You are on page 1of 28

Additional Nursing

procedures
ADMISSION PROCEDUES

Whether routine or emergency admission, make


him comfortable, introduce him to his
roommates & staff; orient him to the
surroundings & routine activities. (hospital rules)
• On admitting children
Speak directly to the child and
allow him to answer before obtaining
more information from the parents.

Tell patient not to take any medication


from home unless ordered by the
doctor.
AIRWAY OBSTRUCTION
Sudden airway obstruction may occur due to
foreign body, mucus or vomitus, when the
tongue blocks the pharynx, trauma,
bronchospasm or bronchoconstriction.
Perform HEIMLICH MANEUVER – an upper-
abdominal thrust to create diaphragmatic
pressure. Used only on conscious adults
For unconscious patients use abdominal thrust.
For obese and pregnant women or had abdominal
surgery, a chest thrust should be used.
• If a patient is unconscious, grasp the tongue
and lower jaw with your thumb and fingers, lift
the jaw to draw the tongue away from the back
of the throat and away from any foreign body.
• If you can see the object, insert your indx
finger into the throat using a hooking motion,
remove the object.
• Ventilate the patient. Do CPR if necessary
PROGRESSIVE
AMBULATION
• When the patient has adjusted to the upright position
after dangling, prepare him to stand.
• Put on his robe, hard slippers or shoes.
• If alert, allow him to stand by himself. Place one hand
under his axilla and one around his waist.
• Encourage him to look forward and not the floor to
maintain balance.
• If a patient needs help position your knees at either side
of his.
• If he can walk safely with assistance , stand beside him
with one hand under his axilla and one around his waist.
• In case of falling protect his head from injury, let him slide
down to the floor.
BACK CARE
• Particularly important for bedridden patients.
• Purpose is to cause cutaneous vasodilation and help
prevent ulcers.
• A gentle massage can be performed after myocardial
infection.
• Put patient on prone position along the side of the
bed nearest you to prevent back strain.
• Expose back and buttocks, minimize exposure with
the use of drape & prevent chills.
• Form a mitt, and lather the back.
• Rinse and dry well, because moisture trapped
between the buttocks can cause chafing and lead to
pressure ulcer.
• Back massage gives the best opportunity to
inspect the skin condition especially the
bony prominences
• Apply lotion on your hand and rub them
together, then apply long firm strokes.
• Lotion reduces friction, and makes the
massage easier.
• Begin from the base moving toward the
shoulder.
• Squeeze the trapezius to help relax the
patient.
• Finish by removing excess lotion, and
replace patient’s gown.
• Use separate lotion for each patient to avoid
contamination. Avoid lotion and powder
together to avoid skin maceration.
• Don’t massage the legs because you might
dislodge a clot.
Bandage, Elastic
• Used to minimize joint swelling after trauma,
immobilize fracture, anchor dressing or as
substitute to antiembolism stockings.
• Check doctor’s order.
• Elevate the extremity for 15 min. before
application to facilitate venous return.
• Do not allow two skin surfaces remain in
contact when wrapped.
• Do not unroll the whole bandage.
• Use figure of eight for the foot.
• Never wrap toes and fingers together
unless absolutely necessary to detect
impaired circulation.
• Check distal circulation regularly
because elastic bandage may tighten
as you apply it.
BED BATH
• Sequence
• Special considerations
• Basin should be filled 2/3 full
BATH, SITZ
• Immersion of the pelvic area in warm
or hot water.
• This promotes wound healing, by
increasing circulation, and reducing
inflammation.
BATH, THERAPEUTIC
• Additives may be oatmeal powder, soluble
cornstarch, or soybean complex.
• Purpose is to soften crusts, scales, & debris,
relieve inflammation, and relieve itching.
• Sodium bicarbonate added to the water
produces an alkaline bath that cools and
help relieve pruritus.
• A medicated tar bath leaves a film of
tar on the skin and works well in
combination with ultraviolet light to
prevent rapid cell turnover
characteristics of psoriasis.
• Duration 15 min.

• Tepid bath.
USE OF BEDPAN OR
URINAL
• Warm under running water.
• Serve tissue paper, and sponge towel
after its use.
BINDERS
Types
1. Straight
2. Scultetus
3. T binder
4. Breast binder
They are also called self-closure; purpose is to
provide support, secure dressing, reduce
tension on suture lines and reduce breast
engorgement.
Wrap binder so it applies even pressure.
BREAST PUMP USE
• It creates a suction to stimulate
lactation.
• Milk may be stored in sterile feeding
bottles,
• Have the mother pump her breast
every 2-3 hrs.around the clock.
BURNS, BIOLOGICAL
DRESSING
• Biological dressing provide temporary covering
for burn wounds and clean granulation tissue.
• Organic materials as:
pigskin
cadaver skin
amniotic membrane
Synthetic material as Biobrane may be applied by
the nurse.
• Gastric tube insertion
• Gastric feeding
• Gastric lavage – for patients with gastric
bleeding, solution may be iced water or
normal saline solution.
Instill 250 ml. before allowing irrigant
to flow out. If a syringe is used instill 50
ml at a time until 250 is reached,
NGT INSERTION
• Special considerations
PAIN MANAGEMENT
• Cognitive therapy
1.Distraction – let patient recall a pleasant
experience or an enjoyable activity. Music may
also be used
2.guided imagery- help him concentrate on a
pleasant image, recalling details such as sight,
sound, smell taste, and touch.
3. Deep breathing – have him stare at an object,
then slowly inhale and exhale as he counts aloud
to maintain a comfortable rate & rhythm, have him
focus on the rise and fall of his abdomen, and to
feel more weightless with each breath.
• Muscle relaxation- have the patient tense a
particular muscle group and note the
sensation. After 5-7 seconds, tell him to relax
the muscles and concentrate on the relaxed
state. Have him note the difference between
the two states. Have him proceed to another
muscle group, and then another, until he has
covered his entire body.
• Document response.
PAP SMEAR
• Cytology
• Many factors can interfere with pap
test like menstruation, or use of
vaginal douche or instillation of
vaginal medication 48 hrs before
specimen collection.
PERINEAL CARE
• Downward stroke, front to back for
the anal area.
• For male clean shaft of penis from tip
down using a circular motion.
• Always pat dry.
POST MORTEM CARE
• Place tags on the body, shroud, and
patient’s belongings.
• Collect valuables and place in a bag.
Place towel under chin to prevent
mouth from opening, remove before
giving the body to the family.
STOOL COLLECTION
• Never refrigerate stool to confirm the
presence of ova and parasite.
T- tube care
• The T- tube is placed in the common bile duct
after cholecystectomy, facilitates biliary drainage
during healing.
• It stays for 7-14 days.
• Normally daily drainage ranges from 500 to 1000
ml. of viscous, green brown liquid.
• Report drainage that exceeds 500 ml in the first
24 hrs. after surgery.
• This amount declines to 200 ml or less in 4 days