Catheterization

Planning/Implementation:

Prepare the client and the equipment, as follows: flashlight or lamp, mask, if required by agency policy, bath blanket and drape, soap, a basin of warm water, a washcloth and towel, disposable gloves, a sterile catheterization kit containing: water-soluble lubricant, sterile gloves, sterile drapes, fenestrated drape(optional) to place over the perineum, antiseptic solution, cotton balls or gauze squares, forceps, basin for urine (base of kit can be used), sterile catheter of appropriate size (eg, for an adult # 14 or #16 is often used), speciemen container as required, bag or receptacle for disposal of the cotton balls. In addition to the equipment used for a straight catheterization, the following equipment is needed: Sterile retention catheter, Prefilled syringes, Nonallergenic tape or Velero, Safety pin or clip, Urine collection bag and tubing (the tubing maybe attached  to the retention catheter if a closed drainage system is used.

Explain to the client why the retention catheter is not to be inserted, how it will be in place, and the urinary drainage equipments need to be handled to maintain and facilitate the drainage of urine. Reassure the client that the procedure is painless. Some client fear spillage of urine when they experience the urge to void during insertion of the catheter and for a short period of time after the catheter is in place. Reassure this client’s that the catheter drains the urine and that the urge to void will disappear. Follow procedure as for straight catheterization up to and including draping the client with a sterile drape. Assist the client’s to a supine position, with knees flexed and thighs externally rotated. Pillow can be used to support the knees and to elevate the buttocks. Drape the client. Cover the client’s chest and abdomen with a black blanket. Pull the client’s gown up over her hips. Cover the client’s chest and abdomen with a bath blanket. Pull the client’s gown up over her hips. Cover her legs and feet as for perineal care. Don disposable gloves. Wash the perineal-genital with warm water and soap. Wear disposable gloves. Rinse and dry the area well. Remove disposable gloves. Obtain assistance if the client requires help in maintaining the required position. Test the catheter balloon. Attach the prefilled syringes to the balloon valve, and inject the fluid. The balloon should inflate appropriately are not leak. Withdraw the fluid and set aside the catheter with the syringe attached for later used. If the balloon leaks or does not inflate adequately, replace the catheter. In such a case, withdraw the fluid, and detach the syringe for later use. Ask another nurse to obtain a second catheter and open the package for you then test the new balloon. Remove the equipment, and obtain another catheter. Then begin again with the new sterile equipment. Follow up steps as for straight catheterization. Lubricate the insertion tip of the catheter. Remove the sterile cap from the specimen container. Expose and clean the urinary meatus and surrounding tissues. Insert the catheter and inflate the balloon. Collect a urine specimen as required. Move the catheter an additional 2.5 to 5 cm (1 to 2 in) beyond the point at which urine began to flow. The balloon of the catheter is located behind the opening at the insertion tip, and sufficient space needs to be provided to inflate the balloon. Inflate the balloon by injecting the contents of the prefilled syringe into the valve of the catheter. If the client complains of discomfort or during the balloon inflation, withdraw the fluid, insert the catheter a little farther, and inflate the balloon size indicates (eg, 5 ml), and remove the syringe. A special valve prevents backflow of the fluid out of the catheter. Follow the agency policy when using a 30 ml balloon. Some agency policies state that only 15 ml of fluid I injected for inflation. Ensure effective balloon inflation.

When the balloon is safely inflated, apply slight tension on the catheter until you feel resistance. Then, release the resistance on the catheter. This keeps the balloon from exerting undue pressure on the neck of the bladder. Anchor the catheter. Tape the catheter with non-allergenic tape to the inside of a female’s thigh or abdomen of a male client. Some nurses prefer taping the catheter to the abdomen whenever there is increased risk of penile scrotal excoriation. Establish effective drainage. Ensure that the emptying base of the drainage bag to the bed frame, using the hook or strap provided. Suspend the bag off the floor, but keep it below the level of the client’s bladder. Coil the drainage tubing loosely beside the client, so that the remaining tubing runs  in a straight line down to the drainage bag. Fasten the vertical tubing to the bedclothes with tape, a tubing clamp, or safety pin and elastic band.

Evaluation:

Document pertinent data. Record the time and date of the catheterization; type and size of catheter, the reason; number of ml of fluid used to inflate the balloon; assessment before and after the procedure, including amount, color, and clarity of urine obtained; whether all urine was emptied from the bladder, and the client’s response.

Administering Oral Medications

Assessment:

Compare medications listed against physician’s orders. Assess psychological and physical status, weight, age, height. Assess ability to swallow medications. Check form of medications available and computes for a safe dosage. Check which vehicles are available for mixing with medications.

Planning:

Plan a method of measuring medication accurately, making medication acceptable to patient, approaching patient appropriately, restraining, if necessary. Determine need for special preparation. Determine needed equipment. Wash hands observing proper technique. Gather needed equipment.

Implementation:

Read from chart/kardex the name of drug ordered. Take drug from shelf, drawer or cubicle, checking label before picking it up. Check label and expiry date on medication. Check label again, with the medication ticket before removing the medication from the container. Prepare correct amount of medication. Pour correct Amount to medicine cup, while keeping bottle facing up. Wipe neck of bottle before replacing cap. Return bottle to shelf, drawer, cubicle or refrigerator, checking label the third time. Place medication on cart or tray with medication card/ticket. Approach and identifies patient through wrist ID or letting him state his name. Explain what to do to patient or watcher and any pertinent specifies related to drug. Add appropriate planned actions related to making medication acceptable to patient. Assist, if necessary, to a comfortable position for taking the drug. Restrain, if necessary. Give medication with a glass of water or juice, if not contraindicated. Watch to make sure medications was properly taken. Leave patient in comfortable position. Perform appropriate aftercare of medication containers, trays and tickets. Wash hands.

Evaluation:

The right patient received the right medication in the right dosage by 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 effect, if present, were promptly identified and recorded. Necessary referrals were made.

Documentation:

Record appropriately according to the policy of the facility.

Changing IV Tubing

Assessment/Planning:

Gather all equipments, as follows: Administration set, Sterilize gauze, Tape or label, IV tubing, Sterile dressing and antiseptic, Clean disposable gloves and solutions ointment. 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. Open administration set and removes protective covering from infusion spike. Using sterile technique, insert into new container. Close clamp on new tubing. Hang IV container on pole and squeeze drip chamber to fill at least halfway. Remove cap at end of tubing, release clamp and allow fluid to move through tubing until air bubbles have disappeared. Close clamp and recap and tubing maintaining sterility of setup. Loosen tape at IV insertion site. Don clean, disposable gloves. Carefully remove dressing and tape. Place sterile gauze square under needle hub. Place new IV tubing to client’s IV site, and loosen protective cap. Clamp the old IV tubing. Steady the needle hub with nondominant hand until change is completed. Remove tubing with dominant hand using a twisting motion. Set old tubing aside. While maintaining sterility, carefully remove cap and insert sterile end of tubing into the needle hub. Twist to secure it. Remove soiled gloves. Open the clamp. Reapply sterile dressing to site according to agency protocol. Regulate the IV flow according to physician’s order. Attached to IV tubing tape or label that states date, time, and your initials. Label container and record procedure according to agency policy. Discard used equipment in proper manner and wash hands.

Evaluation:

Record client’s response to IV infusion.

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.