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.

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.