Administering Oxygen Therapy using Nasal Catheters

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 immediate 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. Ensure that tips of the nasal catheter touches the nasopharynx. Measure from the tip of the patient’s nose to the earlobe. Lubricate and insert catheter. Tape catheter in place. Adjust flow rate. 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

Changing IV Solution

Assessment/Planning:

Gather all equipments, as follows: IV solution as ordered by physician and bring to bedside. Check IV solution and medication additives with physician orders.

Implementation:

Explain procedure to client. Wash hands. Carefully remove protective cover from the new solution container and expose entry site. Close clamp on tubing. Lift container off IV pole and invert it. Quickly remove the spike from the old IV container being careful not to contaminate it. Steady new container and insert spike. Hang on IV pole. Reopen clamp on tubing and adjust flow. Label container according to agency policy. Record on intake and output record and document on chart according to agency policy. Discard used equipment in proper manner. Wash your hands.

Preparing and Administering Intravenous Infusions

Assessment/Planning:

Gather all equipments and bring to bedside, as follows: IV solution, IV pole, IV infusion set, tape, IV tubing, Dressing with betadine or other antiseptic ointment, Needle, tourniquet, arm board, antiseptic swabs, clean disposable gloves. Check IV solution and medication additives with physician orders.

Implementation:

Explain procedure to client. Wash your hands. Prepare IV solution and tubing. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag or bottle as manufacturer directs. Squeeze drp chamber and allow it to fill at least halfway. Remove cap at end of tubing, release clamp, and allow until all air bubbles have disappeared. Close clamp and recap end tubing maintaining sterility of set up. If an electronic device is to be used, follow manufacture’s instructions for inserting tubing and setting infusion rate. Have the client in a low fowler’s position in bed.

Select an appropriate site and palpate accessible veins. If the site is hairy and agency policy permits, shave a 2-inch area around the intended site of entry. Apply a tourniquet 5 to 6 inches above the venipuncture site to obstruct venous blood flow and distend the vein. Direct the ends of the tourniquet away from the site of entry. Check to be sure that the radial pulse is still present. Ask the client to open and close his or her fist. Observe and palpate for a suitable vein. Try the following techniques if the vein cannot be felt. Release the tourniquet and have the client lower his or her arm below the level of the heart to fill the vein. Reapply tourniquet and gently tap over the intended vein to help distend it. Remove tourniquet and place warm compress over the intended vein for 10 to 15 minutes. Don clean, disposable gloves. Cleanse the entry site with an antiseptic solution. Use a circular motion to move from the center outward for several inches. Use the nondominant hand; place about 1 inch or 2 inches below entry site, to hold the skin taut against the vein. Enter the skin gently with the needle held in dominant hand, bevel side-up, at a 30 to 45º angle, and when the needle is through the skin, lower the needle until it is nearby parallel to the skin. While following the course of the vein, advance the needle or catheter into the vein. A sensation of “give” can be felt when the needle enters the vein.

When blood returns to the lumen of the needle, advance the needle farther into the vein. The exact technique depends on the type of the needle used. With an angiocather, the needle is removed, leaving the catheter in place. Quickly remove protective cap from the IV tubing and attach the tubing to the catheter or needle. Stabilize the catheter or needle with nondominant hand and release the tourniquet with your hand. Start the flow of solution promptly by releasing the clamp on the tubing. Examine the tissue around the entry site for signs of infiltration. Support the needle with small piece of gauze under the hub, if necessary, to keep the needle properly positioned in the vein. An antiseptic ointment may be applied to the needle’s site of entry with a sterile dressing according to agency policy. Remove soiled gloves and discard appropriately. Loop the tubing nea the site of entry, and anchor with tape to prevent pull on the needle. Mark the date, time, and type and size of the needle used for the infusion on the tape anchoring the tubing. Anchor arm to an arm board to support, if necessary. Adjust the rate of solution flow according to the amount prescribed and follow manufacturer’s directions of adjusting flow rate on infusion pump. Remove all equipment. Wash hands.

Evaluation

Document the procedure and client’s response. Chart time, site, device used and solution. Return to check flow rate and observe for infiltration 30 minutes after starting infusion.

Complete Bed Bath

Assessment:

            Check the chart for any existing bath plan. Assess the patient to determine if there are other concerns of a higher priority than hygiene-like the need for toileting. Assess for current symptoms related to the medical diagnosis, for fatigue or pain, and for level of sedation. Assess also for hygiene preferences. Check to see whether needed special supplies or equipments are already in the room.

Planning:

            Determine whether or not you will need any assistance. Determine what supplies and equipment are needed. Wash hands. Don gloves if necessary. Obtain the needed supplies.

Implementation:

            Identify the patient. Explain to the patient what you plan to do and how he or she can participate. Prepare equipment supplies and materials and arrange them with paper lining conveniently for use on the bedside chair or over bed table. Raise the bed at a convenient working level. Ensure privacy throughout the procedure. Make sure that the room is free from drafts. Close windows and doors or put off electric fans if any. Get patients vital signs.

Oral Care:

            Assist the client to a sitting position in bed, if health permits. If not, assist the client to aside-lying position with the head on a pillow so that the client can spit out the rinse water. Place a towel under the patient’s chin, tucking it behind the shoulders. Don gloves. Moisten the toothbrush with water from a glass and spread a small amount of toothpaste on it. If no cleansing agent is adequate. Baking soda and mouth wash which are substitutes that also freshen the breath.

            Brush the teeth or hand the brush to the client as follows: Hold the brush at 45º angle; use a small, vibrating, and circular motion with the bristles at the junction of the teeth and gums. Use the same action on the front and the back of the teeth. Use a back-and-forth brushing motion over the biting surfaces of the teeth. Brush the tongue. Allow the patient to rinse the mouth with water, followed by a mouth wash and floss if desired. Wipe patient’s mouth then remove towel on chin afterwards. Rinse equipment and return to its appropriate place. Return bed to low position.

Hair Shampoo

            Loosen linen at foot of bed. Place bath blanket over top sheet and unfold it so that the linens are fully covered. With the client holding the edge of the bath blanket, gently withdraw the top sheet toward the foot of the bed. If top sheet is to be reused, fold it for replacement later, and place in a clean surface. If not, dispose in laundry bag taking care that the linen does not come in contact with your uniform. Assist the client to move near you. Remove client’s gowns or pajamas, keeping the bath blanket over the client. If patient can tolerate, remove pillow. Bring patients head near the edge of the bed. Place waterproof pad under client’s shoulders, neck and head. Place plastic trough spout under head and wash basin at the end of trough, being sure that trough spot extends beyond edge of mattress and runs into wash basin. Place rolled towel under neck and bath towel across shoulders.

Brush and comb hair. Ask client to hold clamp wash cloth over eyes. Place cotton balls in the clients ears. With water pitcher slowly pour water over hair until it is completely wet. Apply diluted shampoo to the scalp. Make a good lather with the shampoo while massaging the scalp with the pads of your fingertips. Massage all areas of the scalp systematically. Rinse the hair thoroughly to remove all the shampoo. Reapply shampoo when needed. Squeeze as much water as possible out of the hair with your hands. Dry the hair thoroughly. Rub the client’s hair then wrap with bath towel. Comb hair to remove tangles. Assist client to comfortable position and complete combing of hair. Invite a parent or family member to participate if desired. Close the window and doors to make sure that the room provide privacy by drawing the curtains or closing the doors. Offer the client a bedpan or urinal or ask whether the client wishes to use the toilet or commode. During the bath, asses each area of the skin carefully. Prepare the bed, and position the client appropriately. Place the bed in the high position. Place an infant or small child on a changing table or elevated crib.

            Remove the top bed linen, and replace it with the bath blanket. If the bed linen is to be reused, place it over the bedside chair. If it is to be changed place it in the linen hamper. Assist the client to move near you. Remove the gown. Make a bath mitt with the washcloth. Wash the face. Place one towel across the client’s chest. Wash the client eyes with water only and dry them well. Use a separate corner of the washcloth for each eye. Wipe from the inner to the outer canthus. Ask whether the client wants soap use on the face. Wash, rinse and dry the client’s face, neck and ears. Wash the arms and hands. Wash the legs and feet. Wash the back and then the perineum. Assist the client with the grooming aid such as powder, lotion or deodorant. Document data.

Preparing a Surgical Bed

Strip the bed. Place and leave the pillows on the bedside chair. Apply the bottom lines as for an occupied bed. Place a bath blanket on the foundation of the bed, if this is an agency practice. Place the top covers of the bed as you would for an unoccupied bed. Do not tuck them in, miter the corners, or make a toe pleat. Make a cuff at top of the bed as you would for an unoccupied bed. Fold the top linens up from the bottom. On the side of the bed where the client will be transferred, fold up the two outer corners of the top linens so they meet in the middle of the bed forming a triangle. Pick up the apex of the triangle, and fanfold the top linens lengthwise to the other side of the bed. Leave the bed in high position with the side rails down. Lock the wheels of the bed if the bed is not to be moved.

Changing an Unoccupied Bed

Assessment:

            Assess client’s health status to determine that the person can safely get out of bed and the client’s pulse and respirations, if indicated. Note all the tubes and equipment connected to the client.

Planning:

            Assemble all equipments and supplies: Two flat sheets, or one fitted and one flat sheet. Cloth drawsheet (optional), One blanket, One bedspread, Waterproof drawsheet or waterproof draw pads (optional), Pillowcases for the head pillows and Plastic laundry bag or portable linen hamper, if available.

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. Place the fresh linen on the client’s chair or overbed table; do not use another client’s bed. Assess and assist the client out of bed. Make sure that this is an appropriate and convenient time for the client to be out of bed. Assist the client to a comfortable chair. Strip the bed.

Check bed linen for any items belonging to the client, and detach the call bell or any drainage tubes from the bed linen. Loosen all bedding systemically, starting at the head of the bed on the far side and moving around the bed up to the head of the bed on the near side. Remove the pillowcases, if soiled and place the pillows on the bedside near the foot of the bed. Fold reusable linens, such as the bedspread and top sheet on the bed, into fourths. First, fold the linen in half by bringing the top edge even with the bottom edge, and then grasp it at the center of the middle fold and bottom edges. Remove the waterproof pad and discard it, if soiled. Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it directly in the linen hamper. Grasp the mattress securely, using the lugs, if present, and move the mattress up to the head of the bed.

Apply the bottom sheet and drawsheet. Place the folded bottom sheet with its center fold on the center of the bed. Make sure the sheet is hem-side down for a smooth foundation. Spread the sheet out over the mattress, and allow a sufficient amount of sheet at the top to tuck under the mattress. Miter the sheet at the top comer on the near side and tuck the sheet under the mattress, working from the head of the bed to the foot. If a waterproof drawsheet is used, place it over the bottom sheet so that the center fold is a the center line of the bed and the top and bottom edges extend from the middle of the client’s back to the area of the mid-thigh or knee. Fanfold the uppermost half of the folded drawsheet at the center or far edge of the bed, and tuck in the near edge.

Lay the cloth drawsheet over the waterproof sheet in the same manner. Before moving to the other side of the bed, place the top linens on the bed hem-side up, unfold them, tuck them in, and miter the bottom corners. Move to the other side and secure the bottom. Move to the other side and secure the bottom linens. Tuck in the bottom sheet under the head of the mattress, pull the sheet firmly, and miter the corner of the sheet. Pull the remainder of the sheet firmly so that there are no wrinkles. Complete this same process for the drawsheets(s). Apply or complete the top sheet, blanket and spread. Place the top sheet, hem side-up, on the bed so that its center fold is at the center of the bed and the top edge is even with the top edge of the mattress.

Unfold the sheet over the bed. Make a vertical or a horizontal toe pleat in the sheet to provide additional room for the client’s feet. Vertical toe pleat- Make a fold in the sheet 5-10 cm (2-4 in) perpendicular to the foot of the bed. Horizontal toe pleat -Make a fold in the sheet 5-10 cm (2-4 in) across the bed near the foot. Follow the same procedure for the blanket and the spread, but place the top edges about 15 cm (6 in) from the head of the bed to allow cuff of sheet to be folded over them Tuck in the sheet, blanket and spread at the foot of the bed, and miter the corner, using all three layers of linen. Leave the sides of the top sheet, blanket, and spread hanging freely, unless toe pleats were provided. Fold the top of the top sheet down over the spread, providing a cuff. Move to the other side of the bed, and secure the top bedding in the same manner.

Put clean pillowcases on the pillows as required. Grasp the closed end of the pillowcase at the center with one hand. Gather up the sides of the pillowcase, and place them over the hand grasping the case. Then grasp the center of the one short side of the pillow through the pillowcase. With the freehand, pull the pillowcase over the pillow. Adjust the pillowcase so that the pillow fits into the corners of the case and the seams are straight. Place the pillows appropriately at the head of the bed.

Provide for client comfort and safety. Attach the signal cord so that the client can conveniently use it. If the bed is currently being used by a client, either fold back the top covers at one side or fanfold them down to the center of the bed. Place the bedside table and the overbed table so that they are available to the client. Leave the bed in the high position if the client is returning by stretcher, or place in the low position if the client is returning to bed after being up. Document and report pertinent data.

Positioning Clients Bed

Assessment:

            Check the client’s physical abilities such as, the ability to understand instructions, degree of comfort or discomfort when moving. If needed, administer analgesics or perform other pain-relief measure, client’s weight and your own strength and ability to move the client.

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:

            Assemble equipment and supplies, and assistive devices such as overhead trapeze, pull and/ or turn sheet, and transfer or sliding bar.

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. Adjust the bed and the client’s position. Adjust the head of the bed to a flat position, or as low as the client can tolerate. Raise the bed to the height of your center of gravity. Lock the wheels on the bed, and raise the rail on the side of the bed opposite you. Remove all pillows, then place one against the head of the bed. Elicit the client’s help in lessening your workload. Ask the client to flex the hips and knees to position the feet so that they can be used effectively for pushing. Ask the client to grasp the head of the bed with both hands and pull during the move or raise the upper part of the body on the elbows and push with the hands and forearms during the move or grasp the overhead trapeze with both hands and lift and pull during the move. Position yourself appropriately, and move the client. Ensure client comfort.

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.

Assessing an Apical-Radial Pulse

Explain the procedure to the patient especially if two nurses are taking the pulse. Position the client appropriately. Assist the client to assume the position described for taking the apical pulse. If previous measurements were taken, determine what position the client assumed, and use the same position. Locate the apical and radial pulse sites. In the two-nurse technique, one nurse locates the apical impulse by palpation or with the stethoscope while the other nurse palpates the radial pulse site. Count the apical and radial pulse rates.

One-Nurse Technique

            Assess the apical pulse for 60 seconds. Assess the radial pulse for 60 seconds. Document and report pertinent assessment data. Promptly report to the nurse in charge any notable changes from previous measurement or any discrepancy between the two pulses. Document the apical and radial (AR) pulse rates, rhythm, volume, and any pulse deficit. Record any other pertinent observations such as pallor, cyanosis, or dyspnea. Check the physician’s order for any directions related to a discrepancy in the AR pulse rates.

            Prepare and position the client appropriately. Make sure the client has not smoke or ingested caffeine within 30 minutes prior to measurement. Make sure that the bladder of the cuff encircles at least two-thirds of the arm and the width of the cuff is appropriate. Position the client in a sitting position unless otherwise specified. Expose the upper arm. Wrap the deflated cuff evenly around the upper arm. Apply the center of the bladder directly over the medial aspect of the arm. This is the client’s initial examination; perform a preliminary palpatory determination of systolic pressure. Palpate the brachial artery with the fingertips. The brachial artery is normally found medially in the antecubital space. Close the valve on the pump by turning the knob clockwise. Pump up the cuff until you no longer feel the brachial pulse. Note the pressure on the sphygmomanometer at which the pulse is no longer felt. Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurements. Position the stethoscope appropriately. Insert the ear attachments of the stethoscope in your ears so that they tilt slightly forward. Ensure the stethoscope hangs freely from the ears to the diaphragm. Place the diaphragm of the stethoscope over the brachial pulse. Use the bell-shaped diaphragm. Hold the diaphragm with the thumb and index finger. Auscultate the client’s blood pressure. Pump up the cuff until the sphygmomanometer registers about 30 mm Hg above the point where the brachial pulse disappeared. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mm Hg per second. Deflate the cuff rapidly and completely. Wait 1 to 2 minutes before making further determinations. Repeat the above steps once or twice as necessary to confirm the accuracy of the reading. Remove the cuff from the client’s arm.

           Evaluation Focus on the blood pressure in relation to baseline data, normal range for age, and health status, relationship to pulse and respiration. Record on appropriate forms/sheets according to hospital policy. Report any abnormal findings to the appropriate person.

Taking Pulse

Assessment:

            Assess appropriate site to obtain pulse. Check pulse with health status changes. Assess for rate, rhythm, pattern, and volume. Take an apical pulse on patients with irregular rhythms or those on heart medications. Take an apical-radial pulse when deficits occur between apical and radial measurements.

Planning:

            To determine if the pulse rate is within normal range and if the rhythm is regular. Evaluate the quality of corresponding arterial pulses. To determine presence of peripheral pulses when palpation is ineffective. To monitor and evaluate changes in the patients health status.

Intervention:

            Position the client appropriately. Demonstrate the procedure to child using a stuffed animal or doll, and allow the child to handle the stethoscope before beginning the procedure. Expose the area of the chest over the apex of the heart. Locate the apical pulse. Palpate the angle of Louis (the angle between the manubrium the top of the sternum). Place your index finger just to the left of the client sternum, and palpate the second intercostals space. Place your middle or next finger in the third intercostals space, and continue palpating downward until you locate the apical pulse, usually about the fifth intercostals space. Auscultate and count heartbeats. Use antiseptic wipes to clean the earpiece and diaphragm of the stethoscope if their cleanliness is in doubt. Warm the diaphragm of the stethoscope by holding it in the palm of the hand for a moment. Insert the earpieces of the stethoscope into the ears. Place the diaphragm of the stethoscope over the apical impulse and listen for normal S1 and S2 heart sounds, which are heard as “lub dub”. Count the heartbeat for 30 seconds and multiply by 2 if the rhythm is irregular or if the apical impulse is being taken on an infant or child. Assess the rhythm and the atrength of the heartbeat. Assess the rhythm of the heartbeat by noting the pattern of intervals between the beats. As normal pulse has an equal time period between the beats. Assess the strength (volume) of the heartbeat. Document and report pertinent assessment data. Record the pulse site and rate, rhythm, and volume. Report to the nurse in charge any pertinent data such as pallor, cyanosis, dyspnea, tachycardia, bradycardia, irregular rhythms, and reduced strength of the heartbeat.