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, or with the use of soap, for the purpose of removing soil, dirt, and/or microorganisms Purposes
To remove possible harmful bacteria from the skin. To loosen and remove soil and grime, body secretions, dead skin cells, and germs.
Equipments • • • • Disinfectant or soap Towel Water Tissue
Implementation STEPS 1. Consider the sink, including the faucet controls, contaminated. 2. Avoid touching the sink. 3. Turn water on using a paper towel and then wet your hands and wrists 4. Work soap into a lather. 5. Vigorously rub together all surfaces of the lathered hands for 15 seconds. Friction helps remove dirt and microorganisms. Wash around and under rings, around cuticles, and under fingernails 6. Apply the handwashing techinques 7. Palm to palm 8. Right palm over the left dorsum and left palm over the right dorsum 9. Palm to palm with finger interlaced 10. Back of the fingers opposing palms with fingers interlocked. RATIONALE This site is unsterile so do not touch it may cause transfer of microorganisms. The inside of the sink and its surfaces are usually littered with microorganisms To avoid touching the faucet Helped most to wash away the microorganisms Provides complete access to fingers, hands, and wrists. When you wear rings, it increases the number of microorganisms on your hands which can then be passed on to patients. Do handwashing technique as follows
11. Rotational rubbing of the right thumb clasped in left palm and vice versa. 12. Rotational rubbing backwards and forwards with clasped finger of right hand in left palm and vice versa. 13. Rinse hands thoroughly under a stream of water. Running water carries away dirt and debris. Point fingers down so water and contamination won't drip toward elbows 14. Dry hands completely with a clean dry paper towel. Rinsing mechanically washes away dirt and microorganisms.
Drying from cleanest (fingertips) to least clean (forearms/wrists) area avoids contamination. Drying hands prevents chapping and roughened skin. To avoid touching the non sterile area Soap is needed because it works by emulsifying fat and oil and lowering surface tension, thus ridding your hands of large amounts of microorganisms. Antiseptic or antibacterial soaps generally help to rid your hands of even larger amounts of microorganisms Always bring alcohol or hand sanitizer if handwashing facilities are no available.
15. Use a dry paper towel to turn faucet off. 16. To keep soap from becoming a breeding place for microorganisms, thoroughly clean soap dispensers before refilling with fresh soap.
17. When handwashing facilities are not available at a remote work site, use an appropriate antiseptic hand cleaner or antiseptic towelettes. As soon as possible, rewash hands with soap and running water.
DONNING AND REMOVING STERILE GLOVES (OPEN METHOD) Purpose • Permits the wearer to handle sterile supplies, instruments, and tissues of the surgical sites.
Planning 1. Check client record, and ask the client about latex allergies. 2. Assemble equipment: • Packages of sterile gloves. 3. Insure sterility of the package of gloves. STEPS 1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how the client can cooperate. 2. Observe other appropriate infection control procedures. 3. Provide drapes and curtains. 4. Open the package of sterile gloves. • Place the package of gloves on a clean, dry surface. • If the gloves are packed in an inner as well as outer package, open the outer package without contaminating the gloves or the inner package. • Remove the inner package from the outer package. 5. Put the first glove on the dominant hand. • If the gloves are packaged so that The hands are not sterile. By touching only the inside of the glove, the nurse avoids contaminating the outside. RATIONALE To ascertain that you are giving care to the right patient and to gain his/her trust and cooperation throughout the procedure.
The inside of the sink and its surfaces are usually littered with microorganisms. For client’s privacy. Any moisture on the surface could contaminate the gloves.
they lie side by side, grasp the glove for the dominant hand by its folded cuff edge (on the palmar side) with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff; Or • If the gloves are packaged one on top of the other grasp the cuff of the top glove as above, using the opposite hand. • Insert the dominant hand into the glove, and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion. • Leave the cuff in place once the nonsterile hand releases the glove. 6. Put the second glove on the nondominant hand. • Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm. • Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm. • Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by sliding the fingers under the cuffs. 7. Remove and dispose of used gloves. • There is no special technique for removing sterile gloves. If they are soiled with secretions, remove them by turning them inside out. 8. Document that sterile technique was used in the performance of the procedure. Evaluation To avoid any legal concerns. To maintain cleanliness. This helps prevent accidental contamination of the glove by the bare hand.
In this position, the thumb is less likely to touch the arm and become contaminated.
Conduct any follow-up indicated during your care to the client. Ensure that adequate numbers and types of sterile supplies are available for the next health care provider.
DONNING A STERILE GOWN AND GLOVES (CLOSED METHOD) Purposes • To enable the nurse to work close to a sterile field and handle sterile object freely. • To protect clients from becoming contaminated with microorganisms on the nurse’s hands, arms, and clothing. Assessment Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves. Check the client record and ask about latex allergies. Use nonlatex gloves whenever possible. Planning Think through the procedure, planning which steps need to be completed before the gloves and gown can be applied. Determine what additional supplies are needed to perform the procedure for this client. Always have an extra pair of sterile gloves available. Equipment • • Sterile pack containing a sterile gown Sterile gloves
Implementation Preparation Ensure the sterility of the package of gloves. Performance STEPS 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how the client can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Do hand washing. RATIONALE To ascertain that you are giving care to the right patient and to gain his/her trust and cooperation throughout the procedure.
To prevent the spread of microorganisms-
causing infection. 3. Provide drapes and curtains. 4. Open the package of sterile gloves. Remove the outer wrap from the sterile gloves and leave the gloves in their inner sterile wrap on the sterile field. 5. Unwrap the sterile gown pack. 6. Put on sterile gown. • Grasp the sterile gown at the crease near the neck, hold it away from you, and permit it to unfold freely, without touching anything, including the uniform. • Put the hands inside the shoulders of the gown without touching the outside of the gown. • If donning sterile gloves by using the closed method, work the hands down the sleeves only to the beginning of the cuffs. Or • If donning the sterile gloves by using the open method, work the hands down the sleeves and through the cuffs. • Have a co-worker grasp the neck ties without touching the outside of the gown and pull the gown upward to cover the neckline of your uniform in front and back. The co-worker ties the neck ties. 7. Open the sterile glove wrapper while the hands are still covered by the sleeves. 8. Put the glove on the nondominant hand. • With the dominant hand, pick-up the opposite glove with the thumb and index finger, handling it through the sleeve. • Position the dominant hand palm upward inside the sleeve. Lay the glove on the opposite gown cuff, thumb side down, with the glove opening pointing toward the fingers. • Use the nondominant hand to grasp the cuff of the glove through the gown cuff, and firmly anchor it. • With the dominant hand working through To facilitate the closed gloving first on the nondominant hand. The gown will e unsterile if its outer surface touches any unsterile objects. For client privacy. If the inner wrapper is not touched, it will remain sterile.
• Or • Have a co-worker take the two ties at each side of the gown and tie them at the back of the gown. using sterile gloves or a sterile forceps or drape. 7 . and sleeve cuff should be considered unsterile. • Extend the fingers into the glove as you pull the glove up over the cuff. remove the attire by turning it inside out. To promote cleanliness. Remove and disposed off used gown and gloves. whichever is higher. • Have a co-worker to hold the waist tie of your gown. Completion of the Gowning. grasp the upper side of the glove’s cuff. If appropriate. • Pull the sleeve up to draw the cuff over the wrist as you extend the fingers of the nondominant hand into the glove’s fingers. making sure that your uniform is completely covered. 12. • Place the glove over the cuff of the second sleeve. 10. Put the glove on the dominant hand. • Place the fingers of the gloved hand under the cuff of the remaining glove. document that sterile To avoid legal issues. since the arms of a scrubbed person must move across a sterile field. 11. and stretch it over the cuff of the gown. To facilitate closed gloving on the dominant hand. Once the nurse approaches the table. Moisture collection and friction areas such as the neckline. 9. • When worn. underarms. This approach keeps the ties sterile. back. the gown is considered contaminated from the waist or table down. • Make a three quarter-turn. The sleeves should be considered sterile from the cuff to 2 in. • If soiled. then take the tie and secure it in front of the gown.its sleeve. above the elbow. shoulders. sterile gowns should be considered sterile in front from the waist to the shoulder.
and is measured in heat units called degrees. immunosuppressive therapy. Ensure that adequate numbers and types of sterile supplies are available for the next health care provider. those who have been exposed to temperature extremes Equipments • • • • • • Thermometer Thermometer sheath or cover Water soluble lubricant for rectal temperature Disposable gloves Towel for axillary temperature Tissues/wipes STEPS ASSESSMENT 1. Purposes • • • • To establish data for subsequent evaluation To identify whether the core temperature is within the normal range To determine changes in the core temperature in response to specific therapies(e. Assess • • • • Clinical signs of fever Clinical signs of hypothermia Site most appropriate for measurement Factors that may alter body temperature RATIONALE 8 . antipyretic medication. Evaluation Conduct any follow-up indicated during your care to the client. invasive procedure) To monitor clients at risk for infection or diagnosis of infection.technique was used in the performance of the procedure. ASSESSING BODY TEMPERATURE Definition Body temperature reflects the balance between the heat produced and the heat lost from the body.g.
g. Check package instructions for length of time to wait prior to reading chemical dot or tape thermometers . Electronic and tympanic thermometers will indicate that the reading is complete through light or tone. introduce self and verify the client using agency protocol. make sure to wait for the appropriate amount of time. Place the thermometer • • Apply a protective sheath or cover if appropriate Lubricate a rectal thermometer -Checking equipments before use promotes accurate result -Introducing self to the client builds rapport. Discuss how the results will be used in planning further care treatments 2. Explaining the procedure is important so the client can anticipate what will happen as the procedure goes on. Verifying the client ensures that the nursing care is given to the right person. lateral or sim’s position for inserting a rectal thermometer) 5. Perform hand hygiene and observe appropriate infection control procedures. Provide for client privacy 4. Prior to performing the procedure. 3. 7. and how he or she can cooperate.To get accurate measurement. Wait the appropriate amount of time. Don gloves if performing a rectal temperature. Place the client in the appropriate position(e. Explain to the client what you are going to do. -Hand washing is important to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease 6.Preparation Check that all equipment is functioning properly Performance 1. Remove the thermometer and discard the cover or wipe a tissue if necessary 9 . why is it necessary.
If the temperature is obviously too high.8. To determine whether the pulse rhythm is regular and the pulse volume is appropriate To determine the equality of corresponding peripheral pulses on each side of the body To monitor and assess changes in the client’s health status To monitor clients at risk for pulse alterations To evaluate blood perfusion to the extremities Equipments • • • Watch with a second hand or indicator If using a DUS:transducer probe. Purposes • • • • • • • To establish baseline data for subsequent evaluation To identify whether the pulse rate is within the normal range. Wash the thermometer if necessary and return it to the storage location 10. recheck it with a thermometer known to be functioning properly 9. Document the temperature in the client record. Read the temperature and record it on your worksheet. or inconsistent with the client’s condition. check that the equipment is RATIONALE 10 . too low. Generally the pulse wave represents the stroke volume output or the amount of blood that enters the arteries with each ventricular contraction. transmission gel Tissues/ wipes IMPLEMENTATION Preparation If using a DUS. stethoscope headset. ASSESSING A PERIPHERAL PULSE Definition A pulse is a wave of blood created by contraction of the left ventricle of the heart.
or of the pulse is irregular. Place the two or three middle finger tips slightly and squarely over the pulse points • Count for 15 seconds and multiply by 4. also take the apical pulse -Using the thumb is contraindicated because the nurse’s thumb has a pulse that could be mistaken for the client’s pulse 11 . Select the pulse point. 5. with the palm facing downward. and how he or she can cooperate. Normally. count for a full minute. Assist the client to comfortable resting position. Perform hand hygiene and observe appropriate infection control procedures --Introducing self to the client builds rapport. introduce self and verify the client using agency protocol. Palpate and count the pulse. Explain to the client what you are going to do. Discuss how the results will be used in planning further care treatments 2. .functioning normally Performance 1. Record the pulse in beats per minute on your worksheet. why is it necessary. Provide for client privacy 4. when obtaining baseline dta. unless it cannot be exposed or circulation to another body area is to be assessed. the forearm can rest across the thigh. Explaining the procedure is important so the client can anticipate what will happen as the procedure goes on. the client’s arm can rest alongside the body or the forearm can rest at a 90degree angle across the chest. Verifying the client ensures that the nursing care is given to the right person. Prior to performing the procedure. If taking the client’s pulse for the first time. the radial pulse is taken. with the palm of the hand facing downward or inward. -Hand washing is important to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease 3. 6. When the radial pulse is assessed. If an irregular pulse is found. For a client who can sit.
Record the rhythm and volume in your work sheet • 8. If this is an initial assessment. • Assess the pulse rhythm by noting the pattern of the intervals between the beats. Document the pulse rate. and volume and your actions in the client record. A normal pulse volume. A normal pulse can be felt with moderate pressure. Purposes • • • • To acquire baseline data against which future measurements can be compared To monitor abnormal respirations and respiratory patterns and identify changes To monitor respirations before or following the administration of a general anesthetic or any medication that influences respirations To monitor clients at risk for respiratory alterations Equipment • Watch with a second hand or indicator RATIONALE IMPLEMENTATION Preparation For a routine assessment of respirations. Inhalation or inspiration refers to the intake of air into the lungs. assess for one minute. rhythm. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. ASSESSING RESPIRATIONS Definition Respiration is the acT of breathing. A forceful pulse volume is full. Assess the pulse rhythm and volume.7. an easily obliterated pulse is weak. Assess the pulse volume. and the pressure is equal with each beat. 12 . A normal pulse has equal time periods between the beats.
Explain to the client what you are going to do. respirations are evenly • Observe the respirations for regular or • 13 . A client who has been exercising will need to rest a few minutes to permit the accelerated respiratory rate to return to normal Performance 1. a large volume of air is exchanged. Observe the depth. Discuss how the results will be used in planning further care treatments 2. -Hand washing is important to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease 3. place a hand against the client’s chest to feel the chest movements with breathing. or place the client’s arm across the chest and observe the chest movements while supposedly taking the radial pulse Count the respiratory rate for 30 seconds are regular. Count for 60 seconds if they are irregular. why is it necessary. Provide for client privacy 4. rhythm. a small volume is exchanged Normally. If you anticipate this. Explaining the procedure is important so the client can anticipate what will happen as the procedure goes on. An inhalation and an exhalation count as one respiration • 5. Perform hand hygiene and observe appropriate infection control procedures . introduce self and verify the client using agency protocol. Prior to performing the procedure. during shallow respirations. Verifying the client ensures that the nursing care is given to the right person. Observe or palpate and count the respiratory rate • The client’s awareness that the nurse is counting the respiratory rate could cause the client to purposefully alter the respiratory pattern.determine the client’s activity schedule and choose a suitable time to monitor the respirations.Introducing self to the client builds rapport. and how he or she can cooperate. • Observe the respirations for depth by watching the movement of the chest • During deep respirations. and character of respirations.
g. respirations are silent and effortless 6. and character on the appropriate record ASSESSING BLOOD PRESSURE Definition Arterial blood pressure is the measure of the pressure exerted by the blood as it flows through the arteries Purposes • • • To obtain a baseline measure of arterial blood pressure for subsequent evaluation To determine the client’s hemodynamic status(e. depth. cardiac output. rapid infusion of fluids or blood products. or acute pain.g. Equipments • • • Stethoscope or DUS Blood pressure cuff of the appropriate size Sphygmomanometer 14 . presence or history of cardiovascular disease. Document the respiratory rate. renal disease. stroke volume of the heart and blood vessel resistance) To identify and monitor changes in blood pressure resulting from a disease process or medical therapy(e. circulatory shock.irregular rhythm • Observe the character of respirationsthe sound they produce and the effort they require • spaced Normally. rhythm.
Provide for client privacy 4. Supported at the heart level. and how he or she can cooperate. Discuss how the results will be used in planning further care treatments 2. introduce self and verify the client using agency protocol. Position the client appropriately • The adult client should be sitting unless otherwise specified. Check for leaks in the tubing of the sphygmomanometer • Make sure that the client has not smoked or ingested coffee within 30 minutes prior to measurement Performance 1. why is it necessary.IMPLEMENTATION Preparation • Ensure that the equipment is intact and functioning properly. but it can vary significantly by position in certain persons Expose the upper arm • Legs crossed at the knee result in elevated systolic and diastolic blood pressures The blood pressure increases when the arm is below the heart level and decreases when the arm is above the heart level • • • 15 . -Hand washing is important to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease 3. standing. The blood pressure is normally similar in sitting. Explain to the client what you are going to do. and caffeine increases the pulse rate. Both of these cause a temporary increase in blood pressure -Introducing self to the client builds rapport. Prior to performing the procedure. Explaining the procedure is important so the client can anticipate what will happen as the procedure goes on. Readings in any other position should be specified. Verifying the client ensures that the nursing care is given to the right person. Both feed should be flat on the floor The elbow should be slightly flexed with the palm of the hand facing up the forearm. and lying positions. Perform hand hygiene and observe appropriate infection control procedures RATIONALE -Smoking constricts blood vessels.
Position the stethoscope appropriately. Locate the brachial artery. • Sounds are heard more clearly when the ear attachments follow the direction of the ear canal If the stethoscope tubings rub against an object. Otherwise. the noise can block the sounds of the blood within the artery Because the blood pressure is a lowfrequency sound.5. perform a preliminary palpatory determination of systolic pressure • Palpate the brachial artery with fingertips Close the valve of the bulb Pump up the cuff until you no longer feel the brachial pulse. false high systolic readings will ocur 7. Apply the center of the bladder directly over the artery. • • • 16 . not on clothing over the site. If this is the client’s initial examination. • Cleanse the earpieces with antiseptic wipe Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward. it is best heard with the bell. Place the stethoscope directly on the skin. Ensure that the stethoscope hangs freely from the ears to the diaphragm. Wrap the deflated cuff evenly around the upper arm. Note the pressure on the sphygmomanometer at which pulse is no longer felt Release the pressure completely in the cuff and wait 1 to 2 minutes before making further assessments • This gives an estimate of the systolic pressure • • • • A waiting period gives the blood trapped in the veins time to be released. At the pressure the blood cannot flow through the artery.shaped diaphragm This is to avoid noise made from rubbing the amplifier against the cloth • • • • Place the bell side of the amplifier of the stethoscope over the brachial pulse site. 6.
-Cuffs can become significantly contaminated. HEAD-TO-TOE ASSESSMENT 17 . repeat the procedure on the client’s other arm. Deflate the cuff rapidly and completely Wait 1 to 2 minutes before making another determinations Repeat the above steps to confirm the accuracy of the reading-especially if it falls outside the normal range. • • If the rate is faster or slower. Wipe the cuff with an approved disinfectant. Auscultate the client’s blood pressure • Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared. Document and report pertinent assessment data according to agency policy. Remove the cuff 11. If this is the client’s initial examination.• Hold the diaphragm with the thumb and the index finger 8. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mm Hg per second. identify the manometer reading Korotkoff phases I. 12. . As the pressure falls. an error in measurement may occur • • There is no clinical significance in phases II and III • • • This permits blood trapped in the veins to be released • 9. There should be a difference of no more than 10 mm Hg between the arms. IV and V. The arm found to have the highest pressure should be used for subsequent examination 10.
To reduce spread of microorganisms. 3. Explain to the client what you are going to do. 2.Definition Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. To obtain baseline physical and mental data on the patient. Introduce self and verify the client’s identity using agency protocol. To supplement. why it is necessary. 3. It can be a complete physical assessment. To obtain data that will help the nurse establish nursing diagnoses and plan patient care. confirm. erect posture. • Gloves Equipments • Lubricants • • • • • • Flashlight or Penlight Laryngeal or Dental mirror Nasal septum Ophthalmoscope Otoscope Percussion (reflex) hammer Tuning Fork Cotton applicators • • • • • • Tongue blades (deppressors) Pencil & paper News print to read Paper clip Snellen chart Substance to smell and taste • • Assessing Appearance and Mental Status PROCEDURE 1. Purposes 1. coordinated 18 . Observe client’s posture and gait. To allay fear and anxiety. height. and health 5. or an assessment of a body part. and how he or she can cooperate. based on his needs. or question data obtained in the nursing history. 2. To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems. 4. RATIONALE To promote client’s cooperation and participation. varies with lifestyle A – Excessively thin or obese N – Relaxed. Perform hand hygiene and observe appropriate infection control procedures. Provide for client privacy 4. an assessment of a body system. lifestyle. A physical assessment should be adjusted to the patient. and weight in relation to the client’s age. Discuss how the results will be used in planning further care or treatments. N – proportionate. Observe body build.
able to follow instructions A – Negative. withdrawn N – Appropriate to situation A .g. makes sense.standing. Measuring the 19 . temperature. 2. jaundice. unkempt N – No body odor. 3. ammonia odor N – no distress noted A – Bending over because of abdominal pain.Inappropriate to situation N – Understandable. color. Assess edema. cyanosis. sitting and walking. Listen for Relevance and organization of thoughts. tremors N – Clean Neat A – dirty.e. hostile. infection). lips. Inspect skin color (best assessed under natural light and on areas not exposed to the sun). 10. from ruddy pink to light pink. wincing. Relate these to the person’s activities prior to the assessment. movement A – Tense. Note body breath odor in relation to activity level. lacks association N – Logical sequence. 12. or labored breathing N – healthy appearance A – Pallor. moderate pace. bent posture.. Observe client’s overall hygiene and grooming. 11. uncoordinated movement. quality (loudness. Note the client’s affect/mood. clear tone and inflection. flight of ideas N – Varies from light to deep brown. weakness. 7. lesions N – Cooperative. Assess the client’s attitude. overgeneralization. Assessing the skin 1. areas of lighter pigmentation (palms. Note obvious signs of health or illness (e. if present (i. no breath odor A – Foul body odor. and organization (coherence of though. erythema N – Generally uniform except in areas exposed to the sun. assess the appropriateness of the client responses. Inspect the uniformity of skin color. shape and degree to which the skin remains indented or pitted when pressed by a finger). 9. frowning. exhibits thought association A – rapid or slow pace. clarity. location. 13. nail beds) in dark skinned people A – areas of either hyperpigmentation or hypopigmentation N – No edema A – see the scale for describing edema 6. from yellow overtones to olive A – Pallor. has sense of reality A – Illogical sequence. vagueness). Listen for quantity of speech (amount and space). 8. slouched. Observe for signs of distress in posture or facial expression. in skin color or breathing).
within normal range A – Generalized hyperthermia/hypothermia. 2. Apply gloves if lesions are open or draining. Inspect fingernail and toenail texture and N – Smooth texture bed color. Describe lesions according to location. color configuration. 4. 5. irregular. 4. palpate. Inspect hair thickness or thinness. Inspect fingernail plate shape to determine its curvature and angle. Observe and palpate skin moisture. Inspect hair texture and oiliness. some birthmarks. lice. type. Palpate lesions to determine shape and texture. Inspect the evenness of growth over the scalp. A – Excessive thickness or thinness or presence of grooves or furrows 20 . may be slower in elders A – Skins stays pinched or tented or moves back slowly N – Evenly distributed hair A – Patches of hair loss N – Thick hair A – very thin hair N – Silky. localized hyperthermia/hypothermia N – When pinched. and ringworm N – Variable A – Hirsutism in women. skin springs back to previous state. Assessing the Hair 1. Assessing the Nails 1. Note presence of infections or infestations by parting the hair in several areas. resilient hair A – Brittle hair. Inspect. N – Freckles. some flat and raised nevi. excessively oily/dry hair N – No infection or infestation A – Flaking. no abrasions or other lesions A – Various interruptions in skin integrity. 3.circumference of the extremity with a millimeter tape may be useful for comparison. or structure. using the backs of your fingers. naturally absent or sparse leg hair. sores. and describe skin lesions. Inspect amount of body hair. nits (louse eggs). distribution. checking behind the ears and along the hairline at the neck. Compare the two feet and the two hands. shape. size. multicolored or raised nevi N – Moisture in skin folds and the axillae A – excessive moisture or excessive dryness N – Uniform. Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity. N – convex curvature A – Spoon nail/clubbing 6. 7. 2. Palpate skin temperature. 5.
nodules. increase skull size with more prominent nose and forehead N . close the eyes tightly. no discharge. Inspect the lower eyelids while the client’s eyes are closed. symmetrically aligned A – Loss of hair.3. Inspect the eyes for edema and hollowness. masses nodules N – Symmetric facial features A . N – Intact epidermis A – hangnails. local deformities from trauma. 1. flaking. Inspect tissues surrounding nails. plaques. no discoloration A – redness. For proper visual examination of the upper eyelids . shape. swelling. puff the cheeks. 4. Inspect the eyebrows for hair distribution and alignment and skin quality and movement. asymmetric features A – Periorbital edema. 5. 3. 2. unequal alignment of eyebrows N – Equally distributed. and smile and show the teeth. Press two or more nails between your thumb and index finger: look for blanching and return of pink color to nail bed. Assessing the Eye structures and Visual acuity N – Hair evenly distributed. and have the client close the eyes. crusting. and symmetry.Increased facial hair. Inspect eyelashes for evenness of distribution and direction of curl.asymmetric facial movements 4.Turned inward N – Skin intact. absence of nodules/masses A – Sebaceous cysts. Use a gentle rotating motion with the fingertips. Inspect the facial features. position and relation to the cornea. 3. ability to blink. Begin at the front and palpate down the midline. 2.prompt return of pink/usual color A . skin intact. sunken eyes N – Symmetric facial movements A .Delayed return of pink or usual color N – Rounded. scaling and flakiness of skin. then palpate each side of head. Note symmetry of facial movements. Ask the client to elevate the eyebrows. elevate the eyebrows with your thumb and index fingers. Inspect the skull for size. Perform blanch test of capillary refill. paronychia N . frown or lower the eyebrows. lesions 21 . thinning of eyebrows.Smooth. Assessing the Skull and Face 1. and frequency of blinking. smooth skull contour A – lack of symmetry. Inspect the eyelids for surface characteristics. curled slightly outward A . Palpate the skull for nodules or masses and depressions. uniform consistency. discharge.
normally 3-7 mm in diameter. Perform the corneal sensitivity test to determine the function of the fifth cranial nerve. and move the light slowly across the corneal surface. 22 . Retract the eyelids with your thumb and index finger. Evert both lower lids and ask the client to look up. surface not smooth 7. 8. and symmetry of size. round. lesions or nodules N – Shiny. indicating that the trigeminal nerve is intact A – one or both eyelids fail to respond N – Black in color. equal in size. nodules or other lesions N – No edema or tenderness over lacrimal gland A – swelling or tenderness over lacrimal duct N – No edema or tearing A – Evidence of increase tearing N – Transparent. Lightly touched the cornea with a corner of the gauze. iris flat and round A – Cloudiness. and from side to side. Inspect the cornea for clarity and texture.transparent. shiny and smooth. smooth border. 9. mydriasis. shape. down. unequal responses. capillaries sometimes evident. pupils converge when near object is moved toward nose 11. exerting pressure over the upper and lower bony orbits. and the presence of lesions. Ask the client to look straight ahead. Inspect the bulbar conjunctiva for color. Then gently retract the lower lids with the index fingers. then bring the gauze toward the outer canthus. 10. absent responses. smooth and pink /red A – extremely pale. Extend your hand behind the client’s field of vision. Extremely red. Inspect the palpebral conjunctiva by everting the lids. 6. Assess each pupil’s direct and consensual reaction to light to determine the function of the third and fourth cranial nerves. 5. N – Pupil’s constrict when looking at near object. excessively pale sclera. Ask the client to keep both eyes open and look straight ahead. details of the iris are visible A – opaque.4. texture. and ask the client to look up. Assess each pupil’s reaction to accommodation. Inspect and palpate the lacrimal gland N . Hold a penlight at an oblique angle to the eye. 12. miosis. Inspect the pupils for color. bulging of iris toward cornea N – Illuminated pupil constricts (direct response) Nonilluminated pupil constricts (consensual response) A – Neither pupil constricts. sclera appears white A – Jaundice sclera. N – Client blinks when the cornea is touched. pupils dilate when looking at far object. anisocoria. Inspect and palpate the lacrimal sac and lacrimal duct.
Assess distance vision by asking the client to wear corrective lenses. Dry cerumen. yellow amber. unless they are use for reading only. 15. firm and not tender. grayish-tan color. dilate or converge 13. and position. symmetrical A – Bluish color of earlobes. flaky. position the client comfortably – seated if possible 2. for distances of only 36cm Assessing the Ears and Hearing 1. blue or deep red. pus.A – One or both pupils fail to constrict. tenderness when moved or pressed N . Assess six ocular movements to determine eye alignment and coordination. or sticky.e. N – Both eyes coordinated. 23 . white. Using an otoscope. skin lesions. and blood. and areas of tenderness. Assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper held at a distance of 36cm. pinna recoils after it is folded A – Lesions. symmetry of size. dull surface N – sound is heard in both ears or is localized at the center of the head A . excessive cerumen obstructing canal N – Pearly gray color. 52. N – color same as facial skin. inspect the external ear canal for cerumen. move in unison A – Eye movements not coordinated or parallel. pallor. Palpate the auricles for texture. To inspect position. scaling. wet cerumen in various shades of brown A – Redness and discharge. scaly skin. note the level at which the superior aspect of the auricle attaches to the head with relation to the eye. Perform weber’s test to assess bone conduction by examining the lateralizationof sounds.. the glasses or lenses should be worn during the test. Inspect the tympanic membrane for color and gloss 5. If the client normally wears corrective lenses. or sound is heard better in ear withpout a 3. 4. one or both eyes fail to follow a penlight in specific directions N – Able to read newsprint A – Difficulty reading newsprint unless due to aging process 14.sound is heard better in impaired ear. elasticity.Distal third contains hair follicles and glands. Inspect the auricles for color. some opacity. i. indicating a bone-conductive hearing loss. N – 20/20 vision on snellen-type chart A – Denominator of 40 0r more on snellentype chart with corrective lenses To make client comfortable. excessive redness N – Mobile. semitransparent A – Pink to red.
uniform pink color. Inspect the outer lips for symmetry of contour. Assessing the Mouth and Oropharynx 1. edematous. leukoplakia N – 32 adult teeth. Lightly palpate the external nose to determine any areas of tenderness. 4. 7. fissures. Palpate the maxillary and frontal sinuses for tenderness. or color and flaring. ill-fitting dentures. N – symmetric and straight. smooth texture.problem. 5. or scales N . and the presence of lesions. soft. no discharge or flaring. clear. soft. crusts. and discharge. ability to purse lips A – pallor. moisture. masses. moist. growths. and texture. blisters. watery discharge. 3. pink gums. color. 3. localized areas of redness or presence of skin lesions N – Not tender A – Tenderness on palpation. Inspect the nasal septum between the nasal chambers. presence of lesions N – Nasal septum intact and in midline A – Septum deviated to the right or to the left N – Not tender A – Tenderness in one or more sinuses N – uniform pink color. shiny tooth enamel. 2. or discharge from the nares. brown or black discoloration of the enamel. smooth. white. no lesions A – Mucosa red. symmetry of contour. swelling. or displacements of bone and cartilage. indicating a sensorineural disturbance Assessing the Nose and Sinuses 1. presence of lesions N – Air moves freely as the client breathes through the nares A – Air movement is restricted in one or both nares To inspect the nasal passages. Inspect the nasal cavities using a flashlight or a nasal spectrum. elastic texture A – Excessive dryness. texture. Inspect the teeth and gums while examining the inner lips and buccal mucosa. 24 . N – Mucosa pink. pallor. 6. uniform color A – asymmetric. moist A – Missing teeth. 2. size. generalized or localized swelling. cyanosis. moist. Observe for the presence of redness. Inspect and palpate the inner lips and buccal mucosa for color. Inspect the external nose for any deviations in shape. abnormal discharge. Determine patency of both nasal cavities. smooth. discharge from nares.
texture. or excoriated areas.excessively red gums 4. Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal swellings or masses. 4. Palpate the tongue and floor of the mouth for any nodules. 2. no dischargeof normal size or not visible A – inflamed. and the presence of bony prominences. Elicit the gag reflex by pressing the posterior tongue with a tongue blade. and the frenulum. Assessing the Neck 1. Inspect the uvula for position and mobility while examining the palates.swelling nodules N – same as color of buccal mucosa and floor of mouth A – Inflammation N – Light pink. Inspect the base of the tongue. 13. Lighter pink hard palate. 25 . lumps. Inspect tongue movement. Inspect the thyroid gland. 8.Unilateral neck swelling. 9. head tilted to one side N – not palpable A – enlarged. palates the same color. presence of discharge. immobility N – pink and smooth posterior wall A – reddened or edematous N – Pink and smooth. 3. head centered A . N – smooth. Palpate the trachea for lateral deviation. Palpate the entire neck for enlarged lymph nodes. 11. shape. 12. irritations N – Positioned in midline of soft palate A – Deviation to one side from tumor or trauma. 7. no tenderness A – Restricted mobility N – Smooth tongue base with prominent veins A – sweeling. 10. Inspect the tonsils for color. Inspect the hard and soft palate for color. Inspect the dentures. intact dentures A – ill-fitting dentures. palpable. swollen N – present A – Absent N – Muscles equal in size. ulceration N – smooth with no palpable nodules A . smooth. soft palate. the mouth floor. possibly tender N – central placement in midline of neck A – deviation to one side N – Not visible on inspection 5. and size. Inspect salivary duct openings for any swelling or redness. more irregular texture A – Discoloration. irritated and excoriated area under dentures N – moves freely. Inspect the oropharynx for color and texture. 6. discharge.
Areas of dullness or flatness over lung tissue N – excursion is 3-5cm. Palpate the thyroid gland for smoothness. N – Anteroposterior to transverse the diameter in ratio of 1:2. Palpate the posterior thorax. Assessing the Thorax and Lungs 1. 2. 6. 3.A – visible diffuseness/local enlargement 5. 11. Palpate the anterior chest. 8. Compare the anteroposterior diameter to the transverse diameter. 4. Inspect the spinal alignment for deformities. A – Barrel chest. Palpate the anterior chest for respiratory excursion. Inspect the costal angle and the angle at which the ribs enter spine. chest assymetric N – Spine vertically aligned A – Exaggerated spinal curvatures N – skin intact A – Skin lesions N – full and symmetric chest expansion A – asymmetric/ decreased chest expansion N – bilateral symmetry of vocal fremitus A – decreased or absent of fremitus N – Percussion notes resonate. 9. except over scapula. Percuss the thorax. Percuss for diaphragmatic excursion. Palpate the posterior chest for respiratory excursion. rhythmic. Inspect breathing patterns. bilaterally in women and 5-6 cm in men A – Restricted excursion N – Vesicular and bronchovesicular breath sounds A – Adventitious breath sounds N – quiet. Inspect the shape and symmetry of the thorax from posterior and lateral views. 10. chest symmetric. 5. Ausculate the chest using the flat-disc diaphragm of the stethoscope. and effortless respirations A – abnormal breathing patterns and sounds N – Costal angle is less than 90 degrees and the ribs insert into the spine at approximately a 45 degree angle A – widened N – full symmetric excursion N – Lobes may not be palpated A – solitary nodules 7. 12. increased anteroposterior to transverse diameter. Palpate the chest for vocal (tactile) fremitus. 26 . lowest point of resonance is at the diaphragm A – Assymetry in percussion.
2. lifts.slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults A – Increased or decreased intensity. s3: in older adults. and tympanic over the underlying stomach A – Asymmetry in percussion notes. 4. increased intensity at pulmonic area. or heaves. tricuspid. Percuss the anterior chest systematically. 16. varying intensity with different beats. pulmonic. Assessing the Heart and Central Vessels 1. Auscultate the carotid artery. Auscultate the trachea.slightly shorter duration than diastole at normal heart rate Diastole: silent interval. Palpate tactile fremitus in the same manner as for the posterior chest. sharp sounding ejection clicks. areas of dullness or flatness over lung tissue N – Bronchial and tubular breath sounds A – Adventitious breath sounds N – Bronchovesicular and vesicular breath sounds A – Adventitious breath sounds N – No pulsations A – pulsations N – S1: usually heard at all sites. Use extreme caution. increased intensity at aortic area. 27 . dull on areas over the heart and the liver. Auscultate the heart in all four anatomic sites: aortic. s4: may be a sign of HPN N – symmetric pulse volume A – asymmetric volumes N – no sound heard on auscultation A – Presence of bruit in one or both arteries 15. Palpate the carotid artery. 14. N – same as posterior vocal fremitus A – same as posterior fremitus N – Percussion notes resonate down to the sixth rib at the level of the diaphragmmbut are flat over areas of heavy muscle and bone. usually louder at base of heart S2: usually heard at all sites. and apical (mitral) 3. Simultaneously inspect and palpate the precordium for the presence of abnormal pulsations.A – Asymmetric/ decreased respiratory excursion 13. Auscultate the anterior chest. usually louder at the base of heart Systole: silent interval.
if obese may be similar in shape to female breasts A – recent change in breast size. presence of distention and nodular bulges at calves. assess the jugular venous pressure (JVP). Palpate the peripheral pulses on both sides of the client’s body individually. If jugular distention is present. a dusky red color when limb is lowered. Assess the peripheral leg veins for signs of phlebitis.5. slightly unequal in size. 28 . and contour or shape while hthe client is in a sitting position. pain in calf muscles with forceful dorsiflexion of the foot N – skin color pink. skin texture resilient and moist A – cyanotic. symmetry. absence of pulsations N – In dependent position. full pulsations A – Asymmetric volumes. Locate the highest visible point distention of the internal jugular vein. 1. 2. If you have difficulty palpating some of the peripheral pulses. simultaneously (except the carotid pulse). smooth and intact. waxy with reduced hair N – capillary refill test immediate return of color A – Delayed return of color N – F: rounded shape. skin thin and shiny or thick. pallor. marked asymmetry N – Skin uniform in color. and systematically to determine the symmetry of pulse volume. Inspect the skin of the hands and feet for color. Capillary refill test: squeeze the client’s fingernail and toenail between your fingers sufficiently to cause blanching Assessing the Breasts and Axillae 1. retraction or dimpling. use a Doppler ultrasound probe. generally symmetric M: breasts even with the chest wall. edema. swelling. Inspect the peripheral veins in the arms and legs for the presence and/ or appearance of superficial veins when limbs are dependent and when limbs are elevated. marked edema. Inspect the breasts for size. brown pigmentation around ankles. The external jugular vein is more easily affected by obstruction or kinking at the base of the neck Assessing the Peripheral Vascular System N – Symmetric pulse volumes. symmetric in size A – tenderness on palpation. no edema. skin cool. Inspect the skin of the breast for localized discolorations or hyperpigmentation. temperature not excessively warm or cold. 2. temperature. and skin changes. when limbs elevated. 3. diffuse symmetric horizontal or vertical vascular pattern in light-skinned 4. 5. dependent rubor. veins collapsed A – Distended veins in the thigh or lower leg or on posterolateral part of calf from knee to ankle N – Limbs not tender.
masses . position. nodules and nipple discharge N . moles and nevi A – Localized discoloration or hyperpigmentation.masses . rounded or schapoid. the breast flatten evenly against the chest wall. or cracks. Palpate the breast for masses. 8. nodules or nipple discharge For client to be knowledgeable on how to examine his/her own breast. masses or nodules A – tenderness. retraction or dimpling. color. and supraclavicular lymph nodes. Observe the vascular pattern. Palpation of the breast is generally performed while the client is supine. Teach the client the technique for breast self-examination. N – round or oval and bilaterally the same color varies widely. subclavicular. uniform color. mass or lesion N – round. shape. 6. 4. swelling. recent inversion of one or both nipples N – no tenderness. masse or n odules R – in the supine position. soft and smooth. 3. Observe abdominal movements associated with respiration. asymmetric contour N – symmetric movement caused by respiration A – limited movement due to pain or disease process N – no visible vascular pattern 3. and lesions. Inspect the abdomen for skin integrity.masses . 2. Palpate the axillary. presence of discharge. color. Assessing the Abdomen 1. silver white striae or surgical scars A – Presence of rash or other lesions N – Flat. or edema. nodules or nipple discharge A – Tenderness. tenderness. people. from light pink to dark brown A – any asymmetry. striae. surface characteristics. or aortic pulsations. and any masses or lesions. Inspect the abdomen for contour and symmetry. 7. 29 . Palpate the areola and the nipples for masses. masses. crusts.tenderness. 5. and equal in size. symmetric contour A – distended. symmetry. discharge. N – unblemished skin. Inspect the nipples for size. both nipples point in same direction A – asymmetrical size and color.localized hypervascular areas. and any discharge from the nipples. swelling. shape. everted. nodules or nipple discharge A . 4. Inspect the areola area for size.no tenderness. similar in color. perstalsis. facilitating palpation N – no tenderness.
A – Visible venous pattern is associated with liver disease. 9. 6. 3. hyperactive and true absence of sounds N – tympany over the stomach and gas filled bowels. Percuss the liver to determine its size N – audible bowel sounds. 11. tense mass N – equal size on both sides of body A – atrophy or hypertrophy. ascites & venocaval obstruction 5. Assesing the Musculoskeletal System 1. Auscultate the abdomen for bowel sounds. Palpate the liver to detect enlargement and tenderness. and peritoneal friction rubs. 4-8cm at the midsternal line A – enlarged size N – no tenderness A – tenderness N – Tenderness may be present near xiphoid process. Palpate the area above the pubic symphysis if the client’s history indicates possible urinary retention. Palpate muscles at rest to determine muscle tonicity. round . absence of friction rub A – hypoactive. or a full bladder A – Large dull areas N – 6-12 cmin the midclavicular line. 5. spasticity. 2. Percuss several areas in each of the four quadrants to determine presence of tympany and dullness. and over sigmoid colon A – generalized/ localized areas of tenderness. Test muscle strength. dullness. e. asymmetry N – No contractures A – malposition of body part. Inspect the muscles for tremors. and smoothness of movement. Perform light palpation first to detect areas of tenderness and/ or muscle guarding. vascular sounds.g. Inspect the muscles for size. mobile or fixed masses N – May not be palpable A – Enlarged N – not palpable A – distended and palpable as smooth. over cecum. Perform deep palpation over all four quadrants. 4. Inspect the muscles and tendons for contractures. Palpate muscles while the client is active and passive for flaccidity. especially over the liver and spleen. 7. 6. Compare the right 30 . 10. foot drop N – No tremors A – Presence of tremor N – normally firm A – atonic N – Smooth coordinated movements A – Flaccidity/spasticity N – equal strength on each body side 8. absence of arterial bruits.
Assess joint range of motion. A – 25% or less of normal strength N – no deformities A – Bones misaligned N – no tenderness and swelling A – tenderness. Apply the Glasgow Coma Scale 4. Inspect the skeleton for normal structure and deformities. Listen for lapses in memory. Determine the client’s orientation to time. Test the cranial nerves. 8. 7. Cranial Nerve V – Trigeminal VI. Cranial Nerve XI – Accesory XII. and person by tactful questioning. Cranial Nerve VII – Facial VIII. Cranial Nerve IV – Trochlear V.side with left side. Inspect the joint for swelling. Cranial Nerve II – Optic III. Cranial Nerve XII – Hypoglossal 31 . Cranial Nerve IX – Glossopharyngeal X. orange/lemon. tongue movement and taste To assess client’s speech for hoarseness To assess the head movement and shrugging of the shoulders To assess protrusion of tongue II. 3.swelling. Cranial Nerve VI – Abducens VII. 9. I. crepitation or nodules N – no swelling. Cranial Nerve X – Vagus. 10. Assessing the Neurological System 1. To assess client ability to swallow . such as coffe. place. peanut butter. Cranial Nerve III – Oculomotor IV. Palpate the bones to locate any areas of edema or tenderness. 2. Cranial Nerve I – Olfactory To assess the client’s ability to recall information. no tenderness A – One or more swollen joints. XI. Cranial Nerve VIII – Auditory IX. To identify different mild aromas. To assess client’s level of conciousness. tenderness N – varies to some degreein accordance with person’s genetic makeup and degree of physical activity A – limited range of motion in one or more joints To assess mental status of the client. chocolate To check visual fields and vision of the client To assess 6 ocular movements and pupil reaction To assess skin sensation of the client To assess direction of gaze Facial expression and taste To assess client ability to hear spoken word and vibrations of tuning fork. vanilla.
Romberg test N – Has upright posture and steady gait with opposing arm swing. has rigid or no arm movements N – Negative Romberg: may sway slightly but is able to maintain upright posture and foot stance A – positive Romberg: can’t maintain foot stance. maintaining balance A – poor posture and unsteady. walks unaided. . N – Performs with coordination and rapidly A – Misses the finger and moves slowly N – performs with accuracy and rapidity A – Moves slowly N – Rapidly touches each finger to thumb with each hand A – cannot coordinate this fine discrete movements with either one or both hands 7.toe or ball of foot to the nurse’s finger N – Demonstrate bilateral equal coordination A – tremors.heel down opposite shin .fingers to thumb N – repeatedly & rhythmically touches the nose A – Misses the nose or give the sloe response N – Can alternately supinate and pronate hands at rapid pace A – slow. Fine Motor Tests for the Lower Extremities. moves the feet apart to maintain stance. 6. Compare the light touch sensation of symmetric areas of the body.walking gait . cant coordinate movement Sensitivity to touch varies among different skin areas 8. staggering gait with wide stance. and irregular timing. clumsy movements. Fine Motor Tests for the Upper Extremities. irregular. Gross Motor and Balance Tests .finger to nose and to the nurses finger .5.alternating supination and pronation of hands and knees . awkward. Light-Touch Sensation. 32 . heel moves off shin N – Moves smoothly with coordination A – misses your finger.Fingers to fingers . bends legs only from hips.Finger to nose test . .
Assessing the Female Genitals and Inguinal Area 1. varicosities or leukoplakia N – Clitoris does not exceed 1 cm in width and 2 cm In lengh. Pain Sensation. Position the client in supine. 10. Inspect the distribution.9. or a drape at all times when not actually being examined. Skin of uvula area slightly darker than the rest of the body. with feet elevated on the stirrups of an examination table. and vaginal orifice when separating the labia minora. no lesions. thinner and straighter after menopause. 2. separate the labia majora and labia minora. 11. scars. Inspect the skin of the pubic area for parasites. swelling or discharge A – Presence of lesions. and characteristics of the pubic hair. distributed in the shape of an inverse triangle A – Scant pubic hair. hair growth should not extend over the abdomen N – pubic skin intact. and relatively symmetric in adult females A – Lice. generally kinky in the menstruating adult. labia round. Tactile Discrimination. Alternately. Temperature Sensation. inflammation swelling or discharge 3. urethral orifice. swelling. urethral orifice appears as a small slit and is the same color as surrounding tissues. heightened or absent sensation N – able to discriminate between hot and cold sensations A – areas of dulled or lost of sensation N – can readily determine the position of fingers and toes A – unable to determine the position of one or more fingers or toes To assess client’s ability to recognize objects by touching them To provide privacy and comfort. Position or Kinesthetic Sensation. and lesions. excoriations. fissures. full. no inflammation. N – there are wide variations. lesions. erythema. inflammation. 4. swelling. Inspect the clitoris. amount. 12. To assess pubic skin adequately. assist the client into the dorsal recumbent position with knees flexed and thighs externally rotated. 33 . Cover the pelvic area with a sheet. To assess pain sensation N – Able to discriminate sharp and dull sensation A – Areas of reduce.
foreskin easily retractable from the glans penis. N – No enlargement or tenderness A – Enlargement and tenderness To provide privacy and comfort. and skin lesions. coarser. Inspect both inguinal areas for bulges while the client is standing. thickening. or drape at all times when not actually being examined. variation in meatal locations N – smooth and semifirm. nodules. 4. discharge. 2.5. 7. 6. if possible. is slightly movable over the underlying structures A – Presence of tenderness. Cover the pelvic area with a sheet. any tightening of skin’ N – Testicles are rubbery. N – Triangular distribution. smooth and free of nodules and masses. swellings. epididymis is nonresilient and painful N – No swelling or bulges A – swelling or bulge N – Intact perianal skin. with uneven surface. Inspect the distribution. 5. and discharge. 8. 34 . often spreading up the abdomen A – scant amount or absence of hair N – Penile skin intact. and symmetry. Palpate the scrotum to assess the status of underlying testes. general size. and moister than perianal skin and usually hairless. swelling or inflammation N – pink and slitlike appearance. immobility N – scrotal skin is darker in color than that of the rest of the body and is loose A – discolorations. usually slightly more pigmented than the skin of the buttocks Anal skin is more pigmented. and spermatic cord. and inflammation. thickening or nodules. and nodules. positioned at the tip of the penis A – Inflammation. Use your thumb and first two fingers. Palpate both testes simultaneously for comparative purposes. Inspect the penile shaft and glans penis for lesions. Inspect the anus and surrounding tissue for color. Palpate the inguinal lymph nodes. Inspect the scrotum for appearance. 3. Palpate the penis for tenderness. and characteristics of pubic hair. Assessing the Rectum and Anus 1. amount. testis is about 2 x 4 cm A – testicles are enlarged. small amount of thick white smegma between the glans and foreskin A – Presence of lesions. inflammation. appears slightly wrinkled and varies in color as widely as other body skin. integrity. nodules. Inspect the urethral meatus for swelling. epididymis. Assessing the Male Genitals and Inguinal Area 1.
On withdrawing the finger from the rectum and anus. masses. If ordered. Assessment ASSESS 35 . N – To contribute to data collection and fulfill procedural requirement. 2. abscesses. excoriations. N – Anal sphincter has good tone. perform a test for occult blood on the stool. A – Hypertonicity/hypotonicity of the anal sphincter N – brown color A – Presence of mucus blood or black tarry stool. 3. lumps or tumors. To make client clean and fell comfortable. Purposes 1. 2. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. 3. To increase sense of wellbeing. protruding hemorrhoids. or rectal prolapse. BED BATH Definition It is a type of bath given while the client is on bed. ulcers. 4. Palpate the rectum for anal sphincter tonicity. observe it for feces.A – Presence of fissures. nodules. fistula openings. inflammations. and tenderness. To promote muscular relaxation and relieve feelings of fatigue.
Adjust the room temperature and ventilation. Introduce self and verify patient’s identification. Condition of the skin ( color. Physical or emotional factors ( e. anxiety and fear ).. abrasions and bruises ) 2. cognition ) Planning 1. 4.. sensitivity to cold. 2. mobility. Explain the procedures. 3.6 Gloves 1.3 Wash cloth 1. Warm room prevents rapid loss of body heat during bathing. Perform hand hygiene. lesions. analgesics ) before the bath 4. Assess the client’s tolerance for the activity. powder and deodorant ) 1.2 Bath blanket 1. Any other aspect of health that may affect the client’s bathing process ( e. Assemble the following equipment: 1. Presence of pain and need for adjunctive measures( e. RATIONALE To determine client’s ability to perform self -care and level of assistance.8 Hygiene supplies ( lotion.9 Bed pan / Urinal 2. presence of pigmented spots. Fatigue.g. To promote client’s cooperation and participation.5 Hamper for soiled linen 1. Provide privacy by drawing the curtains and closing the door. need for control. 36 .7 Soap 1. 3. temperature. texture and turgor. Need for use of clean gloves during the bath 5.g. Implementation STEPS 1. and observe other appropriate infection control procedure. 5. strength..1 Wash basin 1. To allay fear and anxiety.1.4 Patient gown 1.g.
To reduce spread of microorganisms. 10. Wash hands. Adjust bed to a comfortable height position. remove gown first from the uninjured side. ears. Long firm strokes stimulate circulation. If client has an IV. To prevent muscle strain in the part of the healthcare provider. Soap will irritate the eyes. Wash client’s arm with soap and water using long firm strokes from distal to proximal arm including underarm. Do not disconnect tubing. 8. To protect the client’s skin from the nails of the health care provider. 15. 11. Remove the client’s gown while keeping the client covered with a bath blanket. To provide full exposure of body parts during the procedure.6. Rinse and pat dry. Make a mitt of the wash cloth. neck with or without soap as per client’s preference. Blanket provides warmth and privacy. Use separate portion of the wash cloth for the eyes. Warm water promotes comfort and relaxation of muscles. Spread bath towel across patient’s chest tucking it under the chin. Removal of pillow makes it easier to wash client’s ear and neck. Client will feel more comfortable and allow continuity of work. NOTE: a. Offer bedpan or urinal 7. Undressing unaffected or uninjured side first allows easier manipulation of body parts with reduced range of motion. If any extremity is injured. Remove pillow if allowed and place patient in a semi-Fowler’s position. Mitt retains water and heat than a loosely held cloth. Place the bath towel under the arm away from you. Remove the top linen by placing a bath blanket over the client before removing the top sheet. 13. Wash client’s face. b. Pull side rail up and then fill wash basin 2/3 full of warm water. remove gown first from arm without IV. 12. 14. To maintain client safety. 16. 9. Soap tends to dry the face which is exposed to air more than any other parts of the body. Wash client’s eyes with plain water moving from the inner canthus (corner) of the eye to the outer canthus of the eye. 37 .
Bath beginning on the hairline and washing downwards including the buttocks using long firm strokes giving special attention on the folds of buttocks and anus. 20. rinse and dry perineum from the front to the rear giving special attention to skin folds. Repeat procedure for the client’s other arm near you.17. 19. For sanitary purposes. Washing first the arm of the client away from the health care provider prevents contamination of dirt from the arm near the client. To make client comfortable. Apply deodorant. Skin folds accumulate dirt. Assist client to put on a clean gown. comb hair. To prevent soiling of bed. 26. Wash with long firm strokes. For sanitary purposes. place a towel under the buttocks and bring basin and soap within patient’s reach. rinse and dry chest and abdomen using long firm strokes paying attention to skin folds. Dirt accumulates on the fold of the buttocks and anus. Place bath towel over the client’s chest and fold bath blanket down the pubic area. powder and lotion if desired or requested by the patient. Wash. Expose one leg at a time folding blanket toward midline. 24. 18. If unable. 38 . Same as above. Repeat for the other leg near you. Turn patient on his/her side and place towel along side of the back. Replace water. Fold bath towel in half and lay it on bed beside the client. If client is able. 23. Wash. Pat dry thoroughly between toes. To provide privacy and comfort. 27. Immerse and wash feet in basin. 22. To provide warmth and privacy. 21. Instruct client to complete the bath him/herself. Wash both hands. 25. Moisture between digits promotes accumulation of microorganism. place client in a supine position and cover with bath blanket. Place bath towel under the calf of leg away from you. Replace bath water.
lesions. if available. Wash hands. Condition and integrity of skin ( dryness. Conduct appropriate follow-up. Leaving the client’s unit clean and orderly will prevent accidents and show respect for the client. Remove equipment used and store them in proper place. statements regarding comfort ) 2. 29. Document the procedure. Percentage of bath done without assistance 3.28. To contribute to data collection and fulfill procedural requirement. To prevent spread of microorganisms. PERINEAL CARE Definition A cleansing procedure prescribed for cleansing the perineum after various obstetric and gynecological procedures. such as a. Evaluation 1. 30. Sterile and clean perineal care is practiced to remove secretions or dried blood from a wound and to prevent contamination of the urethral and vaginal areas or prineal wounds with fecal matter or urine. turgor. Client strength c. behaviors of acceptance or resistance..g. respiratory rate and effort. redness. and so on) b. Relate to prior assessment data. Note the client’s tolerance of the procedure ( e. Purposes • • To remove normal perineal secretions and odor To promote client comfort Equipments • • • Bath towel Bath blanket Clean gloves 39 . pulse rate.
40 . The bath towel prevents the bed from becoming soiled. the opposite corner at her feet. 4. and other on the sides. Prepare the client: -fold the top of the bed linen to the foot of the bed and fold the gown up to expose the genital area. Explain to the client what you are going to do. Minimum exposure lessen the embarrassment and helps to provide warmth. 2. introduce self and verify the client’s identity using agency protocol. Prior to performing the procedure. FOR FEMALES: -Position the female in a back lying position with knees flexed and spread well apart. -cover her body and legs with a bath blanket positioned so a corner is at her head. Position and drape the client and clean the upper inner thighs. 3. Drape the legs by tucking the bottom corners of the bath blanket under the inner sides of RATIONALE Hygiene is a personal matter. why it is necessary and how he/she can cooperate. -Place a bath towel under the client’s hips 5. Perform hand hygiene and observe other appropriate infection control procedures.• • • • • • • Bath basin with water at 43C to 46C (110F to115F) Soap Washcloth Cotton balls or swabs bed pan to receive rinse water Receptacle Perineal pad STEPS 1. Provide for client privacy by drawing the curtains around the bed or closing the door of the room.
-note particular areas of inflammation. Wipe from the area of least contaminated 9the pubis) to that of greatest (the rectum). The posterior folds of the scrotum may need to be cleaned when the buttocks are cleaned. Inspect the perineal area. Replacing the foreskin prevents constriction of the penis. wash and dry the upper inner thighs. -if the client is uncircumcised. 6. FOR MALES -Wash and dry the penis. -also note excessive discharge or secretions from the orifices and the presence of odors. which may cause edema. Using seperate quarters of the wash cloth or new wipes prevents the transmission of microorganisms from one area to the other. or swelling especially between the labia in females and the scrotal folds in males. and wipe from the pubis to the rectum. wash and dry the upper inner thighs FOR MALES: -position the male client in a supine position with knees slightly flexed and hips slightly externally rotated. Secretions that tend to collect around the labia minora facilitate bacterial growth.Then spread the labia to wash the fills between the labia majora and labia minora -Use separate quarters of the wash cloth for each stroke. FOR FEMALES -Clean the labia majora. Replace the foreskin after cleaning the glans penis. retract the prepuce (foreskin) to expose the glans penis for cleaning. 7.the legs -put on gloves. thus it is usually cleaned after the penis 41 . -Rinse the area well. -Put on gloves. The scrotum tends to be more soiled than the penis because of its proximity to the rectum. excoriation. using firm strokes. -Wash and dry the scrotum. under the foreskin and facilitates bacterial growth. Wash and dry the perineal area.
nurses need to make an occupied bed or prepare a bed for a client who is having surgery or whenever the need arises. wrinkle-free bed foundation. -Assist the client to turn onto side facing away from you. This prevents contamination of the vagina and urethra from the anal area. At times. Inspect the perineal orifices for intactness. especially if linens are soiled. and any localized areas of tenderness. BED MAKING Definition Bed making is the preparation of hospital beds usually after client receives certain care or whenever a bed is unoccupied. if necessary -Dry the area well -For post delivery or menstruating females. A catheter may cause excoriation around the urethra. excoriation. Clean between the buttocks. however. I. -Inspect particularly around the urethra in clients with indwelling catheters. Clean the anus with toilet tissue before washing it.8. 10. 9. -Pay particular attention to the anal area and posterior folds of the scrotum in males. discharge or drainage. Document any unusual findings such as redness. Changing an Unoccupied Bed Purposes • • • To promote the client’s comfort To provide a clean neat environment for the client To provide a smooth. apply a perineal pad as needed from front to back. thus minimizing sources of skin irritation Equipments 42 . skin abrasions.
43 . 2. Raise the bed to a comfortable height. Place the fresh linen on the client’s chair or overbed table. starting at the head of the bed on the far side and moving around the bed up to the head of the bed on the near side. do not use another client’s bed. To show respect to the client and gain cooperation This prevents cross contamination (the movement of microorganisms from one client to another) via soiled linen. Assist the client to a comfortable chair To avoid straining of the body. Strip the bed. Perform hand hygiene and observe other appropriate infection control procedures. and detach the call bell or any drainage tubes from the bed linen Loosen all bedding systematically. 6. Rationale A universal precaution which helps prevent the spread and transmission of infectious organisms. • Moving around the bed systematically prevents stretching and reaching and possible muscle strain. To promote safety • 5. 3. if available Implementation Steps 1.• • • • • • • Two flat sheets or one fitted and one flat sheet Cloth drawsheet (optional) One blanket One bedspread Waterproof pads (optional) Pillowcase(s) for the head pillow(s) Plastic laundry bag or portable linen hamper. Assess and assist the client out of bed • Make sure that this is an appropriate and convenient time for the client to be out of bed. • Check bed linens for any items belonging to the client. Provide for client privacy. 4.
Apply the bottom sheet and drawsheet. not on the floor. First. Place the sheet along the edge of the mattress at the foot of the bed and do not tuck it in. working from the head of the bed to the foot. such as the bedspread and top sheet on the bed.• Remove the pillowcases. and move the mattress up to the head of the bed. into fourths. and place the pillows on the bedside chair near the foot of the bed. • • These actions are essential to prevent the transmission of microorganisms to the nurse and others. Spread the sheet out over the mattress and allow sufficient amount of sheet at the top to tuck under the mattress. • 7. Fold reusable linens. Grasp the mattress securely. • • 44 . hold it away from your uniform. and then grasp it at the center of the middle fold and bottom edges. If a waterproof drawsheet is used. • Place the folded bottom sheet with its center fold on the center of the bed. and place it directly in the linen hamper. Roll all soiled linen inside the bottom sheet. if soiled. using the lugs if present. Remove the waterproof pad and discard it if soiled. • Folding linens saves time and energy when reapplying the linens on the bed and keeps them clean. (unless it is a fitted sheet) Miter the sheet at the top corner on the near side and tuck the sheet under the mattress. fold the linen in half by bringing the top edge. Make sure the sheet is hem side down for a smooth foundation. place it over the bottom sheet so that the centerfold is at the centerline of the bed and the top of bottom edges The top of the sheet needs to be well tucked under to remain securely in place especially when the head of the bed is elevated.
blanket and spread. Optional: Before moving to the other side of the bed. hemside up. place the top linens on the bed hemside up.extend from the middle of the client’s back to the area of the midthigh or knee. • 8. tuck them in. • Lay the cloth drawsheet over the waterproof sheet in the same manner. Fanfold the uppermost half of the folded drawsheet at the center or far edge of the bed and tuck in the near edge. Unfold the sheet over the bed. unfold then. and miter the bottom corners. • 45 . Move to the other side and secure the bottom linens. on the bed so that its centerfold is at the center of the bed and the top edge is even with the top edge of the mattress. • Tuck in the bottom sheet under the head of the mattress. Completing one entire side of the bed at a time saves time and energy. and miter the corner of the sheet. • Place the top sheet. Tuck the sheet in at the side. 9. pull the sheet firmly. • Wrinkles can cause discomfort for the client and breakdown of skin. • Complete this same process for the drawsheet(s). Pull the remainder of the sheet firmly so that there are no wrinkles. Apply or complete the top sheet.
providing a cuff Move to the other side of the bed and secure the top bedding in the same manner. but place the top edges about 15 cm (6 in) from the head of the bed to allow a cuff of sheet to be folded over them Tuck in the sheet. Place the pillows appropriately at the head of the bed. Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are straight. Put clean pillowcases on the pillows as required. and the spread. using all three layers of linen. blanket and spread hanging freely unless toe pleats were provided. Provide for client comfort and safety. 46 . Gather up the sides of the pillowcase and place them over the hand grasping the case. blanket. • • • A smoothly fitting pillowcase is more comfortable than a wrinkled one • 11. Then grasp the center of one short side of the pillow through the pillowcase. • Grasp the closed end of the pillowcase at the center with one hand. and spread at the foot of the bed. With the free hand. pull the pillowcase over the pillow. The cuff of sheet makes it easier for the client to pull the covers up. Leave the sides of the top sheet. Fold the top of the top sheet down over the spread. and miter the corner.• Follow the same procedure for the blanket. • • • 10.
either fold back the top covers at one side or fanfold them down to the center of the bed. • • 12. Some cords have clamps that attach to the sheet or pillowcase.• Attach the signal cord so that the client can conveniently reach it. If the bed is currently being used by a client. as indicated. such as the client’s physical status and pulse and respiratory rates before and after being out of bed. Place the bedside table and the overbed table so that they are available to the client Leave the bed in the high-position if the client is returning by stretcher or place in the low position if the client is returning to bed after being up • This makes it easier for the client to get into bed. Purposes • • To conserve the client’s energy To promote client comfort Equipments • • • Two flat sheets or one fitted and one flat sheet Cloth drawsheet (optional) One blanket 47 . Others are attached by a safety pin. Document and report pertinent data. Changing an Occupied Bed II. • • Bed-making is not normally recorded Record any nursing assessments.
Loosen all top linen at the foot of the bed. Change the bottom sheet and drawsheet. Put on disposable gloves if line is soiled with body fluids. To show respect to the client and gain cooperation • 48 . Provide for client privacy. or replace it with a bath blanket as follows: Spread the bath blanket over the top sheet. Perform hand hygiene and observe other appropriate infection control procedures. c. • Assist the client to turn on the side Rationale To prevent transmission of infectious organisms and spread of infection.• • • • One bedspread Waterproof drawsheet or waterproof pads (optional) Pillowcase(s) for head pillow(s) Plastic laundry bag or portable linen hamper Implementation Steps 1. leaving the blanket in place. Remove the sheet from the bed and place it in the soiled linen hamper. and remove the spread and the blanket Leave the top sheet over the client (the top sheet can remain over the client if it is being changed and if it will provide sufficient warmth). 2. • • Remove any equipment attached to the bed linen such as a signal light. a. Reaching under the blanket from the side. 3. Ask the client to hold the top edge of the blanket b. Remove the top bedding. 4. grasp the top edge of the sheet and draw it down to the foot of the bed.
Raise the side rail before leaving the side of bed.facing away from the side where the clean linen is. • • • • • 49 . Move to the other side of the bed and lower the side rail. If there is no side rail. • Raise the side rail nearest the client. Tuck the sheet under the near half of the bed and miter the corner if a contour sheet is not being used. Move the pillows to the clean side for the client’s use. as close to and under the client as possible. Fanfold the drawsheet and the bottom sheet at the center of the bed. Place the new bottom sheet on the bed. The client rolls over the fanfolded linen at the center of the bed. have another nurse support the client at the edge of the bed. This protects the client from falling. Place the clean drawsheet on the bed with the center fold at the center of the bed. Assist the client to roll over toward you onto the clean side of the bed. Fanfold the uppermost half vertically at the center of the bed and tuck the near side edge under the side of the mattress. • Doing this leaves the near half of the bed free to be changed. and vertically fanfold half to be used on the far side of the bed as close to the client as possible. • Loosen the foundation of the linen on the side of the bed near the linen supply.
Spread the top sheet over the client and either ask the client to hold the top edge of the sheet or tuck it under the shoulders. Determine what position the client requires or prefers and assist the client to that position. 6. Face the top far corner to pull the bottom section c. • 7. Raise the side rails. • • Reposition the pillows at the center of the bed Assist the client to the center of the bed. Facing the side of the bed. Unfold the fanfolded bottom sheet from the center of the bed. Face the far bottom corner to pull the top section Tuck the excess drawsheet under the side of the mattress. Face the side of the bed to pull the middle section b. • • • • 5. use both hands to pull the bottom sheet si that it is smooth and tuck the excess under the side of the mattress. 50 .• Remove the usesd linen and place it in the portable hamper. Apply or complete the top bedding. Place bed in the low position before leaving the bedside. Resposition the client in the center of the bed. Unfold the drawsheet fanfolded at the center of the bed and pull it tightly with both hands. Pull the sheet in three sections a. To promote safety. The sheet should remain over the client when the bath blanket or used sheet is removed.
this metohd of administration is frequently used for allergy testing and tuberculosis (TB) screening.Attach the signal cord to the bed linen within the client’s reach.tuberculin syringe) and #25.1 mL.e. The left arm is commonly used for TB screening and the right arm is used for all other tests. the upper chest.to # 27. and the back beneath the scapulae. 0. ADMINISTERING AN INTRADERMAL INJECTION FOR SKIN TESTS Purposes • Equipments Vial or ampule of the correct medication Sterile 1-mL syringe calibrated into hundredths of a milliliter(i.gauge safety needle that is ¼ to 5/8 inch long Alcohol swabs To provide medication the client requires 51 . Common sites for intradermal injections are the inner lower arm. Usually only a small amount of liquid is used.. Bed-making is not normally recorded. ADMINISTERING INTRADERMAL INJECTION Definition It is the administration of a drug into the dermal layer of the skin just beneath the epidermis. Put items used by the client within easy reach. for example. 8.
This technique is not delegated to UAP. to make sure that the correct medication is being prepared. Read the label on the medication (1) when it is taken from the medication chart. The nurse. however. Check the medication administration record (MAR) • Check the label on the madication carefully against the MAR. problem solving. and sterile technique. Clean gloves Bandage(optional) Epinephrine on hand in case of allergic anaphylactic reaction Assessment Assess: • • • • Appearance of injection site Specific drug action and expected response Client’s knowlegde of drug action and response Check agency protocol about sites to use for skin tests. (2) before withdrawing the medication. Follow the three checks for administering medications. and (3) after withdrawing the medication • Organized the equipment Implementation Steps Rationales 52 . Planning Delegation • The administration of intradermal injections is an invasive technique that involves the application of nursing knowledge. can inform the UAP about symptoms of allergic reactions and the necessity to report those observations immediately to the nurse.
with the bevel of the needle up. 12. Cleanse the skin at the site using a circular motion starting at the center and widening the circle outward. Grasp the syringe in your dominant hand. inflamed. Prepare the medication from the vial or ampule for drug withdrawal. Taut skin allows for easier entry of the needle and less discomfort for the client. Hold the needle almost parallel to the skin surface. The possibility of the medication entering the subcutaneous tissue increases when using an angle greater than 15 degrees. Explain the procedure to the client Information can facilitate acceptance of and compliance with the therapy. Wear disposable gloves as indicated by agency policy. This ensures that the right client receives the medication. Expel any air bubbles from the syringe. 7.1. 3. 6. The bevel up position provides more comfort for the nurse and id faster to administer. Inject the fluid with the nondominant hand. This ensures that the right client receives the medication. a small amount of air will not harm the tissues. or swollen and those that have lesions. Prepare the client 4. Perform hand hygiene and observe other appropriate infection control procedures 2. Prepare the syringe for the injection. pull the skin at the site until it is taut. 9. 5. This verifies that the medication entered the 53 . Small bubbles that adhere to the plunger are of no consequence. close to the hub. holding it between thumb and forefinger. 11. Provide privacy of the client. Select and clean the site To avoid using of sites that are tender. To minimize spread of microorganism. 8. 10.
the time. Do not massage the area dermis. Evaluate the client’s response to the testing substance. 18. Circle the injection site with ink. route. insulin) can then be delivered into the subcutaneous tissues. and nursing assessments. the drug moves into small blood vessels and the bloodstream. 54 . Withdraw the needle quickly at the same angle. The subcutaneous route is used with many protein and polypeptide drugs such as insulin which. Some medications used in testing may cause allergic reations. ADMINISTERING SUBCUTANEOUS INJECTION Definition Under the skin. a needle is inserted just under the skin. Epinephrine may need to be used. Massage can disperse the medication into the tissue or out through the needle insertion site 16. 20. Measure the area of redness and induration in millimeters at the largest diameter and document findings. Document all the relevant information. Evaluate the condition of the site in 24 or 48 hours. if given by mouth. 21. Record the testing material given. 14. dosage. To prevent contamination. depending on the test. Dispose the syringe and needle into the sharps container. To observe for redness or induration.13. 22. Apply a bandage if indicated. 19. 23. Remove the gloves. With a subcutaneous injection. Insert the needle and inject the medication carefully and slowly so that it produces a small wheal on the skin. would be broken down and digested in the intestinal tract. Do not recap the needle in order to prevent needlestick injuries. "Subcutaneous" implies just under the skin. site. 17. After the injection. 15. A drug (for example.
leg.include relevant information about the effects of the medication 6. abdomen can be relaxed. Perform hand hygiene and observe other infection control procedure 2. depending on the site to be used This ensures that the right patient receives the medication • A relaxed position of the site minimizes discomfort Obtain assistance in holding an uncooperative client 5. Provide for client’s privacy Rationales To eliminate/lessen the transfer of microoganisms To provide medication the client requires To allow slower absorption of a medication compared with either the intramuscular or intravenous route To lessen the embarassment of the client and for their own confidentiality 4. swelling.Purposes • • Equipments • • • • • • Client’s MAR or computer printout Vial or ampule of the correct sterile medication Syringe and needle appropriate for the client Antiseptic swabs Dry sterile gauze for opening an ampule (optional) Clean gloves Steps 1. itching or localized inflammation. Explain the purpose of the medication and how it will help. Select a site that is not used frequently • This prevents injury due to sudden movement after needle insertion Information can facilitaye acceptance of and compliance with the therapy 55 . introduce self and verify the client’s identity using agency protocol Assist the client to a position in which the arm. Select and clean the site • Select a site free of tenderness. scarring. hardness. Prepare the client • Prior to performing the procedure. Prepare the medication from the ampule or vial for drug withdrawal 3.
move your non-dominant hand to the end of the plunger. or with palm downward for a 90-degree angle insertion. Prepare the syringe for injection • Remove the needle cap while waiting for the antiseptic to dry.• • Put on clean gloves As agency protocol indicates. Inject the medication • Grasp the syringe in your domonant hand by holding it between your thumb and fingers. Inject the medication by holding the syringe steady and depressing the plunger with a sloe and even pressure It is recommended that with many subcutaneous injections. pinch or spread the skin at the site. Pull the cap straight off to avoid contaminating the needle by the outside edge of the cap • Dispose the needle cap 8. With palm facing to the side or upward for a 45-degree angle insertion. clean the site with an antiseptic swab. and insert the neddle using the dominant hand and a firm steady push When the needle is inserted. the needle should be The needle will become contaminated if it touches anything but inside the cap which is sterile • • • • Holding the syringe steady and 56 . Start at the center of the site and clean in a widening circle to about 5cm Place and hold the swab between the third and fourth fingers of the non-dominant hand These conditions could hinder the absorption of the medication and may also increase the likelihood of injury and discomfort at the inection site The mechanical action of swabbimg removes skin secretions which contains microorganisms • Using this method keeps the swab readily accessible when the needle is withdrawn 7. prepare to inject Using the non-dominant hand.
route and any assessments • • Depressing the skin places countertraction on it and minimizes the client’s discomfort when the needle is withdrawn Many agendies prefer that the medication administration be recorded at the medication record. The nurse’s notes are used when prn medication are given or when there is a special problem 12. Dispose the supplies appropriately Activate the needle safety device or discard the uncapped needle and attached syringe into designated receptacle 11. pulling along the line of insertion while depressing the skin with your non-dominant hand. Purposes 57 . Some medications that are irritating to the subcutaneous tissue may be given into the deep muscle tissue. Injection of medication into muscle tissue forms a deposit of medication that is absorbed gradually into the bloodstream. easiest. and best tolerated of the injection routes. Assess the effectiveness of the medication at the time it is epected to act and document it • Proper disposal prevents the nurse and others from injury and contamination ADMINISTERING MEDICATIONS USING IM INJECTION Definition An intramuscular (IM) injection is the preferred route of administering medication when fairly rapid-acting and long-lasting dosage of medication is required. Remove the needle • Remove the needle smoothly. apply pressure to the site with dry sterile gauze until it stops 10. An intramuscular injection is the safest. dosage. injecting the medication at an even pressure minimizes the discomfort of the client If bleeding occurs. time.embedded within the skin for five seconds after complete depression of the plunger to ensure complete delivery of the dose 9. Document all relevant information • Document the medication given.
Stabilize injection site. Wash Hands. To prevent contamination To know if the medication is expired. 10. Aspirate syringe. Identify patient. To administer the medication at the perfect site To prevent contamination. 15. To offer a faster rate of absorption than the subcutaneous route. Select injection site and position the patient. 5. Do not use it if it is expired.m.• • For the delivery of certain drugs not recommended for other routes of administration. continuous downward 2. Inject medication. Prepare injection site. Insert needle into patient at site selected for injection. To allow the medication into the syringe To know the right patient to be given i. 13. If blood appears in the syringe do not administer the medication. Check expiration date of medication. 7. 6. Checks doctor’s order. Draw medication into syringe. To know if the patient has medication allergies. 58 . or subcutaneous. Prepare the patient. 14. Gather Equipment. Equipments • • • needle and syringe antiseptic pads adhesive bandages or cotton balls STEPS 1. RATIONALE The orders are checked to ensure correct medication is obtained and administered. Remove needle guard or cover. and muscle tissue can often hold a larger volume of fluid without discomfort. for instance intravenous. Avoid bending or touching the needle Firm the injection site with the hand that is free by pinching the skin with the thumb and forefinger A quick insertion of the needle will minimize the pain for the patient. 12. Assemble needle and syringe. 3. Push the plunger into the syringe barrel with a slow. Should be available in the immediate area. The correct dosage may already be prepared by the hospital pharmacy. 9. oral. 8. 4. 11. medication.
Antiseptic swabs 59 . Massage injection site.movement as far as the plunger will go 16. 17. drug abuse. Proper disposal of equipment prevents cross contamination.) . and injury by needles. 18. Dispose expended needle and syringe ADMINISTERING MEDICATIONS USING IV PUSH Purposes .Sterile needles #21 to #25 gauge. Massaging help to disperse the medicine so that it can absorbed more quickly. 2. To prevent contamination Check the patient for any medication reaction.5 cm (1 in.Medication in a vial or ampule . Withdraw needle Remove the needle straight out in same direction as the injection with a quick. Equipments IV push for an existing Line . 19. outward motion.to achieve immediate and maximum effect of the medication. Perform postinjection patient care 20.Sterile syringe (3 to 5 ml) . Cover injection site.
(2) before withdrawing the medication and. .Calculate medication dosage accurately . prepare the medication. Flushing with heparin and saline It is important to have the correct dose and the correct dilution RATIONALE 60 . . Organize the equipment PERFORMANCE 1.Sterile needles (#21 gauge) .Confirm the route is correct 2.Sterile syringe (3ml) (for the saline or heparin push) .prepare 2 syringes.Vial of normal saline to flush the IV catheter or vial of heparin flush solution or both depending on agency practice.Antiseptic swabs . Saline is frequently used for peripheral locks. each with 1 ml of sterile normal saline.Watch with second hand .Sterile syringe (3 to 5 ml) .prepare the medication according to the manufacturer’s direction. b.Disposable gloves Implementation Preparation 1.- Watch with a digital readout or second hand Clean gloves IV Push for an IV lock . IV Lock a. Existing Line . (3) after withdrawing the medication. Read the label on the medication (1) when it is taken from the medication cart .check the label on the medication carefully against the MAR to make sure that the correct medication dose. . Rationale: these maintain the patency of the IV lock. perform hand hygiene and observe other appropriate infection control procedures 2. check the medication administering record .Medication in a vial or ampule .Follow the three checks for correct medication and dose. Flushing with saline .
Include relevant information about the effects of the medication. administer the medication by IV push This creates a turbulence in the flow through the catheter which reduces the residue buildup in the line and the potency for occlusion. using language that the client can understand. provide privacy 6. 3. In some situations.If not previously assessed take the appropriate assessment measures necessary for the medication. . blood will not return even though the lock is patent.prior to performing the procedure.- prepare 1 syringe with 1 ml of heparin flush solution prepare 2 syringes with 1 ml each of sterile. This prevents microorganisms from entering the circulatory system during the needle insertion. -Insert the needle of syringe containing normal saline through the center of the diaphragm and aspirate for blood. prepare the client . This ensures that the right client receives the medication. 5. normal saline draw up the medication into syringe. consult the primary care provider before administering the medication. -Flush the lock by injecting 1ml of saline 61 . This reduces the transmission of microorganisms and reduces the likelihood of the nurse’s hands contacting the client’s blood. put a small gauge syringe needle on the syringe if using a needle system. 8. introduce self and verify the client’s identity using agency protocol.clean the diaphgram with the antiseptic swab. 7. This removes blood and heparin from the IV Lock with Needle . The presence of blood confirms that the catheter or needle is in the vein. If any of the findings are above or below the predetermined parameters. 4. explain the purpose of the medication and how it will help. perform hand hygiene and put on clean gloves.
Withdraw the syringe. Observe the client closely for adverse reactions.inject the medication slowly at the recommended rate of infusion. Place a new sterile cap over the lock. Use a watch or digital readout to time the injection. insert the heparin syringe and inject the heparin solely into the lock. Inject the medication following the precautions described previously. and inject 1 ml of saline The saline injection flushes the medication through the catheter and prepares the lock for heparin if this medication is used. Injecting the drug too rapidly can have a serious untoward reaction. This prevents the transfer of microorganisms. Insert the needle of the syringe containing the prepared medication through the center of the diaphragm.attach the second saline syringe. needle and lock. -Flush the lock with 1 ml of sterile saline remove the syringe insert the syringe containing the medication into the valve. Heparin is incompatible with many medications -if heparin is to be used.insert syringe containing normal saline into the lock. . activate the needle safely clean the diaphragm of the lock.slowly. Activate the needle and safety device. -Remove the needle and syringe. . Existing IV line 62 . Remove the needle and syringe when all medications have administered. Repeat injection of 1ml of saline. -clean the locks diaphragm with an antiseptic swab. These clears the lock of blood. IV Lock with needle system -remmove the protective cap from the needleless port .
and down into the stomach. -Insert the needle of the syringe that contains the medication through the center of the port An injection port must be used because it is self sealing. . past the throat. Any puncture to the plastic tubing will leak. NASOGASTRIC TUBE INSERTION Definition It is a medical process involving the insertion of a plastic tube (nasogastric tube. and vomiting.-identify the injection port closest to the client.stop the IV flow by closing the clamp or pinching the tubing above the injection port -connect the syringe to the IV system a. Equipments 63 . NG tube) through the nose. Some ports have a circle indicating the site for the needle insertion. c. This prevents damage to the IV line and to the diaphragm of the port. This ensures safe drug administration because a too rapid injection could be dangerous. . Purposes • • • • to administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluids into the lungs. Connect the tip of the syringe directly to the port.hold the port steadily.remove the cap from the needleless injection port. Needle system . nausea. needleless system . To remove stomach contents for laboratory analysis To lavage the stomach in case of poisoning or overdose of medication. Use the watch or digital readout to time the medication administration. To establish a means for suctioning stomach contents to prevent gastric distention. -clean the port with an antiseptic swab.Inject the medication at the order rate.
Implementation Preparation -assist the client to a high fowler’s position if his or her health condition permits. The passage of a gastric tube is unpleasant because the gag reflex is activated during insertion.• • • • • • • • • • • • • • large or small bore tube (non latex preferred) non allergic adhesive tape. Rationale: it is often easier to swallow in the position and gravity helps the passage of the tube. Place a towel or disposable pad across the chest. Provide for client privacy Rationale 64 . Raising a finger or hand is often used for this. Establish a method for the client to indicate distress and a desire for you to pause the insertion.5 cm (1 in. why it is necessary. introduce self and verify the clients identity using agency protocol. 2. Prior to performing the insertion. Performance 1.) wide clean gloves water soluble lubricant facial tissues glass of water and drinking straw 20 to 50 ml syringe with an adapter Basin pH test strip or meter bilirubin dipstick stethoscope disposable pad or towel clamp or plug antireflux valve for airvent if salem sump tube is used. Explain to the client what you are going to do. Perform hand hygiene and observe other appropriate infection control procedures 3. and support the head on a pillow. 2. and how he or she can cooperate.
Ask the client to tilt the head forward. 6. relubricate it.put on gloves . this length approximates the distance from the nares to the stomach. Assess the client’s nares. and insert in the other nostril. . ensure stylet or guidewire is secured in position. . withdraw it. Swallowing moves the epiglottis over the opening of the larynx. The tube should never be forced against resistance because of the danger of injury. and gently advance the tube toward the nasopharynx. . 5. An improperly positioned stylet or guidewire can traumatize the nasopharynx. determine how far to insert the tube. and stomach. .Insert the tube with its natural curve toward the client. Withdraw it slightly and inspect the throat by looking through the mouth. prepare the tube . and encourage the client to drink and swallow. into the selected nostril.If the tube meets resistance. a water soluble lubricant dissolves if the tube accidentally enters the lungs hyperextension of the neck reduces the curvature of the nasopharyngeal junction.lubricate the tip of the tube well with water soluble lubricant or water to ease insertion. 65 . . Tilting the head forward facilitates passage of the tube into the posterior pharynx and esophagus rather than into the larynx. Direct the tube along the floor avoids the projections along the lateral wall. insert the tube. Tears are a natural body response. 7. pass the tube 5 to 10 cm with each swallow. the client will feel the tube in the throat and may gag and retch. .Slight pressure and twisting motion are sometimes required to pass the tube into the nasopharynx.if a small bore tube is being used. The tube maybe coiled into the throat. . Ask the client to hyperextended the neck. and some client’s eyes may water at this point.Direct the tube along the floor of the nostril and toward the ear on the side.4.use the tube to mark off the distance from the tip of the client’s nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the xyphoid.In cooperation with the client. esophagus. .Once the tube reaches the nasopharynx. The distance varies from individuals.
Purposes • • • • • • • • To relieve discomfort due to bladder distention or to provide gradual decompression of a distended bladder To assess the amount of residual urine if the bladder empties incompletely To obtain a sterile urine specimen To empty the bladder completely prior to surgery To facilitate accurate measurement of urinary output for critically ill clients whose output needs to be monitored hourly To provide for intermittent or continuous bladder drainage and/or irrigation To prevent urine from contacting an incision after perineal surgery To manage incontinence when other measures have failed 66 . Testing pH is reliable way to determine location of a feeding tube. strict sterile technique is used for catheterization. 10. once correct position. . This is usually performed only when absolutely necessary. ascertain correct placement of the tube. attach the tube to a suction source or feeding apparatus as ordered. date and time of tube insertion. 12.aspirate stomach contents and check the pH which would be acidic. color and amount of gastric contents. 9. 11. Taping in this manner prevents the tube from pressing against and irritating the edge of the nostril. and the tolerance of client to the procedure. secure the tube by taping it to the bridge of the client’s nose. type of suction used. secure the tube to the client’s gown. The tube is attached to prevent it from dangling and pulling.place a stethoscope over the client’s epigastrium and inject 10 to 30 ml of air into the tube while listening to a whooshing sound. Thus. because the danger exists of introducing microorganisms into the bladder. URINARY CATHETERIZATION Definition Urinary catheterization is the introduction of a catheter into the urinary bladder. or clamp the end of the tubing.8. . document the type of tube inserted.
or if temporary decompression/emptying of the bladder is required. Equipments Sterile catheter of appropriate size: (An extra catheter should also be at hand. complete a bladder scan to assess the amount of urine present in the bladder before performing a urethral catheterization. Determine when the client last voided or was last catheterized. Use and indwelling/retention catheter if the bladder must remain empty or continuous urine measurement/collection is needed. Although the entire procedure can require as little as 15 minutes. If possible. Use a straight catheter if only a spot urine specimen is needed. • • • • • • Planning Allow adequate time to perform the catheterization. it should not be performed just prior to or after the client eats. if amount of residual urine is being measured. Percuss the bladder to check for fullness or distention.) • • • Adult female: 14F or 16F Adult male: 18F Children: 8F or 10F Catheterization kit or individual sterile items: 1-2 pair sterile gloves Waterproof drapes Antiseptic solution Cleansing balls Forceps Water-soluble lubricants Urine receptacle Specimen container For an indwelling catheter: • by catheter manufacturer • Syringe prefilled with sterile water in amount specified Collection bag and tubing 67 .Assessment • Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total amount of urine to be removed or size of the catheter to be used. Determine if the client is able to cooperate and hold still during the procedure and if the client can be positioned supine with head relatively flat. Assess the client’s overall condition. When possible. several sources of difficulty could result in a much longer time.
Performance 68 . Perform routine perineal care to cleanse the meatus from gross contamination.) Implementation Preparation If using a catheterization kit. use this time to locate the urinary meatus relative to surrounding structures. read and label carefully to be sure all necessary items are included.2% Xylocaine gel (if agency permits) Disposable clean gloves Supplies for performing perineal cleansing Bath blanket or sheet for draping the client Adequate lighting (Obtain a flashlight or lamp if necessary. For women.
10) Organize the remaining supplies. 6) If using a collecting bag and it is not Since one hand is needed to hold the contained within the catheterization catheter once it is in place. 7) If agency policy permits. To maintain aseptic technique. 8) Open the catheterization kit. c. 2) Perform hand hygiene and observe To prevent infection. Wipe the underside of the shaft to distribute the gel up the urethra. Saturate the cleansing balls with procedure.STEPS RATIONALE 1) Prior to performing the procedure. clean gloves and inject 10 to 15 ml Xylocaine gel into the urethra of the male client. Female: supine with knees flexed. Remove gloves. 9) Put on sterile gloves. open the drainage package and package while two hands are still available place the end of the tubing within reach. apply To provide local anesthetic. a. Remove the specimen container and place it nearby with the lid 69 . To ascertain that you are giving to the right introduce self and verify the client’s client and to gain trust and cooperation identity using agency protocol. why it is necessary. if possible. 4) Place the client in the appropriate To provide access for catheterization. feet about 2 feet apart. throughout the procedure. on the client’s left if you are left-handed. To provide for client privacy. Male: supine. b. open the kit. Wait until 5 minutes for the gel to take effect before inserting the catheter. position. and how he or she can cooperate. To promote an orderly and systematic a. b. the antiseptic solution. handed. thighs slightly abducted or apart. Place To promote cleanliness and avoid a waterproof drape under the contamination throughout the procedure. buttocks (female) or penis (male) without contaminating the center of the drape with your hands. 5) Establish adequate lighting.catheterized. Explain to the client what you are going to do. and hips slightly externally rotated. Stand To provide better viewing of the site to be on the client’s right if you are right.Open the lubricant package. appropriate infection control procedures. 3) Provide drapes.
Relate finding s to previous assessment data if available. Perform a detailed follow-up based on the findings that deviated from expected or normal for the client.Evaluation Conduct appropriate follow-up such as notifying the primary care provider of the catheterization results. and other appropriate instructions. Teach the client how to care for the indwelling catheter. SUCTIONING Definition 70 . to drink more fluids.
1 Ascertain that the apparatus is functional. ineffective coughing.2 Portable or wall suction apparatus: children: 5-10 inches Hg Adults: 7-15 inches Hg 1. Oropharyngeal and nasopharyngeal suctioning is used when the client is able to cough effectively but is unable to clear secretions by expectorating or swallowing. 2. 3. If unconscious.3 Connect one end of connecting tubing to suction machine and place the other end in convenient location. 3. Assess sign and symptoms of upper and lower airway obstruction including wheezes.3 Assist patient to assume position comfortable for nurse and client (usually semifowler’s or sitting upright with head hyperextended. 71 . 2. Prepare suction apparatus. 3. Purposes 1. Prepare patient.1 Suction catheter with intermittent control port of appropriate size for the client: 10-12 years: French 14 Adults: French 12-16 1.1 Explain to patient how procedure will help clear airway and relieve breathing problems. unless contraindicated). 3.2 Explain importance of and encourage coughing during procedure. 3.2 Turn suction device on and set vacuum regulator to appropriated negative pressure. To maintain a patent airway and prevent airway obstructions. 2. lay patient on side facing nurse. Place suction tubing within easy reach. crackles or gurgling on inspiration or expiration. absent or diminished breath sounds.4 Sterile water or normal saline approximately 100ml in a container/glass 1.6 Clean towel 2. sneezing or gagging is normal. To promote respiratory functions (optimal exchange of oxygen and carbon dioxide into and out of the lungs). Explain that coughing.3 Sterile disposable gloves 1. Prepare needed equipment and supplies: 1.4 Place towel across patient chest. Planning 1. Assessment 1. cyanosis. decreased level of consciousness.5 Connecting tubing(optional) 1. To prevent pneumonia that may result from accumulated secretions. 2. Oropharyngeal and nasopharyngeal suctioning may also be appropriate in less responsive or comatose clients who require removal of oral secretions. tachypnea.Suctioning is the removal of airway secretions using negative pressure. It is frequently used after the client coughs. 2. restlessness.
8.Implementation STEPS 1. Using suction while inserting the catheter can cause trauma to the mucosa and removes oxygen from the respiratory tract. 6. apply suction and gently rotate catheter while pulling it slightly upward. 12. Allow adequate time between suction passes for ventilation. Designate one hand as “contaminated”. Coughing facilitates clearing of secretions. 2. Remove oxygen delivery device. Do this quickly inserting catheter with dominant thumb and forefinger into nares using slightly downward slant or through mouth when client breathes in. Prolonged suctioning can induce hypoxia. if applicable with non-dominant hand. 4. Sterilization can be maintained. Check if the equipment is functioning properly by suctioning small amount of normal saline from basin. 3. 7. Aseptically glove both hands. Inspiration open epiglottis and facilitates catheter movement into trachea. This helps the patient raise secretions. Ask patient to deep breath and cough. 5. Wash hands and open suction catheter package. Normal breathing between suctioning helps compensates for any hypoxia induced in the previous suctioning. This suctions the orophrarynx after trachea 72 . Repeat steps 6-9 as needed to clear pharynx or trachea of secretions. Rinsing clears secretions from catheter. Replace oxygen device. 10. Limiting the suction time to 10 seconds or less prevents hypoxia. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Coughing is induced when the trachea is touched. Pick up connecting tubing with non-dominant hand. Once correct position is ascertained. 9. Sterile saline/water is used to flush and lubricate catheter. Fill container with 100ml sterile normal saline/ sterile water. Monitor patient’s cardiopulmonary status between suction passes. Do not allow suction surface other than the inside of the package. When pharynx and trachea are Lubrication makes catheter insertion easier and ensures proper functioning of suction equipment. Rinse catheter and connecting tubing with normal saline until they are cleared. RATIONALE Hand washing prevents transmission of microorganism. Do not force through nares. Handling the sterile catheter with a hand wearing a sterile glove helps prevent introducing microorganisms into the respiratory tract and the clean glove protects the nurse from microorganisms. Encourage patient to cough. Rotation of the catheter prevents trauma to mucous membranes from prolonged suctioning of one area. 11. Adequate time between suctions reoxygenates the lungs. if applicable.
perform oral pharyngeal suctioning to clear mouth secretions. Reposition patient. blood pressure. Report any patient’s intolerance of procedure (changes in vital signs. Compare patient’s respiratory assessment before and after suctioning. 2. 15. Pull glove off inside out so that catheter remains coiled in the glove. Wash hands. Discard in appropriate receptacle. because the mouth is less clean than the trachea. This reduces transmission of microorganism. readjust oxygen to original level. roll catheter around fingers of dominant hand.sufficiently cleared of secretions. Turn off suction device. respiratory rate and oxygen saturation. This contains client’s secretions inside glove to reduce transmission of microorganisms. bleeding. Accumulated respiratory secretions irritate the mucous membranes and are unpleasant for the client. Remove towel and discard remainder of normal saline and dispose of disposable equipment. When suctioning is completed. upper airway noise). 13. 4. laryngospasm. 3. 14. type and amount of secretions removed and complications. Evaluation 1. Pull off the other glove in same way. Measure heart rate. If indicated. 73 . Record the patient’s tolerance of procedure.
5. To provide moderate O2 support and a higher concentration of oxygen and/or humidity than is provided by cannula a. To provide high humidity b. tachypnea. headache. and confusion ) 7. hematocrit. Presence of clinical signs of hypoxemia. ( tachycardia. if available. Chest wall configuration. 2. which can be for a variety of purposes in both chronic and acute patient care. tissue oxygenation is essential for all normal physiological functions. To deliver a relatively low concentration of oxygen when only minimal O2 support is required. c. Results of diagnostic studies. 3. Whether the client has COPD. FACE TENT a. To allow uninterrupted delivery of oxygen while the client ingests food or fluids. • FACE MASK 1. Hemoglobin. Pulmonary function tests. lethargy. if available. 74 . dyspnea. ( tracheal irritation and cough. 7. 2. 1.note whether cyanosis is present Breathing patterns. Chest movements. Arterial blood gases. To provide a high flow of O2 when attached to a Venturi system. 6. Assessment Skin and mucous membrane color. To provide oxygen when a mask is poorly tolerated. complete blood count. cyanosis. Presence of clinical signs of oxygen toxicity. 2.OXYGEN THERAPY (OXYGEN ADMINISTRATION) Definition It is the administration of oxygen as a medical intervention. and in turn. and decreased pulmonary ventilation ) DETERMINE 1. Oxygen is essential for cell metabolism. 4. 4. Oxygen saturation levels. and depth. Vital signs—especially pulse rate and quality and respiratory rate. Presence of clinical signs of hypercarbia. rhythm. Purposes • CANNULA 1. tremor ) 8. dyspnea. 3. Lung sounds. restlessness. hypertension. ( restlessness. 6. 5.
3. according to agency protocol 1.3.2 FACE MASK 1.1 CANNULA 1. 75 . Implementation STEPS 1. according to agency protocol 1. 3.3 Face tent of the appropriate size. Explain the procedure. Determine the need for oxygen therapy. Prepare the client and support people.1.2 Humidifier with distilled water or tap water.3 FACE TENT 1. Introduce self and verify the client’s identity.1Assist the client to a semi-Fowler’s position if possible.2 Explain that oxygen is not dangerous when safety precautions are observed.2 Humidifier with distilled water or tap water. 2. 3. Perform hand hygiene and observe appropriate infection control procedures.2.5 Padding for the elastic band 1.1 Perform a respiratory assessment to develop baseline data if not already available.3. 3.1 Oxygen supply with a flow meter and adapter 1. Inform the client and support people about the safety precautions connected with oxygen use.3 Prescribed face mask of the appropriate size 1. 2. Rationale: This position permits easier chest expansion and hence easier breathing.3.2.4 Tape 1.2. 2.1. Set up oxygen equipment and humidifier.1.4 Padding for the elastic band 1. and verify the order for the therapy.2.3 Nasal Cannula and tubing 1. Assemble the following equipment: 1.1.1 Oxygen supply with a flow meter and adapter 1. i. Attach the flow meter to the RATIONALE To obtain the cooperation of the client.Planning 1.2 Humidifier with distilled water or tap water.1 Oxygen supply with a flow meter and adapter 1.1. according to agency protocol 1.
Put the cannula over the client’s face.wall outlet or tank. and apply it from the nose downward. CANNULA a. with the outlet prongs fitting into the nares and the elastic band around the head. b. iii. 76 . mask or tent. a. 4. Turn on the oxygen at the prescribed rate and ensure proper functioning. and the connections should be airtight. There should be no kinks in the tubing. Attach the humidifier bottle to the base of the flow meter. iv. ii. b. Pad the tubing and band over the ears and cheekbones as needed. You should feel the oxygen at the outlets of the cannula. b. Apply the appropriate oxygen delivery device. Check the oxygen is flowing freely through the tubing. Fit the mask to the contours of the client’s face. The flow meter should be in the off position. Attach the prescribed oxygen tubing and delivery device to the humidifier. Set the oxygen at the flow rate ordered. Secure the elastic band around The mask should mold to the face. If needed. If the cannula will not stay in place. Guide the mask toward the client’s face. FACE MASK a. so that very little oxygen escapes into the eyes or around the cheeks and chin. There should be bubbles in the humidifier as the oxygen flows through. tape it at the sides of the face. c. 5. c. fill the humidifier bottle.
If present. Assess the client regularly for clinical signs of hypoxia. Inspect the facial skin frequently for dampness or chafing. Assess the client’s nares for encrustations and irritation. FACE TENT a. 6. a. Be sure that water is not collecting Padding will prevent irritation from the mask. Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client. Place the tent over the client’s face. and secure the ties around the head. Review oxygen saturation or ABG results if they are available. b. 77 . b. a. FACE MASK OR TENT a. Inspect the equipment on a regular basis. 7. Assess the top of the client’s ears for any signs of irritation from the cannula strap. Assess the client’s vital signs. b. NASAL CANNULA a. and dry and treat it as needed. and ease of respirations. Assess the client in 15 to 30 minutes. Apply a water-soluble lubricant as required to soothe the mucous membranes. and cyanosis. tachycardia. c. and provide support while the client adjusts to the device. restlessness.the client’s head so that the mask is comfortable but snug. depending on the client’s condition. padding with a gauze pad may help relieve the discomfort. Pad the band behind the ears and over bony prominences. level of anxiety. dyspnea. d. Assess the client regularly. confusion. and regularly thereafter.
8.in dependent loops of the tubing. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate..g. Evaluation 1. c. check oxygen saturation to evaluate adequate oxygenation ) 2. Perform follow-up based on findings that deviated from expected or normal for the client. PROVIDING TRACHEOSTOMY CARE Definition 78 . Report significant deviations from normal to the primary care provider. Relate findings to previous data if available ( e. Make sure safety precautions are being followed.
depending on the physician's order. Prepare the client and the equipment • • Assist the client to a semiFowler’s or Fowler’s position Open the tracheostomy kit or sterile basins. To maintain cleanliness and prevent infection To facilitate healing and prevent skin excoriation To promote comfort Equipments • Sterile disposable tracheostomy cleaning kit • Towels or drapes • Sterile suction catheter kit • Sterile normal saline • 2 pairs of sterile gloves • Clean gloves • Moisture proof bag • 4x4 gauze dressing • Clean scissors Steps 1. Prior to performing the procedure. After the site heals. as well as replacing the inner cannula of the tracheostomy tube. Pour the soaking solution and sterilr normal saline into separate containers To promote lung expansion Rationales To make sure that you are going to perform the procedure to the appropriate client To eliminate/lessen the transfer of microoganisms To lessen the embarassment of the client and for their own confidentiality 79 . the entire tracheostomy tube is replaced once or twice per week. Perform hand hygiene and observe other infection control procedures 3. Purposes • • • • To maintain airway patency.A tracheostomy is a surgically created opening in the trachea. introduce self and verify the client’s identity using agency protocol 2. Provide for client’s privacy 4. Tracheostomy care is generally done every eight hours and involves cleaning around the incision. A tracheostomy tube is placed in the incision to secure an airway and to prevent it from closing.
and tracheostomy dressing 5. securing it in place. gently tap the cannula against the inside edge of the sterile saline container. 6. while leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion. suction kit. 7. Clean the incision site and tube flange • Using sterile applicators or gauze dressings moistened with sterile saline.• • Establish a sterile field Open other sterile supplies as needed including sterile applicators. Clean the inner cannula • • Removethe inner cannula from the soaking solution Clean the lumen and the entire inner cannula thouroughly using the brush or pipe cleaners moistened with sterile normal saline Rinse the inner cannula thouroughly in the sterile normal saline To remove secretions and maintain airway • After rinsing. Lock the cannula in place by turning the lock (if present) into position to securethe flange of the inner cannula to the outer cannula 8. Suction tracheostomy tube if needed. Use a pipe cleaner folded half to dry only the inside of the cannula. • Insert the inner cannula y grasping the outer flange and inserting the cannula in the direction of its curvature • This removes excess liquid from the cannula and prevents possible aspiration by the client. clean the incision site Hydrogen peroxide may be used to remove crusty secretions. Thouroughly rinse the cleaned area using gauze squares moistened with sterile normal saline Clean the flange of the tube in This avoids contaminating a clean area with a soiled gauze dressing or applicator • • • 80 . do not dry the outside. Replace the inner cannula.
and the other 20in. from one end of each strip. Change the tracheostomy ties • • Change as needed to keep the skin clean and dry Twill tape and specially manufactured velcro ties are available. thread the slit end of one clean tape through the eye of the tracheostomy flange from the bottom side. pulling it tight until it is securely fastened to the • • Cutting one tape longer than the other allows them to be fastened at the side 81 . then thread the long end of the tape through the slit. ensure that the tracheostomy tube is securely supported 10. one approximately 10in. fold the end of the tape back onto itself about 1in. To do this. potentially creating a tracheal abscess Excessive movement of the tracheostomy tubirritates the trachea Two-strip Method (Twill tapes) • cut two unequal strips of twill tapes.5in. Velcro ties are are becoming commonly used. however it is easily soiled and can trap moisture that leads to irritation of the skin of the neck. long Cut 0. Twill tape is inexpensive and readily available. They are wider more comfortable and cause less skin abrasions Cotton lint or gauze fibers can be aspirated by the client.the same manner Touroughly dry the client’s skin and tube flanges with dry gauze squares 9. lengthwise slit approximately 1in. then cut a slit in the middle of the tape from its folded edge Leaving the old ties in place. Apply sterile dressings • Use commercially prepared tracheostomy dressing of nonraveling material or open and refold a 4x4 gauze into a V shape Place the dressing under the flange of the tracheostomy tube • Hydrogen peroxide can be irritating to the skin and inhibit healingif not thoroughly removed • • While applying the dressing. .
flange • If old ties are very soiled, have an assistant put on sterile gloves and hold the tracheostomy in place while you replace the ties. Repeat the process for the second tie Ask the client to flex the neck. Slip the longer tape under the client’s neck, place a finger between the tape and the client’s neck
of the neck for easy access and to avoid pressure at the back of the neck
Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tubes
Tie the ends of the tape using square knots. Cut off any long ends, leaving approximately 0.5in. Once the clean ties are secured, remove the soiled ties and discard Flexing the neck increases its circumference the way coughing does. Placing a finger under thr ties prevent making the tie too tight, which could interfere with coughing or place pressure to the jugular veins
One-strip Method (twill tape) • Cut a length of twill tape 2.5 times the length needed to go around the neck from one tube flange to the other Thread one end of the tape to the slot on one side of the flange Bring both ends of the tape together Thread the end of the tapr to the client’s neck through the slot from back to front Have the client flex the neck, tie the loose ends with a square knot at the side of the client’s neck, allowing for slack by placing two fingers under the ties. Cut off lomg ends
• • •
Adequate ends beyond the knot prevent the knot from untying
11. Tape and pad the tie knot Place a 4x4 gauze under the tie knot, and apply tape over the knot. 12. Check the tightness of the ties •
Frequently check the tightness of the tracheostmy ties ans position of the tracheostomy tube 13. Document all the relevant information. • Record suctioning, tracheostomy care, and the dressing change, noting your assessment
This reduces ckin irritation from the knot and prevents from confusing the knot with the client’s gown ties Swelling of the neck may cause the ties to become too tight, interfering with coudhing and circulation
INTRAVENOUS FLUID THERAPY Definition
This is essential when client are unable to take foods and fluids orally. It is an efficient and effective method of supplying fluids directly into the intravascular fluid compartment and replacing the electrolyte losses. Purposes • • To supply fluid when clients are unable to take in an adequate volume of fluids by mouth To provide salts and other electrolytes needed to maintain electrolyte balance
Equipments • • • • • • • • • • • infusion set sterile parenteral solution IV pole Adhesive or nonallergenic tape Clean gloves Tourniquet Antiseptic swab IV catheter Sterile gauze dressing Arm splint Towel or pad
STEPS 1. Perform hand hygiene. Identify the client and verify the client’s identity also verify for the order to start an intravenous line. 2. Open and prepare the infusion set. -remove tubing from the container and straighten it out. -slide the tubing clamp along the tubing until it is just below the drip chamber to facilitate its access. -Close the clamp -Leave the ends of the tubing until the infusion is started. 3. Spike the solution container - remove the protective cover from the entry site of the bag. -Remove the cap from the spike
This will maintain the sterility of the tubing.
6. This height is needed to enable gravity to overcome venous pressure and facilitate flow of the solution into the vein. Identify possible venipuncture sites by looking for veins that are relatively straight not sclerotic or tortuous and avoid venous valves. 11. 85 . Prime the tubing. Follow the manufacturer’s instructions. Hang the solution container on the pole. Partially fill the drip chamber with solution -Squeeze the chamber gently until it is half full solution 7. Dilate the vein. Joint flexion increases the risk of irritation of vein wall by catheter. Distending the veins makes it easier to insert the needle properly. 10. 8.and insert the spike into the insertion site of the bag or bottle. 9. Remove the protective cap and hold the tubing over a container. Maintain the sterility of the end of the tubing and the cap. -release the clamp and let the fluid run through the tubing until all bubbles are removed. -Use the client’s non dominant hand. Apply a timing label on the solution container -The timing label may be applied at the time the infusion is started 5. -Adjust the pole so that the container is suspended about 3 ft above the client’s head. -Place the extremity in a dependent position (lower than the clients heart) -Apply a tourniquet firmly 15 to 20cm (6 to 8 in) above the Sclerotic vein may make initiating and maintaining the IV difficult. Tap the tubing if necessary with your fingers to help the bubbles move. Perform hand hygiene just prior to client contact. The tubing is primed to prevent the introduction of air into the client. 4. Gravity sloes venous return and distends the veins. The label is applied upside down so it can be read easily when the container is hanging up. unless contraindicated. Select the venipuncture site.
-Initiate the infusion.5 to 1 cm farther. Insert the catheter and initiate the infusion. -Use the non dominant hand to pull the skin taut below the entry site. The tourniquet must be tight enough to obstruct venous flow but not so tight that it occludes arterial flow.venipuncture site. Looping and securing the tubing prevent the weight of the tubing or any movement from pulling on the needle or catheter 16. -Loop the tubing and secure it with tape. -use circular motion in cleaning the site. Put on clean gloves and clean the venipuncture site. 15. Dress and label the venipuncture site and tubing according to agency policy. -Remove the protective cap from the distal end of the tubing and hold it ready to attach the end of the infusion tubing ti the catheter hub. It can also make initial tissue penetration less painful. 13.Ensure appropriate infusion flow. Tape the catheter. The catheter is advance to ensure that it. 12. This stabilizes the vein and makes the skin taut for needle entry. Obstructing arterial flow inhibits venous filling. and not just the metal needle is in the vein. lower the angle of the catheter until it is almost parallel with the skin and advance the needle and catheter approximately 0. -once blood appears in the lumen of the needle or you feel the lack of resistance . -apply a padded arm board to splint 86 . Explain that the tourniquet will feel tight. 14. Gloves protect the nurse from contamination of the client’s blood. -Release the tourniquet -put pressure on the vein proximal to the catheter to eliminate or reduce blood oozong out of the catheter.
18. 17. The tubing is labeled to ensure that it is changed at regular intervals COLOSTOMY CARE: CHANGING OF COLOSTOMY BAG Definition 87 . any additives. Document relevant data.the joint. as needed. including assessments. -adjust the infusion rate of flow according to the order. Record the start of the infusion . Label the IV tubing -Date and time of attachment and your initial. date and time of the venipuncture amount and type of the solution used.
Provide privacy 6. Waste drains from the colon. 9. Wear clean gloves 8. RATIONALE To determine an effective strategy of changing colostomy bag based on current condition. Remove the soiled plastic stoma bag from the skin carefully. Assess the appearance of the stoma and the condition of the bag and the characteristics of the fecal waste. through a stoma into a collection bag worn near the stomach. 5. Ensures correct client and reinforces detailed instructions client will need to perform self care. a colostomy allows passage of waste from the body. 4. To reduce embarrassment Protects the bed from soiling. Identify the client and explain the procedure. Removes and promotes infection control. Discard soiled stoma bag in plastic waste bag. Equipments • Clean washcloth or 4×4 gauze pads • Warm tap water • Clean gloves • Lubricant or skin cream (optional) • Scissors • Plastic waste bag • Ostomy Wafer • Ostomy Drainage Bag • Disposable bed protector STEPS 1. 2. Prevents contact with fecal matter. Place the disposable bed protector under the client’s hips. 7. which is emptied periodically.A colostomy is a surgical procedure that reroute the colon to an opening made in the abdomen. 88 . To reduce the transmission of microorganisms To promote efficiency. Wash hands. 3. Prevents contamination of the surrounding environment. When injury or disease damages the colon. Gather equipment.
Make sure port closure is closed. 19. 21. To facilitate visualization of the stoma. Remove gloves and wash hands. 16. To prevent edges of wafer from adhering to the client’s body. To prevent feces from leaking during the application. 14.paper backing from wafer and place on skin over stoma. 11. Apply clean gloves. Removes feces from the stoma and skin. CENTRAL VENOUS PRESSURE Definition Ensures a good seal of the wafer to the client’s skin. Paper backing needs to be removed from wafer to become adherent to the skin. Remove disposable bed protector and discard all used equipment. Provides an accurate fit for the ostomy bag. Trace pattern onto the paper back of wafer and cuts as traced. Wash hands. Prevents contamination of the environment. Apply a small amount of lubricant or protective cream around the area of the ostomy. Remove gauze pad from the orifice of stoma. Clean the stoma and skin with warm tap water. Place gauze over orifice of stoma while preparing the wafer and pouch for application. Attach clean stoma bag or pouch to wafer. To maintain aseptic technique throughout the procedure. 15. Pat dry. Reduces microorganism transfer. 89 . 17. Tape wafer edges down with hypoallergenic tape. Remove ion of the stoma. 12. 22.10. Prevents irritation of the skin around the stoma. To provide data needed in the care of the client. 13. 20. Practices clean technique. 18. Record pertinent data.
PTT and CBC. vital signs and hydration status. It provides maximum visibility of veins. Evaluate PT. Assessment 1. Obtain signed permission if needed. reflecting alterations in the right ventricular pressure. This is the baseline position used for subsequent readings.3 IV pole attached to the bed 4. The catheter is attached to an IV infusion and H2O manometer by a three way stopcock or electronic transducer. Check the order for the insertion of a central IV line with CVP manometer. Establish baseline data. To provide an IV route for drawing blood samples. 4. 2. To provide information concerning blood volumes and adequacy of central venous return. Implementation STEPS RATIONALE 1. Place the patient in supine position. Purposes 1. (Lippincott). 4. It facilitates the catheter insertion (Bowden and Greenberg) The level of the right atrium is at the fourth intercostals space midaxillary line. Mark midaxillary line with inedible ink for 90 . Wash hands.1 infusion solution 4. 2. Planning 3. Check patient’s identification and explain the procedure to the patient. Assess patient. Flush IV infusion set and manometer. 5. Assess patient’s ability to participate in and tolerate the procedure. 3.5 Adhesive tape 5. antecubital or femoral vein and threading it into a vena cava. 3. Normal range is 4-10 cm H2O or 2-6 mmHg. Secure all connection. Assemble the following equipment: 4.It is obtained by inserting a catheter into the external jugular. administering fluids or medication and possibly inserting a pacing catheter. To reveal right atrial pressure. 2.4 Arm board 4.2 infusion set with CVP manometer 4.
(Lippincott) This reduces the number of microorganisms. 3. filling to about 20-25 cm.2. It ensures accuracy or readings by eliminating hydrostatic forces (Bowden and Greenberg). 5. This is the baseline position used for subsequent reading. Turn the stopcock so that the IV solution flows into the manometer. subsequent readings to ensure consistency of the zero level. 8. Then turn the stopcock so 91 . The CVP site is surgically cleansed.way stopcock that communicated to an IV and to a manometer. The zero point on the manometer should be on a level with the patient’s right atrium. the pressure to be read will not be altered. thus.al) Measure the CVP: 7. A required pressure must be followed for an accurate reading. 10. Turn the stopcock and fill the tubing with fluid. The physician introduces the CVP catheter percutaneously or by direct venous cutdown and threaded through antecubital. 6. Check the doctor’s order. The CVP catheter is connected to a three. 9. 2. The infusion is adjusted to flow into the patient’s vein by a slow continuous drip. (Lippincott) Using level at right atrium reflects the blood volume and cardiac function of patient (Smith et. Slow continuous drip allow fluids to flow smoothly. Attach the manometer to the IV pole. (Bowden and Greenberg) This will provide the route for an accurate reading of CVP. Place the patient in the identified position and confirm the zero point. A signed permission is needed in measuring the CVP. Position the zero point of the manometer at the level of the right atrium.al) Overfilling the manometer may expose the client to contamination resulting from overflow (Smith et. 4. The catheter may be sutured or tape. Locate the phlebostatic axis mark. Start the IV flow and fill the manometer 10 cm above the anticipated reading (or until the level of 20 cm H2O is reached).1. Turning the stopcock allows the fluid to flow from the bag to the manometer. subclavian or internal/ external jugular vein.2.
blood pressure. Record the CVP and the position of the patient.4 Send the catheter tip for bacteriologic culture when it is removed.2 Change dressing as prescribed. To prevent infection and further complications. This is CVP. To provide accurate data and documentation of patient’s care. Turn the stopcock again to allow IV solution from solution bottle into patient’s veins.2 From indwelling catheter: air embolism. hematoma. Carry outgoing nursing surveillance of the insertion site and maintain aseptic technique. rumbling murmur. Observe the fall in the height of the column of fluid in manometer. hypoxia.1 From the catheter insertion: pneumothorax.. (Lippincott) CVP is interpreted by considering the patient’s entire clinical picture. cardiac output measurements. 12. air embolism. 3. by passing the manometer. Assess the patient’s clinical condition. cardiac arrest. cardiac tamponade. heart rate. 13. infection. Follow up phase: 1.1 Inspect entry site twice daily for signs of inflammation.3 Label to show time/data of change. flow is from a very low microdrip to the catheter. hourly urine output. 11. they may indicate development of infection. Signs and symptoms of air embolism include severe shortness of breath. 3. Record the level at which the solution stabilizes or stops moving downward. 3. 3. 3. 2. Patient’s complaints of new or different pain or shortness of breath must be assessed closely. hemothorax. CARDIOPULMONARY RESUSCITATION Definition 92 . When readings are not being made. Observe the complications: 2. 2. hypotension. Normally the pressure should be between 4 and 11 cm.that the solution in manometer flows into the patient.
termed defibrillation. clear voice. Defibrillation is only effective for certain heart rhythms. Purposes • To restore and maintain breathing and circulation • To provide oxygen and blood flow to the heart. is usually needed to restore a viable or "perfusing" heart rhythm. CPR involves chest compressions at a rate of at least 100 per minute in an effort to create artificial circulation by manually pumping blood through the heart. its main purpose is to restore partial flow of oxygenated blood to the brain and heart. The process of externally providing ventilation is termed artificial respiration.Check the scene for dangers RATIONALE >If you come across someone who is unconscious. you need to quickly make sure there are no dangers to yourself if you choose to help them. namely ventricular fibrillation or pulseless ventricular tachycardia. Equipments • • • • • • • • • • Various types and sizes of gauze pads Bandages Tape Sterile eyewash Ice pack Scissors face shield Mask Gloves Watch/stop watch STEPS 1. CPR may however induce a shockable rhythm. It is indicated in those who are unresponsive with no breathing or only gasps. CPR alone is unlikely to restart the heart. If it still appears to be 2. 93 . they are conscious. In addition the rescuer may provide breaths by either exhaling into their mouth or utilizing a device that pushes air into the lungs. Current recommendations place emphasis on high quality chest compressions over artificial respirations and a method involving only chest compressions is recommended for untrained rescuers. Check the victim for consciousness by shaking or tapping their shoulder and saying in a loud. It may delay tissue death and extend the brief window of opportunity for a successful resuscitation without permanent brain damage. It may be attempted both in and outside of a hospital. rather than asystole or pulseless electrical activity. An administering of an electric shock to the heart. brain. and other vital organs.It is an emergency procedure which is attempted in an effort to return life to a person in cardiac arrest. or they could have been unconscious. >If they respond. They may have just been sleeping. CPR is generally continued until the person regains return of spontaneous circulation (ROSC) or is declared dead.
Do not check for more than 10 seconds. Therefore they may be at risk of the tongue falling to the back of the mouth and obstructing the airway."Are you okay? Are you okay?" 3. Make sure the airway is open. Place your hands on top of each other and place them on the sternum. with elbows locked. > Allow complete chest recoil after each compression. continue with CPR and the next steps. 5. o To check the neck (carotid ) pulse. after drinking a lot of alcohol). Minimize pauses in chest compression that occur when changing providers or preparing for a shock. 6. place your first two fingers on the inside of the ankle. To check the ankle (posterial tibial) pulse. o Other pulse locations are the groin and ankle. Give 30 chest compressions. Compress the chest. Also if they are at risk of vomiting (e. Opening the airway prevents this. Place your hand on the victim's forehead and two fingers on their chin and tilt the head back to open the > No control over the muscles suggests the casualty may be unconscious. place your first two fingers on the thumb side of the victim's wrist. feel for a pulse on the side of the victim's neck closest to you by placing the tips of your first two fingers beside his Adam's apple. Airway. and because one cycle of 30 chest compressions only require 18 seconds. Remember CAB: Chest Compressions. and Breathing. airway opening and rescue breathing are not significantly delayed. an emergency situation > The more people available for this step the better. 4. o To check the wrist (radial) pulse. and do them at a rate of at least 100 compressions per minute. o 7. Send someone to call the Emergency Medical Services (EMS).g. or in the center of the chest (on the breastbone) between the two nipples. however. 94 . by pushing straight down at least 2 inches deep. Check the victim’s pulse. Your ring finger should be on top of the nipple (this will lower the chances of breaking a rib or ribs). Send for help. press the tips of two fingers into the middle of the groin. if they vomit they will not be able to gag and the vomit can enter the lungs. Attempt to limit interruptions to less than 10 seconds 2. > Chest compressions are more critical for correcting abnormal heart rhythms (ventricular fibrillation or pulseless ventricular tachycardia). To check the groin (femoral) pulse. causing death. it can be done alone. If the victim does not have a pulse. o Do 30 of these compressions.
the victim may be choking. > Do abdominal thrusts to remove the obstruction. Give two rescue breaths. If it does not go in again. BLOOD TRANSFUSION Definition 95 . you can stop CPR. reposition the head and try again. see the chest slightly rise and also feel it go in. Make sure you keep your eye on the victim's chest. an AED is available for immediate use. If the victim wakes up. you should and breathing return (signs of life). Keeping the airway open. Repeat the cycle of 30 chest compressions and 2 breaths. or pulse o If the breath goes in. 10. > You should do CPR for 2 minutes (5 cycles of compressions to breaths) before checking for signs of life. emergency personnel arrive. as this will make sure the air goes in the lungs not the stomach. If jaw thrust fails to open the airway. you are too exhausted to continue.airway (if you suspect a neck injury. If the breath goes in. Continue CPR until someone takes over for you. 1. take the fingers that were on the forehead and pinch the victim's nose closed. 8. do a careful head tilt and chin lift. Make sure you breathe slowly. o If the breath does not go in. pull the jaw forward rather than lifting the chin). give a second rescue breath. 8. Make a seal with your mouth over the victim's mouth and breathe out for about one second.
4. 3.4 Pressure bag 1. Assessment 1.Blood products are ordered by the physician to restore circulatory blood volume.5 Unit and hospital number 2. Check that venipuncture was performed with 18 or 19 gauge angiocatheter. It is the responsibility of the physician to determine which blood component should be administered and the reason for the transfusion. Inspect if IV line is flowing. Implementation 96 .2 Intravenous solution with 0. 3.1 Blood filter and tubing 1.6 Expiration date of blood 2. Review baseline vital signs in patient’s medical record before initiating transfusion. Assess integrity and intactness of present intravenous line.6 Cotton balls 2. To restore capacity of the blood to carry oxygen.3 Blood warmer if needed. 2.9% NaCl (Normal Saline) 1. verify blood product and identify the patient’s: 2.5 Disposable gloves 1. 2. Purpose 1. obstructed or infiltrated.2 Blood group and Rh type 2. Administration of blood or blood components is a nursing procedure. 1.8 Clots in blood – if clots are present. Planning 1.3 Crossmatch compatibility 2.7 Type of blood component 2. or platelet concentrates which prevent or treat bleeding. Explain to patient procedure and its purpose. To provide plasma factors such as antihemophilic factor (AHF) or factor VIII. To restore blood volume after severe hemorrhage. 3. With another registered nurse. return blood to blood bank. Prepare the following equipments 1.4 Donor blood group and Rh type 2.1 Name and identification number (verbally and against his armband) 2. improve hemoglobin or correct serum protein levels.
6. Flush IV fluid line (PNSS). Change IV bottle or close IV fluid line and infuse blood. (Timby) This provides route for administering the normal saline or blood. Spike 0.STEPS RATIONALE 1. (Timby) 5. (Timby) Handwashing deters the spread of microorganisms.9 NSS intravenous bag This provides route for administering normal saline. Infusing normal saline before initiating the transfusion clears the IV catheter of incompatible solutions or medications. (Taylor) 4. (Timby) Suction effect causes fluid to move into drip chamber. This complies with the standards of care for administering blood. Open blood administration set.9 NSS 97 . 2. For Y tubing only: a. It provides a baseline for comparison during the transfusion. It prevents also air from moving down the tubing. Obtain baseline vital signs before administering transfusion. Spike blood or blood component unit and fill drip chamber with blood. (Taylor) b. (Kozier) Dextrose may lead to clumping of RBC and hemolysis. Wash hands and apply disposable gloves. (Timby) This provides route for administering blood. (Taylor) 3. Prime tubing with 0. Gloves are used to protect against accidental exposure to patient’s blood. c.
hourly unit of blood is infused. flushing. itching. and a slow rate will minimize the volume of red blood cells infused. ESSENTIAL NEWBORN CARE (Unang Yakap Campaign of the Department of Health) Definiton 98 . c. 8. allow filter to be filled with blood. Evaluation Observe and document for any chill. the infusion rate is increased. 9. Initial flow rate should be 25 ml/min. Spike blood unit..(Taylor) Transfusion reactions typically occur during this period. Monitor patient’s vital signs appropriately: every 5 minutes for first 15minutes. Remain with patient during first 15-20 minutes of transfusion.7. rash. and blood can be stopped immediately. For single tubing with administration: a. (Timby) Suction effect causes fluid to move into drip chamber. dyspnea. If there has been no adverse effect during this time. every 15 minutes for next hour.(Taylor) This removes air from tubing that in large amounts act as an air embolus. This provides route for administering blood. Open roller clamp and allow infusion tubing to fill with blood. hives or other signs of transfusion reactions. (Taylor) b. It prevents also air from moving down the tubing. Squeeze the drip chamber. they can be observed. (Taylor) If complications occur.
the Department of Health launched the Unang Yakap Campaign. It is an evidence-based intervention that emphasizes a core sequence of actions. 99 . Purposes • • • To help improve the health of the newborn through interventions before conception. To reduce neonatal mortality Equipments • • • • • • • • • • • • • • • Suction machine Suction catheter Saline (cool) Clean container for rinsing catheter Vitamin K ampule 1cc syringe Rectal thermometer Terramycin ointment Weighing scale Cord clamp Cotton balls Sterile gloves Sterile gauze 70% alcohol Tape measure Implementation Preparation (first 90 minutes. is organized so that essential time bound interventions are not interrupted. The campaign employs Essential Newborn Care (ENC) Protocol as a strategy to improve the health of the newborn through interventions before conception. and guarantee a healthy child. and in the postnatal period. It should be 25-28°C and free of air drafts. immediately after birth. at perineal bulging. during pregnancy. 3) Arrange needed supplies in linear fashion. With this campaign. low technology package of interventions that will save thousands of lives.On December 7. implement exclusive breastfeeding. with presenting part visible) 1) Check the temperature of the delivery room. performed methodically (step-by-step). and in the postnatal period To ensure that all health providers know how to handle newborn babies. costeffective newborn care intervention that can improve neonatal as well as maternal care. The ENC Protocol provides an evidence-based. low cost. at and soon after birth. the DOH aims to cut down infant mortality in the Philippines by at least half. 2) Notify appropriate staff. ENC is a simple. during pregnancy. and fills a gap for a package of bundled interventions in a guideline format. 4) Check resuscitation equipments. 2009.
5) Wash hands with clean water and soap. 6) Double glove just before delivery. Performance 100 .
III. dry cloth to thoroughly dry the baby by wiping the eyes. 2) Call for help. 3) Transfer to a warm. increase the duration drying) of breastfeeding. 4) Position the newborn prone on the mother’s abdomen or chest. cutting (while on skin-to-skin contact. and allow the “good bacteria” from the mother’s skin to colonize the newborn. 4) Inform the mother that the newborn has difficulty breathing and that you will help the baby to breathe. 6) Cover the newborn’s head with a bonnet. 30 seconds) which is extremely important to survival. • Do not suction unless mouth/nose are blocked secretions or other material. newborn is not breathing or is gasping: 1) Clamp and cut the cord immediately. Immediate and thorough drying (within Immediate drying prevents hypothermia. Properly-timed cord clamping and To increase the baby’s iron reserves. If after 30 seconds of thorough drying. 8) Remove the first set of gloves. face. front and back. arms. 101 . 5) Cover the newborn’s back with a dry blanket. Early skin-to-skin contact (after thorough To provide warmth. 7) Place the identification band on the ankle and take footprints. 5) Start resuscitation protocol. • Do not bathe the newborn earlier than 6 hours of life. head. Notes: • Do note ventilate unless the baby is floppy/limp and not breathing. and legs. • Do not wipe-off vernix caseosa. 1) Use a clean. II. 3) Do a quick check of the newborn’s breathing while drying. firm surface.STEPS Time-bound Procedures RATIONALE I. 3 minutes post-delivery) improve blood circulation and brain hemorrhage. up to reduce the risk of Iron-Deficiency Anemia. 2) Remove the wet cloth. the with • Do not put the newborn on a cold or wet surface.
malformations. Evaluate expected findings as well as any deviations (if any) such as birth injuries.Evaluation Conduct appropriate follow-up such as notifying the primary care provider of the results of the interventions. 102 . or defects.
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