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.