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
______________________________________________________________________________________________________________

MIDTERMS

MIDTERM TOPICS
● Neuro/GCS/NIHSS
● Urinary Catheterization
● Total Parenteral Nutrition (TPN)
● Nasogastric Tube (NGT)

OUTLINE
NEUROLOGICAL ASSESSMENT
I. Glasgow Coma Scale
A. Eye Opening
B. Verbal Response
C. Motor Response
II. NIH Stroke Scale (National Institutes of Health Stroke
Scale)
A. Elements of the NIHSS
a. Level of Consciousness
b. Best Gaze
c. Visual Fields
d. Facial Palsy
e. Motor Arm and Leg
f. Limb Ataxia
g. Sensory
h. Best Language
i. Dysarthria A. EYE OPENING
j. Extinction and Inattention ● Useful as a reflection of the intensity of impairment of activating
B. Important Points functions.
○ important to know possible brain injury
I. GLASGOW COMA SCALE (GCS)
● Spontaneous eye opening (score: 4)
● Dr. Graham M. Teasdale
○ It indicates arousal mechanisms brain stems are active.
○ Professor and head of the department of neurosurgery in
○ It does not imply awareness.
the University of Glasgow (1981 to 2003).
NOTE: In the persistent vegetative or minimally conscious state,
eye opening is characteristically dissociated from evidence of
What were the main factors in the design of the scale?
intellectual function.
→ The approach should be simple and practicable, usable in a
wide range of hospitals by staff without special training.
● Eye opening in response to speech (score: 3)
→ can be utilized by non doctors
○ It is sought by speaking or shouting at the patient.
○ Any sufficiently loud sound can be used, not necessarily
● The Glasgow Coma Scale (GCS) was developed to assess
a command to open the eyes
the level of neurologic injury, and includes assessments of
NOTE: This should be assessed before the patient is physically
movement, speech, and eye opening.
stimulated
● This avoids the need to make arbitrary (Unnecessary)
distinctions between consciousness and different levels of
● Eye opening in response to pain (score: 2)
coma.
○ It is assessed if the person is not opening their eyes to
● Brain injury is often classified as:
sound.
○ Severe (GCS ≤ 8)
○ It should not cause unnecessary injury to the patient.
○ Moderate (GCS 9-12)
○ The stimulus should be pressure on the bed of a
○ Mild (GCS ≥13)
fingernail or supraorbital nerve.
● Quick neurologic assessment for:
NOTE: Options such as rubbing the sternum or pinching the chest
○ Prognosis
or arm do not offer advantages.
○ Victim's ability to maintain patent airway on their own
● It has 3 categories: Eye opening, verbal response, and BEST
● ​An absence of eye opening (score: 1)
motor response
○ There is none.
○ It implies substantial impairment of brain stem arousal
● Has proved a practical and consistent means of monitoring
mechanisms.
the state of head injured patients.
○ Substantial effort should be made earlier to ensure that
○ In the acute stage, changes in conscious level provide
this is not due to an inadequate stimulation.
the best indication of the development of complications
NOTE: It is also important to identify if a lack of eye opening is a
such as intracranial hematoma whilst the depth of coma
consequence of a local injury, for example fronto-basal fractures,
and its duration indicate the degree of ultimate recovery
or sedative and paralyzing medication.
which can be expected.
● take note also of those with supraorbital or orbital
● GCS does not entail assumptions of specific underlying
fractures of the eye that prevent these patients from
anatomical lesions or physiological mechanisms.
opening their eye
○ It means GCS focuses on the physical symptoms not
the underlying ones.

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 B. VERBAL RESPONSE
● Oriented (score: 5)
○ It is the highest level of response and implies
awareness of self and environment.
○ The person should be able to provide answers to at
least three questions:
1. Who they are
2. Where they are
3. The date
○ At least in terms of the year, month, and day
of the week
NOTE: 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 the three
components they can provide.
● Maximum 5 for complete response (complete awareness
of his situation) that means oriented.
● Confused (disoriented) conversation (score: 4)
○ 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.
● Inappropriate Speech (score: 3)
○ 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.
NOTE: If the person responded with an inappropriate answer in
response to the question means a score of 3.
● Incomprehensible Sounds (score: 2)
○ It consist of moaning and groaning, but without any
recognizable words
○ It is commonly produced by stimulation and does not
result in sustained conversation exchange.
NOTE: no conversation at all; In tagalog, umuungol lang ang
patient xd
● No Verbal Response (score: 1)
○ No verbal response upon pain stimulus.
○ Substantial effort should be made earlier to ensure that
this is not due to an inadequate stimulation.
○ does not produce any sound even upon stimulation
NOTE: 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.
○ GOOGLE: Dysphasia (or aphasia) is a disorder of the
language content of speech. People with dysphasia
might have trouble putting the right words together in a
sentence, understanding what others say, reading, and
writing.
● 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.
● Obeying Commands (score: 6)
○ The patient obeys the command
○ 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.
NOTE: 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.
Motor response has a highest score of 6.
● Make sure to analyze if the motor response are coming
from your orders or if it just came from natural reflexes or
abnormal reflexes of the px
● Localization (score: 5)
○ 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.
NOTE: Stimulus to the trunk may result in the arms moving across
the chest in a way that does not represent a specific localized
response.
● Withdrawal response (Flexion) (score: 4)
○ It is recorded if the elbow bends away from the pain
stimulus but the movement is not sufficient to achieve
localization.
● Abnormal flexion response (Decorticate) (score: 3)
○ It is recorded if the elbow bends in decorticate posturing
and the movement is not sufficient to achieve
localization.
● Extension response (Decerebrate) (score: 2)
○ It is recorded if the elbow only straightens and the
movement should not be sufficient to achieve
localization.
● Absence of motor response (score: 1)
○ It is recorded if no limb movement upon pain stimulus
■ not moving anymore
○ It is characterized by rapid withdrawal, abduction of the
shoulder, and external rotation which varies from
stimulation to stimulation
NOTE: Before recording that someone has no motor response,
vigorous and varied efforts should be made.
● 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.
NOTE:
● Inexperienced staff, particularly working outside
neurosurgical centers, find 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.
- In a non specialized area, some degree of diff in
assessing these kinds of responses than those in a
neurosurgical unit
Why is it the best motor response?
● The scale is based upon taking account of the best
response of the better limb.
○ score the unaffected area
○ not the one with weakness
● 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.
NOTE: 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.
■ GOOGLE: Hypoxia - low levels of
oxygen in your body tissues
● 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.
○ importance of physical assessment in these
types of assessment because how will you
know if the px has a head & neck injury
● It is also important to ensure a stimulus of adequate
intensity has been applied.
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 GLASGOW COMA SCALE: CONSISTENCY
● Inter-observer consistency has been examined by
many investigators and has been shown to be robust in a
wide, relevant range of circumstances including
emergency departments, intensive care units and in
pre-hospital care.
● However, consistency cannot be assumed and should be
confirmed and enhanced by training and communication
between staff.
○ if allied health care are performing the test,
there should be a consistent scoring, a
collaboration between the two, and must
understand on how to score the GCS
GLASCOW COMA SCALE: HOW SOON?
● In the acute stage, the sooner an observation is made,
the more useful it is as a guide to predict the ultimate
outcome.
- establish in patient neurological condition right
away
● In the acute state where the patient's state of
consciousness is influenced by remedial disorders.
○ For example hypoxia or hypotension, prognosis
has been based upon an assessment after
sufficient time has passed.
● Post resuscitation GCS usually assess after 6 hours,
resuscitated patients.
○ you don’t assume immediately or conclude after
getting a gcs score, px needs have to
observations first
GLASGOW COMA SCALE: HOW OFTEN?
● The shorter the time between an injury or other event
and the assessment, the more the security about the
stability of a patient's condition
- right after a trauma, you can establish a
baseline
● Observations at frequent intervals are appropriate for
example every few minutes and at least several times
within an hour.
- especially in trauma conditions where is rapid
deterioration
● As time passes the frequency can be reduced, and
related to whether or not there are reasons for
considering the patient needs continuing observation and
care.
- consistent scoring means a reduce or
increase in gcs scoring
- if you have consistent score in gcs (for
example, score of 13) then that can indicate
that you can reduce the frequency of doing
the gcs
GLASGOW COMA SCALE: HOW MUCH CHANGE
MATTER?
● Questions are asked about the extent of change that
should take place in order to trigger action.
● It may determine transfer to another unit e.g. from a
general to a specialist neurosurgical department.
○ E.g: from general ward → ICU unit
● Again, hard and fast rules are not appropriate.
NOTE: The general guidance is that it depends upon where the
patient is showing change from and the extent of the change.
● Generally significant changes when total score reduces
by 2 points or motor response reduces by single point
- Inform the physician immediately, reassess the
patient and plan to transfer the patient in ICU
NOTE: There is a greater degree of consistency in the assessment
of the motor component of the scale than the verbal and eye
features.
GLASGOW COMA SCALE: RELATIONSHIP BETWEEN THE
SCALE AND THE SCORE?
● The total or sum score (coma score) was initially used
as a way of summarizing information, in order to make it
easier to present group data.
○ However, the resulting score proved a useful
and powerful summary of the summary of the
extent of brain dysfunction and showed a
strong relationship with prognosis
● 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.
○ if in a critical setting - we dont give or endorse
the total score; we categorize the gcs scoring
per category(ex: gcs: eye 3 , verbal 4, motor 5)
○ so that the next nurse can ascertain on his own
if you gave an accurate score for each category
because there can be a variance between your
assessment and the other nurse
● A major limitation of the total score is the difficulty to
translate the score into a clear picture of the patient's
actual condition.
○ GCS should be correlated with other diagnostic
exams, not on gcs alone in assessing the
neurological condition of the px
○ Should not rely on GCS scoring alone
● This is particularly a risk in telephone exchanges.
● The lowest score is not 0 nor 1, but 3.
✓ Because if summed up you will have a score of
3 (eye,verbal,motor)
IS THE TOTAL SCORE 14 OR 15?
● It is a result of the differences in the approaches to
assessment of flexion motor responses.
✓ halfway results or response can lead to score of
14 or 15 “hilaw na response”
● In the simpler system, recommended for routine use in
patient monitoring, no attempt is made to distinguish
between normal and abnormal flexion.
✓ This results in a system summing to a total of
14.
● Distinction between normal and abnormal flexion is
important in assessing the significant deterioration
from normal to abnormal brain responses - Important
prognostic factor.
CHILDREN COMA SCALE
● The Glasgow Coma Scale (GCS) as an objective
assessment of neurological function, is of Limited
usefulness in children under 3 years of age
● One of the components of the Glasgow coma scale is the
best verbal response which cannot be assessed in
nonverbal small children
○ Children under 3 years of age still have not fully
developed verbal speech
● A modification of the original Glasgow coma scale was
created for children too young to talk
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 CONCLUSIONS
● Although initially described four decades ago, the
Glasgow approaches to assessment of initial severity
and outcome of brain damage have weathered the test of
time.
- Until now we are still utilizing the GCS in
emergency and critical care unit
● It remains the standard for acute assessment.
● Alternatives to and adaptations of the Glasgow Scales
have been described. Some of these have clear
advantages, for example in relation to children.
B. NIHSS GUIDING PRINCIPLES
● The most reproducible response is generally the first response.
○ meaning the initial response is the best 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.
○ score what you’ve seen, and not what you’ve assumed.
C. INSTRUCTIONS

GLASGOW SCORE LEVEL OF CONSCIOUSNESS

● Determined through interactions with the patient
Score Range Clinical Grading of Head ● Auditory stimulation (normal to loud)
Presentation Injury ● Tactile stimulation (light to painful)
● The investigator must choose a response
Extubated: 3-15 Normal: GCS = 15 Minor: GCS > 13
Intubated: 3-11 T Comatose: GCS < Moderate: GCS
8 9-12 Scoring:
Dead: GCS = 3 Severe: GCS < 8 ● 0 = Alert; keenly responsive
neurologically dead ● 1 = Not alert, but arousable by minor stimulation to obey,
but not biologically answer or respond
dead ● 2 = Not alert, requires repeated stimulation to attend, or is
obtunded and requires strong or painful stimulation to make
movements
● 3 = Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid

● 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 Glasgow Coma Scale to
assist the neurological examination.
○ should have a knowledge of gcs to determine scores
LOC QUESTIONS

● Ask the patient for their age and then wait for their response
● Ask the patient the current month then wait for a response
NOTE:
● Do not give credit for being "close"
Example report ● Do not coach nor give nonverbal cues
GCS 9 = E1 V4 M3 at 07:35 ● wait for the patient’s response and do not lead the answer
Neurologically dead if score is lowest in gcs and as observed
in EEG (encephalogram) Scoring
● 0 = Answers both questions correctly
II. NIH STROKE SCALE (NIHSS) ● 1 = Answers one question correctly
What is the NIHSS and why do we need it? ● 2 = Answers neither question correctly
● Standardized stroke severity scale to describe neurological
deficits in acute stroke patient allows us to:
○ Quantify our clinical exam
○ Determine if the patient's neurological status is improving NOTE:
or deteriorating ● Aphasic patients who do not comprehend the questions will
○ Provide for standardization score 2.
○ Communicate patient status ○ GOOGLE: Aphasia is a brain disorder where a person
has trouble speaking or understanding other people
NEUROLOGICAL EXAMINATION VS NIHSS speaking. This happens with damage or disruptions in
parts of the brain that control spoken language. It often
happens with conditions like stroke.
● Patients unable to speak due to endotracheal intubation,
orotracheal trauma, severe dysarthria from any cause,
language barrier or any other problem not secondary to
aphasia are given a 1.
○ GOOGLE: dysarthria – difficulty speaking caused by
brain damage, which results in an inability to control the
muscles used in speech.

LOC COMMANDS
● Ask the patient to:
○ Open & close their eyes
○ Grip and release the non paretic hand
● Give credit if an unequivocal attempt is made but not
completed due to weakness
A. ELEMENTS OF THE NIH STROKE SCALE ● If the patient does not respond to command, the task should be
● 11-item scoring system demonstrated.
● Integrates components of neurological exam
● Includes testing of LOC, select cranial nerves, motor, sensory,
cerebellar function, language, inattention (neglect) Scoring
● Maximum score: 42, minimum score: 0 ● 0 = Performs both tasks
● Not a linear scale ● 1 = Performs one task

4
 ● 2 = Performs neither task correctly
NOTE: Score only the first attempt

BEST GAZE
● Ask the patient to follow your finger across horizontal eye
movements
● 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
■ Normal response: eyes move in the opposite direction
to head movement
● if you move the head to the left, the eyes
should move to the right
■ Abnormal response: the eyes are fixed in one position
and follow the direction of passive rotation. attempt is
made but not completed due to weakness
● If the patient does not respond to command, FACIAL PALSY
the task should be demonstrated. ● Ask the patient or use pantomime
○ Show their teeth
○ Raise their eyebrows
Scoring ○ Close their eyes tightly
● 0 = Normal horizontal eye movements ● Score symmetry of grimace to noxious stimulation in the
● 1 = Partial gaze palsy - abnormality in one or both aphasic or confused patient
eyes, but forced deviation is not present ○ Tickle each nasal passage one at a time using a
● 2 = Forced deviation or total gaze paresis (not cotton-tipped applicator and observe facial movement
overcome with oculocephalic maneuver) ●
Scoring
VISUAL FIELDS ● 0 = Normal symmetrical movement
● Stand 2 feet from the patient at eye level. Both examiner and ● 1 = Minor paralysis (i.e. flattened nasolabial fold,
patient cover one eye. Ask the patient to look directly into your asymmetry on smiling)
eyes. ● 2 = Partial paralysis (total or near total paralysis of
● Test upper and lower visual fields by confrontation (4 quadrants lower face)
of each eye) ● 3 = Complete paralysis of one or both sides (absence
● Examiner compares this to the "norm" (their own vision) of facial movement in the upper and lower face)
● To test both fields with eyes open, ask patient to indicate where
they see movement (choices: left side, right side, or both) NOTE:
● Aphasic or confused patient: Score symmetry of grimace
to noxious stimulation
Scoring
● 0 = No visual loss
● 1 = Partial hemianopia (sector or
● quadrantanopia)
● 2 = Complete hemianopia
● 3 = Bilateral hemianopia (blind)
NOTE:
● If the patient sees moving fingers, this can be scored as
normal
● 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

5

1. 5 & 6 - Motor Arm and Leg
● Test each limb independently. Start with 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
2. 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
Scoring
● 0 = No drift, limb holds steady for full count (arm: 10
sec, leg: 5 sec)
● 1 = Drifts, but limb does not hit bed or other support
● 2 = Drifts towards bed, but patient has some effort
against gravity
● 3 = Limb falls, no effort against gravity. Trace
muscular contraction present in the limb.
● 4 = No movement
● X = Amputation, joint fusion
3. Limb Ataxia
○ Use "finger-nose-finger" and "heel to shin" tests
○ Test non-paretic side first
○ Look for smooth, accurate movements
○ Consider limb weakness when looking for dysmetria
■ GOOGLE: Dysmetria is the inability to
control the distance, speed, and
range of motion necessary to perform
smoothly coordinated movements.
Dysmetria is a sign of cerebellar
damage, and often presents along
with additional signs, such as loss of
balance and poor coordination of
walking, speech, and eye
movements.
○ Nonverbal cues are permitted
○ Test all four limbs separately
GOOGLE: Limb ataxia is often used to describe ataxia of the
upper limbs resulting from incoordination and tremor and can be
better described by functional impairment, such as clumsiness with
writing, buttoning clothes, or picking up small objects.
Finger-Nose-Finger
● The examiner raises their finger midline 2 feet from the
patient.
○ Patient is asked, "With your right hand, touch
my finger, then touch your nose; do this as fast
as you can." Repeat with the other arm.
Heel to Shin
● 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
Dysmetria: The inability to accurately control the range of
movement in muscle action with the resultant overshooting of the
mark.
Scoring
● 0 = Absent
● 1 = Present in one limb
● 2 = Present in two limbs
NOTE:
● Ataxia is only scored if present. In patients who can't
understand the exam or who is paralyzed, a score of 0
(absent) is given.
● 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.
4. Sensory
○ Use sharp object on 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
● 0 = Normal, no sensory loss
● 1 = Mild to moderate sensory loss; patient is aware
of being touched, but pinprick is less sharp/pull on
the affected side
● 2 = Severe to total sensory loss; patient is aware of
being touched in the face, arm, and leg
NOTE:
● A score of 2 should only be given when severe or total
loss of sensation can be clearly demonstrated
● Stuporous and aphasic patients will probably score 1 or 0
5. Best language
a. Incorporates information collected in preceding
sections.
● Ask patient to perform the following:
■ Name all the objects on the card
■ Read all the sentences
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 ■ Describe what is happening in the
picture Possible Points: Summary
● Give patients adequate time. Patients can also Locranial Nerves (portions of CN II, III, V, VI, VII)
write answers. LOC 7
● If visual loss prevents standard examination: Cranial Nerves 8
○ Place objects in patient's hand Motor 8 x 2 = 16
(naming) Ataxia 2
○ Ask patient to repeat sentences on Sensory 2
the card Language 5
○ Ask patient to produce speech by Inattention 2
asking a question NIHSS Total 42

Scoring NIHSS and Patient Outcomes

● 0 = No aphasia, normal fluency and comprehension
● 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,
examiner must guess what the patient is trying to
communicate
● 3 = Mute, global aphasia: no usable speech, no
auditory comprehension. Patient unable to follow any
one step commands
● Total scores range from 0-42 with higher values
representing more severe infarcts
○ > 25 - Very severe neurological impairment
○ 15 - 24 - Severe impairment
○ 5 - 14 - Moderately severe impairment
○ < 5 - Mild impairment
● A 2 - point (or greater) increase in the NIHSS
administered serially indicates stroke progression. It is
advisable to report this increase.
NOTE: Always use your own judgment.

● Initial score of 7 was found to be important cut-off point

NOTE:
● 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 followed only a few and simple one
step commands would score a 2
6. Dysarthria
○ An adequate sample of speech must be
obtained by asking patient to read or repeat
words from the attached list even if patient is
thought to be normal
○ If the patient has aphasia, the clarity of
articulation of spontaneous speech can be
rated
Scoring
● 0 = Normal
● 1 = Mild to moderate; patient slurs some words but can
be understood
● 2 = Severe; patient's speech is so slurred/ unintelligible
in the absence of or out of proportion to any dysphasia,
or is mute
● X = Intubated or other physical barrier
7. Extinction & Inattention (Neglect)
○ Sufficient information to identify neglect may be
obtained during prior testing
○ If the patient has a severe visual loss www.strokeassociation.org
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.
○ Since the abnormality is scored only if present,
the item is never untestable.
Scoring Communicate the following:
● 0 = No abnormality
● 1 = Visual, tactile, auditory, spatial, or personal
inattention or extinction to bilateral simultaneous
stimulation in one of the sensory modalities.
● 2 = Profound hemi-inattention or hemi-inattention to
more than one modality. Does not recognize its own
hand or orients to only one side of space.
REMEMBER: Document your assessment, intervention plans, and
IMPORTANT POINTS follow up.
● If patient is not cooperative, explanation must be clearly
written on the form
● NIHSS items are rarely untestable
○ NIHSS >7 demonstrated a worsening rate of
65.9%.
○ NIHSS <7 demonstrated a worsening rate of
14.8% and were almost twice (1.9x) as likely to
be functionally normal at 48 hours (45%).
○ NIHSS <5 most strongly associated with D/C
home (meaning discharged to go home)
○ NIHSS 6-13 most strongly associated with D/C
to rehab
○ NIHSS >13 most strongly associated with D/C
to nursing facility
- Needs special care
○ Likelihood of intracranial hemorrhage:
■ NIHSS > 20 = 17% likelihood that you
might suffer from intracranial
hemorrhage
■ NIHSS < 20 = 3% likelihood
NIHSS Online Certification
● In the US, it can be done by nurse and other personnel
but should undergo training
● Online NIHSS Certification available free through the
American Stroke Association
● The online program provides detailed instructions and
demonstration scenarios for practice in scoring the
NIHSS
● Certification is completed by scoring different patient
scenarios
When to Communicate NIHSS Results
● Neurological decline
● New focal deficit
● Advancing neurological deficit
Communicating NIHSS Results
● Total NIHSS score is an important piece of information to
relate patient status along with a full patient assessment.
➢ with the correlation of other diagnostic
assessment
● 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

7
 NIHSS FLOW SHEET

Anatomy of the Nervous System

● NEURONS are the structural and functional unit of the nervous
system
● Neurotransmitters
○ Transmit message from one neuron to another
○ Most neurological disorders are caused by imbalance in
transmission of neurotransmitters
○ (e.i. low serotonin -> epilepsy or decreased dopamine -›
parkinson's)

Neurotransmitter Source Action

Acetylcholine Many areas of the Usually excitatory,

(major transmitter brain, ANS parasympathetic
of the
III. ASSESSMENT OF NEUROLOGICAL parasympathetic
FUNCTIONS IN NURSING system)
Learning Objectives:
● Describe the structure and function of central and
peripheral nervous system Serotonin Brainstem, Restraining, helps
● Enumerate the functions of sympathetic and hypothalamus, control mood,
parasympathetic nervous system spinal cord sleep, inhibits pain
● Discuss the significance of physical assessment in pathways
detecting the abnormalities of the nervous system
● Discuss the various diagnostic procedures used to Dopamine Substantia nigra, Usually restrains,
discuss the abnormalities of the nervous system basal ganglia affects behavior
(attention,
NERVOUS SYSTEM emotions), and fine
● Function of the nervous system is to control all motor, movements
cognitive, autonomic, and behavioral activities happening in
the human body Norepinephrine Brainstem, Usually excitatory,
● Disorders of the nervous system can occur during any point (major transmitter hypothalamus, affects mood and
in life, hence, a nurse must be skilled in its proper of the sympathetic SNS overall activity
assessment (from neonatal to geriatric) system)

Gamma-aminobut Spinal cord, Excitatory amino

yric acid (GABA) cerebellum, some acids
cortical areas

Enkephalin, Nerve terminals in Excitatory,

endorphin the spine, brain, pleasurable
and pituitary gland sensation, inhibits
pain transmission

CENTRAL NERVOUS SYSTEM: BRAIN

● 2% of total body weight
● about 1400g in an average adult
● divided into 3 major areas:
○ Forebrain: cerebrum, thalamus, hypothalamus
○ Midbrain: tectum and tegmentum
○ Hindbrain: cerebellum, pons, medulla

8

FOREBRAIN
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
● Temporal lobe: auditory receptive areas
● Occipital lobe: visual interpretation
- When a certain part of the brain is affected by stroke or
injury
- their functions are affected also (ex. if occipital lobe is
affected, might lead to visual loss)
THALAMUS
● Large mass of gray matter deeply situated in the forebrain
● Primarily as a relay station for all sensations except smell
○ most cranial nerves originates from thalamus
HYPOTHALAMUS
● Controls homeostasis, emotion, thirst, hunger, circadian
rhythms, ANS, and pituitary gland
AMYGDALA
● Located in the temporal lobe
● Involved in memory, emotion, and fear
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 functions such as vision, hearing, eye movement,
and body movement
HINDBRAIN
CEREBELLUM
● Has both excitatory and inhibitory actions
● Largely responsible for coordination of movement
● Controls fine movement, balance, position sense, and
integration of sensory input
PONS
● 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
○ important because connects the right and left
hemisphere of the brain
○ If affected during stroke - you might suffer from
tachycardia or cardiopulmonary arrest
MEDULLA OBLONGATA
● Located between the pons and the spinal cord
● Responsible for maintaining vital body functions such as
breathing and heart rate
● If this is affected, spontaneous breathing can be affected and
possibly diminished, making the person incapable of breathing
on his/her own. Hence, the person is then placed under
intubation.
● Another important part of the brain as it is also called as the
respiratory center
● If the arachnoid/subarachnoid space is filled with blood → it
can compress your cerebellum → increase ICP
CEREBROSPINAL FLUID
● Clear and colorless fluid with specific gravity of 1.007
● Produced from the ventricles and is circulated through the
ventricular system
● Composition of the CSF is similar to that of plasma (component
of the blood)
● Normally, CSF contains few WBCs but no RBCs
● That's why it is clear bc there are no RBCs, if there’s a
presence of RBC, there’s a problem with your CSF
9
 Anatomy of the Cerebral Artery

In the photo, very thin wires are inserted from femoral or radial
artery (sa kamay or singit) towards cerebral artery
- example px has aneurysm, we’re going to insert very thin
wires and we will do endovascular coiling – wherein we
coil the ruptured area of our cerebral arteries
- substitute for cardiovascular bypass

1. Lateral ventricles open in to the third ventricle through foramen

of Monro
2. Third to fourth ventricle through the aqueduct of Sylvius
3. Fourth ventricle to subarachnoid space and spinal cord
4. Returns to the brain and gets reabsorbed by arachnoid villi

Cerebral Circulation
● Refers to the blood flow
● Cerebral circulation receives 15% of the cardiac output or
m 750mL/min
● The brain does not store nutrients and requires high
blood flow
● The brain's blood pathway is unique as it is against
gravity
○ heart is on the chest, and cardiac output goes
to brain through carotid arteries and it is against
gravity because pataas so there has to be
adequate pressure for the blood to go up to the
brain

NOTE: There must be a certain pressure for the blood to flow up
due to gravity
Central Nervous System: Spinal Cord
- only glucose can penetrate blood brain barrier
● The vertebral column is made up of 33 bones
● The spinal cord and medulla form a continuous structure
about 45 cm (18 in) long and about the thickness of a
finger
● Contrary to the brain, the spinal cord consists of gray
matter inside and white matter outside and is protected
by the meninges
● H-shaped structure
● The lower portion of the H is the anterior horn and upper
portion is called the posterior horn, both serving reflex
activity
● The thoracic region of the spinal cord has a projection at
the crossbar of H and is called the lateral horn

10
Cross-section of the Spinal Cord ○ 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 and plays a
role in the maintenance of internal homeostasis

Parasympathetic NS Sympathetic NS

● Controls visceral ● Fight and Flight

function response
● Mainly functions in ● Activated under stressful
quiet and stressful condition
Cranial Nerves and their Primary Functions conditions ● The neurotransmitter is
● The neurotransmitter norepinephrine (NEP) or
is acetylcholine adrenaline
● Located in the ● The response is
craniosacral division 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 EXAMS

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 (as well as maintenance
Spinal Nerves medications)
● 31 pairs (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1
coccygeal)
● Each spinal cord contains a dorsal root and a ventral root

11
 Clinical Manifestations
Assess for major symptoms which may point to neurological
disturbance such as the following:
● Pain
● Paresthesias - refers to a burning or prickling sensation that is
usually felt in the hands, arms, legs, or feet, but can also occur
in other parts of the body.
● 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 Cerebral Function ● Acoustic/Vestibulocochlear Nerve (CN VIII)

○ For hearing
● Mental status: appearance, posture, manner of speech, level of
■ Whisper test: ask the patient to repeat the
consciousness, orientation
numbers which the examiners by standing
● Intelligence quotient
behind the patient and masking the other ear.
● Thought process
Note for asymmetry in hearing.
● Emotional status
● Perception: assess for agnosia
● Motor ability
● Language ability: assess for aphasia

Assessing the Cranial Nerves

● Olfactory Nerve (CN I)
○ Done by asking the person to smell something very
familiar with the eyes closed
● Optic Nerve (CN Il)
○ Done by using a Snellen chart
● Oculomotor, trochlear, and abducens (CN III, IV, VI)
○ Done by observing ocular rotation, conjugate movement,
presence of nystagmus, testing of pupillary reflexes, and
checking for ptosis
○ Nystagmus - Nystagmus is an involuntary rhythmic
side-to-side, up and down or circular motion of the eyes
○ Ptosis - Ptosis is when the upper eyelid droops over the
eye.
● Trigeminal nerve (CN V)
○ Sensory ● Acoustic/vestibulocochlear nerve (CN VIII)
■ Touch one side of the patient's face slightly with ○ To differentiate conductive and sensorineural hearing
a cotton ball and ask the patient to identify loss
whether both sides of the face was touched or ○ Rinne’s test: Place tuning fork next to the mastoid
not process and then behind the ear. Then ask the patient in
■ Touch the sides of the face gently with a safety which position the sound is heard louder. (Normal
pin and ask the patient to verbalize the response: sound should be heard louder in second)
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.
NOTE: The paralyzed side will not move laterally.
➢ For the stretch reflex, demonstrate to the patient what ● Acoustic/vestibulocochlear nerve (CN VIII)
you are going to do. Have the jaws half open and ○ To differentiate conductive and sensorineural hearing
relaxed. Then place your index finger on the tip of the loss
mandible and tap your finger gently but briskly with a ○ Weber's test: Place the tuning fork in the center of the
reflex hammer. forehead and ask which ear sound is heard louder
(Normal response: the sound is heard equally in both
● Facial Nerve (CN VII) ears)
○ The examiner should observe for the symmetry of the
face when the patient performs movement like smiling,
frowning, whistling elevating eyebrows, closing of the
eyelid as the examiner tries to open it
■ Observe for flaccid face
■ Ability to determine sugar & salt

12
 TESTING FOR SUPERFICIAL REFLEXES

Reflex Method Response Interpretation

Corneal touch the sclera blink May be absent

Reflex of each eye on responses is in the case of
the outer corner expected CVA or coma
with a clean
wisp of cotton

Gag touch the equal serious central

Reflex posterior elevation of nervous system
position of the uvula and dysfunction
pharynx with a gag response
cotton tipped is expected
applicator
flexion if the
toe is
expected

Plantar stroking the flexion of the serious central

reflex lateral side of toe is nervous system
the tongue with expected dysfunction
● Glossopharyngeal & Vagus nerves (CN IX & X) a tongue blade
○ Assess the voice: hoarse or nasal
○ Examine palate of uvular displacement Babinski stroke the toes get toes fan out in
○ Observe for symmetrical rise of uvula and soft palate reflex lateral aspect if contracted adults with
when patient says “Ah” the sole of the and draws nervous system
○ Elicit gag reflex foot together disorders
■ Stimulate back of throat each side
■ Normal to gag each time
● Accessory nerve (CN XI) DIAGNOSTIC EXAMS
○ Examine for any atrophy or asymmetry of trapezius
muscle from behind while patient shrugs shoulders Computed Tomography Scan (CT Scan)
against resistance ● Non-invasive/Painless
○ Note for any asymmetry of sternocleidomastoid muscle ● High degree of sensitivity for detecting lesions
as the patient turn head against resistance ● Makes use of a narrow x-ray beam to scan different areas of
● Hypoglossal nerve (CN XII) the body
○ Ask the patient to protrude tongue to note any unilateral
deviation or tremors Nursing interventions
○ Test the strength of the tongue by having the patient ● Teach the patient to lie quietly throughout the procedure
move the tongue side to side against a tongue depressor ● Sedation can be used for agitated patients
Testing for Reflexes ● iodine or shellfish allergy should be reported in case of CT with
● Techniques contrast
○ A reflex hammer is used to elicit the reflex ○ bc of the contrast in CT scan - ask px for allergies in
○ Testing of the reflexes should give symmetrically iodine or shellfish
equivalent results. ● An IV line and a period of fasting (usually 4 hours) are required
■ if not symmetric, there’s a deviation and could prior to the study
mean that the px has a neurological deficit
● Observations Positron Emission Tomography (PET Scan)
○ Absence of reflexes is important ● Computer-based nuclear imaging technique that produces
○ Deep tendon reflexes (DTR) are graded from 0+ to 4+ images of actual organ
● Functioning and produces a series of two-dimensional views at
various levels
Grading Interpretation
Nursing interventions
0 No response ● Explaining the test and the sensations
● Relaxation exercises may reduce anxiety during the test
1+ (+) Diminished reflex
Single Photon Emission CT (SPECT)
2+ (++) Normal response ● Three-dimensional imaging technique that uses radio nuclides
and instruments to detect single photos
3+ (+++) Brisk/hyperactive response ● 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
4+(++++) Clonus/repetitive response
● Major deep tendon reflexes checked Nursing interventions
○ Biceps reflex ● Patient preparation & monitoring
○ Triceps reflexes ● Teaching about what to expect
○ Brachioradialis ● Before the test, the woman who is breastfeeding is instructed
○ Patellar reflex to stop
● Monitor for allergic reactions during and after the procedure
● Testing for Superficial Reflexes
● Ankle/achilles reflex Magnetic Resonance Imaging (MRI)
● Uses a strong magnetic field to obtain the images of the body
● Does not involve ionizing radiation
● Will detect cerebral abnormalities earlier than other test

13
 ○ More reliable than CT scan when diagnosing a patient
who suffered from stroke
● Test takes up an hour to complete
● Procedure is painless
● Loud sound is expected during the procedure
Nursing Interventions
● Explain about the procedure and what to expect
● All metallic objects should be removed
● Clear history to know the presence of any metallic objects in
the body
○ especially if px has implants bc mri can affect those
implants
● No metallic patient care equipment should be brought near the
MRI room
○ so even the medical equipments attached to the patient
should be removed
Cerebral Angiography
● It is an x-ray study of the cerebral circulation with a contrast
agent injected into a selected artery.
● It is a valuable tool to investigate vascular disease, aneurysms,
and arteriovenous malformations.
○ to determine location and severity of the aneurysm
Nursing Intervention
● The pt should be well hydrated
● The locations of the appropriate peripheral pulses are marked
● The patient is instructed to remain immobile during the process
and is told to expect a brief feeling of warmth and a metallic
taste when the contrast agent is injected.
● Patient is sedated
○ We ask for anesthesiologist to sedate the px
● Observe signs and symptoms of complications.
○ usually when dye or contrast media is used, we need to
flush out right after the procedure
○ when the patient has iv lines, the iv regulation is
increased so the contrast media will be
excreted/eliminated right away via urine
● The color and temperature of the involved extremity are
assessed to detect possible embolism.
○ one complications of the procedure, so we have to check
and assess the entrance of the catheter because it could
dislodge and trigger embolism
Myelography
● It is an x-ray of the spinal subarachnoid space taken after the
injection of a contrast agent into the spinal subarachnoid space
through a lumbar puncture.
● It outlines the spinal subarachnoid space and shows any
abnormality of the spinal cord.
● Less sensitive as compared to CT and MRI.
Nursing Interventions
● Inform about what to expect during the procedure and position
change required during the same preparation for lumbar
puncture.
● After the procedure the patient should be in Fowler's position.
● The patient is encouraged to drink water.
● Observe for signs of complication.
Electroencephalogram (EEG)
● It represents a record of the electrical activity generated in the
brain obtained through electrodes applied on the scalp.
○ diagnostic procedure to determine if the patient is
neurologically dead
○ most accurate in terms of determining the neurological
condition of the patient or brain electrical activity
○ no brain electrical activity = neurologically dead
● The EEG is a useful test for diagnosing and evaluating seizure
disorders, coma, or organic brand syndrome.
● Tumors, brain abscesses, blood clots, and infection and also
used in determination of brain death.
● The standard EEG takes 45 to 60 minutes, 12 hours for a sleep
EEG.
Nursing Interventions
● Anti seizure agents, tranquilizers, stimulants, and depressants
should be withheld 24 to 48 hours before an EEG.
● Coffee, tea, chocolate, and cola drinks are omitted in the meal
before the test because of their stimulating effect.
○ avoided because their stimulants
● An EEG requires patient cooperation and ability to lie quietly
during the test.
○ almost motionless - because any movements can affect
the procedure
Electromyogram (EMG)
● It is 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 loud speaker so that both the sound and
appearances of the waves can be analyzed and compared
simultaneously.
● An EMG is useful in determining the presence of a
neuromuscular disorder and myopathies.
○ When a patient is suffering from peripheral pain,
weakness of the extremities. sudden atrophy of the
muscle → you need to undergo EMG
○ Least likely to do because it is very PAINFUL
Nursing Interventions
● The procedure is explained and the patient is warned to expect
a sensation similar to that of an intramuscular injection as the
needle is inserted into the muscle.
○ deeper than IM so feeling is para kang nakukuryente
● The muscles examined may ache for a short time after the
procedure.
Lumbar Puncture & Examination
● Procedure by which CSF is withdrawn by inserting a needle
into the subarachnoid space.
○ done if there is suspicion of viral or bacterial in the
meninges
○ done in a fetal position so the intervertebral space will
expand
● Indications:
○ To obtain CSF for examination
○ To measure or reduce the pressure of CSF
○ To detect subarachnoid block
○ To administer medicine intrathecally
● Preprocedure
○ Obtain written consent
○ Explain 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
■ similar to fetal position
● Procedure (performed by the physician neurosurgeon)
○ Nurse assists the patient to maintain 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
○ 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
○ The tubes of CSF are sent to the laboratory immediately
● Post-procedure
○ 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
Cerebrospinal Fluid Analysis
● CSF should be clear and colorless
14
● Pink, blood-tinged or grossly bloody CSF may indicate a 4. Ensure the client has an empty bladder since bowel
cerebral contusion or laceration sounds may be obscured with a full bladder.
5. Never palpate suspected appendicitis or dissecting
Sample result of Lumbar puncture & examination abdominal aneurysm, polycystic kidney or transplanted
organ. It can precipitate a rupture or organ rejection.
6. Overcome ticklishness and minimize voluntary guarding
by asking client to perform self palpation

PREPARATION
1. Assemble equipment and supplies
■ Examining light
■ Tape measure (metal or non stretchable cloth)
■ Water-soluble skin marking pencil
■ Stethoscope
2. Explain the procedure to the client
3. Wash hands
4. Provide for client privacy
a. most especially for female clients; dapat may
kasama during the assessment and with
curtains or closed doors
more than 1 gram of protein → presence of bacterial infection 5. Determine client's history of the following:
a. Incidence of abdominal pain: its location, onset,
Performance Evaluation Tool - Neurological Assessment sequence and quality
Checklist
● Assessment of Neurological Function C character P provocative, palliative factors
O onset Q quality
L location R radiates
D duration S severity
S severity T time
P pattern
A associated factors

Additional Notes:

COLDSPA - descriptive tool to assess the client’s pain

● Character - describe the signs & symptoms what is the
appearance, feeling, smell, sound,
● Onset - when did it begin? Anong oras, araw kailan
dumating ang pain?
● Location - Saan nararamdaman? may iabng location pa
nararamdaman ang pain?
● Duration - Gaano katagal? How long does it last?
● Severity - pwede mag pa pain scale with 0 as no pain and
10 as extreme pain; how bad is it? how does the pain
bother you?
Day 2, January 26, 2022 ● Pattern - what makes it better or worse, Types of pain
OUTLINE ● Associated factors - What other symptoms occur with the
pain, how does it affect you
ABDOMINAL ASSESSMENT
I. Preparation PQRST
A. Inspection ● Provocative/Applicative - what were u doing when the
B. Auscultation pain started, what makes it better or worse, what seems to
C. Percussion trigger it: stress, activity, position; what relieves it:
D. Palpation massage, heat/cold
II. Urinary Catheterization ● Quality / Quantity - what does it feel like? use words that
A. Female Catheterization describe the pain, Is it
B. Male Catheterization sharp/burning/throbbing/shooting/twisting/stretching kind of
C. Care and Removal of the Indwelling pain?
Catheter ● Radiates - Where is the pain located, does the pain
D. Performing Catheter Irrigation radiate, does it feel like it travels or moves around? from
where?
I. ABDOMINAL ASSESSMENT ● Severity - pain scale ; how severe is the pain from 0-10;
Purposes ask pain scale; 0 as none and 10 as the worse; how bad is
1. To explore gastrointestinal complaints that will help it? does it force you to sit down? napapabagal ka ng kilos?
establish nursing diagnosis and plan of care how does an episode last?
2. To assess abdominal pain and tenderness and to monitor ● Time - timing; ask when and what time that the pain lasts?
client postoperatively how frequent? hourly? when do you usually experience it
3. To determine the presence of masses, lesions and other during the morning or evening? does it lead to anything
abdominal abnormalities. else like signs and symptoms? does it occurs season

Special Considerations TYPES OF PAIN

1. Palpation is done LAST because it can cause movement ● Acute - sudden pain
and stimulation of the bowel which can alter bowel ● Chronic - greater than 6 months; persistent and pabalik
sounds. balik ang pain
2. Ask the client to point to a painful and tender area and ● Cancer pain -
palpate that area LAST. ● Somatic - pain of skeletal muscle; smooth muscle; pain
3. Have warm hands, warm stethoscope and short from ligaments
fingernails.

15
 II. UPPER ABDOMINAL PAIN III. LOWER ABDOMINAL PAIN
● Perforated Peptic Ulcer
○ severe epigastric pain that may radiate to back or APPENDICITIS
shoulder; PERITONEAL SIGNS. ● Periumbilical pain that later localizes to lower right quadrant
○ sudden severe sharp epigastric pain, bloatedness, and ● Perforation - high fever and leukocytosis
feeling of fullness, When perforated, gastric juices and ● Rebound tenderness (Blumberg’s sign)
gas enters the peritoneal cavity leading to chemical
peritonitis. DIVERTICULITIS
○ Symptoms maybe severe pain in the abdomen ● Steady pain in LLQ and tenderness
○ Meron na mga existing peptic ulcer itong mga px with ● Usually common in elderly patients
PPU
○ chemical peritonitis - Hallmark Manifestation: Severe INFLAMMATORY BOWEL DISEASE
pain that can lead to tachycardia, abdominal pain and ● Chronic, crampy pain; diarrhea, blood, and pus in stool
rigidity is the hallmark of perforated peptic ulcer.
Preparation Continuation…
b. Bowel habits
DUODENAL ULCER GASTRIC ULCER c. Incidence of constipation or diarrhea
d. Change in appetite
● steady epigastric pain ● steady epigastric pain e. Food intolerance
relieved by food worsened by food f. Food ingested in last 24 hours
● Pain relieved by meal ● Pain increased by meal g. Specific signs and symptoms
● Occurs 2-3 hrs after meal ● Occurs 30 mins to 1 hr h. Previous problems and treatment
● Most common type after meal
● Dark, tarry stools ● Not as common 6. Ask client to empty the bladder or bowel
(melena) occur. ● Vomiting occur 7. Assist the client to a supine position with the arms placed
comfortably at the sides.
a. Place a small pillow beneath the knees and the head to
CHOLECYSTITIS reduce tension in the abdominal muscles. Expose only
● Cramp-like epigastric pain the client’s abdomen from chest line to the pubic area to
● May radiate to the tip of the right scapula avoid chilling and shivering which can tense the
● Murphy’s Sign - to see if the px is + for Murphy’s sign abdominal muscle
■ Positive Murphy’s Sign
8. Identify landmarks that divide the abdominal region into
quadrants. From tip of xiphoid process to symphysis pubis
and a horizontal line across the umbilicus

IV. ANATOMIC LOCATION OF ORGAN BY

ACUTE PANCREATITIS QUADRANT
● Severe epigastric pain close to the umbilicus often radiates to
the back.
● Cullen’s sign Right Upper Quadrant Left Upper Quadrant
○ Bluish discoloration
○ Found in the periumbilical area
○ Ex: Acute Hemorrhagic Pancreatitis ● Liver ● Stomach
● Turner’s sign ● Gallbladder ● Spleen
○ Bluish discoloration ● Duodenum ● Splenic flexure of colon
○ Found in the flanks ● Head of Pancreas ● Left lobe of liver
○ Ex: Use to diagnose Acute Hemorrhagic Pancreatitis ● Hepatic flexure of colon ● Left kidney and adrenal
● Right kidney and adrenal ● Body of pancreas
● Part of ascending and ● Part of the transverse
transverse colon and descending colon

Right Lower Quadrant Left Lower Quadrant

● Cecum ● Part of the descending

● Appendix
● Right ovary and tube
● Right ureter
● Right spermatic cord
colon
● Sigmoid colon
● Left ovary and tube
● Left ureter
● Left spermatic cord

Rationale ↠ Location of findings by common reference point helps

successive examiners to confirm findings and locate abnormalities.

INSPECTION

16
1. CONTOUR OF THE ABDOMEN describes the nutritional state
and normally ranges from flat to rounded.

Abdominal Findings:
- Scaphoid Abdomen
- Protuberant
- Abdominal Distention

NORMAL VS ABNORMAL

NOTE:
● If the abdomen appears distended, note if distention is
generalized. Look at the flanks on each side.
● If distention is suspected, measure the abdominal girth
by placing tape measure around the abdomen at level of
the umbilicus. Use a marking pen. SYMMETRY OF ABDOMEN
Rationale:
❖ Distention may be caused by 6 F’s: Normal Findings Abnormal Findings
➢ Fat, Flatus, Feces, Fluid, Fibroid, and Fetus
➢ If gas causes distention, flanks do not bulge. If fluid,
flanks bulge. Tumor may cause unilateral bulging. 1. Shine a light across the 1. Bulges, masses
Pregnancy causes symmetrical bulge in the lower abdomen towards you, or 2. Hernia - protrusion of
abdomen. shine lengthwise across abdomen. Viscera
the person. through abnormal
If distention is suspected, measure the abdominal girth by placing 2. Abdomen should be openings in the muscle
tape measure around the abdomen at level of umbilicus symmetric bilaterally. wall.
➢ Consecutive measurement will show any increase or 3. Even small bulges are 3. Note any localized
decrease in abdominal distention highlighted by a shadow. bulging.
4. Step to foot of 4. Hernia, enlarged liver or
examination table to spleen may show
recheck symmetry
5. Ask the person to take a
deep breath, further
highlighting any changes.
Abdomen should stay
smooth and symmetric.

Rationale ↠ changes in symmetry or couture may reveal

underlying masses, fluid collection (ascites) or gaseous distention.
Hernia can also cause the umbilicus to protrude upward.

3. UMBILICUS - normally midline and inverted. Note any

localized bulging, everted with ascites or underlying mass,
bluish periumbilical color with intra-abdominal bleeding
(Cullen’s sign)
4. INSPECT SKIN OF ABDOMEN’S SURFACE for color,
scars, venous patterns, rashes, stretch marks, and artificial
openings
2. SYMMETRY - abdomen should be symmetric, note localized
bulging, visible mass or asymmetric shape.

17
Common causes of rashes are virus (chicken pox, shingles - herpes
zoster), bacteria (impetigo) or or fungi (ringworm, atopic
dermatitis/eczema), insect bites, allergies, psoriasis
other causes include: - Usually nagkakaroon sa abdomen, puwedeng during
● bites or stings pregnancy magkaroon ng spider angiomas
● autoimmune diseases such as psoriasis

Caput medusae- dilation of blood vessels

Rationale ↠ Scars reveal evidence that a client has had a past

trauma or surgery. Venous patterns may reflect liver disease.
Artificial opening indicate bowel diversion.
Herpes Zoster (Shingles)
5. If bruising is noted, ask if the client uses self-administered
injections (insulin or heparin).
- if bruising is located - maybe caused by
injections or intake of medications such as
blood thinners
RATIONALE:
● Scars reveal evidence that client has had a past trauma
or surgery. Venous patterns may reflect liver disease.
Artificial opening indicate bowel diversion.

18
 6. Observe the vascular pattern

Rationale ↠ Visible venous pattern (dilated veins) is associated

with liver disease, ascites and vena cava obstruction

AUSCULTATION
Auscultate the abdomen for bowel sounds and vascular sounds
and peritoneal friction rub. Warm the hands and stethoscope
diaphragms.

Rationale ↠ Cold hands and cold stethoscope may cause the

client to contract muscles and contractions may be heard during
auscultation

1. Begin in the RLQ at the ileocecal valve area because bowel

sounds are always present here normally.

BOWEL SOUNDS are high-pitched gurgling sounds occurring

irregularly from 5-30 times per minute.
● Hyperactive - loud, high pitched, tinkling sounds that signal
increased motility (Borborygmi);
seen in patients with
○ Diarrhea 3. Peritoneal friction rubs are rough, grating sounds like two
○ Early Bowel Obstruction pieces of leather rubbing together; heard over inflamed liver
○ Gastroenteritis and spleen.
● Hypoactive - diminished bowel motility ● Rubs over the liver are mostly neoplastic but may occur
seen in patients with in inflammatory disease including acute cholecystitis
○ Abdominal surgery ● Splenic infarcts can generate left upper quadrant rub
○ Late bowel obstruction
● Absent - absence of bowel motility PERCUSSION
seen in patients with 1. Percuss several areas in each of the 4 quadrants to
○ Peritonitis determine presence of:
○ Paralytic ileus a. tympany (gas in stomach and intestine) and
○ Severe ascites b. dullness (decrease, absence or flatness of resonance
over solid masses or fluid)
NOTE: Absence of bowel sounds established after 5 mins of
listening. Rationale ↠ Large dull area is associated with presence of fluid or
tumor
2. For vascular sounds use the bell of the stethoscope over
aorta, renal arteries, iliac arteries, and femoral arteries. Listen NOTE:
for bruits. Percussion: Tympany is normally present over most of the
a. abdominal bruits - vascular swishing sound abdomen in the supine position. Unusual dullness may be a clue to
heard over the spleen, abdomen, aorta an underlying abdominal mass.
b. nagnnarrow arteries that bring blood to kidneys
kaya nagccause ng elevated protein etc PERCUSS:
c. dx of kidney function and swelling, if not treated ● 4 quadrants for gas or masses
lead to end stage disease with a blood urine ● Liver Span
protenuria ● Spleen Size
d. focal segmental sclerosis - may hyperfiltration ● Costovertebral Angle (CVA) tenderness
dahil da pagnnarow ng arteries na nagccary ng
blood to the kidneys

Rationale ↠ If aortic bruit is auscultated suggesting presence of an

aneurysm, stop assessment and notify physician immediately. →
kasi baka mag rupture ang aneurysm

19
 SYSTEMATIC PERCUSSION

LIVER PERCUSSION PATTERN

1. Begin at a point of tympany in the midclavicular line of RLQ
and percuss upward to the dullness (the lower liver border);
mark the point.
2. Percuss downwards from the point of the lung resonance
above the RUQ to the point of dullness (upper border of the
liver); mark the point.
3. Measure in cm the distance between the two marks in
2. In the right upper quadrant in the midclavicular line, percuss midclavicular line (the liver span).
the borders of the liver.

Rationale ↠ Percussion of liver should help guide subsequent

palpation. The liver border in the midclavicular line should normally
range from 2 ½ to 4 ½ inches.
● 6-12 cm - along midclavicular line
● 4-8 cm - along midsternal line

4. Tympany of gastric air bubbles can be percussed in LUQ over

the anterior lower border of the rib cage.
—
3. Assess for an enlarged spleen by percussing the lowest
interspace of the right anterior axillary line ( should be
tympanic). Ask the patient to take a deep breath and repeat

Rationale ↠ change in percussion note to dullness on inspiration

indicate an enlarged spleen.

SPLEEN PERCUSSION PATTERN

● Splenic dullness maybe heard near left 10th rib posterior to the
mid-axillary line
○ usually not found unless enlarged
○ Obscured by air in the colon
● Percuss at 10th intercostal space to determine with deep
breath

SHIFTING DULLNESS: If dullness on percussion shifts when the

patient is rolled on the side, peritoneal fluid (ascites) may be
present

20
 ● Areas of tenderness

EXAMINING FOR A FLUID WAVE

1. Ask an assistant to press the ulnar side and lateral side of
forearm firmly along the midline of abdomen
2. Firmly place the palmar surface of fingers and hand against
one side of client’s abdomen
3. Use your other hand to tap the opposite side of the abdominal
wall.

2. Perform deep palpation to determine locations, size, shape,

consistency, tenderness, pulsation, and mobility of underlying
organs and masses.

DEEP PALPATION
● Assess for masses or enlarged organs
● Mass descriptors
○ Locations
○ Size
○ Shape
○ Consistency - gaano katigas
○ Tenderness -
○ Pulsations - nagpupulsate ba
○ Mobility

NOTE: Movement of fluid waves against resting hand suggests

large amounts of fluid are present.

Costovertebral Angle (CVA) Tenderness

● It is often associated with renal disease
● Use the heel of your closed fist to strike the patient firmly over
the CVAs.
○ pain may be felt from possible urinary tract infection

REBOUND TENDERNESS AT MCBURNEY'S POINT

● Sharp pain when pressure released in RLQ suggest
appendicitis

PALPATION
1. Perform light palpation first to detect any muscular
resistance (guarding), tenderness of superficial organs or
masses.
- Hindi pwede mabigat or madiin na palpation ang gagawin
sa patient. Dapat light palpation lang muna.

Rationale - tenderness and involuntary guarding indicate Rationale ↠ rebound tenderness (pain on quick withdrawal of the
peritoneal inflammation fingers following palpation) suggests peritoneal irritation as in
acute appendicitis
LIGHT PALPATION
● Assessment of the skin turgor ginagamit para makita na ang sign kung may acute appendicitis
● Muscle tone ang patient
● Superficial lesions or masses

21
 3. Move slowly and gently from one quadrant to the next to ○ It is seen in Acute Cholecystitis. Clients cannot take a
relax and reassure the patient deep breath when examiner's fingers are pressed below
- NOTE: Palpate painful areas LAST! the hepatic margin.

4. Use two hands if the abdomen is obese or muscular, with

one hand on top of the other. The upper hand exerts
pressure downward while the lower hand feels the
abdomen.

● Kehr’s Sign
○ There is a pain felt in the left shoulder when there is
rupture of the spleen.

Palpation using two hands

● Cullen’s Signs
PALPATION OF THE LIVER ○ It is a bluish discoloration of periumbilical area seen in
● Palpate the liver by placing the left hand under the patient’s Acute Hemorrhagic Pancreatitis.
lower right rib cage and the right hand on the abdomen
below the level of liver dullness. Press gently inward and
upward with your fingertips while the patient takes a deep
breath.

Rationale ↠ A normal liver edge may be palpable as a smooth

sharp, regular surface. An enlarged liver will be palpable and may
be tender, hard, or irregular.
● Turner’s Sign
○ ​It is a bluish discoloration of the flanks seen in Acute
Hemorrhagic Pancreatitis.

● Puddle Sign
○ This is to detect minimal fluid collection in the abdomen
NOTE: (less than 120mL)
● Normally palpable near right costal margin, midclavicular line
● Palpate with right hand starting below the umbilicus and moving
upward until liver is palpable
● Remember the liver is a superficial organ

● To palpate the liver edge, place your fingers just below

the costal margin and press firmly
● Ask the patient to take a deep breath. You may feel the
edge of the liver press against or slide under your hand.
● A normal liver is not tender.

PALPATION OF THE SPLEEN ● Rovsing’s Sign

○ This is a test for appendicitis. Do deep palpation on the
● ​Press down just below the left costal margin with your right left lower quadrant. Pain in RLQ is a positive Rovsing's
hand while asking the patient to take a deep breath. It may sign.
help to use your left hand to lift the lower rib cage and flank.
The spleen is not normally palpable on most individuals

PALPATION OF THE KIDNEY

● Difficult to palpate unless enlarged
● With hands perpendicular to the midline between ribcage and
iliac crest, press hands gently but firmly together.
● Have person take a deep breath
● May feel the kidney slide between hands.
● Right kidney is normally lower than the left kidney.

PALPATION OF THE BLADDER ● Psoas’s Sign

● Palpate the area above the pubic symphysis if the client's
history indicates possible urinary retention.
IMPORTANT SIGNS IN ABDOMINAL ASSESSMENT
● Murphy’s Sign
○ Raise the client's right leg from the hip and apply
pressure against the lower thigh. Pain In the RLQ is
associated with irritation of iliopsoas muscle due to
appendicitis.

22
● Obturator Sign
○ It is done by flexing the patient's right thigh at the hip with
the knee bent and rotating the leg internally at the hip.
Right hypogastric pain constitutes a positive obturator
sign.

● Blumberg's Sign or Rebound Tenderness

kapag nilagay ang kamay, walang pain pero kapag tinanggal ang
kamay, mayroong pain

DOCUMENTATION
NOTE: Document findings in the client record

ABDOMiNAL ASSESSMENT CHECKLIST

Abdominal Assessment Youtube Video:

23
 https://www.youtube.com/watch?v=ufW03pXygp4

URINARY CATHETERIZATION

V. 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
○ Urethra
○ Pelvic floor Female and Male Urinary Bladders and Urethras

QUESTIONS

1. What are Pelvic Floor Muscles and can they be

stretched?
2. What strengthens the pelvic floor muscles?

PALPATION OF BLADDER

- palpate for residual urine

- palpation of the bladder begins at the midline
- dull when bladder is percussed

AVERAGE DAILY URINE OUTPUT BY AGE

AGE AMOUNT (mL/cc)

Anterior view 1-2 days 16-60

3-10 days 100-300
10 days - 2 months 250-450
1-3 years 500-600
3-5 years 600-700
5-8 years 700-1,000
8-14 years 800-1,400
14 yrs through adulthood 1,500
Older adulthood 1,500 or less
- pedia: walang amoy yung urine kasi masyado pang konti
- >14 yrs - can exceed 1500 ml pag pinipigilan kasi mas
naiipon
​ALTERATIONS IN URINE PRODUCTION AND ELIMINATION
Posterior view ● Polyuria: Excessive urine production; more than 1500 mL also
called as Diuresis;
○ polydipsia - excessive fluid intake because
these people excrete more than normal hence,
they also drink more water
○ may be associated with diabetes
● Oliguria: Low urine output; Less than 30 mL per hour
● Supposed to be is 1,500 ml oliguria is 500 ml
only
● Anuria: No urine/Without urine/ lack of urine production cause
by kidney failure

24
● Urinary frequency: The need to urinate many times during the ✓ To identify cause of infection
day/night; Urinates more than four to six times a day/ voiding of ✓ For urine culture, urine collection
frequent intervals ✓ 24 hr urine collection - pagkacollect, save and store in
● Nocturia: Voiding more than two or more times at night on a the fridge para di mapanis
regular basis. 4. To assess the amount of residual urine if the bladder empties
○ common in pedia incompletely
● Dysuria: Sensation of pain or burning sensation when ✓ assess the residual urine kaya kinakapag and gladder
urinating; Painful or difficult voiding kung mataas pa rin or nakaumbok pa rin
● Urgency: frequent sudden urge to urinate and is difficult to 5. To provide for intermittent or continuous bladder drainage and
control irrigation
○ strong desire to void ✓ those are for the disease na kailangan icontinuous and
● Urinary Incontinence (UI): Lack of voluntary control over irrigation like pnss/water sa bladder kay may blood clots
urination; loss of bladder control 6. To manage incontinence when other measures have failed
○ this is already a health symptom/disease ✓ kapag wala na talagang solution sa problem
● Enuresis: Bed wetting
○ Involuntary urination of children aged 4-5 yrs EQUIPMENTS
old where control should have been developed ● Screen (if in the ward)
● Retention: Unable to empty all urine in bladder ○ Kapag nasa 3 or 4 ang patients
○ Accumulation of urine → nagdidistend na ang ● Blanket
urinary bladder; hindi nailalabas ○ For privacy
● Flushing tray
FACTORS INFLUENCING A PERSON’S URINARY ○ Magsasalo ng urine
ELIMINATION ● Bed pan
● Growth and development ● Rubber sheet
○ Age, toddler, preschoolers (nagkakaproblema since need ○ If px is bedridden
mag diaper), teachers must teach students to wipe their ● Disposable gloves
genitals from front to back ● Catheterization tray with the following:
● Psychosocial factors ○ Catheter
○ Sa elderly dahil pagdating ng 70 yrs old, humihina na ➢ The bigger the number, the bigger the catheter
ang kidney kaya nag weweaken ang muscles kaya ○ Lubricant
nagkakaroon ng problem like retention ○ Sterile gloves
○ stress – may cause problems sa urinary; puwedeng ○ Kidney basin
mahirapan umihi ang patient ○ Flashlight
○ Environmental factors ○ Specimen bottle
■ may problem ba sa pag ihi ○ Antiseptic cleaning solution
■ mababa ba ang toilet for the elderly ○ Cotton balls
● Fluid intake ○ Forceps
○ What kind of fluid you intake each day ○ Safety pin/tape
○ Required: 6-8 glasses of water everyday = 1-2L ➢ hindi na gumagamit neto, mayroon ng velcro
○ Drinks ○ Syringe with sterile water (not sodium chloride because it
○ If excessive intake - nalulunod ang kidneys can crystalize due to salt content)
○ Coffee/Soda intake - how many cups? does it contain ○ Receptacle/basin
caffeine?; caffeine - diuretic
● Medications SELECTING A URINARY CATHETER
○ Furosemide: Increases urine output ● Determine the catheter length by the client’s gender
● Muscle tone ○ Adult female: 22-cm catheter
○ Affected by aging ○ Adult male: 40-cm catheter
○ Usually yung mga may neurogenic functions; may ● Determine appropriate catheter size of the urethral canal
problem sa muscle tone that may cause urinary problems ○ Children: 8FR or 10FR or 12 FR
● Various diseases and conditions (that can affect urination) ○ Adults:
○ Hypertension ➢ Women: 14FR - green
○ Heart Disease ➢ Men: 16FR/18FR - orange *Use of
○ Neurologic 10cc syringe
○ Benign Prostatic Hyperplasia (BPH) ○ Kapag ooperahan - 20FR 24FR pero threeway siya
■ Common in males
○ Cancer ● Straight cath - pang kukuha lang ng urine
○ Diabetes ● Indwelling cath - may balloon
● Surgical and diagnostic procedure
○ Transurethral Resection of the Prostate (TURP)
○ Cystoscopy
○ Spinal/Epidural anesthesia
● Environmental factors
○ Neurologic dysfunction = immobility

URINARY CATHETERIZATION
● Introduction of a catheter through the urethra to the bladder for
the purpose of withdrawing urine External or Condom Catheter
● Only performed only when absolutely necessary since this
can introduce microorganisms to the body.
○ 80% magkaroon ng urinary tract infection ang
client once catheterization

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

25
 F14 cath with 5cc syringe - 4.7mL

Self-Adhering Condom Catheter (Rolled over Penis)

Urinary Drainage Leg Bag
- every now and then dinadrain kasi maaring mag back-up
sa bladder or urethra and may cause UTI
- maintain sterility kaya ialcohol muna bago ikabit
Sterile Kit
● This is not for perineal care
● this is sterile kit for catheterization
● kulang sa pic is nss - panglinis

Rationale: a twisted condom can obstruct the flow of urine

● inspect penis 30 mins after condom application - baka
may allergy sa latex (s/s: namumula, namamaga)
● Check every 4 hours
● Pagakalagay - check every 30 mins and check the urine
flow
● Check din if too tight ang pagkakalagay. Assess redness
(very tight ung condom) and blistering for the first few
days; kapag may blister → mayroong latex allergy

A three-way foley catheter often used for continuous bladder

irrigation

Indwelling Foley Catheter A Coudé Catheter

● GREEN - 14
● WHITE - 12
● small - may guide wire

26
 Red-Rubber of Plastic Robinson Straight Catheters

eye of the catheter

A. FEMALE CATHETERIZATION ✓ Eases insertion of catheter through urethral canal

PROCEDURE
1. Assemble equipment. Prepare a sterile catheterization set.
✓ Bring two (2) catheters so if the one gets unsterile, you
have extra on hand
✓ To ensure smooth flow of procedure
2. Wash hands
✓ reduce transmission of microorganisms
3. Provide for privacy and explain procedure to client
✓ Ensure cooperation and offer relaxation during procedure
4. Position client into dorsal recumbent or side-lying position
✓ Dorsal recumbent for women
✓ Supine for men
5. Drape the client. Place the blanket in a diamond fashion
✓ Pag nakabuka babae, naka-cover na parang triangle sa
puerta niya
6. Apply gloves
✓ Clean gloves 12. Inflate catheter balloon
7. Wash perineal area and dry ● For an adult indwelling foley catheter, use 5 or 10 mL of
sterile distilled water to inflate the balloon.
i. mL based on the manufacturer - in FEU NRMF,
we use 10 mL
ii. ordinary cath - 5-10mL
iii. pero pag may disease like post TURP - 30mL
and surgeon ang maglalagay
✓ Can minimize urine leakage to ensure that
the catheterization continues easily
✓ Preferably, sterile water is used for inflating
the catheter balloon (FEU-NRMF based)
EQUIPMENT
● Sterile water NOT tap water
○ same osmolality as urine
● Sodium Chloride
○ we use nss bc sodium chloride has salt so it can
crystallize so pag nagballoon ka then NaCl - pwedeng
may matira - and pag hinatak yung catheter, masakit
i-withdraw
● Syringe with no needle
✓ why do we need to do perineal area? Puwedeng tumama
sa hita yung catheter, and maaring madumi ang area
✓ Rule of 7 - labia majora swipe pababa, then next hita 6
swipe away, huli sa gitna labia minora; from inner ->
palabas
✓ Lagay bedpan/kelly pad under
✓ Use betadine 10% solution to clean
8. Remove gloves and wash hands
9. Open catheterization kit.
✓ Use wrapper to establish sterile field to prevent
transmission of microorganisms from table to work area
10. Apply sterile gloves
11. Lubricate the catheter for about 1 to 2 inches, being careful not
to fill the eyes of the catheter.

13. Cleanse urethral meatus, retract labia, pick up a cotton ball

with antiseptic solution and wipe from front to back.
✓ Use the index and middle finger to retract
✓ Once nahawakan na, wag ng tanggalin ang
kamay
✓ Retract upward using fingers

27
14. Pick up the catheter with your dominant hand. Ask the client to
bear down gently and insert a catheter through the urethra Video resources:
meatus. https://www.youtube.com/watch?v=UcNH7ub6iOQ
✓ Use dominant hand and sa iba pinapa-ikot ang hawak ; https://youtu.be/VN3LuGrX6Uo
make sure di tatama sa legs bc for men the whole tubing Euroget - Lidocaine - kasi masakit paginsert ng catheter
is inserted while for women 5 -7 inches is inserted 5-10g of gel for woman
✓ “Hingang malalim” - insert then exhale
✓ Advance catheter 2 -3 inches; kapag pumasok na B. MALE CATHETERIZATION
advance another 2 inches;
✓ Do not force insertion
15. Advance catheter a total of 2 to 3 inches. When urine appears, PROCEDURE
advance another 1 to 2 inches. 1. Assemble equipment. Prepare a sterile catheterization set.
✓ Total: 5 inches (maximum) ✓ Bring two (2) catheters so if the one gets unsterile, you
✓ DO NOT FORCE AGAINST RESISTANCE. Further have extra on hand
advancement can result in coiling. 2. Wash hands
✓ Bearing down - relaxation of urinary external sphincter 3. Provide for privacy and explain procedure to client
✓ if inserted - use unsterile hand to hold the end and sterile 4. Position client into supine position with thighs slightly abducted.
hand connects to the urine bottle 5. Drape the client. Drape the upper trunk with a bath blanket and
16. Place the end of the catheter in the urine receptacle. cover lower extremities with bed sheets.
17. Collect urine specimens if needed. 6. Apply gloves
✓ Catch midstream urine - bc pag nagccollect and collected 7. Wash perineal area and dry
the first output, baka may kasama pang dugo and can 8. Remove gloves and wash hands
lead to false positive blood in the urine 9. Open catheterization kit.
✓ collect more than half of the specimen bottle and label ✓ Use wrapper to establish sterile field to prevent
with name, age, purpose of culture and send right away transmission of microorganisms
to the laboratory bc it will expire after 30 mins 10. Apply sterile gloves
18. When urine flow starts to decrease, withdraw the catheter 11. Lubricate the catheter for about 6 to 7 inches.
slowly about 1 cm at a time until urine barely drips. Then 12. Lift penis with one hand (dominant), cleanse area of meatus
withdraw. with cotton ball in a circular motion.
✓ ✓ Move from meatuse toward the base of the penis.
19. Reattach the water-filled syringe to the inflation port. ✓ Retract foreskin in the uncircumcised male client.
✓ 13. Lift penis perpendicular to the body and steadily insert the
20. Indwelling with retention balloon catheter into the meatus.
● Inflate the retention balloon by injecting required amount 14. Ask the client to breathe deeply and rotate the catheter gently if
of solution slight resistance is met, advance the catheter for about 7 to 9
✓ Do not over or underinflate the balloon. inches.
● If the client experiences pain during balloon inflation, 15. Hold the catheter securely while the bladder empties into sterile
deflate the balloon and insert the catheter further. receptacles.
● Once inflated, gently pull the catheter until the retention 16. When urine flows starts to decrease, withdraw the catheter
balloon is resting against the bladder neck. slowly about 1 cm at a time until urine barely drips, then
● Tape the catheter to the inner thigh. withdraw.
21. Place the drainage bag below the level of the bladder. 17. Indwelling with retention balloon
22. Remove gloves, dispose of materials ● Continue insertion for another 1 to 3 inches.
23. Help client adjust position ● Reattach the water-filler syringe to the inflation port
24. Wash hands ● Inflate the retention balloon
25. Document ● If the client experiences pain during balloon inflation,
deflate the balloon and insert the catheter further.
● Once inflated, gently pull the catheter until the retention
balloon is resting against the bladder neck.
18. Tape the catheter to the abdomen or thigh.

19. Place the drainage bag below the level of the bladder.
20. Remove gloves, dispose of materials, and wash hands.

28
21. Help the client adjust position. 3. Assess complaint of pain or discomfort
22. Document 4. Assess urine color, clarity, odor, and amount
5. Wash hands
6. Provide privacy
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
9. Position client and cover with bath blanket exposing only
perineal area.
○ Female: Dorsal recumbent position
○ Male: Supine position
10. Apply sterile gloves
11. Place rubber sheet under client
12. Provide routine perineal care

Video resources:
https://youtu.be/NBEsPkoDgZk
https://www.youtube.com/watch?v=ntF6a1laSnU
CARE AND REMOVAL OF THE INDWELLING CATHETER
● Catheter care: The cleansing of the perineum and the first 2
inches of the exposed catheter every 8 hours.
CONSIDERATIONS
● Clients with indwelling catheters require specific perineal
hygiene care to reduce the risk of urinary tract infection (UTI).
● The use of powders or lotions on the perineum is
contraindicated because of the risk of growth of
microorganisms, which may ascend the urinary tract.
● Removal of a retention catheter is a skill requiring clean
technique.
○ Requires clean technique
○ Kapag hinugot → may crust iyon kaya
kailangan linisin every 8 hours, especially with
male, parang nagsscab yung dulo so mahirap
hilain pag ay crust
● If the retention catheter balloon is not fully deflated, its removal
can result in trauma and subsequent swelling of the urethral
meatus and urinary retention can occur.
○ Kapag nagpasok ng 5 cc dapat huhugot ng 5cc,
not less
● If the catheter was in place for more than several days, the
client may experience dysuria resulting from inflammation of
the urethral canal and because of the decreased bladder tone,
the client may urinate frequently.
○ Nasanay na may catheter, hindi siya umiihi,
kaya naka relax yung muscles. Nung tinry ng
umihi, nasasaktan na ang patient
EQUIPMENTS
● Disposable gloves
● Rubber sheet
● Blanket
For catheter care
● Soap
● Wash cloth
● Basin
● Water
For removal of catheter
● Syringe
● Waterproof pad
● Alcohol swab
Catheter care
1. Assess urethral meatus and surrounding tissues for
inflammation, swelling, and discharge and ask client if burning
or discomfort is felt.
a. see if there’s local infection or status of hygiene
2. Using a clean washcloth, wipe in circular motion along the
length of the catheter for about 10 cm (4 in)
a. kung ano ang nasa dulo, start from the urethra
and maaring sabunan ang catheter
b. very important that the catheter is secured
3. Replace as necessary the adhesive tape that anchor’s
catheter to client’s leg or abdomen
4. Avoid placing tension on the catheter.
a. Kapag nagkaroon ng tension, maaring
magkaroon ng urethral trauma
5. Replace tubing and collection bag as necessary according to
agency policy, adhering to the principles of surgical asepsis
6. Check drainage tubing and bag to ensure that
a. Tubing is not looped or positioned above level
of bladder
b. Tubing is coiled and secured onto bed linen
c. Tube is not kinked or clamped
✓ If the tube is kinked, urine will not go
down and can result to urine stasis
d. Collection bag is positioned appropriately on
the bed frame.
Catheter removal
1. Place waterproof pad
○ Female: Between thighs
○ Male: Over thighs
2. Remove adhesive tape used to secure and anchor
catheter. Cleanse residue from skin.
3. Insert hub of syringe into inflation valve (balloon proof).
Aspirate entire amount of fluid used to inflate balloon.
4. Pull catheter out smoothly and slowly.
5. Wrap contaminated catheter in waterproof pad. Unhook
collection bag and drainage tubing from bed.
13. Reposition client as necessary. Cleanse perineum. Lower
level of bed and position side rails accordingly.
14. Measure and empty contents of collection bag.
15. Dispose of all contaminated supplies correctly. Remove
gloves and wash hands.
PERFORMING CATHETER IRRIGATION

PROCEDURE
1. Determine how long catheter has been in place
○ Tinatatanggal na after 2 days
○ For complications, maaring tumagal ng 4 to 5 days
2. Observe any discharge or encrustation around the urethral
meatus
○ Seen at the end - uses macroset not microset
○ Observe and check the discharge

29
 ​PURPOSE
➢ To maintain the patency of a urinary catheter and tubing
➢ To free a blockage in a urinary catheter or tubing
TWO TYPES OF IRRIGATION SYSTEMS
■ Closed Bladder Irrigation System: Provides
intermittent or continuous irrigation of the system without
disrupting the sterile alignment of the catheter and
drainage system, thus decreasing the risk of bacteria
entering the urinary tract.
✓ Preferred technique
✓ Lesser chance for infection ■ Double Lumen: One lumen to inflate
✓ Lower risk for UTI balloon one to allow outflow of urine.
● CONTINUOUS IRRIGATION 2. Assess the following:
■ Open Irrigation System: Also used to maintain bladder a. Color of urine and presence of mucus and clots
irrigations are required less frequency and there are no b. Palpate bladder
blood clots or large mucous shreds in the urinary ■ Kung full ba ang bladder or not
drainage. ■ Determines if the system is
✓ Kapag may clots tsaka lang magpupush obstructed
✓ two way c. Existing closed system
● INTERMITTENT IRRIGATION ✓ Note if fluid entering bladder and fluid
draining from bladder are in
EQUIPMENTS appropriate proportions
Closed continuous method ✓ Determine that drainage tubing is not
■ Sterile irrigation solution kinked, clamped off incorrectly or
○ kapag malamig maaring mag spasm ang tiyan, looped below bladder level
kapag mainit naman maaring mapaso kaya ✓ Note amount of fluid remaining in
dapat room temperature existing irrigating solution container
■ Irrigation tubing with clamp d. Review input and output record.
■ IV pole NOTE: If fluid cannot enter or if fluid draining is less than
■ Sterile irrigating solution at room temperature amounts going in, stop the irrigation, assess and notify
■ Sterile graduate container the physician.
■ Sterile 30-50 mL syringe– Used to instill irrigant into
catheter 3. Assess client for presence of bladder spasms and
■ Sterile 19-22 gauge, 1 inch needle discomfort.
■ Antiseptic swab PERFORMANCE PHASE
■ Clamp
1. Wash hands
2. Explain procedure to client
3. Provide privacy
4. Position client in supine position and remove tape that is
anchoring catheter to client.
5. Assess lower abdomen for signs of bladder distention
- check for any malfunctions

Closed intermittent irrigation

1. Pour prescribed room-temperature sterile irrigating
solution in sterile container
Irrigation set a. Minsan iniinit nila ang irrigating solution (NSS)
- 50 ml syringe para di mag cramps
- antiseptic swab 2. Draw sterile solution into syringe using aseptic technique.
- sterile irrigation set 3. Clamp indwelling retention catheter below soft injection
Open intermittent method port or on drainage tubing
■ Sterile irrigation solution at room temperature a. para magkaroon ng pressure kasi pag di naka
■ Asepto syringe with bulb clamp yung injection port, lalabas din yung
■ Sterile kidney basis pinasok mo na solution
■ Waterproof drape 4. Apply gloves
■ Sterile solution container 5. Cleanse catheter injection port with aseptic swab
■ Antiseptic swab 6. Insert needle of syringe through port at 30o angle.
■ Gloves ✓ butasin to inject; slowly
■ Tape 7. Inject fluid into catheter and bladder.
8. Withdraw syringe and remove clamp, allow solution to
PROCEDURE drain intro urinary drainage bag.
✓ Tubing clamp temporarily allows instilled fluid to
PREPARATORY PHASE remain in blassed, especially if irrigant is
1. Check client’s record to determine: medicated.
a. Purpose of closed bladder irrigation Closed continuous irrigation
b. Doctors order for type and amount of irrigant 1. Apply gloves and using aseptic technique, insert spike tip
c. Type of irrigation: continuous or intermittent of sterile irrigation tubing into bag containing irrigation
d. Type of catheter used solution.
■ Triple Lumen: ✓ Reduces transmission of microorganisms
1. One lumen to inflate a ✓ Irrigation solution used in NRMF is NSS
balloon ✓ Parang suwero lang kapag nagspike
2. One to instill irrigant 2. Close clamp on tubing and hang bag of solution on IV
solution, pole.
3. One to allow outflow of the ✓ Prevents loss of irrigating solution
urine. 3. Open clamp and allow solution to flow through tubing,
keeping end of tubing sterile. Close clamp.
✓ Removes air from tubing
4. For continuous irrigation, calculate drip rate and adjust
clamp on irrigation tubing is open, and check volume of
drainage in drainage bag.

30
 ✓ adjust catheter and check drops
5. For intermittent flow, clamp tubing on drainage system,
open clamp on irrigation tubing and allow prescribed
amount of fluid to enter bladder. Close irrigation tubing
clamp and then open drainage tubing clamp.
- Pag mag sstart palang, iclamp ang bag at open
ang irrigation.
- FLUSHING SYSTEM - close irrigation bag, and
open urinal bag
Open Irrigation
1. Apply gloves
2. Open sterile irrigation tray. Establish sterile field and
pour-required amount of sterile solution into sterile
solution container.
✓ Make sure it's sterile to sterile. Sterile field and
sterile solution NOT tap water
3. Position waterproof drape under catheter.
✓ Pwede magleak and magsoil ang linen
4. Aspirate 30 mL of solution into irrigating syringe.
✓ ilagay sa syringe at mag aspirate. Get 50 cc
syringe to aspirate 30cc
5. Moves sterile collection basin close to client’s thigh.
✓ To avoid soiling of linen
6. Wipe connection point between catheter tubing with
antiseptic wipe before disconnecting.
✓ as usual, once you open a catheter, disinfect to
prevent 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.
- Tanggalin yung catheter sa urine bag tas
hayaan pumunta yung urine sa basin.
8. Inserts tip of syringe into lumen of catheter and gently
instil solution.
✓ to avoid bladder spasms
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.
✓ pag nainsert mo na withdraw the syringe and
lower the catheter and allow catheter to drain
✓ 33 degrees angle
10. If solution does not return, have client turn onto side
facing nursing.
✓ If changing position does not help, reinsert
syringe and gently aspirate solution.
✓ Change lang position or baka na kink yung
tubing.
11. After irrigation is complete, remove protector cap from
drainage tubing adapter, cleanse adapter with alcohol
swap, and reinsert adapter into lumen of catheter.
12. Anchor catheter to client's leg or thigh with tape.
- Panibagong tape ang gagamitin
13. Assist client into comfortable position.
- For relaxation and rest of the client
14. Lower bed to lowest position and position side rails
accordingly.
✓ So the patient does not fall after the procedure
15. Dispose of contaminated supplies, remove gloves, and
wash hands.
✓ anchor to prevent trauma
Bladder Irrigation procedure YOUTUBE VIDEO
TOTAL PARENTERAL NUTRITION
● Parenteral - meaning di dadaan sa bibig = Nothing per orem
● is another term used synonymously with parenteral nutrition
● Also referred to as intravenous hyperalimentation
● A method of feeding that bypasses the Gl tract
- Hindi dumidiretso sa Gastrointestinal Tract (GI Tract)
● It meets the patient's nutritional needs by way of nutrient-filled
solutions administered intravenously through a central line,
usually the subclavian or internal jugular veins or it can also be
delivered into the smaller peripheral veins
●
● The IV infusion of (nutritional facts: dextrose, water, fat,
proteins, electrolytes, vitamins, and trace elements)
○ TPN solutions are hypertonic, they are injected into
high-flow central veins because the solution is highly
concentrated.
○ It is diluted by the client’s blood
PURPOSES
● To achieve anabolic state in clients who are unable to maintain
a normal nitrogen balance.
- Anabolic state: the body repairs itself to become bigger
and stronger. = weight gain
- Anabolic - marked by or promoting metabolic activity
concerned with the biosynthesis of complex molecules
san to gogol? merriam webster
- Severe malnutrition
- Severe burns (Third degree - Bawal na kumain)
- Bowel disease disorders (e.g. ulcerative colitis, enteric
fistula, etc.)
- Acute renal failure
- Hepatic failure
- Metastatic Cancer → from kidney, uterus to brain,etc
(metastasis, kumakalat sa kahit anong parte ng katawan)
- Major surgeries that require NPO for at least 5 days
INDICATIONS
● When enteral intake is inadequate or contraindicated (When
NPO) - intake by mouth hindi allowed
● Too low serum Albumin level (<2.5 g/dL)
● Severe risk for malnutrition
PRIMARY COMPONENTS OF TPN (PCF)
● Proteins
● Carbohydrates
● Fats
- TPN solutions are 10% to 50% dextrose in water, plus a
mixture of amino acids and special additives such as the
following additional components
ADDITIONAL COMPONENTS OF TPN
● Electrolytes and Minerals (Sodium, Potassium, Calcium ,
Chloride, Magnesium)
● Vitamins (B complex, C, D, K)
● Trace Elements
- Cobalt, Zinc, Manganese
● Fat emulsions
- may be given to provide essential fatty acids to correct
and/or prevent essential fatty acid deficiency or to
supplement the calories for clients who, for example,
have high-calorie needs or cannot tolerate glucose as the
only calorie source. Given to clients who cannot tolerate
high glucose
31
 Additions must be placed after bag has been activated
● trace elements
● Vitamins
● Electrolytes

Addition of Additives
● Break off white tab with the arrow pointing up on the
additive Port
● Sterile for the first use
● 18-23 g syringe for all additives
● Pierce no more than 10 times

Hanging TPN Bag

NOTE: 1,000 mL of 5% glucose or dextrose contains 50 grams of ● Break off blue tab of the infusion port
sugar. Thus, a liter of this solution provides less than 200 calories ● Infusion set with specific micron - insert spike

HOW TO MIX/ ACTIVATE A 3-CHAMBER TPN BAG MATERIALS NEEDED

● Youtube video: ● TPN solution
Kabiven® three chamber bag activation ‫… د ليث غضنفر شريف‬ - make sure kung anong order ng doctor yun
● Kabiven (Brand of TPN) – Three chamber bag lang din ang infuse
○ for central administration - sa america, sila na ang nag prepare sa
pharmacy
- check px name, birthday, ilang electrolytes
protein etc nakalagay
● Gloves
● Empty syringe
● Multivitamins/additives if there is
● Tubings
● Infusion pump
● Hand sanitizer
- Always observe aseptic technique
- Client is at risk for electrolyte imbalance so
frequent assessment is needed

SIZES: HOW TO PREPARE AND ADMINISTER TPN SOLUTION

● 1026 ml ● Youtube Video: How to prepare and administer TPN
● 1540 ml 1. Prepare a TPN bag with multivitamins
● 2053 ml 2. Attach the needle to the syringe
● 2566 ml 3. Turn the vial all the way
4. Add a little bit of air into your syringe
NOTE: The size depends on the doctor’s order 5. Inject the multivitamin
dextrose, lipids, and amino acids w electrolytes 6. Puncture the outside of the TPN
7. Mix the multivitamins in with the TPN solution
KABIVEN a. rock it like a baby
Inner bag- composed of three chambers b. notice that the colors are light yellow, there
1. Lipid emulsion (white)- blind port shouldn't be any solids specks or particles
2. Amino Acids and electrolytes - additive port 8. Inject the multivitamins into your TPN bag
3. Dextrose - infusion port 9. Set up the tubing
10. Take out the IV tubing
Each port is labeled as function: 11. Take the cap off of the tubing
● Blue port arrow away from the bag - infusion port 12. Insert the spike into the TPN bag with forcible twisting
- 1.2 micron filter motion
● White port arrow towards bag - additive port 13. Raise the TPN bag on the pole and fill the tubing
- Preferably 18-23 gauge 1 ½ needle (40 mm) a. Works by the force of gravity so you should put
● Far left - blind port (should not be used) the tubing lower
b. Fill the TPN solution all the way to the end of
Does not require disinfection for the first use the cap
● THEY ARE STERILE FOR THE FIRST USE. c. It’s alright to have small bubbles in the tubing
● Chamber on left - white (Lipid) 14. Insert the battery
● 2 chambers - clear and colorless 15. Latched on the pump
● Inspect bag prior to activation 16. Connect the tubing to your pump
17. Attach the tubing
Make sure to read all instruction before use 18. Start the pump
- Chamber on left is white and the other 2
- chambers should be clear white ADMINISTERING TPN THROUGH CENTRAL LINE
● Youtube Video:
DISCARD BAG IF: Administering Parenteral Nutrition Through a Central Line
● overpouch is opened or damaged ● Subclavian and Internal Jugular Vein
● more than one chamber is white
● any solutions are yellow LONG TERM TOTAL PARENTERAL NUTRITION
● any seals are broken ● Patients with AIDS
● Advanced cancer
How to Mix/Activate a 3 chamber TPN Bag ● Difficulty swallowing
● Place the bag on the clean flat surface -to open the bag ● Chronic bowel problems
locate the notches and tear it open Partial Peripheral Nutrition (PPN) - is prescribed for patients who
● Inverting bag at least 3 times require nutrient supplementation through a peripheral vein
● Activation steps - white part, text side up and ports away because they have an inadequate intake of oral feedings.
from you
● Roll and push towards the port - takes 5 minutes DISADVANTAGE OF TPN
● Inspect the bag ● TPN therapy is costly.
● Requires constant monitoring

32
● Has potential for causing infections and metabolic and
mechanical complications.
POTENTIAL COMPLICATION OF TPN
● Insertion problems, such as pneumothorax, air embolism, and
thromboembolism
● Infection
● Metabolic alterations, such as hyperglycemia (bc you
introduced dextrose content) or hypoglycemia when the
infusion is discontinued or interrupted
- be careful sa dextrose content lalo na if diabetic
ang client.
● Fluid, electrolyte and acid-base imbalances
● Phlebitis
GUIDELINES FOR MONITORING ADMINISTRATION OF
PARENTERAL NUTRITION
● Use the same catheter lumen for administration or parenteral
nutrition each time the tubing is changed.
○ pwede sa porta cath (for longer used, used also for
cancer px) or subclavian catheter
● Use a pump to administer infusion or parenteral nutrition.
● If the administration of parenteral nutrition is interrupted.
Administer a 5% to 10% dextrose solution to prevent
hypoglycemia.
● Discard unused parenteral nutrition solution within 24 hours.
● Check vital signs every 4 hours to monitor for development of
infection of sepsis
○ need din ng sterile technique when connecting TPN
● Monitor blood glucose levels every 6 hours.
● Use aseptic technique when changing solution, tubing, filter, or
dressings according to agency policy.
○ Pag naglalagay ng extra gamot sa TPN, make sure na
hindi accidentally naprick yung bag kasi sayang
● Check that all connections are securely taped, the catheter is
clamped before opening the system, and the insertion site is
covered with sterile dressing
○ make sure to prime the tubing
● Compare the patient's daily weight to fluid intake and output.
Total weight gain should not be greater than 3 lbs per week.
● Assess serum protein and electrolyte levels for signs of
imbalance
● Due to the high glucose concentration, use tubing with an inline
filter
○ Don't use microset and always use infusion pump
NASOGASTRIC TUBE (NGT)
● 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
○ Why do we need to include the family in the
preparation, feeding, and post procedure care
A. DESCRIPTION
● Short tubes used to intubate the stomach
- There is a standard landmark and
measurement prior to insertion
- Measurement is the key to an effective NGT.
● Inserted from the nose to the stomach
- NGT is indicated to a lot of
complications/conditions
Levine Tube
● Single-lumen nasogastric tube
● Used to remove gastric contents via intermittent
suction or to provide tube feedings
● One of the most common tube used in the hospital
○ Open eyes yun yung nagrreach sa stomach ng
px
A plastic or rubber single-lumen tube with a solid tip that may
be inserted into the stomach via the nose or mouth Used to
drain fluid and gas from the stomach. Single lumen must be
used for irrigation and drainage,so continuous irrigation is not
possible.
Salem Sump Tube
● Double-lumen nasogastric tube with an air vent
● Used for decompression with continuous suction
● Air vent is not to be clamped and is to be kept above the
level of the stomach
● If leakage occurs through the air vent, instill 30 ml of air
into the air vent and irrigate the main lumen with normal
saline (NS).
● Usually used in patients with bleeding
hindi ito masyado ginagamit, kasi usually ginagamit ito sa px na
may bleeding
B. NG TUBE INTUBATION PROCEDURES
● Place the client in high-Fowler's position
● Measure from tip of nose to earlobe to xiphoid process
(NEX) to determine the length of insertion and mark with
tape
● Lubricate tube about 3 inches with a water-soluble jelly
only (oil-soluble is not used), to prevent the development
of pneumonia if the tube accidentally slips into the
bronchus
○ there are some instances na dumidiretso sa
bronchus yung tube, kaya kapag chineck yung
sound sa auscultation, walang abdominal
sound na maririnig
● Instruct the client to bend the head forward, which closes
the epiglottis and opens the esophagus
● Insert into the nostril, advance backward and through the
nasopharynx
- If there is resistance, do not attempt directly
because there might be an obstruction.
Inserting the tube forcefully can cause trauma
or bleeding to the client’s nares. Have the client
rest for a while.
● Have the client take a sip of water and advance tube as
the client swallows
- Px is unconscious: no problem with gag reflex
- Px is conscious: advise the client take sips of
water and ask the patient to swallow while the
tube is advancing
● 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
33
 - STOP and let the client REST for a while (pag F. REMOVAL OF AN NG TUBE
continuous na nagccough ang px, and ● Ask the client to take a deep breath and hold → initial
bumababa na saturation) instructions
● Advance until taped mark is reached; tape in place when ● Remove the tube slowly and evenly over the course of
correct placement is confirmed 3 to 6 seconds (coil the tube around the hand as it is
● If feedings are prescribed, x-ray confirmation should be being removed)
done prior to initiating feedings
- BOARD EXAM RELATED XXII. GI TUBE FEEDINGS
- X-RAY: most ideal assessment (best
confirmatory test to locate the A. GI TUBE FEEDING TUBES
accurate placement of the tube) but ● Nasogastric
not every time we have to do Xray, of ● Nasoduodenal or Nasojejunal - nasa jejunum at
course we have to do our duodenum
responsibility as nurses about the ● Gastrostomy
placement of the tube ● Jejunostomy - opening sa jejunum ng px
● 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

PEG - dulong part naka attach sa stomach ng patient

Technique for Measuring the Distance to Insert the Tube

● from tip of nose to earlobe to xiphoid process (NEX)

C. ASSESSING OF TUBE REPLACEMENT

● 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 alternative method for assessing placement, but is not Sa jejunostomy papadaanin tas doon papasok ang tube
as reliable as an x-ray or checking gastric pH A. TYPE OF FEEDINGS
- pH paper, aspirate → kidney basin (check for ● Bolus - maramihan
bubbles), auscultation ● Continuous - tuloy tuloy
● Cyclical
D. ASSESSING RESIDUAL VOLUMES
● Check residual volumes every 4 hours, before each Bolus
feeding, and before giving medications ● Resembles normal meal feeding pattern
- eg: medications that we’re not - kung paano kumakain ang px
powderized/dissolved ● Can be administered via a syringe or via an intermittent
- TO check kasi baka may bumabara na, may feeding
mga medications na hindi na dissolve - we use the Asepto syringe and kangaroo pump
● Aspirate all stomach contents (residual) and measure for intermittent feeding
amount
● Reinstill residual feeding to prevent excessive fluid and
electrolyte losses unless the residual volume appears
abnormal

E. IRRIGATING AN NG TUBE
● Performed every 4 hours to check the patency of the tube
● Assess placement before irrigating
- hindi basta basta nag i-irrigate, first thing that
you have to do is check if the tube is still in
place
- If not placed properly, there is a risk for
aspiration pneumonia
● Gently instill 30 to 50 ml of water or normal saline (NS)
(depending on agency policy) with an irrigation syringe (or
asepto syringe → malaking syringe na may bullb sa ibabaw)
● Pull back on the syringe plunger to withdraw the fluid to check
patency; repeat if tube remains sluggish
● With an intermittent feeding, approximately 300 to 400 ml
of formula is administered over a 30- to 60-minute period
every 3 to 6 hours
- Use osterized feeding (OF) (naka prepare na or
substitute is Ensure
- hindi pwede madaliin at pwersahin pag bolus
kasi baka di kayanin ng pc
- pag malapot nagaaadd ng NSS para lumabnaw

34

Continuous
- Administered continuously for 24 hours
- An infusion pump regulates the flow → There is a
possibility of increased glucose level so naka monitors sa
RBS ng patient lalo na kung diabetic
- there is a special machine na ginagamit para ma regular
yung flow – kangaroo pump
Cyclical
- Administered either in the daytime or nighttime for 8 to 16
hours
- Feedings at night allow for more freedom during the day
C. ADMINISTERING OF 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
- hindi basta magiinsert
● 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)
- pwedeng thru ph, xray or auscultation
● 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
● For bolus feeding, leave the client in a high-Fowler’s
position for 30 minutes after feeding
○ Supine position is not allowed during and after
feeding
● For continuous or cyclical feeding, keep the client in a
semi-Fowler’s position AT ALL TIMES
D. PRECAUTIONS: GI TUBE FEEDINGS
● Change the feeding container and tubing every 24 hours
○ because there could be impending infection if
left for more than 24 hours
● Do not hang more solution than will be required for a
4-hour period to prevent bacterial growth
- pag may naintroduce na bacterial growth can
lead to infection, mas malala ang mangyayari
sa px
● Check the expiration date on the formula prior to
administering
● Shake the formula well prior to inserting into container
○ Residues settle on the bottom
○ since there could be residue resting on the
bottom, this is to evenly distribute the formula
● Always assess placement of the tube prior to feeding
- important to check prior to feeding
● Always assess bowel sounds; do not administer any
feedings if bowel sounds are absent
- check and notify
● 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 for flushing
● 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 immediately
● Administer feeding at prescribed rate, or via gravity flow
(intermittent, bolus feedings) with a 60-ml syringe with
the plunger removed
○ hindi puwedeng ipwersa gamit yung rubber
cover tas ipupush towards the patient
● Gently flush with 30 to 50 ml of water or normal saline
(dependng on agency policy) with the irrigation syringe
after the feeding
E. COMPLICATIONS OF GI TUBE FEEDINGS
● Aspiration
- May cause respiratory distress → death
● Vomiting
● Diarrhea
- Warm the formula because cold formula may
cause diarrhea
- Make sure the formula is warm
● Clogged Tube
- most common
Preventing Aspiration
● Verify tube placement
● Do not administer feeding if residual is greater than 150
ml
- Patient is still bloated or food is not yet digested
- kaya kapag napakain maaring natitira lang sa
may baga
● Keep the head of the bed elevated
● If aspiration occurs, suction as needed, assess
respiratory rate, auscultate lung sounds, monitor
temperature for aspiration pneumonia, and prepare to
obtain chest radiograph
- If aspiration occurs, suction - PRN
Preventing Vomiting
● Administer feedings slowly, and for bolus feedings, make
the feeding last for 30 minutes (by gravity)
○ huwag magmamadali kaya nga by gravity
● Do not allow feeding to run dry
● Do not allow air to enter the tubing
● Administer feeding at room temperature
● Elevate the head of the bed
● Administer antiemetics as prescribed
○ Metoclopramide (Prasil)
● If client vomits, place in side-lying position
Preventing Diarrhea
● Use fiber-containing feedings
● Administer feeding slowly and at room temperature
Preventing a clogged tube
● Use liquid forms of medication, if possible
→ Enteric coated meds is not included
● Flush the tube with 30 to 50 ml of water or NSS
(depending on agency policy) before and after
medication administration and before and after bolus
feeding
● Flush with water every 4 hours for continuous feeding
○ Need pa rin magbigay ng tubig to prevent
clogging and to flush
35
 XXIII. 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
○ kapag may clogging, huwag ituloy, assess the
patient and the cause of clogging
● Draw up the medication into a catheter tip syringe, clear
excess air, and insert medication into 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)
XIV. THINGS TO REMEMBER
● Reminders:
○ NGT is inserted by the attending physician
○ Administer feedings with the appropriate KCal
computed by the physician
○ Place the patient in a semi/high fowlers position before
feeding.
○ Maintain the patient in a sitting position for 30 minutes
after feeding.
○ Auscultate for bubble sounds before feeding the patient
to 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 using a tongue depressor to dilute
○ It is safe to use powdered medication, pulverize pills
properly to avoid clogging
XXV. NGT PROCEDURE from NURSING MANUAL
Knowledge
1. State the purposes of Inserting NGT
2. Enumerate the indications of NGT
3. Explain the Rationale of each suggested action
4. Enumerate the materials used.
Inserting Nasogastric Tube
● Prepare the materials
● Wash hands, wear gloves.
○ Reduces transmission of microorganisms
○ choose appropriate size of gloves
● 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 nurses action.
● Place bed in high-fowler‘s position.
○ Promotes client’s ability to swallow during the procedure.
Good body mechanics prevent injury to nurse.
○ best position during ngt
● Cover client‘s chest with towel (Have emesis basin and tissues
handy).
○ Prevents soiling of client‟s gown.
○ some patients vomit
● Palpate patient‘s abdomen for distension, pain, and/or rigidity.
● Auscultate for bowel sounds.
○ Baseline determination of level of abdominal distention
and function later serves as comparison once tube is
inserted.
○ dapat may abdominal assessment muna
● Examine nostrils & select the most patent one.
○ Tube passes more easily through nares that is more
patent.
○ kasi baka may obstruction
● Measure the distance to insert tube by placing tip of tube at
patient‘s nostril and extending to tip of earlobe and then to tip
of xiphoid process. Mark tube with an indelible marker.
● Lubricate first 4 inches of the tube with water soluble lubricant.
○ Minimizes friction against nasal mucosa and aids
insertion of tube.
● Ask client to slightly flex the neck backward. Flex position
closes off upper airway to trachea and opens esophagus.
● Gently insert the tube through nostril to back of throat.
Facilitates initial passage of tube through nares and maintains
clear airway for open nares.
○ If resistance is met, try to rotate the tube and see if it
advances.
● If still resistant, withdraw tube, allow client to rest, relubricate
tube and insert into other nares. Forcing against resistance can
cause trauma to mucosa.
○ Continue insertion of tube until just past nasopharynx by
gently rotating tube toward opposite nares.
○ Stop tube advancement, allow client to relax and provide
tissues.
○ Explain that the next step requires swallowing. Give
glass of water unless contraindicated. Tearing is a natural
response to mucosal irritation and excessive salivation
may occur because of oral stimulation. Slipping of water
aids the passage of NG tube into esophagus.
→ If there is difficulty in passing the NG tube ask the
client to sip water slowly through a straw unless oral
fluids are contraindicated. If oral fluids are not allowed,
ask to try dry swallowing while advancing the tube. Tube
may accidentally enter larynx and initiate gag reflex.
Gagging is eased by swallowing of water.
● Discontinue procedure and remove tube if there are signs of
distress, such as gasping, coughing, cyanosis, and inability to
speak or hum.
● Secure the tube with a tape. Tape to cheek. Tube should be
partially anchored before placement is checked.
○ NRMF uses leukoplast
● Check the placement of tube:
○ Inject 10 cc. of air and auscultate for ―woosh sound
● Swooshing” sound, indicates placement
○ Aspirate gastric contents Measure pH of aspirate.
Aspiration of contents provide means to measure fluid pH
and thus determine tube tip placement in gastrointestinal
tract
○ X-ray confirmation The most reliable confirmation
● After the tube is inserted, either clamp end or connect to
drainage bag. Drainage bag is used for gravity drainage.
Intermittent suction is most effective for decompression. Client
for surgery often has tube clamped.
○ Tape tube to nose. Wrap two split ends of tape around
tube Tape anchors tube securely. Explain to the client
that sensation of tube should decrease somewhat with
time. Adaptation to continued sensory stimulus.
● Remove gloves, disposed of used materials.
○ Reduces transmission of microorganisms
● Reassure client.
○ To allay anxiety.
● Position comfortably. Promotes sense of well-being
○ Safety: Once placement is confirmed, place mark, either
a mark or tape, on the tube to indicate where the tube
exist in the nose. Used as a guide to indicate whether
displacement may have occurred.
Irrigating a Nasogastric Tube
● Place client in semi-fowler‘s position.
→ Reduces risk of pulmonary aspiration in event client
vomit
● Check for NGT placement.
3 methods: patency, insertion ngt and aspiration???, xray
● Draw up 30 cc normal saline into irrigating syringe
→ Use of saline minimizes loss of electrolytes from
stomach fluids. This amount of solution will flush length
of tube.
● Gently instill the normal saline into the NGT. Do not force the
solution.
→ Position of syringe prevents introduction of air into
vent tubing. Solution introduced under pressure can
cause gastric trauma. Allow to pass through w gravity
● Withdraw Aspirate the 30 cc. Irrigation solution and empty into
the basin. Irrigation clears tubing, so stomach should remain
empty.
● Repeat the procedure twice
● Record on I&O sheet the irrigation solution that has not been
returned
→ Do not irrigate or rotate tube that has been placed
during gastric or esophageal surgery`
Removing a Nasogastric Tube
● Verify order to discontinue NGT
● Wash hands. Apply gloves.
● Explain the procedure to client.
● Place towel over client‘s chest.
● Clamp or plug tube.
36
● Unpin tube from gown.
● Loosen tape securing tube.
● Take paper towel in nondominant hand and place under chin.
● Instruct client to take and hold a deep breath.
● Pinch tube near nostril and remove with a continuous steady
pull.
● As tube is being removed, hold tube in paper towel or wrap it in
your hands as it is being pulled out. Dispose tube properly.
● Clean client‘s face especially the nares
● Offer oral hygiene.
● Remove gloves
● Assist client in comfortable position
● Wash hands
​XXVI. ADMINISTERING ENTERAL FEEDINGS
​Nursing Procedure Manual by Trina Tan pp. 89-90
XXVII. REFERENCES
● https://slideplayer.com/slide/12363018/
● Nursing Procedure Manual by Trina Tan pp. 85
● Nursing Procedure Manual by Trina Tan pp. 89-90
● Nursing Performance Evaluation Tool pp. 103
FOR NGT RETDEM - SIDE NOTES
● Purposes of NGT - explain everything include the pros
and cons of the entire procedure
● State also the indications - specific output why do we
need to perform NGT
● Rationale of each action
● Identify and prepare the appropriate materials
INSERTING THE NGT
● NGT - depends on the french & size accc to age &
proper measurement
● asepto syringe
● stethoscope - to check if it is properly inserted in ur
stoma
● lubricant - water soluble
● anchor & maintain safety - leucoplast
● kidney basin - esp px has possibility to vomit
● gloves and etc
● #12.2 - we can’t administer cold feeding bc it may cause
abdominal spasm - muscle contraction
● #12.3 - mga readily available sa market usually needs to
be verified before given to the patient
● #12.5 - parang naka IV but this time hindi mabilis kasi
baka maintroduce hyperglycemia
● #12.6 - para mafulush yung natitirang residue
● #13 if youre going to use a large syringe - remove the
plunger na naka attach
● #13.2 - Not thru plunger - agaisnt hospital policy - dapat
formula will be pushed naturally by graity
● # 13.3 - to prevent residue to be stuck sa tubing
● #13.4 - dapat di maexpose baka magkaabdominal pain if
napasukan ng hangin; observe
● 30 mins to 1 hr - hindi muna hihiga ang patient; place the
patient in a moderate high back or semi to high fowler's
kasi may chance na mag aspirate pa ang patient
Day 2 February 2, 2023
ENEMA
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 the presence of
stercobilin and urobilin derived from the red pigment
from bile
○ Amount of defecation varies from person to person,
the sensory nerves nag stimulate which gives the
person the urge to defecate
COLOR
NORMAL:
● ADULT: BROWN (d/t stercobilin or urobilin)
● INFANT: YELLOW

5. cover client;s chest with towel (have emesis basin and ABNORMAL POSSIBLE CAUSE
tissues handy) - bc may mga px na nagvvomit d/t the
proc
CLAY OR Absence of bile pigment (bile
● #7 - hindi basta basta nagiinsert - identify the more WHITE obstruction); diagnostic study using
patent nares barium
● naka wear na gloves and add the lubricant na sa first 4
inches of the tube
● 11 - check first diet of px, pag NPO bawal ito gawin BLACK OR Drug (e.g. iron); bleeding from upper GI
● hindi pwede idiretso pag may cyanosis or prob sa TARRY tract (e.g. stomach, small intestine); diet
breathing ang px so pag may ganun - stop and reassess high in red meat and dark green
the px vegetables (e.g. spinach)
● insert until the tape you measured is already reached
● check placement of tube - ingestion of 10cc of air and
assess swooshing of sound using stet RED Bleeding from lower GI tract (e.g.
rectum), some foods (e.g. beets)
IRRIGATING NGT
● during insertion - high fowler's; pero sa irrigation - naka PALE Malabsorption of fats; diets high in milk
semi fowlers and milk product and low in meat
● check patency of ngt - insert of 10 cc air, aspiration of
gastric content, xray (most ideal)
ORANGE Intestinal infection
REMOVING NGT OR GREEN
● before remove, you need to have an order from the
physician CONSISTENCY
● we instruct the px to do deep breath - pinch tube…
● offer oral hygiene and ALSO hygiene sa nares ng px
NORMAL: Formed, soft, semisolid, moist

ADMINISTERING ENTERAL FEEDINGS ABNORMAL POSSIBLE CAUSE

● food allergies - nakalagay sa KARDEX ng px
● auscultate bowel sounds - ito yung magiinstill tayo ng air
and hear whooshing sound HARD DRY Dehydration; decreased intestinal motility
● walang nagpapakain ng naka supine - elevate 30 degrees resulting from lack of fiber in diet; lack of
● #8 - Use asepto syringe - pang aspirate exercise, emotional upset, laxative abuse
● #9 - Before start of feeding flush 30 ml of water -t oc
check if may problem or if patent parin yung tube
● #12- we need to include the date and time sa feeding na DIARRHEA Increased intestinal motility (e.g. due to
binigay kasi may expiration ang mga iyan

37
 ○ Be aware of a doctor’s order bago mag-enema
irritation of the colon by bacteria) ○ take into consideration why we perform enema sa
patient
SHAPE
PURPOSE
NORMAL: Cylindrical (contour of rectum) about 2.5 (1 in) in
diameter in adults ● To relieve constipation
● To relieve fecal impactions
○ Minsan may mga enema na ginagamitan ng laxatives,
ABNORMAL POSSIBLE CAUSE
consult doctor first
● To cleanse the bowel prior to surgery, childbirth, or
Narrow, Obstructive condition of the rectum diagnostic examination.
pencil-shape ● LOWER GI X-RAY
d, or string
like stool

AMOUNT

NORMAL: Varies with diet (about 100-400 g/day)

ODOR

NORMAL: Aromatic affected by ingested food and bacterial ○ like childbirth

flora ○ Enema is ONLY done at 3cm-4cm (<5cm)
dilatation for pregnant woman.
ABNORMAL POSSIBLE CAUSE ○ Bawal mag-enema ng 10 cm or kapag fully
dilated na yung pregnant woman → maaaring
PUNGENT Infection, blood lumabas yung infant
○ 3 cm or below - allowed to perform enema but if
CONSTITUENTS multiple pregnancy (maluwag na, mas madali
magdilate)
NORMAL: Small amounts of undigested roughage, ○ Lower GI x-ray is called Fluoroscopy. A contrast
sloughed dead bacteria and epithelial cells, fat, protein, agent barium helps make these images. Barium
dried constituents of digestive juices (e.g., bile pigments, enema is used for this.
inorganic matter) ○ Barium enema: chalky powder mixed with water
○ It can help diagnose pain chronic what
ABNORMAL POSSIBLE CAUSE ● To evacuate the bowel in patients with neurologic
dysfunction.
PUS Mucus ○ Can be useful in treating gastrointestinal diseases,
inflammatory bowel disease (IBD), such as ulcerative
PARASITES Bacterial Infection colitis (UC) and Crohn’s disease for patients with
neurologic dysfunction who can’t defecate,
BLOOD Inflammatory condition ○ To treat the inflammation located in the colon
○ Rowasa (Mesalamine Rectal Suspension Enema) -
type of enema for used for those with IBD
LARGE GI Bleeding Malabsorption
○ Corticosteroids could also be prescribed by doctors -
QUANTITIES
medicated anema → ginagamitan ng steroids para sa
OF FAT
mga ulcerative colitis
○ Chronic neurologic diseases - multiple sclerosis,
FOREIGN Accidental ingestion spinal cord injury, and parkinson’s disease
OBJECTS
CAUTION
FECAL ELIMINATION PROBLEMS ● Children below age 10, pregnant women, and those
● Constipation suffering from (hemorrhoids) piles should not use the
○ Decreased frequency of defecation enema
■ Fewer than 3 bowel movements per week - bakit may pregnant women? buntis ay di pwede, full
○ Inferes the passing of dry hard stool or no stool at all term, iaadmit na kasi pwede na manganak
○ Painful defecation, rectal fullness, abnormal - hemorrhoids - baka masundot yung hemorrohoids at
pain, anorexia, nausea, headache, hard form maaring dumugo
stool, straining of stool, incomplete bowel ● Do not add any soap, chemicals, coffee, lemon, etc. to your
elimination enema pot. It needs to be plain water.
● Diarrhea - Be careful with water kasi dapat may specific amount
○ More frequent bowel movements lang nang water ang introduce at kung ano lang order
● Bowel incontinence nang doctor.
● Flatulence - it also depends on the adult: side lying in a left lateral
position, isang knee naka bend
ADMINISTERING ENEMA
● Enema is the introduction of fluid through a tube into
the lower intestinal tract.

38

TYPES OF ENEMA
CLEANSING ENEMA
● Promotes complete evacuation of feces by stimulating
peristalsis through infusion of large volumes of solution into
the colon.
- Intended to remove all feces
- Also given prior surgery kasi dapat malinis ang bituka
- Can be described as high or low
● Agents: Soapsuds, tap water, fleet and saline
○ For diagnostic tests like colonoscopy and xray, to
remove feces in instances of constipation or fecal
impaction
○ Soapsud - timpla ay kakayurin ang perla and boiled
water - tas imimix together then papalamigin ang
solution → used for pregnant women na ipapa enema
○ be careful with soap kasi nakakairita sa bituka, perla
is used kasi mild lang compared to other soap
○ Use tap water, fleet, and saline
○ Safest to use → saline
● High enema: given to clean the colon as much as possible.
Change position frequently.
○ Position: Left Lateral (during administration) → Dorsal
Recumbent → Right Lateral = so that the solution can
follow the large intestine
○ 12 to 18 inches in height or 30 to 49 cm above the
rectum
- Paiba iba ng pwesto.
- Introduced gamit ang water, soapsud, or saline
- The whole intestine is cleaned prior surgery
- Bago i-surgery dapat malinis ang buong bituka
- The higher position means greater flow
● Regular Enema: 12 inches in height
● Low enema: used to clean the rectum and the sigmoid
colon only
○ Position: Left lateral position (during administration)
→ 3 inches in height
RETENTION ENEMAS
● Introduces oil which lubricates the rectum and sigmoid
colon thereby softening the feces. Feces absorb oil and
become softer and easier to pass.
● Agent: Mineral Oil
● The liquid remains for a long period of time, about 1-3
hours.
- We use oil to lubricate rectum and sigmoid
colon
- Kaya retention - kasi magiiwan ka ng enema
sa sigmoid colon for 1-3 hrs
MEDICATED ENEMAS
● Contain pharmacological therapeutic agents and may be
prescribed to reduce dangerously high serum potassium
levels, or to reduce bacteria in the colon before bowel
surgery.
● Agents: Kayexalate Enema, neomycin enema
○ These medications are use para ma reduce yung high
serum potassium level sa bituka
○ Kayexalate Enema - indicated for treatment of
hyperkalemia (incr serum K)
CARMINATIVE ENEMAS
● Promotes expulsion of flatus.
● Agents: MGW (30% Magnesium, 60% Glycerin, and 90%
Water) solution or 1-2-3 Enema
○ herbal oils to help expel gas from the intestines
○ Cathartic drugs - strong or purgative effect; produce
soft or liquids stools acc by abdominal cramps
■ Castor Oil, Cascara, Bisacodyl
○ Laxatives contraindicated sa mga nahihilo, nausea,
cramps, vomiting, and undiagnosed abdominal pain
Position of Enema
○ Depende sa taas or baba ng solution, pag mataas,
the faster the flow, the greater the force to the rectum
○ Low Enema: elevate up to 12 inches / 30 cm above
the rectum
○ High enema: 12- 18 inches / 30-49 cm
○ Pag mataas, mas maraming pupuntahan (entire
bowel) pag mababa, sigmoid colon and rectum lang
talaga
TYPES OF LAXATIVES
BULK FORMING
ACTION: Increases the fluid, gaseous or solid bulk in the
intestine
EXAMPLES: Psyllium hydrophilic mucilloid (Metamucil),
methylcellulose (Citrucel)
PERTINENT ● May take 12 or more hours to act.
TEACHING ● Sufficient fluid must be taken
INFORMATION ● Safe for long- term use.
OSMOTIC/ SALINE
ACTION: Draws water into the intestine by osmosis,
distends the bowel and stimulates peristalsis.
Almost no water nor electrolytes are absorbed
as solution moves through the intestine and
the large fluid volume flushes feces from the
colon. (daniels and Schmelzer, 2013)
EXAMPLES: Four major types of osmotic laxatives:
lactulose, sodium phosphate (tablet form only
requiring prescription; OsmoPrep, Visicol),
magnesium salts (magnesium citrate), and
sodium sulfate (SUPREP) Electrolyte-free
polyethylene glycol 3350 (PEG 3350)
(MiraLAX) PEG-ES (GoLYTELY, NuLUTELY)
PERTINENT ● May be rapid acting
● Can cause fluid and electrolyte
TEACHING
INFORMATION imbalance, particularly in older people
and children with cardiac and renal
disease.
● Use caution when giving to older adults.
● A laxative that is helpful in the treatment
39
 of constipation. It is a powder that is
tasteless when mixed in a flavored liquid
such as juice.
● Used for cleaning of the colon before
colonoscopy.
● Requires drinking a large volume (4 L),
which may be difficult for clients to
tolerate. Has an unpleasant taste.
STIMULANT/ IRRITANT
ACTION: Irritates the intestinal mucosa or stimulates
nerve endings in the wall of the intestine,
causing rapid propulsion of the contents.
Bisacodyl (Dulcolax, Correctol), Senna
EXAMPLE:
(Senokot, Ex-Lax), Cascara, Castor oil
PERTINENT ● Acts more quickly than bulk-forming
TEACHING agents.
INFORMATION ● Fluid is passed with the feces.
● May cause cramps.
● Use only for short periods of time.
● Prolonged use may cause fluid and
electrolyte imbalance
STOOL SOFTENER/ SURFACTANT
ACTION: Softens and delays the drying of the stool;
causes more water and fat to be absorbed into
the stool.
EXAMPLE: Docusate sodium (Colace) Docusate Calcium
(Surfak)
Commercially-prepared Fleet enema (Hypertonic)
● Useful for clients who cannot tolerate large volumes
of fluid. Only 120 to 180 ml is usually effective.Or <
100 ml
○ Considered Hypertonic
○ Usually used in Delivery Room
○ Be careful when using fleet enema because
it may cause circulatory overload
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 (mild, di nakakairritate ng
bituka) it doesn’t irritate the stomach as
much
○ grated, and mixed with boiled water
● then cooled to room temperature
○ Used for delivery, (laboring 3-4 cm)
Oil Retention Enema
● Uses an oil-based solution
○ E.g. 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.
○ 1-2-3 solution
Commonly used Enema Solutions

PERTINENT ● Slow-acting
TEACHING ● may take several days
INFORMATION

LUBRICANT

ACTION: Lubricates the stool and colon mucosa.

EXAMPLES: Mineral Oil (Hales M-O)

PERTINENT ● Prolong use inhibits the absorption of

TEACHING some fat-soluble vitamins.
INFORMATION

TYPES OF ENEMA SOLUTION

Tap Water (Hypotonic)

● Enema should not be repeated after the first
instillation because water toxicity or circulatory
overload can develop.
○ Considered as Hypotonic
○ Be careful when giving tap water enema
because it can cause water toxicity (only 6-8
glasses of water) or circulatory overload can
develop
Normal Saline
● Safest solution, the only enema that children and
infants can tolerate because of their predisposition to
fluid imbalance.
○ Considered as Isotonic
○ Safest solution
○ kung ano shape ng cell walang pagbabago
○ children can only tolerate, since very
sensitive sila EQUIPMENT

40
 ● Disposable gloves ​https://www.youtube.com/watch?v=yXb9VSfX-WY
● Enema container with attached rectal tube
● Correct volume of warmed solution PROCEDURE
● Water-soluble lubricant 1. Check doctor’s order
● Absorbent pads a. The patient should give consent to the procedure.
● Bedpan, commode 2. Prepare the necessary equipment.
● Toilet tissue a. Ensure smooth procedure.
● Heavy Gauge rubber water bottle 3. Explain the procedure to the client.
○ Also used for back pains as heat pad a. Information promotes client cooperation and reduces
● 60 inches Flexible tubing anxiety.
● CLAMP 4. Wash hands.
○ In FEU, Kelly clamp is used a. Reduces transmission of microorganisms.
○ vaginal applicator mas mahaba at mas malapad 5. Warm solution to desired temperature (40C to 43C)
○ rectal applicator is smaller and thinner a. Hot water can burn intestinal mucosa.
● NOZZLE (rectal applicator) b. Cold water can cause abdominal cramping and is
○ For rectal use difficult to retain.
● HOOK c. Lukewarm water should be used; ideal temperature
● VAGINAL APPLICATOR since it is not too warm nor too cold
○ Used for douching (soaking/washing the inside of the 6. Position and drape the client on his left side or on his back
vagina) as dictated by the client‘s comfort and condition.
○ Never used for the rectal area since the vaginal a. Right knee bent: allows for better visualization of the
applicator is longer and it might cause the rectum to anus
tear b. Allows enema solution to flow downward by gravity
along the natural curve of the sigmoid colon and
● Gamit sa retdem: parang pitchel na metal na may rectum, thus improving retention of solution.
butas sa gilid c. Left lateral sim’s position (best position)
i. You will need to lower the bed of the patient
(before turning to the left lateral’s sim) in
order to allow the flow of enema to the
colons.
ii. Consider patients with difficulty in breathing
or headaches by placing their bed at 15
degrees elevation instead.
d. The left lateral position is the most appropriate
position for giving an enema because of the
anatomical characteristics of the colon. This gives the
enema a downward flow into the sigmoid colon,
Heavy Gauge 60’ Flexible Tubing improving retention.
Rubber Water 7. Wear gloves.
Bottle a. Reduces transmission of microorganisms.
8. Place an absorbent pad on the bed under the client.
a. Prevents soiling of linen. Use a dry sheet or kelly pad
b. You may then assess the anus of the patient of
distention, prolapse, or hemorrhoids. (you may place
this as an additional note on your report)
9. Pour the solution into the bag or bucket. Open clamp and
prime tubing and reclamp.
a. Removes air from the tubing.
10. Elevate the solution so that it is no higher than 18 inches
(45 cm) above the level of the anus. Hang the container on
Clamp Hook an IV pole or hold it at the proper height.
a. Pwede hawakan (so you can try first the appropriate
height) or pwede rin i-hang
b. Allows for continuous, slow instillation of the solution,
raising the container too high causes rapid instillation
and possible painful distension of the colon. The
patient may experience stomach pain.
c. It is important to know how high or low your IV stand
should be. If it is not ready, clamp the tube first.
d. Enema Container Height
i. High Enema = 12 to 18 inches (no higher
than 18)
ii. Regular Enema - 12 inches
Nozzle (Rectal Vaginal Applicator Heating Pad iii. Low Enema = 3 inches
Applicator) 11. Lubricate the end of the rectal tube 2 to 3 inches (5 to 7
cm). A disposable enema set may have a pre-lubricated
rectal tube.
a. Allows smooth insertion of the rectal tube without risk
How to Assemble an Enema Bottle of irritation

41
 b. or trauma to the mucosa. 21. Observe feces
c. Use at least 3 water-soluble lubricants (KY jelly) 22. Remove gloves and wash hands.
d. Without lubrication the rectal tube promotes friction a. Reduces transmission of microorganisms.
thus causing pain 23. Document procedure and results.
12. Lift the buttock to expose the anus. Slowly and gently
insert the enema tube 3 to 4 inches (7 to 10 cm) for an Administering a Cleansing Enema
adult. Direct it at an angle pointing toward the umbilicus, not ADMINISTERING A CLEANSING ENEMA
the bladder (to prevent prolapse). Ask the client to take ● When you instruct the patient to turn into a left lateral
several deep breaths. position - consider putting pillows in between the
a. Hindi nakataas, medyo nakaslant kasi kapanaka pint knees
pataas, maaring matusok ang bladder ● This video uses a (commercially prepared) fleet
b. This angle follows the natural contour of the rectum enema
c. Enema Tip Insertion Depth (Do not force the tip) ● Remove air inside the enema bottle before inserting it
i. Adult or Adolescent = 3 to 4 inches ● For our retdem: Icoconnect yung Nelaton sa end ng
ii. Child = 2 to 3 inches tube (color black) nelaton 14 green (common) but in
iii. Infant= 1 to 1 1⁄2 inches school we have 10 which is black
d. Careful insertion prevents trauma to rectal mucosa
from accidental lodging of the tube against the rectal Enema Tip Insertion Depth (yt vid)
wall. Insertion beyond the proper limit can cause ● Adult or adolescent - 3” to 4”
bowel perforation. ● Child - 2” to 3”
e. Check for rectal prolapse or trauma near the rectum ● Infant - 1” to 1 1/2”
area (if there is any)
13. If resistance is met while inserting the tube, permit a small Enema Container Height (yt vid)
amount of solution to enter, withdraw the tube slightly, and ● High Enema - 12” to 18”
then continue to insert it. Do not force entry of the tube. Ask ● Regular Enema - 12”
the patient to take several deep breaths. ● Low Enema - 3”
a. Breathing out promotes relaxation (slight dilation) of
the external anal sphincter. Kapag nagrelax, Terms:
magdidilate at hindi mahihirapan ipasok. ● Diseases Requiring Enema (Indication )
14. Slowly administer fluid for about 5 – 10 minutes. Clamp ● IBD (inflammatory bowel disease) - Mesalamine
tubing or lower container if the patient has a desire to (Brand Name: Pentasa, etc)
defecate or cramping occurs. Instruct the patient to take ● Some also gives corticosteroid medications -
small, fast breaths or to pant. prednisolone UC
a. Temporary cessation of instillation prevents cramping, ● (Ulcerative Colitis)
which may prevent the client from retaining all fluid, ● Parkinson’s disease
altering the effectiveness of the enema.
b. Don't rush because it may cause bloating of the You have to check the doctor's order, consent and what type of
stomach and abdominal cramping which is painful enema to be administered depending on the case of the
15. After the solution has been given, clamp the tubing and patient.
remove the tube. Have a paper towel ready to receive the
tube as it is withdrawn and disposed of properly.
a. Reduces transmission and growth of microorganisms
16. Clean lubricant, solution, and any feces from the anus with
toilet tissue.
a. Provides for the client’s cleanliness and comfort.
b. Can use wet wipes before tissue to prevent leaving
fecal particles
17. Have the client continue to lie on the left side for about 5 to
15 minutes. When there is a strong urge to defecate, assist
to bedside commode, toilet or bedpan.
a. Solution distends bowel (naeexpand)
b. Length of retention varies with the type of enema and
the client’s ability to contract the rectal sphincter.
Longer retention promotes more effective stimulation
of peristalsis and defecation.
18. When there is a strong urge to defecate, assist to bedside
commode, toilet or bedpan.
a. Normal squatting position promotes defecation. (best
position)
b. Squatting is done with the help of a foot stool.
19. Put on gloves and assist the patient, if necessary, with the
cleaning of the anal area. Offer washcloths, soap, and
water for handwashing. Remove gloves.
a. Fecal contents can irritate the skin. Hygiene promotes
the client‟s comfort.
b. If the client is bedridden, the nurse should wash the
anal area.
20. Return to a comfortable position.
a. Promotes of patient's sense of well-being

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