Skills

Nursing Skill Procedures

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Nursing Skills Procedure Manual

Lahore School of Nursing The University of Lahore


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Contributor: Farzana Iqbal Hina Adeel Kousar Parveen (Instructor) (Instructor) (Instructor)

Principal:

Muhammad Afzal


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Table of ContentsSr. No 1 Contents Vital Signs 1.Body Temperature a. Taking oral Temperature b. Taking axillary Temperature c. Taking rectal Temperature 2.Pulse a. Taking radial pulse 3.Respiration 4.Blood pressure Bed making Performing Oral Care Administration of Medicine Simple Enema Inserting a Flatus Tube Care for Nasal-gastric Tube 1. Inserting a Nasal-Gastric Tube 2. Removal a Nasal-Gastric Tube 3. Administering a Nasal-Gastric tube feeding Colostomy Care 1.Feeding via a Gastrostomy and Jejunostomy feeding tube 2.Administering Bolus Feeds 2.Colostomy Irrigation Urinary catheterization 1.Female Urinary Catheterization 2.Male Urinary Catheterization 3.Supra-pubic Urinary Catheterization Performing Surgical Dressing 1. Cleaning a wound and applying surgical dressing I V Cannulation Starting an Intravenous Infusions 1.Maintenence of IV system 2. Changing of IV system Specimen Collection 1. Collecting blood specimen a. Performing Venipuncture b. Assisting in obtaining blood for culture 2. Collecting urine specimen a. Collecting a single voided specimen b. Collecting a 24-hour urine specimen c. Collecting a urine specimen from a retention catheter d. Collecting a urine culture 3. Collecting a stool specimen Application of Restrains Monitoring blood Glucose level Mixing insulin in one syringe Administering Oxygen Assisting a client in ambulation Page No. 06 06 06 09 11 14 17 19 24 27 30 34 37 39 39 47 49 54 54 58 61 66 66 73 79 85 85 91 95 102 105 109 110 110 115 119 119 122 125 128 131 134 137 140 144 152

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Using an Inhaler Using a Nebulizer Performing Nasopharyngeal and Orophsaryngeal Suctioning Performing Adult Cardiopulmonary Resuscitation Assisting with a Lumber Puncture Teaching patient to use an Incentive Spirometer Obtaining an arterial blood specimen for blood gas analysis Eye Care a. Contact lens removal b. Artificial eye removal Performing range of motion exercises

155 158 162 169 174 179 183 189 189 194 200


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I. Basic Nursing Care/ Skill


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Taking Vital Signs Temperature, Pulse, Respiration, Blood pressureDefinition: Taking vital signs are defined as the procedure that takes the sign of basic physiology that includes temperature, pulse, respiration and blood pressure. If any abnormality occurs in the body, vital signs change immediately. Purpose: 1) To assess the clients condition 2) To determine the baseline values for future comparisons 3) To detect changes and abnormalities in the condition of the client Equipments required: 1 2 3 4 5 6 7 8 9 Oral/ axilla / rectal thermometer Stethoscope Sphygmomanometer with appropriate cuff size Watch with a second hand Spirit swab or cotton Sponge towel Paper bag Record form Ball- point pen: blue black red 10 Steel tray: to set all materials 1 1 1 1 1 1 1 3 1 1 1 1

a. Taking Oral Temperature by Glass ThermometerDefinition: Measuring/monitoring patients body temperature using clinical thermometer Purpose: 1) To determine body temperature 2) To assist in diagnosis 3) To evaluate patients recovery from illness 4) To determine if immediate measures should be implemented to reduce dangerous elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patients response once heat conserving or heal reducing measures have been implemented No. Procedure Rationale 1 Place the patient in a comfortable To ensure comfort and accuracy of position temperature reading 2 Wash hands To reduces transmission of micro organisms 3 Hold the stem end of the glass To reduce contamination of thermometer thermometer with finger tips bulb


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Rinse the thermometer in cold water if it is in a disinfectant solution Take wet swabs and wipe thermometer toward fingers in rotating fashion. Dispose of the swab Read mercury level while holding thermometer at eye level and gently rotating it If mercury is above the desired level, securely grasp tip and stand away from solid objects. Sharply flick wrist downward as through cracking a whip. Continue shaking until reading is below 35.5C or 96F Ask the patient to open mouth, and gently place thermometer under tongue in posterior or sublingual pocket, lateral to the centre of the lower jaw Ask the patient to hold thermometer under tongue with lips closed. Caution against biting it. Leave the thermometer inside for 2-3 minutes Carefully remove the thermometer and read at eye level. Inform the patient about this temperature reading Wipe the thermometer with wet cotton swab. Wipe in rotating fashion from fingers, toward bulb Wash the thermometer in cold water, dry and put it , after disinfection , in storage container Wash hands Remove and replace the other articles, after use, in their proper places Record the temperature in the TPR chart and inform the abnormalities to ward sister

To remove solution irritating to oral mucosa To reduce contamination of bulb end

Thermometer reading must be below body temperature before use

Heat from blood vessels in sublingual pocket produces temperature reading

To ensure safety. Breaking of thermometer causes mercury poisoning To allow time for expansion of mercury To ensure accuracy To promote patient participation From the least area of contamination to the most contaminated area To prevent infection. To prevent breakage To reduce transmission of infection For easy availability for next use To detect disease condition earlier


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Procedure Checklist: a. Taking Oral Temperature by Glass ThermometerCheck () Yes or No No 1 2 3 4 5 6 7 Procedure Yes Place the patient in a comfortable position Wash hands Hold the stem end of the glass thermometer with finger tips Rinse the thermometer in cold water if it is in a disinfectant solution Take wet swabs and wipe thermometer toward fingers in rotating fashion. Dispose of the swab Read mercury level while holding thermometer at eye level and gently rotating it If mercury is above the desired level, securely grasp tip and stand away from solid objects. Sharply flick wrist downward as through cracking a whip. Continue shaking until reading is below 35.5C or 96F Ask the patient to open mouth, and gently place thermometer under tongue in posterior or sublingual pocket, lateral to the centre of the lower jaw Ask the patient to hold thermometer under tongue with lips closed. Caution against biting it. Leave the thermometer inside for 2-3 minutes Carefully remove the thermometer and read at eye level. Inform the patient about this temperature reading Wipe the thermometer with wet cotton swab. Wipe in rotating fashion from fingers, toward bulb Wash the thermometer in cold water, dry and put it , after disinfection , in storage container Wash hands Remove and replace the other articles, after use, in their proper places Record the temperature in the TPR chart and inform the abnormalities to ward sister No Comments

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Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________


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b. Taking Axillary Temperature by Glass ThermometerDefinition:Measuring/monitoring patients body temperature using clinical thermometer

Purpose:1) 2) 3) 4) To determine body temperature To assist in diagnosis To evaluate patients recovery from illness To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patients response once heat conserving or heat reducing measures have been implemented

No. 1

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Procedure Bring the articles to the bed side. These are the same as the ones used for oral temperature Screen the bed or close the door Make the patient lying in supine position or sitting Move clothing away from shoulder or arm Repeat steps 2 to 6 used in taking oral temperature Insert thermometer into the center of axilla, lower arm over thermometer and place it across patients chest Hold the thermometer for 5 minutes in axilla Remove the thermometer and swab it with a wet swab, from fingers towards bulb. Dispose of the swab in paper bag Read the thermometer at eye level Inform the patient about this temperature reading Wash the thermometer with soap or soapy swab and rinse it in cold water Disinfect , dry and keep it in storage container Assist the patient in putting on his clothes and put him in a comfortable position Record it in the chart and report, if any abnormality is noticed, to ward sister Wash hands

Rationale For easy availability

To provide privacy. Embarrassment is minimized To provide easy access to axilla For easy exposure of axilla

Maintains proper position

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To ensure accuracy of reading To avoid contact with microorganisms

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To ensure accuracy To give him awareness about his condition To assure cleanliness To prevent breakage To ensure comfort

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For early detection of disease condition and for prompt treatment To prevent transmission of micro organisms


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Procedure Checklist: b. Taking Axillary Temperature by Glass ThermometerCheck () Yes or No No 1 Steps of procedure Bring the articles to the bed side. These are the same as the ones used for oral temperature Screen the bed or close the door Make the patient lying in supine position or sitting Move clothing away from shoulder or arm Repeat steps 2 to 6 used in taking oral temperature Insert thermometer into the center of axilla, lower arm over thermometer and place it across patients chest Hold the thermometer for 5 minutes in axilla Remove the thermometer and swab it with a wet swab, from fingers towards bulb. Dispose of the swab in paper bag Read the thermometer at eye level Inform the patient about this temperature reading Wash the thermometer with soap or soapy swab and rinse it in cold water Disinfect , dry and keep it in storage container Assist the patient in putting on his clothes and put him in a comfortable position Record it in the chart and report, if any abnormality is noticed, to ward sister Wash hands Yes No Comments

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c. Taking Rectal Temperature by Glass ThermometerDefinition:Measuring/monitoring patients body temperature using clinical thermometer

Purpose:1) 2) 3) 4) To determine body temperature To assist in diagnosis To evaluate patients recovery from illness To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5) To evaluate patients response once heat conserving or heal reducing measures have been implemented

No. 1 2 3 4 5 6 7 8

Procedure Screen the patient Upper body and lower extremities should be covered with a sheet Put the patient in left lateral-position. It exposes only anal area Repeat steps 2-6 of oral temperature measurement Separate buttocks to expose anus and clean it if needed Ask the patient to breathe slowly and relax Lubricate the rectal thermometer Insert thermometer bulb 0.5 inch for infant and 1.5 inch for adults into rectum Keep the thermometer inside for two minutes

Rationale To provide privacy To prevent unnecessary exposure To expose area for placing rectal thermometer To have minimum exposure To ensure proper exposure of anus To relax anal sphincter For easy insertion and to prevent trauma to rectal mucosa Ensures adequate exposure against blood vessels in rectal wall To ensure accuracy of reading

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Carefully remove thermometer and wipe it with wet cotton swabs to remove faecal matter and Vaseline Put the swabs into paper bag Read temperature, holding the thermometer at the eye level Record the temperature in the chart and report to ward sister if any abnormalities are detected Take the articles to the utility room, clean and keep them in their respective storage containers and places Make the patient comfortable and let him know about this temperature

To ensure cleanliness

To prevent transmission of micro organisms To ensure accuracy in reading For easy management of patient

For easy availability at any time. To prevent breakage To ensure comfort To gain patients cooperation


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Procedure Checklist c. Taking Rectal Temperature by Glass ThermometerCheck () Yes or No No Steps of Procedure Yes 1 Screen the patient 2 Upper body and lower extremities should be covered with a sheet 3 Put the patient in left lateral-position. It exposes only anal area 4 Repeat steps 2-6 of oral temperature measurement 5 Separate buttocks to expose anus and clean it if needed 6 Ask the patient to breathe slowly and relax 7 Lubricate the rectal thermometer 8 Insert thermometer bulb 0.5 inch for infant and 1.5 inch for adults into rectum 9 Keep the thermometer inside for two minutes 10 Carefully remove thermometer and wipe it with wet cotton swabs to remove faecal matter and Vaseline 11 Put the swabs into paper bag 12 Read temperature, holding the thermometer at the eye level 13 Record the temperature in the chart and report to ward sister if any abnormalities are detected 14 Take the articles to the utility room, clean and keep them in their respective storage containers and places 15 Make the patient comfortable and let him know about this temperature No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: ____________________________________


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d. Measuring a Radial PulseDefinition:Checking presence, rate, rhythm and volume of throbbing of artery

Purpose:1) 2) 3) 4) To determine number of heart beats occurring per minute (rate) To gather information about heart rhythm and pattern of beats To evaluate strength of pulse To assess heart's ability to deliver blood to distant areas of the blood viz. fingers and lower extremities 5) To assess response of heart to cardiac medications, activity, blood volume and gas exchange 6) To assess vascular status of limbs

General instructions for taking pulse: 1) Pulse should not be taken immediately after exercise, in emotional stress or during or after a painful treatment. 2) Count pulse for one full minute, especially when there is irregularity. 3) Observe rate, rhythm, volume and tension of pulse 4) Record pulse immediately 5) Choose suitable site for taking pulse


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Procedure Before taking pulse, consider factors that normally influence pulse character, e.g., age, exercise Explain the procedure to the patient and courage him to relax. Prepare the needed articles pen, pencil, wrist watch with seconds hand, chart Wash hands Place the patient in supine position. Place forearm across the chest, with wrist extended and palm down Place tips of first two fingers of your hand over groove, along radial or thumb side of patients inner wrist Lightly compress against radius After pulse is felt regularly, look at watchs seconds hand and begin to count rate. Start counting with zero, one and so on. Count pulse for full one minute, if irregular, otherwise, 30 seconds, and multiply total by 2. Determine strength of pulse, note thrust of vessel against finger tips Palpate with two fingers, along course of artery, to ward wrist, to determine elasticity of arterial wall Put the patient in a comfortable position Write down the result immediately Remove the articles and keep them their respective places

Rationale To have accurate assessment of pulse

To reduce anxiety and activity To avoid delay To prevent transmission of micro organisms To have proper exposure of artery for palpation Finger tips are more sensitive for palpation. Thumb has pulsation that may interfere with accuracy To count only after timing

To ensure accuracy 30 seconds check is most accurate Strength reflects volume To have an idea about peripheral vascular system To ensure a sense of well-being To avoid errors For easy availability next time


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Procedure Checklist d. Measuring a Radial PulseCheck () Yes or No No 1 Step of procedure Yes Before taking pulse, consider factors that normally influence pulse character, e.g., age, exercise Explain the procedure to the patient and courage him to relax. Prepare the needed articles pen, pencil, wrist watch with seconds hand, chart Wash hands Place the patient in supine position. Place forearm across the chest, with wrist extended and palm down Place tips of first two fingers of your hand over groove, along radial or thumb side of patients inner wrist Lightly compress against radius After pulse is felt regularly, look at watchs seconds hand and begin to count rate. Start counting with zero, one and so on. Count pulse for full one minute, if irregular, otherwise, 30 seconds, and multiply total by 2. Determine strength of pulse, note thrust of vessel against finger tips Palpate with two fingers, along course of artery, to ward wrist, to determine elasticity of arterial wall Put the patient in a comfortable position Write down the result immediately Remove the articles and keep them their respective places No Comments

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e. Counting RespirationDefinition:Monitoring the involuntary process of inspiration and expiration in a patient

Purposes:1) To determine number of respiration occurring per minute 2) To gather information about rhythm and depth 3) To assess response of patient to any related therapy/medication

No. 1 2 3 4 5 6

Procedure If the patient has been active, wait 510 mints. Make the patient comfortable in the bed in fowlers or sitting position Prepare the articles; watch having seconds hand, pen and chart. Provide privacy and wash hands Expose the chest of patient Place the patients arm across lower chest and your hand over his upper abdomen Observe completely, one inspiration and expiration Then, look at the watch and count the respiration for one full minute. Note the depth of respiration by observing chest wall movement while counting rate. Note rhythm of inspiration and expiration Redress the patient and cover him with bed linen Wash hands Inform the patient against his respiration Record it in the chart and report to the ward sister if any abnormalities are detected

Rationale Activity increases respiratory rate and depth An erect, sitting position promotes easy respiration

To prevent transmission of micro organisms To ensure proper exposure to observe the movements of the chest and abdominal wall Hand rises and falls during respiration

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To ensure rate To ensure accuracy To assess disease condition

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Alteration shows disease condition To provide comfort Reduces transmission of micro organisms To ensure understanding of his health- status To ensure accuracy and to give proper treatment


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Procedure Checklist e. Counting RespirationCheck () Yes or No No 1 2 3 4 5 6 Procedure Yes If the patient has been active, wait 5-10 mints. Make the patient comfortable in the bed in fowlers or sitting position Prepare the articles; watch having seconds hand, pen and chart. Provide privacy and wash hands Expose the chest of patient Place the patients arm across lower chest and your hand over his upper abdomen Observe completely, one inspiration and expiration Then, look at the watch and count the respiration for one full minute. Note the depth of respiration by observing chest wall movement while counting rate. Note rhythm of inspiration and expiration Redress the patient and cover him with bed linen Wash hands Inform the patient against his respiration Record it in the chart and report to the ward sister if any abnormalities are detected No Comments

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f. Measuring Blood PressureDefinition:Monitoring blood pressure using palpation and/or sphygmomanometer

Purpose:1) 2) 3) 4) To obtain baseline data for diagnosis and treatment To compare with subsequent changes that may occur during care of patient To assist in evaluating status of patients blood volume, cardiac output and vascular system To evaluate patients response to changes in physical condition as a result of treatment with fluids or medications


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No. 1

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Procedure Explain the procedure to the patient and put him in a comfortable position, either lying down with the arm resting on the bed or sitting with the arm supported on the table at heart-level. Determine the best site for applying the cuff. Dont use bandaged arm or arm with I.V. infusion or an injured arm Bladder and cuff bladder should completely encircle arm without overlapping Place the patient in a sitting or lying position Wash hands Place the patients base upper arm at heart level with palm turned up. Expose the upper arm by removing clothing Palpate brachial artery, place the central bladder above the artery

Rationale To ensure comfort To ensure accurate reading To gain cooperation

Inappropriate selection will not give accurate reading and will cause pain and discomfort to patient To ensure proper reading of blood pressure

To ensure comfort To reduce transmission of micro-organisms To ensure proper reading To ensure proper application of cuff To ensure application of pressure

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Wrap the cuff evenly around upper arm; see step 3.

Loose filling cuff shows false readings

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Place the manometer vertically at eye level

To ensure accurate reading


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Close the valve, deflate the cuff and palpate the radial artery. Pump up air in the cuff until the sphygmomanometer at which the radial pulsation Place the stethoscope earpieces in ears and place its bell over brachial artery in cubital fossa Close valve of pressure bulb clockwise until tight Slowly release valve and allow mercury to fall. Note the point on manometer when first clear sound is heard Continue to deflate the cuff gradually when the sound becomes the muffled and disappears Deflate the cuff rapidly and completely

To identify approximate systolic pressure

To ensure proper hearing

To prevent air leak during inflation First sound indicates systolic pressure

It indicates diastolic pressure

Continuous inflation causes arterial occlusion

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Place the patient in a comfortable position Tell him about his blood pressure Wash hands Record blood pressure in nurses notes and, if any abnormalities are there, report them to ward sister. Keep the stethoscope Sphygmomanometer at proper place in the box

To ensure comfort To give him information about his condition To reduce transmission of micro-organisms To ensure accuracy and proper treatment

To ensure safety of the instrument


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Procedure Checklist f. Measuring Blood PressureCheck () Yes or No No 1 Steps of Procedure Explain the procedure to the patient and put him in a comfortable position, either lying down with the arm resting on the bed or sitting with the arm supported on the table at heart-level. Determine the best site for applying the cuff. Dont use bandaged arm or arm with I.V. infusion or an injured arm Bladder and cuff bladder should completely encircle arm without overlapping Place the patient in a sitting or lying position Wash hands Place the patients base upper arm at heart level with palm turned up. Expose the upper arm by removing clothing Palpate brachial artery, place the central bladder above the artery Wrap the cuff evenly around upper arm; see step 3 Place the manometer vertically at eye level Close the valve, deflate the cuff and palpate the radial artery. Pump up air in the cuff until the sphygmomanometer at which the radial pulsation Place the stethoscope earpieces in ears and place its bell over brachial artery in cubital fossa Close valve of pressure bulb clockwise until tight Slowly release valve and allow mercury to fall. Note the point on manometer when first clear sound is heard Continue to deflate the cuff gradually when the sound becomes the muffled and disappears Deflate the cuff rapidly and completely Yes No Comments

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Place the patient in a comfortable position Tell him about his blood pressure Wash hands Record blood pressure in nurses notes and, if any abnormalities are there, report them to ward sister. Keep the stethoscope Sphygmomanometer at proper place in the box



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Bed MakingDefinition: It is a technique which provides enough area to patient on which he can be comfortable and perform his activities of daily living and also to facilitate therapeutic care. Purpose: 1) 2) 3) 4) To provide, rest, comfort and safety to the patient To help him have a good relaxed sleep To give the room a neat and tidy appearance To provide an opportunity to the nurse for observation and assessment of the nursing needs of the patient 5) To give active and passive exercises to the patient and to promote cleanliness 6) To keep it ready for an emergency in order to economize time and energy. 7) To establish a good nurse patient relationship and to teach the relatives bed-making to take care of the patient in home situations

Equipments: For an ambulatory patient 1 2 3 4 5 6 7 8 9 10 11 Chair / stool / trolley hamper Duster 2 Basin with water/lotion savlon, 1:100 Mattress protector Mattress with cover Long mackintosh Bed sheets 2 Pillow with covers 2 Draw sheet with mackintosh Blankets (if required) Bed spread (counter pane)


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No. 1 2 3 4

Procedure The nurse should wash her hands Collect all needed articles on a chair, stool or trolley Explain to the patient the entire procedure Take off bed clothes, by folding one by one, and place them on a stool/chair/trolley. Shake them gently Discard the soiled linen into the hamper or bucket. Clean and draw the mackintosh, roll it and take it off Take pillows off, shake and change covers Discard dirty linen into the hamper Clean the long mackintosh, roll and keep it on the chair/trolley Dust mattress and Dari with a dry duster Clean bed with wet duster Replace the long mackintosh on the mattress Spread bed sheet (bottom) and make box corners on your side of the bed Spread and draw mackintosh, drawsheet and tuck them on your side Go to the other side of the bed Make the box corner of the sheet at the head end and the foot-end of the bed. Tuck draw-mackintosh and draw-sheet neatly without wrinkles on the side Spread top sheet to the full length of the mattress Spread blankets over the top sheet Tuck at the foot end by making corners Spread counter pane to the full length by making corners Put the pillow case and place the pillow at the head-end, the open end away from entrance

Rationale To reduce infection by reducing microorganisms

To establish a good nurse patient relationship To prevent the spread of micro-organisms

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To prevent the spread of micro-organisms Folding causes creases

To prevent infection

Damp dusting will stain the mattress To prevent cross infection To protect it from soiling Saves many steps Draw sheets protect the bottom sheet from soiling To have a neat appearance and for the comfort of the patients

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To have a neat appearance and also for fixing the sheet in bed


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Procedure Checklist Bed MakingCheck () Yes or No No Steps of Procedure Yes 1 The nurse should wash her hands 2 Collect all needed articles on a chair, stool or trolley 3 Explain to the patient the entire procedure 4 Take off bed clothes, by folding one by one, and place them on a stool/chair/trolley. Shake them gently 5 Discard the soiled linen into the hamper or bucket. 6 Clean and draw the mackintosh, roll it and take it off 7 Take pillows off, shake and change covers 8 Discard dirty linen into the hamper 9 Clean the long mackintosh, roll and keep it on the chair/trolley 10 Dust mattress and Dari with a dry duster 11 Clean bed with wet duster 12 Replace the long mackintosh on the mattress 13 Spread bed sheet (bottom) and make box corners on your side of the bed 14 Spread and draw mackintosh, draw-sheet and tuck them on your side 15 Go to the other side of the bed 16 Make the box corner of the sheet at the head end and the foot-end of the bed. Tuck drawmackintosh and draw-sheet neatly without wrinkles on the side 17 Spread top sheet to the full length of the mattress 18 Spread blankets over the top sheet 19 Tuck at the foot end by making corners 20 Spread counter pane to the full length by making corners 21 Put the pillow case and place the pillow at the head-end, the open end away from entrance No Comments



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Performing Oral CareOral Hygiene: Oral hygiene is important because mouth is the portal of entry of food and digestion starts from mouth. So, the condition of mouth directly affects health. Purpose: 1) 2) 3) 4) 5) To prevent dental carries and tooth decay To feel fresh, clean and socially acceptable To stimulate salivation To prevent inflammation of gums and salivary glands To prevent complications such as stomatitis, glossitis, pyorrhea, parotitis, etc.

Equipments Required: 1 2 3 4 5 6 7 8 9 10 11 12 A tray containing Artery forceps Dissecting forceps Small mackintosh Cotton swabs in a bowl Tongue depressor solution as ordered Feeding cup Gauge pieces in a bowl Paper beg kidney tray Face towel A bowl with clean water

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Solutions used for oral care: 1) 2) 3) 4) No 1 2 3 4 5 6 7 8 Potassium permanganate 1: 5000 solution Hydrogen peroxide 1:8 Sodium chloride 1 teaspoon to 500ml of water Sodium chloride and lime juice mixture Procedure Explain the procedure to the patient Provide Privacy Position the patient in side-lying position toward the dependent side Arrange the articles conveniently Wash hands Place the mackintosh and towel beneath the patients chin Place the kidney tray close to the cheek Use any dentifrice to clean teeth Rational To allay anxiety if not unconscious To give security To prevent aspiration of secretions and to help in drainage To save time and energy To prevent cross infection To prevent soiling bed linen To prevent soiling bed linen To ensure through Cleanliness


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Do not pour water into mouth if the patient is unconscious Wrap a swab around the forceps, covering the tips completely, and clean the mouth systematically. Clean the mouth in the following order: Inside cheeks Gums Teeth Roof of mouth Lips Use tongue depressor, if needed, and wipe the tongue from side to side For a conscious patient, tooth brush and paste can be used; the patient can spit, and water can be poured for washing his mouth Use as many swabs as required till the mouth is clean Repeat the entire procedure with swabs dipped in fresh water When the teeth and tongue are cleaned well, stop the procedure, wipe the lips and face with towel Apply glycerin borax on the cracked lips

Due to poor gag reflex, the fluid will go into lungs It removes secretions and encrustations

It helps in proper visualization of tongue, gums Ensure proper cleanliness

To give a sense of freshness


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Procedure Checklist Giving Mouth CareCheck () Yes or No No Steps of procedure Yes 1 Explain the procedure to the patient 2 Provide Privacy 3 Position the patient in side-lying position toward the dependent side 4 Arrange the articles conveniently 5 Wash hands 6 Place the mackintosh and towel beneath the patients chin 7 Place the kidney tray close to the cheek 8 Use any dentifrice to clean teeth 9 Do not pour water into mouth if the patient is unconscious 10 Wrap a swab around the forceps, covering the tips completely, and clean the mouth systematically. Clean the mouth in the following order: Inside cheeks Gums Teeth Roof of mouth Lips 11 Use tongue depressor, if needed, and wipe the tongue from side to side 12 For a conscious patient, tooth brush and paste can be used; the patient can spit, and water can be poured for washing his mouth 13 Use as many swabs as required till the mouth is clean 14 Repeat the entire procedure with swabs dipped in fresh water 15 When the teeth and tongue are cleaned well, stop the procedure, wipe the lips and face with towel 16 Apply glycerin borax on the cracked lips No Comments

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: ____________________________________


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Administration of MedicineDefinition: A drug medication is a substance used for diagnosis, treatment, cure, relief or prevention of disease. Every drug has got a chemical or pharmacological name and trade name or different trade names by different drug companies. Equipments required: A clean trolley A tray containing 1 2 3 4 5 6 7 8 9 No 1 A bowl of clean water Ounce glass, dropper Teaspoon Drinking water in a feeding cup or glass Mortar and pestle Duster Kidney tray and paper bags Medicine cards Towel to protect patients bed Procedure Assess for contraindication of oral medications such as, dysphagea, nausea, vomiting, bowel inflammation, gastrointestinal surgery, etc. Explain the procedure to the patient Assist the patient to a sitting position Check the medicine card with doctor, s order Wash hands Take appropriate medicine from shelf. Compare the label with the medicine card. Read the expiry date With the medicine card in sight, pour the medication into the ounce glass. Read the lower meniscus Calculate correct drug dose. Take time. Double check calculation Take out tablets in required number into bottle cap; transfer them to medicine cup or paper. Do not touch with fingers. Extra tablets may be returned to the bottle. Rationale Contraindicated conditions will not produce expected effect of the drug due to poor absorption To allay anxiety To ensure comfort To ensure accuracy To reduce transmission of micro-organisms To ensure correctness and accuracy

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To ensure safety second time

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To ensure safety second time To maintain cleanliness of drugs


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While using liquid medicine, pour it from the side of the bottle, away from the label. Hold the ounce glass at the eye level, place the thumb nail at the correct measurement mark and pour the medicine with care. Read the lower meniscus. Excess medicine should be poured into sink. Do not pour it back into the bottle. Place all tablets or capsules given at the same time in one cup or container except liquids. Keep the medicine also in the tray Liquid medicines should not be mixed Take medication to bed side at the correct time Identify the patient by calling his name and recognizing him Verify the identification of the patient with the patient and also with other staff If blood pressure or pulse is to be assessed, assess it before giving medicine. Pulse in case of tab digoxin B.P, in the case of Hypertensives. Give a little water to moisten mouth Give medication one at a time. Give water. Stay with the patient until he takes all the medicines. Check the mouth and ensure that the medicine is swallowed. Lozenges should not be chewed or swallowed Give liquid medicines after giving tablets Place the ounce glass in a bowl of water Help the patient to a comfortable position Wipe the patient, s face and lips, and remove the towel Wash hands Record actual time that each drug was administrated Observe for side effects Wash and place all the articles in their respective places

To ensure correct dosage. To prevent contamination

It is easy for administration

Mixing is hazardous. It will not produce proper result To ensure proper effect To avoid error To identify correctly

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To ensure safety

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To help swallowing To ensure accuracy and safety

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It will not give desired effect

For easy washing To ensure comfort To ensure cleanliness To reduce transmission of micro-organisms

To ensure safety To ensure proper placement


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Procedure Checklist: Administering Oral MedicationCheck () Yes or No No Steps of Procedure Yes 1 Assess for contraindication of oral medications such as, dysphagea, nausea, vomiting, bowel inflammation, gastrointestinal surgery, etc. 2 Explain the procedure to the patient 3 Assist the patient to a sitting position 4 Check the medicine card with doctor, s order 5 Wash hands 6 Take appropriate medicine from shelf. Compare the label with the medicine card. Read the expiry date 7 With the medicine card in sight, pour the medication into the ounce glass. Read the lower meniscus 8 Calculate correct drug dose. Take time. Double check calculation 9 Take out tablets in required number into bottle cap; transfer them to medicine cup or paper. Do not touch with fingers. Extra tablets may be returned to the bottle. 10 While using liquid medicine, pour it from the side of the bottle, away from the label. Hold the ounce glass at the eye level, place the thumb nail at the correct measurement mark and pour the medicine with care. Read the lower meniscus. Excess medicine should be poured into sink. Do not pour it back into the bottle. 11 Place all tablets or capsules given at the same time in one cup or container except liquids. Keep the medicine also in the tray 12 Liquid medicines should not be mixed 13 Take medication to bed side at the correct time 14 Identify the patient by calling his name and recognizing him 15 Verify the identification of the patient with the patient and also with other staff No Comments


33

16

17 18

19 20 21 22 23 24 25 26 27

If blood pressure or pulse is to be assessed, assess it before giving medicine. Pulse in case of tab digoxin B.P, in the case of Hypertensives. Give a little water to moisten mouth Give medication one at a time. Give water. Stay with the patient until he takes all the medicines. Check the mouth and ensure that the medicine is swallowed. Lozenges should not be chewed or swallowed Give liquid medicines after giving tablets Place the ounce glass in a bowl of water Help the patient to a comfortable position Wipe the patient, s face and lips, and remove the towel Wash hands Record actual time that each drug was administrated Observe for side effects Wash and place all the articles in their respective places



34

Giving Simple EnemaDefinition: An Enema is an introduction of fluid into the bowel through the rectum for the purpose of cleansing or to introduce nourishment. Purpose: 1) 2) 3) 4) 5) 6) To stimulate defecation and treat constipation To cleanse bowel before operations, x ray studies To stimulate uterine contraction to hasten child birth To relive retention of urine by stimulating reflex action of bladder To relive gaseous distention by stimulating peristalsis To cleanse bowel prior to retention enema

Equipments required: 1 2 3 4 5 6 7 8 9 10 Enemas can, rubber tubing, glass connection, screw clamp Mackintosh and towel Rectal tube or catheter no. 12 in a kidney tray Vaseline Hot water in a jug Pint measure Soap jelly in a bottle I.V. stand Toilet tray Bed pan - 2

Solution used Soap water soap jelly 50 ml to 1 liter of water Amount of solution Infants Children Adults Temperature of solution Children Adults 100F 105-110F 250 ml or less 250 500 ml 500 1000 ml


35

No 1 2 3

Procedure Explain the procedure to the patient Screen the patient Cover the patient with or top sheet or bath blanket. Place the mackintosh and draw sheet under patients buttocks. Assist the patient to turn to left lateral position Keep articles ready on bed side locker Place the bed pan under the bed over a news paper Wash hands Prepare the soap solution at 105F, by adding 30ml of soap jelly to 600ml of water Attach the rubber tubing to enema can and clamp the tube Hang the - can with the solution on the stand. The height of the can should not be more than 45cms or 18 inch from the anus Attach a catheter to the tubing. Allow a small amount of solution to flow into the kidney tray. Pinch of tubing with fingers Lubricate 2 inch 4 inch of catheter Separate the buttocks Instruct patient to breathe deeply through his mouth Gently insert rectal tube 2 4 inches. Release tubing to allow solution to flow. Allow solution to run slowly with interruptions Give about 500 1000ml of solution Clamp the tubing before emptying the can completely Slowly withdraw the catheter. Cover it with gauge pieces or rags and place it in the kidney tray Encourage the patient to retain solution for a few minutes if possible Give the patient bed pan or take him to bath room Collect specimens if required

Rationale To win his confidence and to get his cooperation To provide privacy To protect bed and linen

4 5 6 7 8

To enhance the flow of solution For easy availability For easy availability To reduce transmission of micro-organisms High temperature solution more than 105F will burn the mucous membrane To ensure safety To enhance and regulate

9 10

11

To expel air

12 13 14 15

To avoid friction To visualize anus To help in relaxation

16 17 18 19

Interruptions of the fluid will relax the bowl

To prevent air entry into the tube To cleanse the tube

20 21 22

To help in proper evacuation

For diagnostic purpose


36

Procedure Checklist Giving Simple EnemaCheck () Yes or No No Steps of procedure Yes No Comments 1 Explain the procedure to the patient 2 Screen the patient 3 Cover the patient with or top sheet or bath blanket. Place the mackintosh and draw sheet under patients buttocks. 4 Assist the patient to turn to left lateral position 5 Keep articles ready on bed side locker 6 Place the bed pan under the bed over a news paper 7 Wash hands 8 Prepare the soap solution at 105F, by adding 30ml of soap jelly to 600ml of water 9 Attach the rubber tubing to enema - can and clamp the tube 10 Hang the - can with the solution on the stand. The height of the can should not be more than 45cms or 18 inch from the anus 11 Attach a catheter to the tubing. Allow a small amount of solution to flow into the kidney tray. Pinch of tubing with fingers 12 Lubricate 2 inch 4 inch of catheter 13 Separate the buttocks 14 Instruct patient to breathe deeply through his mouth 15 Gently insert rectal tube 2 4 inches. Release tubing to allow solution to flow. 16 Allow solution to run slowly with interruptions 17 Give about 500 100ml of solution 18 Clamp the tubing before emptying the can completely 19 Slowly withdraw the catheter. Cover it with gauge pieces or rags and place it in the kidney tray 20 Encourage the patient to retain solution for a few minutes if possible 21 Give the patient bed pan or take him to bath room 22 Collect specimens if required Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: _____________________________________ Instructor:_______________________ Date: _____________________________________


37

Insertion of a flatus tubeDefinition: It is insertion of tube in the lower bowel for the removal of gases Purpose: 1) To remove flatus from the lower bowel Equipment Required: 1 2 3 4 5 6 7 8 No 1 2 3 Screen A tray containing Flatus tube Vaseline Wet swabs in a bowl Paper or mackintosh or towel Paper bag Long artery forceps Procedure Prepare the patient as for enema Place the patient in the left lateral position Lubricate the flatus tube and insert 4inch-6inch into the anal canal, the free end of the tube is kept in water in a kidney tray Keep the tube in place for 20 minutes The presence of air bubbles in the water indicates that flatus is being expelled The tube may be reinserted 4 hourly if required Clean the anal region with swabs Replace the articles after cleaning Rationale To reduce anxiety and save times For easily visualization For easy insertion

4 5

For complete removal of flatus To identify any leakage

6 7 8

For complete removal of flatus To reduce the contamination of other things Foe easy availability for next time


38

Procedure Checklists For insertion of flatus tubeCheck () Yes or No No Steps of procedure 1 Prepare the patient as for enema 2 Place the patient in the left lateral position 3 Lubricate the flatus tube and insert 4inch-6inch into the anal canal, the free end of the tube is kept in water in a kidney tray 4 Keep the tube in place for 20 minutes 5 The presence of air bubbles in the water indicates that flatus is being expelled 6 The tube may be reinserted 4 hourly if required 7 Clean the anal region with swabs 8 Replace the articles after cleaning 9 Record the procedure in the patients chart Yes No Comments



39

Care for Nasal-Gastric Tube a. Inserting a Nasal-Gastric TubeDefinition: Method of introducing a tube through nose into stomach Purpose: 1) To feed client with fluids when oral intake is not possible 2) To dilute and remove consumed poison 3) To instill ice cold solution to control gastric bleeding 4) To prevent stress on operated site by decompressing stomach of secretions and gas 5) To relieve vomiting and distention Equipments: 1 2 3 4 5 6 Nonsterile gloves Ice chips in an emesis basin Towel and tissues Tongue blade Hypoallergenic tape, rubber band, safety pin Wall mount or portable suction equipment as available Procedure Review clients medical record 7 8 9 10 11 12 Cup of ice or water and straw Water-soluble lubricant Flashlight or penlight pH chemstrip 20-ml syringe or asepto syringe, 30 ml or larger with small bore tube Administration set with pump or controller for feeding tube Rationale Confirms physicians prescription for inserting a nasogastric tube; history of nasal or sinus problems. Promotes efficiency. Reduces transfer of microorganisms. Verifies correct client; reduces anxiety and increases client cooperation. Facilitates passage of the tube into the esophagus and swallowing.

No 1

2 3

Gather equipment. Wash hands. Check clients armband; explain procedure, showing items. Place client in Fowlers position, at least a 45 angle or higher, with a pillow behind clients shoulders; provide for privacy. Place comatose clients in semi-Fowlers position. Place towel over chest, put tissues in reach. Don gloves Examine nostrils and assess as client breathes through each nostril. Measure length of tubing needed by using tube as a tape measure: Measure from bridge of clients nose to earlobe to xiphoid process of sternum (Figure A).If tube is to go below stomach (nasoduodenal or nasojejunal),

4

5

6 7

Prevents soiling of gown and bedding and protects nurse from contamination with bodily fluids; lacrimation can occur during insertion through nasal passages Determines the most patent nostril to facilitate insertion. Approximates length of tube needed to reach stomach.


40

add an additional 15 to 20 cm (Figure B). Place a small piece of tape on tube to mark length.

8

9 10

(Figure A) Measuring the Length of Nasogastric Tubing. Have client blow nose and encourage swallowing of water if level of consciousness and treatment plan permit. Lubricate first 4 inches of tube with water soluble lubricant a) Insert tube as follows: b) Gently pass tube into nostril to back of throat (client may gag); aim tube toward back of throat and down. c) When client feels tube in back of throat, use flashlight or penlight to locate tip of tube. d) Instruct client to flex head toward chest.

(Figure B) Measuring Length of Nasoduodenal or Nasojejunal Tubing. Clears nasal passage without pushing microorganisms into inner ear; facilitates passage of tube. Facilitates passage into the nares.

Promotes passage of tube with minimal trauma to mucosa. Ensures tips placement.

11 12

e) Instruct client to swallow, offer ice chips or water, and advance tube as client swallows. f) If resistance is met, rotate tube slowly with downward advancement toward clients closest ear; do not force tube. Withdraw tube immediately if changes occur in respiratory status. Advance tube, giving client sips of water, until taped mark is reached.

Opens esophagus and assists in tube insertion after tube has passed through nasopharynx and reduces risk of tube entering trachea. Assists in pushing tube past oropharynx.

Tube may be coiled or kinked or in the oropharynx or trachea.

Indicates placement of tube in the bronchus or lung. Assists with tube insertion.


41

13

Check placement of tube: Attach syringe to free end of tube and aspirate sample of gastric contents and measure with chemstrip pH (Figure C).

Ensures proper placement in the stomach; pH below 3, tube is in stomach; a pH range of 6 to 7 indicates intestinal sites.

14

(Figure C) For Measuring the pH of Aspirate Leave syringe attached to free end of tube. If prescribed, obtain x-ray; keep client on right side until x-ray is taken. Secure tube with tape as shown in Figure D or use a commercially prepared tube holder.

Prevents leakage of gastric contents. Confirms correct placement; if nasoduodenal or nasojejunal feedings are required, passage through pylorus may require several days. Prevents tube from becoming dislodged.

(Figure D) Securing Tube to the Clients Nose with Tape Split a 4-inch piece of tape to a length of 2 inches and secure tube with tape by placing the intact end of the tape over the bridge of the nose. Wrap split ends around the tube as it exits the nose.

Prevents trauma to nasal mucosa by reducing pressure on nares.

Allows client movement without causing friction nares; metal devices are removed for x-rays to prevent artifacts.


42

Place a rubber band, using a slip knot, around the exposed tube (1218 inches from nose toward chest); after x-ray, pin rubber band to clients gown. Reduces anxiety and teaches client how to prevent tugging on tube with head movement. Provides for decompression as prescribed by physician; intermittent or continuous suctioning is determined by type of tube inserted.

15

Instruct client about movements that can dislodge the tube. a) Gastric decompression: b) Remove syringe from free end of tube and connect tube to suction tubing; set machine on type of suction and pressure as prescribed. c) Levine tubes are connected to intermittent low pressure. d) Salem sump or Andersons tube is connected to continuous low suction. e) Observe nature and amount of gastric tube drainage. f) Assess client for nausea, vomiting, and abdominal distention. Provide oral hygiene and cleanse nares with a tissue. Remove gloves, dispose of contaminated materials in proper container, and wash hands. Position client for comfort, and place call light in easy reach. Document: a) The reason for the tube insertion b) The type of tube inserted c) The type (intermittent or continuous) of suctioning and pressure setting d) The nature and amount of aspirate and e) drainage f) The clients tolerance of the procedure g) The effectiveness of the intervention, such as nausea relieved

16

Provides information about patency of tube and gastric contents. Indicates effectiveness of intervention.

17 18

Promotes comfort. Reduces transmission of microorganisms; protects other workers from coming into contact with objects contaminated with body fluids Promotes comfort and safety. Promotes continuity of care and shows implementation of intervention.

19 20


43

Procedure Checklist Inserting a Nasal-Gastric TubeCheck () Yes or No No 1 2 3 4 Procedure Review clients medical record Gather equipment. Wash hands. Check clients armband; explain procedure, showing items. Place client in Fowlers position, at least a 45 angle or higher, with a pillow behind clients shoulders; provide for privacy. Place comatose clients in semi-Fowlers position. Place towel over chest, put tissues in reach. Don gloves Examine nostrils and assess as client breathes through each nostril. Measure length of tubing needed by using tube as a tape measure: Measure from bridge of clients nose to earlobe to xiphoid process of sternum (Figure A).If tube is to go below stomach (nasoduodenal or nasojejunal), add an additional 15 to 20 cm (Figure B). Place a small piece of tape on tube to mark length. Yes No Comments

5

6 7

8

(Figure A) Measuring the Length of Nasogastric Tubing. Have client blow nose and encourage swallowing of water if level of consciousness and treatment plan permit.


44

9 10

11 12 13

Lubricate first 4 inches of tube with water soluble lubricant g) Insert tube as follows: h) Gently pass tube into nostril to back of throat (client may gag); aim tube toward back of throat and down. i) When client feels tube in back of throat, use flashlight or penlight to locate tip of tube. j) Instruct client to flex head toward chest. k) Instruct client to swallow, offer ice chips or water, and advance tube as client swallows. l) If resistance is met, rotate tube slowly with downward advancement toward clients closest ear; do not force tube. Withdraw tube immediately if changes occur in respiratory status. Advance tube, giving client sips of water, until taped mark is reached. Check placement of tube: Attach syringe to free end of tube and aspirate sample of gastric contents and measure with chemstrip pH (Figure C).

14

(Figure C) For Measuring the pH of Aspirate Leave syringe attached to free end of tube. If prescribed, obtain x-ray; keep client on right side until x-ray is taken. Secure tube with tape as shown in Figure D or use a commercially prepared tube holder.


45

(Figure D) Securing Tube to the Clients Nose with Tape Split a 4-inch piece of tape to a length of 2 inches and secure tube with tape by placing the intact end of the tape over the bridge of the nose. Wrap split ends around the tube as it exits the nose. Place a rubber band, using a slip knot, around the exposed tube (1218 inches from nose toward chest); after x-ray, pin rubber band to clients gown. 15 16 Instruct client about movements that can dislodge the tube. g) Gastric decompression: h) Remove syringe from free end of tube and connect tube to suction tubing; set machine on type of suction and pressure as prescribed. i) Levine tubes are connected to intermittent low pressure. j) Salem sump or Andersons tube is connected to continuous low suction. k) Observe nature and amount of gastric tube drainage. l) Assess client for nausea, vomiting, and abdominal distention. Provide oral hygiene and cleanse nares with a tissue.

17


46

18

19 20

Remove gloves, dispose of contaminated materials in proper container, and wash hands. Position client for comfort, and place call light in easy reach. Document: h) The reason for the tube insertion i) The type of tube inserted j) The type (intermittent or continuous) of suctioning and pressure setting k) The nature and amount of aspirate and l) drainage m) The clients tolerance of the procedure n) The effectiveness of the intervention, such as nausea relieved



47

b. Removal a Nasal-Gastric TubeNo 1 Procedure: Assemble the appropriate equipment, such as kidney tray, tissues or gauze and disposable gloves, at the clients bedside. 2 Explain the client what you are going do. 3 Put on the gloves 4 Remove the tube a) Take out the adhesive tape which holding the nasal-gastric tube to the clients nose b) Remove the tube by deflating any balloons Rationale Organization facilitates accurate skill performance

Providing explanation fosters cooperation To prevent spread of infection

Do not remove the tube if you encounter any resistance not to harm any membranes or organs. Do another attempt in an hour. Continuous slow pulling it out can lead coughing or discomfort

c) Simply pulling it out, slowly at first and then rapidly when the client begins to cough. d) Conceal the tube. 5 Be sure to remove any tapes from the clients face. Acetone may be necessary. Provide mouth care if needed. Put off gloves and perform hand hygiene. Record the date, time and the clients condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal. Sign the signature. Dispose the equipments and replace them. Report to the senior staff.

6 7 8

Acetone helps any adhesive substances from the face. You should also wipe acetone out after removed tapes because acetone remained on the skin may irritate. To provide comfort To prevent the spread of infection Documentation provides coordination of care Giving signature maintains professional accountability

9 10

To prepare for the next procedure To provide continuity of care


48

Procedure Checklist Removal a Nasal-Gastric TubeCheck () Yes or No No 1 Procedure: Yes Assemble the appropriate equipment, such as kidney tray, tissues or gauze and disposable gloves, at the clients bedside. Explain the client what you are going do. Put on the gloves Remove the tube Take out the adhesive tape which holding the nasal-gastric tube to the clients nose Remove the tube by deflating any balloons Simply pulling it out, slowly at first and then rapidly when the client begins to cough. Conceal the tube. Be sure to remove any tapes from the clients face. Acetone may be necessary. Provide mouth care if needed. Put off gloves and perform hand hygiene. Record the date, time and the clients condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal. Sign the signature. Dispose the equipments and replace them. Report to the senior staff. No Comments

2 3 4 e)

f) g)

h) 5

6 7 8

9 10

Recommendation: Pass ____________ Needs more practice __________________________ Student: ________________________ Date: ______________________________________ Instructor:_______________________ Date: _____________________________________


49

Administering Enteral Tube FeedingsDefinition: A nasal-gastric tube feeding is a means of providing liquid nourishment through a tube into the intestinal tract, when client is unable to take food or any nutrients orally Purpose: 1) To provide adequate nutrition 2) To give large amounts of fluids for therapeutic purpose 3) To provide alternative manner to some specific clients who has potential or acquired swallowing difficulties Equipment: 1. Asepto syringe or 20- to 50-ml syringe 2. Emesis basin 3. Formula 4. Infusion pump for feeding tube No 1 2 3 4 5 Procedure Review clients medical record. Gather equipment. Check clients armband. Explain procedure to client. Assemble equipment. If using a bag, fill with prescribed amount of formula

5. 6. 7. 8.

Clean towel Disposable gavage bag and tubing Water to follow feeding Nonsterile gloves Rationale Verifies physicians prescription for appropriate formula and amount. Promotes efficiency during procedure. Verifies correct client. Reduces anxiety and increases client cooperation. Ensures efficiency when initiating feeding.

6 7 8

(Figure A) Preparing Formula Place client on right side in high Fowlers position. Wash hands and don nonsterile gloves. Provide for privacy.

Reduces risk of pulmonary aspiration in event client vomits or regurgitates formula. Reduces transmission of pathogens from gastric contents Places client at ease.


50

9

Observe for abdominal distention; auscultate for bowel sounds. Check feeding tube: Insert syringe into adapter port, aspirate stomach contents, and determine amount of gastric residual. If residual is greater than 50 to 100 ml (or in accordance with agency protocol), hold feeding until residual diminishes. Instill aspirated contents back into feeding tube. Administer tube feeding: IntermittentBolus Pinch the tubing. Remove plunger from barrel of syringe and attach to adapter. Fill syringe with formula Allow formula to infuse slowly; continue adding formula to syringe until prescribed amount has been administered. Flush tubing with 30 to 60 ml or prescribed amount of water. IntermittentGavage Feeding Hang bag on IV pole so that it is 18 inches above the clients head. Remove air from bags tubing. Attach distal end of tubing to feeding tube adapter and adjust drip to infuse over prescribed time. When bag empties of formula, add 30 to 60 ml or prescribed amount of water; close clamp. Change gavage bag every 24 hours or wash reusable gavage bag with soap and hot water every 24 hours. Continuous Gavage Check tube placement at least every 4 hours. Check residual at least every 8 hours. If residual is above 100 ml, stop feeding.

Assesses for delayed gastric emptying; indicates presence of peristalsis and ability of GI tract to digest nutrients. Indicates whether gastric emptying is delayed.

Reduces risk of regurgitation and pulmonary aspiration related to gastric distention.

Prevents electrolyte imbalance. Provides nutrients as prescribed. Prevents air from entering tubing. Provides system to delivery feeding.

Allows gravity to control flow rate, reducing risk of diarrhea from bolus feeding. Prevents air from entering stomach and reduces risk for gas accumulation. Maintains patency of feeding tube.

Allows gravity to promote infusion of formula. Prevents air from entering stomach. Decreases risk of diarrhea

Ensures that remaining formula in tubing is administered and maintains patency of tube; prevents air from entering the stomach. Decreases risk of multiplication of microorganisms in bag and tubing.

Ensures that feeding tube remains in stomach. Indicates ability of GI tract to digest and absorb nutrients. Reduces risk of regurgitation and pulmonary aspiration related to gastric distention.


51

12 13 14 15

Provides comfort and maintains the integrity of buccal cavity. Administer water as prescribed with and Ensures adequate hydration. between feedings. Clamp proximal end of feeding tube Prevents air from entering the tube. after formula has been administered. Remove gloves and wash hands. Reduces risk of transmission of microorganisms. Record total amount of formula and Documents administration of feeding and water administered on I & O form and achievement of expected outcome; for clients response to feeding. example, client tolerates feeding and weight is maintained or increased.

Add prescribed amount of formula to bag for a 4-hour period; dilute with water if prescribed. Hang gavage bag on IV pole. Prime tubing. Thread tubing through feeding pump and attach distal end of tubing to feeding tube adapter; keep tubing straight between bag and pump. Adjust drip rate. Monitor infusion rate and signs of respiratory distress or diarrhea. Flush tube with water every 4 hours as prescribed or following administration of medications. Replace disposable feeding bag at least every 24 hours, in accord with agencys protocol. Turn client every 2 hours. Provide oral hygiene every 2 to 4 hours.

Provides client with prescribed nutrients and prevents bacterial growth (formula is easily contaminated). Removes air from tubing. Provides for controlled flow rate; prevents loops in tubing.

Infuses formula over prescribed time. Prevents complications associated with continuous gavage. Maintains patency of tube. Decreases risks of microorganisms. Promotes digestion and reduces skin breakdown.


52

Procedure Checklist Administering Enteral Tube FeedingsCheck () Yes or No No 1 2 3 4 5 6 7 8 9 Procedure Review clients medical record. Gather equipment. Check clients armband. Explain procedure to client. Assemble equipment. If using a bag, fill with prescribed amount of formula Place client on right side in high Fowlers position. Wash hands and don nonsterile gloves. Provide for privacy. Observe for abdominal distention; auscultate for bowel sounds. Check feeding tube: Insert syringe into adapter port, aspirate stomach contents, and determine amount of gastric residual. If residual is greater than 50 to 100 ml (or in accordance with agency protocol), hold feeding until residual diminishes. Instill aspirated contents back into feeding tube. Administer tube feeding: IntermittentBolus Pinch the tubing. Remove plunger from barrel of syringe and attach to adapter. Fill syringe with formula Allow formula to infuse slowly; continue adding formula to syringe until prescribed amount has been administered. Flush tubing with 30 to 60 ml or prescribed amount of water. IntermittentGavage Feeding Hang bag on IV pole so that it is 18 inches above the clients head. Remove air from bags tubing. Attach distal end of tubing to feeding tube adapter and adjust drip to infuse over prescribed time. When bag empties of formula, add 30 to 60 ml or prescribed amount of water; close clamp. Yes No Comments


53

12 13 14 15

Change gavage bag every 24 hours or wash reusable gavage bag with soap and hot water every 24 hours. Continuous Gavage Check tube placement at least every 4 hours. Check residual at least every 8 hours. If residual is above 100 ml, stop feeding. Add prescribed amount of formula to bag for a 4-hour period; dilute with water if prescribed. Hang gavage bag on IV pole. Prime tubing. Thread tubing through feeding pump and attach distal end of tubing to feeding tube adapter; keep tubing straight between bag and pump. Adjust drip rate. Monitor infusion rate and signs of respiratory distress or diarrhea. Flush tube with water every 4 hours as prescribed or following administration of medications. Replace disposable feeding bag at least every 24 hours, in accord with agencys protocol. Turn client every 2 hours. Provide oral hygiene every 2 to 4 hours. Administer water as prescribed with and between feedings. Clamp proximal end of feeding tube after formula has been administered. Remove gloves and wash hands. Record total amount of formula and water administered on I & O form and clients response to feeding.



54

Feeding via a Gastrostomy and Jejunostomy Feeding TubeDefinition: Jejunostomy is a surgical procedure by which a tube is situated in the lumen of the proximal jejunum, primarily to administer nutrition. Purpose: To provide an alternative to oral and parenteral nutrition Equipments: 1 2 3 4 5 6 7 8 9 10 Sterile dressing pack Sterile gloves Disposable apron Enteral Feeding pump and stand Enteral Feeding system device, labeled enteral color coded purple. Dietetic feeding regimen Record of administration Prescribed feed as per dietetic feeding regimen Freshly drawn tap water unless sterile water specified by managing dietitian Female Luer Lock syringes. Syringe size and quantity will depend on dietetic regimen and size of feeding tube, and will be directed by managing dietitian

No 1

2 3

Procedure Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent Wash and dry hands and apply sterile gloves Apply single use disposable apron

Rationale To reduce potential error of giving feed to wrong patient To enable patient to make an informed decision about their own health care To protect clothing and prevent transfer of transient organisms to a susceptible site To reduce the risk of transfer of transient organisms on the healthcare workers hands To minimize reflux and risk of aspiration

4

5

Position the patient in an upright position (30 - 45) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water from a kitchen sink to ensure the water is fit to drink (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube

To prevent air being in the giving set and causing pump to alarm

To maintain patency of tube


55

6

7

8

9 10

11

Administration:A `no touch` aseptic technique should be used to connect the enteral feeding system device to the enteral feeding tube. If administering feed via a pump, place feed container on a stand. Attach feeding system to prescribed feed and prime system Set feeding pump at prescribed flow rate (as per dietetic regimen) release clamp on feeding tube and start pump Ensure the type of feed and volume given is recorded in the patients health records On completion of feeding, advise carer to switch off feeding pump and close clamp on enteral feeding system and disconnect the feeding system from the feeding tube. If no carer, nurse to re-visit to close enteral feeding system. Post feed:Flush enteral feeding tube with prescribed amount of tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding system and disconnect feeding system from feeding tube this may be done by the nurse or advice appropriate carer. When the feeding tube is not in use the clamp should always remain open. Dispose of feeding equipment in general household waste, remove disposable apron and gloves, wash and dry hands. Document treatment in patients health records.

Aseptic technique is to prevent any contamination of site Feed should be administered at room temperature and stored following manufacturers instructions To allow feed to be administered correctly

To maintain tube patency and ensure fluid requirements are met To close system


To prevent damage to tube To prevent cross infection Enteral feed administration sets are for single use only and must be discarded after each feeding session To comply with PCT health records policy and to maintain accurate records


56

Procedure Checklist Feeding via a Gastrostomy and Jejunostomy feeding tubeCheck () Yes or No No 1 Procedure Yes Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent Wash and dry hands and apply sterile gloves Apply single use disposable apron Position the patient in an upright position (30 - 45) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water from a kitchen sink to ensure the water is fit to drink (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Administration:A `no touch` aseptic technique should be used to connect the enteral feeding system device to the enteral feeding tube. If administering feed via a pump, place feed container on a stand. Attach feeding system to prescribed feed and prime system Set feeding pump at prescribed flow rate (as per dietetic regimen) release clamp on feeding tube and start pump Ensure the type of feed and volume given is recorded in the patients health records On completion of feeding, advise carer to switch off feeding pump and close clamp on enteral feeding system and disconnect the feeding system from the feeding tube. If no carer, nurse to re-visit to close enteral feeding system. No Comments

2 3

4

5

6

7

8


57

9

10

11

Post feed:Flush enteral feeding tube with prescribed amount of tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding system and disconnect feeding system from feeding tube this may be done by the nurse or advice appropriate carer. When the feeding tube is not in use the clamp should always remain open. Dispose of feeding equipment in general household waste, remove disposable apron and gloves, wash and dry hands. Document treatment in patients health records.



58

Administering Bolus FeedsEquipments: 1 2 3 4 5 6 7 8 9 Sterile dressing pack Sterile gloves Single use disposable apron Enteral Feeding system device, labelled enteral colour coded purple. Dietetic feeding regimen Record of administration Prescribed feed as per dietetic feeding regimen Freshly drawn tap water (or sterile water as per dietetic regime) Female Luer Lock syringes. Syringe size and quantity will depend on dietetic regimen and make of feeding tube, and will be directed by managing dietitian Procedure Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent. Wash hands and apply sterile gloves Apply single use disposable apron Rationale To reduce potential error of giving feed to wrong patient To enable patient to make an informed decision about their own health care To reduce the risk of transfer of transient organisms on the healthcare workers hands To protect clothing and prevent transfer of transient organisms to a susceptible site To minimize reflux and risk of aspiration

No 1

2 3

4

5

6 7

Position the patient in an upright position (30- 45) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:To maintain patency of tube Flush enteral feeding tube with prescribed amount of freshly drawn tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Attach an enteral syringe without the To allow feed to be administered plunger to the feeding tube Slowly pour the prescribed quantity of To allow feed to be administered feed into the syringe. If the feed is running too quickly or slowly altering the height of the syringe slightly may help. The plunger can be used to apply gentle pressure if the feed is running too slowly. Do not apply pressure with force.


59

8

9

10

11

When the prescribed feed has been delivered, flush tube with freshly drawn tap water, (or sterile water as per dietetic regime) remove the syringe. Ensure type of feed and volume given is recorded in the patients health records Dispose of feeding equipment in general household waste, remove gloves, wash and dry hands Document all care in patients records


To maintain accurate records

To prevent cross infection

To promote safe continuity of health care


60

Procedure Checklist Procedure for Administering Bolus FeedsCheck () Yes or No No 1 Procedure Yes Confirm identity of patient, by asking for full name and date of birth, clarify with carers' if patient not able to do so Explain the procedure to patient, obtain valid consent. Wash hands and apply sterile gloves Apply single use disposable apron Position the patient in an upright position (30- 45) i.e. sitting in a chair. If in bed upper body should be elevated using pillows Prior to administration of feed:Flush enteral feeding tube with prescribed amount of freshly drawn tap water (or sterile water as per dietetic regime), with enteral syringe. Close clamp on feeding tube Attach an enteral syringe without the plunger to the feeding tube Slowly pour the prescribed quantity of feed into the syringe. If the feed is running too quickly or slowly altering the height of the syringe slightly may help. The plunger can be used to apply gentle pressure if the feed is running too slowly. When the prescribed feed has been delivered, flush tube with freshly drawn tap water, remove the syringe. Ensure type of feed and volume given is recorded in the patients health records Dispose of feeding equipment in general household waste, remove gloves, wash and dry hands Document all care in patients records No Comments

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5

6 7

8

9

10

11



61

Colostomy IrrigationDefinition: Colostomy irrigation is a way to regulate the intestinal activity of colostomized patients, followed by emptying the colon Purpose: 1) To promote the emptying of the fecal content 2) To reduce the formation of gas since, by removing the residues 3) To maintain normal bowel function 4) To avoid constipation Equipments: A trolley [which is cleansed with an appropriate solution] with the following: 1 Irrigation container 2 Irrigation fluid 500 to 1,000 ml lukewarm water or other solution 3 Soft rubber catheter No. 22 or No. 24 4 New colostomy appliance 5 Irrigation sleeve 6 Disposable gloves 7 Apron 8 Lubricant 9 Receiver / plastic bag for the disposal of old colostomy pouch / dressing 10 Cotton wool swabs 11 Protector / plastic sheet [if patient is confined to bed] 12 Bedpan

No 1

2

3

Procedure Verify physicians order, progress notes, and nursing care plan for colostomy. Assess patients condition to determine if procedure should be done in bed or in the bathroom Ensure privacy.

Rationale To obtain specific instructions and / or information. To facilitate the patient in comfortable position

4 5 6 7 8

To avoid unnecessary embarrassment to the patient during the procedure. Respect for patients privacy is an essential aspect of the holistic care of a patient. Wash hands and dry hands.(refer Hand To reduce nosocomial infection. washing procedure) Don gloves. To reduce nosocomial infection. Assemble equipment correctly It ensures the procedure is carried out smoothly. Explain procedure to patient. To allay fears and gain patients confidence and cooperation. Position patient. Lie patient on the side To facilitate the patient closest to the stoma or in supine position if patient is confined to bed. Sit the patient on toilet if ambulatory


62

9

10 11 12

13 14

15

16

Remove regular ostomy pouch by unsnapping the pouch from the skin barrier with flange Cleanse stoma and surrounding skin area. Apply irrigator sleeve by snapping it onto the skin barrier with flange. Connect irrigation bag to tubing. The two pieces slide apart and push together. If stoma protrudes, use the cone tip. Put on glove, lubricate small finger and gently insert into colostomy Fill irrigating bag with 1000 mL lukewarm water. If new ostomy, begin with 250 mL lukewarm water, or as ordered by physician. Hang bag so that bottom of bag is at patients shoulder level, (Figure 3) or if patient is on bed rest, 18 inches ( 45 cm ) above stoma.. Allow small amount of water to run through tubing to clear it of air.

Proper disposal of the colostomy to avoid contamination. Ist promotes comfort and hygiene.

To determine the direction of the lumen.

It ensures the irrigation fluid will flow by gravity

17

19 20

21

22

23

Air will not be introduced into the colon that could cause discomfort to the patient If using a catheter, lubricate and gently Ensures a smooth entry into the stoma and insert about two inches avoids friction. If any resistance is felt, change direction of catheter and/or allow small amount of water to flow through catheter before attempting to insert it further. If using cone tip, hold snugly into stoma. Open clamp and allow water to enter bowl. Patient may complain of cramping if irrigation flows too rapidly. If cramping occurs, clamp off tubing until cramps subside. Remove catheter and fold over top of To prevent return from splashing drain sleeve and fasten closed with clamp provided Allow about 15-20 minutes for most of drainage to return, then rinse sleeve with lukewarm water through top of sleeve Fold end of irrigating sleeve up twice and clip to top, thus making a temporary catch bag. Patient may now go out into room for remaining 45 minutes.


63

24

25

26 27

28

After 1-hour, rinse irrigating sleeve and remove by unsnapping it from skin barrier with flange. Apply clean pouch by snapping it onto skin barrier with flange. May apply Banish deodorant into pouch. Wash and dry hands. Wash irrigating equipment and allow to dry. Place patients name and room number on a piece of tape and attach to equipment hanging in the bathroom Complete Documentation (type and amount of irrigant, whether cone tip or cath use, description of stoma, amount and type of returns, If wafer and pouch changed, description of peristomal skin).

To reduce the risk of nosocomial infection. The clean equipment will be ready for re-use.

To determine skin / stoma integrity and to detect early signs of infection and any possible problems.


64

Procedure Checklist Colostomy irrigationCheck () Yes or No No 1 Procedure Yes Verify physicians order, progress notes, and nursing care plan for colostomy. Assess patients condition to determine if procedure should be done in bed or in the bathroom Ensure privacy. Wash hands and dry hands.(refer Hand washing procedure) Don gloves. Assemble equipment correctly Explain procedure to patient. Position patient. Lie patient on the side closest to the stoma or in supine position if patient is confined to bed. Sit the patient on toilet if ambulatory Remove regular ostomy pouch by unsnapping the pouch from the skin barrier with flange Cleanse stoma and surrounding skin area. Apply irrigator sleeve by snapping it onto the skin barrier with flange. Connect irrigation bag to tubing. The two pieces slide apart and push together. If stoma protrudes, use the cone tip. Put on glove, lubricate small finger and gently insert into colostomy Fill irrigating bag with 1000 mL lukewarm water. If new ostomy, begin with 250 mL lukewarm water, or as ordered by physician. Hang bag so that bottom of bag is at patients shoulder level, (Figure 3) or if patient is on bed rest, 18 inches ( 45 cm ) above stoma.. Allow small amount of water to run through tubing to clear it of air. If using a catheter, lubricate and gently insert about two inches If using cone tip, hold snugly into stoma. No Comments

2

3 4 5 6 7 8

9

10 11 12

13 14

15

16 17 19


65

20

21

22

23

24

25

26 27

28

Open clamp and allow water to enter bowl. Patient may complain of cramping if irrigation flows too rapidly. If cramping occurs, clamp off tubing until cramps subside. Remove catheter and fold over top of drain sleeve and fasten closed with clamp provided Allow about 15-20 minutes for most of drainage to return, then rinse sleeve with lukewarm water through top of sleeve Fold end of irrigating sleeve up twice and clip to top, thus making a temporary catch bag. Patient may now go out into room for remaining 45 minutes. After 1-hour, rinse irrigating sleeve and remove by unsnapping it from skin barrier with flange. Apply clean pouch by snapping it onto skin barrier with flange. May apply Banish deodorant into pouch. Wash and dry hands. Wash irrigating equipment and allow to dry. Place patients name and room number on a piece of tape and attach to equipment hanging in the bathroom Complete Documentation (type and amount of irrigant, whether cone tip or cath use, description of stoma, amount and type of returns, If wafer and pouch changed, description of peristomal skin).



66

Urinary CatheterizationDefinition: Urinary catheterization is the insertion of a catheter into a patient's bladder. The catheter is used as a conduit to drain urine from the bladder into an attached bag or container. Purpose: 1) To relieve urinary retention and 2) To promote the comfort and dignity in palliative patients Equipments: 1 Single use disposable apron 2 Catheter: 3 Sterile dressing pack 4 Additional pair of single use disposable sterile gloves