Essentials in Nursing

Companion to

Chapter One

Vital Signs
1.1. Measuring Body Temperature 1.2. Radial and Apical Pulses Assessment 1.3. Assessing Respirations 1.4. Measuring Oxygen Saturation (Pulse Oximetry) 1.5. Measuring Blood Pressure (BP)

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1.1. Measuring

Body Temperature

Physiology
The difference between the amount of heat produced by physiological processes and the quantity of heat lost to external environment is commonly termed as body temperature. The human body's temperature-control mechanisms maintain the body's core temperature. Skin or surface temperature however varies depending on factors such as blood flow and heat loss due to environmental influence.

Importance of Measuring Body Temperature

Besides being an effective indicator of the presence of infections and other physiological disorders, body temperature measurement is primarily aimed at obtaining a representative average temperature of core body tissue. It is an important tool for bringing balance between heat lost and heat produced also known as thermoregulation. Although cardiovascular and neurological mechanisms regulate the said relationship, the nurse's role in promoting temperature regulation cannot be undermined. Through the application of knowledge in temperature control mechanisms, the nurse contributes to the process of thermoregulation.

Neural & Vascular Control of Body Temperature

The one primarily responsible for controlling body temperature is the hypothalamus. It detects minor changes in temperature. Temperature characterized by comfort is known as a set point, this is the baseline by which the heat system operates. Heat loss is controlled by the anterior hypothalamus while the posterior hypothalamus has control over heat production. When anterior hypothalamus nerve cells heats up beyond the set point, reduction of body temperature is facilitated by sending out impulses. There are several mechanisms responsible for heat loss, these include: Sweating Vasodilation Inhibition of heat production
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Heat loss is promoted by the redistribution of blood to surface vessels. Once the hypothalamus detects body temperature lower than setpoint, the body institutes its heat conservation mechanisms. Vasoconstriction reduces blood flow to the skin. Voluntary muscle contraction prevents further heat loss, this comes in the form of shivering.

Bodys Heat Production

The human body primarily produce heat through metabolism. It is the chemical reaction in all the bodys cells, the primary fuel for which is food. The amount of energy needed for metabolism is called metabolic rate. It is increased by activities which require additional chemical reactions. There exists a relationship between metabolism and heat production: an increase in the bodys metabolism means an increase in heat production.

Factors Affecting Body Temperature

Age

Newborns temperature control mechanisms are not fully developed that they require extra care in protecting them from environmental temperatures. Up to 30% of a babys body heat is lost through the head, this is why a cap is needed to prevent heat loss. Clothing must also be adequate so as to prevent exposure to extreme temperatures. Heat productions in infants declines steadily as they grow older. Human thermoregulation remains unsteady until puberty, normal temperature range declines gradually as older adulthood approaches. Older adults on the other hand undergo deterioration of temperature mechanisms, which is why they are sensitive to temperature extremes.
Circadian rhythm

Within a period of 24 hrs, it is but natural for body temperature to change. Temperature however, is one of the most stable rhythms in humans, body temperature is usually at its lowest between 1:00 and 4:00 a.m. Body temperature rises steadily during the day until about 6:00 p.m, at which time, maximum temperature value occurs. In general age does not alter circadian temperature rhythm.
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Hormonal and neural stimulation caused by physical and emotional stress increase body temperature. Metabolism is increased by these physiological changes, thereby increasing heat production.
Exercise

Increased blood supply, carbohydrate and fat breakdown are required for muscle activity. Heat production results from this increase in metabolism. Heat production can be caused by any form of physical exercise, thus effecting a rise in temperature.
Environment

Environment exerts significant influence on body temperature. Assessment of temperature in a warm place may produce high readings, because the patient may not be able to adequately regulate body temperature by heat loss mechanisms. Likewise, assessment of body temperature on a patient who has had prolonged exposure to cold surroundings without adequate clothing, could yield low body temperature readings. Because of infants and older adults less efficient heat loss regulation mechanisms, they are the ones most prone to temperature alterations from environmental temperatures.

Assessment Sites
Although there are several sites where body temperature can be assessed, intensive care settings require the use of core temperatures from the pulmonary, artery, esophagus and urinary bladder. These measurements require the use of invasive devices attached to body cavities and organs. Common sites of body temperature measurements on the other hand, although similarly invasive, can be used intermittently. Sites such as the tymphanic membrane, mouth, rectum and axillary sites provide useful measurements. This method of body temperature measurement uses thermometers as a common tool.

Kinds of Thermometers Used in Body Temperature Measurement

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Glass thermometer Electronic thermometer Disposable thermometer

Materials Required
Appropriate thermometer Soft tissue/alcohol swab Lubricant (for rectal measurements) Pencil, pen, vital sign flow sheet/ form Disposable gloves

Procedures for Measuring Body Temperature and Rationale

Assess for temperature changes and factors that may affect body RATIONALE: Physical signs/symptoms may indicate abnormal temperature. Check patient for any activity that may interfere with accuracy of measurement. Physical signs/symptoms may indicate abnormal temperature. RATIONALE: Food/Fluid intake or smoking may affect temperature readings gleaned from oral cavity. Choose appropriate site and measurement device to be used. RATIONALE: Selection of site depends on advantages/disadvantages. Patients who are in isolation are advised to use glass thermometers. Explain to patient how the process is to be carried out and the importance of keeping proper body position. RATIONALE: Patients often display curiosity and should be warned against premature removal of thermometer. Wash hands. Assist client in establishing a comfortable position. RATIONALE: Transmission of microorganisms is reduced. Patient comfort and accuracy of temperature reading are ensured.
OBTAIN TEMPERATURE READING

Oral temperature using glass thermometer:

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Wear disposable gloves. (optional) RATIONALE: Observes proper infection control precautions in handling items soiled with bodily fluids. Hold tip of glass thermometer using fingertips. RATIONALE: Reduces/prevents contamination of thermometer bulb. Determine mercury level while gently rotating thermometer at eye level. Hold tip of thermometer securely and flick wrist in upward and downward motion until reading reaches below 35.5C. Ask client to open mouth, then place thermometer under the tongue in posterior sublingual pocket lateral to center of lower jaw. RATIONALE: Temperature reading is produced by heat from superficial blood vessels in sublingual pocket. Ask client to hold thermometer in place with lips, cautioning him/her of danger of biting down on thermometer. RATIONALE: Maintains proper thermometer position during measurement. Thermometer breakage may injure mucosa and cause mercury poisoning. Leave thermometer in place for 3 minutes or as required by institution. RATIONALE: Hotzclaw (1998) recommends 3 mins as proper period for temperature measurement. Remove thermometer from client's mouth and take reading at eye level. Rotate thermometer until scale appears. RATIONALE: Proper reading of mercury scale is achieved at eye level. Wipe thermometer with alcohol swab. Discard tissue. Replace thermometer in appropriate container. RATIONALE: Cross contamination is prevented. Remove and properly dispose of gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Oral temperature measurement using electronic thermometer:
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Wear disposable gloves (optional). RATIONALE: Use of oral probe cover may eliminate need to wear disposable gloves. Remove thermometer pack from its charging unit. Attach oral probe to thermometer unit. Hold top of probe stem carefully so as not to apply pressure on the ejection button. RATIONALE: Charging provides power for the unit's battery. Plastic probe cover is released by the ejection button. Slide disposable probe cover over thermometer probe, locking it in place. RATIONALE: Plastic cover cannot break in patient's mouth and transmission of microorganism is prevented between clients. Ask client to open mouth. Place probe under tongue in posterior sublingual pocket lateral to center of jaw. RATIONALE: Temperature reading is produced by heat from superficial blood vessels in sublingual pocket. Ask client to hold thermometer by keeping lips closed. RATIONALE: Proper position of thermometer during measurement is maintained. Leave probe in place until audible sound is produced and temperature reading appears on digital display. Remove probe from client's mouth. RATIONALE: Probe must be kept in place until signal is heard, in this way accurate reading is ensured. Discard disposable probe cover by pushing ejection button located on thermometer stem. RATIONALE: Transmission of microorganisms is reduced. Replace thermometer stem to storage well of recording unit. RATIONALE: Probe is protected from damage. Digital reading disappears upon return of probe to storage. Remove and dispose of gloves properly. Wash hands. RATIONALE: Transmission of microorganisms is reduced.
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Rectal temperature measurement using glass thermometer: Provide client with needed privacy. RATIONALE: Maintains privacy, minimizes embarrassment and comfort is provided. Put on disposable gloves. RATIONALE: Standard precautions are maintained with exposure to items soiled by bodily fluids. Read thermometer's mercury level by rotating at eye level. If mercury is above desired level, securely hold thermometer by the tip and flick wrist downward until reading reaches below 35.5C. RATIONALE: Reading should be lower than patient's actual body temperature before use of thermometer. Mercury level is lowered by brisk shaking. Squeeze some lubricant onto a tissue. Dip blunt end of thermometer into lubricant covering 2.5 to 3.5 cm of the thermometer for adult clients. RATIONALE: Minimizes trauma to rectal mucosa. Contamination of remaining lubricant in container is prevented. Expose anus by separating client's buttocks with the use of nondominant hand. Ask client to relax by breathing slowly. RATIONALE: Anus is fully exposed for thermometer insertion. Relaxes anal sphincter. Insert thermometer gently into client's anus (3.5 cm for adult clients) towards the direction of the umbilicus. Avoid forcing thermometer. RATIONALE: Adequate exposure against blood vessels in rectal wall is ensured. If resistance is encountered during insertion process, immediately withdraw thermometer. RATIONALE: Trauma to mucosa is prevented as glass thermometer may break. Remove thermometer and wipe off any secretions from the thermometer using alcohol swab. Discard swab properly.
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RATIONALE: Cross contamination is prevented.

Read thermometer at eye level. Thermometer scale will appear by rotating thermometer. RATIONALE: Accurate temperature reading is ensured. Use a piece of soft tissue in wiping the client's anal area. Dispose of tissue and assist client to a comfortable position. RATIONALE: Hygiene and comfort is provided to patient. Replace thermometer in appropriate storage container. RATIONALE: Proper storage prevents breakage and safeguards against mercury spillage. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Rectal temperature measurement using electronic thermometer: Separate thermometer pack from charging unit. Attach rectal probe to thermometer unit. Hold the top of the probe stem. RATIONALE: Charging provides battery power. Plastic probe cover is released by the ejection button. Place disposable plastic probe cover over probe and lock it in place. RATIONALE: Transmission of microorganisms between clients is prevented by probe cover. Hold thermometer probe in place until audible signal is heard and temperature reading appears on the digital display. Remove probe from client's anus. RATIONALE: Probe is to be kept in place until signal occurs to effect accurate measurement. Discard plastic probe cover by pushing the ejection button on the thermometer stem. RATIONALE: Transfer of microorganisms is reduced. Replace thermometer stem in the storage well of the recording unit.
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RATIONALE: Battery charge is maintained. Wipe client's anal area using a piece of soft tissue. Discard tissue and assist client to a comfortable position. RATIONALE: Provides patient with comfort and hygiene Remove disposable gloves and discard properly. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Re-attach thermometer to charging unit. RATIONALE: Battery charge is maintained. Axillary temperature measurement using glass thermometer: Wash hands. RATIONALE: Transmission of microorganisms is reduced.

Provide client with needed privacy. RATIONALE: Privacy is provided and embarrassment is reduced. Assist client to supine or sitting position. RATIONALE: Easy access to axilla is provided. Partially remove client's gown or clothing away from shoulder and arm. RATIONALE: Axilla is exposed for easy placement of thermometer. Place thermometer in the center of client's axilla with lower arm over thermometer and place arm across chest. RATIONALE: Proper thermometer position against axilla blood vessels is maintained. Keep thermometer in place for 3 minutes or as required by the agency. RATIONALE: It has been established that 3 mins of measuring time is sufficient to obtain accurate reading. Remove thermometer, wipe off any secretions on thermometer using alcohol swab. Discard swab properly. RATIONALE: Transmission of microorganisms is reduced. Take thermometer reading at eye level.
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RATIONALE: Ensures accurate reading.

Place thermometer at client's bedside inside protective storage container. RATIONALE: Probe is protected from damage; digital reading disappears upon replacement of probe. Assist client in putting back on clothes or gown. RATIONALE: Privacy is provided and comfort is restored. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Axillary temperature measurement with the use of electronic thermometer: Assist client to establishing supine or sitting position. RATIONALE: Easy access to axilla is provided. Take thermometer pack from its charging unit, ensuring that axillary probe is attached to the thermometer unit. Hold top of probe stem. RATIONALE: Charging provides battery power. Plastic probe cover is released by the ejection button. Slide clean disposable probe cover over thermometer probe and lock it in place. RATIONALE: Cover prevents microorganisms' transmission in between patients. Raise client's arm away from the torso and examine for skin lesions and excess in perspiration. Place probe in the center of the client's axial. Lower arm over the probe and place arm across chest. RATIONALE: Maintains proper thermometer position against blood vessels in the axilla. Leave probe in place until audible signal is heard and temperature reading appears on the digital display. RATIONALE: To ensure accurate reading, probe must be kept in place until signal is heard.
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Discard plastic probe cover by pushing the ejection button on the probe stem. RATIONALE: Transmission of microorganisms is reduced. Return probe to recording unit's storage well. RATIONALE: Probe is protected from damage. Digital reading disappears upon replacement of probe. Assist client to achieve comfortable position. RATIONALE: Provides patient with comfort and privacy. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Put thermometer back in charger. RATIONALE: Battery charge is maintained. Tympanic membrane temperature measurement using electronic thermometer: Assist client to achieve comfortable position with the head facing side, away from nurse. RATIONALE: Comfort is provided and auditory canal is exposed for accurate reading. Detach thermometer unit from charging base carefully avoiding application of pressure over the ejection button. RATIONALE: Battery power is provided by the base, the ejection button releases probe. Put disposable speculum cover over tip and lock it in place. RATIONALE: Protection of lens cover from dust, fingerprints or earwax. Insert speculum into ear canal referring to manufacturer instructions tympanic probe positioning: RATIONALE: Accurate reading is ensured. Pull ear pinna in an upward and backward direction for adults. Pull ear pinna in downward and backward direction for children. RATIONALE: External auditory canal is straightened for exposure of tympanic
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membrane. Move thermometer following a figure-eight pattern. RATIONALE: Allows for the detection of maximum tympanic membrane heat radiation. Gently fit probe in ear canal and keep it in place. RATIONALE: Seals auditory canal from ambient temperature to avoid inaccurate reading. Point probe toward client's nose. RATIONALE: Appropriate assessment site. Depress handheld unit's scan button. Keep probe in place until audible signal occurs and temperature reading appears on the digital display. RATIONALE: Scan button's depression detects infrared energy. Keep otoscope in place to ensure reading accuracy. Remove speculum carefully from client's auditory canal. RATIONALE: Avoids discomfort Discard plastic probe cover by pushing ejection button on handheld unit. RATIONALE: Transmission of microorganisms is reduced. If a second reading is needed, replace cover and wait for 2-3 mins. RATIONALE: Lens cover must be free of cerumen to maintain optical path. Assist client to a comfortable position. RATIONALE: Provides patient with comfort. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Discuss findings with client as required. RATIONALE: Patient participation is promoted in care and understanding of health status. If temperature assessment is being done for the first time, consider temperature as baseline & normal range for client's age
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group.
RATIONALE: Used

in comparing future temperature measurements.

Compare temperature reading to previous baseline and normal range for client's age group. RATIONALE: Temperature comparison indicates presence of abnormality. Second measurements confirm abnormality in body temperature. Record temperature reading and report abnormal findings. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
1.2. Assessing

Radial & Apical Pulse

Pulse
The bounding of blood flow at different points of the human body is called pulse. It indicates the circulating status of the body. The importance of circulation lies in its distribution of much needed nutrients to the body's cells. Continuous blood flow therefore plays an important role in the body's health.

Physiology
Blood circulation in the human body is a continuous cycle, which begins in the heart. Cardiac contraction sends blood to the aorta, which in turn pumps them into the distal ends of arteries. Pulse wave movement changes from the time blood volume is ejected by the heart to its passage through small arteries. A pulse wave reaching a peripheral artery can be felt by lightly palpating the artery against underlying bone or muscle. The palpable bounding of blood flow in the peripheral artery is known as the pulse. The pulse rate is the number of pulsing sensations occurring in a minute. The amount or volume of blood pumped out by the heart in one minute is called the cardiac output. All arteries may be palpated and assessed for pulse rate but the carotid and radial arteries offers easy palpation of peripheral pulse sites. As cardiac output declines in patients whose conditions worsen,
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the carotid artery in these cases is the most optimal site for finding a pulse.

Radial and Apical Pulse

Radial and apical pulses, though sharing certain similarities differ in the way they are assessed. In radial pulse assessment, pulse rate, rhythm and equality are measured whereas only rhythm and rate are measured in the assessment of the apical pulse.

Importance of Pulse Assessment

Through pulse assessment, the general state of a patient's cardiovascular health can be determined. Nursing diagnoses can also be derived from the procedure where appropriate nursing care plans can be drafted and afterwards implemented.

Materials Required
Stethoscope Wristwatch with second hand or digital display Pen, pencil, vital sign flow sheet/record form Alcohol Swab

Procedure for Measuring Radial/Apical Pulse & Rationale

Identify need for measurement of radial or apical pulse. RATIONALE: Certain health conditions may effect pulse alterations (e.g., heart disease, cardiac dysrhytmias, and surgery). Determine factors influencing pulse rate. RATIONALE: Allows for the accurate assessment of presence of pulse alterations and its significance. Know previous baseline apical rate (if available) from client's record. RATIONALE: Allows for assessment for condition change, provides comparison for future apical pulse measurements. Explain to the client the assessment of pulse or heart rate. Encourage relaxation and try to keep client from speaking.
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RATIONALE:

Heart rate may be affected by activity and anxiety.

Wash hands. RATIONALE: Transmission of microorganisms is reduced. Provide needed privacy. RATIONALE: Patient is given privacy and embarrassment is minimized. RADIAL P ULSE Assist client to sitting or supine position RATIONALE: Allows for easy access to pulse sites. If client is in supine position, place his/her forearm across upper abdomen or lower chest, extending the wrist straight. If in a sitting position, bend the client's elbow 90 with the lower arm being supported on a chair or on your arm. Flex client's wrist slightly with palm down. RATIONALE: Allows for full exposure of artery for palpation. Place tips of first two fingers over groove along the radial or thumb side of client's inner wrist. RATIONALE: Arterial palpation is rendered by using fingertips which are the most sensitive parts of the hands. Compress lightly against client's radius, initially obliterate pulse, then relax pressure. RATIONALE: Use of moderate pressure effects more accurate assessment of pulse. Determine pulse strength. RATIONALE: Volume of blood ejected against arterial wall is reflected by pulse strength. When pulse can be regularly felt, refer to watch's second hand and begin counting rate. RATIONALE: Pulse palpation ensures accurate pulse rate measurement. Timing should begin with zero with count of one as first beat after timing begins. If pulse is regular, count rate for 30 seconds and multiply by two.
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RATIONALE: Slow,

rapid or regular pulse rate may be accurately measured by a 30-sec count.

If irregular pulse rate, count rate for 60 secs. Assess frequency and irregular pattern. RATIONALE: Transmission of pulse wave may be influenced by inefficient heart contractions, thus interfering with cardiac output, which results in irregular pulse. Accurate count is ensured with long count.
APICAL PULSE

Assist client to supine sitting position. Expose sternum and left side of the client's chest. RATIONALE: Portion of chest wall is exposed for selection of auscultatory site. Determine anatomical reference so that the point of maximal impulse may be identified. RATIONALE: Allows for proper placement of stethoscope over heart apex, making hearing of heartbeat sounds easy and clear. Put stethoscope's diaphragm in palm of hand for 5-10 secs. RATIONALE: Warming of metal/plastic diaphragm promotes patient comfort. Put stethoscope's diaphragm over maximal impulse point at the fifth intercoastal space at the left midclavicular line and auscultate for normal S1 and S2 heart sounds. RATIONALE: Avoids sound distortion by allowing stethoscope tubing to go straight. When regular S1 and S2 are heard, begin count rate with reference to watch's second hand. RATIONALE: Clear auscultation of sound allows for accurate measurement of apical heart rate. Timing starts with zero. Count of one begins with the first auscultated sound after timing starts. In case of regular apical rate, count for 30 secs. And multiply by 2. RATIONALE: Assessment of regular apical rate can be done within 30 secs. If rate is irregular, and/or client is on cardiovascular medication, count for 60 seconds. RATIONALE: Measurement over longer interval allows for more accurate assessment of irregular apical rate.
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Note regularity of dysrythmia, if any. RATIONALE: Inefficient heart contraction and cardiac output alteration may be determined with regular occurrence of dysrhythmia. Assist client in re-establishing comfortable position. RATIONALE: Restores patient comfort. Wipe stethoscope's earpieces and diaphragm with alcohol swab as needed. RATIONALE: Transmission of microorganisms is reduced. Discuss findings with client as deemed necessary. RATIONALE: Patient participation in care and understanding of health status is promoted. Wash hands. RATIONALE: Transmission of microorganisms is reduced Compare readings with previous baseline and /or acceptable range of heart rate for client's age group. RATIONALE: Condition changes and alterations are evaluated. Compare peripheral pulse rate to apical rate and note any discrepancy. RATIONALE: Pulse deficit which may indicate cardiovascular problems may be derived from difference between measurements. Compare radial pulse equality and note any discrepancy. RATIONALE: Differences between radial arteries are indicative of compromised peripheral vascular system. Correlate pulse rate with data gleaned from blood pressure and related signs and symptoms. RATIONALE: There is an interrelation between pulse rate and blood pressure. Record pulse rate with assessment site and report abnormal findings. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
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1.3.

Assessment of Respiration

Respiration
Human life depends primarily on the presence of oxygen in body cells and the removal of carbon dioxide from them. This condition is achieved through the process of respiration. This mechanism of the human body involves three other processes namely: Ventilation Diffusion Perfusion Assessment of all three processes can be done interdependently. However, integration of assessment data from all three processes is required to analyze an individual's respiratory efficiency. The processes are also known to be interdependent with one process affecting the other. Similarly, the process of respiration can be influenced by a number of factors which includes: Exercise Acute pain Anxiety Smoking Body position Medication Neurological injury Hemoglobin function

Physiological Control
Breathing is generally a passive process. Normally, a person thinks little about it. The respiratory center in the brain stem regulates the involuntary control of respiration. Adults normally breathe in a smooth, uninterrupted pattern, about 12 to 20 times a minute. Ventilation is regulated by level of CO2, O2 and hydrogen ion concentration (pH) in the arterial blood. The most important factor in the control of ventilation is the level of CO2 (carbon dioxide) in the
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arterial blood. An elevation in the CO2 level causes the respiratory control system in the brain to increase the rate and depth of breathing. The increased ventilatory effort removes excess CO2 by increasing exhalation. However, clients with chronic lung disease have ongoing hypercarbia. For these clients, chemoreceptors in the cartoid artery and aorta are sensitive to hypoxemia or low levels of arterial O2. If arterial oxygen level falls, these receptors signal the brain to increase the rate and depth of ventilation. Hypoxemia helps control ventilation in clients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows the client to breathe, administration of high oxygen levels can however be fatal for clients with chronic lung disease.

Mechanics of Breathing
Although breathing is normally passive, muscular work is involved in moving the lungs and chest wall. Inspiration is an active process. During inspiration, the respiratory center sends impulses along the phrenic nerve, causing the diaphragm contraction. Abdominal organs move downward and forward, increasing the length of the chest cavity to move air into the lungs. The diaphragm moves approximately 1 cm (4/10 inch) and the ribs retract upward from the body's midline approximately 1.2 to 2.5 cm (1/2 to 1 inch). During a normal, relaxed breath, a person inhales about 500 ml of air. This amount is referred to as the tidal volume. During expiration, the diaphragm relaxes and the abdominal organs return to their original positions. The lung and chest wall return to a relaxed position. Expiration is a passive process. The normal rate and depth of ventilation, eupnea, is interrupted by sighing. The sigh, a prolonged deeper breath, is a protective psychological mechanism for expanding small airways and alveoli not ventilated during a normal breath. An accurate assessment of respirations depends on the nurse's recognition of normal thoracic and abdominal movements. During quiet breathing, the chest wall gently rises and falls. Contraction of the intercostal muscles between the ribs or contraction of the muscles in the neck and shoulders, the accessory of muscles of breathing, are not visible. During normal quiet breathing, diaphragmatic movement causes the abdominal cavity to rise and fall.
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Assessment
Although respiration is the easiest vital sign to assess, it is also the most susceptible to inaccurate measurement. As tempting as it may be, nurses should be cautioned against estimating respirations. Observation and chest wall movement palpation are required for accurate measurement of respirations.

Indications for Assessing Respiration

Respiration is the exchange of oxygen and carbon dioxide between the cells of the body and the environment through rhythmic expansion and deflation of the lungs. Each respiration consists of an inhalation, exhalation and the pause which follows. The respiratory rate may be assessed to: Establish a baseline respiratory rate Monitor the patient's condition during and following investigative procedures and treatments (e.g., aspiration of pleural cavity, pleural biopsy, peritoneal dialysis) Estimate the degree of dysfunction and the effect of treatment As mentioned earlier, an accurate assessment of respiratory efficiency requires assessment data of the ventilation, diffusion and perfusion processes. Assessment of the last two processes can be done through measuring oxygen saturation in the blood. Since oxygen attaches to hemoglobin molecules, measuring the percentage of hemoglobin bound with oxygen in arterial blood is the percentage of hemoglobin saturation (SaO2) which is normally between 95 to 100%. A sudden change in the character of respirations may be important. Because respiration is tied to the function of numerous body systems, the nurse must consider all variables when changes occur. For example, a drop in respirations occurring in a client after head trauma may signify injury to the brain stem. Abdominal trauma may injure the phrenic nerve, which is responsible for diaphragmatic contraction. The nurse must understand the extent of the injury and the implications to the respiratory system. A skillful nurse does not let a client know that respirations are being
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assessed. A client aware of the nurse's intentions may consciously alter the rate and depth of breathing. Assessment can be best done immediately after measuring pulse rate, with the nurse's hand still on the client's wrist as it rests over the chest or abdomen. When assessing a client's respirations, the nurse should keep in mind the client's usual ventilatory rate and pattern, the influence any disease or illness has on respiratory function, the relationship between respiratory and cardiovascular function and the influence of therapies on respirations. The objective measurements of an assessment of respiratory status include the rate and depth of breathing and the rhythm of ventilatory movements. Respiratory Rate. The nurse observes a full inspiration and expiration when counting ventilation or respiration rate. The respiratory rate varies with age. The usual range of respiratory rate declines throughout life. A respiratory monitoring device that aids the nurse's assessment is the apnea monitor. This device uses leads attached to the client's chest wall that sense movement. The absence of chest wall movement is interpreted by the monitor as apnea and triggers an alarm. Apnea monitoring is used frequently on infants in the hospital and at home to observe for prolonged anemic events. Non-invasive monitoring provides information that helps the nurse assess the rate, depth and rhythm of respiration more knowledgeably.
Pertinent Laboratory Values

Arterial blood gases (ABGs): Normal ABGs (values may vary slightly within institutions): pH = 7.35-7.45 PaCO2 = 35-45 PaO2 = 80-100 SaO2 = 94%-98% Arterial blood gases measure arterial blood pH, pressure of O2 and CO2 and arterial O2 saturation, which reflects client's oxygenation status. Pulse oximetry (SpO2): Acceptable SpO2 90%-100%; 85%-89%
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may be acceptable for certain chronic disease conditions; less than 85% is abnormal. SpO2 less than 85% is often accompanied by changes in respiratory rate, depth and rhythm. Complete blood count (CBC): Normal CBC for adults ( values may vary within institutions): Hemoglobin: 14 to 18 g/100 ml, males: 12 to 16 g/100 ml, females. Hematocrit: 40% to 54%, males; 38% to 47%, females. Red blood cell count: 4.6 to 6.2 million/ ul, males; 4.2 to 5.4 million/ ul females. Complete blood count measures red cell count, volume of red blood cells, and concentration of hemoglobin, which reflects client's capacity to carry O2 . Ventilatory Depth. The depth of respirations is assessed by observing the degree of excursion or movement in the chest wall. The nurse subjectively describes ventilatory movements as deep, normal or shallow. A deep respiration involves a full expansion of the lungs with full exhalation. Respirations are shallow when only a small quantity of air passes through the lungs and ventilatory movement is difficult to see. More objective techniques are used if the nurse observes that chest excursion is unusually shallow. Ventilatory Rhythm. Breathing pattern can be determined by observing the chest or the abdomen. Diaphragmatic breathing results from the contraction and relaxation of the diaphragm and is best observed by watching abdominal movements. Healthy men and children usually demonstrate diaphragmatic breathing. Women tend to use thoracic muscles to breathe, with movements observed in the upper chest. Labored respirations usually involve the accessory muscles of respirations visible in the neck. When something such as a foreign body interferes with air movement in and out of the lungs, the intercostal spaces retract during inspirations. A longer expiration phase is evident when the outward flow of air is obstructed. With normal breathing, a regular interval occurs after each respiratory cycle. Infants tend to breathe less regularly. The young child may breathe slowly for a few seconds and then suddenly breathe more
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rapidly. While assessing respirations, the nurse estimates the time interval after each respiratory cycle. Respiration is regular or irregular in rhythm.

Assessment of Diffusion and Perfusion

The respiratory process of diffusion and perfusion can be evaluated by measuring the oxygen saturation of the blood. Blood flow through the pulmonary capillaries provides red cells for oxygen attachment. After oxygen diffuses from the alveoli into the pulmonary blood, most of the oxygen attaches to hemoglobin molecules in red blood cells. Red blood cells carry the oxygenated hemoglobin molecules to the left side of the heart and out to the peripheral capillaries, where oxygen detaches, depending on the needs of the tissues. The percentage of the hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin (or SaO2). It is usually 95% and 100%. SaO2 is affected by factors that interfere with ventilation, perfusion or diffusion. The saturation of venous is lower because the tissues have removed some of the oxygen from the hemoglobin molecules. A normal value for SaO2 is 70%. SaO2 is affected by factors that interfere with or increase the tissue's need for oxygen.

Related information
Rate. Normal respiratory rates vary according to age. The accepted normal range is: Healthy adults: 14 - 20 per min Adolescents: 18 - 22 per min Children: 22 - 28 per min Infants: 30 or more per min Depth. The depth of respiration is approximately the same for each person and can be described as normal, shallow or deep. Pattern. A normal breathing pattern is effortless, evenly paced, regular and automatic. Abnormal patterns may be described as: Dyspnea. Difficult, labored breathing. The nostrils are dilated and the chest wall and shoulder girdle are raised and lowered in an exagger26

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ated fashion. Cheyne - Stokes. There is a gradual increase in the depth of respiration followed by a gradual decrease and then a period of no respiration (apnea). This syndrome is associated with terminal illness. Kussmaul's respirations. There is an increased rate and depth of respiration with panting and long grunting expirations. This syndrome may be associated with lobar pneumonia. Stertorous respirations. These are noisy respirations caused by excessive secretions in the trachea or bronchi. It may also be a sign of partial airway obstruction. Stridor. A harsh, high-pitched noise on inspiration caused by laryngeal obstruction.

Materials Required
Wristwatch with second hand/digital display Pen, pencil, vital sign flow sheet/record form

Procedures for Assessing Respiration & Rationale

Identify need to assess client's respirations. RATIONALE: Client may be at risk for ventilation alterations. These may be known by respiratory rate, depth and rhythm changes. Assess pertinent laboratory values. RATIONALE: Arterial blood pH may be measured by arterial blood gases, partial O2 and CO2 and arterial O2 pressure, which reflects patient's oxygenation status. Determine previous baseline respiratory rate (if available) from client's record. RATIONALE: Allows for the assessment of any change in condition. May be used for comparison with future respiratory measurements. Assist client to comfortable position, preferably lying or sitting with head of the bed elevated at 45 to 60 degrees. RATIONALE: Uncomfortable position affects assessment results.

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Provide needed privacy. RATIONALE: Privacy is provided and embarrassment is reduced. Patient anxiety is reduced. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Ensure client's chest is visible. Move client's linen or gown if necessary. RATIONALE: Provides a clear view of chest wall and abdominal movements. Place client's arm in relaxed position across lower chest or abdomen or place your hand over upper abdomen. RATIONALE: Allows for subtle assessment of respiratory rate. After observing cycle, look at watch's second hand and begin counting rate. RATIONALE: Timing starts with count of one since respiratory rate occurs slower than pulse. If rhythm is regular, count respiratory rate in 30 sec and multiply by 2. RATIONALE: Respiratory rate is the number of respirations per min. If rhythm is irregular, with rate of less than 12 or greater than 20, count respirations for 60 seconds. RATIONALE: Assessment for at least one minute is required for possible irregularities. Take note of respiration depth. RATIONALE: Ventilatory movement's character may reveal disease state. Note ventilatory cycle rhythm. RATIONALE: Specific type of alterations may be revealed by ventilations character. Replace client's gown and bed linen. RATIONALE: Comfort is restored and well-being promoted. Wash hands. RATIONALE: Transmission of microorganisms is reduced.
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Discuss findings with client as necessary. RATIONALE: Patient participation in care and understanding of health status is promoted. If respirations are being assessed for the first time, determine rate, rhythm and depth as baseline if within normal range. RATIONALE: May be used to compare with future respiratory assessment. Compare respirations with client's previous baseline and abnormal rate, rhythm and depth. RATIONALE: Allows for assessment of changes in patient's condition and presence of respiratory alterations.
1.4. Measuring Arterial

Oxygen Saturation

The recent development of a device known as the pulse oximeter allows for the indirect measurement of patients' arterial oxygen saturation. But as reliable as the device is known to be, oxygen saturation measurement can be influenced by many factors rendering measurement inaccuracy. Factors such as light transmission or peripheral arterial pulsations can interfere with the accuracy of the procedures outcome.

Materials Required
Oximeter Oximeter probe appropriate for client and manufacturer recommended Acetone/nail polish remover Pen, pencil, vital sign flow sheet/record form

Procedure for Measuring Arterial Oxygen Saturation & Rationale

Identify patient and need to measure patient's oxygen saturation. RATIONALE: Some conditions may put patient at risk for oxygen saturation decrease. These include acute/chronic respiratory function, recovery from general anesthesia and traumatic injury to chest wall.
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Assess for factors that may influence measurement of SpO2. RATIONALE: Facilitates accurate assessment of alterations in oxygen saturation. SpO2 assessment can be influenced by peripheral vasoconstriction related to hypothermia. Review client's record for prescribed order. RATIONALE: Oxygen saturation assessment may require physicians order. Determine previous SpO2 baseline (if available) from client's record. RATIONALE: Basis for comparision is provided. Facilitates assessment of patient status for formulation of possible intervention. Explain to patient the purpose of the procedure (if conscious). RATIONALE: Improves patients knowledge of procedure. Reduces anxiety and promotes cooperation. Locate site for sensor probe placement (feet, earlobe, hands) RATIONALE: SpO assessment can be influenced by peripheral vasoconstriction. 2 Large fluctuations in minute ventilation and possible SpO2 reading errors are prevented. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assist client to comfortable position. If finger is chosen as monitoring site, support client's lower arm. RATIONALE: Proper probe positioning is ensured. Motion artifact that may interfere with SpO2 reading is reduced. Tell patient to breathe normally. RATIONALE: Large fluctuations in respiratory rate, depth and possible SpO 2 alterations are prevented. Remove any fingernail polish from finger to be assessed. RATIONALE: Accurate SpO reading is ensured. Opaque finger nail coatings 2 could reduce light transmission. Light emissions are absorbed by nail polish with blue pigment and may render inaccurate readings. Attach sensor probe to monitoring site. Instruct client that clip30

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on probe will not hurt but feel like a clothespin on the finger. RATIONALE: Informs patient of expected sensations. Turn on oximeter by activating power. Observe pulse waveform/ intensity display and audible beep. Correlate client's pulse rate with radial pulse. RATIONALE: Detection of pulse/presence of signal interference is enabled by pulse waveform/intensity display. SpO2 value is proportional to pitch of audible beep. Oximeter accuracy is ensured by doublechecking pulse. Oximeter pulse rate, patients radial and apical pulse should have the same value. Leave probe in place until oximeter readout displays constant value and pulse display reaches full strength during individual cardiac cycle. Read SpO2 on digital display. RATIONALE: Depending on site chosen, reading may take 10 to 30 seconds. Tell client that the oximeter alarm will sound if probe falls off or was moved. RATIONALE: Cautions patient against accidental removal of probe. Verify SpO2 alarm limits and alarm volume for continuous monitoring. Check that alarms are on. Assess skin integrity under sensor probe and relocate sensor probe every 4 hrs. at least. RATIONALE: Avoids startling patients and visitors. Disruption of skin integrity may result from spring tension of probe or sensitivity to disposable sensor probe adhesive. Discuss findings with client as necessary. RATIONALE: Patient participation in care is promoted. Detach probe and turn oximeter power off after intermittent measurements. Store probe in appropriate location. RATIONALE: Leaving oximeter on can deplete battery power. Prevents damaging of sensor probe. Assist client to comfortable position. RATIONALE: Restores patient comfort. Wash hands.
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RATIONALE: Reduces transmission of

microorganisms.

Compare SpO2 reading with client baseline and acceptable values. RATIONALE: Presence of abnormality is revealed by comparison. Correlate SpO2 reading with SaO2 reading gleaned from arterial blood gas measurements, if available. RATIONALE: Reliability of non-invasive assessment is determined. Correlate SpO2 reading with data obtained from respiratory assessment. RATIONALE: Ventilation, perfusion and diffusion assessment data are interrelated. Report and record SpO2 readings, respiratory status, oxygen therapy and client response. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
1.5. Measuring

Blood Pressure (BP)

Blood Pressure is the force exerted on the walls of arteries created by pulsing blood coming from the heart. Systematic or arterial blood pressure is considered an accurate basis for determining the state of a person's cardiovascular health. Changes in pressure enables blood to flow throughout the circulatory system. Blood moves from high to low pressure areas of the circulatory system. Contraction of the heart forces blood under high pressure into the aorta. The peak of maximum pressure upon blood ejection is called systolic blood pressure. Arterial blood exerts a minimum pressure known as diastolic pressure when ventricles relax. It is the minimal blood pressure exerted against the walls of arteries. The standard unit for blood pressure measurement is millimeters of mercury (mm Hg). It indicates the height at which the blood pressure can raise a column of mercury. Blood pressure is recorded with
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a systolic reading first followed by the diastolic blood. (e.g., 120/80). The pulse pressure is the difference between systolic and diastolic pressure. For a blood pressure of 120/80, the pulse pressure is 40.

Arterial Blood Flow Physiology

Blood pressure reflects the interrelationship among the following: Cardiac output Peripheral vascular resistance Blood volume Blood viscosity Artery elasticity. A nurse's knowledge of these hemodynamic variables aids during assessment of alterations in blood pressure.
Cardiac Output

An individual's cardiac output (CO) is the volume of blood pumped by the heart (stroke volume [SV]) during 1 min (heart rate [HR]):
CO = HR SV

Blood pressure (BP) depends on the cardiac output and peripheral vascular resistance (R):
BP = CO R

When volume increases in a blood vessel, the pressure in that space rises. Therefore, as cardiac output increases, more blood is pumped against arterial walls, which causes an increase in blood pressure. Cardiac output may increase as a result of the following: Increased heart rate Greater heart muscle contractility Increase in blood volume. Heart rate alterations may occur faster than changes in muscle contractility or blood volume. A rise in heart rate may reduce diastolic filling time and end-diastolic volume. A decrease in blood pressure therefore occurs.
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Peripheral Resistance Blood goes through a network of arteries, arterioles, capillaries, venules and veins. Arteries and arterioles are surrounded by smooth muscle that contracts or relaxes to change the lumen's size. Arteries and arteriole size alters to adjust flow of blood to local tissue needs. For example, when a major organ requires more blood, the peripheral arteries constrict, decreasing blood being supplied. More blood becomes available to the major organ due to the resistance change in the periphery. Arteries and arterioles normally stay partially constricted so as to maintain constant blood flow. Peripheral vascular resistance is blood flow resistance determined by vascular musculature tone and blood vessel diameter. The smaller the blood vessel's lumen, the greater peripheral vascular resistance to blood flow. Arterial blood pressure rises with a resistance increase. Resistance reduction from vessel dilation on the other hand effects a drop in blood pressure. Blood Volume The volume of blood flowing within the circulatory system affects blood pressure. Most adults have a total circulating blood volume of 5000 ml. Blood volume normally remains constant. A rise in blood volume results in an increase in pressure exerted against arterial walls. An example of this is the way rapid, uncontrolled infusion of intravenous fluids increases blood pressure. Blood pressure likewise falls when circulating blood volume decreases, as in the case of hemorrhage or dehydration. Viscosity Blood thickness or viscosity of blood affects the ease with which blood circulates through small blood vessels. Blood viscosity is determined by the hematocrit--the percentage of blood cells in the blood. Slow blood flow results from a rise in hematocrit., increasing arterial blood pressure. In this case, the heart must increase contraction force to move viscous blood through the circulatory system. Elasticity Normally, arterial walls are elastic and easily distensible. As pressure within the arteries increases, the diameter of vessel walls increases to accommodate the pressure change. Arterial distensibility prevents wide
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fluctuations in blood pressure. However, in certain illnesses , such as arteriosclerosis, the vessel walls lose their elasticity and are replaced by fibrous tissue that is unable to stretch well. Reduction in elasticity results in increased resistance to blood flow. As a result, when the left ventricle ejects its stroke volume, the blood vessels become unyielding to pressure. Instead, a given volume of blood is forced through the rigid walls of the arteries and a rise in systematic pressure results. Reduced arterial elasticity elevates systolic more than diastolic pressure. Each factor affects the other significantly. For example, a decline in arterial elasticity results in an increase in peripheral vascular resistance. The cardio vascular system's complex control normally prevents any single factor from permanently altering blood pressure. For example, a fall in blood volume is compensated by a vascular resistance increase.

Factors Influencing BP
Although blood pressure is not constant, many factors influence it during the day. A single blood pressure measurement cannot accurately reflect a patient's blood pressure. Even under ideal conditions, blood pressure varies. What guides nursing intervention is blood pressure trends and not individual measurements. Understanding these factors ensures a more accurate blood pressure readings interpretation. Age Normal blood pressure levels vary throughout an individual's life. They increase during childhood. A child or adolescent's blood pressure level is assessed owing to consideration body size and age. The blood pressure of an infant ranges from 65-115/42-80, normal blood pressure of a 7-year-old is 87-117/48-64. Heavier and/or taller children tend to have higher blood pressures than smaller children of the same age. Blood pressure continues to vary according to body size during adolescence. Advancing age tend to increase an adult's blood pressure. The optimal blood pressure level for a healthy middle-age adult is 120/80 with acceptable values of <130/<85 as the norm. Decreased vessel
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elasticity contribute to the rise in systolic pressure among older adults. Stress Heart rate, cardiac output and peripheral vascular resistance increase as a result of sympathetic stimulation brought about by anxiety, fear, pain and emotional stress resulting from sympathetic stimulation. Sympathetic stimulation's effects increase blood pressure Race The incidence of hypertension (high blood pressure) is higher in African-Americans than in European-Americans. African-Americans tend to develop more severe hypertension at an earlier age and have twice the risk of complications such as stroke and heart attack. Genetic and environmental factors are believed to be contributing factors. Hypertension-related deaths are also higher among African-Americans. Medications Some medications can affect blood pressure directly or indirectly. In assessing blood pressure, the nurse asks whether the patient is taking anti-hypertensive or other cardiac medications, which could lower blood pressure. Narcotic analgesics is another class of medications which can lower blood pressure. Diurnal Variation Blood pressure levels may undergo changes over the course of a day. It is typically lowest during early morning, rises gradually during the morning and afternoon and peaks in the late afternoon or evening. No two individuals share the same pattern or degree of change in blood pressure. Gender No clinically significant difference in blood pressure levels between boys and girls has ever been found. Following puberty, higher blood pressure readings have been seen in males. Women on the other hand tend to have higher levels of blood pressure than men after menopause.
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The most typical change in blood pressure is hypertension. It is a leading factor responsible for deaths from strokes and is a contributing factor to myocardial infarctions (heart attacks). It is often asymptomatic and characterized by persistent elevated blood pressure. Hypertension in adults is diagnosed when an average of two or more diastolic readings on at least two visits yield 90 mm Hg or higher or when the average of multiple systolic blood pressures on two or more subsequent visits is consistently higher than 135 mm Hg. Hypertension categories have been developed to establish medical intervention. A single measurement reflecting elevated blood pressure does not qualify as a diagnosis of hypertension. If the nurse however assesses a high reading during the first blood pressure measurement (e.g., 150/90 mm Hg), the client is encouraged to come back for another check-up within 2 months. Hypertension is associated with the thickening and loss of elasticity in the walls of the arteries. In such cases, the heart must continually pump against greater resistance. This results in a decrease in blood flow to vital organs such as the heart, brain and kidney. Risks for Developing Hypertension Family history of hypertension. Obesity Cigarette smoking and/or heavy alcohol consumption High sodium (salt) intake Sedentary lifestyle Continued exposure to stress In diabetic patients, older adults and African-Americans, the incidence of hypertension is greater. When a patient is diagnosed with hypertension, the nurse helps in educating him/her on blood pressure values, long-term follow-up care and therapy, the usual lack of symptoms (the fact that it may not be "felt"), therapy's ability to control but not cure hypertension and a consistently followed treatment that can ensure a relatively normal lifestyle.
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Hypotension is basically considered present when systolic blood pressure falls to 90 mm Hg or below. Although normally, some adults have a low blood pressure, for the majority of individuals, low blood pressure is an abnormal finding associated with illness. The condition results from the dilation of the arteries in the vascular bed, loss of a significant amount of blood volume (e.g., hemorrhage) or the failure of the of the heart muscle to adequately pump (e.g., myocardial infarction). Hypotension associated with pallor, skin mottling, clamminess, confusion, increased heart rate or decreased urine output is considered life threatening and should be immediately reported to a physician. Orthostatic hypotension, also known as postural hypotension, happens when a normotensive person develops symptoms of low blood pressure when rising to an upright position. When a healthy individual shifts from a lying, to sitting, to standing position, the legs' peripheral blood vessels constrict. Lower extremity vessels constriction, when standing prevents blood pooling in the legs caused by gravity. When a patient has a decreased blood volume, the blood vessels are already constricted. When a patient with a depleted blood volume stands up, there is a significant blood pressure drop. Heart rate therefore increases to compensate for the reduced cardiac output. Individuals who are dehydrated, anemic or have gone through prolonged bed rest or recent blood loss are at risk for orthostatic hypotension. Misuse of some medications can likewise cause orthostatic hypotension, especially among older adults or young patients. Measurement of blood pressure is therefore a must before such medications are administered. Measurements of orthostatic vital sign include blood pressure and pulse assessment with the patient in supine, sitting and standing positions. In recording orthostatic blood pressure measurements, the nurse records the patient's position in addition to the blood pressure measurement. Example: 140/80 mm Hg supine 132/72 mm Hg sitting 108/60 mm Hg standing
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The readings are obtained 1 to 3 minutes after the patient changes position. Orthostatic hypotension in most cases, is detected within a minute standing. If orthostatic hypotension is assessed, the client is assisted to a lying position and the physician or nurse in charge is notified. While obtaining orthostatic measurements, the nurse observes for other symptoms of hypotension (i.e., fainting, weakness or light-headedness). The skill of orthostatic measurement requires critical thinking and nursing judgment.

Blood Pressure Assessment

Arterial blood pressure may be measured either directly (invasively) or indirectly (non-invasively). The indirect method involves inserting a thin catheter into an artery. Tubing connects the catheter to an electronic monitoring equipment. Constant arterial pressure waveform and reading are displayed in a monitor. Invasive blood pressure monitoring is used only in intensive care settings because of the risk of sudden blood loss from an artery. The most common non-invasive method involves use of the sphygmomanometer and stethoscope. Blood pressure is measured indirectly by auscultation or palpation. Auscultation is the most widely used technique.
Blood Pressure Equipment

A sphygmomanometer and stethoscope are used in indirectly assessing blood pressure. It is composed of a pressure manometer, an occlusive cloth or vinyl cuff that encloses an inflatable rubber bladder and a pressure bulb with a release valve that inflates the bladder. There are two types of manometers: Aneroid Mercury The aneroid manometer has glass-enclosed circular gauges containing a needle that registers millimeter calibrations. Before using the aneroid model, one must make sure that the needle is pointing to zero and the manometer is correctly calibrated. Aneroid sphygmomanometer requires biomedical calibration at routine intervals, this is to verify their accuracy. Aneroid manometers have the advantages of being lightweight, portable and compact. The aneroid instrument how39

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ever, is less reliable than the mercury type since its metal parts are subject to temperature expansion or contraction. Mercury manometers on the other hand, are more accurate than aneroid types. Repeated calibrations are not necessary. The mercury manometer is an upright tube containing mercury. Pressure created by the inflation of the bladder moves the column of mercury upward against the force of gravity. Millimeter calibrations mark the height of the mercury column. The mercury column must be at zero when the cuff is deflated. The mercury column should fall freely as pressure is released, this is to ensure accurate readings. Readings are obtained by looking at the meniscus of the mercury at eye level. This is where the crescent-shaped top of the mercury column aligns with the manometer scale. Distorted readings result from looking up or down at the mercury. There are however disadvantages to the mercury manometer, these are the potential for breakage and release of mercury. If not properly contained, mercury is a health hazard. Compression cuffs made of cloth or disposable vinyl contain the inflatable bladder and come in several sizes. The size selected is proportional to the circumference of the limb being assessed. Ideally, the width of the cuff should be 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb on which the cuff is to be used. The bladder, enclosed by the cuff, should encircle

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Infection Control
2.1. Hand Washing and Asepsis 2.2. Sterile Field Preparation 2.3. Surgical Hand Washing 2.4. Sterile Gown Application and Performing Closed Gloving

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at least two-thirds of the arm of an adult and the entire arm of a child. In children, the lower edge of the cuff should be above the antecubital fossa, allowing for placement of the stethoscope bell or diaphragm. Correct cuff size should be applied in order to obtain accurate blood pressure measurements. Inspection of the parts of the release valve and pressure bulb should be done before using a sphygmomanometer. The valve should be clean and freely moveable in either direction. Regulation of the pressure cuff may become difficult if it sticks or becomes too tightly closed. The pressure bulb should be free of leaks. Auscultation. A quiet room and a comfortable temperature is the best environment for blood pressure measurement by auscultation. Sitting is the preferred patient position although the patient may lie or stand. Readings obtained with patient in supine, sitting and standing positions are similar in most cases. Documentation of the patient's blood pressure and pulse rate in all three positions are used in obtaining orthostatic measurements. The client's position during routine blood pressure determination should be the same during each measurement to permit a meaningful comparison of values. A nurse should attempt to control factors responsible for high readings (i.e. pain, anxiety or exertion) before assessment. Blood pressure measurement can be affected by a patient's perception of a stressful physical or interpersonal environment, this is why blood pressure readings taken at a patient's workplace or in a physician's office are often higher than those taken at home. During initial assessment, a nurse should obtain and record blood pressure from both arms. Normally, there is a difference of 5 to 10 mm Hg between the arms. In subsequent assessments, blood pressure should be assessed in the arm with the higher pressure. Differences in blood pressure greater than 10 mm Hg indicate vascular problems in the arms with the lower pressure. Patient's usual blood pressure is asked by the nurse. If the patient does not know, the nurse informs him after measuring and recording the blood pressure. This provides for patient education on opti42

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mal blood pressure values, hypertension risk factors and hypertension dangers. Indirect arterial blood pressure measurement is based on the principle of pressure. Blood flows freely through an artery until pressure to tissues is applied by an inflated cuff, making the artery collapse. Systolic pressure is what occurs after release of the cuff pressure, where blood flow returns and sound is heard through auscultation. In 1905, Korotkoff, a Russian surgeon, first described the sound heard over an artery distal to the blood pressure cuff. The first Korotkoff sound is a clear rhythmical tapping which gradually increases in intensity. The sound's onset corresponds to the systolic pressure. A sound much like a murmur or swishing sound occurs as the cuff deflates, this is the second Korotkoff sound. Distention of the artery causes turbulence in blood flow. The third Korotkoff sound is characterized by a crisper and more intense tapping. The fourth Korotkoff sounds becomes muffled and low pitch with further deflation of the cuff. Cuff pressure falls below the pressure within the walls of the vessel, this is the diastolic pressure in infants and children. The absence of sound is the fifth Korotkoff sound. In adolescents and adults, this sound corresponds to the diastolic pressure. In some patients, the sounds are clear and distinct, while only the beginning and ending sounds are clear in others The American Heart Association recommends recording two numbers for a blood pressure measurement: Point on the manometer when the first sound is heard for systolic. Point on the manometer when the fifth sound is heard for diastolic. Some institutions also recommend recording the point when the fourth sound is heard, specifically for patients with hypertension. Slash lines divide the numbers (e.g., 120/80 or 120/100/80) and uses the arm to measure blood pressure (e.g., right arm [RA] 130/70) and patient position during pressure assessment (e.g., sitting). Blood pressure findings are often used as bases for various medical decisions and nursing interventions concerning a patient's health. This is why the significance of accurate blood pressure measurement cannot be
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undermined. Potential Auscultation Errors There are different causes for errors in blood pressure readings if auscultation is not performed correctly. In case of doubt about the accuracy of a reading, a nurse should ask a colleague to reassess blood pressure. BP Assessment in Children Children from 3 years of age through adolescence should be subjected to blood pressure assessment at least once a year. Blood pressure in children alters as they grow and develop. Blood pressure assessment can help parents in the detection of risk for hypertension. There are several stumbling blocks to obtaining accurate blood pressure readings in infants and children: Careful selection of appropriate cuff size is required of different arm size. Cuff selection based on name of the cuff is discouraged. Restlessness and anxiety in infants and children make it difficult to obtain blood pressure readings. It is recommended that a delay of at least 15 minutes to allow children be provided to enable them to recover from recent activities and apprehension. Cooperation can be increased by preparing the child for unusual sensation from pressure cuff. Auscultation errors may result from placing stethoscope too firmly on the antecubital fossa. Low frequency and amplitude makes Korotkoff sounds difficult to hear in children. A pediatric stethoscope bell can be helpful in these cases. Utrasonic Stethoscope If weak arterial pulse renders a nurse unable to auscultate sounds, the use of an ultrasonic stethoscope is recommended. This stethoscope allows the nurse to hear low-frequency systolic sounds. It is commonly used in blood pressure measurement of infants, children and adults

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with low blood pressure. Palpation The indirect palpation technique is useful for patients whose arterial pulsations are too weak to emit Korotkoff sounds. Conditions resulting in systolic blood pressure that is too low to accurately auscultate include severe blood loss and decreased heart contractility. Palpation can only assess systolic blood pressure as diastolic pressure is difficult to determine by palpation. The diastolic level is marked by a subtle change in sensation usually in the form of a thin, snapping vibration. When using the palpation technique, recording of the systolic value and the measurement method is required (e.g., RA 90/-, palpated, supine).

Procedures for Measuring Blood Pressure & Rationale

Identify need to assess client's BP. RATIONALE: Certain health conditions put patients at risk for BP changes (e.g., cardiovascular disease history, renal disease, diabetes, circulatory shock, etc.). Determine best location for BP assessment and cuff size. RATIONALE: Selection of inappropriate site may result in poor sound amplification rendering inaccurate measurement. Determine previous baseline BP (if available) from client's record. RATIONALE: Inaccurate readings may result from selection of inappropriate cuff size. Discourage client from engaging in exercise and smoking 30 mins before assessment of BP. RATIONALE: False BP elevation may result from exercise/smoking prior to BP measurement. Assist client to achieving lying or sitting position. Make sure that the room is warm, quiet and relaxing. RATIONALE: Patient comfort is maintained during BP measurement otherwise, environment may result in undue stress, which may affect BP reading.
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Explain to patient the procedure to be performed and have patient rest for at least 5 mins before taking measurement. RATIONALE: Patient anxiety which may influence BP measurement is reduced. Reading may increase as a result of talking with the patient during measurement. Wash hands. RATIONALE: Transmission of microorganisms is reduced. With patient sitting or lying, position patient's forearm or thigh and provide support if needed. RATIONALE: Diastolic pressure may increase as a result of isometric exercises due to absence of extremity support. Expose arm or thigh by removing clothing if necessary. RATIONALE: Proper cuff application is ensured. Palpate brachial artery or politeal artery. Position cuff 2.5 cm above pulsation site. Center bladder of cuff artery. With cuff deflated, wrap cuff evenly and snugly around upper arm. RATIONALE: Proper pressure application is ensured during inflation. False readings can be caused by loose-fitting cuff. Vertically position manometer at eye level, not more than 1 meter way from the client. RATIONALE: Looking at the meniscus of the mercury at eye level ensures accurate readings. Reading may be distorted by looking up or down at the mercury. Determine baseline BP by palpating brachial or radial artery with fingertips of one hand while inflating cuff rapidly to a pressure of 30 mm Hg above point at which pulse disappears. Deflate cuff slowly when pulse reappears. RATIONALE: False low reading is prevented. Palpation can determine maximal inflation point for accurate reading. Use of ultrasonic stethoscope is advised if pulse cannot be palpated. Deflate cuff full and wait for 30 seconds. RATIONALE: False high reading and venous congestion can be avoided by deflating cuff.
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Using stethoscope, make sure that sounds are clear and not muffled. RATIONALE: Earpiece should follow ear canal's angle to maximize hearing. Relocate brachial or politeal artery and place bell or diaphragm chestpiece over it. RATIONALE: Sound reception is ensured by proper placement of stethoscope. Improper positioning may muffle sound which may result in low systolic and false high diastolic reading. Tightly close valve of pressure bulb by turning it clockwise. RATIONALE: Air leak is prevented during inflation. Inflate cuff to 30 mm Hg above palpate systolic pressure. RATIONALE: Accurate measurement is ensured by inflating cuff until Korotkoff sound is heard at 30 mm HG. Release valve slowly and allow mercury to fall at a rate of 2 to 3 mm Hg/sec. RATIONALE: Inaccurate reading may result from too slow or rapid release of valve. Note point on manometer when first clear sound is heard. RATIONALE: Systolic pressure is indicated by first Korotkoff sound. Continue to deflate cuff and note point at which muffled or dampened sound appears. RATIONALE: Distinct sound muffling or the fourth Korotkoff indicates diastolic pressure in children. Continue to deflate cuff gradually and note point at which sound disappears. Note pressure to nearest 2 mm Hg. RATIONALE: For diastolic pressure in adults, the fifth Korotkoff sound is used as indication. Deflate cuff rapidly and completely remove cuff from client's arm unless there is a need to repeat measurement. RATIONALE: Arterial occlusion may result from continuous cuff inflation. If this is the first assessment of the client, repeat procedure on the other arm.
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RATIONALE:

Detection of circulation problem may be done by comparison of readings from both extremities (a difference of 5 to 10mm Hg between extremities).

Assist patient in returning to comfortable position and replace clothing on upper arm. RATIONALE: Restores patient comfort and well-being. Discuss findings with patient as necessary. RATIONALE: Patient participation in care is encouraged. Wash hands. RATIONALE: Transmission of microorganisms is minimized. Record BP and report abnormal findings. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

2.1. Hand

Washing and Asepsis

Asepsis is commonly defined as the absence of pathogenic organisms. Hand washing is a proven method of asepsis, which effectively minimizes the onset and spread of infection. It is the brief but vigorous rubbing together of all the hands' surface lathered with soap or antibacterial hand washing agents, followed by a thorough rinsing in a continuous stream of water. The purpose of this procedure is to remove dirt and any transient organisms from the hands and the reduction of microorganism count. Hand contamination is the most common cause of cross infection, diseases can be easily communicated from one person to another through hand contact or touching objects which have been contaminated. If a nurse fails to wash hands after handling articles, which are contaminated, he/she is most likely to spread infection.
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Factors Influencing Frequency of Hand Washing

Intensity of contacts with patients Patient/nurse's susceptibility to infection Contamination degree that could result from contact Procedure/activity to be performed

Situations Where Hand Washing is Necessary

When hands are visibly soiled Before and after contact with patient Before performing invasive procedures (e.g., intravascular catheter/indwelling catheter insertion) After contact with a source of microorganism (e.g., blood/ body fluids, mucous membrane or potentially contaminated objects) After removal of gloves

Methods of Hand Washing

It has been established that washing hands for at least 10-15 secs. will kill most transient microorganisms in the skin. Wash time however may depend on how severely soiled the hands are. Ordinary soap may be used in routine hand washing procedures. But in order to inhibit microorganism and reduce infection level, antiseptic agents should be used. Antibacterial soaps are also in wide use when it comes to areas or situations wherein the nurse has to reduce total microbial counts in the hands. This commonly occurs when the nurse comes in contact with patients who have wounds, bruises or those who are immunosuppressed. These agents are also used when the nurse is to perform an invasive procedure. In cases when facilities for hand washing may be considered inadequate, alcohol-based solutions are used. Normal hand washing should, however be immediately performed as soon as possible. Nurses are the ones who are tasked to educate patients/visitors on how to properly perform hand washing. Education is especially important if care is to continue at home.

Materials Required
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Deep sink Antiseptic detergent/soap Towel Running water

Procedures for Performing Hand Washing & Rationale

Inspect hands for breaks/cuts in skin or cuticles. Make sure to report and cover lesions before providing patient care. RATIONALE: Open cuts or wounds may be penetrated or may harbor microorganisms. Inspect hands for heavy soiling/dirt. Inspect nails for length. RATIONALE: Longer hand washing is required. Most microbes present in the hands come from under the fingernails. Pull uniform sleeves above wrists. Wristwatch and rings should be removed during washing. RATIONALE: Total access to fingers, hands and wrists is provided. Number of microorganisms may increase from wearing rings. Stand in front of sink, keeping hands and uniform away from sink surface. RATIONALE: Avoiding reaching into sink and touching edge prevents contamination. Turn on water by turning faucet on or using knee/foot control to regulate water flow and temperature. RATIONALE: Be careful not to splash water into uniform. Splashing water in uniform may result in contamination as moisture breeds microorganisms. Regulate water flow to achieve warm temperature. RATIONALE: Warm water removes less of protective oil compared to hot water. Wet hands and wrists thoroughly under running water. Hands and forearms should be lower than elbows during washing. RATIONALE: Since the hands are the most contaminated area, it should be washed after the elbows following the rule of washing from the
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least to the most contaminated area. Use soap or apply a small amount of antiseptic. Lather thoroughly. RATIONALE: Antiseptics eliminate bacteria but may irritate the skin. Their use depends on the procedure to be performed. Build lather and use plenty of friction for a minimum of 10-15 secs. Interlace fingers. Rub palms and back of hands using circular motion at least 5X for each hand. Keep fingertips down. RATIONALE: Soap emulsifies fat and oil thereby facilitating the cleaning process. Dirt and transient bacteria are removed by friction and rubbing. Interlacing fingers ensures total cleansing. Use both hands to clean fingernails using additional soap. RATIONALE: Areas under the fingernails are highly contaminated which may result in infection. Rinse hands and wrists thoroughly, keeping elbows up and hands down. RATIONALE: Dirt and microorganisms are washed away. Use paper towel, single use towel or warm dryer to dry hands. Dry hands thoroughly from fingers to wrists and forearms. RATIONALE: Contamination is prevented by drying from the least to the most contaminated areas. Discard used paper towel properly. RATIONALE: Transfer of microorganisms is prevented. Turn off water flow using foot or knee pedals. Use clean, dry paper towel to turn off hand faucet. Avoid touching with hands. RATIONALE: Prevents transfer of pathogens by capillary action. Inspect hands surface for signs of soil or contamination. RATIONALE: Determines adequacy of hand washing. Examine hands for dermatitis or cracked skin. RATIONALE: Determines skin complications resulting from excessive hand washing.
2.2.

Preparing a Sterile Field

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Chapter Three

Administering Medications
3.1. Administering Oral Medications 3.2. Administering Nasal Instillations 3.3. Administering Eye/Ear Medications 3.4. Administering Vaginal Instillations 3.5. Administering Rectal Suppositories 3.6. Instructing Client How to Use Metered-Dose Inhalers 3.7. Injections Preparation 3.8. Injections Administration 3.9. Adding Medications to IV Fluid Containers

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Administering Medications
The nurse is expected to perform accurate administration of drugs at all times. Preparation of medication requires absolute focus, which is why a medication nurse should not venture in any other task while doing so. To ensure safe drug administration, the following guidelines must be observed by the nurse. These are the "ten rights" of drug administration: 1. The right drug 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right advice 8. The complete drug history 9. The drug allergies 10. The drug

Kinds of Medications
There are a wide variety of medications and their respective routes. This is why it is imperative that nurses are able to distinguish medications sharing common characteristics by class. Classifying medications is usually indicative of the following: Medication's effect on a body system. Symptoms relieved by the medication. Desired effect of the medication.

Administration Routes
Medication or drug properties and their desired effect on patients' physical and mental states directly influence medications' route of administration. The nurse, in cooperation with the prescribing physician usually determines the best possible route for drug administration. As earlier indicated, there are a variety of routes by which drugs may be administered depending on how they are prescribed. These are:
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Oral routes - medication is given by mouth accompanied by fluid. Sublingual route - medication is absorbed by placing it under the patient's tongue. Buccal administration - dissolution of the medication by placing it against the cheeks' mucous membranes. Parenteral routes - is the injection of medication into body tissues. There are four major injection sites: Subcutaneous - injecting medication into tissues just under the dermis of the skin. Intramuscular - injecting into a muscle. Intravenous - Injecting into a vein. Intradermal - injecting into the dermis just below the epidermis. Epidural - administration of medication via the epidural space using a catheter. Intrathecal - administration of medication using a catheter placed into the subarachnoid space. Intraosseous - medication infusion directly into the bone marrow. Intraperitoneal - administration of medication into the peritoneal cavity. Intrapleural - administration of medication through the chest wall and directly into the pleural space. Intraarterial - administration of the medication directly into the arteries. Topical - application of medication onto the skin and mucous membranes. Inhalation - administration of medication through nasal passages.
3.1. Administering

Oral Medications

The most common and equally convenient way of administering medication is through the patient's mouth. Minimal problems are
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often associated with patients' ingestion or self-administration of oral medications. Medications in tablet or capsule form can be administered with fluid as allowed. However, there are cases wherein swallowing medications by mouth may be contraindicated. The following are primary contraindications to administering medication by mouth: Presence of gastrointestinal alterations. Patient's inability to swallow food/fluids. Use of gastric suction. In administering oral medication, it is extremely important to remember to protect the patient from aspiration. Aspiration occurs when fluid, food or medication intended for gastrointestinal administration is accidentally administered into the patient's respiratory tract. The patient can be protected from aspiration through assessing his/ her ability to manage oral medication. Patient positioning is also important during oral medication administration, sitting position is commonly ideal for patients receiving oral medication provided that it is not contraindicated to the patient's condition. The lateral position can also be utilized if the need arises. For patients with nasogastric feeding tubes, medications in tablet form may be administered by crushing and feeding them through the nasogastric tube.

Materials Required
Medication cart/tray Disposable medication caps Glass of water/juice Drinking straw Pill-crushing device (optional)

Procedures for Administering Oral Medications & Rationale

Assess patient for any contraindication to oral medication. RATIONALE: Medication distribution, absorption and excretion can be influenced by changes in gastrointestinal function.
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Assess patient's medical, allergy, medication and diet history. RATIONALE: These factors may affect medication action. Client's medication requirements may also be determined by these factors. Review data on assessment and laboratory results that may influence the procedure. RATIONALE: Contraindication to certain medications may be determined by laboratory results. Assess patient's knowledge of health and medication use. RATIONALE: Useful in determining patient's adherence to medication at home. Patient's medication tolerance can also be assessed in this manner. Assess patient's fluid preference. RATIONALE: Patient's fluid intake is reinforced by offering fluids during medication administration. Swallowing and absorption of medication in the gastrointestinal tract are facilitated by fluid intake. Check record's accuracy and completeness with prescribing physician's written medication order. RATIONALE: Medication order is most reliable reference of medication to be administered to patient. Medication preparation: Wash hands. RATIONALE: Reduces transmission of microorganisms. Arrange medication cups/trays in preparation area or place medication cart outside patient's room. RATIONALE: Errors in medication administration is prevented and preparation time is reduced. Prepare individual medication a patient at a time. Keep all record pages of individual patients together. RATIONALE: Medication preparation error is avoided. Choose correct drug from stock. Calculate drug dose as ordered. Re-check calculation. RATIONALE: Risk for error is reduced.
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Prepare capsules or tables with a floor stock bottle by pouring needed dose into bottle cap and transferring medication to medication cap. Avoid touching medication with fingers. Excess capsules or tablets can be returned to bottle. Using a pill-cutting tool or a gloved hand, break prescored medications. RATIONALE: Wastage of medication is avoided. Accuracy of dosage is ensured. Prepare unit-dose capsules or tablets by placing packaged capsule or tablet straight into medicine cup. Avoid removing wrapper. RATIONALE: Cleanliness of medications is ensured and medication name is identified. Simultaneously put capsules or tablets to be given to client in one medicine cup except when client requires pre-administration examination.. RATIONALE: Separation of medication with assessment requirements makes withholding of medication easier for nurse. In case of difficulty in swallowing, use a pill-crushing device to help client. If there's no such tool available, use two medication cups and pulverize tablet using a blunt instrument. Pulverized tablet can be combined with a little quantity of soft food. RATIONALE: Eases swallowing of medications in large tablet form. Preparation of liquid medication: Remove container cap. Place cap upside down. RATIONALE: Contamination from inside of cap is prevented. Hold bottle with label against palms. RATIONALE: Soiling of label is avoided. Hold medicine cup at eye level. Fill to desired amount based on the scale. RATIONALE: Accuracy of medication measurement is assured. Dispose of any excess medication into sink. Use paper towel to wipe neck of bottle. RATIONALE: Contamination of bottle contents is avoided. Draw volume of liquid medication taking in less than 10 ml. In
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syringe without needle. RATIONALE: Prevents overdosage. In the preparation of narcotics, check records for previous drug count and compare to drug supply. Check all medications' expiry dates. RATIONALE: Expired medication may cause patient harm or not have the desired effect. Compare prepared drug and container to record. RATIONALE: Reduces errors in administration. Replace containers/unused unit-dose medication in shelf/drawer. Recheck labels. RATIONALE: Reduces errors in administration. Drugs should never be left unattended. RATIONALE: Safekeeping of medication is nurse's responsibility. Administering medications: Administer medication to patient at correct time. RATIONALE: Desired therapeutic effects are ensured by administering medication within 30 min before or after prescribed time. Compare name on record with patient's identification bracelet. Ask patient's name. RATIONALE: ID bracelet is most reliable source of patient identification. Explain purpose of each medication and its action to patient. Entertain patient's questions (if any) about drugs he/she is receiving. RATIONALE: Compliance with medication therapy is improved by providing patient with understanding of medication he/she is receiving. Assist client to sitting or side-lying position if the former cannot be achieved. RATIONALE: Aspiration is prevented during swallowing of medication. Proper administration of drugs: Have client hold solid medication in hand/cup before placing in mouth. RATIONALE: Patient is familiarized with medication.
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Offer fluids (water/juice) to aid patient in swallowing medications. Give patient carbonated water if not contraindicated. RATIONALE: Swallowing is eased and fluid intake is improved. For administration of sublingual medication, tell patient to place medication under tongue until it dissolves. Tell patient to avoid swallowing medicine. RATIONALE: Medication is absorbed through blood vessels beneath patient's tongue. Swallowing sublingual medication will render it ineffective because gastric juices will destroy it. For buccally administered drugs, tell patient to place medication against cheek's mucous membranes until dissolved. Avoid administration of fluids until medication dissolves. RATIONALE: Buccal medications act locally through the mucosa or systemically as they adhere to the saliva. For powdered medications, mix them with liquids at bedside give to patient to drink. Tell patient about hazards of chewing or swallowing lozenges. RATIONALE: Medications such as lozenges are absorbed through the oral mucosa. Immediately give effervescent powders/tablet to client after dissolution. RATIONALE: Powdered medications may harden and become difficult to swallow if prepared in advance. For patient who can not hold medications, place medication cup to patient's lips and carefully introduce medication one at a time.

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RATIONALE:

Aspiration by introduction of multiple tablets is prevented.

Discard any tablet/capsule that may fall to the floor and repeat preparation. RATIONALE: Medications that have touched the floor are considered contaminated. Stay by bedside until patient swallows all medications. Patient should be asked to open mouth if there is uncertainty. RATIONALE: Patient's receipt of proper dose is ensured. In administering highly acidic medications, give patient a snack (non-fat) if not contraindicated. RATIONALE: Gastric irritation is reduced. Return patient to comfortable position. RATIONALE: Patient comfort is restored. Discard soiled supplies. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Return to patient's room and evaluate his/her response to the medication. RATIONALE: Medication's desired effect, side effects and allergic reactions are determined. Ask patient/family member to identify medication name, its purpose, action and possible side effects. RATIONALE: Patient/family's understanding of medication is determined. Notify prescribing physician in case of toxic effect, allergic reactions or side effects. Discontinue medication dose. RATIONALE: Prescriber is notified of possible need to change or discontinue medication. Record oral medications administration/withholding. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

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3.2. Administering Nasal Instillations

Patients suffering from nasal sinus alterations are usually given medication by drops, spray or tampons. Decongestant sprays are used in relieving sinus congestion and cold symptoms. For children, saline drops are commonly used as decongestant as it is safer than nasal preparations. Sprays are most useful for patients who are self-medicating, but nasal drops are proven to be more effective in the treatment of sinus infections. In this type of administration, the nurse is expected to learn the importance of positioning the patient so as to maximize the possibility of properly and accurately administering the drug. For nosebleeds, tampons and packs treated with epinephrine are used since they reduce the flow of blood.

Materials Required
Medication with dropper/spray container Facial tissue Disposable gloves Penlight

Procedure for Administering Nasal Instillations

Determine which of patient's sinuses are affected before using nasal drops. RATIONALE: Ensures that medication is introduced on the affected sinus. Assess patient history for hypertension, heart disease, diabetes mellitus and hyperthyroidism. RATIONALE: Patients with histories of these conditions are contraindicated to decongestants that stimulate the central nervous system. Examine condition of patient's nose and sinuses. Palpate sinuses for tenderness. RATIONALE: Baseline for monitoring medication effects is provided. Nasal discharge may interfere with administration. Assess patient knowledge of use/technique for instillation and potential to learn self-administration.
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RATIONALE:

Aids in teaching patient self-instillation of medication.

Explain to patient procedure regarding positioning and expected sensations. RATIONALE: Reduces patient's anxiety by anticipation of procedure experience. Wash hands. RATIONALE: Reduces transmission of microorganisms. Place medications/supplies by bedside. RATIONALE: Provides easy access to medication. Instruct patient to clear nasal passages by gently clearing/blowing nose. RATIONALE: Clears away mucus and secretions that may interfere with installation of medication. Administration of nasal drops: Assist client in achieving supine position. Positioning patient's head: Tilt patient's head backward to gain access to posterior pharynx. To gain access to ethmoid or sphenoid sinus, tilt patient's head back over edge of bed or put a small pillow under patient's shoulder and tilt head back. To gain access to frontal and maxillary sinuses, tilt patient's head back over edge of bed or place pillow with head turned to side to be treated. RATIONALE: Allows for easy access to nasal passages. Use non-dominant hand to support patient's head. RATIONALE: Neck muscle strain is prevented. Patient should be instructed to breathe through the mouth. RATIONALE: Chances of aspirating nasal drops into trachea and lungs is reduced. While holding dropper 1 cm above patient's nose, administer needed number of drops toward ethmoid bone's midline. RATIONALE: Dropper contamination is prevented. Distribution of medication over nasal mucosa is ensured. Instruct patient to remain in supine position for 5 mins.
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RATIONALE:

Premature ejection of medication through nares is avoided.

Offer patient facial tissue to blot runny nose. Warn client against blowing nose for several mins. RATIONALE: Allows for maximum absorption of medication. Assist client in achieving comfortable position after drug's absorption. RATIONALE: Restores patient comfort. Discard soiled supplies properly. RATIONALE: Orderly environment is maintained. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Observe patient for 15-30 mins after administration for onset of side effects. RATIONALE: Systemic reaction can be caused by medication absorbed through mucosa. Inquire if patient is able to breathe through nostrils after administration of decongestant. RATIONALE: Effects of decongestant medication is determined. Re-check nasal passages' condition between instillations. RATIONALE: Patient's response to medication is determined. Have patient review risks of decongestant overuse and administration methods. RATIONALE: Patient's capacity for self-medication is determined. Ask patient to demonstrate self-administration. RATIONALE: Learning is demonstrated. Record medication administration and patient response. Report presence of any unusual systemic effects. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
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3.3. Administering

Eye/Ear Medications

Eye Medications
Medications also commonly used by patients are eye drops or ointments. Certain eye conditions such as cataract extraction and glaucoma however may need prescription drugs in the form of ophthalmic medications. Because most patients using eye medications are adults, the nurse most of the time instructs the patient and family members on the proper techniques of instilling eye medication. This is usually done through return demonstrations. Patient compliance can be greatly affected through proper education.

Materials Required
Medication with sterile eye dropper/ointment tube Cotton ball/tissue Washbasin filled with warm water and washcloth Eye patch and tape Disposable gloves

Ear Medications
The internal part of the ear is extremely temperature sensitive, which calls for the instillation of drops at room temperature. Failure to do so may result in vertigo or nausea. Sterile drops are often used in cases of ruptured eardrums. The use of non-sterile ear drops often cause infection. The nurse is usually required to assess the patient for any damage to the ear drums. Occlusion of the ear canal using a dropper or irrigating syringe is discouraged as it may injure the ear drum. As the ear structures of children significantly differ from those of adults, the nurse should take extra care in instilling eardrops. The ear canal should be straightened before the instillation of drops. Failure to do so may result in the possibility of the medication not reaching
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the internal ear structure.

Materials Required
Ear medication with dropper Cotton ball or tissue

Procedures in Administering Ophthalmic Medications & Rationale

Review prescribing physician's medication order. Identify patient. RATIONALE: Ensures correct administration of medication and that correct patient receives right medication. Carry out an assessment of patient's external eye structures. RATIONALE: Baseline for determining patient reaction to medication is established. Assess patient's history for allergies to eye medications. Inquire if patient has any allergy to latex. RATIONALE: Allergic response is avoided, prompts nurse to use non-latex gloves. Assess patient for any symptoms of visual changes. RATIONALE: Some medications alter these symptoms, enables nurse to recognize changes in patient's condition. Determine patient's level of consciousness and capacity to carry out directions. RATIONALE: Patients who become combative during onset of procedure may cause further accidental eye injury. Determine patient's knowledge of drug therapy and willingness to self-medicate. RATIONALE: Determines need for health teaching. Assess ability of patient to hold/manipulate eye-dropper. RATIONALE: Determines patient's capacity to self-medicate. Explain procedure to patient. RATIONALE: Improves patient anxiety and promotes cooperation.
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Wash hands. RATIONALE: Transmission of microorganisms is reduced. Place supplies by patient's bedside. RATIONALE: Provides nurse with easy access to equipment/supplies. Apply gloves. RATIONALE: Reduces transmission of microorganisms. Have patient lie in a supine position or sit back on a chair lightly hyper extending head. RATIONALE: Nurse is provided with easy access to patient's eye. Drainage of medication to outer canthus is minimized. Clean away any crust or drainage on patient's eyelids/inner cantus. To soften dried crusts, soak and remove by using a damp cloth or cotton ball for a few mins. RATIONALE: Microorganisms thrive in crusts/drainage. Easy removal is facilitated by soaking. Entry of microorganism into lacrimal duct is avoided. With non-dominant hand, hold tissue/cotton ball to patient's cheekbones below lower eyelid. RATIONALE: Cotton or tissue absorbs medication that may escape eye. Gently use thumb or forefinger against bony orbit with tissue/ cotton ball below lower lid. RATIONALE: Lower conjunctival sac is exposed. Pressure and trauma to eyeball are avoided. Fingers are prevented from touching eye. Ask patient to look up to ceiling. RATIONALE: Cornea is retracted upward away from conjunctival sac. Stimulation of blink reflex is reduced.
ADMINISTERING EYEDROPS

Rest non-dominant hand on patient's forehead. Hold medication eye dropper/opthalmic solution approximately 1-2 cm above conjunctive sac. RATIONALE: Accidental contact of eyedropper with eye structures is prevented. Eye injury and dropper contamination are avoided.
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Instill required number of medication drops into conjunctival sac. RATIONALE: The normal capacity of conjunctival sac is 1 to 2 drops. Even distribution of medication is ensured. Repeat procedure in case patient blinks or closes eye or drops fail to land on conjunctival sac. RATIONALE: Medication's desired effect can only be attained if drops enter conjunctival sac. Have client close eyes gently after instillation of drops. RATIONALE: Medication distribution is ensured. Medication present in conjunctival sac can be forced out by squinting or squeezing of eyelids. For drugs with systemic effects, use a clean piece of tissue to apply gentle pressure on patient's nasolacrimal duct for 30-60 secs. RATIONALE: Overflow of medication into nasal/pharyngeal passages is avoided. Absorption of medication into systemic circulation is prevented. INSTILLING EYE OINTMENT Have patient look up at ceiling. RATIONALE: Cornea is retracted upward away from conjunctival sac. Stimulation of blink reflex is reduced. Hold ointment applicator above lower lid margin. Apply thin film along lower eyelid's inner edge, from the inner to the outer canthus of the conjunctiva. RATIONALE: Medication is distributed evenly across eye and lid margin. Ask patient to close eye and using a circular motion, rub lid gently with a cotton ball (if not contraindicated). RATIONALE: Medication is further distributed. Applying intraocular disk: Wash hands. Apply gloves. RATIONALE: Reduces transmission of microorganisms. Open disk package. Gently press disk with fingertip until it adheres to finger. Place disk's convex side on fingertip.
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RATIONALE:

Disk is inspected for damage.

With non-dominant hand, pull client's lower eyelid gently away from eye. Have client look up at ceiling. RATIONALE: Conjunctival sac is exposed for placement of disk. Put disk in the conjunctival sac, making it float on the sclera in between lower eyelid and iris. Pull patient's lower eyelid out and over disk. Proper delivery of medication is ensured. Removal: Wash hands. Apply gloves. RATIONALE: Reduces transmission of microorganisms. Explain the procedure to patient. Improves patients understanding of procedure. Reduces anxiety and promotes cooperation. Expose disk by gently pulling on patient's lower eyelid. With forefinger and thumb of other hand, lift disk out of patient's eye by pinching it. Gently wipe excess medication on eyelid (if any), wipe from inner to outer canthus. RATIONALE: Trauma to the eye is avoided and comfort restored. For patient with an eye patch, replace patch with a clean one. Make sure the patch covers the entire eye. Secure by applying tape without applying pressure to eye. RATIONALE: Possibility of infection is reduced. Remove and dispose of gloves properly. Discard soiled supplies properly. Wash hands. RATIONALE: Reduces transmission of microorganisms. Observe patient's response to instillation. Ask patient for any feeling of discomfort. RATIONALE: Medication action is determined. Have client discuss drug's purpose, action, side effects and technique of instillation.
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RATIONALE:

Patient's level of understanding is assessed.

Ask client to demonstrate self-instillation of next dose. RATIONALE: Determines patient's capacity to self-medicate. Record drug administration and take note of the appearance of patient's eye. Record and report adverse side effects. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
3.4. Administering

Vaginal Instillations

Vaginal medications often come in the form of suppositories, foam, jellies or cream, but the most commonly used are those in suppository form. The suppository melts at room temperature so that it should be refrigerated before any instillation is performed. Upon insertion of suppository into the vaginal cavity, body temperature tends to melt it allowing for distribution and subsequent absorption of the drug. Inserting vaginal suppositories requires the nurse to don disposable gloves. Because of the procedure's relative simplicity, many female patients prefer to insert vaginal suppositories on their own. Perineal pads should be provided to patients to catch vaginal drainage after insertion. Other forms of vaginal medications are applied using applicators.

Materials Required
Vaginal cream, jelly, foam or suppository or irrigating solution Applicator Disposable gloves Tissue/cotton balls Perineal pad Drape KY jelly Bed pan
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Douche container

Procedures in Administering Vaginal Medications & Rationale

Check medication order. RATIONALE: Safe and accurate medication administration is ensured. Wash hands. RATIONALE: Reduces transmission of microorganisms. Prepare necessary equipment/supplies. Identify patient and explain procedure. RATIONALE: Provides easy access to materials needed. Ensures that correct patient receives correct medication. Assess patient's external genitalia and vaginal canal. RATIONALE: Baseline information for monitoring of medication action is provided. Assess patient for ability to manipulate medication applicator and position him/herself. RATIONALE: Determines level of assistance to be provided to patient. Explain to patient the procedure. RATIONALE: Patient's understanding of procedure is improved. Reduces anxiety and promotes cooperation. Arrange equipment/supplies by bedside. RATIONALE: Provides nurse with easy access to equipment/supplies. Provide needed privacy. RATIONALE: Minimizes patient's embarrassment. Help patient establish dorsal recumbent position. RATIONALE: Exposes vaginal canal. Suppository is allowed to dissolve without escaping vaginal orifice.
RATIONALE:

Drape patient's abdomen and lower extremities. Minimizes patient's embarrassment.

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RATIONALE:

Put on disposable gloves. Reduces transmission of microorganisms.

Inserting suppository: Remove suppository from wrapper. Lubricate smooth and rounded end. Lubricate dominant hand's gloved finger. RATIONALE: Friction against mucosal surfaces is reduced during insertion. With non-dominant gloved hand, retract patient's labial folds. RATIONALE: Vaginal orifice is exposed. Insert suppository's rounded end about 7.5-10 cm along posterior wall of vaginal canal. RATIONALE: Even distribution of medication along vaginal cavity walls is ensured. Withdraw finger. Wipe away lubricant from patient's orifice and labia. RATIONALE: Patient comfort is restored. Application of cream or foam: Follow directions in filling applicator. With non-dominant gloved hand, retract patient's labial folds. RATIONALE: Prevents overdosage of medication. Vaginal orifice is exposed. Insert applicator 5-7.5 cm with dominant gloved hand. Push plunger. RATIONALE: Even distribution of medication along vaginal cavity wall is ensured. Withdraw applicator, place it on a paper towel. Wipe lubricant from patient orifice and labia. RATIONALE: Microorganisms may be present in residual cream in applicator. Remove disposable gloves and discard properly. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Wash and store applicator for future use. RATIONALE: Microorganisms present in applicator are removed.
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Have patient remain flat on her back for at least 10 mins. RATIONALE: Even distribution and absorption of medication is ensured. Offer perineal pad to patient. RATIONALE: Vaginal discharge is prevented from soiling patient's clothing. Assess condition of patient's vaginal canal and external genitalia in between cream/foam application. RATIONALE: Determines medication action and relief from irritation. Record administration of medication. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
3.5. Administering Rectal Suppositories

Rectal suppositories differ from vaginal suppositories in that they are thinner and are more shaped like bullets. This shape is adopted so as to prevent anal trauma during insertion. Medications contained in rectal suppositories usually have local effects such as anti-pyretic effects. Rectal suppositories are best refrigerated pending administration. When administering rectal suppositories, the nurse should insert the medication past the internal anal sphincter and against the rectal mucosa. The purpose of this is to facilitate absorption of the medication by the mucosa. In some cases it may be imperative to clear the rectum of any fecal matter before insertion using a cleansing enema.

Procedures for Administering Rectal Suppositories & Rationale

Check medication order. RATIONALE: Safe and accurate administration of medication is ensured. Check patient's medical record for rectal surgery or bleeding. RATIONALE: Condition maybe contraindicated to suppository use.
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Wash hands. RATIONALE: Reduces transmission of microorganisms. Prepare necessary equipment/supplies. Put on disposable gloves. RATIONALE: Provides easy access to materials needed. Saves time. Contact with fecal matter is minimized. Reduces transmission of microorganisms. Identify patient. RATIONALE: Ensures that correct medication is administered to correct patient. Explain to patient the procedure. RATIONALE: Provides patient with understanding of procedure. Reduces anxiety and promotes cooperation. Place supplies at patient's bedside. RATIONALE: Provides nurse with easy access to supplies. Provide needed privacy. RATIONALE: Reduces patient's embarrassment. Assist patient in achieving Sims' position. RATIONALE: Exposes patient's anus and helps relax external anal sphincter. Drape patient completely except for anal area. Prevents unnecessary exposure of patients private parts. Assess condition of patient's external anus. Palpate rectal walls. RATIONALE: Presence of active rectal bleeding is assessed. Presence of fecal matter in rectum, which may interfere with medication administration is determined. If gloves become soiled, remove and replace with new ones. Unwrap suppository and lubricate rounded end. Apply lubrication to finger of gloved dominant hand. RATIONALE: Maintains sterility. Friction during suppository insertion is reduced. Have patient take slow, deep breaths through the mouth to relax anal sphincter.
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RATIONALE:

Relaxes anal sphincter and prevents pain from forceful insertion of suppository.

Use non-dominant hand to retract patient's buttocks. RATIONALE: Exposes external anal sphincter. Gently insert suppository through anus using index finger of dominant hand. Push suppository through anus past internal sphincter and place against rectal wall, 10 cm for adults/5 cm for children and infants. RATIONALE: Medication must come in contact with rectal mucosa to facilitate absorption. Withdraw finger. Wipe client's anal area. RATIONALE: Restores patient comfort. Remove and discard gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Make sure patient will have help in reaching bedpan/toilet if suppository contains laxative or fecal softener. RATIONALE: Provides patient with sense of control over elimination. Have patient remain flat on back for 5 mins. RATIONALE: Expulsion of suppository is prevented. Return after 5 mins to check if suppository was expelled. RATIONALE: Reinsertion of suppository maybe needed. Thirty mins after administration, observe patient for suppository's effects. RATIONALE: Medication action is evaluated. Record medication administration. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
3.6. Instructing

Client How to Use Metered-Dose

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Physiology
Administration of medication through the use of handheld inhalers, usually are dispersed by aerosol spray, mist or powder aimed at reaching lung airways. Medication is rapidly absorbed by the alveolocapillary network. These inhalers are designed to have local effects the most common of which is bronchodilation. Many inhalers of these types however have been proven to have systemic side effects. Patients with chronic respiratory disease (e.g., asthma, emphysema or bronchitis) are usually those who receive frequent medication by inhalation. Inhalers provide relief from airway obstruction .

Importance
Because patients who suffer from chronic respiratory diseases depend on the use of inhalers, they need to be educated on the use of the drug and its proper administration.

Mechanics of Delivery
A metered-dose inhaler delivers an accurately measured dose of medication with each push of the canister. Approximately 5-10 pounds of pressure is required to activate the aerosol. The nurse needs to have knowledge of this because of the fact that hand strength in older patients are significantly diminished compared to young adults and the like. The nurse is the one tasked with evaluating the patient's capability to properly use the inhaler.

Materials Required
Metered-dose inhaler with medication canister Facial tissue (optional) Washbasin with warm water Paper towel/towel

Instructing Client How to Use Metered-Dose Inhalers

Assess patient's ability to hold, manipulate and press canister and inhaler. RATIONALE: Patient's ability to use inhaler is determined.
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Appraise patients readiness and ability to learn. RATIONALE: Determines patient's capacity to learn. Assess patient's knowledgeability about his/her disease and purpose/action of the medication. RATIONALE: Patient's knowledge of condition and medication is vital in understanding inhaler use. Assess medication schedule and number of inhalations necessary for each dose. RATIONALE: Influences nurse's explanation on use of inhaler. Assess patient technique in inhaler use if previously instructed in self-administration. RATIONALE: Reflects patient's ability to self-medicate and level of assistance required. A comfortable environment should be provided in instructing the patient. RATIONALE: Provides an atmosphere conducive to learning. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Prepare equipment needed. Give patient time to manipulate inhaler, canister and spacer device. Explain/demonstrate method of fitting canister into inhaler. RATIONALE: Provides easy access to materials needed and saves time. Familiarizes patient with inhaler. Explain to patient the meaning of metered dose and cautions against the danger of inhaler overuse and side effects of the drug. RATIONALE: Protects patient against excessive inhalation. Steps for administering inhaled dose of medication: Detach inhaler's mouthpiece cover. Shake inhaler well. RATIONALE: Fine particles are aerosolized. Ask patient to take a deep breath and exhale.
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RATIONALE:

Patient's airway is prepared for medication.

Instruct patient to position inhaler: Place inhaler in patient's mouth with opening toward back of the throat. Position device 3.5-5 cm from the mouth. RATIONALE: Aerosol spray is directed toward airway. With proper position achieved, ask patient to hold inhaler at the mouthpiece using thumb and index and middle finger at the top. RATIONALE: Use of a three-point/lateral hand position to activate canister is best method to use metered-dose inhalers. Have patient tilt head back slightly. Ask patient to inhale deeply and slowly through mouth, afterwards instruct patient to fully depress medication canister. RATIONALE: Distribution of medication to airways is ensured. Inhalation through mouth distributes medication more evenly than through nose. Ask patient to hold breath for about 10 secs. RATIONALE: Deeper branches of airways are reached by tiny aerosol drops. Instruct patient to exhale through pursed lips. RATIONALE: Tiny airways are kept open during exhalation. Explain and demonstrate to patient steps in administering inhaled dose of medications with the use of a spacer such as an aerochamber: Detach inhaler's mouthpiece cover and aerochamber's mouthpiece. Insert inhaler into aerochamber's end. Shake inhaler well. RATIONALE: Fine particles are aerosolized. Instruct patient to place aerochamber mouthpiece into mouth and close lips. Caution patient against inserting mouthpiece beyond raised lip. Tell patient to avoid covering inhalation slots with lips. Ask patient to perform normal breathing through aerochamber mouthpiece. RATIONALE: Patient is relaxed before medication delivery. Ask patient to press medication canister to spray a puff into
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aerochamber. RATIONALE: Allows fine particles to be inhaled. Ask patient to take full, slow breaths for 5 secs. RATIONALE: Particles are distributed in deeper airways. Tell patient to fully hold breath for 5-10 secs. RATIONALE: Full medication distribution is ensured. Patient should be instructed to wait 2-5 mins between inhalations or as prescribed. RATIONALE: Inhalation of medication must be done in a sequential manner. Airways are opened and inflammation is reduced by first inhalation, while deeper airways are penetrated by second and third inhalations. Caution patient not to repeat inhalations before next scheduled dose. RATIONALE: Prevents medication overdosage. Constant drug levels are ensured and side effects minimized. Explain to patient possible gagging sensation inside throat which may be caused by medication droplets. RATIONALE: Incorrect spray and inhalation results to gagging. Demonstrate to client removal of medication canister and cleaning of inhaler in warm water. RATIONALE: Spray accumulation around mouthpiece may interfere with medication distribution. Ask patient to explain and demonstrate steps in inhaler use. RATIONALE: Patient's understanding of procedure is assessed. Have patient explain medication schedule. RATIONALE: Medication compliance is ensured. Ask patient to describe medication's side effects and proper situation for calling physician. RATIONALE: Enables patient to determine medication overuse or ineffectiveness. Assess patient respirations and auscultate lungs after medication
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instillation.
RATIONALE:

Breathing pattern status and ventilation adequacy are determined.

Record procedure, patient education and ability to self-administer medication. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
3.7. Preparing Injections

Parenteral Administration
Injections are commonly used in the parenteral administration of medication. Aseptic technique should be observed at all times since this is a procedure of an invasive nature. Skill in handling injections is required of a nurse performing the procedure. The effects of parenteral administration comes immediately after instillation depending on the absorption rate of the medication.

Types of Injections
Subcutaneous injections

This type of injection is the placement of medication in the dermis' loose connective tissue. In this type of injection, medication absorption is slow compared to intramuscular injection. This is because of the minimal blood supply in subcutaneous tissues. Medication absorption however is imminent in patients who have normal circulatory status. There are a number of sites in which to perform subcutaneous injections: Outer posterior aspects of the upper arms. Abdomen from below the costal margins to the iliac crests. Anterior aspects of the thighs. Scapular areas of the upper back. Upper ventral/dorsal gluteal areas.
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It should be noted that a selected injection site should be free of lesions, bony prominences or large underlying muscles/nerves. Since subcutaneous tissue may be irritated by solutions, injections are limited to small doses of water-soluble medications.

Intramuscular injections
This type of injection is probably the best in terms of medication absorption owing to the muscles' large supply of blood. Risk of tissue damage is also minimal even if medication enters deep muscle. The risk of medication entering a blood vessel however is present. Long and large needles are often used in intramuscular injections so as to penetrate deep muscle tissue. The amount of adipose tissue present in an injection site often serves as basis for needle selection. Ninety (90) degrees is the angle of insertion for intramuscular injections. The volume of medication usually depends on the age group where the patient belongs. Before injecting, it is imperative to assess muscle integrity. The muscle should be free of tenderness. Repeated injection into a muscle could cause discomfort and therefore should be avoided. Palpation of the muscle is usually how the nurse assesses for any hardened lesions. Helping the patient assume a comfortable position before injection may help prevent discomfort.

Techniques in intramuscular injection

Z-Track method. This method minimizes irritation by sealing the medication in muscle tissue. Injection site should preferably be larger, deeper muscles. Air-lock Technique. The use of this method usually reduces irritation in subcutaneous injections during withdrawal of the needle. It involves injection of a small volume of air behind a bolus of medication which clears the needle of medication. It prevents tracking of the medication through subcutaneous tissue. Intradermal injections. Intradermal injections are usually done when doing skin testing. This is due the fact that most of these medications are potent, injecting them into the dermis (which has less blood supply) slows down absorption. This may cause anaphylactic reactions on
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the part of the patient which may occur if the medication enters circulation. Tuberculin or small hypodermic syringes are usually used in skin testing. The angle of insertion is usually 5-15 degrees. Upon injection, a bleb similar to a mosquito bite will appear on the skin surface.

Injection Preparation
From an ampule

Single-dose medications usually come in ampule form. Ampules are made of glass which can be readily snapped at the neck to gain access to the medication. Once open, medication may be aspirated with the use of a plain or a filter needle.
From a vial

Single or multi-dose medications are usually contained in a vial, which has a rubber seal on top. Vials may contain medication in liquid or dry form. For dry medications, the label on the vial usually indicates the appropriate solvent to be used in diluting the dry component. Commonly used diluents are normal saline and sterile distilled water. A vial being a closed container, requires the injection of air into it in order to facilitate easy aspiration of medication. Failure to do so would create a vacuum inside the container thereby making medication withdrawal difficult.

Medication Mixing
It is usually possible to mix 2 compatible medications in a single injection provided the desired dose is within acceptable limits. The nurse in cases where there is doubt on the compatibility of medications should at all times consult a pharmacist. There are three principles, which the nurse should observe when mixing medications from two vials: Avoid contaminating a medication with another. Make sure of the final dose's accuracy. Aseptic technique should at all times be maintained. A single syringe usually suffices in mixing medications from two vials. The nurse usually injects volume of air equivalent to the first
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medication's required dose. The air in the syringe is then injected into the first vial making sure to avoid touching the medication with the needle. The needle is then withdrawn and the same process is repeated for the second vial. Medication is then withdrawn from the second vial, application of a fresh sterile needle is then needed to avoid medication contamination. The nurse then withdraws medication from the first vial, thereby completing the dose.
From one vial and one ampule

This is a relatively simple procedure. This is because there is no need to add air in order to withdraw medication from an ampule. Medication is prepared first from the vial, after which the same needle is used to withdraw medication from the ampule. Through this method, contamination of solution in the vial is prevented.

Materials Required
Ampule

Syringe and 2 pcs. of needles Gauze pad/alcohol swab

Vial

Syringe and 2 pcs. of needles Gauze pad/alcohol swab Diluent (normal saline or sterile water)

Procedure for Preparing Injections & Rationale

Check medication order. RATIONALE: Accurate medication administration is ensured. Review important information related to medication. RATIONALE: Proper medication administration is achieved, patient's response to medication is monitored. Assess patient's body build, muscle size and weight. RATIONALE: Syringe type and size to be used is determined. MEDICATION
PREPARATION

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Ampule preparation: Use finger to tap ampule lightly and quickly until fluid moves from ampule's neck. RATIONALE: Fluid above ampule neck is dislodged. Place small gauze pad around ampule's neck. RATIONALE: Protects nurse from possible injury from broken off glass tip. Check ampule if it is filled, then quickly and firmly snap ampule's neck, holding it away from body. RATIONALE: Set ampule on a flat surface or hold it upside down. Prevents injury. Insert syringe/filter needle into ampule opening. Avoid touching ampule's rim with needle tip/shaft. RATIONALE: Ampule's broken rim is contaminated. Make sure needle is under surface of liquid. Bring all fluid within needle's reach by tipping ampule. RATIONALE: Fluid is pulled into syringe by negative pressure created by withdrawal of plunger. Avoid expelling air into ampule if air bubbles are aspirated. RATIONALE: Fluid may be expelled out of ampule by air pressure. Expel excess air bubbles by removing needle from ampule. Hold syringe with needle pointing up. Make bubbles rise by tapping side of syringe. Slightly draw back plunger and eject air by pushing plunger upward. Avoid ejecting fluid. RATIONALE: Fluid is allowed to settle in barrel's bottom. Fluid within needle enters barrel by pulling back on plunger. Air present in top of barrel and needle is expelled. Dispose of excess fluid in syringe in sink. Vertically hold syringe with needle upwards and slightly slanted toward sink. Eject excess fluid slowly into sink. Hold syringe vertically to recheck fluid level. RATIONALE: Medication is safely disposed of. Medication is expelled without

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flowing down needle shaft. Proper dose is ensured by rechecking fluid level. Use syringe's safety cap to cover needle. If presence of medication on needle shaft is suspected, change syringe or use filter needle. Needle contamination is prevented. Tracking of medication through skin and SQ tissues is prevented. Vial containing solution: Expose sterile rubber seal by removing cap covering top of unused vial, keeping rubber seal sterile. If a multidose vial is in use, wipe surface of rubber seal briskly and firmly using alcohol swab and allow it to dry. RATIONALE: Contamination of rubber seal is prevented by cap. Coating of needle with alcohol which may mix with medication is prevented by letting alcohol dry. Get syringe and remove needle cap. Draw amount of air into syringe equivalent to medication volume to be aspirated by pulling back on plunger. RATIONALE: Buildup of negative pressure in vial is avoided during medication aspiration. Place vial on flat surface and place needle tip with beveled tip entering center of rubber seal. Exert pressure on needle tip while inserting. RATIONALE: Seal's center is easier to penetrate because it's thinner. Prevents rubber seal coring which could enter vial/needle. Inject air into vial airspace while holding plunger. RATIONALE: Bubble formation and dose inaccuracy is prevented. Plunger should be held with firm pressure as it may be forced backward by air pressure from the vial. Invert vial while firmly holding syringe and plunger. Vial should be held between nondominant hand's thumb and middle fingers. Hold syringe barrel's end and plunger using thumb and forefinger of dominant hand in order to counteract pressure inside vial. RATIONALE: Avoids accidental spillage. Fluid is allowed to settle in lower half
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of container. Forceful movement of plunger allows for manipulation of syringe. Keep needle tip below fluid level. RATIONALE: Aspiration of air is prevented. Allow air pressure coming from vial to gradually fill syringe with medication. Slightly pull back on plunger to get correct amount of solution. RATIONALE: Fluid is forced into syringe by positive pressure within vial. When desired amount of medication is taken, place needle in to airspace of vial. Carefully tap syringe barrel's side to dislodge any air bubbles. Expel any remaining air into vial. RATIONALE: Needle may be bent by forceful tapping of barrel. Medication can be displaced by presence of air which may cause dosage error. Pull back on syringe's barrel to remove needle from vial. RATIONALE: Medication loss may stem from separation of plunger from barrel as a result of pulling on plunger instead of the barrel. Syringe should be held at a 90 angle at eye level to ensure that correct volume is obtained and there are no air bubbles. Tap barrel to dislodge remaining air bubbles (if any). Slightly draw plunger back and push plunger up to expel air. Avoid ejecting fluid. RATIONALE: Fluid is allowed to settle in barrel's bottom. Fluid within needle enters barrel by pulling back on plunger. Air is expelled from barrel If medication is to be injected into patient's tissue, change needle to suitable gauge and length in accordance with medication route. RATIONALE: New needle is sharper than one that has been inserted through a rubber stopper. Needle will not track medication through tissues since no fluid is present in needle. In using multidose vials, create label reflecting date of mixing, concentration and drug/ml and your initials. RATIONALE: Correct preparation of future doses is ensured. Some medications
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should be discarded after a certain period from time of mixing. Vial containing powder (medication reconstitution): Remove cap from vial of powdered medication and cap from diluent. RATIONALE: Contamination of rubber seal is prevented by cap. Insert needle's tip through center of powdered medication's rubber seal. RATIONALE: Diluent is prepared for injection into vial with powder medication. Thoroughly mix medication. Roll vial in palm. RATIONALE: Proper dispersal of medication throughout solution is ensured. Avoid shaking. RATIONALE: Bubbles can be produced by shaking. Determine dose after reconstituting by reading label carefully. RATIONALE: Dose to be given is determined by medication concentration (mg/ ml). Clean work area. RATIONALE: Accidental injury to staff is prevented by proper disposal of glass and needle. Transmission of infection is reduced. Wash hands. RATIONALE: Reduces spread of microorganisms.
3.8. Injection Administration

There are different injection routes by which to administer medication, depending on the type of tissue where the injection is to be done. Medication absorption and action depends largely on the tissue characteristics. There are three things that a nurse should know before injecting a medication: Volume of medication to be administered.

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Viscosity and characteristic of medication. Injection sites' anatomical structure. There are consequences in case a nurse fails to properly administer an injection, these include nerve or bone damage during insertion, tissue damage and pain for the patient and accidental injection of air into a vein or artery. For some reason, many patients most specially children fear injections. There are however ways by which a nurse can minimize patient discomfort during needle insertion: Use of a sharp beveled needle in the smallest length possible. Reduction of muscular tension through positioning of patient in the most comfortable manner as possible. Proper selection of injection site. Conversing with the patient so as to divert attention from the injection. Minimizing tissue pulling by quick and smooth insertion of needle. Slow and steady injection of the medication.

Procedure for Injection Administration & Rationale

Check order for medication. RATIONALE: Safe and correct administration of medication is ensured. Check patient for history of allergies. RATIONALE: Substances to which patient is allergic should not be administered. Assess patient for contraindication to subcutaneous or intramuscular injections. RATIONALE: Physiological changes associated with aging or illness may affect amount of SQ tissue a patient has. Accurately prepare medication dose from ampule/vial. Check carefully and be sure to expel all air. RATIONALE: Medication is poorly absorbed by atrophied muscle. It may also be impaired by factors impeding blood flow to muscles. Identify patient.
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Ensures that correct drug is administered to correct patient. Explain procedure to patient. Patient's understanding of procedure is improved. Provide necessary privacy. RATIONALE: Patient embarrassment is reduced. Wash hands. RATIONALE: Transmission of microorganism is reduced. CHOOSE
IDEAL INJECTION SITE . INSPECT SKIN FOR BRUISES , INFLAM MATION OR EDEMA

For Subcutaneous Injections (SQ): Palpate site for masses/tenderness, these areas should be avoided. Check accuracy of needle size by site's skinfold using thumb and forefinger. Measure fold from top to bottom. For Intramuscular Injections (IM): Examine muscle size and integrity, palpate for tender/hard areas. These areas should be avoided. Rotate sites for frequent injections. For Intradermal Injections (ID): Check arm for discoloration/lesions. Choose site 3-4 finger widths below antecubital space and a hand width above wrist. RATIONALE: Injection site must be free of abnormalities which may hinder absorption of medication. Frequently used site could result in lypohypertrophy (fatty tissue growth increase). ASSIST PATIENT TO ESTABLISHING A COMFORTABLE POSITION For SQ Injections: Ask patient to relax arm, leg or the abdomen, depending on where injection site is. RATIONALE: Discomfort is minimized by relaxation of site. For IM Injections: Assist patient to a lying (flat or side) or prone position depending on where injection site is. RATIONALE: Strain on muscle is reduced and discomfort caused by injection is
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reduced. For ID Injections: Ask patient to extend elbow and use forearm to support it. RATIONALE: Injection site is stabilized easing accessibility. Use anatomical landmarks to relocate injection site. RATIONALE: Injury to nerves, bones and blood vessels is prevented. Use antiseptic swab to clean site. Apply swab at site's center and rotate outward in a circular motion. Discard swab. RATIONALE: Secretions harboring microorganisms are removed. Hold another swab/cotton ball between third and fourth fingers of non-dominant hand. RATIONALE: Easy access to swab/cotton after withdrawal of needle is provided. Remove needle cap. Hold syringe between non-dominant hand's thumb and forefinger: For SQ/IM Injections: Hold like a dart with palm down. For ID Injections: Hold with needle's bevel pointed upward. RATIONALE: Position ensures delivery of medication to tissues below dermis. ADMINISTER INJECTION SQ Injection: For medium-built patient, tightly spread skin across site or pinch using non-dominant hand. RATIONALE: Tight skins are more easily penetrated by needle than loose skin. Quickly and firmly inject needle and at a 45 angle underneath tissue fold. Patient discomfort is minimized. For overweight patient, pinch site's skin and inject needle at a 90 angle below tissue fold. RATIONALE: Patients who are obese have fatty tissue layers above SQ layer. After needle's entry into site, hold syringe barrel's lower end using non-dominant hand. Hold end of plunger with dominant hand. Avoid moving syringe while aspirating drug. If blood en90

ters syringe, discard medication and syringe and repeat procedure. RATIONALE: Smooth manipulation of syringe parts is a must to properly inject medication. Displacement of needle caused by syringe movement can cause patient discomfort. Aspiration of blood indicates intravenous placement of needle. Heparin injection aspiration may cause needle to move, resulting in tissue damage and bleeding. Slowly inject medication. IM Injection: Pull skin down on selected site in a Z-track. RATIONALE: Needle insertion is facilitated. Zigzag path through tissues is created to prevent medication tracking. Quickly inject needle at a 90 angle. Slowly inject medication. RATIONALE: Pain and tissue trauma is reduced Wait for about 10 secs before steadily withdrawing needle. Place antiseptic swab/cotton over site. RATIONALE: Discomfort during needle withdrawal is minimized. ID Injection: Use non-dominant hand to stretch skin across chosen site using thumb or forefinger. RATIONALE: Tight skin is more easily penetrated by needle. Place needle against skin and slowly insert at a 5-15 angle until resistance is encountered. Push needle into epidermis about 3 mm below surface of skin. Make sure that needle tip can be seen through skin. RATIONALE: Placement of needle tip in dermis is ensured. Slowly inject medication. If no resistance is encountered, withdraw needle and repeat procedure. RATIONALE: Patient discomfort is minimized. Dermal layer does not easily expand when injected with medication. A small bleb about 6 mm in diameter should appear on skin surface while medication is being injected. RATIONALE: Deposit of medication into dermis is determined. Gently apply alcohol swab over site while needle is being with91 drawn.

Chapter Four

Hygiene
4.1. Bathing a Client 4.2. Providing Perineal Care 4.3. Administering a Back Rub 4.4. Performing Foot and Nail Care 4.5. Providing Oral Hygiene 4.6. Performing Mouth Care for an Unconscious or Debilitated Client 4.7. Caring for Clients with Contact Lenses 4.8. Making an Occupied Bed

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4.1. Bathing

a Patient

Bathing is an integral part of personal hygiene. The quality and extent of a patient's bath and the methods of implementation depend largely on the patient's physical capabilities, health and needed degree of hygiene. A complete bed bath is usually given to a patient who is totally dependent and requires complete hygiene. Complete bed bath has been found to increase oxygen consumption in healthy men, therefore making it an extremely tiring procedure for patients. It is the nurse's responsibility to assess whether the patient can tolerate a complete bed bath. This can be done by measuring vital signs before and after the bed bath. A partial bed bath on the other hand involves bathing of only specific parts of the patient's body. These parts are assumed to be potential sources of discomfort and odor if left unbathed. Aging patients are usually the ones who require partial bed baths. In bathing a patient, it is imperative that the nurse assess the condition of the patient's skin. It will aid in determining if the patient needs to use soap during the bath or if the patient needs a bath on a daily basis. This is done specifically to avoid drying the patient's skin.

Guidelines in the Provision of Bed Baths

Provide needed privacy Maintain patient safety Maintain room warmth Promote patient independence Anticipate patient needs

Bathing Infants
Special precautions should be taken when bathing infants. Bathing greatly reduces infants' body temperature, which makes it necessary for the nurse to keep the infant covered before performing the procedure. Warm water temperature should also be kept and the procedure should be done as quickly as possible.
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Infant skin pH should also be taken into consideration, which is why only warm water is used during bed bath after birth. In older infants however, gentle soap may be used as soiling increases, use of alkaline soaps is however, discouraged.

Materials Required
Soap and water Bedpan Towels Washcloth Bathrobe Slippers Clean gown

Procedures for Bathing a Patient & Rationale

Assess patient for activity and musculoskeletal function tolerance. RATIONALE: Provides data for determining patient's level of self-care performance and type of bath to be administered. Review specific precautions (if any) regarding patient positioning/movement. RATIONALE: Identifies level of assistance needed by patient to avoid injury. Explain to patient the procedure and ask for bathing preferences if any. RATIONALE: Promotes self-esteem through enhancement of patient participation. Provide needed comfort and privacy. RATIONALE: Reduces patient embarrassment by avoiding unnecessary exposure of patient's private body parts. Prepare necessary equipment/supplies. RATIONALE: Organizes performance of procedure by making needed materials accessible. Saves time and minimizes patient discomfort.
BATHING PROCEDURE

Complete/partial bedbath: Offer patient bedpan, towel and washcloth.

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RATIONALE:

Prevents interruptions during bathing.

Wash hands. RATIONALE: Reduces transmission of microorganisms. Wear disposable gloves if necessary. RATIONALE: Reduces risk for infection. Assist patient to comfortable position, making sure that body alignment is maintained. Position patient on side of the bed closest to you and place bed in high position. RATIONALE: Protects nurse against back strain and provides easy access to patient. Loosen top covers at bed's foot and place bath blanket over top sheet. Fold top sheet before removing from under blanket. Fold top sheet if it is to be reused. RATIONALE: Prevents soiling of linen. Assist patient in removing gown. RATIONALE: Provides full access to inner body parts during bath. Fill up to two thirds of washbasin with warm water. Have patient test water's temperature. If desired, put lotion's plastic container in bath water to make it warm. RATIONALE: Prevents unnecessary chilling and burns. Warm water enhances muscle relaxation and restores comfort. Bath water makes lotion warm. If allowed, remove pillow and raise bed's head 30-45. Put bath towel underneath patient's head. Put second bath towel over patient's chest. RATIONALE: Anatomical alignment allows for easy access to ears, neck and nape. Towels catch water and soap droplets, preventing soiling of linen and bath blanket. To form mitt, fold washcloth around fingers of hand. Wet mitt and wring thoroughly. RATIONALE: Loosely held washcloth does not hold water and heat as compared to a mitt. Prevents cold edges of towel from touching patient.
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Avoids splashing. Use plain warm water to wash patient's eyes. Ask if patient is wearing contact lenses. Different sections of mitt should be used in each eye. Clean eyes from inner to outer canthus. Use a damp cloth to soak any crust on eyelid for 2-3 mins before trying to remove. Gently and thoroughly dry eye. RATIONALE: Soap may hurt patient's eyes. Use of different sections minimizes cross contamination. Applying pressure on eye may result in injury. Wash, rinse and thoroughly dry patient's cheeks, forehead, nose, neck and ears. RATIONALE: Soap and water traces may irritate patient's skin. Remove bath blanket from patient's arm. Put bath towel under arm. Move to other side of the bed to wash arm. RATIONALE: Prevents water and soap from spilling onto linen. Use soap and water to bathe patient's arm using long, firm strokes from distal to proximal areas. Raise and support patient's arm above head (if applicable) while washing axilla. RATIONALE: Removal of debris and bacteria occurs when soap lowers surface tension and during friction. Circulation is stimulated by long firm strokes. Normal range of motion is exercised by arm elevation during exposure of axillar area. Thoroughly rinse and dry arm and axilla. If desired, apply deodorant or talcum powder. RATIONALE: Wetness causes skin irritation. Use of deodorants prevents bacterial growth. Talcum powder minimizes sweating. Lay folded bath towel (half folded) beside patient. Put basin on towel and immerse patient's hand in water. Soak hand from 3-5 mins before proceeding to wash hand and fingernails. Remove hand from basin and dry thoroughly. RATIONALE: Soaking promotes circulation through vasodilation, it also loosens dirt, callouses and cuticles. Remnants of soap and water cause wetness which harbors bacterial growth and skin breakdown.
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Move to other side of the bed and repeat steps previous steps for other arm. RATIONALE: Facilitates circulation and restores patient comfort. Prevents transmission of infection from other side of patient's body. Check bath water's temperature and change if needed. RATIONALE: Prevents accidental burns. Cover patient's chest with bath towel and fold blanket down to umbilicus. Use long, firm strokes with mitted hand in bathing patient's chest. For female patient, wash skinfolds under breasts. Patient's chest should be kept covered between washing and rinsing. Dry chest thoroughly. RATIONALE: Prevents unnecessary exposure of body patient's private body parts. Restores warmth and comfort. Put bath towel (lengthwise) over patient's chest and abdomen. Blanket should be folded down to above patient's pubic region. RATIONALE: Prevents unnecessary exposure of body patient's private body parts. Lift bath towel and bathe patient's abdomen using mitted hand. Stroke from side to side, keeping patient's abdomen covered throughout the process. Dry thoroughly. RATIONALE: Moisture harbors bacterial growth especially in skinfolds which may contain sediments. These sites are prone to irritation and tissue breakdown. Assist patient in putting on clean gown/pajama top. RATIONALE: Promotes body image and enhances patient self-esteem. Restores patient comfort. Cover patient's chest and abdomen with bath blanket's top. Fold blanket toward midline to expose patient's leg. Patient's perineum should be covered. RATIONALE: Prevents unnecessary exposure of patient's private parts. Position your arm under patient's leg to bend patient's leg at knee. Slightly elevate leg from mattress and put bath towel under leg (lengthwise). Instruct patient to hold leg still. Place basin on
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bath towel and secure it next to the foot to be washed. RATIONALE: Supporting the joints prevents musculoskeletal strain. Towel prevents soiling of linen. Allowing patient to hold leg facilitates assessment of leg strength. Soak patient's feet after bathing (if allowed). RATIONALE: Soaking promotes circulation through vasodilation, it also loosens dirt, callouses and cuticles. Remnants of soap and water cause wetness which harbors bacterial growth and skin breakdown. Using long, firm strokes, wash patient from ankle to knee and from knee to thigh (if allowed). Dry thoroughly. RATIONALE: Enhances circulation. Wash patient's foot, ensuring to clean between toes. Clean and clip nails as needed. Dry well and apply lotion to dry skin. Avoid massaging reddened areas of patient's skin. RATIONALE: Moisture harbors bacterial growth especially in skinfolds which may contain sediments. These sites are prone to irritation and tissue breakdown. Lotion provides sufficient moisture to condition skin. Move to other side of the bed and repeat steps for patient's other leg and foot. RATIONALE: Facilitates circulation and restores patient comfort. Prevents transmission of infection from other side of patient's body. Cover patient with bath blanket and change bath water. RATIONALE: Restores warmth and observes hygiene. Assist client to establishing a prone/side-lying position. Put towel (lengthwise) along patient's side. RATIONALE: Provides easy access to back portion of patient's body for cleaning. Towel prevents soiling of linen. Slide bath blanket over shoulders and thigh to keep patient draped. Using long, firm strokes, wash, rinse and dry back from neck to buttocks. Give patient a back rub. RATIONALE: Ensures unnecessary exposure of patient's private parts. Back rub promotes circulation and promotes comfort.
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Assist patient in establishing a supine position. Use towel to cover patient's chest and upper extremities. Expose only patient's genitalia. Wash, rinse and dry perineum. RATIONALE: Reduces patient embarrassment by preventing unnecessary exposure of patient's private parts. Apply body lotion/oil to patient if so desired. RATIONALE: Provides sufficient moisture to condition skin. Assist client in dressing and comb patient's hair. RATIONALE: Promotes body image and enhances self-esteem. Remake patient's bed. RATIONALE: Removes creases on linen that might cause pressure sores. Restores comfort and promotes rest. Put soiled linens in laundry bag. Clean and store bathing equipment. Wash hands. RATIONALE: Reduces transmission of microorganisms. Tub bath/shower: Assess patient condition and review precautionary orders. RATIONALE: Ensures patient safety during performance of procedure. Schedule use of tub/shower. RATIONALE: Patient's state of readiness for procedure is ensured. Check cleanliness of tub/shower, if applicable utilize cleaning techniques as per institution's policy. Put a rubber mat on tub/ shower bottom. RATIONALE: Minimizes risk for contamination and ensures safety. Prepare all hygienic aids, toiletries and linen. RATIONALE: Provides easy access to equipment/supplies. Saves time. Have patient wear bath robe and slippers and assist in going to bathroom (if needed). RATIONALE: Robe and slippers facilitate easy exposure of patient's body during procedure. Avoids unnecessary exposure of patient's private

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parts during ambulation of patient to bathroom. Promotes warmth and comfort. Fill tub halfway with warm water. Have patient test water and adjust temperature if necessary. Instruct client on the use of hot and cold faucet. Warn patient against use of oil inside tub. RATIONALE: Prevents accidental burns. Use of oil may cause accidental slipping and fall when patient is in tub. Tell client to remain in tub for not more than 20 mins. RATIONALE: Warm water promotes vasodilation. Prolonged stay may cause dizziness. Return to bathroom when patient calls. RATIONALE: Promotes independence and enhances self-esteem. Leaving patient provides privacy. Drain tub completely before patient attempts to get out. Place towel on patient's shoulder and assist as deemed necessary. RATIONALE: Ensures patient safety. Assist patient in dressing as needed. RATIONALE: Promotes independence and enhances self-esteem Assist patient to room and in establishing comfortable position. RATIONALE: Restores patient comfort. Wash hands. RATIONALE: Reduces transmission of microorganisms. Observe patient's skin especially areas previously soiled, reddened or showing any sign of breakdown. Ask patient to rate level of comfort. RATIONALE: Evaluates effectiveness of procedure. Record procedure accurately. Record patient's skin condition and significant findings if any. Report any alteration in patient's skin integrity. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also
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serve for legal purposes.

4.2. Providing

Perineal Care

Perineal care is a part of a complete bed bath. Patients who require perineal care are those who are deemed to be most susceptible to infection (i.e., uncircumcised males, patients with indwelling catheters or those recovering from genital/rectal surgery). Perineal care, being of a personal nature requires a nurse to allow independent patients to do it for themselves. Patients practicing self-care are prone to overlook problems such as vaginal discharge or skin irritation. It is the nurse's responsibility to be alert and on the look out for such problems.

Materials Required
Soap and water Towel Blanket Gloves Underpad/toilet tissue Washbasin

Procedure for the Provision of Perineal Care & Rationales

Assess patient's risk for developing genital, urinary tract or reproductive tract infections. RATIONALE: Secretions in the skin of the genitalia prevents transmission of microorganisms. Assess patient's cognitive/musculoskeletal function. RATIONALE: Self-care promotes patient independence and self worth. If patient is capable, allow him/her to carry out the procedure. Assess genitalia for inflammation, skin breakdown or infection. RATIONALE: Extent of perineal care varies in accordance with degree of infection or inflammation.
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Assess patient's knowledge of the importance of perineal hygiene. Explain to client purpose and nature of procedure. RATIONALE: Enhances patient understanding, cooperation and lessens anxiety. Prepare needed equipment/supplies. RATIONALE: Organizes working environment, saves time and provides easy access to materials needed. Provide needed privacy. RATIONALE: Prevents unnecessary exposure of patients private parts and reduces patient embarrassment. Position bed to comfortable working position. Put towel (lengthwise) along side of patient. Use a bath blanket to keep patient covered. RATIONALE: Prevents back strains on the part of the nurse. Towel prevents soiling of linen. Bath blanket provides needed privacy. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Remove any fecal matter using a fold of underpad/toilet tissue. Cleanse patient's buttocks and anus, washing beginning from front to back. Dry area thoroughly. If gloves become soiled, change them. RATIONALE: Ensures asepsis. Reduces transmission of microorganisms. Expose patient's genital area by raising patient's gown. Diamond drape patient. Fill washbasin with warm water. RATIONALE: Provides easy access to patient's perineal area while ensuring privacy. Put washbsin and toilet tissue on overbed table. RATIONALE: Provides easy access to equipment/supplies. PROVISION OF PERINEAL CARE Female perineal care: Assist patient to establishing dorsal recumbent position. Assist patient in flexing knees and spreading legs. RATIONALE: Exposes patient's perineum for flushing.
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Fold bath blanket's lower corner up between patient's legs onto the abdomen. Thoroughly wash and dry patient's upper thighs. RATIONALE: Prevents spread of infection. Wet areas harbor microorganisms. Wash patient's labia majora, using non-dominant hand to gently retract labia from thigh. Use dominant hand to wash skinfolds. Wipe beginning from perineum to rectum. Repeat procedure on opposite side using a different section of the washcloth. Thoroughly rinse and dry area. RATIONALE: Microorganisms thrive in between skinfolds. Direction of wiping prevents contamination of genitalia. Using non-dominant hand, separate labia and expose urethral meatus and vaginal orifice. Use one smooth stroke to wash downward from pubic area to rectum. Use different sections of the washcloth for each stroke. Clean labia minora, clitoris and vaginal orifice thoroughly. RATIONALE: Use of different sections prevents contamination. Drying area prevents skin breakdown. If patient uses a bedpan, pour warm water over perineal area use front-to-back method in thoroughly drying perineal area. RATIONALE: Warm water promotes circulation and restores comfort. Running water flushes away soap and microorganisms. It is more effective than wiping. Fold bath blanket's corner back between patient's legs and over perineum. Have patient lower legs and establish comfortable position. RATIONALE: Prevents unnecessary exposure of patient's private parts. Male perineal care: Assist patient in establishing supine position and note any difficulty in mobility. RATIONALE: Provides access to male genitalia. Fold bath blanket's top half below patient's penis. Wash and dry patient's upper thighs. RATIONALE: Protects surrounding skin from contamination by penile secre104

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tions. Provides patient privacy for the duration of the whole procedure. Raise patient's penis gently and put bath towel underneath it. Grasp penis' shaft gently. For uncircumcised patient, retract foreskin. Perform procedure at a later time if patient has an erection. RATIONALE: Prevents pooling of moisture in the inguinal area. Proper handling prevents erection. Foreskin is cleared of accumulated secretions and microorganisms Begin washing at the tip of patient's penis at urethral meatus. Use a circular motion, cleansing from meatus outward. Dispose of washcloth and repeat procedure using clean cloth until penis is clean. Gently rinse and dry area. RATIONALE: The direction of washing must begin from the cleanest to the most contaminated part to avoid spread of microorganisms to the urethra. Return foreskin to natural position. RATIONALE: Local edema might result from constriction of blood vessels. Use gentle but firm downward strokes in washing shaft of penis. Rinse and dry penis thoroughly. Ask patient to slightly spread legs apart. RATIONALE: Washing direction prevents erection. Accumulated secretions are removed. Cleanse scrotum gently, lifting carefully and washing underlying skin folds. Rinse and dry thoroughly. RATIONALE: Scrotal tissue is sensitive to pain. Application of excessive pressure must be avoided. Fold bath blanket over patient's perineum and assist patient to side-lying position. Cleanse patient's anal area. RATIONALE: Prevents unnecessary exposure of patient's private parts. Remove and properly dispose of gloves. RATIONALE: Prevents spread of infection. Assist patient to establishing a comfortable position and cover
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with sheet. RATIONALE: Restores patient comfort. Dispose of all used equipment and soiled linen. RATIONALE: Reduces transmission of microorganisms. Examine surface of patient's external genitalia and surrounding area. RATIONALE: Evaluates effectiveness of procedure and determines needed intervention. Observe for abnormal drainage from patient's genitalia. RATIONALE: Determines presence of any infection. Record and report procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
4.3. Administering

a Back Rub

Physiology
A back rub or massage is usually given after a bed bath. It is known to promote circulation and relaxation and relieve muscular tension. Studies reveal that long, slow, gliding strokes reduce heart and respiratory rate. Great reductions in systolic/diastolic blood pressure were observed in males. Patients have been known to report improved comfort after a back rub. In providing a back rub, it is recommended that relaxation be enhanced through noise reduction and provision of comfort to the patient. It is also imperative that the nurse determine any contraindications before administering a back rub.

Materials Required
Lotion Towel
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Procedure for Administering a Back Rub & Rationale

Assess patient for contraindication. RATIONALE: Prevents further tissue injury (if present). If needed, measure patient's pulse and blood pressure. RATIONALE: Establishes baseline values. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Prepare necessary equipment/supplies. RATIONALE: Organizes working environment and saves time. Adjust bed height to comfortable position. RATIONALE: Protects nurse from back strain. Assist patient to a prone or side-lying position with back toward you. RATIONALE: Provides easy access to patient's back side. Provide needed privacy. RATIONALE: Reduces patient embarrassment. Expose back, shoulders, upper arms and buttocks of patient. RATIONALE: Provides easy access to patient's back side. Use warm water to wash hands. RATIONALE: Cold hands can cause muscular tension due to vasoconstriction. Use lotion in hands or under warm water. RATIONALE: Prevents startled response. Lotion provides for easy gliding of hands on skin surface. Apply lotion to sacral area. Using continuous and firm upward strokes beginning from buttocks to shoulders, over upper arms and back to buttocks. RATIONALE: Promotes relaxation, comfort and circulation.
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Warm lotion in hands or under warm water. Apply lotion to sacral area using an upward motion, moving from buttocks to shoulder, upper arms and back to buttocks. Continue this process for 3 mins. Grasp patient's skin between thumb and fingers using an upward motion. Do this from one side of the spine beginning from the buttocks to shoulders and nape. Repeat this procedure on the other side. RATIONALE: Promotes circulation, has soothing effects. Use long stroking movements to end massage. Tell patient that the massage is to be ended. RATIONALE: Prepares patient for end of the procedure. Ask or assist client in moving to other side and repeat procedure. RATIONALE: Promotes self-worth and independence. Relieves anxiety. Assist client in dressing and establishing a comfortable position. RATIONALE: Restores patient comfort. Dispose of soiled towel properly. Wash hands. RATIONALE: Reduces spread of infection. Assess patient's comfort and for presence of any tension or pain. Reassess patient's blood pressure and pulse. RATIONALE: Evaluates effectiveness of procedure. Record patient's reaction to massage and skin condition. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
4.4. Performing

Foot and Nail Care

Physiology
Foot and nail care is also a part of total hygiene and therefore should be done routinely. Softening of the cuticles is done by soaking, cleansing and drying, nail trimming usually follows.
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It is the duty of the nurse to teach the patient and family about the proper method for nail cleaning and trimming. Methods to avoid infection should also be stressed. Care should also be taken for patients who have diabetes mellitus as they are prone to foot infection due to poor circulation. The nurse should be observant for changes, which may indicate peripheral neuropathy and vascular insufficiency. The nurse is encouraged to teach the patient the following guidelines for proper foot and nail care: Daily inspection of feet Thorough examination of the feet of patients with diabetes mellitus. Daily washing of the feet using lukewarm water. Avoid cutting corns/calluses and the use of commercial removers. Application of unscented foot powder to perspiring feet. Application of lanolin or baby oil to dry portions of the feet. For diabetic patients, toenails should be filed straight across and square. Avoid the use of scissors/clippers. Consult physician before application of medication for athlete's foot. Avoid wearing elastic stockings. Wear clean socks. Avoid walking barefooted. Make sure shoes are properly fitted. Avoid wearing new shoes for extended period of time. Exercise regularly to promote circulation. Avoid the application of hot water bottles or heating pads.

Materials Required
Disposable bath mat Emesis basin Orange stick Nail clipper Nail file Washcloth Disposable gloves

Procedure in Performing Foot & Nail Care &

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Rationale
Check patient's fingers, toes, feet and nails. RATIONALE: Assessment findings identify level of hygiene required. Examine circulation to toes, feet and fingers of patient. RATIONALE: Alteration in circulation affects nail and skin integrity. Assess patient's walking gait. RATIONALE: Unnatural gait of limping are signs of painful disorders. For female patients, ask if they use nail polish and polish remover frequently. RATIONALE: Excessive dryness can be caused by these products. Assess type of footwear that patient wears. RATIONALE: Nail and foot problems may be caused by ill-fitted shoes/footwear. Assess patient's risk for foot/nail problems. RATIONALE: There are factors that ncrease susceptibility to nail problem (i.e., age). Older adults may have poor vision and coordination and other degenerative conditions. Assess ability of patient to care for nails/feet. RATIONALE: Identifies level of assistance needed by patient. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Promotes cooperation. If institution policy requires, obtain physician's order for cutting patient's nails. RATIONALE: Some patients may be prone to skin breakdown and infection, thus a medical order is required. Wash hands. RATIONALE: Reduces transmission of microorganisms. Prepare necessary equipment. RATIONALE: Organizes working environment and saves time.
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Provide needed privacy. RATIONALE: Reduces patient embarrassment. Have ambulatory patient sit on bedside chair. Put disposable bath mat on floor under patient's feet. RATIONALE: Makes patient comfortable while feet are soaked in basin. Mat protects feet from being soiled. Fill washbasin with warm water and check temperature. RATIONALE: Thickened epidermal layers and nails are softened by warm water. Promotes circulation and reduces inflammation of skin. Put basin on bath mat or towel and assist patient in placing feet in basin. RATIONALE: Patient may have muscular difficulty in positioning feet. Assistance protects patient from injuries. Fill emesis basin with warm water and place basin on paper towels on overbed table. RATIONALE: Thickened epidermal layers and nails are softened by warm water. Promotes circulation and reduces inflammation of skin. Have patient place fingers in emesis basin. RATIONALE: Thickened epidermal layers and nails are softened by warm water. Promotes circulation and reduces inflammation of skin. Soak patient's feet and fingernails for 10-20 mins (if not contraindicated). Rewarm water after 10 mins. RATIONALE: This is typical period of time it takes for corns, calluses, cuticles and nails to soften. Use orange stick to gently clean under patient's fingernails while fingers are immersed. Remove basin and dry patient's fingers thoroughly. RATIONALE: Orange stick reaches inner corners of nails, removing dirt and grime. Drying helps prevent microorganisms from thriving in nails. Clip patient's fingernails straight across. Use a nail file to shape patient's nails. RATIONALE: Prevents accidental cutting of skin.
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Use orange stick to gently push patient's cuticles back. RATIONALE: Reaches cuticles and prepares them for cutting. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Use a washcloth to scrub calloused areas of patient's feet. RATIONALE: Facilitates removal of dry skin. Use orange stick to gently clean under patient's toe nails. Remove patient's feet from basin and dry thoroughly. RATIONALE: Orange stick reaches inner corners of nails, removing dirt and grime. Drying helps prevent microorganisms from thriving in nails. In clipping toenails, follow procedures for clipping fingernails. Avoid filing toenails' corners. RATIONALE: Prevents accidental cutting of skin. Apply lotion to patient's hands and feet and assist patient to a comfortable position. RATIONALE: Prevents dryness and tissue breakdown. Remove and dispose of gloves properly. Clean and restore equipment for future use. RATIONALE: Prevents transmission of microorganisms. Allows for easy location of equipment in the future. Dispose of soiled linens properly. Wash hands. RATIONALE: Reduces spread of infection. Examine patient's nails and surrounding areas. RATIONALE: Evaluates effectiveness of procedure. Ask patient to explain/demonstrate nail care. RATIONALE: Determines patients ability to carry out procedure. Observe patient's walking gait after procedure. RATIONALE: Compares assessment findings prior to performance of procedure. Record and report procedure. RATIONALE: Documentation facilitates communication with other health team
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members. Serves as future reference for nursing care. May also serve for legal purposes.
4.6. Providing

Oral Hygiene

Physiology
The primary purpose of oral hygiene is the promotion or maintenance of healthy mouth, teeth and gums. Brushing cleans the teeth of food particles, plaque and bacteria. Flossing prevents gum inflammation and infection. Complete oral hygiene enhances well-being and stimulates a patient's appetite. The nurse is highly useful in the maintenance of oral hygiene by educating the patient on the correct techniques and schedule. Educating patients on common gum and tooth problems often motivates them to observe oral hygiene practices

Brushing /Flossing
Brushing the teeth 3 times a day is basic to an effective oral hygiene routine. Toothbrush to be used should have a straight handle and a small brush so that all areas can be reached. All surfaces of the teeth should be brushed thoroughly with the use of a fluoride toothpaste. For patients with sensitive gums, soft bristled toothbrushes may be used. The amount of help that a patient may require in brushing may vary. Patients who are capable of self-care should be encouraged to do so.

Materials Required
Toothbrush Toothpaste Dental floss Wash basin Towel

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Procedure for Providing Oral Hygiene & Rationale

Wash hands. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Inspect integrity of patient's lips, teeth, buccal mucosa, gums, palate and tongue. RATIONALE: Identifies frequency and extent of oral care needed by patient. Assess patient for common oral problems. RATIONALE: Identifies the degree of health-teaching and type of oral care to be rendered. Remove gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Determine patient's oral hygiene practices. RATIONALE: Identifies client's incorrect and appropriate techniques in oral care. Provides baseline data for health teaching. Assess patient's capability to use a toothbrush. RATIONALE: Level of assistance needed is determined. Promotes independence. Prepare needed equipment. RATIONALE: Organizes work environment and provides easy access to materials needed. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Put paper towels on overbed table, making sure that other equipment are within reach. RATIONALE: Provides easy access to materials needed. Raise bed to a comfortable working position. RATIONALE: Protects nurse from back strain. Maintains correct body alignment. Put towel over patient's chest. RATIONALE: Prevents soiling of patient's clothes.
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Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Put some toothpaste onto toothbrush. Wet toothbrush. RATIONALE: Toothpaste softens food particles in the oral orifice. Water aids in distribution of toothpaste. Hold toothbrush to patient's gumline at a 45 angle. Brush inner and outer surfaces of patient's upper and lower teeth. Clean biting surfaces and sides of teeth. RATIONALE: Facilitates brushing of inner and outer areas of the teeth. Have patient try to lightly brush surface and sides of tongue. Caution patient against starting a gag reflex. RATIONALE: Some food particles and microorganisms are deposited in these areas. Gagging may cause aspiration of toothpaste. Have patient rinse mouth thoroughly. RATIONALE: Water removes food particles and microorganisms and toothpaste from the oral orifice. Have patient rinse mouth using mouthwash (if desired). RATIONALE: Provides antiseptic action and pleasant taste in the mouth. Assist in wiping patient's mouth. RATIONALE: Promotes comfort and body image. Have patient perform flossing. Have patient rinse mouth with cool water and spit in emesis basin. Assist in wiping patient's mouth. RATIONALE: Removes hard food particles not reached by brushing. Assist in returning patient to a comfortable position. Clean and restore used equipment for future use. RATIONALE: Restores patient comfort. Clean overbed table. Dispose of soiled linens and paper towels properly. Remove and dispose of soiled gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assess patient's feeling in oral cavity.
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RATIONALE:

Evaluates effectiveness of procedure.

Ask patient to describe proper oral hygiene techniques. RATIONALE: Evaluates patient's ability to carry out procedure. Record and report procedure and observations. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
4.6. Performing

Mouth Care for an Unconscious or Debilitated Client

Patients with Special Needs

Due to high level of dependence, some patients may require special oral hygiene methods. Unconscious patients are prone to drying of salivary secretions due to their incapacity to eat or drink and rendering them unable to swallow salivary secretions. The adverse effects of certain procedures (i.e., chemotherapy, radiation and nasogastric tube intubation) may cause the patient to develop stomatitis. In cases like this, gentle brushing is recommended so as to avoid bleeding of the gums. Use of commercial mouthwashes should also be avoided. Periodontal disease predominant among patients with diabetes mellitus should likewise receive gentle oral mouth care. Dental visits are also recommended.

Materials Required

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Procedure for Mouth Care for an Unconscious/ Debilitated Patient & Rationale
Wash hands. Wear clean disposable gloves. RATIONALE: Reduces transmission of microorganisms. Assess patient for presence of gag reflex. RATIONALE: Gag reflex may cause aspiration. Examine patient's oral cavity. RATIONALE: Determines frequency and extent of oral hygiene needed. Remove gloves and wash hands. RATIONALE: Reduces transmission of microorganisms. Assess patient for risk of oral hygiene problems. RATIONALE: Alterations in oral cavity indicate frequency or precautions in oral care. Have client lie on side with head turned toward dependent side. Make sure that bed's head is lowered. RATIONALE: Prevents risk of aspiration. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Wash hands. Wear clean disposable gloves. RATIONALE: Reduces transmission of microorganisms. Arrange equipment on overbed table over paper towels. Prepare suction if needed. RATIONALE: Organizes working environment and saves time. Provides easy access to materials needed. Suction may be used to prevent aspiration. Provide needed privacy. RATIONALE: Reduces patient embarrassment. Raise bed to highest horizontal level and position patient close to side of bed. Turn patient's head toward mattress. Place towel
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under patient's head and emesis basin under patient's chin. RATIONALE: Protects nurse from back strain. Use a padded tongue depressor or soft bristled toothbrush to separate patient's upper from lower teeth. Make sure that patient is relaxed and avoid using force. RATIONALE: Prevents soiling of patient's gown and allows patient to spit on basin. Use toothbrush to cleanse patient's mouth. Initially clean chewing and inner tooth surfaces. Clean roof of mouth, gums and inside of cheeks. Brush tongue gently to avoid stimulating gag reflex. Use a bulb syringe to rinse patient's mouth. Repeat rinsing procedure several times. RATIONALE: Toothbrush removes food particles. If secretions accumulate, use suction. RATIONALE: Prevents aspiration. Apply thin layer of KY Jelly to patient's lips. RATIONALE: Promotes moisture and conditions skin. Inform patient of procedure's completion. (if conscious) RATIONALE: Provides sensory stimulation. Remove and dispose of gloves properly. RATIONALE: Reduces transmission of microorganisms. Return patient to a comfortable position. RATIONALE: Restores patient comfort. Clean and restore equipment for future use. RATIONALE: Ensures easy location of equipment in the future. Dispose of soiled linens properly. Wash hands. RATIONALE: Reduces transmission of microorganisms. Re-apply gloves and inspect patient's oral cavity. RATIONALE: Evaluates effectiveness of procedure. Record and report procedures and observations.
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RATIONALE:

Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

4.7. Caring

for Clients with Contact Lenses

Basic Eye Care

Eye cleansing involves the use of a clean washcloth moistened with water. The use of soap is not encouraged as it may irritate the eye. Pressure should never be applied when washing the eye to avoid injury. Frequent eye care is most needed by unconscious patients because secretions may collect in the eyelids and inner canthus in the absence of blink reflex. To prevent corneal drying and irritation, placing an eyepatch over the eye is recommended. Consult the attending physician in administering eye lubrication.

Materials Required
Towel Disposable gloves Sterile saline solution Towel Contact lenses storage Non-cosmetic soap Tap water

Procedure for Caring for Clients with Contact Lenses

Place towel below patient's face. RATIONALE: Towel is used to catch lens if it falls and prevents soiling of patient's clothes. Examine patient's eyes or ask him/her if contact lenses are in place. RATIONALE: Verifies if lenses are in place.
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Inquire if patient feels any discomfort in the eyes. RATIONALE: Eye injury may result from prolonged wearing or damaged contact lenses. Ask patient for any unusual vision signs or symptoms. RATIONALE: Determines need to change lens or existence of eye condition. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Assist patient to establishing a sitting or supine position. RATIONALE: Ensures comfortable patient position. Protects nurse from back strain. Prepare necessary equipment. RATIONALE: Organizes working environment and saves time. CONTACT LENS REMOVAL: Soft lenses: Wash hands. If necessary, wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Place towel below patient's face. RATIONALE: Towel is used to catch lens if it falls and prevents soiling of patient's clothes. Put a few drops of sterile saline solution onto patient's eye. RATIONALE: Saline eases removal of contact lenses. Instruct patient to look straight ahead and retract patient's eyelids using middle finger. RATIONALE: Distracts patient's visual focus, facilitating removal of lens. Using pad of index finger, slide lens off cornea and onto white of eye. RATIONALE: Prevents cornea and sclera from accidental injury. Gently pull upper eyelid down using thumb of other hand and slightly compress lens between thumb and index finger.
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RATIONALE:

Facilitates entry of air into lens and releases suction to scleral surface.

Pinch lens gently and lift out of the eye. Clean and rinse lens. Put lens in storage case. RATIONALE: Protects lens from tearing/damage. Repeat procedure for other eye. Secure storage case's cover and label with patient's name and room number. RATIONALE: Prevents incorrect re-application of lens to the wrong patient. Assess condition of patient's eyes after removal of the lenses. RATIONALE: Evaluates effectiveness of procedure. Properly dispose of soiled towel. Remove and properly dispose of gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Rigid lenses: Wash hands. Wear disposable gloves if needed. RATIONALE: Reduces transmission of microorganisms. Put towel below patient's face. RATIONALE: Prevents soiling of clients gown and linens. Make sure that lens is situated directly over cornea. RATIONALE: Facilitates comfortable removal or grasping of lens. Put index finger on patient's eye's outer corner and gently draw back skin toward patient's eye. RATIONALE: Maneuvers contact lens to desired position for easier removal. Ask patient to blink. Pressure on eyelid should not be released until blink is completed. RATIONALE: Maneuvers contact lens to desired position to allow grasping by index finger and thumb. Retract eye lids gently beyond lens' edges if lens fails to pop out. Gently press lower eyelid against lens' lower edge.
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RATIONALE:

Maneuvers contact lens to desired position to allow grasping by index and thumb.

Allow both eyelids to slightly close, and grasp lens as it rises from the eye. Hold lens in hand. RATIONALE: Facilitates blinking clearing eyes from irritation caused by fingers. Cleanse and rinse lens. Store lens properly using storage case with convex side down. RATIONALE: Prevents spread of microorganism. Protects lens from damage. Repeat steps for other eye. Label storage case with patient's name and room number. RATIONALE: Prevents error when applying lens to clients. Properly dispose of soiled towel. Remove and properly dispose of gloves. Wash hands. RATIONALE: Prevents spread of microorganisms. Cleansing and disinfecting contact lenses: Wash hands. RATIONALE: Prevents spread of microorganisms. Prepare needed supplies by patient's bedside. RATIONALE: Organizes working environment and saves time. Carefully open lens container and remove lens. RATIONALE: Prevents accidental tearing of lens. Apply one or two drops of cleaning solution to lens. RATIONALE: Removes dirt and disinfects lens without damaging its surface. Gently but thoroughly rub lens on both sides for 20-30 secs. For soft lenses, use index/little finger to clean lens. For rigid lenses, use cotton applicator soaked in cleaning solution. RATIONALE: Prevents nails from accidentally tearing lens. Rinse lens thoroughly over emesis basin using manufacturer-rec-

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ommended rinsing solution (soft lenses) or tap water (rigid lenses). RATIONALE: Prevents lens contamination and damage. Put lens in appropriate storage case filled with storage solution. RATIONALE: Lubricates lens, prevents drying and damage. Repeat procedure for other lens. LENS INSERTION Soft lenses: Wash hands using non-cosmetic soap. RATIONALE: Reduces transmission of microorganisms. Non-cosmetic soap won't damage lens. Apply disposable gloves if needed. RATIONALE: Reduces transmission of microorganisms. Put a towel over patient's chest. RATIONALE: Protects patient's clothes from getting soiled. Towel catches lens in case it falls. Take right lens from storage case and rinse using rinsing solution. Examine lens for foreign materials, tears and damage. RATIONALE: Prevents misapplication of lens and eye irritation. Make sure that lens is not inverted. RATIONALE: Prevents eye injury. Expose patient's iris by retracting upper eyelid using middle/ index finger of free hand. RATIONALE: Ensures accuracy of lens placement. Use middle finger of hand with lens to pull down patient's lower eyelid. RATIONALE: Facilitates easy placement of lens. Ask patient to look straight ahead. Place lens directly on cornea and slowly release eyelids. RATIONALE: Distracts patient's visual focus, facilitating removal of lens. Instruct patient to close eye slowly and roll it toward the lens if
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the lens is not in place. RATIONALE: Facilitates placement of lens. Ask patient to blink for several times. Make sure that lens is centered over cornea. RATIONALE: Ensures that lens is accurately set in place. Repeat steps procedure for other eye. If patient has blurred vision: Retract patient's eyelids and locate lens' position. Have patient look in direction opposite of lens and apply pressure to lower eyelid using index finger. Position lens over cornea. RATIONALE: Corrects lens position. Dispose of soiled supplies properly. Rinse lens case and allow to dry. Wash hands. RATIONALE: Reduces transmission of microorganisms. Rigid lenses: Wash hands. If needed, wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Put a towel over patient's chest. RATIONALE: Protects patient's clothes from getting soiled. Towel catches lens in case it falls. Remove lens from case and rinse with tap water. RATIONALE: Rinses off old solution from lens that may harm cornea and sclera. Use prescribed wetting solution to wet lens on both sides. RATIONALE: Lubricates lens and prevents eye injury. Place lens (concave side up) on index finger's tip of non-dominant hand. RATIONALE: Facilitates suction effect over eye, facilitates easy attachment of lens to cornea. Ask patient to look straight ahead and retract lower eyelid. Put lens directly over center of cornea. RATIONALE: Evaluates effectiveness of procedure.
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Instruct patient to close eyes. RATIONALE: Maneuvers lens to proper placement. Make sure that lens is centered over cornea. RATIONALE: Ensures comfort and correct vision. Repeat procedure for other eye. Help patient return to a comfortable position. RATIONALE: Restores comfort. Properly dispose of soiled supplies. Rinse case and allow to dry. Wash hands. RATIONALE: Reduces transmission of microorganisms. Ask patient how lens feels after removal and reinsertion. RATIONALE: Evaluates effectiveness of procedure. Examine patient's eyes for possible infection. RATIONALE: Provides data for additional nursing intervention. Record and report procedure and observations. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
4.8.

Making an Occupied Bed

Bed Making
A patient's bed should be kept clean and comfortable at all times. It is therefore necessary to inspect the bed for cleanliness, dryness and smoothness. It is also a must for the nurse to check the bed for soiling for patients suffering from incontinence, draining wounds and diaphoresis. Bed making is usually done in the morning after bathing a patient or when the patient is taking a shower. The nurse is expected to keep the bed wrinkle free throughout the day. The bed should also be checked for food particles as the patient eats in bed. Soiled linens should be
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changed as a matter of routine. In changing bed linen, soiled linen should be kept away from the nurses uniform in observance of principles of medical asepsis. Fanning linens should never be done as it may cause the spread of microorganisms. Proper body mechanics should be observed during bed making. Raising the bed to its highest position eliminates the need to bend or stretch over the mattress. In applying new linen, the nurse moves back and forth to the bed's opposite sides. Body mechanics is specially important in positioning the patient while in bed. The nurse carries out bed making activities with the patient confined in bed so as to conserve time and energy. Privacy, safety and comfort of the patient should be taken into consideration at all times. After making the bed, the nurse should return the bed to its lowest horizontal position as a measure to prevent the patient from falling should he/she move in and out of bed alone. The bed should be made when it is unoccupied as much as possible. The nurse should be decisive in judging whether a patient may be permitted to sit on a chair while the bed is being made. Basic principles of occupied bed making is usually followed in making an unoccupied bed.

Linens
For any health institution, an ample supply of linen is important. For economic reasons, excess linens should not be brought into the patient's room, doing so would warrant that the linens whether used or not be discarded for laundering. Bed linen and patient's personal items should be gathered before beginning. This is to give the nurse easy access to all materials required in preparing the bed and the room. To make bed making easier and prevent the spread of microorganisms, bed linens are pressed and folded. A complete linen change is not always a necessity, the nurse may opt to reuse the mattress pad, sheet, blanket and bed spread if they are not wet or soiled. To minimize the spread of infection, linen disposal must be done.
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Guidelines for linen disposal are usually provided by the institution. After patient discharge, all bed linen is sent to the laundry. Housekeeping staff are the ones who clean the mattress and bed, after which new linen can be applied. Materials Required Linen bag (s) Mattress pad (if soiled) Bottom sheet (flat/fitted) Drawsheet Top sheet Blanket Bedspread Waterproof pads/bath blankets Pillowcases Bedside chair/table Disposable gloves (optional)

Procedures for Making and Occupied Bed & Rationale

Assess patient for incontinence and check if he/she has any excess drainage on bed linen. RATIONALE: Determines need for protective pads and additional linen. Check orders for specific precautions on positioning of patient. RATIONALE: Protects patient from injury. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Prepare necessary equipment/supplies. RATIONALE: Organizes work environment. Ensures easy access to materials required. Wash hands. RATIONALE: Reduces transmission of microorganisms. Provide needed privacy. RATIONALE: Reduces patient embarrassment.
127 Position patient flat on bed. Adjust bed height to appropriate

Chapter Five

Oxygen Support
5.1. Suctioning 5.2. Care of Clients with Chest Tubes 5.3.[1] Applying a Nasal Cannula 5.3.[2] Using Portable Liquid Oxygen Equipment 5.4. Cardiopulmonary Resuscitation

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5.1.

Suctioning

Techniques
In cases a patient fails to clear respiratory tract secretions through coughing, suctioning is used to clear the airways. There are a variety of suctioning techniques: Oropharyngeal suctioning / Nasopharyngeal suctioning - The oropharynx extends from the back of the mouth from the soft palate above the hyoid bone's level, it is also where tonsils are contained. The nasopharynx lies behind the nose extending to the soft palate's level. This type of suctioning is used when the patient is capable of coughing but is not capable of expectorating or swallowing. The procedure should only be performed after the patient has coughed to reduce patient fatigue. Orotracheal suctioning / Nasotracheal suctioning - This type of suctioning is performed when the patient with pulmonary secretions is unable to clear/expectorate secretions by coughing and when there is no artificial airway present. A catheter is inserted through the mouth or nose into the trachea. The usual preferred route is the nose due to its minimal stimulation of the gag reflex. It is similar to the nasopharyngeal suctioning, the only difference is that the catheter tip is moved farther into the patient's trachea. The whole procedure should be done quickly (15 secs). The patient should also be allowed to rest between catheter passes. Oxygen cannula/mask (if present) should be replaced when the patient is resting. Artificial airway suctioning - An artificial airway is used in patients with decreased consciousness level. It is also used for patients who have airway obstruction. Its primary function is to remove tracheobronchial secretions. There are two types of artificial airways: Oral airway Tracheal airway These techniques are all in common use. Since the oropharynx and the trachea are considered sterile, sterile technique is used in performing the procedure/s. The oropharynx and the trachea should be suctioned first before the suctioning of oral secretions. A rounded130

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tipped catheter with side holes at the catheter's distal end is used in performing the procedure. Patient assessment is required in determining the frequency of suctioning. The nurse should monitor the patient to ensure adequate oxygenation. Suctioning too frequently could result in the patient's development of hypoxemia, hypotension, arrythmias and potential trauma to the lungs' mucosa.

Materials needed
Towel Disposable goggles Suction kit/catheter Sterile basin Sterile saline solution Water-based lubricant Assess patient for signs/symptoms of airway obstruction. RATIONALE: Physical signs include RR rate, depth and rhythm changes, skin discoloration, altered level of consciousness etc. Determine patient's understanding of procedure. RATIONALE: Determines degree/level of health teaching needed by the patient. Obtain physician's order. RATIONALE: Institution may require physician's order for this procedure. Explain to patient the purpose of the procedure and its expected sensations. RATIONALE: Improves patient's understanding of the procedure and reduces anxiety. Assist patient to a comfortable position. RATIONALE: Suctioning is uncomfortable, correct positioning minimizes discomfort and prevents injury. Place towel across patient's chest. RATIONALE: Prevents soiling of patient's clothes. Wash hands. Wear disposable goggles if splashing is likely to oc131

Procedure for Suctioning & Rationale

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cur.
RATIONALE:

Prevents transmission of microorganisms.

Connect one end of tubing to suction machine and other end in a location near patient. Turn device on and set vacuum regulator to appropriate negative pressure. RATIONALE: Hypoxia can occur from excessive negative pressure which may damage nasopharyngeal and tracheal mucosa. Increase oxygen therapy to 100% or as physician's order. Ask patient to breathe deeply. RATIONALE: Hyperoxygenation prepares patient for O . 2 Preparation of suction catheter: Use aseptic technique in opening suction kit/catheter. RATIONALE: Prevents transmission of microorganisms into nasopharyngeal cavities which may cause infection. Open sterile basin and place on bedside table. Fill basin with approximately 100 ml of sterile normal saline solution/water. RATIONALE: Cleans tubings of secretions without risk of contamination. Open water-based lubricant. RATIONALE: Lubricant prevents lipoid aspiration. Wear sterile disposable gloves. RATIONALE: Reduces transmission of microorganisms. Use dominant hand to pick-up catheter, avoid touching nonsterile surfaces. With non-dominant hand, pick-up connecting tubing Attach catheter to tubing. RATIONALE: Connects suction to catheter while maintaining sterility. Suction small amount of normal saline from basin. RATIONALE: Saline serves as internal catheter lubricant and checks patency of catheter. Use water-soluble lubricant to coat distal 6 to 8 cm of catheter. For oral suction, do not use lubricant. RATIONALE: Lubricates tip of catheter for easier introduction.
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Suction airway: Insert catheter at suitable distance for child/adult. Prevents trauma. Nasopharyngeal and nasotracheal: Remove patient's oxygen delivery apparatus (if present). Insert catheter gently but quickly into patient's naris during inhalation. Insert at a slight downward slant or through mouth. Do not suction. Position patient's head to left/right and pull catheter back 1 cm if resistance is encountered. RATIONALE: Allows introduction of catheter while preventing trauma. Use intermittent suction for about 10-15 secs. Withdraw catheter as you rotate it back and forth in between thumb of dominant hand and forefinger. Patient should be encouraged to cough. RATIONALE: Prevents mucosal injury and cardiopulmonary compromise due to vagal overload and hypoxemia. Use normal saline or water to rinse catheter and connecting tubing until clear. Ensures that catheter is free from obstructing mucous and secretion which affects suctioning's efficacy. Assess if patient needs additional suctioning. Adequate time should be allowed between suction passes. Have patient take deep breaths and cough. RATIONALE: Observe for cardiopulmonary symptoms of O deprivation. En2 courages deep breathing which facilitates alveolar reoxygenation and reventilation. When secretions have cleared, perform oropharyngeal suctioning. Nose should not be suctioned again after mouth has been suctioned. RATIONALE: Oral mucosa has more microorganisms than the nares. Removes upper airway secretions. OROPHARYNGEAL Insert catheter into mouth of patient along gumline and into pharynx. Move catheter around oral cavity until secretions are
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cleared. Coughing should be encouraged. Avoid dislodging any oral tubing. RATIONALE: Catheter provides deep suctioning, care should therefore be taken. Use water in cup/basin to rinse catheter until connecting tubing is free of secretions. Turn suction off. Wash patient's face if secretions are present. RATIONALE: Liberates tube of obstructive secretions while preventing spread of microorganisms. ENDOTRACHEAL/TRACHEAL TUBE Before suctioning, patient should be hyperinflated/ hyperoxygenated. RATIONALE: Negative pressure may cause atelectaris. Oxygenation prepares lung for O2 storage. Remove oxygen delivery apparatus. Use thumb and forefinger of dominant hand to insert catheter (avoid applying suction) into artificial airway until resistance is encountered. Pull catheter back 1 cm. RATIONALE: Allows for insertion of catheter. Apply intermittent suction and withdraw catheter slowly as you rotate it back and forth between thumb and forefinger of dominant hand. Patient should be encouraged to cough. Caution against respiratory distress. RATIONALE: Fingers facilitate insertion pressure. Shut swivel adapter and encourage patient to take deep breaths. RATIONALE: Opens paryngeal orifice for catheter to reach secretion. Use normal saline to rinse catheter and connecting tubing until clear. RATIONALE: Maintains patency of catheter. Assess patient's cardiopulmonary status. RATIONALE: Evaluates effectiveness of the procedure. Repeat previous steps once or twice more until secretions are clear. Ample time should be allowed between suction passes.
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RATIONALE:

Facilitates reoxygenation.

Perform oropharyngeal/nasopharyngeal suctioning. Avoid reinserting catheter into endotracheal/ tracheostomy tube. RATIONALE: Prevents contamination of passages by microorganisms. Oropharyngeal and nasopharyngeal tube have more microorganisms than endo/tracheostomy tube, which is considered sterile. Wind catheter around dominant fingers and pull glove from inside out so that catheter coil remains inside glove. Pull other glove over first glove and discard properly. Turn off suction. RATIONALE: Encloses contaminated/used catheter in glove, preventing spread of microorganisms. Remove towel and properly discard. RATIONALE: Reduces transmission of microorganisms. Readjust oxygen level (if present). RATIONALE: Facilitates sufficient oxygenation. Assist patient to a comfortable position. RATIONALE: Restores patient comfort. Discard remaining saline properly. Clean or replace basin. Remove and discard disposable goggles. Wash hands. RATIONALE: Reduces transmission of microorganisms. Compare patient's respiratory assessments before and after procedure. Ask patient if breathing is easier. Examine airway secretions. RATIONALE: Evaluates effectiveness of procedure. Record and report secretion amount and characteristics, respiratory status and patient response to procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
5.2. Care

of Clients with Chest Tubes

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Physiology
The primary purpose of inserting tubes into the pleural space is to drain any present air or fluids, it is also needed to re-establish intrapleural and intrapulmonic pressures. A chest tube comes in the form of a catheter which is inserted through the thorax. Chest tubes are also used after chest surgery and chest trauma for pneumothorax/ hemothorax to promote re-expansion of the lungs. A pneumothorax is defined as a collection of air in the pleural space. Loss of negative intrapleural pressure can cause lung collapse. These may come in the form of chest trauma due to stabbing or as the result of a car accident. A pneumothorax may be caused by the rupture of an emphysematous bleb on the lung's surface. Pain is the most common symptom of pneumothorax, this is because atmospheric air irritates the parietal pleura. Dyspnea is a common occurrence which may increase as the pneumothorax size increases. A hemothorax on the other hand is blood and fluid accumulation in the pleural cavity between the parietal and visceral pleurae. This condition is usually the result of trauma. Counter-pressure is produced preventing the lung from full expansion. The rupture of small blood vessels from inflammatory processes (i.e., pneumonia or tuberculosis) may also cause hemothorax. Symptoms include pain and dyspnea, shock may also be observed in case of severe blood loss. The simplest closed drainage system is the one bottle system. It serves as a collector and a water seal. Fluid ascension is seen during normal respiration, fluid descends during expiration. This system is used for smaller drainage amounts (i.e., emphysema). A two-bottle system is commonly employed in the evacuation of any volume of air/fluid using a controlled suction. The suction-control bottle contains a long tube submerge in water, which is vented to the atmosphere. There are two short tubes present, with the second tube connected to a suction tube. There are also disposable systems, these are one-piece units which are made of plastic. These duplicate the three-bottle system. These
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units are widely used because of cost-effectiveness and facilitating of autotransfusion, such as those usually done in open-heart surgeries. The nurse's knowledge of chest tube care and troubleshooting reduces the patient's risk for complications.

Troubleshooting
Clamping of chest tubes is not recommended when the patient is being transported. The drainage unit/bottles should be handled with care and the drainage device below the patient's chest should be maintained. In case the tubing is disconnected from the bottles, the patient should be instructed to exhale as much as possible. The tips of the tubing should be cleansed and immediately reattached to the bottles. In case the bottle breaks, the tubing should immediately be submerged in a container of sterile water. Chest tube removal requires preparation of the patient. Patient should be encouraged to report sensations during removal of tubes. Commonly observed sensations include: Burning Pain Pulling sensation

Procedure for Care of Patients with Chest Tubes & Rationale

Assess patient for respiratory distress. Note for chest pain, breath sounds over lung area and vital signs. RATIONALE: Chest tubes are intended to relieve patient of respiratory distress by reestablishing normal pressures in the intrapleural and intrapulmonic areas. Observe patient for any increase in respiratory distress. RATIONALE: Cyanosis, assymetrical lung/chest expansion, changes in the nor-

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mal rate, depth and rhythm of respiration are symptoms to be observed. The following should also be observed: Dressing of the chest tube. RATIONALE: Excessive soaking with blood and pus and serosanguinous secretions may be observed. Presence of kinks, dependent loops or clots in tubing. RATIONALE: These products obstruct the patency of the tube. Chest drainage system. RATIONALE: Two shrouded hemostats for each tube should be provided. Attach hemostats to top of bed using adhesive tape. Prevents positive pressure from entering the lungs in case of accidental disconnection. Ways of positioning patient: Evacuate air using Semi-Fowler's position. Drain fluid using HighFowler's position. RATIONALE: Facilitates lung expansion, pushes air off the intrapleural and intrapulmonic space into the bottle. Air in the lungs rises to highest point in chest. Tubes are usually inserted in anterior midclaviculum, 2nd and 3rd intercoastal space. Connection between chest and drainage tubes should be maintained. Re-check if it is properly taped in place. RATIONALE: Air leaks causes breaks in airtight system. Coil any excess tubing and place on mattress beside patient. Secure it with a rubber band. Adjust tubing to hang from top of mattress to drainage chamber. Time of drainage start should be indicated. Stripping or milking of tubing should only be done if so indicated. RATIONALE: Excess tubes may serve as collecting point for drainage products resulting in patency obstruction. Wash hands. RATIONALE: Reduces transmission of microorganisms.
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Observe the following: Chest tube dressing, tubing and drainage chamber; water seal for fluctuations; bubbling in water-seal bottle/chamber; fluid drainage type and amount; vital signs and skin color of patient; bubbling in suction-control chamber. Record/report chest tubes, dressing status and patient responses. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
5.3. Applying a Nasal Cannula

Oxygen Maintenance and Promotion

In meeting oxygenation needs, lung function promotion, secretion mobilization and patent airway maintenance is required. Oxygenation however is not confined to these situations, oxygen therapy may also be used in maintaining a healthy level of tissue oxygenation.

Goals of Oxygen Therapy

The primary goal of oxygen therapy is the prevention or provision of relief of hypoxia. Controlled oxygen administration may benefit any patient who impaired tissue oxygenation. With all its therapeutic effects, oxygen however can not be used as a substitute for other treatment forms. It should also be only used when indicated. Oxygen being synonymous as any drug, should be treated as such. This is why oxygen dosage should be monitored at all times. Routine check of prescriber's orders should also be performed so as to verify that the patient is receiving the accurate oxygen concentration.

Safety Precautions
Since oxygen is a highly combustible gas, care should be taken to avoid igniting fire in a patient's room. In high concentrations, oxygen can readily fuel a fire. The following measures should be observed in the promotion of safety: Placing of "no smoking" signs on the patient's room. Inform visitors and other people that smoking is not allowed inside the room. Determine that all electrical equipment/apparatus are in good order.
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Fire procedures and exits should be studied and committed to memory. Perform routine checks of oxygen levels in portable tanks for transport.

Procedure for Applying a Nasal Cannula & Rationale

Assess respiratory status of patient. RATIONALE: Cardiac dysrhythmias and death may result from hypoxia if left untreated. Effectiveness of oxygen therapy is decreased by presence of airway secretions. Explain to patient and family the nature and purpose of the procedure. RATIONALE: Improves patients understanding of procedure. Reduces anxiety and promotes cooperation. Prepare necessary equipment/supplies. RATIONALE: Organizes working environment. Provides nurse with easy access to materials needed. Wash hands. RATIONALE: Reduces transmission of microorganisms. Connect nasal cannula to source of humidified oxygen. RATIONALE: Humidifier lubricates and moisturizes air passages. Adjust oxygen flow to prescribed rate. RATIONALE: Oxygen should not be given in excess of prescription. In some conditions, too much oxygen may be harmful. Attach cannula's tips to nares. RATIONALE: Tip to nares is the route of oxygenation. Adjust band until cannula fits snugly. Ask patient of any discomfort. RATIONALE: Cannula can be kept in place if its not too tight and patient is comfortable despite pressure. Secure tubing to patient's clothes. RATIONALE: Prevents dislodging of cannula and facilitates head movement.
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Cannula should be checked every 8 hrs. RATIONALE: Prevents inhalation of dehumidified O Ensures tube patency 2. and O2 flow. Humidification jar should be kept filled at all times. RATIONALE: Ensures sufficient moisture in the nares. Prevents tissue breakdown and patient discomfort. Check physician orders and oxygen flow rate every 8 hrs. RATIONALE: Patency and prescription of oxygen must be monitored to prevent physiological damage. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assess if patient is experiencing relief. RATIONALE: Evaluates the effectiveness of the procedure. Record procedure and pertinent observations. Report therapy and patient's response. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
5.4. Using

Portable Oxygen Equipment

Oxygen Supply
The patient can be supplied with oxygen either through oxygen tanks or a permanent wall pipe system. Regulators are used to control the amount of oxygen delivered. Portable oxygen tanks may also be used in situations where home care is permitted.

Oxygen Delivery Methods

Oxygen may be delivered through the following methods: Nasal cannula Nasal catheter
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Transtracheal Oxygen Oxygen mask

Procedure in Using Portable Liquid Oxygen Equipment & Rationale

Examine patient's need for equipment. RATIONALE: Conditions such as RHF, cor pulmonale or polycythemia need home oxygen. Food candidates are those with PaO2 <55 mm Hg or O2sat = 88% on room air, PaO2 of 55 to 59 mm Hg or O2sat of 86%--89%. Give procedure details to patient and family. RATIONALE: Improves patients knowledge of procedure. Reduces anxiety and promotes cooperations. Set up equipment. RATIONALE: Organizes working environment, provides easy access to materials needed and saves time. Wash hands. RATIONALE: Reduces transmission of microorganisms. Explain steps for oxygen therapy. RATIONALE: Teaches patient psychomotor skills. Set up primary and portable oxygen. RATIONALE: Portable oxygen replaces bulgy compressed oxygen cylinders. Request patient or family to do every step with guidance. RATIONALE: Provides opportunity for correction of errors in technique, and discussion of implications. Explain to family signs and symptoms of hypoxia and respiratory tract infection. Order patient and family to inform physician when signs or symptoms of respiratory infection or hypoxia occurs. RATIONALE: Educates family on possible emergency conditions that may arise. Wash hands. RATIONALE: Reduces transmission of microorganisms.
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Document teaching, provided information and patient/family's comprehension. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
5.5. Cardiopulmonary Resuscitation (CPR)

Rationale
Cardiac arrest is associated with the absence of pulse and respiration. In a situation when the nurse determines that the patient has suffered a cardiac arrest, the initiation of cardiopulmonary resuscitation (CPR) is needed. CPR is a basic emergency procedure which provides artificial respiration and manual external cardiac massage. The following are the ABCs of CPR: Airway establishment Breathing initiation Circulation maintenance Re-assessment of proper head position is required in the performance of this procedure. The patient's airway must also be checked for possible obstruction. It must be noted that CPR will not benefit the patient if the airway is blocked. The primary objective in performing CPR is to have oxygenated blood circulate to the patient's brain, thus preventing tissue damage.

Procedures in Cardiopulmonary Resuscitation (CPR) & Rationale

Examine victim for unresponsiveness. RATIONALE: Confirms patients level of consciousness. Call emergency service (police, hospital, etc.). RATIONALE: Antidysrhythmic drugs are often needed by most adult victims who are in ventricular fibrillation and need defibrillation. Assess breathlessness of victim and carotid (adult)/brachial pulse (children). 143 RATIONALE: CPR is contraindicated to (+) pulse and (+) RR.

Chapter Six

Intravenous Therapy
6.1. Peripheral IV Infusion Initiation 6.2. IV Flow Rate Initiation 6.3. Changing IV Solution & Infusion Tubing 6.4. Changing Peripheral IV Dressing

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6.1. Initiating

Peripheral IV Infusion

Anatomy and Physiology

Fluid, electrolyte and acid-base balances within the body are important in maintaining health and function of all body systems. Water and electrolytes intake and output as well as regulation by the renal and pulmonary systems maintain these balances. Since acid-base balance is crucial for numerous physiological processes, imbalances can result in the alteration of respiration, metabolism and function of the central nervous system. Body fluid (water and electrolytes) makes up approximately 60% of a typical adults weight. It is located in two compartments. The first, the intracellular space or fluid in the cells, represents around twothirds of entire body fluid and is primarily located in the skeletal muscle mass. The other one, the extracellular space or fluid outside the cells, is divided into three fluid spaces: the transcellular fluids, which are secreted to cushion, protect, and nourish body organs, the intravascular fluids, which are located in the blood vessels, and interstitial fluids which surround the cell.

Composition of Body Fluids

Water, as it moves through the various compartments of the body, contains electrolytesor substances that like minerals or salts. When melted or dissolved in water or another solvent, an electrolyte is a compound or an element that separates into ions and is capable of carrying an electrical charge. Negatively-charged electrolytes are called anions, while positively-charged ones are called cations. Electrolytes are crucial to many bodily functions. The value mEq/L, or milliequivalents per liter, corresponds to the number of grams of the particular electrolyte (solute) dissolved in one liter of plasma (solution). A solvent is the solution in which the solute is dissolved. Minerals, which are ingested into the body as compounds, are typically called by the name of the phosphate, metal, nonmetal or radical instead of the name of the compound to which they belong. They are constituents of all body fluids and tissues. Crucial in maintaining
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physiological processes, minerals can also function as catalysts in nerve response, metabolism of nutrients and muscle contraction. They also strengthen skeletal structures as well as regulate hormone production and electrolyte balance. Solutions are classified either as hypotonic or hypertonic isotonic. An isotonic solution is one with similar osmolarity as blood plasma. A hypotonic solution is one with higher osmotic pressure that pulls fluid from cells, while an isotonic solution is one with equal osmotic pressure that expands the fluid volume without causing a fluid shift from one compartment to another. A hypotonic solution is a solution with lower osmotic pressure that causes fluid to move into cells, causing them to enlarge.

Movement of Body Fluids

Fluids and electrolytes continuously shift from one compartment to another to facilitate several bodily processes like urine formation, acid-base balance and tissue oxygenation. Since cell membranes that separate the body fluid compartments are selectively permeable, water can pass through them effortlessly. On the other hand, most molecules and ions pass through them relatively slower. Solutes and fluids move across these membranes following four process, namely, active transport, filtration, diffusion and osmosis. Osmosis is a process that involves the transfer of a pure solvent (such as water) through a semi-permeable membrane from an area of lower solute concentration to an area of higher solute concentration. The membrane is impermeable to the solute but is permeable to the solvent. A solutions concentration is measured in osmols, which indicate the amount of a substance in a solution in the form of ions, molecules or both. Waters drawing power is called osmotic pressure and such is dependent on the number of molecules in a solution. Osmolarity refers to the osmotic pressure of a solution and this is expressed in osmols or milliosmols per kilogram (mOsm/kg) of the solution. Plasma proteins affect the osmotic pressure of the blood, particularly albumina serum protein produced naturally by the body. Albumin causes colloid osmotic or oncotic pressure, which tends to maintain fluids in the intravascular compartment. At the venous end of the capillaries, this oncotic pressure together with decreased venous
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hydrostatic pressure draw water and waste products back into the capillaries to be filtered by the kidneys. Diffusion is the movement of a solute, either substance or gas, in a solution from an area of higher concentration across a semipermeable membrane to an area of lower concentration, this results in an even distribution of the solute in a solution. Concentration agent is the difference between the two areas of concentration. The process by which water and diffusible substances move together in response to fluid pressure is called filtration. This process is active specifically in capillary beds where differences in hydrostatic pressure determine water movement. Metabolic activity and use of energy to move materials across cell membranes are required for active transport. This process allows cells to take in larger molecules than their normal capacity. Active transport is facilitated by carrier molecules inside a cell that combine themselves with incoming molecules.

Regulation of Body Fluids

Fluid intake, hormonal controls and fluid output regulate body fluids. Homeostasis is the physiological balance of fluids. Primarily, fluid intake is regulated through the thirst mechanism, whose control is located in the hypothalamus of the brain. The serum osmotic pressure is constantly monitored by osmoreceptors. When osmolality increases, there is an stimulation in the hypothalamus. The average daily fluid intake of an adult is around 2200 to 2700 ml daily oral intake accounts for 1100 to 1400 ml, daily solid foods intake around 800 to 1000 ml and daily oxidative metabolism, which is the by-product of cellular metabolism of ingested solid foods, is 300 ml. Aided by various body hormones that control metabolic processes of the body, hormonal regulation follows a number of mechanisms. For one, antidiuretic hormone (ADH), stored in the posterior pituitary gland, is released in response to alterations in blood osmolarity. Stimulation of osmoreceptors in the hypothalamus occurs when there is an increase in the osmolarity to release the hormone, working di148

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rectly on the renal tubules and collecting ducts to make them more permeable to water. In turn, this causes water to return to systemic circulation to dilute the blood and lower its osmolarity. The adrenal cortex releases aldosterone to respond to increased plasma potassium levels or as part of the renin-angiotensin-aldosterone mechanism to fight hypovolemia. Aldosterone acts on the distal portion of the renal tubule to increase the secretion and excretion of potassium and hydrogen and reabsorption of sodium. Since sodium retention results in water retention, aldosterone release functions as volume regulator. Secreted by the kidneys, renin is a preolytic enzyme that responds to decreased renal perfusion secondary to a decrease in extracellular volume. It acts to produce angiotensin I which causes vasoconstriction. On the other hand, angiotensin I is typically reduced immediately by an enzyme that converts it into angiotensin II which causes massive selective vasoconstriction of numerous blood vessels and relocates and increases blood flow to the kidneys, improving renal perfusion. When sodium concentration is low, angiotensin II stimulates the release of aldosterone. Regulation of fluid output or water loss happens through four organs: kidneys, skin, lungs and the gastrointestinal tract. The kidneys are the major regulatory organs of fluid balance, receiving around 180 L of plasma to filter daily and producing 1200 to 1500 ml of urine per day. Water loss via the skin is regulated by the sympathetic nervous system that activates the bodys sweat glands. Either sensible or insensible loss, water loss from the skin averages between 500 to 600 ml per day. The lungs expire around 400 ml of fluid daily. Lastly, the GI tract has a key function in fluid regulation as around 3 to 6 L of isotonic fluid is transported into the GI tract and returned to the extracellular fluid. Normally, an average adult looses approximately 100 to 200 ml of the 3 to 6 L of isotonic fluid per day via the feces.

Physical Assessment
A thorough assessment of the patient is vital since fluid and electrolyte imbalances of acid-base disturbances can impact all body systems. While assessing each system, the nurse carefully considers the potential signs and symptoms as a result of any imbalance. Signs and symptoms of imbalances are identified by physical assessment. Such
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manifestations may be marked, minimal or even absent. It was suggested that specific assessment parameters must be taken into account when assessing a patient for disorders in fluid, electrolyte and acid-base balance. These include intake and output (I&O), urine volume and concentration, skin signs such as turgor, temperature and moisture, body weight, objective measures of fluid loss such as tearing and salivation, subjective complaints of thirst, edema, neuromuscular signs and cardio-pulmonary signs such as respirations, heart rhythm, central venous pressure, neck veins or external jugular vein distention, blood pressure (supine and upright to check for orthostatic changes) and pulse. Other parameters include sensations, behavioral changes, gastrointestinal functions and unusual odors. Measuring Fluid Intake and Output. The Fluid Balance Record is a documentation of a persons fluid intake (either oral, which includes all liquid and semi-liquid materials ingested through the mouth, parenteral or via gavage or tube feedings) and fluid output (all liquids excreted from the body like urine, stool, GI/nasal suction drainage, wound drainage, vomit and sweat). The Fluid Balance Record assists in diagnosing and anticipating imbalances; it also helps in measuring fluid replacement requirements. I&O is a tool for documenting all types of intake and output. When hospitalized, a patients I&O measurements are needed in monitoring fluid balance. However, accurate I&O measurements can only be achieved through patients and significant others assistance and cooperation. Urine Volume. The normal urine output in adult is between 1-2 L per day. Urine output will either increase or decrease depending on an individuals intake and the amount of insensible loss. In most clinical settings, baseline urine output is approximately 30 mL per hour. Urine Concentration. Specific gravity is used to measure urine concentration. It is inversely related to urine volumethe higher volume of urine, the lower the specific gravity and vice versa. However, specific gravity is not a very dependable indicator of concentration compared to urine osmolality since an increase in protein or glucose content in urine can result in a false high specific gravity. Factors that affect the decrease or increase in urine specific gravity are the same for urine osmolality. Normal specific gravity ranges from 1.003 to
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1.030. When diluted, specific gravity is between 1.001 and 1.030; when concentrated, it is between 1.003 and 1.040. Urine pH is the hydrogen ion concentration of the urine. It is a measurement of the acid or alkaline content of urine. One of the mechanisms that maintain normal acid-base balance of the body is the kidneys secretion of acidic or alkaline urine. Urine pH ranges between 4.6 to 8.0, with an average of 6.0. The normal urine osmolality is dependent on several clinical parameters although the acceptable range is between 50 to 1400 mOsm/kg. Skin Turgor. Skin turgor (firmness, elasticity, tonicity, etc.) shows the hydration status of a person. Skin with normal turgor can be easily moved when lifted and immediately goes back to its prior position. As a person ages, the skin tend to lessen its turgor. Thus, when the skin of an elderly patient is pinched, it tends to remain elevated when lifted (or tents) and returns relatively slower compared to younger ones. Tongue Turgor and Mucous Membrane Moisture. The tongue is normally is smooth underneath and is covered with papillae on the dorsum. Patients with normal hydration have moist tongue and oral cavity, without evidence of cracks or fissures on the surface, and with smooth and intact lips. Body Weight. Several factors affect the total body weight (TBW) of a patient. These are sex, height, bone structure and fluid status. Approximately 20% of a persons TBW is extracellular fluid (ECF), while around 40% is intracellular fluid (ICF). One liter of body fluid is almost equal to 1 kg of TBW. Thus, a gain or loss of 1 kg in TBW is equal to around 1 L of ICF and ECF gain or loss. In a healthy adult, TBW must remain unaltered. But for patients with third-space shifting, a gain in weight is possible in spite of FVD in the intravascular space. Thirst. Located in the hypothalamus is the thirst center. Osmoreceptors contract to stimulate thirst and increase oral intake as fluid is lost. While hydration stabilizes, the osmoreceptors water content increases, making the thirst response disappear. Tearing and Salivation. Tears are produced by the body to lubri151

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cate the eyes to protect them from abrasions. The eyes must remain moist for them to be healthy. The lacrimal gland produces a persons tears, it is located under the outer one-third of the upper eyelid. For every blink of an eye, the eyelid spreads the tears over the eyes surface and pumps tears into the lacrimal duct that drains the tears into the nose. This is the reason why a persons nose runs when he/she cries. Salivation is stimulated by factors such as smells, thoughts or the actual presence of food. Salivation is used by the body to lubricate food to facilitate its movement into the GI tract. Temperature. The main function of the skin is to control temperature. As the body cools down, blood capillaries widen (vasodilation) Electrolytes Extracellular (mEq/L) to transport more blood near the skin surface.Intracellularfunction of The main (mEq/L) the skin is temperature regulation. When the body cools down, the Sodium (Na+) 135 - 154 15 20 blood capillaries widen (called vasodilation) to transfer 155 blood more 3.5 - 5 150 Potassium (K+) near the skin surface to enable heat loss into the surroundings via 12 Calcium (Ca++) 4.5 - 5.5 radiation and(HCO3-) Bicarbonate convection. During- this process, sweat is12 25 27 10 produced, which as it evaporates, has a cooling effect on the body while hairs lie Chloride (Cl-) 98 - 106 14 flat to allow(Mg++) air to escape -faster. On the other hand, as the Magnesium warm 4.5 5.5 27 29 body warms(PO43-) 100 104 Phosphate up, blood capillaries in4.6 skin become narrower (vaso1.7 - the constriction) to lessen heat loss, decrease sweating (also to lessen loss of heat), and hairs become erect to trap air to prevent warm air Acid-Base Balance from escaping fast. Arterial blood gases (ABGs): Normal ABGs (values may vary slightly Edema. Edema is an abnormal hydration status. Skin is normally within institutions): pliant with good elasticity, without the presence of swelling. Edema is pH - 7.35-7.45 into the interstitial tissue. It is a type of abnora disposal of fluid PaCO2 - 35-45 mm Hg mal fluid retention in the body. PaO2 - 80-100 mm Hg Pulse and Heart Rhythm. The normal pulse is regular and strong. SaO2 94%-98% A normal heart rate is approximately 60 to 100 beats per minute. Arterial blood gases measure arterial blood pH, pressure of O2 and Respiration. TheO2 saturation, which reflects patient'sto 20 breaths CO2 and arterial normal respiratory rate is around 12 oxygenation per minute. The normal respiratory pattern is regular with bilateral status. chest expansion. Lung sounds are clear to auscultation. Pulse oximetry (SpO2): Acceptable SpO2 90%-100%; 85%-89% Neck Vein acceptable forVenous Pressure (CVP). Since CVP is may be and Central certain chronic disease conditions; less the pressure inis abnormal. near the right atrium of the heart, the than 85% the large vein determination of the CVP offers a direct measurement of the alterations in pressure of blood going back to the heart. As fluids shift toward the upper body, pressure in the veins close to the heart must increase, resulting in increased central pressure. As upper body fluid 152 normalizes or decreases, a corresponding normalization or flow

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SpO2 less than 85% is often accompanied by changes in respiratory rate, depth and rhythm. Base Excess: +2
Blood Chemistry and Studies

Complete blood count (CBC): Normal CBC for adults (values may vary within institutions): Hemoglobin: 14 to 18 g/100 ml, males: 12 to 16 g/100 ml, females. Hematocrit: 40% to 54%, males; 38% to 47%, females. Red blood cell count: 4.6 to 6.2 million/ ul, males; 4.2 to 5.4 million/ ul females. Complete blood count measures red cell count, volume of red blood cells, and concentration of hemoglobin, which reflects patient's capacity to carry O2. Creatinine - 0.5 - 1.2 mg/100 ml Blood Urea Nitrogen - 10 - 25 mg/100 ml Urine specific gravity - 1.010 - 1.025

Intravenous Fluid Therapy

IV fluid therapy or replacement is the administration of fluid solution in the body that enables direct access to the vascular system permitting the infusion of continuous fluids over a period of time to correct or prevent fluid and electrolyte disturbances. When the physician orders IV administration, the nurse must know the following: the correct ordered solution, the needed equipment, the required procedures to initiate infusion, technique in regulating infusion rate and maintaining the system, method in identifying and correcting problems and the procedure to discontinue the infusion if necessary.

Purpose of Intravenous Fluid Therapy

Each type of IV solution has its own specific purpose. In general, IV fluids are administered to: Provide water, electrolytes, and nutrients to meet daily requirements
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Replace water and correct electrolyte deficits; and/or, Provide a medium for intravenous administration of medications and parenteral nutrition.

Intravenous Fluid Therapy Solutions

There are three categories of IV solutions, namely: hypotonic, hypertonic and isotonic solutions.
Solutions solutions are those that have an effective osmolality lower Concentration Other Names Hypotonic

than theinbody fluids. Hypertonic solutions are those that have an Dextrose Water Solutions Dextrose osmolality W effective5% in Water1 higher that body Isotonic IsotonicD5solutions are fluids. Dextrose 10% in similar D10 W Hypertonic those that haveWater effective osmolality like those of body fluids. Generally, isotonic fluids are commonly used for extracellular volSaline Solutions ume Sodium Chloride (half normal saline) Hypotonic 0.45% replacement. The decision to use what type of IV solution de0.45% NS pends on the specific fluid and 2electrolyte imbalance. 0.45% NaCl 0.9% Sodium Chloride (normal saline) Isotonic
3%-5% Sodium Chloride

Types of Intravenous Solutions

Dextrose in Saline Solutions Dextrose 5% in 0.9% Sodium Chloride

Hypertonic

PNSS 3%-5% NS 3%-5% NaCl D5 0.9% NaCl D5 0.9% NS D5 NSS D5 0.45% NaCl D5 0.45% NS PLR or Plain LR D5 LR

Hypertonic

Dextrose 5% in 0.45% Sodium Chloride

Hypertonic

Multiple Electrolyte Solutions Lactated Ringers3 Dextrose 5% in Lactated Ringers

1

Isotonic

Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments. 2 Although it is an isotonic because the total concentration of electrolytes equals the plasma concentration, it contains 154 mEq of both sodium and chloride which is a higher concentration of these electrolytes than in plasma. 3 Contains sodium, potassium, calcium, chloride and lactate. 4 Plain Normal Saline Solution

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Types and Uses of Intravenous Fluids

Solution Osmolality Usage and Limitations Provides free water (hypotonic) to the extracellular and intracellular spaces, as the dextrose is quickly metabolized; promotes renal elimination of solutes; treats hypernatremia; does not provide electrolytes; one liter is 170 calories Osmotic diuretic; provides free water and 340 calories per liter, but no electrolytes; hypertonic solutions may irritate the veins Osmotic diuretic; provides calories, but no electrolytes; solutions containing more than 10% dextrose must be infused in a central line Osmotic diuretic; provides calories, but no electrolytes For daily maintenance of body fluids when Cl and Na are required; treats hypernatremia; replaces hypotonic losses; 170 calories pre liter To promote renal function and excretion; basically the same as .45NS except provides 170 calories per liter To treat fluid volume deficit; for daily maintenance of body fluids and nutrition; basically the same as NS, except provides 170 calories per liter To replace calories, fluid, sodium and chloride Assists with renal function; provides free water, Na and Cl.; replaces normal hypotonic daily fluid losses- assists with daily D5W - 5% Dextrose isotonic (252 mOsm/L) in water

hypertonic (505 D10W - 10% Dextrose in water mOsm/L)

hypertonic (1011 D20W - 20% Dextrose in water mOsm/L)

hypertonic (1700 D50W - 50% Dextrose in water mOsm/L) isotonic (320 mOsm/L) D5 1/4 NS - 5% Dextrose & 0.2NaCl

D5 1/2 NS - 5% Dextrose & 0.45 NaCl

hypertonic (406 mOsm/L)

D5NS - 5% Dextrose hypertonic (559 mOsm/L) & 0.9 NaCl

hypertonic (812 D10NS - 10% Dextrose & 0.9NaCl mOsm/L) 1/2 NS - 0.45%NaCl hypotonic (154 mOsm/ L)

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Solution

Osmolality

Usage and Limitations body fluid needs, but not with electrolyte replacement or provision of calories.

NS - 0.9% NaCl

isotonic (308mOsm/L)

Replaces NaCl deficit and restores/expands extracellular fluid volume; the only solution that may be administered with blood products--does not provide free water that causes hemolysis of red blood cells Raises Na osmolality in the blood; removes excess intracellular fluid; infuse slowly; monitor for pulmonary edema and intravascular volume overload Replaces K, Na, Cl. and Ca.; does not contain lactate, which can be harmful to those who are unable to metabolize lactic acid; does not provide free water Closely resemble the electrolyte composition of normal blood serum and plasma; will need additional K; does not provide calories or free water; used to treat losses from lower GI tract and burns.

3%NS

hypertonic (1026 mOsm/L)

Ringer's Solution

isotonic (309 mOsm/L)

Lactated Ringer's Solution

isotonic (273 mOsm/L)

D5LR - 5% Dextrose hypertonic (524 mOsm/ Same as Lactated Ringers, plus in Lactated Ringers L) calories D10LR - 10% Dextrose in Lactated Ringers hypertonic (776 mOsm/ Same as Lactated Ringers, plus L) extra calories Plasma expander Plasma expander Depressant diuretic effects, provides calories

10% Dextran 40 in isotonic (252 mOsm/L) 5% Dextrose 10% Dextran 40 in isotonic (308 mOsm/L) 0.9%NS 5% Alcohol in 5% Dextrose hypertonic (1114 mOsm/L)

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Solution 8% Amino Acids Osmolality Usage and Limitations

hypertonic (950 mOsm/ Provides protein in varying L) percentages; assists with tissue repair and to correct negative nitrogen balance isotonic (280-300 mOsm/L) isotonic (330 - 340 mOsm/L Provides fatty acids and calories Provides calories and fatty acids; contraindicated in patients with liver damage or altered fat metabolism

Intralipids 10% Intralipids 20%

Factors Affecting Venipuncture

Venipuncture is the ability to gain access to the venous system for administering fluids and medications. Factors that influence venipuncture include: Condition of the vein Type of fluid / medication to be infused Duration of therapy Patient's age and size Patient's medical history and current health status Skill of the health provider.

Assessment Sites
Designated as peripheral locations, veins of the extremities are the preferred assessment sites for they are relatively safe and easy to enter, particularly the upper extremities, which are most commonly used sites. These include medial antebrachial veins, cephalic veins, median cubital, metacarpal veins, digital veins, and basilic veins. Under extreme situations and only with a physician's order should one use leg veins as assessment sites due to the high risk of thromboembolism. One should also refrain from using veins proximal to previous IV infiltration or phlebitic sites as well as thrombosed or sclerosed veins. Arms affected by edema, fracture, infection, blood clot, skin breakdown or operative site or those with an arteriovenous
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shunt or fistula must be avoided. The arms on the side of a mastectomy must also be avoided. Finally, always administer venipuncture on other side of the affected site due to impaired venous return, such that if the affected site is at the left, venipuncture must be done on the right and vice-versa. Central veins normally utilized by physicians as venipuncture sites include internal jugular and subclavian veins. Despite the collapse of peripheral sites, it is possible to access or cannulate these larger vessels; they actually allow administration of high osmolar solutions. However, hazards are greater when using these sites, including the inadvertent entry into an artery or dipleural space. Prior to venipuncture site selection, it is ideal that both hands and arms be thoroughly inspected. Allocation must be made if it does not impede mobility, thus the antecubal fossa is always the last option. Generally, the most distal area of the hand or arm is selected first to allow subsequent IVs to move upward progressively. Generally speaking, it is better to try to cannulate the most distal veins first. If for example, the antecubital veins are ruined as a result of failed cannulation attempts this can cause problems in the event of a successful cannulation further down. Any drugs or fluids put through the cannula may extravasate at the failed cannula site. The cephalic vein is one of the best veins available. That's why it's also known as the 'Housemans' vein (a Houseman is a very junior doctor in the UK). It tends to be large, and the forearm provides a natural splint. If you place the cannula too far distally along the vein, you can run into problems with the wrist joint, and are getting close to the radial nerve. Also the tendons that control the thumb can obscure the vein. These problems can usually be avoided by moving a little further proximally along the vein. The basilic vein is often overlooked, hiding as it does along the ulnar border of the hand and forearm. On the plus side, it's often fairly large - on the minus side it can roll like a tanker in a rough sea and can have more valves than a submarine. The dorsal veins are typically manageable as the metacarpals splint cannulae well (Weinstein, 1997), but they can be quite small. If the
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patient is elderly, look elsewhere. The lack of turgor in the skin and loss of subcutaneous tissue make it quite difficult to cannulate these veins in oldler individuals. Cannulation of the antecubital veins can also cause problems as the cannula may occlude as the patient bends his/her arm. Avoid, if you can, areas where cannulation or venipuncture has previously taken place. Repeated puncture of the vein wall can result and is painful. In general, locate the vein section with the straightest appearance. Choose a vein that has a firm, round appearance or feel when palpated. Avoid areas where the vein crosses over joints. If the IV treatment is for a life-threatening illness or injury, your choice may be limited to an area that remains open during hypoperfusion. Otherwise, limit IV access to the more distal areas of the extremities. Dorsal digital veins. Flow along lateral portion of fingers and are joined to each other by communicating branches Available for IVs accommodating a small gauge IV catheter (22 or 24 gauge). Need to be properly supported with a tongue blade or hand board. Usually not very stable and not a primary site choice. Metacarpal veins. Formed by union of digital veins (dorsal venous area). Ideal position for IV use - primary choice IVs. Venipuncture should be started at the most distal point on the extremity. Proper support is needed after IV infusion is initiated to prevent movement of IV catheter. Veins are thin with inadequate tissue and muscle support in the elderly. Cephalic vein. Flows upward along the radial border of the forearm producing branches to both surfaces of the forearm Because of their size and location, they provide an excellent site for IV infusion, readily accommodates large gauge IV catheters and is available for venipuncture in the upper arm region. Accessory cephalic vein. Originates from either a plexus on the back of

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the forearm or dorsal venous network, branches off from the cephalic vein just above the wrist and flows back into the main cephalic vein at a higher point, and readily accommodates large gauge IV catheters. Basilic vein. Originates in the ulnar portion of the dorsal venous network. Ascends along the ulnar portion of the forearm. It curves toward the anterior surface of the arm just below the elbow. It meets with the median cubital vein below the elbow. Is available for venipuncture above the antecubital fossa in the upper arm region. Often overlooked because of its inconspicuous position. An infusion set is used to deliver a fixed volume of IV fluid at a fixed Median antebrachial added medication. A venous plexus on the set is rate, usually with vein. Arises from the primary IV solution hand and extendsthe spike adaptor at the the anterior surface of the foreattached to along the ulnar side on distal end of the in-line burette arm.Clamps on into the basilicclosed while thecubital of the in-line set. It empties both sets are vein or median spike vein. It is not always easily seen. into a fluid container. A small amount of fluid burette is inserted (depending on size) is released into the burette and the primary IV Median cephalic and median basilic veins. Locatedfilled toantecubital fossa. solution set below is primed. The burette is in the the desired level It should be a last resort site for blood draws the fluid via favorable and the clamp closed. Medication is added to and is not a the injecsite for prolonged infusions. tion port on the burette if desired. The primary set is opened and the drip rate adjusted to normal. Fluid flow will stop when the burette is Infusion Set empty. The use of a burette allows fine control of fluid volume and Tubinginadvertant over-transfusion. A at the proximal end, a spike avoids with a spike and roller clamp solution burette (incorporatadapter at the solution set and a burette) is preferred to centre. Buing a primary distal end and a graduated burette in the this device retteto infectionan air inlet and injectionindividually proximal in a peel due possesses risks. Infusion sets are port on its wrapped end and may containsizes required of 150ml burette (most common). pouch with a ball valve at the base.

IV needles and catheters

Steel Needles. Example: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge). Over the Needle Catheters. Example: peripheral IV catheter. This is the kind of catheter most commonly used. Inside the Needle Catheters. Example: midline and extended dwell catheters. Catheters (and needles) are sized by their diameter, which is
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called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20gauge catheter in a smaller vein will do.

Materials Required IV stand IV fluids as ordered IV tubings IV connection tube or extension tube (if needed) IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) -

the greater the gauge the smaller the needle cannula and viceversa. Band-aid tape Micropore tape Assess the medical record of the patient, following the 'five rights' of medication administration. RATIONALE: This procedure is an interdependent nursing procedure which needs physicians order before initiation. Ensures avoidance of medication errors. Monitor for sign and symptoms of electrolyte or fluid imbalances. RATIONALE: Ensures accuracy of fluid to be transfused and provides baseline data for care management. Evaluate previous experience of patient with intravenous therapy. RATIONALE: Provides baseline data for client education regarding the procedure. Check physician's order for blood transfusion or surgery. RATIONALE: IV catheter size must always be considered for BT which requires bigger gauges of needle such as 18 and 20.
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Evaluate patient's laboratory data and allergies (if any). RATIONALE: Some of the materials needed for IV insertion may cause allergies such as iodine adhesive or latex which have available substitutes in the Central Supply Room. Examine patient for risk factors. RATIONALE: Conditions such as renal failure and CHF may need strict IVF regulation and microset use may be required for they cannot adapt to sudden circulating volume elevation. Give details of procedures to patient. Help patient assume a comfortable lying or sitting position. RATIONALE: Reduces anxiety and enhances cooperation. Wash hands. RATIONALE: Reduces transmission of microorganisms. Arrange equipment to be used on overbed table or bedside stand. RATIONALE: Provides easy accessibility, maintains sterile field and saves time. If possible, change gown of patient to an easily removable one. RATIONALE: Avoids accidental removal during hygienic measures such as changing of gown. Observe sterile technique at all times. Open sterile packages. RATIONALE: Maintains sterility of equipment minimizes if not prevents transmission of organisms which may cause infection. Inspect IV solution. Ensure prescribed additives (e.g., vitamins, potassium) have been included. Inspect solution for expiration date, clarity, and color. Inspect if bag has leaks. RATIONALE: Ensures accuracy of administration and absence of medication errors. Open infusion set. Put roller clamp around 2-4 cm under drip chamber and turn off roller clamp. Take off protective sheath over IV tubing port. Put infusion set in fluid bottle or bag. RATIONALE: Steps to initiate priming of IVF tubing with fluid for infusion, following sterile technique.
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Take off protective cap from tubing insertion spike and put spike into the mouth of IV bag. RATIONALE: Allows fluid to enter tubing. Wash rubber stopper of bottled solutions using an antiseptic and put spike into the IV bottle's rubber stopper. RATIONALE: Prevents entrance of microorganism into the IVF via the spike. Use IV solution to prime infusion tubing. Compress drip chamber and release. Allow it to fill from one third to one half of the tubing. RATIONALE: Prevents air bubbles which interfere in the IV tubing, produces negative pressure in the bottle pulling fluid into the drip chamber. Take off protector cap. Release slowly roller clamp to enable fluid to drip from tubing to needle adapter. Turn off roller clamp once tubing is primed. RATIONALE: Avoids spillage of fluid which may affect accuracy of intake monitoring. Remove air bubbles from tubing. Tightly tap IV tubing where air bubbles are present. Inspect the whole tubing to assure the total elimination of air bubbles. RATIONALE: Large air bubbles may cause air embolism. On the tubing's end, put back tubing cap protector. RATIONALE: Maintains asepsis. Prevents contamination of fluid by microorganisms. Optional: Set up normal saline lock or heparin for infusion. RATIONALE: Heparin acts as plug to prevent blood clotting and air formation. Observe sterile technique while connecting IV plug to the loop or short extension tubing. Inject around 1-3 ml normal saline via the plug and through the loop or short extension tubing. RATIONALE: Sterility is maintained. Wear disposable gloves. RATIONALE: Transmission of microorganisms is reduced.
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Determine site for IV replacement. Begin from most distal part of the body. Anticipate replacement within 72 hrs. Put tourniquet around 10-15 cm over the insertion site. Verify for presence of distal pulse. RATIONALE: Venous return must be impeded to prevent bleeding once vein is punctured. Choose well-dilated vein. RATIONALE: Size should be able to accommodate catheter. Execute vein dilation using the following steps: Rub the extremity from distal to proximal sites under the projected site for venipuncture. RATIONALE: Enhances vein dilation. Request patient to open and close his/her arm where the site has been chosen. RATIONALE: Dilation of vein is further increased. Bring down the extremity where the site has been chosen. RATIONALE: Against gravitational pull, blood pulled in before the tourniquet enhances dilation of distal vein. Temporarily free tourniquet. If necessary, trim excess hair at site. RATIONALE: Hair hinders proper vein visualization. Shaving however should be avoided as much as possible as it may cause exposure to infection. Sterilize the insertion site with povidone-iodine solution with firm, circular motion. Avoid touching sterilized site. Let site dry for 2 mins. If patient displays allergic reaction to iodine, use 70% alcohol and let it dry for at least 1 min. RATIONALE: Circular motion prevents contamination of sterilized site. Alcohol washes iodine away in case of allergic reaction. Carry out venipuncture. To anchor vein, put thumb on vein and stretch skin away from insertion direction 7-10 cm distal to the site. RATIONALE: Stabilizes insertion site.
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For butterfly needle, position needle at a 20-30 angle with bevel up a little distal from actual venipuncture site. RATIONALE: Prevents through and through hitting of vein. For over-the-needle catheter, insert with bevel up at a 20-30 angle a little distal to site and along the vein's direction. RATIONALE: Prevents through and through hitting of vein. For needleless IV catheter safety device, insert following the same technique. Determine if there is blood return through flashback chamber of over-the-needle catheter or tubing of butterfly needle. Bring down needle until nearly flush with skin. Continue inserting butterfly needle until its hub reaches venipuncture area. Proceed inserting the over-the-needle catheter a quarter inch into vein; loosen stylet afterwards. Proceed inserting catheter into vein until its hub reaches venipuncture area. Once loosened, avoid reinserting stylet. RATIONALE: IV reinsertion may cause infection. Steady catheter using one hand by putting pressure on vein on top of insertion area or over the hub. Free tourniquet and take sylet off the over-the-needle catheter. Refrain from recapping stylet. Take off stylet while sliding protective guard over stylet. RATIONALE: Prevents clotting, venous return goes back. Attach needle of heparin lock or adapter of administration set with the hub of butterfly tubing or over-the-needle catheter. Refrain from touching the point of entry of needle adapter. RATIONALE: Initiates IV flow and prevents contamination. Bloodless technique: With thumb, put pressure on tip of inserted catheter. Take off cap and connect tubing to catheter hub using index finger or thumb. RATIONALE: Impedes venous return. Slowly let go of roller clamp to start infusion at a rate to preserve IV line patency. RATIONALE: Initiation of IV flow is ensured. Blood clotting is prevented. Fasten IV needle or catheter:
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Put a thin piece of tape below catheter hub with sticky side facing opposite catheter; run tape over catheter. Put another piece of tape over the hub of catheter. RATIONALE: Needle movement and accidental dislodging is prevented. Place sterile dressing on the site. RATIONALE: Minimizes risk of infection. For transparent dressing, take off adherent backing, then apply dressing on the site. Flatten dressing on the site, but refrain from covering the end of catheter hub. RATIONALE: Direct view of insertion site is facilitated. Provides access to cathter hum in case troubleshooting is required. Fold a 2X2 piece of dressing into half, cover with tape, and put beneath catheter hub. Coil a loop of tubing and fasten on tubing and gauze. RATIONALE: Injury from pressure on skin caused by catheter hub is prevented. Stabilizes catheter in the vein. Administer IV fluid by adjusting flow rate to adjust drops per minute: RATIONALE: Cardiac overload is prevented. Heparin lock: wash out using 1-3 ml heparin (10-100 u/ml). Saline lock: wash out using 1-3 ml sterile normal saline. Record time and date, catheter and gauge size, and placement of IV dressing and line. RATIONALE: Baseline information for future dressing changes is provided. Serves as reference for reinsertion schedule. Properly dispose of used needles and dispose supplies. RATIONALE: Health workers are protected from contamination. Take off gloves and wash hands. RATIONALE: Minimizes transmission of microorganisms. Monitor patient each hour to establish whether fluid is properly infusing. RATIONALE: Prevents complications (i.e., hypoinfusion or overinfusion).
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Monitor patient each hour to check reaction to therapy. RATIONALE: Opportunity for necessary intervention is provided. Document peripheral IV insertion. Document and report the response of patient to IV fluid, including amount infused, and system integrity and patency. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for gtt purposes. volume legal factor
hour minute

6.2.

IV Flow Rate Regulation

Importance of Proper Regulation and Monitoring of Flow Rate

Similar to the purpose of parental nutrition that aids in body nourishment and fluid replacement and the rights of drug administration, IV flow rate monitoring and regulation seeks to infuse the proper dose and exact amount of fluids required by the patient. Following the pharmacological approach, the nurse plays an important role in the curative side as well as in the prevention of potential complications arising from IV fluid infusion.

Factors Affecting IV Gravity Flow

Principles that control movement of fluid in general also apply to the flow of intravenous infusion: Flow is directly proportional to the height of the liquid column. Elevating the infusion container can enhance a sluggish flow. Flow is directly proportional to the tubings diameter. By changing the tubing diameter, clamp on the IV tubing regulates flow. Thus, cannulas of large gauge allow faster flow as compared with those of small gauge. Flow is inversely proportional to the tubings length. Extending an IV line will slow down the flow. Flow is inversely proportional to the fluids viscosity. Viscous IV solutions e.g., blood and total parental nutrition fluidsneed larger cannula
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as compared to water or saline solutions.

Monitoring the Flow Rate

Since a number of factors impact gravity flow, changes in the speed of flow relative to original speed are normal. It is thus imperative that frequent monitoring of IV infusions be made to ensure that fluid flows at intended rate. IV container must be marked with tape to quickly indicate if the proper amount has been infused. Calculation of flow rate must be made upon initiation and monitored at least every hour. To calculate flow rate, one must determine the number of drops delivered per ml, but this varies according to equipment and is normally printed on the solution set packaging. Formula for calculating drop rate is: Flow Rate =
Note: Microdrop rate = 60 gtts Macrodrop rate = 15 mgtts

Various types of infusion pumps are available to facilitate IV fluid delivery. Compared with routine gravity-flow setups, these devices make possible the more accurate administration of fluids and medications. For instance, there are volumetric pumps, which have flow rates calibrated in terms of milliliters per hour. There are those called infusion controllers, which are calibrated in drops per minute. Considering the great variety among these devices, it is crucial to carefully read the manufacturers directions prior to usage. However, despite the technological advances in infusion pumps, it is still best to conduct frequent monitoring of infusion and patient.

ProcedRegulating IV Flow Rate

Monitor the patency of IV line and catheter or needle. RATIONALE: Infiltrated IV needle may cause tissue trauma and inaccurate medication input rate. Verify from medical record of client for proper infusion additives, solution, and time. RATIONALE: Prescribers order is confirmed.
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Validate knowledge of client on the effect of position of IV site on flow rate. RATIONALE: Serves as baseline for patient health teaching. Enhances selfesteem and patient participation in care. Check how client feels on venipuncture site. RATIONALE: Pain sensation may indicate infiltration/infection. Measure flow rate. RATIONALE: Ensures that no cardiac overload arises from hyperinfusion or hypoinfusion which may result in further fluid and electrolyte imbalance Verify infusion sets calibration in drops per milliliter (gtt/ml). Choose formula to use in calculating flow rate after verifying ml/hr. RATIONALE: Ensures accurate drip rate and regulation. Read to client the orders of prescriber, follow five rights for proper solution and correct additives. RATIONALE: Medication error is avoided. Establish hourly rate. RATIONALE: Immediate correction in case of infusion delay/advance resulting from insertion site patency is ensured Put fluid indicator tape or any adhesive on IV bag or bottle near to volume markings. RATIONALE: Provides easy and faster visualization of IV fluid level. Based on infusion sets drop factor, calculate minute rate. RATIONALE: Infusion set brands may have varying drip factors. By counting drip chamber drops for 60 secs, time flow rate. Adjust roller clamp either to decrease or increase infusion rate. RATIONALE: This is the universally accepted method of accurate drip rate counting during IV regulation.

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For infusion controller or pump, follow these: Put electronic eye on drip chamber under the origin of drop and increase the fluid level in chamber. You can also opt to consult manufacturer for instructions. When using the controller, make sure that IV bag is 1 m higher than the IV site. RATIONALE: Electronic eye has a drip sensor which counts drip rate. Different manufacturers have unique features. Height facilitates gravitational pull on fluid. Put IV infusion tubing inside the ridges of control box along the flows direction (You can also opt to consult manufacturer for instructions). Choose volume per hour or drops per minute and lock the door to chamber. Turn the power on, then push the start button. RATIONALE: Ridges are sensors which detect fluid running along the tube. Accurate fluid input is achieved by correct fluid regulation by computer. While using the infusion pump or controller, open drip regulator. RATIONALE: Regulator no longer regulates drip rate, it may therefore be kept fully open. For infiltration follow as per agency policy, observe IV site and infusion rates. RATIONALE: Prevents tissue trauma and ensures accurate infusion rate. When alarm sounds, examine the systems patency and integrity. RATIONALE: Alarm indicates problem with patency and integrity (empty IV bottle, kinks, etc.). For volume control device, observe the following: Put device for volume control between insertion spike of infusion set and IV bag. RATIONALE: Ensures accurate fluid volume input. Assign a fluid allotment of 2 into device. RATIONALE: Provides ample time for nurse to replace IV bags in case assessment time is delayed.

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Examine system every hour. Put fluid to volume control as the need arise. Control flow rate. RATIONALE: Ensures accuracy of infusion by monitoring patency. Monitor client for signs and symptoms of dehydration or overhydration. Re-regulation of flow rate is an immediate intervention if the two conditions are observed. Assess patient for infiltration signs, such as on-site inflammation, kink or knot in infusion tubing, and clot in catheter. RATIONALE: Prevents further tissue trauma and delay in infusion. Document and report the following: infusion rates, electronic infusion device used, responses of client, and solutions. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
6.3.

Changing IV Solution & Infusion Tubing

Materials Required
IV stand IV fluids as ordered IV tubings IV connection tube or extension tube (if needed) IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) the greater the gauge the smaller the needle cannula and viceversa. Band-aid tape Micropore tape

Procedures for IV Solution Changing & Infusion Tubing & Rationale

To change IV solution, follow these procedures:

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Verify orders of prescriber and record time and date solution was last changed. RATIONALE: Procedure must be ordered by physician, IV changing schedule must be scheduled as per institutions policy or as indicated. Establish the compatibility of IV fluids and additives. RATIONALE: Medication error is avoided. Establish the understanding of client of the requirement for continued IV therapy. RATIONALE: Provides opportunity for health teaching and medication compliance is encouraged. Examine patency of present IV access area. RATIONALE: Accurate delivery of fluid is ensured and tissue trauma is prevented. Set up the next solution 60 min prior to need. Verify that the solution is correct and labeled properly and is not expired. RATIONALE: Prevents delays and anticipates emptying of IV bottle. Be prepared to change solution when supply reaches below 50 ml of fluid. RATIONALE: Anticipates emptying of IV bag/bottle.
RATIONALE:

Give procedure details to client. Improves patients understanding of procedure.

Maintain drip chamber at least 50% full. RATIONALE: Ensures negative pressure in IV fluid bottle and prevents bubbles from entering tube. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Set up new solution when changing is necessary. Take the protective cover off the IV tubing port. RATIONALE: Contamination of spike is prevented. To stop flow rate, adjust roller clamp. RATIONALE: Roller clamp blocks fluid flow in tubing, used in adjusting IV
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fluid flow rate. Discard used IV fluid container from IV pole. Take spike off from old solution bottle or bag. Without touching the tip, put spike into new bottle or bag. RATIONALE: Asepsis is maintained. Hang new solution bottle or bag. Monitor presence of air in tubing. Eliminate bubbles in tubing by inserting a needle or syringe into a port under the air and aspirating into the syringe. Sterilize port with alcohol; let it dry first before inserting needle into the port. RATIONALE: Accurate IV flow rate is ensured. Air embolism is prevented. Ensure that drip chamber is at least 1/3 full. When drip chamber is very full, squeeze off tubing under the drip chamber, turn container upside down, pinch the drip chamber, hang up the bag or bottle, and let go of the tubing. RATIONALE: Accurate IV flow rate is ensured. Air embolism is prevented Control the flow to the prescribed rate. RATIONALE: Accurate fluid and electrolyte infusion is achieved. Monitor client for symptoms and signs of dehydration or overhydration. RATIONALE: Provides baseline information for assessment and nursing management. Monitor client for development of complications and the patency of IV system. RATIONALE: Presence of dislodging, infiltration, infection etc. is determined. To change infusion tubing, follow these procedures: RATIONALE: Decide if a new infusion set is required. Follow recommendations to avoid infection. Monitor tubing for occlusions. RATIONALE: Occlusions hinder fluid flow. Prevents blood clotting at catheter end. Give details of the procedure to client. RATIONALE: Decreases patient anxiety and cooperation is enhanced.

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Wash hands. RATIONALE: Reduces transmission of microorganisms. Open the new infusion set by maintaining protective coverings above infusion spike and connector site for IV catheter or butterfly needle. RATIONALE: Prevents contamination. Wear non-sterile disposable gloves. RATIONALE: Reduces risk of blood-borne infection. Take IV dressing off but refrain from removing the tape that secures catheter or needle to skin. RATIONALE: Infection is prevented. To infuse IV, observe the following: Turn off the roller clamp. RATIONALE: Stops fluid from flowing. Keep vein open rate. RATIONALE: Ensures patency of catheter, while reducing IV flow rate. Compress fill chamber and drip chamber. RATIONALE: Air is prevented from entering tubing. Take old tubing off solution; 1 m above IV site, tape or hang drip chamber on IV pole. RATIONALE: Allows space for the new IV bag to be spiked. Tubings are primed and freed from air spaces. Put the new tubings insertion spike into the old solution bottle or bag; hang solution bottle or bag on IV pole. Compress and allow drip chamber to flow on new tubing. Gradually load drip chamber 1/31/2 full. RATIONALE: IV flow to tubing is initiated. Gradually open roller clamp, take protective cap off from needle adapter, flush tubing with solution, then replace cap afterwards. RATIONALE: Tubing is primed with fluid. Switch roller clamp to off position.
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RATIONALE:

Spillage of IV fluid is avoided.

For heparin lock, observe the following: In connecting the new injection cap to the tubing or loop, follow the sterile method. RATIONALE: Infection control is observed. Cleanse injection cap with cotton and alcohol. Put 13 ml saline in syringe and inject via injection cap into the loop or short extension tubing. RATIONALE: Infection is avoided. Seals off IV port from clots. Steady the hub of needle or catheter. Put pressure on the vein a little over insertion area. Gradually remove old tubing. Sustain hubs stability and immediately insert the new tubings heparin lock or needle adapter into the hub. RATIONALE: Bleeding of insertion site is avoided. Open new tubings roller clamp. Let solution run quickly for 30 60 secs. RATIONALE: Ensures IV patency. Control IV drip as ordered. Observe rate every hr. RATIONALE: Avoids overhydration or hypoinfusion. If needed, apply new dressing. RATIONALE: Infection is prevented. Dispose of old tubing properly. RATIONALE: Contamination is avoided. Take off and throw away gloves. Wash hands. RATIONALE: Transmission of microorganisms is reduced. Assess flow rate and monitor connection area for leakage. RATIONALE: Accurate fluid delivery is ensured. Document the procedure. RATIONALE: May be used for legal and care management purposes.

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Stick a preprinted label or piece of tape and write the time and date of tubing change. Attach this to tubing under drip chamber level. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
6.4. Changing

Peripheral IV Dressing

Materials Required
IV stand IV fluids as ordered IV tubings IV connection tube or extension tube (if needed) IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) the greater the gauge the smaller the needle cannula and viceversa. Band-aid tape Micropore tape

Procedure for Changing Peripheral IV Dressing & Rationale

Establish the date when dressing was last changed. RATIONALE: Provides information regarding length of time present dressing has been in place. In addition, nurse is able to plan for dressing change. Monitor current dressing for intactness and moisture. RATIONALE: Moisture is a medium for bacterial growth and renders dressing contaminated. Palpate catheter area via the intact dressing to address discomfort or inflammation. RATIONALE: Unexplained decrease in flow rate requires the nurse to investigate placement and patency of the IV catheter. Pain can be associated with both phlebitis and infiltration.
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Check exposed catheter area for infiltration or swelling. RATIONALE: Indicates fluid infusing into surrounding tissues. Will require

Chapter Seven

Nutrition & Metabolism

7.1. Inserting Small-Bore Nasoenteric Tube for Enteral Feedings 7.2. Administration of Enteral Feedings via Nasogastric Tubes. 7.3. Administration of Enteral Feedings via Gastronomy or Jejunostomy Tubes 7.4. Administration of Cleansing Enema 7.5. Pouching an Ostomy 7.6. Colostomy Irrigation 7.7. Inserting and Maintaining a Nasogastric Tube

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7.1. Inserting

Small-Bore Nasoenteric Tube for Enteral Feedings (NGT Insertion)

Anatomy and Physiology

The gastrointestinal system is responsible for digestion, the process which basically breaks down food particles into small molecules for digestion, nutrient absorption into the bloodstream, and elimination of undigested/unabsorbed food particles and other waste materials from the body. The gastrointestinal (GI) system is a complex system for processing food, extracting nutrients and eliminating wastes. The alimentary canal begins in the mouth and ends at the anus. The processes chewing, swallowing, digestion, absorption and defecation are controlled by autonomic, nervous and hormonal mechanisms. Digestive glands act to provide moisture, lubrication, emulsification and enzymes for digestion of proteins, carbohydrates and fats. This mechanical breakdown reduced the food into its simplest form by the use of enzymes secreted in all parts of the GI system. Enzymes are an essential component of the chemistry of digestion, these are proteinlike substances that act as catalysts to speed up chemical reactions. Each enzymes have one specific functions best at a specific pH. The secretions of the GI tract have vastly different pH levels. Saliva is relatively neutral, gastric juice is highly acidic and the secretions of the small intestine are alkaline. Anatomically, the GI tract is a tube that from the exterior to the lumen is composed of connective tissue, smooth muscle layers with embedded nervous plexus, connective tissue, and an inner epithelial layer. The epithelial type, muscle thickness, glandular elements and nervous supply differ in the various functional regions, as does the diameter and shape of the tube. The mechanical, chemical and hormonal activities of digestion are independent. Enzymes activities are dependent on the mechanical breakdown of food to increase its surface area for chemical action. Hormones regulate the flow of digestive secretions needed for enzyme supply, and digestion may also be decreased or increased by strong emotional states. The secretion of digestive juices and the motility of the GIT are also regulated by the physical, hormonal and
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chemical factors as they are bound to psychological, emotional and nervous system alterations. GIT action is increased by nerve stimulation from the parasympathetic nervous system.
Gastrointestinal Hormones

The GI tract is the largest endocrine gland in the body with the endocrine cells being diffusely scattered in the mucosa over the length of the alimentary canal. Food in the lumen of the gut is the normal stimulus for secretion of GI hormones but nervous system activity, stretch or chemical stimulation may also cause the release of GI hormones. The hormones enter the blood stream to effect tissues distant from the releasing cells. GI hormones regulate the digestive process, motility and blood flow of the GI tract and influence the growth of the pancreas and GI tract. Many of the GI hormones are also found in the central nervous system where they may play a role in appetite control, satiety or nerve transmission to the GI tract. Secretin is a 27 amino acid peptide hormone produced in the duodenum and released in response to a luminal pH of less than 4.5. It stimulates fluid and bicarbonate release from the pancreas and stimulates pepsinogen secretion. Cholecystokinin (CCK) is secreted by the endocrine cells of the duodenum and proximal jejunum. CCK exists in a plurality of forms containing 8 to 58 amino acids. It is released by the presence of long chain fatty acids in the chyme. It stimulates pancreatic enzyme synthesis and secretion, increases gall bladder emptying and decreases gastric emptying. A chronic effect of CCK is the stimulation of DNA synthesis in the exocrine pancreas and growth of mucosal tissue. Gastrin is a 17 amino acid polypeptide hormone made in the duodenum and pyloric antrum. The presence of digested protein in the stomach and duodenum stimulate its release. Gastrin stimulates acid secretion from the parietal cells of the gastric glands and pepsinogen secretion from the chief cells. Histamine is a mediator in the gastrin stimulated release of gastric acid. Gastrin also stimulates nucleic acid and protein synthesis and growth of the exocrine pancreas, mucosa of the small and large intestines and glandular stomach.

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Gastric inhibitory peptide (GIP) is a 43 amino acid peptide that causes insulin release from the endocrine pancreas. It also inhibits gastrin release and gastric acid secretion. Vasoactive intestinal polypeptide (VIP) is a 28 amino acid polypeptide that stimulates bicarbonate release from the pancreas, lipolysis and glycogenolysis in the small intestine and pancreas, decreased GI muscle tone and vasodialation. Ghrelin is 28 amino acid peptide found in the stomach and hypothalamus. It is released from the stomach and acts at the hypothalamus to increase caloric intake. It also directly stimulates the pituitary to increase growth hormone secretion. Ghrelin also acts locally as a paracrine hormone to cause gastric acid secretion and motility. Fasting increases the production of ghrelin.
Digestive Glands

The various salivary glands add water, electrolytes, mucous and salivary amylase to the food as it is chewed. Secretory cells filter and modify the blood to produce saliva. In humans these secretions are mostly water. Parotid, submaxillary, sublingual glands add saliva to the food during mastication. Salivary amylase begins the breakdown of carbohydrates while the food is still in the mouth. Salivary lysozyme lyses bacterial cell walls. Mucopolysaccharides act as lubricants and water acts to extract flavors from food. Salivary secretion is controlled by the nervous system. Gastric glands are present throughout the mucosa of the stomach. These deep tubular glands secrete electrolytes and produce pepsinogen and other proteases at the bottom (chief cells), hydrochloric acid in the neck and body of the gland (parietal cells), and mucous at the neck and opening of the gland. The mucous acts to protect the gastric lining from the acid and enzymes present. Parietal cells also produce a protein called intrinsic factor that is necessary for the absorption of vitamin B12 in the ileum. Pepsinogen is activated by the removal of a small fragment. Pepsin works optimally to digest proteins at a pH of 1.5-2.5. The enzyme rennin is most active in infants where it causes milk proteins to curdle. The pancreas has two glandular portions, the endocrine portion and
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the exocrine protein. Cells of the pancreatic islet make up the endocrine portion and secrete insulin and glucagon into the blood stream as needed. The exocrine portion participates in digestion by the secretion of the natural antacid, bicarbonate, electrolytes, fluid and digestive enzymes that are added to the contents of the duodenum. Secretion by the exocrine pancreas is regulated mostly by GI hormones with some minor influence of the nervous system. The secretions of the pancreas are rich in bicarbonate and other electrolytes. The bicarbonate and electrolytes help to buffer the incoming acidic chyme from the stomach. Pancreatic enzymes are made by the acinar cells and packaged as inactive precursors into granules prior to release. The enzymes are activated by cleavage of small fragments when acted upon by other pancreatic or intestinal enzymes. Pancreatic trypsinogen, chymotrypsinogen, carboxypeptidase, aminopeptidase, lipase, amylase, ribonucleases, deoxyribonucleases, elastase, alkaline phosphatase, cholesterol esterase and other enzymes reduce food stuffs to absorbable elements. The liver is an important metabolic, digestive, and excretory organ. It participates in digestive function by the production of bile which when added to the duodenal contents emulsifies fats enabling them to be broken down. Bile is produced in the liver but is stored in the gall bladder until it is needed. In the gall bladder the bile is concentrated by the removal of water and the addition of bicarbonate. Bile salts are steroid or cholesterol derivatives synthesized or recovered from the blood by liver cells. Liver cells also make and secrete lecithin that emulsifies dietary fats. Products of hemoglobin metabolism are excreted in bile salts. In an enterohepatic circulation process bile salts and other substances enter the lumen of the GI tract in the duodenum and are reabsorbed further down the intestine into the blood. The substances are removed from the blood again by liver cells. Intestinal secretions participate in digestion by adding fluid, electrolytes, and enzymes. Enzymes include intestinal amylase, enterokinase, disaccharidases, peptidases, lipases, nucleotidases and nucleosidases. Some of these enzymes are free in the lumen due to the digestion of
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sloughed mucosal cells. Intestinal secretion is both passive, due to the concentration of lumen contents, and active. Active secretion is usually directed at a specific ion with others following for electrical neutrality. Water follows because of osmotic pressure. Cholera toxin and E.coli enterotoxins simulate active intestinal secretion and therefore cause diarrhea.
Digestion Process

Beginning in the mouth, digestion is initiated with the help of the teeth that breaks down the food mechanically and salivary enzymes which chemically reacts on food. The features of the oral cavity participate in digestion by reducing the food to smaller pieces, moistening and lubricating the food and by the addition of amylase for the breakdown of carbohydrates. The teeth are specialized for cutting and grinding the food into small pieces so that there is more surface area for digestive enzymes to work on and to ease swallowing. The tongue moves the food around within the mouth and has taste receptors for sweet, salt, sour, and bitter. Salivary glands add saliva which contains water, ions, salivary amylase and mucous. The food is mixed with saliva which contains ptyalin, a salivary amylase that acts on cooked starch to begin its conversion to maltose. When the food bolus is of the proper consistency, the tongue moves it to the back of the mouth where swallowing is initiated. The epiglottis covers the trachea as the bolus is passed into the esophagus. The bolus stretches the esophagus initiating smooth muscle contractions that push the bolus along toward the stomach in peristaltic waves. Food materials then pass through the esophagus, situated in the mediastinum of the thoracic cavity, posterior to the heart and trachea, and anterior to the spine. The esophagus joins the stomach near the diaphragm which normally pinches the esophagus closed due to its muscular tone. Stomach movement also helps to keep the esophagus closed. The net effect is that the esophageal-gastric junction can withstand 10-20 mmHg pressure from the stomach. The stomach, located in the upper portion of the abdomen to the left of the midline, under the left diaphragm, secretes hydrochloric acid and is a distensible pouch with around 1500 ml capacity. The esophagogastric junction, the inlet to the stomach, is surrounded by
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the lower esophageal sphincter-a ring of smooth muscle that, on contraction, closes off the stomach from the esophagus. The stomach can be divided into four anatomic regions, namely the cardia, fundus, body and polyrus (outlet). It is a muscular pear-shaped organ where serious digestion begins. Three layers of smooth muscle act to mix the incoming food bolus with gastric fluids. Glands within the stomach lining produce hydrochloric acid (pH<1) and the enzyme precursor pepsinogen. Pepsin becomes active in the acidic environment of the stomach. The stomach is separated into three functional areas: the cardiac, fundic and pyloric regions. The cardiac region is closest to the heart and contains the esophageal junction and only a few glands. The fundic region contains complex glands secreting hydrochloric acid, mucous, intrinsic factor, pepsinogen and other proteases. The pyloric region contains very few glandular elements, other than mucous producing cells, but rather serves as a muscular gatekeeper to the duodenum, the first portion of the small intestine. Circular smooth muscle located in the wall of pylorus forms the pyloric sphincter which regulates the opening between the stomach and small intestine. The longest segment of the gastrointestinal (GI) tract, the small intestines represent around two-thirds of the total length of the GI tract. It is divided into three anatomical parts-duodenum (upper part), jejunum (middle part), and ileum (lower part). The penultimate part is the large intestine (ascending, transverse and descending segment), which then goes to sigmoid colon, to the rectum, and, finally, to the anus. The gastric contents are emptied into the small intestine as long as the paticle sizes are not too large or the duodenal pressure is not too high. Other factors involved in gastric emptying include the temperature of the chyme, duodenal pH, and osmolarity of chyme. The duodenum accepts material from the stomach at a relatively constant caloric rate such that highly caloric chyme enters the duodenum at a slower rate. Emulsifying bile enters the duodenum from the gall bladder and pancreatic secretions water, enzymes and sodium bicarbonate) are added here as well. Most digestion and absorption occurs in the upper two thirds (duodenum and jejunum) of the almost nine foot long small intestine and removal of water and bile salts occurs

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in the lower one third (ileum). Cells lining the lumen of the small intestine are called enterocytes. These cells are replaced every 3-5 days by new cells arising from deep within simple tubular glands (crypts of Lieberkuhn). The interior lining of the small intestine has numerous projections into the lumen called villi. The villi function to increase the surface area available for digestion and absorption. Enterocytes also have adaptations to increase absorptive surface area on their luminal border called microvilli.
Nutrition

A nutrient is any element or compound that is necessary for or contributes to an organism's metabolism, growth or other functioning. There are six nutrient groups and these can be divided into those that provide energy and those that otherwise support metabolic processes in the body. These are: Substances that provide energy:

Carbohydrates: compounds made up of sugars that are used or Proteins: nitrogenous organic compounds, including amino acids,
stored as energy that provide the building blocks (amino acids) for enzymes and other proteins within the body Fats: including fatty acids (a fat is an assemblage of three fatty acids linked to a central glycerine molecule)
The energy content of fat is 9 kcal/g; of proteins and carbohydrates 4 kcal/g. Ethanol (grain alcohol) has an energy content of 7 kcal/g.

Substances that support metabolism:

Minerals: generally trace elements, salts or ions such as copper Vitamins: organic compounds essential to the body's functioning,
directly involved in all the chemical reactions of life-sometimes referred to as the forgotten nutrient. Any classification of "nutrientsis likely to be arbitrary, since nutrition is a developing science and we are becoming more aware of a wider
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and iron essential to normal metabolism

Water: absolute requirement for normal growth and metabolism

usually acting as coenzymes

Nutrition & Metabolism

range of nutrients essential for health. Any organic compound metabolised by the body will be used for its energy content, utilized for structural purposes (growth or replacement of living structures) or participate in chemical reactions necessary for life. Any particular substance can play more than one role in the body, although these roles may be poorly understood. These comments are reinforced by the discovery of the group of nutrients called phytonutrients. Our knowledge of these is limited, they are organic compounds from plants essential for normal functioning of a body and having complex hormonal effects on health or playing an active role in the amelioration of disease. They are not easily classified in the traditional nutrition categories.
Importance

For situations when it is difficult to maintain nutritional balance as the patient cannot cooperate with feeding or when the body cannot tolerate oral feeding, tube feeding is administered. This method is also done for unconscious patients to supply their nutritional needs until they regain consciousness. Tube feeding formulas are prepared to supply such patients with a well-balanced and complete diet. One of the nurse's basic functions is to efficiently and carefully provide feedings to patients via the feeding tube until they can eat without assistance. In fact, the nurse plays a key role in curative and rehabilitative nutritional requirements of the patient. Competency in gastric intubation (lavage, gavage) and enteral feeding is crucial in the promotion and maintenance of patient's nutritional needs. Gastric tube insertion is not exclusively for nutritional purposes as it is also used for:

Stomach decompression and removal of gas and fluid Gastrointestinal motility diagnosis Administration of medications Treatment of an obstruction or bleeding site Procurement of gastric contents for analysis

Factors Affecting Nasogastric Tube insertion and

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Tube Feeding Site of insertion Types and sizes of tube Nutritional status Medical history and present condition Types of total parenteral nutrition Patient's size and age Duration of nutritional therapy Tube patency Health provider's skills Assessment sites
Gastric tube can be inserted either in the mouth (oro) or nose (naso). Nasogastric entry is the more commonly used method since it has less episodes of vomiting and lesser discomfort complaints. However, oral fluid intake can also be used. Assessment of insertion sites must always be performed, checking for dryness, sore, polyps or mass. Once resistance is encountered, refrain from pushing forcefully. When the patient chokes, has breathing difficulty or is cyanotic, pull out tube immediately since these are clear symptoms that tube is in the lungs, causing obstruction in airway.

Materials Required Micropore tape or safety pin Plaster tape Asepto syringe Nasogastric tube (French 16 for adult, french 8 feeding tube for

Note: Feeding tube via esophagostomy, gastrostomy and jejunostomy are inserted surgically. 186

infants) or the types of tube to be used as ordered (Levin tube, Gastric Sump tube, Nutriflex tube, Moss Tube or SengstakenBlakemore tube) Kidney basin with half-filled water KY Jelly Stethoscope Sterile gloves and mask

Nutrition & Metabolism

Procedure for Inserting Small-Bore Nasoentric Tube for Enteral Feedings & Rationale
Examine if patient requires enteral tube feeding. RATIONALE: Assessment provides data for institutional management and nursing approach. Evaluate patient for proper administration route: Alternately close nostrils of patient. Tell patient to breathe. RATIONALE: Nasal obstructions and difficulty of breathing are revealed Examine for gag reflex. RATIONALE: Tolerance for P.O. feeding is determined. Assess medical history of patient for aspiration risks and nasal problemsMinimizes aspiration risks with proper positioning and patency check. Nasal problems may call for oro pharyngeal route of the tenteral tube to avoid further trauma. Assess order of prescriber for tube type, size and enteral feeding schedule. RATIONALE: Ensures that right procedure is accurately carried out. Wash hands. RATIONALE: Minimizes transmission of microorganisms. Give procedure details to patient. RATIONALE: Improves patient's understanding of procedure. Reduces patient anxiety and enhances cooperation. Position on bed's similar side as insertion nares. Unless contraindicated, help patient assume high Fowler's position. Put pillow under head and shoulders of patient. RATIONALE: Allows gravitational pull on tube and opens oral passage for easy and smooth insertion. Cover patient's chest with bath towel. Put facial tissues near the work area. RATIONALE: Prevents patient's clothes from getting soiled. Calculate tube's length for insertion and label with tape. determine space between tip of patient's nose to earlobe to xiphoid
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process of sternum. RATIONALE: Prevents tissue injury and ensures tubing patency. Set up nasointestinal or nasogastric tube for intubation: Avoid using ice plastic tubes. RATIONALE: Ice plastic tubes may cause discomfort due to cold temperature and result in tissue spasm. Insert 10-ml water from catheter-tip syringe or 30-ml or bigger Luer-Lock into the tube. Ensure that guidewire is firmly placed against weighted tip and that both Luer-Lock attachments are securely connected. RATIONALE: Patency is ensured by testing passage and fluid flow. Prepare a 10-cm long hypoallergenic plaster. RATIONALE: Reduces risk for contact dermatitis. Wear disposable gloves. RATIONALE: Reduces risk for infection and contamination from secretions. With surface lubricant, immerse tube into glass of water. Put in tube via the nostril of patient to throat's back. Point toward back and down to ear's direction. Bend head of patient to direction of chest once tube has passed via nasopharynx. Stress on the need of the patient to breathe in and swallow through mouth during the process. Move tube forward every time patient swallows until the time preferred length has transpired. Refrain from forcing tube. If resistance is met or patient begins to cough, choke or become cyanotic, stop advancing tube and pull it back. RATIONALE: Allows for smooth insertion of tube into orifice by following anatomical contour. Check for position of tube in back of throat with penlight and tongue blade. RATIONALE: Accurate insertion of nasogastric tube is viewed. Perform measures to verify placement of tube: Inject 30-ml of air into tube, and aspirate gastrointestinal contents with a syringe.
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RATIONALE:

Presence of gastric secretions confirms the location of tube's tip in the stomach.

Measure pH and observe appearance of gastrointestinal contents. Apply tincture of benzoin or other skin adhesive on tip of patient's nose and tube. Allow to dry. Remove gloves and secure tube with tape, avoiding applying pressure on nares: Split one end of tape lengthwise 5 cm. Place the intact end of tape over bridge of patient's nose. Wrap each of the 5-cm strips around tube as it exits patient's nose. RATIONALE: Tape anchors tube to the nasal skin. Fasten end of nasogastric tube to patient's gown by looping rubber band around tube in slip knot. Pin rubber band to gown. RATIONALE: Accidental pulling of tube is prevented. For intestinal placement, position patient on right side if possible until confirmation of placement. Otherwise, assist patient to a comfortable position. RATIONALE: Anatomical position is followed, facilitating proper placement. Obtain x-ray film of patient's abdomen. RATIONALE: Correct placement of tube is confirmed. Apply gloves. RATIONALE: Reduces risk of infection. Administer oral hygiene. RATIONALE: Enhances integrity of oral mucosa membrane. Cleanse tubing at nostril. RATIONALE: Promotes patient comfort and reduces risk of infection. Remove gloves. Dispose of equipment. Wash hands. RATIONALE: Reduces transmission of microorganisms. Inspect patient's nares and oropharynx for any irritation after insertion. RATIONALE: Complications are prevented by early intervention.
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Ask if patient feels comfortable. RATIONALE: Minimizes patient's anxiety and encourages verbalization of feelings. Observe patient for gagging or difficulty of breathing. RATIONALE: Gagging may cause vomiting and puts patient at risk of aspiration. Oxygenation must not be hindered. Record/report type and size of tube insertion and position and patient's tolerance of procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
7.2. Administration

of Enteral Feedings via Nasoenteric Tubes

Materials Required Micropore tape or safety pin Plaster tape Asepto syringe Nasogastric tube (French 16 for adult, french 8 feeding tube for

infants) or the types of tube to be used as ordered (Levin tube, Gastric Sump tube, Nutriflex tube, Moss Tube or SengstakenBlakemore tube) Kidney basin half-filled with water KY Jelly Stethoscope Sterile gloves and mask

Procedure for Administering of Enteral Tube Feedings via Nasoenteric Tubes & Rationale
Examine the need of client for enteral tube feedings. RATIONALE: Inability to receive oral feeding puts patient at risk for nutritional
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depletion. Before feeding, auscultate client for bowel sounds. RATIONALE: Digestion and absorption in the gastrointestinal tract are evidenced by bowel sounds. Get baseline weight and laboratory values of client. Examine client for deficit or excess in fluid volume, and abnormalities in electrolyte and metabolism. RATIONALE: Serves as point of reference for determining effectiveness of enteral feedings. Ascertain order of prescriber for feeding formula, route, rate and frequency. RATIONALE: Ensures proper performance of procedure. Give procedure details to patient. RATIONALE: Ensures cooperation by reducing anxiety. Wash hands. RATIONALE: Reduces transmission of microorganisms. To administer formula, prepare feeding container following these steps: Put formula at room temperature. Cold formula increases vasoconstriction which may cause gastric cramping. Either attach tubing to contain as necessary or set up ready-tohang container. Contamination is prevented. Thoroughly shake formula container. Pour formula into container and tubing. Either put patient in high Fowler's position or raise bed's head by 30. - Gravitational pull on feeding is ensured and aspiration is prevented. Establish placement of tube: To check for gastric residual, aspirate gastric contents. Put aspirated content back to stomach except when the volume goes
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beyond 150 ml. Presence of tube's end in stomach will reveal presence of gastric secretions. When evaluating tube placement, results must be considered. INITIATING FEEDING : For intermittent or bolus feeding method: Squeeze feeding tube's proximal end. RATIONALE: Prevents entry of air into stomach. Take plunger off syringe. Connect syringe barrel to tube's end. RATIONALE: Port for feeding formula is established. Put the measured amount of formula into syringe. Let go of the tube and raise syringe high enough to enable gravity to empty it gradually. Refill and repeat the process until patient has consumed prescribed formula. RATIONALE: Feeding process is initiated. For feeding bag, hang it on IV pole. Put prescribed amount of formula into the feeding bag. For 30 mins, slowly allow bag to empty. RATIONALE: Risk of abdominal discomfort is reduced. Unless contraindicated, flush tubing using water once bolus or intermittent feeding is completed. RATIONALE: Provides water source to promote fluid and electrolyte balance. For continuous-drip technique: Suspend tubing or feeding bag on IV pole. RATIONALE: Facilitates gravitational pull to allow descent of formula to GI tract. Attach tubing's distal end to the feeding tube's proximal end. RATIONALE: Allows contact between formula bag and enteral tube. Turn infusion pump on and set rate, attach tubing. RATIONALE: Sets feeding machine on. Gradually continue tube feeding as per guidelines.
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RATIONALE:

Follow physician's written orders regarding feeding and adhere to institutional guidelines to minimize if not avoid errors.

Clamp the feeding tube's proximal end when tubing feedings are not being administered. RATIONALE: Entry of air to gastrointestinal tract is prevented. With diluted formula, administer water through feeding tube as per order. RATIONALE: Provides water source to promote fluid and electrolyte balance. Whenever feedings are stopped, use warm water to rinse bag and tubing. RATIONALE: Minimizes bacterial growth. Every 4 hrs, measure aspirate amount. RATIONALE: Gastrointestinal tract tolerance is determined. Every 6 hrs, observe finger-stick blood glucose of patient up to the time maximum administration is achieved and sustained for 24 hrs. RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption and reaction to tube feeding. Every 24 hrs, observe intake and output of patient. RATIONALE: Renal output illustrates circulating fluid volume. Presence of imbalances is determined. Daily, weigh patient up to the time maximum administration is achieved and sustained for 24 hrs. Afterwards, weight patient thrice a week. RATIONALE: Weight gain is an objective indicator of nutritional status. A sudden increase in weight by 2lb/24 is indicative of fluids retention. Monitor return of normal laboratory values. RATIONALE: Normal laboratory values such as albumin illustrate good nutritional progress. 20. Document and report status of feeding tube, type of feeding, tolerance of patient, and adverse effects.
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RATIONALE:

Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

7.3. Administration of Enteral Feedings via Gastrostomy or Jejunostomy Tube

Materials Required

Gastrostomy tube Jejunostomy tube Micropore tape or safety pin Plaster tape Asepto syringe Nasogastric tube (French 16 for adult, french 8 feeding tube for infants) or the types of tube to be used as ordered (Levin tube, Gastric Sump tube, Nutriflex tube, Moss Tube or sengstaken-blakemore tube) Kidney basin with half-filled water KY Jelly Stethoscope Sterile gloves and mask

Procedure in administering Enteral Feedings Via Gastrostomy or Jejunostomy Tube & Rationale
Examine requirement of patient for enteral tube feedings. RATIONALE: Ensures accurate performance of procedure. Before feeding, auscultate patient for bowel sounds. If bowel sounds are absent, consult physician. RATIONALE: Peristalsis resulting in bowel sounds reduces risk of aspiration and abdominal distention. Get baseline weight and laboratory value of patient.
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RATIONALE:

Provides data for evaluating the efficacy of enteral feeding.

Check order for formula, route, rate, and frequency. RATIONALE: Ensures that right procedure is performed on right patient. Give procedure details to patient. RATIONALE: Improves patient's understanding of procedure. Reduces patient anxiety and encourages cooperation. To administer formula, prepare feeding container: Put formula at room temperature. RATIONALE: Cold formula results in cramping due to vasoconstriction and decreases peristalsis. As required, attach tubing to container or prepare ready-to-hang bag. RATIONALE: Height of bag facilitates gravitational pull on contents into gastrointestinal tract. Pour formula into container and tubing. RATIONALE: Tubing delivers formula to the gastrointestinal tract. Raise bed's head to 30-45. RATIONALE: Aspiration is prevented. Check placement of tube: When using gastrostomy tube, aspirate gastric juices of patient and verify pH and appearance. Unless volume goes over 150 ml, return aspirated contents. RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption and reaction to tube feeding. When using jejunostomy tube, aspirate intestinal secretions of patient and verify pH and appearance. RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption and reaction to tube feeding. With 30 ml of water, flush tube. RATIONALE: Maintains fluid and electrolyte balance. Ensures tube patency. Initiate syringe feedings:
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RATIONALE:

This route of feeding is given continuously to ensure proper absorption. Initial feedings are given bolus to check patient's tolerance of formula.

Squeeze gastrostomy tube's proximal end. RATIONALE: Prevents entry of air into gastrointestinal tract. 10.2. Take off plunger and connect syringe's barrel to tube's end. Fill syringe with formula. RATIONALE: Initiates feeding process. 10.3. Gradually let syringe empty. Refill syringe until patient has received prescribed amount of formula. RATIONALE: Provides time for gastrointestinal tract digestion and absorption to ensure nutritional improvement. Initiate continuous-drip feedings: Fill feeding container with amount of formula sufficient for 4 feeding. RATIONALE: Feeding process is initiated. Allows sufficient amount of formula to run for designated period (4 hrs). Put container on IV pole. Remove air from tubing. RATIONALE: Height of bag facilitates gravitational pull on contents into gastrointestinal tract. As per manufacturer instructions, thread tubing on pump. RATIONALE: Facilitates regular drip of formula based on prescribed time and amount. Attach tubing to feeding tube's end. RATIONALE: Establishes connection between two separate tubes. Start infusion at prescribed rate. Examine skin of patient around tube exit area. Daily cleanse skin using warm water and mild soap. It is not recommended to apply dressings around the exit area. RATIONALE: Inform physician of any sign of irritation, infection or tube displacement.
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Discard supplies and wash hands. RATIONALE: Infection is prevented. Every 4 hrs, measure aspirate amount. Illustrates evidence of gastrointestinal tract's formula tolerance. Every 6 hrs, observe finger-stick blood glucose of patient up to the time maximum administration is achieved and sustained for 24 hrs. RATIONALE: Provides data for patient's glucose tolerance. 16. Every 24 hrs, observe intake and output of patient. RATIONALE: Renal output illustrates circulating fluid volume. Presence of imbalances is determined. Daily, weigh patient up to the time maximum administration is achieved and sustained for 24 hrs. Afterwards, weight patient thrice a week. RATIONALE: Weight gain is an objective indicator of nutritional status. A sudden increase in weight by 2lb/24 is indicative of fluids retention. Monitor return of normal laboratory values. RATIONALE: Normal laboratory values such as albumin illustrate good nutritional progress.
RATIONALE: Document and report status of feeding tube, type of feeding, tolerance of patient, and adverse effects. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

7.4. Administration

of Cleansing Enema

Physiology
The small intestine is about 6 meters (20 feet) long. It is coiled in the center of the abdominal cavity (see picture). The small intestine is divided into 3 sections: upper, jejunum, and ileum. The lining of the
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small intestine secretes a hormone called secretin, which stimulates the pancreas to produce digestive enzymes. Most absorption of digested foods also occurs in the small intestine. From the stomach, food passes into the duodenum portion of the small intestine and, then, into the very long, coiled section of the small intestine. The total length of the small intestine in adult men averages over twenty feet. The great length of the small intestine is but one adaptation it possesses aimed at increasing the absorptive surface area of its lumen. The large intestine has a larger width but is only 1.5 meters (5 feet) long. The large intestine is divided into 6 parts: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. From the small intestine, the unabsorbed food passes into the large intestine or colon, at the lower right-hand portion of the abdominal cavity. Near the juncture of the small and large intestines, a blind sac or caecum, tipped by the appendix projects off the large intestine. Both the caecum and appendix are functionally unimportant in humans. The large intestine has three segments: the ascending colon, which runs up the right side of the abdominal cavity, the transverse colon, which runs across the top of the abdominal cavity, and the descending colon, which runs down the left side of the abdominal cavity. The large intestine reabsorbs the large quantities of water used to secrete enzymes into the upper portions of the digestive tract. In addition, the large intestine excretes salts, such as calcium and iron, when the salts' blood concentrations are too high. The large numbers of bacteria that inhabit the large intestine feed on the undigested food and make up half of the dry weight of feces. The rectum is the last segment of the large intestine. It stores feces until defecation when the feces are eliminated from the rectum through the anus. The ultimate digestion process occurs in the large intestine, involving the elimination of undigested and unabsorbed food materials, including waste products from the body. The cecum or junction between the large and small intestines is located in the lower right portion of the abdomen. The ileocecal valve, which controls the passage of intestinal contents into the large intestine, is located in this junction, together with the vermiform appendix.
Absorption Process

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Peristalsis continues in the small intestine, mixing the secretions with chyme. Small intestine as the primary absorption site for nutrients is lined with fingerlike projections called the villi, which increase the surface area available for absorption. The mixture becomes increasingly alkaline, inhibiting the action of the gastric enzymes and promoting the action of the duodenal secretions. The epithelial cells of the small intestines brush border microvilli secrete enzymes to facilitate digestion. These include sucrase, lactase, maltase, lipase and peptidase. The major portion of digestion occurs in the small intestine, producing glucose, fructose and galactose from carbohydrates; amino acids and dipeptides from proteins; fatty acids, glycerides and glycerol from lipids. Nutrients are absorbed by means of passive diffusion, osmosis, active transport and pinocytosis. Approximately 5 are required to pass food through the small intestine via peristalsis. The large intestine is composed of a descending segment on the abdomen's left side, an ascending segment on the abdomen's right side and a traverse segment that extends. Two parts comprise the terminal portion of the large intestine-the rectum and the sigmoid colon. As the rectum is directly connected to the anus, the anal outlet is regulated by a network of striated muscle that forms the external and internal anal sphincter. In the colon, ions are secreted for elimination or recovered along with water from the chyme. Colonic bacteria modify the contents such that biogenic amines like histamine or serotonin may be formed, the yellowish bile pigments are altered causing a brown color, and fermentation produces the odor causing chemicals in feces. Bacteria also make vitamin K and some B-complex vitamins that are absorbed in the colon. The bacterial flora vary with individuals and can change with diet, medication or environmental changes. Such changes may cause diarrhea, gas or constipation. The colon is separated into three anatomic regions; the ascending, transverse and descending. The ascending and transverse sections absorb water and electrolytes and excrete metal ions. The descending colon removes water from the feces and controls the delivery of feces to the rectum. Wastes are removed by defecation as initiated by stretching of the rectal walls. The main source of water absorption is via the intestine. Approxi199

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mately 8.5 L of GI secretions and 1.5 L of oral intake, totaling of 10 L of fluids must be managed daily within the GI tract. The small intestine reabsorbs 9.5 L and approximately 0.4 L is reabsorbed in the colon. The remaining 0.1 L is eliminated in the feces.
Metabolism

Metabolism refers to all the biochemical reactions within the cells of the body. Metabolic processes can be anabolic (building) or catabolic (breaking). Anabolism is the building of more complex biochemical substances by synthesis of nutrients. Anabolism occurs when lean muscle is added through diet and exercise. Amino acids are anabolized into tissues, hormones and enzymes. Catabolism is the breakdown of biochemical substances into simpler substances. Starvation is an example of catabolism when wastin of body tissue occurs. Normal metabolism and anabolism are physiologically possible when the body is in positive nitrogen balance, whereas catabolism occurs during physiologic states of negative nitrogen balance. Nutrients absorbed in the intestines, including water are transported through the circulatory system to body tissues. Through the chemical changes of metabolism nutrients are converted into a number of substances required by the body. Carbohydrates, protein, and fat undergo metabolism to produce chemical energy and to maintain a balance between anabolism and catabolism. To carry out the body's work, the chemical energy produced by metabolism is converted to other types of energy by differnect tissues. Muscle contraction involves mechanical energy, nervous system function involves electrical energy, and the mechanism of heat production involve thermal energy. All of these forms of energy originate in metabolism.
Elimination

Chyme is moved by peristaltic action through the ileocecal valve into the large intestine, where it becomes feces. As feces move toward the rectum, water is absorbed in the mucosa. The longer the material stays in the large intestine, the more water is absorbed causing the feces to become firmer and results in constipation. Exercise and fiber stimulate peristalsis and water maintains consistency. Feces contain cellulose and similar indigestible substances, sloughed epithelial
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cells from the GIT, digestive secretions, water and microbes.

Importance

Enema cleansing is vital in order to: Empty the bowels of feces Obtain stool specimen Achieve thorough cleansing before operation, diagnostic procedure or in the presence of irritating substance Factors Affecting the Administration of Cleansing Enema

Insertion site Type of solution Type of enema Reason for enema Age and size of patient Medical history and present health status

Assessment Sites
Rectal and anal site should be inspected for the presence of sore, ulcers, mass, bleeding, pain and fistula. A patient suspected for perforation, bleeding, colonic anomaly and appendicitis should not be subjected to this procedure. If resistance upon insertion is noted and severe pain is encountered, never forcefully administer the enema.

Materials Required
Enema tray Irrigating can One-foot long rubber tubing Clamp or stopcock Rectal tube (French 16-24) Kidney basin Disposable gloves and mask Stand Vaseline or KY Jelly
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Perineal care kit and bed pan

Procedure in Administering Cleansing Enema & Rationale

Assess patient status. RATIONALE: Determines type of enema to be used and precautions to be observed. Assess patient for intracranial pressure increase, glaucoma or recent rectal/prostate surgery. RATIONALE: Observes patient for conditions contraindicated to enema. Check patient's medical record. RATIONALE: Purpose of enema administration is determined. Review physician order for enema. RATIONALE: Confirms need for performance of procedure. Prepare needed equipment/supplies. RATIONALE: Provides easy access to materials needed. Conserves time and controls infection. Explain procedure to patient. RATIONALE: Provides opportunity to educate patient. Patient anxiety is reduced and facilitates cooperation. Prepare enema bag with solution and rectal tube. Wash hands and apply disposable gloves. RATIONALE: Reduces transmission of microorganisms. Provide needed privacy. RATIONALE: Reduces patient embarrassment. Assist patient to establishing left side-lying position, make sure that right knee is flexed. RATIONALE: Allows for smooth flow and retention of solution following anatomical location of colon. Place waterproof pad beneath patient's hips and buttocks.

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RATIONALE:

Prevents soiling of linen.

Cover patient with bath blanket leaving rectal area and anus accessible. RATIONALE: Prevents unnecessary exposure of patient's private body parts. Put bedpan in a readily accessible place. RATIONALE: Bedpan is to be used if patient fails to retain enema.
ENEMA ADMINISTRATION

Prepackaged disposable container (fleet enema): Remove cap from rectal tip. RATIONALE: Opens rectal catheter tip. Lubrication facilitates insertion without irritation. Locate rectum by gently separating patient's buttocks. Ask patient to relax by slowly breathing out through the mouth. RATIONALE: Promotes relaxation of external rectal sphincter. Gently insert tip of bottle into rectum (about 7.5-10 cm in adult, 5-7.5 cm in child, 2.5-3.75 cm in infants) RATIONALE: Prevents trauma to the rectal orifice. Squeeze bottle until entire solution has entered rectum and colon. Wait until patient feels urge to defecate. RATIONALE: Hypertonicity of solution stimulates defecation.
ENEMA BAG

Pour warm solution into enema bag by warming tap water from faucet. Put saline container into a basin of hot water. Add saline to enema bag. Check solution temperature. RATIONALE: Cold solution can cause vasoconstriction resulting in cramping. Hot solution however can burn intestinal mucosa. Have solution fill tubing by raising container and releasing clamp. RATIONALE: Gravity allows solution drainage to start. Reclamp tubing. Lubricate tip of rectal tube (about 6-8 cm) using KY jelly. RATIONALE: Controls solution loss.
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Locate anus by gently separating patient's buttocks. Have patient relax by slowly breathing out through the mouth. RATIONALE: Promotes relaxation of external rectal sphincter. Insert rectal tube tip into patient's rectum. Constantly point tip in direction of patient's umbilicus. RATIONALE: Ensures smooth insertion following anatomical contour of rectum and colon. Allow solution to slowly enter rectum by opening regulating clamp. Container should be held at patient's hip level. RATIONALE: Gradual entry of solution decreases patient discomfort. Slowly raise container above patient's anus. RATIONALE: Container level controls speed of solution flow, the higher it is , the faster the descent of solution. If patient complains of cramping or fluid escapes around tubing, lower container/clamp tubing. RATIONALE: Provides time to assess and establish patency of tube. After solution is exhausted, clamp tubing. RATIONALE: Avoids entry of air to rectum. Put layers of tissue paper around tube/anus and gently withdraw rectal tube. RATIONALE: Prevents soiling of linen. Explain normalcy of feeling of distention to patient. Instruct patient to retain solution for as long as possible. RATIONALE: Decreases patient anxiety and increases cooperation. Discard enema container or rinse thoroughly using soap and warm water (for reusable containers). RATIONALE: Reduces transmission of microorganisms. Assist patient in going to the bathroom or aid patient in positioning bedpan. RATIONALE: Distention of colon is uncomfortable. Client needs physical support. Squatting position facilitates easier defecation due to gravity
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and colon's anatomical position. Examine patient's feces. Inspect color, consistency and amount of stool and fluid. Patient should be cautioned against flushing the toilet. RATIONALE: Ensures complete evacuation of solution and provides data for assessment. If needed, assist patient in washing anal area using soap and warm water. RATIONALE: Hygiene enhances patient comfort and prevents infection. Remove and dispose of gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assess condition of patient's abdomen. RATIONALE: Complete evacuation is determined. Record enema type and volume given and characteristics of results. RATIONALE: For use for future legal and care management purposes. If patient is unable to defecate, report to physician. RATIONALE: Prevents occurrence of further complications or fatal effects of enema to the patient. This may be an indication of a serious condition, prompt report to the physician may save the patient from fatal conditions arising.
7.5. Pouching

an Ostomy

Anatomy and Physiology

Ostomy is a surgical procedure used to create an opening for urine and feces to be released from the body. Certain diseases of the bowel

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or urinary tract involve removing all or part of the intestine or bladder, creating the need for an alternate way to eliminate feces and urine. Thus, an opening is surgically created in the abdomen for body wastes to pass through. The surgical procedure is called an ostomy. The opening that is created at the end of the bowel or ureter is called a stoma, which is pulled through the abdominal wall. Different types of ostomy are performed depending on how much and what part of the intestines or bladder is removed. The three most common types of ostomies are the following: Colostomy is done when a small portion of the colon (large intestine) is brought to the surface of the abdominal wall to allow stool to be eliminated. A colostomy may be temporary or permanent. A permanent colostomy usually involves the loss of the rectum. The need for a colostomy arises when the patient has cancer, diverticulitis, imperforate anus, Hirschsprung's disease or trauma to the affected area. Ileostomy is an opening created in the small intestine to bypass the colon for stool elimination. The end of the ileum, which is the lowest part of the small intestine, is brought through the abdominal wall to form a stoma. Ileoanal reservoir surgery is an alternative to a permanent ileostomy. Requiring two surgical procedures, the first involves the removal of the colon and rectum and a temporary ileostomy is created; the second creates an internal pouch from a portion of the small intestine to hold stool. This is then attached to the anus. Since the muscle of the rectum is left in place, there is now control over bowel movements. An ileostomy might be performed due to ulcerative colitis, Crohn's disease or familial polyposis Urostomy is a surgical procedure that diverts urine away from a diseased or defective bladder. There are several methods to create urostomy, the most common is called an ileal or cecal conduit. Either a section at the end of the small intestine (ileum) or at the beginning of the large intestine (cecum) is relocated surgically to form a stoma for urine to pass out of the body. Other common names for this procedure are ileal loop or colon conduit. A urostomy may be performed due to bladder cancer, spinal cord injuries, malfunction of the bladder, and birth defects such as spina bifida.
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Since colostomy, ileostomy, and urostomy bypass the sphincter muscle, there is no voluntary control over bowel movements and an external pouch must be worn to catch the discharge. The skin around the stoma, called the peristomal skin, must be protected from direct contact with discharge. The discharge can be irritating to the stoma since it is very high in digestive enzymes. The peristomal skin should be cleansed with plain soap and rinsed with water at each change of the pouch. The stoma can change in size due to weight gain/loss or several other situations. To ensure proper fit of discharge pouch the stoma should be measured each time supplies are purchased. Ostomy can give rise to infections to some patients. Leakage from around due to an improperly fitted pouch can result in skin irritations or rashes around the stoma. The best ways to prevent these include correctly fitting the pouch and carefully cleaning the skin around the stoma after each change.

Assessment Sites
Normal results

Ostomy pouches are typically not noticeable and can be worn under almost any kind of clothing. There are typically no restrictions of activity, sport or travel for people with ostomy. However, there are certain contact sports that would warrant special protection for the stoma. After recovery from surgery, most people with ostomies can resume a balanced diet. Also, ostomy surgery does not generally interfere with a person's sexual or reproductive capacities.
Abnormal results

Water and electrolyte loss may occur after an ileostomy. To prevent hydration, it may be required to drink large amounts of fluid or fruit juice every day. Digestion and absorption of medications may also be affected after an ostomy. For instance, eating high-fiber foods can cause blockages in the ileum, especially after surgery. Chewing food well helps break fiber into smaller pieces and makes it less likely to accumulate at a narrow point in the bowel.

Ostomy Pouch
An ostomy pouch is primarily to collect fecal matter. An ideal pouching
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system provides skin protection, fecal material collection, comfort and odor management. Numerous types of pouching systems are available. The nurse should consider the following to ensure that the pouch fits appropriately:

Type and location of the ostomy Type and amount of ostomy drainage Size and contour of abdomen Skin condition around the stoma Patient's physical activities Patient preference Equipment cost

A pouch and a skin barrier are the two basic components of a pouching system. There are two types of systems-the adhesive and nonadhesive systems. Pouches may also come in one or two pieces which are commonly disposable or reusable. Some have pre-cut openings while others require custom cutting of the stoma opening. Wafers, pastes, powders and liquid films are among the commonly used skin barriers. One-piece pouch systems have wafer barriers permanently attached to the ostomy pouch, while two-piece systems may have the pouch detached from the skin barrier for the purpose of emptying/changing. It minimizes the risk of skin damage from frequent skin barrier removal from the peristomal skin. In the twopiece system, care should be taken to ensure that the skin barrier and pouch have the appropriate size and similar manufacturer. The nurse should also make sure that the pouch to be used is for fecal material collection.

Materials Required
Pouch of correct size and type Pouch closure device (i.e., clamp) Adhesive remover (optional) Clean disposable gloves
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Deodorant Gauze pads Towel Basin with warm water Scissors Skin barrier (i.e., sealant wipes/wafer) Adhesive tape Identify patient and identify type and location of patient's ostomy. RATIONALE: Confirms patient's identity and provides data for nursing precautions and management. Check the skin integrity of area around stoma. RATIONALE: Determines appropriate stoma to be used. Note amount of fecal material present in pouch or on dressing. RATIONALE: Measures input and output ratio. Determine patient's capacity for self-care. Provides opportunity for health teaching. Encourages independence and enhances patient's self-esteem. Wash hands. RATIONALE: Reduces transmission of microorganisms. Prepare necessary equipment. RATIONALE: Saves time and ensures easy access to equipment/supplies. Assist patient in going to the bathroom or provide needed privacy at bedside. RATIONALE: Reduces patient embarrassment. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Remove soiled dressing/appliance.
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Placement of new appliance is facilitated. Cleanse area around stoma using mild soap and warm water. Inspect skin for redness/irritation. RATIONALE: Reduces risk of infection while avoiding irritation. Provides assessment data for nursing management. Use a piece of tissue to cover stoma. Change cover as needed during entire procedure. RATIONALE: Aseptic measure reduces patient discomfort.
RATIONALE:

Carefully dry skin around stoma, apply protective cream as necessary. RATIONALE: Prevents irritation and leakage. Ensures full adhesion. Make sure that skin is completely dry before reapplying pouch. RATIONALE: Prevents irritation and tissue breakdown. Remove stoma covering and apply clean pouch/dressing. Remove gloves and wash hands. RATIONALE: Reduces transmission of microorganisms Record procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
7.6. Colostomy

Irrigation

Anatomy and Physiology

Colostomy is a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body and to treat various disorders of the large intestine, including cancer, obstruction, inflammatory bowel disease, ruptured diverticulum, ischemia (compromised blood supply) or traumatic injury. Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing. Permanent colostomies are performed when the distal bowel (bowel at the farthest distance) must be removed or is blocked and inoper210

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able. Although colorectal cancer is the most common indication for a permanent colostomy, only about 10-15% of patients with this diagnosis require a colostomy.

Types of Colostomy
End colostomy. The functioning end of the intestine (the section of bowel that remains connected to the upper gastrointestinal tract) is brought out onto the surface of the abdomen, forming the stoma by cuffing the intestine back on itself and suturing the end to the skin. The surface of the stoma is actually the lining of the intestine, usually appearing moist and pink. The distal portion of bowel (now connected only to the rectum) may be removed or sutured closed and left in the abdomen. An end colostomy is usually a permanent ostomy, resulting from trauma, cancer or another pathological condition. Double-barrel colostomy. This colostomy creates two separate stomas on the abdominal wall. The proximal stoma is the functional end that is connected to the upper gastrointestinal tract and will drain stool. The distal stoma, called the mucous fistula and is connected to the rectum, drains small amounts of mucus material. This is typically a temporary colostomy performed to rest an area of bowel, which is closed later. Loop colostomy. This colostomy involves the bringing of a loop of bowel through an incision in the abdominal wall. The loop fastened to the outside of the abdomen using a plastic rod slipped beneath it. An incision is made in the bowel to enable the passage of stool pass through the loop colostomy. Approximately 7-10 days after surgery, the supporting rod is removed when healing has occurred that will prevent the loop of bowel from retracting into the abdomen. Usually, a loop colostomy is done to create a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured.

Types of Colostomies according to location

Ascending. Found on the right abdomen, this type of colostomy has an opening created from the ascending colon. Since the stoma is
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created from the first section of the colon, stool is more liquid and contains digestive enzymes that irritate the skin. This type of colostomy surgery is the least common. Transverse. This type may have one or two openings in the upper abdomen, middle or right side that are created from the transverse colon. When there are two openings in the stoma (called a doublebarrel colostomy), one is used to pass stool and the other, mucus. The stool has passed through the ascending colon, so it tends to be liquid to semi formed. Descending or sigmoid. For this type of surgery, the descending or sigmoid colon is used to create a stoma, typically on the left lower abdomen. This is the most common type of colostomy surgery and generally produces stool that is formed to semi formed because it has passed through the ascending and transverse colon.

Risks
Potential complications of colostomy surgery include:

excessive bleeding surgical wound infection thrombophlebitis (inflammation and blood clot to veins in the legs) pneumonia pulmonary embolism (blood clot or air bubble in the lungs' blood supply)

Assessment Sites
Normal results

Total healing is expected without complications. The period of time required for recovery from the surgery varies depending on the patient's overall health prior to surgery. The colostomy patient without other medical complications should be able to resume normal day-to-day activities once recovered from the surgery.

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The nurse should be made aware of any of the following problems after surgery: increased pain, swelling, redness, drainage or bleeding in the surgical area; headache, muscle aches, dizziness or fever; and increased abdominal pain or swelling, constipation, nausea or vomiting or black, tarry stools. Stomal complications to be monitored include: Death (necrosis) of stomal tissue. This complication is caused by inadequate blood supply and is usually visible 12-24 after the operation and may require additional surgery. Retraction (stoma is flush with the abdomen surface or has moved below it). This complication is caused by insufficient stomal length and may be managed by use of special pouching supplies. Another option is elective revision of the stoma. Prolapse (stoma increases length above the surface of the abdomen). This type normally results from an inadequate fixation of the bowel to the abdominal wall or an overly large opening in the abdominal wall. Surgical correction is required when blood supply is compromised. Stenosis (narrowing at the opening of the stoma). This is typically related to infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia. Surgery to reshape the stoma may be required with severe stenosis. Parastomal hernia (bowel causing bulge in the abdominal wall next to the stoma). This complication is due to the placement of the stoma where the abdominal wall is weak or creation of an overly large opening in the abdominal wall. Using an ostomy support belt and special pouching supplies may be required. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location. Colostomy irrigation is an alternative management procedure given to patients with an end colostomy in the sigmoid or descending colon. Colostomy irrigation involves patients giving themselves an enema through their stoma to initiate evacuation of stool from the
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large bowel. This gives the patient total freedom to defecate for around 24-48 . Frequency of irrigation varies but it is advised that it be conducted everyday until leakage stops. Steadily, extend irrigate every two days. Usually, it takes 2 weeks before the bowel adapts to the procedure. Afterwards, a regime can be selected to match the patient's particular needs. The time of day that irrigation is performed is not important although most patients prefer to do it in the morning. Ideally, every irrigation should be conducted at the same time every day, but this is not that crucial.

Materials Required
Irrigating tube Irrigating solution (tepid water or saline) Lubricant Pouch of correct size and type Pouch closure device (i.e., clamp)

Procedures for Colostomy Irrigation & Rationale

Assess irrigation frequency and stool characteristics. RATIONALE: Reduces transmission of microorganisms Prolonged constipation requires irrigation. Assess patient's schedule of ostomy irrigation or check physician's order. RATIONALE: Reduces transmission of microorganisms Establishes routine bowel emptying. Confirms physician's order. Assess patient's understanding of the procedure and ability to perform self-care. RATIONALE: Reduces transmission of microorganisms Determines needed health teaching and level of nursing assistance needed by patient. Explain procedure to patient. RATIONALE: Reduces transmission of microorganisms Improves patient's level of understanding of procedure. Reduces anxiety and enhances
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cooperation. Choose proper time for performing procedure (1 after meal). RATIONALE: Duodenal reflex is the ideal time to carry out procedure. Assist patient to establishing sitting position or if in bed, have patient lie on one side. RATIONALE: Promotes patient comfort during procedure. Wash hands and apply disposable gloves. RATIONALE: Reduces transmission of microorganisms. Provide needed privacy. RATIONALE: Reduces patient embarrassment. Remove pouch and cleanse skin. RATIONALE: Allows for attachment of irrigation sleeve. Apply irrigation sleeve, roll up so that only bottom touches toilet water (for patient in bed, clip bottom of drain sleeve). RATIONALE: Directs evacuated stool to toilet. Fill container with appropriate amount of irrigating solution (500600 ml tepid water or saline). Hang in pole so that container is level with patient's shoulder. RATIONALE: Exact amount of solution facilitates colon distention and emptying. Cold water may cause syncope, while hot water may burn colon mucosa. Height influences speed of solution flow. Attach cone to irrigating tube, allow fluid to run through entire tube length. RATIONALE: Air is pushed out. Apply lubricant to cone. RATIONALE: Prevents trauma to the stoma. Insert cone through irrigation sleeve's top. RATIONALE: Ensures confinement of stool to sleeve. Gently but firmly insert cone into stoma. Make sure that stoma is dilated before irrigating.
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RATIONALE:

Prevents trauma and ensures introduction of solution to colon.

Begin solution flow and readjust cone position as needed. RATIONALE: Ensures sufficient distention and avoids leakage. Adjust solution flow by raising/lowering container. Hang irrigation bag 18 inches above stoma. RATIONALE: Container height facilitates increase in speed of irrigating solution's flow, which should be controlled to avoid cramping. Slowly administer 500-1000 ml of solution over a rate of 15 mins. Pause if patient cramps. RATIONALE: Administers sufficient amount of solution to cause distention. Pause prevents leakage of solution. After solution runs in, clamp tubing and remove cone. Seal top of irrigation sleeve. A small gush of fluid should be obtained. RATIONALE: Prevents reflux contents. Clamp sleeve's top. RATIONALE: Prevents spillage of solution. After most of solution returns, use water to rinse sleeve. Fold with end up, fasten to top and have patient mobilize. RATIONALE: Allows patient to move conveniently while waiting for 1 hr (irrigation time). Upon return of all feces, rinse sleeve with water and liquid cleanser and remove. Wash sleeve using soap and water, rinse and let dry. Store sleeve for future use. RATIONALE: Reduces transmission of microorganisms. Allows for reuse of sleeve. Apply new pouch. RATIONALE: Avoids tissue breakdown and leakage. Dispose of equipment properly. RATIONALE: Rationale Wash hands.
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RATIONALE:

Reduces transmission of microorganisms.

Inspect fecal material and fluid volume and characteristics. RATIONALE: Provides data for evaluation of success of procedure. Note patient's response to procedure. Inquire for any discomfort or pain. RATIONALE: Measures patient's tolerance for procedure. Palpate and auscultate abdomen. RATIONALE: Assess for possibility of injury such as perforation. Assist patient to establishing a comfortable position. RATIONALE: Restores patient comfort. Record procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
7.7. Insertion/Maintenance

of Nasogastric Tube

Materials Required

Micropore tape or safety pin Plaster tape Asepto syringe Nasogastric tube (French 16 for adult, french 8 feeding tube for infants) or the types of tube to be used as ordered (Levin tube, Gastric Sump tube, Nutriflex tube, Moss Tube or sengstaken-blakemore tube) Kidney basin with half-filled water KY Jelly Stethoscope Sterile gloves and mask

Procedures for Insertion/Maintenance of Nasogastric Tube & Rationale

Examine patient's nasal and oral cavity.

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Specimen Collection
8.1. Collection of Midstream (Clean-Voided) Urine Specimen 8.2. Insertion of a Straight or Indwelling Catheter

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8.1.

Collection of a Midstream (Clean-Voided) Urine Specimen

Anatomy and Physiology

The urinary system basically maintains the volume and composition of body fluids within normal limits, with the primary activity of eliminating body of waste products that accumulate as a result of cellular metabolism. This system maintains a suitable fluid volume by regulating the amount of water that is excreted in the urine. This system also regulates the concentrations of various electrolytes in the body fluids and maintains normal pH of the blood. Aside from maintaining fluid homeostasis in the body, the urinary system also controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. The urinary system includes the kidneys, bladder and tubes. These organs control the amount of water and salts that are absorbed back into the blood and what is taken out as waste. This system also acts as a filtering mechanism for the blood. The urinary system consists of the two kidneys, the bladder and the adjoining tubes. They help urine produced to pass through the ureters into the bladder where it is stored until evacuated. Urine is then expelled from the body through a single tube called the urethra. The kidneys are two large, bean-shaped organs designed to filter waste materials from the blood. They also assist in controlling the rate of red blood cell formation, and in the regulation of blood pressure, the absorption of calcium ions, and the volume, composition, and pH of body fluids. The kidneys are located in the upper posterior part of the abdominal cavity, one on each side of the spinal column. The suprarenal (adrenal) gland sits like a cap on top of each kidney. A considerable volume of fat protect the kidneys and are supported by connective tissues and the peritoneum. The dilated upper end of the ureter is attached to the hollow side of each kidney, forming the renal pelvis. It can be said that the kidneys are the filters of the blood. Every minute, one-fourth of the body's blood-approximately 1200 ml220

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passes through the kidneys. Each kidney is composed of about one million microscopic filters called nephrons. These micro-filters eliminate toxins and waste materials from the blood and for maintain the electrolyte balance by selectively eliminating some electrolytes while retaining others, according to the body's needs. The kidneys also help regulate other bodily functions by secreting the hormones renin, erythropoietin, and prostaglandins. Renin helps control blood pressure and erythropoietin stimulates the body to produce more red blood cells. Kidneys primarily function to regulate electrolytes and fluids, the acidbase balance composition of body fluids, blood pressure, as well as remove metabolic end-products from the blood. The formation of urine is the product of these processes. Urine is transported from the kidneys through the ureters into the urinary bladder where it will be temporarily stored. During urination, the bladder contracts and the urine is excreted form the body through the urethra. About 150 L (33 gallons) of fluid pass through your kidneys every day. But 99% of this cleaned and goes back into your blood. In their lifetimes, adults pass about 40,000 L (8,800 gallons) of urine. This is enough to fill 500 bath tubs. The ureters' only function is to carry urine from each kidney to the urinary bladder. The ureters are two membranous tubes 1 mm to 1 cm in diameter and about 25 cm in length. Urine is transported through the ureters by peristaltic waves (produced by the ureter's muscular walls). The urinary bladder is the temporary storage compartment of urine. The bladder possesses features that enable urine to enter, be stored, and later be released for evacuation from the body. It can hold between one half to two cups of urine before it needs to be emptied. Everyday about two to five cups of urine pass through the bladder. The more water you drink, the more urine is produced. If it is hot outside and you produce a lot of sweat, you will not make as much urine. The bladder is a hollow, expandable, muscular organ located in the pelvic girdle. Although the shape of the bladder is spherical, its shape is altered by the pressures of surrounding organs. When it is empty, the inner walls of the bladder form folds. But as the bladder
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fills with urine, the walls become smoother. The urethra is a tube that connects the urinary bladder to the outside of the body. The urethra has an excretory function in both sexes, to pass urine to the outside. For males, it also has a reproductive function-as a passage for sperm. Not surprisingly men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis). The length and the presence of several bends in a male's urethra make catheterization more difficult among men. Male urethra is approximately 8 inches (20 cm) long and opens at the end of the penis. This is divided into three parts, named after the location: the prostatic urethra of about 2.5 cm long crosses through the prostate gland and there is a small opening where the vas deferens enters, the membranous urethra is a small (1 or 2 cm) portion passing through the external urethral sphincter and this is the narrowest part of the urethra, the spongy (or penile) urethra runs along the length of the penis on its ventral (underneath) surface and it is about 15-16 cm in length, and travels through the corpus spongiosum. On the other hand, the female urethra is about 1-1.5 inches (2.5-4 cm) long and opens in the vulva between the clitoris and the vaginal opening. The external urethral sphincter is the skeletal muscle that allows voluntary control over urination. The urinary meatus is the external urethral orifice.
The Urine

Urine is formed through a series of processes in the nephron, including filtration, reabsorption and secretion. About 96% of urine is water, the remaining are waste salts and a substance called urea. Urea is made during the breakdown of proteins in your liver. Urea may also leave your body in sweat. If urea builds up in your body, it is a sign that your kidneys are not working properly. Kidney failure can be fatal if it is not treated quickly. Urination Micturition). The process of expelling urine from the bladder is called urination or micturition. It involves the contraction of the detrusor muscle, and pressure from surrounding structures. Urination also involves the relaxation of the external urethral sphincter. Composed of voluntary muscular tissue, the external urethral sphincter surrounds the urethra about 3 centimeters from the bladder.
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The distention of the bladder typically stimulates urination as it gets filled with urine. When the walls of the bladder contract, nerve receptors are stimulated, triggering the urination reflex. The urination reflex causes the internal urethral sphincter to open and the external urethral sphincter to relax, which will enable the bladder to empty. The bladder can hold up to 600 ml of urine. The desire to urinate may not occur until the bladder contains. Filtration. from a glomerular capillary, urine formation begins when water and various dissolved substances and are filtered out of blood plasma into the glomerular capsule. The filtered substance (glomerular filtrate) leaves the glomerular capsule and enters the renal tubule. Reabsorption. As glomerular filtrate passes through the renal tubule, some of the filtrate is reabsorbed into the blood of the peritubular capillary. The filtrate entering the peritubular capillary will repeat the filtration cycle. This process of reabsorption changes the composition of urine. For example, the filtrate entering the renal tubule is high in sugar content, but because of the reabsorption process, urine secreted from the body does not contain sugar. Secretion. Secretion involves the process wherein the peritubular capillary transports certain substances directly into the fluid of the renal tubule. These substances are transported by similar mechanisms as used in the reabsorption process, but done in reverse. For instance, certain organic compounds, such as penicillin and histamine, are secreted directly from the proximal convoluted tubule to the renal tubule. Also, large quantities of hydrogen ions are secreted in this same manner. The secretion of hydrogen ions plays an important role in regulating pH of body fluids. The glomerulus filters gallons of blood daily. It is estimated that 2,500 gallons of blood pass through the kidneys in 24? and about 80 gallons of glomerular filtrate. All the water from this filtrate is reabsorbed in the renal tubules except that containing the concentrated waste products. Although the average amount of urine an adult excretes varies from

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1,000 to 1,500 ml per day, the amount of urine excreted varies greatly with temperature, water intake and state of health. No matter how much water one drinks, the blood will always remain at a constant concentration, and the excess water will be excreted by the kidneys. A large water intake does not put a strain on the kidneys. Instead it eases the load of concentration placed on the kidneys.
Importance

Urine specimen obtained by the nurse is crucial in diagnoses and therapies of a patient. To competently handle this procedure, the nurse must know a number of pertinent information, including the rationale for the test involved, teaching/information dissemination and preparation of the patient, proper technique in obtaining and handling urine specimens and post-urine test procedures. A knowledgeable and skillful nurse is necessary to obtain an accurate result.

Factors Affecting Collection of Midstream (CleanVoided) Urine Specimen

Sterility of the container (specimen bottle) Cleansing agent used in perineal care Urge to urinate Mental and physical conditions Medical history and present conditions Types of urine examination and analysis Compliance with preparation

Assessment Sites
The urethral meatus and surrounding area must be assessed for color and foul smelling odor. The nurse must check for presence of sore and ulcers. These conditions may have an impact on the result of the urine analysis.
Laboratory Examinations Assessment

Urinalysis tests pH. Indicates acid-base balance. Normal values range from 4.6 to 8.0 (6.0 average). A higher result indicates a loss of acid (Alkademia
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or alkaline pH) which may be from bacteruria, urinary tract infection (caused by Pseudomonas or Proteus organisms) or a diet high in fruits and vegetables. Lower than normal results indicate Acidemia (acid urine) which may be from metabolic or respiratory acidosis, starvation, diarrhea or a diet high in meat protein or cranberries. Appearance. Normally clear, presence of pus, red blood cells, bacteria or certain foods (e.g., large amoutns of fat), urates or phosphates may cause cloudy urine. Color. Normal color is Amber yellow. Abnormally colored urine may indicate a pathological condition (e.g., bleeding from kidneys produces dark red urine; bleeding from the urinary track produces bright red urine). Dark yellow urine may indicate the presence of bilirubin or urobilinogen. Pseudomanas organisums usually produce a green urine, where certain foods and medicines change urine color (e.g., beets can cause a red urine, rhubarb can cause a brown colored urine.) Many commonly used drugs can affect the color of urine. Odor. A severe smell of acetone can occur with diabetic ketosis. Infected urine has an unpleasant order. Specific Gravity. This may increase with dehydration, pituitary tumor that causes the release of excessive amounts of ADH, a decrease in renal blood flow, glucosuria and proteinuria. Normal values range from 1.005 to 1.0A decrease in specific gravity may indicate overhydration, diabetes insipidus and chronic renal failure.
Microscopic examinations

Red Blood Cells (RBC), White Blood Cells (WBC) and Casts (White Blood Cell clumps indicating pyelonephritis or Red Blood Cell clumps indicating glomerulonephritis). Normal values would be up to 2 RBCs and up to 4 WBCs at low-power field, negative or occasional hyaline, no crystals or bacteria. Elevated RBC may indicate microscopic hematuria. Elevated WBC and the presence of bacteria may indicate urinary track infection. Hyaline casts are conglomerations of protein and signal proteinuria. Crystals occur with high serum acid levels (gout). Phosphate and calcium oxalate crystals may indicate hyperparathyroidism or malabsorption states.
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Urine Chemistry

ALB (Albumin) Urine Protein. Normal values range up to 8 mg/dl. Any elevated results indicate the presence of protein in the urine which may be due to glumerulonephritis or preeclampsia in pregant women. GLU (Glucose) Urine. There should be no Glucose in a urine sample. Any levels may occur in diabetics not well controlled with hypoglycemic agents, IV administration of dextrose-containting fluids, central nervous system disorders (e.g., stroke), Cushning's syndrome, severe stress, infections and certain drugs (e.g., ascorbic acid, aspirin, keflin, epinephrine, and streptomycin). Ketones. Any keytone levels may occur in poorly controlled diabetes (most often in juvenile diabetes). Nondiabetic patients may elevate levels with dehydration, starvation or excessive aspirin ingestion. PAP (Prostatic Acid Phosphate). This test diagnoses prostatic carcinoma, monitors efficacy of treatment for prostatic carcinmoma and investigates alleged rape because phosphate occurs in high constrations in seminal fluid. Normal value ranges from 0.10 to 0.63U/ml (BesseyLowry), 0.5 to 2.0U/ml (Bodansky), 1.0 to 4.0 U/ml (KingArmstrong) or 0.0 to 0.8 U/L at 37?C (SI units) in adults and 6.4 to 15.2 U/L in children. Aldosterone. Diagnosing pathological conditions when increased results accompany decreased renin level such as aldosteronism (Conn's syndrome). Normal values range from 1 to 21 ng/dl (morning, standing, peripheral vein), 3.2 to 11.6ng/dl (morning, supine for 2?, peripheral vein) or 2 to 16ug/25? in Urine. Elevated results could indicate hyponatremia, hyperkalemia, stress, Cushing's syndrome, malignant hypertension, generalized edema (from congestive heart failure, nephrotic syndrome, cirrhosis), renal ischemia and Bartter's syndrome (a renin-producing renal tumor). Pregnancy and oral contraceptives can also increase levels. Diuretics and steroids promote sodium excretion and may raise aldosterone levels. Decreased aldosterone levels are seen with high sodium diets or hypokalemia. Aldosterone can also indicate Addison's disease or toxemia of pregnancy. Antihypertensives may also reduce levels because they promote sodium and water retention.
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ACE (Angiotensin-Converting Enzyume); SACE. Used to test severity of or response to therapy for diagnosed sarcoidosis.Normal test results values range from 23 to 57 U/ml (units - nanomoles/min). Elevated levels of ACE may indicate sarcoidosis. Other conditions that may cause a higher result than normal may be Gaucher's disease (a rare familial disorder of fat metabolism), leprosy, alcoholic cirrhosis, active histoplasmosis, tuberculosis, Hodgkin's disease, myeloma, scleroderma, pulmonary embolism, and idiopathic pulmonary fibrosis. Lower than normal levels may be expected with sarcoidosis treated with prednisone. ASO Titer (Antistreptolysin O Titer). This is used in the diagnosis of streptococcal infections such as rheumatic fever, scarlet fever, bacterial endocarditis and glomerulonephritis. Elevated ASO usually indicates a recent infection with group A betahemolytic streptococcus. Normal values range (less than) <160 Todd units/ml for adults, newborn similar to mother's value, (less than) <50 Todd units/ml for 6 months to 2 year olds, (less than) <160 Todd units/ml for 2 to 4 year olds, (less than) <200 Todd units/mo for 5 to 12 year olds. Plasma Renin Activity. This test is used to measure plasma aldosterone level for a differential diagnosis of hyperaldosteronism. It is also used to detect essential, renal or renovascular hypertension. Normal values range from 2.9 to 24 ng/ml/h in a 20 to 39 years old adult taken from an upright position, sodium depleted peripheral vein or 2.9 to 10.8 ng/ml/h in a (greater than) >40 years old. Results vary for a sodium replete Normal adult value range from 0.1 to 4.3 ng/ ml/h age 20 to 39 years old taken in an upright position from a peripheral vein or 0.1 to 3ng/ml/h in a (greater than) >40 years old. An Increased results in aldosterone accompany with a decreased renin level may indicate aldosteronism (Conn's syndrome) or primary hyperaldosteronism. Pregnancy and several drugs (e.g., oral contraceptives, antihypertensives, vasodilators) and certain foods (e.g., licorice) affect renin levels. Elevated renin levels may indicate essential hypertension, malignant or renovascular hypertension, Addison's disease, cirrhosis, hypokalemia, hemorrhage, and reni-producing renal tumors (Bartter's syndrome). Decreased levels could be associated with salt-retaining steroid therapy and antidiuretic hormone therapy.
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BUN (Blood Urea Nitrogen). Part of a renal function test BUN levels indicate primary renal disease (e.g., glomerulonephritis, pyelonephritis, acute tubular necrosis and urinary obstrction from tumor or stones). Normal value ranges from 5 to 20mg/dl. An elevated level my indicate the kidneys are overwhelmed by excessive amounts of protein for hepatic catabolism and so are unable to excrete the sudden load of urea. BUN level may increase in gastrointestinal (GI) bleeding disorders. Decreased BUN levels can occur from toxins (e.g., gentamicin, tobromycin, myoglbin and free hemoglobin), overhydration or dehydration, shock, congestive heart failure, liver failure, negative nitrogen balance and pregnancy. CREA (Creatinine). Normal values range from 0.7 to 1.5 mg/dl. Elevated results may indicate renal disorders (e.g., glomerulonephritis, pyelonephritis, acute tubular necrosis and urinary obstructions). Bun-Creatinine ratio may be used to assess kidney function. A normal value would expect a 20 (BUN) to 1 (Createnine) ratio (some sources use 15:1). When BUN level is elevated out of proportion to the creatinine level this may indicate dehydration, gastrointestinal bleeding or malnutrition. When BUN level decreased out of proprtion to the creatinine level, then low protein intake, overhydration or severe liver failure is indicated. If both levels are elevated this may be due to kidney failure or disease. Creatinine Clearance. This is used to assess renal function. Normal urine sample value ranges from 95 to 104 ml/min for men and 95 to 125 ml/min for women. Lower than normal results may indicate renal artery atherosclerosis, dehydration or shock. Most primary renal diseases (e.g., glomerulonephritis and acute tubular necrosis) cause a decrease in creatinine clearance level. Long standing obstruction to urinary outflow can cause decreased levels.
Other Urinary Tests

24-hr Urine Test for Vanillylmandelic Acid (VMA) and Catecholamines. Diagnose hypertension secondary to pheochromocytoma. Normal Values range from 1 to 9 mg/24. Catecholamines Epinephrine range from 5 to 40ug/24, Norepinephrine range from 10 to 80 ug/24, Metanephrine range from 24 to 96 ug/24 and
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Normetanephrime ranges from 75 to 375 ug/24. One or all results in excessive quanities in a 24-hour collection of urine may indicate pheochromocytoma. Elevated VMA and catecholamine levels also appear in neuroblastomas, ganglioneuromas, and ganglioblastomas. Severe stress, strenuous exercise and acute anxiety can cause elevated catecholamine results. Reagent strip method (dipstick) is the most commonly employed method to test for proteinuria. It tests mainly for albumin, is sensitive to 1030 mg/dl and is read out by a color change. The intensity of the color change is proportional to the concentration of protein, with trace = 10-30 mg/dl, 1 + = 30 mg/ dl, 2 + = 100 mg/dl, 3 + = 500 mg/dl, and 4 + >1000 mg/dl. Highly concentrated or alkaline (pH>8) specimens may give a false positive reaction, while very dilute urine and globulins may give a false negative reaction.

Materials Required
Perineal care materials (mild hypo-allegenic soap with tap water) Sterile specimen bottle Disposable gloves

Procedures for Collecting Midstream (CleanVoided) Urine Specimen & Rationale

Evaluate status of patient. RATIONALE: Assesses patient's bladder for fullness, ability to cooperate and level of assistance needed. Set up equipment and supplies. RATIONALE: Facilitates easy access to materials. Maintains sterility. Organizes nurse's working environment and saves time. Give procedure details to patient. RATIONALE: Improves patient's understanding of procedure. Reduces anxiety and promotes cooperation. Unless contraindicated, give fluids 30 mins before specimen collection. RATIONALE: Encourages urination.
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Wash hands. RATIONALE: Reduces transmission of microorganisms. Give privacy. RATIONALE: Reduces patient embarrassment. Assist or allow patient to cleanse perineal site. RATIONALE: Encourages patient independence. Set up sterile kit and prepare properly. RATIONALE: Maintains sterile field, controls spread of infection. Wear sterile gloves. RATIONALE: Prevents spread of infection. Open specimen container by placing cap with inside area facing up. RATIONALE: Prevents contamination of cap. Apply antiseptic to gauze or cotton balls. RATIONALE: To be used for further cleansing of the urethra. Let patient cleanse perineal site or assist in the process and collect specimen: RATIONALE: Enhances patient's self-esteem and independence. For male patient, cleanse penis of patient and rinse. Pass container into stream after patient starts to urinate and gather 30-60 ml of urine. For female patient, cleanse perineal area of patient and rinse. Pass container into stream after patient starts to urinate and gather 30-60 ml of urine. RATIONALE: Decreases bacterial levels. Container will hold specimen collected. Before urine flow ends, remove container. RATIONALE: Prevents urine contamination by skin flora. Cover container with cap. RATIONALE: Maintains specimen sterility. Wipe off excess urine outside of container.
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RATIONALE:

Prevents spread of microorganisms from specimen

Put container in a plastic specimen bag. RATIONALE: Additional infection control measure. If applicable, remove bedpan and help patient assume a comfortable position. RATIONALE: Restores patient comfort. Properly label specimen; attach laboratory requisition slip. RATIONALE: Ensures proper identification of specimen donor and diagnosis. Take off and discard gloves. Wash hands. RATIONALE: Prevents bacterial growth in the specimen. Ensures accurate analysis. Either immediately bring specimen to laboratory within 15 mins or put in refrigerator. RATIONALE: Refrigeration preserves specimen integrity. Document time and date specimen collection. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
8.2. Insertion

of a Straight or Indwelling Catheter

A urinary catheter is any tube system placed in the body to drain and collect urine from the bladder. A Foley catheter is a soft plastic or rubber tube that is inserted into the bladder to drain the urine. Urinary catheters are sometimes recommended as way to manage urinary incontinence and urinary retention in both men and women.

Urinary Catheters
Urinary catheters may be used to drain the bladder. This is often a last resort because of the possible complications associated with continuous catheter usage. Complications of catheter use may include: urinary tract and/or kidney infections, blood infections (septicemia), urethral injury, skin breakdown, bladder stones, and blood in the
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urine (hematuria). After many years of catheter use, bladder cancer may also develop. Your health care provider may recommend use of a catheter for short term use or long term use (indwelling). The catheter may be left in place during this time or you may be instructed on a procedure for placing a catheter just long enough to empty the bladder and then remove it (clean intermittent self catheterization). Catheters come in a large variety of sizes (12 Fr., 14 Fr.,... 30 Fr.), materials (latex, silicone, Teflon) and types (Foley catheter, straight catheter, coude tip catheter). It is recommended that you use the smallest size of catheter, if possible. Commonly, a size 14 Fr. or size 16 Fr. catheter is used. Some people may require larger catheters to control leakage of urine around the catheter or if the urine is thick and bloody or contains large amounts of sediment. Be aware that larger catheters are more likely to cause damage to the urethra. Some people have developed allergies or sensitivity to latex after long term latex catheter use; these people should use the silicone or Teflon catheters.

Long Term (Indwelling) Urethral Catheters

A catheter that is left in place for a period of time may be attached to a drainage bag to collect the urine. There are two types of drainage bags. One type is a leg bag, which is a smaller drainage device that attaches by elastic bands to the leg. A leg bag is usually worn during the day since it fits discreetly under pants or skirts, and is easily emptied into the toilet. The other type of drainage bag is a larger drainage device (down drain) that may be used during the night. This device is usually hung on the bed or placed on the floor.

Importance
Insertion of this device is required in order to:

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Prevent or relieve over distention owing to patient's inability to urinate Empty the bladder as: - prior to instillation, irrigation, operation or delivery

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- prevention of complication when voluntary urination is contraindicated Secure urine for analysis and culture Remove residual urine Manage incontinence when all other measures have failed Provide for intermittent or continuous bladder drainage and irrigation. Prevent urine from contacting an incision after perineal surgery Facilitate an accurate measurement of urinary output. Empty the bladder completely prior to surgery to prevent inadvertent injury to adjacent organs. Site of Insertion Type of catheter

Factors Affecting Urinary Catheterization

Assessment Sites
Urethral meatus and surrounding area should be assessed for color and foul smelling odor. The nurse should inspect for the presence of sore and ulcers, lump or mass and fistula. Upon insertion, if resistance is encountered, do not attempt to insert the catheter forcefully.

Materials Required

Perineal care materials Catheter (straight or indwelling) female : french 10-12 male : french 14-18 child : 5-10 Sterile and disposable gloves KY Jelly Kidney basin Cotton balls
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Anti-septic solutions Clamp 10 cc syringe Sterile saline solution

Procedures for Insertion of a Straight or Indwelling Catheter & Rationale

Evaluate status of patient. RATIONALE: Provides baseline data for nursing care management. Assess medical record of patient. RATIONALE: Determines patient diagnosis and existing care management. Evaluate knowledge of patient of catheterization's purpose. Give procedure details to patient. RATIONALE: Provides opportunity for health teaching. Improves patient's understanding of procedure. Reduces anxiety and enhances cooperation. If needed, make arrangements for assistance. RATIONALE: Prevents muscle strain/injury on part of the nurse. Start intake and output monitoring. RATIONALE: Determines function of the kidneys. Wash hands. RATIONALE: Reduces transmission of microorganisms. Give privacy. RATIONALE: Reduces patient embarrassment. Elevate bed to proper working level. If right-handed, stand on bed's left side, if left-handed, stand on right side. Clear bedside table and prepare equipment. RATIONALE: Good body alignment is maintained. Provides for good organization during performance of procedure. Elevate side rail located on bed's opposite side. Bring down side rail on working side.
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RATIONALE:

Prevents patient injury from falling.

Put under patient the waterproof pad. RATIONALE: Prevents soiling of linen. Put patient to proper position: For female patient, help patient to dorsal recumbent position. Request patient to relax thighs to enable external rotation of hip joints. If patient cannot be placed in supine position, put patient in side-lying position with upper leg flexed at knee and hip. For male patient, help patient to supine position with slightly abducted thighs. RATIONALE: Exposes perineal area. Drape patient: For female patient, diamond drape patient. For male patient, drape upper trunk of patient using bath blanket. Cover lower extremities using bed sheets, leaving genitalia exposed. RATIONALE: Prevents unnecessary exposure of patient's private body parts. Wear disposable gloves. RATIONALE: Reduces risk of infection. As needed, cleanse perineal area of patient using soap and water and completely dry area. RATIONALE: Prevents growth of infectious microorganisms and promotes patient comfort. Take gloves off. RATIONALE: Facilitates ease in carrying out procedure. To illuminate perineal area, position light. RATIONALE: Provides a better view of perineum. After opening draining system package, put drainage bag on top of edge of bed frame's bottom. Position drainage tube up between mattress and side rail (indwelling catheter only). As per instructions, open catheterization kit, maintaining container's bottom sterile. Wear sterile gloves. Prepare supplies on sterile field.
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Open inner sterile package containing catheter. Apply sterile antiseptic solution to the appropriate compartment containing sterile cotton balls and open packet containing lubricant. Take specimen container off (lid must be loosely put above) and pre-filled syringe from tray's collection compartment. Put them aside on sterile field. RATIONALE: Contamination is avoided. Risk of infection is reduced. Try balloon. Inject fluid from prefilled syringe into balloon port. RATIONALE: Product is tested for defects. For female patients, lubricate 2.5-5 cm of catheter. For male patients, lubricate 12.5-17.5 cm. RATIONALE: Facilitates easier and smoother insertion. Male patients require more lubrication owing to length of the male urethra. Put sterile drape: For female patient, let drapes' top edges to form cuff above both hands. Put down drape on bed between the thighs of patient. Slip cuffed edge a little below buttocks of patient. Lift fenestrated sterile drape and let it unfold without contacting an unsterile object. Put drape over perineum of patient, with labia exposed. For male patient: Using the first method, place drape over thighs of patient and below penis without totally opening fenestrated drape. Using the second method, place drape over thighs of patient slightly under penis. Lift fenestrated sterile drape, let it unfold, and drape it on penis, with fenestrated slit placed over penis. RATIONALE: Prevents unnecessary exposure of patient's private parts, while maintaining sterility. Reduces patient anxiety. Put sterile tray and content on sterile drape between the thighs of patient and open specimen container. RATIONALE: Sterility is maintained. Cleanse urethral meatus: For female patient, retract labia of patient using nondominant hand to completely expose urethral meatus and sustain
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nondominant hand's position throughout the process. Pick up antiseptic solution-saturated cotton balls using forceps and clean perineal area wiping front to back, from clitoris to anus. Include wiping far labial fold, near labial fold, and center of urethral meatus. For male patient, use nondominant hand to retract foreskin of the penis of patient and hold penis at shaft slightly under glans. Retract urethral meatus between thumb and forefinger and sustain nondominant hand's position throughout the process. Pick up antiseptic solution-saturated cotton balls using forceps and clean penis. In circular motion, move cotton ball starting from urethral meatus toward glans' base. Repeat procedure three more times using a new cotton ball for each instance. RATIONALE: Ensures sterility of procedure. Using gloved dominant hand, pick up catheter 7.5-10 cm from catheter tip. Hold catheter's end loosely coiled in dominant hand's palm. Facilitates insertion without contamination. Insert catheter: For female patient: As if voiding urine, have patient gently bear down. through urethral meatus, insert catheter slowly. RATIONALE: Provides a better view of urinary miatus expansion. Move catheter 5-7.5 cm in adult or until the time urine oozes out of the end of catheter. Without forcing, move catheter another 2.5-5 cm as urine appears. Put catheter's end in urine tray receptacle. RATIONALE: Determines length of urinary miatus while catching urinary output. Let labia off and, with dominant hand, firmly hold catheter and inflate retention catheter's balloon. RATIONALE: Anchors catheter in the bladder. For male patient: Raise penis of patient to a perpendicular position to his body and put light traction. RATIONALE: Eases catheter insertion by straightening urethral passage. As if voiding urine, have patient gently bear down. Through urethral meatus, insert catheter slowly. 237

Chapter Nine

Catheterization
9.1. Care of Indwelling Catheter 9.2. Irrigation of Closed and Open Catheter 9.3. Condom Catheter Application

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9.1. Care

of Indwelling Catheter

[For lecture, please refer to 8.2]

Materials Required
Perineal care materials Catheter (straight or indwelling) female : french 10-12 male : french 14-18 child : 5-10 Sterile and disposable gloves KY Jelly Kidney basin Cotton balls Anti-septic solutions Clamp 10 cc syringe Sterile saline solution

Procedures for Care of Indwelling Catheter & Rationale

Evaluate bowel incontinence or discomfort of patient at insertion site of catheter. RATIONALE: Accumulation of secretions or feces causes irritation to perineal tissues and acts as a source of bacterial growth. Set up equipment and supplies. RATIONALE: Right preparation conserves time and energy for the nurse and provides comfort for the patient. Give procedure details to patient. Give privacy. RATIONALE: Information promotes patient's cooperation and reduces anxiety. Reduces embarrassment for the patient and providing privacy is one of the patient's rights. Wash hands. RATIONALE: Reduces spread of microorganisms.
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Properly position patient. Put waterproof pad under patient. RATIONALE: Ensures easy access to perineal tissues. Prevents soiling of linen. Drape patient. Wear disposable gloves. RATIONALE: Prevents unnecessary exposure of urethral areas. Reduces spread of microorganisms. Unfasten anchor tapes to free tubing of catheter. RATIONALE: For easy manipulation of catheter tube and facilitates tasks. Expose and examine urethral meatus of patient. RATIONALE: Determines presence of local infection and status of hygiene. Wash perineal tissues of patient with soap and water. RATIONALE: Promotes perineal hygiene. For female patient, wash labia minora and labium majora, cleaning toward anus. Put catheter down. RATIONALE: Provides full visualization of urethral meatus. Full retraction prevents contamination during cleansing. For male patient, first wash around catheter, going toward glans and meatus in circular manner. RATIONALE: Accidental dropping of penis during cleansing requires repeat of procedure. Reevaluate meatus of patient for discharge. RATIONALE: Determines presence of local infection and status of hygiene. In a circular motion, wipe using soap and water around 10 cm below catheter's length. RATIONALE: Reduces presence of secretion or drainage on exterior of catheter surface. If ordered, administer antibiotic ointment along catheter and on meatus. RATIONALE: Further reduces growth of microorganism at insertion site.

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Remove gloves and supplies. Wash hands. RATIONALE: Reduces spread of microorganism and risk nosocomial infection. Document and report status of patient's catheter. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
9.2. Irrigation

of Closed & Open Catheter

Materials Required
Perineal care materials Catheter (straight or indwelling) female : french 10-12 male : french 14-18 child : 5-10 Sterile and disposable gloves KY Jelly Kidney basin Cotton balls Anti-septic solutions Clamp 10 cc syringe Sterile saline solution

Procedures for the Irrigation of Closed & Open Catheter and Rationale
Check order of prescriber. RATIONALE: RATIONALE: Catheter irrigation is an invasive procedure and a dependent nursing procedure therefore needs doctor's order. Examine amount and appearance of urine of client and type catheter used. RATIONALE: Urine characteristics and quantity is a good indicator of kidney function. This can also be affected by the type of catheter used.
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Establish catheter patency. RATIONALE: Out put quantity and quality may be affected by any tubing obstruction. Measure urine in drainage bag. RATIONALE: Intake and out put should be commensurate, alteration in the balance affects homeostatsis. Give procedure details to client. RATIONALE: Any procedure that is to be done is a primary patient concern, its an illustration of respect to patient's privacy. Wash hands. RATIONALE: Ensures infection control. Wear disposable gloves for closed method (see below). RATIONALE: Maintains sterility and protects nurse from urine contamination. Give privacy. RATIONALE: Avoids unnecessary exposure minimizes client's discomfort. Examine if client has bladder distention. RATIONALE: Distention may be a sign of obstructed or dislodged tubing. Properly position client. RATIONALE: Obstruction or kinking may also be related to posture.
CLOSED INTERMITTENT IRRIGATION

Set up solution and inject into syringe. RATIONALE: Usage of syringe will accurately administer medication internally without spillage. Attach indwelling catheter under injection port. RATIONALE: Seals the syringe tip towards the catheter administration port. Use swab to cleanse port. RATIONALE: Ensures infection control. Draw syringe at 30 angle. RATIONALE: Enhances gravitational pull of syringe fluid.
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Inject fluid gradually into bladder and catheter. RATIONALE: So as not to cause discomfort and trauma to bladder. Remove syringe, take off clamp, and let solution to drain into bag. RATIONALE: Ends the irrigation of fluid, avoids backflow of irrigating solution to syringe.
CLOSED CONTINUOUS IRRIGATION

Observing aseptic method, draw irrigation tubing's tip into bag containing solution. RATIONALE: Gravitational pull facilitates irrigation. Close tubing clamp and put solution on IV pole. RATIONALE: Facilitates higher (Bag on the pole) to lower (patient's catheter) movement of fluid . Open clamp to let solution flow through tubing and then close clamp. RATIONALE: Opens the flow tube, initiating irrigation. Using a triple lumen catheter or Y connector, securely attach irrigation tubing to double lumen catheter. RATIONALE: Ensures closed system, eliminates entrance of pathogens from the surrounding. Intermittent flow: Clamp tubing on drainage and open irrigation tubing. Let prescribed amount to go into bladder. Afterwards, close irrigation clamp and open drainage clamp. RATIONALE: Avoids excessive amount to enter into the bladder that would cause trauma, irritation or discomfort. Continuous irrigation: Measure drip rate and adjust tubing clamp. Determine patency and security of system. RATIONALE: The physician have already anticipated the bladder's capacity to hold continous irrigation, removing solid particles inside such as blood clots.
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Open irrigation: RATIONALE: Time to relieve the bladder from fluid volume and flush solid sediments inside. Set up sterile supplies. RATIONALE: Ensures aseptic field to prevent infection. Wear sterile gloves and position waterproof drape. RATIONALE: Ensures infection control and avoids spillage of irrigation on bed. Aspirate 30 ml of solution into sterile irrigating syringe. RATIONALE: Flushes out solid particles from the bladder by initiating negative pressure. Detach catheter from drainage tubing. Let urine flow into basin. Cover tubing's open end with sterile cap. Assist pressure to draw fluid volume from the inside of the bladder. Inject syringe, slowly instill solution, then withdraw syringe. RATIONALE: Creates a cycle of introduction of irrigating solution and withdrawal to achieve purpose of flushing and , softening obstructive particles. Let solution flow into basin. Repeat procedure until drainage is empty. RATIONALE: Limits the irrigation process until therapeutic level based on doctor's order. When irrigation is finished, initiate closed drainage system. RATIONALE: Prevents entrance of pathogens into the tubing to the bladder. Either change client position or gently aspirate solution if solution does not come back. RATIONALE: Moving client from one position to another aids in gravitational pull of irrigating solution from the inside of the bladder. Anchor back catheter to client. RATIONALE: Avoids disconnection by pulling. Help client assume comfortable position.

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RATIONALE:

Changing position may to drain irrigating fluid may cause to assume uncontrollable position.

If indicated, bring down bed and elevate side rails. RATIONALE: Ensures safety from injury such as fall. Discard supplies. RATIONALE: Avoids contamination. Take off and discard gloves. RATIONALE: Aseptic measures. Wash hands. RATIONALE: The best method to avoid infection. Measure usage of irrigation fluid then subtract from total drainage. RATIONALE: Ensures balance of input and output, avoids retention that may harm patient. Document and report amount and type of irrigation, drainage character, and any abnormal findings. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
9.3. Condom

Catheter Application

Condom Catheter
The systems for men usually consist of a pouch or condom like device that is securely placed around the penis. This is often called a condom catheter. A drainage tube is attached at the tip of the device to remove urine. The drainage tube then empties into a storage bag, which can be emptied directly into the toilet. Condom catheters are most effective when applied to a clean, dry penis. It is sometimes helpful to trim excess pubic hair from the area, because excess hair may prevent the appliance from securely attaching to the penis. These devices must be changed at least every other day, to protect the skin
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of the penis and prevent urinary tract infections. Make sure the condom device fits snugly but not too tightly, as this may cause skin breakdown.

Materials Required
Perineal care materials Sterile and disposable gloves Condom catheter

Procedures for Condom Catheter Application and Rationale

Examine urinary status of patient. RATIONALE: Assessment provides baseline data for nursing care. Evaluate mental status of patient. RATIONALE: Invasive procedures needs client's permission, abnormal mental status prevents the client to decide for himself. Study the penis condition of patient. RATIONALE: Assess for redness prior to procedure which can be mistaken as contact irritation. Determine knowledge of patient on the aim of using condom catheter. Give procedure details to patient. RATIONALE: Awareness minimizes fears, resistance to cooperate and promotes self esteem. Coordinate for assistance if moving dependent patient. RATIONALE: Over exertion during lifting procedures can strain or injure nurse's back. Wash hands. RATIONALE: Ensures asepsis. Give privacy. RATIONALE: Assures respect to client. Elevate bed to proper working level. Lift up side rail on bed's opposite then bring down side rail on working side.
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RATIONALE:

To ensure safety from fall through nurse's opposite side.

Help patient assume a supine position then cover patient's upper torso with bath blanket. Since only genitalia must be exposed, fold sheets. RATIONALE: Ensures privacy and unnecessary exposures. Set up urinary drainage collection tubing and bag. Clamp off port of drainage bag and secure collection bag to bed frame. Carry drainage tubing up via side rails and onto bed. If needed, leg bag for connection to condom catheter. RATIONALE: To avoid spillage of urine from the bag caused by accidental rupture or disconnection from tubing. Wear disposable gloves. RATIONALE: Ensure infection control. Cleanse perineal area of patient and dry completely. RATIONALE: Ensures dryness, comfort and prevents growth of microorganisms since wetness encourages bacterial growth. Trim hair at base of penis of patient. RATIONALE: Avoid hindrance during adhesive or snap application. Administer skin preparation to penis of patient and let it dry. RATIONALE: Ensures infection control. Bring foreskin back to normal position if patient is uncircumcised hile use dominant hand to hold condom sheath and penis tip, then gradually roll sheath onto patient's penis. RATIONALE: Avoids discomfort and provides stability of the organ during application. Using strip of elastic adhesive, spiral wrap penile shaft of patient. Avoid using tape since it may prevent circulation. RATIONALE: Absence of tape's elasticity results to tight which impedes circulation. Attach drainage tubing to condom catheter's end. It is possible to attach catheter to large volume bag or leg bag. RATIONALE: Facilitates collection of urine into the bag.
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Put tubing's excess coiling on bed and secure to sheet's bottom. RATIONALE: Avoids accidental pulling of excess tubings.

Chapter Ten

Special Therapeutic Procedures

10.1. Elastic Stockings Application 10.2. Positioning Clients in Bed 10.3. Transfer Techniques 10.4. Assessing for Risk of Pressure Ulcer Development 10.5. Pressure Ulcer Treatment 10.6. Performing Wound Irrigations 10.7. Applying an Abdominal, T, or Breast Binder 10.8. Elastic Bandage Application 10.9. Moist Hot Compress Application 10.10. Postoperative Exercises Demonstration 10.11. Crutches

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10.1. Elastic

Stockings Application (Anti-embolic stockings)

Anatomy and Physiology

Circulatory System

The purpose of the circulatory system is to deliver oxygen and nutrients throughout the body and to remove waste products. Your arteries are muscular tubes that vary in size and extend into all parts of your body. They carry oxygen and nutrient enriched blood to your muscles and organs. Veins are collapsible tubes that carry waste products and deoxygenated blood from your muscles and organs back to the heart and lungs.
Peripheral Circulation/Venous Valves

There are three primary parts to the peripheral venous system. The deep venous system, superficial venous system and the perforator/ communicator veins. All of these systems return blood back from your arms and legs to your heart. When you breath and move your arms and legs blood is propelled toward your heart. Valves inside your veins help prevent your blood from flowing backward into your arms and legs. Sometimes these valves become damaged and can no longer prevent the backward flow of blood into your arms and leg. This is called venous valvular incompetence and may cause varicose veins and or swelling in the affected extremity. Deep Venous System. The deep veins are well supported by muscle tissue and protected by the bones in your body. These veins have a direct route back to your heart and lungs. Superficial Venous System. The superficial veins lie close to the skin and are not as well protected or supported. These veins do not have a direct route back to the heart. They lead back to the heart by either connecting to the deep veins or by connecting through a perforator/ communicator veins.
Risk Factors

Changes in medications
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History of venous thrombosis Obesity Pregnancy Prolonged bed rest or immobilization Surgery Trauma to blood vessel Peripheral Venous Examination

Assessment
This test is to provide information about blood clots that can form inside your veins. By placing a special probe (a microphone-like device) on your arms/legs, the vascular technologist examines the veins using ultrasound, which can help physicians determine if you have a blood clot. Using this information, your medical caregiver can make specific recommendation about any further testing or procedures that may follow the examination. You will be asked to lie down on a table and exposing your arms or legs. The technician will then place a water based gel on the areas that he/she will need to examine. The time the exam takes is different for each person, but you can expect about 45 minutes for the exam. There are several reasons your medical care giver may request this examination. The following are examples of these symptoms: Swelling Difficulty Breathing Chest Pain Pain in your legs or arms Ulcers Inflammation of the skin
Peripheral Venous Examination

Duplex Imaging and Physiological Testing (Doppler) of the Deep & Superficial Venous System examines the different parts of the following: Lower Extremities Deep Venous System

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Common Femoral Vein Superficial Femoral Vein Proximal Deep Profunda Vein Popliteal Vein Posterior Tibial Veins Peroneal Veins Deep Muscular Calf Veins Superficial Venous System Greater Saphenous Vein Lesser Saphenous Vein Varicosities Communicator/Perforator Veins (When Indicated) Upper Extremities Deep Venous System Internal Jugular Vein Subclavian Vein Axillary Vein Brachial Vein Radial Vein Ulnar Vein Superficial Venous System Basilic Vein Cephalic Vein Dependent on a properly-functioning cardiovascular system, adequate perfusion is necessary for oxygenation and nutrition of body tissues. Various factors control sufficient blood flow, such as efficient pumping action of the heart, patent and responsive blood vessels, and an adequate circulating blood volume. Likewise, activity of the nervous system, viscosity of blood, and the metabolic requirements of tissues influence the rate of blood flow and thus the adequacy of blood flow. Venous insufficiency is often accompanied by edema and decreased oxygen and nutrient composites in tissue. Since Iymph drainage can be augmented by external pressure, proximal venous flow also benefits from external compression. use of pneumatic compression devices to treat venous insufficiency has proven highly successful. Pumping promotes cutaneous circulation, which in turn, increases the oxy252

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gen content of tissues.

The Elastic Stockings (Anti-embolic )

The wearing of anti-embolic stockings is prescribed to improve the circulation; prevent blood clots from forming in the legs (due to a reduction in physical activity); and to reduce ankle swelling which helps your wounds to heal. These help increase venous return. Elastic stockings should be worn during the day and taken off and washed at night until the first post-operative appointment with your visiting medical practitioner or as otherwise prescribed by the visiting medical practitioner. The stockings are left insitu except for bathing and are not routinely taken off at night and replaced in the morning. These stockings are designed to reduce the risk of thrombo-embolic disease caused by immobilization. Compression stockings are an important part of the management of chronic venous ulcers, varicose eczema, and edema. They are graded according to the level of ankle pressure they exert. DVA supports a full assessment including doppler, before their application to exclude any contraindications for use, particularly to exclude arterial insufficiency. A trained fitter should measure the individual to ensure correct fit. Below knee compression stockings are adequate in most situations and promote higher degrees of compliance and independence in the entitled person. It is necessary to take these stockings off at night and replace them in the morning ideally before getting out of bed so that there is no opportunity for dependent edema to accumulate.
Importance

To provide firm support to the soft tissues Prevent venous blood from pooling Prevent blood clots from developing in the deep veins To maintain venous return To provide adequate and equal pressure without impairing blood flow Factors Affecting Application of Elastic Stockings Age and size of patient Size of anti-embolic stockings Compliance with the treatment
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Medical history and present health conditions Skin condition Environment and climate Treatment duration Virchow's triad (Rudolf Ludwig Karl Virchow) Hypercoagulability: all patients with clotting disorders, fever or dehydration; during patency and first 6 weeks postpartum if the woman was confined to bed; and with oral contraceptive use (especially if patient smokes) Venous wall abnormalities: local trauma, orthopedic surgeries, major abdominal surgery, varicose veins, atherosclerosis. Blood stasis: immobility, obesity, pregnancy.

Assessment Sites
It is important that extremities be assessed for cyanosis, sores and ulcer, pressure sites and inflammation signs. If on maintained stockings, observe for capillary refill, impaired blood flow and compartment syndrome.

Materials Required
Correct size of anti-embolic stockings

Procedures for Elastic Stockings Application & Rationale

Determine patient's need for elastic stockings. RATIONALE: Patient must have at least one of the alterations based on Vinchow's triad. Assess for signs/conditions that might be contraindicated to the use of elastic stockings. RATIONALE: Skin lesions, skin graft and disproportionately large thighs are contraindicated to this procedure. Review prescriber's order. RATIONALE: Ensures that correct procedure is performed on the correct patient. Assess patient's understanding of elastic stockings application.
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RATIONALE:

Provides opportunity for health teaching. Reduces patient anxiety and promotes cooperation.

Assess and record condition of patient's skin and legs circulation. Explain to patient the procedure and reasons for applying stockings. RATIONALE: Provides baseline data on circulatory and integumentary condition needed for care management. Measure patient's legs to determine proper size of stockings to be applied. RATIONALE: Appropriate stocking size prevents excessive compression and injury to skin and blood vessels. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assist patient to establish supine position. RATIONALE: Eases stockings application and promotes even distribution of blood. Clean patient's legs and apply a small amount of talcum powder if not contraindicated. RATIONALE: Eases application of stockings as powder reduces friction. Stockings application: Turn stockings inside out. RATIONALE: Facilitates easier application of stockings. Position patient's toes into foot of stocking. Make sure that sock is smooth. RATIONALE: Circulation can be impeded by wrinkles in stockings. Slide remaining parts of stocking into patient's foot. Check covering of toes and position of heel. RATIONALE: Toes must be covered to avoid constriction Slide stocking up to patient's calf until totally extended and smooth. RATIONALE: Ridges can obstruct venous return.
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Caution patient against partially rolling stocking down. RATIONALE: Rolling stockings down can cause constricting action. Assist patient to comfortable position. RATIONALE: Restores patient comfort. Wash hands. RATIONALE: Reduces transmission of microorganisms. Examine stocking, making sure there are no wrinkles. RATIONALE: Circulation can be impeded by wrinkles in stockings. Observe patient's reaction to stockings. RATIONALE: Determines presence of discomfort or adaptation to applied stockings. Stockings should be removed at least once every 8 hrs, assess skin and circulation of legs. RATIONALE: Ensures good skin circulation. Record procedure and report skin condition and circulatory assessment. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.2. Positioning

Patients in Bed

Anatomy and Physiology

Body mechanics is the process by which the body moves and maintains balance via the most efficient utilization of all body parts to avoid harm to other body parts. It is also the efficient coordination and safe use of the body to produce motion and maintenance of balance during any activity. Proper movement optimizes body functioning of the musculoskeletal system. Structure reduces the energy necessary for movement and maintaining balance, thus reducing fatigue.
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Body alignment is the arrangement of body parts in relation to each other. Sound body alignment promotes maximum balance and body functioning in whatever position the patient assumes, whether lying down, sitting or standing. Good body alignment and good posture are synonymous in context.
Importance

Provision of comfort is the intervention that covers the promotive, curative, preventive, rehabilitative, and palliative aspects of care. To provide safety and comfort to both patients and health care provider, the nurse must be knowledgeable and competent in applying the body mechanics principles.

Factors Affecting Positioning and Transferring Patients

Medical history and present health condition Age, weight, height and size of patient Compliance with the procedure Skill and strength of health care provider Mental status Muscle strength and endurance of the patient

Assessment Sites
The nurse must take into account the affected, injured or problem area of the patients. Presence of bed sores should also be checked. Most importantly, the nurse must assess the muscle tone, strength, endurance of the patient and recovery or improvement.

Materials Required
Turning team Linen Mattress Drape Supportive tool such as overhead trapeze, bars, canes etc.

Procedures for Positioning Patients in Bed & Rationale

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With patient lying down, assess patient's body alignment and comfort level. RATIONALE: Alignment and position is determined when patient is lying down. Provides baseline data for evaluation of procedure's effectiveness. Assess patient's physical capacity to aid in moving and mobility. RATIONALE: Encourages patient independence Raise bed to achieve comfortable height. RATIONALE: Promotes proper body mechanics and avoids lifting-related injuries. Remove pillows or any devices used in previous position. RATIONALE: Removes interference during movement. Ask for assistance if necessary. RATIONALE: Ensures nurse and patient safety. Explain procedure to patient. RATIONALE: Reduces patient anxiety and promotes cooperation.
PATIENT POSITIONING IN BED

Move immobile patient in bed (single nurse): Have patient lie on back with head of bed in a flat position. RATIONALE: Minimizes gravitational pull on patient's upper extremeties which may hinder the procedure. Remove pillow from under patient's head and place it at head of bed. RATIONALE: Prevents patient from accidentally bumping head on board. Start with patient's feet. Face bed's foot at a 45? angle. Place feet apart with foot nearest bed's head behind other foot. If needed, flex knees and hips to bring arms level with patient's legs. Shift weight from front to back leg. Slide patient's legs diagonally toward bed's head. RATIONALE: These parts can move by following the upper extremeties because they are lighter. Ensures proper balance when nurse is facing the

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direction of movement. Shifting weight from one leg to the other decreases force exerted to move load. Diagonal movement allows pull on the direction of force. Flexing knees lowers nurse's center of gravity, thigh muscles are utilized instead of back muscles. Move parallel to patient's hips. Flex knees and hips (if needed) to bring arms level with hips of patient. RATIONALE: Maintains nurse's proper body alignment. Flexed knees lowers center of gravity and uses thigh muscles instead of back muscles. Diagonally, slide patient's hips toward bed's head. RATIONALE: Facilitates alignment of patient's feet and hips. Move parallel to patient's head and shoulders. Flex knees and hips (if needed) to bring arms level with patient's body. RATIONALE: Body alignment is maintained. Brings nurse closer to patient's body. The center of gravityis lowered. Prevents usage of back muscles, thigh muscles are used instead. Slide arm nearest to head of bed underneath patient's neck. Reach hand under patient to support patient's shoulders. RATIONALE: Prevents injury during movement by supporting the head and neck. Maintains alignment of body parts. Put other arm under upper portion of patient's back. RATIONALE: Reduces friction during movement while patient's body weight is supported. Diagonally slide patient's trunk, shoulders, head, and neck toward head of bed. RATIONALE: Patient's body is re-aligned on one side of bed. Repeat procedure while alternating sides until patient reaches appropriate position in bed. RATIONALE: Organizes positioning steps. Assisting patient in moving up in bed (one or two nurses): Have patient lie on back with bed head flat. RATIONALE: Minimizes pull of gravity on patient's upper extremities.
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Remove pillow from beneath patient's head and shoulders. Put pillow at head of bed. RATIONALE: Prevents accidental bumping of patient's head on board. Face head of bed. RATIONALE: Maintains proper alignment. Put one arm under patient's shoulder and the other beneath the thighs. Alternative position: One nurse should be positioned at patient's upper body. The nurse will put arm closest to head of bed beneath patient's head and opposite shoulder. The other arm (nurse) should be placed under patient's nearest arm and shoulder. Another nurse will be positioned at patient's lower torso. This nurse will put arms under patient's lower back/torso. RATIONALE: Evenly distributes support to patient's musculoskeletal system. Place feet apart, with foot closest to head of bed behind other foot. RATIONALE: Ensures nurse's balance. Flex knees/hips. Weight should be shifted from front to back leg. Move patient and drawsheet/pullsheet to appropriate position in bed. RATIONALE: Ensures proper balance when shifting weight. Focuses strain on thigh muscles instead of back muscles, thereby preventing injury. Position patient in Fowler's position (supported): Bed should be elevated 45-60 degrees. Have patient rest head against a mattress or pillow. RATIONALE: Cervical vertebrae contracture is prevented. If patient doesn't have control of arms and hands, support them using pillows. RATIONALE: Prevents shoulder dislocation from unsupported arms. Prevents venous pooling. Place pillow at lower back of patient. RATIONALE: Supports the spine to maintain alignment. Put a small pillow or roll under patient's thigh. Do the same for
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patient's ankles. RATIONALE: Prevents pressure on heels from mattress. Positioning a hemiplegic patient in Fowler's position (supported): Head of bed must be elevated 45-60 degrees. Assist patient to a sitting position as straight as possible and support patient's affected shoulder. RATIONALE: Decreases intracranial pressure, avoids patient's tendency to slump forward. Prevents danger of aspiration. Position patient's head on small pillow. Chin should be slightly forward, taking care to avoid hyperextension of the neck. RATIONALE: Too many pillows may result in hyperextended neck flexion contracture. Support patient's involved arm and hand using overbed table. Put arm away from patient's side and use pillow to support the elbow. RATIONALE: Edema, sublaxation of shoulder and pain may occur from failure of the paralyzed muscle to voluntarily resist gravity. Position patient's flaccid hand in normal resting position with wrist slightly extended. Maintain arches of hand and partially flex fingers. Clasp patient's hands together. RATIONALE: Prevents contracture of the hands and maintains their functionality. Position spastic hand with wrist in neutral position or slightly extended. RATIONALE: Prevents flexor spasticity of the hands, maintains functional level. Place pillow or folded blanket under patient's knees to flex patient's knees and hips. RATIONALE: Joint mobility may result without proper alignment and hyperextension of the knees and hips. Use a firm pillow, footboard or high-top sneakers to support patient's feet in dorsiflexion.
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RATIONALE:

Prevents foot drop.

Positioning patient in supine position: Have patient lie on back with head of bed flat. RATIONALE: Position is important in preparation for assuming supine position. Put a small rolled towel underneath patient's lumbar area. RATIONALE: Protects the lumbar spine from disalignment. Put a pillow under patient's upper shoulders, neck or head. RATIONALE: Prevents cervical lumbar spine flexion contractures. Put trochanter rolls or sandbags parallel to lateral surface of patient's thighs. RATIONALE: Prevents external hip rotation. Elevate patient heels by putting a small pillow/roll under patient's ankles. RATIONALE: Prevents pressure sores. Put foot board or firm pillows against bottom of patient's feet. Put high-top sneakers on patient's feet. RATIONALE: Prevents foot drop. Put pillows under patient's pronated forearms taking care to keep patient's upper arms parallel to the body. RATIONALE: Maintains correct body alignment. Minimizes internal rotation of shoulder. Prevents extension of elbows. Put hand rolls in patient's hands. RATIONALE: Extension and abduction of thumb are reduced. Keeps thumb slightly abducted and in opposition to fingers. Positioning a hemiplegic patient in supine position: Have patient lie on back with head of bed flat. RATIONALE: Allows patient to be put in a supine position. Put folded towel/small pillow under patient's shoulder or affected side. RATIONALE: Pain, joint contracture and sublaxation will be reduced. Mobility
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of shoulder muscles is maintained. Affected arm should be kept away from patient's body, with elbow extended and palm up. RATIONALE: Mobility of arm, joints and shoulders are maintained. Put a folded towel underneath patient's hip on involved side. RATIONALE: Spasticity of leg is diminished by maintaining proper hip position. Support patient's affected knee using a pillow/folded blanket to flex knee 30?. RATIONALE: Maintains leg alignment, preventing internal rotation of hips. Use soft pillow to support patient's feet at right angle to leg. RATIONALE: Prevents foot drop. Position patient in prone position: Roll patient over arm with one arm positioned near patient's body, elbow straight, and hand under hip. Have patient lie on abdomen in center of bed. RATIONALE: Proper alignment prevents contractures. Turn patient's head to one side. Use a small pillow to support head. RATIONALE: Cervical vertebrae hyperextension/flexion. Put a small pillow under patient's abdomen, below diaphragm level. RATIONALE: Pain and discomfort from weight pressure on female breast are prevented. Support patient's arms in flexed position level at the shoulders. RATIONALE: Reduces risk for joint dislocation. Support patient's lower legs. Use pillows to elevate toes. RATIONALE: Pressure on toes is minimized. External rotation of legs is prevented. Positioning hemiplegic patient in prone position: Have patient move toward unaffected side. RATIONALE: Patient is rolled onto center of bed while maintaining proper body alignment.
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Roll patient onto side and place pillow on patient's abdomen. RATIONALE: Reduces lower back strain caused by hyperextension of lumbar vertebrae. Help patient roll onto abdomen by positioning involved arm close to patient's body with elbow straight and hand under hip. RATIONALE: Prevents injury to paralyzed body part. Turn patient's head toward involved side and position involved arm out to side. Elbow should be bend and hand toward head of the bed. If possible, extend patient's fingers. RATIONALE: Neck and truck extension is promoted, which are vital when standing and walking. Slightly flex patient's knees by placing pillow under legs (from knees to ankles). RATIONALE: Prevents joint immobility due to prolonged hyperextension. Patient's feet should be kept at right angles to legs. use a pillow high enough, keeping toes off the mattress. RATIONALE: Ensures dorsiflexion and prevents foot drop. Position patient in lateral position: Lower bed's head or as low as patient can tolerate. RATIONALE: Relieves pressure on bony prominences. Restores patient comfort. Position patient on side of bed. RATIONALE: Provides patient with room to turn to side. Turn patient onto side and roll patient toward you. RATIONALE: Protects patient against injury from fall. Put a pillow under patient's head and neck. RATIONALE: Prevents lateral neck flexion. Prevents strain on sternocleidomastoid muscle. Move patient's shoulder blade forward. RATIONALE: Prevents patient's weight from resting directly on shoulder joints. Position both arms in slightly flexed position. support upper arm by pillow level and other arm by mattress.
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RATIONALE:

Prevents internal rotation abduction of shoulders.

Put tuck-back pillow behind patient's back. RATIONALE: Maintains patient on side. Support semi-flexed upper leg with a pillow. RATIONALE: Prevents hyperextension of leg. Place sandbag parallel to plantar surface of patient's dependent foot. Put high-top sneakers on patient's feet. RATIONALE: Prevents foot drop. Maintains foot dorsiflexion. Position patient in Sim's position: Completely lower head of the bed. RATIONALE: Facilitates proper body alignment while patient is lying down. Have patient establish supine position. RATIONALE: Prepares patient for position change. Position patient in a lateral position, partially lying on abdomen. RATIONALE: Patient is rolled partially on abdomen. Put a small under patient's head. RATIONALE: Prevents lateral neck flexion. Support arm on level with shoulder by putting a pillow under patient's flexed upper arm. RATIONALE: Internal rotation of shoulder is prevented. Support leg on level with hip by putting a pillow under patient's flexed upper legs. RATIONALE: Internal rotation of hip and abduction of leg is prevented. Put sandbags parallel to plantar surface of patient's feet. Put hightop sneakers on patient's feet. RATIONALE: Prevents foot drop. Wash hands. RATIONALE: Reduces transmission of microorganisms. Position bed to desired height.
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RATIONALE:

Ensures patient's comfort and safety.

Observe body alignment, position, and level of comfort of patient. RATIONALE: Evaluates effectiveness of positioning. Additional support such as pillows and trochanter may be added. Assess patient for areas of erythema or skin breakdown. RATIONALE: Anticipates any complication that may arise due to immobility. Record each change in position including amount of assistance required and patient's response and tolerance. Record/report any signs of redness (e.g., areas over bony prominences). RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.3. Transfer Techniques

Materials Required
Transfer team Linen Mattress Drape Supportive tool such as overhead trapeze, bars, canes etc.

Procedures for Transfer Techniques & Rationale

Assess patient's status and identify risks for problems with transfer. RATIONALE: Furnishes the nurse with information such as patient's physical status, level of consciousness and comprehension. Explain procedure to patient. RATIONALE: Improves patient's understanding of procedure. Reduces patient anxiety and promotes cooperation. Provide needed privacy.
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RATIONALE:

Reduces patient embarrassment.

Wash hands. RATIONALE: Reduces transmission of microorganisms.

TRANFER PATIENT

Assist patient to establishing sitting position (bed). RATIONALE: Allows for diaphragmatic expansion. Improves oxygenation. Put patient in a supine position. RATIONALE: Allows nurse to examine appropriateness of body alignment. Face head of bed and remove pillows. RATIONALE: Proper body alignment decreases nurse's risk for back injury. Place feet apart with foot closer to bed behind other foot. RATIONALE: Facilitates center of gravity. Improves balance and maintains body mechanics. Place hand farther from patient under patient's shoulders. Support patient's head and cervical vertebrae. RATIONALE: Supports head and back of patient, preventing cervical injury. Put hand on surface of bed. RATIONALE: Provides additional balance and support. Shift weight from front to back leg to raise patient to a sitting position. RATIONALE: Overcomes inertia and shifts patient's weight to direction of movement. Using arm on bed surface, push against bed. RATIONALE: Bracing provides additional support and balance. Prevents back injury. Assist patient to a sitting position on side of bed (bed in low position): Raise head of bed 30. RATIONALE: Reduces effort required to lift patient to sitting position. Turn patient to side of bed where he/she will be sitting.
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RATIONALE:

Protects patient against injury from falling. Prepares him/her to movement to side of bed.

Stand opposite patient's hips and turn diagonally. You should be facing patient and far corner of foot of bed. RATIONALE: Center of gravity is shifted proximally to patient. Avoids twisting of nurse's body, which may cause back injury. Place feet apart with foot closer to bed head in front of the other foot. RATIONALE: Facilitates center of gravity. Improves balance and maintains body mechanics. Put arm closer head of bed under patient's shoulder to support his/her head and neck. Place other arm closer to head and neck. RATIONALE: Supports head and back of patient, preventing cervical injury. Move patient's lower legs and feet over side of bed. pivot toward rear leg and allow patient's upper legs to swing downward. RATIONALE: Quickens pace of patient's movement from one surface to another. Shift weight to rear leg and elevate patient at the same time. RATIONALE: Facilitates shifting of patient's weight to direction of motion. Stay in front of patient until he/she regains balance. RATIONALE: Prevents injury. Anticipates need for support. Transfer patient from bed to chair (bed in low position): Assist patient to establishing a sitting position on side of bed. RATIONALE: Provides easy access to chair during transfer. If needed, apply transfer belt or other transfer aid to patient. RATIONALE: Ensures physical stability of patient during transfer. Make sure that the patient has stable, non-skid shoes. put strong leg forward and weak leg back. RATIONALE: Prevents injury. Spread feet apart and flex hips and knees. Align knees with patient's knees.
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RATIONALE:

Wide base of support provides balance.

Grasp transfer belt (if present) or reach through patient's axillae and put hands on patient's scapulas. RATIONALE: Reduces pressure on axillae. On count of three, rock patient up to a standing position while straightening hips and legs. Keep knees slightly flexed. If patient is able, instruct him/her to push up using hands. Provides patient's body with momentum and muscular effort to lift patient. Use knee to maintain stability of patient's weak/paralyzed leg. RATIONALE: Prevents loss of balance. Use foot farther from chair to pivot. RATIONALE: Provides ample space for movement. Speeds up movement. Ask patient to use chair's armrests for support. Ease patient into chair. RATIONALE: Reinforces patient stability. Assess patient for proper alignment for sitting position. Paralyzed extremities should be supported. For flaccid arms, use a lap board. Support legs using bath blanket or pillow. RATIONALE: Poor body alignment may cause patient injury. Acknowledge patient's progress, effort, and performance. RATIONALE: Acknowledges patient's efforts. Perform three-person carry from bed to stretcher (bed at stretcher level): With two other nurses, stand side by side facing patient's bed. RATIONALE: Facilitates proper body mechanics. Each nurse should assume responsibility for the head and shoulders, hips, and thigh and ankle areas. RATIONALE: Evenly distributes patient's body weight. Lifting nurses will put arms under the three areas, securing fingers around patient's body. RATIONALE: Delegates weight on forearms of lifter.
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Lifters will roll patient toward them. Lift patient and hold against chest on count of three. RATIONALE: Distributes body weight over lifter's base of support. Lifters will step back and pivot toward stretcher on second count of three. RATIONALE: Shifts patient's weight towards stretcher. Lifters will lower patient onto stretcher's center by flexing knees and hips until elbows are level with stretcher's edge. RATIONALE: Keeps alignment (lifters') to prevent patient injury. Assess body alignment of patient. RATIONALE: Evaluates effectiveness of procedure and determines need for modifications. Wash hands and assess patient's tolerance. RATIONALE: Reduces transmission of microorganisms. Record each transfer/position change and response and tolerance of patient. Record/report any signs of redness. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.4. Assessing Patients for Risk of Development

of Pressure Ulcer
Anatomy and Physiology
The integumentary system, consisting of the skin, hair and nails, act as a barrier to protect the body from the outside world. It also functions to retain body fluids, protect against disease, eliminate waste products, and regulate body temperature. The word integument comes from a latin word that means to "cover", hence the most important function of the integumentary system is protection. The five main functions of the integumentary system are: serving as a
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barrier against infection and injury, helping to regulate body temperature, removing waste products from the body, providing protection against ultraviolet radiation from the sun and producing vitamin D. The skin is the largest organ of the body and is indispensable for human life. This organ forms a barrier between the internal organs and the external environment as well as participates in many vital functions of the body. The skin is continuous, composed of the mucous membranes at the external openings of the digestive, respiratory and urogenital systems. Because the skin contains several types of sensory receptors, it serves as the gateway through which sensations such as pressure, heat, cold and pain are transmitted to the nervous system. The skin is composed of two main layers - the epidermis and dermis. The outer most layer of skin is known as the epidermis. It is composed of many sheets of flattened, scaly epithelial cells. This is a thin outer layer of skin. Its layers are made of mostly dead cells. Most of the cells of the epidermis undergo rapid cell division (mitosis). As new cells are produced, they push older cells to the surface of the skin. The older cells become flattened, lose their cellular contents and begin making keratin, a tough fibrous protein and forms the basic structure of hair, nails and calluses. Eventually, the keratin-producing cells (keratincytes) die and form a tough, flexible waterproof covering on the surface of the skin. Our thickest epidermis in on the palms and soles. This outer layer of dead cells is shed or washed away once every 14 to 28 days.The epidermis contains melanocytes, cells that produce melanin, a dark brown pigment.. Melanin is important for protection, by absorption of ultraviolet radiation from the sun. All people, but especially people with Light Skin, need to minimize exposure to the sun and protect themselves from its ultraviolet radiation, which can damage DNA in skin cells and lead to deadly forms of skin cancer. There are no blood vessels in the epidermis that is why a small scratch will not cause bleeding. The dermis is the innermost thick layer of the skin composed of living cells. The dermis lies beneath the epidermis and contains blood vessels, nerve endings, glands, sense organs, smooth muscles and hair
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follicles. The dermis helps us to control our body temperature. On a cold day when the body needs to conserve heat, the blood vessels in the dermis narrow. On hot days, the blood vessels widen, warming the skin and increasing heat loss. Tiny muscle fibers attach to hair follicles contract and pull hair upright when you are cold or afraid, producing what is commonly called goose bumps. Beneath the dermis is the hypodermis, the subcutaneous layer of the skin which contains fato and loose connective tissue that insulates the body and acts as an energy reserve. The dermis contains two major types of glands: sweat glands and sebaceous or oil glands. These glands pass through the epidermis and release their products at the surface of the skin. Sweat glands produce the watery secretions known as sweat which contains salt, water and other compund. These secretions are stimulated by nerve impulses that cause the production of sweat when the temperature of the body is raised. They help to cool the body. Sebaceous glands (oil glands) produce oily secretions known as sebum that spreads out along the surface of the skin and keeps the keratin rich epidermis flexible and waterproof. The production of sebum is controlled by hormones. Oil glands are usually connected by tiny ducts (exocrine glands) to hair follicles. Sebum coats the surface of the skin and the shafts of hair, preventing excess water loss and lubricating and softening the skin and hair. Sebum is mildly toxic to some bacteria. When the skin is put on pressure, the skin of the foot may be subject to friction. This will separate layers of epidermis or separate the epidermis from the dermis, and tissue fluid may collect, causing a blister or ulcers sores. If the skin is subjected to pressure, the rate of mitosis will increase and create a thicker epidermis; we call this a callus.
Characteristics of Normal Skin

This is the least common skin type, many people could have almost perfect skin, but never completely. The goal of skin care is to get the skin's condition as close a possible to normal. Usually the combinations are normal to dry, normal and mature or normal and dehydrated. Main skin care goal is to Protect the skin. The following are characteristics of normal skin: Texture of skin is smooth Complexion is even; no redness blotchy spots, oiliness, no overly
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shiny T-Zone Pores are barely visible The skin has a spongy feel when touched The skin layers are not deficient of any nutrients and minerals

Pressure Ulcer
A pressure ulcer is an area of skin and tissue that becomes injured or broken down. Generally, pressure ulcers occur when a person is in a sitting or lying position for too long without shifting his or her weight. The constant pressure against the skin causes a decreased blood supply to that area. Without a blood supply, the area cannot survive and the affected tissue dies. The most common places for pressure ulcers are over bony prominences (bones close to the skin), such as the elbow, heels, hips, ankles, shoulders, back, and the back of the head. While it is more common for people to get pressure ulcers if they spend most of their time in bed or use a wheelchair, people who can walk can also get pressure ulcers when they are bedridden as a result of an acute illness or injury.
Causes

Factors which increase risk for pressure ulcers include: Age -- elderly people are at higher risk Inability to move certain parts of the body without assistance, such as with spinal or brain injury patients, and patients with neuromuscular diseases Malnourishment Being bedridden or in a wheelchair Having a chronic condition, such as diabetes or artery disease, that prevents areas of the body from receiving proper blood flow and nutrition Urinary incontinence or bowel incontinence (moisture next to the skin for long periods of time can cause skin irritation that may lead to skin breakdown) Fragile skin Mental disability from conditions, such as Alzheimer's (some
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patients may not be capable of taking the proper steps toward prevention and may not seek appropriate treatment when an ulcer has formed)
Symptoms & Signs

The National Pressure Ulcer Advisory Panel (NPUAP) in the United States created a process for evaluating pressure sores based on a staging system from Stage I (earliest signs) to Stage IV (worst): Stage I: A reddened area on the skin that, when pressed, is "nonblanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. Importance The nurse is responsible for the assessment of patient risk for developing pressure ulcer, being the most common complications of debilitating condition, as a preventive approach to avoid the occurrence of other serious health problems. If these complications happen as a result of patient's severe condition, the nurse is in charge of curative and rehabilitative aspects of care.
Factors that Contribute to Pressure Ulcer Development

Immobility, compromised mobility and debilitation Prolonged pressure on tissue Loss of protective reflexes, sensory deficit or loss Poor skin or tissue perfusion Malnutrition, decreased nutritional status Friction, shearing forces and trauma Altered skin moisture (excessively dry or moist) Incontinence of urine or feces Age and gerantologic conditions Equipments: casts, traction, restraints, etc.
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Environment Types of linen and mattress Poor continuous monitoring by the health care provider

Assessment Sites
In examining a patient for pressure ulcer for potential or actual problem, the nurse should first take into account the factors that contribute to pressure ulcer development. For every shift, the nurse must conduct total skin condition assessment, inspect every pressure site and bony prominences for necrosis, skin breaks, inflammation, edema, blisters, sores, mottled skin, blanching response, erythema, and other signs of infection. Color and odor discharges must also be assessed, together with the size and location. The nurse may use a grading system to describe its severity.

Materials Required
Grading system of pressure ulcer Ballpen and charts for documentation Powder Sterile cotton balls and gauze Antiseptic solutions Solutions as ordered to treat the type of infection or invading microorganism Antibiotic pads and plaster Sterile water or saline solution Applicator Irrigating syringe or tube Forceps Sterile gloves Mask and gown

Procedure for Assessing Patient for Risk of Developing Pressure Ulcer & Rationale
Identify general risk of patient developing pressure ulcer. RATIONALE: Evaluates need for additional nursing interventions such as application of topical agents.
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Assess skin condition over areas of pressure. RATIONALE: May indicate/locate source of pressure such as catheters, linen, etc. Assess patient for regions of possible pressure. RATIONALE: Multiple sites of necrosis should be located during physical assessment to be able to implement appropriate nursing care. Observe patient's preferred positions when in bed/chair. RATIONALE: Promotes patient comfort. Observe mobility and ability of patient to start and assist with position changes. RATIONALE: Enhances patient participation and self-esteem. Patient should be assisted in establishing any of the following positions: supine, prone or 30-degree lateral. RATIONALE: Exposure to friction worsens when patient is totally dependent in changing positions. Palpate any discolored or mottled region of patient's skin. RATIONALE: Early interventions could minimize complications. Monitor length of period that any discoloration may persist. RATIONALE: Redness usually lasts for half of the time when hypoxia occurred. Obtain patient's nutritional assessment data. RATIONALE: Poor nutrition contributes to skin susceptibility to pressure trauma. Assess patient/family's knowledge of risk for pressure ulcers. RATIONALE: Provides opportunity for patient health education. Observe patient's tolerance for position change. Record/report patient's risk assessment and preventive measures used if any. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.5. Pressure Ulcer Treatment
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Materials Required
Grading system of pressure ulcer Ballpen and charts for documentation Powder Sterile cotton balls and gauze Antiseptic solutions Solutions as ordered to treat the type of infection or invading microorganism Antibiotic pads and plaster Sterile water or saline solution Applicator Irrigating syringe or tube Forceps Sterile gloves Mask and gown

Procedures for Pressure Ulcer Treatment & Rationale

Assess patient's comfort level and need for pain medication. RATIONALE: Pain assessment is needed prior to dressing change to achieve better tolerance and illicit patient cooperation. Determine if patient is allergic to topical agents. RATIONALE: Skin reactions may be caused by allergy to topical agents such as povidone iodine. Review physician's order for topical agent/dressing. RATIONALE: Confirms appropriate medication and treatment. Wash hands. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Position patient for removal of dressing. RATIONALE: Provides easy access to affected area. Assess pressure ulcer and surrounding area of skin to determine stage of the ulcer: RATIONALE: Note color, moisture, and appearance of skin around ulcer and
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the ulcer itself. Use sterile cotton swab to measure pressure ulcer depth. To measure depth of skin undermined by tissue necrosis, use sterile cotton swab to measure and probe beneath skin edges gently. RATIONALE: Comprehensive assessment of presence of ulcer determines the type of care management to be carried out. Use warm water to gently wash skin around ulcer. Rinse area thoroughly with water. RATIONALE: Water may eradicate resident bacteria. Do not use soap as it may irritate skin. Gently pat skin with a towel to dry skin. RATIONALE: Moisture worsens maceration of affected tissue. Use normal saline/cleansing agent to thoroughly cleanse ulcer. for deep ulcers, use irrigating syringe. RATIONALE: Solution removes debris. Application of soaked dressing removes previously applied enzymes.
FOLLOW PRESCRIPTION IN THE APPLICATION OF TOPICAL AGENTS

Enzymes: Limit application of thin layer of ointment over ulcers necrotic areas. RATIONALE: Thin layer is absorbs easily and effectively while excessive amounts can irritate surrounding tissue. Apply gauze dressing directly over ulcer. Securely tape dressing in place. RATIONALE: Protects wound from bacteria. Gel agents: Use applicator/gloved hand to cover ulcer surface with gel agents. RATIONALE: When used as applicator, glove maintains sterility. Completely cover ulcer by applying dry gauze or transparent dressing over gel. RATIONALE: Dressing holds gel on wound surface.
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Calcium alginates: Use applicator/gloved hand to pack wound with alginate. RATIONALE: When used as applicator, glove maintains sterility. Apply dry gauze over alginate. RATIONALE: Gauze holds alginate on wound surface. Assist patient to comfortable position. RATIONALE: Restores patient comfort. Remove and dispose of gloves. Discard soiled supplies and wash hands. RATIONALE: Reduces transmission of microorganisms. Observe ulcer's surrounding skin for inflammation, edema, and tenderness. RATIONALE: Evaluates efficiency of procedure for purpose of comparison in the assessment of patient prognosis. Monitor patient for signs of infection. RATIONALE: Early detection ensures early management. Record and report procedure and ulcer appearance. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.6. Performing

Wound Irrigations

Anatomy and Physiology

Wound is resulted from any breaks in the continuity of the skin. Wound healing is a complex and dynamic process of restoring cellular structures and tissue layers. The human adult wound healing process can be divided into 3 distinct phases: the inflammatory phase, the proliferative phase, and the remodeling phase. Within these 3 broad phases is a complex and coordinated series of events that includes chemotaxis, phagocytosis, neocollagenesis, collagen degra279

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dation, and collagen remodeling. In addition, angiogenesis, epithelization, and the production of new glycosaminoglycans (GAGs) and proteoglycans are vital to the wound healing milieu. The culmination of these biological processes results in the replacement of normal skin structures with fibroblastic mediated scar tissue. This process can go awry and produce an exuberance of fibroblastic proliferation with a resultant hypertrophic scar, which by definition is confined to the wound site. Further exuberance can result in keloid formation where scar production extends beyond the area of the original insult. Conversely, insufficient healing can result in atrophic scar formation.

Categories of Wound Healing

Although various categories of wound healing have been described, the ultimate outcome of any healing process is repair of a tissue defect. Primary healing, delayed primary healing, and healing by secondary intention are the 3 main categories of wound healing. Even though different categories exist, the interactions of cellular and extracellular constituents are similar. Category 1. Primary wound healing or healing by first intention occurs within hours of repairing a full-thickness surgical incision. This surgical insult results in the mortality of a minimal number of cellular constituents. Category 2. If the wound edges are not reapproximated immediately, delayed primary wound healing transpires. This type of healing may be desired in the case of contaminated wounds. By the fourth day, phagocytosis of contaminated tissues is well underway, and the processes of epithelization, collagen deposition, and maturation are occurring. Foreign materials are walled off by macrophages that may metamorphose into epithelioid cells, which are encircled by mononuclear leukocytes, forming granulomas. Usually the wound is closed surgically at this juncture, and if the "cleansing" of the wound is incomplete, chronic inflammation can ensue, resulting in prominent scarring. Category 3. A third type of healing is known as secondary healing or healing by secondary intention. In this type of healing, a full-thickness
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wound is allowed to close and heal. Secondary healing results in an inflammatory response that is more intense than with primary wound healing. In addition, a larger quantity of granulomatous tissue is fabricated because of the need for wound closure. Secondary healing results in pronounced contraction of wounds. Fibroblastic differentiation into myofibroblasts, which resemble contractile smooth muscle, is believed to contribute to wound contraction. These myofibroblasts are maximally present in the wound from the 10th-21st days. Category 4. Epithelization is the process by which epithelial cells migrate and replicate via mitoses and traverse the wound. This occurs as part of the phases of wound healing, which are discussed in Sequence of Events in Wound Healing. In wounds that are partial thickness, involving only the epidermis and superficial dermis, epithelization is the predominant method by which healing occurs. Wound contracture is not a common component of this process if only the epidermis or epidermis and superficial dermis are involved.

Overview of Wound Healing

The amalgam of coordinated events that constitute the process of wound healing is quite complex. The steps in the procession of wound healing include inflammation, the fibroblastic phase, scar maturation, and wound contracture (Tanenbaum, 1995; Cahill, 1993). Wound contracture is a process that occurs throughout the healing process, commencing in the fibroblastic stage (Tanenbaum, 1995). The inflammatory phase occurs immediately following the injury and lasts approximately 6 days. The fibroblastic phase occurs at the termination of the inflammatory phase and can last up to 4 weeks. Scar maturation begins at the fourth week and can last for years (Tanenbaum, 1995). An analogous system depicts the 4 phases as hemostasis, inflammation, granulation, and remodeling in a continuous symbiotic process (Cho, 1998).

Phases of Wound Healing

Following tissue injury via an incision, the initial response is usually bleeding. The cascade of vasoconstriction and coagulation commences with clotted blood immediately impregnating the wound, leading to
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hemostasis, and with dehydration, a scab forms. An influx of inflammatory cells follows, with the release of cellular substances and mediators. Angiogenesis and re-epithelization occur and the deposition of new cellular and extracellular components ensues. Initial phase - Hemostasis. Following vasoconstriction, platelets adhere to damaged endothelium and discharge adenosine diphosphate (ADP), promoting thrombocyte clumping, which dams the wound. The inflammatory phase is initiated by the release of numerous cytokines by platelets. Alpha granules liberate platelet-derived growth factor (PDGF), platelet factor IV, and transforming growth factor beta (TGF-b), while vasoactive amines such as histamine and serotonin are released from dense bodies found in thrombocytes. PDGF is chemotactic for fibroblasts and along with TGF-b is a potent modulator of fibroblastic mitosis, leading to prolific collagen fibril construction in later phases. Fibrinogen is cleaved into fibrin and the framework for completion of the coagulation process is formed. Fibrin provides the structural support for cellular constituents of inflammation. This process starts immediately after the insult and may continue for a few days. Second phase - Inflammation. Within the first 6-8 hours, the next phase of the healing process is underway, with polymorphonuclear leukocytes (PMNs) engorging the wound. TGF-b facilitates PMN migration from surrounding blood vessels where they extrude themselves from these vessels. These cells "cleanse" the wound, clearing it of debris. The PMNs attain their maximal numbers in 24-48 hours and commence their departure by hour Other chemotactic agents are released, including fibroblastic growth factor (FGF), transforming growth factors (TGF-b and TGF-a), PDGF, and plasma-activated complements C3a and C5a (anaphylactic toxins). They are sequestered by macrophages or interred within the scab or eschar (Habif, 1996). As the process continues, monocytes also exude from the vessels. These are termed macrophages. The macrophages continue the cleansing process and manufacture various growth factors during days 3-4. The macrophages orchestrate the multiplication of endothelial cells with the sprouting of new blood vessels, the duplication of smooth muscle cells, and the creation of the milieu created by the fibroblast. Many factors influencing the wound healing pro282

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cess are secreted by macrophages. These include TGFs, cytokines and interleukin-1 (IL-1), tumor necrosis factor (TNF), and PDGF. Third phase - Granulation. This phase consists of different subphases. These subphases do not happen in discrete time frames but constitute an overall and ongoing process. The subphases are "fibroplasia, matrix deposition, angiogenesis and re-epithelialization" (Cho, 1998). In days 5-7, fibroblasts have migrated into the wound, laying down new collagen of the subtypes I and III. Early in normal wound healing, type III collagen predominates but is later replaced by type I collagen. Tropocollagen is the precursor of all collagen types and is transformed within the cell's rough endoplasmic reticulum, where proline and lysine are hydroxylated. Disulfide bonds are established, allowing 3 tropocollagen strands to form a triple left-handed triple helix, termed procollagen. As the procollagen is secreted into the extracellular space, peptidases in the cell wall cleave terminal peptide chains, creating true collagen fibrils. The wound is suffused with GAGs and fibronectin produced by fibroblasts. These GAGs include heparan sulfate, hyaluronic acid, chondroitin sulfate, and keratan sulfate. Proteoglycans are GAGs that are bonded covalently to a protein core and contribute to matrix deposition. Angiogenesis is the product of parent vessel offshoots. The formation of new vasculature requires extracellular matrix and basement membrane degradation followed by migration, mitosis, and maturation of endothelial cells. Basic FGF and vascular endothelial growth factor are believed to modulate angiogenesis. Re-epithelization occurs with the migration of cells from the periphery of the wound and adnexal structures. This process commences with the spreading of cells within 24 hours. Division of peripheral cells occurs in hours 48-72, resulting in a thin epithelial cell layer, which bridges the wound. Epidermal growth factors are believed to play a key role in this aspect of wound healing. This succession of subphases can last up to 4 weeks in the clean and uncontaminated wound. Fourth phase - Remodeling. After the third week, the wound undergoes constant alterations, known as remodeling, which can last for years after the initial injury occurred. Collagen is degraded and deposited in an equilibrium-producing fashion, resulting in no change in the
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amount of collagen present in the wound. The collagen deposition in normal wound healing reaches a peak by the third week after the wound is created. Contraction of the wound is an ongoing process resulting in part from the proliferation of the specialized fibroblasts termed myofibroblasts, which resemble contractile smooth muscle cells. Wound contraction occurs to a greater extent with secondary healing than with primary healing. Maximal tensile strength of the wound is achieved by the 12th week, and the ultimate resultant scar has only four fifths or 80%, of the tensile strength of the original skin that it has replaced. The process of wound healing constitutes an array of interrelated and concomitant events, culminating in the development of scar tissue to replace the tissue that has been injured or lost.
Importance

The nurse's main goal for taking good care of patients with wound is the prevention of infection and the rise of resulting complications. Thus, proper knowledge and skills in the handling and management of wound is imperative. Actually, correct care of wound enhances the curative aspect of care.

Factors Affecting the Healing of Wound

Nutritional status Medical history and present health conditions Age and gerantologic conditions Size, deepness and severity of the wound Cause of the wound Compliance to pharmacological regimen Personal hygiene Skin integrity Blood circulation Altered skin moisture Presence of equipments: cast, traction, bead, implants, etc. Environment

Assessment Sites
The nurse is responsible for the assessment of signs and symptoms
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of inflammation. Presence and characteristics of discharges must be observed. Level of healing must also be evaluated, together with the rise of complications. Presence of microorganism must be inspected and the difference of healthy wound from gangrene.

Materials Required
Ordered pain relievers and analgesics Prescribed solutions Antiseptic solutions Irrigating tube and syringe Sterile forceps Sterile gloves Mask and gown Sterile scissors Sterile bowl Sterile gauze Micropore tape Basin or bed pan

Procedures for Performing Wound Irrigation & Rationale

Assess patient's level of pain. RATIONALE: Discomfort may be related directly to wound or indirectly to muscle tension or immobility. Review prescriber's order for open wound irrigation. RATIONALE: Open wound irrigation requires medical order, including type of solutions use. Assess signs/symptoms related to open wound. RATIONALE: Data are used as baseline to indicate change in condition of wound. May indicate response to infection. Amount will decrease as healing takes place. Strong odor indicates infectious process. Leukocytes produce thick drainage. Determines stage of healing. Explain procedure to patient. RATIONALE: Information will reduce patient's anxiety.
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Prescribed analgesic should be administered 30-45 mins before beginning procedure. RATIONALE: Increased comfort level permits patient to move more easily and be positioned to facilitate wound irrigation. Assist patient to a comfortable position. Make sure of irrigation solution's gravitational flow into wound. RATIONALE: Directing solution from top to bottom of wound and from clean to contaminated area prevents further infection. Positioning patient during planning stage provides bed surfaces for later preparation of equipment. Warm irrigation to body temperature. RATIONALE: Warmed solution increases comfort and reduces vascular constriction response in tissues. Wash hands. RATIONALE: Reduces transmission of microorganisms. Form cuff on waterproof bag and place near bed. RATIONALE: Cuffing helps to maintain large opening, thereby permitting placement of contaminated dressing without touching refuse bag itself. Provide needed privacy. RATIONALE: Reduces embarrassment for the patient and providing privacy is one of the patient's rights. If necessary, apply gown/goggles. RATIONALE: Protects nurse from splashes or sprays of blood and body fluids. Wear disposable gloves. RATIONALE: Remove soiled wound dressing and properly discard. Remove and dispose of gloves. RATIONALE: Reduces transmission of microorganisms. Prepare needed supplies. RATIONALE: Right preparation conserves time and energy for the nurse and provides comfort for the patient. Apply sterile gown.
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RATIONALE:

Observes aseptic technique.

Irrigate wound: For wound with wide opening: Fill syringe with irrigating solution. RATIONALE: Flushing wound helps remove debris and facilitates healing by secondary intention. Attach 19-gauge needle/angiocatheter to syringe. RATIONALE: Provides ideal pressure of cleansing and removal of debris. Hold syringe tip about 2.5 cm over wound's upper end over area to be cleansed. RATIONALE: Prevents syringe contamination. Careful placement of the syringe prevents unsafe pressure of the following solution. Use continuous pressure to flush wound. Repeat steps until drained solution becomes clear. RATIONALE: Clear indicates that all debris has been removed. For deep wound with small opening: Attach soft angiocatheter to filled syringe. RATIONALE: Catheter permits direct flow of irrigant into wound. Expect wound to take longer to empty when opening is small. Use irrigating solution to lubricate catheter tip. gently insert catheter tip and pull out about 1 cm. RATIONALE: Removes tip from fragile inner wall of wound. Use slow continuous pressure to flush wound. RATIONALE: Clear indicates that all debris has been removed. Pinch off catheter below syringe while keeping catheter in place. RATIONALE: Avoids contamination of sterile solution. Remove syringe and refill. Reattach to catheter and repeat procedure until drained solution becomes clear. RATIONALE: Clear indicates that all debris has been removed. Cleanse wound with non-bacteriostatic saline and if necessary,
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obtain cultures. RATIONALE: Routine cultures of open wounds is not recommended in the AHCPR guidelines (1994). They recommend using quantitative bacterial cultures (tissue biopsy or wound fluid by needle aspiration) rather than swab cultures, which often detect only surface bacterial contaminants. Use gauze to dry wound edges. RATIONALE: Prevents maceration of surrounding tissue from excess moisture. Apply dressing. RATIONALE: Maintains protective barrier and healing environment for wound. Remove gloves. RATIONALE: Prevents transfer of microorganisms. Assist patient to comfortable position. RATIONALE: Promotes comfort. Dispose of equipment and soiled supplies properly. Wash hands. RATIONALE: Reduces transmission of microorganisms. Periodically inspect dressing. RATIONALE: Identifies wound-healing progress and determines type of wound cleansing needed. Determines patient's response to wound irrigation and need to modify plan of care. Examine skin integrity. RATIONALE: Determines if extension of wound has occurred. Observe patient for any sign of discomfort. RATIONALE: Patient's pain should not increase as a result of wound irrigation. Record procedure and patient response. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes. Immediately report any fresh bleeding, increase in pain, irrigant retention or signs of shock to attending physician. RATIONALE: Patient's pain should not increase as a result of wound irrigation.
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10.7. Application

of an Abdominal, T or Breast

Binder
Importance
Some of the great nursing roles that should never be undermined are the provision of comfort, alleviation of pain, and prevention of complications. Binders and bandages are applied to promote comfort as well as immobilize, protect, and provide pressure, warmth, and support to the affected body parts.

Factors Affecting the Application of Abdominal, T or Breast Binder

Age and size of patient Size and types or binder or bandage Size of affected sites Sites of application Reason for the application of binder or bandage Compliance with the treatment Medical history and present health condition Skin condition and integrity Environment and climate Duration of treatment

Assessment Sites
Affected sites should be assessed for wound, fracture, severity of trauma, pressure sites, cyanosis, sores and ulcer, and signs of inflammation/infection. Thorough observation for capillary refill, impaired blood flow and compartment syndrome must be conducted. Effectiveness of treatment should also be monitored.

Materials Required
Binder or bandages Disposable gloves

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Dressing tray (as needed)

Procedure for Applying Abdominal, T or Breast Binder & Rationale

Assess patient's need for support of thorax/abdomen. Observe patient's ability to breathe deeply and cough effectively. RATIONALE: Provides baseline data for determining patient's coughing and breathing. Alteration in coughing/breathing can lead to inadequate oxygenation. Review patient's record for use of prescribed binder. RATIONALE: Application of abdominal, T or breast binder is an independent nursing intervention. In some cases, physician insight is required. Inspect patient's skin integrity. RATIONALE: Binder may cause additional pressure, excoriation or worsen skin condition.. Inspect for any present surgical dressing. RATIONALE: Any binder application can be done after change of dressing or reinforcement Assess patient's level of comfort. RATIONALE: Data will determine effectiveness of binder placement. Assess patient for kind of binder to be applied. RATIONALE: Proper fit of binder is ensured. Explain procedure to patient. RATIONALE: Promotes patient's understanding of procedure, relieves anxiety and enhances cooperation. Educate patient/caregiver on procedure. RATIONALE: Ensures continuity of care after discharge. Wash hands. Wear disposable gloves. RATIONALE: Reduces transmission of microorganisms. Provide needed privacy. RATIONALE: Reduces patient embarrassment.
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APPLY BINDER

Abdominal binder: Place patient in supine position. Slightly elevate head with knees slightly flexed. RATIONALE: Relaxes muscles including abdominal organ. Fanfold binder's far side toward binder's midline. RATIONALE: Prepares support for abdominal organs. Reduces period of time in which patient is in uncomfortable position. Help patient roll away from you while firmly supporting abdominal incision and dressing with hands. RATIONALE: Reduces patient pain and discomfort. Place fan-folded ends beneath patient. RATIONALE: Permits placement and placement of binder with minimal discomfort. Assist patient in rolling over onto folded ends. Smoothly unfold and stretch ends out on bed's far side. RATIONALE: Ensures wrinkle-free binding avoids disruption of skin integrity and comfort. Ask patient to roll back to supine position. When binder is closed, it facilitates support of incision site. Boosts patient's confidence to cough. Center patient over binder by adjusting binder using symphysis pubis and costal margins as lower and upper landmarks. Ensures centered support of binder for affected side which reduces lung expansion. Close binder. Pull one end over middle of patient's abdomen. While tension on that end is maintained, pull opposite end over center, secure with Valero closure tabs, metal fasteners or safety pins. Ensures full support of affected area. Improves comfort. Assess patient's comfort level. Evaluates effectiveness of procedure.
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Adjust binder as deemed appropriate. Prevents impeding of circulation. Promotes lung expansion and patient comfort. Single T and double T-binders: Assist patient in establishing dorsal recumbent position. Slightly flex lower extremities with hips slightly rotated outward. Relaxes muscles in perineal organs. Ask patient to raise hips and put horizontal band around patient's waist. Vertical tails should be extended past patient's buttocks. Overlap waistband in front and secure using safety pins. Allows binder to be inserted, running through buttock area. Complete binder application: Single-T binder: Put remaining vertical strip over perineal dressing working up and below center horizontal band's front. Bring ends over waistband. Secure all thicknesses using safety pins. Double-T binder: Bring remaining vertical strips over perineal/suprapubic dressing with each tail supporting one side of the scrotum proceeding upward on either side of penis Continue drawing ends behind and downward in front of horizontal band. Secure thicknesses using safety pin. RATIONALE: Provides perineal muscle and organ support. Ensures proper placement of perineal muscle and suprapubic dressing. Assess patient's level of comfort. If necessary, adjust front pins and tails ensuring that tails are not too tight. If any area rubs against surrounding tissue, increase padding. RATIONALE: Evaluates effectiveness of procedure. Ask patient regarding binder removal before urinating/defecating. Inform patient that binder needs to be replaced after performing the said bodily functions. RATIONALE: Prevents soiling of binder. Reduces risk of infection. Breast binder: Assist patient in putting arms through armholes of binder. RATIONALE: Arm holes serve as access to support breast weight.
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Assist patient in establishing supine position in bed. RATIONALE: Ensures proper placement of perineal muscle and suprapubic dressing. Area under patient's breast should be padded if needed. RATIONALE: Prevents excoriation or irritation due to contact between skin and undersurface. Secure binder beginning at the nipple level. Close binder above and then below nipple line until binder is closed. RATIONALE: Uneven pressure is prevented by horizontal placement of safety pins. Adjust binder as needed. RATIONALE: Facilitates proper breathing. Remove and dispose of gloves. Wash hands. RATIONALE: Prevents cross infections. Observe skin integrity, circulation and characteristic around wound site. RATIONALE: Determines that binder has not resulted in complication to skin, wound or underlying germs. Assess patient's ventilation. RATIONALE: dentifies any impaired ventilation and potential pulmonary complications. Record and report procedure. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes. Report ineffective lung expansion (if any) to physician immediately. RATIONALE: Ineffective lung expansion results from tight application of binder.

10.8. Elastic Bandage Application

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Materials Required
Binder or bandages Disposable gloves Dressing tray (as needed)

Procedures for Elastic Bandage Application & Rationale

Examine patient's skin integrity. RATIONALE: Altered skin integrity contraindicates to use of elastic bandages. Assess patient's surgical dressing. RATIONALE: Surgical dressing replacement or reinforcement precedes application of any bandage. Observe circulation distal to bandage. RATIONALE: Comparison of area before and after application of bandage is necessary to ensure continued adequate circulation. Impairment of circulation may result in coolness to touch when compared with opposite side of body, cyanosis or pallor of skin, diminished or absent pulses, edema or localized pooling, and numbness or tingling of part. Review patient's record for specific orders related to elastic bandage application. RATIONALE: Specific prescription may direct procedure, including factors such as extent of application (e.g., toe to knee, toe to groin) and duration of treatment. Identify patient/caregiver's knowledge level and skill in elastic bandage application. RATIONALE: Ensures that planning and teaching are individualized. Explain procedure to patient. RATIONALE: Increased knowledge promotes cooperation and reduces anxieties. Wash hands. If drainage is present, wear disposable gloves. RATIONALE: Reduces spread of microorganisms. Provide needed privacy.
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RATIONALE:

Maintains patient's comfort and dignity.

Assist patient to a comfortable position. RATIONALE: Maintains alignment. Prevents muscoskeletal deformity. Use dominant hand to hold roll of elastic bandage, use other hand to hold bandage beginning at distal body part. Transfer roll to dominant hand in wrapping bandage. RATIONALE: Maintains appropriate and consistent bandage tension. Bandage should be applied from distal point toward proximal boundary. Use a variety of turns to cover various shapes of body parts. RATIONALE: Bandage is applied in manner that conforms evenly to body part and promotes venous return. Unroll and slightly stretch bandage. RATIONALE: Maintains uniform bandage tension. Overlap turns by -2/3 width of bandage roll. RATIONALE: Prevents uneven bandage tension and circulatory impairment. Use clip/tape to secure first bandage before applying additional rolls. Do not leave uncovered skin surface in applying additional rolls. Secure final bandage. RATIONALE: Prevents wrinkling or loose ends. Remove and dispose of gloves. Wash hands. RATIONALE: Reduces transmission of microorganisms. Assess patient's distal circulation upon completion of bandage application or at least twice every 8 hrs. RATIONALE: Early detection and management of circulatory impairment ensures healthy neurovascular status. Neurovascular changes indicate impaired venous return. Determines if bandage is too tight, which restricts movement or determines if joint immobility is attained. Record and report condition of patient's wound, dressing integrity, bandage application, circulation and comfort level of patient.
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RATIONALE:

Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.

10.9. Moist Hot Compress Application to an Open Wound

Importance
Since heat primarily promotes blood vessel dilation and opens pores and stoma, it enables good blood flow and circulation. Its comfort effect is also remarkable. Application of its therapeutic effect causes changes in the circulation of a local or remote site, thus, heat: Relieves pain and congestion Hastens suppuration Relaxes muscles, and Increases metabolism.
Factors Affecting the Application of Moist Hot Compress to an Open Wound

Temperature and environment Reasons for treatment Types of solutions Types, sites, size, characteristics, severity and cause of wound Nutritional status Medical history and present health conditions Age and gerontologic condition Compliance to pharmacological regimen Personal hygiene Skin integrity Blood circulation Altered skin moisture Presence of equipments: cast, traction, bead, implants, dressings, bandages, etc.

Assessment Sites
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Assessment for signs and symptoms of infection must be conducted. Presence and characteristics of discharges must be observed. Level of healing must also be evaluated, together with the rise of complications. Presence of microorganism must be inspected and the difference of healthy wound from gangrene.

Materials Required
Heating equipment Sterile towel Sterile gauze Solutions as ordered Sterile container Sterile gloves Sterile dressing materials Sterile basin Sterile forceps

Procedures for Moist Hot Compress Application to an Open Wound & Rationale
Re-check patient's record for hot compress order. RATIONALE: Ensures safe and correct application. Assess condition of patient's exposed skin/wound on which compress is to be applied. RATIONALE: Provides baseline data to determine changes in skin during heat application. Assess patient's extremities for sensitivity to temperature and pain. RATIONALE: Patients insensitive to heat or cold sensations must be monitored closely during treatment. To identify any systemic contraindications to application of heat, refer to patient's record. RATIONALE: Heat causes vasodilation, which aggravates active bleeding. Heat applied to localized area of acute inflammation or tumor may cause rupture or activate cell growth. Prepare necessary equipment/supplies.
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RATIONALE:

Organization of supplies prevents unnecessary delays in the procedure.

Explain procedure and expected sensations. Explain precautions to prevent burning. RATIONALE: Minimizes patient's anxiety and promotes cooperation during the procedure. Provide needed privacy. RATIONALE: Decreases drafts, thus decreasing the transmission of microorganisms. Provides for patient privacy. Assist patient to establishing comfortable position. Put waterproof pad under body part to be treated. RATIONALE: Compress remains in place for several minutes. Limited mobility in uncomfortable position causes muscular stress. Pad prevents soiling of linen. Expose body part to be covered by compress. Use bath blanket to drape rest of patient's body. RATIONALE: Prevents unnecessary cooling and exposure of body part. Wash hands. RATIONALE: Reduces transmission of microorganisms.
COMPRESS PREPARATION
RATIONALE:

Ensures orderly procedure.

Pour solution into sterile container. Open sterile packages and drop gauze into container. Adjust temperature. RATIONALE: Compresses must retain warmth for therapeutic benefit. Wear disposable gloves. RATIONALE: Remove soiled dressing from wound. Dispose of gloves/soiled dressing properly. Reduces transmission of microorganisms. Assess wound's condition and surrounding skin. RATIONALE: Provides baseline to determine skin changes following compress
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application. Wear sterile gloves. RATIONALE: Allows nurse to manipulate sterile dressing and touch open wound. Pick-up a layer of sterile gauze and wring out excess solution. lightly apply gauze to wound. RATIONALE: Excess moisture macerates skin and increases risks of burns and infection. Skin is sensitive to sudden change in temperature. Lift edge to assess for redness after a few seconds. RATIONALE: Increased redness indicates burn. If compress is tolerated, snugly pack gauze against wound. All wound surfaces should be covered by compress. RATIONALE: Packing of compress prevents rapid cooling from underlying air currents. Cover compress with dry sterile dressing and bath towel. pin/tie to secure if needed. RATIONALE: Dry sterile dressing will prevent transfer of microorganisms to wound via capillary action caused by moist compress. Towel insulates compress to prevent heat loss. Remove sterile gloves. RATIONALE: Reduces transmission of microorganisms. Hot compress should be changed every 5 mins or as prescribed. RATIONALE: Prevents cooling and maintains therapeutic benefit of compress. After appropriated time, wear disposable gloves and remove pad, towel, and compress. Re-assess wound and skin condition. Replace dry sterile dressing. RATIONALE: Continues exposure to moisture will macerate skin. Prevents entrance of microorganisms into wound site. Assist patient to a comfortable position. RATIONALE: Maintains patient's comfort.

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Properly dispose of equipment and soiled supplies. Wash hands. RATIONALE: Reduces transmission of microorganisms. Examine area covered with compress every 5-10 mins. RATIONALE: Assists in determining effects of application. Ask patient for any unusual burning sensation not felt before application. RATIONALE: It may be difficult to assess burn merely by color changes if wound is inflamed or drainage is present. Record procedure and condition of wound/skin, treatment, and patient's response to compress. RATIONALE: Documentation facilitates communication with other health team members. Serves as future reference for nursing care. May also serve for legal purposes.
10.10. Post-operative Exercises Demonstration

Anatomy and Physiology

Stress is a collective term for a number of psychologic and physiologic factors that cause neurochemical changes inside the body. These factors include tissue damage, pain, immobilization, anesthesia, blood loss and fever. By combining both psychologic and physiologic factors, the stressful stimuli imposed by surgery encourage the stress response.

Importance
One of the foremost impact of sickness, both benign or malignant, is the impairment of physical mobility, particularly in patients who have undergone operative procedures. Early recovery can be greatly facilitated by effective demonstration and patient's compliance to post-operative exercises. Range of motion maintains muscle tone and joint mobility as well as promotes blood circulation. Likewise, good breathing exercises encourage effective pulmonary function. Above all, sound post-operative exercises help prevent postopera300

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tive complications. Executing these maneuvers normally help patient not to undergo lengthy rehabilitation.

Factors Affecting Compliance to Postoperative Exercises

Effectiveness of the nurse education Medical history and present health condition Mental status of the patient Environment Support system Age and size of the patient Kinds of operation the patient has undergone Therapy and treatment Contraptions Patient's knowledge and anticipation about medical condition

Assessment Sites
The nurse's primary considerations before starting postoperative exercises include the vital signs, wound and drainage, cardiovascular status, neurologic status, respiratory status, tubes and contraptions. Patient's capability and understanding about the procedures must also be assessed. The nurse must also be skilled/knowledgeable about post-operative exercise indications and contraindications.

Materials Required
Turning team Exercising materials Support tools such as bars, canes, trapeze, etc. Spirometry or pulmonary function test gadget

Procedures for Post-operative Exercises Demonstration & Rationale

Assess patient for any risk of post-operative complications. RATIONALE: Exercise may also cause post operative injury, assessment prevents injury. Explain to patient purpose and importance of exercises. RATIONALE: Immobility is often a problem 20 to pain, proper explanation develops client's determination to move. 301

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(no author). (2003). Competencies essentials for nursing. Manila: Educational Publishing House. Altman, J.B. (n.d.). Delmars Fundamental and Advanced Nursing Skills. (2nd Ed.). Altman, J.B. (n.d.). Delmars Fundamental and Advanced Nursing Skills. Checklist. Benenson, A.S. (1995). Control of communicable diseases manual. Washington, DC: American Public Health Association. Centers for Disease Control and Prevention. (1994). Guideline for preventing the transmission of myobacterium tuberculosis in healthcare facilities. Federal Register 59, 208, 54242. Cox, C. L. and McGrath, A. (1999) Respiratory assessment in critical care units. Intensive & Critical Care Nursing 15(4): 226-234. Ellis, J. et al. (1992). Modules for basic nursing skills. (5th Ed.) Manila: Educational Publishing House. Ellis, J. et al. (1992). Modules for basic nursing skills. (6th Ed.). Manila: C&E Publishing. Endacott, R. and Jenks, C. (1997) RCN: continuing education. Respiratory assessment in A&E. Emergency Nurse 5(4): 3138. Finesilver, C. (1992) Respiratory assessment. RN 55(2): 22-30. Fritz, D. J. (1997) Fine tune your physical assessment of the lungs and respiratory system. Home Care Provider 2(6): 299-305. Gumban, J. et al. (2004). Basic Nursing Procedures Performance Checklist for Level 2. Wiseman Books. Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical Nursing Skills and Techniques St Louis: Mosby. Ch.11 pp 196239.

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Mallett, J. and Dougherty, L. (2000) Observations. Manual of Clinical Nursing Procedures Oxford: Blackwell Science. Ch.28 pp 402432. Marchese, T. W. and Diamond, F. B. (1995) Primary care for women: comprehensive assessment of the respiratory system. Journal of Nurse-Midwifery 40(2): 150-162. Owen, A. (1998) Respiratory assessment revisited. Nursing 28(4): 4849. Pereira, L.J. et. al. (1990). The effect of surgical handwashing routines on the microbial counts of operating room nurses. American Journal of Infection Control, 18, 354. Potter, P.A. (2001). Fundamentals of nursing: Singapore: Harcourt Asia. Stevens, S. and Becker, K. L. (1988) How to perform picture-perfect respiratory assessment. Nursing 18(1): 57-63. Thompson, J.M. et al. (1989). Mosbys manual of clinical nursing. (2nd ed.). St. Louis: Mosby. Thompson, J.M. et. al. (1999). Whaley and Wongs nursing care of infants and children. (6th ed.). St. Louis: Mosby. Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and observation - 2... no. 4.2. Nursing Times 93(44): insert-Nov. Torrance, C. and Elley, K. (1997) Practical procedures for nurses. Respiration: technique and observation - 1... no. 4.1. Nursing Times 93(43): insert-28. Udan, Q.J. (n.d.). Mastering fundamentals of nursing. Manila: Jade Book Store. Weinstein, S.A. et. al. (1989). Bacterial surface contamination of patients linen: isolation precautions versus standard care. American Journal of Infection Control, 17, (5), 264. Woodrow, P. (2002) Assessing respiratory function in older people. Nursing Older People.
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