ADMINISTERING OXYGEN VIA NASAL CANNULA

Procedure Rationale

Equipment needed:

 Oxygen tank with oxygen gauge

 Flow meter
 Nasal cannula
 Humidifier
 Face mask
 Distilled or tap water
To make sure that the procedure will be done to
1. Identify the patient.
the correct patient
To obtain baseline data.
2. Assess the need for oxygen and verify the order for the therapy.
For legal purposes.
3. Position the patient in semi-fowler. To permit chest expansion and easier breathing.
4. Explain safety precautions connected with oxygen use. For client’s and significant others’ awareness
For the equipment to be readily available at the
bedside.
5. Prepare the materials.

To reduce time consumption.

6. Explain the procedure and its importance. To gain patient’s cooperation.
7. Wash hands. For infection control

8. Set up the oxygen equipment.

a. Attach the flow meter to the tank. The flow meter should be in the off
position.
b. Fill the humidifier bottle with distilled water or tap water. This can be done
before coming to the bedside.
c. Attach the humidifier to the base of the flow meter.
d. Attach the prescribed oxygen tubing and delivery device to the humidifier.

o To note if the oxygen is flowing freely

through the tubing, that there are no kinks, if
connections are airtight.
9. Turn on the oxygen at a prescribed rate and ensure proper functioning.
o To check if there are bubbles in the humidifier
as the oxygen flows through. You should feel
the oxygen at the edge of the cannula or mask.

10.    Apply the appropriate oxygen device.

CANNULA
a. Put the cannula over the client’s face, with the outlet prongs fitting into the
nares and the tubing anchored at both ears then under the chin.
b. If the cannula does not stay in place, tape it at the sides of the face.

FACE MASK

a. Guide the mask toward the client’s face and apple it from the nose downward.
b. Fit the mask to the contour of the client’s face so that very little oxygen
escapes into the eyes or around the cheeks or chin.
c. Secure the elastic band around the head.

11.    Document pertinent data.

Good morning ma’am. I am Lee Shane Pablo and today I will be showing you my return demonstration in administering
oxygen via nasal cannula.

So the materials that we will be needing for this procedure are oxygen tank with oxygen gauge, flow meter nasal cannula,
humidifier, face mask and distilled or tap water.

OBTAINING RADIAL PULSE

1. Gather equipment needed for the procedure.

 Wrist watch with second hand

2. Prior to performing the procedure, introduce yourself and verify the client’s identity using agency protocol. Explain to the client and the
family 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.

3. Perform hand hygiene and observe other appropriate infection control procedures.

4. Provide for client privacy.

5. Determine which method to use.

6. Prepare the equipment to be used.

7. Assist the client to a comfortable resting position, with wrist extended and the palm of the hand facing downward. Palpate and count the
pulse.

 Place two or three middle fingertips lightly and squarely over the pulse point. Do not use the thumb.
 Press the radial site using moderate pressure to feel the pulse.
RATIONALE: Using the thumb is contraindicated because the nurse’s thumb has a pulse that could be mistaken for the client’s pulse.

APICAL PULSE TAKING

1. Gather equipment needed for the procedure.

o Stethoscope
o Wrist watch with second hand
o Antiseptic wipes or cotton ball with alcohol

2. Prior to performing the procedure, introduce yourself and verify the client’s identity using agency protocol. Explain to the client and the family
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.

3. Perform hand hygiene and observe other appropriate infection control procedures.

4. Provide for client privacy.

5. Clean ear pieces and diaphragm of stethoscope with antiseptic wipes. Warm the diaphragm of the stethoscope by holding it in the palm of the
hand for a few seconds.
RATIONALE: The diaphragm needs to be cleaned and disinfected if soiled with body substances. Both earpieces and diaphragms have been
shown to harbor pathogenic bacteria.
The metal of the diaphragm is usually cold and can startle the client when placed immediately on the chest.

6. Assist client in a comfortable supine position or in a sitting position on bed or on a chair.

7. Expose the area of the chest. Palpate the 5th ICS and move to midclavicular line. Place diaphragm over apex of heart.
RATIONALE: The heartbeat is normally loudest over the apex of the heart. Each lub-dub is counted as one heartbeat.

8. Listen to normal heart sounds and count the heart beat for a full minute using wrist watch with a second hand.
RATIONALE: A 60-second count provides a more accurate assessment of an irregular pulse than a 30-second count.

9. Document the pulse rate and rhythm in the client’s record.

ASSESSING RESPIRATION

PROCEDURE RATIONALE

Equipment’s needed:

o wrist watch with second hand

 Do not let the patient know that you’re counting the

1. While the finger tips are still in place after counting the
respirations of the client, she/he may alter or control
pulse rate, observe the patient’s respirations.
her/his breathing

2. Count the rise and fall of the chest and abdomen as one  For accurate counting: 1 inhalation (rise on the abdomen
 ASSESSING RESPIRATION

PROCEDURE RATIONALE

respiration in full minute. or chest) & 1 exhalation (fall of abdomen or respiration)

  If the rise and fall of the chest cannot be clearly is equal to 1 full respiration
appreciated, place a hand against the client’s chest to
feel the client’s chest movements, or place the
client’s arm across the chest and observe the chest
movements while supposedly taking the radial pulse.
Because young children are diaphragmatic breathers,
observe the rise and fall of the abdomen.

3. Evaluate the respiration in terms of rate, depth, rhythm,

 To note and refer for any abnormal observations
and character.

4. Wash your hands.  To avoid cross infection

5. Record the rate of respiration and any observations noted

 For proper documentation
on the appropriate form.

BLOOD PRESSURE TAKING 

PROCEDURE:
1. Gather equipment needed for the procedure.
o Stethoscope
o Blood pressure cuff of the appropriate size
o Sphygmomanometer
RATIONALE: To organize equipment and accurate skill performance.

2. Prior to performing the procedure, introduce yourself and verify the client’s identity using agency protocol. Explain to the
client and the family 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.
RATIONALE: To ensure that the client understands the procedure gives valid consent.
3. Perform hand hygiene and observe other appropriate infection control procedures.
RATIONALE: To minimize the risk of infection.

4. Provide for client privacy.

RATIONALE: It helps to build and develop trust.

5. Check the equipment.

 Ensure that the cuff is deflated completely and thumbscrew is re-tighten fully.
 Check for leaks in the tubing between the cuff and the sphygmomanometer.
 Cuff is of appropriate size.
RATIONALE:  To ensure that the equipment is intact and functioning properly.

6. Position the client appropriately.

 Place the client in a relaxed and comfortable sitting, standing, or lying position.
 Place the client’s arm at approximately heart level with the palm of the hand facing up; support the arm so it is relaxed.
RATIONALE: Legs crossed at the knee results in elevated systolic and diastolic blood pressures.
Ø  The blood pressure increases when the arm is below heart level and decreases when the arm is above heart level.

7. Wrap the deflated cuff evenly around the upper arm 1-2 inches above elbow (ante cubital fossa).
 Client on sitting/standing position- cuff placed at the level of the client’s heart.
RATIONALE:  The bladder inside the cuff must be directly over the artery to be compressed if the reading is to be
accurate.

8. If this is the client’s initial examination, perform a preliminary palpatory determination of systolic pressure.
RATIONALE: The initial estimate tells the nurse the maximal pressure to which the sphygmomanometer needs to be
elevated in subsequent determinations. It also prevents underestimation of the systolic pressure or overestimation of the
diastolic pressure should an auscultatory gap occur.
 Palpate the brachial or radial artery with the fingertips.
 Close the valve on the bulb.
 Inflate cuff until brachial or radial pulse can no longer be felt.
 This provides an estimation of systolic pressure.
 Deflate the cuff completely and wait 1- 2 minutes before continuing to measure.
RATIONALE: A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic
readings will occur.

9. Place the bell of the stethoscope over the brachial pulse site.
RATIONALE: Because the blood pressure is a low-frequency sound, it is best heard with the bell-shaped diaphragm.

10. Apply just enough pressure on the stethoscope to keep it in its place over the brachial artery.
RATIONALE: To keep it in place and avoid muffled sounds or sounds of distortion.

11. Inflate the cuff to a point 30 mmHg above the last recorded palpatory reading until the pulse can no longer be heard or
palpated.

12. Rotate the thumbscrew slowly in a counter clockwise motion allowing the cuff to deflate slowly at 2-3mmHg per
second.
 Watch the gauge at which a sharp thud sound is heard; the reading at that level is the systolic pressure.
  Watch the gauge at which the last pulse is heard- the reading at that level is the diastolic pressure.
RATIONALE: If the rate is faster or slower, an error in measurement may occur

13. If there is a need to check it again, release pressure until the level is down to zero.

14. Release pressure, remove cuff and clean the equipment. Make the client comfortable.
RATIONALE: This permits blood trapped in the veins to be released.
Cuffs can become significantly contaminated. This decreases the risk of spreading infection by sharing cuffs.

15. Perform hand hygiene.

16. Record the blood pressure in the appropriate form.

RATIONALE: To ensure adequate record keeping, and enable good communication and continued care of client.

After taking the blood pressure, we will now proceed in taking the apical pulse.

We need to