NCM 116 RLE

Care of Clients with Problems in Nutrition & GI Metabolism and Endocrine, Perception &
Coordination (Acute & Chronic)
L E C / PROF. BUTAWAN, CASTRO, CHIU, MARCELO, MARQUEZ, SUMILANG
______________________________________________________________________________________________________________
PRELIMS - WEEK 3
DAY 1
OUTLINE ● Quick neurologic assessment for: prognosis and victim’s
ability to maintain patent airway on their own.
I. Glasgow Coma Scale
A. Eye Opening
B. Verbal Response ● The Glasgow Coma Scale has proved a practical and
C. Motor Response consistent means of monitoring the state of head injured
II. NIHSS Stroke Scale patients
III. Cranial Nerves Assessment ● In the acute stage, changes in conscious level provide the best
indication of the development of complications such as
intracranial haematoma whilst the depth of coma and its
GLASGOW COMA SCALE
duration indicate the degree of ultimate recovery which can be
● Graham M. Teasdale was professor and head of the expected.
Department of Neurosurgery, University of Glasgow (1981 - ● GCS does not entail assumptions of specific underlying
2003)
● What were the main factors on the design of the scale? anatomical lesions or physiological mechanisms
○ The approach should be simple and practical,
usable in a wide range of hospitals by staff without A. EYE OPENING
special training. ● Useful as a reflection of the intensity of impairment of
● The Glasgow Coma Scale (GCS) was developed to assess activating functions
the level of neurologic injury, and includes assessment of
movement, speech, and eye opening. 4: SPONTANEOUS EYE OPENING
● it indicates arousal mechanisms brain stems are active
COMPONENT TESTED Score ● it does not imply awareness
● In the persistent vegetative or minimally conscious state, eye
Eye Response
opening is characteristically dissociated from the evidence of
Eyes open spontaneously 4 intellectual function.

Eye opening to verbal command 3

3: EYE OPENING IN RESPONSE TO SPEECH
Eye opening to pain 2 ● It is sought by speaking or shouting at the patient
● Any sufficiently loud sound can be used, not necessarily a
No eye opening 1 command to open the eyes.
● This should be assessed before the patient is physically
Motor Response
stimulated.
Obeys command 6
2: EYE OPENING IN RESPONSE TO PAIN
Localises pain 5
● It is assessed if the person is not opening their eyes to sound.
Withdraws from pain 4 ● It should not cause unnecessary injury to the patient.
○ There are a lot of techniques used in eliciting pain
Flexion response to pain 3 but not causing injury.
Extension response to pain 2 ● The stimulus should be pressure on the bed of a fingernail or
supraorbital nerve.
No motor response 1 ● Options such as rubbing the sternum or pinching the chest or
arm do not offer advantages.
Verbal Response

Oriented 5 1: AN ABSENCE OF EYE OPENING

● It implies substantial impairment of brain stem arousal
Confused 4
mechanisms
Inappropriate words 3 ● Substantial effort should be made earlier to ensure that this is
not due to an inadequate stimulation.
Incomprehensible sounds 2 ● It is also important to identify if a lack of eye opening is a
No verbal response 1 consequence of a local injury, for example frontobasal
fractures, or sedative and paralyzing medication.
● This avoids the need to make arbitrary distinctions between
B. VERBAL RESPONSE
consciousness and different levels of coma.
○ Severe (GCS < 8) 5: ORIENTED
○ Moderate (GCS 9-12)
○ Mild (GCS > 13) ● It is the highest level of response and implies awareness of

1
 self and environment
● This person should be able to provide awareness to at least
three questions:
○ Who they are
○ Where they are: The date – at least in terms of the
year, month and date of the week.
● A person who can answer some but not all these questions
can be subcategorized as partially oriented, either specifying
what information that they are able to give or how many out of
three components they can provide.
4: CONFUSED CONVERSATION
● It is recorded if the patient engages in conversation but is
unable to provide any of the foregoing three points of
information.
● The key factor is that the person can produce appropriate
phrases or sentences.
3: INAPPROPRIATE SPEECH
● It is assigned if the person produces only one or two words, in
an exclamatory way, often swearing
● It is commonly produced by stimulation and does not result in
sustained conversation exchange.
2: INCOMPREHENSIBLE SOUNDS
● It consists of moaning and groaning, but without any
recognizable words.
● It is commonly produced by stimulation and does not result in
sustained conversation exchange.
1: NO VERBAL RESPONSE
1. No verbal response upon pain stimulus
2. Substantial effort should be made earlier to ensure that this is
not due to an inadequate stimulation.
● The verbal response may be affected as a result of focal
brain damage rather than a general impairment of function.
For example, an impaired verbal response in an otherwise
apparently alert person should raise the suspicion of
dysphasia.
● The use of endotracheal intubation clearly precludes a
verbal response.
C. MOTOR RESPONSE
● The assessment of motor responsiveness becomes important
in a person not conversing to at least a confused level.
6: OBEYING COMMANDS
● It is the best response possible.
● Confirmation of the specificity of the response by squeezing
and releasing the fingers or holding up the arms or other
movement elicited by verbal command.
● It is important to be aware that motor responses can occur as
a primitive grasp reflex or a startle response or even a simple
posture adjustment.
5: LOCALIZATION
● It is done with the application of pressure on the supraorbital
notch.
● Localizing should be recorded only if the person’s hand
reaches above the clavicle in an attempt to remove the
stimulus.
● If in doubt, stimulation can be applied to more than one site to
ensure that the hand attempts to remove it.
● Stimulus to the trunk may result in the arms moving across the
chest in a way that does not represent a specific localized
response.
4: A WITHDRAWAL RESPONSE
● It is recorded if the elbow bends away from the pain stimulus
but the movement is not sufficient to achieve localization.
3: AN ABNORMAL FLEXION RESPONSE (DECORTICATE)
● It is recorded if the elbow bends in decorticate posturing and
the movement is not sufficient to achieve localization.
2: AN ABNORMAL EXTENSION RESPONSE
(DECEREBRATE)
● It is recorded if the elbow only straightens and the movement
is not sufficient to achieve localization.
1: ABSENCE OF MOTOR RESPONSE
● It is recorded if no limb movement upon pain stimulus
● Before recording that someone has no motor response,
vigorous and tried(?) efforts should be made.
WHAT KIND OF FLEXION MOVEMENTS CAN BE RECOGNIZED?
● Normal Flexion Movement – It is characterized by rapid
withdrawal, abduction of the shoulder, and external rotation
which varies from stimulation to stimulation.
● Abnormal flexion movement – It is present when the
response is slow, stereotyped
○ That is repeated time after time
○ And results in the arm moving to an adducted
internally rotated position, characteristic of the
hemiplegic or so called decorticate posture.
● Inexperienced staff, particularly working outside neurosurgical
centers, finding the distinction very difficult to make with
consistency. For this reason, in the acute stage, it is sufficient in
monitoring most patients to record simply that flexion is
present.
WHY IS IT THE BEST MOTOR RESPONSE?
● The scale is based upon taking account of the best response of
the better limb.
● The highest level of response achieved provides the most
consistent assessment of the patient’s state and the best guide
to the integrity of the remaining brain function.
● A difference between the two sides may indicate focal brain
damage. The worst or most abnormal response also should be
noted in order to identify the site of focal damage
WHAT NEEDS TO BE CHECKED IF THERE IS APPARENTLY NO
RESPONSE?
● An absence of motor response clearly equates to a severe
depression of function.
● Before ascribing this to structural damage it is important to
exclude other cases
○ For example the effects of systemic insults such as
hypoxia, hypotension or the use of drugs.
● Comparison should be made of the responses in the legs and
arms with those is head and neck injury in order to alert the
examiner to the possibility of spinal cord or brain stem injury.
● It is also important to ensure a stimulus of adequate intensity
has been applied.
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 ● A major limitation of the total score is the difficulty to translate
GLASGOW COMA SCALE: GENERAL QUESTIONS the score into a clear picture of the patient’s actual condition.
○ You do not rely alone on the patient's GCS scoring
CONSISTENCY
to assess the general condition.
● Inter-observer consistency has been examined by many
● This is particularly a risk in telephone exchanges.
investigators and has been shown to be robust in a wide,
● The lowest score is not 0 nor 1, but 3.
relevant range of circumstances including emergency
department intensive care units and in pre-hospital care.
IS THE TOTAL SCORE 14 OR 15?
● However, consistency cannot be assumed and should be
● It is a result of the differences in the approaches to
confirmed and enhanced by training and communication
assessment of flexion motor responses.
between staff.
● In the simpler system, recommended for routine use in patient
HOW SOON? monitoring, no attempt is made to distinguish between normal
and abnormal flexion. This results in a system summing to a
● In the acute stage, the sooner an observation is made, the
total of 14.
more useful it is as a guide to predict the ultimate outcome.
● Distinction between normal and abnormal flexion is important
● In the acute state where the patient's state of consciousness is
in assessing the significant deterioration from normal to
influenced by remedial disorders. For example hypoxia or
abnormal brain responses - Important prognostic factor.
hypotension, prognosis has been based upon an assessment
after sufficient time has passed.
● POst resuscitation GCS is usually assessed after 6 hours, in a
well resuscitated patient. CHILDREN COMA SCALE
● The Glasgow Coma Scale (GCS) as an objective assessment
HOW OFTEN? of neurological function is of limited usefulness in children
● The shorter the time between an injury or other event and the under 3 years of age
assessment, the more the security about the stability of a ● One of the components of the Glasgow Coma Scale is the
patient's condition best verbal response which cannot be assessed in nonverbal
● Observations at frequent intervals are appropriate for example small children in relation to language development.
every few minutes and at least several times within an hour. ● A modification of the original Glasgow coma scale was created
● As time passes the frequency can be reduced, and related to for children too young to talk.
whether or not there are reasons for considering the patient
needs continuing observation and care. PAEDIATRIC COMA SCALE
Table 1. Glasgow Coma Scale Modified For Pediatric Patients
HOW MUCH CHANGE MATTER?
● Questions are asked about the extent of change that should Eye Opening Response < 1 year
take place in order to trigger action.
4 Spontaneous
● It may determine transfer to another unit e.g. from a general to
a specialist neurosurgical department. 3 To shout
● Again, hard and fast rules are not appropriate.
2 To pain

● The general guidance is that it depends upon where the 1 None

patient is showing change from and the extent of the change.
Verbal Response 0 to 2 years
○ Generally significant changes when total score
reduces by 2 points or motor response reduces by 5 Babbles, coos appropriately
single point.
4 Cries but is inconsolable
■ Immediately report to the doctor possible
for transfer in a specialty unit. 3 Persistent crying or screaming in pain

● There is a greater degree of consistency in the assessment 2 Grunts or moans to pain

of the motor component of the scale than the verbal and eye 1 None
features.
Motor Response < 1 year
RELATIONSHIP BETWEEN THE SCALE AND THE SCORE? 6 Spontaneous
● The total or sum score (coma score) was initially used as a
way of summarizing information, in order to make it easier to 5 Localizes pain
present group data. 4 Withdraws to pain
○ If you are in a critical unit, you do not give the total
score during endorsement. They are categorized. 3 Abnormal flexion to pain
(decerebrate)
(E.g. eye - 4, verbal - 4, motor - 6)
● However, the resulting score proved a useful and powerful 2 Abnormal extension to pain
(decorticate)
summary of the summary of the extent of brain dysfunction
and showed a strong relationship with prognosis 1 None
● When describing an individual patient, especially when
communicating with colleagues, it is always preferable to refer
to the responses observed and not to rely upon
communication through the intermediary of numbers or a total
score.

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 Table 4. Pediatrics Glasgow Coma Scale For
Nonverbal Children.
Extubated: 3 - 15
SCORE RANGE
Eye Response
Intubated: 3 - 11T
Spontaneous 4

To speech 3 Normal: GCS = 15

To pain 2 CLINICAL PRESENTATION

Comatose: GCS ≤ 8
No response 1
Dead: GCS = 3
Motor Response

Follows command 6 Minor: GCS ≥ 13

Localizes pain 5
Moderate: = GCS 9 - 12
Withdraws to pain 4 GRADING OF HEAD INJURY

Decorticate flexion 3 Severe: GCS ≤ 8

Decerebrate extension 2
Example report: GCS = E2 V4 M3 at 07:35
No response 1
GS 3: dead
Verbal Response - neurologically dead but may not be biologically dead.
Coos, babbles 5 - No brain activity on the EEG.
- Biologically dead: patient is asystole
Irritable cry 4

Cries to pain 3

Moans to pain 2
NIHSS STROKE SCALE
No response 1 ● Standardized stroke severity scale to describe neurological
Simpson and Reilly (1982) deficits in acute stroke patient allows us to:
○ Quantify our clinical exam
CHILD’S GLASGOW COMA SCALE ○ Determine if the patient's neurological status is
improving or deteriorating
○ Provide for standardization
○ Communicate patient status

- Glascow coma is designed as a rapid assessment in any

scenario or cases. While NIH Stroke Scale, it is for stroke
cases only.

ELEMENTS OF THE NIH STROKE SCALE

● 11-item scoring system
● Integrates components of neurological exam
● Includes testing of LOC, select cranial nerves, motor, sensory,
cerebellar function, language, inattention (neglect)
● Maximum score: 42, minimum score: 0
● Not a linear scale

NEUROLOGICAL EXAMINATION & NIHSS

British Pediatric Neurology Association

NEUROLOGICAL EXAMINATION NIHSS

CONCLUSIONS
● Although initially described four decades ago, the Glasgow
● LOC ● LOC
approaches to assessment of initial severity and outcome of
● Mental Status and ● Best Gaze
brain damage have weathered the test of time. Cognitive Function ● Visual field Testing
● It remains the standard for acute assessment. ● Cranial Nerves ● Facial Paresis
● Alternatives to and adaptations of the Glasgow Scales have ● Motor Systems ● Arm and Leg function
been described. Some of these have clear advantages, for ● Sensory Function ● Limb ataxia
example in relation to children. ● Cerebellar system ● Sensory
(coordination and gait) ● Best Language
● Reflexes ● Dysarthria
● Extinction &
inattention

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NIHSS GUIDING PRINCIPLES
● The most reproducible response is generally the first response
● Do not coach patients unless specified in the instructions
● Some items are scored only if definitely present
● Record what the patient does, not what you think the patient
can do
1A. LEVEL OF CONSCIOUSNESS
INSTRUCTIONS
● Determined through interactions with the patient
● Auditory stimulation (normal to loud)
● Tactile stimulation (light to painful)
● The investigator must choose a response
SCORING
0 Alert, keenly responsive
1 Not alert, but arousable by minor stimulation to
obey, answer or respond
2 Not alert, requires repeated stimulation to
attend, or is obtunded and required strong or
painful stimulation to make movements
3 Responds only with reflex motor or autonomic
effects or totally unresponsive, flaccid
NOTE:
A 3 is scored only if the patient makes no movement (other
than reflexive posturing) in response to noxious stimulation.
If the patient scores 2 or 3, use the GCS to assist the
neurological examination.
1B. LEVEL OF CONSCIOUSNESS
INSTRUCTIONS
● Ask the patient for their age then wait for response
● Ask the patient the current month then wait for a response
○ Do not give credit for being “close”
○ Do not coach nor give nonverbal cues
● Just wait for the patient’s response. Do not lead him/her.
SCORING
0 Answers both questions correctly
1 Answers one question correctly
2 Answers neither question correctly
NOTE:
Aphasic patients who do not comprehend the questions will
score 2
Patients unable to speak due to intubation, endotracheal
orotracheal trauma, severe dysarthria from any cause,
language barrier or any other problem not secondary to
aphasia are given a 1
1C. LEVEL OF CONSCIOUSNESS
INSTRUCTIONS
● Ask the patient to:
○ Open and close their eyes
○ Grip and release the non paretic hand
○ Give credit if an unequivocal attempt is made but not
completed due to weakness
● If patient does not respond to command, the task should be
demonstrated
SCORING
0 Performs both tasks
1 Performs one task
2 Performs neither task correctly
● Score only the first attempt
2. BEST GAZE
● Ask the patient to follow your finger across horizontal eye
movements
○ You can coach the px.
● Aphasic or confused patients: use tracking
● Unconscious patients: use oculocephalic maneuver
● Okay to coach
● Tracking: establishing eye contact and moving about the
patient from side to side and observing if the patient's eyes
follow
● The oculocephalic reflex (doll's eyes) assessed by briskly
rotating the patient's head side to side
SCORING
0 Normal horizontal eye movements
1 Partial gaze palsy – abnormality in one or
both eyes, but forced deviation is not present
2 Forces deviation or total gaze paresis (not
overcome with oculocephalic maneuver)
NOTE:
Normal response: eyes move in the opposite direction to
head movement
Abnormal response: the eyes are fixed in one position and
follow the direction of passive rotation
3. VISUAL FIELDS
● Stand 2 feet from the patient at eye level. Both examiner and
patient cover one eye. Ask the patient to look directly into your
eyes.
● Test upper and lower visual fields by confrontation (4
quadrants of each eye) Examiner compares this to the "norm"
(their own vision)
● To test both fields with eyes open, ask patient to indicate
where they see movement (choices: left side, right side, or
both)
5
 NOTE:
SCORING
If the patient sees moving fingers, this can be scored as
normal. 0 Normal symmetrical movement

If there is unilateral blindness or enucleation, score visual
fields in the other eye.
If there is extinction during double simultaneous stimulation,
score a 1 and use the results to answer question 11.
1 Minor paralysis (i.e. flattened nasolabial fold,
asymmetry on smiling)
2 Partial paralysis (total or near total paralysis of
lower face)

Visual Deficits 3 Complete paralysis of one or both sides (absence

of facial movement in the upper and lower face)

NOTE:

Aphasic or confused patient: Score symmetry of grimace

to noxious stimulation

5. MOTOR ARM & LEG

INSTRUCTION
Test each limb independently. start with a non-paretic arm.
● Place limb in the appropriate position
○ Extend arm (palm down) 90° sitting/45° supine
○ Leg 30° supine
● Drift = arm falls before 10 sec or leg before 5 sec
○ Dip vs. Drift
○ Dip: very small change with instantaneous correction
○ Drift: limb lowers to any significant degree. Drift is
never normal.
● Count out loud & using your fingers in patient's view
● Aphasic patient: use urgency in voice and pantomime to
encourage

4. FACIAL PALSY SCORING

INSTRUCTIONS 0 No drift, limb holds steady for full count (arm: 10

● Ask the patient or use pantomime sec, leg: 5 sec)
○ Show their teeth
○ Raise their eyebrows 1 Drifts, but limb does not hit bed or other support
○ Close their eyes tightly
2 Drifts towards bed, but patient has some effort
● Score symmetry of grimace to noxious stimulation in the against gravity
aphasic or confused patient (tickle each nasal passage one at
a time using a cotton-tipped applicator and observe facial
3 Limb falls, no effort against gravity. Trace
movement)
muscular contraction present in limb.

6
 NOTE:
4 No movement
Ataxia is only scored if present. In patients who can't
X Amputation, joint fusion understand the exam or who is paralyzed, a score of 0
(absent) is given.

Arm tested in pronated position If the patient has mild ataxia and you cannot be certain that it
is out of proportion to demonstrated weakness, give a score
of 0.

8. SENSORY
INSTRUCTION
● Use sharp object on the face, arms (not hands), trunk, and
legs. Compare pinprick in same location on both sides
● Ask patient if they can feel the pinprick, if it is different from
side to side, and how it is different
● Record grimace or withdrawal from noxious stimulus in
obtunded or aphasic patients. Only record sensory loss due to
stroke
● Only record sensory loss if it is clearly demonstrated

SCORING
Used with permission from Southeast Toronto Stroke Region
0 Normal, no sensory loss

7. LIMB ATAXIA 1 Mild to moderate sensory loss; patient is aware of

● Use "finger-nose-finger" and "heel to shin" tests
● Test non-paretic side first (non-affected area)
● Look for smooth, accurate movements
● Consider limb weakness when looking for dysmetria
● Nonverbal cues are permitted
● Test all four limbs separately
being touched, but pinprick is less sharp/dull on
the affected side
2 Severe to total sensory loss; patient is aware of
being touched in the face, arm, and leg

NOTE:
INSTRUCTIONS
A score of 2 should only be given when severe or total loss
FINGER-NOSE-FINGER of sensation can be clearly demonstrated
The examiner raises their finger midline 2 feet from the patient
Patient is asked, "With your right hand, touch my finger, then touch your
Stuporous and aphasic patients will probably score 1 or 0
nose; do this as fast as you can." Repeat with the other arm.

HEEL TO SHIN 9. BEST LANGUAGE

Patient can be lying on their back or sitting
Ask patient to slide one heel down shin of the opposite leg, then repeat
the same procedure on the other side
NOTE:
Dysmetria: the inability to accurately control the range of
movement in muscle action with the resultant overshooting
of the mark
LIMB ATAXIA SCORING
● Incorporates information collected in preceding sections
○ Ask patient to perform the following: Name all the
objects on the card
○ Read all the sentences
○ Describe what is happening in the picture
○ Give patient adequate time. Patient can also write
answers.
● If visual loss prevents standard examination:
○ Place objects in patient's hand (naming)
● Ask patient to repeat sentences on the card
● Ask patient to produce speech by asking a question

0 Absent
SCORING
1 Present in One limb
0 No aphasia, normal fluency and comprehension
2 Present in Two limbs
1 Mild to moderate aphasia: some obvious loss of
fluency or comprehension, but able to "get their
ideas across"

2 Severe aphasia: all communication limited,

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 examiner must guess what the patient is trying to more than one modality. Does not recognize its own
communicate hand or orients to only one side of space.

3 Mute, global aphasia: no useable speech, no

auditory comprehension. Patient unable to follow IMPORTANT POINTS
any one step commands ● If patient is not cooperative, explanation must be clearly written
on the form
NOTE: ● NIHSS items are rarely unstable

To choose between a score of 1 or 2, use all provided

materials. It is anticipated that a patient who missed more
than two thirds of the naming objects and sentences or who POSSIBLE POINTS: SUMMARY
followed only a few and simple one step commands would
score a 2. Cranial Nerves (portions of CN II, III, V, VI, VII)

Motor 8 8x2 = 16
Ataxia 2
10. DYSARTHRIA Sensory 2
● An adequate sample of speech must be obtained by asking
Language 2
patient to read or repeat words from the attached list even if
Inattention 2
patient is thought to be normal
—-------------------------------------------------------------
● If the patient has aphasia, the clarity of articulation of
NIHSS TOTAL: 42
spontaneous speech can be rated

SCORING
NIHSS AND PATIENT OUTCOMES
0 Normal

1 Mild to moderate; patient slurs some words but can Total scores range from 0-42 with higher values representing
be understood more severe infarcts

2 Severe; patient's speech is so slurred/unintelligible > 25 Very severe neurological impairment

in the absence of or out of proportion to any
dysphasia, or is mute 15 - 24 Severe impairment

5 - 14 Moderately severe impairment

X The presence of visual spatial neglect or
anosognosia may also be taken as evidence of <5 Mild Impairment
abnormality.

NOTE:

11. EXTINCTION & INATTENTION (NEGLECT)
● Sufficient information to identify neglect may be obtained
during prior testing • If the patient has a severe visual loss
preventing visual double simultaneous stimulation, and the
cutaneous stimuli are normal, the score is normal.
● If the patient has aphasia but does not appear to attend to both
sides, the score is normal.
● The presence of visual spatial neglect or anosognosia may
also be taken as evidence of abnormality.
A 2-point (or greater) increase in the NIHSS
administered serially indicates stroke progression. It is
advisable to report this increase.
● report to the doctor or your manager.
● perform further assessment
SCORING
Initial score of 7 was found to be important cut-off point

NIHSS > 7 demonstrated a worsening rate of 65.9%

Since the abnormality is scored only if present, the item is never
untestable.
NIHSS < 7 demonstrated a worsening rate of 14.8% and
SCORING were almost were almost
twice (1.9x) as likely to be functionally normal
0 No Abnormality at 48 hours (45%)

1 Visual, tactile, auditory, spatial, or personal

inattention or extinction to bilateral simultaneous NIHSS < 5 most strongly associated with D/C home
stimulation in one of the sensory modalities"

2 Profound hemi-inattention or hemi-inattention to NIHSS 6-13 most strongly associated with D/C to rehab

8
 NIHSS > 13 most strongly associated with D/C to nursing
facility

Likelihood of
intracranial
hemorrhage:

NIHSS > 20 17% likelihood

NIHISS < 20 3% likelihood

Online NIHSS Certification

● Online NIHSS Certification available free through the American
Stroke Association
○ prior to the pandemic, stroke unit nurses actively
attended seminars and training.
● The online program provides detailed instructions and
demonstration scenarios for practice in scoring the NIHSS ANATOMY OF NERVOUS SYSTEM
● Certification is completed by scoring different patient scenarios ● Neurons are the structural and functional unit of the nervous
system
When to communicate NIHSS Results ● Neurotransmitter
● Neurological decline ○ Transmit message from one neuron to another
● Now focal deficit ○ Most neurological disorders are caused by
● Advancing neurological deficit imbalance in transmission of neurotransmitters (e.i.
low serotonin - epilepsy,decreased dopamine-
Communicating NIHSS Results parkinson’s)
Total NIHSS score is an important piece of information to relate patient
status along with a full patient assessment.

Communicate the following:

● Which neurological area has changed
● How it has changed
● Other new findings (vital signs, pupils, cranial nerve deficits,
mental status, etc.)

Document your assessment, intervention plans and follow-up.

ASSESSMENT OF NEUROLOGIC FUNCTION IN NURSING

● Describe the structure and function of the central

and peripheral nervous system
● Enumerates the functions of the sympathetic and
parasympathetic nervous system
● Discuss the significance of physical assessment in
detecting the abnormalities of the nervous system
● Discuss the various diagnostic procedures used to
discuss the abnormalities of the nervous system

NERVOUS SYSTEM
● Function of the nervous system is to control all motor,
cognitive, autonomic and behavioral activities happening in the
human body
● Disorders of the nervous system can occur during any point in
life,hence a nurse must be skilled in its proper assessment.

CNS: BRAIN
● 2% of total body weight
● About 1400g in an average adult
● Divided into 3 Major areas
○ Forebrain: cerebrum, thalamus
○ Midbrain: Tectum and tegmentum
○ Hindbrain: Cerebellum, pons, medulla
■ It is difficult to operate when the pons and

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 medulla are affected. 2. Pons (Hindbrain)
● Bridge between the two halves of the cerebellum
and between the medulla and cerebrum
● Contains motor and sensory pathways
● Portion of it controls the heart, respiration, and
blood pressure

3. Medulla Oblongata (Hindbrain)

● Located between the pons and the spinal cord
● Responsible for maintaining vital body functions
such as breathing and heart rate
FOREBRAIN
1. Cerebrum
● Consists of 2 hemispheres that are incompletely
separated by the great longitudinal fissure
● Both hemispheres are divided into frontal lobe,
parietal lobe, temporal lobe and occipital lobe.
● Frontal lobe: largest lobe, specialized in
concentration, thought formation, and judgment
● Parietal lobe: analyzes sensory information and
gives orientation
cross section of skull
● Temporal lobe: auditory receptive areas
● Occipital lobe: visual interpretation CEREBROSPINAL FLUID
○ The patient may lose vision or peripheral
● Clear and colorless fluid with specific gravity of 1.007
vision.
● Produced from the ventricles and is circulated through the
ventricular system
● Composition of the CSF is similar to that of plasma
● Normally, CSF contains few WBCs but no RBCs

2. Thalamus
● Large mass of gray matter deep situated in the
forebrain
3. Hypothalamus
● Controls homeostasis,
emotion,thirst,hunger,circadian rhythms,ANS,and
pituitary gland.
4. Amygdala
● Located in the temporal lobe
● Involved in memory, emotion, and fear
5. Hippocampus
● Important for learning and memory, for converting
short-term memory to a more permanent memory,
and for recalling spatial relationships

MIDBRAIN

● Rostral part of the brainstem which includes the tectum and

tegmentum
● involved in function such as vision, hearing, eye movement

HINDBRAIN CEREBRAL CIRCULATION

1. Cerebellum
● Has both excitatory and inhibitory actions
● Largely responsible for coordination of
sense,and integration of sensory input
● Controls fine movement, balance position sense
and integration.
● Cerebral circulation receives 15% of the cardiac output or
750ml/min
● The brain does not store nutrients and requires high blood flow
○ Glucose is the only nutrient that crosses
the blood-brain barrier, it is consumed by
the brain. It helps the brain function.
○ If hypoglycemic, and cannot sustain the

10
 nutritional requirements of the brain
(glucose) will lead to LOSS OF
CONSCIOUSNESS
● The brian’s blood pathway is unique as it is against gravity

CRANIAL NERVES

● CN 1 – Olfactory Nerve
○ Sensory
○ Major function: Sense of smell
○ Locations of cells whose axons from the nerve:
Nasal epithelium

● CN II – Optic Nerve
○ Sensory
○ MF: Vision
○ Location of cells: Retina

● CN III – Oculomotor Nerve

○ Motor
○ MF: Eye movements, pupillary constriction and
accommodation, muscle of upper eyelid
○ Location of cells: Oculomotor nucleus in midbrain;
Edinge Westphal

● CN IV – Trochlear Nerve
○ Motor
○ MF: Eye movements (Intorsion and downward gaze)
○ Location of cells: Trochlear nucleus in midbrain

● CN V – Trigeminal Nerve
○ Sensory and Motor
○ MF: Somatic sensation from face, mouth,
cornea; muscles of mastication
○ Location of cells: Trigeminal motor
nucleus in pons: trigeminal sensory
ganglion (Gasserian Ganglion)

Cerebral Arteries ● CN VI – Abducens Nerve

○ Motor
CNS: SPINAL CORD ○ MF: Eye movements (Abduction or lateral
● The vertebral column is made up of 33 bones movements)
● Thespinal cord and medulla form a continuous structure about ○ Location of cells: Abducens nucleus in
45cm(18in) long and about the thickness of a finger pons
● Contrary the brain ,spinal cord consist of gray matter inside
and white matter outside and protected by meninges
● The spinal cord is an H-shaped structure ● CN VII – Facial Nerve
● The Lower position of the H is the anterior horn, and upper ○ Sensory and Motor
position is called the posterior horn, both serving reflex activity ○ MF: Controls the muscles of facial expression;
● The thoracic region of the spinal cord has a projection of the taste from anterior tongue; lacrimal and salivary
crossbar of H is called the lateral horn cross section of spinal glands
cord ○ Location of cells: Facial motor nucleus in pons;
superior salivatory nuclei in pons: geniculate
ganglion

● CN VIII – Vestibulocochlear (Auditory) Nerve

○ Sensory
○ MF: Hearing, sense of balance
○ Location of cells: Spiral ganglion,

11
 ● CN IX – Glossopharyngeal Nerve
○ Sensory and Motor
○ MF: Sensation from posterior tongue and
pharynx: taste from posterior tongue:
carotid baroreceptors and
chemoreceptors: salivary gland
○ Location of cells: Nucleus ambiguus in
medulla: inferior salivatory nucleus in
pons: glossopharyngeal ganglia
● CN X – Vagus Nerve
○ Sensory and Motor
○ MF: Autonomic functions of gut, cardiac
inhibition, sensation from larynx and
pharynx, muscles of vocal cords;
swallowing
○ Location of cells: Dorsal motor nucleus of
vagus; nucleus ambiguus; vagal nerve
ganglion
● CN XI – Spinal Accessory Nerve
○ Motor
○ MF: Shoulder and neck muscles
○ Location of cells: Spinal accessory
nucleus in superior cervical cord
● CN XII – Hypoglossal Nerve
○ Motor
○ MF: Movements of tongue
○ Location of cells: Hypoglossal nucleus in
medulla
● Each spinal cord contains a dorsal root and a
ventral root
● The dorsal root are sensory and transmits
sensory impulses from a specific areas of the
body to dorsal ganglia of the spinal cord
● The ventral root are motor and transmits
impulses from the spinal cord to the body
PERIPHERAL NERVOUS SYSTEM: AUTONOMIC NERVOUS
SYSTEM
● Regulates the activities of internal organs anc plays a
role in the maintenance of internal homeostasis
PARASYMPATHETIC NERVOUS SYSTEM
● Controls visceral function
● Mainly functions in quiet and stressful conditions
● Neurotransmitter: Acetylcholine
● Located in the craniosacral division
● Assessing the cranial nerves
SYMPATHETIC NERVOUS SYSTEM
● Fight and flight response
● Activates under stressful condition
● Neurotransmitter: norepinephrine (NEP) or adrenaline
● The response is adrenergic
● Located in the thoracolumbar division
PERIPHERAL NERVOUS SYSTEM: SOMATIC NERVOUS
SYSTEM
● Responsible for carrying motor and sensory information to
and from the nervous system and all voluntary muscle
movements
● Consists of:
○ Sensory neurons: carries information from
nerves to the CNS
○ Motor neurons: carries information from CNS to
the nerves
NEUROLOGICAL EXAM / ASSESSMENT
HEALTH HISTORY
● Details about the onset, character, severity, location,
duration, and frequency of symptoms and signs;
precipitating, aggravating, and relieving factors; progression,
remission, and exacerbation;
any family history of genetic diseases
● History of trauma or falls that may have involved the head or
spinal cord
● Use of alcohol and medications
CLINICAL MANIFESTATION
● Assess for major symptoms which may point to neurological
disturbance such as the following:
○ Pain
○ Paresthesias
○ Seizures
○ Visual disturbance
○ Weakness
○ Vertigo
○ Abnormal sensation
○ Imbalance
PHYSICAL EXAMINATION
● Detailed and thorough physical examination is
needed to evaluate the functioning of the nervous
system
Assessing the cerebral function
● Mental status: appearance, posture, manner of
speech, level of consciousness, orientation
● Intelligence quotient
● Thought process
● Emotional status
● Perception: assess for agnosia
● Motor ability
● Language ability: assess for aphasia
1. Olfactory Nerve (CN I)
● Done by asking the person to smell something very
familiar with the eyes closed
2. Optic Nerve (CN II)
● Done by using a snellen chart to test the visual acuity
3. Oculomotor, Trochlear, and Abducens (CN III, IV, VI)
● Done by observing ocular rotation, conjugate
movement, presence of nystagmus, testing of
12
 pupillary reflexes, and checking for ptosis
● To differentiate conductive and sensorineural hearing loss
4. Trigeminal Nerve (CN V) → Weber's test: Place the tuning fork in the centre of the
● Sensory forehead and ask which ear sound is heard louder
→ Touch one side of the patient's face slightly with a (Normal response: the sound is heard equally in both
cotton ball and ask the patient to identify whether ears)
both sides of the face was touched or not
→ Touch the sides of the face gently with a sa
safety pin and ask the patient to verbalize the
difference in the sensation of pain
→ Testing for corneal reflex and pain sensation
● Motor
→ Observe skin over the temporal and masseter
muscles. Concavity or asymmetry suggests
atrophy. The tip of the mandible should be in the
midline.
→ Ask the patient to clench his or her jaws.
Palpate the masseter and temporal muscles for
asymmetry of volume and for tone.
→ Observe for deviation of the tip of the mandible as
the jaws are opened.
→ Ask the patient to move the jaw from the side to
side against the resistance of your palm. The 7. Glossopharyngeal & Vagus Nerves (CN IX & X)
paralyzed side will not move laterally. ● Assess voice: hoarse/nasal
→ For the stretch reflex, demonstrate to the patient ● Examine palate of uvular displacement
what you are going to do. Have the jaws half ● Observe for symmetrical rise of uvula and soft palate when
open and relaxed. Then place your index finger patient says "Ah"
on the tip of the mandible and tap your finger ● Elicit gag reflex
gently but briskly with a reflex hammer. → Stimulate back of throat each side
→ Normal to gag each time
5. Facial Nerve (CN VII)
● The examiner should observe for the symmetry of 8. Accessory Nerve (CN XI)
the face when the patient performs movement life ● Examine for any atrophy or asymmetry of trapezius muscle
smiling, frowning, whistling elevating eyebrows, from behind while patient shrugs shoulders against
closing of the eyelid as the examiner tries to open it resistance
● Observe for flaccid face ● Note for any asymmetry of sternocleidomastoid muscle as
● Ability to determine sugar & salt the patient turn head against resistance

- Hypoglossal Nerve (CN XII)

● Ask the patient to protrude tongue to note any
unilateral deviation or tremors
● Test the strength of the tongue by having the patient
move the tongue side to side against a tongue
depressor.

TESTING FOR REFLEXES

Technique
● A reflex hammer is used to elicit the reflex
● Testing of the reflexes should give symmetrically equivalent
results
○ deviation in results means px suffering in neuroogic
6. Acoustic/Vestibulocochlear Nerve (CN VIII) deficit
● For hearing Observations
○ Whisper test: ask the patient to repeat the numbers ● Absence of reflexes is important
● Deep tendon reflexes (DTR) are graded from 0 to 4+
which the examiners by standing behind the patient
and masking the other ear. Note for asymmetry in
hearing. Grading Interpretation
● To differentiate conductive and sensorineural hearing loss
→ Rinnes test: Place tuning fork next to the mastoid process 0 No response
and then behind the ear. Then ask the patient in which 1+ (+) Diminished reflex
position the sound is heard louder. (Normal response: 2+ (++) Normal response
sound should be heard louder in second)
3+ (+++) Brisk/hyperactive response
4+ (++++) Clonus/repetitive response

13
Testing for Superficial reflexes ● Perfusion study that captures a moment of cerebral blood
flow at the time of injection of a radionuclide and helps to see
the contrast between normal and abnormal tissue
Reflex Method Response Interpretation
Nursing Interventions
Corneal Touch the Blink May be absent
● Patient preparation & monitoring
Reflex sclera of response is in case of CVA
each eye expected or coma ● Teaching about what to expect
on the outer ● Before the test, the woman who is breastfeeding is instructed
corner with to stop
clean wisp ● Monitor for allergic reactions during and after the procedure
of a cotton
D. MAGNETIC RESONANCE IMAGING (MRI)
● Uses a strong magnetic field to obtain the images of the body
Gag reflex Touch the Equal Absent in
● Does not involve ionizing radiation
posterior elevation CVA,paralysis
potion of the of uvula and ● Will detect cerebral abnormalities earlier than other tests
pharynx with gag ● Test takes up an hour to complete
a cotton ● Procedure is painless
tipped ● Loud sound is expected during the procedure
applicator ● A noninvasive procedure.
● The image of the organs is far better than a CT Scan.

Plantar reflex Stroking the Flexion of the Serious Nursing Interventions

lateral toe is central ● Explain about the procedure and what to expect
side of the expected nervous
● All metallic objects should be removed
tongue with system
a tongue blade dysfunction → Due to the magnets
● Clear history to know the presence of any metallic objects in
the body
Babinski Stroke the Toes get Toes fan out in → The magnets could heat up and the patient may
reflex lateral contracted adults with experience pain.
aspect of and nervous ● No metallic patient care equipment should be brought near
the sole of draws system the MRI room
the foot together disorders
E. CEREBRAL ANGIOGRAPHY
● It is an x-ray study of the cerebral circulation with a
contrast agent injected into a selected artery
→ Usually done in the Cath lab.
COMMON DIAGNOSTIC TESTS
→ The diagnostic catheter will be inserted from the femoral
artery to the cerebral artery, with a guide wire. Then dye is
A. COMPUTED TOMOGRAPHY (CT) SCAN injected near the carotid artery.
→ Done one side at a time
1. Non-invasive and painless
2. High degree of sensitivity for detecting lesions ● It is a valuable tool to investigate vascular disease,
3. Makes use of a narrow x-ray beam to scan different areas of aneurysms, and arteriovenous malformations.
the body Nursing Interventions
→ 2 types: plain and with contrast ● The patient should be well hydrated.
● The locations of the appropriate peripheral pulses are
Nursing Interventions marked.
1. Teach the patient to lie quietly throughout the procedure ● The patient is instructed to remain immobile during
2. Sedation can be used for agitated patients with iodine or the process and is told to expect a brief feeling of
shellfish allergy should be reported in case of CT with warmth a metallic taste when the contrast agent is
contrast injected.
3. An IV line and a period of fasting (usually 4 hours are ● Observe for signs and symptoms of complications.
required prior to the study → Complications are possible embolism
→ When we insert catheter, there is a possibility that
B. POSITRON EMISSION TOMOGRAPHY (PET) SCAN) a thrombus is dislodged, and may travel to
● Computer-based nuclear imaging technique that produces pulmonary/cardiac/cerebral area
images of actual organ ● The color and temperature of the involved extremity
● Functioning and produces a series of two-dimensional views are assessed to detect possible embolism.
at various levels ● → Assess for possible embolism post-cerebral
angiography.
Nursing Interventions
● Explaining the test and the sensations F. MYELOGRAPHY
● Relaxation exercises may reduce anxiety during the test
● It is an x-ray of the spinal subarachnoid space taken
after the injection of a contrast agent into the spinal
C. SINGLE PHOTON EMISSION CT(SPECT)
subarachnoid space through a lumbar puncture.
● Three-dimensional imaging technique that uses radionuclides ● It outlines the spinal subarachnoid space and shows
and instruments to detect single photos any abnormality of the spinal cord.

14
 ● Less sensitive as compared to CT and MRI.
Nursing Intervention
● Inform about what to expect during the procedure
and position change required during the same
preparation for lumbar puncture.
● After the procedure patient should be in fowler's position.
● The patient is encouraged to drink water.
● Observe for signs of complication.
G. ELECTROENCEPHALOGRAM (EEG)
● It represents a record of the electrical activity generated in
the brain obtained through electrodes applied on the scalp.
● The EEG is a useful test for diagnosing and evaluating
seizure disorders, coma, or organic brand syndrome.
● Tumors, brain abscesses, blood clots, and infections and also
used in the determination of brain death.
● The standard EEG takes 45 to 60 minutes, 12 hours for a
sleep EEG.
Nursing Interventions
● Anti-seizure agents (e.g. Dilantin, D, tranquilizers,
stimulants, and antidepressants should be withheld
24 to 48 hours before EEG
● Coffee, tea, chocolate, and cola drinks are omitted in
the meal before the test because of their stimulating
effect.
• Avoid any variable that may alter the result
of the exam
● An EEG requires patient cooperation and the ability
to lie quietly during the test.
• It is difficult to perform this procedure on a
child since the client is required to lie
steadily.
H. ELECTROMYOGRAM(EMG)
● obtained by introducing needle electrodes into the
skeletal muscles to measure changes in the
electrical potential of the muscles and the nerves
leading to them.
● The electrical potentials are shown on an
oscilloscope and amplified by a loudspeaker so that
both the sound and appearance of the waves can be
analyzed and compared simultaneously.
● An EMG is useful in determining the presence of a
neuromuscular disorder and myopathies.
Nursing Intervention
● The procedure is explained and the patient is
warned to expect a sensation similar to that of an
intramuscular injection as the The muscles
examined may ache for a short time after the
procedure.
○ Some patients may be unable to continue due
to pain.
L. LUMBAR PUNCTURE & EXAMINATION
● Procedure by which CSF is withdrawn by inserting a needing
into the subarachnoid space
● Indications:
→ To obtain CSF for examination
→ To measure or reduce the pressure of CSF
→ To detect subarachnoid block
→ To administer medicine intrathecally
→ introduction between intervertebral space
Preprocedure
● Obtain written consent
● Explain the procedure to the patient and tell what to expect
● Reassure the patient and provide support
● Instruct the patient to void before the procedure
● Assist the patient to lateral recumbent position with maximum
flexion of the thighs (parang fetal position)
Procedure
● Performed by the physician
● Nurse assists the patient to maintain a position to avoid
sudden movement, which can lead to trauma.
● The patient is encouraged to relax and is instructed to
breathe normally
● Describe the procedure step by step as it proceeds (Pag mas
malaki pasyente, mas mahirap ipaflex)
● The physician cleanses the puncture site with an antiseptic
solution and drapes the site
● Local anesthetic is injected to numb the puncture site
● A spinal needle is inserted into the subarachnoid space
through the third and fourth or fourth and fifth lumbar
interspace
● A specimen of CSF is removed and usually collected in three
test tubes, labeled in order of collection
● A small dressing is applied to the puncture site o The tubes
of CS are sent to the laboratory
immediately
Postprocedure
● Instruct the patient to lie prone for 2 to 3 hours to separate
and alignment of the dural and arachnoid needle puncture in
the meninges to reduce leakage of CSF
● A post puncture headache is common after the procedure
which is usually relieved by positioning, rest, analgesic
agents, and hydration
→ Instruct the patient to lie for about 6 hours to prevent a
spinal headache.
J. CEREBROSPINAL FLUID ANALYSIS
● CSF should be clear and colorless
● Pink, blood-tinged or grossly bloody CSF may indicate a
cerebral contusion or laceration
Neurological assessment checklist
YOUTUBE VIDEOS: MOODLE
● Glasgow Coma Scale made easy
● The NIHSS Scale
● Cranial Nerve Examination Nursing | Cranial …
● Routine Neurological Assessments- Nursing …
15
 ● BLUMBERG’S SIGN OR REBOUND TENDERNESS II. URINARY CATHETERIZATION

REVIEW OF ANATOMY AND PHYSIOLOGY OF URINARY

SYSTEMS
Physiology of Urinary Elimination
Upper Urinary Tract
● Kidneys
● Ureter
○ 25-30CM (10-12 IN) long
○ 1.25CM (0.5 IN) diameter

Lower Urinary Tract

● Bladder
No severe pain in palpation, pain only occurs during release of palpation.
● Urethra
● Pelvic floor
NOTE:

Document findings in the client record

REVIEW OF ABDOMINAL ASSESSMENT- Pages 29, 30 of 154

VIDEO: Abdominal Assessment -Clinical Skills-

For male urinary tract:

● Bladder is in front of the rectum and above the posterior
gland.
● In males, the ureter is 8 in. or 20 cm long.

24
For female urinary tract: AVERAGE DAILY URINE OUTPUT BY AGE
● In females, the ureter is 3-4 cm long.
● Female urinary tract lies posterior to symphysis pubis
AGE AMOUNT (ML)
QUESTIONS:
1-2 days 16-60
1. Do you think pelvic floor muscles can be
strengthened? provide your rationale 3-10 days 100-300
- Yes, it helps to improve bladder and
bowel control. 10 days – 2 months 250-450
- Improved recovery after pregnancy
2. Explain how exercising the pelvic floor muscles 1-3 years 500-600
helps the pelvic floor.
- Pelvic muscles weaken as a person 3-5 years 600-700
aged especially women due to the
menopausal stage (as well as during 5-8 years 700-1,000
childbirth, chronic constipation,
overweight, aging, and lack of general 8-14 years 800-1400
fitness). Exercising helps strengthen the
pelvic floor muscle. 14 years through adulthood 1,500
- Exercises: Kegel exercise
Older Adulthood 1500 or less

NOTE:

Infants’ urine is not yet concentrated since their kidneys are

not yet fully developed.

1-3 years old: start of toilet training.

ALTERATIONS IN URINE PRODUCTION AND ELIMINATION

● Polyuria: Excessive urine production
○ more than 1,500 a day
○ Polydipsia – excessive fluid intake
● Oliguria: Low urine output; Less than 30 mL per hour.
○ Less than 500mL per day.
● Anuria: No urine/Without urine
○ indicates problem with kidney
● Urinary frequency: Voiding at frequent intervals; The need to
urinate many times during the day/night; Urinates 4-6 times a
day
● Nocturia: Voiding more than two or more times at night on a
regular basis. Common to toddlers or preschoolers
● Dysuria: Voiding that is painful; Sensation of pain or burning
sensation when urinating
● Urgency: frequent sudden urge to urinate and is difficult to
control
● Incontinence: Lack of voluntary control over urination, loss of
bladder control
■ 4-5 years of age – acquired voluntary
voiding
● Retention: Unable to empty all urine in bladder
○ Urine accumulates in bladder
● Enuresis: Bed wetting, involuntary urination in children

FACTORS INFLUENCING A PERSON’S URINARY ELIMINATION

● Growth and development
○ School age: proper hygiene to prevent UTI
especially to girls.
○ Old age: weakened pelvic muscles
Purpose of palpation of bladder: to check the residual urine ● Psychosocial factors
● begin at the midline ○ stress
● Fluid intake

25
 ○ What fluids does the client take daily?
○ Required amount: 6-8 glasses a day
○ Caffeinated drinks, ask how many cups of coffee or
other beverages iniinom per day.
● Medications
○ Furosemide: Increases urine output
● Muscle tone
○ Affected by aging
● Various diseases and conditions
○ Quadriplegic
○ Hypertension
○ Heart Disease
○ Neurologic
○ Benign Prostatic Hyperplasia (BPH)
○ Cancer
○ Diabetes
● Surgical and diagnostic procedure
○ Transurethral Resection of the prostate (TURP)
○ Cystoscopy: continuous irrigation in the catheter
○ Spinal/Epidural anesthesia
● Environmental factors
○ Neurologic dysfunction = immobility
○ safety pin/tape
○ syringe with sterile water
○ receptacle/basin
SELECTING A URINARY CATHETER
● Determine the catheter length by the client’s gender
○ Adult female: 22-cm catheter
○ Adult male: 40-cm catheter
● Determine appropriate catheter size of the urethral canal
○ Children: 8FR or 10FR
○ Adults:
■ Women: 14FR (green)
■ Men: 16FR/18FR *Use of 10cc (orange)
syringe
■ 12FR (white)
■ 20-24 FR (three-way) for operation
○ straight catheter - no balloon
○ indwelling catheter - with balloon
● the smaller balloon allow complete urine emptying?
● 30ml balloon commonly use for surgery (TURP)
● 5ml - 10 ml commonly used in normal catheterization
● TURP - Transurethral Resection of the Prostate

CATHETERIZATION
● Introduction of a catheter through the urethra to the bladder
for the purpose of withdrawing urine
● Only performed only when absolutely necessary since this
can introduce microorganisms to the body.

PURPOSES
1. To prevent and relieve over distention of the bladder owing to
the inability to urinate
2. To empty the bladder as a measure, preparatory to instillation,
irrigation, or operation or when obstetrical or post-operative
condition contraindicates a voluntary urination in the normal
way
3. To obtain a urine specimen
● To identify cause of infection
● 24 urine albumin: make sure to check px chart
● Store the specimen in a refrigerator
4. To assess the amount of residual urine if the bladder empties
incompletely
● check if naka umbok parin yung bladder.
5. To provide for intermittent or continuous bladder drainage and
irrigation
6. To manage incontinence when other measures have failed

EQUIPMENT
● Screen (if in the ward)
● Blanket: for privacy
● Flushing tray
● Bed pan
● Rubber sheet
● Disposable gloves
● catheterization tray with the following:
○ Catheter: The bigger the number, the bigger the
catheter
○ Lubricant
○ sterile gloves
○ kidney basin
○ Flashlight
○ Specimen bottle
○ Antiseptic cleaning solution
○ cotton balls
○ forceps

26
 for specimen collection only

FEMALE CATHETERIZATION

PROCEDURE
1. Assemble equipment. Prepare a sterile catheterization set.
2. Wash hands
3. Provide for privacy and explain procedure to client to promote
cooperation
4. Position client into dorsal recumbent or side lying position
(Female) supine position (male)
5. Drape client: place blanket in a diamond fashion

CONDOM CATHETER
● After insertion wait for 30 minutes then check every 4 hours
and urine flow
● Assess the penis for urine discoloration, redness, blisters
● Check for latex allergy

6. Apply gloves
7. Wash perineal area and dry
a. Apply rule of 7:
i. From Urethra to vagina
ii. Right labia minora
iii. Left labia minora
iv. Right labia majora
v. Left labia majora
vi. Urethra to vagina
vii. Vagina to anus
8. Remove gloves and wash hands.

27
 9. Open the catheterization kit. Use a wrapper to establish a 26. Wash hands. Reduces transmission of microorganism
sterile field. Prevents transmission of microorganisms from 27. Document
table or work area to sterile supplies
10. Apply sterile gloves Use 5-10 grams of gel
11. Lubricate the catheter for about 1 to 2 inches being careful
not to fill the eyes of the catheter. Eases insertion of catheter
through urethral canal.
→ Do not fill the eyes of the IFC, may cause blockage
→ Apply on the tip and the body of the catheter.
→ Apply as many KY as possible, it is safe because it is
water soluble
12. cleanse urethral meatus, retract labia, pick up cotton ball with
antiseptic solution and wipe from front to back

13. Pick up the catheter with your dominant hand. ask the client
to breakdown gently and insert catheter through urethral
meatus
a. Advice to deep breathe then insert the catheter
b. advance 2-3 inches

VIDEOS:
Straight Catheter Insertion on Female: Clinical Nursing Skills | @…
Catheterization with indwelling catheter (Woman)

HOW TO INFLATE A CATHETER BALLOON

14. Advance catheter a total of 2 to 3 inches, when urine appears
advance another 1 to 2 inches. Do not
force against resistance. Female urethra is short. Presence of
urine indicates that catheter tip is in
bladder or lower urethra. Advancement of catheter ensures
bladder placement.
15. Place the end of the catheter in the urine receptacle.
16. Collect urine specimen as needed. Allows sterile specimen to
be obtained for culture analysis.
17. When urine flow starts to decrease, withdraw catheter slowly
about 1 cm at a time till urine barely drips, then withdraw
INDWELLING WITH RETENTION BALLOON
18. Reattach the water-filled syringe to the inflation port
19. Inflate the retention balloon by injecting required amount of
solution Inflation of balloon anchors catheter tip in place
above bladder outlet to prevent removal of catheter. A 5 ml
balloon is commonly used. Do not over inflate or under inflate
the balloon.
20. If the client experiences pain during balloon inflation, deflate
the balloon and insert the catheter further. The balloon may
not be entirely in the bladder.
21. Once inflated, gently pull the catheter until the retention
balloon is resting against the bladder neck. Anchoring
catheter reduces pressure on urethra, thus reducing
possibility of tissue injury.
22. Tape the catheter to inner thigh.
23. Place drainage bag below the level of the bladder.
a. urine bag should not be higher than the bladder
24. Remove gloves, dispose of materials
25. Help client adjust position. Maintains comfort and security.
● For Adult Indwelling Foley Catheter: Use 5 or 10 mL of sterile
distilled water to inflate the balloon can minimize urine
leakage to ensure that the catheterization continues safely.
EQUIPMENT
● Sterile Water- ideal solution for balloon in catheterization/
→ Osmolality is 0, same with urine
● Sodium Chloride - with salt contents
○ Difference from sterile water: Sodium chloride can
crystallize, difficult to deflate
● Syringe without needle
MALE URINARY CATHETERIZATION
PROCEDURE
1. Assemble equipment. Prepare sterile catheterization set.
Ensure smooth flow of procedure.
2. Wash hands Reduces transmission of microorganisms.
Infection is common after Catheterization.
3. Provide for privacy and explain procedure to client. Ensures
cooperation and aids in relaxation during procedure
4. Position client into supine position with thighs slightly
abducted. A comfortable position for client that aids in
visualization.
5. Drape client: drape upper trunk with bath blanket and cover
lower extremities with bed sheets. Avoids unnecessary

28
 exposure of body parts and maintains client‟s comfort.
6. Apply gloves. Reduce transmission of microorganisms
7. Wash the perineal area and dry. Reduces microorganisms
near urethral meatus
8. Remove gloves and wash hands.
9. Open the catheterization kit. Use a wrapper to establish a
sterile field. Prevents transmission of microorganisms from
table or work area to sterile supplies
10. Apply sterile gloves. Allows nurse to handle sterile supplies
without contamination.
11. Lubricate the catheter for about 6 to 7 inches. Eases insertion
of catheter through the urethral canal.
12. Lift penis with one hand, cleanse area of meatus with cotton
ball in a circular motion. Move from meatus toward the base of
the penis. Reduces the number of microorganisms at urethral
meatus and moves from areas of least to most contamination.
Dominant hand remains sterile *Retract foreskin in the
uncircumcised male client Accidental release of foreskin or
dropping of penis requires process to be repeated because
area has been contaminated.
13. Lift penis perpendicular to the body, steadily insert catheter
into the meatus. Straightens urethral canal to ease catheter
insertion.
14. Ask the client to breathe deeply and rotate catheter gently if
slight resistance is met, advance catheter for about 7 to 9
inches. The adult male urethra is long. It is normal to meet
resistance at the prostatic sphincter, just hold catheter firmly
against sphincter without forcing the catheter. After few
seconds, sphincter relaxes and catheter is advanced. VIDEO:
15. Hold the catheter securely while the bladder empties into a Straight Catheter Insertion on Male - Clinical Nursing Skills | @L…
sterile receptacle. Collection of urine prevents soiling and
provides output measurement. CARE AND REMOVAL OF THE INDWELLING CATHETER
16. When urine flows starts to decrease, withdraw the catheter
● Catheter care
slowly about 1 cm at a time till urine barely drips, then
→ is the cleansing of the perineum and the first two inches of
withdraw.
the exposed catheter every eight hours.
INDWELLING WITH RETENTION BALLOON ● 7.5 betadine use in OR, then rinse with sterile water and pat
dry
17. Continue insertion for another 1-3 inches.
18. Reattach the water-filled syringe to the inflation port.
CONSIDERATIONS
19. Inflate the retention balloon Inflation of balloon anchors
1. Clients with indwelling catheter require specific perineal
catheter tip in place above bladder outlet to prevent removal of
hygiene care to reduce the risk of urinary tract infection (UTI)
catheter. A 5 ml balloon is commonly used. Do not over inflate
2. The use of powders or lotions on the perineum is
or under inflate the balloon.
contraindicated because of the risk of growth of
20. If the client experiences pain during balloon inflation, deflate
microorganisms, which may ascend the urinary.
the balloon and insert the catheter further. The balloon may not
a. Results to ascending infection
be entirely in the bladder.
3. Removal of a retention catheter is a skill requiring clean
21. Once inflated, gently pull the catheter until the retention
technique
balloon is resting against the bladder neck. 4. If the retention catheter balloon is not fully deflated. Its
22. Tape the catheter to the abdomen or thigh. Anchoring catheter removal can result in trauma and subsequent swelling of
reduces pressure on urethra, thus reducing possibility of tissue urethral meatus and urinary retention can occur.
injury. a. The amount infused should also be the amount
23. Place drainage bag below the level of the bladder. removed
24. Remove gloves, dispose of materials & wash hands Reduces
b. E.g. If 5cc is introduced, 5cc should also be
transmission of microorganisms removed
25. Help client adjust position. Maintains comfort and security. 5. If the catheter was in place for more than several days, the
26. Document. client may experience dysuria resulting from inflammation of
the urethral canal and because of decreased bladder tone.
Client may urinate frequently

EQUIPMENT
● Disposable gloves
● Rubber sheet
● Blanket

29
For Catheter Care: 20. Remove adhesive tape used to secure and anchor catheters.
● Soap Cleanse any residue from skin. Removes source of irritants on
● Wash cloth skin. Allows for easy catheter removal.
● Basin
21. Insert hub of syringe into inflation valve (balloon proof).
● Water
Aspirate the entire amount of fluid used to inflate the balloon.
For Removing a Catheter: Deflate balloon to allow removal. If the solution is not
● Syringe completely aspirated, it can cause trauma to the urethral wall
● Waterproof Pad as the catheter is removed.
● Alcohol Swab 22. Pull the catheter out smoothly and slowly. Prevents trauma to
urethral mucosa.
23. Wrap contaminated catheter in waterproof pad. Unhook
PROCEDURE collection bag and drainage tubing from bed. Prevents
1. Determine how long catheter has been in place contamination of nurse‟s hands.
2. Observe any discharge or encrustation around the urethral 24. Reposition client as necessary. Cleanse perineum. Lower level
meatus (also observe the characteristics of the discharge) of bed and position side rails accordingly. Promotes client
3. Assess complaint of pain or discomfort comfort and safety.
4. Assess urine color, clarity, odor, and amount 25. Measure and empty contents of collection bag. Provides
5. Wash hands accurate recording of urinary output.
6. Provide privacy 26. Dispose of all contaminated supplies
7. Raise the bed to appropriate working height. If the side rails
are raised, lower the side rail on the working side.
8. Prepare equipment and bring to bedside PERFORMING CATHETER IRRIGATION
9. Position client and cover with bath blanket exposing only
perineal area.
a. Female: Dorsal recumbent position
b. Male: Supine position

CATHETER CARE
10. Place rubber sheet under client
11. Provide routine perineal care
12. Assess urethral meatus and surrounding tissues for
inflammation, swelling and discharge and ask client if burning
or discomfort is felt. Determines local infection and status of
hygiene.
13. Using a clean wash cloth, wipe in circular motion along length
of catheter for about 10 cm (4 inches). Reduces presence of
secretions or drainage on outside catheter surface.
14. Replace as necessary the adhesive tape that anchor‘s
catheter to the client's leg or abdomen. Secures catheter in
place.
15. Avoid placing tension on the catheter. Tension causes urethral
trauma.
16. Replace tubing and collection bag as necessary, according to
agency policy, adhering to principles of surgical asepsis.
Urinary tubing and collection bag should be changed if there closed bladder irrigation system
are signs of leakage, odor or sediment build up.
17. Check drainage tubing and bag to ensure that: PURPOSE
a. Tubing is not looped or positioned above the level
of the bladder. Prevents pooling of urine and reflux 1. To maintain the patency of a urinary catheter and tubing.
of urine into bladder. 2. To free a blockage in a urinary catheter or tubing.
b. Tubing is coiled and secured onto bed linen.
Prevents looping of tubing and subsequent pooling TWO TYPES OF IRRIGATION SYSTEMS
of urine 1. Closed bladder irrigation system – provides intermittent or
c. Tube is not kinked or clamped. Prevents stasis or continuous irrigation of the system without disrupting the sterile
urine in the bladder. alignment of the catheter and drainage system, thus
d. Collection bag is positioned appropriately on the bed decreasing the risk of bacteria entering the urinary tract.
frame. Ensures appropriate drainage of urine. a. Used most frequently in clients who have had
18. Collection bag should be emptied as necessary but at least 8 genitourinary surgery.
hours. Urine in a collection bag is an excellent medium for b. less infection
growth of microorganisms. 2. Open irrigation system – is also used to maintain catheter
patency and when bladder irrigations are required less
CATHETER REMOVAL frequently and there are no blood clots or large mucous shreds
19. Place a waterproof pad. Prevents soiling of bed linen. in the urinary drainage.
a. Female: between thighs
b. Male: over thigh

30
EQUIPMENT iii. Note amount of fluid remaining in
Closed Continuous Method existing irrigating solution container.
1. Sterile irrigating solution 1. If fluid cannot enter or if fluid
2. Irrigation tubing with clamp draining is less than amounts
3. IV pole going in, stop the irrigation,
assess and notify the
Closed Intermittent Method physician.
4. Sterile irrigating solution at room temperature iv. Review input and output record.
5. Sterile graduate container Determines baseline for prior output
6. Sterile 30 – 50 ml syringe (used to instill irrigant into catheter) measures.
7. Sterile 19 – 22 gauge 1 inch needle 3. Assess the client for presence of bladder spasms and
8. Antiseptic swab discomfort. Reveals need for bladder irrigation.
9. Clamp
Performance Phase
Open Intermittent Method 4. Wash hands. Reduces transmission of microorganisms.
10. Sterile irrigating solution at room temperature 5. Explain procedure to client. Helps client relax and promotes
11. Asepto syringe with bulb cooperation
12. Sterile kidney basis 6. Provide privacy. Promotes client‟s self-esteem.
13. Waterproof drape 7. Position client in supine position and remove tape that is
14. Sterile solution container anchoring catheter to client. Allows for client comfort.
15. Antiseptic swab 8. Assess lower abdomen for signs of bladder distention.
16. Gloves Detects if catheter or closed irrigation system is
17. Tape malfunctioning, blocking urinary drainage.

PROCEDURE Closed Intermittent Irrigation

Preparatory Phase
1. Check client‘s record to determine:
a. Purpose of closed bladder irrigation. Allows nurse
to anticipate observations to make.
b. Doctor‘s order for type and amount of irrigant.
Ensures that correct medication or solution and
amount will be administered.
c. Type of irrigation: continuous or intermittent. Allows
nurse to select proper equipment.
d. Type of catheter used:
i. Triple lumen – One lumen to inflate
balloon, One to instill irrigant solution,
One to allow outflow of urine
ii. Double lumen – One lumen to inflate
balloon, One to allow outflow of urine
9. Pour prescribed room-temperature sterile irrigating solution
in sterile container.
10. Draw sterile solution into syringe using aseptic technique.
Ensures sterility of irrigating fluid.
11. Clamp indwelling retention catheter below soft injection port
or on drainage tubing. Occlusion of catheter provides
resistance against which can be forcefully instilled into
catheter.
12. Apply gloves. Reduces risk of exposure to body fluids.
13. Cleanse catheter injection port with aseptic swab. Reduces
transmission of infection.
14. Insert needle of syringe through port at 30o angle. Ensures
needle tip enters lumen of catheter and that needle does not
puncture tubing.
15. Inject fluid into catheter and bladder. The injection dislodges
clots and sediment.
16. Withdraw syringe and remove clamp, allow solution to drain
into urinary drainage bag. (Tubing clamped temporarily to
allow instilled fluid to remain in bladder, especially if irrigant is
medicated). Allows drainage to flow via gravity.

Closed Continuous Irrigation

1. Apply gloves and using aseptic technique, insert (spike) tip of
sterile irrigation tubing into bag containing irrigation solution.
Reduces transmission of microorganisms.
2. Close clamp on tubing and hang bag of solution on IV pole.
Prevents loss of irrigating solution.
3. Open clamp and allow solution to flow through tubing,
keeping end of tubing sterile; close clamp.
4. Removes air from tubing.
5. For continuous irrigation, calculate drip rate and adjust
clamp on irrigation tubing accordingly; be sure clamp on
drainage tubing is open, and check volume of drainage in
drainage bag.
- Ensures continuous even irrigation of catheter
2. Assess the following:
system. Prevents accumulation of solution in
a. Color of urine and presence of mucus and clots.
bladder, which may cause bladder distention and
Indicates if client is bleeding or sloughing tissue
possible injury.
and determines necessity for increasing irrigation
6. For intermittent flow, clamp tubing on drainage system,
rates.
open clamp on irrigation tubing and allow prescribed amount
b. Palpate bladder
of fluid to enter bladder; close irrigation tubing clamp and
c. Existing closed systems
then open drainage tubing clamp.
i. Note if fluid entering bladder and fluid
7. Fluid is instilled through catheter into bladder, flushing
draining from bladder are in appropriate
system. Fluid drains out after irrigation is complete.
proportions. To determine presence of
distention.
Open Irrigation
ii. Determine that drainage tubing is not
1. Apply gloves.
kinked, clamped off incorrectly or looped
2. Open sterile irrigation tray; establish sterile field and
below bladder level. Determines if
pour-required amount of sterile solution into
system is obstructed.
sterile solution container.

31
 ➢ Adheres to principle of surgical asepsis.
3. Position waterproof drape under catheter
➢ Prevents soiling of bed linen.
4. Aspirate 30 ml of solution into irrigating syringe. Prepares
irrigant for instillation into catheter.
5. Move the sterile collection basin close to client‘s thigh.
Prevents soiling of bed linen and prohibits reaching over
sterile area.
6. Wipe connection point between catheter tubing with
antiseptic wipe before disconnecting. Reduces transmission
of microorganisms.
7. Disconnect catheter from drainage tubing, allowing urine to
flow into sterile collection basis; cover open end of drainage
tubing with sterile protective cap and position tubing so it
stays coiled on top of bed. Maintains sterility of inner aspect
of catheter lumen and drainage tubing.
8. Inserts the tip of syringe into lumen of catheter and gently
instill solution. Reduces incidence of bladder spasm but
clears catheter of obstruction.
9. Withdraw syringe, lower catheter and allow solution to drain
into basin. Repeat, instilling solution and draining several
times until drainage is clear of clots and sediment. Allows
drainage to flow by gravity.
10. If solution does not return, have client turn onto side facing
nurse, if changing position does not help, reinsert syringe and
gently aspirate solution.
11. After irrigation is complete, remove protector cap from
drainage tubing adapter, cleanse adapter with alcohol swab
and reinsert adapter into lumen of catheter.
12. Anchor catheter to client‘s leg or thigh with tape.
13. Assist client into a comfortable position. Promotes relaxation
and rest.
14. Lower bed to lowest position and position side rails
accordingly. Promotes client‟s safety.
15. Dispose of contaminated supplies, remove gloves and wash
hands.

VIDEO: Bladder Irrigation Procedure

NOTE:

When the patient is with a catheter,

- Bath:soaking the body in a tub filled with water →
May cause irritation (Not advisable)
- Shower: standing under a spray of water.
(Advisable)

32
 recently introduced devices do not require this calibration. blood cell, which is, on average, around 60 to 120 days.
● Analysis of the red blood cell and its attached glycated
ADVANTAGES hemoglobin reveals the average blood glucose levels in the
client over those 2 to 4 months.
● In patients requiring insulin therapy (both type 1 diabetes and
● Normal HBAlc: 3.5 to 6 percent (15 to 42 mmol/mol).
in patients with type 2 diabetes requiring intensive insulin
● A result of glycosylated hemoglobin (HbA1c) >6.5% confirms
therapy and or sulfonylureas, flash monitoring has been
the presence of diabetes.
demonstrated to be cost-effective when compared to CBG
● Pharmacological intervention is required in clients with HBA1c
self-monitoring of blood glucose (SMBG)
levels greater than 7.0% → Metformin maintenance med can
● Interstitial glucose measurements are recorded as frequently
be started
as every 5 minutes every hour, which has the benefit of
monitoring for hypoglycemia during sleep at night

DISADVANTAGES IV. NASOGASTRIC TUBE (NGT)

Important Reminders:
● Very expensive
● Glucose is first seen in blood before it is seen in the interstitial
fluid, which the CGM measures and hence may not always be
a reliable indicator in rapidly changing blood glucose levels.
● The high cost of sensors and machines may not make this a
viable option in economically less advantaged clients and
communities where health care is not subsidized by insurance
or the government → Instead of asking the patient to do CGM
we just recommend them to perform self monitoring
RESULTS, REPORTING, AND CRITICAL FINDINGS
● Blood glucose is measured in mmol/L (millimoles per liter) or
mg/dL (milligrams per decilitre)
● Normal range: 4 to 6 mmol or about 72 to 108 mg/dL
● Common types of tubes used in the clinical setting
● Assessment points related to the specific type of tube
● Procedures for insertion of a particular tube
● Standard (universal) precautions Handling infectious
materials
● Verifying correct placement and procedures for administering
medications or feedings if appropriate
➔ Monitor: pH, Auscultation, XRay
➔ It is uncomfortable to the client if XRay is frequently
used to check if the tube is correctly placed.
● Interventions related to the care of the client
➔ Best time to feed the client, position, preparation of
feeding
● Interventions associated with complications or emergencies
that may occur
● Client/family education regarding care at home

C. LAB-BASED GLUCOSE TESTING

● Lab-based testing is required for the appropriate diagnosis of NASOGASTRIC TUBE (NGT)
diabetes. ● Description: Short tubes used to intubate the stomach
○ There is a standard landmark and measurement
prior to insertion
PREDIABETES
○ Measurement is the key to an effective NGT.
● Impaired fasting glucose range: 5.6 to 6.9 mmol per L, or 100 ● Inserted from the nose to the stomach
to 125 mg/dL. ○ NGT is indicated to a lot of complications/conditions
● Impaired (oral glucose tolerance test) glucose tolerance range
at two hours post 75 gram oral glucose ingestion: 7.8 to 11.0
mol, or 140 to 199 mg/dL.
TYPES OF TUBING
DIABETES
LEVINE TUBE
ORAL GLUCOSE TOLERANCE TEST
● Single-lumen nasogastric tube
● Oral Glucose Tolerance Test to confirm the diagnosis. ● Used to remove gastric contents via intermittent suction or to
● Advice the client to eat and drink over 150 grams per day of provide tube feedings
carbohydrate foods for three days. ● One of the most common tube used in the hospital
● The client will need to fast overnight for at least 8 to 16 hours
before the test.
● A fasting blood sample is collected, and a sweet drink
containing 75 grams of glucose is given to the client after the
fasting blood sample collection; further blood sample is
collected at two hours following the consumption of the
glucose drink.
● Glucose tolerance range at two hours post 75-gram oral
glucose ingestion: ≥11.1 mmol, or ≥200 mg/dL.
● Random venous blood glucose of at or above 11.1mmol/L
(2200 mg/dL), or fasting blood glucose at or above 7 mmol/L
(2126 mg/dL) on two or more separate occasions indicates the
client is likely to have diabetes.

HEMOGLOBIN A1C (HBA1C)

● Glucose molecules tend to attach to hemoglobin.

SALEM SUMP TUBE
● This test interprets the percentage of glucose molecules that
combine with hemoglobin to form glycated hemoglobin. ● Double-lumen nasogastric tube with an air vent
● Once glucose molecules combine with the hemoglobin, the ● Used for decompression with continuous suction
merger (glycated hemoglobin) remains for the life of the red ● Air vent is not to be clamped and is to be kept above the level
 of the stomach alternative method for assessing placement, but is not as
● If leakage occurs through the air vent, instill 30 ml of air into reliable as an x-ray or checking gastric pH
the air vent and irrigate the main lumen with normal saline → pH paper, aspirate → kidney basin (check for
(NS). bubbles), auscultation
● Usually used in patients with bleeding
C. ASSESSING RESIDUAL VOLUMES
● Check residual volumes every 4 hours, before each feeding,
and before giving medications
→ eg: medications that we’re not powderized/dissolved (baka
nakabara na)
● Aspirate all stomach contents (residual) and measure amount
● Reinstill residual feeding to prevent excessive fluid and
electrolyte losses unless the residual volume appears
abnormal

D. IRRIGATING A NG TUBE
● Performed every 4 hours to check the patency of the tube
● 1st thing to do always is assess placement before irrigating
→ If not placed properly, there is a risk for aspiration
pneumonia
● Gently instill 30 to 50 ml of water or normal saline (NS)
A. NGT INTUBATION PROCEDURE (depending on agency policy) with an irrigation syringe (or
● Place the client in high-Fowler's position asepto syringe)
● Measure from tip of nose to earlobe to xiphoid process ● Pull back on the syringe plunger to withdraw the fluid to
(NEX) to determine the length of insertion and mark with tape check patency; repeat if tube remains sluggish
● Lubricate tube about 3 inches with a water-soluble jelly only
(oil-soluble is not used) to prevent the development of E. REMOVAL OF AN NG TUBE
pneumonia if the tube accidentally slips into the bronchus
● Ask the client to take a deep breath and hold
● Instruct the client to bend the head forward, which closes the
● Remove the tube slowly and evenly over the course of 3 to
epiglottis and opens the esophagus
6 seconds (coil the tube around the hand as it is being
● Insert into the nostril, advance backward and through the
removed)
nasopharynx
➔ If there is resistance, do not attempt directly
V. GI TUBE FEEDING
because there might be an obstruction. Inserting the
tube forcefully can cause trauma or bleeding to the
A. GI TUBE FEEDING TUBES
client’s nares. Have the client rest for a while.
● Nasogastric
● Have the client take a sip of water and advance tube as the
● Nasoduodenal or Nasojejunal
client swallows
● Gastrostomy (PEG): surgically attached in the stomach
➔ Px is unconscious: no problem with gag reflex
● Jejunostomy: opening in the jejunum
➔ Px is conscious: advise the client take sips of water
● Do not force the tube
● If the client experiences any respiratory distress (coughing or
choking) during insertion, pull back on the tube and wait until
the distress subsides
➔ Most common thing that a patient may experience
during insertion
➔ STOP and let the client REST for a while
● Advance until taped mark is reached; tape in place when
correct placement is confirmed
● If feedings are prescribed, x-ray confirmation should be done
prior to initiating feedings
➔ X-RAY: most ideal assessment (best confirmatory
test to locate the accurate placement of the tube)
● When gastrointestinal (GI) tubes are attached to suction,
suction may be continuous or intermittent, with a pressure not
exceeding 25 mmHg as prescribed by the physician

B. ASSESSING NG TUBE PLACEMENT

● The most reliable method to determine placement is by x-ray
● Assess placement every 4 hours and before administering
feedings or medications
● Assess placement by aspirating gastric contents and
measuring the pH, which should be 4 or less (pH values
greater than 6 indicate intestinal placement)
● Inserting 5 to 10 ml of air into the NG tube and listening for
the rush of air over the stomach with a stethoscope is an
 CONTINUOUS
Percutaneous Endoscopic Gastrostomy (PEG) Tube
● Administered continuously for 24 hours
● An infusion pump regulates the flow
○ There is a possibility of increased glucose level (?)

Percutaneous Endoscopic Jejunostomy (PEG) Tube CYCLICA

● Administered either in the daytime or nighttime for 8 to 16

hours
● an infusion pump regulates the flow
● Feedings at night allow for more freedom during the day

C. ADMINISTERING GI TUBE FEEDINGS

● Position the client in high-Fowler’s and on the right side if
comatose to prevent aspiration
● Warm feeding to room temperature to prevent diarrhea and
cramps
● Aspirate all stomach contents (residual), measure the amount,
and return the contents to the stomach to prevent electrolyte
imbalances
● Check physician’s order and agency policy regarding residual
amounts; usually if the residual is less than 100 to 150 ml,
feeding is administered; if greater than 150 ml, hold the
feeding
● Assess tube placement by aspirating gastric contents and
measuring the pH (should be 4 or less)
● Assess bowel sounds; hold feeding and notify the physician if
bowel sounds are absent
○ The tube might not be in place
● Use a feeding pump for continuous or cyclical feedings
B. TYPES OF GI TUBE FEEDINGS
● For bolus feeding, leave the client in a high-Fowler’s
position for 30 minutes after feeding
BOLUS ○ Supine position is not allowed during and after
feeding
● Resembles normal meal feeding patterns
○ If unconscious: put the bed in a high fowlers
● Can be administered via a syringe or via an intermittent
● For continuous or cyclical feeding keep the client in a
feeding
semi-fowler’s position AT ALL TIMES
○ Asepto syringe and kangaroo pump
○ Not 5ml or 10ml syringe
● With an intermittent feeding, approximately 300 to 400 ml of
PRECAUTIONS
formula is administered over a 30- to 60-minute period every 3
● Change the feeding container and tubing every 24 hours
to 6 hours
○ to prevent infection
○ Use osterized feeding (OF)
● Do not hang more solution than will be required for a 4-hour
period to prevent bacterial growth
● Check the expiration date on the formula prior to administering
● Shake the formula well prior to inserting into container
○ Residues settle on the bottom
● Always assess placement of the tube prior to feeding
● Always assess bowel sounds; do not administer any feedings
if bowel sounds are absent
● If an obstruction occurs, try flushing with water, saline,
cranberry juice, ginger ale, or cola, if not contraindicated, after
checking placement
○ Usually distilled water is preferred
syringe feeding ● Add a drop of methylene blue to the feeding, particularly with
clients who have endotracheal or tracheal tubes; suspect
 tracheoesophageal fistula when blue gastric contents appear
in tracheal excretion and if this is noted, notify the physician ● Danger for patients with diabetes. Monitor RBS,
immediately because there is a possibility that blood sugar can
● Administer feeding at prescribed rate, or via gravity flow shoot up
(intermittent, bolus feedings) with a 60-ml syringe with the ● If OF is too viscous, add a little bit of water and
plunger removed mix/push the feeding with a tongue depressor
● Gently flush with 30 to 50 ml of water or normal saline
(depending on agency policy) with the irrigation syringe after
the feeding A. THINGS TO REMEMBER
● NGT is inserted by the attending physician
D. COMPLICATIONS OF GI TUBE FEEDINGS ● Administer feedings with the appropriate KCal computed by
● Aspiration the physician
○ may cause respiratory distress → death ● Place the patient in a semi/high fowler's position before
● Vomiting feeding.
● Diarrhea ● Maintain the patient in a sitting position for 30 minutes after
○ Warm the formula because cold formula may cause feeding.
diarrhea ● Auscultate for bubble sounds before feeding the patient to
● Clogged tube check the patency of the tube.
● Don't push the plunger, just let gravity do its thing
● If OF is thick, add a small amount of distilled water and mix
PREVENTING ASPIRATION using a tongue depressor to dilute
● Verify tube placement ● It is safe to use powdered medication, pulverize pills properly
● Do not administer feeding if residual is greater than 150 ml to avoid clogging
○ Patient is still bloated or food is not yet digested
● Keep the head of the bed elevated B. NGT PROCEDURE (CHECKLIST)
○ before and after feeding, head should be elevated
● If aspiration occurs, suction as needed, assess respiratory KNOWLEDGE
rate, auscultate lung sounds, monitor temperature for
aspiration pneumonia, and prep 1. State the purposes of Inserting NGT
2. Enumerate the indications of NGT
PREVENTING VOMITING 3. Explain the Rationale of each suggested action
● Administer feedings slowly, and for bolus feedings, make the 4. Enumerate the materials used.
feeding last for 30 minutes (by gravity)
● Do not allow feeding to run dry INSERTING NASOGASTRIC TUBE
● Do not allow air to enter the tubing
● Administer feeding at room temperature 1. Prepare the materials
● Elevate the head of the bed a. 14 or 16 Fr NG tube (smaller-lumen catheters are
● Administer antiemetics as prescribed [e.g. Metoclopramide not used for decompression in adults because
(Plasil)] they must be able to remove thick secretions.
● If client vomits, place in side-lying position
b. Water-soluble lubricating jelly
c. Stethoscope
PREVENTING DIARRHEA
d. pH test strips (measure gastric aspirate acidity)
● Use fiber-containing feedings e. Tongue blade
● Administer feeding slowly and at room temperature f. Flashlight
g. Asepto bulb or catheter-tipped syringe
PREVENTING A CLOGGED TUBE h. 1 inch wide hypoallergenic tape
i. Safety pin and rubber band
1. Use liquid forms of medication, if possible
j. Clamp, drainage bag or suction machine
○ Enteric coated meds is not included
k. Bath towel
2. Flush the tube with 30 to 50 ml of water or NS (depending on
l. Glass of water with straw
agency policy) before and after medication administration and
m. Facial tissues
before and after bolus feeding
n. Normal saline
3. Flush with water every 4 hours for continuous feeding
o. Disposable gloves

2. Wash hands, wear gloves.

VI. MEDICATIONS VIA GI TUBE
● Crush medications or use elixir forms of medications; assure
that the medication ordered can be crushed or that the
capsule can be opened
● Dissolve crushed medication or capsule contents in 5 to 10
ml of water
● Check placement and residual prior to instilling medications
● Draw up the medication into a catheter tip syringe, clear
excess air, and insert medication into the tube
○ air is not allowed to enter the tube
● Flush with 30 to 50 ml of water or NS (depending on agency
policy)
● Clamp the tube for 30 to 60 minutes (depending on
medication and agency policy)
NOTE:
➔ Reduces transmission of microorganisms
3. Explain procedure to client and develop a hand signal.
Prevents error in placing tube in wrong client.
➔ Explanation gains client‟s cooperation and ability to
anticipate nurse‟s action.
4. Place bed in high-fowler‘s position.
➔ Promotes client’s ability to swallow during the
procedure. Good body mechanics prevent injury to
nurse.
5. Cover client‘s chest with towel (Have emesis basin and tissues
handy).
➔ Prevents soiling of client’s gown.
6. Palpate patient‘s abdomen for distension, pain, and/or rigidity.
 Auscultate for bowel sounds. 18. Position comfortably. Promotes sense of well-being
➔ Baseline determination of level of abdominal ➔ Safety: Once placement is confirmed, place a mark,
distention and function later serves as comparison either a mark or tape, on the tube to indicate where
once tube is inserted. the tube exists in the nose. Used as a guide to
7. Examine nostrils & select the most patent one. indicate whether displacement may have occurred.
➔ Tube passes more easily through nares that is more
patent. IRRIGATING A NASOGASTRIC TUBE
➔ Assess for any obstruction
1. Place the client in the semi-fowler's position.
8. Measure the distance to insert tube by placing tip of tube at
➔ Reduces risk of pulmonary aspiration in event client
patient‘s nostril and extending to tip of earlobe and then to tip
vomit
of xiphoid process (NEX - nose, earlobe, xiphoid process).
2. Check for NGT placement.
Mark tube with an indelible marker.
3. Draw up 30 cc normal saline into irrigating syringe
9. Lubricate first 4 inches of the tube with water soluble lubricant.
➔ Use of saline minimizes loss of electrolytes from
➔ Minimizes friction against nasal mucosa and aids
stomach fluids.
insertion of tube.
4. This amount of solution will flush the length of the tube.
10. Ask client to slightly flex the neck backward. Flex position
5. Gently instill the normal saline into the NGT. Do not force the
closes off upper airway to trachea and opens esophagus.
➔ solution.
11. Gently insert the tube through nostril to back of throat.
➔ Position of syringe prevents introduction of air into
Facilitates initial passage of tube through nares and maintains
vent tubing.
clear airway for open nares.
6. Solution introduced under pressure can cause gastric trauma.
➔ If resistance is met, try to rotate the tube and see if it
7. Withdraw Aspirate the 30 cc. Irrigation solution and empty into
advances. If still resistant, withdraw tube, allow client
the basin. Irrigation clears tubing, so the stomach should
to rest, relubricate tube and insert into other nares.
remain empty.
Forcing against resistance can cause trauma to
8. Repeat the procedure twice
mucosa.
9. Record on I&O sheet the irrigation solution that has not been
➔ Continue insertion of tube until just past
returned
nasopharynx by gently rotating tube toward opposite
➔ Do not irrigate or rotate tPlace client in the
nares.
semi-fowler's position.
➔ Stop tube advancement, allow client to relax and
➔ Reduces risk of pulmonary aspiration in event client
provide tissues.
vomit
➔ Explain that the next step requires swallowing. Give
a glass of water unless contraindicated. Tearing is a
REMOVING A NASOGASTRIC TUBE
natural response to mucosal irritation and excessive
salivation may occur because of oral stimulation. 1. Verify order to discontinue NGT
Slipping of water aids the passage of the NG tube 2. Wash hands. Apply gloves.
into the esophagus. 3. Explain the procedure to client.
➔ If there is difficulty in passing the NG tube ask the ➔ Instruct to do deep breathing
4. Place the towel over client‘s chest.
client to sip water slowly through a straw unless oral
5. Clamp or plug tube.
fluids are contraindicated. If oral fluids are not 6. Unpin tube from gown.
allowed, ask to try dry swallowing while advancing 7. Loosen tape securing tube.
the tube. Tube may accidentally enter the larynx and 8. Take paper towel in nondominant hand and place under
initiate gag reflex. Gagging is eased by swallowing chin. Instruct client to take and hold a deep breath.
of water. 9. Pinch tube near nostril and remove with a continuous
12. Discontinue procedure and remove tube if there are signs of steady pull. As tube is being removed, hold tube in
distress, such as gasping, coughing, cyanosis, and inability to paper towel or wrap it in your hands as it is being pulled
speak or hum. out. Dispose tube properly.
13. Secure the tube with a tape. Tape to cheek. Tube should be 10. Clean client‘s face especially the nares
partially anchored before placement is checked. ➔ Expect secretions or maybe blood
14. Check the placement of tube: 11. Offer oral hygiene.
➔ Inject 10 cc. of air and auscultate for ―woosh ➔ Also clean the nares
12. Remove gloves
sound. Swooshing” sound, indicates placement
13. Assist client in comfortable position
➔ Aspirate gastric contents Measure pH of aspirate. 14. Wash hands
Aspiration of contents provide means to measure
fluid pH and thus determine tube tip placement in
gastrointestinal tract VII. ADMINISTERING ENTERAL FEEDING (CHECKLIST)
➔ X-ray: the most reliable confirmation 1. Place client in high-fowler‘s position or elevate head of bed at
15. After the tube is inserted, either clamp end or connect to the least 30 degrees
drainage bag. Drainage bag is used for gravity drainage. 2. Put on gloves. Unpin tube from patient‘s gown. Verify the
Intermittent suction is most effective for decompression. Client position of the marking on the tube at the nostril. Measure
for surgery often has tube clamped. length of exposed tube and compare with the documented
➔ Tape tube to nose. Wrap two split ends of tape length.
3. Determine placement:Attach syringe to end of tube and
around tube Tape anchors tube securely. Explain to
aspirate a small amount of stomach contents. Check the pH.
the client that sensation of tube should decrease Visualize aspirated contents, checking for color and
somewhat with time. Adaptation to continued consistency
sensory stimulus. 4. After multiple steps have been taken to ensure that the
16. Remove gloves, dispose of used materials. feeding tube is located in the stomach or small
➔ Reduces transmission of microorganisms intestine,aspirate all gastric contents with the syringe and
measures to check for the residual amount of feeding in the
17. Reassure client to allay anxiety.
 stomach. Return aspirated contents to stomach unless the
volume exceeds 100 ml. (check agency policy)
5. Flush 30 ml of water
6. Initiate feeding
7. Using Feeding bag/container
a. Label bag and/or tubing with date and time. Hang
bag on IV pole and adjust to about 12ǁ above the
stomach. Clamp tubing
b. Have tube feeding at room temperature
c. Check the expiration date of the formula.
d. Cleanse top of feeding container with a disinfectant
before opening it. Pour formula into feeding bag
and allow solution to run through tubing. Close
clamp.
e. Attach feeding setup to feeding tube, open clamp,
andregulate drip according to the medical order, or
allow feeding to run in over 30 minutes.
f. Add 30 to 60 mL (1–2 oz) of water for irrigation to
feeding bag when feeding is almost completed and
allow it to run through the tube.
g. Clamp tubing immediately after water has been
instilled. Disconnect feeding setup from feeding
tube.Clamp tube and cover end with cap.
8. Using a Large Syringe
a. Remove plunger from 30- or 60-mL syringe.
b. Attach syringe to feeding tube, pour pre measured
amount of tube feeding formula into syringe, open
clamp, and allow food to enter tube. Regulate rate,
fast or slow, by height of the syringe. Do not push
formula with syringe plunger.
c. Add 30 to 60 mL (1–2 oz) of water for irrigation
syringe when feeding is almost completed, and
allow it to run through the tube.
d. When syringe has emptied, hold syringe high and
disconnect from tube. Clamp tube and cover end
with cap.
9. Observe the patient‘s response during and after tube feeding
and assess the abdomen at least once a shift.
10. Have patient remain in upright position for at least1 hour after
feeding.
11. Remove equipment and return patient to a position of
comfort. Remove gloves.
12. Wash Hands.
DAY 2
VII. ENEMA
Learning Objectives:
1. Define the enema & enumerate the purposes of enema
2. Identify the factors that affect bowel elimination
3. Explain why enemas are given
4. Assess the patient before giving administering enema
5. Ability to administer enema for the patient
DEFECATION
● Defecation is the expulsion of feces from the anus and
rectum. It is also called a bowel movement
○ Normal color is brown due to stercobilin and urobilin
derived from bile and bilirubin.
○ Enema → Sensory nerves in the rectum get stimulated
→ urge to defecate
FECAL ELIMINATION
● Constipation
○ Decreased frequency of defecation
○ Passing of dry hard stool or no stool at all
○ Less than or fewer than 3x a week
○ Painful defecation, rectal fullness, abnormal pain,
anorexia,
○ nausea, headache
● Diarrhea
● Bowel incontinence
○ not being able to control bowel movements
● Flatulence
○ passing of gas in the anal passage.
ADMINISTERING ENEMA
● ENEMA: Introduction of fluid through a tube into lower
intestinal tract.
○ can help treat an inflamed bowel disease
PURPOSE
● To relieve constipation
● To relieve fecal impactions
● To cleanse the bowel prior to surgery, childbirth, or diagnostic
examination.
➔ Enema is ONLY done at <3cm dilatation for
pregnant woman.
➔ Lower GI x-ray is called Fluoroscopy. Real time
movement of the GI tract. A contrast agent barium
helps make these images. Barium enema is used for
this. Pain, chronic constipation, blood in the stool
● To evacuate the bowel in patients with neurologic dysfunction.
➔ Can be useful in treating gastrointestinal diseases,
inflammatory
➔ Inflammatory bowel disease (IBD), ulcerative colitis
(UC) and for patients with Crohn’s disease.
➔ neurologic dysfunction who can’t defecate
(Parkinson’s Disease, Spinal Cord problem)
➔ S/Sx: constipation, fecal incontinence
CAUTION!
Children below age 10, pregnant woman, and those suffering
from (hemorrhoids) piles should not use the enema
Do not add any soap, chemicals, coffee, lemon etc. in your
enema pot it needs to be plain water.
 ● If there is infection of bacteria or helmit.

CARMINATIVE ENEMA

● Promotes expulsion of flatus.

● Agents: MGW (30% Magnesium, 60% Glycerin, and 90%
Water) solution or 1-2-3 Enema

NOTE:

● Higher = Greater flow and force

● Should not be held higher than 12-18 inch above
the rectum

TYPES OF ENEMA Cleansing/Fleeting Enema

Enema Tip Insertion Depth
CLEANSING ENEMA ● Adult or adolescent: 3” to 4”
● Child: 2” to 3”
● Promotes complete evacuation of feces by stimulating
● Infant: 1” to 1 ½”
peristalsis through infusion of large volumes of solution into the
*Do not force the tip
colon.
● Agents: Soapsuds (grated perla mixed in hot water), tap
Enema Container Height above the rectum
water, fleet and saline (safest to use)
● High: 12” to 18”
○ For surgery
● Regular: 12
○ For diagnostic tests like x-ray and colonoscopy, to
● Low: 3”
remove feces in instances of constipation or fecal
impaction
● Cathartic Drugs: relieve constipation and promote
● High enema: given as much of the colon as possible. Change
defecation
position frequently.
○ Castor Oil
○ Before surgery, all the colon should be clean.
○ Castara
○ (Position: Left Lateral → Dorsal Recumbent → Right
○ Phenolphthalein
Lateral = Following the large intestine)
○ Bisacodyl
○ 12 to 18 inches in height above the rectum
● Regular Enema: 12 inches in height above the rectum
● Low enema: used to clean the rectum and the sigmoid and
colon ONLY
○ Position: Left lateral LAXATIVES
○ 3 inches in height above the rectum

NOTE:

RETENTION ENEMA ● Never prescribe these medications without

guidance of a physician since laxatives can cause
● Introduces oil, which lubricates the rectum and sigmoid colon
aggravation of the condition, especially to patients
thereby softening the feces. Feces absorb oil and become
who have possible underlying comorbidities.
softer and easier to pass.
● Advise them to seek medical attention.
● Agents: Mineral Oil
● Laxatives are contraindicated in patients with
○ Oil is retained for a long period of time (1-3hrs)
nausea, colic, cramps, undiagnosed abdominal
pain,
MEDICATED ENEMA

● Contain pharmacological therapeutic agents and may be

prescribed to reduce dangerously high serum potassium
TYPES OF ENEMA SOLUTION
levels, or to reduce bacteria in the colon before bowel surgery.
● Tap Water (Hypotonic)
● Agents: Kayexalate Enema (for hyperkalemia), neomycin
○ Enema should not be repeated after first instillation
enema
because of water toxicity or circulatory overload
 can develop.
○ Capacity of bladder is 1,500mL only
○ Cell bloats

● Normal Saline (Isotonic)

○ Safest solution, the only enema that children and
infants can tolerate because of their predisposition
to fluid imbalance.
○ Shape of the cell remains the same ○
● Clamp
● Commercially-prepared Fleet enema (Hypertonic) ○ In FEU, Kelly clamp is used
○ Useful for clients who cannot tolerate large volumes
of fluid.
○ Only 120 to 180 ml is usually effective.
○ Usually used in Delivery Room

● Soapsuds Solution
○ Pure soap added to either tap water or normal
saline, depending on the client's condition and
frequency of administration.
○ Can use Perla bar soap (mild), grated, and mixed ● Nozzle (rectal applicator)
with boiled water then cooled to room temperature
○ It has soap-water ratio so be careful
○ Used for delivery, (laboring 3-4 cm)
● Oil Retention Enema
○ Uses an oil-based solution
○ castor oil/mineral oil
● Carminative Solution
○ Provides relief from gaseous distention. Example is
MGW solution, which contains 30 ml of
magnesium, 60 ml of glycerine and 90 ml of
water ● Hook

● Vaginal Applicator
○ Used for douching (soaking/washing the inside of
the vagina)
○ Never used for the rectal area since the vaginal
applicator is longer and it might cause the rectum
to tear
EQUIPMENTS
● Disposable gloves
● Enema container with attached rectal tube
● Correct volume of warmed solution
● Water-soluble lubricant (KY Jelly)
● Absorbent pads
● Bedpan, commode (if patient can’t walk to the bathroom)
● Toilet tissue
● Heavy Gauge rubber water bottle
○ Also used for back pains as heat pad

PROCEDURES

1. Check doctor’s order

➔ The patient should give consent to the procedure

2. Prepare the necessary equipment.

➔ Ensure smooth procedure.

○ 3. Explain the procedure to the client.

● 60 inches Flexible tubing