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.