REGULATING INTRAVENOUS FLOW RATE. Before the infusion of the IV solution is begun, the nurse should mathematically convert the rate of infusion prescribed by the physician into comparable drops per minute. Purpose: 1. To comply with prescribed rate ordered by the physician, 2. To maintain an equal and constant rate of fluid administration throughout the duration of the infusion 3. To assist in reassessing the progress of the fluid infusion. 4, Toprevent circulatory overload or insufficient correction of hypovolemia. ‘Nursing Consideration: 41. Read the current written medical order forthe volume and number of hours of infusion. 2, Determine the manufacture's drop factor and the ratio pf drops per mililiter. 3, The hourly rate of infusion will not deviate by more or less than 25%of houriy-calculated rate. Equipment: 41. Jot down notebook and ball pen. 2. Wristwatch with a second hand. 3. Strip of tape as marker or to be used as time strip if necessary. Procedure Action Rationale 41. Check the physician's order This ensures the correct solution is being given with correct medication and determines the exact time for administration ofthe solution. Any interference with the patency of the IV line 2. Check the patency ofthe IV line and needle. influence the IV flow rate 3. Verify the drop factor (number of drops in 1 The drop factor of the equipment varies according t mi) of the equipment in use manufacturer and will be displayed on the outer Equipment labeled as micro drop pr mini drop is s and delivers 60 mgttimi but macrdrop delivery s} vary. Some of the more common types of eq) according to manufacturer are Travenol Macrodrop gttim!, Abbott Macrodrop, 15 gtt/ml, and Macrodrop, 15 gti 4, Caloulate the flow rate using the standard formula. 130p with the me period | ine: will systems quipment drop, 10, McGAw a. Standard Formula: Rate = Volume (cc) x att factor (co ‘Duration(hrs)x60 min/hr-constant Duration= Volume (cc) x at factor (co) Rate(ati/min)x60 min/hr-constant Example: 1, How many hours would 500 cc DsIMB last if the rate is 30 mgtts/min Duration = 500 cc x 60 mattsice 30 mgtts/min x60 mine = 167 hs 2. How many cofhr will you consume? 167 30 cote 5. Count the drops per minute in the drip amber. Hold the watch beside the chamber. 6. Adjust the IV clamp as needed and recount the drops per minute 7. Monitor the IV flow rate at frequent intervals. Document the client's response to the infusion athe prescribe rate. Sample Document: Date Time 4728/2001 4:45 PM anal ol Mus Procecres 2005 Holding the watch next to the drip chamber allows the eyes to focus on drops and the second hand on the waich to provide an accurate count, This regulates the fow rate into the drip chamber. This provides for observation of the IV infusion and ensure documentation ofthe client's response to the IV infusion, Nurse's Notes: D3IMB 500 ce with _ amp. Benutrex C regulated at 30 gtts/ min. armboard applied to limit movement of extremity. IVF continues to infuse at above rate. No tendemess or swelling is site. No dyspnea or shortness of breath noted. Voided once, soaking wet his diaper. €. Tan, S. NCOLLECTING A SPUTUM SPECIMEN Definition: Sputumis the mucous secretion from the lungs, bronchi and trache. Purposes: 1. For culture and sensitivity test 2. Toiidentify cancer in the lung and its specific cell type. 3. To identity the presence and acid-fast bacilli. Equipment: sterile container with a cover ‘plain the procedure to the client 2. Make sure the client can expectorate the putum directly into the sputum cup. Leave the container with the client if assistance is not ined, Ask the client to sit and to breathe deeply nice and then cough up 1-2 tbsp. (15-30 ml) or depending on the specified amount, Ask the client to hold the sputum cup (or hold and expectorate into it, making sure that the sputum does not come in contact with outside of ntainer. 5. Cover the container immediately after the lection, Determine the respiration rate and any ‘onormates or dificult in breathing 7. Assess the color ofthe client's skin especially any cyanosis, 1 2. Disinfectant and CB to cleanse the outside ofthe container and tissue paper to dry it 3. Accompleted label for the container, with identifying information about the client 4. Acompleted requisition to accompany the specimen tothe laboratory. 5. Mouth wash Procedure : Action Rationale ‘An explanation provides reassurance and promotes cooperation. Prevents the spread of microorganism. Containing the sputum within the cup restricts the spread of microorganisms to others. Covering the container prevents the inadvertent spread of ‘microorganisms. This indicates impaired blood oxygenation8. Wipe the outside of the container with disinfectant if the sputum has contacted the outside surface 8. Place the completed label on container, (name room number, purpose, specimen series number. 10. Provide the client with water to rinse the ‘mount. 11. Together with the laboratory requisition slip, send the specimen to the laboratory within 20 minutes. 12. Document collection of the sputum specimen on the client's chart. Inciude the color, consistency, amount and odor experienced by the cient Prevents the spread of microorganisms, Labeling ensure proper identification ofthe specimen. This removes any unpleasant taste ‘Overgrowth of other organisms can interfere with the results if the specimen remains at room temperature extended period of time, A written provides accurate documentation of procedure, Note: Collect the sputum specimen(not saliva) early in the moming before breakfast to obtain the overnight accumulation of secretion ate Dare of Kidapawan Cals Manual of Nursing Procedures 2005,RESPERATORY SYSTEM ADMINISTERING OXYGEN Purposes: 1. Toraieve dyspnea 2. To reduce or prevent hypoxemia and hypoxia 3. To alleviate the anxiety associated with the struggle to breathe. Possible Nursing Diagnoses: Ineffective Breathing Patterns Impaired Gas Exchange Activity Intolerance Anxiety Altered Comfort Procedure: I NASAL CATHETER Action 1. Explain the procedure tothe client and review safely precautions necessary when oxygen is in use, 2. Measure from the tip of the nose to the love of the ear and insert gently. 3. Fasten to bridge of nose ands forehead or cheek with adhesive tape. 4, Encourage the client to breath through his rose with his mouth closed. 5. Wash your hands. 6. Record the time therapy as started, rate of oxygen flow per minute, and client's response to therapy. 7. If oxygen therapy is to be discounted, close oxygen regulator outlet and tank valve, Withdraw catheter very gently. Cleanse patient's nostril after 8. Do after care of equipment. Rinse catheter with cold water and soap. Irigate with the use of syringe to remove mucus. Bring oxygen set- up to storage room 138 Rationale ‘An explanation relieves apprehension and pro cooperation. The nurse promotes the safety of the ol and others by providing pertinent information. ‘An insertion of the correct length of catheter faci ‘oxygen administration and comiort forthe client. Correct placement of fastener facilities 0 administration and comfort for the client. Keeping the mouth closed provides optimal delivery oxygen to the cen’ lungs. Handwashing deters the spread of microorganism. The client's respiration, color and so on indicate effectiveness ofthe oxygen therapy. When performing these tasks the nurse demonstrate ‘conscientious concem forthe client's comfort.7 NASAL CANNULA Action Explain the procedure to the client and 2w safety precautions necessary when nis in use. Place “No Smocking’ sign © Wash your hands nnect the nasal cannula to the oxygen set- © “umidifier. if using a wall outlet as oxygen plug flowmeter into the outlet by until it snaps into the place. if a lock button is present, depress it as you @ flowmeter. 202 the prongs inthe clients nostrils a. Around the clent's head. . Over the behind each ear with the adjuster comfortably Under the chin, gauze pads at the ear beneath the 3s necessary rage the client to breathe through his h his mouth closed your hands, move and clean the cannula and nares af 'y 8 hours or accord to agency ation. Check the nares for evidence ion or bleeding, wsk lain the procedure to the client, review the Precautions, piace sign indicating oxygen tion in appropriate areas. © Wesh your hands, Rationale An explanation relieves apprehension and promotes ‘cooperation. Oxygen supports combustion. The nurse Promotes the safety of the client and other by providing Pertinent information Hand washing deters the spread of microorganisms. Oxygen forced through a water reservoir is humidified before it is delivered to the client, thus preventing dehydration of the mucous membranes, Correct placement of prongs and fastener faci ‘oxygen administration and comfort forthe client. Pads reduce the iritation and pressure and protect the skin, Keeping the mouth closed provide optimum delivery of oxygen to the lungs. Hand washing deters from the spread of microorganisms, The client's respirations, color and so on indicate the effectiveness of the oxygen therapy The continued presence of the cannula causes irritation and dryness of the mucous membranes. Humidification Counteracts. The drying effects of oxygen. ‘An explanation relieves apprehension and promotes the client's cooperation. Oxygen supports combustion. These nurse promotes the safety of the client and others by providing pertinent information. Hand washing3. Attach the face mask to the oxygen setup with humidification, Start the flow of oxygen at the specified rate. (Refer to procedure in nasal cannula) 4, Position the face _mask over the clients nose and mouth. Adjust. it with the elastic strap so that the mask fits snugly but comfortably on the face. 5. Use gauze pads to reduce irritation on the clients ears and scalp. 6. Wash your hands. 7. Remove the mask and dry the skin every 2 t0 3 hours if the oxygen is running continuously. Do not powder around the mask. 8. Open the tent as litle as possible by organizing nursing care. 9. Assess the client at frequent intervals (vital signs, color, response to therapy) 10. Changes the client's gown and linen as necessary. Edges of the tent may be loosened and the tent may be secured with a bath blanket under the client's chin when performing hygienic care or other procedures. ‘1, Record the type of therapy and the client's response, Sample Documentation: Date 51/2/2002 Oxygen forced through a water reservoir is before it is delivered to the client, thus dehydration of the mucous membranes. AA loose or poorly fiting mask will result in oxygen decreased therapeutic value. Masks may cause 2 suffocation, and the client may need frequent atts reassurance, Pads reduce initation and pressure and protect the Hand washing deters the spread of microorganisms. The tight-fiting mask and the moisture from cond can ifntate the skin on the face, There is danger of = powder if itis placed on the mask Oxygen escapes each time the tend is opened the tent closed maintains the oxygen content. Oxygen toxicity may develop in response to ex; high concentration of oxygen. When performing these tasks the nurse demo: ‘conscientious concem for the client's comfort and we A written summary provides an accurate documer the care and response ofthe client to treatment. Nurse's Notes Restless during sleep, R- 32, P-118, BP - 148 /90. Slightly cyanotic, Placed in high Fowlers position. Or via nasal cannula administered at 4 Umin. as ordered. D. Cruz, $.N. “Tie Dae of Kiapswan Callens Marl of Nursing Procedures 2005‘SUCTIONING THE NASOPHARYNGEAL AND OROPHARYNGEAL AREAS ‘The oropharynx extends behind the mouth from the soft palate above the level of the hyoid bone: and contains the tonsils. The nasopharynx is located the nose and extends to the level of the soft palate COropharynx or nasopharyngeal suctioning is used when the client is able to cough effectively but is unable to clear secretions by expectorating or swallowing Purposes: To remove excess saliva or emesis from the oral cavity To clear the upper airway of mucoid secretions. To promote adequate gas exchange, To prevent pneumonia and atelectasis. To obtain sputum culture. To relieve respiratory distress. Possible Nursing Diagnosis: Anvity Ineffective Airway Clearance High Risk for impaired Gas Exchange High Risk for Aitered Cardiac Output High Risk for Injections “WwFOds 7 High Risk for Inury High Risk for Aitered Oral Mucous Membrane Indication for Suctioning: i When the patient starts to cough, and cannot expectorate respiratory secretions or has coarse bubbling or gurgling noises with respiration. Equipment: Suction apparatus Sterile suction catheter (with suction control port) Sterile water or saline Sterile container Stefile gloves Clean towel 5 cc. Syringe (for tracheotomy suctioning) Size of suction catheter Duration of Suctioning Intervals Newborn :Fr. 6 3-5 seconds Infant Child Adutt Fr. 68 548 seconds 5 minutes: 810 8-10 seconds 1246 410-15 seconds ‘ets Dar ot Kapawan Clog Manual of Hing Procedures 2008,Action 1. Prepare equipment atthe bedside. 2. Explain fo the client how the procedure will help to clear the airway and relieve breathing problems. Explain that coughing, sneezing of gagging is normal 3. Wash your hands, 4. Properly position the client. For conscious client: a. Semi-Fowler's position with ‘head turned fo one side for oral suctioning, b. Semi-Fowler's position with ‘neck hyperextended for nasal oral suction. For unconscious client: ©. Lateral position facing the nurse, 5. Place a towel on the pillow or under the client's chin 6. Turn the suction on to the appropriate pressure if applicable 7. Pour sterile water or NSS into sterile container. 8. Peel back the wrapper of the catheter until the adapter is exposed. 9. Apply a sterile glove to your dominant hand. remove wrapper around the catheter with the ite Dae of Kdapawen Cogs Nenulof Musing Procedures 2005 Rationale Preparation of equipment allows smooth performance of the procedure without interruption, An explanation of the procedure relieves the client's, anxiety about procedure. Hand washing deters the spread of microorganisms. Positioning of the head to one side or hyperextending the neck promotes smooth insertion of the catheter into the ‘oropharynx or nasopharynx, respectively. The lateral position prevents the client’s tongue from obstructing the client's airway, promotes drainage of pulmonary secretions, and prevent aspiration of {gastrointestinal contents. Soiling of the bed linen or the client's bed clothes from secretions is prevented. Secretions on the towel can be discarded, thus reducing spread of bacteria Proper suction pressure provides safe negative pressure according to the client's age. Excessive negative pressure can precipitate pneumothorax Sterile solution is needed to lubricate the catheter to decrease friction and promote smooth passage of the catheter. To facilitate easy removal ofthe catheter from the wrapper. The sterile gloves maintains asepsis as catheter is passed into the client's mount or nose. 143Yyour remove it from the wrapper 10, Holding the sterile suction catheter with the gloved hand, connect it to the suction tubing that is held with the unsterile hand. 11. Approximate the distance between the Glient’s ear lobe and tip of the nose and place the thumb and forefinger of gloves hand at that point (6-8 inches), 12. Moisten the catheter tip with sterile solution, Apply suction with catheter tip in the solution, 13. Suction: 2. For nasopharyngeal suctioning gently insert catheter nto one Most. Guide the catheter ‘medially along the floor of the nasal cavity. Do not force the patent apply suction during insertion ty the other. Do not .For oropharyngeal. suctioning, gently insert the catheter into (one side of the mouth and slide the catheter to the oropharynx, Do not apply suction during insertion, 14. Apply suction by occluding the suction Control port with the thumb of unsterile hand. Gently rotate the catheter with the thumb and index finger of the glove hand as you withdraw it 18. Flush the catheter with sterile solution by Placing itn the solution and applying suction, 144 ‘non dominant unsterle hand, coll the catheter around your dominant hand using fingers as Sterility is maintained, This distance ensure that the suction catheter remains the pharyngeal region. Insertion of the catheter past Point places the catheter into the trachea Moistening the catheter tip reduces friction and eases insertion of catheter. Applying suction while the catheter = in the sterile solution ensures that suction equipment = functioning before catheter is inserted, ‘The catheter avoids the nasal turbinates and enters more: easily into nasopharynx to the oral and nasal mucosa during catheter insertion, ‘Stimulation ofthe gag reflex is reduces. Occluding of suction port activates suction pressure Suctioning is intermittently done as the catheter is withdrawn. Rotation removes secretions from all surfaces Of the airway and prevents trauma from suction pressure on one area. Suctioning also removes air. The client's oxygen supply could be severely reduces ifthe procedure fasts longer than 15 seconds. the interval between suctioning provide the client with the opportunity to increase his oxygen intake Flushing the catheter with sterile solution removes Secretions from the catheter and lubricates the catheter for the nest suctioning ‘Note Dane of Kapauan Colage Manual of Nursing Procedres 20055. Ifthe client is able, ask him to deep breathe 3nd cough between suctions. Deep breathing and c with ao th upper airway where they can be removeg with the catheter. If the client is able to Cough productively, further suctioning may not be needed tf he airway id clear ‘upon auscultation ‘ughing promote mobilization of Suctioning is needed, repeat steps 12-14, 7. Suction secretions in mouth or under tongue Asepsis is maintained. The mo: 2 suctonng the oropharynx or nasopharyn uth should be suctioned only after the sterile areas are thorou vghly suctioned, When procedure is completed, tum off Keeping contaminated articles confined to certain areas on machine, Dispose gloves and catheter erly. Wash your hands, Offer oral h ygiene. Place client rfortable position, Displays concem forthe clan's comfort se auscultation to listen to the chest to Listening to the tung sounds the effectiveness of suctioning Fespiratory passage ways are helps determine whether the lear of secretions Records the time of suctioning, amount, = =stency, color and odor of secretions and nts response to the procedure. E " bottle atthe end of every shift Recorting this information documents that the procedure was completed and the clients status during and after the impty procedure, Sore the catheter according to the agsncy’s doctor's reference. mele Documentation: Time Nurses's Note 8:30 AM Garang respiration audible, Nasal faxing rng 20,,P ~100 and regular, BP —140/199 Encouraged to breathe deeply and to Cough. Unable to Cough out secretions effectively 835 AM Suctioning of the oro pharynx done, Removed. moderate 0 deep breathing, RR -24 Abnormal respiratory sound not noted . neath care providing, JL Tan, 8.N,SUCTIONING THE TRACHEOSTOMY Tracheostomy suctioning is the removal of secretions from the trachea or bronchi by means of a ‘suction catheter inserted either through the mouth, nose or trachea or tracheostomy or endotracheal tube, ‘A. Tracheostomy is suctioned to: Clear the airway of secretions Relieve respiratory distress. Reduce or prevent hypoxia, Prevent the unconscious or paralyzed patient from aspirating food or secretions. Aliays anxity Possible Nursing Diagnoses: Anxiety Ineffective Airway Clearance Impaired Gas Exchange Potential for Infection Impaired Verbal Communication Potential for Injury Potential Altered Oral Mucous Membrane Equipment 1. Suction apparatus 2. Sterile aspirating catheter Infants : Fr. 6 to 8 Children :Fr.8 to 10 Adults : Fr. 12to 16 Sterile container Sterile gloves Sterile NSS Clean towel or sterile drape (optional) Procedure Action Rationale 1. Obtain focus assessments of An immediate baseline data serves as an index for needing cardiopulmonary function suctioning as well as a bases for evaluating its effectiveness. 2. Prepare equipment atthe bedside. Preparation of alow smooth performance of the procedure without interruption, 3. Explain the procedure to the client. ‘An explanation relieves apprehension and facilities cooperation 4, Wash your hands. Hand washing deters the spread of microorganisms. 5, Assist the client to a semi-Fowier' positon it A sitting position helps the client to cough and breathe ‘conscious. An unconscious client should be more easily. This position also uses gravity to ald in the 146 ote Dae of Keagaon Clogs Manual of Nursing Pecesres 2005placed in the lateral position facing you. 6. Place a towel across the client's chest. Turn the suction on to the appropriate oressure a. Wall unt: Adult: 110 ~150 mmHg Child : 95 ~110 mmHg Infant: 50-95 mmbg ». Portable unit Adu: 10 ~150 mmHg Child: 5 10 mmHg Infant: 2-5 mmHg 3. Open the sterile container and place it on the dside table or over bed table without contaminating the inner surface 9. Pour sterile saline or water into the container. 10, Hyper oxygenate the client for 1-2 minutes. 1. Apply a sterile glove to your dominant ‘and, remove wrapper round the catheter with non-dominant unsterle hand and discard, 2, Holding the sterile suction catheter with the oves hand, connect it to the suction tubing at is held with the unsterile hand, Moisten the catheter by dipping into the container of sterile saline. Occlude the suction ol port to check suction. Remove the oxygen administration uipment with the unsterle hand. Using the sterile hand, gently insert the itheter into the trachea. Advance the catheter 2 125 cm (4-5 inches) or until the client insertion of the catheter. A lateral position prevents the airway from becoming obstructed and promotes drainage of secretions, Absorbent material protects the client and bed linen. Proper suction pressure provide safe negative pressure according to the client's age. Excessive negative pressure can precipitate a pneumothorax. The chambers within the container maintain the sterility of items tat willbe in direct contact with the clients airway. Sterile solution is needed to lubricate the catheter to decrease friction and promote smooth passage of the catheter Providing increased percentage of oxygen prevents hypoxia during suctioning, The sterile gloves reduces the risk of infection Sterile technique prevent introducing organisms into the respiratory tract. Lubricating the inside of the catheter with saline helps move secretions through the catheter. Occluding the suction control port while the catheter is in sterile solution ensures that suction equipment is functioning well before insertion. Removing the oxygen allows access to the tracheostomy tube, Using the suction while inserting the catheter can cause trauma to the mucosa and removes oxygen ffom the respiratory tract 147‘coughs. Do not occlude the suction control port ‘when inserting the catheter. 16. Apply suction by occluding the suction control port with the thumb of the unsterile hand, Gently rotate the catheter withthe thumb and index finger of the gloved hand as you withdraw it. Limit suctioning to 10-15 seconds duration only, 1t3-5 minutes interval a. Instill NSS into trachestomy tube wuth the use of syringe to loosen secretions. ‘Ages Amout of NSS Instiled Infants - 1-2cec Children - 2-30 Adults -5 0c 17. Encourage the client to cough during suctioning 18. Flush the catheter with saline an assess the need to repeat suctioning. Allow the client to fest at least 3-5 minutes between suctions. Readminister oxygen between suctioning efforts and when suctioning is completed. 19. When the procedure is completed, tum off the suction and disconnect the catheter from the suction tubing. Remove the sterile glove inside out and dispose the glove, catheter and container in a waste receptacle. Wash hands. 20 Adjust the client's position, Auscuttate the chest to evaluate breath sound. 21, Prepare equipment for next suctioning. 22. Record the time of the suctioning and the nature and amount of secretions. Also note the character of the client's respirations before and after suctioning, Occlusion of suction control port activates from pressure. Rotation removes secretions from alls the airway and prevents trauma from suction p the area of the airway. Suctioning also removes client's oxygen supply could be surely reduces Procedure lasts longer than 15 seconds time Suctioning provides the client with the oppo increase his oxygen intake. Coughing helps loosen and move secretions to the: the catheter. Flushing cleanses the catheter and lubricates it © next insertion. Allowing a time interval and replan oxygen help compensate for hypoxia induces previous suctioning, 3 Keeping contaminated articles confined to certain transmission of microorganisms. Hand washing spread of microorganisms by direct contact. Reassessment helps evaluate the effect of suctioning Ready access to suction equipment is provided, es ifthe cents experiencing respiratory distress. A written summary provides accurate docume: comprehensive care Manoa of Ning Procedres 2005‘STOOL SPECIMEN COLLECTION synonyms: stool parasites Nemaiieiesg Neraasanqrs Explanation of the test: Many parasitic infections are “silent” or produce only mild symptoms paeth babel 120 be dapnased leigh a sted examination because hel causative ager Purpose of the test: ‘Stool exam testis used to make a differential diagnosis of the cause of protractes diarrhea with the aforementioned characteristic. Significant Findings: ‘Trophozoites of Entamoeba hystoiytica Cysts of Giardia lamblia Presence of helminths larvae, ova or progiottids. “Tangle number of Cryptosporidiosis and Biastocysts hominis if othe organisms have been ruled cut Other parasites. ‘Sample Collection: 41, Fresh, warm, non formed stools are usually required for protozoan screening, 2. Examination for helminths can be done with formed stool. 3. The first stool in the morning is usually preferred. 4. Stool must be delivered to the laboratory in 30 minutes or lass after defecation 5. Collection cups should be filed in an upright position. 6. To prevent the spread of infection, wear gloves when filing the collection cup or whenever = contact withthe stool and wash hands at least in beginning and with patient contact 7. For maximum detection of parasites, three non-formed stools should be collected over 2 5-ty period, every other day (stool series). 8. Label the sample container with the patient's name, type of test, form number, physician's and the date and time. Patient Preparation: Pretest assessment: Check whether the patient has received mineral oll, a waxy suppository, barium X-ray with 4 days before this test. If s0, notify the laboratory and physician because the test probabiy have to be delayed, Patient Teaching: 1. Explain what day(s) the sample willbe collected and the preferred time for stool collection, based! the presumed type of infection and laboratory scheduling. Stress the importance of samples & sent tothe laboratory immediately. 2. If adependent: aot ‘Notre Dame of Kidapawan College Marva of Nursing Proosdes 208‘2. Explain why anything that might be contaminated with stool is best handles with gloves, both by the patient and health care worker, and why hand washing is necessary as well. . Explain the mechanisms for spread of infection and lor reinfection and ways to prevent it 3, ambulatory and capable of seft-care and / or not hospitalized: a. Provide with tell where toilet collection containers are available and explain how to use it in the toilet for collecting the stool specimen. . Inform the person that the collection cup should be filed one fourth ful (more that one sample maybe requested) and that itis important to keep the id clean of any feces. c. Stress the importance of hand washing aftr urinating and defecation. a il on ‘ete Dar ol Kapaa Cola Manvel o Nursing Procedures 2006GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY FEEDING Definition: Administering of liquid feelings to the stomach, duodenum and jejunum; may be ‘administered by intermittent or continuous feeding. Procedure Action 1, Prepare the medication 1.4 Liquid preparation of the drug may be used when available 41.2 Tablets are reduced to as fine powder as possible using mortar and pestle. Sustained - action dosage forms however, must not be pulverized, Capsules which contain 2 powder may be emptied of their contents. The resulting powder, then is mixed with a small amount of fluid, usually 20-30 mi of water or normal saline the same way 2s in tablets Soft gelatin capsules may be_pricked in one end and the liquid squeezed ut into a plastic medicine container. 2. Identify the patient. 3. Elevate the patient's head 30-45? 4, Administer 10-20 co of water to assure potency, 5. Administer the drug or feeding, 6.Flush with 30 co. Of water. 7. Pug the gastrostomy tube. 8. Instruct the patient to retain position for 30 minutes. Rationale ‘Simplifies the task on hand. The client will receive an inaccurate dose of the drug, Facilitates flow of drug through the tube, To avoid aspiration during and following administration of the medication. To prevent clogging To prevent leakage and gastic reflux into the esophagus and enhance the normal digestive process. “Note Dane ofKiapansn Colage Marva of Nursing Proce 2008‘STRO-INTESTINAL SYSTEM ADMINISTERING A CLEANSING ENEMA nition: An enema is the introduction of a solution into the large intestine via the rectum. The instilled solution distends the lower bowel, may irritate intestinal mucosa, and thus increase peristalsis. Purposes: 4. Torelive constipation or fecal impaction. 2. To prevent involuntary escape of fecal material during surgical procedures. 3. To promote visualization of the lower intestinal tract when an X-ray or endoscopic examination if performed, Tohelp establish bowel function during the bowel retaining program 5. Toremove the contrast media used following upper or lower gastrointestinal X-rays. assification: NAME PURPOSE © Non-Retention ~ a type of enema which is almost completely expelled within 45 minutes, Cleansing of Evacuating To evaluate lower bowel before diagnostic studies of surgery. 2 Retention Soften and lubricates stool for easy evacuation. Carminative For the relief of distension caused by flatus. To destroy and expel worms. Depends on the medication To provide nourishment. commended volume 1. Non-etention enema Adult = 750 ~ 1,000 mi School age -500- 1,000 mi Todd Preschooler - 250-500 mi Infant ~50~ 250 mi 2. Retention enema — 250 mi or less sible Nursing Diagnoses: Altered Bowel Elimination: Constipation 4. Knowledge Deficit Atered Comfort 5, Self-Care Deficit: Tolleting Atered Health Maintenance 6. High Risk for Injury ‘idapawan College 4 aorta tsEquipment: 1. A tray containing the folowing rectal catheter (Fr, 14-16 for adults; Fr. 10-12 for children) '. enema can with tubing ©. lubricant 4. pitcher with hot and cold water @. sting rod {solution as ordered by the physician ~SSS.NSS, tap water 9. toilet paper ‘. bath thermometer i kidney basin | working gloves . apron or gown to protect the uniform 2, Bedpan with cover 1. Bed protector 2, Ifigation stand or IV stand Procedure Action 1. Review the written medical order. 2. Explains the procedure and plan with the client when he will defecate - on a bedpan, ‘commode or nearby bathroom ready for his use. 3. Wash your hands 4. Assemble the necessary equipment in the . utlty room. Connect the rubber tubing to the . irigating can and close the stop cock. 5. Prepare needed solution. Warm premixed soap sud solution by soaking the container in a basin with hot water. Check the temperature with the back of your hand. pour mixture in the irigatng can. 6. Connect tio of the rectal tube and expel the air directly to the kidney basin, Replace catheter in its wrapper. 7. Cover the tray and bring itto the bedside. 154 Rationale Reading the order ensures that the nurse follow doctor's directions, The client’ is better able to relax and cooperate familiar with the procedure and is provided eve readiness when he feels the urge to defecate. D: usually occurs within 5-10 minutes, Hand washing deters the spread of microorganisms. Organization promotes efficient time management. The nurse is held accountable for any injury burning. Although permitting air to enter the intestine is not ‘itmay further distend the intestine. Ensuring the client's privacy and warm aids in 1 The position of the rectining person has not been. alter the results of the enema significant. Gloves protect the nurse from contact with micro inthe feces, Note Dae of Kita Coleoe Manca sing Procedes 2005is jin jon nS 8. Provides patient's 9. Puton working gloves 10. Hang the irrigating can about 18 inches above the level ofthe client's anus 11. Lubricate tube 2-3 inches. 12, Place a bed protector under the client 13, Position and drape the client in left Sim's position with the anus exposed or as dictated by client's comfort and condition. 14. Lift the clients buttocks to expose the anus iowly and genty insert tne rectal tube directing itat an angel pointing toward the umbilicus Adults ~ 10 cm (2-4 inches) Children ~ 5-7.5 om (2-3 inches) Infants ~ 2.5 - 3.8 cm (1-1.5 inches) 15. Ifthe is resistance in the insertior small amount of solution to enter. W tube slightly then continued to insert. Do not force entry of the tube. Ask the client to take several deep breaths through the mouth, 16. Open the stop cock and introduce the solution slowly over a period of 5 to 10 minutes, Neire Dame of Kidapawan College anual faring Procearas 2005 Height at which solution is hung determines its force. Excessive pressure can force colonic bacteria into the small ntestne of may rupture the colon. Lubrication facilitates the insertion of the rectal tube through the anal sphincter and prevents injury to. the mucosa ‘A bath blanket and bed protector protects the bed linen from descending colon, Facilitates the flow of the solution by gravity into the descending colon. Good visualization of the anus helps prevent injury to tissues. The anal canal is approximately 2.5 om to § cm (1- 2 inches) in length. The tube should be inserted past the intemal anal sphincter. Further insertion may damage intestinal mucosa. The suggested angle follows the normal intestinal contour. Slow insertion of the tube minimize spasms ofthe intestinal wall and sphincter. Resistance may be due to spasms of the intestine or failure of the internal sphincter to open. The solution may help to reduce spasms and relax the sphincter, thus ‘making continued insertion of the tube safe, Forcing a tube may cause injury. to the intestinal wall, Taking deep breaths help relax the anal sphincter and abdominal muscle. Introducing the solution siowly helps prevent rapid distention ofthe intestine and a desire to defecate Various technique can be use to help the client relax muscles and prevent, the expulsion of the solution Prematurely. This amount of time usually allows muscular contraction to become sufficient fo produce good resultHold the tube in place, {7 Close the stop, the client has the desire to defecate or cramping occurs. The client may be instructed to take small fast breaths or to pant. 18. After the solution has been given, close the stop and withdraw tube gently but quickly. Have the client retain the solution until the urge to defecate becomes strong, usually in about §-15 minutes. 19. Repeat steps 13-17 until flow is clear. 20. Wrap the tp of the rectal catheter with toilet paper and place in a kidney basin, 21. Remove the loves turning them inside out and place in the kidney basin 22. When the client has the strong urge to defecate, place him in a sitting position on a bbedpan or assist him to the comfort room, 23 Observe the character of the stool and the client's reaction to the enema. (color, Consistency, approximate amount, presence of blood, mucus, etc.) Remind the client not to flush the toilet before the nurse inspects the result of enema. If patient has hemorhoids instruct to bear down gently during the tube insertion. This causes the anus to open and facilitates insertion, Observe for syncope, decreased heart rate and cardiac dysrhythmias, Vagal stimulation can occur from distention of the bowel 24. Assist the client if necessary with cleansing the anal area. offer soap and water to wash his hands and tissue to dry them, 25. Leave the client clean and comfortable. Cate for equipment properly 26. Record the procedure and the results ofthe enema 156 The gloves are removed in a manner which prevents to {avoid contact with any microorganisms that may be present on the outside ofthe gloves, The siting position is most natural and facilitates the act of defecation The nurse needs to evaluate the record the client's response to treatment. Cleansing deters the spread of microorganisms After care of equipment prevents the spread of microorganisms, ‘A writen summary documents the care provided and the client's response. “We Dae of Rlspawan Colage Manual of Musing Poceires 2005Purposes: 4. Torelieve constipation. 2. To relieve intestinal flatus. ADMINISTERING PRE-PACKAGED ENEMA 3. To prepare the lower colon for treatment exam, 4. To prevent new infection from maternal feces. Equipment: Pre-packaged enema Bed protector Bedpan, commode or toilet Toilet paper Lubricant Working gloves Procedure Action 1. Review the physician's order for the type of enema to be given 2. Checks the client's medical diagnosis and other health problems. 3. Check VS, 4, Soreen the client by closing door and curtains around the bed 5. Raised the bed to a comfortable height 6. Place in left Sim's position, 7. Puton gloves 8. Place the bed protector. 9. Remove the cap on the enema tip and check the tip for adequacy of lubrication (or follow ‘manufacturer's direction). 10. Separate client's buttocks and insert the enema tp 1-2 inches toward the umbilicus 11, Squeeze and roll the enema container, Dari of Kegan Coops Mano Nursing Prods 2005 Rationale You may not legally complete the treatment without the order. Alerts you to potential problems that could occur as a result, of the enema administration Provides privacy. Re:juces the strains placed on the back. Facilitates the flow of enema solution by gravity in the natural direction of the colo. When there is a chance of coming into contact with feces, gloves should be worn to prevent possible transmission of ‘microorganisms, z Prevents soiling of fnen, Prelubricated tips may dry withthe passage of time This decreases the chance of scraping the client's rectal wall Rolling the container dispenses the solution into the intestine 159toward the client's rectum unt all ofthe solution is administered Promotes peristalsis and more complete evaluation. 42. Remove the container and ask the client to Facilitates retention of the enema solution. retain the solution for 5-10 minutes. 43, Hold together the buttocks of an infant or ‘An upright sitting position. Facilitates defection by gravity, anyone else to retain the solution. 14, Place the client in a siting position in a bbedgan or assist in getting to the bathroom. 4. Stay with the client and observe for Observation of the feces is necessary for accurate response including untoward S/S charting 46. Instruct client not to flush the toilet and note Fecal material is caustic to the skin. the character to the stools, 17. Cleanse the rectal area with tollet paper and water. 18. Dispose of an clean equipment. 19, Remove gloves, 20. Do hand washing. 21, Retum client 's bed to original height, 23. Record the procedure and other pertinent observations. 160 ate Dane of Rison Cotege Manual of Nursing Procedures 2005,1 2. 3. minutes, URINARY SYSTEM ‘ae Dane of i Narva of Nur COLLECTION OF URINE SPECIMEN A. CLEAN CATCH MIDSTREAM URINE Equipment: Sterile collection container with cover Label External douche tray FEMALE: Instruct patient to cleanse the periurethral area with soap and water and dry Advice to sit with legs separate atthe toilet. Open the sterile container, placing the lid up on a firm surface with in easy reach. Using thumb and forefinger, separate the meatus. MALE Instruct client to cleanse the head of the penis by retracting the glands penis to effectively cleanse the meatus. Let patient urinate into the toilet and to place the collection cup under the stream of urine. instruct, to fil the container with approximately 15-30 cc of urine and to close tightly. Label and transport tothe laboratory with the request form. B. CLOSE DRAINAGE SYSTEM Equipment: Rubber band and catheter clamp Working gloves Sterile specimen container and label CB with antiseptic Sterile 10 ml. Syringe with 32 or 25 gauge needle Procedure Action Rationale 1. Gather equipment Promotes efficiency. 2. Explain procedure to cient Aliays anxiety, increases participation. 3. Manipulate the drainage tubing so that the Facilitates urine to flow the drainage bag, provides the rie inthe tubing goes into the bag urine sample 4, Clamps the drainage tubing below the aspiration port. Leave clamped for 30 to $0 1615, Wash hands and don gloves. 6. Provides privacy, 7. Cleanse the aspiration port with an antiseptic solution; let dry. 8, Remove all airin the needle and syringe. 9. Insert the needle into aspiration port and aspirate 15-30 ce. 40, Transfer urine specimen to container. 41, Remove gloves and dispose properly. 42, Label specimen and send to laboratory. Decreases transmission of microorganisms. Decrease embarrassment. Inhibits grown and reproduction of microorganisms. Aliows for withdrawal of the correct amount of urine. Provides sufficient urine for analysis. Prevents contamination of sterile specimen, ensures cllere accuracy, prevent spillage. Decreases transmission of microorganisms. Prevents contamination of sterile specimen, ensures clien= ‘accuracy. ‘ire Dare of Kapawan Coles Manual f Nursing Procure 2005,TESTING BLOOD FOR GLUCOSE OR HEMOGLUCOOTEST Zefiion itis Immediate measurement of blood for glucose using blood sample from a finger stick or hee! stick Normal Values: ‘Adult = 80 - 120 mg% * PPealycemia in newbom in defined as blood sugar below 30 ms %: in children end ads f below 50 msgs%. Equipment: 1. cotton balls with ROH 2. dry cotton bal 3. Glucometer set 4. matching strip 5. working gloves Procedure Action Rationale 1. Check the doctor's order. 2. Wash hands, Deters spread of microorganisms, 3. Assemble all equipment and bring to bedside. Promotes organization of procedure 4. Identity the patient Reduces risk of errors. 5. Explain the proce:ture to the patientwatcher. Elicits cooperations's 6. Puton the gloves Prevents transmission of microorganisms, 7. Select the punture site (fingers, toes, hee!s) 8. Disinfect the site with CB with ROH. Wipe dry Decrease risk of infection. with CB, 8. Tum on and set the glucometer to the Ensure accuracy of result appropriate codem e.g. code 9 10. Let a drop of blood fall on the appropriate Portion ofthe reagent strip. 41. Apply pressure on the packed site with a dry cB Prevent bleeding, 12, Insert the reagent strip into glucometer for reading 13, Take not ofthe reading; and confirm it with Double checking decreases risk of errors. the clinical instruPrevents transmission of microorganisms. 414. Remove gloves and discard used needle, CB and strip tothe appropriate container. Provides information to health care team regarding the client's response to the treatment; and legal record of.care given. 45. Record time, result and patient's response/s to the procedure, Tle Dae of Kidapanan Coleoe ano oF ig Proccrs 2005ARTERIAL BLOOD GAS (ABG) ANALYSIS Atifcial Blood Gas (ABG) analysis evaluates gas exchange in the lungs by measuring the partial pressures of oxygen (PaCOr) and carton dioxide (PaO:), and the pH of an arterial sample. PaCO2 indicates how much oxygen are delivering o the blood. PaCO indicates how much oxygen the lungs are delivering to the blood. PACOr indicates how efficiently the eliminate carbon dioxide. The pH indicates the acid-base level Of the blood, or the hydrogen ion (H*) concentration. A blood sample for ABG analysis may be drawn by Percutaneous arterial punchture or from an arterial line Purposes: _1. To evaluate the efficiency of pulmonary gas exchange. 2. To assess integrity ofthe ventilatory control system. 3. To determine the acid-base level ofthe blood. 4. To monitor respiratory therapy. Patient preparation: As appropriates, explain that this test evaluates oxygen delivery to the blood and ‘elimination of carbon dioxide. Inform the patient that the test requires a blood sample. Instruct the patient to breath normally during the test, and warn that a brief cramping or trobbing pain may occur at the puncture site. Procedure: Perform an arterial puncture. Before sending the sample to the laboratory, information on the requisition sip * Indicate whether the patient was breathing room ait or receiving oxygen therapy when the sample was drawn. If he was receiving oxygen therapy, give the flow rate * Ifthe patient is receiving mechanical ventilation, note the FQz and tdal volume. * Record the patient's temperature and respiratory. Precautions: if the patients is receiving oxygen therapy, discontinue oxygen therapy from 15-20 minutes before drawing the sample to measure ABGs on room air. Value: Normal ABG values fall within the following ranges. 75 to 100 mm Hg. 35 to 45 mm Hg, 7:35 to 7:42 18% to 23% 94% to 100% 220.26 meq iter Implications of results: Low PaCO2, O;CT and O2 saturation levels, in combination with a high PaCO> value, may be due to conditions that impair respiratory function, such as respiratory muscle weakness or paralysis (in Guillain-Barre Syndrome or myasthenia gravis) respiratory center inhibition (from head injury, brain tumor, or drug abuse, for example, and airway obstruction, similarly low readings is result from bronchiole obstruction caused by asthma or emphysema, from an abnormal ventiation-pertusion ration caused by partially blocked alveoli or pulmonary capilaries, or from alveoli that are damaged or filed with fluid because pf disease, hemorrhage or neer-drowning 201When inspired air conditions insufficient oxygen, PaCOz OxCT and O; Sat. also decrease, but PaCO; may be normal. Such findings are common in pneumothorax, impaired diffusion between alveoli and blood or in an arteriovenous shunt that permits blood to bypass the lungs. Posttest care * After applying pressure tothe puncture site, tape a gauze pad fimly over it ‘+ Monitor vital signs, and observe signs of circulatory impairment, such’ as swelling, discoloration, pain, numbness or tingling in the bandaged arm ofr leg, Watch for bieeding from the puncture site.CAPILLARY FRAGILITY TOURNIQUET TEST, RUMPEL-LEDDE CAPILLARY TEST ‘Anon specif method for evaluating bleeding tendencies, the capltary traglity test (positive pressure test) measures capillaries’ ability to remain intact under increased intracepillary pressure. In this (eet a blood preseure cuff place around the patients upper arm and the presse raised to a point midway tetween the systolic and diastolic blood but no highest than 100 mm Hg. At this psi blood can enter the ily return to circulation Pressure f maintained for § minutes. This len pers) arm and hand but can not e increase of pressure may cause bleeding ofthe caplaries and formation of pelschih the arm, wrist oF ere namber of petecniae within the given circular space lis recorded asthe tet result Purposes: ‘1. Toassess the fragilty or capillary walls 2. Toidentiy platelet deficiency (thrombocytopenia) that this test helps identify abnormal bleeding tendencies. Inform the patient Patient Preparation: Explain feel discomfort from the pressure of the that restriction of foods and fluids is not required and that he may blood pressure cut. Procedure: To perform this test, select and mark a"2" (8 em) space on the patient's forearm, Select 2 s trate tee from petechiae, otherwise record the numberof petechiae present on the Ste before starting the test The patent's skin temperature and the room temperature should be normal presse cuft Festen the cuf around the arm, and raise the pressure to appoint midway between he systolic and diastole blood pressures. Maintain this pressure for § minutes; then release the cu Count the number of petechiae that appear in the "2" space. Record test results precautions: Do not repeat this teston the same arm within one week eres contvaindicates in patients with disseminated intravascular cogulaton (DIC) or other bleeding disorders, and in those with significant petechiae. Values: A few petechiae may normally be present before the tes. Fewer than 10 petechiae the fore arm vinutes after the testis considered normal, or negative; more than 10 petechiae |S considered as positive resutt ‘The following scale me also be used to report test result: Number of petechiae Score Oto 10 t+ 11 t0.20 2 211050 3+ 51 or more 4 Implication of result: A positive fnding (more than 10 petechiae present, of © Sore of 2+ to 4+ indicates weakness of the capillary walls (vascular purpura) or platelet defect, and occurs conditions’such as thrombocytopenia, purpura sens, Vit. K deficiency, dysproteinemia, polyeytnemia 912 and in severe deficiencies of factor Vl, fbrinogen, or prothrombin. Posttest Care: Encourage the patient to open and close his hand a few times to hasten retum of blood to the forearm, a 203 rat spawn ColegPOST MORTEM CARE Definition: \tis care given after death, Purposes: 2 7Obtepare the body in manner that wil educe the familys distress when viewing the body 2. Toprevent distortions in the body's appearance, Anticipated Response: 1. The family receives support as they experience and express grief. 2. The hospital staff complies wih legal requirements regarding completion of health certifcate, consent forms for autopsy and request for organ donation, 3. The client's body is protected ftom the skin damage or other injury post mortem Adverse Response 1. Family members are unable to express grief 2. Skin surfaces are damaged during preparation and position of the body. 3. You have dificult locating the next of kin for legal decision regarding organ donation, Permission for autopsy, or location and name ofthe mortuary to which the body is fo be sent. Diagnoses: _Y) ie 1, Anticipating Grieving, we 2. Dysfunctional Grieving 3. Hopeless 4 Ineffective Individual Coping Equipment: A basin halt-filed with water Towel and wash cloth Cotton Identification tags (2) Safety pins Rod or forceps Mortuary gown Clean disposable gloves Plastic bag for soled equipment Working gloves Tape if not using shroud kit Procedure Action Rationale 1. Always let the doctor pronounce the client This is necessary legal procedure dead. Note the exact tome of death. 2. Screen the bed in the ward Other clients may be upset with the sight the roommate's. death. The family will appreciate privacy with the body. 204 Notre Dame of Kidapawan College Mani cuir Pca 20053. Wash hands, 4, Assemble the equipment for the cleaning, \wrapping and identifying the body. 5. Puton working gloves 6. Place the body supine with the arms extended at the side or folded over the abdomen 7. Close the eyelids by applying gentle Pressure. If lids’ do not close, saturate cotton with water and place it over the eyes (remove after, 8, Replace or retain dentures within the mouth. 8. Place a small towel under the chin to close an open mouth. 10. Removes soiled dressings, venipuncture devices, indwelling catheter, and so on and disposable all contaminated and soiled items to appropriate containers. 11. Pack all body orifices with cotton using forceps or rod. If to be embalmed immediately, Packing is not necessary. 12, Cleanse any obviously solled areas of the body, Provide grooming and hygiene to the person's face and hair by: ‘a. washing any secretions from the face. . Combining the hair in a neat sty , Removing any hair clips and pins 13. Remove or make inventory of the valuable stil attached to the body. 14, Put on mortuary gown if any. Attach identification tag to the right great toe or right ankle, 18. Cover the body with a clean cotton sheat and tape it. Attach the second identification tag atthe top of the sheet. ‘Note Dame of Kiapanan Co Menlo Nursing Pocedies 20 The body is prepared in a clean condition before itis transferred to the mortuary A normal anatomical position prevents, Discoloration of the skin from pooling blood in the area visible in a casket The eyes may not be easily closed if the time between the death and preparation the body is prolonged, Creates a natural sleeping appearance Dentures maintain the natural contour of the face. They may be dificult to insert several hours after death. if the mouth is allowed to remaining open, it may resist closing tater. Live pathogens continue to be present even though the client is deed. A container acts as transmission barrier 10 control the spread of microorganisms. Stool or urine may be released after death when the sphincters relax. Because the mortcian washed the body, a complete bath is not required. Cleansing the and grooming the body provides support to the family All personal valuables must be accounted for. Tagging facilities determination of the identity of one body ‘rom another: Covering the body promotes respect and prevents its observation dy curious onlookers.46, Removes gloves. Hand washing deters the spread of microorganism. 47. Wash your hands. Valuables must be safeguard until they can be returned to the family. 48. Endorse valuable to the family or fock in a ‘The permanent records should note where and to whom, ‘safe and state on the client's record, the body was endorsed. 49. Complete charting and death certificate. The unit must be cleaned and disinfected for subsequent use 114, Prepare the room for terminal disinfection. ‘Sample Document: Date Time Nurse's Note 5/31/2000 10:00 AM Last rites administered by Fr. Leville, NO or pulse obtained. Pupils are fixed are fixed and dilated ROD Informed. 10.05 AM Pronounced dead by Dr. Wedding ring gives to wife. Post mortem care Performed, 10:30 AM Taken to morgue. |.G0,5.N.