FUNDAMENTALS OF NURSING (PROCEDURES)

Carielle Joy V. Rio, R.N., M.A.N.

INFECTION CONTROL
Types of infection:
Exogenous infection
Endogenous infection
Modes of transmission:
Contact
o Direct
o Indirect
Droplet
Airborne
Vehicle
Vector
Stages of infectious process:
Incubation
Prodromal period
Illness stage
Convalescence
Types of immunity:
Active
o Natural
o Artificial

Passive
o Natural
o Artificial

Specific vs. Non-specific defenses:

Specific defenses:
o Antibody mediated
o Cell mediated

Non-specific defense:
o Skin
o Gastric acid
o Inflammatory response

Stages of the inflammatory response:

1st stage- vascular and cellular responses
2nd stage- exudate production

3rd stage- reparative phase

Standard Precautions- designed for all clients in the hospital
- assume that every person is potentially infected
- utilize gloves when there is a potential contact with blood, all body fluids,
secretions, & excretions except sweat, non-intact skin; and mucus membranes and
use mask, eye protection, clean gown
Transmission Based Precautions:
Airborne precaution
- private room with negative pressure
- N 95 respirator
- limit movements outside the room to essential purposes
Droplet Precaution
- private room
- mask w/ in 3 feet
- limit movements outside the room to essential purposes
Contact precaution

Donning and removal of personal protective equipments:

Donning
1. Gown
2. Face mask
3. Eyewear
4. Gloves

Removal
1. Gloves
2. Eyewear
3. Gown
4. Mask

PHYSICAL ASSESSMENT
Components of nursing assessment:
1. Health history
2. Physical assessment
- complete assessment
- assessment of body system
- assessment of body parts
Health History:
- biographic data
- chief complaint
- history of present illness
- past history
- family history of illness
- review of systems
- lifestyle
- social data
- psychologic data
Positions during assessment:
- sitting
- lithotomy
- knee chest

- Sims
- prone
Methods of Examining:
Inspection
Palpation
- deep
- light
Percussion
- direct
- indirect
Auscultation
Assessment of vital signs:
Body temperature:
Core temperature
Surface temperature
Variation in body temperature by age:
Newborn
36.1-37.7
1 year
37.7
2 years
37.2
5 years
37.0
Adult
36.4 (axillary)/
37.8 (rectal)
Duration of measurement:
Oral (2-3 minutes)
Axillary (5-9 minutes)
Rectal (2 minutes)
Conversion:
C = 5/9 x (F-32)
F = 9/5 x C + 32
Alterations in body temperature:
Hyperthermia/ Pyrexia
- intermittent
- remittent
- relapsing
- constant
Hypothermia
Pulse
Sites:
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Dosalis pedis

6. Radial
7. Femoral
8. Popliteal
9. Posterior tibial

Assessing the pulses:

Pulse rate
Newborn- 1 month
1 year
2 years
6 years
Adult

80 180
80 140
80 130
75 120
60 100

Pulse rhythm
Pulse volume
0 - Absent
1 - Thready
2 - Normal
3 - Bounding
Assessing the respiration:
Rate
Variations in respiratory rate by age:
Newborn
1 year
2 years
8 years
Adult

30 80
20 40
20 30
15 25
12 20

Depth
Deep
Shallow
Volume
Hyperventilation
Hypoventilation
Rhythm
Ease
Quality
Assessing the blood pressure:
Variations in blood pressure by age:
Newborn
1 year
6 years
10 years
14 years
Adult

73/ 55
90/ 55
95/ 57
102/ 62
120/ 80
120/ 80

When not to use an arm?

Injury in the arms, shoulders or hand
Cast or bulky bandage
Breast or axilla surgery
IV infusion or BT running
AV Fistula

Errors in blood pressure reading:

Too high:
Narrow cuff
Unsupported arms
Immediately after meal
Insufficient rest
Repeating immediately
Unevenly wrapped
Too low:
Wide cuff
Arm above the heart
Physical assessment:
Skin

color
abnormal findings:

edema
temperature
turgor
lesions
abnormal findings:

moisture
abnormal findings:

cyanosis
palor
jaundice
erythema
hyperpigmentation

macule
patch
papule
plaque
nodule
tumor
vesicles
bulla
pustule
wheal
telangiectacia
petechiae
hyperhydrosis
bromhidrosis
anhydrosis

Hair

distribution, thickness, texture, infection, infestation, body hair

color, curve, grooves, blanch test

abnormalities: koilonychia
paronychia
clubbing

Nails

Neck

neck muscles
head movement and muscle strength
lymph nodes
abnormal findings: palpable and tender
palpable and non-tender
trachea
abnormal finding: deviated trachea
thyroid gland
abnormal finding: enlarged thyroid

Chest

shape
abnormal findings: barrel chest
pigeon chest
funnel chest
symmetry
spinal alignment
abnormal findings: scoliosis
lordosis
kyphosis
thoracic expansion
tactile fremitus
abnormal findings: increased tactile fremitus
decreased tactile fremitus
breath sounds
normal breath sounds: bronchial
bronchovesicular
vesicular
abnormal findings: stridor
wheezing
crackles
gurgles
bubbling
pleural friction rub

Head:

inspect skull for size

abnormal findings: macrocephaly
microcephaly
shape and symmetry
palpate skull for nodules, masses or depressions
inspect the facial features
inspect eyes for edema
inspect the eyes for hollowness
note symmetry of facial movements

inspect the external eye structures

inspect the eyelids for surface characteristics, ability to blink and frequency of blinking
inspect the conjunctiva
palpate the nasolacrimal duct, lacrimal sac and gland

Eyes:

perform cornea sensitivity test

assess for PERRLA
assess the extraocular muscles
assess visual acuity

inspect the auricles for color, symmetry, and position

inspect the inner ear
palpate the auricles for texture, elasticity, and tenderness
assess gross hearing acuity
whisper test
watch-tick test
Webers test
Normal finding: no lateralization of sound
Conductive hearing loss: lateralization on the affected ear.
Sensorineural hearing loss: lateralization on the unaffected ear.
Rinnes test
Normal finding: air conduction 3x longer than bone conduction
Conductive hearing loss: bone conduction is equal or longer than air conduction.

Ears:

Nose and Sinuses:

inspect the external nose for:
shape and size
color
flaring
discharges
lightly palpate the external nose to determine any areas of:
tenderness
masses
displacement of bones
inspect the nasal cavity
palpate the frontal and maxillary sinuses
transilluminate the frontal sinus
transilluminate the maxillary sinus
Lips and Buccal Mucosa
inspect lips for:
symmetry of contour
color
texture
inspect and palpate the inner lips and buccal mucosa for:
color
moisture
texture
lesions
Teeth and Gums
inspect the teeth and gums while examining the buccal mucosa
inspect the dentures
Tongue and Floor of Mouth
inspect the surface for:
position
color
texture
inspect tongue movement
inspect the tongue, mouth floor, and frenulum
palpate the tongue and floor of mouth for any nodules, lumps, or excoriated areas

Palates and Uvula

inspect the hard and soft palate for:
color
shape
texture
presence of bony prominence
inspect the uvula for position and mobility
Oropharynx and Tonsils
inspect the oropharynx for color and texture
inspect the tonsils for color, discharges, and size
elicit a gag reflex
Grading System for Tonsil Size:
1
Normal
2
Between the pillars and the uvula
3
Touches the uvula
4
One or both tonsils extend to the midline
Neurologic System
Mental status exam:
Language (aphasia)
sensory
motor
mixed
Orientation
time
place
person
Memory
immediate recall
recent
remote
Attention span and calculation
Level of Consciousness:
Glasgow Coma Scale
Eyes

Spontaneously
To speech
To pain
No response

4
3
2
1

Verbal response

Oriented
Confused
Inappropriate words
Incomprehensible sounds
No response

5
4
3
2
1

Motor response
Obeys command
Localizes pain
Withdraws from pain
Flexion
Extension
Flaccid

6
5
4
3
2
1

Level of Consciousness:
Conscious
Lethargic
Stuporous
Semi-comatose
Comatose
Reflexes

biceps (C- 5 & 6)

triceps (C- 7 & 8)
brachioradialis (C- 3 & 6)
patellar (L- 2, 3 & 4)
Achilles (S- 1 & 2)
plantar

Grading reflex response:

0
no reflex
1
minimal activity
2
normal
3
more than normal
4
hyperactive
Motor Functions
gross motor balance
standing in one foot with eyes closed
heel-to-toe walking
toe or heel walking
finger-to-nose test
alternating supination and pronation of hands on knees
finger to nose- to nurses finger
fingers-to-fingers
fingers to thumb
heel down opposite shin
Sensory Function:
light touch sensation
pain sensation
temperature sensation
position or kinesthetic sensation
tactile discrimination
stereognosis
Musculoskeletal System:
Bones
structure
deformities
tenderness
Muscle
muscle size

contractures
abnormal movements
muscle tone
smoothness of movement
muscle strength

Joints
swelling
movement
crepitations
nodules

Cardiovascular System:
Heart- inspect, palpate and auscultate the precordium

Right 2nd intercostal space- aortic area

Left 2nd intercostal space- pulmonic area
Left 5th intercostal space- tricuspid or right ventricular area
Left 5th intercostal space (midclavicular line)- mitral area

Peripheral Vascular System:

palpate the peripheral pulses
auscultate the carotid arteries
inspect the jugular vein
abnormal findings: flat
distended
inspect the peripheral veins
assess peripheral perfusion
capillary refill test
Allens test
Breast and Axilla:
inspect size, symmetry, contour and shape
inspect skin color, retractions, dimpling, swelling or edema
accentuate any retractions
inspect areola for size, shape, symmetry, color, any masses or lesions
inspect the nipples for size, shape, position, color, discharges, lesions
palpate the axillary, subclavicular, supraclavicular lymph nodes
palpate the breast and nipples
Abdomen:
inspect for skin integrity, contour, and symmetry
observe abdominal movements
auscultate for:
bowel sounds
vascular sounds
peritoneal friction rub
palpate the four quadrants
palpate the liver
palpate the bladder
Female Genitalia:
inspect the distribution, amount, and characteristic of pubic hair
inspect the skin of the pubic hair for parasites, swelling and lesions
inspect the clitoris and vaginal orifice

inspect the cervical os and vagina

palpate the Skenes grand and Bartholins gland
assess the pelvic musculature
abnormal findings: cystocele
rectocele

Male Genitalia
inspect the distribution, amount and characteristics of the pubic hair
inspect the penile shaft and the glans penis for lesions, nodules, and inflammation
inspect the urethral meatus for swelling, inflammation and discharges
inspect the scrotum for appearance, general size and symmetry
palpate the penis for tenderness, thickening and nodules
palpate the scrotum
palpate the inguinal area for bulges
Rectum and Anus
inspect the anus and surrounding tissue for color, integrity, and skin lesions
palpate the rectum for anal sphincter tonicity, nodules, masses and tenderness
observe the color of feces when withdrawing the fingers
normal: brown
abnormal: green
bloody
black tarry
ash-colored
palpate the prostate gland
palpate the cervix

MEDICATION ADMINISTRATION
Pharmakokinetics:
Absorption: the process by which drug passes into the bloodstream
Distribution: the transportation of a drug from the site of absorption to the site of action
Metabolism: is the process by which a drug is converted to its less active form
Excretion: the process by which the drug is removed from the body
Types of medication action:
Therapeutic effect
Side effect
Adverse effect
Toxic effect
Idiosyncratic effect
Allergic reaction
Iatrogenic effect
Types of medication order:
Stat order
Single order
Standing order
Prn order

Types of drug preparation:

Aqueous solution
Aqueous suspension
Capsule
Elixir
Extract
Liniments
Tablet
Syrup
Suppository
Cream

10 Rights
1. Medication
2. Dose
3. Time
4. Route
5. Client
6. Client education
7. Right documentation
8. Right to refuse
9. Right assessment
10. Right evaluation
Systems of Measurement:
Metric
1ml
4-5 ml
15 ml
30 ml
60mg

Apocthecaries
15 minims
1 fluid dram
4 fluid drams
1 fluid ounce
1 grain

Household
15 gtts
1 teaspoon
1 tablespoon

Routes for medication administration:

Oral
Parenteral

o Subcutaneous
Sites: abdomen, upper anterior arm, anterior thigh
Needle: 5/8. 25G to 26G
o Intramuscular
Sites: vastus lateralis
rectus femoris
dorsogluteal
ventrogluteal
deltoid

Needle:
5/8, 25G-27G (infants)
1, 22G-23G (toddler/preschooler)
1 1/2, 22G-23G (adults)
o Intravenous
Bolus
Piggyback
o Intradermal
Needle: 3/8 to 5/8, 25G to 26G

Topical
o Transdermal
- apply on hairless area
- apply on areas not prone to movement
- do not trim or cut transdermal patches
o Inhalation
Without spacer: place mouthpiece 1-2 inches in front of the open mouth
With spacer: place spacer mouthpiece in the mouth
o Ophthalmic
Eye drop: lower conjunctival sac
Ointment: inner ridge of the eyelid
o Otic
o Nasal
Eustachian tube: supine
Ethmoid/sphenoid sinus: head tilted back
Maxillary/frontal sinus: head tilted back towards the affected side
Intravenous Therapy
Common intravenous solutions:
0.45% saline (1/2 NS)
0.9% saline (NS)
5% dextrose in water
5% dextrose in 0.225% saline
Lactated ringers
5% dextrose in LR soln
5% dextrose in 0.45% saline
5% dextrose in 0.9% saline
10% dextrose in water
Types of infusion:
Peripheral
Central
Continuous
Intermittent
Sites for IV insertion:

- hypotonic
- isotonic
- isotonic
- isotonic
- isotonic
- hypertonic
- hypertonic
- hypertonic
- hypertonic

Complications of IV therapy:
Infection
Air embolism
Hypersensitivity reaction
Circulatory overload
Infiltration
Phlebitis
Blood Transfusion:
Types of blood components:
Whole blood
Packed RBC
Fresh frozen plasma
Clotting factors
DOs when administering blood products:
Check patients baseline data.
Check the blood product:
Blood product
Blood type and Rh
Unit number
Expiration date and time
Use only PNSS with any blood product.
Use blood transfusion set.
Administer blood slowly during the first 15 min.
Monitor patient for transfusion reactions.
Administration of each unit should not exceed 4 hours.
Transfusion reactions:
Hemolytic
Febrile
Allergic
Hypervolemia
Sepsis
RESPIRATION
- is the process of gaseous exchange between the individual and the environment.

Three parts of the respiration process:

1. Pulmonary ventilation
2. Diffusion of gases
3. Transport of gases
Four factors that affects ventilation:
1. Adequate atmospheric oxygen
2. Clear air passages
3. Adequate pulmonary compliance & recoil
4. Regulation of respiration

Alterations in breathing pattern:

Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Orthopnea
Cheyne stokes breathing
Kussmauls beathing
Types of oxygen delivery:
Cannula
O2 (L/min)

Simple face mask

O2 (L/min)

1
2
3
4
5-6

24-45%
24%
28%
32%
36%
40%

5-6
7-8
10

40-60%
40%
50%
60%

6-10

60-90%

10

95-100%

4
6.8

24% (blue)
35% (green)

Partial re-breather mask

Non-rebreather mask
Venturi mask

Chest physiotherapy
Percussion or clapping
o cover area with gown or towel
o percuss affected lung segments for 1-2 minutes
Vibration
o high frequency quivering of the chest wall

o vibrate 5 times over each lung segment

Postural drainage
o Upper lobes: patient sits upright
o Posterior: patient sits up and leans forward over the back of chair at a 30 degrees angle
o Anterior: patient lies on his or her back with arms on the sides
o Lower lobes: patient lies on his or her stomach

Artificial airways:
Orotracheal tube
Nasotracheal tube
Care of patients with endotracheal tubes:
x-ray after initial placement
auscultate both sides of the chest
auscultate over the stomach
monitor skin and mucus membrane. Move to the opposite side of the mouth daily.
keep resuscitation bag at bed side

Tracheostomy
- surgical incision in the trachea
Care of patients with tracheostomy:
assess respiration
monitor ABG
suction secretions
assess stoma for blood and mucus
keep ambubag, tracheostomy set, clamps at bedside
Complications of tracheostomy:
Tracheomalacia
Tracheal stenosis
Tracheoesophageal fistula
Tracheal innominate artery fistula
Chest tube drainage system:
returns negative pressure to the intra-pleural space
removes abnormal accumulation of air and fluids from the pleural space
Care of patients with chest tube drainage:
monitor fluctuation level
note for gentle bubbling
x-ray before and after initial placement
do not strip or milk
keep occlusive dressing and extra bottle at bedside
If the bottle cracks or breaks:
insert the tube into a bottle with sterile water
If the tube is accidentally pulled out:
pinch the skin opening
instruct patient to bear down
apply occlusive sterile dressing
NUTRITION AND METABOLISM

Caloric value
- amount of energy that a nutrient or food supplies to the body.
Carbohydrates
Protein
Fat

- 4 kcal/gram
- 4 kcal/gram
- 9 kcal/gram

Serving sizes:
Carbohydrates
1 serving = 1 slice of bread
= cup of rice or noodles
Vegetable
1 serving = 1 cup raw leafy
= cup other veggies
= cup frozen or cup dried veggies

Fruits
1 serving = 1 medium apple, banana,
= 1 medium orange
= cup canned fruits,
= cup fruit juice
Meat and poultry
1 serving = 1 egg
= cup cooked legumes
= 2-3 oz of lean meat
Milk products
1 serving = 8 oz milk
= 2/3 cup ice cream
Assessment of nutritional status:
Tricept skin fold measurement
Mid-arm muscle circumference
Body mass index
BMI Classification:
Underweight
<18.5
Normal
18.5 - 24.9
Overweight
25 - 29.9
Obese
30 - 34.9 (I)
35 - 39.9 (II)
Extreme obese 40 and above (III)
Therapeutic diets:
Clear liquid
post-operative, initial feeding after complete bowel rest
consist of foods which are relatively transparent and stays liquid at body temperature
water, clear broth, gelatin, hard candy, popsicles and carbonated beverages
dairy products are not allowed

client should not stay on clear liquid diet for more than a day or two

Full liquid diet

second diet after clear liquid following surgery, or if the client is unable to chew
includes clear and opaque liquid foods and those that liquefy at body temperature
includes items like ice cream, breakfast drinks, milk, custard, strained soups, strained vegetable
juices
Bland diet
usually prescribed for patients with gastritis, ulcers, reflux esophagitis and other GI disorders
bland foods are less like to form gas and are less irritating to the gastric mucosa
foods to be avoided include alcohol, caffeine-containing beverages, pepper and spicy foods
Low residue diet
this diet supplies foods that are least likely to form an obstruction when the intestinal tract is
narrowed by inflammation or scarring
foods to be avoided are raw fruits, except banana, vegetables, seeds, plant fibers, and whole grains

Nasogastric tube insertion:

Purposes:
gavage
lavage
GI decompression
medication administration
Nursing care during insertion:
high fowlers position
measure from the tip of nose to earlobe to xyphoid process
instruct the client to slightly bend the head forward
give the client sips of water
do not force if there is resistance
if the client experiences any respiratory distress during insertion, pull back on the tube and wait
until the distress subsides
radiography (after initial placement)
Administration of NGT feeding:
1. Elevate patients head of bed.
2. Verify tube placement & measure residual
3. Flush with 30 mL of water
4. Initiate feeding.
If using a feeding bag, place formula in bag & prime tubing. Attach the distal end of the
tubing to the proximal end of the feeding tube.
If using a syringe, insert tip of the syringe to the feeding tube. Pour desired amount of
formula and hold the syringe 12-18 inches above the insertion site.
Pour formula (no more than the volume to be delivered in 4 hours) in the feeding bag
& prime tubing. Connect feeding through feeding pump & attach distal end of the tubing to
proximal end of the feeding tube. Set hourly rate.
5. Flush with 30 mL of water
Flush every 3-4 hours if using continuous feeding.
6. Clamp NGT.

Common complications of NGT feeding:

Intolerance of feeding
Aspiration.
Diarrhea (> 3x/24 hrs)
Hyperglycemia
Fluid imbalance
Total Parenteral Nutrition (TPN)
supplies nutrients via the vein
indicated for clients whose GI tract is severely dysfunctional or clients with multiple
gastrointestinal surgeries
CPN (4 wks or more)
PPN (5-7 days)
Complications:
air embolism
fluid overload
hyperglycemia or hypoglycemia
infection

Weight reduction and gain:

Realistic goal is 1 lb/week
o 1 lb = 3500 cal
Decrease or increase intake by 500 cal/day to meet the goal.
Weight loss is more rapid if calorie reduction is combined with exercise (30 min. 3x/week)

FECAL ELIMINATION:
Common fecal elimination problems:
Constipation
Fecal impaction
Diarrhea
Fecal incontinence
Flatulence
Helminths
Diagnostic studies:
Visualization studies:
o anoscopy
o proctosigmoidoscopy
o colonoscopy
Fecalysis
Occult blood test
Enema
Types of enema:
Cleansing enema

o High
o Low
Carminative enema
Retention enema
Return flow enema

Types of enema solution:

Tap water enema
Soapsuds enema
Saline enema
Oil retention enema
Commercial enema
Comfort and Safety measures for giving enemas:
Ensure that there is a readily available bathroom or bedpan.
Observe standard precautions.
Solution temp for adults:
40.5 C
children: 37 C
Left Sims position
Height: 12 inches above the anus
Lubricated enema tubing is inserted only 6 inches into the adults rectum.
Give the solution slowly: 10-15 minutes/ 750-1000 mL

Tube size:
Infants: F 10-12
Toddlers: F 14-16
School age: F 16-18
Adults: F 22-30
Volume of solution:
Infants: 50-250 mL
Toddlers: 200-300 mL
School age: 300-500 mL
Adolescents: 500-1000 mL
Adults: 500- 1000 mL
Bowel diversions:
Gastrostomy
Jejunostomy
Ileostomy
Colostomy
Assessing the stoma for:
Color
Size and shape
Bleeding
Skin integrity
Amount and type of feces
Comfort

Symptoms to monitor in a patient with bowel diversions:

Fever of 101 F or greater
Redness of the stoma
A severe change in pain
Abdominal bloating
Nausea or vomiting
Severe diarrhea
Lack of passing gas or moving bowels
Difficulty with stoma appliance placement

MOBILITY AND EXERCISE

Guidelines for body movement:
Adjust working area to waist level and keep your body close to the area.
Implications: elevate adjustable beds and overbed tables, and lower the side rails to prevent
stretching and reaching.
Face in the direction of the task. If a change of direction is required, turn the body and extremities
as a single unit pivoting.
Use the palmar grip when grasping and lifting objects. Finger alone have little power. The strength
of the entire hand should be used.
When picking up heavy objects. Squat rather than stoop.
Lift objects by flexing the hips and knees, placing one foot forward and keeping the shoulders in
the same plane as the pelvis.
Implication: bending forward at the waist produces unnatural body alignment and causes back
strain.
Lift items with a bent elbow for added involvement of the muscles of the upper chest, shoulders
and upper arms.
Friction can be reduced by application of an intermediate surface.
Make your body movements smooth and rhythmic. Sudden jerky movements expend more energy
than controlled smooth motions and put more strain on the muscles.
Whenever the clients health permits, ask him or her to assist with the movement. This also helps
maintain some degree of independence on the part of the client.
Range of motion exercise
Types:
Active
Passive
Active-assistive
Resistive
Positioning clients in bed:
Dorsal Recumbent Position
Unsupported Position

Problem to be Prevented

Corrective Measures

Head is flat on bed

surface

Hyperextension of neck in
thick-cheated person

Pillow of suitable thickness under head

and shoulders if necessary for alignment

Lumbar curvature of
spine is apparent

Posterior flexion of lumbar

curvature

Roll on small pillow under lumbar

curvature.

Legs may be
externally rotated

External rotation of legs

Roll or sandbag placed laterally to be

trochanter of the femur

Legs are extended

Hyperextensions of knees

Small pillow under the thigh to flex the

knee slightly

Feet assume plantar

flexion

Plantar flexion (foor drop)

Footboard or rolled pillow to support feet

in dorsal flexion

Prone Position
Unsupported Position

Problem to be Prevented

Corrective Measures

Head is turned to side and Flexion or hyperextension of

neck is slightly flexed
neck

Small pillow under the head unless

contraindicated because of promotion of
mucous drainage from the mouth
Body lies flat on abdomen Hyperextension of lumbar
Small pillow or roll under the abdomen, just
accentuating lumbar
curvature; difficulty breathing; below the diaphragm
curvature
pressure on breast (women);
pressure on the genitals (men)
Toes rest on bed surface; Plantar flexion of feet (foot
feet are in plantar flexion drop)

Allow feet to fall naturally over the end of the

mattress, or support the lower legs on a pillow
so that the toes do not touch the bed

Lateral Position
Unsupported Position
Problem to be Prevented
Body is turned to the
Lateral flexion and fatigue or
side, both arms in the
sternocleidomastoid muscles
front of the body, weight
resting primarily on the
lateral aspects of the
scapula and the ilium
Upper arm and shoulder
are rotated internally and
adducted
Upper thigh and leg are
rotated internally and
adducted

Unsupported Position

Internal rotation and adduction of

shoulder and subsequent limited
function; impaired chest expansion
Internal rotation and adduction of the
femur; twisting of the spine

Corrective Measures
Pillow under head and neck to provide
good alignment

Pillow under upper arm to place it in

good alignment; lower arm should be
flexed comfortably
Pillow under leg and thigh to place
them in good alignment; shoulders and
hips should be aligned

Sims (Semi-Prone) Position

Problem to be prevented

Head rests on bed surface;Lateral flexion of the neck

weight in borne by lateral
aspects of cranial and
facial bones

Corrective Measures

Pillow supports head, maintaining it in

good alignment unless drainage from
the mouth is required

Upper shoulder and arm Internal rotation of shoulder and arm; Pillow under upper arm to prevent
are internally rotated
pressure on chest, restricting expansioninternal rotation
during breathing
Upper leg and thigh are Internal rotation and adduction of hip Pillow under upper leg to support it in
adducted and internally and leg
alignment
rotated
Feet assume plantar
Foot drop
Sandbags to support feet in dorsal
flexion
flexion

Mechanical aids for walking:

Canes
When maximum support is needed:
1. Hold the cane with the hand on the stronger side of the body.
2. Move the cane forward about 1 foot.
3. Move the affected leg towards the cane.
4. Move the unaffected leg ahead of the cane and the affected leg.
When less support is required:
1. Move the cane and the affected leg forward at the same time
2. Move the stronger leg forward
Walkers:
When maximum support is required:
1. move the walker ahead about 6 inches
2. move the right foot up to the walker
3. move the left foot up tot the right foot
If one leg is weaker than the other:
1. move the walker and affected leg all together
2. move the stronger leg ahead
Crutches:
Measuring clients for crutches:
The client lies supine and the nurse measures from the anterior fold of the axilla to the
heel of the foot and adds 1 inch.
Angle of elbow flexion should be about 30.
Four point gait:
1. Move the right crutch ahead
2. Move the left foot forward
3. Move the left crutch forward
4. Move the right foot forward
Three point gait:
1. Move both crutches and weaker leg forward
2. Move the stronger leg forward
Two point gait:
1. Move the left crutch and right foot forward together
2. Move the right crutch and left foot ahead together
Swing to gait:

1. Move both crutches ahead together

2. Lift the body weight by the arms and swing to the crutch
Swing through gait:
1. Move both crutches ahead together
2. Lift the body weight by the arms and swing through and beyond the crutch

URINARY ELIMINATION:
Characteristics of normal urine:
1200 to1500 mL/ 24 hrs
clear, straw or amber
faint aromatic
no microorganisms present
pH 4.5-8
1.010 to 1.030 specific gravity
no glucose
no ketones
no blood
no albumin
Diagnostics:
Urinalysis
Culture and sensitivity tests
24-hour urine collection
Radiographic tests
o KUB
o IVP
o RP
Blood vessel exam
o Renal angiography
Urinary catheterization:
Indwelling- Foley catheter
Straight- Robinsoncatheter
Sizes:
Fr 8-10 for children
Fr 14-16 for women
Fr 16-18 for men
Position:
Women
Men
Length of insertion:
Children = 2.5 cm ( 1 inch)
Female = 5 cm (2 inches)
Male = 18-20 cm. (8 inches)
Proper anchoring:
thigh, right angle = female
thigh/abdomen = male

Condom catheter:
Using a strip of elastic adhesive, spiral wrap penile shaft of the patient.
Attach tubing to the condom catheters end.