ETT Suction

Purpose- to facilitate a patient airway

Indication- heart rate is going up
- Mucus secretion
- Patient feeling restlessness
Explain procedure to the To allay anxiety and to gain
patient. Good morning Mr. patient cooperates.
S, I am nurse Saadiya and I
am going to perform
endotracheal tube suction
since there is presence of
abnormal lung sound (due
to mucus). This is done to
clear your airway. Is it okay
with you
Gather equipment Ambu bag- attach to
oxygen, suction machine-
set it to 70 to 150mmHg,
Yankeur suction, trolley,
sterile dressing
Wash hand and dry. Don To minimize
sterile gloves microorganism.
Attach suction catheter to Check potency of suction
tubing from machine. Soak catheter. Assistant hyper
the tip of catheter in normal oxygenate the patient (5
saline to lubricate times)
Insert and kink the catheter To avoid trauma to airway
while pushing it down to
pharynx till resistance is
met, release and suction in
circular motion while
withdrawing catheter
Discard suction catheter, To remove secretion, use
suction the nose Yankeur suction to remove
secretion from mouth
Assistant: to hyper To patient does not
oxygenate become hypoxic and
correct patient back to the
ventilator
Terminate the procedure
Reassess respiratory status No longer is restlessness,
heart rate normalize, no
sign of mucus secretion.
Thanks client for his
cooperate
Discard my equipment and To prevent microorganisms
wash hand
Document relevant To ensure that care is
information documented for good
clinical communication

Chest pain assessment

Indication- to determine if chest pain is cardiac in nature
Gather equipment Oxygen saturation,
sphygmomanometer,
Evidence of therapeutic Clear explanation to
communication patient
I will begin by checking
patient vitals
Onset When did it first occur?
Provocative/ palliative What bring it on? What
were you doing when you
first noticed it? What make
it better? Worse?
Quality or quantity How does it feel like? Is it
sharp, dull, crushing?
Region or radiation Where is it? Can you point
it? Does it spread
anywhere?
Severity How bad is it ( on scale of
1 to 10)
Timing Does the pain come and
go. Duration- how long
does it last? Frequency-
how often does it occur?
Thanks client for his
cooperation
Discard my equipment and To prevent
wash hand microorganisms
Document relevant To ensure care is
Information documented for good
clinical communication.

Abdominal palpation
Purpose- assess fetal size and growth, auscultate fetal
heart rate. Locate fetal part to indicate position and
presentation.
Perform hand hygiene.
Ensure hand is dry and
warm
Introduce yourself to client
and give clear explanation
of procedure
Provide privacy. Ensure
bladder is empty
Ensure client is in supine
position
Expose abdomen
adequately to symphysis
pubic
Visual inspection
A.Note abdominal size
B.Observe abdominal
shape
C. Inspect abdomen
Reduce maternal
discomfort and risk for
causing contraction of
uterine muscle
Promote understanding and
allay anxiety
Full bladder can reduce the
accuracy of fungal height
measurement
To aid in relaxation of
abdominal muscle
The women modesty and
privacy is respected
A full bladder, distended
colon may affect estimation
of fetal size
If is longer indicate
longitudinal lie however,
shape is low and broad
may point to transverse lie.
Primigravid uterus is ovoid
in shape compared to multi
gravid uterus which is
rounded shape.
Scar indicate previous
 for scar
D. Examine skin
Ask client for fetal
movement
Palpation- Leopold
maneuver
1st maneuver (fetal grip)-
face toward client, place
hand on each side of
fundus
2nd maneuver (lateral grip)-
face toward client, place
one hand on umbilicus and
palpate with the other and
vice versa
3rd maneuver (Pawlik’s
grip)- place palm above
symphysis pubis to grasp
lower pole of uterus and
make gentle movement
side to side
4th maneuver (deep pelvic
grip)- face client feet- place flexion of fetal head. To
both hand pointing inward
and downward
Ensure proper
documentation of finding on
abdominal surgery
Pregnancy can cause striae
gravidarum more common
in younger women
Determine fetal wellbeing
It determine of presentation
whether Cephalic or
breech. It also diagnosis
the lie and presentation of
fetus
To determine fetal position
that aid in locating and
assaulting fetal heart
 Auscultate fetal heart
rate for one minute and
record in women
medical folder
To determine the descent
of presenting part
(engagement)
To determine the degree of
determine attitude.
folder

Assist in feeding a child

Purpose- to assist child to obtain nourishment and fluid
Equipment- a meal tray with correct food and fluids
- An extra napkin or small towel to protect
child`s cloth and bedlinen.
- A straw, special drinking cup
Identify child and assess the To provide better care
child’s ability to eat and
swallow
Explain procedure if To allay anxiety and feat
condition and age allows
Wash hands, provide child Shallow bowl to help
size utensil young children scoop up
food easily
Consider food temperature Not that too cold or too hot
Assist child in sitting position Help to swallow food
easily
Assist child to identify food Make meal time pleasant
on tray
Encourage child to eat Enhances independence
independently assisting
where needed
Ensure hot drink is not It may scald the client
offered when hot
Allow ample time for child to To feel fuller and satisfied
chew and swallow food
Provide child with fluids as
requested if not use straw
After meal, assist child to
clean his hand and mouth
Record amount of fluid
taken
Record significant
assessment such as amount
of food intake if calories
count needed
To avoid risk of chocking
Enhances personal
cleanliness and hygiene
To assess body’s fluid
balance
Record progress of care.

Assisting in feeding an adult

Purpose- to assist client to obtain nourishment and fluid
Equipment- a meal tray with correct food and fluids
- An extra napkin or small towel to protect
clients clothes and bedlinen
- A straw, special drinking cup

Identify client and assess To provide better care

the client ability to eat and
swallow
Explain procedure if To allay anxiety and feat
condition and age allows
Wash hands, provide client Shallow bowl to help
size utensil young children scoop up
food easily
Consider food temperature Not that too cold or too
hot
Assist client in sitting Help to swallow food
position easily
Assist client to identify food Make meal time pleasant
on tray
Encourage client to eat Enhances independence
independently assisting
where needed
Ensure hot drink is not It may scald the client
offered when hot
Allow ample time for client to To feel fuller and satisfied
chew and swallow food
Provide client with fluids as To avoid risk of chocking
requested if not use straw
After meal, assist client to Enhances personal
clean his hand and mouth cleanliness and hygiene
Record amount of fluid taken To assess body’s fluid
balance
Record significant Record progress of care.
assessment such as amount
of food intake if calories
count needed

Cord care
Explain procedure to To allay anxiety and fear
parents
Wash hand and wear To prevent cross infection
sterile gloves
Demonstrate to mother how To provide knowledge and
to treat Cord skills to mother
 o Expose Cord
o Hold Cord upright
position
o For fresh Cord, swab To visualize Cord well
from top to base
o Swab base of Cord
with chlorohexidine
0.5% in SVM 70%
o Use new swab to clean
stem of Cord from
stump upwards
Prevent infection
Use dry swab to clear To provide comfort and
excessive solution prevent skin irritation
Wash hands and terminate To prevent cross Infection
procedure
Document care carried out Provide information on
progress of care

Assist in tube feeding

Purpose- to assist child or adult to obtain nourishment
and fluid
Equipment- kidney dish with 30 or 50ml syringe with
cover
Greet client and explain To allay anxiety and fear
procedure
Gather equipment: It’s within the reach
o 50, 30ml syringe
 o Kidney dish with
Cover
o Ordered fluid in
closed container
o Gauze
o Measuring jug
Wash hand and dry Minimize spread of
thoroughly microorganism
Position semi fowler To reduce risk of aspiration
Flush feeding tube with Prevent drug nutrient
water before interaction
administration
Measure fluid as order
Attach feeding syringe and
gently pour fluid Into
syringe
Let fluid flow freely To promote comfort
Flush with water to declog Prevent blocking of feeding
feeding tube tube
Document care carried out Monitor progress of care

Oral temperature
Equipment- oral temperature
-Cotton swab to wipe thermometer
- Temperature chart
- Pen to record temperature
Explain procedure to client To allay anxiety and fear
Remove thermometer from
container and wipe from
bulb end to finger In a
rotating direction. Discard
cotton swap
Start thermometer and
bring it to 0’c
Ask client to open his or her
mouth, place thermometer
at base of tongue
Ask client to close lip not
teeth around thermometer
Leave thermometer for 3
minutes
Remove thermometer and
record reading
Wipe using cotton swap,
starting at end held by you
and wipe rotating manner
toward the bulb.
Rectum temperature
Explain procedure to client
Remove thermometer and
wipe from bulb end to finger
in rotating manner. Discard
cotton swap
Start thermometer and
bring it to 0’c
Provide privacy
Wipe from dirtiest to
cleanliness to disinfectant
To get accurate reading
Reflect core temperature in
larger blood vessel of
posterior pocket
To prevent biting on
thermometer
Sufficient time for
thermometer to beep
To get accurate reading
Wiped from area of least
contaminated to most
contaminate.
To allay anxiety and fear
To disinfect it
To get accurate reading
To avoid embarrassment
Assist patient in lateral or Easy visualization of
prone position rectum
Place lubricant on To lubricant facilitates
thermometer. For an adult, insertion.
lubricate 2.5 to 4cm (1 to
1.5 inch). For an infant,
lubricate 1.5 to 2.5cm (0.5
to 1 inch)
Ask client to take deep Take deep breath relaxes
breath, and insert external sphincter muscle
thermometer into anus. thus easing insertion
(1.5cm for an infant, 4cm
for an adult).
Hold thermometer in place To get accurate reading
for 1 minutes
Remove thermometer and To get accurate reading.
record reading
Wipe using cotton swap, Wipe from least
starting at end held by you contaminated to most
and wipe in rotating manner contaminate.
toward bulb

Complex Wound Packing

Wipe dressing trolley with To prevent spread of
antiseptic solution microorganism
Gather equipment and set To ease out procedure
up trolley
- Dressing tray,
soiled
container
 - Clean and
sterile glove,
50cc syringe,
normal saline
- Sterile scissor
- Sterile
dressing pad,
gauze packs
plaster
Give clear explanation to Help patient understanding
patient on procedure and relieve
anxiety
Position patient comfortably To achieve access to
wound and soothe pain
Wheel trolley to bedside Provide privacy increase
and screen curtains patients trust and reduce
embarrassment
Wear gown and put on To prevent introduction of
gloves infection to wound
Remove solid dressing: To evaluate wound status
Noted soiled pack to
determine amount of
packing and dressing used
and done. If pack is dry and
cannot be removed, then
moist pack and remove
slowly. Assess color, odour
consistency and dispose
into waterproof bag
Wash hand with soap and Reduce transmission of
water and dry well. microorganism
Establish sterile field:
-Put on sterile gloves
-Open sterile dressing tray
and pour prescribed
solution into Gallipots
-Wet Gauze and squeeze
out excess so packing is
damp
Clean wound: -swab wound once only
-Using forceps swab and working from wound
irrigate wound. outwards
-Use separate swab for -Prevent contaminating
cleansing stroke from least previously cleaned area
contaminated
- Assess wound to monitor -Reduces excess moisture.
healing and condition of
surrounding skin
-Dry wound using same
techniques
Pack wound: This will expand with
-Dip Gauze into normal exudates or discharges
saline, squeeze then insert
into base of wound using
less than required amount
to fill cavity
- Use forceps to push
gently into base of cavity
Apply dry dressing: -To ensure optimal
-Aseptic technique apply absorption
dressing in layer
-Dry Gauze than dressing
pad and if more drainage, a
thicker pad is applied
-more padding at lower end
Remove gloves and
discard, secure dressing
with plaster
-Tape strip are applied at
end of dressing
-Tape strip are spaced
evenly in middle of dressing
-Tape is extended 5 to 8cm
beyond edge of dressing.
Unscreen curtain, return
dressing trolley to dressing
room and terminate
procedure
Wash hand
Documentation
-This is absorb extra
drainage brought by gravity
-Support wound and ensure
placement and stability of
dressing.
-Dressing cannot be folded
back to expose wound
- Dressing does not gape
-This will secure adheres to
skin
Ready for next use
Reduce spreading of
microorganism
Provide progress of care
and implementation of care
plan.

Administration of oral medication

Purpose: to administer safe and accurate therapeutic
medication
Equipment- medication trolley
- Medication cups
- Medication chart
- Hand towel
 - Jug of water
- Bowl of water
Wash and dry hand To minimize risk of cross
infection
Set up drug trolley To check that medication is
required
Before administering: To protect the client from
-drug harm
-dose
-time and date of
administration
-route and method of
administration
-diluent as appropriate
-validity of prescription
-signature of doctor
- the prescription is legible
Select required medication Expiry date is dangerous
and check expiry date
Measure dose and check To avoid medication error
label with medication
ordered
Recheck medication with To avoid medication error
another nurse and check
identity of client
Administer medication To treat patient condition.
Offer a glass of water To facilitate in swallowing
Record drug and dose Reduce medication error
given in medication chart
Rinse medication cup and Maintain cleanliness and
dry utensil and replace minimize transfer of
trolley microorganism
Return trolley to usual To terminate procedure
place
Document Evidence of care carried
out

Administration of topical medication

Purpose- to apply on skin to achieve maximum
therapeutic effects on the client.
Equipment- drug chart
- Ointment/ lotion
- Disposable gloves
- Sterile swab
Explain procedure to client
Check client folder and
drug chart
Assist in required position
Use Aseptic technique if
skin is broken
Wearing sterile glove if
medication is to be rubbed
into skin
If preparation cause
staining, advise client.
Remove used equipment,
wash hand and record
administration in notes
To allay anxiety and fear
Ensure giving of correct
drug and dose
To prevent cross infection
To prevent local infection
Minimize risk of cross
infection
Adequate precaution are
taken and prevent
unwanted stains
Terminate procedure
-To maintain accurate
records
Client need to be monitored Confirms effective
to make sure medication treatment.
has desired effect

Administration of ear medication

Purpose- to instill medication in client ear to achieve
maximum therapeutic effects.
Equipment- medication bottle with dropper
- Disposable gloves
- Facial tissue
- Ear buds
Confirm patient identity and To avoid wrong
physician order administering of medication
Explain procedure to the To ensure privacy
client
Consult patient To ensure correct
prescription: medication given
-drug
-dose
-time and date of
administration
-validity of prescription
-signature of doctor
Ask client to lie on side with Ensure best position for
ear to be treated uppermost insertion of drops
Pull back cartilaginous part Prepare auditory meatus
of pinna backward and for installation of drops
upward
Allows drop to fall in
direction of external canal
Advise client to remain in
side lying position for 1-2
minutes
Terminate procedure and
wash hands
Sign medication chart and
document
To ensure medication
reaches the area requiring
therapy
Allow medication to reach
eardrum and be absorbed
Minimizes cross infection
Maintain accurate record.

Administration of oxygen therapy

Purpose- to administer sufficient oxygen to maintain
tissue oxygenation at functional level.
Equipment- oxygen flow meter
- Access to oxygen wall outlet
- Oxygen tubing/ masks
- Humidifier if needed
- Sterile/ distil water for humidifier
- Pulse oximeter
Wash hand with soap and Reduce transmission of
water and dry well microorganism
Attach oxygen mask to Humidification help prevent
oxygen tubing to flow meter drying of nasal
Adjust oxygen flow rate to To determine appropriate
prescribed dosage oxygen level
Apply oxygen delivery To allow direct flow of
device and adjust elastic oxygen into patient’s
headband until it fits respiratory tract
comfortably
Observe for proper function To secure device
of oxygen delivery: comfortably in place
-nasal cannula
- simple face mask
- partial rebreather
-non-rebreather
-venture mask

Assess flow meter and To enhance safe and

oxygen source proper set
up:
-oxygen is highly flammable
Monitor change in oxygen
flow rate with pulse
oximetry
Wash hand with soap and
water
Evaluation:
-improved level of
consciousness
- deceased fatigue
- normal blood pressure
-absence of dizziness
Monitor pulse oximetry for
oxygen saturation
Assess adequacy of
oxygen flow
Observe client nasal
effective oxygen flow
Maintain oxygen saturation
and pulse rate
Reduce transmission of
microorganism.
Provide assessment of
effectiveness of
intervention
Document clients level of
oxygenation
Ensure patency of oxygen
device
Oxygen therapy can cause
mucous membrane
Unexpected outcome:
-skin breakdown
-irritation
-drying of nasal mucosa
-sinus pain
Documentation and
reporting:
-Record respiratory
assessment finding
-method of delivery
-flow rate
-clients response
drying of nasal mucous and
skin breakdown
Uncorrected hypoxia can
result in unconsciousness,
death and cardiac
arrhythmia.
Document clients response
to therapy and oxygen
delivery method.

Inhalation medication using small volume nebulizer

Purpose- to provide a rapid intervention of medication
through aero-solized form
Equipment- medication ordered
- Diluent (sterile water/ normal saline)
- Nebulizer machine, ventolin cup, mask and
tubing
- Syringes
- Stethoscope
- Medication chart
Explain procedure to client To alleviate anxiety
Verify medication order on To avoid wrong
client medication chart administering of medication
Take equipment to bedside, To save time, minimize
wash hand and screen bed cross infection and provide
privacy
Add prescribed medication To ensure proper dose and
delivery of Ordered
medication
Have client hold facemask To allow correct delivery of
firmly against face medication
Semi fowler position To ensure clients comfort
Switch on nebulizer Verifies equipment is
machine working properly
Advice client to take deep Maximizes effectiveness of
breath slowly and exhale medication
passively.
When medication is Ensure machine in good
completely nebulizer, turn working order
off machine and remove
facemask from client
Assess clients pulse, To evaluate effectiveness
respiratory rate and breath of procedure
sound
Document activity Client progress of care
Cleaning of nebulizer: Ensures disinfection of
-remove tubing and mask equipment
-soak in 1% chlorine(Milton)
solution for 20 minutes
-rinse off with distilled water

-Ready for next use.

 Rectal medication
Purpose- to administer medication into client`s system
- To relieve constipation and alleviate
abdominal distention
Equipment – rectal suppository
- Lubricating jelly
- Disposable gloves
- Tissue
- Bedpan and cover
- Draw sheet
Explain procedure to client. Client understand
If administering procedure and maintain
suppository, it is best to do valid consent
after client had emptied
his/her bowels
Take equipment to bed side To provide privacy
and screen bed
Wash hands and put on Reduce transmission of
gloves microorganism
Position client laterally Place client for good
exposure for anal opening
Place tissue under buttocks To protect bed linen
Remove suppository from Decrease chance of tearing
wrapper and lubricate tip rectal membranes
with gel
Gently spread buttock with Expose anal opening
non dominant hand and -suppository is likely to
insert suppository blunt end retained if blunt end is
first, advancing it for about inserted first
2-4cm
Instruct client to take deep Relaxes sphincter muscle
breath through mouth facilitating insertion
-wipe excess lubricant
away from skin and release -promotes clients comfort
buttocks
Instruct client to squeeze It allow suppository to melt
buttock together for 3-4 and release active
minutes and to retain ingredients
suppository for at least 20
minutes
Cover client with bed sheet To ensure clients comfort
and Unscreen bed
Terminate procedure and Reduce risk of infection
wash hands
Record insertion of To record progress of care
suppository and its effect
on integrated notes
Observe client for any To monitor for any
adverse reactions and complication
report immediately

Electrocardiogram (ECG)
Purpose- to determine baseline of cardiac function, to
determine electrical conduction of heart and to detect any
abnormality.
Equipment- ECG machine, chest and limb electrode,
ECG gel, ECG paper, tissue or towel, 1 draw sheet, razor
 Removal of suture from wound
Purpose- to remove non absorbable sutures from the
wound.
Objective- to promote wound healing
- Eliminate risk of any skin separation and
infection
Equipment- sterile dressing tray, sterile glove, cleaning
solution- normal saline, dressing pads, gauze, scissor,
tape.
 Blood transfusion

Insulin administration
 Nasogastric tube insertion
Indication- gavage- feeding, lavage- removal of stomach
content, decompression- removal of stomach
 Female urinary catheterization
Indication- urinary obstruction, surgery purpose