Surgical Scrub Procedure: Five-Minute Scrub

Planning/Implementation:

Wet the hands and forearms. Apply 2 to 3 ml (6 drops) of antiseptic agent from the dispenser to the hands. Wash the hands and arms several times thoroughly to 2 inches (5cm) above the elbows. Rinse thoroughly under running water, with the hands upward, allowing water to drip from flexed elbows. Take a sterile brush or sponge (from a package or dispenser) and apply an antiseptic agent (if it is not impregnated in the brush). Scrub each individual finger, nails and hands, a half-minute for each hand. Hold the brush in one hand and both hands under running water, and clean under the fingernails with a metal disposable plastic nail cleaner. Discard the cleaner after use. Again scrub each individual finger, nails, and hands wit the brush a half minute for each hand, maintaining lather. Rinse the hands and brush, and discard the brush and sponge. Reapply the antimicrobial agent, and wash the hands and arms with friction to the elbow for 3 minutes. Intersperse the fingers to cleanse between them.  Rinse the arms and hands as before.

Gowning and Gloving: Closed Gloved Technique

Planning/Implementation:

Gowning:

Reach down to the sterile package and lift the folded gown directly upward. Step back away from the table, into an obstructed area to provide a wide margin of safety while gowning. Holding the folded gown, carefully locate the neckband with both hands, let the gown fold, keeping the inside of the gown with bare hands. Holding the hands at shoulder level, slip both arms into the armholes simultaneously. The circulator brings the gown over the shoulders.

Gloving:

Using the left hand and keeping it within the cuff of then left sleeve, pick up the right glove, from the inner wrap of the glove package, by grasping the folded cuff. Extend the right forearm with the palm upward. Place the palm of the glove against the palm of the right hand, grasping in the right hand, grasping in the right hand and top edge of the cuff, above the palm. In correct position, gloved fingers are pointing toward you and the thumb of the glove is to the right. The thumb side of the glove is down. Grasp the back of the cuff in the left hand and turn it over the end of the right sleeve and hand. The cuff of the glove is now over the stockinette cuff of the gown, with the hand still inside the sleeve. Grasp the top of the right glove and underlying gown sleeve with the covered left hand. Pull the glove on over the extended right finger until it is completely covers the stockinette cuff. Glove the left hand in the same manner, reversing hands,. Use the gloved right hand to pull on left glove.

Leopold’s Maneuver

Planning/Implementation:

First Maneuver:

With the examiner standing on the right side facing on the client, palpate side of the fundus with both palms, fingertips to determine which fetal pole is in the uterine fundus. For cephalic presentation: a hard, movable, regular mass is palpated whine a breach presentation, would be smooth, irregular, and slightly movable. With the fingers of the left hand, start from the umbilicus, count the number of finger breadths to the height of the fundus. This width approximate age of gestation (1 fingerbreadth to 1 month gestation)

Second Maneuver:

Place hands on the sides of abdomen downward to determine position of anterior shoulder, back and extremities.

Third Maneuver:

Grasp lower uterine segment between thumb and fingers of right hand to determine presentation and engagement.

Fourth Maneuver:

Examiner faces the foot part of the client. Palpate with both hands the sides of the fundus to confirm findings during the maneuver. Whether cephalic or breech presentation or how far engagement has occurred.

Administering an Intradermal Injection

Assessment:

Appearance of injection site. Specific drug action and expected response. Client’s knowledge of drug action and response.

Planning:

Assemble equipment and supplies, such as: Vial or ampule of the correct medication. Sterile 1 ml syringe calibrated into hundredths of a milliliter and a 25 to 27 gauge needle that is ¼ to ⅝ inch long. Alcohol swabs. 2” x 2” sterile gauze square, nonsterile gloves, band-aid, and epinephrine on hand. Check the MAR (medication Administration Record); Physician’s order. Check the label on the medication carefully against the MAR to make sure that the correct medication is being prepared. Follow the three  checks for administering medications. Read the label1 on the medication: When it is taken from the medication cart, before withdrawing the medication and after withdrawing the medication. Organize the equipment.

Implementation:

Wash hands and observe other appropriate infection control procedures. Prepare the medication from the vial or ampule for drug withdrawal. Prepare the client. Check the client’s identification band. Explain to the client that the medication will produce a small wheal, sometimes called a bleb. Provide for client privacy. Select and clean the site. Select a site. Avoid using sites that are tender, inflamed, or swollen, and those that have lesions. Put on gloves. Cleanse the skin at the site using a firm circular motion, starting at the center and widening the circle outward. Allow the area to dry thoroughly. Prepare the syringe for injection. Remove the needle cap while waiting for the antiseptic to dry. Expel any air bubbles from the syringe. Grasp the syringe in your dominant hand, holding it between thumb and forefinger. Hold the needle almost parallel to the skin surface, with the needle bevel up. Inject the fluid. With the nondominant hand, pull the skin at the site until it is taut. Insert the tip of the needle far enough to place the bevel through the epidermis into the dermis. The outline bevel should be visible under the skin surface. Stabilize the syringe and needle, and inject the medication carefully and slowly, so that it produces a small wheal on the skin. Withdraw the needle quickly at the same angle that it was inserted. Apply a band-aid, if indicated. Do not massage the area. Dispose of the syringe and needle safely. Remove gloves. Circle the injection site with ink to observe for redness or induration per agency policy. Document all relevant information. Record the testing material given, the time, dosage, route site, and nursing assessments.

Thermometer Technique

Planning/Implementation:

Identify your client and explain the procedure. Using the bag technique lay out, put out the thermometer leaving the case inside the bag. Check if mercury in the thermometer is at the level of 35ºC. Place the thermometer beneath. Wiping is done from a clean the tongue or in patient’s axilla to a dirty area and take the temperature, pulse and respiration following the procedure in taking “vital signs”

Remove the thermometer from patient’s mouth/axilla and wipe with the one dry cotton ball from your fingers downward to the bulb in a twisting motion. Discard used cotton ball. Read the thermometer. Clean the thermometer in a downward spiral motion from the stem to the bulb, holding it over the waste paper bag using the following bag technique: 1^st – 3 cotton balls moistened with soap. Discard. 2^nd – 3 cotton balls moistened with alcohol, then wrap around the bulb of the thermometer and lay it inide the kidney basin.

Note: Oral temperature is taken 2-3minutes; per axilla 5-8 minutes and per rectum, 1 minute. After the care is given and health teaching is over, remove the cotton ball wrapped around the thermometer. Wipe with a dry cotton and return to the case.

Evaluation and Documentation:

Clients condition. Intervention done. Health teachings given.

Nebulization

Assessment:

Assess patient for obstruction of the airway. Assess patient respiratory status. Assess characteristics of secretions. Check with doctor’s order.

Planning:

Prepare materials needed, as follows: Nebulizer machine, mouthpiece, T-piece, cap, medication cup, nebulizer air – inlet connector, bottle, tubing and aerosol mask. Gather and bring to bedside.

Implementation:

Wash your hands before preparing medications. Identify patient. Before initial operation place the nebulizer on a leveled surface. Open door to storage equipment. Make sure the power is in the OFF position. Unwrap power cord and plug power cord into an appropriate wall outlet. Assemble clean nebulizer parts by placing a buffle on medication cup. Holding cup stationary, screw on nebulizer cap. Add prescrined medication through the opening on cap using a medicine dropper or pre-measured container. Assemble mouthpiece and T-piece (if applicable) and insert into the top of the nebulizer cap. If usig an aerosol mask, insert the bottom part of the mask directly into the top of the nebulizer cap. Attach tubing to nebulizer air-outlet connector. Press the power switch ‘on’ to the start the compressor. Begin treatment by placing  the mouthpiece between teeth. With mouth closed, inhale deeply and slowly through mouth as aerosol begins to flow, then exhale slowly through the mouthpiece. If the treatment needs to be interrupted, simply press power switch ‘off’. If an aerosol mask is used, place the mask over mouth and nose. As aerosol begins to flow, inhale deeply and slowly through mouth then exhale slowly. After nebulization, turn the switch off. Unplug power cord from wall outlet. Disconnect the parts and the tubing to set aside. Disassemble mouthpiece or  mask from cap. Wash all items, except tubing in a hot water/dishwashing detergent. Rinse under top water for 30 seconds to remove detergent residue. Allow air to dry.

Evaluation:

Increased comfort and breathing efficiency for patient’s with ASTHMA & COPD. Clear breath sounds and liquefied secretions.

Documentation:

Record the date and time of the treatment. Note the amount of secretions.

Gowning and Gloving: Open Gloved Technique

Planning/Implementation:

Reach down to the sterile package and lift the folded gown directly upward. Step back away from the table, into a clear area, to provide a wide margin of safety while gowning. Holding the folded gown, carefully locate the neckband. Holding the inside front of the gown just below the neckband with both hands, let the gown unfold, keeping the inside of the gown toward the body. Holding the hands at shoulder level, slip them into the armholed simultaneously, without touching the sterile exterior of the gown with bare hands. The circular reaches inside the gown to the sleeve seams and pulls the sleeves over the hands to the wrists.

Gloving:

This method of gloving uses a skin-to-skin, glove-to-glove technique technique. The hand, although scrubbed, is not sterile and must not contact the exterior of the sterile gloves. The everted cuff on the gloved exposes the inner surfaces. The first glove is put on with skin-to-skin technique, bare hand to inside cuff. The sterile fingers of that goved hand then may touch the sterile exterior of the second glove, that is, glove-to-glove technique. With the left hand, grasp the cuff of the right glove on the fold. Pick up the glove on the fold. Pick up the glove and step back from the table. Look behind you before moving. Insert the right hand into the glove and pull it on, leaving hr cuff turned well down over the hand. Slip the fingers of the gloved right hand under the everted cuff of the left glove. Pick up the glove and step back. Insert the hand into the left glove and pull it on, leaving the cuff turned down over the hand. With the fingers of the right hand, pull the cuff of the left glove over the cuff of the left sleeve.If the stockinette is not tight, fold a pleat, holding it with the right thumb while pulling the glove over the cuff. Avoid touching the bare wrists.

Logrolling a Client

Assessment:

Determine assistive devices that will be required and encumbrances to movement, such as an IV or a heavy cast on one leg. Medications the client is receiving, as certain medications may hamper movement or alertness of the client. Assistance required from other health care personnel.

Planning/Implementation:

Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Position yourself and the client appropriately before performing the move. Stand on the same side of the bed, and assume a broader stance with one foot ahead of the other. Place the client’s arms across the chest. Lean your trunk, and flex your hips, knees, and ankles. Place your arms under the client. Tighten your gluteal, abdominal, leg, and arm muscle. Pull the client to the side of the bed. One nurse counts: One, two, three, go. Then, at the same time, all staff members pull the client to the side of the bed by shifting their weight to the back foot. Elevate the side rail on this side of the bed. Move to the other side of the bed, and place supportive devices for the client when turned. Place a pillow where it will support the client’s head after the turn. Place one or two pillows between the client’s leg to support the upper leg when the client is turned.

Roll and position the client in proper alignment. Use a turn sheet to facilitate logrolling. First, stand with another nurse on the same side of the bed. Assume a broad stance with one foot forward, and grasp half of the fanfolded or rolled edge of the turn sheet. On a signal, pull the client toward both of you. Before turning the client, place pillow supports for the head and legs. Then, go to the other side of the bed (farthest from the client), and assume a stable stance. Reaching over the client, grasp the far edges of the turn sheet, and roll the client toward you. The second nurse (behind the client) helps turn the client and provides pillow supports to ensure good alignment in the lateral position.

Evaluation:

           

            Document all relevant information. Record the tine and change of position moved from and position moved to, any signs of pressure areas, use of support devices, ability of client to assist in moving and turning and response of client to moving and turning.

Turning a Client to the Lateral or Prone Position in Bed

Assessment:

Determine assistive devices that will be required and encumbrances to movement, such as an IV or a heavy cast on one leg. Medications the client is receiving, as certain medications may hamper movement or alertness of the client. Assistance required from other health care personnel.

Planning/Implementation:

Explain to the client what you are going to do, why it is necessary, and how she can cooperate. Wash hands and observe other appropriate infection control procedures. Provide for client privacy. Position yourself and the client appropriately before performing the move. Pull or roll the client toward you to the lateral position. Instead of abducting the far arm, keep the client’s arm alongside the body for the client to roll over. Roll the client completely onto the abdomen. Never pull a client across the bed while he is in the prone position.

Evaluation:

           

            Document all relevant information. Record the tine and change of position moved from and position moved to, any signs of pressure areas, use of support devices, ability of client to assist in moving and turning and response of client to moving and turning.

Cord Dressing

Planning/Implementation:

Gather all necessary equipments, as follows: Bottle of alcohol 70%,containers with applicators, baby binder and waste receptacle. Wash hands thoroughly, remove baby’s binder. Inspect the cord. Apply alcohol 70% with the used of sterile applicators. One three times. Expose cord after 24 hours, if cord is dry, remove cord pin. Apply baby’s binder. Return baby to crib. Return equipments to proper place.

Heat and Acetic Acid Test

Planning/Implementation:

Gather equipment needed, as follows: test tube, 5% acetic acid, Fill a test tube ¾ full of clean urine and gently heat the upper portion to boil, boil for 1-2 minutes. A turbidity is either due to phosphates, carbonates or albumin. Add 3 drops of 5% acetic acid drop by drop, doiling between each drop. A white-cloud now appearing is due to early phosphate or carbonates, a faint trace of albumin may appear only  upon the addition of the acid. The addition of too much acid may dissolve faint traces of albumin and give a faculty negative reaction. In order to detest slight traces, the tube must be held against a black background. Record results as:

Negative -       no closeness is perceptible

Trace -             no cloudiness is perceptible against a black background

+          -           cloudiness is distinct but not gramular against a black background and can barely be seen when held up to the light.

+ + +   -           cloud is distinct and gramular light (0.2 – 0.5 Gm. %)

+ + + + + -       cloud is dense with large flocculi, any solidity ( 0.5 Gm. %) albumin becomes solid and boiling.

Administering Injections

Assessment:

Compare medications listed against physician’s orders. Check if drug requires skin testing of if ST has been done, checks for result. Assess psychological and physical status including size and general build, and assess need for assistance. Check for age, weight and height. Check medication available and reference for safe child’s dosage. Determine appropriate needle and syringe to be used. Determine other equipment needed.

Planning:

Plan a method of approaching and restraining a child appropriately. Wash hands observing proper technique. Gather needed equipment.

Implementation:

Rea form charts/kardex the name of drug ordered. Take from shelf/drawer and check label and expiry date of medication. Draw up correct dosage of medication from vial. Clean top of vial and allow to dry. Discard alcohol swab appropriately. Prepare syringe and needle. Draw appropriate volume of air into syringe. Insert needle into vial through rubber stopper. Inject air into vial. Pick up vial nondominant hand, and withdraw required volume of drug. Examine for air bubbles and expel them. Recheck volume of medication for accuracy. Remove needle from vial. Replace needle guard. Change needle appropriate for injection. Observe sterile technique  throughout the procedure. From vials, wash hands and observe other appropriate infection control procedures. Prepare the medication vial for drug withdrawal. Mix the solution, if necessary, by rotating the vial between the palms of the hands, not by shaking. Remove the protective cap or clean the rubber cap of a previously opened vial with an antiseptic wipe by rubbing in a circular motion. Withdraw the medication. Attach a filter needle, as agency practice dictates, to draw up premised liquid medications from multi-dose vials. Ensure that the needle is firmly attached to the syringe. Remove the cap from the needle, then draw up into the syringe the  amount of air equal to the volume of the medication to be withdrawn. Carefully insert the needle into the upright vial through the center of rubber cap, maintaining the sterility of the needle. Inject the air into the vial, keeping the bevel of the needle above the surface of the medication. Withdraw the prescribed amount of medication using either one of the following methods: Hold the vial down, move the needle tip so that it is below the fluid level, and withdraw the medication. Avoid drawing up the last drops of the vial. Invert the vial, ensure the needle tip is below the fluid level. And gradually withdraw the medication. Hold the syringe and vial at eye level to determine that the correct dosage of drug is drawn into the syringe. Eject air remaining at the top of the syringe into the vial. When the correct volume of medication is obtained, withdraw the needle from the vial and replace the cap over the needle using the scoop method, thus maintaining its sterility. If necessary, tap the syringe barrel to dislodge any air bubbles presenting the syringe. Replace the filter needle, if used, with a regular needle and cover of the correct gauge and length before injecting the client.

Evaluation:

The right patient received the right medication in the right dosage by the right route at the right time. The criteria, specified in the plan of care(NCP) established for ascertaining the effectiveness of a specific drug were used. Side effects, if present, were promptly identified and recorded.    Necessary referrals were made.

Documentation:

Record appropriately according to the policy of the facility.

Tracheostomy Care

Assessment:

Assess breathing pattern. Listen to the breath sounds. Observe for infection. Observe for hypoxia. Assess the needs of the patient with a tracheostomy for suctioning and cleaning.

Planning:

Wash your hands. Obtain the necessary equipment, as follows: Tracheostomy tube, mask, sterile gloves, self-inflating breathing bag, sterile water, sterile suction catheter, sterile syringe, normal saline if saline is to be instilled, sterile gauze squares, eye protection, portable suction machine and suction trap, if a spectrum specimen is needed.

Implementation:

Identify the patient. Provide privacy. Explain the procedure. Establish a way communicating with a tracheostomy patient. Test the suction apparatus. Place the patient on supine or in Mid-fowler’s position. Turn the patients head slightly toward you. Place the unconscious patient in the lateral position facing you. Put an eye protection and mask. Prepare 5ml sterile saline in a syringe. Open the sterile suction set, and prepare the equipment. Place the drape from the kit or a clean towel over the patient’s chest. Most kits contain a pocket of solution, sterile gloves, the sterile suction catheter and sterile gauzesquares. If the kit contains all this equipment, first put on gloves. Pour the saline into the basin. Hold the catheter in your dominant hand. And use the non-dominant hand to hold the suction taking to control the suction and to handle any after unsterile object. The non-dominant hand is now contaminated and cannot touch the catheter. The second person attaches the breathing bag to the oxygen source and prepares to ventilate the patient. The second person attaches the breathing bag to the tracheostomy tube and provides three deep breaths coordinated with the patients breathing pattern. Instill the  normal saline into the tracheostomy. Control the suction with your unsterile gloved hand while suctioning with your sterile hand. Insert the catheter 4 to 5 inches into the tracheostomy without occluding the part on the suctioning catheters. Apply the suction by closing the system. This is done placing you thumb over the post or side opening at the base of the catheter. Apply suction for only 10 seconds. Withdraw the catheter, rotating it gently while you continue suctioning. Rinse the catheter with sterile water or normal saline. The second person provides ventilation immediately after the suction catheter is removed. Observe the patient for dyspnea after the suction catheter is removed. If hypoxia occurs, immediately provides additional deep breaths of oxygen. Turn off the suction and listen for clear breath sounds. If breathing is not clear, repeat suctioning method. If breathing sounds clear, uses the breathing bag to provide 3 or 4 deep breaths of oxygen Disconnect the catheter from the suction tubing. Grasp the cuff of the sterile glove, and pull the glove down over the used catheter. Discard all disposable equipment. Wash your hands and provide oral hygiene.

Evaluation:

Evaluate using the following criteria: tracheostomy tube in place, respiratory rate and depth normal, breath sounds clear and patient resting comfortably.

Documentation:

Record the procedure and observation on the patients chart. Amount and description of secretions and patient’s response to the procedure.

Surgical Scrub Procedure: Brush-Stroke Method

A prescribed number of brush strokes, applied lengthwise of the brush or sponge, is used for each surface of the fingers, hands and arms. A short prescrub wash loosen surface debris and transient organisms. Scrub by brush or sponge removes resident flora.

Wet the hands and arms. Wash the hands and arms thoroughly to 2 inches (5cm) above the elbow with an antiseptic agent. With the hands held under running water, clean under the fingernails carefully with a metal or disposable plastic nail cleaner. Discard the cleaner after  use. Rinse the hands and arms thoroughly under running water, keeping the hands up and allowing water to drip from the elbows. Take a sterile brush or sponge from a dispenser or package. Apply an antiseptic agent to the brush or sponge (if not previously impregnated.) scrub the nails of one hand 30 strokes, all side of each finger 20 strokes, the back of the hand 20 strokes, the back of the hand 20 strokes, the arms 20 strokes for each third of the arm, to 2 inches (5cm) above the elbow. Repeat step 6 for the other hand and arm. Rinse the hands and arms thoroughly.

Bag Technique

Planning:

Gather all necessary equipment, as follows: paper lining, extra paper for making bag for waste materials (paper bag), plastic/linen lining, apron, hand towel in plastic bag, soap in soap dish, thermometers in case (one oral and rectal), 2 pairs of scissors (1 surgical and 1 bandage), 2 pairs of forceps (curved and straight), syringes (5ml and 2 ml), Hypodermic needles G. 19, 22, 23, 25, sterile dressings (OS, CB), sterile cord tie, adhesive plaster, dressing (OS, cotton ball), alcohol lamp, Tape measure, Baby’s scale, 1 pair of rubber gloves, 2 test tubes, test tube holder, and Medicines: betadine, 70% alcohol, Ophthalmic ointment, Zephiran solution, hydrogen peroxide, spirit of ammonia, acetic acid, and benedict’s solution.

Implementation:

Upon arriving at the client’s home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put bag’s handle or strap beneath the bag. Ask for a basin of water and a glass of water if faucet is not available. Place these outside the work area. Take out hand towel, soap dish and apron and place them at one corner of the work area (within the confines of the linen/plastic lining). Do hand washing. Wipe, dry with towel. Leave the plastic wrappers of the towel in soap dish in the bag. Put on apron right side out and wrong side with crease touching the body, sliding the head into the neck strap. Neatly tie the straps at the back. Put out things most needed for the specific case (e.g. thermometer, kidney basin, cotton ball, waste paper bag) and place at one corner of the work area. Place waste paper bag outside of work area. Close the bag. Proceed to the specific nursing care or treatment. After completing nursing care or treatment, clean and alcoholized the things used. Do hand washing again. Open the bag and put back all articles in their proper places. Remove apron folding away from the body, with soiled side folded inwards, and the clean side out. Place it in the bag. Fold the lien/plastic lining, clean: place it in the bag and close the bag. Make post-visit conference on matters relevant for future visit health care, taking anecdotal notes preparatory to final reporting. Make appointment for the next visit (either home or clinic), taking note of the date, time and purpose.

After care

Before keeping all articles in the bag, clean and alcoholized them. Get the bag from the table, fold the paper lining (and insert), and place in between the flaps and cover the bag.

Inserting a Nasogastric Tube

Assessment:

Check the physician’s orders. Assess the patient’s capabilities for cooperating with the procedure. Determine where the needed equipment is located.

Planning:

Wash your hands. Gather the equipment, as follows: Stethoscope, restraint or hand mitts (for infant or small children), asepto syringe, tongue balde, sterile disposable gloves, water soluble lubricant, tissues, glass of water with drinking, straw, kidney basin, nasogastric tube- appropriate size, adhesive tapes, safety pin and towel. Before insertinga nasogastric tube determine the size of tube to be inserted and whether or not the tube is to be attached to a suction. If it is necessary, plan for any assistance.

Implementation:

Identify the patient. Explain the procedure to the patient and why it is needed. Place the patient in high fowler’s position if possible. Put a clean towel over the patient’s chest to protect the linen. Prepare nose skin for tape. Put on gloves. Determine how far to insert the tube. Use the tube to mark off the distance from the tip of the client’s nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the sternum. Mark the tube with a piece of tape. Lubricate the tube with a water-soluble lubricant. Lubricate the portion of the tube from tip to marking. Flex the patient’s head slightly forward. Have a basin in the patient’s lap and tissues handy. If orders allow, have the patient sip water and swallow while you gently but steadily advance the tube. There may be some temporary gagging, caused by the gag reflex, but this should subside as the tube is progressed. Using tape, secure the tube in the patient’s nose. Check to see if the end of the tube in the stomach. If it is curled in the back of the throat, it is uncomfortable and ineffective. You can easily check this by asking the patient to open the mouth or by holding down the tongue with a tongue depressor. Using a flashlight, you can see if the tube is curled in the  back of the throat. You can check the tube’s position in several ways, some are more reliable than others. Keep the free end of the tube plugged at all times except when checking position, feeding, or irritating. Secure tubing’s using adhesive tapes. Coil free end and pin to the clothing. Help the patient to a comfortable position. Provide frequent oronasal care. Dispose of gloves, and wash your hands.

Evaluation:

Evaluate using the following criteria: Patient comfortable, No irritation at nostrils, Normal breathing rate and rhythm, No indications of nausea or regurgitation, Tube properly placed.

Documentation:

Initiate an intake and output patient record. Document the following on the patient record: Type and size of the tube inserted, Amount and characteristics of any drainage returned. Patient response to the procedure. Add to the Nursing care plan information pertinent to care needed.

Nasogastric Tube Feeding

Assessment:

Check the physician’s order. Read any observations about previous feeding noted on the patient’s chart. Wash your hands.

Planning:

Gather any equipment you will need, as follows: Feeding formula-warm is indicated, drinking water, stethoscope and towel.

Implementation:

Identify the patient. Explain what you are going to do. Place the patient in semi-fowler’s position. Drape chest with towel. Test the placement of the tube and for residual formula. Asepto syringe method. When you use this method, hold the syringe manually, and fill and refill. Again, do not allow the water or formula to fall below the narrowing at the bottom of the syringe. Flush with prescribed amount of water.  Use gravity flow to move the formula through the tube. If the flow slows down or stops, gentle pressure on the asepto bulb or ”milking” the tubing may help. If the patient gags during the feeding, stop the procedure. After the feeding, clamo the tube or plug it. Reposition the patient in low or semi-fowler’s position. If the patient is comatose, the head should be turned to one side. Wash your hands.

Evaluation:

Return to the patient in approximately 30 minutes.

Documentation:

Record on the medication sheet or progress notes. Your notes should indicate the date, time,  type, and amount of formula, amount of water and patient’s response.

Removing a Nasogastric Tube

Assessment:

Verify that the tube is no longer needed and that the physician has ordered the removal. Check the physician’s order.

Planning:

Wash your hands. Obtain paper. Gather all materials needed, as follows: Clean gloves, Paper towels, towel and Oral hygiene tray.

Implementation:

Identify the patient. Explain to the patient that although removing the tube will be uncomfortable, it will be over quickly. Drape patients with a towel. If suction is operating, turn it off, and disconnect the tube. Put on gloves, and pinch the tube closed or plug it. Withdraw the tube smoothly in a continuous motion. Place the soiled tubing in the paper towel and cover it. Provide comfort, and give mouth care. Measure secretions in the collection container. Dispose of the equipment and gloves properly. Wash your hands.

Evaluation:

Evaluate using the following criteria; patient comfortable,and no abdominal distention present.

Documentation:

Document the time the tube was removed, the amount and description of material in the collection container, and the patient’s response to the procedure.

Providing Perineal-Genital Care: Male

Assessment:

Assess for the presence of irritation, excoriation, inflammation or swelling, excessive discharge, odor, pain or discomfort, urinary or fecal incontinence, recent rectal or perineal surgery and indwelling catheter. Determine perineal-genital hygiene practices and self-care abilities.

Planning:

Delegation, perineal-genital care can be delegated to UAP. If the client has recently had perineal, rectal, or genital surgery, the nurse needs to assess if it is appropriate for the UAP to perform perineal-genital care. Prepare equipment to be used.

Equipment:

Perineal-genital care provided in conjunction with the bed bath: bath towel, bath blanket, clean gloves, bath basin with water at 43 to 46ºC (110 to 115ºF), soap and wash cloth.

Special perineal-genital care: bath towel, bath blanket, clean gloves, cotton balls or swabs, cotton balls or swabs, solution bottle, pitcher, or container filled with warm water or a prescribed solution, bedpan to receive rinse water, moisture-resistant bag or receptacle for use and perineal pad.

Implementation:

Determine whether the client is experiencing any discomfort in the perineal-genital area. Obtain and prepare the necessary equipment and supplies. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate, being particularly sensitive to any embarrassment felt by the client. Wash hands and observe other appropriate infection control procedures (e.g., clean gloves). Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Prepare the client: fold the top linen to the foot of the bed and fold the gown up to expose the genital area. Place a bath towel under the client’s hips. Position and drape the client and clean the upper inner thighs.

Position the male client in a supine position with knees slightly flexed and hips slightly externally rotated. Put on gloves, wash and dry the upper inner thighs. Inspect the perineal area. Note any particular areas of inflammation, excoriation, or swelling, especially between the labia in females and the scrotal folds in males. Also note excessive discharge or secretions from the orifices and the presence of odor. Wash and dry the penis, using firm strokes. If the client is uncircumcised, retract the prepuce (foreskin) to expose the glans penis (the tip of the penis) for cleaning. Replace the foreskin after cleaning the glans penis. Wash and dry the scrotum. The posterior folds of the scrotum may need to be cleaned when the buttocks are cleaned.          

Inspect the perineal orifices for intactness. Inspect particularly around the urethra in clients with indwelling catheters. Clean between the buttocks. Assist the client to turn onto the side facing away from you. Pay particular attention to the anal area and posterior folds of the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary. Dry the area well. For postdelivery or menstruating females, apply a perineal pad as needed from front to back. Document any unusual findings such as redness, excoriation, skin breakdown, discharge or drainage and any localized areas of tenderness.

Evaluation:

Relate current assessment to previous assessments. Conduct appropriate follow-up such as prescribed ointment for excoriation. Report any deviation from normal to the physician.

Providing Perineal-Genital Care: Female

Assessment:

Assess for the presence of irritation, excoriation, inflammation or swelling, excessive discharge, odor, pain or discomfort, urinary or fecal incontinence, recent rectal or perineal surgery and indwelling catheter. Determine perineal-genital hygiene practices and self-care abilities.

Planning:

Delegation, perineal-genital care can be delegated to UAP. If the client has recently had perineal, rectal, or genital surgery, the nurse needs to assess if it is appropriate for the UAP to perform perineal-genital care. Prepare equipment to be used.

Equipment:

Perineal-genital care provided in conjunction with the bed bath: bath towel, bath blanket, clean gloves, bath basin with water at 43 to 46ºC (110 to 115ºF), soap and wash cloth.

Special perineal-genital care: bath towel, bath blanket, clean gloves, cotton balls or swabs, cotton balls or swabs, solution bottle, pitcher, or container filled with warm water or a prescribed solution, bedpan to receive rinse water, moisture-resistant bag or receptacle for use and perineal pad.

Implementation:

Determine whether the client is experiencing any discomfort in the perineal-genital area. Obtain and prepare the necessary equipment and supplies. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate, being particularly sensitive to any embarrassment felt by the client. Wash hands and observe other appropriate infection control procedures (e.g., clean gloves). Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the need for privacy. Prepare the client: fold the top linen to the foot of the bed and fold the gown up to expose the genital area. Place a bath towel under the client’s hips. Position and drape the client and clean the upper inner thighs.

Position the female in back-lying position with the knees flexed and spread well apart. Cover her body and legs with the bath blanket. Drape the legs by tucking the bottom corners of the bath blanket under the inner sides of the legs. Bring the middle portion of the blanket up over the public area. Put on gloves, wash and dry the upper inner thighs. Inspect the perineal area. Note any particular areas of inflammation, excoriation, or swelling, especially between the labia in females and the scrotal folds in males. Also note excesswive discharge or secretions from the orifices and the presence of odor. Clean the labia majora. Then spread the labia to wash the folds between the labia majora and the labia minora. Use separate quarters of the washcloth for each stroke, and wipe  from the pubis to the rectum. For, menstruating women and clients with indwelling catheter, use clean wipes, cotton balls, or gauze. Take a clean ball for each stroke. Rinse the area well. You may place the client on a bedpan and use a periwash or solution bottle to pour warm water over the area. Dry the perineum thoroughly, paying particular attention to the folds between the labia.

Inspect the perineal orifices for intactness. Inspect particularly around the urethra in clients with indwelling catheters. Clean between the buttocks. Assist the client to turn onto the side facing away from you. Pay particular attention to the anal area and posterior folds of the scrotum in males. Clean the anus with toilet tissue before washing it, if necessary. Dry the area well. For postdelivery or menstruating females, apply a perineal pad as needed from front to back. Document any unusual findings such as redness, excoriation, skin breakdown, discharge or drainage and any localized areas of tenderness.

Evaluation:

Relate current assessment to previous assessments. Conduct appropriate follow-up such as prescribed ointment for excoriation. Report any deviation from normal to the physician.

Gowning and Gloving with Another Person

Planning/Implementation:

Gowning:

A team member in sterile gown and gloves may assist the surgeon by taking the following steps: Open the hand towel and lay it on the surgeon’s hand, being careful not to touch the hand. Unfold t.h0e gown carefully, holding it at the neckband. Keeping your hands on the outside of the Gown under a protective cuff of the neck and shoulder area, offer the inside of the gown to the surgeon. He or she slips the arms into the sleeves. Release the gown. The surgeon holds arms outstretched while he circulator pulls the gown onto the shoulder and adjusts the sleeves so that cuffs are properly placed. In doing so, only the inside of the gown is touched at the seams.

Gloving:

Pick up the right glove, grasp it firmly, with the fingers under the everted cuff. Hold the palm of the glove toward the surgeon. Stretch the cuff sufficiently for the surgeon to introduce the hand. Avoid touching the hand by holding your thumbs out. Exert upward pressure as the surgeon plunges the hand into the glove. Unfold the everted glove cuff over the cuff of the sleeve. Repeat for the left hand. If a sterile vest is needed, hold it for the surgeon to slip the hands into the armholes. Be careful not to contaminate gloved at the neck level. If the gown is a wraparound, assist the surgeon.

Occasionally a contaminated gown must be changed during a surgical procedure. The circular unfastens the neck and waist. Grasped at the shoulders, the gown is always removed first. The gloves are removed using glove-to-glove and then skin-to-skin technique. If only the sleeve is contaminated, a sterile sleeve maybe put on over the contaminated one.

The gown is always removed before the gloves at the end of the surgical procedure. The circular unfastens the neck and back closures of the gown so the wearer does not contaminate his or her scrub suit. If wearing a wraparound gown, the wearer unfastens the waist closure n front. The gown is always removed inside out to protect the arms and scrub suit from contaminated outside of the gown. To remove: Grasp the right shoulder of the loosened gown with the left hand and pull the gown downward from the shoulder and off the right arm, turning the sleeve inside out. Turn the outside of the gown away from the body with flexed elbows. Grasp left shoulder with the right hand and remove the gown entirely pulling it off inside out. Discard in a laundry hamper or in a trash receptacle (if disposable).

Benedict’s Test

Planning/Implementation:

Gather equipment needed, as follows: Test tube (10 cc), Urine, Benedict’s solution (5ml), Medicine dropper, Alcohol Lamp, Test tube holder and Test tube rack. Put 5 ml of benedict’s solution into the  test tube. Heat over flame. Drop 3-5 cc of urine and boil. Leave the mixture to cool at room temperature. Read and interpret the result. Record the result.

Interpretation Color Glucose Present

Blue                                         Negative

Green                                      Trace

Green with yellow precipitate     +

Yellow to dark green                   + +

Brown                                          + + +

Orange                                         + + + +

Explain to the client the significance of the findings and give health teachings.

Gowning and Gloving: Drying Hands and Arms

Planning/Implementation:

After scrubbing, hands and arms must be thoroughly dried before the sterile gown is donned to prevent contamination of the gown by strike through of organisms from wet skin. The gown package for the scrub person contains one sterile gown, folded before sterilization, with the inside out, so that the bare scrubbed hands will not contaminate the sterile outside of the gown. A towel for drying the hands is placed on top of the gown during packing. The hands is placed on top of the gown during packing the Hands are dried as follows. Reach down to the opened sterile package and pick up the towel. Be careful not to drip water onto the pack. Be sure no one is within arm’s reach. Open the towel full-length, holding one end away from non-sterile scrub attire. Bend slightly forward to avoid letting the towel touch the attire. Dry both hands thoroughly but independently. To dry one arm, hold the towel in the opposite hand and, using an oscillating motion of the arm, draw the towel up to the elbow. Carefully revere the towel, still holding it away from the body. Dry the opposite hand arm on the unused (now uppermost) end of the towel.

Performing Postural Drainage

Assessment:

Listen to breath sound. Assess patient respiratory status. Observe the quality or characteristic of secretions. Identify what are the underlying complications. Note time of eating.

Planning/Implementation:

Gather materials needed, as follows: Pillows, Container for sputum, Hospital bed and towel. Establish the location of such lung segment. If the entire lung is to undergo chest physiotherapy, the most affected lobe or segment should be drained first. Protect patient from falling by keeping side rails up when possible. If possible, arrange for privacy during procedure. Stay with the patient during initial procedure. Administer treatment every two to four hours as ordered. Prepare patient by discussing certain exercises. Explain the importance of practicing PVD exercise after an operation to counteract affect of hypoventilation and to prevent complications. Demonstrate steps, allowing time fore patients practice. Place towel over skin to prevent reddened areas when performing. Instruct patient especially those with COPD, to perform diaphragmatic breathing with daily activities (sitting/walking) and to practice graded exercises to improve general physical fitness. Auscultate all lobes for adventitious sounds – prior to initiating PVD. Check chart for physicians order which is needed to perform postural drainage. Identify the specific segments of the lung, to be drained. Wash your hands for infection control. Proper poisoning of the patient. Placing one large or 2 small pillow to place under the patients hips to provide correct position. Obtain pillows and a sputum cup and tissues for the patient to use for expectorated secretions. Obtain clean gloves if the patient is unable to manage his/her secretions. Identify the patient to be sure you are performing the procedures for correct patient. Explain to the patient in the purpose and method of postural drainage, using the basic principles of health teaching. Position the patient. Drain the upper lobes. Have the patient sit up if possible. Have the patient lean to the right side. Have the patient lean forward at a 30º to 45º angle for 5 minutes. Have the patient lean backward at a 30º to 45º angle for 5 minutes. Have the patient lie in the abdomen, back and both sides while horizontal to drain the remaining segment of the upper lobes. Drain the lower lobes. Have the patient cough forcefully (lying on the abdomen) to expel secretions. Return the patient to a comfortable position after mouth care, and allow for a rest period.

Evaluation:

Coughing is more productive and effective. Lungs cleared for any breath sounds upon auscultation. Complications are prevented. Patient resting comfortably.

Performing Vibration

Assessment:

Listen to breath sound. Assess patient respiratory status. Observe the quality or characteristic of secretions. Identify what are the underlying complications. Note time of eating.

Planning/Implementation:

Gather materials needed, as follows: Pillows, Container for sputum, Hospital bed and towel. Establish the location of such lung segment. If the entire lung is to undergo chest physiotherapy, the most affected lobe or segment should be drained first. Protect patient from falling by keeping side rails up when possible. If possible, arrange for privacy during procedure. Stay with the patient during initial procedure. Administer treatment every two to four hours as ordered. Prepare patient by discussing certain exercises. Explain the importance of practicing PVD exercise after an operation to counteract affect of hypoventilation and to prevent complications. Demonstrate steps, allowing time fore patients practice. Place towel over skin to prevent reddened areas when performing. Instruct patient especially those with COPD, to perform diaphragmatic breathing with daily activities (sitting/walking) and to practice graded exercises to improve general physical fitness. Auscultate all lobes for adventitious sounds – prior to initiating PVD. Place your flattened hands, one over the other ( or side by side) against the affected chest area. Ask the client to inhale deeply through the mouth and exhale slowly through pursed lips of the nose. During the exhalation, straighten your elbow, and lean slightly against the clients chest while tesing your arm and shoulder muscles in isometric contractions. Vibrate during five rxhalations over one affected lung segment. Encourage the client’s lung and compare the findings to the baseline data. Auscultate the client’s lung and compare the findings to the baseline data. Document the percussion and vibration. Note the amount, color and character of expectorated secretions. Return the patient to a comfortable position after mouth care, and allow for a rest period.

Evaluation:

Coughing is more productive and effective. Lungs cleared for any breath sounds upon auscultation. Complications are prevented. Patient resting comfortably.

Performing Percussion

Assessment:

Listen to breath sound. Assess patient respiratory status. Observe the quality or characteristic of secretions. Identify what are the underlying complications. Note time of eating.

Planning/Implementation:

Gather materials needed, as follows: Pillows, Container for sputum, Hospital bed and towel. Establish the location of such lung segment. If the entire lung is to undergo chest physiotherapy, the most affected lobe or segment should be drained first. Protect patient from falling by keeping side rails up when possible. If possible, arrange for privacy during procedure. Stay with the patient during initial procedure. Administer treatment every two to four hours as ordered. Prepare patient by discussing certain exercises. Explain the importance of practicing PVD exercise after an operation to counteract affect of hypoventilation and to prevent complications. Demonstrate steps, allowing time fore patients practice. Place towel over skin to prevent reddened areas when performing. Instruct patient especially those with COPD, to perform diaphragmatic breathing with daily activities (sitting/walking) and to practice graded exercises to improve general physical fitness. Auscultate all lobes for adventitious sounds – prior to initiating PVD. Ensure that the area to be percussed is covered. Ask patient to beath slowly and deeply. Cup your hands hold your fingers and thumb together, and flex slightly to form a cup, as you would to scoop cup water. Relax your wrists, and flex your elbow. With both hands cupped, alternately flex and extend the wrists rapidly to slap the chest. Percuss each affected lung segment for 1-2 minutes. The percussing action should produce a hollow, popping sound when done correctly. Return the patient to a comfortable position after mouth care, and allow for a rest period.

Evaluation:

Coughing is more productive and effective. Lungs cleared for any breath sounds upon auscultation. Complications are prevented. Patient resting comfortably.

Administering Oxygen using Self Inflating Breathing Bag/Mask

Assessment:

Check airway patency. Assess patient’s respiratory status. Observe breathing pattern. Observe for signs of hypoxia. Check the physician’s immediate status. Identify the types of oxygen source in the facility.

Planning:

Plan for any assistance needed. Choose the appropriate equipment for the method of oxygen administration ordered. Gather the materials needed, as follows: Flow meter, Lubricant, Regulator, Connecting tube, Humidifier, Humidity tent/croup tent, Oxygen catheter, self-inflating bag, Oxygen mask, Pulse Oximeter, Nasal catheter, Sterile water, and Oxygen tank. Wash your hands. Check the innediate environment.

Implementation:

Identify the patient. Carefully and calmly explain what you are going to do. Connect flowmeter to the oxygen source. Attach humidifier filled with sterile water. Attach humidifier filled with sterile water. Attach the oxygen supply tube to the cannula, catheter or mask. Turn on oxygen and test flow by placing over hand. Allow 3 to 5 L oxygen to flow through the tubing. Proceed to specific procedure you are using. Assess patient for need for breathing assistance of for hyperoxygenation before suctioning. Wash your hands for asepsis. Obtain assistance if needed. Identify the patient. Explain to the patient what you are doing. Connect the mask to the oxygen supply and turn on the highest flow rate that does not cause the device to stick or jam. Apply the mask sbugly over the patient’s nose and mouth to form an occlusive seal. Compress the bag as completely as possible to force air into the patient’s nose and mouth. Release the bag to allow expiration. Count 1, 2, 3, 4. Repeat compression in a rhythmic pattern to provide ventilation at a rate of 12 breaths/minutes or for the desired number of deep breaths. Assess the effectiveness of the oxygen delivery. Explain safety precaution to the patient and significant others. Assess the patient’s nose and mouth and provides oronasal care. Stay with the patient. Post “oxygen in use” sign on the patient’s door. Check physician’s order to discontinue oxygen. Turn off the flow meter followed by the oxygen tank.

Evaluation:

Breathing pattern, regular and at normal rate. Pink color in nail, lips, conjuctiva, and eyes. No disorientation, confusion, difficulty with cognition. Patient resting comfortably. Laboratory measurement of arterial O2 concentration (PaO2) or Hgb O2 saturation (Hgsat) within normal limits.

Documentation:

Date and time O2 started. Method of delivery. Specific O2 concentration or flow rate in L/min. Subjective and objective

Administering Oxygen by Oxygen Humidity Tent

Assessment:

Check airway patency. Assess patient’s respiratory status. Observe breathing pattern. Observe for signs of hypoxia. Check the physician’s immediate status. Identify the types of oxygen source in the facility.

Planning:

Plan for any assistance needed. Choose the appropriate equipment for the method of oxygen administration ordered. Gather the materials needed, as follows: Flow meter, Lubricant, Regulator, Connecting tube, Humidifier, Humidity tent/croup tent, Oxygen catheter, self-inflating bag, Oxygen mask, Pulse Oximeter, Nasal catheter, Sterile water, and Oxygen tank. Wash your hands. Check the innediate environment.

Implementation:

Identify the patient. Carefully and calmly explain what you are going to do. Connect flowmeter to the oxygen source. Attach humidifier filled with sterile water. Attach humidifier filled with sterile water. Attach the oxygen supply tube to the cannula, catheter or mask. Turn on oxygen and test flow by placing over hand. Allow 3 to 5 L oxygen to flow through the tubing. Proceed to specific procedure you are using. Prepare the “tent” by attaching the metal frame to the bedsprings of the crib and suspending that canopy from the fame. Be certain that all access ports are closed. Tuck all sides of the canopy securely under the crib mattress. Ensure that the ice trough is filled with ice and the under jar with sterile water up to indicator liner. Attach the tent to the oxygen or compressed air source. Turn on the oxygen and adjust the flow rate to 15 L/min for about 15 minutes. Open the value that controls the mist output. Check the doctor’s order to see if it is to be left open continuously or partially or opened intermittently. Adjust the oxygen flow rate to the ordered level of oxygen after 15 minutes. Place the child in tent.  Assess the effectiveness of the oxygen delivery. Explain safety precaution to the patient and significant others. Assess the patient’s nose and mouth and provides oronasal care. Stay with the patient. Post “oxygen in use” sign on the patient’s door. Check physician’s order to discontinue oxygen. Turn off the flow meter followed by the oxygen tank.

Evaluation:

Breathing pattern, regular and at normal rate. Pink color in nail, lips, conjuctiva, and eyes. No disorientation, confusion, difficulty with cognition. Patient resting comfortably. Laboratory measurement of arterial O2 concentration (PaO2) or Hgb O2 saturation (Hgsat) within normal limits.

Documentation:

Date and time O2 started. Method of delivery. Specific O2 concentration or flow rate in L/min. Subjective and objective