feet apart in a broad


stance.
Increases stability and provides balance. Promotes good body
mechanics.
On signal, rock and shift weight

from back to front leg, moving


patient upward in bed in one
smooth motion. If possible,
patient can assist with this
move by pushing with his
or her legs. Repeat the move
if necessary.
Provides additional force of
body weight, reduces force
needed to move load and
decreases work of muscles
during movement. Patients
assistance lessens strain on
nurses back muscles and
promotes patient autonomy.
FIGURE 23.1A

After each positioning, realign patient, replace pillows and

other positioning aids. Replace bed to safe position; remove


gloves and other protective equipment; wash hands.
Promotes patient comfort. Maintains correct body alignment. Reduces
transmission of microorganisms.

Turning a Patient in Bed


Position patient near far side of bed in supine position.
Provides room for patient to safely turn to side.
Position patients near arm across the chest. Slightly abduct

the patients far shoulder from the side of the body. Place the
patients near ankle and foot across the far ankle and foot.
Prevents injury to patients arm. Facilitates movement during roll.

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436 C h a p t e r 2 3 Transfer and Positioning


Place your hands on patients

far shoulder and hip and roll


patient toward you. If drawsheet is in place, grasp it near
patients shoulder and hip
instead.
Maintains proper body alignment. Drawsheet provides
continuous support for
patients back and should
be used when available.

FIGURE 23.1B

Stand opposite patients center with feet in wide stance and one

foot ahead of the other. Tighten abdominal and gluteal muscles,


and ex your knees.
Promotes good body mechanics. Wide stance provides a stable base of
support. Increases stability and provides balance.
Position patient with pillows and other positioning aids; raise side

rails; lower bed; remove gloves and other protective equipment;


wash hands.
Promotes safety and reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient was repositioned without injury and reports comfort


Patient will maintain adequate skin integrity after moving and
positioning therapy

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients body alignment and position, and comfort level.


change in skin condition.

Any

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P r o c e d u r e 2 3 . 2 Transferring a Patient from Bed to Wheelchair 437

PROCEDURE 23.2
Transferring a Patient from Bed to Wheelchair
OVERVIEW

To promote safety, prevent injury, and maintain correct body


alignment.
P R E PA R AT I O N

Check prescribers orders for specic restrictions regarding patient


activity and positioning.
Assess patients ability and motivation to assist.
Determine patients and/or caregivers ability to understand and
follow instructions.
Assess joint mobility and muscle strength of extremities.
Determine presence and location of any equipment and tubing.

Special Considerations
Some patients may need analgesic medication to enhance comfort
prior to moving.
Elderly, Pediatric, Confused, and Physically
or Mentally Challenged Patients
May require more time, teaching, and assistance.
Involve family and/or caregiver in teaching of this procedure.
Monitor activity while in wheelchair.
Use seat belts/special restraint devices that fasten behind the wheelchair to protect from sliding down and falling.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to tolerate moving, sitting, and/or
standing
Self-care decit related to mental and/or physical impairment

EXPECTED OUTCOMES

Patient will be transferred from bed to wheelchair without injury and


with minimal or no discomfort
Patient and/or caregiver will be able to assist with the procedure

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438 C h a p t e r 2 3 Transfer and Positioning


EQUIPMENT/SUPPLIES

Wheelchair
Clean gloves
Any other personal protective equipment as needed
I M P L E M E N TAT I O N
Explain procedure to patient and signicant others.
Reduces anxiety and enhances participation.
Wash hands and don gloves.
Reduces spread of microorganisms.
Close door or curtain.
Provides for privacy.
Assist patient to put on robe and non-slippers or shoes.
Promotes safety by reducing the risk for falls and injury.
Place bed in lowest position.
Facilitates transfer to wheelchair.
Position the wheelchair as close as possible to the bedside facing the

foot of the bed. When sitting at side of bed, patient should be able to
steady self by using the hand on the unaffected side to grasp the
arm of the wheelchair.
Facilitates use of stronger side to provide balance and improve stability
during transfer.
Lock wheels of bed and wheelchair. Raise foot pedals on wheelchair.
Promotes patient safety.
Raise head of bed to highest position.
Decreased expenditure of energy.
Assist patient to sitting position on side of bed by supporting

patients head and neck while moving patients legs over edge of the
bed to dangle. Steady patient in this position for a few minutes.
Facilitates transfer to the wheelchair and allows circulatory system to adjust
to change in position (reduces risk for postural hypotension).
To assist patient to standing position, face patient and brace your

feet and knees against the patient (especially against the patients
affected extremity).
Promotes stability and use of unaffected extremities to facilitate movement.
Pivot the patient (on unaffected limb if applicable) toward seat

of chair with legs positioned against the chair.


Enhances patients sense of security and ensures proper position before
sitting.

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P r o c e d u r e 2 3 . 3 Teaching Hip Precautions 439


The patient may use one arm (the unaffected limb if applicable)

to place on the arm of the wheelchair while slowly easing self to


sitting position in wheelchair.
Ability to use own arm provides support and stability for patient.
Continue to brace patients knees with your knees and ex your

hips and knees when lowering patient to sitting position.


Reduces potential for strain on the nurses back.
Adjust or support patients position with pillows where necessary.
Promotes proper body alignment and comfort.
Place call light within reach.
Promotes patient safety.
Remove gloves and other protective equipment, and wash hands.
Reduces spread of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients tolerance of activity


Assess patients ability to transfer safely
Reinforce teaching

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient tolerance of procedure and length of time in


wheelchair.
Ability to assist with transfer.
Patients level of comfort during transfer and while
sitting in wheelchair.

PROCEDURE 23.3
Teaching Hip Precautions
OVERVIEW

To facilitate postoperative recovery and prevent articial hip


dislocation.

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440 C h a p t e r 2 3 Transfer and Positioning


P R E PA R AT I O N

Check prescribers orders for specic restrictions regarding patient


activity and positioning.
Assess patients readiness and ability to learn.

Special Considerations
Some patients may need analgesic medication to enhance comfort
prior to moving.
Elderly, Pediatric, Confused, and Physically
or Mentally Challenged Patients
May require more time, teaching, and assistance.
Involve family and/or caregiver in teaching of this procedure.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to tolerate moving
Self-care decit related to mental or physical impairment
Risk for injury related to improper use of positioning techniques

EXPECTED OUTCOMES

Patient will be free of complications from hip replacement


Patient will use and maintain proper positioning for optimum
comfort
EQUIPMENT/SUPPLIES

Wedge or pillow
I M P L E M E N TAT I O N
Teach patient to avoid:

Adduction of legs by using abduction pillow or bed pillow


between legs.
Hip exion, external rotation.
Crossing leg (either in bed or seated).
Bending hip past 90 degrees.
Turning or rolling foot of operated leg inward.
Lying on operated hip.

Maintains proper position and reduces risk for hip dislocation.

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P r o c e d u r e 2 3 . 3 Teaching Hip Precautions 441

FIGURE 23.3A Abductor pillow prevents

hip adduction.
Instruct patient to keep the abduction wedge or pillow between

knees/legs when in bed.


Prevents patient from crossing legs.
Correct hip flexion

90

FIGURE 23.3B

Incorrect hip flexion

90

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442 C h a p t e r 2 3 Transfer and Positioning


Instruct patient to keep the toe of affected leg pointed forward

when standing, sitting, or lying. Also, instruct patient not to stand


pigeon toed.
Maintains proper position and reduces risk for hip dislocation.
Instruct patient on signs and symptoms of dislocated hip (begins

with popping or slipping sensation; patient will not be able to bear


weight on affected limb and may experience a fair amount of pain
and discomfort). If signs and symptoms are experienced, notify prescriber immediately.
The earlier complications are identied and treated, the less permanent the
damage that will occur.
Instruct patient on looking after hip joint:

Look for signs and symptoms of infection in the hip including pain,
redness, swelling, or increased warmth.
Follow all instructions regarding any activity or positioning limitations or restrictions.

The earlier complications are identied and treated, the less permanent the
damage that will occur.

Assist patient or have patient perform leg exercises as ordered by


prescriber.
Reduces risk for blood clots forming in legs and possibly traveling to lungs.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients understanding of hip precautions


Monitor patients position to maintain hip abduction and leg in neutral position
Provide written instructions for discharge activities and positioning

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patient/caregiver understanding and willingness to follow hip


precautions.
Patients self-care capabilities.
Patients level of comfort and response to positioning and
pain management.

C H A P T E R

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24
Orthopedic
Interventions
24.1
24.2
24.3
24.4
24.5

Providing Cast Care, 444


Managing Skin Traction, 448
Managing Skeletal Traction, 453
Applying a Moist Compress, 456
Applying an Ice Bag, Ice Pack, or Collar, 459

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444 C h a p t e r 2 4 Orthopedic Interventions

PROCEDURE 24.1
Providing Cast Care
OVERVIEW

To immobilize an injured structure that needs to maintain anatomical position.


Used chiey for fractures after they have been realigned.

P R E PA R AT I O N

Maintaining the castpreventing cracks, exposure to dirt, wetness;


keeping it clean.
Evaluation of extremity in the castswelling, circulation.
Detecting and evaluating bleeding.

Special Considerations
If the patient has had a compound fracture that required internal
xation or open reduction, the nurse should watch the cast for
signs of bleeding for the rst 24 to 48 hours.
Elderly Patient
Elderly patients, due to trauma and pain medication, can easily
become disoriented and lose balance or have difficulty with
unbalanced gait.
Pediatric Patient
With pediatric patients, it is especially important to instruct the
family in recognizing signs of infection and drainage, and in
the need to discourage children from scratching under the cast.
Instruct on ways to keep cast dry, especially when patient needs
to be bathed.
R E L E VA N T N U R S I N G D I A G N O S E S

Alteration in comfort related to trauma


Impaired tissue perfusion related to trauma
EXPECTED OUTCOMES

Patient will not experience pain, discoloration, or sensory or motor


impairment of affected extremity
Extremity in the cast will have good capillary rell

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P r o c e d u r e 2 4 . 1 Providing Cast Care 445

Patient will be able to ambulate and perform active range-of-motion


(ROM) and isometric exercises as ordered by physician
No evidence of neurovascular impairment in extremity in the cast
No evidence of infection

EQUIPMENT/SUPPLIES

Thermometer (to monitor for signs of infection)


Pillows
Bed linens
Towels
Washcloths
Alcohol pads
I M P L E M E N TAT I O N
Explain to the patient that you will be assessing the status of the

cast and extremity every 1 to 2 hours.


Understanding promotes acceptance.
Remove any cast residue that might be around the cast and on the

skin.
This residue can be irritating to the patients skin. Removing it can prevent
rashes or skin irritation.
Elevate the extremity in the cast. Determine that each distal joint is

higher than the preceding one.


Elevation promotes venous return and decreases swelling that could increase
pressure and compromise neurovascular integrity.
Ice bags can be placed next to a cast, especially next to an incision

if physician warrants its use.


This controls swelling and bleeding.
Expose cast directly to the airdo not cover the cast with blankets

or sheets.
A cast produces heat as it dries, and if it is covered up, moisture can accumulate and delay the drying process.
Ensure that nothing rests or lays on a wet cast. Pillows are to be used

under the cast to allow the cast to dry on a soft surface. Handle the
cast only if necessary and use only the palms of your hands,

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446 C h a p t e r 2 4 Orthopedic Interventions


Heavy objects or pressure from ngers that are placed on a wet cast can
cause indentation and pressure points. This can result in neurovascular
compromise.

FIGURE 24.1 Handle wet cast with palms

only.
Footboards or cradles can be used to keep the patient covered but

off wet cast.


Linen can be supported on these cradles or footboards to provide warmth
and protect patients privacy. This will still allow air to circulate for the cast
to dry.
Turn patient to a different position every 2 hours.
Repositioning helps to expose the cast to air and allows the cast to dry evenly.
Assess for signs and symptoms of excess swelling and pressure

on the casted extremity every 30 minutes initially, then every 1 to


2 hours, if the assessment has been normal:
Inspect and palpate to test for swelling, paleness, cyanosis, coolness
of the skin.
Check for capillary rell by putting pressure on the nail bed and
releasing to determine return of blood ow to nail bed.
Take pulses distal to casted areas.
Determine degree of sensation in the extremity, and take note of
any change.
Ask patient to alert you to any areas of numbness or tingling.
Check temperature of the skin above and below the casted
extremity.
Ask the patient to move his or her ngers or toes (whatever applicable) to check ability for movement.
The cast is a rigid object that cannot expand when the tissue under it expands
or swells. When the extremity does swell, neurovascular integrity can be compromised. Frequent assessments help to identify problems before they occur.

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P r o c e d u r e 2 4 . 1 Providing Cast Care 447


Watch for signs of drainage or bleeding on the cast.
Bleeding can occur especially with compound fractures and open reduction.
Venous blood turns brown and stops in a short time; arterial bleeding is
bright red and continues to spread on the cast.
Draw a ring around the drainage and add date, time, and initials.

Infection will produce drainage that may produce an odor. The color
of the drainage will be tan or light brown.
Determine degree of bleeding or discharge.
Change a patients position every 1 to 2 hours.
Mobility can decrease incidence of venous stasis, which could lead to vein
thrombosis and pressure spots, leading to skin breakdown.
Encourage ROM exercises for all extremities. Isometric exercises can

be used for the cast extremity.


Exercise promotes circulation and muscle tone and prevents atrophy of
casted muscles.
Inspect the edges of the cast for rough edges or chipping plaster.

Cover rough edges with tape.


Rough edges or chipped areas can cause skin abrasion and subsequent
breakdown. Pieces of chipped plaster can become lodged inside the cast and
further compromise skin integrity.
Instruct patient not to insert objects into casted extremity, such as

straws and tooth brushes, when skin itches.


Skin becomes dry and itchy under cast. Keeping skin lubricated by using
lotion can help with dry itchy skin.
Objects inserted inside cast can increase chance for skin abrasion and further
skin breakdown.
Periodically remove dry, aked skin debris or chipped plaster from

inside the cast with vacuum cleaner or hair dryer hose using cool
settings.
Air can blow out debris keeping area free of debris.
Protect the cast from wetness, especially when patient needs to

bathe. Cover the cast with plastic wrap and tape securely whenever
patient needs to perform personal hygiene.
Wet plaster softens and is not as strong as it needs to be to be an effective
immobilizer. Plastic wrap can be taped securely and is waterproof if applied
correctly.
Instruct patient on avoiding overstrenuous activities that may dis-

lodge or misalign extremity or cast.


Patient may dislodge or misalign extremity or cast and cause trauma to
injured extremity.

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448 C h a p t e r 2 4 Orthopedic Interventions


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Casted extremity should be assessed every 30 minutes for 1 to 2


hours and, if assessment is within normal limits, then every hour for
24 hours and, if assessment is within normal limits, every 4 hours
from that time on
Check cast daily for odor, drainage, bleeding, cracks, crumbling
plaster
Neurovascular checks: temperature, color, capillary rell, edema,
numbness, tingling sensation every 30 minutes for 1 to 2 hours
and, if assessment is within normal limits, every hour for 24 hours
and, if assessment is within normal limits, every 4 hours from that
time on
Instruct patient on avoiding overstrenuous activities that may
dislodge or misalign extremity or cast

KEY POINTS

FOR

REPORTING

AND

RECORDING

Neurovascular assessment ndings.


Patients complaints and nursing responses.
Presence of any drainage.
Patients acceptance of cast.
Type of cast applied if applied on your shift.
Patients complaints and nursing responses.

PROCEDURE 24.2
Managing Skin Traction
OVERVIEW

To provide pull and counterpull on a particular area of an


extremity.
To provide correct alignment of bony ends.

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P r o c e d u r e 2 4 . 2 Managing Skin Traction 449


P R E PA R AT I O N

Applied directly to the skeletal system by attaching weight to the


skin.
Comes in various types, such as Bucks traction or Russells traction.

FIGURE 24.2A Bucks traction.

Overbed frame

Trapeze

Russells
traction

FIGURE 24.2B Russells traction.

Usually applied while patient is in bed.


The pull is achieved by using weights in the form of sandbags, freeweight discs; counterpull is produced by patients own weight.
Traction is possible through use of slings, ropes, pulleys, and weights.

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450 C h a p t e r 2 4 Orthopedic Interventions

Special Considerations
Patients with previous compromised neurovascular status need extra
assessment. Nurse should check patients status every 30 minutes to
ensure that no further loss of integrity is noted.
Elderly Patient
Elderly patient has increased chance for venous stasis. Extra care
needs to be taken to ensure the patient is free of thrombosis and
emboli.
Constipation is another concern due to decreased motility, poor
appetite, and decreased intake of uids. Nurse needs to determine
patients bowel habits and provide measures to ensure adequate
elimination.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to impaired blood ow


Risk for infection related to diabetes
EXPECTED OUTCOMES

Extremity is maintained in correct position


Bone ends are aligned and do not override
Skin of affected extremity remains intact
Patient maintains good body alignment

EQUIPMENT/SUPPLIES

Ropes, pulleys, and weights


Tape
Foam rubber or plastic sheeting
Metal block spreader
Traction foam boot
Elastic bandage
Sheepskin pad
Shock blocks
I M P L E M E N TAT I O N
Review the physicians order and ensure that you have correct trac-

tion equipment available.


There are different types of traction. Making sure you are setting up for the
correct, prescribed type will prevent injury to the patient.
Explain the procedure to the patient.
Understanding promotes acceptance.

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P r o c e d u r e 2 4 . 2 Managing Skin Traction 451


Most hospitals have an orthopedic technician who sets up the trac-

tion. If the hospital does not have a technician, review the procedure
with other nurses who may have experience in setting up traction.
Call the orthopedic technician and provide him with copy of physicians
order for traction.
If you anticipate that the patient will have pain or discomfort during

the procedure, consider premedicating the patient as ordered by


physician.
Providing premedication will lessen the pain and discomfort when applying
skin traction or assessing the traction effectiveness. Make sure there is a
physician order; if there is not one, call physician and explain your desire to
provide the patient with pain relief.
Lay out all equipment.
Facilitates procedure, ensures safe efficient care of patient.
Place bed in semi-Trendelenburg position. Make sure this position

will not compromise patients conditionverify with physician


before moving patient to this position.
Trendelenburg position helps keep the traction intact, but in some cases
patients cannot tolerate this position without compromise in respiratory
status.
Inspect skin for any signs of abrasion or lesions that could be

disturbed when skin traction is applied. Make sure skin is clean


and dry.
Skin traction (tape and pressure) placed over abraded areas could aggravate
skin condition.
Assess neurovascular status of patients extremities, and document

ndings for referral later.


Sets a baseline for later comparison.
Position the patient in the center of the bed in good body

alignment.
Ensures effective counterpull without compromising neurovascular status.
Have a second person support the affected extremity so that you

can apply the elastic bandage and foam boot.


Ensures that the affected extremity remains in alignment; reduces discomfort; allows the nurse the ability to apply the foot boot and elastic bandage
(from the ankle up to knee).
Place leg in foam boot, making sure to adjust the heel of the foot

snugly into boot.


Prevents neurovascular compromise.

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452 C h a p t e r 2 4 Orthopedic Interventions


Secure Velcro bootstraps, but avoid bony prominences.
Prevents skin abrasion and breakdown.
Apply metal spreader to allow the nurse to attach ropes and weights

as directed by physician.
Spreads the ropes to equal distance so that traction is equally distributed.
Apply weights, making sure they are not touching the bed, frame, or

oor.
Weights should be free for adequate counterpull.
Check with physician to determine the need for thromboembolic

disease stockings (TEDS) to other extremity.


Prophylaxis against venous stasis.
Assess neurovascular status of patients extremities and document

ndings every 30 minutes when rst applied; if there is no change,


check status every 1 to 2 hours.
This ensures adequate neurovascular integrity. Changes can be quickly
noted.
Check patients position every 1 to 2 hours to ensure that the patient

is in proper position to allow adequate counterpull of traction.


Allows adequate counterpull of traction.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Determine that patient is in good body alignment


Check to make sure elastic bandage and foot boot are in proper
position
Check that traction is equally distributed
Determine if patient is warm and free of discomfort
Assess neurovascular status

KEY POINTS

FOR

REPORTING

AND

RECORDING

Neurovascular status before and after traction applied.


is maintained.
Patient comfort.
Skin integrity.
Traction

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P r o c e d u r e 2 4 . 3 Managing Skeletal Traction 453

PROCEDURE 24.3
Managing Skeletal Traction
OVERVIEW

To provide pull and counterpull on a particular area of an extremity.


To provide correct alignment of bony ends.

FIGURE 24.3A Balanced suspension and skeletal traction for femur.

P R E PA R AT I O N

Applied directly to the skeletal system by attaching weight to the


bone.
Usually applied in the operating room and maintained while patient
is in bed.
The pull is achieved by using weights in the form of sandbags and
free-weight discs; counterpull is produced by patients own weight.
Traction is possible through use of slings, ropes, pulleys, and weights.

Special Considerations
Elderly Patient
Skin is fragile and needs extra protectiontake care to protect bony
prominences to prevent skin breakdown.
Encourage range-of-motion (ROM) exercises to prevent venous stasis.
Encourage the patient to decorate his or her room to feel more at
home.

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454 C h a p t e r 2 4 Orthopedic Interventions

Encourage visitors.
Encourage self-care activities.
Pediatric Patient
Check patients positionthe child is small and can change position,
making traction inadequate or harmful to neurovascular integrity.
Check to make sure patient has safe toys to play with.
Take precautions when child eats in the supine positionavoid
aspiration.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to impaired blood ow


Risk for infection related to trauma
EXPECTED OUTCOMES

Extremity is maintained in correct position


Bone ends are aligned and do not override
Skin of affected extremity remains intact with no signs of infection
Patient maintains good body alignment

EQUIPMENT/SUPPLIES

Slings, ropes, pulleys, and weights


Tape
Sterile cotton tip applicators
Hydrogen peroxide
Normal saline solution
Foam rubber or plastic
I M P L E M E N TAT I O N
Traction is usually applied in the operating room under aseptic

technique.
Procedure is painful and requires bone alignment and perforation of skin.
General anesthesia is usually required to allow the surgeon to manipulate
the fracture and align it correctly.
When patient returns to his or her room, the nurse should inspect

the traction and other equipment to make sure weights and traction
equipment are applied correctly.
Ensures proper functioning of equipment, preventing injury.
Make sure the patients bed has trapeze attached to bed frame.
This will allow patient to move safely and perform ROM exercises, keeping
muscles from atrophy.

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P r o c e d u r e 2 4 . 3 Managing Skeletal Traction 455


Regularly check to make sure patient is in center of bed.
Good body alignment adequate counterpull of traction.
Avoid tucking in bed clothes.
Tucking in bed clothes can impede traction.
Instruct patient and family regarding ROM and body positions.
Patient needs to be reminded not to turn to the side, because it disrupts traction integrity.
Allow patient to do as much self care as possiblepersonal hygiene,

etc.
Self-care activities can help a patient feel condent and useful.
Clean back and buttocks and provide lotion and extra padding to

body prominences each day.


Helps the patient feel clean; keeps skin from breakdown.
Apply sheepskin or egg-crate mattress to patients bed to protect

skin from abrasion and pressure, especially to heels, back, pelvis,


and elbows.
Avoids skin breakdown and provides comfort for patient.
Avoid using more than two pillows under patients head.
Pillows can disrupt counterpull of traction.
Use fracture bedpan for patients elimination needs.
Facilitates elimination and ensures counterpull of traction.
Encourage ROM exercisesisometric and isotonic exercisesand

frequent dorsiexion of extremities.


Facilitates circulation and prevents venous stasis.
Inspect skin areas around traction attachment, checking for redness

and swelling.
Keeps skin from infection and further breakdown.
Clean skeletal attachment areas as directed by physician.
Keeps skin from infection and further breakdown.
Cover sharp edges or points with gauze or tape.
Prevents possible injury to patient, family, or caregiver.
Assess neurovascular status as directed by physician.
Ensures proper circulation and nerve integrity.
Allow patient to schedule personal activities and decorate room.
Encourages self-control; prevents social isolation.

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456 C h a p t e r 2 4 Orthopedic Interventions


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Neurovascular state of extremity checked often to ensure adequate


circulation and nerve function
Frequent encouragement of patient to perform ROM exercises and
set times for the patient to perform that are understandable to nurse
and patient
Vital signs taken as ordered
Patients mental status will remain normal
Integrity of the skin maintained
Integrity of traction maintained

KEY POINTS

FOR

REPORTING

AND

RECORDING

Neurovascular state of extremity in traction.


Patients ability to perform ROM exercises and times performed.
Vital signs.
Patients mental status.
Integrity of the skin.
Integrity of traction.
Bowel and bladder integrity.
Intake and output.

PROCEDURE 24.4
Applying a Moist Compress
OVERVIEW

Local applications of moisture to an area to reduce pain, swelling,


and temperature.
P R E PA R AT I O N

May be hot or cold applications depending on desired purpose.


Several layers of moist cloths may be used.
Application of heat is generally more concentrated than cold.
Duration of use longer than a soak.
Application of hot or cold moist compresses will depend on patients
tolerance.

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P r o c e d u r e 2 4 . 4 Applying a Moist Compress 457

Special Considerations
With elderly and pediatric patients, do not use too hot or too cold
compresses due to fragility of skin.
Protect bed linens from wetness, which could further compromise
skin integrity.
R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to impaired blood ow


Risk for infection related to diabetes
EXPECTED OUTCOMES

Reduced swelling
Reduced bleeding
Keeps area lubricated
Decreased pain

EQUIPMENT/SUPPLIES

Clean basin
Clean washcloths
Tape
Plastic wrap/bag
Linen saver/chucks
Disposable gloves
Gauze pads
Hot water, or
Ice water
I M P L E M E N TAT I O N
Check physicians order for application of moist compresses:

check to see if order calls for hot or cold applications.


Ensures that correct process is followed as ordered by attending
physician.
Gather all equipment to the bedside.
Facilitates procedure, saves time.
Explain process to the patient.
Understanding promotes acceptance.
Prepare moist compress by soaking gauze pads in selected solution

(hot/cold).

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458 C h a p t e r 2 4 Orthopedic Interventions


Make sure gauze pads are big enough and plentiful enough to cover
area desired.
Make sure they are thoroughly soaked before applying to area.
Don gloves.
Prevents transfer of microorganisms.
Cover with dry covering, preferably a plastic bag or linen saver,

and mold it to the body area.


Insulates the heat or cold application and concentrates it on the desired
area.
Check area every 15 minutes to ensure heat is not cool and cold

is not warm.
Keeps temperature even to area that needs the application of moist
compress.
Apply moist compress for approximately 15 to 30 minutes four to

ve times per day (check physician order).


Avoid overexposure to moist compress, which may impair skin
integrity.
Keep the patient as dry as possiblecheck to make sure you have

dried area after moist compress has been completed.


Promotes comfort.
Assess the effects of the application of moist compresses.
Report and record the positive and negative effects of the application
this may require the nurse to adjust plan of care if the treatment is
not favorable or if the patient does not tolerate the procedure.
Dispose of gloves and all contaminated equipment.
Prevents transfer of microorganisms.
Reposition patient in comfortable position.
Promotes comfort.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess area every 4 to 6 hours to determine effectiveness of


treatment
Ask patient to evaluate effectiveness of the treatment
Patient will have reduced pain, swelling, and redness of area

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P r o c e d u r e 2 4 . 5 Applying an Ice Bag, Ice Pack, or Collar 459

KEY POINTS

FOR

REPORTING

AND

RECORDING

Patients tolerance to treatment.


times and duration.
Physical effects of the application of moist compresses.
Treatment

PROCEDURE 24.5
Applying an Ice Bag, Ice Pack, or Collar
OVERVIEW

To reduce swelling and pain.


To control bleeding by constricting blood vessels.
To reduce body temperature and bodys metabolic rate.
To produce an anesthetic effect.

P R E PA R AT I O N

No one optimum temperature can be documented for cold


applications.
Selection of temperature depends on duration of application,
method of application, condition of the patient, and condition
and sensitivity of the skin.
It is considered dangerous to expose skin to extreme cold
temperatures.

R E L E VA N T N U R S I N G D I A G N O S E S

Altered tissue perfusion related to impaired blood ow


Risk for infection related to impaired tissue integrity

Special Considerations
Very cold temperatures should be avoided in skin disease.
Avoid use of cold applications in patients with circulatory or heart
disease.
Always consider patients age and condition of the skin before
application of cold therapy.
Check elderly and pediatric patients skin and effects of cold treatment on their fragile skin.
Watch for possible sharp edges on ice that could abrade skin.

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460 C h a p t e r 2 4 Orthopedic Interventions


EXPECTED OUTCOMES

Reduction of edema at trauma site


Decreased pain sensation
No alteration in skin integrity

EQUIPMENT/SUPPLIES

Ice bag, collar, plastic bag


Bed protection (plastic diaper or chucks)
Cold solution or crushed ice
Tape
Towels (2)
I M P L E M E N TAT I O N
Check physicians order for cold application and determine what

equipment is necessary.
Promotes effective use of time.
Gather equipment to bedside.
Promotes effective use of time.
Explain procedure to the patient.
Understanding promotes acceptance.
Fill bag/collar with ice. If using a commercial ice pack, make sure

pack is not leaking; chemicals could cause damage to skin.


Provides the main cold application.
Squeeze excess air from bag or collar.

Commercial ice pack will already be free of air but will need to be
shaken to distribute inner contents.
Allows the bag/collar to lie at and ice to evenly lay around collar.
Tape/secure bag/collar.
Make sure ice does not leak out and wet the patients clothes or bed linen.
Cover the bag/collar with towel, and secure with tape.
Provides smooth soft covering to prevent direct contact of plastic to skin,
which could impair skin integrity.
If the patient has an open wound or drainage, don gloves. Remove

old dressing or cold packs from area, noting amount and quality of
drainage. Remove gloves and don new pair.
Reduces transmission of microorganisms.

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P r o c e d u r e 2 4 . 5 Applying an Ice Bag, Ice Pack, or Collar 461


Place covered ice bag/collar/pack on affected area.
Allows the transfer of cold to area affected.
Assess patients tolerance to cold application. If patient cannot toler-

ate sensation of cold, apply a second towel over the bag/collar/pack.


Assessing skin and patients tolerance of cold will allow better treatment of
area and better patient compliance.
After 30 minutes, terminate cold treatment, and gently dry area

treated.
Allows the nurse to assess for redness and how well the treatment affected
edema/swelling.
If dressing is needed, follow guidelines for application of dressing.
Decreases chances for infection and promotes wound healing.
Remove all soiled equipment, and reposition patient as he desires.
Eliminates chances for cross contamination and provides patient comfort.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient verbalizes positive effects of treatment


Decreased edema
No complications evidenced from treatment
Decreased pain

KEY POINTS
Treatment

FOR

REPORTING

AND

area before and after therapy.


Duration of treatment.
Patients tolerance to the treatment.
Effects of treatment.
Date and times treatment used.
Where cold treatment was applied.

RECORDING

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C H A P T E R

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25
Beds, Frames,
and Mattresses
25.1 Placing the Patient on a Specialty
Surface, 464
25.2 Placing the Patient on an Air-Suspension
or Air-Fluidized Bed, 467

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464 C h a p t e r 2 5 Beds, Frames, and Mattresses

PROCEDURE 25.1
Placing the Patient on a Specialty Surface
OVERVIEW

To reduce pressure on tissues underlying bony prominences.


To be used as a replacement mattress or used as an overlay that rests
on top of an existing mattress.
To promote optimal comfort and body alignment.

P R E PA R AT I O N

Determine patients ability to understand procedure.


Determine patients ability to participate.
Assess patients skin for erythema, induration, and blistering, especially over bony prominences.
Assess patients level of comfort and presence of pain.

Special Considerations
Depending on medical condition, some patients may need analgesic
medication to enhance comfort before moving.
Elderly, Pediatric, Confused, and Physically
or Mentally Challenged Patients
May take more time to complete procedure, especially if patient is
immobile.
Involve family/caregiver if indicated.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to tolerate moving
Impaired skin integrity related to prolonged pressure on joints and
bony prominences

EXPECTED OUTCOMES

Patients skin remains intact without evidence of abnormal reactive


hyperemia or mottling
Existing pressure ulcers show evidence of healing by formation of
granulation tissue
Patient exhibits signs of comfort after specialty surface is in place

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P r o c e d u r e 2 5 . 1 Placing the Patient on a Specialty Surface 465


EQUIPMENT/SUPPLIES

Mattress support surface of:


Foam or air overlay
Foam or air mattress
Clean gloves
Sheets for bed and mattress
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure and how patient

can assist if indicated. Assess patients ability to move if on


bed rest. Conrm type of support surface to be used with
prescriber.
Meets patients right to be informed; encourages cooperation and
participation; identies type of support surface most benecial to
the patient.
Gather equipment and place at bedside; adjust lighting as

needed.
Enhances organization; ensures good visualization to prepare
bedding.
Wash hands and don clean gloves.
Reduces transmission of infectious microorganisms.
Apply support surface to bed (bed may be occupied or

unoccupied). (See Chapter 1).


Ensures correct application of the surface support whether the
bed is occupied or unoccupied.

Applying a Foam-Mattress Replacement


Remove the mattress and replace with foam mattress.

Remove cushions as needed in areas of high risk for skin


breakdown, such as elbows and heels. Apply sheet, and
avoid wrinkles.
To reduce pressure in direct contact with skin surfaces.

Applying a Foam-Mattress Overlay


Apply foam overlay directly on hospital mattress.

Leave thin, protective covering in place. Apply sheet. Avoid


wrinkles.
Foam egg-crate surface is primarily for comfort. It reduces pressure in
direct contact with the skin.

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466 C h a p t e r 2 5 Beds, Frames, and Mattresses

FIGURE 25.1 Egg-crate mattress.

Applying an Air-Mattress Replacement


Remove standard hospital mattress and replace with air mattress.

Use blower to inate to the appropriate pressure. Apply sheet, and


avoid wrinkles. Limit the use of incontinent pads.
Air pressure is used to distribute patients weight. A company representative
usually participates in the setup of this device.

Applying an Air-Mattress Overlay


Apply deated overlay directly over the bed mattress. Use supplied

aps or clips to secure mattress. Use blower or other continuous


ination device to inate mattress to the desired pressure. Apply
sheet, and avoid wrinkles. Check cycling on continuous-cycling unit.
Avoid use of sharp objects near mattress.
Intermittent cycling inates portions of the mattress at a time, which alternates pressure against the skin; checking cycling on the unit ensures proper
functioning; avoiding use of sharp objects near the mattress ensures that the
mattress material will not be punctured.

With Any Support Surface


Reposition patient over support surface as frequently as condition

allows to minimize pressure (see Chapter 23). Perform range-ofmotion (ROM) exercises every shift as tolerated (see Chapter 22).
Enhances patient comfort, relieves pressure, and facilitates removal of secretions from the airways.
Range-of-motion (ROM) exercises are necessary to prevent contractures and
promote good circulation.
Remove gloves and wash hands before leaving patients room.
Prevents transmission of infectious microorganisms.

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Page 467

P r o c e d u r e 2 5 . 2 Placing the Patient on an Air-Suspension Bed 467


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate in procedure


Inspect skin condition every 2 hours
Monitor turning schedule and assess effectiveness of the support
mattress
Inspect any existing pressure ulcers for evidence of granulation
tissue
Assess patients comfort level at least every 2 hours or PRN

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time support surface was applied.


Patients overall skin condition.
Patient participation in moving and turning schedule.

PROCEDURE 25.2
Placing the Patient on an Air-Suspension
or Air-Fluidized Bed
OVERVIEW

To reduce pressure on tissues underlying bony prominences.


To promote optimal skin integrity in the immobile or bedridden
patient.
To promote optimal comfort and body alignment by cushioning
support and redistributing weight.
To reduce the effects of shear, friction, maceration, and pressure.

P R E PA R AT I O N

Determine patients ability to understand the purpose of using an


air-suspension or air-uidized bed.
Determine patients ability to participate.
Assess patients skin for erythema, induration, and blistering, especially over bony prominences (risk for pressure-ulcer formation).
Assess patients level of comfort and presence of pain.

Special Considerations
Depending on medical condition, some patients may require analgesic medication to enhance comfort before moving.

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468 C h a p t e r 2 5 Beds, Frames, and Mattresses

Elderly, Pediatric, Confused, and Physically


or Mentally Challenged Patients
May take more time to complete procedure, especially if patient is
immobile.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular decit


Pain/discomfort related to inability to tolerate moving
Impaired skin integrity related to prolonged pressure on joints and
bony prominences

EXPECTED OUTCOMES

Patients skin remains intact without evidence of abnormal reactive


hyperemia or mottling
Existing pressure ulcers show evidence of healing by formation of
granulation tissue
Patient exhibits signs of comfort after being placed on specialty bed

EQUIPMENT/SUPPLIES

Air-suspension or air-uidized bed (as ordered/indicated)


Gortex sheet (supplied by distributor)
Clean gloves
Disposable bed pads, if indicated
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist if indicated. Assess patients ability to move if on bed rest.


Meets patients right to be informed; encourages cooperation
and participation.
Have bed placed in patients room. Gather all other equipment

needed and place at bedside, and adjust lighting as needed.


Enhances organization; ensures good visualization to prepare bedding.
Wash hands and don clean gloves.
Reduces transmission of infectious microorganisms.
After applying Gortex sheet and disposable pads (if needed), transfer

patient onto air-suspension bed using appropriate transfer techniques (see Chapter 23).
Ensures correct transfer techniques and reduces the risk for injury.

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Page 469

P r o c e d u r e 2 5 . 2 Placing the Patient on an Air-Suspension Bed 469


Turn bed on by depressing switch.
Activates air action of bed operation.
Position patient.
Promotes patient comfort and maintains proper body alignment.
Establish and maintain a turning schedule, as indicated by patients

plan of care, diagnosis, and mobility status.


Frequent turning is necessary to prevent skin breakdown and facilitate
removal of secretions from the airways.
Establish a schedule and perform ROM exercises as indicated by

patients plan of care, diagnosis, and mobility status (see Chapter 22).
Frequent and consistent exercising is necessary to prevent joint deformity,
contractures, and skin breakdown.
Activate maximum ination switch for turning, positioning, use of

bedpan, or other procedures. Release maximum ination when procedure concluded.


Maximum ination hardens the bed, thereby eliminating pressure relief. A
rm surface is necessary for turning and various other procedures.
Leave patient in a comfortable position with side rails up.
To ensure patient comfort and safety.
Remove gloves and wash hands.
To prevent transmission of infectious microorganisms.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate in procedure


Inspect skin condition every 2 hours or according to turning schedule and PRN to determine any changes and assessing effectiveness
of the air-suspension or air-uidized bed
Inspect any existing pressure ulcers for evidence of granulation tissue
Assess patients comfort level at least every 2 hours and PRN

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time air-suspension or air-uidized bed was applied.


Patient participation in moving and turning schedule.
Overall skin condition and any problems patient has with the
air-suspension or air-uidized bed.

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Page 470

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Page 471

U N I T

C H A P T E R

Integumentary
System and
Wound Care

26
Pressure Ulcers
26.1 Assessing Pressure Ulcer Risk, 472
26.2 Implementing Pressure-Ulcer Prevention
Strategies, 477
26.3 Assessing Wounds and Staging Pressure
Ulcers, 480

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472 C h a p t e r 2 6 Pressure Ulcers

PROCEDURE 26.1
Assessing Pressure Ulcer Risk
OVERVIEW

To provide a method for evaluating a patient for the presence of risk


factors that could lead to the development of a pressure ulcer.
To determine the presence of risk factors, provide a rationale for
implementing preventive measures to avoid pressure ulcers, and
maintain skin integrity.
To perform a skin assessment for the presence of any lesions,
ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture,
or dryness.

P R E PA R AT I O N

Screen all patients on admission to determine the presence of risk


factors that may result in a pressure ulcer. Note whether there is any
history of a pressure ulcer or skin problem.
Use a risk assessment tool to identify risk factors: immobility, inactivity, incontinence, malnutrition, friction, and shear.
Perform a head-to-toe skin assessment to determine any abnormal
skin ndings: lesions, ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture, or dryness.
Document all ndings, be specic in describing any problems, and
illustrate ndings on the skin assessment form. (Forms vary according to facility.)
Identify the patient at risk for developing a pressure ulcer, according
to the Norton Scale, the Braden Scale, or the preferred risk assessment scale in the facility.
Institute the protocol for prevention of pressure ulcers based on the
risk assessment.
Obtain specic skin care orders when there is a problem.
Determine if there are other factors that may place the patient
at risk for a pressure ulcer, such as altered mental status, unstable
vital signs.
Reassess every patient at least every 48 hours and perform risk
assessment at any time when there has been a signicant change in
the patients condition to prevent skin breakdown.
Continue to monitor and document the skin condition and report
any change in skin integrity promptly to prevent a pressure ulcer.
Always document any special protocols, including skin or ulcer care
or special pressure-reduction mattresses or beds.

26Rhoads(F)-26
5/3/07

Physical
Condition
4
3
2
1

Alert
Apathetic
Confused
Stupor

Activity
4
3
2
1

Ambulant
Walk/help
Chair-bound
Bed

Mobility
4
3
2
1

Full
Slightly limited
Very limited
Immobile

Incontinent
4
3
2
1

Not
Occasional
Usually/urine
Doubly

4
3
2
1

Total
Score

Name/Date

The Norton Scale uses five criteria to assess patients' risk for pressure ulcers. Scores of 14 or less indicate
liability to ulcers; scores of <12 indicate very high risk.
Norton, D., McLaren, R. & Exton-Smith, A. N. (1975). An investigation of geriatric nursing problems in hospitals. Edinburgh, UK:
Churchill Livingstone. Used with permission.

FIGURE 26.1A Norton scale for assessing risk of pressure ulcers.

Page 473

Good
Fair
Poor
Very bad

Mental
Condition

1:52 PM

Norton Scale for Assessing Risk of Pressure Ulcers

473

4. No Impairment
Responds to verbal commands.
Has no sensory deficit which would
limit ability to feel or voice pain or
discomfort.

MOISTURE
Degree to which skin
is exposed to moisture

1. Constantly Moist
Skin is kept moist almost constantly
by perspiration, urine, etc. Dampness
is detected every time patient is
moved or turned.

2. Very Moist
Skin is often, but not always moist. Linen
must be changed at least once a shift.

3. Occasionally Moist
Skin is occasionally moist, requiring an
extra linen change approximately once a day.

4. Rarely Moist
Skin usually dry, linen only requires
changing at routine intervals.

ACTIVITY
degree of physical
activity

1. Bedfast
Confined to bed.

2. Chairfast
Ability to walk severly limited or nonexistent. Cannot bear own weight and/or
must be assisted into chair or wheelchair.

3. Walks Occasionally
Walks occasionally during day, but for very
short distances, with or without assistance.
Spends majority of each shift in bed or chair.

4. Walks Frequently
Walks outside room at least twice a
day and inside room at least once
every two hours during waking hours.

MOBILITY
ability to change and
control body position

1. Completely Immobile
Does not make even slight changes
in body or extremity position without
assistance.

2. Very Limited
Makes occasional slight changes in body
or extremity position but unable to make
frequent or significant changes
independently.

3. Slightly Limited
Makes frequent though slight changes in
body or extremity position independently.

4. No Limitation
Makes major and frequent changes in
position without assistance.

NUTRITION
usual food intake
pattern

1. Very Poor
Never eats a complete meal. Rarely
eats more than 1/2 of any food
offered. Eats 2 servings or less of
protein (meat or dairy products) per
day. Takes fluids poorly. Does not
take a liquid dietary supplement
OR
is NPO and/or maintained on clear
fluids or IVs for more than 5 days.

2. Probably Inadequate
Rarely eats a complete meal and generally
eats only about 1/2 of any food offered.
Protein intake includes only 3 servings of
meat or dairy products per day.
Occasionally will take a dietary supplement.
OR
receives less than optimum amount of
liquid diet or tube feeding.

3. Adequate
Eats over half of most meals. Eats a total
of 4 servings of protein (meat, dairy
products) per day. Occasionally will refuse
a meal, but will usually take a supplement
when offered
OR
is on a tube feeding or TPN regimen which
probably meets most nutritional needs.

4. Excellent
Eats most of every meal. Never
refuses a meal. Usually eats a total of
4 or more servings of meat and dairy
products. Occasionally eats between
meals. Does not require
supplementation.

FRICTION & SHEAR

1. Problem
Requires moderate to maximum
assistance in moving. Complete lifting
without sliding against sheets in
impossible. Frequently slides down in
bed or chair, requiring frequent repositioning with maximum assistance.
Spastic, contractures or agitation
leads to almost constant friction.

2. Potential Problem
Moves feebly or requires minimum
assistance. During a move skin probably
slides to some extent against sheets,
chair, restraints or other devices.
Maintains relatively good position in chair
or bed most of the time but occasionally
slides down.

3. No Apparent Problem
Moves in bed and in chair independently
and has sufficient muscle strength to lift up
completely during move. Maintains good
position in bed or chair..

Total Score

FIGURE 26.1B The Braden scale for predicting pressure sore risk.

Page 474

3. Slightly Limited
Responds to verbal commands, but cannot
always communicate discomfort or the
need to be turned.
OR
has some sensory impairment which limits
ability to feel pain or discomfort in 1 or 2
extremities.

1:52 PM

2. Very Limited
Responds only to painful stimuli. Cannot
communicate discomfort except by
moaning or restlessness.
OR
has a sensory impairment which limits the
ability to feel pain or discomfort over 1/2
of body.

5/3/07

1. Completely Limited
Unresponsive (does not moan, flinch,
or grasp) to painful stimuli, due to
diminished level of consciousness
or sedation.
OR
limited ability to feel pain over most
of body.

26Rhoads(F)-26

Date of Assessment

SENSORY
PERCEPTION
ability to respond
meaningfully to
pressure-related
discomfort

474 C h a p t e r 2 6 Pressure Ulcers

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK


Evaluators Name

Patients Name

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P r o c e d u r e 2 6 . 1 Assessing Pressure Ulcer Risk 475

Special Considerations
Patients who have had surgery, life-threatening illnesses, chronic
debilitating disease, immune-compromised illnesses, or any sudden
change in condition, such as cardiac arrest, are at increased risk for
skin breakdown and need skin assessment every shift to help avoid
skin breakdown.
Elderly and Physically Challenged Patients
May have several risk factors on admission; therefore, the risk category will require immediate initiation of the prevention protocol to
avoid pressure ulcer development.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Physical Mobility related to trauma, surgery, or neuromuscular decit


Impaired Skin Integrity related to prolonged pressure on joints and
bony prominences
Ineffective Communication related to illness

EXPECTED OUTCOMES

Factors that place a patient at risk for developing a pressure ulcer


will be recognized, reported, and documented
Patient will be assessed for pressure ulcer risk in a timely manner,
and a prevention plan will be instituted
Patient will maintain optimal skin integrity

EQUIPMENT/SUPPLIES

Risk assessment tool (Norton Scale, Braden Scale, or specic risk


assessment tool for facility)
Standard facility admission form for documentation of skin assessment
Nursing record or ow sheet for ongoing skin assessment
Adequate lighting to perform thorough skin assessment
Measuring device to document size of skin lesion, ulcer, or other
abnormal nding
Sheet or appropriate drape for patient comfort during the skin
assessment
Any Personal Protective Equipment (PPE), such as gloves, mask, gown,
goggles, as indicated by patients diagnosis

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476 C h a p t e r 2 6 Pressure Ulcers


I M P L E M E N TAT I O N
Perform skin assessment on admission, and complete admission

assessment form. Explain procedure to patient and/or caregiver. Use


clean gloves and/or any other PPE if indicated.
Determines whether skin is intact or if there is a pressure ulcer or skin problem at time of admission. Provides baseline documentation of skin condition.
Provides explanation to patient and/or caregiver.
Reduces transmission of microorganisms.
Assess risk with risk assessment scale.
Determines risk category and potential for skin breakdown.
Initiate prevention protocol based on risk assessment and risk fac-

tors identied. Check on prevention protocol and strategies.


Prevention strategies decrease the risk for developing a pressure ulcer.
Consistent turning, skin care, and incontinence management increase the
potential for maintaining skin integrity.
Document all preventive care or wound care if there is a skin

problem.
Documentation ensures that care was provided. Flow sheets provide adequate documentation; record additional description as needed in the narrative and nurses notes.
Communicate all skin care with nursing staff, and promptly notify

the patients prescriber when there is a change in the skin condition.


Prompt notication ensures that any necessary change will be made to
reduce risk for further skin damage.
Continue to assess the patients skin for changes: nonblanching

erythema, swelling, moisture may increase risk for a pressure ulcer.


Skin assessment must be included in the head-to-toe assessment; regular
skin assessment ensures that any change will be noted and prevention methods will be initiated.
After completing assessment, remove gloves and PPE, and wash

hands.
Reduces transmission of infectious organisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Skin assessment is completed on every new admission


Risk assessment and risk category are established for every patient
Preventive skin care measures are instituted according to the risk
category of every patient
Routine skin assessment is performed each shift, or according to
the established standards of the facility, and documented

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Page 477

P r o c e d u r e 2 6 . 2 Implementing Pressure-Ulcer Strategies 477

Patient maintains optimal skin integrity


Any change in skin integrity is documented and communicated
promptly, and appropriate preventive or treatment measures are
instituted

KEY POINTS

FOR

REPORTING

AND

RECORDING

An

admission skin assessment was performed, and the risk


category for the patient is established.
A prevention protocol was initiated.
A routine skin assessment was done as per the facilitys standard of care.
Prescriber was notied of any change in skin integrity.

PROCEDURE 26.2
Implementing Pressure-Ulcer Prevention Strategies
OVERVIEW

To decrease the incidence of pressure ulcers and maintain skin


integrity for the patient at risk for a pressure ulcer.
P R E PA R AT I O N

Skin assessment and determining the risk category are essential


steps in the process of implementing strategies for pressure ulcer
prevention.
The risk assessment (Norton Scale, Braden Scale; see Procedure 26.1)
provides the caregiver with an overall risk category. The assessment
also identies the specic areas of concern that contribute to the
patients risk score (mental status, mobility, moisture, activity, nutrition, friction, shear).
Reassessment is essential for determining changes in the skin;
assessment intervals should be at least every 48 hours; any critical
change in the patients condition requires a reassessment.
Prevention strategies must be consistent; the nurse implements
the prevention protocol according to the facilitys standard of care:

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478 C h a p t e r 2 6 Pressure Ulcers

turning schedules, moisture barriers for the skin, pressure reduction


mattresses or beds, nutritional interventions, and shear and friction
reduction techniques.
Documentation of all pressure-ulcer prevention strategies is
essential.
Special Considerations
Some patients may require heel-propping and turning; skin barrier
products provide important preventive measures to promote maintenance of skin integrity.
Patients who are critically ill, postoperative, immunocompromised,
or with chronic debilitating disease need careful monitoring of vital
signs, sedation, immunosuppression, and nutrition status because
these are important risk factors that may lead to skin breakdown.
Elderly, Confused, and Physically Challenged Patients
Need frequent skin assessment for signs of erythema, excess moisture, or dryness.
Use protective measures for incontinence.
Note mental status and mobility.
Require specic turning schedule and careful handling.
R E L AT E D N U R S I N G D I A G N O S E S

Altered nutrition-related inability to swallow or poor appetite due to


stroke or debilitating illness
Impaired skin integrity related to prolonged pressure on joints and
bony prominences
Impaired mobility related to trauma, surgery, or chronic debilitating
illness

EXPECTED OUTCOMES

Pressure-ulcer prevention strategies will be implemented according


to the risk assessment and risk category
Pressure-ulcer prevention strategies are implemented and revised if
there is a change in the skin condition
Each risk assessment point is addressed with a nursing intervention
to promote skin integrity and prevent a pressure ulcer
Skin assessment and preventive strategies are documented
Patient will maintain optimal skin integrity
The nurse recognizes actual and potential skin problems, communicates the problem, and implements the prevention strategies in a
timely manner

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Page 479

P r o c e d u r e 2 6 . 2 Implementing Pressure-Ulcer Strategies 479


EQUIPMENT/SUPPLIES

Pressure ulcer prevention protocol


Risk assessment form
Admission skin assessment form
Clean gloves and Personal Protective Equipment (PPE), such as gloves,
mask, gown, and goggles (as indicated)
I M P L E M E N TAT I O N
Perform skin assessment on admission and at recommended inter-

vals according to facility standards.


Provides baseline data to determine the need for implementing pressureulcer prevention strategies.
Wear PPE as indicated by patient diagnosis.
Reduces transmission of infectious microorganisms.
Identify patients who are at risk for pressure ulcer.
Determines the degree of risk and provides rationale for implementing preventive measures.
Implement necessary preventive measures according to the risk

factors identied with the risk assessment.


Preventive measures maintain skin integrity and reduce risk for developing a
pressure ulcer.
Explain to the patient and caregiver the process of preventive

skin care.
Patient and caregiver will recognize risk factors. They can assist with preventive measures.
Communicate and document all preventive strategies according to

the facility standard of care.


Promotes continuity of care; reduces risk for pressure ulcer; enhances healing
of actual skin breakdown.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Pressure ulcer incidence rate is decreased


Staff awareness is increased to prevent skin breakdown
Actual skin problems are managed appropriately
Patient and caregiver education promotes pressure-ulcer prevention
and improves quality of life for patients who are at risk for pressure
ulcer

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Page 480

480 C h a p t e r 2 6 Pressure Ulcers

KEY POINTS

FOR

REPORTING

AND

RECORDING

Skin assessment has been done and the prevention strategy is


initiated according to the risk category and facility protocol.
Patients response to the prevention strategy.
If there has been a change in the health status, the patients
risk category has changed.
If there is actual skin breakdown, treatment measures are
initiated.
Patient and/or caregiver education is ongoing.

PROCEDURE 26.3
Assessing Wounds and Staging Pressure Ulcers
OVERVIEW

Wound Assessment

To obtain baseline data to measure wound healing. Wound assessment includes:


Obtaining information relating to patient history.
Identifying the etiology of the wound, the patient environment, and
caregiver support.
Noting wound characteristics.
Identifying other conditions that may effect wound healing.

Staging Pressure Ulcers


To classify the ulcer by dening the depth of tissue destruction.
Staging is determined at the initial assessment by the level of deepest tissue involvement.
Staging is a factor in determining treatment.

P R E PA R AT I O N

Wound Assessment
Screen all patients on admission and perform a head-to-toe assessment to identify wounds using assessment tools, such as, Norton or
Braden scale.
Document ndings on forms specific to wound care as used per
facility protocol.
Collaborate with prescriber regarding plan of care, such as wound
care, activity, and nutrition therapy.
Reassess wounds according to plan of care, and monitor progress.

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Page 481

P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 481

Staging Pressure Ulcers


Staging a pressure ulcer is determined at the initial assessment. The
exception is the presence of eschar (hard, black, leathery surface); it is
impossible to declare the stage of a pressure ulcer covered with
eschar.
The stage of the ulcer is determined by the level of tissue destruction. Stages are dened as follows:

Epidermis
Dermis
Fat
Muscle
Bone

Stage I

Stage II

Stage III

Stage IV

FIGURE 26.3 Pressure sore stages.

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482 C h a p t e r 2 6 Pressure Ulcers

Stage I: nonblanchable erythema of intact skin; often the early


warning of tissue destruction; dark-skinned patients may have purple discoloration, warmth, or induration.
Stage II: partial thickness skin loss involving the epidermis, dermis,
or both; the ulcer is supercial and may present as a blister or
abrasion.
Stage III: full thickness tissue destruction of the subcutaneous tissue that may extend down to but not through the underlying fascia. The ulcer appears as a deep crater with or without
undermining.
Stage IV: full-thickness skin loss with extensive tissue destruction or
damage to muscle, bone, or other structures, such as the joint capsule. There may be undermining and sinus tracts as well.
Describe a pressure ulcer by its stage, and document the wound size,
drainage, odor, granulation tissue, contraction, epithelialization, and
peri-ulcer skin condition.
Special Considerations
Skin assessment may not always be simple on patients with a cast,
compression wrap, anti-embolism hose, or a brace; therefore, more
time must be devoted to their assessment and treatment. Be alert to
complaints of pain, and remove these items for a more thorough
assessment.
Stage I ulcers may not be accurately or reliably assessed in patients
with dark skin; therefore, assessment ndings of warmth, induration,
or purplish discoloration may be the only indication of a stage 1
ulcer in this population.
Elderly and Critically Ill Patients, and Those with Circulatory Compromise
Are priority for immediate identication and treatment of pressure
ulcers.
RELEVENT NURSING DIAGNOSES

Impaired skin Integrity related to prolonged pressure on joints and


bony prominences
Impaired physical mobility related to trauma, surgery, or chronic
debilitating disease
At risk for infection related to invasion of microorganisms into
open wounds and/or ulcers

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Page 483

P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 483


EXPECTED OUTCOMES

Patient will be screened immediately, and causative factors of


wounds or ulcers will be identied
A treatment plan will be initiated immediately, including wound care
and nutrition
Monitoring wound and pressure-ulcer healing will be ongoing, and
the patient will maintain optimal wound healing

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves and other Personal Protective Equipment


(PPE), such as gown, mask, and goggles, as indicated
Measuring apparatus: paper or plastic ruler
Sterile cotton-tipped applicator
Pen or pencil and paper
Documentation form to record pressure-ulcer stage
I M P L E M E N TAT I O N
Review prescribers order.
Determines if wound dressing can be removed.
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient/caregiver.
Decreases anxiety.
Position patient so that wound is accessible.
Facilitates access to the wound.
Don gloves and/or other PPE as indicated.
Reduces transmission of microorganisms.
Remove soiled dressing; observe dressing for exudate characteristics

(color, consistency, odor, and amount).


Provides information about the status of the wound.
Discard soiled dressing according to institutional policy. Don sterile

gloves, if indicated.
Reduces transmission of infection and microorganisms.

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484 C h a p t e r 2 6 Pressure Ulcers


Identify the anatomical location of wound or pressure ulcer. Use

descriptors of bony prominences, if appropriate.


Facilitates communication between health-care providers; identies healing
potential.
Observe wound for extent of tissue damage (full or partial thick-

ness). If pressure related, can stage IIV.


Provides a baseline for further evaluation; enhances communication
between health-care providers.
Observe the wound-bed color and appearance. Note presence of

devitalized tissue or slough, eschar, granulation, or epithelial tissue.


Observe the wound margins. Record amount of granulation tissue,
slough, eschar, and epithelial tissue in percentages.
Provides information about the status of the wound.
Gently probe the wound/pressure ulcer using a sterile, cotton-tipped

applicator for any tunnels, sinus tracts, and undermining. Measure


tunnels or undermining depth of wound cavity by placing cotton tip
at deepest part of cavity or tract and then marking the applicator at
skin level. Next, place it next to a measuring guide calibrated in centimeters.
Provides information about the status of the wound.
Observe the wound for exudate; note color, amount, consistency, and

presence of odor.
Provides information about the status of the wound.
Observe and palpate the skin around the wound/pressure ulcer

(peri-wound area). Note: color, condition of the area, warmth, pain,


and any presence of induration or edema.
Provides information about the status of the wound.
Measure the wound/pressure ulcer by gently placing a sterile, cot-

ton-tipped applicator in the wound nding the greatest length


(head to toe), mark the applicator with a nger and place it next to a
measuring guide calibrated in centimeters. Repeat above for width
(side to side) and depth.
Provides information as to what to expect during the wound healing process.
Follow-up measurements quantify changes in wound size and predict
wound healing.
Implement prescribed treatment measures for wound/pressure

ulcer.
Follows protocol and prescribers orders and provides consistent care that
promotes timely healing.

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P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 485


Discard soiled gloves, cotton-tipped applicators, and measuring

devices in appropriate receptacles.


Reduces transmission of infectious microorganisms.
Wash hands.
Reduces transmission of infection.
Document appropriate information according to protocol about

wound care or pressure-ulcer staging and care.


Follows prescribers orders and established protocol, and enhances communication among members of the health-care team.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Skin problems are correctly identied and treatment is initiated,


monitored, and maintained
Documentation is consistent in the patient record
Staff awareness is increased so that skin care is consistent

KEY POINTS

FOR

Wound/pressure

REPORTING

AND

RECORDING

ulcer location, appearance, and extent of tissue damage.


Dimensions of wound or staging of pressure ulcer.
Exudate, including characteristics.
Prescriber notied of skin condition and any complications.
Treatment initiated or in progress.

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C H A P T E R

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27
Wound Care
27.1
27.2
27.3
27.4
27.5

Applying a Pressure Bandage, 488


Administering a Sitz Bath, 490
Performing Wound Irrigation, 493
Managing Wound Drainage, 495
Teaching Self-Management of
Wound-Drainage Devices, 498
27.6 Applying Wound Dressings, 501
27.7 Applying and Managing a V.A.C. ATS
System, 506

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488 C h a p t e r 2 7 Wound Care

PROCEDURE 27.1
Applying a Pressure Bandage
OVERVIEW

To control or eliminate bleeding from a surgical or a traumatic


wound.
P R E PA R AT I O N

Assess wound immediately, and take action as indicated because


bleeding could range from oozing (capillary), to steady ow
(venous), to gushing or pulsing (arterial), which could be lifethreatening.
Assess limbs for impaired circulation.

Special Considerations
If bleeding is severe (arterial), sterile supplies are not necessary,
because speed is more critical. If dressings are not available, strips
of clothing may be used.
Elderly and Pediatric Patients
Will require careful handling when applying pressure on body parts
and are more at risk for complications from extensive blood loss.
R E L E VA N T N U R S I N G D I A G N O S E S

Fluid Volume Decit related to severe bleeding from surgery or traumatic event to a body part
Impaired Tissue Integrity related to trauma to skin and blood vessels

EXPECTED OUTCOMES

Bleeding is controlled or stopped


Circulation is not affected
Patient sustains minimal blood loss
Wound does not get infected

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves


Rolled gauze
Gauze 4 4s
Surgipad
Elastic-type rolled bandage (Ace wrap)
Silk or foam-type tape
Strips of fabric, if in an emergency setting

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P r o c e d u r e 2 7 . 1 Applying a Pressure Bandage 489


I M P L E M E N TAT I O N
If bleeding is severe (arterial), alert staff to contact prescriber and

assist in applying a pressure dressing.


Enhances efficiency and patient safety.
Wash hands, if time or situation allows.
Reduces transmission of microorganisms.
Organize equipment, if time allows.
Enhances efficiency and patient safety.
Don nonsterile gloves, if time allows; in a nonclinical setting, create

a barrier with clothing or plastic, if possible.


Reduces transmission of microorganisms.
Place patient in supine position and elevate affected extremity

above heart level, if possible.


Reduces blood ow to affected extremity.
Select appropriate size and number of gauze pads or surgipads

depending on the severity of the bleeding to be controlled. Fold


gauze in half or quarters for increased pressure; use pressure when
applying to the affected area.
Absorbs excess blood, reduces transmission of microorganisms, aids in blood
clotting, and compresses the open blood vessel.
Apply direct pressure to affected area using palm of gloved hand

directly over the dressing for 5 to 10 minutes.


Aids in blood clotting and compresses the open blood vessel.
Continue applying pressure when securing the dressing with either

a bandage or a tape product.


Trunk woundssecure dressing occlusively with tape product.
Extremity woundssecure dressing by wrapping extremity in
a circular fashion with rolled elastic bandage.
Aids in blood clotting and compresses the open blood vessel.
After the bandage is in place, check the pulse to the affected

extremity.
Ensures that circulation is not interrupted.
If bleeding continues, apply additional dressing material directly

over previous dressing, with direct pressure over the bleeding site.
Aids in blood clotting and compresses the open blood vessel.

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490 C h a p t e r 2 7 Wound Care


Once bleeding has stopped, observe dressing for any strike-through

bleeding requiring additional dressings. Observe extremity for any


bluish discoloration, coolness, or lack of pulse.
Provides information about the status of the bleeding and possible impaired
circulation, if the bandage is too tight.
Remove soiled gloves and discard in appropriate container; wash

hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients response, level of consciousness, and vital signs


Evaluate dressing/bandage for any additional bleeding
Assess for impaired circulation if extremity is affected
Notify prescriber of patients condition

KEY POINTS

FOR

REPORTING

AND

RECORDING

Location of the bleeding.


and type of dressings applied.
Time required for the bleeding to stop.
How the patient tolerated the procedure and current condition.
When the prescriber was notied.
Amount

PROCEDURE 27.2
Administering a Sitz Bath
OVERVIEW

To relieve pain from surgery in the rectal or genital areas.


To ease discomfort and reduce inammation in the area of the rectum and perineum.
Indicated for hemorrhoids, uterine cramps, prostatitis, and infections
of bladder, prostate, or vagina.

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P r o c e d u r e 2 7 . 2 Administering a Sitz Bath 491


P R E PA R AT I O N

Check prescribers orders for any additives to the water.


Check water temperature with a thermometer; it should be 100F
to 102F.
Determine patient/caregiver understanding and assistance with
procedure.
Check patient record to determine if an infection is present.

Special Considerations
Depending on medical condition, some patients may need frequent
monitoring or an attendant.
Elderly and Pediatric Patients
May need warm water temperature owing to fragile and sensitive
skin.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Skin Integrity related to surgery and/or inammation


to the rectum and/or perineum
Pain/Discomfort related inammation of the rectum and/or
perineum

EXPECTED OUTCOMES

Patient will experience relief of discomfort in the affected area


Patient will experience a decrease in inammation to the area
Patient will experience optimal healing at the affected site

EQUIPMENT/SUPPLIES

Tub or portable device for use on toilet


Thermometer
Towels
Clean gloves, other Personal Protective Equipment (PPE), such as
gown, goggles, and mask, as indicated by patients diagnosis.
I M P L E M E N TAT I O N
Identify patient; explain procedure and include family/caregiver,

if indicated; assess ability to participate.


Reduces anxiety; encourages participation.
Wash hands and don gloves and/or other PPE.
Reduces transmission of microorganisms.

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492 C h a p t e r 2 7 Wound Care


Make certain that the tub is clean or set up portable equipment that

ts on a standard toilet.
Reduces transmission of microorganisms
Place towel in tub for patient to sit on.
Promotes comfort.
Fill tub with 3 to 4 inches water. Use appropriate amount for

portable device.
Only the buttocks and genital area are to be soaked.
Check temperature of water. Temperature should be 100F to 102F,

or follow facility protocol.


Provides for patient safety and comfort.
Patient sits in the tub or on portable device for 10 to 15 minutes or

time according to policy. Remove any dressings prior to the sitz bath.
Relieves discomfort, reduces inammation.
On exiting the tub or portable unit, the area should be carefully

patted dry and, if ordered, clean dressings applied.


Protects wound and promotes healing.
Assist patient back to bed or chair.
Ensures safety and comfort.
Clean equipment; remove gloves; wash hands.
Reduces transmission of infectious organisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate skin integrity and report to prescriber


Assess patients response to sitz bath and any complications

KEY POINTS
Temperature

FOR

REPORTING

AND

RECORDING

of the water.
of the wound or the genital area.
Date and time of sitz bath and patients tolerance.
Appearance

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P r o c e d u r e 2 7 . 3 Performing Wound Irrigation 493

PROCEDURE 27.3
Performing Wound Irrigation
OVERVIEW

To cleanse the wound of all devitalized tissue.


To decrease bacterial contamination and promote optimal wound
healing.
P R E PA R AT I O N

Wound cleansers should not be toxic to tissue, but could cause local
irritation.
Self-contained, sterile systems for wound irrigation are available
that deliver uid at elevated pressures with varying spray
patterns.
Antiseptics should be used only if necessary to control bacterial
overgrowth.
Review patient record to determine if infection is documented.

Special Considerations
Some patients may have an allergy or sensitivity to certain wound
cleansers or antimicrobial solutions.
Pediatric Patient
Allow parents to stay with infant or child to provide comfort.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to surgery or trauma


Risk for infection related to invasion of infectious microorganisms
into an open wound
Pain/discomfort related to manipulation of impaired tissue and/or
sensitivity to irrigant

EXPECTED OUTCOMES

Devitalized tissue will be removed


Wound will exhibit signs of healing, such as decreased erythema,
edema, and exudates
Patient will experience increased comfort as healing progresses
Wound infection will subside

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EQUIPMENT/SUPPLIES

35-mL syringe and 19-gauge needle


Clean gloves, other Personal Protective Equipment (PPE), such as
gown, goggles, and mask, as indicated
Wound cleanser
Bag for soiled dressings
Towels or drapes to drape the wound
Gauze, absorbent pads, and tape to redress the wound
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Identify patient; explain procedure to patient/family/caregiver as

indicated.
Reduces anxiety, reinforces teaching.
Position patient for access to wound.
Facilitates procedure and enhances comfort.
Don gloves; remove dressing and place in bag for disposal.
Reduces transmission of microorganisms.
Drape wound with towels/drapes.
Connes irrigant solution to wound area and reduces spread of infection.
Draw wound solution into

syringe; direct stream of


irrigant to all areas of the
wound, using gauze to absorb
solution or emesis basin to
collect solution.
Removes necrotic debris;
promotes wound healing.

FIGURE 27.3 Direct stream of irrig-

ant to all areas of the wound.

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P r o c e d u r e 2 7 . 3 Performing Wound Irrigation 495


Assess wound for healing.
Wound assessment identies healing or deterioration and contributes to
decision making for subsequent care.
Redress wound as indicated/ordered.
Protects wound, promotes healing.
Remove towel/drape; remove gloves and dispose in trash container;

wash hands.
Reduces spread of infectious microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

When the wound is clean and free of debris, irrigation can be discontinued, and the wound can then be gently cleansed at each dressing
change

KEY POINTS

FOR

REPORTING

AND

RECORDING

Wound

assessment parameters, such as size, edema, erythema,


and exudates.
Complications, such as infection.
Patients tolerance of the procedure and participation.

PROCEDURE 27.4
Managing Wound Drainage
OVERVIEW

To contain the drainage, protect the skin, and control odor.


P R E PA R AT I O N

Draining wounds may be a result of trauma, surgery, or disease.


Fluid and electrolyte problems and disruptions in skin integrity may
occur.
Appropriate management increases patient comfort and can reduce
complications and facilitate healing.
Equipment will be chosen depending on type and quantity of
drainage:
Copious: over 50 mL per day can best be managed with pouching,
especially if the effluent is harmful to the skin.

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496 C h a p t e r 2 7 Wound Care

Less copious: under 50 mL per day and not harmful to the skin can
be managed with absorbent dressings and skin sealants to protect
the peri-wound skin.
Special Considerations
Provide teaching of wound care and pouching to client and/or caregiver before discharge.
Geriatric and Pediatric Patients
Take extra time and care because skin is fragile.
Involve parent/caregiver in wound drainage management.
Home Health Patient
During discharge planning, make arrangements for home health to
follow, and monitor patient and/or caregiver compliance and skill
with wound-drainage management.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to trauma or surgery


Potential for infection related to invasion of infectious microorganisms into wound
Pain/discomfort related to impaired tissue and irritation of wound
drainage

EXPECTED OUTCOMES

Skin will be protected against excessive drainage


Patient will experience increased comfort due to drainage containment and odor control
Drainage can be measured accurately

EQUIPMENT/SUPPLIES

Wound drainage pouch


Nonsterile gloves, gauze, wound cleanser, bag for disposal of soiled
dressings
Skin sealant, drainage collector, paste, adhesive tape
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.

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P r o c e d u r e 2 7 . 4 Managing Wound Drainage 497


Explain procedure to patient/family.
Reduces anxiety, reinforces teaching.
Position patient for access to wound.
Facilitates procedure.
Don nonsterile gloves, remove dressing and place in bag for

disposal.
Reduces transmission of microorganisms.
Gently ush wound with wound cleanser.
Removes necrotic debris, reduces spread of infection.
Assess wound for healing.
Assessment of wound identies healing or deterioration and contributes to
decision-making for subsequent care.
Dry periwound area by patting gently.
Allows application of skin sealant and wound-drainage device.

Pouching procedure:
Trace pattern on back of pouch cut opening 1/8- to 1/4-inch larger

than opening on skin.


Too large an opening will expose skin to harmful drainage. Too small an
opening will cause leakage and decrease wear time.
Apply paste around wound opening to ll in uneven spaces and

cover exposed skin.


Protects exposed skin from drainage and extends wear time by preventing
leakage under the edge of the pouch.
Apply pouch, centering pouch opening over wound opening.
Provides for proper location of pouch, collection of drainage, and protection
of the skin.
Apply tape to picture-frame edges of pouch.
Promotes increased wear time.
Connect pouch to drainage bag.
Draining effluent away from pouch increases wear time, prevents leakage
onto skin, and aids in measurement of drainage.
Remove gloves and discard into disposal bag.
Reduces spread of infection.
Wash hands.
Reduces spread of infection.

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498 C h a p t e r 2 7 Wound Care


E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Reassess efficacy of wound management system at each change


Assess patients tolerance of the wound management system

KEY POINTS

FOR

REPORTING

AND

RECORDING

Wound

assessment parameters and changes in the wound.


Patients tolerance of the procedure.
Effectiveness of the procedure, such as skin protection, odor
control, and containment of drainage.

PROCEDURE 27.5
Teaching Self-Management of Wound-Drainage Devices
OVERVIEW

To assist the patient with the transition process from hospital to


home.
To maintain function of the device while preventing complications.

P R E PA R AT I O N

Determine patient/caregivers basic knowledge about the wounddrainage device.


Prepare and initiate a teaching plan, including the purpose, function, and routine care of the device, and present to patient and/or
caregiver.
Assess patient/caregivers basic knowledge about signs and symptoms of complications or problems and appropriate intervention.

Special Considerations
Provide teaching of self-management of wound-drainage devices to
patient/caregiver/family before discharge.
Teaching should be based on individual needs and abilities.
Home Health Patient
During discharge planning, make arrangements for home health
to follow and monitor progress and/or complications with selfmanagement of wound-drainage devices.

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P r o c e d u r e 2 7 . 5 Teaching Self-Management of Wound-Drainage 499


R E L E VA N T N U R S I N G D I A G N O S E S

Decient knowledge related to managing wound drainage devices


Ineffective individual and/or family coping related to stress of dealing with wound-drainage and care
Noncompliance related to fear/depression of dealing with wounddrainage devices

EXPECTED OUTCOMES

Patient/caregiver can accurately apply the device


Drainage, odor, and protection of skin will be managed
Complications of using the devices will be prevented

EQUIPMENT/SUPPLIES

Wound drainage device


Nonsterile gloves, gauze, wound cleanser, bag for disposal of soiled
dressing
Written instructions for patient/caregiver
Anatomical chart or diagram
I M P L E M E N TAT I O N
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Explain procedure to patient/caregiver.
Reduces anxiety, reinforces teaching.
Position patient for access to wound.
Facilitates dressing change.
Don nonsterile gloves; remove dressing and place in bag for

disposal.
Reduces transmission of microorganisms.
Gently ush wound with wound cleanser.
Removes necrotic debris, reduces spread of infection.
Assess wound for healing.
Assessment of wound identies healing or deterioration and contributes to
decision-making for subsequent care.

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500 C h a p t e r 2 7 Wound Care


Dry periwound area by patting

gently.
Allows for application of skin
barrier and/or adhesive backing
of wound-drainage device.

FIGURE 27.5 Teach patient to


carefully dry periwound edges.

Explain and demonstrate procedure to patient/caregiver.


Contributes to patient/caregiver understanding and builds condence
Allow patient/caregiver to return demonstration if time allows, or do

a return demonstration at the next procedure.


Contributes to patient/caregiver understanding and builds condence.
Review procedure with patient/caregiver at each teaching session,

allowing patient/caregiver to do more each time.


Builds condence and gradually shifts responsibility to patient/caregiver.
Remove gloves and discard into disposal bag.
Reduces spread of infection.
Wash hands.
Reduces spread of infection.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient/caregiver understanding and ability at each teaching


session
Provide written instructions and arrange for acquisition of supplies
at discharge
Allow time to teach and for patient/caregiver to return demonstrate
Follow-up practice sessions should be provided

KEY POINTS

FOR

REPORTING

AND

RECORDING

Procedure as taught.
Patient/caregiver understanding and ability.
Plans for follow-up teaching.

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 501

PROCEDURE 27.6
Applying Wound Dressings
OVERVIEW

Wet-to-Dry Dressings are appropriate for surgical wounds, full thickness wounds, pressure ulcers, and vascular ulcers.
Hydrogel Dressings are to help maintain a moist wound environment and may be used on stage I through stage IV wounds. They are
available in amorphous and sheet forms, as well as packing strips
impregnated with the gel.
Transparent Film Dressings are thin, transparent polyurethane
sheets with one side coated with an adhesive. They are appropriate
for partial thickness wounds, skin tears, and stage I and II pressure
ulcers and are used as primary or secondary dressings.
Hydrocolloid Dressings are combinations of gels and adhesives that
form a gel when in contact with wound uid. The adhesive side will
adhere to most moist surfaces, but not to the wound base. They are
appropriate for partial thickness wounds, skin tears, shallow fullthickness wounds, venous stasis ulcers, and stage I through III pressure ulcers.

P R E PA R AT I O N

Check prescribers order for specic type of dressing ordered for


wound.

Wet-to-Dry Dressings
Easy and inexpensive.
May cause bleeding of wound bed on removal if dry (mechanical
dbridement).
May cause maceration of periwound if gauze is too wet or there are
large amounts of exudates.

Hydrogels
Prevent desiccation.
Easy to use and relatively inexpensive.
May cause maceration of periwound skin (also with Transparent Film
and Hydrocolloid Dressings).

Transparent Film and Hydrocolloid Dressings

The dressing should overlap onto intact skin approximately 1 inch.


May cause epidermal stripping to periwound skin on removal.

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502 C h a p t e r 2 7 Wound Care

Contraindicated in arterial, infected, puncture, stage III and IV


pressure ulcers, third-degree burns, and draining wounds.
Edges of hydrocolloid dressings may roll up in sacral areas; consider
taping all edges down or select a product with a border.

Special Considerations
Conduct patient/caregiver teaching as indicated for type and
application of wound dressing.
Elderly and Pediatric Patients
May require more time to apply to fragile skin.
For elderly patients, use skin sealant for skin protection.
Home Health Patient
During discharge planning, arrange for home health to follow and
assist in additional teaching of wound dressings as needed.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Skin Integrity related to surgery or trauma


Potential for Infection related to invasion of infectious microorganisms into an open wound
Pain/Discomfort related to cleaning wound and applying dressing

EXPECTED OUTCOMES

Removal of necrotic tissue by promoting mechanical dbridement


and supporting autolytic dbridement
Prevention of infection
Wound healing

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves


Gauze sponges
Rolled cotton gauze and scissors (for wet-to-dry)
0.9% saline solution, unless physician order species a different
solution
Secondary dressing supplies: surgipad, additional gauze, and tape
or island dressing with tape border
Specialty dressing as ordered/indicated: hydrogel, transparent lm,
or hydrocolloid

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 503


I M P L E M E N TAT I O N
Review prescribers order.
Determines appropriate treatment and dressing for patient.
Wash hands.
Reduces transmission of microorganisms.
Organize equipment according to type of dressing to be used.
Enhances efficiency and patient safety.
Position patient so that wound is accessible.
Facilitates access to the wound.
Don nonsterile gloves, remove soiled dressings, and dispose

dressings and soiled gloves in appropriate bag.


Reduces transmission of infection and microorganisms.
Don nonsterile or sterile gloves (if sterile dressing change).
Reduces transmission of microorganisms.
Gently cleanse wound with 0.9% saline solution or other wound

cleansers as indicated.
Removes necrotic debris.
Assess wound (including periwound as indicated).
Provides information about the status of a wound; contributes to decisions
for subsequent care.
Using gauze sponge, dry periwound or ulcer area by patting or

gently wiping away from wound.


Dries and maintains integrity of periwound without contaminating the
wound with skin ora.

For Wet-to-Dry Dressing


Moisten gauze sponges or

rolled gauze with appropriate


solution, wring out excess
(gauze is to be damp, not dripping), open gauze sponges,
and gently ll cavity of wound
ensuring moist dressing is not
on the surrounding skin.
Note: Use rolled gauze if size
of wound requires more than
one gauze sponge.

FIGURE 27.6A Place moistened

gauze in wound cavity while avoidProvides a moist environment,


obliterates dead space, absorbs ing wound edges.
exudate, adheres to the necrotic tissue when allowed to completely dry.

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504 C h a p t e r 2 7 Wound Care


Apply and secure secondary dressing if indicated. Use Montgomery

straps, if indicated, depending on type and location of wound, and


frequency of dressing changes. Remove gloves and discard according to institutional policy.
Protects wound and decreases transmission of microorganisms.
Wash hands.
Reduces transmission of microorganisms.

For Hydrogel Dressing


Follow initial steps for applying a wet-to-dry dressing up to and

including drying the periwound edge:


Apply dressing in size appropriate to cover the wound. If using
amorphous hydrogel, apply to wound and cover with gauze or
composite dressing, loosely packing if necessary.
Remove gloves and discard according to institutional policy.
Absorbs exudates, eliminates dead space, promotes moist healing, and prevents epidural stripping.
Reduces spread of infection.
Wash hands.
Reduces transmission of microorganisms.

For Transparent Dressing


Follow initial steps for apply-

ing a wet-to-dry dressing up


to and including drying the
periwound edge:
Apply dressing with adhesive
side towards patient taking
care to avoid any creases or
skin folds beneath the dressing.
Tape edges of transparent lm
if dressing is in a highly mobile
area.
Remove gloves and discard
according to institutional
FIGURE 27.6B Take care to avoid
policy.
creasing lm.
Provides a moist environment, facilitates autolytic dbridement, protects
wound from bacterial invasion, and protects periwound margins from exudates.
Wash hands.
Reduces transmission of microorganisms.

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 505

For Hydrocolloid Dressing


Follow initial steps for applying

a wet-to-dry dressing up to and


including drying the periwound
edge:
Apply adhesive side toward
patient, taking care to avoid
forming any creases or skin
folds beneath the dressing.
Warm the dressing by placing
palm of hand directly over
dressing for 30 to 60 seconds.
May apply tape to all edges if
FIGURE 27.6C Apply hydrocolloid
in sacral region.
dressing.
Remove gloves and discard
according to institutional policy.
Provides a moist environment, facilitates autolytic dbridement, absorbs a
small-to-moderate amount of exudates, protects wound from bacterial invasion, protects periwound margins from exudates, protects vulnerable skin
from friction, and prevents edges from rolling up.
Wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients response and tolerance of dressing change


Assess wound at each dressing change

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

of wound: location, extent of tissue damage,


wound appearance including periwound, dimensions,
characteristics of exudate.
Patients tolerance of dressing change.
Changes in the wound.

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506 C h a p t e r 2 7 Wound Care

PROCEDURE 27.7
Applying and Managing a V.A.C. ATSTM System
OVERVIEW

To promote granulation tissue formation.


To promote wound contraction.
To provide moist wound healing.
To remove infectious material.
To remove excess wound exudate or edema.
To stabilize new skin grafts or aps.
V.A.C. ATS System is a vacuum-assisted closure device using the
T.R.A.C. technology for pressure sensing. V.A.C. systems are appropriate for patients who would benet from negative pressure, such as
those with stage III and stage IV pressure ulcers, open chronic
wounds, neuropathic ulcers, acute and traumatic wounds, skin grafts
and aps, and dehisced wounds.

P R E PA R AT I O N

A thin wound covering such as Adaptic (Johnson & Johnson Inc.,


New Brunswick, NJ), Mepitel (Mlnlycke Health Care AB, Gothenborg,
Sweden) or Drynet Wound Veil (Smith & Nephew, Inc., London,
England) may be indicated over fragile wound beds to prevent
adherence or to protect blood vessels or organs in deep or open
cavity wounds.
Careful use in patients with active bleeding, irradiated, sutured
blood vessels or organs, currently taking anticoagulants.
Certied Wound, Ostomy, and Continence Nurses may assist in
appropriate sponge dressing selection and application.
Contraindicated in malignancy in the wound, necrotic tissue with
eschar, untreated osteomyelitis, in direct contact with exposed blood
vessels or organs, nonenteric and unexplored stulas.

Special Considerations
Some patients may require additional preventative measures in
conjunction with the V.A.C. System, such as heel-propping and
skin-barrier products.
Patients who are critically ill, postoperative, immunocompromised,
or with chronic debilitating disease need careful monitoring of vital
signs, sedation, immunosuppression, and nutrition status that may
prolong adequate wound healing.

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P r o c e d u r e 2 7 . 7 Applying and Managing a V.A.C. ATSTM System 507

Dressings require changing in approximately 48 hours to two to


three times a week.
Assess and premedicate with pain medication as ordered.
Elderly, Pediatric, Confused, and Physically Challenged Patients
Need a specic skin assessment and turning schedule.
Use protective measures for incontinence.
Note mental status and mobility.
R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to surgery or trauma


Potential for infection related to invasion of infectious microorganisms into an open wound
Pain/discomfort related to cleaning wound and applying V.A.C.
System

EXPECTED OUTCOMES

Formation of granulation tissue (some adherence is expected when


using the black V.A.C. GranuFoam Dressing) (KCI Medical Ltd., San
Antonio, TX)
Wound contraction
Decreased edema
Wound healing

EQUIPMENT/SUPPLIES

Nonsterile gloves
Sterile gloves
Wound cleanser or 0.9% saline solution, unless physician order species a different solution
V.A.C. ATS System
V.A.C. GranuFoam Dressing
(black sponge) or V.A.C.
Vers-Foam (sterile water
premoistened white sponge)
(KCI Medical Ltd., San
Antonio, TX)

FIGURE 27.7A Foam sponge,

drapes, and suction wafer

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508 C h a p t e r 2 7 Wound Care

Gauze sponges
T.R.A.C. Pad and V.A.C. Drape dressing (KCI Medical Ltd.,
San Antonio, TX)
1000-mL canister
Sterile scissors
I M P L E M E N TAT I O N
Review physicians order.
Determines appropriate treatment.
Wash hands.
Reduces transmission of microorganisms.
Organize equipment.
Enhances efficiency and patient safety.
Position patient so wound is accessible.
Facilitates access to the wound.
Don nonsterile gloves. Gently remove the dressing in the direction

of the hair growth while supporting the surrounding skin; dispose


dressing and soiled gloves in appropriate bag.
Decreases discomfort, reduces epidermal stripping, reduces transmission
of infection and microorganisms.
Don sterile gloves.
Reduces transmission of microorganisms.
Gently cleanse wound with wound cleanser, 0.9% saline solution,

or prescribed solution using sterile gauze sponges.


Removes necrotic debris.
Assess wound including periwound.
Provides information about the status of a wound, contributes to decisions
for subsequent care.
Using gauze sponge, dry periwound area by patting or gently wiping

away from wound.


Dries and maintains integrity of periwound without contaminating the
wound with skin ora.

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P r o c e d u r e 2 7 . 7 Applying and Managing a V.A.C. ATSTM System 509


Cut desired foam the size and

shape of the wound. May require


the use of more than one piece
of sponge. Keep in mind the
sponges need to touch to
provide negative pressure.
Sizing the foam appropriately
prevents periwound maceration.

FIGURE 27.7B Cut foam to t into


the wound bed.

Apply wound protective layer against wound, if indicated.


Protects fragile wound bed from adherence.
Apply or pack the cavity with

the cut to t foam, apply the


drape lm dressing taking care
not to pinch intact skin and
ensuring the lm is adhering to
at least 3 to 5 cm of intact skin,
cut an opening in the drape
dressing over the sponge area,
apply the T.R.A.C. Pad over the
cutout opening and connect to
the canister, turn the V.A.C. ATS
System on; general settings
include continuous suction of
125 mm Hg for adult patients,
observe for the pruning
of the foam dressing.

FIGURE 27.7C Cut hole in drape

lm over the foam sponge.

Applies negative pressure, removes


excess wound exudate away from
wound; protects wound from
bacterial invasion and trauma.

FIGURE 27.7D Apply T.R.A.C. over


the cutout, opening in the drape.

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510 C h a p t e r 2 7 Wound Care

FIGURE 27.7E Observe pruning


of the foam, and drape dressing
after suction is applied.

Remove gloves and discard in appropriate bag.


Reduces transmission of microorganisms.
Wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patients response and tolerance of dressing change


Assess the sponge for pruning (a compression of the sponge)
Assess wound at each dressing change

KEY POINTS
Assessment

FOR

REPORTING

AND

RECORDING

of wound: location, extent of tissue damage,


wound appearance including periwound, dimensions, characteristics of exudate.
Patients tolerance of dressing change.
Settings of the V.A.C.ATS System.
Type of sponge used.
Compression of the sponge, called pruning.

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U N I T

C H A P T E R

Specimen
Collection

10

28
Collecting Blood
Samples
28.1 Performing Venipuncture, 512
28.2 Obtaining a Blood Glucose Level by
Finger Stick, 517
28.3 Obtaining a Specimen for Arterial Blood
Gas Analysis, 520

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512 C h a p t e r 2 8 Collecting Blood Samples

PROCEDURE 28.1
Performing Venipuncture
OVERVIEW

To collect a venous blood specimen for laboratory examination.


P R E PA R AT I O N

Determine agency policy regarding personnel certied to perform


venipuncture.
Determine method of collectionsyringe or Vacutainer.
Determine special conditions, such as fasting, specied collection
time, and/or administration of drugs before or after collection.
Determine if bleeding and/or clotting time may be increased due to
medication or pathologic condition; determine contraindications for
venipuncture of a specic site.
Determine patients ability to understand, cooperate, and assist in
the procedure.

Special Considerations
For patients needing blood cultures, collect from two different sites;
inoculate anaerobic culture rst, then aerobic.
Do not collect sample from an extremity where blood or IV uids are
infusing or from lower extremity.
Elderly and Pediatric Patients
Apply warm compresses and use small-bore catheters to promote
optimal conditions for collection.
Allow parents to hold children and infants for comfort, if possible.
R E L E VA N T N U R S I N G D I A G N O S E S

Potential for injury related to trauma to blood vessel during


venipuncture
Risk for infection related to invasion of microorganisms at the
venipuncture site

EXPECTED OUTCOMES

Venipuncture site shows no evidence of bleeding, hematoma, or


infection
Sterile specimen is collected in proper container

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P r o c e d u r e 2 8 . 1 Performing Venipuncture 513


EQUIPMENT/SUPPLIES

Alcohol or povidone-iodine swab


Disposable, clean gloves
Small pillow or folded towel
Sterile 22 gauze pads
Rubber tourniquet
Tape or Band-Aid
Completed identication label
Completed laboratory requisition
Plastic bags for specimen transport
Needle/equipment disposal container; blood tubes
Syringe Method
Sterile needles: 2021 gauge (adult): 2325 gauge (children and older
adults)
Sterile syringe (volume determined by amount of blood sample
needed)
Vacutainer Method
Vacutainer tube with needle holder
Sterile double-ended needles: 2021 gauge (adults): 2325 gauge
(children and older adults)
Blood Culture
Sterile needle: 2021 gauge (adult): 2325 gauge (children and older
adults)
Anaerobic and aerobic culture bottles
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist.
Ensures accurate testing; meets patients right to be informed; encourages
cooperation and participation.
Determine that special test-related conditions have been met.
Test may require fasting, specied time, or administration of medicines
before or after the test.
Determine risks for increased bleeding or clotting time.
Patient may have bleeding disorder or be on anticoagulant therapy.
Determine contraindications for a venipuncture site.
Venipuncture is avoided in areas of an infusion, hematoma, arteriovenous
shunt, or in the same arm as mastectomy.
Wash hands, provide privacy, and raise bed to working height.
Reduces spread of microorganisms; provides comfort and safety to patient
and nurse.

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514 C h a p t e r 2 8 Collecting Blood Samples


Place patient in supine or semi-Fowlers position with arm extended;

support upper arm with pillow or towel.


Stabilizes extremity and facilitates access to site.
Don nonsterile gloves.
Reduces exposure to blood-borne pathogens.
Wrap tourniquet around extremity 510 cm (24 inches) above site.
Tourniquet obstructs venous return to the heart and dilates vein facilitating
palpation or visualization.
Palpate distal pulse below the tourniquet; reapply less tightly if pulse

is not palpable.
Arterial blood circulation will be interrupted by a tourniquet that is applied
too tightly.
Instruct patient to pump st several times.
Promotes distention of veins.
Inspect extremity, select straight, easily visualized vein; palpate to

assess elasticity. Apply warm compresses if vein is not visible or easily palpated.
Facilitates venipuncture; rigid veins are more difficult to puncture. Warmth
dilates blood vessels.
Remove tourniquet within one minute. Wait additional minute

before reapplying or selecting another site.


Prolonged pressure will alter blood circulation and cause patient discomfort.

Syringe Method
Select proper-size syringe and needle.
Size depends on test to be performed and patient age and/or physical characteristics.
Clean site with alcohol or povidone-iodine swab using a circular

motion from site outward to an area of 5 cm (2 inches); allow area


to dry.
Reduces bacteria on skin surface from invading puncture site; drying of site
reduces sting of venipuncture and supports antimicrobial effect.
Remove needle cover; inform patient to expect a stick.
Meets patient need to be informed, and assists in controlling patient anxiety.
Pull skin taut 2.5 cm (1 inch) below proposed venipuncture site with

thumb or forenger of nondominant hand to stabilize vein.


Prevents rolling of vein during insertion of needle.

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P r o c e d u r e 2 8 . 1 Performing Venipuncture 515


With bevel up, slowly insert needle at 5- to 30-degree angle into

vein; may feel a pop as needle enters vein.


Reduces vein injury and penetration of both sides of vein.
Pull back gently on plunger of syringe and observe for blood return.
Creates vacuum necessary to aspirate the blood into the syringe.
Validates that needle is in vein.
Withdraw volume of blood required for test.
Ensures accurate test results.
Release tourniquet.
Minimizes bleeding when needle is removed from site.
Place 2 2 gauze or alcohol swab over site; withdraw needle and

apply pressure.
Reduces patient discomfort and vein injury.
Transfer specimen to blood tubes using one hand to insert needle

into blood tube stopper; allow vacuum to ll tube.


Prevents damage to red blood cells; prevents needle-stick injury.
Gently rotate blood in tube back and forth 8 to 10 times.
Mixes additives in tube with blood to prevent clotting.

Vacutainer Method
Place double-ended needle on Vacutainer tube.
Double-end long needle used to puncture vein and short needle to puncture
blood tube stopper.
Place correctly colored blood tube inside Vacutainer without punc-

turing rubber stopper.


Ensures accurate test results.
Remove needle from Vacutainer; inform patient to expect a stick.
Meets patient need to be informed and assists in controlling patient anxiety.
Pull skin taut 2.5 cm (1 inch) below site with thumb or forenger of

nondominant hand to stabilize vein.


Prevents rolling of vein during insertion of needle.
Hold Vacutainer needle with bevel up at 15- to 30-degree angle.

Insert slowly into vein.


Reduces vein injury and penetration of both sides of vein.
Hold Vacutainer rmly, and push blood tube into needle of holder.
Puncturing stopper allows blood to ow into tube.

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516 C h a p t e r 2 8 Collecting Blood Samples


Observe blood ow into tube.
Validates vacuum is present and needle is in vein.
Holding Vacutainer securely in place, remove tube when lled, and

add additional tubes to vacutainer as necessary.


Prevents needle from penetrating vein or dislodging from vein.
Release tourniquet, apply 22 gauze over puncture site, and with-

draw needle from Vacutainer.


Minimizes bleeding at site, vein trauma, and patient discomfort.
Apply pressure to site for 2 to 3 minutes or until bleeding stops; tape

gauze securely.
Reduces bleeding and hematoma formation.
Clean tubes with alcohol if outside is contaminated with blood.
Prevents transmission of blood-borne pathogens to others.
Label each tube, and attach lab requisitions.
Ensures accurate reporting of patients test results and appropriate therapy.
Dispose of contaminated needles, syringes, and equipment into

sharps container and/or appropriate container.


Prevents transmission of blood-borne pathogens.
Put specimens in appropriate container for transport to laboratory;

remove gloves and wash hands.


Prevents transfer of microorganisms; fresh specimen ensures accurate
patient results and appropriate therapy.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe venipuncture site for bleeding, hematoma, or signs of


infection
Check test results, and inform prescriber of abnormal ndings

KEY POINTS

FOR

REPORTING

Date, time of specimen collection


of site
Disposition of specimen
Test results
Assessment

AND

RECORDING

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P r o c e d u r e 2 8 . 2 Obtaining a Blood Glucose Level by Finger Stick 517

PROCEDURE 28.2
Obtaining a Blood Glucose Level by Finger Stick
OVERVIEW

To measure the amount of glucose in the blood.


A drop of capillary blood is obtained by skin puncture on the nger
by a single lancet or a device that holds a lancet and then is applied
to a reagent test strip that is placed in a glucose monitor to be read.
P R E PA R AT I O N

Sterile asepsis and standard precautions are used throughout the


procedure.
Make sure enough blood is obtained to ensure accurate test results.
Assess patient/caregiver understanding about procedure and provide teaching.

Special Considerations
Patients who have had repeated sticks over time may have calloused
ngers.
Blood sugar level should be checked before meals or as ordered to
determine insulin dosages.
Hold the hand in a dependent position before the stick to increase
blood ow to the area.
Elderly Patient
Possible visual impairment reduces ability to read meter accurately;
assistance with sticks may be necessary.
May be necessary to warm ngertips to produce vasodilation to
obtain blood sample.
Pediatric Patient
Heel and great-toe sticks can be used, especially on infants; warming
the area with a warm cloth will increase blood ow.
Allow children to choose puncture site if feasible, and incorporate
use of play therapy.
EXPECTED OUTCOMES

Normal blood glucose level


No tissue damage or infection to puncture site
Adequate amount of blood obtained to get accurate results
Patient is educated about proper technique and normal blood glucose level

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518 C h a p t e r 2 8 Collecting Blood Samples


EQUIPMENT/SUPPLIES

Sterile single lancet or automatic lancet


Capillary tube
Glucose reagent test strip
Antiseptic swab
Cotton ball or gauze pad
Soap and water
Clean gloves
Glucose meter
Biohazard bag
Sharps container
I M P L E M E N TAT I O N
Check prescribers order for frequency of glucose status. Identify

patient and explain procedure; provide privacy.


Frequency is based on patients glucose status; ensures accurate testing;
enhances cooperation and understanding; allays embarrassment.
Gather equipment, and wash hands.
Organization promotes successful and time-efficient collection;
decreases spread of microorganisms.
Don clean gloves.
Provides protective barrier.
Assess area for puncture site.
The most vascular areas with fewer nerve endings are the outer
aspect of heel and toes, sides of ngers. Heels and toes are more
frequently used for infants.
Choose site for nger stick and massage toward puncture

site.
Increases blood ow to site.
Cleanse with soap and water or alcohol swab; allow to dry.
Warm water increases blood ow. Reduces bacteria on skin surface
from invading puncture site; drying reduces sting of puncture
and supports antimicrobial effect.
Uncover lancet or activate the automated lancet twisting.
Preparation promotes success.

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P r o c e d u r e 2 8 . 2 Obtaining a Blood Glucose Level by Finger Stick 519


Place automated lancet rmly

against side of nger, and


gently press the activating
button. Hold the single
lancet perpendicular
to site.
Ensures correct position.

FIGURE 28.2A Proper position

of lancet.
Wipe away the rst drop of blood with gauze or cotton ball.
Contains more serum, which can dilute blood specimen and alter
results.
Stroke from base of nger, toe, or heel to puncture site. Do not

squeeze puncture site.


Stroking in a massaging motion will increase blood ow; squeezing
will increase serum and dilute specimen.
Fill capillary tube with blood

by placing tip of tube at base


of drop of blood; or if using
reagent strip, place next to
blood drop, making sure
that enough blood is
absorbed by the strip
for accurate results.
Ensures accuracy of testing.
FIGURE 28.2B Apply blood drop to

reagent.
Apply pressure to puncture site for 15 to 30 seconds with gauze

to stop bleeding.
Direct pressure reduces bleeding.
If using a glucose meter, allow blood to stay on strip for specied

time and then place in meter for digital readout.


Ensures accurate testing.

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520 C h a p t e r 2 8 Collecting Blood Samples


Discard used equipment into biohazard bags or sharps container,

remove gloves and wash hands.


Decreases spread of blood-borne pathogens.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare patients value with normal lab values, and inform prescriber of abnormal ndings
Inspect puncture site for further bleeding
Administer drug therapy, if ordered, for abnormal glucose level

KEY POINTS

FOR

REPORTING

AND

RECORDING

Time

and site of stick


Patients glucose level
If any drug therapy was administeredtype, amount, location
of injection
Any teaching provided

PROCEDURE 28.3
Obtaining a Specimen for Arterial Blood Gas Analysis
OVERVIEW

To provide assessment of a patients ventilation and oxygenation


status and acidbase balance.
Parameters include:
Arterial oxygen saturation.
Arterial blood pH.
Partial pressure of oxygen.
Partial pressure of carbon dioxide.

P R E PA R AT I O N

Dyspnea, increase in respiratory rate, unequal respiratory pattern,


abnormal breath sounds, and alteration in level of consciousness
may indicate need for arterial blood gas (ABG) analysis.
Prepare patient that procedure is painful.

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P r o c e d u r e 2 8 . 3 Obtaining a Specimen for Arterial Blood Gas 521

Factors that may inuence results of ABG include use or nonuse of


oxygen, any recent change in amount of oxygen being delivered, use
of tracheal suctioning before obtaining ABG.

Special Considerations
Some patients may require additional instruction about procedure.
Pediatric, Confused, and Combative Patients
May require more than one person to obtain sample.
R E L E VA N T N U R S I N G D I A G N O S E S

Pain/discomfort related to needle insertion depth into skin and


artery
Risk for injury related to improperly done procedure

EXPECTED OUTCOMES

Sample is appropriate for blood gas analysis


Neurovascular checks to involved extremity will reveal a warm
extremity with pulses and capillary rell of less than 3 seconds
EQUIPMENT/SUPPLIES

3-mL heparinized syringe


23- or 25-gauge 1-inch needle
2 alcohol swabs
2 2 gauze
Clean gloves
Tape
Plastic bag with crushed ice
Goggles
Requisition and identication labels
1:1000 heparin solution, if needed
I M P L E M E N TAT I O N
Check prescribers order.
Identies specimen ordered, ensuring correct collection methodology.
Identify patient, and explain procedure.
Ensures accurate testing; promotes cooperation and understanding.
Wash hands, and gather equipment.
Decreases spread of microorganisms; organization promotes successful
and time-efficient collection.

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522 C h a p t e r 2 8 Collecting Blood Samples


Prepare heparinized syringe if agency does not have preprepared

syringe.
Heparin prevents blood specimen from clotting.
Aspirate 0.5 mL of the 1:1000 heparin solution into syringe, after

wiping top of vial with alcohol swab. Withdraw the plunger to the
end of the syringe so that the heparin coats all sides of the syringe.
Eject the heparin into the sink.
Preparation of syringe for accurate testing.
Don clean gloves and goggles.
Serve as protective barriers for the nurse.
Inspect and palpate radial site. Perform Allens Test to determine col-

lateral circulation. Have patient make st and nurse applies pressure


over ulnar and radial arteries using index and middle ngers. Have
patient open and close st several times. Release pressure over ulnar
artery and watch for ushing of palm and ngers within 15 seconds.
If collateral circulation is present, the hand will ush upon releasing the ulnar
artery. If there is no ushing, do not use that radial artery. Assess the other
hand.
Hyperextend the selected wrist.
Decreases mobility of the artery.
Cleanse site with alcohol swab using circular motions.
Application of bacteriostatic agent and use of friction from clean to dirty
area decreases number of microorganisms.
Feel for radial pulse with index nger of nondominant hand; as you

hold needle at a 45-degree angle, insert needle bevel up into site of


pulsation.
Angle enhances arterial collection.
Once blood enters syringe, do not advance syringe further into

artery.
Arterial pulsations will ll the syringe, reducing presence of air bubbles that
may alter test results.
Place alcohol swab next to needle site, and withdraw needle.
Stabilizes skin as needle is withdrawn.
Apply pressure over the puncture site with gauze sponges for 5 to

10 minutes. May apply pressure dressing with gauze and tape for an
additional 5 minutes for patients with anticoagulant therapy.
Promotes coagulation at site.

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P r o c e d u r e 2 8 . 3 Obtaining a Specimen for Arterial Blood Gas 523


Continue to monitor site for bleeding.
Arterial puncture sites require continuing monitoring.
Assess pulse and neurovascular status.
Denotes change in arterial ow.
Expel air from syringe; apply protective needle cap per agency

policy.
Air can elevate arterial oxygen pressure and decrease arterial carbon dioxide
pressure.
Attach requisition to syringe, documenting percentage of oxygen

therapy patient is receiving; place syringe in plastic bag with ice, and
send specimen to lab.
Oxygen administration alters test results; coldness decreases metabolism
within cell.
Remove gloves and wash hands.
Decreases spread of blood-borne pathogens.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe site for bleeding or extremity for vascular complications


Compare patients results with normal ranges, and notify prescriber
of abnormal ndings
Continue respiratory and neurologic assessment
Discuss appropriate therapy

KEY POINTS

FOR

REPORTING

AND

RECORDING

Record date and time specimen collected and sent to lab.


State site used to collect specimen.
Neurovascular assessment of site before and after puncture
and any complications.
Respiratory/neurologic assessment.

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C H A P T E R

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Page 525

29
Collecting Urine
Samples
29.1 Collecting a Midstream
Urine Specimen, 526
29.2 Collecting a Timed (24-Hour) Urine
Specimen, 528
29.3 Collecting a Sterile Urine Specimen from
an Indwelling Catheter, 531
29.4 Measuring Specic Gravity of Urine, 533

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526 C h a p t e r 2 9 Collecting Urine Samples

PROCEDURE 29.1
Collecting a Midstream Urine Specimen
OVERVIEW

To obtain a urine specimen for culture and sensitivity testing.


This will determine the types of microorganisms present and
the antibiotics to which the microorganisms are sensitive.
Results are determined at 24 and 48 hours after collection.
P R E PA R AT I O N

Determine patients ability to understand and cooperate in the


procedure.
Determine signs and symptoms of urinary infection.
Determine patients mobility and independence in collecting a
midstream specimen while voiding.

Special Considerations
Avoid collecting specimen during defecation.
Note if patient is having menstrual period.
Elderly, Pediatric, and Physically Challenged Patients
Determine if they can assist or need assistance.
Have parent stay with children.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible urinary tract infection


EXPECTED OUTCOMES

Collection of an uncontaminated urine specimen


Test results reveal no abnormalities of urine
EQUIPMENT/SUPPLIES

Kit for clean-voided urine


Sterile cotton balls or 22 gauze pads
Cleansing towelette
Povidone-iodine solution
Sterile container
Clean gloves
Bedpan, urinal, or commode
Specimen hat if all urine must be measured
Potty chair for child
Completed specimen identication label
Completed laboratory requisition form

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P r o c e d u r e 2 9 . 1 Collecting a Midstream Urine Specimen 527


I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist.
Ensures accurate testing; meets patients right to be informed; encourages
cooperation and participation.
Wash hands.
Reduces transmission of microorganisms.
Provide privacy.
If patient is unable to use bathroom and collect specimen independ-

ently, provide a commode, bedpan, or urinal.


Open clean catch kit without contaminating it. If patient is obtaining

the specimen independently, tell him or her how to open without


contaminating the specimen container.
Prevents contamination of the specimen.
Instruct ambulatory female patient to put on clean gloves the spread

the labia with ngers of nondominant hand.


Tell patient to use the towelette and clean urinary meatus wiping
from front to back once. (For the patient requiring assistance, put on
clean gloves and clean the patient as described.)
Reduces transmission of microorganisms and reduces contamination of
specimen with transient bacteria.
Cleans from area of least contamination to greatest contamination;
decreases bacterial levels on the area.
Instruct male patient to put on clean gloves and hold penis with

nondominant hand, retracting foreskin if not circumcised. Tell patient


to use the towelette and clean the urinary meatus in a circular
motion. (For the patient requiring assistance, put on clean gloves
and clean the patient as described above.)
Decreases microorganisms.
Instruct female patient to hold labia open, void for a few seconds,

then place container into stream of urine and collect specimen without touching container to perineum.
Instruct male patient to collect specimen without the penis touching
the specimen cup.
Clears bacteria from the distal urethra and meatus; prevents contamination
of the specimen.
Collect 3060 mL of urine. Remove container before the ow of urine

stops and before letting go of the labia or penis.


Prevents contamination of the specimen.

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528 C h a p t e r 2 9 Collecting Urine Samples


Tightly close the container, touching only the outside of container

and cap.
Prevents contamination of the specimen.
Clean outside of the container if contaminated with urine.
Prevents transfer of microorganisms to others.
Label container, attach lab requisition. Note on lab requisition if

patient is on antibiotic therapy or if patient is menstruating.


Ensures accurate reporting of patients test results and appropriate
therapy.
Refrigerate specimen if it cannot be transported immediately.
Prevents deterioration of urine from bacterial contamination when left at
room temperature.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance


Observe characteristics of urine and signs of urinary infection
Check test results, and inform prescriber of abnormal ndings
Discuss appropriate therapy with prescriber

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of specimen collection.


Characteristics of urine and signs of urinary infection.
Disposition of specimen.

PROCEDURE 29.2
Collecting a Timed (24-Hour) Urine Specimen
OVERVIEW

To measure the amounts of substances, such as adrenocorticosteroids, hormones, glucose, proteins, electrolytes, or creatinine in the
urine.
To measure the dilution or concentration of the urine.

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P r o c e d u r e 2 9 . 2 Collecting a Timed (24-Hour) Urine Specimen 529


P R E PA R AT I O N

Determine patients ability to understand, cooperate, and assist in


the procedure.
Discard rst-voided specimen of the morning.
Begin test at time rst specimen is discarded.
Collect all specimens until the time period ends, transferring each
specimen immediately into a large collection bottle.
Repeat the test if a specimen is lost.
Store collection bottle in ice. Use preservatives as indicated.
Collect last specimen as close to the end of the collection period
as possible.
Determine if any uid/dietary requirements or medications are
associated with the testing.

Special Considerations
Elderly and Pediatric Patients
Use pediatric bags as indicated.
Remind older adults and children regarding collection of
specimen.
R E L E VA N T N U R S I N G D I A G N O S E S

Decient knowledge related to unfamiliar procedure


EXPECTED OUTCOMES

Collection of all of the patients urine specimens in the test


period
Urine collection is not contaminated by feces, blood, or toilet
tissue
Test results reveal no abnormalities of urine

EQUIPMENT/SUPPLIES

Large capped collection bottle with preservative as ordered; basin


with ice
Bedpan, urinal, commode, specimen hat, or potty chair
Graduated measuring cup
Completed specimen identication label
Completed laboratory requisition
Instruction sign to remind patient/staff to save urine specimens
Clean gloves

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530 C h a p t e r 2 9 Collecting Urine Samples


I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist. Explain that specimens must be free of feces, blood, and toilet
tissue.
Ensures accurate testing; meets patients right to be informed; encourages
cooperation and participation.
Ensures accurate lab results.
Instruct patient regarding uid/dietary requirements or medication

administration.
Specic tests may have special requirements.
Post instruction signs on door and bathroom; inform staff or other

departments if necessary.
Informed personnel prevents loss of specimen.
Add preservative to container if ordered. Fill basin with ice or refrig-

erate specimen, if requested by lab.


Maintains urine integrity.
If patient is unable to collect specimen in bathroom independently,

obtain a commode, bedpan, or urinal.


Discard rst morning specimen. Note the time, as this constitutes the

beginning of the collection period. Note time on lab requisition.


Collection period begins with empty bladder.
Collect all urine specimens for the next 24 hours (or duration of test,

if other than 24-hour test) and empty into the large collection bottle.
Ensures accuracy of lab results.
Instruct patient to drink two glasses of water 1 hour prior to the end

of the collection period, unless restricted.


Facilitates patients ability to void at end of test period.
Instruct patient to void within the last 15 minutes of the test.
Ensures timely completion of test.
Label collection bottle and transport to lab with attached requisition.
Ensures accurate reporting of patients test results and appropriate therapy.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe characteristics and amount of urine


Check test results and inform prescriber of abnormal ndings
Discuss appropriate therapy with prescriber

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P r o c e d u r e 2 9 . 3 Indwelling Catheters 531

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date, starting and ending time of specimen collection.


medication, uid, or dietary requirements.
Disposition of specimen.
Any

PROCEDURE 29.3
Collecting a Sterile Urine Specimen from
an Indwelling Catheter
OVERVIEW

To obtain a sterile specimen for examination of the composition


of urine or for culture.
P R E PA R AT I O N

Determine patients ability to understand, cooperate, and assist in


the procedure.
Determine signs and symptoms of urinary infection.
Determine if urinary closed system has sampling port.
Use strict aseptic technique in the specimen collection.
Determine amount of urine needed.

Special Considerations
Maintain sterility of closed system drainage.
R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection related to break in a sterile system


EXPECTED OUTCOMES

Collection of uncontaminated urine specimen


Urinary drainage system remains intact
Test results reveal no abnormalities of the urine

EQUIPMENT/SUPPLIES

3-mL syringe with 21-gauge 1-inch needle for culture; 20-mL syringe
with 21-gauge 1-inch needle for routine urinalysis
Metal clamp or rubber band
Alcohol or povidone-iodine swab
Clean gloves

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532 C h a p t e r 2 9 Collecting Urine Samples


I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist.
Ensures accurate testing; meets patients right to be informed; encourages
cooperation and participation.
Clamp urine tubing below the port for 15 to 30 minutes unless con-

traindicated by agency.
Ensures adequate amount of urine to be collected.
Wash hands, put on gloves.
Reduces transfer of microorganisms.
Position patient for easy access to aspiration port; cleanse port with

antiseptic swab.
Ensures collection; reduces transmission of microorganisms.
Insert needle with appropri-

ate syringe at a 3045 degree


angle into port.
Facilitates sealing of the
port after insertion.

FIGURE 29.3 Obtaining a sterile

urine specimen from an indwelling


catheter.
Aspirate sample by gently pulling on syringe plunger.
Provides ample urine specimen for collection.
Remove needle from port, and wipe port with antiseptic swab.
Reduces transmission of microorganisms.
Remove clamp, and allow urine to drain.
Restores urinary drainage system.
Transfer urine to sterile urine specimen container without contami-

nating the container. Tightly close cap.


Ensures sterility of specimen.
Remove and discard gloves and soiled supplies. Wash hands.
Reduces transmission of microorganisms.

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P r o c e d u r e 2 9 . 4 Measuring Specic Gravity of Urine 533


Label specimen container and transport to lab with attached

requisition.
Ensures accurate reporting of patients test results and appropriate therapy.
Refrigerate specimen if it cannot be transported immediately.
Prevents deterioration of urine from bacterial contamination when left at
room temperature.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Check test results and inform physician of abnormal ndings


Discuss appropriate therapy with provider
Observe urinary drainage system to ensure that it is intact and
patent
Assess urine for signs of infection

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date and time of sterile specimen collection per closed urinary system port.
Characteristics of urine and signs of urinary infection.
Note restoration of closed urinary system drainage.
Disposition of specimen.

PROCEDURE 29.4
Measuring Specic Gravity of Urine
OVERVIEW

To determine the patients kidney function, hydration status, and


requirement for uid intake.
P R E PA R AT I O N

Determine patients ability to understand, cooperate, and assist in


the procedure.
Assess patients signs of hydration, especially skin turgor, mucous
membranes, intake and output, and fontanels in infants.
Determine patient history of renal disease.

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534 C h a p t e r 2 9 Collecting Urine Samples

Special Considerations
Medications or uid restrictions may affect test results.
Report test results in relation to age of patient.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible imbalanced uid volume related to disease process


EXPECTED OUTCOMES

Collection of uncontaminated urine specimen.


Test results reveal no abnormalities of urine.
EQUIPMENT/SUPPLIES

Calibrated urinometer
Multistix reagent test strips
Refractometer
Clean, dry, glass cylinder
Medicine dropper
Clean gloves
Slide
I M P L E M E N TAT I O N
Identify patient; explain purpose, procedure, and how patient can

assist, as indicated.
Ensures accurate testing; meets patients right to be informed; encourages
cooperation and participation.
Explain that specimen must be free of feces, blood, and toilet tissue.
Ensures accurate test results.
Wash hands and put on gloves.
Reduces transmission of microorganisms.
Collect fresh specimen of urine.
Ensures accurate test results.

Urinometer Method
Pour urine to ll 2/3 to 3/4 of glass cylinder, and twirl stem gently.
Urinometer oats when cylinder is 2/3 full; twirling keeps urinometer
from touching sides of cylinder.
When urinometer stops bobbing, hold urinometer scale at eye level

and read point where urine level touches lowest point of meniscus
of the calibrated scale.

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P r o c e d u r e 2 9 . 4 Measuring Specic Gravity of Urine 535


The depth the urinometer oats is in relation to the concentration of dissolved solutes in urine.
Discard urine; wash cylinder in cool water.
Warm water coagulates protein on glass surface.
Wash hands.
Reduces transmission of microorganisms.

Multistix Reagent Strip Method


Place end of strip into urine sample.
Activates chemical reagent strip.
Wait designated time, read color of strip, and compare to color chart

on bottle.
Time exposure measures specic gravity.
Discard urine and strip; wash hands.
Reduces transmission of microorganisms.

Refractometer Method
Place 1 drop of urine on slide, and view through refractometer.
Refractometer visualizes the density of urine on a calibrated scale.
Discard urine and slide; rinse dropper in cool water; wash hands.
Reduces transmission of microorganisms.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Check test results and inform provider of abnormal ndings.


Discuss appropriate therapy with provider

KEY POINTS

FOR

REPORTING

AND

RECORDING

Date, time, and result of test.


Notication to provider of abnormal ndings.

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C H A P T E R

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30
Collecting Other
Specimens
30.1 Collecting a Nose or Throat Specimen
for Culture, 538
30.2 Collecting a Sputum Specimen, 541
30.3 Obtaining a Wound Drainage
Specimen, 545

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538 C h a p t e r 3 0 Collecting Other Specimens

PROCEDURE 30.1
Collecting a Nose or Throat Specimen for Culture
OVERVIEW

To determine the presence of pathogenic microorganisms.


P R E PA R AT I O N

Specimen collection may cause gagging or mucosal discomfort.


Nurse may need assistance in obtaining specimens from children
and confused or combative patients.
Always read directions on commercially prepared culture tubes to
ensure correct collection and transport of specimen.

Special Considerations
Specimen collection may cause gagging or mucosal discomfort;
therefore, extra time may be necessary if the patient gags.
Pediatric, Confused, and Combative Patients
May need more than one person to collect specimen.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible infection
Potential for injury related to movement during procedure causing
nasal mucosa irritation
EXPECTED OUTCOMES

Collected specimen is not contaminated


Specimen is transported to lab in required time frame and in appropriate collection tube
Specimen contains no pathogenic microorganisms
No trauma to throat/nasal mucosa

EQUIPMENT/SUPPLIES

Tongue depressor
Clean gloves
Culture tubes with culture swabs
Emesis basin
Tissues
Light source
Laboratory requisitions and identication labels
Penlight

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P r o c e d u r e 3 0 . 1 Collecting a Nose or Throat Specimen for Culture 539


I M P L E M E N TAT I O N
Check prescribers orders.
Identies type of culture ordered, ensuring identication of the appropriate
container and time frame needed to send culture to lab.
Identify patient and assess functional ability.
Ensures accurate testing; determines amount of assistance needed.
Wash hands, and gather equipment.
Decreases spread of microorganisms; organization promotes successful and
time-efficient collection.
Explain purpose and procedure of test; provide privacy.
Enhances cooperation and understanding; allays embarrassment.

Collection of Throat Specimen


Place patient in semi-Fowlers position with head tilted back; use

light source; provide emesis basin.


Allows easy visualization and access to oral structures; stimulation of gag
reex may induce vomiting.
Don clean gloves.
Provides protective barrier.
Loosen sterile culture swab from culture tube.
Allows easy removal of swab.
Have patient open mouth, and depress tongue with tongue

depressor.
Depressing tongue prevents contamination of swab by oral mucosa;
depression of the anterior portion of tongue decreases gag reex.
Insert swab without touching any oral structures.
Prevents contamination with resident bacteria.
Gently swab throat at tonsillar area, contacting purulent/inamed

area.
Permits exposure to sites with pathogenic microorganisms.
Remove culture swab without touching oral structures and place in

culture tube, crushing ampule until culture medium saturates end of


swab.
Preserves bacteria sample until testing.

Collection of Nasal Specimen


Position patient with head back and check nasal passages for

patency with a penlight.


Ensures larger access to obtain specimen.

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540 C h a p t e r 3 0 Collecting Other Specimens


Insert culture swab into nasal passage to inamed area, being careful

not to touch other nasal structures.


Prevents contamination of swab prior to collection of specimen.
Gently and rapidly rotate swab at site and move from nasal passage

without touching sides of nasal passage.


Prevents contamination of collected specimen by resident bacteria.
Offer patient tissues to blow nose.
Promotes comfort.
Securely place top on culture tube and discard tongue depressor

into trash.
Prevents spread of microorganisms.
Position patient comfortably.
Enhances comfort.
Wash hands.
Prevents spread of microorganisms.
Attach completed identication label and lab requisition to culture

tube. Send to lab immediately.


Ensures accurate reporting of patients test results and appropriate therapy;
fresh specimen enhances accurate test results.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Check patients nasal/throat passage for evidence of trauma, such as


bleeding
Check test results and inform prescriber of abnormal nding
Discuss appropriate therapy with prescriber

KEY POINTS
Assessment

FOR

REPORTING

of nasal/oral mucosa.
Date, time, and type of culture.
Describe any exudates.
Patients tolerance of procedure.
Time sent to laboratory.

AND

RECORDING

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P r o c e d u r e 3 0 . 2 Collecting a Sputum Specimen 541

PROCEDURE 30.2
Collecting a Sputum Specimen
OVERVIEW

To aid in diagnosis of respiratory conditions.


P R E PA R AT I O N

Early-morning specimen provides an adequate amount and more


easily expectorated specimen.
Assess patients knowledge about and ability to effectively cough to
facilitate sputum expectoration.
Adhere to rigid aseptic technique to avoid specimen contamination.
If unable to obtain specimen, collecting of sputum may have to be
done through suctioning of secretions, or enhanced through the use
of bronchodilators, nebulization treatments, or chest physiotherapy.

Special Considerations
If patient develops respiratory distress during procedure, it may be
necessary to stop and provide oxygen until breathing is improved.
Some patients may need additional instruction on how to effectively
cough to facilitate sputum expectoration.
Postoperative patients may require splinting of surgical site to effectively cough and prevent injury.
R E L E VA N T N U R S I N G D I A G N O S E S

Possible respiratory tract infection


EXPECTED OUTCOMES

Obtain an uncontaminated sputum specimen


Test results do not reveal abnormal cells or pathogenic microorganisms
No respiratory distress experienced by patient during or after
procedure
No injury experienced to abdominal area during coughing (if incision is present)

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542 C h a p t e r 3 0 Collecting Other Specimens

EQUIPMENT/SUPPLIES

Sterile specimen container


Tissues
Clean gloves
Gown, goggles, and mask, if indicated
Small lab transport container as indicated by agency
Identication and requisition labels
Additional equipment needed for suction:
Suction device
Sterile suction catheter
Sterile gloves
Sterile sputum trapLufkins
Oxygen, if indicated
I M P L E M E N TAT I O N
Check prescribers orders.
Ensures collection of correct type of specimen.
Identify patient and explain procedure, assessing patients ability to

cough.
Enhances cooperation and understanding; a deep cough produces sputum
from the tracheobronchial tree ensuring accurate specimen analysis.
Assess respiratory status.
Provides a baseline assessment.
Gather equipment and wash your hands.
Preparation promotes success; decreases spread of microorganisms.
Provide privacy.
Allays embarrassment.

Expectorated Specimen
Don clean gloves. If indicated, don gown, goggles, and mask.
Prevents cross-contamination from patient secretions.
Place patient in upright position and provide specimen container.
Facilitates lung expansion and coughing.
Splint an abdominal incision with your hands or a pillow.
Minimizes muscle use and discomfort, encouraging a deeper cough.
Instruct patient to take several breaths without exhaling completely,

then cough deeply, expectorating sputum with an intense cough


into the specimen container.

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P r o c e d u r e 3 0 . 2 Collecting a Sputum Specimen 543


Opens airways, loosens secretions, mobilizes secretions into larger airways,
and forcefully expels secretions.
Obtain 510 mL of sputum and cap container; place in appropriate

container per agency policy.


Ensures accurate testing.

Suctioned Specimen
Set up suction equipment.
Preparation promotes success.
Connect sputum trap to

suction tube.
Allows suction to the trap.

FIGURE 30.2A Attach suction tube

to specimen container.
Apply sterile glove to dominant hand and connect sterile suction

catheter to sputum trap.


Tracheobronchial tree is sterile environment.
Insert the sterile catheter tube into the respiratory tract (nasophar-

ynx or tracheostomy) without applying suction.


Decreases trauma to respiratory tract during insertion of catheter.
Apply suction intermittently as patient coughs and while withdraw-

ing catheter.
Do not apply suction longer than 10 to 15 seconds at a time to prevent an
alteration in respiratory status.

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544 C h a p t e r 3 0 Collecting Other Specimens


Detach catheter from trap

and dispose in trash bin. Cap


trap and place in appropriate
agency container.
Reduces spread of microorganisms.

FIGURE 30.2B Obtaining a sterile


urine specimen from an indwelling
catheter.

Wash hands.
Decreases spread of microorganisms.
Label and send specimen to lab immediately.
Ensures accurate lab results and appropriate therapy; bacteria count
increases quickly in room temperature.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe respiratory status during entire procedure


Check test results and inform prescriber of abnormal ndings
Discuss appropriate therapy with prescriber
Observe character of sputum, making sure that specimen is not
saliva.
Observe patients tolerance of procedure.

KEY POINTS

FOR

REPORTING

AND

RECORDING

Describe amount, color and consistency of sputum.


Patients tolerance of procedure.
Respiratory status throughout procedure.
Method of collection
Time specimen collected and sent to lab

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P r o c e d u r e 3 0 . 3 Obtaining a Wound Drainage Specimen 545

PROCEDURE 30.3
Obtaining a Wound Drainage Specimen
OVERVIEW

To identify the type and number of pathogenic organisms present.


P R E PA R AT I O N

Often will be obtained during dressing-change procedure.


Collect specimen from wound, not from skin around wound, unless
ordered. Do not collect from old exudate.
A large wound may need to have several cultures taken from different areas of wound.

Special Considerations
Some patients may require analgesic medication at least 15 to 30
minutes prior to specimen collection.
Pediatric, Confused, and Combative Patients
May need more than one person to collect specimen.
Have parent stay with infant or child when possible, to comfort.
R E L E VA N T N U R S I N G D I A G N O S E S

Pain/discomfort related to tissue manipulation during specimen


collection
EXPECTED OUTCOMES

No bacterial growth
Wound culture is not contaminated by supercial skin microbes
Specimen is transported to lab in required time frame and in appropriate collection container
No discomfort for patient

EQUIPMENT/SUPPLIES

Clean gloves2 pair


Sterile gloves1 pair
Plastic disposable bag
Dressing materials
Appropriate culture tube with swabs and transport medium
Identication and requisition labels
Gown, goggles, and mask, if indicated
Transport container as indicated by agency

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546 C h a p t e r 3 0 Collecting Other Specimens


I M P L E M E N TAT I O N
Check prescribers orders.
Ensures correct type of culture, anaerobic or aerobic, and site of culture.
Identify patient and explain procedure.
Ensures accurate testing; promotes cooperation and understanding.
Give analgesic if indicated.
Decreases discomfort.
Provide privacy; gather equipment, and wash hands.
Promotes relaxation and allays undue embarrassment; preparation promotes successful and time-efficient collection; decreases spread of microorganisms.
Open any sterile items, and place in easy reach.
Provides an accessible sterile eld.
Don clean gloves.
Provides barrier to patients microorganisms.
Remove soiled dressings and discard in plastic disposable bag.
Decreases spread of microorganisms.
Remove gloves, and don clean gloves.
Provides barrier to patient microorganisms.
Obtain culture swab from

culture tube and place tip


into wound, rotating tip in
drainage. Remove from
wound and place swab into
culture tube. Crush end of
tube, activating medium, and
push tip of swab into medium.
Ensures needed medium to
keep organisms viable until
growth of culture.
FIGURE 30.3 Rotate cotton swab in

wound drainage.
Place specimen in agency-appropriate transport container; remove

gloves and wash hands.


Decreases spread of microorganisms.

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P r o c e d u r e 3 0 . 3 Obtaining a Wound Drainage Specimen 547


Label specimen with requisition and identication and send to lab

immediately. Note on label any current antibiotic or antifungal


therapy.
Ensures accurate testing; ensures microorganism viability for correct analysis
results. Drug therapy may lead to false-negative lab results.
Don sterile gloves, and replace dressings using sterile technique.
Prevents wound contamination.
Remove gloves and wash hands.
Decreases spread of microorganisms.
Place patient in comfortable position.
Promotes comfort and well-being.
E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess wound and drainage characteristics


Assess and control pain level post-procedure if indicated
Check test results and notify prescriber of abnormal ndings
Discuss appropriate therapy with prescriber

KEY POINTS
Describe

FOR

REPORTING

AND

RECORDING

wound and drainage, including unusual


characteristics.
Type of culture done.
Area from which culture is taken.
Time specimen collected and sent to lab.
Patient toleration of procedure.

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Page 549

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Anderson, D. J., & Webster, C. S. (2001). Nursing and health care management issues: A systems approach to the reduction of medication error on
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Aufseeser-Weiss, M. R., & Ondeck, D. A. (2001). Medication use risk management: Hospital meets home care. Journal of Nursing Care Quality,
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Austin, S. (2001). A safe standard of care for medication administration.
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Website references:
http://www.kcil.com/products/VAC/index.asp
http://www.medicalmultimediagroup.com/pated/joints/hip/hip_pre.html
http://www.nursing.uiowa.edu/sites/chronicwound/!de2.htm
http://www.eakin.co.uk/products/items/?title_id4&Image_ID3.gif

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C R E D I T S

Chapter 3
Pages 3248: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.

Chapter 4
Pages 5563: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.
Pages 64104: From Dillon, P. (2007). Nursing Health Assessment, 2/e.
Philadelphia, PA: FA Davis Company.
Page 107: From Williams, L and Hopper, P. (2007). Understanding Medical
Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 5
Pages 137, 140, 141, 147: From Wilkinson, J, Van Leuven, K. (2007).
Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.
Page 143: From Williams, L and Hopper, P. (2007). Understanding Medical
Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 6
Pages 152167, 173190: From Wilkinson, J, Van Leuven, K. (2007).
Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 7
Pages 200201: From Kisner, C, Colby L. (2002). Therapeutic Exercise:
Foundations and Techniques, 4/e. Philadelphia, PA: FA Davis Company.

Chapter 8
Pages 208214: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.

Chapter 9
Pages 237238: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.

Chapter 10
Pages 244261: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.

Chapter 11
Pages 267269: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philadelphia, PA: FA Davis Company.

Chapter 12
Pages 280284, 300301: From Phillips, L. (2006). IV Therapy Notes.
Philadelphia, PA: FA Davis Company.

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Pages 286287: From Phillips, L. (2006). Manual of IV Therapeutics.
Philadelphia, PA: FA Davis Company

Chapter 15
Pages 334335: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of
Nursing. Philad