CHAPTER 7

CARE of CLIENTS with

PROBLEMS in
OXYGENATION, FLUID
and ELECTROLYTE
BALANCE,
METABOLISM, and

 Tracheostomy
 Chest Physiotherapy
 Blood Transfusion
 Catheterization
 Urinalysis
 Hot Sitz Bath
 Fecalysis
 Enema Soap Sud
 Ostomy Care

239
 TRACHEOSTOMY CARE
DEFINITION

A tracheostomy is an artificial opening in the neck into the windpipe (trachea). This
opening is called a stoma. It allows air to go in and out of the lungs. It also allows any mucus to
be removed. A small tube (the tracheostomy tube) is inserted through this opening. Breathing
occurs through this tube.

TRACHEOSTOMY CARE

Keeping the tracheostomy site clean and dry, preventing irritation and infection.

PARTS OF THE TRACHEOSTOMY SET

Your new airway is kept open by using a tracheostomy tube. You may have only 1 tube
(an outer cannula) or you may have 2 tubes (an outer cannula and an inner cannula). Tubes are
made of metal or synthetic materials.

15 mm CONNECTOR
INNER CANNULA

NECK FLANGE

INFLATION LINE

CUFF OUTER CANNULA

LUER VALVE
OBTURATOR
CUFF PORT

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1. Cuff

- The “balloon” on the end of the tracheostomy tube. When inflated, it forms a seal against the
wall of your windpipe. This stops the air flow through your mouth and nose so that you breathe
through the tracheostomy tube. You are unable to speak when the cuff is inflated.

2. Inflation line

- Thin plastic tubing that carries air to and from the cuff

3. Cuff port

- a small, plastic balloon-like component on the end of the inflation line. The cuff port shows if
the cuff is inflated. It is also called a pilot balloon.

4. Luer valve

- Where the syringe is connected to inflate or deflate the cuff.

5. 15mm connector

- Part of the tracheostomy tube or inner cannula that sticks out at the neck. Ventilator tubing, a
manual
Resuscitation bag or a speaking valve may be connected to the 15mm connector.

6. Neck flange /plate

- Usually contains product information and has holes on either side for securing neck ties.

7. Outer cannula (CAN-you-luh)

- The tube that is inserted into your windpipe. It stays there all the time and may have another
part (the inner cannula) that slides inside of it.

8. Inner cannula

- The tube that fits inside your outer tracheostomy tube. It is removed for cleaning or
replacement.

9. Obturator (OB-ter-ay-ter)

- A guide used to insert the tracheostomy tube.

ASSESSMENT

1. Assess respiratory status including ease of breathing, rate, rhythm, depth, lung
sounds, and oxygen saturation level
2. Assess pulse rate
3. Assess character and amount of secretions from tracheostomy site
4. Assess presence of drainage on tracheostomy dressing or ties
5. Assess appearance of incision (note any redness, swelling, purulent discharge,
or odor)

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OBJECTIVES

1. To maintain patent airway

2. To maintain cleanliness and prevent infection at the tracheostomy site
3. To facilitate healing and prevent skin excoriation around the tracheostomy incision
4. To promote comfort
5. To prevent tracheal damage or necrosis

EQUIPMENT

Tracheostomy care kit – containing the following:

❖ Two (2) sterile containers or basins/sterile bowl

❖ Sterile cotton-tip applicators
❖ Sterile pipe cleaner
❖ Sterile nylon brush
❖ Sterile 4 x 4 gauze pads
❖ Sterile drapes
❖ Tracheostomy ties (twill tape or Velcro)
❖ Two (2) pairs of sterile gloves
❖ Plastic disposal bag or biohazard container for disposal/kidney basin
❖ Sterile cleaning solution
❖ Hydrogen peroxide
❖ Sodium chloride 0.9% or normal saline solution
❖ Suction kit and suction equipment
❖ Sterile precut 4 x 4 drain sponges
❖ Scissors
❖ Personal protective devices (optional): gown, mask and goggles or face shield

PROCEDURE

STEPS RATIONALE
1. Explain procedure to client Explanation facilitates cooperation and provides
reassurance for client
2. Assist the client to a semi-fowler’s Semi-fowler’s position allows comfortable access
position. Remove pillows from behind to the tracheostomy site, and removal of pillows
the client’s head. reduces neck flexion.
3. Place a towel or linen-saver over the To prevent gown from getting wet.
patient’s chest
4. Place plastic bag or disposal container Prevents contamination of sterile field or stoma.
within easy reach. Position in an area
that does not require crossing over the
sterile field or stoma to discard soiled
items.
STEPS RATIONALE
4. Perform hand hygiene and open Hand hygiene deters spread of microorganism
necessary supplies
5. Prepare supplies before cleaning inner
cannula

242
 a. Open tracheostomy care kit and
separate basins touching only the
edges. If kit is not available, open
two sterile basins/bowl.
b. Fill one basin ½ in deep with
hydrogen peroxide
c. Fill other basin ½ in deep with
saline
d. Open sterile brush or pipe cleaners
if they are not already available in a
cleaning kit. Open additional sterile
gauze pad
6. Don disposable gloves ( alternatively,
puts a sterile glove on the dominant
hand and a clean glove on the other
hand. )
7. Suction the tracheostomy tube
8. Remove the oxygen source if one is
present.
Basins/bowls are sterile receptacles for cleaning
cannulas
Hydrogen peroxide facilitates removal of dry,
encrusted secretions
Saline rinses and removes hydrogen peroxide
and lubricates the outer surface of the inner
cannula for easier reinsertion.
Sterile brush or pipe cleaner provides friction to
clean inner surface of cannula
Gloves protect from exposure to blood and body
fluids
Suctioning removes any remaining secretions
Releasing the lock permits removal of the inner
cannula

Rotate the lock on the inner cannula in a To avoid discomfort to the patient
counterclockwise motion to release it. To avoid cross infection
9. Gently remove the inner cannula and Soaking in hydrogen peroxide loosens dry,
carefully drop it in the basin with hardened secretions
hydrogen peroxide.
10. Remove the soiled tracheostomy Removing the gloves over the old dressing
dressing. Place the soiled dressing in permits containment of infectious exudates (if
your gloved hand and peel the glove present)
off so that it turns inside out over the
dressing. Discard the glove and the
dressing
11. Clean the inner cannula:
a. Don sterile gloves Sterile gloves maintains surgical asepsis
b. Remove inner cannula from
soaking solution. Moisten bush or
pipe cleaners in saline and insert
into tube to remove secretions.
Inspect the cannula for cleanliness
by holding it at eye level and
looking through it into the light.
c. Agitate cannula in saline solution. Saline rinses inner cannula. Tapping tube
Remove and tap against inner against basin removes excess saline in inner
surface of the basin tube
d. Place on sterile gauze pad
Placing on sterile gauze maintains sterility and
frees both hands for suctioning

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 STEPS RATIONALE
1. Remove the oxygen source, using
non dominant hand, (if the patient
requires supplemental oxygen).

Suction the outer cannula using sterile Suctioning removes any remaining secretions
technique

2. Reinsert the inner cannula into the To avoid discomfort to the patient.
patient’s tracheostomy in the
direction of the curvature. To secure inner cannula
Following the manufacturer instructions, To prevent cannula from falling out during
locks the inner cannula in place securely. coughing or movement.
Reattaches the oxygen source if
indicated.

14. Clean the incision site. Dip cotton- Saline is nonirritating to tissue. Cleansing from
tipped applicator in saline and clean stoma outward and using each applicator only
stoma under faceplate/flange. Use once promotes aseptic technique
each applicator only once, moving
from stoma site outward.
Hydrogen peroxide may cause tissue damage
Apply hydrogen peroxide (usually in and needs to be removed from skin and
a half-strength solution mixed with surrounding area
sterile normal saline) to area around
stoma, faceplate, and outer cannula if
secretions prove difficult to remove.
Rinse area with saline.

15. Pat skin gently with dry 4” x 4” gauze Gauze removes excess moisture

16. Apply antibiotic ointment around To prevent bacterial growth/to prevent infection
incision site, if indicated

17. Slide commercially prepared Lint or gauze fibers can be aspirated into the
tracheostomy dressing of non- trachea and cause irritation, potentially creating
raveling material or 4” x4” inch gauze a tracheal abscess
dressing under faceplate

While applying the dressing, ensure Excessive movement of the tracheostomy tube
that the tracheostomy tube is irritates the trachea
securely supported.

18. Inspect the ties or strap securing the
faceplate. If damp or soiled, carefully
cut the ties (or loosen the Velcro to
remove a strap)
Ties or straps that are wet contribute to skin
breakdown or infection.
NOTE:
Tracheostomy ties should not be removed or
changed for the first 24 hours after
tracheostomy tube insertion to prevent
dislodgement of the tube and bleeding from the
stoma

244
 STEPS RATIONALE
19. Change the tracheostomy tape
a. Leave soiled tape in place until Leaving tape in place ensures that tracheostomy
new one is applied will not be expelled if client coughs or moves.
NOTE: If it is difficult to thread new
ties onto the faceplate with old
ties in place, have an assistant
put on a sterile glove and hold
the tracheostomy in place while
you replace the ties. This is
very important because
movement of the tube during
this procedure may cause
irritation and stimulate
coughing. Coughing can
dislodge the tube if the ties are
undone This provides for secure attachment with knot in
front at neck plate. Diagonal cut facilitates
b. Cut piece of twill tape 2.5 times the insertion of tape into openings on faceplate.
length needed to go around the
client’s neck. Trim ends of tape on
the diagonal Doing so provides attachment for one side of
faceplate.
c. Insert one end of tape through
faceplate opening alongside old
tape. Pull through until both ends Flexing the neck increases its circumference the
are even way coughing does. Placing a finger under the
tie prevents making the tie too tight, which could
d. Slide both tapes under client’s interfere with coughing or place pressure on the
neck and insert one end through jugular veins
remaining opening on other side of
face plate. Pull snugly and tie
ends in double square knot
allowing for slack by placing a
finger between the tape and New tape provides for secure attachment
client’s neck. Ask client to flex
his/her neck. Velcro straps may be more comfortable for
some clients and are easier to adjust for proper
e. Carefully remove old tape. fit

f. To replace a Velcro strap: place

new strap behind client’s neck and
thread ends through faceplate
eyelets. Adjust tightness as above
and secure Velcro
20. Remove gloves and discard. Perform To reduce the spread of microorganisms
hand hygiene
21. Check the tightness of the ties. Swelling of the neck may cause the ties to
a. frequently check the tightness of become too tight, interfering with coughing and
the tracheostomy ties and position circulation. Ties can loosen in restless clients,
of the tracheostomy tube. allowing the tracheostomy tube to extrude from
the stoma

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 (Place at least 1 finger between the
tip of the string on the client’s neck
to check looseness of the ties.
STEPS
21. Document assessments and
completion of procedure, note the
appearance of the stoma site and
any exudates
RATIONALE
Assessment and accurate documentation
provide for comprehensive care. Increasing
exudates or a change in its color or character
may indicate infection.

EVALUATION

1. Patient adequately ventilated (with absence of respiratory distress).

2. Secretions easily suctioned.
3. Tracheostomy site remains free of infection.
4. Patient able to eat without aspirating food.
5. Tracheal damage or necrosis is prevented.

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 CHEST PHYSIOTHERAPY
DEFINITION

It is a technique used to mobilize or loose secretions in the lungs and respiratory tract. It
consists of external mechanical maneuvers, such as chest percussion, postural drainage,
vibrations to augment mobilization and clearance of airway secretions, diaphragmatic breathing
with pursed lips, coughing and controlled coughing.

Chest percussion with postural drainage is effective and recommended for patients with
secretions that cannot be readily removed by the normal cough reflex.

Chest percussion utilizes the striking force with cupped hands over the chest wall. The
striking force causes air to be trapped between the hands and chest wall.

Results of chest percussion:

1. Vibrations move through the thorax shaking loose adherent secretions and;
2. The vibrations increase ciliary movement which in turn increases the mucociliary
clearance mechanism.

Postural drainage utilizes gravity to facilitate drainage of secretions.

The combined use of these two qualities produces increased removal of bronchial secretions and
helps improved airway patency.

ASSESSMENT

1. Determine the normal range of patient’s vital signs. Conditions requiring CPT, such as
atelectasis, and pneumonia, affects vital signs.
2. Determine the patient’s medications. Certain medications, particularly diuretics,
antihypertensive cause fluid and hemodynamics changes. These decrease patient’s
tolerance to positional changes and postural drainage.
3. Determine the patient’s medical history; certain conditions such as increased ICP, spinal
cord injuries and abdominal aneurysm resection, contraindicate the positional change to
postural drainage. Thoracic trauma and chest surgeries also contraindicate percussion
and vibration.
4. Determine the patient’s cognitive level of functioning. Participating in controlled cough
techniques requires the patient to follow instructions.
5. Assess patient’s exercise tolerance. CPT maneuvers are fatiguing. Gradual increase in
activity and through CPT, patient tolerance to the procedure improves.

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OBJECTIVES

1. To mobilize and eliminate secretions.

2. To reexpand lung tissue.
3. To promote efficient use of respiratory muscles.
4. To prevent or treat atelectasis.
5. To prevent pneumonia.

GENERAL CONSIDERATIONS

1. For optimal effectiveness and safety, modify chest physiotherapy according to the
patient’s condition. For example, initiate or increase the flow of supplemental oxygen, if
indicated. Also, suction the patient who has an ineffective cough reflex. If the patient tires
quickly during therapy, shorten the sessions because fatigue leads to shallow respirations
and increased hypoxia.
2. Maintain adequate hydration in the patient receiving chest physiotherapy. Avoid
performing postural drainage immediately before or within 1 ½ hours after meals to avoid
nausea, vomiting, and aspiration of food or vomitus.
3. Because chest percussion can induce bronchospasm, any adjunct treatment (for example,
intermittent positive-pressure breathing, aerosol, or nebulization therapy) should precede
chest physiotherapy.
4. Refrain from percussing over the spine, liver, kidneys, or spleen to avoid injury to the spine
or internal organs. Also avoid performing percussion on bare skin or the female patient’s
breasts. Percuss over soft clothing (but not over buttons, snaps, or zippers), or place a
thin towel over the chest wal. Remember to remove jewelry that might scratch or bruise
the patient.
5. Explain coughing and deep-breathing exercises preoperatively so that the patient can
practice when he’s pain-free and better able to concentrate. Postoperatively, splint the
patient’s incision using your hands or, if possible, teach the patient to splint it himself to
minimize pain during coughing.
6. Try to schedule the last session just before bedtime to help maximize the patient’s
oxygenation while he’s sleeping.

POSITIONING A PATIENT FOR POSTURAL DRAINAGE

UPPER LOBE
(APICAL SEGMENT)
Upper Lobe (Apical Segment)

The bed or drainage table flat.

The patient leans back on a
pillow at 30° angle. Percussion
should be done over the area
between the clavicle and top of
the scapula on each side.

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 UPPER LOBE
(ANTERIOR SEGMENT)
Upper lobe (Anterior Segment)

The bed or drainage table should

be flat. The patient lies on his
back with a pillow under the
knees. Percuss between the
clavicle and nipple on each side
of the chest.

UPPER LOBE
(POSTERIOR SEGMENT)

Upper lobe (Posterior Segment)

The bed of drainage table should

be flat. The patient leans over a
folded pillow at a 30˚ angle.
Percuss over the upper back on
each side of the chest.

RIGHT MIDDLE LOBE

Right Middle Lobe (Internal and (INTERNAL AND MEDICAL SEGMENTS)
Medial Segment)

The foot of the drainage table or

bed should be elevated 14
inches approximately 15° angle.
The patient lies head down on
his left side and rotates ¼ turn
backward. A pillow may be
placed behind the patient from
shoulder to hip. The knees
should be flexed. Percuss over
the right nipple area.

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 LOWER LOBE
Lower lobe (Superior Segment) (SUPERIOR SEGMENT)

The drainage table or bed should

be flat. The patient lies on his
abdomen with a pillow under the
hips. Percuss over the middle of
the back below the tip of the
scapula on either side of the
spine.

LOWER LOBE (ANTERIOR BASAL

SEGMENT)
Lower lobe (Anterior Basal
Segment)

The foot of the drainage table or

bed should be elevated 18
inches or 30˚ angle. The patient
lies on his side with his head
down and a pillow under his
knees. Percuss over the lower
ribs just underneath the axilla.

LOWER LOBE
(POSTERIOR BASAL SEGMENT)

Lower lobe (Posterior Basal

Segment)

The foot of the drainage table or

bed should be elevated 18
inches or 30˚ angle. The patient
lies on his abdomen and then
should rotate ¼ turn upward. The
upper leg can be flexed over a
pillow for support. Perucss over
the uppermost portion of the
lower ribs.

250
PERFORMING PERCUSSION AND VIBRATION

To perform percussion, instructs the patient to breathe slowly and deeply, using the
diaphragm, to promote relaxation. Hold your hands in a cupped shape, with fingers flexed and
thumbs pressed tightly against your index fingers. Percuss each segment for 1 to 2 minutes by
alternating your hands against the patient in a rhythmic manner. Listen for a hollow sound on
percussion to verify correct performance of the technique.

To perform vibration, ask the patient to inhale deeply and then exhale slowly through
pursed lips. During exhalation, firmly press your fingers and the palms of you hands against the
chest wall. Tense the muscles of your arms and shoulders in an isometric contraction to send
fine vibrations through the chest wall. Vibrate during five exhalations over each chest segment.

251
PROCEDURE

STEPS RATIONALE
1. Check the physician’s order for specification of To ensure correct order.
any particular area.
2. Review the chart for the following: patient’s To determine a patient’s medical history.
diagnosis, progress notes, chest x-ray
interpretation, laboratory results and previous
respiratory therapy notes.
3. Gather the equipment at the patient’s bedside. To save time, energy and effort.
4. Wash hands prior to initiating therapy. To remove microorganisms.
5. Confirm the patient’s identity using two patient To ensure correct patient for therapy.
identifiers.
6. Explain the procedure to the patient. To gain cooperation of the patient.
7. Auscultate the patient’s lungs. To determine baseline respiratory status.
8. Position the patient for drainage of congested To facilitate drainage of secretions.
lobes of segments.
a. Upper lobe (Apical Segment) Bed or
drainage table flat. The patient leans back on a
pillow at 30º angle. Percussion should be done
over the area between the clavicle and top of the
scapula on each side.
b. Upper lobe (Anterior Segment) The bed or
drainage table should be flat. The patient lies on
his back with a pillow under the knees. Percuss
between the clavicle and nipple on each side of
the chest.
c. Upper lobe (Posterior Segment) The bed or
drainage table should be flat. The patient
leans over a folded pillow at a 30º angle.
Percuss over the upper back on each side of
the chest.
d. Right Middle Lobe (Internal and Medial
Segments) The foot of the drainage table or bed
should be elevated 14 inches approximately 15º
angle. The patient lies head down on his left side
and rotates ¼ turn backward. A pillow may be
placed behind the patient from shoulder to hip.
The knees should be flexed. Percuss over the
right nipple area.
e. Lower lobe (Superior Segment) The
drainage table or bed should be flat. The
patient lies on his abdomen with a pillow under
the hips. Percuss over the middle of the back
below the tip of the scapula on either side of
the spine.
f. Lower lobe (Anterior Basal Segment) The
foot of the drainage table or bed should be
elevated 18 inches or approximately 30 º angles.
The patient lies on his side with his head down

252
 and a pillow under his knees. Percuss over the
lower ribs just underneath the axilla.
STEPS RATIONALE
g. Lower lobe (Posterior Basal Segment) The
foot of the drainage table or bed should be
elevated 18 inches or 30º angle. The patient lies
on his abdomen and then should rotate ¼ turn
upward. The upper leg can be flexed over a
pillow for support. Percuss over the uppermost
portion of the lower ribs.
9. Percuss the desired area 2-3 minutes out of 5 The striking force causes air to be trapped
minutes in the postural drainage position. between the hands and the chest wall thus
Continue this method for 15 minutes. loosen secretions.
10. Allow the patient to cough, expectorate and To remove loosened secretions.
rest as often as necessary.
11. Provide oral hygiene. To remove secretions that may have a foul
odor.
12. Auscultate the patient’s lungs. To evaluate the effectiveness of therapy.
13. Reposition the patient as he was prior to To provide comfort.
therapy.
14. Instruct the patient as to the probable after
effects of therapy. There may be delayed
expectoration after the therapist leaves the
patient’s room.
15. Charting:
a. Note the lobes or segments drained and
percussed.
b. State whether the patient has had a productive
cough or non-productive cough. If it was
productive, note the sputum quantity, color and
viscosity.
c. any adverse reaction or effect on the patient
during and/or after therapy should be noted.
d. Sign date, time of completion of therapy and
your name.

EVALUATION

1. Increased expectoration of secretions occurred.

2. Lung sounds improved.
3. Efficient use of respiratory muscles promoted.

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 BLOOD TRANSFUSION
DEFINITION

BLOOD TRANSFUSION is the infusion of whole blood or a blood component such as

plasma, red blood cells, or platelets into a patient’s venous circulation.

ASSESSMENT

1. Obtain a baseline assessment of the patient, including vital signs, condition of the skin,
heart and lung sounds and urinary output.
2. Review most recent laboratory values.
3. Ask patient about any previous history of transfusions, including the number he or she has
had, and any reactions experienced during a transfusion.
4. Inspect the IV insertion site and check the type of solution being given.

EQUIPMENT

Blood product Cross-matching card/yellow card

Blood administration set BP Apparatus
0.9% Normal Saline Stethoscope
IV pole Thermometer
IV catheter (20 gauge or larger) Kidney basin
Disposable gloves Flow Sheet
Tape

PROCEDURE

STEPS
1. Determine whether patient knows the reason
for transfusion. Ask if the patient has had a
transfusion reaction in the past.
2. Explain procedure to the patient. Check for
signed consent for transfusion. Advise patient
to report chills, itching, rash, or unusual
symptoms.
3. Perform hand hygiene and put on clean
gloves.
4. Hand container of 0.9% normal saline with
blood administration set to initiate IV infusion
and follow administration of blood.
5. Start IV with #18 or #19 catheter if not already
present. Keep IV open by starting flow of
normal saline.
RATIONALE
This directs teaching before beginning
transfusion.
Explanation provides reassurance and
facilitates cooperation. Prompt reporting of any
reaction to transfusion necessitates stopping
immediately.
Hand hygiene deters the spread of
microorganisms. Gloves protect against
accidental exposure to the patient’s blood.
Dextrose may lead to clumping of RBC and
hemolysis. Filter in blood administration set
removes particulate material formed during
storage of blood.
Large-bore needle or catheter is necessary for
infusion of blood products. The lumen must be
large enough not to cause damage to RBC. IV

254
 should be started prior to obtaining blood in
case procedure takes longer than 30 minutes.
STEPS RATIONALE
Blood must be stored in refrigerated unit at
6. Obtain blood product from blood bank
carefully controlled temperature (4 degrees
according to agency policy.
Celsius).
Most agencies require two Registered Nurses
7. Complete identification and check the
to verify information: unit numbers match; ABO
following:
group and Rh type are the same; expiration
A. Identification number
date (after 35 days, red blood cells begin to
B. Blood group and type
deteriorate). Blood is never administered to a
C. Expiration date
patient without an identification band. If clots
D. Patient’s name
are present, blood should be returned to the
E. Inspect blood for clots
blood bank.
8. Take baseline set of Vital Signs before Any changes in Vital Signs during the
beginning transfusion. transfusion may indicate a reaction.
9. Start infusion of the blood product:
A. Priming is necessary for blood to flow
A. Prime in-line filter with blood
properly.
B. Start administration slowly (no more than 25 B. Transfusion reactions typically occur during
– 50 mL for the first 15 minutes). Stay with this period, and slow rate will minimize the
the patient for the first 5 – 15 minutes of volume of red blood cells infused.
transfusion.
C. Check vital signs at least every 15 minutes C. If there had been no adverse effects during
for the first half hour after the start of the this time, the infusion rate is increased. If
transfusion. Follow the institution’s complications occur, they can be observed
recommendations for vital signs during the and the transfusion can be stopped
remainder of the transfusion. immediately.
D. Observe patient for flushing, dyspnea, D. These symptoms may be early indication of
itching, hives, or rash. a transfusion reaction.

E. Use a blood warming devise, if indicated, E. Rapid administration of cold blood can result
especially with rapid transfusions through a in cardiac arrhythmias.
CVP catheter.
10. Maintain the prescribed flow rate as ordered
or as deemed appropriate by the patient’s
overall condition, keeping in mind the outer
Rate must be carefully controlled, and patient’s
limits for safe administration. Assess
reaction must be monitored on a frequent
frequently for transfusion reaction. Stop blood
basis.
transfusion and allow saline to flow if you
suspect a reaction. Notify physician and blood
bank.
11. When transfusion is complete, infuse 0.9% Saline prevents hemolysis of RBC and clears
normal saline. remainder of blood in IV line.
12. Record administration of blood and patient’s
reaction as ordered by agency. Return blood This provides for accurate documentation of
transfusion bag to blood bank according to patient’s response to blood transfusion.
agency policy.

255
EVALUATION

1. The patient receives the blood transfusion without any evidence of a transfusion reaction
or complication.
2. The patient exhibits signs and symptoms of fluid balance, improved cardiac output, and
enhanced peripheral tissue perfusion.

B.S. Aquino Drive, Bacolod City

Dr. Pablo O. Torre Neg. Occ. 6100, Philippines

MEMORIAL HOSPITAL

LABORATORY DEPARTMENT

CROSSMATCHING CARD

Name of Patient Date

Doctor Room No.

Diagnosis

Patient’s Blood Type

Donor’s Blood Type Amount

Serial B.S.
No. Aquino Drive, Bacolod City Exp. Date VDRL

Dr. Pablo O. Torre Neg. Occ. 6100, Philippines BLOOD BANK

HBSAg

MEMORIAL HOSPITAL
Malaria

Anti-HCV

Anti-HIV

Crossmatched
CROSS-MATCHING CARD Result

Name of Patient Date

Doctor Room No.

Medical Technologist
Diagnosis

Patient’s Blood Type Amount Serial No.

Donor’s Blood Type VDRL Exp. Date

Malaria
256
HBs-Ag

Crossmatched Anti-HCV
 CATHETERIZATION
DEFINITION

Assisting in the introduction of a catheter into the bladder through the urethra for the
relief of urinary retention or for emptying the bladder

Catheter - is a thin, clean hollow tube which is usually made of soft plastic or rubber.

ASSESSMENT

1. Determine the most appropriate method of catheterization based on the purpose and
any criteria specified in the order such as total amount of urine to be removed or size of
catheter to be used
2. Assess the client’s overall condition e.g. mobility and physical limitations, ability to
cooperate in positioning. Determine if the client is able to cooperate and hold still during
the procedure and if the client can be positioned supine with head relatively flat.
3. Determine when the client last voided or was last catheterized.
4. Percuss the bladder to check for fullness or distention.
5. Assess presence of pathological condition that may impair passage of catheter from the
urethra into the bladder.
6. Assess purpose of catheterization.
➢ Use a straight catheter if only a spot urine specimen is needed, if amount of
residual urine is being measured, or if temporary decompression/emptying of the
bladder is required
➢ Use an indwelling/retention catheter if the bladder must remain empty or
continuous urine measurement/collection is needed.
7. Assess if client is allergic to antiseptic, tape or rubber
8. Assess need for perineal care before catheterization
9. When possible, complete a bladder scan to assess the amount of urine present in the
bladder before performing a urethral catheterization

OBJECTIVES

1. To relieve discomfort due to bladder distention or to provide gradual decompression of a

distended bladder
2. To assess the amount of residual urine if the bladder empties incompletely
3. To obtain a sterile urine specimen
4. To provide for intermittent or continuous bladder drainage and/or irrigation
5. To obtain a urine specimen when a specimen cannot be secured satisfactorily by other
means. Examples include collecting an uncontaminated specimen from a woman who is
menstruating or from an incontinent patient
6. To empty the bladder completely prior, during, or after the surgery, or before certain
diagnostic procedures
7. To facilitate accurate measurement of urinary output for critically ill client whose output
needs to be monitored hourly
8. To prevent urine from contacting an incision after perineal surgery
9. To manage incontinence when other measures have failed.

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GENERAL CONSIDERATIONS

1. Identify the status of patient for appropriate preparation of catheter size.

2. Follow proper hand washing techniques.
3. Do not allow the spigot on the drainage bag to touch a contaminated surface.
4. Do not open the drainage system at connection points to obtain specimens or measure
urine.
5. If the drainage tubing becomes disconnected, do not touch the ends of the catheter or
tubing. Wipe the ends of the tube with antiseptic solution before reconnecting.
6. Prevent pooling of urine and reflux of urine into the bladder.
7. Remove the catheter as soon as possible after conferring with physician.

TYPES OF CATHETERIZATION

1. Foley catheter/indwelling urethral catheter/retention catheter

→ used if the catheter is to remain in place for continuous drainage
→ It is designed so that it does not slip out of the bladder.
→ A balloon is inflated to ensure that the catheter remains in the bladder once it is
inserted
→ The foley catheter has more than one lumen or open tube within the catheter.
a. In a double-lumen catheter, one lumen is connected directly on the
balloon, which is inflated with sterile water; the other is the lumen
through which the urine drains.
b. The triple-lumen catheter provides an additional lumen for the instillation
of irrigating solution.

2. Intermittent catheter/straight catheter has a single lumen.

→ It is used to drain the bladder for shorter periods (5-10 minutes).
a. coude catheter is a variation of the straight catheter. It is more rigid
than other straight catheters and has a tapered, curved tip. This
catheter may be used for men with prostatic hypertrophy because it is
more easily controlled and less traumatic on insertion

PARTS OF THE CATHETER

258
INDICATIONS:

1. Spinal cord injury & Pelvic nerve damage

2. Neuromuscular degeneration
3. Incompetent bladder
4. Prostate enlargement
5. Clients undergoing surgical repair of the urethra and surrounding structures
6. Critically ill or comatose client
7. Urinary retention with recurrent episodes of Urinary Tract Infection
8. Clients with skin rashes, ulcer or wounds irritated by contact with urine
9. Pre-operative/post-operative client
10. Pre-partum/post-partum client
11. Urinary incontinence

EQUIPMENT

A. Straight Catheterization

1. Catheterization tray
➢straight catheter
➢sterile gauze (2)
➢sterile bowl
➢sterile towel with hole (for male clients)
➢pair of sterile glove
➢antiseptic solution (Betadine)
➢Sterile forceps

2. flashlight/lamp (optional)
3. water-soluble lubricant
4. sterile specimen container
5. flushing tray
6. bedpan
7. waste receptacle

B. Indwelling Catheterization

1. Catheterization tray
➢ sterile gauze (2)
➢ sterile bowl
➢ sterile towel with hole (male)
➢ pair of sterile gloves

2. flashlight/lamp (optional)
3. indwelling catheter / foley catheter – specific size: male (16-18 french)
female (12-14 french)
4. drainage bag and tubing
5. water soluble lubricant (K.Y. jelly)
6. syringe prefilled with sterile water in amount specified by catheter
manufacturer (minimum of 5 ml to maximum of 10 ml specified)
7. sterile specimen container (if needed)
8. flushing tray
9. bedpan

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 10. 2% Xylocaine gel (if agency permits)
11. waste receptacle

PROCEDURE
STRAIGHT CATHETERIZATION (Male & Female)

STEPS RATIONALE
PREPARATION OF EQUIPMENT
1. Obtain treatment card from the nurse and check To make sure that you will perform correct
with doctor’s order. procedure to the right patient.
2. Bring equipment to bedside table. Perform Organization facilitates performance of the
hand hygiene task & to save time, energy & effort. Hand
hygiene deters spread of microorganisms.
3. Check lighting source Good lighting is necessary to see the
meatus clearly
PREPARATION OF THE PATIENT
1. Identify the client and explain the procedure An explanation encourages patient
and its purpose cooperation and reduces apprehension
2. Provide for privacy by closing the curtains or The procedure may be embarrassing for
door the client
3. Assist client in the appropriate position. Good visualization of the meatus is
a. Female: Supine with the knees flexed and important. Embarrassment, chilliness, and
the feet about 2 feet apart and drape the feeling tense can interfere with introducing
client. Or if preferable, the client can be the catheter. The patient’s comfort will
placed in the side-lying position. promote relaxation.

b. Male – supine, thighs slightly abducted or

apart.

- Lower side rails on working side Promotes use of proper body mechanics
4. Drape the client with top sheet. To avoid unnecessary exposure
a. Female
a.1. assist client to side near you
a.2 loosen foot part of the top sheet
a.3. use diagonal draping
b. Male
b.1 expose only the penis and a small
surrounding area
5. Provide perineal care if needed. Perform Clean technique decreases the possibility
proper hand washing again. of introducing organisms into the bladder
6. Place catheter tray between thighs To provide easy access to supplies
7. Place waste receptacle at an area near you

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8. Open sterile pack using sterile technique.
9. Offer the pair of sterile gloves to the doctor
10. Place adequate amount of water soluble
lubricant over the non-dominant hand after
the doctor cleanses the urinary meatus
11. Instruct client to breath through the mouth
while doctor inserts catheter to the urinary
meatus
12. Place distal end of catheter in sterile bowl to
measure urine volume.
Collect urine specimen if needed. Fill sterile
specimen container to the desired level by
holding end of catheter over the specimen
bottle
After the collection of the specimen the doctor
removes the catheter smoothly and slowly
13. Remove the equipment and position the
client comfortable in bed. Clean and dry the
perineal area, if necessary.
Care for the equipment according to agency
policy. Send the urine specimen to the laboratory
promptly
14. Perform proper hand washing.
15. Record the time of the catheterization, the
amount of urine removed, a description of the
urine, the patient’s reaction to the procedure, and
your name
261
Sterile technique protects the patient and
prevents the spread of microorganisms
Lubrication facilitates the insertion of the
catheter and reduces trauma to the tissues
The sphincter relaxes, and the catheter can
enter the bladder easily when the client
relaxes.
In general, no more than 750-1000 ml of
urine should be removed at one time.
Pelvic floor blood vessels may become
engorged from the sudden release of
pressure leading to possible hypotensive
episode.
Allows sterile specimen to be obtained for
culture analysis or routine urinalysis
Urine kept at room temperature may cause
organisms, if present, to grow and distort
laboratory findings
Proper hand washing deters the spread of
microorganisms
A careful record is important for planning
the patient’s care.
 INDWELLING CATHETERIZATION (Male & Female)
STEPS
1. Follow steps of straight catheterization from
numbers 1-9
2. Open the foley catheter and serve to the
physician
The catheter balloon should be tested before
insertion:
a. Remove the protective cap on the tip of the
syringe and attach the syringe prefilled with
sterile water to injection port. Inject
appropriate amount of fluid. If the balloon
inflates properly, withdraw fluid and leave the
syringe attached to the port
3. Place adequate amount of water soluble
lubricant over the non-dominant hand after the
doctor cleanses the urinary meatus
4. Instruct client to breath through the mouth
while doctor inserts catheter to the urinary
meatus
5. Inflate the balloon according to the
manufacturer’s recommendation. Inject the
entire volume supplied in the pre-filled syringe
6. Attach end of catheter to drainage system.
Place drainage bag in a dependent position
7. Tape catheter
a. Female: Secure the catheter to the upper
thigh with a Velcro leg strap or
hypoallergenic tape. Leave some slack
in the catheter to allow for leg
movement
b. Male: Secure the catheter on the upper
thigh or lower abdomen with the penis
directed toward the client’s chest. Slack
should be left in the catheter to prevent
tension
8. Check that the drainage tubing is not kinked
and that movement of side rails does not
interfere with catheter or drainage bag.
9. Remove the equipment and male the client
comfortable in bed. Clean and dry the
perineal area, if necessary. Care for the
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RATIONALE
Only the outer pack of the foley catheter is
opened to maintain the sterility.
A balloon that does not inflate or that leaks
needs to be replaced before insertion in the
patient
Lubrication facilitates the insertion of the
catheter and reduces trauma to the tissues
The sphincter relaxes, and the catheter can
enter the bladder easily when the client
relaxes.
The balloon anchors the catheter in place in
the bladder. Sterile water is used to inflate
the balloon as a precaution in case the
balloon ruptures
Closed drainage system minimizes the risk
for organisms being introduced into the
bladder.
Dependent position of drainage bag
promotes flow of urine from the bladder.
Proper attachment prevents trauma to the
urethra and meatus from tension on the
tubing.
To prevent irritation at the angle of the
penis and scrotum. Slack left in the
catheter allows for penile erection, which
can occur naturally during sleep.
This facilitates drainage of urine and
prevents the backflow of urine
Urine kept at room temperature may cause
organisms, if present, to grow and distort
laboratory findings
 equipment according to agency policy. Send
the urine specimen to the laboratory promptly
10. Perform hand hygiene Hand hygiene deters the spread of
microorganisms
11. Record the time of the catheterization, the A careful record is important for planning
amount of urine removed, a description of the the patient’s care.
urine, the patient’s reaction to the procedure,
and your name

SPECIAL CONSIDERATIONS

If there is not an immediate flow of urine after the catheter has been inserted, several
measures may prove helpful:
1. Have the client take a deep breath, which helps to relax the perineal and abdominal
muscles.
2. Rotate the catheter slightly because a drainage hole may be resting against the bladder
wall.
3. Raise the head of the patient’s bed to increase pressure in the bladder area
4. Place a gloved finger in the vagina to feel digitally for the position of the catheter through
the anterior vaginal wall
5. (Male) If resistance is met while inserting the catheter and rotating the catheter does not
help, do not use force. Enlargement of the prostate gland is commonly seen in men
over 50 years. A special crook-tipped catheter called a coude catheter may be required
to maneuver past the prostate gland.

EVALUATION

4. Residual urine measured

5. Sterile urine specimen obtained
6. Catheterization performed using sterile techniques
7. Retention catheter inserted without difficulty
8. Bladder emptied when patient is unable to void

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 URINALYSIS

DEFINITION

A diagnostic procedure by obtaining urine for laboratory examination

ASSESSMENT

1. Determine which tests are to be performed for the particular patient and the type of
specimen required. Some of the tests are done only with a physician's order.

2. Review the procedure and equipment needed, carefully checking the following (some
hospitals maintain a guide to specific laboratory tests that a nurse can use as a quick
reference)
a. Whether a patient's written consent is needed
b. The equipment needed for the test and for any monitoring of the patient
c. The type of specimen container required
d. Specific procedure for obtaining the specimen

3. Assess status of client as to:

a. When client last voided (this may indicate bladder fullness)
b. Level of awareness or developmental stage (This reveals client's ability to
cooperate during procedure)
c. Mobility, balance and physical limitations (to determine level of assistance)

4. Assess client's understanding of purpose of test and method of collection (information

allows you to clarify misunderstanding and promotes client cooperation).

5. Identify if signs and symptoms of urinary tract infections are present.

a. Frequency d. Flank pain
b. Urgency e. Fever
c. Hematuria f. Cloudy urine with sediments

OBJECTIVES

1. To instruct the patient in the method for obtaining a specimen

2. To obtain a non-contaminated urine specimen for culture and sensitivity
3. To determine an accurate estimate of work performed by the kidney
4. To maintain the collection of urine for 24 hours
5. To aid the physician in arriving at a diagnosis

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EQUIPMENT

• Sterile specimen collection cup or bottle or jar

• Gloves (sterile or non sterile)
• Bed pan, bedside commode, urinal
• 3 to 5 cc sterile syringe with needle (gauge 23 or 25)
• Anti-microbial swab/alcohol swab
• Plastic bag (use for placing specimen collection cup or bottle or jar before sending to the
laboratory)
• Specimen label

GENERAL CONSIDERATIONS

1. Urine must not be contaminated by toilet tissue vaginal and other discharges and not
mixed with stools.
2. Early morning urine obtained before breakfast is preferred for a single urine specimen.
3. Aseptic catheterization may be done as ordered if a sterile specimen is needed and if
patient is menstruating.
4. If the patient has an infectious disease, note this on the specimen label and specimen
container to protect the laboratory personnel who will handle the specimen.
5. If client does not feel urge to void, provide fluids to drink 1/2 hour before collection unless
contraindicated (ex. Fluid restriction). This improves likelihood of client being able to void.
6. If client is menstruating, indicate information on laboratory requisition.
7. Collect urine in the drainage bag unless it is the first urine drained into a new sterile bag.
(Bacteria grow rapidly in the drainage bag and could cause a false measurement).
8. For infants or toddlers who are not toilet trained, the nurse may use special collection
devices. Clear plastic, single use bags with self-adhering material can be attached over
the child's urethral meatus. Specimens should not be obtained by squeezing urine from
the diaper material.
9. It is no longer recommended to catheterize a client just to obtain a specimen because of
the high risk of causing an infection thru the introduction of the microorganisms into the
urinary tract.

TYPES OF URINE SPECIMEN COLLECTION:

1. Random specimen/routine urinalysis

 A random routine urine specimen can be collected with a client voiding naturally or
from a Foley catheter or urinary diversion collection bag.
 The specimen should be clean but need not be sterile.
 Random specimens are used for urinalysis testing or measurements of specific
gravity, pH, or glucose levels.
 The client voids into a clean urine cup, urinal or bedpan.
 Only 120 ml (4 ounces) or urine is needed for accurate testing.
 After the specimen is collected the nurse placed the lid tightly on the specimen
container washes off any urine that splashed on the outside of the container.
 The container is placed in a plastic bag and sends the labeled specimen promptly to
the laboratory.

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2. Clean-voided or midstream specimen
 This type of specimen is needed to test urine for culture and sensitivity.
 To obtain a specimen relatively free of the microorganisms growing in the lower
urethra, the nurse instructs the client on the method for obtaining a clean voided
specimen.
 After appropriate cleansing of the external genitalia. A client begins the urinary stream,
allowing the initial portion to escape.
 Then during the middle portion of voiding, the client collects the specimen. Collecting
30 to 50 ml of urine.
 The initial stream of urine cleans or flushes the urethral orifice and meatus or resident
bacteria.

3. Time urine specimens/24 hour urine specimen

 Used to test renal function and urine composition requiring collection of urine over 2-
12 or 24-hour intervals.
 The timed collection period begins after the client urinates.
 The nurse discards the sample and indicates the starting time on the collection
container and on the laboratory requisition.
 The client then collects all urine voided in the timed period.
 Each voiding is collected in a clean container and immediately emptied into the larger
container.
 Any missed specimens will make test results inaccurate.
 The collection container may contain a preservative or require refrigeration.
 The client should void the last specimen at the end of the time period.

4. Sterile specimen from an indwelling catheter

 This is another method of collecting a urine specimen for culture.
 Obtain sterile syringe with needle and alcohol swab (a small gauge needle is best to
prevent creation of a permanent hole in the catheter port).
 The nurse washes hands and applies non-sterile gloves to prevent transmission of
microorganisms.
 Clamp the tubing just below the site chosen for withdrawal, allowing fresh,
uncontaminated urine to collect in the tube.
 Wipe entry port on tubing thoroughly with alcohol/anti-microbial swab.
 Insert the needle at a 30-degree angle ensures entrance into the catheter lumen.
 While aspirating 3 to 5 ml of urine the nurse must be careful not to raise the tubing,
which would cause urine to flow back into bladder.
 Remove syringe from catheter and unclamp catheter if it was clamped.
 After obtaining the specimen transfer the urine into a sterile container using sterile
aseptic technique.
 Dispose equipment safely and properly and wash hands to reduce the transfer of
microorganisms to other clients and health care workers.

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PROCEDURE: COLLECTING MIDSTREAM URINE
STEPS
1. Verify doctor’s orders.
2. Gather equipment.
3. Explain the procedure to the patient or watcher.
a. Reason midstream specimen is
needed
b. Ways client and family can assist
c. Ways to obtain specimen free of feces
4. Provide privacy for client by closing door or bed
curtain.
5. Give client or family members soap, washcloth,
and towel to cleanse perineal area.
6. Wear non-sterile gloves and assist non-
ambulatory clients with perineal care. Assist
female client onto bedpan.
7. Change gloves, if necessary.
8. Using surgical asepsis, open sterile kit or
prepare sterile supplies. Wear sterile gloves
after opening sterile specimen cup, placing cap
with sterile inside surface up, and do not touch microorganisms to the specimen from the
inside of container or cap.
9. Pour antiseptic solution over cotton balls or Cotton balls or gauze pads will be used to
gauze pads unless kit contains prepared gauze further cleanse the perineum.
pads in antiseptic solution.
10. Assist or allow client to independently cleanse
perineum and collect specimen.
RATIONALE
To ensure accuracy of doctor’s order.
To save time effort and energy.
Helps client understand the procedure.
Feces change characteristics of urine and
may cause abnormal value.
Privacy allows client to relax and produce
specimen more quickly.
Client may prefer to wash own perineal area.
Prevents transmission of microorganisms to
nurse, provides easy access to perineal area
to collect specimen.
Reduces transfer of infection.
Sterile technique is essential to maintain
sterility of equipment and specimen. Sterile
gloves prevent the transmission of
nurse or from the client to the nurse.
Contaminated specimen is most frequent
reason for inaccurate reporting of urine
cultures and sensitivities.

FEMALE

STEPS RATIONALE
A. Spread labia with thumb and forefinger of Provides access to urethral meatus.
non-dominant hand.
B. Cleanse area with cotton ball or gauze, Cleanse from area of least contamination to
moving from front (above urethral orifice) area of greatest contamination to decrease
to back (towards anus). bacteria levels.
C. If agency policy indicates, rinse area with Prevents contamination of specimen with
sterile water, and dry with dry cotton ball or antiseptic solution.
gauze.
D. While continuing to hold labia apart, client Initial stream flushes out microorganisms
should initiate stream and after stream is that accumulate at urethral meatus.
achieved, pass container into stream and
collect 30 to 60 ml.

267
 MALE

STEPS RATIONALE
A. Hold penis with one hand and using circular Cleanse from area of least contamination to
motion and antiseptic swab, cleanse end area of greatest contamination to decrease
of penis, moving from center to outside. In bacterial levels.
uncircumcised men, the foreskin should be
retracted prior to cleansing.

B. If agency procedure indicates, rinse area Prevents contamination of specimen with

with sterile water, and dry with cotton or antiseptic solution.
gauze.
Initial stream flushes out microorganisms
C. After client has initiated urine stream, pass that accumulate at urethral meatus and
specimen collection container into stream, prevents transfer into specimen.
and collect 30 to 60 ml.
11. Remove specimen container before flow of Prevents contamination of specimen with
urine stops and before releasing penis. Client skin flora. If foreskin is not replaced,
finishes voiding in bedpan or toilet. If foreskin swelling and constriction may occur, causing
was retracted for specimen collection, it must pain and possible obstruction to urine flow.
be replaced over the glans.
12. Replace cap securely on specimen container Retains sterility of inside of container and
(touch outside only). prevents spillage of urine.
13. Cleanse any urine from exterior surface of Prevents transfer of microorganisms to
container, and place in a plastic specimen bag. others.

14. Remove bedpan (if applicable) and assist Promotes a relaxing environment.
client to comfortable position.
15. Label specimen and attach laboratory request. Prevents inaccurate identification that could
lead to errors in diagnosis or treatment.
16. Remove gloves, dispose in proper receptacle, Reduces transmission of infection.
and wash hands.
17. Transport specimen to laboratory within 15 Bacteria grow quickly in urine and specimen
minutes or refrigerate immediately. should be analyzed immediately to obtain
correct results.

RECORDING AND REPORTING

 Record date and time urine was taken.

 Specimen was obtained, and place information in nurse’s notes.
 Exact time for 24-hour specimen.
 Amount of urine obtained (MIO sheet).
 Color, consistency and odor of urine.
 Method used to obtain specimen.

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EVALUATION

1. Patient is able to obtain a non-contaminated urine specimen.

2. 24-hour urine specimen collected appropriately.
3. Compare the results of this test with the normal values for such a test and any previous
results for that patient. Identify any abnormalities.
4. Evaluate the patient’s physical, psychosocial and psychological responses to having the
test done.

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 HOT SITZ BATH
DEFINITION

It is a local application of moist heat in which the buttocks’ lower trunk (pelvic area)
is immersed in warm water.

ASSESSMENT

1. Assess skin condition for possible complications such as redness, burns, and
blisters related to previous application of moist heat.
2. Determine if sterile technique is required.
3. Check for length of time heat treatment is ordered.
4. Assess vital signs, especially respirations in debilitated patients before applying
heat.

OBJECTIVES

1. To relieve congestion in the pelvic area.

2. To relieve tenesmus (ineffectual & painful straining at stool)
3. To relieve painful hemorrhoids
4. To relieve pain following cystoscopy, vaginal hysterectomy, vulvectomies (excision
of the vulva), episiotomy during childbirth & hemorrhoidectomy
5. t o relieve muscle spasm
6. to soften exudates
7. to hasten the suppuration process
8. to hasten healing

EQUIPMENT

• Sitz bath basin

• Bath towels
• Pitcher of very hot water
• Ice cap
• Hot water bag

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GENERAL CONSIDERATIONS

1. Initial temperature of water for sitz bath is 98F - 110F or (36.6C – 43.3C) which is
gradually increased to temperature of 110°F - 120°F or (43.3C – 48.8C) or as hot as
the patient can tolerate.

2. Prevent overexposure of the client by draping bath blankets around the client’s
shoulders and thighs and controlling drafts.

3. The client should be able to sit in the basin or tub with feet flat on the floor and without
pressure on the sacrum or thighs because exposure of a large portion of the body to
heat can cause extensive vasodilatation.

4. It may be necessary to add warm water during the procedure, which normally lasts 20
minutes, to maintain a constant temperature.

PROCEDURE

STEPS
1. Check physician’s order for sitz bath.
2. Wash hands.
3. Identify the patient.
4. Explain the procedure.
5. Make patient void before the procedure.
6. Gather equipment.
Sitz bath basin fits under the toilet seat.
7. Assist the patient to the bathroom. If the room
is some distance away, you may want the
patient to push a wheelchair.
8. Fill the sitz bath basin with enough water. The
water shed. Start with initial temperature of
98ºF (36.6C) or check with your hand to
determine the temperature of water.
9. Provide for the patient’s privacy and warmth.
10. Remove the patient’s clothing & any dressings
that are present. Assess the area being
treated.
11. Assist patient into the sitz bath tub, supporting
the back with rolled towels.
12. Wrap a bath blanket around the patient’s
shoulders
13. Place a cold compress (ice cap) at the back of
the neck or on the head.
RATIONALE
To ensure safe and correct application.
Reduces transmission of microorganisms.
To be sure you are carrying out the
procedure for the correct patient.
Explanation gains client’s cooperation.(For
the patient to be aware on the purpose and
procedure.)
To empty the urinary bladder.
To save effort and energy.
To provide a portable sitz bath treatment.
Fill clean tub about one third (1/3) full with
warm water.
Rolled towel is used to pad the back to assist
with body alignment.
This protects the patient’s from feeling chilly
and form exposure.
To help alleviate feeling of weakness. Less
amount of blood in the head will cause to
faint and ice cap is applied to cause the
blood vessels to constrict so that blood will
remain on the head.

271
 14. Place hot water bag to patient’s feet. So that blood will not go to the buttocks,
because if less blood is in the feet, it will
cause chilling.
15. Maintain the temperature of the water.
a. Check the water temperature every now To prevent burning.
and then.
b. Add hot water slowly by pouring from a
pitcher. Agitate the water in the basin
while adding additional hot water.
STEPS RATIONALE
16. Stay in the room for the 1st five minutes or for To do proper assessment if patient
the entire treatment. experience any discomfort.
(Do not leave the patient alone unless it is
absolutely certain that it is safe to do so.)
17. Observe the client for signs of weakness, Typical signs of faintness include skin pallor,
dizziness, fatigue or faintness. a rapid pulse rate, and nausea.

a. Take the patient’s blood pressure, pulse

rate & respiration, if necessary.

b. Discontinue the bath if the patient shows

any signs of fainting.
18. Assist the patient out of the tub when the
prescribed time has passed. Procedure takes
20 minutes.
19. Assist the patient when drying the area, if
necessary.
20. Examine the treated area and reapply the clean
perineal dressing, if necessary.
21. Assist the patient back to the room.
22. Assist the patient to a lying position in bed and Maintain patients comfort.
instruct client to remain in bed until normal
circulation returns.
23. After care of all equipment used.

EVALUATION
1. Increased circulation occurs to affected area.
2. Increased warmth occurs to area of application.
3. Suppuration progresses.
4. Pain is decreased with heat application.

RECORDING AND REPORTING

Record procedure on patient’s chart.
 Date and time bath was given
 Temperature of water
 Duration of bath
 Effect and reaction of patient
 Type of solution
 Type of heat application
 Condition and appearance of wound
 Comfort of patient

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 FECALYSIS
DEFINITION

The method of obtaining a stool specimen from the patient for laboratory examination

ASSESSMENT

1. Determine the purpose of the test.

2. Determine the eliminatory status of the patient.
E.g. - Liquid stool
- Formed stool
3. Assess gastrointestinal tract dysfunction.

OBJECTIVES

1. To obtain stool specimen for diagnosing dysfunction in bowel elimination

2. To assess for perforation or bleeding from a gastric ulcer
3. To detect presence of parasites
4. To determine effectiveness of therapy

EQUIPMENT

• Bed pan with cover

• Screen
• Specimen container (clean, not necessarily sterile)
• Tongue depressor
• Tissue paper
• Small plastic bag or plastic liner (used when stool is loose or watery)
• Disposable gloves

GENERAL CONSIDERATIONS

1. Void first because the laboratory study may be inaccurate if the stool contains urine.
2. Use a clean or sterile bedpan or the bedside commode, depending on the specific
specimen required.
3. Defecate into the required container rather than the toilet bowl because the water in the
bowl may affect the analysis results.
4. Do not place toilet tissue in the bedpan or specimen container because contents in the
paper may influence laboratory results.
5. Notify the nurse when the specimen is available, so that it may be collected and
transported to the laboratory in the required manner.
6. Collecting of stool specimen from an older child who is toilet trained is the same as
collecting such specimen from an adult.
7. If a specimen is needed from a patient whose stools are loose or watery enough to be
absorbed in the diaper, line the diaper with a piece of cellophane or plastic. Place this
liner between the diaper and the skin.

273
 8. Check the patient frequently to see if bowel movement has occurred.
9. Stool specimen should not be contaminated with urine or water or vaginal discharge.
10. Fresh specimen should be obtained for examination so test results will not be distorted by
time lapse.
11. Collect exudates, mucus or blood with the specimen.

PROCEDURE
STEPS RATIONALE
1. Gather all equipment and take them to the This will serve to alert whoever cares for the
patient’s unit. patient that a stool specimen is needed.
When the nurse answers the patient’s
request to remove the bedpan, supplies will
be convenient for use in collecting the
specimen.
2. Approach the patient, check the identification To assure patient’s cooperation especially to
band and explain that a stool specimen is patient with bathroom privilege.
needed.
3. Instruct the patient how to collect the
specimen To protect the client from fecal
A. Let the client wear a clean gloves contamination.
B. Place a clean plastic bag over a bedpan/ To keep the specimen free from
commode or toilet seats. contamination of water that is in the toilet
C. Instruct client to pass on that plastic bag. seats and micro organism in the bedpan or
commode.
D. Obtain a stool specimen using a
disposable For effective scooping of appropriate
Spoon. amount of specimen.
E. Choose the end tip of the stool if it is For better examination, the end tip of the
formed. stool is believed to contain most of the
materials that comes from the moving of the
bowel.
4. For weak patient, paralyzed patient, surgical Privacy and comfort facilitates easy
patient or child, provide privacy and offer defecation.
bedpan.
5. Apply disposable gloves. Prevents transmission of microorganisms
6. Remove bedpan after defecation. Clean To obtain specimen easily
patient.
7. Take the bedpan to the bathroom. It would be easier to empty the bedpan after
obtaining specimen. Prevents you from
going back and forth. At the same time,
provide a clean environment to the patient
and the family.

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 STEPS RATIONALE
8. Using disposable spoon, collect the needed Collect small amount of stool.
amount of feces from client’s bedpan.

➢ Formed stool – one (1) inch or 2 – 5 cms.

➢ Liquid stool – 15 to 30 ml.

Be sure not to spill the feces. To avoid contamination.

9. Transfer feces to clean specimen container Dirty specimen container alters the stool
without touching container outside surface. thus the desired examination cannot be
properly obtained.
10. Dispose tongue depressor and replace cover To prevent spillage
of specimen container securely.
11. Label the specimen container properly. Check Incorrect label will cause laboratory to give
the name of patient, age, room and the wrong information. The doctor could
request for specimen specific examination. therefore order incorrect medication or
treatment because of error in labeling a
specimen.
12. Transfer specimen into clean plastic bag for Stool specimen should be examined warm
transport and assure prompt delivery of and while still fresh because time changes
specimen to laboratory. and temperature alter the stool and will yield
inaccurate result. Organisms must be seen
in their active stages, as loose fluid stools
are likely to contain trophozoites, or
intestinal amoeba and flagellates.
13. Remove gloves and wash hands. Reduces transmission of infection

EVALUATION

1. Specimen meets laboratory equipment for diagnostic testing.

2. Patient does not experience undue discomfort or embarrassment during the procedure.

RECORDING/REPORTING

Accurately describe to chart the following:

 Time specimen was collected

 Color, amount and consistency of stool (note any foul smell)
 Type of specimen collected
 Nature of test for which the specimen was collected
 Condition of the skin

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 ENEMA SOAP SUD
DEFINITION

The introduction of large amount of solution into the colon through the rectum to stimulate
peristaltic action thereby promoting evacuation

ASSESSMENT

1. Assess status of client: last bowel movement, normal bowel patterns, hemorrhoids,
mobility, external sphincter control, and abdominal pain.
2. Assess for presence of increased intracranial pressure, glaucoma or recent rectal or
prostate surgery.
3. Determine client’s level of understanding of purpose of enema.
4. Check client’s medical record to clarify the rationale for the enema.
5. Review physician’s order for enema.

PURPOSES

1. To relieve constipation or fecal impaction

2. To prevent involuntary escape of fecal material during surgical procedures
3. To cleanse the bowel prior to surgery, childbirth or diagnostic examination
4. To promote visualization of the intestinal tract by radiographic or instrument
examination
5. To help establish regular bowel function during a bowel training program

EQUIPMENT

Disposable gloves
Water soluble lubricant
Waterproof, absorbent pads (or rubber draw sheet)
Bath blanket (or the top sheet will do if not available)
Toilet tissue
Bedpan, bedside commode, or access to toilet
Washbasin, washcloths, towel and soap
Intravenous pole
Enema bag administration
❖ Enema container
❖ Tubing and clamp (if not already attached to container)
❖ Appropriate size rectal tube
Adult: 22 to 30 Fr.
Child: 12 to 18 Fr.

Correct volume of warmed solution

❖ Adult: 750 to 1000 ml
❖ Child:
❖ Infant - 150 to 250 ml
❖ Toddler - 250 to 350 ml
❖ School Age child – 300 to 500 ml
❖ Adolescent – 500 to 750 ml

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 Packed Enema
❖ Prepackaged enema container with rectal tip

Types of ENEMAS:
1. Cleansing - to evacuate lower bowel before diagnostic studies or surgery
2. Retention – soften and lubricate stool for easy evacuation
3. Carminative (return flow) – relief of distention due to flatus
4. Medication – will depend on what medication is introduced

GENERAL CONSIDERATIONS

1. If client is suspected of having poor sphincter control, position on bedpan. Client will
have difficulty retaining enema solution.
2. When enema is ordered “until clear” observe contents of solution passed. Return is
“clear” when no solid fecal material exists, but solution may be colored.
3. Cleansing enema include tap water, normal saline, soapsuds solution and low-volume
hypertonic saline.
4. Infants and children should receive only normal saline because they are at risk for fluid
imbalance.
5. Caution should be used when administering large volume enemas because fluids and
electrolyte imbalance may occur

COMMONLY USED ENEMA SOLUTIONS

TIME TO
ADVERSE
SOLUTION AMOUNT ACTION TAKE
EFFECTS
EFFECT
 Tap water 500 – 1,000 ml. Distends intestines, 15 minutes Fluid and
(hypotonic) increases electrolyte
peristalsis, softens imbalance, water
stools intoxication
 Normal 500 – 1,000 ml. Distends intestine, 15 minutes Fluid and
saline increases electrolyte
(isotonic) peristalsis, softens imbalance,
stools sodium retention
 Soap 500 – 1,000 ml. Distends intestine, 10 – 15 Rectal mucosa
(concentrate at 3 irritates intestinal minutes irritation or
– 5 ml./1,000 ml.) mucosa, softens damage
stool
 Hypertonic 70 – 130 ml. Distends intestine, 5 – 10 Sodium retention
irritates intestinal minutes
mucosa
 Oil (mineral, 150 – 200 ml. Lubricates stool and 30 minutes
olive, or intestinal mucosa
cotton- seed
oil)

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 PROCEDURE
1. Collect appropriate equipment
2. Correctly identify client and explain procedure.
3. Assemble enema bag (can) with appropriate
solution and rectal tube.
4. Wash hands and use gloves.
5. Provide privacy by closing curtains around bed
or closing door.
6. Raise bed to appropriate working height for
nurse: raise side rail on opposite side.
RATIONALE
To save time, effort and energy
Information promotes client cooperation and
reduces anxiety.
Reduces transmission of microorganisms.
Reduces embarrassment for client.
Promotes good body mechanics and client
safety.

7. Place waterproof pad (rubber draw sheet) under Prevents soiling of linen.
hips and buttocks.
8. Assist client into left side lying (Sim’s) position Allows enema solution to flow downward by
with right knee flexed. Children may also be gravity along natural curve of sigmoid colon
placed in dorsal recumbent position. and rectum, thus improving retention of
solution.
9. Cover client with bath blanket, exposing only Provides warmth, reduces exposure of body
rectal area, clearly visualizing anus. parts and allows client to feel more relaxed
and comfortable.
10. Place bedpan or commode in easily accessible Used in case client is unable to retain enema
position. If client will be expelling contents in solution.
toilet, ensure that toilet is free. ( f client will be
getting up to bathroom to expel enema, place
client’s slippers and bathrobe in easily
accessible position).
10.1. Administering Enema Lubrication provides for smooth insertion of
A. Remove plastic cap from rectal tip. Tip is rectal tube without causing rectal irritation or
already lubricated, but more jelly can be trauma.
applied as needed.
Breathing out promotes relaxation of external
B. Gently separate buttocks and locate rectal sphincter.
rectum. Instruct client to relax by breathing
out slowly through mouth.
Gentle insertion prevents trauma to rectal
C. Insert tip of bottle gently into rectum. mucosa.
Adult: 7.5 to 10 cm (3 to 4 in.)
Child: 5 to 7.5 cm (2 to 3 in.)
Infant: 2.5 to 3.75 cm (1 – 1 ½ in.)
Hypertonic solutions require only small
D. Squeeze bottle until all of solution has volumes to stimulate defecation.
entered rectum and colon. Instruct client
to retain solution until the urge to defecate
occurs, usually 2 to 5 minutes.

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10.2 Enema Bag (Can)
A. Add warmed solution to enema bag (can).
Warm tap water as it flows from faucet.
Place saline container in basin of hot
water before adding saline to enema bag
(can). Check temperature of solution with
bath thermometer or by pouring small
amount of solution over inner wrist.
Enemas administered to adults are
usually given at 1050 - 1100 F (40.5-430C
and those with children are usually
administered at 1000 F (37.70 C)
B. Raise container, release clamp, and allow
solution to flow long enough to fill tubing.
(Prime Tubing)
C. Re-clamp tubing when primed.
D. Lubricate 6 to 8 cm (2 1/2 to 4 in.) of tip of
rectal tube with lubricating jelly.
E. Gently separate buttocks and locate anus.
Instruct client to relax by breathing out slowly
through mouth.
F. Insert tip of rectal tube slowly by pointing tip
in direction of client’s umbilicus. Length of
insertion varies:
Adult: 7.5 to 10 cm (3 to 4 in.)
Child: 5 to 7.5 cm (2 to 3 in.)
Infant: 2.5 to 3.75 cm (1 to 1 ½ in.)
G. Hold tubing in rectum constantly until end of
fluid instillation.
H. Open regulating clamp and allow solution to
enter slowly with container at client’s hip
level.
I. Raise height of enema container slowly to
appropriate level above anus:
High enema: 30 to 45 cm (12 to 18 in.)
Regular enema: 30 cm (12 in.)
Low Enema: 7.5 cm (3 in.)
J. Lower container or clamp tubing if client
complains of cramping or if fluid escapes
around rectal tube.
K. Clamp tubing after all solution is instilled.
L. Place layers of toilet tissue around tube at
anus and gently withdraws rectal tube.
M. Explain to client that feeling of distention is
normal. Ask client to retain solution as long
as possible while lying quietly in bed. (For
infant or young child, gently hold buttocks
together for a few minutes).
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Enemas work best when solution is warm.
Hot water can burn intestinal mucosa. Cold
water can cause abdominal cramping and is
difficult to retain.
Solution should be at least body temperature
to prevent cramping and discomfort
Removes air from tubing which could cause
intestinal distention and discomfort.
Prevents further loss of solution.
Allows smooth insertion of rectal tube without
risk of irritation or trauma to mucosa.
Breathing out promotes relaxation of external
anal sphincter.
Careful insertion prevents trauma to rectal
mucosa from accidental lodging of tube
against rectal wall. Insertion beyond proper
limit can cause bowel perforation. Insertion of
rectal tube toward the umbilicus guide tube
along rectum.
Bowel contraction can cause expulsion of
rectal tube.
Rapid instillation can stimulate evacuation of rectal
tube.
Allows for continuous, slow instillation of
solution. Raising container high causes rapid
instillation and possible painful distention of
colon. High pressure can cause rupture of
bowel in infant.
Temporary cessation of instillation prevents
cramping, which may prevent client from
retaining all fluid, altering effectiveness of
enema.
Prevent entrance of air into rectum.
Provides client’s comfort and cleanliness.
Solution distends bowel. Length or retention
varies with type of enema and client’s ability to
contract rectal sphincter. Longer retention
promotes more effective stimulation of
peristalsis and defection.
 N. Discard enema container and tubing in Reduces transmission and growth of
proper receptacle or rinse out thoroughly with microorganisms.
warm soap and water if container is to be
reused.
O. Assist client to bathroom or help to position Normal squatting position promotes
client on bedpan. defecation.
P. If the client is using the bathroom instruct Provides a record of results. Determine if
not to flush the toilet bowl when finished. stool is evacuated or fluid is retained and
Observe and inspect character and solution note for presence of blood or mucus.
passed. (Take note of color, consistency
and amount of stool/fluid)

Q. Assist client as needed to wash anal area Fecal contents can irritate skin. Hygiene
with warm soap and water (if nurse promotes client’s comfort.
administers perineal care, use gloves).

R. Remove and discard gloves. Wash hands. Reduces transmission of microorganisms.

S. Assess condition of abdomen, cramping, Determines if distention is relieved. Excess
rigidity, or distention can indicate a serious volume can distend or perforate the bowel.
problem.

EVALUATION

1. Increased comfort and relief from abdominal distention

2. Patient for diagnostic examination or surgery is prepared with clear return flow.
3. Relief from fecal impaction is obtained.

RECORDING AND REPORTING

 Record type and volume of enema given and characteristics of result.

 Report to physician failure of client to defecate.

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 OSTOMY CARE
DEFINITION

The management and support of a patient with a surgical opening created in an

ileum or colon for the temporary or permanent passage of feces. In most cases, the
opening is covered with a temporary disposable bag.

ASSESSMENT

1. Identify the type of ostomy the patient has and its location.
2. Assess frequency of defecation and character of stool.
3. Assess time when client normally irrigates.
4. Assess client understanding of procedure and ability to perform techniques.
5. Identify signs and symptoms associated with altered elimination patterns.
6. Determine impact of underlying illness, activity patterns and diagnostic test on
bowel elimination patterns.
7. Assess skin integrity around stoma, noting presence of scars, folds on
protuberance of skin.
8. Assess condition of the existing bag for leakage and not appearance with
underlying stoma and surgical incision.
9. Assess patient’s feeling about colostomy management.

OBJECTIVES

1. To establish regular bowel elimination

2. To keep the skin around the stoma site clean and dry
3. To be able to keep the patient free of odor as possible
4. To assist patient to become proficient in ostomy care
5. To determine client’s knowledge and understanding of ostomy
6. To develop client’s positive attitude toward living with an ostomy

GENERAL CONSIDERATIONS

Preparation before the procedure:

1. Explain procedure (if client is unfamiliar with technique) or allow client to organize
steps for pouch change. Be sure clients observe the procedure.

2. Select optimal time to change pouch (when client is comfortable between meals or
before administration of medications that may affect bowel function).

3. Collect appropriate equipment.

4. Close room curtain or doors. Provide privacy.

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 5. Many different types of pouches/appliances are available; the nurse should always
read manufacturer’s instructions or check with the enterostomal therapist before
handling unfamiliar equipment.

6. Flatus may cause a pouch to balloon out. This requires immediate attention
because if flatus is not released, the pouch may separate from the skin barrier,
causing seepage of fecal contents or release of fecal odor. Open the clamp and
release the flatus. Never puncture a hole in the pouch/appliance.

7. A one-piece appliance makes application easier for an older patient, particularly if

impaired vision or compromised mobility from arthritis is present.

TYPE OF OSTOMIES:

COLOSTOMY – a temporary or permanent opening of

the colon through the abdominal wall when it is
impossible for the feces to progress through
the colon and out the anus because of some
pathologic condition.

ILEOSTOMY – a surgical formation of an opening of the

ileum onto the surface of the abdomen, through
which fecal matter is emptied.

JEJUNOSTOMY – a surgical-created opening between

the jejunum of the small intestine and the
abdominal wall to allow fecal elimination.

TYPES OF COLOSTOMY:

A. TEMPORARY COLOSTOMY

❖ Often done for perforated or obstructed bowel caused by diversities,

vulvulus, ischemia, trauma
❖ Allow diseased portion of the bowel to rest and heal

B. PERMANENT COLOSTOMY

❖ Performed to provide means of elimination when rectum or anus is non-

functional as a result of disease or birth defects
❖ Commonly performed for disease such as cancer of the bowel

LOCATION OF THE VARIOUS COLOSTOMIES:

1. Sigmoid colostomy
2. Descending colostomy
3. Transverse colostomy
4. Ascending colostomy
5. Ileostomy

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EQUIPMENT

• Skin barrier (stomahesive, hollihesive, karaya paste)

• Ostomy bag
• Large syringe
• Mild soap or NSS
• Plastic bag
• Dry cotton balls
• Kidney basin
• Bath towel
• Rubber protector
• Warm water
• Forceps
• Disposable gloves

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PROCEDURE

STEPS RATIONALE
1. Explain procedure (if client is unfamiliar with Promotes cooperation and boost confidence
technique). Allow client to organize steps for in ability to perform procedure
pouch change. Be sure client observes
procedure.
2. Provides privacy
3. Place protective pad under the client’s hip on Protects bed from soiling
the side of the stoma.
4. Assist client to a semi-lateral position, with the Position the client and position the pouch
stoma and pouch position downward the bed downward so it will drain with gravity
surface.
5. Wash hands and wear gloves. Reduces transmission of infection
6. Fill large syringe (bulb or 50 cc) with warm Prepare for later use
water. Place in small basin next to the
bedside.
7. Remove the soiled pouch by gently pressing on Reduces trauma to the peristomal skin;
the skin while pulling the pouch. jerking can cause skin tears
8. Dispose the soiled pouch in the plastic bag and Avoid odors lingering the room which is
tie to seal odor. unpleasant to client or staff
9. Using forceps and cotton balls, wash skin Removes fecal material and pathogens and
gently with mild soap and water or with NSS to prepares the skin for pouch reapplication.
remove secretions from the skin. Secretion acts as irritant to skin. Bacteria in
fecal secretions can enter incision area/new
colostomy and cause infection.
10. Rinse soap off thoroughly. Blot dry. Use of any soap could result in film or
residue being left behind. This soap residue
can result in chemical reactions or burns and
can cause premature leakage because of
interference with pouch adhesions. Pat dry
gently to avoid trauma.
11. Inspect the peristomal skin for redness, altered Peristomal skin conditions cause morbidity
skin integrity or rashes; consult if lesions of the and problem with pouch application unless
peristomal skin are observed. managed properly.
12. Prepare ostomy pouch. Cut hole in center of Avoid risk cut of stoma and ensures better
faceplate 1/8 inch larger than hole in barrier. seal with barrier
13. Apply skin sealant or skin paste if indicated. Promotes an effective seal and protects the
Apply skin barrier. peristomal skin
14. Remove paper backing from pouch faceplate Reduces risk of wrinkling that can occur if
and apply gently. water is applied to skin before pouch is
attached; gives better leak-proof seal.
15. Press into place for 1 – 3 minutes while Creates wrinkle-free secure seal onto skin
smoothing out creases or wrinkles.
16. Removes gloves and discard. Wash hands. Reduces risk of transfer of microorganisms
17. Assist client to comfortable position if Ensure client comfort
necessary.
18. Dispose of used equipment according to Proper disposal of equipment prevent
agency policy. contamination from microorganism

284
 19. Note type and size of pouch, condition of Document client status and condition of
stoma, drainage amount, odor and stoma
surrounding skin, as well as client response.

EVALUATION

1. Demonstrate knowledge and positive attitude towards colostomy care.

2. Colon empty of its contents such as feces, gas and mucus.
3. Patient is free from odor.
4. Demonstrate pouch changing and healthy skin around stoma.
5. Client copes with changed body image, manages care of stoma.

285