Companion 2 Nursing Body Final2pdf

Essentialsin Nursing

Companion to

Vital SignsChapter One

1.1. Measuring Body Temperature

1.2. Radial and Apical Pulses Assessment

1.3. Assessing Respirations

1.4. Measuring Oxygen Saturation (Pulse Oximetry)

1.5. Measuring Blood Pressure (BP)

4

Companion to ESSENTIALS IN NURSING

1.1. Measuring Body Temperature

PhysiologyThe difference between the amount of heat produced by physi-ological processes and the quantity of heat lost to external environ-ment is commonly termed as body temperature. The human body'stemperature-control mechanisms maintain the body's core tempera-ture. Skin or surface temperature however varies depending on fac-tors such as blood flow and heat loss due to environmental influ-ence.

Importance of Measuring Body TemperatureBesides being an effective indicator of the presence of infectionsand other physiological disorders, body temperature measurement isprimarily aimed at obtaining a representative average temperature ofcore body tissue. It is an important tool for bringing balance be-tween heat lost and heat produced also known as thermoregulation.Although cardiovascular and neurological mechanisms regulate thesaid relationship, the nurse's role in promoting temperature regula-tion cannot be undermined. Through the application of knowledgein temperature control mechanisms, the nurse contributes to the pro-cess of thermoregulation.

Neural & Vascular Control of Body TemperatureThe one primarily responsible for controlling body temperature isthe hypothalamus. It detects minor changes in temperature. Tem-perature characterized by comfort is known as a set point, this is thebaseline by which the heat system operates. Heat loss is controlled bythe anterior hypothalamus while the posterior hypothalamus has con-trol over heat production.When anterior hypothalamus nerve cells heats up beyond the set point,reduction of body temperature is facilitated by sending out impulses.There are several mechanisms responsible for heat loss, these include:

Sweating Vasodilation Inhibition of heat production

5

Heat loss is promoted by the redistribution of blood to surfacevessels. Once the hypothalamus detects body temperature lower thansetpoint, the body institutes its heat conservation mechanisms. Vaso-constriction reduces blood flow to the skin. Voluntary muscle con-traction prevents further heat loss, this comes in the form of shiver-ing.

Body’s Heat ProductionThe human body primarily produce heat through metabolism. It is thechemical reaction in all the body’s cells, the primary fuel for which isfood. The amount of energy needed for metabolism is called meta-bolic rate. It is increased by activities which require additional chemicalreactions. There exists a relationship between metabolism and heatproduction: an increase in the body’s metabolism means an increasein heat production.

Factors Affecting Body TemperatureAgeNewborns’ temperature control mechanisms are not fully developedthat they require extra care in protecting them from environmentaltemperatures. Up to 30% of a baby’s body heat is lost through thehead, this is why a cap is needed to prevent heat loss. Clothing mustalso be adequate so as to prevent exposure to extreme temperatures.Heat productions in infants declines steadily as they grow older. Hu-man thermoregulation remains unsteady until puberty, normal tem-perature range declines gradually as older adulthood approaches. Olderadults on the other hand undergo deterioration of temperaturemechanisms, which is why they are sensitive to temperature extremes.

Circadian rhythmWithin a period of 24 hrs, it is but natural for body temperature tochange. Temperature however, is one of the most stable rhythms inhumans, body temperature is usually at its lowest between 1:00 and4:00 a.m. Body temperature rises steadily during the day until about6:00 p.m, at which time, maximum temperature value occurs. In gen-eral age does not alter circadian temperature rhythm.

Vital Signs

6


StressHormonal and neural stimulation caused by physical and emotionalstress increase body temperature. Metabolism is increased by thesephysiological changes, thereby increasing heat production.

ExerciseIncreased blood supply, carbohydrate and fat breakdown are re-quired for muscle activity. Heat production results from this increasein metabolism. Heat production can be caused by any form of physi-cal exercise, thus effecting a rise in temperature.

EnvironmentEnvironment exerts significant influence on body temperature. As-sessment of temperature in a warm place may produce high read-ings, because the patient may not be able to adequately regulate bodytemperature by heat loss mechanisms. Likewise, assessment of bodytemperature on a patient who has had prolonged exposure to coldsurroundings without adequate clothing, could yield low body tem-perature readings. Because of infants and older adult’s less efficientheat loss regulation mechanisms, they are the ones most prone totemperature alterations from environmental temperatures.

Assessment SitesAlthough there are several sites where body temperature can be as-sessed, intensive care settings require the use of core temperaturesfrom the pulmonary, artery, esophagus and urinary bladder. Thesemeasurements require the use of invasive devices attached to bodycavities and organs.Common sites of body temperature measurements on the otherhand, although similarly invasive, can be used intermittently. Sites suchas the tymphanic membrane, mouth, rectum and axillary sites pro-vide useful measurements. This method of body temperature mea-surement uses thermometers as a common tool.

Kinds of Thermometers Used in Body TemperatureMeasurement

7

Glass thermometer Electronic thermometer Disposable thermometer

Materials Required Appropriate thermometer Soft tissue/alcohol swab Lubricant (for rectal measurements) Pencil, pen, vital sign flow sheet/

form Disposable gloves

Procedures for Measuring Body Temperature andRationale

Assess for temperature changes and factors that may affect bodyRATIONALE: Physical signs/symptoms may indicate abnormal temperature.Check patient for any activity that may interfere with accuracy ofmeasurement. Physical signs/symptoms may indicate abnormaltemperature.RATIONALE: Food/Fluid intake or smoking may affect temperature readings

gleaned from oral cavity.Choose appropriate site and measurement device to be used.RATIONALE: Selection of site depends on advantages/disadvantages. Patients

who are in isolation are advised to use glass thermometers.Explain to patient how the process is to be carried out and theimportance of keeping proper body position.RATIONALE: Patients often display curiosity and should be warned against

premature removal of thermometer.Wash hands. Assist client in establishing a comfortable position.RATIONALE: Transmission of microorganisms is reduced. Patient comfort and

accuracy of temperature reading are ensured.OBTAIN TEMPERATURE READING

Oral temperature using glass thermometer:

Vital Signs

8


Wear disposable gloves. (optional)RATIONALE: Observes proper infection control precautions in handling items

soiled with bodily fluids.Hold tip of glass thermometer using fingertips.RATIONALE: Reduces/prevents contamination of thermometer bulb.Determine mercury level while gently rotating thermometer ateye level. Hold tip of thermometer securely and flick wrist inupward and downward motion until reading reaches below35.5°C. Ask client to open mouth, then place thermometer underthe tongue in posterior sublingual pocket lateral to center oflower jaw.RATIONALE: Temperature reading is produced by heat from superficial blood

vessels in sublingual pocket.Ask client to hold thermometer in place with lips, cautioninghim/her of danger of biting down on thermometer.RATIONALE: Maintains proper thermometer position during measurement. Ther-

mometer breakage may injure mucosa and cause mercury poi-soning.

Leave thermometer in place for 3 minutes or as required byinstitution.RATIONALE: Hotzclaw (1998) recommends 3 mins as proper period for tem-

perature measurement.Remove thermometer from client's mouth and take reading ateye level. Rotate thermometer until scale appears.RATIONALE: Proper reading of mercury scale is achieved at eye level.Wipe thermometer with alcohol swab. Discard tissue. Replacethermometer in appropriate container.RATIONALE: Cross contamination is prevented.Remove and properly dispose of gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Oral temperature measurement using electronic ther-mometer:

9

Wear disposable gloves (optional).RATIONALE: Use of oral probe cover may eliminate need to wear disposable

gloves.Remove thermometer pack from its charging unit. Attach oralprobe to thermometer unit. Hold top of probe stem carefullyso as not to apply pressure on the ejection button.RATIONALE: Charging provides power for the unit's battery. Plastic probe

cover is released by the ejection button.Slide disposable probe cover over thermometer probe, lockingit in place.RATIONALE: Plastic cover cannot break in patient's mouth and transmission of

microorganism is prevented between clients.Ask client to open mouth. Place probe under tongue in posteriorsublingual pocket lateral to center of jaw.RATIONALE: Temperature reading is produced by heat from superficial blood

vessels in sublingual pocket.Ask client to hold thermometer by keeping lips closed.RATIONALE: Proper position of thermometer during measurement is main-

tained.Leave probe in place until audible sound is produced and tem-perature reading appears on digital display. Remove probe fromclient's mouth.RATIONALE: Probe must be kept in place until signal is heard, in this way

accurate reading is ensured.Discard disposable probe cover by pushing ejection button lo-cated on thermometer stem.RATIONALE: Transmission of microorganisms is reduced.Replace thermometer stem to storage well of recording unit.RATIONALE: Probe is protected from damage. Digital reading disappears upon

return of probe to storage.Remove and dispose of gloves properly. Wash hands.RATIONALE: Transmission of microorganisms is reduced.

Vital Signs

10


Rectal temperature measurement using glass thermom-eter:Provide client with needed privacy.RATIONALE: Maintains privacy, minimizes embarrassment and comfort is pro-

vided.Put on disposable gloves.RATIONALE: Standard precautions are maintained with exposure to items soiled

by bodily fluids.Read thermometer's mercury level by rotating at eye level. Ifmercury is above desired level, securely hold thermometer bythe tip and flick wrist downward until reading reaches below35.5°C.RATIONALE: Reading should be lower than patient's actual body temperature

before use of thermometer. Mercury level is lowered by brisk shaking.Squeeze some lubricant onto a tissue. Dip blunt end of ther-mometer into lubricant covering 2.5 to 3.5 cm of the thermom-eter for adult clients.RATIONALE: Minimizes trauma to rectal mucosa. Contamination of remaining

lubricant in container is prevented.Expose anus by separating client's buttocks with the use of non-dominant hand. Ask client to relax by breathing slowly.RATIONALE: Anus is fully exposed for thermometer insertion. Relaxes anal

sphincter.Insert thermometer gently into client's anus (3.5 cm for adultclients) towards the direction of the umbilicus. Avoid forcingthermometer.RATIONALE: Adequate exposure against blood vessels in rectal wall is ensured.If resistance is encountered during insertion process, immedi-ately withdraw thermometer.RATIONALE: Trauma to mucosa is prevented as glass thermometer may break.Remove thermometer and wipe off any secretions from the ther-mometer using alcohol swab. Discard swab properly.

11

RATIONALE: Cross contamination is prevented.Read thermometer at eye level. Thermometer scale will appearby rotating thermometer.RATIONALE: Accurate temperature reading is ensured.Use a piece of soft tissue in wiping the client's anal area. Disposeof tissue and assist client to a comfortable position.RATIONALE: Hygiene and comfort is provided to patient.Replace thermometer in appropriate storage container.RATIONALE: Proper storage prevents breakage and safeguards against mercury

spillage.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Rectal temperature measurement using electronic ther-mometer:Separate thermometer pack from charging unit. Attach rectalprobe to thermometer unit. Hold the top of the probe stem.RATIONALE: Charging provides battery power. Plastic probe cover is released

by the ejection button.Place disposable plastic probe cover over probe and lock it inplace.RATIONALE: Transmission of microorganisms between clients is prevented by

probe cover.Hold thermometer probe in place until audible signal is heardand temperature reading appears on the digital display. Removeprobe from client's anus.RATIONALE: Probe is to be kept in place until signal occurs to effect accurate

measurement.Discard plastic probe cover by pushing the ejection button onthe thermometer stem.RATIONALE: Transfer of microorganisms is reduced.Replace thermometer stem in the storage well of the recordingunit.

Vital Signs

12


RATIONALE: Battery charge is maintained.Wipe client's anal area using a piece of soft tissue. Discard tissueand assist client to a comfortable position.RATIONALE: Provides patient with comfort and hygieneRemove disposable gloves and discard properly. Wash hands.RATIONALE: Transmission of microorganisms is reduced.Re-attach thermometer to charging unit.RATIONALE: Battery charge is maintained.Axillary temperature measurement using glass ther-mometer:Wash hands.RATIONALE: Transmission of microorganisms is reduced.Provide client with needed privacy.RATIONALE: Privacy is provided and embarrassment is reduced.Assist client to supine or sitting position.RATIONALE: Easy access to axilla is provided.Partially remove client's gown or clothing away from shoulderand arm.RATIONALE: Axilla is exposed for easy placement of thermometer.Place thermometer in the center of client's axilla with lowerarm over thermometer and place arm across chest.RATIONALE: Proper thermometer position against axilla blood vessels is main-

tained.Keep thermometer in place for 3 minutes or as required by theagency.RATIONALE: It has been established that 3 mins of measuring time is sufficient

to obtain accurate reading.Remove thermometer, wipe off any secretions on thermom-eter using alcohol swab. Discard swab properly.RATIONALE: Transmission of microorganisms is reduced.Take thermometer reading at eye level.

13

RATIONALE: Ensures accurate reading.Place thermometer at client's bedside inside protective storagecontainer.RATIONALE: Probe is protected from damage; digital reading disappears upon

replacement of probe.Assist client in putting back on clothes or gown.RATIONALE: Privacy is provided and comfort is restored.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Axillary temperature measurement with the use of elec-tronic thermometer:Assist client to establishing supine or sitting position.RATIONALE: Easy access to axilla is provided.Take thermometer pack from its charging unit, ensuring that ax-illary probe is attached to the thermometer unit. Hold top ofprobe stem.RATIONALE: Charging provides battery power. Plastic probe cover is released

by the ejection button.Slide clean disposable probe cover over thermometer probe andlock it in place.RATIONALE: Cover prevents microorganisms' transmission in between patients.Raise client's arm away from the torso and examine for skinlesions and excess in perspiration. Place probe in the center ofthe client's axial. Lower arm over the probe and place arm acrosschest.RATIONALE: Maintains proper thermometer position against blood vessels in the

axilla.Leave probe in place until audible signal is heard and tempera-ture reading appears on the digital display.RATIONALE: To ensure accurate reading, probe must be kept in place until

signal is heard.

Vital Signs

14


Discard plastic probe cover by pushing the ejection button onthe probe stem.RATIONALE: Transmission of microorganisms is reduced.Return probe to recording unit's storage well.RATIONALE: Probe is protected from damage. Digital reading disappears upon

replacement of probe.Assist client to achieve comfortable position.RATIONALE: Provides patient with comfort and privacy.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Put thermometer back in charger.RATIONALE: Battery charge is maintained.Tympanic membrane temperature measurement usingelectronic thermometer:Assist client to achieve comfortable position with the head facingside, away from nurse.RATIONALE: Comfort is provided and auditory canal is exposed for accurate

reading.Detach thermometer unit from charging base carefully avoidingapplication of pressure over the ejection button.RATIONALE: Battery power is provided by the base, the ejection button releases

probe.Put disposable speculum cover over tip and lock it in place.RATIONALE: Protection of lens cover from dust, fingerprints or earwax.Insert speculum into ear canal referring to manufacturer instruc-tions tympanic probe positioning:RATIONALE: Accurate reading is ensured.Pull ear pinna in an upward and backward direction for adults.Pull ear pinna in downward and backward direction for chil-dren.RATIONALE: External auditory canal is straightened for exposure of tympanic

15

membrane.Move thermometer following a figure-eight pattern.RATIONALE: Allows for the detection of maximum tympanic membrane heat

radiation.Gently fit probe in ear canal and keep it in place.RATIONALE: Seals auditory canal from ambient temperature to avoid inaccu-

rate reading.Point probe toward client's nose.RATIONALE: Appropriate assessment site.Depress handheld unit's scan button. Keep probe in place untilaudible signal occurs and temperature reading appears on thedigital display.RATIONALE: Scan button's depression detects infrared energy. Keep otoscope in

place to ensure reading accuracy.Remove speculum carefully from client's auditory canal.RATIONALE: Avoids discomfortDiscard plastic probe cover by pushing ejection button onhandheld unit.RATIONALE: Transmission of microorganisms is reduced.If a second reading is needed, replace cover and wait for 2-3mins.RATIONALE: Lens cover must be free of cerumen to maintain optical path.Assist client to a comfortable position.RATIONALE: Provides patient with comfort.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Discuss findings with client as required.RATIONALE: Patient participation is promoted in care and understanding of

health status.If temperature assessment is being done for the first time, con-sider temperature as baseline & normal range for client's age

Vital Signs

16


group.RATIONALE: Used in comparing future temperature measurements.Compare temperature reading to previous baseline and normalrange for client's age group.RATIONALE: Temperature comparison indicates presence of abnormality. Sec-

ond measurements confirm abnormality in body temperature.Record temperature reading and report abnormal findings.RATIONALE: Documentation facilitates communication with other health team

members. Serves as future reference for nursing care. May alsoserve for legal purposes.

1.2. Assessing Radial & Apical Pulse

PulseThe bounding of blood flow at different points of the human bodyis called pulse. It indicates the circulating status of the body. Theimportance of circulation lies in its distribution of much needednutrients to the body's cells. Continuous blood flow therefore playsan important role in the body's health.

PhysiologyBlood circulation in the human body is a continuous cycle, whichbegins in the heart. Cardiac contraction sends blood to the aorta,which in turn pumps them into the distal ends of arteries. Pulse wavemovement changes from the time blood volume is ejected by theheart to its passage through small arteries. A pulse wave reaching aperipheral artery can be felt by lightly palpating the artery againstunderlying bone or muscle. The palpable bounding of blood flowin the peripheral artery is known as the pulse. The pulse rate is thenumber of pulsing sensations occurring in a minute. The amount orvolume of blood pumped out by the heart in one minute is calledthe cardiac output.All arteries may be palpated and assessed for pulse rate but the ca-rotid and radial arteries offers easy palpation of peripheral pulsesites. As cardiac output declines in patients whose conditions worsen,

17

the carotid artery in these cases is the most optimal site for finding apulse.

Radial and Apical PulseRadial and apical pulses, though sharing certain similarities differ inthe way they are assessed. In radial pulse assessment, pulse rate, rhythmand equality are measured whereas only rhythm and rate are mea-sured in the assessment of the apical pulse.

Importance of Pulse AssessmentThrough pulse assessment, the general state of a patient's cardiovas-cular health can be determined. Nursing diagnoses can also be de-rived from the procedure where appropriate nursing care plans canbe drafted and afterwards implemented.

Materials Required Stethoscope Wristwatch with second hand or digital display Pen, pencil, vital sign flow sheet/record form Alcohol Swab

Procedure for Measuring Radial/Apical Pulse &Rationale

Identify need for measurement of radial or apical pulse.RATIONALE: Certain health conditions may effect pulse alterations (e.g., heart

disease, cardiac dysrhytmias, and surgery).Determine factors influencing pulse rate.RATIONALE: Allows for the accurate assessment of presence of pulse alterations

and its significance.Know previous baseline apical rate (if available) from client'srecord.RATIONALE: Allows for assessment for condition change, provides comparison

for future apical pulse measurements.Explain to the client the assessment of pulse or heart rate. En-courage relaxation and try to keep client from speaking.

Vital Signs

18


RATIONALE: Heart rate may be affected by activity and anxiety.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Provide needed privacy.RATIONALE: Patient is given privacy and embarrassment is minimized.RADIAL PULSE

Assist client to sitting or supine positionRATIONALE: Allows for easy access to pulse sites.If client is in supine position, place his/her forearm across upperabdomen or lower chest, extending the wrist straight. If in asitting position, bend the client's elbow 90° with the lower armbeing supported on a chair or on your arm. Flex client's wristslightly with palm down.RATIONALE: Allows for full exposure of artery for palpation.Place tips of first two fingers over groove along the radial orthumb side of client's inner wrist.RATIONALE: Arterial palpation is rendered by using fingertips which are the

most sensitive parts of the hands.Compress lightly against client's radius, initially obliterate pulse,then relax pressure.RATIONALE: Use of moderate pressure effects more accurate assessment of pulse.Determine pulse strength.RATIONALE: Volume of blood ejected against arterial wall is reflected by pulse

strength.When pulse can be regularly felt, refer to watch's second handand begin counting rate.RATIONALE: Pulse palpation ensures accurate pulse rate measurement. Timing

should begin with zero with count of one as first beat after timingbegins.

If pulse is regular, count rate for 30 seconds and multiply bytwo.

19

RATIONALE: Slow, rapid or regular pulse rate may be accurately measured by a30-sec count.

If irregular pulse rate, count rate for 60 secs. Assess frequencyand irregular pattern.RATIONALE: Transmission of pulse wave may be influenced by inefficient heart

contractions, thus interfering with cardiac output, which results inirregular pulse. Accurate count is ensured with long count.

APICAL PULSE

Assist client to supine sitting position. Expose sternum and leftside of the client's chest.RATIONALE: Portion of chest wall is exposed for selection of auscultatory site.Determine anatomical reference so that the point of maximalimpulse may be identified.RATIONALE: Allows for proper placement of stethoscope over heart apex, mak-

ing hearing of heartbeat sounds easy and clear.Put stethoscope's diaphragm in palm of hand for 5-10 secs.RATIONALE: Warming of metal/plastic diaphragm promotes patient comfort.Put stethoscope's diaphragm over maximal impulse point at thefifth intercoastal space at the left midclavicular line and auscultatefor normal S1 and S2 heart sounds.RATIONALE: Avoids sound distortion by allowing stethoscope tubing to go straight.When regular S1 and S2 are heard, begin count rate with refer-ence to watch's second hand.RATIONALE: Clear auscultation of sound allows for accurate measurement of

apical heart rate. Timing starts with zero. Count of one beginswith the first auscultated sound after timing starts.

In case of regular apical rate, count for 30 secs. And multiply by2.RATIONALE: Assessment of regular apical rate can be done within 30 secs.If rate is irregular, and/or client is on cardiovascular medication,count for 60 seconds.RATIONALE: Measurement over longer interval allows for more accurate assess-

ment of irregular apical rate.

Vital Signs

20


Note regularity of dysrythmia, if any.RATIONALE: Inefficient heart contraction and cardiac output alteration may be

determined with regular occurrence of dysrhythmia.Assist client in re-establishing comfortable position.RATIONALE: Restores patient comfort.Wipe stethoscope's earpieces and diaphragm with alcohol swabas needed.RATIONALE: Transmission of microorganisms is reduced.Discuss findings with client as deemed necessary.RATIONALE: Patient participation in care and understanding of health status is

promoted.Wash hands.RATIONALE: Transmission of microorganisms is reducedCompare readings with previous baseline and /or acceptablerange of heart rate for client's age group.RATIONALE: Condition changes and alterations are evaluated.Compare peripheral pulse rate to apical rate and note any dis-crepancy.RATIONALE: Pulse deficit which may indicate cardiovascular problems may be

derived from difference between measurements.Compare radial pulse equality and note any discrepancy.RATIONALE: Differences between radial arteries are indicative of compromised

peripheral vascular system.Correlate pulse rate with data gleaned from blood pressure andrelated signs and symptoms.RATIONALE: There is an interrelation between pulse rate and blood pressure.Record pulse rate with assessment site and report abnormal find-ings.RATIONALE: Documentation facilitates communication with other health team


21

1.3. Assessment of Respiration

RespirationHuman life depends primarily on the presence of oxygen in bodycells and the removal of carbon dioxide from them. This conditionis achieved through the process of respiration. This mechanism ofthe human body involves three other processes namely:

Ventilation Diffusion Perfusion

Assessment of all three processes can be done interdependently.However, integration of assessment data from all three processes isrequired to analyze an individual's respiratory efficiency. The pro-cesses are also known to be interdependent with one process affect-ing the other.Similarly, the process of respiration can be influenced by a numberof factors which includes:

Exercise Acute pain Anxiety Smoking Body position Medication Neurological injury Hemoglobin function

Physiological ControlBreathing is generally a passive process. Normally, a person thinkslittle about it. The respiratory center in the brain stem regulates theinvoluntary control of respiration. Adults normally breathe in asmooth, uninterrupted pattern, about 12 to 20 times a minute.Ventilation is regulated by level of CO2, O2 and hydrogen ion con-centration (pH) in the arterial blood. The most important factor inthe control of ventilation is the level of CO2 (carbon dioxide) in the

Vital Signs

22


arterial blood. An elevation in the CO2 level causes the respiratorycontrol system in the brain to increase the rate and depth of breath-ing. The increased ventilatory effort removes excess CO2 by increas-ing exhalation. However, clients with chronic lung disease have on-going hypercarbia. For these clients, chemoreceptors in the cartoidartery and aorta are sensitive to hypoxemia or low levels of arterialO2. If arterial oxygen level falls, these receptors signal the brain toincrease the rate and depth of ventilation. Hypoxemia helps controlventilation in clients with chronic lung disease. Because low levels ofarterial O2 provide the stimulus that allows the client to breathe, ad-ministration of high oxygen levels can however be fatal for clientswith chronic lung disease.

Mechanics of BreathingAlthough breathing is normally passive, muscular work is involved inmoving the lungs and chest wall. Inspiration is an active process.During inspiration, the respiratory center sends impulses along thephrenic nerve, causing the diaphragm contraction. Abdominal or-gans move downward and forward, increasing the length of thechest cavity to move air into the lungs. The diaphragm moves ap-proximately 1 cm (4/10 inch) and the ribs retract upward from thebody's midline approximately 1.2 to 2.5 cm (1/2 to 1 inch). Duringa normal, relaxed breath, a person inhales about 500 ml of air. Thisamount is referred to as the tidal volume. During expiration, thediaphragm relaxes and the abdominal organs return to their originalpositions. The lung and chest wall return to a relaxed position. Expi-ration is a passive process. The normal rate and depth of ventilation,eupnea, is interrupted by sighing. The sigh, a prolonged deeper breath,is a protective psychological mechanism for expanding small airwaysand alveoli not ventilated during a normal breath.An accurate assessment of respirations depends on the nurse's rec-ognition of normal thoracic and abdominal movements. During quietbreathing, the chest wall gently rises and falls. Contraction of theintercostal muscles between the ribs or contraction of the muscles inthe neck and shoulders, the accessory of muscles of breathing, arenot visible. During normal quiet breathing, diaphragmatic move-ment causes the abdominal cavity to rise and fall.

23

AssessmentAlthough respiration is the easiest vital sign to assess, it is also themost susceptible to inaccurate measurement. As tempting as it maybe, nurses should be cautioned against estimating respirations. Ob-servation and chest wall movement palpation are required for accu-rate measurement of respirations.

Indications for Assessing RespirationRespiration is the exchange of oxygen and carbon dioxide betweenthe cells of the body and the environment through rhythmic expan-sion and deflation of the lungs. Each respiration consists of an inha-lation, exhalation and the pause which follows. The respiratory ratemay be assessed to:

Establish a baseline respiratory rate Monitor the patient's condition during and following investigativeprocedures and treatments (e.g., aspiration of pleural cavity,pleural biopsy, peritoneal dialysis)

Estimate the degree of dysfunction and the effect of treatmentAs mentioned earlier, an accurate assessment of respiratory efficiencyrequires assessment data of the ventilation, diffusion and perfusionprocesses. Assessment of the last two processes can be done throughmeasuring oxygen saturation in the blood.Since oxygen attaches to hemoglobin molecules, measuring the per-centage of hemoglobin bound with oxygen in arterial blood is thepercentage of hemoglobin saturation (SaO2) which is normally be-tween 95 to 100%.A sudden change in the character of respirations may be important.Because respiration is tied to the function of numerous body sys-tems, the nurse must consider all variables when changes occur. Forexample, a drop in respirations occurring in a client after head traumamay signify injury to the brain stem. Abdominal trauma may injurethe phrenic nerve, which is responsible for diaphragmatic contrac-tion. The nurse must understand the extent of the injury and theimplications to the respiratory system.A skillful nurse does not let a client know that respirations are being

Vital Signs

24


assessed. A client aware of the nurse's intentions may consciouslyalter the rate and depth of breathing. Assessment can be best doneimmediately after measuring pulse rate, with the nurse's hand still onthe client's wrist as it rests over the chest or abdomen. When assess-ing a client's respirations, the nurse should keep in mind the client'susual ventilatory rate and pattern, the influence any disease or illnesshas on respiratory function, the relationship between respiratory andcardiovascular function and the influence of therapies on respira-tions. The objective measurements of an assessment of respiratorystatus include the rate and depth of breathing and the rhythm ofventilatory movements.Respiratory Rate. The nurse observes a full inspiration and expirationwhen counting ventilation or respiration rate. The respiratory ratevaries with age. The usual range of respiratory rate declines through-out life.A respiratory monitoring device that aids the nurse's assessment isthe apnea monitor. This device uses leads attached to the client's chestwall that sense movement. The absence of chest wall movement isinterpreted by the monitor as apnea and triggers an alarm. Apneamonitoring is used frequently on infants in the hospital and at hometo observe for prolonged anemic events. Non-invasive monitoringprovides information that helps the nurse assess the rate, depth andrhythm of respiration more knowledgeably.

Pertinent Laboratory ValuesArterial blood gases (ABGs): Normal ABGs (values may vary slightlywithin institutions):

pH = 7.35-7.45 PaCO2 = 35-45 PaO2 = 80-100 SaO2 = 94%-98%

Arterial blood gases measure arterial blood pH, pressure of O2 andCO2 and arterial O2 saturation, which reflects client's oxygenationstatus.Pulse oximetry (SpO2): Acceptable SpO2 90%-100%; 85%-89%

25

may be acceptable for certain chronic disease conditions; less than85% is abnormal.SpO2 less than 85% is often accompanied by changes in respiratoryrate, depth and rhythm.Complete blood count (CBC): Normal CBC for adults ( valuesmay vary within institutions):

Hemoglobin: 14 to 18 g/100 ml, males: 12 to 16 g/100 ml,females.

Hematocrit: 40% to 54%, males; 38% to 47%, females.Red blood cell count: 4.6 to 6.2 million/ ul, males; 4.2 to 5.4

million/ ul females.Complete blood count measures red cell count, volume of red bloodcells, and concentration of hemoglobin, which reflects client's capac-ity to carry O2 .Ventilatory Depth. The depth of respirations is assessed by ob-serving the degree of excursion or movement in the chest wall. Thenurse subjectively describes ventilatory movements as deep, normalor shallow. A deep respiration involves a full expansion of the lungswith full exhalation. Respirations are shallow when only a small quantityof air passes through the lungs and ventilatory movement is difficultto see. More objective techniques are used if the nurse observes thatchest excursion is unusually shallow.Ventilatory Rhythm. Breathing pattern can be determined by ob-serving the chest or the abdomen. Diaphragmatic breathing resultsfrom the contraction and relaxation of the diaphragm and is bestobserved by watching abdominal movements. Healthy men and chil-dren usually demonstrate diaphragmatic breathing. Women tend touse thoracic muscles to breathe, with movements observed in theupper chest. Labored respirations usually involve the accessory musclesof respirations visible in the neck. When something such as a foreignbody interferes with air movement in and out of the lungs, the inter-costal spaces retract during inspirations. A longer expiration phase isevident when the outward flow of air is obstructed.With normal breathing, a regular interval occurs after each respira-tory cycle. Infants tend to breathe less regularly. The young child maybreathe slowly for a few seconds and then suddenly breathe more

Vital Signs

26


rapidly. While assessing respirations, the nurse estimates the time in-terval after each respiratory cycle. Respiration is regular or irregularin rhythm.

Assessment of Diffusion and PerfusionThe respiratory process of diffusion and perfusion can be evaluatedby measuring the oxygen saturation of the blood. Blood flow throughthe pulmonary capillaries provides red cells for oxygen attachment.After oxygen diffuses from the alveoli into the pulmonary blood,most of the oxygen attaches to hemoglobin molecules in red bloodcells. Red blood cells carry the oxygenated hemoglobin molecules tothe left side of the heart and out to the peripheral capillaries, whereoxygen detaches, depending on the needs of the tissues.The percentage of the hemoglobin that is bound with oxygen in thearteries is the percent of saturation of hemoglobin (or SaO2). It isusually 95% and 100%. SaO2 is affected by factors that interferewith ventilation, perfusion or diffusion. The saturation of venous islower because the tissues have removed some of the oxygen fromthe hemoglobin molecules. A normal value for SaO2 is 70%. SaO2 isaffected by factors that interfere with or increase the tissue's need foroxygen.

Related informationRate. Normal respiratory rates vary according to age. The acceptednormal range is:

Healthy adults: 14 - 20 per min Adolescents: 18 - 22 per min Children: 22 - 28 per min Infants: 30 or more per min

Depth. The depth of respiration is approximately the same for eachperson and can be described as normal, shallow or deep.Pattern. A normal breathing pattern is effortless, evenly paced, regu-lar and automatic. Abnormal patterns may be described as:Dyspnea. Difficult, labored breathing. The nostrils are dilated and thechest wall and shoulder girdle are raised and lowered in an exagger-

27

ated fashion.Cheyne - Stokes. There is a gradual increase in the depth of respirationfollowed by a gradual decrease and then a period of no respiration(apnea). This syndrome is associated with terminal illness.Kussmaul's respirations. There is an increased rate and depth of respira-tion with panting and long grunting expirations. This syndrome maybe associated with lobar pneumonia.Stertorous respirations. These are noisy respirations caused by excessivesecretions in the trachea or bronchi. It may also be a sign of partialairway obstruction.Stridor. A harsh, high-pitched noise on inspiration caused by laryngealobstruction.

Materials Required Wristwatch with second hand/digital display Pen, pencil, vital sign flow sheet/record form

Procedures for Assessing Respiration & RationaleIdentify need to assess client's respirations.RATIONALE: Client may be at risk for ventilation alterations. These may be

known by respiratory rate, depth and rhythm changes.Assess pertinent laboratory values.RATIONALE: Arterial blood pH may be measured by arterial blood gases,

partial O2 and CO2 and arterial O2 pressure, which reflectspatient's oxygenation status.

Determine previous baseline respiratory rate (if available) fromclient's record.RATIONALE: Allows for the assessment of any change in condition. May be used

for comparison with future respiratory measurements.Assist client to comfortable position, preferably lying or sittingwith head of the bed elevated at 45 to 60 degrees.RATIONALE: Uncomfortable position affects assessment results.

Vital Signs

28


Provide needed privacy.RATIONALE: Privacy is provided and embarrassment is reduced. Patient anxi-

ety is reduced.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Ensure client's chest is visible. Move client's linen or gown ifnecessary.RATIONALE: Provides a clear view of chest wall and abdominal movements.Place client's arm in relaxed position across lower chest or abdo-men or place your hand over upper abdomen.RATIONALE: Allows for subtle assessment of respiratory rate.After observing cycle, look at watch's second hand and begincounting rate.RATIONALE: Timing starts with count of one since respiratory rate occurs

slower than pulse.If rhythm is regular, count respiratory rate in 30 sec and multiplyby 2.RATIONALE: Respiratory rate is the number of respirations per min.If rhythm is irregular, with rate of less than 12 or greater than 20,count respirations for 60 seconds.RATIONALE: Assessment for at least one minute is required for possible irregu-

larities.Take note of respiration depth.RATIONALE: Ventilatory movement's character may reveal disease state.Note ventilatory cycle rhythm.RATIONALE: Specific type of alterations may be revealed by ventilation’s charac-

ter.Replace client's gown and bed linen.RATIONALE: Comfort is restored and well-being promoted.Wash hands.RATIONALE: Transmission of microorganisms is reduced.

29

Discuss findings with client as necessary.RATIONALE: Patient participation in care and understanding of health status is pro-

moted.If respirations are being assessed for the first time, determinerate, rhythm and depth as baseline if within normal range.RATIONALE: May be used to compare with future respiratory assessment.Compare respirations with client's previous baseline and abnor-mal rate, rhythm and depth.RATIONALE: Allows for assessment of changes in patient's condition and pres-

ence of respiratory alterations.

1.4. Measuring Arterial Oxygen SaturationThe recent development of a device known as the pulse oximeter al-lows for the indirect measurement of patients' arterial oxygen satu-ration. But as reliable as the device is known to be, oxygen saturationmeasurement can be influenced by many factors rendering measure-ment inaccuracy. Factors such as light transmission or peripheral arte-rial pulsations can interfere with the accuracy of the procedure’s out-come.

Materials Required Oximeter Oximeter probe appropriate for client and manufacturerrecommended

Acetone/nail polish remover Pen, pencil, vital sign flow sheet/record form

Procedure for Measuring Arterial OxygenSaturation & Rationale

Identify patient and need to measure patient's oxygen saturation.RATIONALE: Some conditions may put patient at risk for oxygen saturation

decrease. These include acute/chronic respiratory function, recov-ery from general anesthesia and traumatic injury to chest wall.

Vital Signs

30


Assess for factors that may influence measurement of SpO2.RATIONALE: Facilitates accurate assessment of alterations in oxygen satura-

tion. SpO2 assessment can be influenced by peripheral vasocon-striction related to hypothermia.

Review client's record for prescribed order.RATIONALE: Oxygen saturation assessment may require physician’s order.Determine previous SpO2 baseline (if available) from client'srecord.RATIONALE: Basis for comparision is provided. Facilitates assessment of patient

status for formulation of possible intervention.Explain to patient the purpose of the procedure (if conscious).RATIONALE: Improves patient’s knowledge of procedure. Reduces anxiety and

promotes cooperation.Locate site for sensor probe placement (feet, earlobe, hands)RATIONALE: SpO2 assessment can be influenced by peripheral vasoconstriction.

Large fluctuations in minute ventilation and possible SpO2 read-ing errors are prevented.

Wash hands.RATIONALE: Reduces transmission of microorganisms.Assist client to comfortable position. If finger is chosen as moni-toring site, support client's lower arm.RATIONALE: Proper probe positioning is ensured. Motion artifact that may

interfere with SpO2 reading is reduced.Tell patient to breathe normally.RATIONALE: Large fluctuations in respiratory rate, depth and possible SpO2

alterations are prevented.Remove any fingernail polish from finger to be assessed.RATIONALE: Accurate SpO2 reading is ensured. Opaque finger nail coatings

could reduce light transmission. Light emissions are absorbed bynail polish with blue pigment and may render inaccurate readings.

Attach sensor probe to monitoring site. Instruct client that clip-

31

on probe will not hurt but feel like a clothespin on the finger.RATIONALE: Informs patient of expected sensations.Turn on oximeter by activating power. Observe pulse waveform/intensity display and audible beep. Correlate client's pulse ratewith radial pulse.RATIONALE: Detection of pulse/presence of signal interference is enabled by

pulse waveform/intensity display. SpO2 value is proportional topitch of audible beep. Oximeter accuracy is ensured by double-checking pulse. Oximeter pulse rate, patient’s radial and apicalpulse should have the same value.

Leave probe in place until oximeter readout displays constantvalue and pulse display reaches full strength during individualcardiac cycle. Read SpO2 on digital display.RATIONALE: Depending on site chosen, reading may take 10 to 30 seconds.Tell client that the oximeter alarm will sound if probe falls offor was moved.RATIONALE: Cautions patient against accidental removal of probe.Verify SpO2 alarm limits and alarm volume for continuous moni-toring. Check that alarms are on. Assess skin integrity under sen-sor probe and relocate sensor probe every 4 hrs. at least.RATIONALE: Avoids startling patients and visitors. Disruption of skin integ-

rity may result from spring tension of probe or sensitivity to dis-posable sensor probe adhesive.

Discuss findings with client as necessary.RATIONALE: Patient participation in care is promoted.Detach probe and turn oximeter power off after intermittentmeasurements. Store probe in appropriate location.RATIONALE: Leaving oximeter on can deplete battery power. Prevents damag-

ing of sensor probe.Assist client to comfortable position.RATIONALE: Restores patient comfort.Wash hands.

Vital Signs

32


RATIONALE: Reduces transmission of microorganisms. Compare SpO2 reading with client baseline and acceptable val-ues.RATIONALE: Presence of abnormality is revealed by comparison.Correlate SpO2 reading with SaO2 reading gleaned from arterialblood gas measurements, if available.RATIONALE: Reliability of non-invasive assessment is determined.Correlate SpO2 reading with data obtained from respiratory as-sessment.RATIONALE: Ventilation, perfusion and diffusion assessment data are interre-

lated.Report and record SpO2 readings, respiratory status, oxygentherapy and client response.RATIONALE: Documentation facilitates communication with other health team


1.5. Measuring Blood Pressure (BP)Blood Pressure is the force exerted on the walls of arteries createdby pulsing blood coming from the heart. Systematic or arterial bloodpressure is considered an accurate basis for determining the state ofa person's cardiovascular health. Changes in pressure enables bloodto flow throughout the circulatory system. Blood moves from highto low pressure areas of the circulatory system. Contraction of theheart forces blood under high pressure into the aorta. The peak ofmaximum pressure upon blood ejection is called systolic blood pressure.Arterial blood exerts a minimum pressure known as diastolic pressurewhen ventricles relax. It is the minimal blood pressure exerted againstthe walls of arteries.The standard unit for blood pressure measurement is millimeters ofmercury (mm Hg). It indicates the height at which the blood pres-sure can raise a column of mercury. Blood pressure is recorded with

33

a systolic reading first followed by the diastolic blood. (e.g., 120/80).The pulse pressure is the difference between systolic and diastolicpressure. For a blood pressure of 120/80, the pulse pressure is 40.

Arterial Blood Flow PhysiologyBlood pressure reflects the interrelationship among the following:

Cardiac output Peripheral vascular resistance Blood volume Blood viscosity Artery elasticity.

A nurse's knowledge of these hemodynamic variables aids duringassessment of alterations in blood pressure.

Cardiac OutputAn individual's cardiac output (CO) is the volume of blood pumpedby the heart (stroke volume [SV]) during 1 min (heart rate [HR]):

CO = HR × SV

Blood pressure (BP) depends on the cardiac output and peripheralvascular resistance (R):

BP = CO × R

When volume increases in a blood vessel, the pressure in that spacerises. Therefore, as cardiac output increases, more blood is pumpedagainst arterial walls, which causes an increase in blood pressure.Cardiac output may increase as a result of the following:

Increased heart rate Greater heart muscle contractility Increase in blood volume.

Heart rate alterations may occur faster than changes in muscle con-tractility or blood volume. A rise in heart rate may reduce diastolicfilling time and end-diastolic volume. A decrease in blood pressuretherefore occurs.

Hemodynamic Factors

Vital Signs

34


Peripheral ResistanceBlood goes through a network of arteries, arterioles, capillaries, venulesand veins. Arteries and arterioles are surrounded by smooth musclethat contracts or relaxes to change the lumen's size. Arteries and arte-riole size alters to adjust flow of blood to local tissue needs. Forexample, when a major organ requires more blood, the peripheralarteries constrict, decreasing blood being supplied. More blood be-comes available to the major organ due to the resistance change inthe periphery. Arteries and arterioles normally stay partially constrictedso as to maintain constant blood flow. Peripheral vascular resistanceis blood flow resistance determined by vascular musculature toneand blood vessel diameter. The smaller the blood vessel's lumen, thegreater peripheral vascular resistance to blood flow. Arterial bloodpressure rises with a resistance increase. Resistance reduction fromvessel dilation on the other hand effects a drop in blood pressure.Blood VolumeThe volume of blood flowing within the circulatory system affectsblood pressure. Most adults have a total circulating blood volumeof 5000 ml. Blood volume normally remains constant. A rise inblood volume results in an increase in pressure exerted against arte-rial walls. An example of this is the way rapid, uncontrolled infusionof intravenous fluids increases blood pressure. Blood pressure like-wise falls when circulating blood volume decreases, as in the case ofhemorrhage or dehydration.ViscosityBlood thickness or viscosity of blood affects the ease with which bloodcirculates through small blood vessels. Blood viscosity is determinedby the hematocrit--the percentage of blood cells in the blood. Slowblood flow results from a rise in hematocrit., increasing arterial bloodpressure. In this case, the heart must increase contraction force tomove viscous blood through the circulatory system.ElasticityNormally, arterial walls are elastic and easily distensible. As pressurewithin the arteries increases, the diameter of vessel walls increases toaccommodate the pressure change. Arterial distensibility prevents wide

35

fluctuations in blood pressure. However, in certain illnesses , such asarteriosclerosis, the vessel walls lose their elasticity and are replacedby fibrous tissue that is unable to stretch well. Reduction in elasticityresults in increased resistance to blood flow. As a result, when the leftventricle ejects its stroke volume, the blood vessels become unyield-ing to pressure. Instead, a given volume of blood is forced throughthe rigid walls of the arteries and a rise in systematic pressure results.Reduced arterial elasticity elevates systolic more than diastolic pres-sure.Each factor affects the other significantly. For example, a decline inarterial elasticity results in an increase in peripheral vascular resistance.The cardio vascular system's complex control normally prevents anysingle factor from permanently altering blood pressure. For example,a fall in blood volume is compensated by a vascular resistance in-crease.

Factors Influencing BPAlthough blood pressure is not constant, many factors influence itduring the day. A single blood pressure measurement cannot accu-rately reflect a patient's blood pressure. Even under ideal conditions,blood pressure varies. What guides nursing intervention is blood pres-sure trends and not individual measurements. Understanding thesefactors ensures a more accurate blood pressure readings interpreta-tion.AgeNormal blood pressure levels vary throughout an individual's life.They increase during childhood. A child or adolescent's blood pres-sure level is assessed owing to consideration body size and age. Theblood pressure of an infant ranges from 65-115/42-80, normal bloodpressure of a 7-year-old is 87-117/48-64. Heavier and/or taller chil-dren tend to have higher blood pressures than smaller children ofthe same age. Blood pressure continues to vary according to bodysize during adolescence.Advancing age tend to increase an adult's blood pressure. The opti-mal blood pressure level for a healthy middle-age adult is 120/80with acceptable values of <130/<85 as the norm. Decreased vessel

Vital Signs

36


elasticity contribute to the rise in systolic pressure among older adults.StressHeart rate, cardiac output and peripheral vascular resistance increaseas a result of sympathetic stimulation brought about by anxiety, fear,pain and emotional stress resulting from sympathetic stimulation.Sympathetic stimulation's effects increase blood pressureRaceThe incidence of hypertension (high blood pressure) is higher in Afri-can-Americans than in European-Americans. African-Americans tendto develop more severe hypertension at an earlier age and have twicethe risk of complications such as stroke and heart attack. Geneticand environmental factors are believed to be contributing factors.Hypertension-related deaths are also higher among African-Ameri-cans.MedicationsSome medications can affect blood pressure directly or indirectly. Inassessing blood pressure, the nurse asks whether the patient is takinganti-hypertensive or other cardiac medications, which could lowerblood pressure. Narcotic analgesics is another class of medicationswhich can lower blood pressure.Diurnal VariationBlood pressure levels may undergo changes over the course of aday. It is typically lowest during early morning, rises gradually duringthe morning and afternoon and peaks in the late afternoon or evening.No two individuals share the same pattern or degree of change inblood pressure.GenderNo clinically significant difference in blood pressure levels betweenboys and girls has ever been found. Following puberty, higher bloodpressure readings have been seen in males. Women on the other handtend to have higher levels of blood pressure than men after meno-pause.

37

HypertensionThe most typical change in blood pressure is hypertension. It is a lead-ing factor responsible for deaths from strokes and is a contributingfactor to myocardial infarctions (heart attacks). It is often asymp-tomatic and characterized by persistent elevated blood pressure.Hypertension in adults is diagnosed when an average of two ormore diastolic readings on at least two visits yield 90 mm Hg orhigher or when the average of multiple systolic blood pressures ontwo or more subsequent visits is consistently higher than 135 mmHg. Hypertension categories have been developed to establish medi-cal intervention. A single measurement reflecting elevated blood pres-sure does not qualify as a diagnosis of hypertension. If the nursehowever assesses a high reading during the first blood pressure mea-surement (e.g., 150/90 mm Hg), the client is encouraged to comeback for another check-up within 2 months.Hypertension is associated with the thickening and loss of elasticityin the walls of the arteries. In such cases, the heart must continuallypump against greater resistance. This results in a decrease in bloodflow to vital organs such as the heart, brain and kidney.

Risks for Developing Hypertension Family history of hypertension. Obesity Cigarette smoking and/or heavy alcohol consumption High sodium (salt) intake Sedentary lifestyle Continued exposure to stress

In diabetic patients, older adults and African-Americans, the inci-dence of hypertension is greater. When a patient is diagnosed withhypertension, the nurse helps in educating him/her on blood pres-sure values, long-term follow-up care and therapy, the usual lack ofsymptoms (the fact that it may not be "felt"), therapy's ability tocontrol but not cure hypertension and a consistently followed treat-ment that can ensure a relatively normal lifestyle.

Hypotension

Vital Signs

38


Hypotension is basically considered present when systolic blood pres-sure falls to 90 mm Hg or below. Although normally, some adultshave a low blood pressure, for the majority of individuals, low bloodpressure is an abnormal finding associated with illness.The condition results from the dilation of the arteries in the vascularbed, loss of a significant amount of blood volume (e.g., hemor-rhage) or the failure of the of the heart muscle to adequately pump(e.g., myocardial infarction). Hypotension associated with pallor, skinmottling, clamminess, confusion, increased heart rate or decreasedurine output is considered life threatening and should be immedi-ately reported to a physician.Orthostatic hypotension, also known as postural hypotension, happenswhen a normotensive person develops symptoms of low bloodpressure when rising to an upright position. When a healthy indi-vidual shifts from a lying, to sitting, to standing position, the legs'peripheral blood vessels constrict. Lower extremity vessels constric-tion, when standing prevents blood pooling in the legs caused bygravity. When a patient has a decreased blood volume, the bloodvessels are already constricted. When a patient with a depleted bloodvolume stands up, there is a significant blood pressure drop. Heartrate therefore increases to compensate for the reduced cardiac out-put. Individuals who are dehydrated, anemic or have gone throughprolonged bed rest or recent blood loss are at risk for orthostatichypotension. Misuse of some medications can likewise cause ortho-static hypotension, especially among older adults or young patients.Measurement of blood pressure is therefore a must before suchmedications are administered.Measurements of orthostatic vital sign include blood pressure andpulse assessment with the patient in supine, sitting and standing posi-tions. In recording orthostatic blood pressure measurements, the nurserecords the patient's position in addition to the blood pressure mea-surement. Example: 140/80 mm Hg supine

132/72 mm Hg sitting108/60 mm Hg standing

39

The readings are obtained 1 to 3 minutes after the patient changesposition. Orthostatic hypotension in most cases, is detected within aminute standing. If orthostatic hypotension is assessed, the client isassisted to a lying position and the physician or nurse in charge isnotified. While obtaining orthostatic measurements, the nurse ob-serves for other symptoms of hypotension (i.e., fainting, weaknessor light-headedness). The skill of orthostatic measurement requirescritical thinking and nursing judgment.

Blood Pressure AssessmentArterial blood pressure may be measured either directly (invasively)or indirectly (non-invasively). The indirect method involves insertinga thin catheter into an artery. Tubing connects the catheter to an elec-tronic monitoring equipment. Constant arterial pressure waveformand reading are displayed in a monitor. Invasive blood pressuremonitoring is used only in intensive care settings because of the riskof sudden blood loss from an artery.The most common non-invasive method involves use of the sphyg-momanometer and stethoscope. Blood pressure is measured indi-rectly by auscultation or palpation. Auscultation is the most widelyused technique.

Blood Pressure EquipmentA sphygmomanometer and stethoscope are used in indirectly assessingblood pressure. It is composed of a pressure manometer, an occlu-sive cloth or vinyl cuff that encloses an inflatable rubber bladder anda pressure bulb with a release valve that inflates the bladder. Thereare two types of manometers:

Aneroid Mercury

The aneroid manometer has glass-enclosed circular gauges containing aneedle that registers millimeter calibrations. Before using the aneroidmodel, one must make sure that the needle is pointing to zero andthe manometer is correctly calibrated. Aneroid sphygmomanometerrequires biomedical calibration at routine intervals, this is to verifytheir accuracy. Aneroid manometers have the advantages of beinglightweight, portable and compact. The aneroid instrument how-

Vital Signs

40


ever, is less reliable than the mercury type since its metal parts aresubject to temperature expansion or contraction.Mercury manometers on the other hand, are more accurate than aneroidtypes. Repeated calibrations are not necessary. The mercury manom-eter is an upright tube containing mercury. Pressure created by theinflation of the bladder moves the column of mercury upwardagainst the force of gravity. Millimeter calibrations mark the heightof the mercury column. The mercury column must be at zero whenthe cuff is deflated. The mercury column should fall freely as pres-sure is released, this is to ensure accurate readings. Readings are ob-tained by looking at the meniscus of the mercury at eye level. This iswhere the crescent-shaped top of the mercury column aligns withthe manometer scale. Distorted readings result from looking up ordown at the mercury. There are however disadvantages to the mer-cury manometer, these are the potential for breakage and release ofmercury. If not properly contained, mercury is a health hazard.Compression cuffs made of cloth or disposable vinyl contain theinflatable bladder and come in several sizes. The size selected is pro-portional to the circumference of the limb being assessed. Ideally,the width of the cuff should be 40% of the circumference (or 20%wider than the diameter) of the midpoint of the limb on which thecuff is to be used. The bladder, enclosed by the cuff, should encircle

Infection ControlChapter Two

2.1. Hand Washing and Asepsis

2.2. Sterile Field Preparation

2.3. Surgical Hand Washing

2.4. Sterile Gown Application and Performing ClosedGloving

42


at least two-thirds of the arm of an adult and the entire arm of achild. In children, the lower edge of the cuff should be above theantecubital fossa, allowing for placement of the stethoscope bell ordiaphragm. Correct cuff size should be applied in order to obtainaccurate blood pressure measurements.Inspection of the parts of the release valve and pressure bulb shouldbe done before using a sphygmomanometer. The valve should beclean and freely moveable in either direction. Regulation of the pres-sure cuff may become difficult if it sticks or becomes too tightlyclosed. The pressure bulb should be free of leaks.Auscultation.A quiet room and a comfortable temperature is the best environ-ment for blood pressure measurement by auscultation. Sitting is thepreferred patient position although the patient may lie or stand. Read-ings obtained with patient in supine, sitting and standing positions aresimilar in most cases. Documentation of the patient's blood pressureand pulse rate in all three positions are used in obtaining orthostaticmeasurements.The client's position during routine blood pressure determinationshould be the same during each measurement to permit a meaning-ful comparison of values. A nurse should attempt to control factorsresponsible for high readings (i.e. pain, anxiety or exertion) beforeassessment. Blood pressure measurement can be affected by a patient'sperception of a stressful physical or interpersonal environment, thisis why blood pressure readings taken at a patient's workplace or in aphysician's office are often higher than those taken at home.During initial assessment, a nurse should obtain and record bloodpressure from both arms. Normally, there is a difference of 5 to 10mm Hg between the arms. In subsequent assessments, blood pres-sure should be assessed in the arm with the higher pressure. Differ-ences in blood pressure greater than 10 mm Hg indicate vascularproblems in the arms with the lower pressure.Patient's usual blood pressure is asked by the nurse. If the patientdoes not know, the nurse informs him after measuring and record-ing the blood pressure. This provides for patient education on opti-

43

mal blood pressure values, hypertension risk factors and hyperten-sion dangers.Indirect arterial blood pressure measurement is based on the prin-ciple of pressure. Blood flows freely through an artery until pressureto tissues is applied by an inflated cuff, making the artery collapse.Systolic pressure is what occurs after release of the cuff pressure,where blood flow returns and sound is heard through auscultation.In 1905, Korotkoff, a Russian surgeon, first described the soundheard over an artery distal to the blood pressure cuff. The firstKorotkoff sound is a clear rhythmical tapping which gradually in-creases in intensity. The sound's onset corresponds to the systolicpressure. A sound much like a murmur or swishing sound occurs asthe cuff deflates, this is the second Korotkoff sound. Distention ofthe artery causes turbulence in blood flow. The third Korotkoff soundis characterized by a crisper and more intense tapping. The fourthKorotkoff sounds becomes muffled and low pitch with furtherdeflation of the cuff. Cuff pressure falls below the pressure withinthe walls of the vessel, this is the diastolic pressure in infants andchildren. The absence of sound is the fifth Korotkoff sound. Inadolescents and adults, this sound corresponds to the diastolic pres-sure. In some patients, the sounds are clear and distinct, while onlythe beginning and ending sounds are clear in othersThe American Heart Association recommends recording two num-bers for a blood pressure measurement:

Point on the manometer when the first sound is heard forsystolic.

Point on the manometer when the fifth sound is heard fordiastolic.

Some institutions also recommend recording the point when thefourth sound is heard, specifically for patients with hypertension. Slashlines divide the numbers (e.g., 120/80 or 120/100/80) and uses thearm to measure blood pressure (e.g., right arm [RA] 130/70) andpatient position during pressure assessment (e.g., sitting). Blood pres-sure findings are often used as bases for various medical decisionsand nursing interventions concerning a patient's health. This is whythe significance of accurate blood pressure measurement cannot be

Infection Control

44


undermined.Potential Auscultation ErrorsThere are different causes for errors in blood pressure readings ifauscultation is not performed correctly. In case of doubt about theaccuracy of a reading, a nurse should ask a colleague to reassessblood pressure.BP Assessment in ChildrenChildren from 3 years of age through adolescence should be sub-jected to blood pressure assessment at least once a year. Blood pres-sure in children alters as they grow and develop. Blood pressureassessment can help parents in the detection of risk for hypertension.There are several stumbling blocks to obtaining accurate blood pres-sure readings in infants and children:Careful selection of appropriate cuff size is required of differentarm size. Cuff selection based on name of the cuff is discouraged.

Restlessness and anxiety in infants and children make it difficultto obtain blood pressure readings. It is recommended that adelay of at least 15 minutes to allow children be provided toenable them to recover from recent activities and apprehension.Cooperation can be increased by preparing the child for unusualsensation from pressure cuff.

Auscultation errors may result from placing stethoscope toofirmly on the antecubital fossa.

Low frequency and amplitude makes Korotkoff sounds difficultto hear in children. A pediatric stethoscope bell can be helpful inthese cases.

Utrasonic StethoscopeIf weak arterial pulse renders a nurse unable to auscultate sounds, theuse of an ultrasonic stethoscope is recommended. This stethoscope al-lows the nurse to hear low-frequency systolic sounds. It is commonlyused in blood pressure measurement of infants, children and adults

45

Infection Control

with low blood pressure.PalpationThe indirect palpation technique is useful for patients whose arterialpulsations are too weak to emit Korotkoff sounds. Conditions re-sulting in systolic blood pressure that is too low to accurately auscul-tate include severe blood loss and decreased heart contractility. Pal-pation can only assess systolic blood pressure as diastolic pressure isdifficult to determine by palpation. The diastolic level is marked by asubtle change in sensation usually in the form of a thin, snappingvibration. When using the palpation technique, recording of the sys-tolic value and the measurement method is required (e.g., RA 90/-,palpated, supine).

Procedures for Measuring Blood Pressure &Rationale

Identify need to assess client's BP.RATIONALE: Certain health conditions put patients at risk for BP changes

(e.g., cardiovascular disease history, renal disease, diabetes, circu-latory shock, etc.).

Determine best location for BP assessment and cuff size.RATIONALE: Selection of inappropriate site may result in poor sound amplifica-

tion rendering inaccurate measurement.Determine previous baseline BP (if available) from client's record.RATIONALE: Inaccurate readings may result from selection of inappropriate

cuff size.Discourage client from engaging in exercise and smoking 30 minsbefore assessment of BP.RATIONALE: False BP elevation may result from exercise/smoking prior to BP

measurement.Assist client to achieving lying or sitting position. Make sure thatthe room is warm, quiet and relaxing.RATIONALE: Patient comfort is maintained during BP measurement otherwise,

environment may result in undue stress, which may affect BPreading.

46


Explain to patient the procedure to be performed and have pa-tient rest for at least 5 mins before taking measurement.RATIONALE: Patient anxiety which may influence BP measurement is reduced.

Reading may increase as a result of talking with the patientduring measurement.

Wash hands.RATIONALE: Transmission of microorganisms is reduced.With patient sitting or lying, position patient's forearm or thighand provide support if needed.RATIONALE: Diastolic pressure may increase as a result of isometric exercises

due to absence of extremity support.Expose arm or thigh by removing clothing if necessary.RATIONALE: Proper cuff application is ensured.Palpate brachial artery or politeal artery. Position cuff 2.5 cmabove pulsation site. Center bladder of cuff artery. With cuffdeflated, wrap cuff evenly and snugly around upper arm.RATIONALE: Proper pressure application is ensured during inflation. False readings

can be caused by loose-fitting cuff.Vertically position manometer at eye level, not more than 1 meterway from the client.RATIONALE: Looking at the meniscus of the mercury at eye level ensures accu-

rate readings. Reading may be distorted by looking up or down atthe mercury.

Determine baseline BP by palpating brachial or radial artery withfingertips of one hand while inflating cuff rapidly to a pressureof 30 mm Hg above point at which pulse disappears. Deflatecuff slowly when pulse reappears.RATIONALE: False low reading is prevented. Palpation can determine maximal

inflation point for accurate reading. Use of ultrasonic stethoscopeis advised if pulse cannot be palpated.

Deflate cuff full and wait for 30 seconds.RATIONALE: False high reading and venous congestion can be avoided by deflat-

ing cuff.

47

Using stethoscope, make sure that sounds are clear and not muffled.RATIONALE: Earpiece should follow ear canal's angle to maximize hearing.Relocate brachial or politeal artery and place bell or diaphragmchestpiece over it.RATIONALE: Sound reception is ensured by proper placement of stethoscope.

Improper positioning may muffle sound which may result in lowsystolic and false high diastolic reading.

Tightly close valve of pressure bulb by turning it clockwise.RATIONALE: Air leak is prevented during inflation.Inflate cuff to 30 mm Hg above palpate systolic pressure.RATIONALE: Accurate measurement is ensured by inflating cuff until Korotkoff

sound is heard at 30 mm HG.Release valve slowly and allow mercury to fall at a rate of 2 to 3mm Hg/sec.RATIONALE: Inaccurate reading may result from too slow or rapid release of

valve.Note point on manometer when first clear sound is heard.RATIONALE: Systolic pressure is indicated by first Korotkoff sound.Continue to deflate cuff and note point at which muffled ordampened sound appears.RATIONALE: Distinct sound muffling or the fourth Korotkoff indicates diastolic

pressure in children.Continue to deflate cuff gradually and note point at which sounddisappears. Note pressure to nearest 2 mm Hg.RATIONALE: For diastolic pressure in adults, the fifth Korotkoff sound is used

as indication.Deflate cuff rapidly and completely remove cuff from client'sarm unless there is a need to repeat measurement.RATIONALE: Arterial occlusion may result from continuous cuff inflation.If this is the first assessment of the client, repeat procedure onthe other arm.

Infection Control

48


RATIONALE: Detection of circulation problem may be done by comparison ofreadings from both extremities (a difference of 5 to 10mm Hgbetween extremities).

Assist patient in returning to comfortable position and replaceclothing on upper arm.RATIONALE: Restores patient comfort and well-being.Discuss findings with patient as necessary.RATIONALE: Patient participation in care is encouraged.Wash hands.RATIONALE: Transmission of microorganisms is minimized.Record BP and report abnormal findings.RATIONALE: Documentation facilitates communication with other health team


2.1. Hand Washing and AsepsisAsepsis is commonly defined as the absence of pathogenic organ-isms. Hand washing is a proven method of asepsis, which effectivelyminimizes the onset and spread of infection. It is the brief but vigor-ous rubbing together of all the hands' surface lathered with soap orantibacterial hand washing agents, followed by a thorough rinsing ina continuous stream of water.The purpose of this procedure is to remove dirt and any transientorganisms from the hands and the reduction of microorganism count.Hand contamination is the most common cause of cross infection,diseases can be easily communicated from one person to anotherthrough hand contact or touching objects which have been contami-nated. If a nurse fails to wash hands after handling articles, which arecontaminated, he/she is most likely to spread infection.

49

Infection Control

Factors Influencing Frequency of Hand Washing Intensity of contacts with patients Patient/nurse's susceptibility to infection Contamination degree that could result from contact Procedure/activity to be performed

Situations Where Hand Washing is Necessary When hands are visibly soiled Before and after contact with patient Before performing invasive procedures (e.g., intravascularcatheter/indwelling catheter insertion)

After contact with a source of microorganism (e.g., blood/body fluids, mucous membrane or potentially contaminatedobjects)

After removal of gloves

Methods of Hand WashingIt has been established that washing hands for at least 10-15 secs. willkill most transient microorganisms in the skin. Wash time howevermay depend on how severely soiled the hands are. Ordinary soapmay be used in routine hand washing procedures. But in order toinhibit microorganism and reduce infection level, antiseptic agentsshould be used. Antibacterial soaps are also in wide use when it comesto areas or situations wherein the nurse has to reduce total microbialcounts in the hands. This commonly occurs when the nurse comes incontact with patients who have wounds, bruises or those who areimmunosuppressed. These agents are also used when the nurse is toperform an invasive procedure.In cases when facilities for hand washing may be considered inad-equate, alcohol-based solutions are used. Normal hand washingshould, however be immediately performed as soon as possible.Nurses are the ones who are tasked to educate patients/visitors onhow to properly perform hand washing. Education is especially im-portant if care is to continue at home.

Materials Required

50


Deep sink Antiseptic detergent/soap Towel Running water

Procedures for Performing Hand Washing &Rationale

Inspect hands for breaks/cuts in skin or cuticles. Make sure toreport and cover lesions before providing patient care.RATIONALE: Open cuts or wounds may be penetrated or may harbor microor-

ganisms.Inspect hands for heavy soiling/dirt. Inspect nails for length.RATIONALE: Longer hand washing is required. Most microbes present in the

hands come from under the fingernails.Pull uniform sleeves above wrists. Wristwatch and rings shouldbe removed during washing.RATIONALE: Total access to fingers, hands and wrists is provided. Number of

microorganisms may increase from wearing rings.Stand in front of sink, keeping hands and uniform away fromsink surface.RATIONALE: Avoiding reaching into sink and touching edge prevents contami-

nation.Turn on water by turning faucet on or using knee/foot controlto regulate water flow and temperature.RATIONALE: Be careful not to splash water into uniform. Splashing water in

uniform may result in contamination as moisture breeds microor-ganisms.

Regulate water flow to achieve warm temperature.RATIONALE: Warm water removes less of protective oil compared to hot water.Wet hands and wrists thoroughly under running water. Handsand forearms should be lower than elbows during washing.RATIONALE: Since the hands are the most contaminated area, it should be

washed after the elbows following the rule of washing from the

51

Infection Control

least to the most contaminated area.Use soap or apply a small amount of antiseptic. Lather thor-oughly.RATIONALE: Antiseptics eliminate bacteria but may irritate the skin. Their use

depends on the procedure to be performed.Build lather and use plenty of friction for a minimum of 10-15secs. Interlace fingers. Rub palms and back of hands using circu-lar motion at least 5X for each hand. Keep fingertips down.RATIONALE: Soap emulsifies fat and oil thereby facilitating the cleaning process.

Dirt and transient bacteria are removed by friction and rubbing.Interlacing fingers ensures total cleansing.

Use both hands to clean fingernails using additional soap.RATIONALE: Areas under the fingernails are highly contaminated which may

result in infection.Rinse hands and wrists thoroughly, keeping elbows up and handsdown.RATIONALE: Dirt and microorganisms are washed away.Use paper towel, single use towel or warm dryer to dry hands.Dry hands thoroughly from fingers to wrists and forearms.RATIONALE: Contamination is prevented by drying from the least to the most

contaminated areas.Discard used paper towel properly.RATIONALE: Transfer of microorganisms is prevented.Turn off water flow using foot or knee pedals. Use clean, drypaper towel to turn off hand faucet. Avoid touching with hands.RATIONALE: Prevents transfer of pathogens by capillary action.Inspect hands surface for signs of soil or contamination.RATIONALE: Determines adequacy of hand washing.Examine hands for dermatitis or cracked skin.RATIONALE: Determines skin complications resulting from excessive hand washing.

2.2. Preparing a Sterile Field

52


53

AdministeringMedications

Chapter Three

3.1. Administering Oral Medications

3.2. Administering Nasal Instillations

3.3. Administering Eye/Ear Medications

3.4. Administering Vaginal Instillations

3.5. Administering Rectal Suppositories

3.6. Instructing Client How to Use Metered-Dose Inhalers

3.7. Injections Preparation

3.8. Injections Administration

3.9. Adding Medications to IV Fluid Containers

54


Administering MedicationsThe nurse is expected to perform accurate administration of drugsat all times. Preparation of medication requires absolute focus, whichis why a medication nurse should not venture in any other task whiledoing so. To ensure safe drug administration, the following guide-lines must be observed by the nurse. These are the "ten rights" ofdrug administration:

1. The right drug 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right advice 8. The complete drug history 9. The drug allergies10. The drug

Kinds of MedicationsThere are a wide variety of medications and their respective routes.This is why it is imperative that nurses are able to distinguish medica-tions sharing common characteristics by class. Classifying medica-tions is usually indicative of the following:

Medication's effect on a body system. Symptoms relieved by the medication. Desired effect of the medication.

Administration RoutesMedication or drug properties and their desired effect on patients'physical and mental states directly influence medications' route ofadministration. The nurse, in cooperation with the prescribing physi-cian usually determines the best possible route for drug administra-tion.As earlier indicated, there are a variety of routes by which drugs maybe administered depending on how they are prescribed. These are:

55

Administering Medications

Oral routes - medication is given by mouth accompanied by fluid.Sublingual route - medication is absorbed by placing it under the patient'stongue.Buccal administration - dissolution of the medication by placing it againstthe cheeks' mucous membranes.Parenteral routes - is the injection of medication into body tissues. Thereare four major injection sites:

Subcutaneous - injecting medication into tissues just under thedermis of the skin.

Intramuscular - injecting into a muscle. Intravenous - Injecting into a vein. Intradermal - injecting into the dermis just below the epidermis.

Epidural - administration of medication via the epidural space usinga catheter.Intrathecal - administration of medication using a catheter placed intothe subarachnoid space.Intraosseous - medication infusion directly into the bone marrow.Intraperitoneal - administration of medication into the peritoneal cav-ity.Intrapleural - administration of medication through the chest walland directly into the pleural space.Intraarterial - administration of the medication directly into the arter-ies.Topical - application of medication onto the skin and mucous mem-branes.Inhalation - administration of medication through nasal passages.

3.1. Administering Oral MedicationsThe most common and equally convenient way of administeringmedication is through the patient's mouth. Minimal problems are

56


often associated with patients' ingestion or self-administration of oralmedications. Medications in tablet or capsule form can be adminis-tered with fluid as allowed.However, there are cases wherein swallowing medications by mouthmay be contraindicated. The following are primary contraindicationsto administering medication by mouth:

Presence of gastrointestinal alterations. Patient's inability to swallow food/fluids. Use of gastric suction.

In administering oral medication, it is extremely important to re-member to protect the patient from aspiration. Aspiration occurswhen fluid, food or medication intended for gastrointestinal admin-istration is accidentally administered into the patient's respiratory tract.The patient can be protected from aspiration through assessing his/her ability to manage oral medication. Patient positioning is also im-portant during oral medication administration, sitting position is com-monly ideal for patients receiving oral medication provided that it isnot contraindicated to the patient's condition. The lateral positioncan also be utilized if the need arises.For patients with nasogastric feeding tubes, medications in tablet formmay be administered by crushing and feeding them through thenasogastric tube.

Materials Required Medication cart/tray Disposable medication caps Glass of water/juice Drinking straw Pill-crushing device (optional)

Procedures for Administering Oral Medications &Rationale

Assess patient for any contraindication to oral medication.RATIONALE: Medication distribution, absorption and excretion can be influ-

enced by changes in gastrointestinal function.

57


Assess patient's medical, allergy, medication and diet history.RATIONALE: These factors may affect medication action. Client's medication

requirements may also be determined by these factors.Review data on assessment and laboratory results that may influ-ence the procedure.RATIONALE: Contraindication to certain medications may be determined by

laboratory results.Assess patient's knowledge of health and medication use.RATIONALE: Useful in determining patient's adherence to medication at home.

Patient's medication tolerance can also be assessed in this manner.Assess patient's fluid preference.RATIONALE: Patient's fluid intake is reinforced by offering fluids during medi-

cation administration. Swallowing and absorption of medicationin the gastrointestinal tract are facilitated by fluid intake.

Check record's accuracy and completeness with prescribingphysician's written medication order.RATIONALE: Medication order is most reliable reference of medication to be

administered to patient.Medication preparation:Wash hands.RATIONALE: Reduces transmission of microorganisms.Arrange medication cups/trays in preparation area or place medi-cation cart outside patient's room.RATIONALE: Errors in medication administration is prevented and prepara-

tion time is reduced.Prepare individual medication a patient at a time. Keep all recordpages of individual patients together.RATIONALE: Medication preparation error is avoided.Choose correct drug from stock. Calculate drug dose as ordered.Re-check calculation.RATIONALE: Risk for error is reduced.

58


Prepare capsules or tables with a floor stock bottle by pouringneeded dose into bottle cap and transferring medication to medi-cation cap. Avoid touching medication with fingers. Excess cap-sules or tablets can be returned to bottle. Using a pill-cutting toolor a gloved hand, break prescored medications.RATIONALE: Wastage of medication is avoided. Accuracy of dosage is ensured.Prepare unit-dose capsules or tablets by placing packaged cap-sule or tablet straight into medicine cup. Avoid removing wrap-per.RATIONALE: Cleanliness of medications is ensured and medication name is

identified.Simultaneously put capsules or tablets to be given to client in onemedicine cup except when client requires pre-administration ex-amination..RATIONALE: Separation of medication with assessment requirements makes

withholding of medication easier for nurse.In case of difficulty in swallowing, use a pill-crushing device tohelp client. If there's no such tool available, use two medicationcups and pulverize tablet using a blunt instrument. Pulverizedtablet can be combined with a little quantity of soft food.RATIONALE: Eases swallowing of medications in large tablet form.Preparation of liquid medication:Remove container cap. Place cap upside down.RATIONALE: Contamination from inside of cap is prevented.Hold bottle with label against palms.RATIONALE: Soiling of label is avoided.Hold medicine cup at eye level. Fill to desired amount based onthe scale.RATIONALE: Accuracy of medication measurement is assured.Dispose of any excess medication into sink. Use paper towel towipe neck of bottle.RATIONALE: Contamination of bottle contents is avoided.Draw volume of liquid medication taking in less than 10 ml. In

59


syringe without needle.RATIONALE: Prevents overdosage. In the preparation of narcotics, check records

for previous drug count and compare to drug supply.Check all medications' expiry dates.RATIONALE: Expired medication may cause patient harm or not have the

desired effect.Compare prepared drug and container to record.RATIONALE: Reduces errors in administration.Replace containers/unused unit-dose medication in shelf/drawer.Recheck labels.RATIONALE: Reduces errors in administration.Drugs should never be left unattended.RATIONALE: Safekeeping of medication is nurse's responsibility.Administering medications:Administer medication to patient at correct time.RATIONALE: Desired therapeutic effects are ensured by administering medica-

tion within 30 min before or after prescribed time.Compare name on record with patient's identification bracelet.Ask patient's name.RATIONALE: ID bracelet is most reliable source of patient identification.Explain purpose of each medication and its action to patient.Entertain patient's questions (if any) about drugs he/she is re-ceiving.RATIONALE: Compliance with medication therapy is improved by providing

patient with understanding of medication he/she is receiving.Assist client to sitting or side-lying position if the former cannotbe achieved.RATIONALE: Aspiration is prevented during swallowing of medication.Proper administration of drugs:Have client hold solid medication in hand/cup before placing inmouth.RATIONALE: Patient is familiarized with medication.

60


Offer fluids (water/juice) to aid patient in swallowing medica-tions. Give patient carbonated water if not contraindicated.RATIONALE: Swallowing is eased and fluid intake is improved.For administration of sublingual medication, tell patient to placemedication under tongue until it dissolves. Tell patient to avoidswallowing medicine.RATIONALE: Medication is absorbed through blood vessels beneath patient's

tongue. Swallowing sublingual medication will render it ineffectivebecause gastric juices will destroy it.

For buccally administered drugs, tell patient to place medicationagainst cheek's mucous membranes until dissolved. Avoid ad-ministration of fluids until medication dissolves.RATIONALE: Buccal medications act locally through the mucosa or systemically

as they adhere to the saliva.For powdered medications, mix them with liquids at bedsidegive to patient to drink. Tell patient about hazards of chewing orswallowing lozenges.RATIONALE: Medications such as lozenges are absorbed through the oral mu-

cosa.Immediately give effervescent powders/tablet to client after dis-solution.RATIONALE: Powdered medications may harden and become difficult to swal-

low if prepared in advance.For patient who can not hold medications, place medication cupto patient's lips and carefully introduce medication one at a time.

61


RATIONALE: Aspiration by introduction of multiple tablets is prevented.Discard any tablet/capsule that may fall to the floor and repeatpreparation.RATIONALE: Medications that have touched the floor are considered contami-

nated.Stay by bedside until patient swallows all medications. Patientshould be asked to open mouth if there is uncertainty.RATIONALE: Patient's receipt of proper dose is ensured.In administering highly acidic medications, give patient a snack(non-fat) if not contraindicated.RATIONALE: Gastric irritation is reduced.Return patient to comfortable position.RATIONALE: Patient comfort is restored.Discard soiled supplies. Wash hands.RATIONALE: Transmission of microorganisms is reduced.Return to patient's room and evaluate his/her response to themedication.RATIONALE: Medication's desired effect, side effects and allergic reactions are

determined.Ask patient/family member to identify medication name, itspurpose, action and possible side effects.RATIONALE: Patient/family's understanding of medication is determined.Notify prescribing physician in case of toxic effect, allergic reac-tions or side effects. Discontinue medication dose.RATIONALE: Prescriber is notified of possible need to change or discontinue

medication.Record oral medications administration/withholding.RATIONALE: Documentation facilitates communication with other health team


62


3.2. Administering Nasal InstillationsPatients suffering from nasal sinus alterations are usually given medi-cation by drops, spray or tampons. Decongestant sprays are used inrelieving sinus congestion and cold symptoms. For children, salinedrops are commonly used as decongestant as it is safer than nasalpreparations. Sprays are most useful for patients who are self-medi-cating, but nasal drops are proven to be more effective in the treat-ment of sinus infections.In this type of administration, the nurse is expected to learn the im-portance of positioning the patient so as to maximize the possibilityof properly and accurately administering the drug. For nosebleeds,tampons and packs treated with epinephrine are used since they re-duce the flow of blood.

Materials Required Medication with dropper/spray container Facial tissue Disposable gloves Penlight

Procedure for Administering Nasal InstillationsDetermine which of patient's sinuses are affected before usingnasal drops.RATIONALE: Ensures that medication is introduced on the affected sinus.Assess patient history for hypertension, heart disease, diabetesmellitus and hyperthyroidism.RATIONALE: Patients with histories of these conditions are contraindicated to

decongestants that stimulate the central nervous system.Examine condition of patient's nose and sinuses. Palpate sinusesfor tenderness.RATIONALE: Baseline for monitoring medication effects is provided. Nasal dis-

charge may interfere with administration.Assess patient knowledge of use/technique for instillation andpotential to learn self-administration.

63


RATIONALE: Aids in teaching patient self-instillation of medication.Explain to patient procedure regarding positioning and expectedsensations.RATIONALE: Reduces patient's anxiety by anticipation of procedure experience.Wash hands.RATIONALE: Reduces transmission of microorganisms.Place medications/supplies by bedside.RATIONALE: Provides easy access to medication.Instruct patient to clear nasal passages by gently clearing/blow-ing nose.RATIONALE: Clears away mucus and secretions that may interfere with instal-

lation of medication.Administration of nasal drops:Assist client in achieving supine position.Positioning patient's head: Tilt patient's head backward to gainaccess to posterior pharynx. To gain access to ethmoid or sphe-noid sinus, tilt patient's head back over edge of bed or put asmall pillow under patient's shoulder and tilt head back. To gainaccess to frontal and maxillary sinuses, tilt patient's head backover edge of bed or place pillow with head turned to side to betreated.RATIONALE: Allows for easy access to nasal passages.Use non-dominant hand to support patient's head.RATIONALE: Neck muscle strain is prevented.Patient should be instructed to breathe through the mouth.RATIONALE: Chances of aspirating nasal drops into trachea and lungs is re-

duced.While holding dropper 1 cm above patient's nose, administerneeded number of drops toward ethmoid bone's midline.RATIONALE: Dropper contamination is prevented. Distribution of medication

over nasal mucosa is ensured.Instruct patient to remain in supine position for 5 mins.

64


RATIONALE: Premature ejection of medication through nares is avoided.Offer patient facial tissue to blot runny nose. Warn client againstblowing nose for several mins.RATIONALE: Allows for maximum absorption of medication.Assist client in achieving comfortable position after drug's ab-sorption.RATIONALE: Restores patient comfort.Discard soiled supplies properly.RATIONALE: Orderly environment is maintained.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Observe patient for 15-30 mins after administration for onsetof side effects.RATIONALE: Systemic reaction can be caused by medication absorbed through

mucosa.Inquire if patient is able to breathe through nostrils after admin-istration of decongestant.RATIONALE: Effects of decongestant medication is determined.Re-check nasal passages' condition between instillations.RATIONALE: Patient's response to medication is determined.Have patient review risks of decongestant overuse and adminis-tration methods.RATIONALE: Patient's capacity for self-medication is determined.Ask patient to demonstrate self-administration.RATIONALE: Learning is demonstrated.Record medication administration and patient response. Reportpresence of any unusual systemic effects.RATIONALE: Documentation facilitates communication with other health team


65


3.3. Administering Eye/Ear Medications

Eye MedicationsMedications also commonly used by patients are eye drops or oint-ments. Certain eye conditions such as cataract extraction and glau-coma however may need prescription drugs in the form of oph-thalmic medications.Because most patients using eye medications are adults, the nursemost of the time instructs the patient and family members on theproper techniques of instilling eye medication. This is usually donethrough return demonstrations. Patient compliance can be greatlyaffected through proper education.

Materials Required Medication with sterile eye dropper/ointment tube Cotton ball/tissue Washbasin filled with warm water and washcloth Eye patch and tape Disposable gloves

Ear MedicationsThe internal part of the ear is extremely temperature sensitive, whichcalls for the instillation of drops at room temperature. Failure to doso may result in vertigo or nausea. Sterile drops are often used incases of ruptured eardrums. The use of non-sterile ear drops oftencause infection. The nurse is usually required to assess the patient forany damage to the ear drums. Occlusion of the ear canal using adropper or irrigating syringe is discouraged as it may injure the eardrum.As the ear structures of children significantly differ from those ofadults, the nurse should take extra care in instilling eardrops. The earcanal should be straightened before the instillation of drops. Failureto do so may result in the possibility of the medication not reaching

66


the internal ear structure.

Materials Required Ear medication with dropper Cotton ball or tissue

Procedures in Administering OphthalmicMedications & Rationale

Review prescribing physician's medication order. Identify patient.RATIONALE: Ensures correct administration of medication and that correct

patient receives right medication.Carry out an assessment of patient's external eye structures.RATIONALE: Baseline for determining patient reaction to medication is estab-

lished.Assess patient's history for allergies to eye medications. Inquire ifpatient has any allergy to latex.RATIONALE: Allergic response is avoided, prompts nurse to use non-latex

gloves.Assess patient for any symptoms of visual changes.RATIONALE: Some medications alter these symptoms, enables nurse to recognize

changes in patient's condition.Determine patient's level of consciousness and capacity to carryout directions.RATIONALE: Patients who become combative during onset of procedure may

cause further accidental eye injury.Determine patient's knowledge of drug therapy and willingnessto self-medicate.RATIONALE: Determines need for health teaching.Assess ability of patient to hold/manipulate eye-dropper.RATIONALE: Determines patient's capacity to self-medicate.Explain procedure to patient.RATIONALE: Improves patient anxiety and promotes cooperation.

67

Wash hands.RATIONALE: Transmission of microorganisms is reduced.Place supplies by patient's bedside.RATIONALE: Provides nurse with easy access to equipment/supplies.Apply gloves.RATIONALE: Reduces transmission of microorganisms.Have patient lie in a supine position or sit back on a chair lightlyhyper extending head.RATIONALE: Nurse is provided with easy access to patient's eye. Drainage of

medication to outer canthus is minimized.Clean away any crust or drainage on patient's eyelids/inner cantus.To soften dried crusts, soak and remove by using a damp clothor cotton ball for a few mins.RATIONALE: Microorganisms thrive in crusts/drainage. Easy removal is facili-

tated by soaking. Entry of microorganism into lacrimal duct isavoided.

With non-dominant hand, hold tissue/cotton ball to patient'scheekbones below lower eyelid.RATIONALE: Cotton or tissue absorbs medication that may escape eye.Gently use thumb or forefinger against bony orbit with tissue/cotton ball below lower lid.RATIONALE: Lower conjunctival sac is exposed. Pressure and trauma to eye-

ball are avoided. Fingers are prevented from touching eye.Ask patient to look up to ceiling.RATIONALE: Cornea is retracted upward away from conjunctival sac. Stimu-

lation of blink reflex is reduced.ADMINISTERING EYEDROPS

Rest non-dominant hand on patient's forehead. Hold medica-tion eye dropper/opthalmic solution approximately 1-2 cm aboveconjunctive sac.RATIONALE: Accidental contact of eyedropper with eye structures is prevented.

Eye injury and dropper contamination are avoided.


68


Instill required number of medication drops into conjunctivalsac.RATIONALE: The normal capacity of conjunctival sac is 1 to 2 drops. Even

distribution of medication is ensured.Repeat procedure in case patient blinks or closes eye or dropsfail to land on conjunctival sac.RATIONALE: Medication's desired effect can only be attained if drops enter

conjunctival sac.Have client close eyes gently after instillation of drops.RATIONALE: Medication distribution is ensured. Medication present in conjunc-

tival sac can be forced out by squinting or squeezing of eyelids.For drugs with systemic effects, use a clean piece of tissue toapply gentle pressure on patient's nasolacrimal duct for 30-60secs.RATIONALE: Overflow of medication into nasal/pharyngeal passages is avoided.

Absorption of medication into systemic circulation is prevented.INSTILLING EYE OINTMENT

Have patient look up at ceiling.RATIONALE: Cornea is retracted upward away from conjunctival sac. Stimu-

lation of blink reflex is reduced.Hold ointment applicator above lower lid margin. Apply thinfilm along lower eyelid's inner edge, from the inner to the outercanthus of the conjunctiva.RATIONALE: Medication is distributed evenly across eye and lid margin.Ask patient to close eye and using a circular motion, rub lid gen-tly with a cotton ball (if not contraindicated).RATIONALE: Medication is further distributed.Applying intraocular disk:Wash hands. Apply gloves.RATIONALE: Reduces transmission of microorganisms.Open disk package. Gently press disk with fingertip until it ad-heres to finger. Place disk's convex side on fingertip.

69

RATIONALE: Disk is inspected for damage.With non-dominant hand, pull client's lower eyelid gently awayfrom eye. Have client look up at ceiling.RATIONALE: Conjunctival sac is exposed for placement of disk.Put disk in the conjunctival sac, making it float on the sclera inbetween lower eyelid and iris. Pull patient's lower eyelid out andover disk.Proper delivery of medication is ensured.Removal:Wash hands. Apply gloves.RATIONALE: Reduces transmission of microorganisms.Explain the procedure to patient.Improves patient’s understanding of procedure. Reduces anxiety and pro-

motes cooperation.Expose disk by gently pulling on patient's lower eyelid. Withforefinger and thumb of other hand, lift disk out of patient's eyeby pinching it. Gently wipe excess medication on eyelid (if any),wipe from inner to outer canthus.RATIONALE: Trauma to the eye is avoided and comfort restored.For patient with an eye patch, replace patch with a clean one.Make sure the patch covers the entire eye. Secure by applyingtape without applying pressure to eye.RATIONALE: Possibility of infection is reduced.Remove and dispose of gloves properly. Discard soiled suppliesproperly. Wash hands.RATIONALE: Reduces transmission of microorganisms.Observe patient's response to instillation. Ask patient for anyfeeling of discomfort.RATIONALE: Medication action is determined.Have client discuss drug's purpose, action, side effects and tech-nique of instillation.


70


RATIONALE: Patient's level of understanding is assessed.Ask client to demonstrate self-instillation of next dose.RATIONALE: Determines patient's capacity to self-medicate.Record drug administration and take note of the appearance ofpatient's eye. Record and report adverse side effects.RATIONALE: Documentation facilitates communication with other health team


3.4. Administering Vaginal InstillationsVaginal medications often come in the form of suppositories, foam,jellies or cream, but the most commonly used are those in supposi-tory form. The suppository melts at room temperature so that itshould be refrigerated before any instillation is performed. Uponinsertion of suppository into the vaginal cavity, body temperaturetends to melt it allowing for distribution and subsequent absorptionof the drug. Inserting vaginal suppositories requires the nurse to dondisposable gloves.Because of the procedure's relative simplicity, many female patientsprefer to insert vaginal suppositories on their own. Perineal padsshould be provided to patients to catch vaginal drainage after inser-tion. Other forms of vaginal medications are applied using applica-tors.

Materials Required Vaginal cream, jelly, foam or suppository or irrigating solution Applicator Disposable gloves Tissue/cotton balls Perineal pad Drape KY jelly Bed pan

71

Douche container

Procedures in Administering Vaginal Medications &Rationale

Check medication order.RATIONALE: Safe and accurate medication administration is ensured.Wash hands.RATIONALE: Reduces transmission of microorganisms.Prepare necessary equipment/supplies. Identify patient and ex-plain procedure.RATIONALE: Provides easy access to materials needed. Ensures that correct

patient receives correct medication.Assess patient's external genitalia and vaginal canal.RATIONALE: Baseline information for monitoring of medication action is pro-

vided.Assess patient for ability to manipulate medication applicator andposition him/herself.RATIONALE: Determines level of assistance to be provided to patient.Explain to patient the procedure.RATIONALE: Patient's understanding of procedure is improved. Reduces anxi-

ety and promotes cooperation.Arrange equipment/supplies by bedside.RATIONALE: Provides nurse with easy access to equipment/supplies.Provide needed privacy.RATIONALE: Minimizes patient's embarrassment.Help patient establish dorsal recumbent position.RATIONALE: Exposes vaginal canal. Suppository is allowed to dissolve without

escaping vaginal orifice.RATIONALE: Drape patient's abdomen and lower extremities.Minimizes patient's embarrassment.


72


RATIONALE: Put on disposable gloves.Reduces transmission of microorganisms.Inserting suppository:Remove suppository from wrapper. Lubricate smooth androunded end. Lubricate dominant hand's gloved finger.RATIONALE: Friction against mucosal surfaces is reduced during insertion.With non-dominant gloved hand, retract patient's labial folds.RATIONALE: Vaginal orifice is exposed.Insert suppository's rounded end about 7.5-10 cm along poste-rior wall of vaginal canal.RATIONALE: Even distribution of medication along vaginal cavity walls is

ensured.Withdraw finger. Wipe away lubricant from patient's orifice andlabia.RATIONALE: Patient comfort is restored.Application of cream or foam:Follow directions in filling applicator. With non-dominant glovedhand, retract patient's labial folds.RATIONALE: Prevents overdosage of medication. Vaginal orifice is exposed.Insert applicator 5-7.5 cm with dominant gloved hand. Pushplunger.RATIONALE: Even distribution of medication along vaginal cavity wall is

ensured.Withdraw applicator, place it on a paper towel. Wipe lubricantfrom patient orifice and labia.RATIONALE: Microorganisms may be present in residual cream in applicator.Remove disposable gloves and discard properly. Wash hands.RATIONALE: Transmission of microorganisms is reduced.Wash and store applicator for future use.RATIONALE: Microorganisms present in applicator are removed.

73

Have patient remain flat on her back for at least 10 mins.RATIONALE: Even distribution and absorption of medication is ensured.Offer perineal pad to patient.RATIONALE: Vaginal discharge is prevented from soiling patient's clothing.Assess condition of patient's vaginal canal and external genitaliain between cream/foam application.RATIONALE: Determines medication action and relief from irritation.Record administration of medication.RATIONALE: Documentation facilitates communication with other health team


3.5. Administering Rectal SuppositoriesRectal suppositories differ from vaginal suppositories in that they arethinner and are more shaped like bullets. This shape is adopted so asto prevent anal trauma during insertion. Medications contained inrectal suppositories usually have local effects such as anti-pyretic ef-fects. Rectal suppositories are best refrigerated pending administra-tion.When administering rectal suppositories, the nurse should insert themedication past the internal anal sphincter and against the rectal mu-cosa. The purpose of this is to facilitate absorption of the medica-tion by the mucosa. In some cases it may be imperative to clear therectum of any fecal matter before insertion using a cleansing enema.

Procedures for Administering Rectal Suppositories& Rationale

Check medication order.RATIONALE: Safe and accurate administration of medication is ensured.Check patient's medical record for rectal surgery or bleeding.RATIONALE: Condition maybe contraindicated to suppository use.


74


Wash hands.RATIONALE: Reduces transmission of microorganisms.Prepare necessary equipment/supplies. Put on disposable gloves.RATIONALE: Provides easy access to materials needed. Saves time. Contact with

fecal matter is minimized. Reduces transmission of microorgan-isms.

Identify patient.RATIONALE: Ensures that correct medication is administered to correct pa-

tient.Explain to patient the procedure.RATIONALE: Provides patient with understanding of procedure. Reduces anxi-

ety and promotes cooperation.Place supplies at patient's bedside.RATIONALE: Provides nurse with easy access to supplies.Provide needed privacy.RATIONALE: Reduces patient's embarrassment.Assist patient in achieving Sims' position.RATIONALE: Exposes patient's anus and helps relax external anal sphincter.Drape patient completely except for anal area.Prevents unnecessary exposure of patient’s private parts.Assess condition of patient's external anus. Palpate rectal walls.RATIONALE: Presence of active rectal bleeding is assessed. Presence of fecal

matter in rectum, which may interfere with medication adminis-tration is determined.

If gloves become soiled, remove and replace with new ones.Unwrap suppository and lubricate rounded end. Apply lubrica-tion to finger of gloved dominant hand.RATIONALE: Maintains sterility. Friction during suppository insertion is re-

duced.Have patient take slow, deep breaths through the mouth to relaxanal sphincter.

75

RATIONALE: Relaxes anal sphincter and prevents pain from forceful insertionof suppository.

Use non-dominant hand to retract patient's buttocks.RATIONALE: Exposes external anal sphincter.Gently insert suppository through anus using index finger ofdominant hand. Push suppository through anus past internalsphincter and place against rectal wall, 10 cm for adults/5 cmfor children and infants.RATIONALE: Medication must come in contact with rectal mucosa to facilitate

absorption.Withdraw finger. Wipe client's anal area.RATIONALE: Restores patient comfort.Remove and discard gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Make sure patient will have help in reaching bedpan/toilet ifsuppository contains laxative or fecal softener.RATIONALE: Provides patient with sense of control over elimination.Have patient remain flat on back for 5 mins.RATIONALE: Expulsion of suppository is prevented.Return after 5 mins to check if suppository was expelled.RATIONALE: Reinsertion of suppository maybe needed.Thirty mins after administration, observe patient for suppository'seffects.RATIONALE: Medication action is evaluated.Record medication administration.RATIONALE: Documentation facilitates communication with other health team


3.6. Instructing Client How to Use Metered-DoseInhalers


76


PhysiologyAdministration of medication through the use of handheld inhalers,usually are dispersed by aerosol spray, mist or powder aimed at reach-ing lung airways. Medication is rapidly absorbed by the alveolocapillarynetwork. These inhalers are designed to have local effects the mostcommon of which is bronchodilation. Many inhalers of these typeshowever have been proven to have systemic side effects.Patients with chronic respiratory disease (e.g., asthma, emphysema orbronchitis) are usually those who receive frequent medication by in-halation. Inhalers provide relief from airway obstruction .

ImportanceBecause patients who suffer from chronic respiratory diseases de-pend on the use of inhalers, they need to be educated on the use ofthe drug and its proper administration.

Mechanics of DeliveryA metered-dose inhaler delivers an accurately measured dose ofmedication with each push of the canister. Approximately 5-10pounds of pressure is required to activate the aerosol. The nurseneeds to have knowledge of this because of the fact that hand strengthin older patients are significantly diminished compared to young adultsand the like. The nurse is the one tasked with evaluating the patient'scapability to properly use the inhaler.

Materials Required Metered-dose inhaler with medication canister Facial tissue (optional) Washbasin with warm water Paper towel/towel

Instructing Client How to Use Metered-DoseInhalers

Assess patient's ability to hold, manipulate and press canister andinhaler.RATIONALE: Patient's ability to use inhaler is determined.

77

Appraise patient’s readiness and ability to learn.RATIONALE: Determines patient's capacity to learn.Assess patient's knowledgeability about his/her disease and pur-pose/action of the medication.RATIONALE: Patient's knowledge of condition and medication is vital in under-

standing inhaler use.Assess medication schedule and number of inhalations necessaryfor each dose.RATIONALE: Influences nurse's explanation on use of inhaler.Assess patient technique in inhaler use if previously instructed inself-administration.RATIONALE: Reflects patient's ability to self-medicate and level of assistance

required.A comfortable environment should be provided in instructingthe patient.RATIONALE: Provides an atmosphere conducive to learning.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Prepare equipment needed. Give patient time to manipulate in-haler, canister and spacer device. Explain/demonstrate methodof fitting canister into inhaler.RATIONALE: Provides easy access to materials needed and saves time. Familiar-

izes patient with inhaler.Explain to patient the meaning of metered dose and cautionsagainst the danger of inhaler overuse and side effects of thedrug.RATIONALE: Protects patient against excessive inhalation.Steps for administering inhaled dose of medication:Detach inhaler's mouthpiece cover. Shake inhaler well.RATIONALE: Fine particles are aerosolized.Ask patient to take a deep breath and exhale.


78


RATIONALE: Patient's airway is prepared for medication.Instruct patient to position inhaler:Place inhaler in patient's mouth with opening toward back ofthe throat. Position device 3.5-5 cm from the mouth.RATIONALE: Aerosol spray is directed toward airway.With proper position achieved, ask patient to hold inhaler at themouthpiece using thumb and index and middle finger at the top.RATIONALE: Use of a three-point/lateral hand position to activate canister is

best method to use metered-dose inhalers.Have patient tilt head back slightly. Ask patient to inhale deeplyand slowly through mouth, afterwards instruct patient to fullydepress medication canister.RATIONALE: Distribution of medication to airways is ensured. Inhalation

through mouth distributes medication more evenly than throughnose.

Ask patient to hold breath for about 10 secs.RATIONALE: Deeper branches of airways are reached by tiny aerosol drops.Instruct patient to exhale through pursed lips.RATIONALE: Tiny airways are kept open during exhalation.Explain and demonstrate to patient steps in administer-ing inhaled dose of medications with the use of a spacersuch as an aerochamber:Detach inhaler's mouthpiece cover and aerochamber's mouth-piece. Insert inhaler into aerochamber's end. Shake inhaler well.RATIONALE: Fine particles are aerosolized.Instruct patient to place aerochamber mouthpiece into mouthand close lips. Caution patient against inserting mouthpiece be-yond raised lip. Tell patient to avoid covering inhalation slotswith lips. Ask patient to perform normal breathing throughaerochamber mouthpiece.RATIONALE: Patient is relaxed before medication delivery.Ask patient to press medication canister to spray a puff into

79

aerochamber.RATIONALE: Allows fine particles to be inhaled.Ask patient to take full, slow breaths for 5 secs.RATIONALE: Particles are distributed in deeper airways.Tell patient to fully hold breath for 5-10 secs.RATIONALE: Full medication distribution is ensured.Patient should be instructed to wait 2-5 mins between inhalationsor as prescribed.RATIONALE: Inhalation of medication must be done in a sequential manner.

Airways are opened and inflammation is reduced by first inhala-tion, while deeper airways are penetrated by second and thirdinhalations.

Caution patient not to repeat inhalations before next scheduleddose.RATIONALE: Prevents medication overdosage. Constant drug levels are ensured

and side effects minimized.Explain to patient possible gagging sensation inside throat whichmay be caused by medication droplets.RATIONALE: Incorrect spray and inhalation results to gagging.Demonstrate to client removal of medication canister and clean-ing of inhaler in warm water.RATIONALE: Spray accumulation around mouthpiece may interfere with medi-

cation distribution.Ask patient to explain and demonstrate steps in inhaler use.RATIONALE: Patient's understanding of procedure is assessed.Have patient explain medication schedule.RATIONALE: Medication compliance is ensured.Ask patient to describe medication's side effects and proper situ-ation for calling physician.RATIONALE: Enables patient to determine medication overuse or ineffectiveness.Assess patient respirations and auscultate lungs after medication


80


instillation.RATIONALE: Breathing pattern status and ventilation adequacy are deter-

mined.Record procedure, patient education and ability to self-adminis-ter medication.RATIONALE: Documentation facilitates communication with other health team


3.7. Preparing Injections

Parenteral AdministrationInjections are commonly used in the parenteral administration ofmedication. Aseptic technique should be observed at all times sincethis is a procedure of an invasive nature. Skill in handling injections isrequired of a nurse performing the procedure. The effects ofparenteral administration comes immediately after instillation depend-ing on the absorption rate of the medication.

Types of InjectionsSubcutaneous injectionsThis type of injection is the placement of medication in the dermis'loose connective tissue. In this type of injection, medication absorp-tion is slow compared to intramuscular injection. This is because ofthe minimal blood supply in subcutaneous tissues. Medication ab-sorption however is imminent in patients who have normal circula-tory status.There are a number of sites in which to perform subcutaneous injec-tions:

Outer posterior aspects of the upper arms. Abdomen from below the costal margins to the iliac crests. Anterior aspects of the thighs. Scapular areas of the upper back. Upper ventral/dorsal gluteal areas.

81

It should be noted that a selected injection site should be free oflesions, bony prominences or large underlying muscles/nerves.Since subcutaneous tissue may be irritated by solutions, injections arelimited to small doses of water-soluble medications.

Intramuscular injectionsThis type of injection is probably the best in terms of medicationabsorption owing to the muscles' large supply of blood. Risk oftissue damage is also minimal even if medication enters deep muscle.The risk of medication entering a blood vessel however is present.Long and large needles are often used in intramuscular injections soas to penetrate deep muscle tissue. The amount of adipose tissuepresent in an injection site often serves as basis for needle selection.Ninety (90) degrees is the angle of insertion for intramuscular injec-tions. The volume of medication usually depends on the age groupwhere the patient belongs.Before injecting, it is imperative to assess muscle integrity. The muscleshould be free of tenderness. Repeated injection into a muscle couldcause discomfort and therefore should be avoided. Palpation of themuscle is usually how the nurse assesses for any hardened lesions.Helping the patient assume a comfortable position before injectionmay help prevent discomfort.

Techniques in intramuscular injectionZ-Track method. This method minimizes irritation by sealing the medi-cation in muscle tissue. Injection site should preferably be larger, deepermuscles.Air-lock Technique. The use of this method usually reduces irritation insubcutaneous injections during withdrawal of the needle. It involvesinjection of a small volume of air behind a bolus of medicationwhich clears the needle of medication. It prevents tracking of themedication through subcutaneous tissue.Intradermal injections. Intradermal injections are usually done when doingskin testing. This is due the fact that most of these medications arepotent, injecting them into the dermis (which has less blood supply)slows down absorption. This may cause anaphylactic reactions on


82


the part of the patient which may occur if the medication enterscirculation.Tuberculin or small hypodermic syringes are usually used in skin test-ing. The angle of insertion is usually 5-15 degrees. Upon injection, ableb similar to a mosquito bite will appear on the skin surface.

Injection PreparationFrom an ampuleSingle-dose medications usually come in ampule form. Ampules aremade of glass which can be readily snapped at the neck to gainaccess to the medication. Once open, medication may be aspiratedwith the use of a plain or a filter needle.

From a vialSingle or multi-dose medications are usually contained in a vial, whichhas a rubber seal on top. Vials may contain medication in liquid ordry form. For dry medications, the label on the vial usually indicatesthe appropriate solvent to be used in diluting the dry component.Commonly used diluents are normal saline and sterile distilled water.A vial being a closed container, requires the injection of air into it inorder to facilitate easy aspiration of medication. Failure to do sowould create a vacuum inside the container thereby making medica-tion withdrawal difficult.

Medication MixingIt is usually possible to mix 2 compatible medications in a singleinjection provided the desired dose is within acceptable limits. Thenurse in cases where there is doubt on the compatibility of medica-tions should at all times consult a pharmacist.There are three principles, which the nurse should observe whenmixing medications from two vials:

Avoid contaminating a medication with another. Make sure of the final dose's accuracy. Aseptic technique should at all times be maintained.

A single syringe usually suffices in mixing medications from two vi-als. The nurse usually injects volume of air equivalent to the first

83

medication's required dose. The air in the syringe is then injected intothe first vial making sure to avoid touching the medication with theneedle. The needle is then withdrawn and the same process is re-peated for the second vial. Medication is then withdrawn from thesecond vial, application of a fresh sterile needle is then needed toavoid medication contamination. The nurse then withdraws medica-tion from the first vial, thereby completing the dose.

From one vial and one ampuleThis is a relatively simple procedure. This is because there is no needto add air in order to withdraw medication from an ampule. Medi-cation is prepared first from the vial, afterwhich the same needle is used to withdraw medication from theampule. Through this method, contamination of solution in the vialis prevented.

Materials RequiredAmpule

Syringe and 2 pcs. of needles Gauze pad/alcohol swab

Vial Syringe and 2 pcs. of needles Gauze pad/alcohol swab Diluent (normal saline or sterile water)

Procedure for Preparing Injections & RationaleCheck medication order.RATIONALE: Accurate medication administration is ensured.Review important information related to medication.RATIONALE: Proper medication administration is achieved, patient's response

to medication is monitored.Assess patient's body build, muscle size and weight.RATIONALE: Syringe type and size to be used is determined.MEDICATION PREPARATION


84


Ampule preparation:Use finger to tap ampule lightly and quickly until fluid movesfrom ampule's neck.RATIONALE: Fluid above ampule neck is dislodged.Place small gauze pad around ampule's neck.RATIONALE: Protects nurse from possible injury from broken off glass tip.Check ampule if it is filled, then quickly and firmly snap ampule'sneck, holding it away from body.RATIONALE: Set ampule on a flat surface or hold it upside down. Prevents

injury.Insert syringe/filter needle into ampule opening. Avoid touchingampule's rim with needle tip/shaft.RATIONALE: Ampule's broken rim is contaminated.Make sure needle is under surface of liquid. Bring all fluid withinneedle's reach by tipping ampule.RATIONALE: Fluid is pulled into syringe by negative pressure created by with-

drawal of plunger.Avoid expelling air into ampule if air bubbles are aspirated.RATIONALE: Fluid may be expelled out of ampule by air pressure.Expel excess air bubbles by removing needle from ampule. Holdsyringe with needle pointing up. Make bubbles rise by tappingside of syringe. Slightly draw back plunger and eject air by push-ing plunger upward. Avoid ejecting fluid.RATIONALE: Fluid is allowed to settle in barrel's bottom. Fluid within needle

enters barrel by pulling back on plunger. Air present in top ofbarrel and needle is expelled.

Dispose of excess fluid in syringe in sink. Vertically hold syringewith needle upwards and slightly slanted toward sink. Eject ex-cess fluid slowly into sink. Hold syringe vertically to recheck fluidlevel.RATIONALE: Medication is safely disposed of. Medication is expelled without

85

flowing down needle shaft. Proper dose is ensured by recheckingfluid level.

Use syringe's safety cap to cover needle. If presence of medica-tion on needle shaft is suspected, change syringe or use filter needle.Needle contamination is prevented. Tracking of medication through skin

and SQ tissues is prevented.Vial containing solution:Expose sterile rubber seal by removing cap covering top ofunused vial, keeping rubber seal sterile. If a multidose vial is inuse, wipe surface of rubber seal briskly and firmly using alcoholswab and allow it to dry.RATIONALE: Contamination of rubber seal is prevented by cap. Coating of

needle with alcohol which may mix with medication is preventedby letting alcohol dry.

Get syringe and remove needle cap. Draw amount of air intosyringe equivalent to medication volume to be aspirated by pull-ing back on plunger.RATIONALE: Buildup of negative pressure in vial is avoided during medication

aspiration.Place vial on flat surface and place needle tip with beveled tipentering center of rubber seal. Exert pressure on needle tip whileinserting.RATIONALE: Seal's center is easier to penetrate because it's thinner. Prevents

rubber seal coring which could enter vial/needle.Inject air into vial airspace while holding plunger.RATIONALE: Bubble formation and dose inaccuracy is prevented.Plunger should be held with firm pressure as it may be forcedbackward by air pressure from the vial. Invert vial while firmlyholding syringe and plunger. Vial should be held between non-dominant hand's thumb and middle fingers. Hold syringe barrel'send and plunger using thumb and forefinger of dominant handin order to counteract pressure inside vial.RATIONALE: Avoids accidental spillage. Fluid is allowed to settle in lower half


86


of container. Forceful movement of plunger allows for manipula-tion of syringe.

Keep needle tip below fluid level.RATIONALE: Aspiration of air is prevented.Allow air pressure coming from vial to gradually fill syringe withmedication. Slightly pull back on plunger to get correct amountof solution.RATIONALE: Fluid is forced into syringe by positive pressure within vial.When desired amount of medication is taken, place needle in toairspace of vial. Carefully tap syringe barrel's side to dislodgeany air bubbles. Expel any remaining air into vial.RATIONALE: Needle may be bent by forceful tapping of barrel. Medication can

be displaced by presence of air which may cause dosage error.Pull back on syringe's barrel to remove needle from vial.RATIONALE: Medication loss may stem from separation of plunger from barrel

as a result of pulling on plunger instead of the barrel.Syringe should be held at a 90° angle at eye level to ensure thatcorrect volume is obtained and there are no air bubbles. Tapbarrel to dislodge remaining air bubbles (if any). Slightly drawplunger back and push plunger up to expel air. Avoid ejectingfluid.RATIONALE: Fluid is allowed to settle in barrel's bottom. Fluid within needle

enters barrel by pulling back on plunger. Air is expelled frombarrel

If medication is to be injected into patient's tissue, change needleto suitable gauge and length in accordance with medication route.RATIONALE: New needle is sharper than one that has been inserted through a

rubber stopper. Needle will not track medication through tissuessince no fluid is present in needle.

In using multidose vials, create label reflecting date of mixing,concentration and drug/ml and your initials.RATIONALE: Correct preparation of future doses is ensured. Some medications

87

should be discarded after a certain period from time of mixing.Vial containing powder (medication reconstitution):Remove cap from vial of powdered medication and cap fromdiluent.RATIONALE: Contamination of rubber seal is prevented by cap.Insert needle's tip through center of powdered medication's rub-ber seal.RATIONALE: Diluent is prepared for injection into vial with powder medication.Thoroughly mix medication. Roll vial in palm.RATIONALE: Proper dispersal of medication throughout solution is ensured.Avoid shaking.RATIONALE: Bubbles can be produced by shaking.Determine dose after reconstituting by reading label carefully.RATIONALE: Dose to be given is determined by medication concentration (mg/

ml).Clean work area.RATIONALE: Accidental injury to staff is prevented by proper disposal of glass

and needle. Transmission of infection is reduced.Wash hands.RATIONALE: Reduces spread of microorganisms.

3.8. Injection AdministrationThere are different injection routes by which to administer medica-tion, depending on the type of tissue where the injection is to bedone. Medication absorption and action depends largely on the tis-sue characteristics. There are three things that a nurse should knowbefore injecting a medication:

Volume of medication to be administered.


88


Viscosity and characteristic of medication. Injection sites' anatomical structure.

There are consequences in case a nurse fails to properly administer aninjection, these include nerve or bone damage during insertion, tissuedamage and pain for the patient and accidental injection of air into avein or artery.For some reason, many patients most specially children fear injec-tions. There are however ways by which a nurse can minimize patientdiscomfort during needle insertion:

Use of a sharp beveled needle in the smallest length possible. Reduction of muscular tension through positioning of patient inthe most comfortable manner as possible.

Proper selection of injection site. Conversing with the patient so as to divert attention from theinjection.

Minimizing tissue pulling by quick and smooth insertion of needle. Slow and steady injection of the medication.

Procedure for Injection Administration &Rationale

Check order for medication.RATIONALE: Safe and correct administration of medication is ensured.Check patient for history of allergies.RATIONALE: Substances to which patient is allergic should not be administered.Assess patient for contraindication to subcutaneous or intramus-cular injections.RATIONALE: Physiological changes associated with aging or illness may affect

amount of SQ tissue a patient has.Accurately prepare medication dose from ampule/vial. Checkcarefully and be sure to expel all air.RATIONALE: Medication is poorly absorbed by atrophied muscle. It may also be

impaired by factors impeding blood flow to muscles.Identify patient.

89

Ensures that correct drug is administered to correct patient.Explain procedure to patient.Patient's understanding of procedure is improved.Provide necessary privacy.RATIONALE: Patient embarrassment is reduced.Wash hands.RATIONALE: Transmission of microorganism is reduced.CHOOSE IDEAL INJECTION SITE. INSPECT SKIN FOR BRUISES, INFLAM-MATION OR EDEMA

For Subcutaneous Injections (SQ):Palpate site for masses/tenderness, these areas should be avoided.Check accuracy of needle size by site's skinfold using thumband forefinger. Measure fold from top to bottom.For Intramuscular Injections (IM):Examine muscle size and integrity, palpate for tender/hard areas.These areas should be avoided. Rotate sites for frequent injec-tions.For Intradermal Injections (ID):Check arm for discoloration/lesions. Choose site 3-4 finger widthsbelow antecubital space and a hand width above wrist.RATIONALE: Injection site must be free of abnormalities which may hinder

absorption of medication. Frequently used site could result inlypohypertrophy (fatty tissue growth increase).

ASSIST PATIENT TO ESTABLISHING A COMFORTABLE POSITION

For SQ Injections:Ask patient to relax arm, leg or the abdomen, depending onwhere injection site is.RATIONALE: Discomfort is minimized by relaxation of site.For IM Injections:Assist patient to a lying (flat or side) or prone position dependingon where injection site is.RATIONALE: Strain on muscle is reduced and discomfort caused by injection is


90


reduced.For ID Injections:Ask patient to extend elbow and use forearm to support it.RATIONALE: Injection site is stabilized easing accessibility.Use anatomical landmarks to relocate injection site.RATIONALE: Injury to nerves, bones and blood vessels is prevented.Use antiseptic swab to clean site. Apply swab at site's center androtate outward in a circular motion. Discard swab.RATIONALE: Secretions harboring microorganisms are removed.Hold another swab/cotton ball between third and fourth fingersof non-dominant hand.RATIONALE: Easy access to swab/cotton after withdrawal of needle is pro-

vided.Remove needle cap. Hold syringe between non-dominant hand'sthumb and forefinger:For SQ/IM Injections: Hold like a dart with palm down.For ID Injections: Hold with needle's bevel pointed upward.RATIONALE: Position ensures delivery of medication to tissues below dermis.ADMINISTER INJECTION

SQ Injection:For medium-built patient, tightly spread skin across site or pinchusing non-dominant hand.RATIONALE: Tight skins are more easily penetrated by needle than loose skin.Quickly and firmly inject needle and at a 45° angle underneathtissue fold.Patient discomfort is minimized. For overweight patient, pinchsite's skin and inject needle at a 90° angle below tissue fold.RATIONALE: Patients who are obese have fatty tissue layers above SQ layer.After needle's entry into site, hold syringe barrel's lower end us-ing non-dominant hand. Hold end of plunger with dominanthand. Avoid moving syringe while aspirating drug. If blood en-

91

ters syringe, discard medication and syringe and repeat proce-dure.RATIONALE: Smooth manipulation of syringe parts is a must to properly inject

medication. Displacement of needle caused by syringe movementcan cause patient discomfort. Aspiration of blood indicates intra-venous placement of needle. Heparin injection aspiration may causeneedle to move, resulting in tissue damage and bleeding.

Slowly inject medication.IM Injection:Pull skin down on selected site in a Z-track.RATIONALE: Needle insertion is facilitated. Zigzag path through tissues is

created to prevent medication tracking.Quickly inject needle at a 90° angle. Slowly inject medication.RATIONALE: Pain and tissue trauma is reducedWait for about 10 secs before steadily withdrawing needle. Placeantiseptic swab/cotton over site.RATIONALE: Discomfort during needle withdrawal is minimized.ID Injection:Use non-dominant hand to stretch skin across chosen site usingthumb or forefinger.RATIONALE: Tight skin is more easily penetrated by needle.Place needle against skin and slowly insert at a 5-15° angle untilresistance is encountered. Push needle into epidermis about 3mm below surface of skin. Make sure that needle tip can be seenthrough skin.RATIONALE: Placement of needle tip in dermis is ensured.Slowly inject medication. If no resistance is encountered, with-draw needle and repeat procedure.RATIONALE: Patient discomfort is minimized. Dermal layer does not easily

expand when injected with medication.A small bleb about 6 mm in diameter should appear on skinsurface while medication is being injected.RATIONALE: Deposit of medication into dermis is determined.Gently apply alcohol swab over site while needle is being with-drawn.

HygieneChapter Four

4.1. Bathing a Client

4.2. Providing Perineal Care

4.3. Administering a Back Rub

4.4. Performing Foot and Nail Care

4.5. Providing Oral Hygiene

4.6. Performing Mouth Care for an Unconscious orDebilitated Client

4.7. Caring for Clients with Contact Lenses

4.8. Making an Occupied Bed

94


4.1. Bathing a PatientBathing is an integral part of personal hygiene. The quality and extentof a patient's bath and the methods of implementation depend largelyon the patient's physical capabilities, health and needed degree ofhygiene.A complete bed bath is usually given to a patient who is totally de-pendent and requires complete hygiene. Complete bed bath has beenfound to increase oxygen consumption in healthy men, thereforemaking it an extremely tiring procedure for patients. It is the nurse'sresponsibility to assess whether the patient can tolerate a completebed bath. This can be done by measuring vital signs before and afterthe bed bath.A partial bed bath on the other hand involves bathing of only spe-cific parts of the patient's body. These parts are assumed to be po-tential sources of discomfort and odor if left unbathed. Aging pa-tients are usually the ones who require partial bed baths.In bathing a patient, it is imperative that the nurse assess the conditionof the patient's skin. It will aid in determining if the patient needs touse soap during the bath or if the patient needs a bath on a dailybasis. This is done specifically to avoid drying the patient's skin.

Guidelines in the Provision of Bed BathsProvide needed privacyMaintain patient safetyMaintain room warmthPromote patient independenceAnticipate patient needs

Bathing InfantsSpecial precautions should be taken when bathing infants. Bathinggreatly reduces infants' body temperature, which makes it necessaryfor the nurse to keep the infant covered before performing the pro-cedure. Warm water temperature should also be kept and the proce-dure should be done as quickly as possible.

95

Hygiene

Infant skin pH should also be taken into consideration, which is whyonly warm water is used during bed bath after birth. In older infantshowever, gentle soap may be used as soiling increases, use of alkalinesoaps is however, discouraged.

Materials Required Soap and water Bedpan Towels Washcloth Bathrobe Slippers Clean gown

Procedures for Bathing a Patient & RationaleAssess patient for activity and musculoskeletal function tolerance.RATIONALE: Provides data for determining patient's level of self-care perfor-

mance and type of bath to be administered.Review specific precautions (if any) regarding patient position-ing/movement.RATIONALE: Identifies level of assistance needed by patient to avoid injury.Explain to patient the procedure and ask for bathing preferencesif any.RATIONALE: Promotes self-esteem through enhancement of patient participa-

tion.Provide needed comfort and privacy.RATIONALE: Reduces patient embarrassment by avoiding unnecessary exposure

of patient's private body parts.Prepare necessary equipment/supplies.RATIONALE: Organizes performance of procedure by making needed materials

accessible. Saves time and minimizes patient discomfort.BATHING PROCEDURE

Complete/partial bedbath:Offer patient bedpan, towel and washcloth.

96


RATIONALE: Prevents interruptions during bathing.Wash hands.RATIONALE: Reduces transmission of microorganisms.Wear disposable gloves if necessary.RATIONALE: Reduces risk for infection.Assist patient to comfortable position, making sure that bodyalignment is maintained. Position patient on side of the bed clos-est to you and place bed in high position.RATIONALE: Protects nurse against back strain and provides easy access to

patient.Loosen top covers at bed's foot and place bath blanket over topsheet. Fold top sheet before removing from under blanket. Foldtop sheet if it is to be reused.RATIONALE: Prevents soiling of linen.Assist patient in removing gown.RATIONALE: Provides full access to inner body parts during bath.Fill up to two thirds of washbasin with warm water. Have pa-tient test water's temperature. If desired, put lotion's plastic con-tainer in bath water to make it warm.RATIONALE: Prevents unnecessary chilling and burns. Warm water enhances

muscle relaxation and restores comfort. Bath water makes lotionwarm.

If allowed, remove pillow and raise bed's head 30-45°. Put bathtowel underneath patient's head. Put second bath towel overpatient's chest.RATIONALE: Anatomical alignment allows for easy access to ears, neck and

nape. Towels catch water and soap droplets, preventing soiling oflinen and bath blanket.

To form mitt, fold washcloth around fingers of hand. Wet mittand wring thoroughly.RATIONALE: Loosely held washcloth does not hold water and heat as compared

to a mitt. Prevents cold edges of towel from touching patient.

97

Avoids splashing.Use plain warm water to wash patient's eyes. Ask if patient iswearing contact lenses. Different sections of mitt should be usedin each eye. Clean eyes from inner to outer canthus. Use a dampcloth to soak any crust on eyelid for 2-3 mins before trying toremove. Gently and thoroughly dry eye.RATIONALE: Soap may hurt patient's eyes. Use of different sections minimizes

cross contamination. Applying pressure on eye may result in in-jury.

Wash, rinse and thoroughly dry patient's cheeks, forehead, nose,neck and ears.RATIONALE: Soap and water traces may irritate patient's skin.Remove bath blanket from patient's arm. Put bath towel underarm. Move to other side of the bed to wash arm.RATIONALE: Prevents water and soap from spilling onto linen.Use soap and water to bathe patient's arm using long, firm strokesfrom distal to proximal areas. Raise and support patient's armabove head (if applicable) while washing axilla.RATIONALE: Removal of debris and bacteria occurs when soap lowers surface

tension and during friction. Circulation is stimulated by long firmstrokes. Normal range of motion is exercised by arm elevationduring exposure of axillar area.

Thoroughly rinse and dry arm and axilla. If desired, apply de-odorant or talcum powder.RATIONALE: Wetness causes skin irritation. Use of deodorants prevents bacte-

rial growth. Talcum powder minimizes sweating.Lay folded bath towel (half folded) beside patient. Put basin ontowel and immerse patient's hand in water. Soak hand from 3-5mins before proceeding to wash hand and fingernails. Removehand from basin and dry thoroughly.RATIONALE: Soaking promotes circulation through vasodilation, it also loosens

dirt, callouses and cuticles. Remnants of soap and water causewetness which harbors bacterial growth and skin breakdown.

Hygiene

98


Move to other side of the bed and repeat steps previous stepsfor other arm.RATIONALE: Facilitates circulation and restores patient comfort. Prevents trans-

mission of infection from other side of patient's body.Check bath water's temperature and change if needed.RATIONALE: Prevents accidental burns.Cover patient's chest with bath towel and fold blanket down toumbilicus. Use long, firm strokes with mitted hand in bathingpatient's chest. For female patient, wash skinfolds under breasts.Patient's chest should be kept covered between washing and rins-ing. Dry chest thoroughly.RATIONALE: Prevents unnecessary exposure of body patient's private body

parts. Restores warmth and comfort.Put bath towel (lengthwise) over patient's chest and abdomen.Blanket should be folded down to above patient's pubic region.RATIONALE: Prevents unnecessary exposure of body patient's private body

parts.Lift bath towel and bathe patient's abdomen using mitted hand.Stroke from side to side, keeping patient's abdomen coveredthroughout the process. Dry thoroughly.RATIONALE: Moisture harbors bacterial growth especially in skinfolds which

may contain sediments. These sites are prone to irritation andtissue breakdown.

Assist patient in putting on clean gown/pajama top.RATIONALE: Promotes body image and enhances patient self-esteem. Restores

patient comfort.Cover patient's chest and abdomen with bath blanket's top. Foldblanket toward midline to expose patient's leg. Patient's perineumshould be covered.RATIONALE: Prevents unnecessary exposure of patient's private parts.Position your arm under patient's leg to bend patient's leg atknee. Slightly elevate leg from mattress and put bath towel underleg (lengthwise). Instruct patient to hold leg still. Place basin on

99

bath towel and secure it next to the foot to be washed.RATIONALE: Supporting the joints prevents musculoskeletal strain. Towel pre-

vents soiling of linen. Allowing patient to hold leg facilitates as-sessment of leg strength.

Soak patient's feet after bathing (if allowed).RATIONALE: Soaking promotes circulation through vasodilation, it also loosens

dirt, callouses and cuticles. Remnants of soap and water causewetness which harbors bacterial growth and skin breakdown.

Using long, firm strokes, wash patient from ankle to knee andfrom knee to thigh (if allowed). Dry thoroughly.RATIONALE: Enhances circulation.Wash patient's foot, ensuring to clean between toes. Clean andclip nails as needed. Dry well and apply lotion to dry skin. Avoidmassaging reddened areas of patient's skin.RATIONALE: Moisture harbors bacterial growth especially in skinfolds which

may contain sediments. These sites are prone to irritation andtissue breakdown. Lotion provides sufficient moisture to conditionskin.

Move to other side of the bed and repeat steps for patient'sother leg and foot.RATIONALE: Facilitates circulation and restores patient comfort. Prevents trans-

mission of infection from other side of patient's body.Cover patient with bath blanket and change bath water.RATIONALE: Restores warmth and observes hygiene.Assist client to establishing a prone/side-lying position. Put towel(lengthwise) along patient's side.RATIONALE: Provides easy access to back portion of patient's body for cleaning.

Towel prevents soiling of linen.Slide bath blanket over shoulders and thigh to keep patient draped.Using long, firm strokes, wash, rinse and dry back from neck tobuttocks. Give patient a back rub.RATIONALE: Ensures unnecessary exposure of patient's private parts. Back

rub promotes circulation and promotes comfort.

Hygiene

100


Assist patient in establishing a supine position. Use towel to coverpatient's chest and upper extremities. Expose only patient's geni-talia. Wash, rinse and dry perineum.RATIONALE: Reduces patient embarrassment by preventing unnecessary expo-

sure of patient's private parts.Apply body lotion/oil to patient if so desired.RATIONALE: Provides sufficient moisture to condition skin.Assist client in dressing and comb patient's hair.RATIONALE: Promotes body image and enhances self-esteem.Remake patient's bed.RATIONALE: Removes creases on linen that might cause pressure sores. Restores

comfort and promotes rest.Put soiled linens in laundry bag. Clean and store bathing equip-ment. Wash hands.RATIONALE: Reduces transmission of microorganisms.Tub bath/shower:Assess patient condition and review precautionary orders.RATIONALE: Ensures patient safety during performance of procedure.Schedule use of tub/shower.RATIONALE: Patient's state of readiness for procedure is ensured.Check cleanliness of tub/shower, if applicable utilize cleaningtechniques as per institution's policy. Put a rubber mat on tub/shower bottom.RATIONALE: Minimizes risk for contamination and ensures safety.Prepare all hygienic aids, toiletries and linen.RATIONALE: Provides easy access to equipment/supplies. Saves time.Have patient wear bath robe and slippers and assist in going tobathroom (if needed).RATIONALE: Robe and slippers facilitate easy exposure of patient's body dur-

ing procedure. Avoids unnecessary exposure of patient's private

101

parts during ambulation of patient to bathroom. Promotes warmthand comfort.

Fill tub halfway with warm water. Have patient test water andadjust temperature if necessary. Instruct client on the use of hotand cold faucet. Warn patient against use of oil inside tub.RATIONALE: Prevents accidental burns. Use of oil may cause accidental slip-

ping and fall when patient is in tub.Tell client to remain in tub for not more than 20 mins.RATIONALE: Warm water promotes vasodilation. Prolonged stay may cause

dizziness.Return to bathroom when patient calls.RATIONALE: Promotes independence and enhances self-esteem. Leaving patient

provides privacy.Drain tub completely before patient attempts to get out. Placetowel on patient's shoulder and assist as deemed necessary.RATIONALE: Ensures patient safety.Assist patient in dressing as needed.RATIONALE: Promotes independence and enhances self-esteemAssist patient to room and in establishing comfortable position.RATIONALE: Restores patient comfort.Wash hands.RATIONALE: Reduces transmission of microorganisms.Observe patient's skin especially areas previously soiled, reddenedor showing any sign of breakdown. Ask patient to rate level ofcomfort.RATIONALE: Evaluates effectiveness of procedure.Record procedure accurately. Record patient's skin condition andsignificant findings if any. Report any alteration in patient's skinintegrity.RATIONALE: Documentation facilitates communication with other health team

members. Serves as future reference for nursing care. May also

Hygiene

102


serve for legal purposes.

4.2. Providing Perineal CarePerineal care is a part of a complete bed bath. Patients who requireperineal care are those who are deemed to be most susceptible toinfection (i.e., uncircumcised males, patients with indwelling cathetersor those recovering from genital/rectal surgery). Perineal care, beingof a personal nature requires a nurse to allow independent patientsto do it for themselves.Patients practicing self-care are prone to overlook problems such asvaginal discharge or skin irritation. It is the nurse's responsibility to bealert and on the look out for such problems.

Materials Required• Soap and water• Towel• Blanket• Gloves• Underpad/toilet tissue• Washbasin

Procedure for the Provision of Perineal Care &Rationales

Assess patient's risk for developing genital, urinary tract or re-productive tract infections.RATIONALE: Secretions in the skin of the genitalia prevents transmission of

microorganisms.Assess patient's cognitive/musculoskeletal function.RATIONALE: Self-care promotes patient independence and self worth. If pa-

tient is capable, allow him/her to carry out the procedure.Assess genitalia for inflammation, skin breakdown or infection.RATIONALE: Extent of perineal care varies in accordance with degree of

infection or inflammation.

103

Assess patient's knowledge of the importance of perineal hy-giene. Explain to client purpose and nature of procedure.RATIONALE: Enhances patient understanding, cooperation and lessens anxiety.Prepare needed equipment/supplies.RATIONALE: Organizes working environment, saves time and provides easy

access to materials needed.Provide needed privacy.RATIONALE: Prevents unnecessary exposure of patients private parts and

reduces patient embarrassment.Position bed to comfortable working position. Put towel (length-wise) along side of patient. Use a bath blanket to keep patientcovered.RATIONALE: Prevents back strains on the part of the nurse. Towel prevents

soiling of linen. Bath blanket provides needed privacy.Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Remove any fecal matter using a fold of underpad/toilet tissue.Cleanse patient's buttocks and anus, washing beginning from frontto back. Dry area thoroughly. If gloves become soiled, changethem.RATIONALE: Ensures asepsis. Reduces transmission of microorganisms.Expose patient's genital area by raising patient's gown. Diamonddrape patient. Fill washbasin with warm water.RATIONALE: Provides easy access to patient's perineal area while ensuring

privacy.Put washbsin and toilet tissue on overbed table.RATIONALE: Provides easy access to equipment/supplies.PROVISION OF PERINEAL CARE

Female perineal care:Assist patient to establishing dorsal recumbent position. Assistpatient in flexing knees and spreading legs.RATIONALE: Exposes patient's perineum for flushing.

Hygiene

104


Fold bath blanket's lower corner up between patient's legs ontothe abdomen. Thoroughly wash and dry patient's upper thighs.RATIONALE: Prevents spread of infection. Wet areas harbor microorganisms.Wash patient's labia majora, using non-dominant hand to gentlyretract labia from thigh. Use dominant hand to wash skinfolds.Wipe beginning from perineum to rectum. Repeat procedure onopposite side using a different section of the washcloth. Thor-oughly rinse and dry area.RATIONALE: Microorganisms thrive in between skinfolds. Direction of wiping

prevents contamination of genitalia.Using non-dominant hand, separate labia and expose urethralmeatus and vaginal orifice. Use one smooth stroke to wash down-ward from pubic area to rectum. Use different sections of thewashcloth for each stroke. Clean labia minora, clitoris and vagi-nal orifice thoroughly.RATIONALE: Use of different sections prevents contamination. Drying area

prevents skin breakdown.If patient uses a bedpan, pour warm water over perineal areause front-to-back method in thoroughly drying perineal area.RATIONALE: Warm water promotes circulation and restores comfort. Running

water flushes away soap and microorganisms. It is more effectivethan wiping.

Fold bath blanket's corner back between patient's legs and overperineum. Have patient lower legs and establish comfortableposition.RATIONALE: Prevents unnecessary exposure of patient's private parts.Male perineal care:Assist patient in establishing supine position and note any diffi-culty in mobility.RATIONALE: Provides access to male genitalia.Fold bath blanket's top half below patient's penis. Wash and drypatient's upper thighs.RATIONALE: Protects surrounding skin from contamination by penile secre-

105

tions. Provides patient privacy for the duration of the whole pro-cedure.

Raise patient's penis gently and put bath towel underneath it. Grasppenis' shaft gently. For uncircumcised patient, retract foreskin.Perform procedure at a later time if patient has an erection.RATIONALE: Prevents pooling of moisture in the inguinal area. Proper han-

dling prevents erection. Foreskin is cleared of accumulated secre-tions and microorganisms

Begin washing at the tip of patient's penis at urethral meatus. Usea circular motion, cleansing from meatus outward. Dispose ofwashcloth and repeat procedure using clean cloth until penis isclean. Gently rinse and dry area.RATIONALE: The direction of washing must begin from the cleanest to the most

contaminated part to avoid spread of microorganisms to the ure-thra.

Return foreskin to natural position.RATIONALE: Local edema might result from constriction of blood vessels.Use gentle but firm downward strokes in washing shaft of pe-nis. Rinse and dry penis thoroughly. Ask patient to slightly spreadlegs apart.RATIONALE: Washing direction prevents erection. Accumulated secretions are

removed.Cleanse scrotum gently, lifting carefully and washing underlyingskin folds. Rinse and dry thoroughly.RATIONALE: Scrotal tissue is sensitive to pain. Application of excessive pres-

sure must be avoided.Fold bath blanket over patient's perineum and assist patient toside-lying position. Cleanse patient's anal area.RATIONALE: Prevents unnecessary exposure of patient's private parts.Remove and properly dispose of gloves.RATIONALE: Prevents spread of infection.Assist patient to establishing a comfortable position and cover

Hygiene

106


with sheet.RATIONALE: Restores patient comfort.Dispose of all used equipment and soiled linen.RATIONALE: Reduces transmission of microorganisms.Examine surface of patient's external genitalia and surroundingarea.RATIONALE: Evaluates effectiveness of procedure and determines needed inter-

vention.Observe for abnormal drainage from patient's genitalia.RATIONALE: Determines presence of any infection.Record and report procedure.RATIONALE: Documentation facilitates communication with other health team


4.3. Administering a Back Rub

PhysiologyA back rub or massage is usually given after a bed bath. It is knownto promote circulation and relaxation and relieve muscular tension.Studies reveal that long, slow, gliding strokes reduce heart and respi-ratory rate. Great reductions in systolic/diastolic blood pressure wereobserved in males. Patients have been known to report improvedcomfort after a back rub.In providing a back rub, it is recommended that relaxation be en-hanced through noise reduction and provision of comfort to thepatient. It is also imperative that the nurse determine anycontraindications before administering a back rub.

Materials Required Lotion Towel

107

Procedure for Administering a Back Rub &Rationale

Assess patient for contraindication.RATIONALE: Prevents further tissue injury (if present).If needed, measure patient's pulse and blood pressure.RATIONALE: Establishes baseline values.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Prepare necessary equipment/supplies.RATIONALE: Organizes working environment and saves time.Adjust bed height to comfortable position.RATIONALE: Protects nurse from back strain.Assist patient to a prone or side-lying position with back towardyou.RATIONALE: Provides easy access to patient's back side.Provide needed privacy.RATIONALE: Reduces patient embarrassment.Expose back, shoulders, upper arms and buttocks of patient.RATIONALE: Provides easy access to patient's back side.Use warm water to wash hands.RATIONALE: Cold hands can cause muscular tension due to vasoconstriction.Use lotion in hands or under warm water.RATIONALE: Prevents startled response. Lotion provides for easy gliding of

hands on skin surface.Apply lotion to sacral area. Using continuous and firm upwardstrokes beginning from buttocks to shoulders, over upper armsand back to buttocks.RATIONALE: Promotes relaxation, comfort and circulation.

Hygiene

108


Warm lotion in hands or under warm water. Apply lotion tosacral area using an upward motion, moving from buttocks toshoulder, upper arms and back to buttocks. Continue this pro-cess for 3 mins. Grasp patient's skin between thumb and fingersusing an upward motion. Do this from one side of the spinebeginning from the buttocks to shoulders and nape. Repeat thisprocedure on the other side.RATIONALE: Promotes circulation, has soothing effects.Use long stroking movements to end massage. Tell patient thatthe massage is to be ended.RATIONALE: Prepares patient for end of the procedure.Ask or assist client in moving to other side and repeat procedure.RATIONALE: Promotes self-worth and independence. Relieves anxiety.Assist client in dressing and establishing a comfortable position.RATIONALE: Restores patient comfort.Dispose of soiled towel properly. Wash hands.RATIONALE: Reduces spread of infection.Assess patient's comfort and for presence of any tension or pain.Reassess patient's blood pressure and pulse.RATIONALE: Evaluates effectiveness of procedure.Record patient's reaction to massage and skin condition.RATIONALE: Documentation facilitates communication with other health team


4.4. Performing Foot and Nail Care

PhysiologyFoot and nail care is also a part of total hygiene and therefore shouldbe done routinely. Softening of the cuticles is done by soaking, cleans-ing and drying, nail trimming usually follows.

109

It is the duty of the nurse to teach the patient and family about theproper method for nail cleaning and trimming. Methods to avoidinfection should also be stressed. Care should also be taken for pa-tients who have diabetes mellitus as they are prone to foot infectiondue to poor circulation. The nurse should be observant for changes,which may indicate peripheral neuropathy and vascular insufficiency.The nurse is encouraged to teach the patient the following guidelinesfor proper foot and nail care:

• Daily inspection of feet• Thorough examination of the feet of patients with diabetes

mellitus.• Daily washing of the feet using lukewarm water.• Avoid cutting corns/calluses and the use of commercial removers.• Application of unscented foot powder to perspiring feet.• Application of lanolin or baby oil to dry portions of the feet.• For diabetic patients, toenails should be filed straight across and

square. Avoid the use of scissors/clippers.• Consult physician before application of medication for athlete's

foot.• Avoid wearing elastic stockings.• Wear clean socks.• Avoid walking barefooted.• Make sure shoes are properly fitted.• Avoid wearing new shoes for extended period of time.• Exercise regularly to promote circulation.• Avoid the application of hot water bottles or heating pads.

Materials Required• Disposable bath mat• Emesis basin• Orange stick• Nail clipper• Nail file• Washcloth• Disposable gloves

Procedure in Performing Foot & Nail Care &

Hygiene

110


RationaleCheck patient's fingers, toes, feet and nails.RATIONALE: Assessment findings identify level of hygiene required.Examine circulation to toes, feet and fingers of patient.RATIONALE: Alteration in circulation affects nail and skin integrity.Assess patient's walking gait.RATIONALE: Unnatural gait of limping are signs of painful disorders.For female patients, ask if they use nail polish and polish re-mover frequently.RATIONALE: Excessive dryness can be caused by these products.Assess type of footwear that patient wears.RATIONALE: Nail and foot problems may be caused by ill-fitted shoes/foot-

wear.Assess patient's risk for foot/nail problems.RATIONALE: There are factors that ncrease susceptibility to nail problem (i.e.,

age). Older adults may have poor vision and coordination andother degenerative conditions.

Assess ability of patient to care for nails/feet.RATIONALE: Identifies level of assistance needed by patient.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Promotes coop-

eration.If institution policy requires, obtain physician's order for cuttingpatient's nails.RATIONALE: Some patients may be prone to skin breakdown and infection,

thus a medical order is required.Wash hands.RATIONALE: Reduces transmission of microorganisms.Prepare necessary equipment.RATIONALE: Organizes working environment and saves time.

111

Provide needed privacy.RATIONALE: Reduces patient embarrassment.Have ambulatory patient sit on bedside chair. Put disposable bathmat on floor under patient's feet.RATIONALE: Makes patient comfortable while feet are soaked in basin. Mat

protects feet from being soiled.Fill washbasin with warm water and check temperature.RATIONALE: Thickened epidermal layers and nails are softened by warm wa-

ter. Promotes circulation and reduces inflammation of skin.Put basin on bath mat or towel and assist patient in placing feetin basin.RATIONALE: Patient may have muscular difficulty in positioning feet. Assis-

tance protects patient from injuries.Fill emesis basin with warm water and place basin on papertowels on overbed table.RATIONALE: Thickened epidermal layers and nails are softened by warm wa-

ter. Promotes circulation and reduces inflammation of skin.Have patient place fingers in emesis basin.RATIONALE: Thickened epidermal layers and nails are softened by warm wa-

ter. Promotes circulation and reduces inflammation of skin.Soak patient's feet and fingernails for 10-20 mins (if not con-traindicated). Rewarm water after 10 mins.RATIONALE: This is typical period of time it takes for corns, calluses, cuticles

and nails to soften.Use orange stick to gently clean under patient's fingernails whilefingers are immersed. Remove basin and dry patient's fingersthoroughly.RATIONALE: Orange stick reaches inner corners of nails, removing dirt and

grime. Drying helps prevent microorganisms from thriving in nails.Clip patient's fingernails straight across. Use a nail file to shapepatient's nails.RATIONALE: Prevents accidental cutting of skin.

Hygiene

112


Use orange stick to gently push patient's cuticles back.RATIONALE: Reaches cuticles and prepares them for cutting.Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Use a washcloth to scrub calloused areas of patient's feet.RATIONALE: Facilitates removal of dry skin.Use orange stick to gently clean under patient's toe nails. Removepatient's feet from basin and dry thoroughly.RATIONALE: Orange stick reaches inner corners of nails, removing dirt and

grime. Drying helps prevent microorganisms from thriving in nails.In clipping toenails, follow procedures for clipping fingernails.Avoid filing toenails' corners.RATIONALE: Prevents accidental cutting of skin.Apply lotion to patient's hands and feet and assist patient to acomfortable position.RATIONALE: Prevents dryness and tissue breakdown.Remove and dispose of gloves properly. Clean and restore equip-ment for future use.RATIONALE: Prevents transmission of microorganisms. Allows for easy loca-

tion of equipment in the future.Dispose of soiled linens properly. Wash hands.RATIONALE: Reduces spread of infection.Examine patient's nails and surrounding areas.RATIONALE: Evaluates effectiveness of procedure.Ask patient to explain/demonstrate nail care.RATIONALE: Determines patient’s ability to carry out procedure.Observe patient's walking gait after procedure.RATIONALE: Compares assessment findings prior to performance of procedure.Record and report procedure.RATIONALE: Documentation facilitates communication with other health team

113


4.6. Providing Oral Hygiene

PhysiologyThe primary purpose of oral hygiene is the promotion or mainte-nance of healthy mouth, teeth and gums. Brushing cleans the teeth offood particles, plaque and bacteria. Flossing prevents gum inflam-mation and infection.Complete oral hygiene enhances well-being and stimulates a patient'sappetite. The nurse is highly useful in the maintenance of oral hygieneby educating the patient on the correct techniques and schedule. Edu-cating patients on common gum and tooth problems often moti-vates them to observe oral hygiene practices

Brushing /FlossingBrushing the teeth 3 times a day is basic to an effective oral hygieneroutine. Toothbrush to be used should have a straight handle and asmall brush so that all areas can be reached. All surfaces of the teethshould be brushed thoroughly with the use of a fluoride toothpaste.For patients with sensitive gums, soft bristled toothbrushes may beused.The amount of help that a patient may require in brushing may vary.Patients who are capable of self-care should be encouraged to doso.

Materials Required• Toothbrush• Toothpaste• Dental floss• Wash basin• Towel

Hygiene

114


Procedure for Providing Oral Hygiene & RationaleWash hands. Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Inspect integrity of patient's lips, teeth, buccal mucosa, gums,palate and tongue.RATIONALE: Identifies frequency and extent of oral care needed by patient.Assess patient for common oral problems.RATIONALE: Identifies the degree of health-teaching and type of oral care to be

rendered.Remove gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Determine patient's oral hygiene practices.RATIONALE: Identifies client's incorrect and appropriate techniques in oral

care. Provides baseline data for health teaching.Assess patient's capability to use a toothbrush.RATIONALE: Level of assistance needed is determined. Promotes independence.Prepare needed equipment.RATIONALE: Organizes work environment and provides easy access to materi-

als needed.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Put paper towels on overbed table, making sure that other equip-ment are within reach.RATIONALE: Provides easy access to materials needed.Raise bed to a comfortable working position.RATIONALE: Protects nurse from back strain. Maintains correct body align-

ment.Put towel over patient's chest.RATIONALE: Prevents soiling of patient's clothes.

115

Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Put some toothpaste onto toothbrush. Wet toothbrush.RATIONALE: Toothpaste softens food particles in the oral orifice. Water aids in

distribution of toothpaste.Hold toothbrush to patient's gumline at a 45 angle. Brush innerand outer surfaces of patient's upper and lower teeth. Clean bit-ing surfaces and sides of teeth.RATIONALE: Facilitates brushing of inner and outer areas of the teeth.Have patient try to lightly brush surface and sides of tongue.Caution patient against starting a gag reflex.RATIONALE: Some food particles and microorganisms are deposited in these

areas. Gagging may cause aspiration of toothpaste.Have patient rinse mouth thoroughly.RATIONALE: Water removes food particles and microorganisms and toothpaste

from the oral orifice.Have patient rinse mouth using mouthwash (if desired).RATIONALE: Provides antiseptic action and pleasant taste in the mouth.Assist in wiping patient's mouth.RATIONALE: Promotes comfort and body image.Have patient perform flossing. Have patient rinse mouth withcool water and spit in emesis basin. Assist in wiping patient'smouth.RATIONALE: Removes hard food particles not reached by brushing.Assist in returning patient to a comfortable position. Clean andrestore used equipment for future use.RATIONALE: Restores patient comfort.Clean overbed table. Dispose of soiled linens and paper towelsproperly. Remove and dispose of soiled gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Assess patient's feeling in oral cavity.

Hygiene

116


RATIONALE: Evaluates effectiveness of procedure.Ask patient to describe proper oral hygiene techniques.RATIONALE: Evaluates patient's ability to carry out procedure.Record and report procedure and observations.RATIONALE: Documentation facilitates communication with other health team


4.6. Performing Mouth Care for an Unconsciousor Debilitated Client

Patients with Special NeedsDue to high level of dependence, some patients may require specialoral hygiene methods. Unconscious patients are prone to drying ofsalivary secretions due to their incapacity to eat or drink and render-ing them unable to swallow salivary secretions.The adverse effects of certain procedures (i.e., chemotherapy, radia-tion and nasogastric tube intubation) may cause the patient to de-velop stomatitis. In cases like this, gentle brushing is recommendedso as to avoid bleeding of the gums. Use of commercial mouth-washes should also be avoided. Periodontal disease predominantamong patients with diabetes mellitus should likewise receive gentleoral mouth care. Dental visits are also recommended.

Materials Required• Gloves• Paper towels• Suction (if necessary)• Emesis basin• Tongue depressor• Toothbrush• Toothpaste• KY jelly

117

Procedure for Mouth Care for an Unconscious/Debilitated Patient & Rationale

Wash hands. Wear clean disposable gloves.RATIONALE: Reduces transmission of microorganisms.Assess patient for presence of gag reflex.RATIONALE: Gag reflex may cause aspiration.Examine patient's oral cavity.RATIONALE: Determines frequency and extent of oral hygiene needed.Remove gloves and wash hands.RATIONALE: Reduces transmission of microorganisms.Assess patient for risk of oral hygiene problems.RATIONALE: Alterations in oral cavity indicate frequency or precautions in oral

care.Have client lie on side with head turned toward dependent side.Make sure that bed's head is lowered.RATIONALE: Prevents risk of aspiration.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Wash hands. Wear clean disposable gloves.RATIONALE: Reduces transmission of microorganisms.Arrange equipment on overbed table over paper towels. Preparesuction if needed.RATIONALE: Organizes working environment and saves time. Provides easy

access to materials needed. Suction may be used to prevent aspira-tion.

Provide needed privacy.RATIONALE: Reduces patient embarrassment.Raise bed to highest horizontal level and position patient close toside of bed. Turn patient's head toward mattress. Place towel

Hygiene

118


under patient's head and emesis basin under patient's chin.RATIONALE: Protects nurse from back strain.Use a padded tongue depressor or soft bristled toothbrush toseparate patient's upper from lower teeth. Make sure that patientis relaxed and avoid using force.RATIONALE: Prevents soiling of patient's gown and allows patient to spit on

basin.Use toothbrush to cleanse patient's mouth. Initially clean chew-ing and inner tooth surfaces. Clean roof of mouth, gums andinside of cheeks. Brush tongue gently to avoid stimulating gagreflex. Use a bulb syringe to rinse patient's mouth. Repeat rinsingprocedure several times.RATIONALE: Toothbrush removes food particles.If secretions accumulate, use suction.RATIONALE: Prevents aspiration.Apply thin layer of KY Jelly to patient's lips.RATIONALE: Promotes moisture and conditions skin.Inform patient of procedure's completion. (if conscious)RATIONALE: Provides sensory stimulation.Remove and dispose of gloves properly.RATIONALE: Reduces transmission of microorganisms.Return patient to a comfortable position.RATIONALE: Restores patient comfort.Clean and restore equipment for future use.RATIONALE: Ensures easy location of equipment in the future.Dispose of soiled linens properly. Wash hands.RATIONALE: Reduces transmission of microorganisms.Re-apply gloves and inspect patient's oral cavity.RATIONALE: Evaluates effectiveness of procedure.Record and report procedures and observations.

119

RATIONALE: Documentation facilitates communication with other health teammembers. Serves as future reference for nursing care. May alsoserve for legal purposes.

4.7. Caring for Clients with Contact Lenses

Basic Eye CareEye cleansing involves the use of a clean washcloth moistened withwater. The use of soap is not encouraged as it may irritate the eye.Pressure should never be applied when washing the eye to avoidinjury.Frequent eye care is most needed by unconscious patients becausesecretions may collect in the eyelids and inner canthus in the absenceof blink reflex. To prevent corneal drying and irritation, placing aneyepatch over the eye is recommended. Consult the attending physi-cian in administering eye lubrication.

Materials Required• Towel• Disposable gloves• Sterile saline solution• Towel• Contact lenses storage• Non-cosmetic soap• Tap water

Procedure for Caring for Clients with ContactLenses

Place towel below patient's face.RATIONALE: Towel is used to catch lens if it falls and prevents soiling of

patient's clothes.Examine patient's eyes or ask him/her if contact lenses are inplace.RATIONALE: Verifies if lenses are in place.

Hygiene

120


Inquire if patient feels any discomfort in the eyes.RATIONALE: Eye injury may result from prolonged wearing or damaged con-

tact lenses.Ask patient for any unusual vision signs or symptoms.RATIONALE: Determines need to change lens or existence of eye condition.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Assist patient to establishing a sitting or supine position.RATIONALE: Ensures comfortable patient position. Protects nurse from back

strain.Prepare necessary equipment.RATIONALE: Organizes working environment and saves time.CONTACT LENS REMOVAL:Soft lenses:Wash hands. If necessary, wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Place towel below patient's face.RATIONALE: Towel is used to catch lens if it falls and prevents soiling of

patient's clothes.Put a few drops of sterile saline solution onto patient's eye.RATIONALE: Saline eases removal of contact lenses.Instruct patient to look straight ahead and retract patient's eyelidsusing middle finger.RATIONALE: Distracts patient's visual focus, facilitating removal of lens.Using pad of index finger, slide lens off cornea and onto whiteof eye.RATIONALE: Prevents cornea and sclera from accidental injury.Gently pull upper eyelid down using thumb of other hand andslightly compress lens between thumb and index finger.

121

RATIONALE: Facilitates entry of air into lens and releases suction to scleralsurface.

Pinch lens gently and lift out of the eye. Clean and rinse lens. Putlens in storage case.RATIONALE: Protects lens from tearing/damage.Repeat procedure for other eye.Secure storage case's cover and label with patient's name androom number.RATIONALE: Prevents incorrect re-application of lens to the wrong patient.Assess condition of patient's eyes after removal of the lenses.RATIONALE: Evaluates effectiveness of procedure.Properly dispose of soiled towel. Remove and properly disposeof gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Rigid lenses:Wash hands. Wear disposable gloves if needed.RATIONALE: Reduces transmission of microorganisms.Put towel below patient's face.RATIONALE: Prevents soiling of clients gown and linens.Make sure that lens is situated directly over cornea.RATIONALE: Facilitates comfortable removal or grasping of lens.Put index finger on patient's eye's outer corner and gently drawback skin toward patient's eye.RATIONALE: Maneuvers contact lens to desired position for easier removal.Ask patient to blink. Pressure on eyelid should not be releaseduntil blink is completed.RATIONALE: Maneuvers contact lens to desired position to allow grasping by

index finger and thumb.Retract eye lids gently beyond lens' edges if lens fails to pop out.Gently press lower eyelid against lens' lower edge.

Hygiene

122


RATIONALE: Maneuvers contact lens to desired position to allow grasping byindex and thumb.

Allow both eyelids to slightly close, and grasp lens as it rises fromthe eye. Hold lens in hand.RATIONALE: Facilitates blinking clearing eyes from irritation caused by fingers.Cleanse and rinse lens. Store lens properly using storage case withconvex side down.RATIONALE: Prevents spread of microorganism. Protects lens from damage.Repeat steps for other eye. Label storage case with patient's nameand room number.RATIONALE: Prevents error when applying lens to clients.Properly dispose of soiled towel. Remove and properly disposeof gloves.Wash hands.RATIONALE: Prevents spread of microorganisms.Cleansing and disinfecting contact lenses:Wash hands.RATIONALE: Prevents spread of microorganisms.Prepare needed supplies by patient's bedside.RATIONALE: Organizes working environment and saves time.Carefully open lens container and remove lens.RATIONALE: Prevents accidental tearing of lens.Apply one or two drops of cleaning solution to lens.RATIONALE: Removes dirt and disinfects lens without damaging its surface.Gently but thoroughly rub lens on both sides for 20-30 secs. Forsoft lenses, use index/little finger to clean lens. For rigid lenses,use cotton applicator soaked in cleaning solution.RATIONALE: Prevents nails from accidentally tearing lens.Rinse lens thoroughly over emesis basin using manufacturer-rec-

123

ommended rinsing solution (soft lenses) or tap water (rigid lenses).RATIONALE: Prevents lens contamination and damage.Put lens in appropriate storage case filled with storage solution.RATIONALE: Lubricates lens, prevents drying and damage.Repeat procedure for other lens.LENS INSERTION

Soft lenses:Wash hands using non-cosmetic soap.RATIONALE: Reduces transmission of microorganisms. Non-cosmetic soap won't

damage lens.Apply disposable gloves if needed.RATIONALE: Reduces transmission of microorganisms.Put a towel over patient's chest.RATIONALE: Protects patient's clothes from getting soiled. Towel catches lens in

case it falls.Take right lens from storage case and rinse using rinsing solution.Examine lens for foreign materials, tears and damage.RATIONALE: Prevents misapplication of lens and eye irritation.Make sure that lens is not inverted.RATIONALE: Prevents eye injury.Expose patient's iris by retracting upper eyelid using middle/index finger of free hand.RATIONALE: Ensures accuracy of lens placement.Use middle finger of hand with lens to pull down patient's lowereyelid.RATIONALE: Facilitates easy placement of lens.Ask patient to look straight ahead. Place lens directly on corneaand slowly release eyelids.RATIONALE: Distracts patient's visual focus, facilitating removal of lens.Instruct patient to close eye slowly and roll it toward the lens if

Hygiene

124


the lens is not in place.RATIONALE: Facilitates placement of lens.Ask patient to blink for several times. Make sure that lens is cen-tered over cornea.RATIONALE: Ensures that lens is accurately set in place.Repeat steps procedure for other eye.If patient has blurred vision: Retract patient's eyelids and locatelens' position. Have patient look in direction opposite of lensand apply pressure to lower eyelid using index finger. Positionlens over cornea.RATIONALE: Corrects lens position.Dispose of soiled supplies properly. Rinse lens case and allow todry. Wash hands.RATIONALE: Reduces transmission of microorganisms.Rigid lenses: Wash hands. If needed, wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Put a towel over patient's chest.RATIONALE: Protects patient's clothes from getting soiled. Towel catches lens in

case it falls.Remove lens from case and rinse with tap water.RATIONALE: Rinses off old solution from lens that may harm cornea and

sclera.Use prescribed wetting solution to wet lens on both sides.RATIONALE: Lubricates lens and prevents eye injury.Place lens (concave side up) on index finger's tip of non-domi-nant hand.RATIONALE: Facilitates suction effect over eye, facilitates easy attachment of

lens to cornea.Ask patient to look straight ahead and retract lower eyelid. Putlens directly over center of cornea.RATIONALE: Evaluates effectiveness of procedure.

125

Instruct patient to close eyes.RATIONALE: Maneuvers lens to proper placement.Make sure that lens is centered over cornea.RATIONALE: Ensures comfort and correct vision.Repeat procedure for other eye. Help patient return to a com-fortable position.RATIONALE: Restores comfort.Properly dispose of soiled supplies. Rinse case and allow to dry.Wash hands.RATIONALE: Reduces transmission of microorganisms.Ask patient how lens feels after removal and reinsertion.RATIONALE: Evaluates effectiveness of procedure.Examine patient's eyes for possible infection.RATIONALE: Provides data for additional nursing intervention.Record and report procedure and observations. RATIONALE: Documentation facilitates communication with other

health team members. Serves as future reference for nursing care.May also serve for legal purposes.

4.8. Making an Occupied Bed

Bed MakingA patient's bed should be kept clean and comfortable at all times. Itis therefore necessary to inspect the bed for cleanliness, dryness andsmoothness. It is also a must for the nurse to check the bed forsoiling for patients suffering from incontinence, draining woundsand diaphoresis.Bed making is usually done in the morning after bathing a patient orwhen the patient is taking a shower. The nurse is expected to keep thebed wrinkle free throughout the day. The bed should also be checkedfor food particles as the patient eats in bed. Soiled linens should be

Hygiene

126


changed as a matter of routine.In changing bed linen, soiled linen should be kept away from thenurses uniform in observance of principles of medical asepsis. Fan-ning linens should never be done as it may cause the spread of mi-croorganisms.Proper body mechanics should be observed during bed making.Raising the bed to its highest position eliminates the need to bend orstretch over the mattress. In applying new linen, the nurse movesback and forth to the bed's opposite sides. Body mechanics is spe-cially important in positioning the patient while in bed.The nurse carries out bed making activities with the patient confinedin bed so as to conserve time and energy. Privacy, safety and com-fort of the patient should be taken into consideration at all times.After making the bed, the nurse should return the bed to its lowesthorizontal position as a measure to prevent the patient from fallingshould he/she move in and out of bed alone.The bed should be made when it is unoccupied as much as possible.The nurse should be decisive in judging whether a patient may bepermitted to sit on a chair while the bed is being made. Basic prin-ciples of occupied bed making is usually followed in making anunoccupied bed.

LinensFor any health institution, an ample supply of linen is important. Foreconomic reasons, excess linens should not be brought into the patient'sroom, doing so would warrant that the linens whether used or notbe discarded for laundering. Bed linen and patient's personal itemsshould be gathered before beginning.This is to give the nurse easy access to all materials required in prepar-ing the bed and the room. To make bed making easier and preventthe spread of microorganisms, bed linens are pressed and folded. Acomplete linen change is not always a necessity, the nurse may opt toreuse the mattress pad, sheet, blanket and bed spread if they are notwet or soiled.To minimize the spread of infection, linen disposal must be done.

127

Guidelines for linen disposal are usually provided by the institution.After patient discharge, all bed linen is sent to the laundry. House-keeping staff are the ones who clean the mattress and bed, afterwhich new linen can be applied.Materials Required

• Linen bag (s)• Mattress pad (if soiled)• Bottom sheet (flat/fitted)• Drawsheet• Top sheet• Blanket• Bedspread• Waterproof pads/bath blankets• Pillowcases• Bedside chair/table• Disposable gloves (optional)

Procedures for Making and Occupied Bed &Rationale

Assess patient for incontinence and check if he/she has any ex-cess drainage on bed linen.RATIONALE: Determines need for protective pads and additional linen.Check orders for specific precautions on positioning of patient.RATIONALE: Protects patient from injury.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Prepare necessary equipment/supplies.RATIONALE: Organizes work environment. Ensures easy access to materials

required.Wash hands.RATIONALE: Reduces transmission of microorganisms.Provide needed privacy.RATIONALE: Reduces patient embarrassment.Position patient flat on bed. Adjust bed height to appropriate

Oxygen SupportChapter Five

5.1. Suctioning

5.2. Care of Clients with Chest Tubes

5.3.[1] Applying a Nasal Cannula

5.3.[2] Using Portable Liquid Oxygen Equipment

5.4. Cardiopulmonary Resuscitation

130


5.1. Suctioning

TechniquesIn cases a patient fails to clear respiratory tract secretions throughcoughing, suctioning is used to clear the airways. There are a varietyof suctioning techniques:Oropharyngeal suctioning / Nasopharyngeal suctioning - The oropharynxextends from the back of the mouth from the soft palate above thehyoid bone's level, it is also where tonsils are contained. The na-sopharynx lies behind the nose extending to the soft palate's level.This type of suctioning is used when the patient is capable of cough-ing but is not capable of expectorating or swallowing. The proce-dure should only be performed after the patient has coughed toreduce patient fatigue.Orotracheal suctioning / Nasotracheal suctioning - This type of suctioningis performed when the patient with pulmonary secretions is unableto clear/expectorate secretions by coughing and when there is noartificial airway present. A catheter is inserted through the mouth ornose into the trachea. The usual preferred route is the nose due to itsminimal stimulation of the gag reflex. It is similar to the nasopharyn-geal suctioning, the only difference is that the catheter tip is movedfarther into the patient's trachea. The whole procedure should bedone quickly (15 secs). The patient should also be allowed to restbetween catheter passes. Oxygen cannula/mask (if present) shouldbe replaced when the patient is resting.Artificial airway suctioning - An artificial airway is used in patients withdecreased consciousness level. It is also used for patients who haveairway obstruction. Its primary function is to remove tracheobron-chial secretions. There are two types of artificial airways:

• Oral airway• Tracheal airway

These techniques are all in common use. Since the oropharynx andthe trachea are considered sterile, sterile technique is used in per-forming the procedure/s. The oropharynx and the trachea shouldbe suctioned first before the suctioning of oral secretions. A rounded-

131

tipped catheter with side holes at the catheter's distal end is used inperforming the procedure. Patient assessment is required in deter-mining the frequency of suctioning. The nurse should monitor thepatient to ensure adequate oxygenation. Suctioning too frequentlycould result in the patient's development of hypoxemia, hypoten-sion, arrythmias and potential trauma to the lungs' mucosa.

Materials needed• Towel• Disposable goggles• Suction kit/catheter• Sterile basin• Sterile saline solution• Water-based lubricant

Procedure for Suctioning & RationaleAssess patient for signs/symptoms of airway obstruction.RATIONALE: Physical signs include RR rate, depth and rhythm changes, skin

discoloration, altered level of consciousness etc.Determine patient's understanding of procedure.RATIONALE: Determines degree/level of health teaching needed by the patient.Obtain physician's order.RATIONALE: Institution may require physician's order for this procedure.Explain to patient the purpose of the procedure and its expectedsensations.RATIONALE: Improves patient's understanding of the procedure and reduces

anxiety.Assist patient to a comfortable position.RATIONALE: Suctioning is uncomfortable, correct positioning minimizes discom-

fort and prevents injury.Place towel across patient's chest.RATIONALE: Prevents soiling of patient's clothes.Wash hands. Wear disposable goggles if splashing is likely to oc-

Oxygen Therapy

132


cur.RATIONALE: Prevents transmission of microorganisms.Connect one end of tubing to suction machine and other end ina location near patient. Turn device on and set vacuum regulatorto appropriate negative pressure.RATIONALE: Hypoxia can occur from excessive negative pressure which may

damage nasopharyngeal and tracheal mucosa.Increase oxygen therapy to 100% or as physician's order. Askpatient to breathe deeply.RATIONALE: Hyperoxygenation prepares patient for O2.Preparation of suction catheter:Use aseptic technique in opening suction kit/catheter.RATIONALE: Prevents transmission of microorganisms into nasopharyngeal

cavities which may cause infection.Open sterile basin and place on bedside table. Fill basin withapproximately 100 ml of sterile normal saline solution/water.RATIONALE: Cleans tubings of secretions without risk of contamination.Open water-based lubricant.RATIONALE: Lubricant prevents lipoid aspiration.Wear sterile disposable gloves.RATIONALE: Reduces transmission of microorganisms.Use dominant hand to pick-up catheter, avoid touching non-sterile surfaces. With non-dominant hand, pick-up connectingtubing Attach catheter to tubing.RATIONALE: Connects suction to catheter while maintaining sterility.Suction small amount of normal saline from basin.RATIONALE: Saline serves as internal catheter lubricant and checks patency of

catheter.Use water-soluble lubricant to coat distal 6 to 8 cm of catheter.For oral suction, do not use lubricant.RATIONALE: Lubricates tip of catheter for easier introduction.

133

Suction airway:Insert catheter at suitable distance for child/adult.Prevents trauma.Nasopharyngeal and nasotracheal:Remove patient's oxygen delivery apparatus (if present). Insertcatheter gently but quickly into patient's naris during inhalation.Insert at a slight downward slant or through mouth. Do notsuction. Position patient's head to left/right and pull catheter back1 cm if resistance is encountered.RATIONALE: Allows introduction of catheter while preventing trauma.Use intermittent suction for about 10-15 secs. Withdraw catheteras you rotate it back and forth in between thumb of dominanthand and forefinger. Patient should be encouraged to cough.RATIONALE: Prevents mucosal injury and cardiopulmonary compromise due to

vagal overload and hypoxemia.Use normal saline or water to rinse catheter and connecting tub-ing until clear.Ensures that catheter is free from obstructing mucous and secretion which

affects suctioning's efficacy.Assess if patient needs additional suctioning. Adequate time shouldbe allowed between suction passes. Have patient take deep breathsand cough.RATIONALE: Observe for cardiopulmonary symptoms of O2 deprivation. En-

courages deep breathing which facilitates alveolar reoxygenationand reventilation.

When secretions have cleared, perform oropharyngeal suctioning.Nose should not be suctioned again after mouth has beensuctioned.RATIONALE: Oral mucosa has more microorganisms than the nares. Removes

upper airway secretions.OROPHARYNGEAL

Insert catheter into mouth of patient along gumline and intopharynx. Move catheter around oral cavity until secretions are

Oxygen Therapy

134


cleared. Coughing should be encouraged. Avoid dislodging anyoral tubing.RATIONALE: Catheter provides deep suctioning, care should therefore be taken.Use water in cup/basin to rinse catheter until connecting tubingis free of secretions. Turn suction off. Wash patient's face if se-cretions are present.RATIONALE: Liberates tube of obstructive secretions while preventing spread of

microorganisms.ENDOTRACHEAL/TRACHEAL TUBE

Before suctioning, patient should be hyperinflated/hyperoxygenated.RATIONALE: Negative pressure may cause atelectaris. Oxygenation prepares

lung for O2 storage.Remove oxygen delivery apparatus. Use thumb and forefingerof dominant hand to insert catheter (avoid applying suction) intoartificial airway until resistance is encountered. Pull catheter back1 cm.RATIONALE: Allows for insertion of catheter.Apply intermittent suction and withdraw catheter slowly as yourotate it back and forth between thumb and forefinger of domi-nant hand. Patient should be encouraged to cough. Caution againstrespiratory distress.RATIONALE: Fingers facilitate insertion pressure.Shut swivel adapter and encourage patient to take deep breaths.RATIONALE: Opens paryngeal orifice for catheter to reach secretion.Use normal saline to rinse catheter and connecting tubing untilclear.RATIONALE: Maintains patency of catheter.Assess patient's cardiopulmonary status.RATIONALE: Evaluates effectiveness of the procedure.Repeat previous steps once or twice more until secretions areclear. Ample time should be allowed between suction passes.

135

RATIONALE: Facilitates reoxygenation.Perform oropharyngeal/nasopharyngeal suctioning. Avoid rein-serting catheter into endotracheal/ tracheostomy tube.RATIONALE: Prevents contamination of passages by microorganisms. Oropha-

ryngeal and nasopharyngeal tube have more microorganisms thanendo/tracheostomy tube, which is considered sterile.

Wind catheter around dominant fingers and pull glove from in-side out so that catheter coil remains inside glove. Pull other gloveover first glove and discard properly. Turn off suction.RATIONALE: Encloses contaminated/used catheter in glove, preventing spread

of microorganisms.Remove towel and properly discard.RATIONALE: Reduces transmission of microorganisms.Readjust oxygen level (if present).RATIONALE: Facilitates sufficient oxygenation.Assist patient to a comfortable position.RATIONALE: Restores patient comfort.Discard remaining saline properly. Clean or replace basin. Re-move and discard disposable goggles. Wash hands.RATIONALE: Reduces transmission of microorganisms.Compare patient's respiratory assessments before and after pro-cedure. Ask patient if breathing is easier. Examine airway secre-tions.RATIONALE: Evaluates effectiveness of procedure.Record and report secretion amount and characteristics, respira-tory status and patient response to procedure.RATIONALE: Documentation facilitates communication with other health team


5.2. Care of Clients with Chest Tubes

Oxygen Therapy

136


PhysiologyThe primary purpose of inserting tubes into the pleural space is todrain any present air or fluids, it is also needed to re-establish intra-pleural and intrapulmonic pressures. A chest tube comes in the formof a catheter which is inserted through the thorax. Chest tubes arealso used after chest surgery and chest trauma for pneumothorax/hemothorax to promote re-expansion of the lungs.A pneumothorax is defined as a collection of air in the pleural space.Loss of negative intrapleural pressure can cause lung collapse. Thesemay come in the form of chest trauma due to stabbing or as theresult of a car accident. A pneumothorax may be caused by therupture of an emphysematous bleb on the lung's surface.Pain is the most common symptom of pneumothorax, this is be-cause atmospheric air irritates the parietal pleura. Dyspnea is a com-mon occurrence which may increase as the pneumothorax size in-creases.A hemothorax on the other hand is blood and fluid accumulation inthe pleural cavity between the parietal and visceral pleurae. This con-dition is usually the result of trauma. Counter-pressure is producedpreventing the lung from full expansion. The rupture of small bloodvessels from inflammatory processes (i.e., pneumonia or tuberculo-sis) may also cause hemothorax. Symptoms include pain and dysp-nea, shock may also be observed in case of severe blood loss.The simplest closed drainage system is the one bottle system. It servesas a collector and a water seal. Fluid ascension is seen during normalrespiration, fluid descends during expiration. This system is used forsmaller drainage amounts (i.e., emphysema).A two-bottle system is commonly employed in the evacuation ofany volume of air/fluid using a controlled suction. The suction-con-trol bottle contains a long tube submerge in water, which is vented tothe atmosphere. There are two short tubes present, with the secondtube connected to a suction tube.There are also disposable systems, these are one-piece units whichare made of plastic. These duplicate the three-bottle system. These

137

units are widely used because of cost-effectiveness and facilitating ofautotransfusion, such as those usually done in open-heart surgeries.The nurse's knowledge of chest tube care and troubleshooting re-duces the patient's risk for complications.

TroubleshootingClamping of chest tubes is not recommended when the patient isbeing transported. The drainage unit/bottles should be handled withcare and the drainage device below the patient's chest should bemaintained. In case the tubing is disconnected from the bottles, thepatient should be instructed to exhale as much as possible. The tipsof the tubing should be cleansed and immediately reattached to thebottles. In case the bottle breaks, the tubing should immediately besubmerged in a container of sterile water.Chest tube removal requires preparation of the patient. Patient shouldbe encouraged to report sensations during removal of tubes. Com-monly observed sensations include:

• Burning• Pain• Pulling sensation

Procedure for Care of Patients with Chest Tubes &Rationale

Assess patient for respiratory distress. Note for chest pain, breathsounds over lung area and vital signs.RATIONALE: Chest tubes are intended to relieve patient of respiratory distress

by reestablishing normal pressures in the intrapleural and intra-pulmonic areas.

Observe patient for any increase in respiratory distress.RATIONALE: Cyanosis, assymetrical lung/chest expansion, changes in the nor-

Oxygen Therapy

138


mal rate, depth and rhythm of respiration are symptoms to beobserved.

The following should also be observed:Dressing of the chest tube.RATIONALE: Excessive soaking with blood and pus and serosanguinous secre-

tions may be observed.Presence of kinks, dependent loops or clots in tubing.RATIONALE: These products obstruct the patency of the tube.Chest drainage system.RATIONALE: Two shrouded hemostats for each tube should be provided. Attach

hemostats to top of bed using adhesive tape.Prevents positive pressure from entering the lungs in case ofaccidental disconnection.Ways of positioning patient:Evacuate air using Semi-Fowler's position. Drain fluid using High-Fowler's position.RATIONALE: Facilitates lung expansion, pushes air off the intrapleural and

intrapulmonic space into the bottle. Air in the lungs rises to high-est point in chest. Tubes are usually inserted in anteriormidclaviculum, 2nd and 3rd intercoastal space.

Connection between chest and drainage tubes should be main-tained. Re-check if it is properly taped in place.RATIONALE: Air leaks causes breaks in airtight system.Coil any excess tubing and place on mattress beside patient. Se-cure it with a rubber band. Adjust tubing to hang from top ofmattress to drainage chamber. Time of drainage start should beindicated. Stripping or milking of tubing should only be done ifso indicated.RATIONALE: Excess tubes may serve as collecting point for drainage products

resulting in patency obstruction.Wash hands.RATIONALE: Reduces transmission of microorganisms.

139

Observe the following:Chest tube dressing, tubing and drainage chamber; water seal forfluctuations; bubbling in water-seal bottle/chamber; fluid drain-age type and amount; vital signs and skin color of patient; bub-bling in suction-control chamber.Record/report chest tubes, dressing status and patient responses.RATIONALE: Documentation facilitates communication with other health team


5.3. Applying a Nasal Cannula

Oxygen Maintenance and PromotionIn meeting oxygenation needs, lung function promotion, secretionmobilization and patent airway maintenance is required. Oxygen-ation however is not confined to these situations, oxygen therapymay also be used in maintaining a healthy level of tissue oxygenation.

Goals of Oxygen TherapyThe primary goal of oxygen therapy is the prevention or provisionof relief of hypoxia. Controlled oxygen administration may benefitany patient who impaired tissue oxygenation. With all its therapeuticeffects, oxygen however can not be used as a substitute for othertreatment forms. It should also be only used when indicated. Oxy-gen being synonymous as any drug, should be treated as such. This iswhy oxygen dosage should be monitored at all times. Routine checkof prescriber's orders should also be performed so as to verify thatthe patient is receiving the accurate oxygen concentration.

Safety PrecautionsSince oxygen is a highly combustible gas, care should be taken toavoid igniting fire in a patient's room. In high concentrations, oxygencan readily fuel a fire. The following measures should be observed inthe promotion of safety:Placing of "no smoking" signs on the patient's room. Inform visi-tors and other people that smoking is not allowed inside the room.Determine that all electrical equipment/apparatus are in good order.

Oxygen Therapy

140


Fire procedures and exits should be studied and committed tomemory. Perform routine checks of oxygen levels in portable tanksfor transport.

Procedure for Applying a Nasal Cannula &Rationale

Assess respiratory status of patient.RATIONALE: Cardiac dysrhythmias and death may result from hypoxia if left

untreated. Effectiveness of oxygen therapy is decreased by presenceof airway secretions.

Explain to patient and family the nature and purpose of theprocedure.RATIONALE: Improves patient’s understanding of procedure. Reduces anxiety

and promotes cooperation.Prepare necessary equipment/supplies.RATIONALE: Organizes working environment. Provides nurse with easy access

to materials needed.Wash hands.RATIONALE: Reduces transmission of microorganisms.Connect nasal cannula to source of humidified oxygen.RATIONALE: Humidifier lubricates and moisturizes air passages.Adjust oxygen flow to prescribed rate.RATIONALE: Oxygen should not be given in excess of prescription. In some

conditions, too much oxygen may be harmful.Attach cannula's tips to nares.RATIONALE: Tip to nares is the route of oxygenation.Adjust band until cannula fits snugly. Ask patient of any discom-fort.RATIONALE: Cannula can be kept in place if it’s not too tight and patient is

comfortable despite pressure.Secure tubing to patient's clothes.RATIONALE: Prevents dislodging of cannula and facilitates head movement.

141

Cannula should be checked every 8 hrs.RATIONALE: Prevents inhalation of dehumidified O2. Ensures tube patency

and O2 flow.Humidification jar should be kept filled at all times.RATIONALE: Ensures sufficient moisture in the nares. Prevents tissue break-

down and patient discomfort.Check physician orders and oxygen flow rate every 8 hrs.RATIONALE: Patency and prescription of oxygen must be monitored to prevent

physiological damage.Wash hands.RATIONALE: Reduces transmission of microorganisms.Assess if patient is experiencing relief.RATIONALE: Evaluates the effectiveness of the procedure.Record procedure and pertinent observations. Report therapyand patient's response.RATIONALE: Documentation facilitates communication with other health team

members. Serves as future reference for nursing care. May also servefor legal purposes.

5.4. Using Portable Oxygen Equipment

Oxygen SupplyThe patient can be supplied with oxygen either through oxygen tanksor a permanent wall pipe system. Regulators are used to control theamount of oxygen delivered. Portable oxygen tanks may also beused in situations where home care is permitted.

Oxygen Delivery MethodsOxygen may be delivered through the following methods:

• Nasal cannula• Nasal catheter

Oxygen Therapy

142


• Transtracheal Oxygen• Oxygen mask

Procedure in Using Portable Liquid OxygenEquipment & Rationale

Examine patient's need for equipment.RATIONALE: Conditions such as RHF, cor pulmonale or polycythemia need

home oxygen. Food candidates are those with PaO2 <55 mm Hgor O2sat = 88% on room air, PaO2 of 55 to 59 mm Hg orO2sat of 86%--89%.

Give procedure details to patient and family.RATIONALE: Improves patient’s knowledge of procedure. Reduces anxiety and

promotes cooperations.Set up equipment.RATIONALE: Organizes working environment, provides easy access to materials

needed and saves time.Wash hands.RATIONALE: Reduces transmission of microorganisms.Explain steps for oxygen therapy.RATIONALE: Teaches patient psychomotor skills.Set up primary and portable oxygen.RATIONALE: Portable oxygen replaces bulgy compressed oxygen cylinders.Request patient or family to do every step with guidance.RATIONALE: Provides opportunity for correction of errors in technique, and

discussion of implications.Explain to family signs and symptoms of hypoxia and respira-tory tract infection. Order patient and family to inform physicianwhen signs or symptoms of respiratory infection or hypoxiaoccurs.RATIONALE: Educates family on possible emergency conditions that may arise.Wash hands.RATIONALE: Reduces transmission of microorganisms.

143

Document teaching, provided information and patient/family'scomprehension.RATIONALE: Documentation facilitates communication with other health team


5.5. Cardiopulmonary Resuscitation (CPR)

RationaleCardiac arrest is associated with the absence of pulse and respiration.In a situation when the nurse determines that the patient has suffereda cardiac arrest, the initiation of cardiopulmonary resuscitation (CPR)is needed. CPR is a basic emergency procedure which provides arti-ficial respiration and manual external cardiac massage.The following are the “ABCs” of CPR:

• Airway establishment• Breathing initiation• Circulation maintenance

Re-assessment of proper head position is required in the perfor-mance of this procedure. The patient's airway must also be checkedfor possible obstruction. It must be noted that CPR will not benefitthe patient if the airway is blocked. The primary objective in per-forming CPR is to have oxygenated blood circulate to the patient'sbrain, thus preventing tissue damage.

Procedures in Cardiopulmonary Resuscitation(CPR) & Rationale

Examine victim for unresponsiveness.RATIONALE: Confirms patient’s level of consciousness.Call emergency service (police, hospital, etc.).RATIONALE: Antidysrhythmic drugs are often needed by most adult victims

who are in ventricular fibrillation and need defibrillation.Assess breathlessness of victim and carotid (adult)/brachial pulse(children).RATIONALE: CPR is contraindicated to (+) pulse and (+) RR.

Intravenous TherapyChapter Six

6.1. Peripheral IV Infusion Initiation

6.2. IV Flow Rate Initiation

6.3. Changing IV Solution & Infusion Tubing

6.4. Changing Peripheral IV Dressing

146


6.1. Initiating Peripheral IV Infusion

Anatomy and PhysiologyFluid, electrolyte and acid-base balances within the body are important inmaintaining health and function of all body systems. Water and elec-trolytes intake and output as well as regulation by the renal and pul-monary systems maintain these balances. Since acid-base balance iscrucial for numerous physiological processes, imbalances can resultin the alteration of respiration, metabolism and function of the cen-tral nervous system.Body fluid (water and electrolytes) makes up approximately 60% ofa typical adult’s weight. It is located in two compartments. The first,the intracellular space or fluid in the cells, represents around two-thirds of entire body fluid and is primarily located in the skeletalmuscle mass. The other one, the extracellular space or fluid outsidethe cells, is divided into three fluid spaces: the transcellular fluids,which are secreted to cushion, protect, and nourish body organs, theintravascular fluids, which are located in the blood vessels, and inter-stitial fluids which surround the cell.

Composition of Body FluidsWater, as it moves through the various compartments of the body,contains electrolytes—or substances that like minerals or salts. Whenmelted or dissolved in water or another solvent, an electrolyte is acompound or an element that separates into ions and is capable ofcarrying an electrical charge. Negatively-charged electrolytes are calledanions, while positively-charged ones are called cations.Electrolytes are crucial to many bodily functions. The value ‘mEq/L,’or milliequivalents per liter, corresponds to the number of grams ofthe particular electrolyte (solute) dissolved in one liter of plasma (so-lution). A solvent is the solution in which the solute is dissolved.Minerals, which are ingested into the body as compounds, are typi-cally called by the name of the phosphate, metal, nonmetal or radicalinstead of the name of the compound to which they belong. Theyare constituents of all body fluids and tissues. Crucial in maintaining

147

Intravenous Therapy

physiological processes, minerals can also function as catalysts in nerveresponse, metabolism of nutrients and muscle contraction. They alsostrengthen skeletal structures as well as regulate hormone productionand electrolyte balance.Solutions are classified either as hypotonic or hypertonic isotonic. Anisotonic solution is one with similar osmolarity as blood plasma. Ahypotonic solution is one with higher osmotic pressure that pullsfluid from cells, while an isotonic solution is one with equal osmoticpressure that expands the fluid volume without causing a fluid shiftfrom one compartment to another. A hypotonic solution is a solu-tion with lower osmotic pressure that causes fluid to move into cells,causing them to enlarge.

Movement of Body FluidsFluids and electrolytes continuously shift from one compartment toanother to facilitate several bodily processes like urine formation,acid-base balance and tissue oxygenation. Since cell membranes thatseparate the body fluid compartments are selectively permeable, watercan pass through them effortlessly. On the other hand, most mol-ecules and ions pass through them relatively slower. Solutes and flu-ids move across these membranes following four process, namely,active transport, filtration, diffusion and osmosis.Osmosis is a process that involves the transfer of a pure solvent (suchas water) through a semi-permeable membrane from an area oflower solute concentration to an area of higher solute concentration.The membrane is impermeable to the solute but is permeable to thesolvent. A solution’s concentration is measured in osmols, which in-dicate the amount of a substance in a solution in the form of ions,molecules or both. Water’s drawing power is called osmotic pressureand such is dependent on the number of molecules in a solution.Osmolarity refers to the osmotic pressure of a solution and this isexpressed in osmols or milliosmols per kilogram (mOsm/kg) ofthe solution. Plasma proteins affect the osmotic pressure of the blood,particularly albumin—a serum protein produced naturally by the body.Albumin causes colloid osmotic or oncotic pressure, which tends tomaintain fluids in the intravascular compartment. At the venous endof the capillaries, this oncotic pressure together with decreased venous

148


hydrostatic pressure draw water and waste products back into thecapillaries to be filtered by the kidneys.Diffusion is the movement of a solute, either substance or gas, in asolution from an area of higher concentration across a semiperme-able membrane to an area of lower concentration, this results in aneven distribution of the solute in a solution. Concentration agent isthe difference between the two areas of concentration.The process by which water and diffusible substances move togetherin response to fluid pressure is called filtration. This process is activespecifically in capillary beds where differences in hydrostatic pressuredetermine water movement.Metabolic activity and use of energy to move materials across cellmembranes are required for active transport. This process allows cellsto take in larger molecules than their normal capacity. Active transportis facilitated by carrier molecules inside a cell that combine them-selves with incoming molecules.

Regulation of Body FluidsFluid intake, hormonal controls and fluid output regulate body flu-ids. Homeostasis is the physiological balance of fluids.Primarily, fluid intake is regulated through the thirst mechanism, whosecontrol is located in the hypothalamus of the brain. The serum os-motic pressure is constantly monitored by osmoreceptors. Whenosmolality increases, there is an stimulation in the hypothalamus. Theaverage daily fluid intake of an adult is around 2200 to 2700 ml—daily oral intake accounts for 1100 to 1400 ml, daily solid foodsintake around 800 to 1000 ml and daily oxidative metabolism, whichis the by-product of cellular metabolism of ingested solid foods, is300 ml.Aided by various body hormones that control metabolic processesof the body, hormonal regulation follows a number of mechanisms.For one, antidiuretic hormone (ADH), stored in the posterior pitu-itary gland, is released in response to alterations in blood osmolarity.Stimulation of osmoreceptors in the hypothalamus occurs when thereis an increase in the osmolarity to release the hormone, working di-

149

rectly on the renal tubules and collecting ducts to make them morepermeable to water. In turn, this causes water to return to systemiccirculation to dilute the blood and lower its osmolarity.The adrenal cortex releases aldosterone to respond to increased plasmapotassium levels or as part of the renin-angiotensin-aldosteronemechanism to fight hypovolemia. Aldosterone acts on the distal por-tion of the renal tubule to increase the secretion and excretion ofpotassium and hydrogen and reabsorption of sodium. Since sodiumretention results in water retention, aldosterone release functions asvolume regulator. Secreted by the kidneys, renin is a preolytic enzymethat responds to decreased renal perfusion secondary to a decreasein extracellular volume. It acts to produce angiotensin I which causesvasoconstriction. On the other hand, angiotensin I is typically reducedimmediately by an enzyme that converts it into angiotensin II whichcauses massive selective vasoconstriction of numerous blood vesselsand relocates and increases blood flow to the kidneys, improvingrenal perfusion. When sodium concentration is low, angiotensin IIstimulates the release of aldosterone.Regulation of fluid output or water loss happens through four or-gans: kidneys, skin, lungs and the gastrointestinal tract. The kidneysare the major regulatory organs of fluid balance, receiving around180 L of plasma to filter daily and producing 1200 to 1500 ml ofurine per day. Water loss via the skin is regulated by the sympatheticnervous system that activates the body’s sweat glands. Either sensibleor insensible loss, water loss from the skin averages between 500 to600 ml per day. The lungs expire around 400 ml of fluid daily. Lastly,the GI tract has a key function in fluid regulation as around 3 to 6 Lof isotonic fluid is transported into the GI tract and returned to theextracellular fluid. Normally, an average adult looses approximately100 to 200 ml of the 3 to 6 L of isotonic fluid per day via the feces.

Physical AssessmentA thorough assessment of the patient is vital since fluid and electro-lyte imbalances of acid-base disturbances can impact all body sys-tems. While assessing each system, the nurse carefully considers thepotential signs and symptoms as a result of any imbalance. Signs andsymptoms of imbalances are identified by physical assessment. Such

Intravenous Therapy

150


manifestations may be marked, minimal or even absent. It was sug-gested that specific assessment parameters must be taken into ac-count when assessing a patient for disorders in fluid, electrolyte andacid-base balance. These include intake and output (I&O), urine vol-ume and concentration, skin signs such as turgor, temperature andmoisture, body weight, objective measures of fluid loss such as tear-ing and salivation, subjective complaints of thirst, edema, neuromus-cular signs and cardio-pulmonary signs such as respirations, heartrhythm, central venous pressure, neck veins or external jugular veindistention, blood pressure (supine and upright to check for orthos-tatic changes) and pulse. Other parameters include sensations, behav-ioral changes, gastrointestinal functions and unusual odors.Measuring Fluid Intake and Output. The Fluid Balance Recordis a documentation of a person’s fluid intake (either oral, which in-cludes all liquid and semi-liquid materials ingested through the mouth,parenteral or via gavage or tube feedings) and fluid output (all liquidsexcreted from the body like urine, stool, GI/nasal suction drainage,wound drainage, vomit and sweat). The Fluid Balance Record assistsin diagnosing and anticipating imbalances; it also helps in measuringfluid replacement requirements. I&O is a tool for documenting alltypes of intake and output. When hospitalized, a patient’s I&O mea-surements are needed in monitoring fluid balance. However, accu-rate I&O measurements can only be achieved through patient’s andsignificant other’s assistance and cooperation.Urine Volume. The normal urine output in adult is between 1-2 Lper day. Urine output will either increase or decrease depending onan individual’s intake and the amount of insensible loss. In most clini-cal settings, baseline urine output is approximately 30 mL per hour.Urine Concentration. Specific gravity is used to measure urine con-centration. It is inversely related to urine volume—the higher volumeof urine, the lower the specific gravity and vice versa. However,specific gravity is not a very dependable indicator of concentrationcompared to urine osmolality since an increase in protein or glucosecontent in urine can result in a false high specific gravity. Factors thataffect the decrease or increase in urine specific gravity are the samefor urine osmolality. Normal specific gravity ranges from 1.003 to

151

1.030. When diluted, specific gravity is between 1.001 and 1.030;when concentrated, it is between 1.003 and 1.040. Urine pH is thehydrogen ion concentration of the urine. It is a measurement of theacid or alkaline content of urine. One of the mechanisms that main-tain normal acid-base balance of the body is the kidney’s secretionof acidic or alkaline urine. Urine pH ranges between 4.6 to 8.0, withan average of 6.0. The normal urine osmolality is dependent onseveral clinical parameters although the acceptable range is between50 to 1400 mOsm/kg.Skin Turgor. Skin turgor (firmness, elasticity, tonicity, etc.) shows thehydration status of a person. Skin with normal turgor can be easilymoved when lifted and immediately goes back to its prior position.As a person ages, the skin tend to lessen its turgor. Thus, when theskin of an elderly patient is pinched, it tends to remain elevated whenlifted (or ‘tents’) and returns relatively slower compared to youngerones.Tongue Turgor and Mucous Membrane Moisture. The tongueis normally is smooth underneath and is covered with papillae on thedorsum. Patients with normal hydration have moist tongue and oralcavity, without evidence of cracks or fissures on the surface, andwith smooth and intact lips.Body Weight. Several factors affect the total body weight (TBW)of a patient. These are sex, height, bone structure and fluid status.Approximately 20% of a person’s TBW is extracellular fluid (ECF),while around 40% is intracellular fluid (ICF). One liter of body fluidis almost equal to 1 kg of TBW. Thus, a gain or loss of 1 kg in TBWis equal to around 1 L of ICF and ECF gain or loss. In a healthyadult, TBW must remain unaltered. But for patients with third-spaceshifting, a gain in weight is possible in spite of FVD in the intravascu-lar space.Thirst. Located in the hypothalamus is the thirst center.Osmoreceptors contract to stimulate thirst and increase oral intake asfluid is lost. While hydration stabilizes, the osmoreceptors’ water con-tent increases, making the thirst response disappear.Tearing and Salivation. Tears are produced by the body to lubri-

Intravenous Therapy

152


cate the eyes to protect them from abrasions. The eyes must remainmoist for them to be healthy. The lacrimal gland produces a person’stears, it is located under the outer one-third of the upper eyelid. Forevery blink of an eye, the eyelid spreads the tears over the eye’s sur-face and pumps tears into the lacrimal duct that drains the tears intothe nose. This is the reason why a person’s nose runs when he/shecries. Salivation is stimulated by factors such as smells, thoughts orthe actual presence of food. Salivation is used by the body to lubri-cate food to facilitate its movement into the GI tract.Temperature. The main function of the skin is to control tempera-ture. As the body cools down, blood capillaries widen (vasodilation)to transport more blood near the skin surface. The main function ofthe skin is temperature regulation. When the body cools down, theblood capillaries widen (called vasodilation) to transfer more bloodnear the skin surface to enable heat loss into the surroundings viaradiation and convection. During this process, sweat is produced,which as it evaporates, has a cooling effect on the body while hairs lieflat to allow warm air to escape faster. On the other hand, as thebody warms up, blood capillaries in the skin become narrower (vaso-constriction) to lessen heat loss, decrease sweating (also to lessen lossof heat), and hairs become erect to trap air to prevent warm airfrom escaping fast.Edema. Edema is an abnormal hydration status. Skin is normallypliant with good elasticity, without the presence of swelling. Edemais a disposal of fluid into the interstitial tissue. It is a type of abnor-mal fluid retention in the body.Pulse and Heart Rhythm. The normal pulse is regular and strong.A normal heart rate is approximately 60 to 100 beats per minute.Respiration. The normal respiratory rate is around 12 to 20 breathsper minute. The normal respiratory pattern is regular with bilateralchest expansion. Lung sounds are clear to auscultation.Neck Vein and Central Venous Pressure (CVP). Since CVP isthe pressure in the large vein near the right atrium of the heart, thedetermination of the CVP offers a direct measurement of the alter-ations in pressure of blood going back to the heart. As fluids shifttoward the upper body, pressure in the veins close to the heart mustincrease, resulting in increased central pressure. As upper body fluidflow normalizes or decreases, a corresponding normalization or

Electrolytes

Sodium (Na+)Potassium (K+)Calcium (Ca++)Bicarbonate (HCO3-)Chloride (Cl-)Magnesium (Mg++)Phosphate (PO43-)

Extracellular (mEq/L)

135 - 1543.5 - 5

4.5 - 5.525 - 27

98 - 1064.5 - 5.51.7 - 4.6

Intracellular (mEq/L)

15 – 20150 – 155

1 – 210 – 12

1 – 427 – 29

100 – 104

Acid-Base BalanceArterial blood gases (ABGs): Normal ABGs (values may vary slightlywithin institutions):

pH - 7.35-7.45PaCO2 - 35-45 mm HgPaO2 - 80-100 mm HgSaO2 94%-98%

Arterial blood gases measure arterial blood pH, pressure of O2 andCO2 and arterial O2 saturation, which reflects patient's oxygenationstatus.

Pulse oximetry (SpO2): Acceptable SpO2 90%-100%; 85%-89%may be acceptable for certain chronic disease conditions; lessthan 85% is abnormal.

153

SpO2 less than 85% is often accompanied by changes in respiratoryrate, depth and rhythm.

Base Excess: +2

Blood Chemistry and StudiesComplete blood count (CBC):Normal CBC for adults (values may vary within institutions):

Hemoglobin: 14 to 18 g/100 ml, males: 12 to 16 g/100 ml, females.Hematocrit: 40% to 54%, males; 38% to 47%, females.Red blood cell count: 4.6 to 6.2 million/ ul, males; 4.2 to 5.4

million/ ul females.Complete blood count measures red cell count, volume of red bloodcells, and concentration of hemoglobin, which reflects patient's ca-pacity to carry O2.

Creatinine - 0.5 - 1.2 mg/100 mlBlood Urea Nitrogen - 10 - 25 mg/100 mlUrine specific gravity - 1.010 - 1.025

Intravenous Fluid TherapyIV fluid therapy or replacement is the administration of fluid solu-tion in the body that enables direct access to the vascular systempermitting the infusion of continuous fluids over a period of timeto correct or prevent fluid and electrolyte disturbances.When the physician orders IV administration, the nurse must knowthe following: the correct ordered solution, the needed equipment,the required procedures to initiate infusion, technique in regulatinginfusion rate and maintaining the system, method in identifying andcorrecting problems and the procedure to discontinue the infusion ifnecessary.

Purpose of Intravenous Fluid TherapyEach type of IV solution has its own specific purpose. In general, IVfluids are administered to:

Provide water, electrolytes, and nutrients to meet dailyrequirements

Intravenous Therapy

154


Replace water and correct electrolyte deficits; and/or, Provide a medium for intravenous administration of medicationsand parenteral nutrition.

Intravenous Fluid Therapy SolutionsThere are three categories of IV solutions, namely: hypotonic, hyper-tonic and isotonic solutions.Hypotonic solutions are those that have an effective osmolality lowerthan the body fluids. Hypertonic solutions are those that have aneffective osmolality higher that body fluids. Isotonic solutions arethose that have similar effective osmolality like those of body fluids.Generally, isotonic fluids are commonly used for extracellular vol-ume replacement. The decision to use what type of IV solution de-pends on the specific fluid and electrolyte imbalance.

Types of Intravenous Solutions

Solutions

Dextrose in Water SolutionsDextrose 5% in Water1

Dextrose 10% in Water

Saline Solutions0.45% Sodium Chloride (half normal saline)0.9% Sodium Chloride (normal saline) 2

3%-5% Sodium Chloride

Dextrose in Saline SolutionsDextrose 5% in 0.9% Sodium Chloride

Dextrose 5% in 0.45% Sodium Chloride

Multiple Electrolyte SolutionsLactated Ringer’s3

Dextrose 5% in Lactated Ringer’s

Concentration

IsotonicHypertonic

HypotonicIsotonicHypertonic

Hypertonic

Hypertonic

Isotonic

Other Names

D5 WD10 W

0.45% NS0.45% NaClPNSS3%-5% NS3%-5% NaCl

D5 0.9% NaClD5 0.9% NSD5 NSSD5 0.45% NaClD5 0.45% NS

PLR or Plain LRD5 LR

1 Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluidcompartments. 2 Although it is an isotonic because the total concentration of electrolytesequals the plasma concentration, it contains 154 mEq of both sodium and chloride which isa higher concentration of these electrolytes than in plasma. 3 Contains sodium, potassium,calcium, chloride and lactate. 4 Plain Normal Saline Solution

155

Types and Uses of Intravenous FluidsSolution

D5W - 5% Dextrosein water

D10W - 10%Dextrose in water



D5 1/4 NS - 5%Dextrose & 0.2NaCl

D5 1/2 NS - 5%Dextrose & 0.45NaCl

D5NS - 5% Dextrose& 0.9 NaCl

D10NS - 10%Dextrose & 0.9NaCl

1/2 NS - 0.45%NaCl

Osmolality

isotonic (252 mOsm/L)

hypertonic (505mOsm/L)







hypotonic (154 mOsm/L)

Usage and Limitations

Provides free water (hypotonic)to the extracellular andintracellular spaces, as thedextrose is quickly metabolized;promotes renal elimination ofsolutes; treats hypernatremia;does not provide electrolytes;one liter is 170 calories

Osmotic diuretic; provides freewater and 340 calories per liter,but no electrolytes; hypertonicsolutions may irritate the veins

Osmotic diuretic; providescalories, but no electrolytes;solutions containing more than10% dextrose must be infused ina central line

Osmotic diuretic; providescalories, but no electrolytes

For daily maintenance of bodyfluids when Cl and Na arerequired; treats hypernatremia;replaces hypotonic losses; 170calories pre liter

To promote renal function andexcretion; basically the same as.45NS except provides 170calories per liter

To treat fluid volume deficit; fordaily maintenance of body fluidsand nutrition; basically the sameas NS, except provides 170calories per liter

To replace calories, fluid, sodiumand chloride

Assists with renal function;provides free water, Na and Cl.;replaces normal hypotonic dailyfluid losses- assists with daily

Intravenous Therapy

156


NS - 0.9% NaCl

3%NS

Ringer's Solution

Lactated Ringer'sSolution

D5LR - 5% Dextrosein Lactated Ringers

D10LR - 10%Dextrose inLactated Ringers

10% Dextran 40 in5% Dextrose

10% Dextran 40 in0.9%NS

5% Alcohol in 5%Dextrose

isotonic (308mOsm/L)




hypertonic (524 mOsm/L)





body fluid needs, but not withelectrolyte replacement orprovision of calories.

Replaces NaCl deficit andrestores/expands extracellularfluid volume; the only solutionthat may be administered withblood products--does notprovide free water that causeshemolysis of red blood cells

Raises Na osmolality in the blood;removes excess intracellularfluid; infuse slowly; monitor forpulmonary edema and intravas-cular volume overload

Replaces K, Na, Cl. and Ca.; doesnot contain lactate, which canbe harmful to those who areunable to metabolize lactic acid;does not provide free water

Closely resemble the electrolytecomposition of normal bloodserum and plasma; will needadditional K; does not providecalories or free water; used totreat losses from lower GI tractand burns.

Same as Lactated Ringers, pluscalories

Same as Lactated Ringers, plusextra calories

Plasma expander

Plasma expander

Depressant diuretic effects,provides calories

Solution Osmolality Usage and Limitations

157

Solution Osmolality Usage and Limitations

8% Amino Acids

Intralipids 10%

Intralipids 20%


isotonic (280-300mOsm/L)

isotonic (330 - 340mOsm/L

Provides protein in varyingpercentages; assists with tissuerepair and to correct negativenitrogen balance

Provides fatty acids and calories

Provides calories and fattyacids; contraindicated inpatients with liver damage oraltered fat metabolism

Factors Affecting VenipunctureVenipuncture is the ability to gain access to the venous system foradministering fluids and medications. Factors that influence venipunc-ture include:

• Condition of the vein• Type of fluid / medication to be infused• Duration of therapy• Patient's age and size• Patient's medical history and current health status• Skill of the health provider.

Assessment SitesDesignated as peripheral locations, veins of the extremities are thepreferred assessment sites for they are relatively safe and easy to en-ter, particularly the upper extremities, which are most commonlyused sites. These include medial antebrachial veins, cephalic veins,median cubital, metacarpal veins, digital veins, and basilic veins.Under extreme situations and only with a physician's order shouldone use leg veins as assessment sites due to the high risk of throm-boembolism. One should also refrain from using veins proximal toprevious IV infiltration or phlebitic sites as well as thrombosed orsclerosed veins. Arms affected by edema, fracture, infection, bloodclot, skin breakdown or operative site or those with an arteriovenous

Intravenous Therapy

158


shunt or fistula must be avoided.The arms on the side of a mastectomy must also be avoided. Finally,always administer venipuncture on other side of the affected site dueto impaired venous return, such that if the affected site is at the left,venipuncture must be done on the right and vice-versa.Central veins normally utilized by physicians as venipuncture sitesinclude internal jugular and subclavian veins. Despite the collapse ofperipheral sites, it is possible to access or cannulate these larger ves-sels; they actually allow administration of high osmolar solutions.However, hazards are greater when using these sites, including theinadvertent entry into an artery or dipleural space.Prior to venipuncture site selection, it is ideal that both hands andarms be thoroughly inspected. Allocation must be made if it doesnot impede mobility, thus the antecubal fossa is always the last op-tion. Generally, the most distal area of the hand or arm is selectedfirst to allow subsequent IVs to move upward progressively.Generally speaking, it is better to try to cannulate the most distal veinsfirst. If for example, the antecubital veins are ruined as a result offailed cannulation attempts this can cause problems in the event of asuccessful cannulation further down. Any drugs or fluids put throughthe cannula may extravasate at the failed cannula site.The cephalic vein is one of the best veins available. That's why it'salso known as the 'Housemans' vein (a Houseman is a very juniordoctor in the UK). It tends to be large, and the forearm provides anatural splint. If you place the cannula too far distally along the vein,you can run into problems with the wrist joint, and are getting closeto the radial nerve. Also the tendons that control the thumb canobscure the vein. These problems can usually be avoided by movinga little further proximally along the vein.The basilic vein is often overlooked, hiding as it does along the ulnarborder of the hand and forearm. On the plus side, it's often fairlylarge - on the minus side it can roll like a tanker in a rough sea and canhave more valves than a submarine.The dorsal veins are typically manageable as the metacarpals splintcannulae well (Weinstein, 1997), but they can be quite small. If the

159

patient is elderly, look elsewhere. The lack of turgor in the skin andloss of subcutaneous tissue make it quite difficult to cannulate theseveins in oldler individuals.Cannulation of the antecubital veins can also cause problems as thecannula may occlude as the patient bends his/her arm.Avoid, if you can, areas where cannulation or venipuncture has pre-viously taken place. Repeated puncture of the vein wall can resultand is painful.In general, locate the vein section with the straightest appearance.Choose a vein that has a firm, round appearance or feel when pal-pated. Avoid areas where the vein crosses over joints.If the IV treatment is for a life-threatening illness or injury, yourchoice may be limited to an area that remains open duringhypoperfusion. Otherwise, limit IV access to the more distal areas ofthe extremities.Dorsal digital veins. Flow along lateral portion of fingers and are joinedto each other by communicating branches Available for IVs accom-modating a small gauge IV catheter (22 or 24 gauge). Need to beproperly supported with a tongue blade or hand board. Usually notvery stable and not a primary site choice.Metacarpal veins. Formed by union of digital veins (dorsal venousarea). Ideal position for IV use - primary choice IVs. Venipunctureshould be started at the most distal point on the extremity. Propersupport is needed after IV infusion is initiated to prevent movementof IV catheter. Veins are thin with inadequate tissue and muscle sup-port in the elderly.Cephalic vein. Flows upward along the radial border of the forearmproducing branches to both surfaces of the forearm Because oftheir size and location, they provide an excellent site for IV infusion,readily accommodates large gauge IV catheters and is available forvenipuncture in the upper arm region.Accessory cephalic vein. Originates from either a plexus on the back of

Intravenous Therapy

160


the forearm or dorsal venous network, branches off from the cephalicvein just above the wrist and flows back into the main cephalic veinat a higher point, and readily accommodates large gauge IV cath-eters.Basilic vein. Originates in the ulnar portion of the dorsal venous net-work. Ascends along the ulnar portion of the forearm. It curvestoward the anterior surface of the arm just below the elbow. It meetswith the median cubital vein below the elbow. Is available for veni-puncture above the antecubital fossa in the upper arm region. Oftenoverlooked because of its inconspicuous position.Median antebrachial vein. Arises from the venous plexus on the handand extends along the ulnar side on the anterior surface of the fore-arm. It empties into the basilic vein or median cubital vein. It is notalways easily seen.Median cephalic and median basilic veins. Located in the antecubital fossa.It should be a last resort site for blood draws and is not a favorablesite for prolonged infusions.

Infusion SetTubing with a spike and roller clamp at the proximal end, a spikeadapter at the distal end and a graduated burette in the centre. Bu-rette possesses an air inlet and injection port on its proximal end andmay contain a ball valve at the base.

An infusion set is used to deliver a fixed volume of IV fluid at a fixedrate, usually with added medication. A primary IV solution set isattached to the spike adaptor at the distal end of the in-line buretteset. Clamps on both sets are closed while the spike of the in-lineburette is inserted into a fluid container. A small amount of fluid(depending on size) is released into the burette and the primary IVsolution set below is primed. The burette is filled to the desired leveland the clamp closed. Medication is added to the fluid via the injec-tion port on the burette if desired. The primary set is opened and thedrip rate adjusted to normal. Fluid flow will stop when the burette isempty. The use of a burette allows fine control of fluid volume andavoids inadvertant over-transfusion. A solution burette (incorporat-ing a primary solution set and a burette) is preferred to this devicedue to infection risks. Infusion sets are individually wrapped in a peelpouch with sizes required of 150ml burette (most common).

IV needles and cathetersSteel Needles. Example: Butterfly catheter. They are named after thewing-like plastic tabs at the base of the needle. They are used todeliver small quantities of medicines, to deliver fluids via the scalpveins in infants, and sometimes to draw blood samples (although notroutinely, since the small diameter may damage blood cells). Theseare small gauge needles (i.e. 23 gauge).Over the Needle Catheters. Example: peripheral IV catheter. This is thekind of catheter most commonly used.Inside the Needle Catheters. Example: midline and extended dwell cath-eters. Catheters (and needles) are sized by their diameter, which is

161

called the gauge. The smaller the diameter, the larger the gauge. There-fore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obvi-ously, the greater the diameter, the more fluid can be delivered. Todeliver large amounts of fluid, you should select a large vein and usea 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

Materials Required• IV stand• IV fluids as ordered• IV tubings• IV connection tube or extension tube (if needed)• IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) -

the greater the gauge the smaller the needle cannula and vice-versa.

• Band-aid tape• Micropore tape

Procedure for Initiating Peripheral IV InfusionAssess the medical record of the patient, following the 'five rights'of medication administration.RATIONALE: This procedure is an interdependent nursing procedure which

needs physicians order before initiation. Ensures avoidance ofmedication errors.

Monitor for sign and symptoms of electrolyte or fluid imbal-ances.RATIONALE: Ensures accuracy of fluid to be transfused and provides baseline

data for care management.Evaluate previous experience of patient with intravenous therapy.RATIONALE: Provides baseline data for client education regarding the proce-

dure.Check physician's order for blood transfusion or surgery.RATIONALE: IV catheter size must always be considered for BT which requires

bigger gauges of needle such as 18 and 20.

Intravenous Therapy

162


Evaluate patient's laboratory data and allergies (if any).RATIONALE: Some of the materials needed for IV insertion may cause allergies

such as iodine adhesive or latex which have available substitutes inthe Central Supply Room.

Examine patient for risk factors.RATIONALE: Conditions such as renal failure and CHF may need strict IVF

regulation and microset use may be required for they cannot adaptto sudden circulating volume elevation.

Give details of procedures to patient. Help patient assume acomfortable lying or sitting position.RATIONALE: Reduces anxiety and enhances cooperation.Wash hands.RATIONALE: Reduces transmission of microorganisms.Arrange equipment to be used on overbed table or bedside stand.RATIONALE: Provides easy accessibility, maintains sterile field and saves time.If possible, change gown of patient to an easily removable one.RATIONALE: Avoids accidental removal during hygienic measures such as changing

of gown.Observe sterile technique at all times. Open sterile packages.RATIONALE: Maintains sterility of equipment minimizes if not prevents trans-

mission of organisms which may cause infection.Inspect IV solution. Ensure prescribed additives (e.g., vitamins,potassium) have been included. Inspect solution for expirationdate, clarity, and color. Inspect if bag has leaks.RATIONALE: Ensures accuracy of administration and absence of medication

errors.Open infusion set. Put roller clamp around 2-4 cm under dripchamber and turn off roller clamp. Take off protective sheathover IV tubing port. Put infusion set in fluid bottle or bag.RATIONALE: Steps to initiate priming of IVF tubing with fluid for infusion,

following sterile technique.

163

Take off protective cap from tubing insertion spike and put spikeinto the mouth of IV bag.RATIONALE: Allows fluid to enter tubing.Wash rubber stopper of bottled solutions using an antiseptic andput spike into the IV bottle's rubber stopper.RATIONALE: Prevents entrance of microorganism into the IVF via the spike.Use IV solution to prime infusion tubing. Compress drip cham-ber and release. Allow it to fill from one third to one half of thetubing.RATIONALE: Prevents air bubbles which interfere in the IV tubing, produces

negative pressure in the bottle pulling fluid into the drip chamber.Take off protector cap. Release slowly roller clamp to enablefluid to drip from tubing to needle adapter. Turn off roller clamponce tubing is primed.RATIONALE: Avoids spillage of fluid which may affect accuracy of intake

monitoring.Remove air bubbles from tubing. Tightly tap IV tubing whereair bubbles are present. Inspect the whole tubing to assure thetotal elimination of air bubbles.RATIONALE: Large air bubbles may cause air embolism.On the tubing's end, put back tubing cap protector.RATIONALE: Maintains asepsis. Prevents contamination of fluid by microor-

ganisms.Optional: Set up normal saline lock or heparin for infusion.RATIONALE: Heparin acts as plug to prevent blood clotting and air formation.Observe sterile technique while connecting IV plug to the loopor short extension tubing. Inject around 1-3 ml normal saline viathe plug and through the loop or short extension tubing.RATIONALE: Sterility is maintained.Wear disposable gloves.RATIONALE: Transmission of microorganisms is reduced.

Intravenous Therapy

164


Determine site for IV replacement. Begin from most distal partof the body. Anticipate replacement within 72 hrs. Put tourniquetaround 10-15 cm over the insertion site. Verify for presence ofdistal pulse.RATIONALE: Venous return must be impeded to prevent bleeding once vein is

punctured.Choose well-dilated vein.RATIONALE: Size should be able to accommodate catheter.Execute vein dilation using the following steps:Rub the extremity from distal to proximal sites under the pro-jected site for venipuncture.RATIONALE: Enhances vein dilation.Request patient to open and close his/her arm where the site hasbeen chosen.RATIONALE: Dilation of vein is further increased.Bring down the extremity where the site has been chosen.RATIONALE: Against gravitational pull, blood pulled in before the tourniquet

enhances dilation of distal vein.Temporarily free tourniquet. If necessary, trim excess hair at site.RATIONALE: Hair hinders proper vein visualization. Shaving however should

be avoided as much as possible as it may cause exposure to infec-tion.

Sterilize the insertion site with povidone-iodine solution with firm,circular motion. Avoid touching sterilized site. Let site dry for 2mins. If patient displays allergic reaction to iodine, use 70% alco-hol and let it dry for at least 1 min.RATIONALE: Circular motion prevents contamination of sterilized site. Alcohol

washes iodine away in case of allergic reaction.Carry out venipuncture. To anchor vein, put thumb on vein andstretch skin away from insertion direction 7-10 cm distal to thesite.RATIONALE: Stabilizes insertion site.

165

For butterfly needle, position needle at a 20°-30° angle with bevelup a little distal from actual venipuncture site.RATIONALE: Prevents through and through hitting of vein.For over-the-needle catheter, insert with bevel up at a 20°-30°angle a little distal to site and along the vein's direction.RATIONALE: Prevents through and through hitting of vein.For needleless IV catheter safety device, insert following the sametechnique.Determine if there is blood return through flashback chamberof over-the-needle catheter or tubing of butterfly needle. Bringdown needle until nearly flush with skin. Continue inserting but-terfly needle until its hub reaches venipuncture area. Proceed in-serting the over-the-needle catheter a quarter inch into vein; loosenstylet afterwards. Proceed inserting catheter into vein until its hubreaches venipuncture area. Once loosened, avoid reinserting stylet.RATIONALE: IV reinsertion may cause infection.Steady catheter using one hand by putting pressure on vein ontop of insertion area or over the hub. Free tourniquet and takesylet off the over-the-needle catheter. Refrain from recappingstylet. Take off stylet while sliding protective guard over stylet.RATIONALE: Prevents clotting, venous return goes back.Attach needle of heparin lock or adapter of administration setwith the hub of butterfly tubing or over-the-needle catheter.Refrain from touching the point of entry of needle adapter.RATIONALE: Initiates IV flow and prevents contamination.Bloodless technique: With thumb, put pressure on tip of insertedcatheter. Take off cap and connect tubing to catheter hub usingindex finger or thumb.RATIONALE: Impedes venous return.Slowly let go of roller clamp to start infusion at a rate to pre-serve IV line patency.RATIONALE: Initiation of IV flow is ensured. Blood clotting is prevented.Fasten IV needle or catheter:

Intravenous Therapy

166


Put a thin piece of tape below catheter hub with sticky side fac-ing opposite catheter; run tape over catheter. Put another pieceof tape over the hub of catheter.RATIONALE: Needle movement and accidental dislodging is prevented.Place sterile dressing on the site.RATIONALE: Minimizes risk of infection.For transparent dressing, take off adherent backing, then applydressing on the site. Flatten dressing on the site, but refrain fromcovering the end of catheter hub.RATIONALE: Direct view of insertion site is facilitated. Provides access to

cathter hum in case troubleshooting is required.Fold a 2X2 piece of dressing into half, cover with tape, and putbeneath catheter hub. Coil a loop of tubing and fasten on tubingand gauze.RATIONALE: Injury from pressure on skin caused by catheter hub is prevented.

Stabilizes catheter in the vein.Administer IV fluid by adjusting flow rate to adjust drops perminute:RATIONALE: Cardiac overload is prevented.Heparin lock: wash out using 1-3 ml heparin (10-100 u/ml). Sa-line lock: wash out using 1-3 ml sterile normal saline. Recordtime and date, catheter and gauge size, and placement of IVdressing and line.RATIONALE: Baseline information for future dressing changes is provided. Serves

as reference for reinsertion schedule.Properly dispose of used needles and dispose supplies.RATIONALE: Health workers are protected from contamination.Take off gloves and wash hands.RATIONALE: Minimizes transmission of microorganisms.Monitor patient each hour to establish whether fluid is properlyinfusing.RATIONALE: Prevents complications (i.e., hypoinfusion or overinfusion).

167

Monitor patient each hour to check reaction to therapy.RATIONALE: Opportunity for necessary intervention is provided.Document peripheral IV insertion. Document and report theresponse of patient to IV fluid, including amount infused, andsystem integrity and patency.RATIONALE: Documentation facilitates communication with other health team


6.2. IV Flow Rate Regulation

Importance of Proper Regulation and Monitoringof Flow RateSimilar to the purpose of parental nutrition that aids in body nour-ishment and fluid replacement and the rights of drug administration,IV flow rate monitoring and regulation seeks to infuse the properdose and exact amount of fluids required by the patient. Followingthe pharmacological approach, the nurse plays an important role inthe curative side as well as in the prevention of potential complica-tions arising from IV fluid infusion.

Factors Affecting IV Gravity FlowPrinciples that control movement of fluid in general also apply to theflow of intravenous infusion:

Flow is directly proportional to the height of the liquid column. Elevatingthe infusion container can enhance a sluggish flow.

Flow is directly proportional to the tubing’s diameter. By changing thetubing diameter, clamp on the IV tubing regulates flow. Thus,cannulas of large gauge allow faster flow as compared withthose of small gauge.

Flow is inversely proportional to the tubing’s length. Extending an IV linewill slow down the flow.

Flow is inversely proportional to the fluid’s viscosity. Viscous IV solutions—e.g., blood and total parental nutrition fluids—need larger cannula

minute hour factor gtt volume

ΧΧ

Intravenous Therapy

168


as compared to water or saline solutions.

Monitoring the Flow RateSince a number of factors impact gravity flow, changes in the speedof flow relative to original speed are normal. It is thus imperativethat frequent monitoring of IV infusions be made to ensure thatfluid flows at intended rate. IV container must be marked with tapeto quickly indicate if the proper amount has been infused. Calcula-tion of flow rate must be made upon initiation and monitored atleast every hour. To calculate flow rate, one must determine the num-ber of drops delivered per ml, but this varies according to equip-ment and is normally printed on the solution set packaging. Formulafor calculating drop rate is:Flow Rate =

Note: Microdrop rate = 60 gttsMacrodrop rate = 15 mgtts

Various types of infusion pumps are available to facilitate IV fluiddelivery. Compared with routine gravity-flow setups, these devicesmake possible the more accurate administration of fluids and medi-cations. For instance, there are volumetric pumps, which have flowrates calibrated in terms of milliliters per hour. There are those calledinfusion controllers, which are calibrated in drops per minute. Con-sidering the great variety among these devices, it is crucial to carefullyread the manufacturer’s directions prior to usage. However, despitethe technological advances in infusion pumps, it is still best to con-duct frequent monitoring of infusion and patient.

ProcedRegulating IV Flow RateMonitor the patency of IV line and catheter or needle.RATIONALE: Infiltrated IV needle may cause tissue trauma and inaccurate

medication input rate.Verify from medical record of client for proper infusion addi-tives, solution, and time.RATIONALE: Prescriber’s order is confirmed.

169

Validate knowledge of client on the effect of position of IV siteon flow rate.RATIONALE: Serves as baseline for patient health teaching. Enhances self-

esteem and patient participation in care.Check how client feels on venipuncture site.RATIONALE: Pain sensation may indicate infiltration/infection.Measure flow rate.RATIONALE: Ensures that no cardiac overload arises from hyperinfusion or

hypoinfusion which may result in further fluid and electrolyte im-balance

Verify infusion set’s calibration in drops per milliliter (gtt/ml).Choose formula to use in calculating flow rate after verifyingml/hr.RATIONALE: Ensures accurate drip rate and regulation.Read to client the orders of prescriber, follow ‘five rights’ forproper solution and correct additives.RATIONALE: Medication error is avoided.Establish hourly rate.RATIONALE: Immediate correction in case of infusion delay/advance resulting

from insertion site patency is ensuredPut fluid indicator tape or any adhesive on IV bag or bottle nearto volume markings.RATIONALE: Provides easy and faster visualization of IV fluid level.Based on infusion set’s drop factor, calculate minute rate.RATIONALE: Infusion set brands may have varying drip factors.By counting drip chamber drops for 60 secs, time flow rate.Adjust roller clamp either to decrease or increase infusion rate.RATIONALE: This is the universally accepted method of accurate drip rate

counting during IV regulation.

Intravenous Therapy

170


For infusion controller or pump, follow these:Put electronic eye on drip chamber under the origin of drop andincrease the fluid level in chamber. You can also opt to consultmanufacturer for instructions. When using the controller, makesure that IV bag is 1 m higher than the IV site.RATIONALE: Electronic eye has a drip sensor which counts drip rate. Different

manufacturers have unique features. Height facilitates gravita-tional pull on fluid.

Put IV infusion tubing inside the ridges of control box along theflow’s direction (You can also opt to consult manufacturer forinstructions). Choose volume per hour or drops per minute andlock the door to chamber. Turn the power on, then push the‘start’ button.RATIONALE: Ridges are sensors which detect fluid running along the tube.

Accurate fluid input is achieved by correct fluid regulation bycomputer.

While using the infusion pump or controller, open drip regulator.RATIONALE: Regulator no longer regulates drip rate, it may therefore be kept

fully open.For infiltration follow as per agency policy, observe IV site andinfusion rates.RATIONALE: Prevents tissue trauma and ensures accurate infusion rate.When alarm sounds, examine the system’s patency and integrity.RATIONALE: Alarm indicates problem with patency and integrity (empty IV

bottle, kinks, etc.).For volume control device, observe the following:Put device for volume control between insertion spike of infu-sion set and IV bag.RATIONALE: Ensures accurate fluid volume input.Assign a fluid allotment of 2° into device.RATIONALE: Provides ample time for nurse to replace IV bags in case assess-

ment time is delayed.

171

Examine system every hour. Put fluid to volume control as theneed arise. Control flow rate.RATIONALE: Ensures accuracy of infusion by monitoring patency.Monitor client for signs and symptoms of dehydration oroverhydration.Re-regulation of flow rate is an immediate intervention if the two conditions

are observed.Assess patient for infiltration signs, such as on-site inflammation,kink or knot in infusion tubing, and clot in catheter.RATIONALE: Prevents further tissue trauma and delay in infusion.Document and report the following: infusion rates, electronicinfusion device used, responses of client, and solutions.RATIONALE: Documentation facilitates communication with other health team


6.3. Changing IV Solution & Infusion Tubing

Materials Required• IV stand• IV fluids as ordered• IV tubings• IV connection tube or extension tube (if needed)• IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) –



Procedures for IV Solution Changing & InfusionTubing & Rationale

To change IV solution, follow these procedures:

Intravenous Therapy

172


Verify orders of prescriber and record time and date solutionwas last changed.RATIONALE: Procedure must be ordered by physician, IV changing schedule

must be scheduled as per institution’s policy or as indicated.Establish the compatibility of IV fluids and additives.RATIONALE: Medication error is avoided.Establish the understanding of client of the requirement forcontinued IV therapy.RATIONALE: Provides opportunity for health teaching and medication compli-

ance is encouraged.Examine patency of present IV access area.RATIONALE: Accurate delivery of fluid is ensured and tissue trauma is pre-

vented.Set up the next solution 60 min prior to need. Verify that thesolution is correct and labeled properly and is not expired.RATIONALE: Prevents delays and anticipates emptying of IV bottle.Be prepared to change solution when supply reaches below 50ml of fluid.RATIONALE: Anticipates emptying of IV bag/bottle. Give procedure details to client.RATIONALE: Improves patient’s understanding of procedure.Maintain drip chamber at least 50% full.RATIONALE: Ensures negative pressure in IV fluid bottle and prevents bubbles

from entering tube.Wash hands.RATIONALE: Transmission of microorganisms is reduced.Set up new solution when changing is necessary. Take theprotective cover off the IV tubing port.RATIONALE: Contamination of spike is prevented.To stop flow rate, adjust roller clamp.RATIONALE: Roller clamp blocks fluid flow in tubing, used in adjusting IV

173

fluid flow rate.Discard used IV fluid container from IV pole. Take spike offfrom old solution bottle or bag. Without touching the tip, putspike into new bottle or bag.RATIONALE: Asepsis is maintained.Hang new solution bottle or bag. Monitor presence of air intubing. Eliminate bubbles in tubing by inserting a needle or syringeinto a port under the air and aspirating into the syringe. Sterilizeport with alcohol; let it dry first before inserting needle into theport.RATIONALE: Accurate IV flow rate is ensured. Air embolism is prevented.Ensure that drip chamber is at least 1/3–½ full. When dripchamber is very full, squeeze off tubing under the drip chamber,turn container upside down, pinch the drip chamber, hang upthe bag or bottle, and let go of the tubing.RATIONALE: Accurate IV flow rate is ensured. Air embolism is preventedControl the flow to the prescribed rate.RATIONALE: Accurate fluid and electrolyte infusion is achieved.Monitor client for symptoms and signs of dehydration oroverhydration.RATIONALE: Provides baseline information for assessment and nursing manage-

ment.Monitor client for development of complications and the patencyof IV system.RATIONALE: Presence of dislodging, infiltration, infection etc. is determined.To change infusion tubing, follow these procedures:RATIONALE: Decide if a new infusion set is required.Follow recommendations to avoid infection. Monitor tubing forocclusions.RATIONALE: Occlusions hinder fluid flow. Prevents blood clotting at catheter

end.Give details of the procedure to client.RATIONALE: Decreases patient anxiety and cooperation is enhanced.

Intravenous Therapy

174


Wash hands.RATIONALE: Reduces transmission of microorganisms.Open the new infusion set by maintaining protective coveringsabove infusion spike and connector site for IV catheter or butterflyneedle.RATIONALE: Prevents contamination.Wear non-sterile disposable gloves.RATIONALE: Reduces risk of blood-borne infection.Take IV dressing off but refrain from removing the tape thatsecures catheter or needle to skin.RATIONALE: Infection is prevented.To infuse IV, observe the following:Turn off the roller clamp.RATIONALE: Stops fluid from flowing.Keep vein open rate.RATIONALE: Ensures patency of catheter, while reducing IV flow rate.Compress fill chamber and drip chamber.RATIONALE: Air is prevented from entering tubing.Take old tubing off solution; 1 m above IV site, tape or hangdrip chamber on IV pole.RATIONALE: Allows space for the new IV bag to be spiked. Tubings are

primed and freed from air spaces.Put the new tubing’s insertion spike into the old solution bottleor bag; hang solution bottle or bag on IV pole. Compress andallow drip chamber to flow on new tubing. Gradually load dripchamber 1/3–1/2 full.RATIONALE: IV flow to tubing is initiated.Gradually open roller clamp, take protective cap off from needleadapter, flush tubing with solution, then replace cap afterwards.RATIONALE: Tubing is primed with fluid.Switch roller clamp to off position.

175

RATIONALE: Spillage of IV fluid is avoided.For heparin lock, observe the following:In connecting the new injection cap to the tubing or loop, followthe sterile method.RATIONALE: Infection control is observed.Cleanse injection cap with cotton and alcohol. Put 1–3 ml salinein syringe and inject via injection cap into the loop or shortextension tubing.RATIONALE: Infection is avoided. Seals off IV port from clots.Steady the hub of needle or catheter. Put pressure on the vein alittle over insertion area. Gradually remove old tubing. Sustainhub’s stability and immediately insert the new tubing’s heparinlock or needle adapter into the hub.RATIONALE: Bleeding of insertion site is avoided.Open new tubing’s roller clamp. Let solution run quickly for 30–60 secs.RATIONALE: Ensures IV patency.Control IV drip as ordered. Observe rate every hr.RATIONALE: Avoids overhydration or hypoinfusion.If needed, apply new dressing.RATIONALE: Infection is prevented.Dispose of old tubing properly.RATIONALE: Contamination is avoided.Take off and throw away gloves. Wash hands.RATIONALE: Transmission of microorganisms is reduced.Assess flow rate and monitor connection area for leakage.RATIONALE: Accurate fluid delivery is ensured.Document the procedure.RATIONALE: May be used for legal and care management purposes.

Intravenous Therapy

176


Stick a preprinted label or piece of tape and write the time anddate of tubing change. Attach this to tubing under drip chamberlevel.RATIONALE: Documentation facilitates communication with other health team


6.4. Changing Peripheral IV Dressing

Materials Required• IV stand• IV fluids as ordered• IV tubings• IV connection tube or extension tube (if needed)• IV Cannula / catheter or butterfly (gauges 18, 20, 22, & 24) –



Procedure for Changing Peripheral IV Dressing &Rationale

Establish the date when dressing was last changed.RATIONALE: Provides information regarding length of time present dressing

has been in place. In addition, nurse is able to plan for dressingchange.

Monitor current dressing for intactness and moisture.RATIONALE: Moisture is a medium for bacterial growth and renders dressing

contaminated.Palpate catheter area via the intact dressing to address discom-fort or inflammation.RATIONALE: Unexplained decrease in flow rate requires the nurse to investigate

placement and patency of the IV catheter. Pain can be associatedwith both phlebitis and infiltration.

Check exposed catheter area for infiltration or swelling.RATIONALE: Indicates fluid infusing into surrounding tissues. Will require

Nutrition &Metabolism

Chapter Seven

7.1. Inserting Small-Bore Nasoenteric Tube for EnteralFeedings

7.2. Administration of Enteral Feedings via NasogastricTubes.

7.3. Administration of Enteral Feedings via Gastronomy orJejunostomy Tubes

7.4. Administration of Cleansing Enema

7.5. Pouching an Ostomy

7.6. Colostomy Irrigation

7.7. Inserting and Maintaining a Nasogastric Tube

178


7.1. Inserting Small-Bore Nasoenteric Tube forEnteral Feedings (NGT Insertion)

Anatomy and PhysiologyThe gastrointestinal system is responsible for digestion, the processwhich basically breaks down food particles into small molecules fordigestion, nutrient absorption into the bloodstream, and eliminationof undigested/unabsorbed food particles and other waste materialsfrom the body. The gastrointestinal (GI) system is a complex systemfor processing food, extracting nutrients and eliminating wastes. Thealimentary canal begins in the mouth and ends at the anus. The pro-cesses chewing, swallowing, digestion, absorption and defecation arecontrolled by autonomic, nervous and hormonal mechanisms. Di-gestive glands act to provide moisture, lubrication, emulsification andenzymes for digestion of proteins, carbohydrates and fats. This me-chanical breakdown reduced the food into its simplest form by theuse of enzymes secreted in all parts of the GI system. Enzymes arean essential component of the chemistry of digestion, these areproteinlike substances that act as catalysts to speed up chemical reac-tions. Each enzymes have one specific functions best at a specific pH.The secretions of the GI tract have vastly different pH levels. Salivais relatively neutral, gastric juice is highly acidic and the secretions ofthe small intestine are alkaline.Anatomically, the GI tract is a tube that from the exterior to thelumen is composed of connective tissue, smooth muscle layers withembedded nervous plexus, connective tissue, and an inner epitheliallayer. The epithelial type, muscle thickness, glandular elements andnervous supply differ in the various functional regions, as does thediameter and shape of the tube.The mechanical, chemical and hormonal activities of digestion areindependent. Enzymes activities are dependent on the mechanicalbreakdown of food to increase its surface area for chemical action.Hormones regulate the flow of digestive secretions needed for en-zyme supply, and digestion may also be decreased or increased bystrong emotional states. The secretion of digestive juices and themotility of the GIT are also regulated by the physical, hormonal and

179

chemical factors as they are bound to psychological, emotional andnervous system alterations. GIT action is increased by nerve stimula-tion from the parasympathetic nervous system.

Gastrointestinal HormonesThe GI tract is the largest endocrine gland in the body with the en-docrine cells being diffusely scattered in the mucosa over the lengthof the alimentary canal. Food in the lumen of the gut is the normalstimulus for secretion of GI hormones but nervous system activity,stretch or chemical stimulation may also cause the release of GI hor-mones. The hormones enter the blood stream to effect tissues dis-tant from the releasing cells. GI hormones regulate the digestive pro-cess, motility and blood flow of the GI tract and influence the growthof the pancreas and GI tract. Many of the GI hormones are alsofound in the central nervous system where they may play a role inappetite control, satiety or nerve transmission to the GI tract.Secretin is a 27 amino acid peptide hormone produced in the duode-num and released in response to a luminal pH of less than 4.5. Itstimulates fluid and bicarbonate release from the pancreas and stimu-lates pepsinogen secretion.Cholecystokinin (CCK) is secreted by the endocrine cells of the duode-num and proximal jejunum. CCK exists in a plurality of forms con-taining 8 to 58 amino acids. It is released by the presence of longchain fatty acids in the chyme. It stimulates pancreatic enzyme synthe-sis and secretion, increases gall bladder emptying and decreases gas-tric emptying. A chronic effect of CCK is the stimulation of DNAsynthesis in the exocrine pancreas and growth of mucosal tissue.Gastrin is a 17 amino acid polypeptide hormone made in the duode-num and pyloric antrum. The presence of digested protein in thestomach and duodenum stimulate its release. Gastrin stimulates acidsecretion from the parietal cells of the gastric glands and pepsinogensecretion from the chief cells. Histamine is a mediator in the gastrinstimulated release of gastric acid. Gastrin also stimulates nucleic acidand protein synthesis and growth of the exocrine pancreas, mucosaof the small and large intestines and glandular stomach.

Nutrition & Metabolism

180


Gastric inhibitory peptide (GIP) is a 43 amino acid peptide that causesinsulin release from the endocrine pancreas. It also inhibits gastrinrelease and gastric acid secretion.Vasoactive intestinal polypeptide (VIP) is a 28 amino acid polypep-tide that stimulates bicarbonate release from the pancreas, lipolysisand glycogenolysis in the small intestine and pancreas, decreased GImuscle tone and vasodialation.Ghrelin is 28 amino acid peptide found in the stomach and hypo-thalamus. It is released from the stomach and acts at the hypothala-mus to increase caloric intake. It also directly stimulates the pituitaryto increase growth hormone secretion. Ghrelin also acts locally as aparacrine hormone to cause gastric acid secretion and motility. Fast-ing increases the production of ghrelin.

Digestive GlandsThe various salivary glands add water, electrolytes, mucous and sali-vary amylase to the food as it is chewed. Secretory cells filter andmodify the blood to produce saliva. In humans these secretions aremostly water. Parotid, submaxillary, sublingual glands add saliva tothe food during mastication. Salivary amylase begins the breakdownof carbohydrates while the food is still in the mouth. Salivary lysozymelyses bacterial cell walls. Mucopolysaccharides act as lubricants andwater acts to extract flavors from food. Salivary secretion is con-trolled by the nervous system.Gastric glands are present throughout the mucosa of the stomach.These deep tubular glands secrete electrolytes and produce pepsino-gen and other proteases at the bottom (chief cells), hydrochloric acidin the neck and body of the gland (parietal cells), and mucous at theneck and opening of the gland. The mucous acts to protect the gas-tric lining from the acid and enzymes present. Parietal cells also pro-duce a protein called intrinsic factor that is necessary for the absorp-tion of vitamin B12 in the ileum. Pepsinogen is activated by the re-moval of a small fragment. Pepsin works optimally to digest pro-teins at a pH of 1.5-2.5. The enzyme rennin is most active in infantswhere it causes milk proteins to curdle.The pancreas has two glandular portions, the endocrine portion and

181

the exocrine protein. Cells of the pancreatic islet make up the endo-crine portion and secrete insulin and glucagon into the blood streamas needed. The exocrine portion participates in digestion by the se-cretion of the natural antacid, bicarbonate, electrolytes, fluid and di-gestive enzymes that are added to the contents of the duodenum.Secretion by the exocrine pancreas is regulated mostly by GI hor-mones with some minor influence of the nervous system. The secre-tions of the pancreas are rich in bicarbonate and other electrolytes.The bicarbonate and electrolytes help to buffer the incoming acidicchyme from the stomach.Pancreatic enzymes are made by the acinar cells and packaged asinactive precursors into granules prior to release. The enzymes areactivated by cleavage of small fragments when acted upon by otherpancreatic or intestinal enzymes. Pancreatic trypsinogen, chymotrypsi-nogen, carboxypeptidase, aminopeptidase, lipase, amylase, ribonu-cleases, deoxyribonucleases, elastase, alkaline phosphatase, cholesterolesterase and other enzymes reduce food stuffs to absorbable ele-ments.The liver is an important metabolic, digestive, and excretory organ. Itparticipates in digestive function by the production of bile whichwhen added to the duodenal contents emulsifies fats enabling themto be broken down. Bile is produced in the liver but is stored in thegall bladder until it is needed. In the gall bladder the bile is concen-trated by the removal of water and the addition of bicarbonate. Bilesalts are steroid or cholesterol derivatives synthesized or recoveredfrom the blood by liver cells. Liver cells also make and secrete leci-thin that emulsifies dietary fats. Products of hemoglobin metabolismare excreted in bile salts. In an enterohepatic circulation process bilesalts and other substances enter the lumen of the GI tract in theduodenum and are reabsorbed further down the intestine into theblood. The substances are removed from the blood again by livercells.Intestinal secretions participate in digestion by adding fluid, electro-lytes, and enzymes. Enzymes include intestinal amylase, enterokinase,disaccharidases, peptidases, lipases, nucleotidases and nucleosidases.Some of these enzymes are free in the lumen due to the digestion of


182


sloughed mucosal cells. Intestinal secretion is both passive, due to theconcentration of lumen contents, and active. Active secretion is usu-ally directed at a specific ion with others following for electrical neu-trality. Water follows because of osmotic pressure. Cholera toxinand E.coli enterotoxins simulate active intestinal secretion and there-fore cause diarrhea.

Digestion ProcessBeginning in the mouth, digestion is initiated with the help of theteeth that breaks down the food mechanically and salivary enzymeswhich chemically reacts on food. The features of the oral cavity par-ticipate in digestion by reducing the food to smaller pieces, moisten-ing and lubricating the food and by the addition of amylase for thebreakdown of carbohydrates. The teeth are specialized for cuttingand grinding the food into small pieces so that there is more surfacearea for digestive enzymes to work on and to ease swallowing. Thetongue moves the food around within the mouth and has taste re-ceptors for sweet, salt, sour, and bitter. Salivary glands add salivawhich contains water, ions, salivary amylase and mucous. The food ismixed with saliva which contains ptyalin, a salivary amylase that actson cooked starch to begin its conversion to maltose. When the foodbolus is of the proper consistency, the tongue moves it to the backof the mouth where swallowing is initiated. The epiglottis covers thetrachea as the bolus is passed into the esophagus. The bolus stretchesthe esophagus initiating smooth muscle contractions that push thebolus along toward the stomach in peristaltic waves.Food materials then pass through the esophagus, situated in the me-diastinum of the thoracic cavity, posterior to the heart and trachea,and anterior to the spine. The esophagus joins the stomach near thediaphragm which normally pinches the esophagus closed due to itsmuscular tone. Stomach movement also helps to keep the esophagusclosed. The net effect is that the esophageal-gastric junction can with-stand 10-20 mmHg pressure from the stomach.The stomach, located in the upper portion of the abdomen to theleft of the midline, under the left diaphragm, secretes hydrochloricacid and is a distensible pouch with around 1500 ml capacity. Theesophagogastric junction, the inlet to the stomach, is surrounded by

183

the lower esophageal sphincter-a ring of smooth muscle that, oncontraction, closes off the stomach from the esophagus. The stom-ach can be divided into four anatomic regions, namely the cardia,fundus, body and polyrus (outlet). It is a muscular pear-shaped or-gan where serious digestion begins. Three layers of smooth muscleact to mix the incoming food bolus with gastric fluids. Glands withinthe stomach lining produce hydrochloric acid (pH<1) and the en-zyme precursor pepsinogen. Pepsin becomes active in the acidic en-vironment of the stomach. The stomach is separated into three func-tional areas: the cardiac, fundic and pyloric regions. The cardiac re-gion is closest to the heart and contains the esophageal junction andonly a few glands. The fundic region contains complex glands secret-ing hydrochloric acid, mucous, intrinsic factor, pepsinogen and otherproteases. The pyloric region contains very few glandular elements,other than mucous producing cells, but rather serves as a musculargatekeeper to the duodenum, the first portion of the small intestine.Circular smooth muscle located in the wall of pylorus forms thepyloric sphincter which regulates the opening between the stomachand small intestine.The longest segment of the gastrointestinal (GI) tract, the small intes-tines represent around two-thirds of the total length of the GI tract.It is divided into three anatomical parts-duodenum (upper part), je-junum (middle part), and ileum (lower part). The penultimate part isthe large intestine (ascending, transverse and descending segment),which then goes to sigmoid colon, to the rectum, and, finally, to theanus. The gastric contents are emptied into the small intestine as longas the paticle sizes are not too large or the duodenal pressure is nottoo high. Other factors involved in gastric emptying include the tem-perature of the chyme, duodenal pH, and osmolarity of chyme. Theduodenum accepts material from the stomach at a relatively constantcaloric rate such that highly caloric chyme enters the duodenum at aslower rate. Emulsifying bile enters the duodenum from the gall blad-der and pancreatic secretions water, enzymes and sodium bicarbon-ate) are added here as well. Most digestion and absorption occurs inthe upper two thirds (duodenum and jejunum) of the almost ninefoot long small intestine and removal of water and bile salts occurs


184


in the lower one third (ileum). Cells lining the lumen of the smallintestine are called enterocytes. These cells are replaced every 3-5 daysby new cells arising from deep within simple tubular glands (cryptsof Lieberkuhn). The interior lining of the small intestine has numer-ous projections into the lumen called villi. The villi function to in-crease the surface area available for digestion and absorption.Enterocytes also have adaptations to increase absorptive surface areaon their luminal border called microvilli.

NutritionA nutrient is any element or compound that is necessary for or con-tributes to an organism's metabolism, growth or other functioning.There are six nutrient groups and these can be divided into those thatprovide energy and those that otherwise support metabolic pro-cesses in the body. These are:Substances that provide energy:

• Carbohydrates: compounds made up of sugars that are used orstored as energy

• Proteins: nitrogenous organic compounds, including amino acids,that provide the building blocks (amino acids) for enzymes andother proteins within the body

• Fats: including fatty acids (a fat is an assemblage of three fattyacids linked to a central glycerine molecule)

The energy content of fat is 9 kcal/g; of proteins and carbohydrates 4kcal/g. Ethanol (grain alcohol) has an energy content of 7 kcal/g.

Substances that support metabolism:• Minerals: generally trace elements, salts or ions such as copper

and iron essential to normal metabolism• Vitamins: organic compounds essential to the body's functioning,

usually acting as coenzymes• Water: absolute requirement for normal growth and metabolism

directly involved in all the chemical reactions of life-sometimesreferred to as the forgotten nutrient.

Any classification of "nutrientsis likely to be arbitrary, since nutritionis a developing science and we are becoming more aware of a wider

185

range of nutrients essential for health. Any organic compoundmetabolised by the body will be used for its energy content, utilizedfor structural purposes (growth or replacement of living structures)or participate in chemical reactions necessary for life. Any particularsubstance can play more than one role in the body, although theseroles may be poorly understood.These comments are reinforced by the discovery of the group ofnutrients called phytonutrients. Our knowledge of these is limited,they are organic compounds from plants essential for normal func-tioning of a body and having complex hormonal effects on healthor playing an active role in the amelioration of disease. They are noteasily classified in the traditional nutrition categories.

ImportanceFor situations when it is difficult to maintain nutritional balance as thepatient cannot cooperate with feeding or when the body cannot tol-erate oral feeding, tube feeding is administered. This method is alsodone for unconscious patients to supply their nutritional needs untilthey regain consciousness. Tube feeding formulas are prepared tosupply such patients with a well-balanced and complete diet.One of the nurse's basic functions is to efficiently and carefully pro-vide feedings to patients via the feeding tube until they can eat with-out assistance. In fact, the nurse plays a key role in curative and reha-bilitative nutritional requirements of the patient. Competency in gas-tric intubation (lavage, gavage) and enteral feeding is crucial in thepromotion and maintenance of patient's nutritional needs.Gastric tube insertion is not exclusively for nutritional purposes as itis also used for:

• Stomach decompression and removal of gas and fluid• Gastrointestinal motility diagnosis• Administration of medications• Treatment of an obstruction or bleeding site• Procurement of gastric contents for analysis

Factors Affecting Nasogastric Tube insertion and


186


Tube Feeding• Site of insertion• Types and sizes of tube• Nutritional status• Medical history and present condition• Types of total parenteral nutrition• Patient's size and age• Duration of nutritional therapy• Tube patency• Health provider's skills

Assessment sitesGastric tube can be inserted either in the mouth (oro) or nose (naso).Nasogastric entry is the more commonly used method since it hasless episodes of vomiting and lesser discomfort complaints. How-ever, oral fluid intake can also be used. Assessment of insertion sitesmust always be performed, checking for dryness, sore, polyps ormass. Once resistance is encountered, refrain from pushing force-fully. When the patient chokes, has breathing difficulty or is cyanotic,pull out tube immediately since these are clear symptoms that tube isin the lungs, causing obstruction in airway.

Materials Required• Micropore tape or safety pin• Plaster tape• Asepto syringe• Nasogastric tube (French 16 for adult, french 8 feeding tube for

infants) or the types of tube to be used as ordered (Levin tube,Gastric Sump tube, Nutriflex tube, Moss Tube or Sengstaken-Blakemore tube)

• Kidney basin with half-filled water• KY Jelly• Stethoscope• Sterile gloves and maskNote: Feeding tube via esophagostomy, gastrostomy and jejunostomy areinserted surgically.

187

Procedure for Inserting Small-Bore NasoentricTube for Enteral Feedings & Rationale

Examine if patient requires enteral tube feeding.RATIONALE: Assessment provides data for institutional management and nurs-

ing approach.Evaluate patient for proper administration route:Alternately close nostrils of patient. Tell patient to breathe.RATIONALE: Nasal obstructions and difficulty of breathing are revealedExamine for gag reflex.RATIONALE: Tolerance for P.O. feeding is determined.Assess medical history of patient for aspiration risks and nasalproblemsMinimizes aspiration risks with proper positioning andpatency check. Nasal problems may call for oro pharyngeal routeof the tenteral tube to avoid further trauma. Assess order ofprescriber for tube type, size and enteral feeding schedule.RATIONALE: Ensures that right procedure is accurately carried out.Wash hands.RATIONALE: Minimizes transmission of microorganisms.Give procedure details to patient.RATIONALE: Improves patient's understanding of procedure. Reduces patient

anxiety and enhances cooperation.Position on bed's similar side as insertion nares. Unless contrain-dicated, help patient assume high Fowler's position. Put pillowunder head and shoulders of patient.RATIONALE: Allows gravitational pull on tube and opens oral passage for easy

and smooth insertion.Cover patient's chest with bath towel. Put facial tissues near thework area.RATIONALE: Prevents patient's clothes from getting soiled.Calculate tube's length for insertion and label with tape. deter-mine space between tip of patient's nose to earlobe to xiphoid


188


process of sternum.RATIONALE: Prevents tissue injury and ensures tubing patency.Set up nasointestinal or nasogastric tube for intubation:Avoid using ice plastic tubes.RATIONALE: Ice plastic tubes may cause discomfort due to cold temperature and

result in tissue spasm.Insert 10-ml water from catheter-tip syringe or 30-ml or biggerLuer-Lock into the tube. Ensure that guidewire is firmly placedagainst weighted tip and that both Luer-Lock attachments aresecurely connected.RATIONALE: Patency is ensured by testing passage and fluid flow.Prepare a 10-cm long hypoallergenic plaster.RATIONALE: Reduces risk for contact dermatitis.Wear disposable gloves.RATIONALE: Reduces risk for infection and contamination from secretions.With surface lubricant, immerse tube into glass of water. Put intube via the nostril of patient to throat's back. Point toward backand down to ear's direction. Bend head of patient to directionof chest once tube has passed via nasopharynx. Stress on theneed of the patient to breathe in and swallow through mouthduring the process. Move tube forward every time patient swal-lows until the time preferred length has transpired. Refrain fromforcing tube. If resistance is met or patient begins to cough, chokeor become cyanotic, stop advancing tube and pull it back.RATIONALE: Allows for smooth insertion of tube into orifice by following

anatomical contour.Check for position of tube in back of throat with penlight andtongue blade.RATIONALE: Accurate insertion of nasogastric tube is viewed.Perform measures to verify placement of tube:Inject 30-ml of air into tube, and aspirate gastrointestinal con-tents with a syringe.

189

RATIONALE: Presence of gastric secretions confirms the location of tube's tip inthe stomach.

Measure pH and observe appearance of gastrointestinal con-tents. Apply tincture of benzoin or other skin adhesive on tip ofpatient's nose and tube. Allow to dry.Remove gloves and secure tube with tape, avoiding ap-plying pressure on nares:Split one end of tape lengthwise 5 cm. Place the intact end oftape over bridge of patient's nose. Wrap each of the 5-cm stripsaround tube as it exits patient's nose.RATIONALE: Tape anchors tube to the nasal skin.Fasten end of nasogastric tube to patient's gown by loopingrubber band around tube in slip knot. Pin rubber band to gown.RATIONALE: Accidental pulling of tube is prevented.For intestinal placement, position patient on right side if possibleuntil confirmation of placement. Otherwise, assist patient to acomfortable position.RATIONALE: Anatomical position is followed, facilitating proper placement.Obtain x-ray film of patient's abdomen.RATIONALE: Correct placement of tube is confirmed.Apply gloves.RATIONALE: Reduces risk of infection.Administer oral hygiene.RATIONALE: Enhances integrity of oral mucosa membrane.Cleanse tubing at nostril.RATIONALE: Promotes patient comfort and reduces risk of infection.Remove gloves. Dispose of equipment. Wash hands.RATIONALE: Reduces transmission of microorganisms.Inspect patient's nares and oropharynx for any irritation afterinsertion.RATIONALE: Complications are prevented by early intervention.


190


Ask if patient feels comfortable.RATIONALE: Minimizes patient's anxiety and encourages verbalization of

feelings.Observe patient for gagging or difficulty of breathing.RATIONALE: Gagging may cause vomiting and puts patient at risk of aspira-

tion. Oxygenation must not be hindered.Record/report type and size of tube insertion and position andpatient's tolerance of procedure.RATIONALE: Documentation facilitates communication with other health team


7.2. Administration of Enteral Feedings viaNasoenteric Tubes

Materials Required• Micropore tape or safety pin• Plaster tape• Asepto syringe• Nasogastric tube (French 16 for adult, french 8 feeding tube for

infants) or the types of tube to be used as ordered (Levin tube,Gastric Sump tube, Nutriflex tube, Moss Tube or Sengstaken-Blakemore tube)

• Kidney basin half-filled with water• KY Jelly• Stethoscope• Sterile gloves and mask

Procedure for Administering of Enteral TubeFeedings via Nasoenteric Tubes & Rationale

Examine the need of client for enteral tube feedings.RATIONALE: Inability to receive oral feeding puts patient at risk for nutritional

191

depletion.Before feeding, auscultate client for bowel sounds.RATIONALE: Digestion and absorption in the gastrointestinal tract are evi-

denced by bowel sounds.Get baseline weight and laboratory values of client. Examineclient for deficit or excess in fluid volume, and abnormalities inelectrolyte and metabolism.RATIONALE: Serves as point of reference for determining effectiveness of enteral

feedings.Ascertain order of prescriber for feeding formula, route, rateand frequency.RATIONALE: Ensures proper performance of procedure.Give procedure details to patient.RATIONALE: Ensures cooperation by reducing anxiety.Wash hands.RATIONALE: Reduces transmission of microorganisms.To administer formula, prepare feeding container fol-lowing these steps:Put formula at room temperature.Cold formula increases vasoconstriction which may cause gastric cramping.Either attach tubing to contain as necessary or set up ready-to-hang container.Contamination is prevented.Thoroughly shake formula container. Pour formula into con-tainer and tubing.Either put patient in high Fowler's position or raise bed's headby 30°.- Gravitational pull on feeding is ensured and aspiration is prevented.Establish placement of tube:To check for gastric residual, aspirate gastric contents. Put aspi-rated content back to stomach except when the volume goes


192


beyond 150 ml.Presence of tube's end in stomach will reveal presence of gastric secretions.When evaluating tube placement, results must be considered.INITIATING FEEDING:For intermittent or bolus feeding method:Squeeze feeding tube's proximal end.RATIONALE: Prevents entry of air into stomach.Take plunger off syringe. Connect syringe barrel to tube's end.RATIONALE: Port for feeding formula is established.Put the measured amount of formula into syringe. Let go of thetube and raise syringe high enough to enable gravity to empty itgradually. Refill and repeat the process until patient has consumedprescribed formula.RATIONALE: Feeding process is initiated.For feeding bag, hang it on IV pole. Put prescribed amount offormula into the feeding bag. For 30 mins, slowly allow bag toempty.RATIONALE: Risk of abdominal discomfort is reduced.Unless contraindicated, flush tubing using water once bolus orintermittent feeding is completed.RATIONALE: Provides water source to promote fluid and electrolyte balance.For continuous-drip technique:Suspend tubing or feeding bag on IV pole.RATIONALE: Facilitates gravitational pull to allow descent of formula to GI

tract.Attach tubing's distal end to the feeding tube's proximal end.RATIONALE: Allows contact between formula bag and enteral tube.Turn infusion pump on and set rate, attach tubing.RATIONALE: Sets feeding machine on.Gradually continue tube feeding as per guidelines.

193

RATIONALE: Follow physician's written orders regarding feeding and adhere toinstitutional guidelines to minimize if not avoid errors.

Clamp the feeding tube's proximal end when tubing feedingsare not being administered.RATIONALE: Entry of air to gastrointestinal tract is prevented.With diluted formula, administer water through feeding tube asper order.RATIONALE: Provides water source to promote fluid and electrolyte balance.Whenever feedings are stopped, use warm water to rinse bagand tubing.RATIONALE: Minimizes bacterial growth.Every 4 hrs, measure aspirate amount.RATIONALE: Gastrointestinal tract tolerance is determined.Every 6 hrs, observe finger-stick blood glucose of patient up tothe time maximum administration is achieved and sustained for24 hrs.RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption

and reaction to tube feeding.Every 24 hrs, observe intake and output of patient.RATIONALE: Renal output illustrates circulating fluid volume. Presence of

imbalances is determined.Daily, weigh patient up to the time maximum administration isachieved and sustained for 24 hrs. Afterwards, weight patientthrice a week.RATIONALE: Weight gain is an objective indicator of nutritional status. A

sudden increase in weight by 2lb/24° is indicative of fluids reten-tion.

Monitor return of normal laboratory values.RATIONALE: Normal laboratory values such as albumin illustrate good nutri-

tional progress.20. Document and report status of feeding tube, type of feed-ing, tolerance of patient, and adverse effects.


194



7.3. Administration of Enteral Feedings viaGastrostomy or Jejunostomy Tube

Materials Required• Gastrostomy tube• Jejunostomy tube• Micropore tape or safety pin• Plaster tape• Asepto syringe• Nasogastric tube (French 16 for adult, french 8 feeding tube

for infants) or the types of tube to be used as ordered (Levintube, Gastric Sump tube, Nutriflex tube, Moss Tube orsengstaken-blakemore tube)

• Kidney basin with half-filled water• KY Jelly• Stethoscope• Sterile gloves and mask

Procedure in administering Enteral Feedings ViaGastrostomy or Jejunostomy Tube & Rationale

Examine requirement of patient for enteral tube feedings.RATIONALE: Ensures accurate performance of procedure.Before feeding, auscultate patient for bowel sounds. If bowelsounds are absent, consult physician.RATIONALE: Peristalsis resulting in bowel sounds reduces risk of aspiration

and abdominal distention.Get baseline weight and laboratory value of patient.

195

RATIONALE: Provides data for evaluating the efficacy of enteral feeding.Check order for formula, route, rate, and frequency.RATIONALE: Ensures that right procedure is performed on right patient.Give procedure details to patient.RATIONALE: Improves patient's understanding of procedure. Reduces patient

anxiety and encourages cooperation.To administer formula, prepare feeding container:Put formula at room temperature.RATIONALE: Cold formula results in cramping due to vasoconstriction and

decreases peristalsis.As required, attach tubing to container or prepare ready-to-hangbag.RATIONALE: Height of bag facilitates gravitational pull on contents into gas-

trointestinal tract.Pour formula into container and tubing.RATIONALE: Tubing delivers formula to the gastrointestinal tract.Raise bed's head to 30°-45°.RATIONALE: Aspiration is prevented.Check placement of tube:When using gastrostomy tube, aspirate gastric juices of patientand verify pH and appearance. Unless volume goes over 150 ml,return aspirated contents.RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption and

reaction to tube feeding.When using jejunostomy tube, aspirate intestinal secretions ofpatient and verify pH and appearance.RATIONALE: Evaluates gastrointestinal functions (i.e., digestion, absorption

and reaction to tube feeding.With 30 ml of water, flush tube.RATIONALE: Maintains fluid and electrolyte balance. Ensures tube patency.Initiate syringe feedings:


196


RATIONALE: This route of feeding is given continuously to ensure proper ab-sorption. Initial feedings are given bolus to check patient's toler-ance of formula.

Squeeze gastrostomy tube's proximal end.RATIONALE: Prevents entry of air into gastrointestinal tract.10.2. Take off plunger and connect syringe's barrel to tube's end.Fill syringe with formula.RATIONALE: Initiates feeding process.10.3. Gradually let syringe empty. Refill syringe until patient hasreceived prescribed amount of formula.RATIONALE: Provides time for gastrointestinal tract digestion and absorption

to ensure nutritional improvement.Initiate continuous-drip feedings:Fill feeding container with amount of formula sufficient for 4feeding.RATIONALE: Feeding process is initiated. Allows sufficient amount of formula

to run for designated period (4 hrs).Put container on IV pole. Remove air from tubing.RATIONALE: Height of bag facilitates gravitational pull on contents into gas-

trointestinal tract.As per manufacturer instructions, thread tubing on pump.RATIONALE: Facilitates regular drip of formula based on prescribed time and

amount.Attach tubing to feeding tube's end.RATIONALE: Establishes connection between two separate tubes.Start infusion at prescribed rate. Examine skin of patient aroundtube exit area. Daily cleanse skin using warm water and mildsoap. It is not recommended to apply dressings around the exitarea.RATIONALE: Inform physician of any sign of irritation, infection or tube

displacement.

197

Discard supplies and wash hands.RATIONALE: Infection is prevented.Every 4 hrs, measure aspirate amount.Illustrates evidence of gastrointestinal tract's formula tolerance.Every 6 hrs, observe finger-stick blood glucose of patient up tothe time maximum administration is achieved and sustained for24 hrs.RATIONALE: Provides data for patient's glucose tolerance.16. Every 24 hrs, observe intake and output of patient.RATIONALE: Renal output illustrates circulating fluid volume. Presence of

imbalances is determined.Daily, weigh patient up to the time maximum administration isachieved and sustained for 24 hrs. Afterwards, weight patientthrice a week.RATIONALE: Weight gain is an objective indicator of nutritional status. A

sudden increase in weight by 2lb/24° is indicative of fluids reten-tion.

Monitor return of normal laboratory values.RATIONALE: Normal laboratory values such as albumin illustrate good nutri-

tional progress.RATIONALE: Document and report status of feeding tube, type offeeding, tolerance of patient, and adverse effects.RATIONALE: Documentation facilitates communication with other health team


7.4. Administration of Cleansing Enema

PhysiologyThe small intestine is about 6 meters (20 feet) long. It is coiled in thecenter of the abdominal cavity (see picture). The small intestine isdivided into 3 sections: upper, jejunum, and ileum. The lining of the

198


small intestine secretes a hormone called secretin, which stimulatesthe pancreas to produce digestive enzymes. Most absorption of di-gested foods also occurs in the small intestine. From the stomach,food passes into the duodenum portion of the small intestine and,then, into the very long, coiled section of the small intestine. The totallength of the small intestine in adult men averages over twenty feet.The great length of the small intestine is but one adaptation it pos-sesses aimed at increasing the absorptive surface area of its lumen.The large intestine has a larger width but is only 1.5 meters (5 feet)long. The large intestine is divided into 6 parts: cecum, ascendingcolon, transverse colon, descending colon, sigmoid colon, and rec-tum. From the small intestine, the unabsorbed food passes into thelarge intestine or colon, at the lower right-hand portion of the ab-dominal cavity. Near the juncture of the small and large intestines, ablind sac or caecum, tipped by the appendix projects off the largeintestine. Both the caecum and appendix are functionally unimpor-tant in humans. The large intestine has three segments: the ascendingcolon, which runs up the right side of the abdominal cavity, the trans-verse colon, which runs across the top of the abdominal cavity, andthe descending colon, which runs down the left side of the abdomi-nal cavity. The large intestine reabsorbs the large quantities of waterused to secrete enzymes into the upper portions of the digestivetract. In addition, the large intestine excretes salts, such as calcium andiron, when the salts' blood concentrations are too high. The largenumbers of bacteria that inhabit the large intestine feed on the undi-gested food and make up half of the dry weight of feces. The rec-tum is the last segment of the large intestine. It stores feces untildefecation when the feces are eliminated from the rectum throughthe anus. The ultimate digestion process occurs in the large intestine,involving the elimination of undigested and unabsorbed food mate-rials, including waste products from the body. The cecum or junc-tion between the large and small intestines is located in the lowerright portion of the abdomen. The ileocecal valve, which controlsthe passage of intestinal contents into the large intestine, is located inthis junction, together with the vermiform appendix.

Absorption Process

199

Peristalsis continues in the small intestine, mixing the secretions withchyme. Small intestine as the primary absorption site for nutrients islined with fingerlike projections called the villi, which increase thesurface area available for absorption. The mixture becomes increas-ingly alkaline, inhibiting the action of the gastric enzymes and pro-moting the action of the duodenal secretions. The epithelial cells ofthe small intestines brush border microvilli secrete enzymes to facili-tate digestion. These include sucrase, lactase, maltase, lipase and pep-tidase. The major portion of digestion occurs in the small intestine,producing glucose, fructose and galactose from carbohydrates; aminoacids and dipeptides from proteins; fatty acids, glycerides and glyc-erol from lipids. Nutrients are absorbed by means of passive diffu-sion, osmosis, active transport and pinocytosis. Approximately 5 arerequired to pass food through the small intestine via peristalsis.The large intestine is composed of a descending segment on theabdomen's left side, an ascending segment on the abdomen's rightside and a traverse segment that extends. Two parts comprise theterminal portion of the large intestine-the rectum and the sigmoidcolon. As the rectum is directly connected to the anus, the anal outletis regulated by a network of striated muscle that forms the externaland internal anal sphincter.In the colon, ions are secreted for elimination or recovered alongwith water from the chyme. Colonic bacteria modify the contentssuch that biogenic amines like histamine or serotonin may be formed,the yellowish bile pigments are altered causing a brown color, andfermentation produces the odor causing chemicals in feces. Bacteriaalso make vitamin K and some B-complex vitamins that are ab-sorbed in the colon. The bacterial flora vary with individuals and canchange with diet, medication or environmental changes. Such changesmay cause diarrhea, gas or constipation. The colon is separated intothree anatomic regions; the ascending, transverse and descending. Theascending and transverse sections absorb water and electrolytes andexcrete metal ions. The descending colon removes water from thefeces and controls the delivery of feces to the rectum. Wastes areremoved by defecation as initiated by stretching of the rectal walls.The main source of water absorption is via the intestine. Approxi-


200


mately 8.5 L of GI secretions and 1.5 L of oral intake, totaling of10 L of fluids must be managed daily within the GI tract. The smallintestine reabsorbs 9.5 L and approximately 0.4 L is reabsorbed inthe colon. The remaining 0.1 L is eliminated in the feces.

MetabolismMetabolism refers to all the biochemical reactions within the cells ofthe body. Metabolic processes can be anabolic (building) or catabolic(breaking). Anabolism is the building of more complex biochemicalsubstances by synthesis of nutrients. Anabolism occurs when leanmuscle is added through diet and exercise. Amino acids are anabolizedinto tissues, hormones and enzymes. Catabolism is the breakdownof biochemical substances into simpler substances. Starvation is anexample of catabolism when wastin of body tissue occurs. Normalmetabolism and anabolism are physiologically possible when the bodyis in positive nitrogen balance, whereas catabolism occurs duringphysiologic states of negative nitrogen balance.Nutrients absorbed in the intestines, including water are transportedthrough the circulatory system to body tissues. Through the chemicalchanges of metabolism nutrients are converted into a number ofsubstances required by the body. Carbohydrates, protein, and fatundergo metabolism to produce chemical energy and to maintain abalance between anabolism and catabolism. To carry out the body'swork, the chemical energy produced by metabolism is converted toother types of energy by differnect tissues. Muscle contraction in-volves mechanical energy, nervous system function involves electricalenergy, and the mechanism of heat production involve thermal en-ergy. All of these forms of energy originate in metabolism.

EliminationChyme is moved by peristaltic action through the ileocecal valve intothe large intestine, where it becomes feces. As feces move toward therectum, water is absorbed in the mucosa. The longer the materialstays in the large intestine, the more water is absorbed causing thefeces to become firmer and results in constipation. Exercise andfiber stimulate peristalsis and water maintains consistency. Feces con-tain cellulose and similar indigestible substances, sloughed epithelial

201

cells from the GIT, digestive secretions, water and microbes.

ImportanceEnema cleansing is vital in order to:

• Empty the bowels of feces• Obtain stool specimen• Achieve thorough cleansing before operation, diagnostic

procedure or in the presence of irritating substanceFactors Affecting the Administration of Cleansing Enema

• Insertion site• Type of solution• Type of enema• Reason for enema• Age and size of patient• Medical history and present health status

Assessment SitesRectal and anal site should be inspected for the presence of sore,ulcers, mass, bleeding, pain and fistula. A patient suspected for per-foration, bleeding, colonic anomaly and appendicitis should not besubjected to this procedure. If resistance upon insertion is noted andsevere pain is encountered, never forcefully administer the enema.

Materials Required• Enema tray• Irrigating can• One-foot long rubber tubing• Clamp or stopcock• Rectal tube (French 16-24)• Kidney basin• Disposable gloves and mask• Stand• Vaseline or KY Jelly


202


• Perineal care kit and bed pan

Procedure in Administering Cleansing Enema &Rationale

Assess patient status.RATIONALE: Determines type of enema to be used and precautions to be

observed.Assess patient for intracranial pressure increase, glaucoma or re-cent rectal/prostate surgery. RATIONALE: Observes patient for conditions contraindicated to enema.Check patient's medical record.RATIONALE: Purpose of enema administration is determined.Review physician order for enema.RATIONALE: Confirms need for performance of procedure.Prepare needed equipment/supplies.RATIONALE: Provides easy access to materials needed. Conserves time and

controls infection.Explain procedure to patient.RATIONALE: Provides opportunity to educate patient. Patient anxiety is re-

duced and facilitates cooperation.Prepare enema bag with solution and rectal tube. Wash handsand apply disposable gloves.RATIONALE: Reduces transmission of microorganisms.Provide needed privacy.RATIONALE: Reduces patient embarrassment.Assist patient to establishing left side-lying position, make surethat right knee is flexed.RATIONALE: Allows for smooth flow and retention of solution following ana-

tomical location of colon.Place waterproof pad beneath patient's hips and buttocks.

203

RATIONALE: Prevents soiling of linen.Cover patient with bath blanket leaving rectal area and anus ac-cessible.RATIONALE: Prevents unnecessary exposure of patient's private body parts.Put bedpan in a readily accessible place.RATIONALE: Bedpan is to be used if patient fails to retain enema.ENEMA ADMINISTRATION

Prepackaged disposable container (fleet enema):Remove cap from rectal tip.RATIONALE: Opens rectal catheter tip. Lubrication facilitates insertion without

irritation.Locate rectum by gently separating patient's buttocks. Ask pa-tient to relax by slowly breathing out through the mouth.RATIONALE: Promotes relaxation of external rectal sphincter.Gently insert tip of bottle into rectum (about 7.5-10 cm in adult,5-7.5 cm in child, 2.5-3.75 cm in infants)RATIONALE: Prevents trauma to the rectal orifice.Squeeze bottle until entire solution has entered rectum and colon.Wait until patient feels urge to defecate.RATIONALE: Hypertonicity of solution stimulates defecation.ENEMA BAG

Pour warm solution into enema bag by warming tap water fromfaucet. Put saline container into a basin of hot water. Add salineto enema bag. Check solution temperature.RATIONALE: Cold solution can cause vasoconstriction resulting in cramping.

Hot solution however can burn intestinal mucosa.Have solution fill tubing by raising container and releasing clamp.RATIONALE: Gravity allows solution drainage to start.Reclamp tubing. Lubricate tip of rectal tube (about 6-8 cm) us-ing KY jelly.RATIONALE: Controls solution loss.


204


Locate anus by gently separating patient's buttocks. Have patientrelax by slowly breathing out through the mouth.RATIONALE: Promotes relaxation of external rectal sphincter.Insert rectal tube tip into patient's rectum. Constantly point tip indirection of patient's umbilicus.RATIONALE: Ensures smooth insertion following anatomical contour of rectum

and colon.Allow solution to slowly enter rectum by opening regulatingclamp. Container should be held at patient's hip level.RATIONALE: Gradual entry of solution decreases patient discomfort.Slowly raise container above patient's anus.RATIONALE: Container level controls speed of solution flow, the higher it is , the

faster the descent of solution.If patient complains of cramping or fluid escapes around tub-ing, lower container/clamp tubing.RATIONALE: Provides time to assess and establish patency of tube.After solution is exhausted, clamp tubing.RATIONALE: Avoids entry of air to rectum.Put layers of tissue paper around tube/anus and gently with-draw rectal tube.RATIONALE: Prevents soiling of linen.Explain normalcy of feeling of distention to patient. Instructpatient to retain solution for as long as possible.RATIONALE: Decreases patient anxiety and increases cooperation.Discard enema container or rinse thoroughly using soap and warmwater (for reusable containers).RATIONALE: Reduces transmission of microorganisms.Assist patient in going to the bathroom or aid patient in position-ing bedpan.RATIONALE: Distention of colon is uncomfortable. Client needs physical sup-

port. Squatting position facilitates easier defecation due to gravity

205

and colon's anatomical position.Examine patient's feces. Inspect color, consistency and amountof stool and fluid. Patient should be cautioned against flushingthe toilet.RATIONALE: Ensures complete evacuation of solution and provides data for

assessment.If needed, assist patient in washing anal area using soap and warmwater.RATIONALE: Hygiene enhances patient comfort and prevents infection.Remove and dispose of gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Assess condition of patient's abdomen.RATIONALE: Complete evacuation is determined.Record enema type and volume given and characteristics of re-sults.RATIONALE: For use for future legal and care management purposes.If patient is unable to defecate, report to physician.RATIONALE: Prevents occurrence of further complications or fatal effects of en-

ema to the patient. This may be an indication of a serious condition,prompt report to the physician may save the patient from fatalconditions arising.

7.5. Pouching an Ostomy

Anatomy and PhysiologyOstomy is a surgical procedure used to create an opening for urineand feces to be released from the body. Certain diseases of the bowel


206


or urinary tract involve removing all or part of the intestine or blad-der, creating the need for an alternate way to eliminate feces andurine. Thus, an opening is surgically created in the abdomen for bodywastes to pass through. The surgical procedure is called an ostomy.The opening that is created at the end of the bowel or ureter is calleda stoma, which is pulled through the abdominal wall. Different typesof ostomy are performed depending on how much and what partof the intestines or bladder is removed.The three most common types of ostomies are the following:Colostomy is done when a small portion of the colon (large intes-tine) is brought to the surface of the abdominal wall to allow stoolto be eliminated. A colostomy may be temporary or permanent. Apermanent colostomy usually involves the loss of the rectum. Theneed for a colostomy arises when the patient has cancer, diverticulitis,imperforate anus, Hirschsprung's disease or trauma to the affectedarea.Ileostomy is an opening created in the small intestine to bypass thecolon for stool elimination. The end of the ileum, which is the lowestpart of the small intestine, is brought through the abdominal wall toform a stoma. Ileoanal reservoir surgery is an alternative to a perma-nent ileostomy. Requiring two surgical procedures, the first involvesthe removal of the colon and rectum and a temporary ileostomy iscreated; the second creates an internal pouch from a portion of thesmall intestine to hold stool. This is then attached to the anus. Sincethe muscle of the rectum is left in place, there is now control overbowel movements. An ileostomy might be performed due to ulcer-ative colitis, Crohn's disease or familial polyposisUrostomy is a surgical procedure that diverts urine away from adiseased or defective bladder. There are several methods to createurostomy, the most common is called an ileal or cecal conduit. Eithera section at the end of the small intestine (ileum) or at the beginningof the large intestine (cecum) is relocated surgically to form a stomafor urine to pass out of the body. Other common names for thisprocedure are ileal loop or colon conduit. A urostomy may be per-formed due to bladder cancer, spinal cord injuries, malfunction ofthe bladder, and birth defects such as spina bifida.

207

Since colostomy, ileostomy, and urostomy bypass the sphinctermuscle, there is no voluntary control over bowel movements and anexternal pouch must be worn to catch the discharge.The skin around the stoma, called the peristomal skin, must be pro-tected from direct contact with discharge. The discharge can be irri-tating to the stoma since it is very high in digestive enzymes. Theperistomal skin should be cleansed with plain soap and rinsed withwater at each change of the pouch. The stoma can change in size dueto weight gain/loss or several other situations. To ensure proper fitof discharge pouch the stoma should be measured each time sup-plies are purchased.Ostomy can give rise to infections to some patients. Leakage fromaround due to an improperly fitted pouch can result in skin irritationsor rashes around the stoma. The best ways to prevent these includecorrectly fitting the pouch and carefully cleaning the skin around thestoma after each change.

Assessment SitesNormal resultsOstomy pouches are typically not noticeable and can be worn underalmost any kind of clothing. There are typically no restrictions ofactivity, sport or travel for people with ostomy. However, there arecertain contact sports that would warrant special protection for thestoma. After recovery from surgery, most people with ostomies canresume a balanced diet. Also, ostomy surgery does not generally in-terfere with a person's sexual or reproductive capacities.

Abnormal resultsWater and electrolyte loss may occur after an ileostomy. To preventhydration, it may be required to drink large amounts of fluid or fruitjuice every day. Digestion and absorption of medications may alsobe affected after an ostomy. For instance, eating high-fiber foods cancause blockages in the ileum, especially after surgery. Chewing foodwell helps break fiber into smaller pieces and makes it less likely toaccumulate at a narrow point in the bowel.

Ostomy PouchAn ostomy pouch is primarily to collect fecal matter. An ideal pouching


208


system provides skin protection, fecal material collection, comfortand odor management.Numerous types of pouching systems are available. The nurse shouldconsider the following to ensure that the pouch fits appropriately:

• Type and location of the ostomy• Type and amount of ostomy drainage• Size and contour of abdomen• Skin condition around the stoma• Patient's physical activities• Patient preference• Equipment cost

A pouch and a skin barrier are the two basic components of a pouch-ing system. There are two types of systems-the adhesive and non-adhesive systems. Pouches may also come in one or two pieces whichare commonly disposable or reusable. Some have pre-cut openingswhile others require custom cutting of the stoma opening.Wafers, pastes, powders and liquid films are among the commonlyused skin barriers. One-piece pouch systems have wafer barriers per-manently attached to the ostomy pouch, while two-piece systemsmay have the pouch detached from the skin barrier for the purposeof emptying/changing. It minimizes the risk of skin damage fromfrequent skin barrier removal from the peristomal skin. In the two-piece system, care should be taken to ensure that the skin barrier andpouch have the appropriate size and similar manufacturer. The nurseshould also make sure that the pouch to be used is for fecal materialcollection.

Materials RequiredPouch of correct size and type• Pouch closure device (i.e., clamp)• Adhesive remover (optional)• Clean disposable gloves

209

• Deodorant• Gauze pads• Towel• Basin with warm water• Scissors• Skin barrier (i.e., sealant wipes/wafer)• Adhesive tape

Procedures for Pouching an Ostomy & RationaleIdentify patient and identify type and location of patient's os-tomy.RATIONALE: Confirms patient's identity and provides data for nursing precau-

tions and management.Check the skin integrity of area around stoma.RATIONALE: Determines appropriate stoma to be used.Note amount of fecal material present in pouch or on dressing.RATIONALE: Measures input and output ratio.Determine patient's capacity for self-care.Provides opportunity for health teaching. Encourages independence and en-

hances patient's self-esteem.Wash hands.RATIONALE: Reduces transmission of microorganisms.Prepare necessary equipment.RATIONALE: Saves time and ensures easy access to equipment/supplies.Assist patient in going to the bathroom or provide needed pri-vacy at bedside.RATIONALE: Reduces patient embarrassment.Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Remove soiled dressing/appliance.


210


RATIONALE: Placement of new appliance is facilitated.Cleanse area around stoma using mild soap and warm water.Inspect skin for redness/irritation.RATIONALE: Reduces risk of infection while avoiding irritation. Pro-vides assessment data for nursing management.Use a piece of tissue to cover stoma. Change cover as neededduring entire procedure.RATIONALE: Aseptic measure reduces patient discomfort.Carefully dry skin around stoma, apply protective cream as nec-essary.RATIONALE: Prevents irritation and leakage. Ensures full adhesion.Make sure that skin is completely dry before reapplying pouch.RATIONALE: Prevents irritation and tissue breakdown.Remove stoma covering and apply clean pouch/dressing. Re-move gloves and wash hands.RATIONALE: Reduces transmission of microorganismsRecord procedure.RATIONALE: Documentation facilitates communication with other health team


7.6. Colostomy Irrigation

Anatomy and PhysiologyColostomy is a surgical procedure where a portion of the large in-testine is brought through the abdominal wall to carry stool out ofthe body and to treat various disorders of the large intestine, includ-ing cancer, obstruction, inflammatory bowel disease, ruptured diver-ticulum, ischemia (compromised blood supply) or traumatic injury.Temporary colostomies are created to divert stool from injured ordiseased portions of the large intestine, allowing rest and healing.Permanent colostomies are performed when the distal bowel (bowelat the farthest distance) must be removed or is blocked and inoper-

211

able. Although colorectal cancer is the most common indication fora permanent colostomy, only about 10-15% of patients with thisdiagnosis require a colostomy.

Types of ColostomyEnd colostomy. The functioning end of the intestine (the section ofbowel that remains connected to the upper gastrointestinal tract) isbrought out onto the surface of the abdomen, forming the stomaby cuffing the intestine back on itself and suturing the end to the skin.The surface of the stoma is actually the lining of the intestine, usuallyappearing moist and pink. The distal portion of bowel (now con-nected only to the rectum) may be removed or sutured closed andleft in the abdomen. An end colostomy is usually a permanent os-tomy, resulting from trauma, cancer or another pathological condi-tion.Double-barrel colostomy. This colostomy creates two separate stomason the abdominal wall. The proximal stoma is the functional end thatis connected to the upper gastrointestinal tract and will drain stool.The distal stoma, called the mucous fistula and is connected to therectum, drains small amounts of mucus material. This is typically atemporary colostomy performed to rest an area of bowel, which isclosed later.Loop colostomy. This colostomy involves the bringing of a loop ofbowel through an incision in the abdominal wall. The loop fastenedto the outside of the abdomen using a plastic rod slipped beneath it.An incision is made in the bowel to enable the passage of stool passthrough the loop colostomy. Approximately 7-10 days after surgery,the supporting rod is removed when healing has occurred that willprevent the loop of bowel from retracting into the abdomen. Usu-ally, a loop colostomy is done to create a temporary stoma to divertstool away from an area of intestine that has been blocked or rup-tured.

Types of Colostomies according to locationAscending. Found on the right abdomen, this type of colostomy hasan opening created from the ascending colon. Since the stoma is


212


created from the first section of the colon, stool is more liquid andcontains digestive enzymes that irritate the skin. This type of colos-tomy surgery is the least common.Transverse. This type may have one or two openings in the upperabdomen, middle or right side that are created from the transversecolon. When there are two openings in the stoma (called a double-barrel colostomy), one is used to pass stool and the other, mucus.The stool has passed through the ascending colon, so it tends to beliquid to semi formed.Descending or sigmoid. For this type of surgery, the descending or sig-moid colon is used to create a stoma, typically on the left lowerabdomen. This is the most common type of colostomy surgery andgenerally produces stool that is formed to semi formed because ithas passed through the ascending and transverse colon.

RisksPotential complications of colostomy surgery include:

• excessive bleeding• surgical wound infection• thrombophlebitis (inflammation and blood clot to veins in the

legs)• pneumonia• pulmonary embolism (blood clot or air bubble in the lungs'

blood supply)

Assessment SitesNormal resultsTotal healing is expected without complications. The period of timerequired for recovery from the surgery varies depending on thepatient's overall health prior to surgery. The colostomy patient with-out other medical complications should be able to resume normalday-to-day activities once recovered from the surgery.

213

Abnormal resultsThe nurse should be made aware of any of the following problemsafter surgery: increased pain, swelling, redness, drainage or bleedingin the surgical area; headache, muscle aches, dizziness or fever; andincreased abdominal pain or swelling, constipation, nausea or vomit-ing or black, tarry stools.Stomal complications to be monitored include:Death (necrosis) of stomal tissue. This complication is caused by inad-equate blood supply and is usually visible 12-24 after the operationand may require additional surgery.Retraction (stoma is flush with the abdomen surface or has movedbelow it). This complication is caused by insufficient stomal lengthand may be managed by use of special pouching supplies. Anotheroption is elective revision of the stoma.Prolapse (stoma increases length above the surface of the abdomen).This type normally results from an inadequate fixation of the bowelto the abdominal wall or an overly large opening in the abdominalwall. Surgical correction is required when blood supply is compro-mised.Stenosis (narrowing at the opening of the stoma). This is typicallyrelated to infection around the stoma or scarring. Mild stenosis canbe removed under local anesthesia. Surgery to reshape the stomamay be required with severe stenosis.Parastomal hernia (bowel causing bulge in the abdominal wall next tothe stoma). This complication is due to the placement of the stomawhere the abdominal wall is weak or creation of an overly largeopening in the abdominal wall. Using an ostomy support belt andspecial pouching supplies may be required. If severe, the defect inthe abdominal wall should be repaired and the stoma moved toanother location.Colostomy irrigation is an alternative management procedure givento patients with an end colostomy in the sigmoid or descending co-lon. Colostomy irrigation involves patients giving themselves an en-ema through their stoma to initiate evacuation of stool from the


214


large bowel. This gives the patient total freedom to defecate foraround 24-48 .Frequency of irrigation varies but it is advised that it be conductedeveryday until leakage stops. Steadily, extend irrigate every two days.Usually, it takes 2 weeks before the bowel adapts to the procedure.Afterwards, a regime can be selected to match the patient's particularneeds.The time of day that irrigation is performed is not important al-though most patients prefer to do it in the morning. Ideally, everyirrigation should be conducted at the same time every day, but this isnot that crucial.

Materials RequiredIrrigating tubeIrrigating solution (tepid water or saline)LubricantPouch of correct size and typePouch closure device (i.e., clamp)

Procedures for Colostomy Irrigation & RationaleAssess irrigation frequency and stool characteristics.RATIONALE: Reduces transmission of microorganisms Prolonged constipation

requires irrigation.Assess patient's schedule of ostomy irrigation or check physician'sorder.RATIONALE: Reduces transmission of microorganisms Establishesroutine bowel emptying. Confirms physician's order.Assess patient's understanding of the procedure and ability toperform self-care.RATIONALE: Reduces transmission of microorganisms Determines needed health

teaching and level of nursing assistance needed by patient.Explain procedure to patient.RATIONALE: Reduces transmission of microorganisms Improves patient's level

of understanding of procedure. Reduces anxiety and enhances

215

cooperation.Choose proper time for performing procedure (1 after meal).RATIONALE: Duodenal reflex is the ideal time to carry out procedure.Assist patient to establishing sitting position or if in bed, havepatient lie on one side.RATIONALE: Promotes patient comfort during procedure.Wash hands and apply disposable gloves.RATIONALE: Reduces transmission of microorganisms.Provide needed privacy.RATIONALE: Reduces patient embarrassment.Remove pouch and cleanse skin.RATIONALE: Allows for attachment of irrigation sleeve.Apply irrigation sleeve, roll up so that only bottom touches toiletwater (for patient in bed, clip bottom of drain sleeve).RATIONALE: Directs evacuated stool to toilet.Fill container with appropriate amount of irrigating solution (500-600 ml tepid water or saline). Hang in pole so that container islevel with patient's shoulder.RATIONALE: Exact amount of solution facilitates colon distention and empty-

ing. Cold water may cause syncope, while hot water may burncolon mucosa. Height influences speed of solution flow.

Attach cone to irrigating tube, allow fluid to run through entiretube length.RATIONALE: Air is pushed out.Apply lubricant to cone.RATIONALE: Prevents trauma to the stoma.Insert cone through irrigation sleeve's top.RATIONALE: Ensures confinement of stool to sleeve.Gently but firmly insert cone into stoma. Make sure that stoma isdilated before irrigating.


216


RATIONALE: Prevents trauma and ensures introduction of solution to colon.Begin solution flow and readjust cone position as needed.RATIONALE: Ensures sufficient distention and avoids leakage.Adjust solution flow by raising/lowering container. Hang irriga-tion bag 18 inches above stoma.RATIONALE: Container height facilitates increase in speed of irrigating solution's

flow, which should be controlled to avoid cramping.Slowly administer 500-1000 ml of solution over a rate of 15mins. Pause if patient cramps.RATIONALE: Administers sufficient amount of solution to cause distention.

Pause prevents leakage of solution.After solution runs in, clamp tubing and remove cone. Seal topof irrigation sleeve. A small gush of fluid should be obtained.RATIONALE: Prevents reflux contents.Clamp sleeve's top.RATIONALE: Prevents spillage of solution.After most of solution returns, use water to rinse sleeve. Foldwith end up, fasten to top and have patient mobilize.RATIONALE: Allows patient to move conveniently while waiting for 1 hr (irri-

gation time).Upon return of all feces, rinse sleeve with water and liquid cleanserand remove. Wash sleeve using soap and water, rinse and let dry.Store sleeve for future use.RATIONALE: Reduces transmission of microorganisms. Allows for reuse of

sleeve.Apply new pouch.RATIONALE: Avoids tissue breakdown and leakage.Dispose of equipment properly.RATIONALE: RationaleWash hands.

217

RATIONALE: Reduces transmission of microorganisms.Inspect fecal material and fluid volume and characteristics.RATIONALE: Provides data for evaluation of success of procedure.Note patient's response to procedure. Inquire for any discom-fort or pain.RATIONALE: Measures patient's tolerance for procedure.Palpate and auscultate abdomen.RATIONALE: Assess for possibility of injury such as perforation.Assist patient to establishing a comfortable position.RATIONALE: Restores patient comfort.Record procedure.RATIONALE: Documentation facilitates communication with other health team


7.7. Insertion/Maintenance of Nasogastric Tube

Materials Required• Micropore tape or safety pin• Plaster tape• Asepto syringe• Nasogastric tube (French 16 for adult, french 8 feeding tube

for infants) or the types of tube to be used as ordered (Levintube, Gastric Sump tube, Nutriflex tube, Moss Tube orsengstaken-blakemore tube)

• Kidney basin with half-filled water• KY Jelly• Stethoscope• Sterile gloves and mask

Procedures for Insertion/Maintenance ofNasogastric Tube & Rationale

Examine patient's nasal and oral cavity.


219

SpecimenCollection

Chapter Eight

8.1. Collection of Midstream (Clean-Voided)Urine Specimen

8.2. Insertion of a Straight or Indwelling Catheter

220


8.1. Collection of a Midstream (Clean-Voided)Urine Specimen

Anatomy and PhysiologyThe urinary system basically maintains the volume and compositionof body fluids within normal limits, with the primary activity ofeliminating body of waste products that accumulate as a result ofcellular metabolism. This system maintains a suitable fluid volume byregulating the amount of water that is excreted in the urine. Thissystem also regulates the concentrations of various electrolytes in thebody fluids and maintains normal pH of the blood. Aside frommaintaining fluid homeostasis in the body, the urinary system alsocontrols red blood cell production by secreting the hormone eryth-ropoietin. The urinary system also plays a role in maintaining normalblood pressure by secreting the enzyme renin. The urinary systemincludes the kidneys, bladder and tubes. These organs control theamount of water and salts that are absorbed back into the bloodand what is taken out as waste. This system also acts as a filteringmechanism for the blood.The urinary system consists of the two kidneys, the bladder and theadjoining tubes. They help urine produced to pass through the ure-ters into the bladder where it is stored until evacuated. Urine is thenexpelled from the body through a single tube called the urethra. Thekidneys are two large, bean-shaped organs designed to filter wastematerials from the blood. They also assist in controlling the rate ofred blood cell formation, and in the regulation of blood pressure,the absorption of calcium ions, and the volume, composition, andpH of body fluids. The kidneys are located in the upper posteriorpart of the abdominal cavity, one on each side of the spinal column.The suprarenal (adrenal) gland sits like a cap on top of each kidney.A considerable volume of fat protect the kidneys and are supportedby connective tissues and the peritoneum. The dilated upper end ofthe ureter is attached to the hollow side of each kidney, forming therenal pelvis.It can be said that the kidneys are the filters of the blood. Everyminute, one-fourth of the body's blood-approximately 1200 ml-

221

passes through the kidneys. Each kidney is composed of about onemillion microscopic filters called nephrons. These micro-filters elimi-nate toxins and waste materials from the blood and for maintain theelectrolyte balance by selectively eliminating some electrolytes whileretaining others, according to the body's needs. The kidneys also helpregulate other bodily functions by secreting the hormones renin, eryth-ropoietin, and prostaglandins. Renin helps control blood pressureand erythropoietin stimulates the body to produce more red bloodcells.Kidneys primarily function to regulate electrolytes and fluids, the acid-base balance composition of body fluids, blood pressure, as well asremove metabolic end-products from the blood. The formation ofurine is the product of these processes. Urine is transported from thekidneys through the ureters into the urinary bladder where it will betemporarily stored. During urination, the bladder contracts and theurine is excreted form the body through the urethra. About 150 L(33 gallons) of fluid pass through your kidneys every day. But 99%of this cleaned and goes back into your blood. In their lifetimes,adults pass about 40,000 L (8,800 gallons) of urine. This is enough tofill 500 bath tubs.The ureters' only function is to carry urine from each kidney to theurinary bladder. The ureters are two membranous tubes 1 mm to 1cm in diameter and about 25 cm in length. Urine is transportedthrough the ureters by peristaltic waves (produced by the ureter'smuscular walls).The urinary bladder is the temporary storage compartment of urine.The bladder possesses features that enable urine to enter, be stored,and later be released for evacuation from the body. It can hold be-tween one half to two cups of urine before it needs to be emptied.Everyday about two to five cups of urine pass through the bladder.The more water you drink, the more urine is produced. If it is hotoutside and you produce a lot of sweat, you will not make as muchurine. The bladder is a hollow, expandable, muscular organ locatedin the pelvic girdle. Although the shape of the bladder is spherical, itsshape is altered by the pressures of surrounding organs. When it isempty, the inner walls of the bladder form folds. But as the bladder

Specimen Collection

222


fills with urine, the walls become smoother.The urethra is a tube that connects the urinary bladder to the outsideof the body. The urethra has an excretory function in both sexes, topass urine to the outside. For males, it also has a reproductive func-tion-as a passage for sperm. Not surprisingly men have a longerurethra than women. This means that women tend to be more sus-ceptible to infections of the bladder (cystitis). The length and thepresence of several bends in a male's urethra make catheterizationmore difficult among men. Male urethra is approximately 8 inches(20 cm) long and opens at the end of the penis. This is divided intothree parts, named after the location: the prostatic urethra of about2.5 cm long crosses through the prostate gland and there is a smallopening where the vas deferens enters, the membranous urethra is asmall (1 or 2 cm) portion passing through the external urethral sphincterand this is the narrowest part of the urethra, the spongy (or penile)urethra runs along the length of the penis on its ventral (underneath)surface and it is about 15-16 cm in length, and travels through thecorpus spongiosum. On the other hand, the female urethra is about1-1.5 inches (2.5-4 cm) long and opens in the vulva between theclitoris and the vaginal opening. The external urethral sphincter is theskeletal muscle that allows voluntary control over urination. The uri-nary meatus is the external urethral orifice.

The UrineUrine is formed through a series of processes in the nephron, in-cluding filtration, reabsorption and secretion. About 96% of urine iswater, the remaining are waste salts and a substance called urea. Ureais made during the breakdown of proteins in your liver. Urea mayalso leave your body in sweat. If urea builds up in your body, it is asign that your kidneys are not working properly. Kidney failure canbe fatal if it is not treated quickly.Urination Micturition). The process of expelling urine from the bladderis called urination or micturition. It involves the contraction of thedetrusor muscle, and pressure from surrounding structures. Urina-tion also involves the relaxation of the external urethral sphincter.Composed of voluntary muscular tissue, the external urethral sphinctersurrounds the urethra about 3 centimeters from the bladder.

223

The distention of the bladder typically stimulates urination as it getsfilled with urine. When the walls of the bladder contract, nerve re-ceptors are stimulated, triggering the urination reflex. The urinationreflex causes the internal urethral sphincter to open and the externalurethral sphincter to relax, which will enable the bladder to empty.The bladder can hold up to 600 ml of urine. The desire to urinatemay not occur until the bladder contains.Filtration. from a glomerular capillary, urine formation begins whenwater and various dissolved substances and are filtered out of bloodplasma into the glomerular capsule. The filtered substance (glomeru-lar filtrate) leaves the glomerular capsule and enters the renal tubule.Reabsorption. As glomerular filtrate passes through the renal tubule,some of the filtrate is reabsorbed into the blood of the peritubularcapillary. The filtrate entering the peritubular capillary will repeat thefiltration cycle. This process of reabsorption changes the composi-tion of urine. For example, the filtrate entering the renal tubule is highin sugar content, but because of the reabsorption process, urine se-creted from the body does not contain sugar.Secretion. Secretion involves the process wherein the peritubular cap-illary transports certain substances directly into the fluid of the renaltubule. These substances are transported by similar mechanisms asused in the reabsorption process, but done in reverse. For instance,certain organic compounds, such as penicillin and histamine, are se-creted directly from the proximal convoluted tubule to the renaltubule. Also, large quantities of hydrogen ions are secreted in thissame manner. The secretion of hydrogen ions plays an importantrole in regulating pH of body fluids.The glomerulus filters gallons of blood daily. It is estimated that2,500 gallons of blood pass through the kidneys in 24? and about 80gallons of glomerular filtrate. All the water from this filtrate is reab-sorbed in the renal tubules except that containing the concentratedwaste products.Although the average amount of urine an adult excretes varies from

Specimen Collection

224


1,000 to 1,500 ml per day, the amount of urine excreted varies greatlywith temperature, water intake and state of health. No matter howmuch water one drinks, the blood will always remain at a constantconcentration, and the excess water will be excreted by the kidneys.A large water intake does not put a strain on the kidneys. Instead iteases the load of concentration placed on the kidneys.

ImportanceUrine specimen obtained by the nurse is crucial in diagnoses andtherapies of a patient. To competently handle this procedure, thenurse must know a number of pertinent information, including therationale for the test involved, teaching/information disseminationand preparation of the patient, proper technique in obtaining andhandling urine specimens and post-urine test procedures. A knowl-edgeable and skillful nurse is necessary to obtain an accurate result.

Factors Affecting Collection of Midstream (Clean-Voided) Urine Specimen

Sterility of the container (specimen bottle) Cleansing agent used in perineal care Urge to urinate Mental and physical conditions Medical history and present conditions Types of urine examination and analysis Compliance with preparation

Assessment SitesThe urethral meatus and surrounding area must be assessed for colorand foul smelling odor. The nurse must check for presence of soreand ulcers. These conditions may have an impact on the result of theurine analysis.

Laboratory Examinations AssessmentUrinalysis tests

pH. Indicates acid-base balance. Normal values range from 4.6 to8.0 (6.0 average). A higher result indicates a loss of acid (Alkademia

225

or alkaline pH) which may be from bacteruria, urinary tract infection(caused by Pseudomonas or Proteus organisms) or a diet high infruits and vegetables. Lower than normal results indicate Acidemia(acid urine) which may be from metabolic or respiratory acidosis,starvation, diarrhea or a diet high in meat protein or cranberries.Appearance. Normally clear, presence of pus, red blood cells, bacteriaor certain foods (e.g., large amoutns of fat), urates or phosphatesmay cause cloudy urine.Color. Normal color is Amber yellow. Abnormally colored urine mayindicate a pathological condition (e.g., bleeding from kidneys pro-duces dark red urine; bleeding from the urinary track produces brightred urine). Dark yellow urine may indicate the presence of bilirubinor urobilinogen. Pseudomanas organisums usually produce a greenurine, where certain foods and medicines change urine color (e.g.,beets can cause a red urine, rhubarb can cause a brown coloredurine.) Many commonly used drugs can affect the color of urine.Odor. A severe smell of acetone can occur with diabetic ketosis. In-fected urine has an unpleasant order.Specific Gravity. This may increase with dehydration, pituitary tumorthat causes the release of excessive amounts of ADH, a decrease inrenal blood flow, glucosuria and proteinuria. Normal values rangefrom 1.005 to 1.0A decrease in specific gravity may indicateoverhydration, diabetes insipidus and chronic renal failure.

Microscopic examinationsRed Blood Cells (RBC), White Blood Cells (WBC) and Casts (White BloodCell clumps indicating pyelonephritis or Red Blood Cell clumps indi-cating glomerulonephritis). Normal values would be up to 2 RBCsand up to 4 WBCs at low-power field, negative or occasional hya-line, no crystals or bacteria. Elevated RBC may indicate microscopichematuria. Elevated WBC and the presence of bacteria may indicateurinary track infection. Hyaline casts are conglomerations of proteinand signal proteinuria. Crystals occur with high serum acid levels(gout). Phosphate and calcium oxalate crystals may indicate hyper-parathyroidism or malabsorption states.

Specimen Collection

226


Urine ChemistryALB (Albumin) Urine Protein. Normal values range up to 8 mg/dl.Any elevated results indicate the presence of protein in the urinewhich may be due to glumerulonephritis or preeclampsia in pregantwomen.GLU (Glucose) Urine. There should be no Glucose in a urine sample.Any levels may occur in diabetics not well controlled with hypogly-cemic agents, IV administration of dextrose-containting fluids, cen-tral nervous system disorders (e.g., stroke), Cushning's syndrome,severe stress, infections and certain drugs (e.g., ascorbic acid, aspirin,keflin, epinephrine, and streptomycin).Ketones. Any keytone levels may occur in poorly controlled diabetes(most often in juvenile diabetes). Nondiabetic patients may elevatelevels with dehydration, starvation or excessive aspirin ingestion.PAP (Prostatic Acid Phosphate). This test diagnoses prostatic carcinoma,monitors efficacy of treatment for prostatic carcinmoma and inves-tigates alleged rape because phosphate occurs in high constrations inseminal fluid. Normal value ranges from 0.10 to 0.63U/ml (Bessey-Lowry), 0.5 to 2.0U/ml (Bodansky), 1.0 to 4.0 U/ml (King-Armstrong) or 0.0 to 0.8 U/L at 37?C (SI units) in adults and 6.4 to15.2 U/L in children.Aldosterone. Diagnosing pathological conditions when increased re-sults accompany decreased renin level such as aldosteronism (Conn'ssyndrome). Normal values range from 1 to 21 ng/dl (morning, stand-ing, peripheral vein), 3.2 to 11.6ng/dl (morning, supine for 2?, pe-ripheral vein) or 2 to 16ug/25? in Urine. Elevated results could indi-cate hyponatremia, hyperkalemia, stress, Cushing's syndrome, malig-nant hypertension, generalized edema (from congestive heart failure,nephrotic syndrome, cirrhosis), renal ischemia and Bartter's syndrome(a renin-producing renal tumor). Pregnancy and oral contraceptivescan also increase levels. Diuretics and steroids promote sodium ex-cretion and may raise aldosterone levels. Decreased aldosterone lev-els are seen with high sodium diets or hypokalemia. Aldosterone canalso indicate Addison's disease or toxemia of pregnancy.Antihypertensives may also reduce levels because they promote so-dium and water retention.

227

ACE (Angiotensin-Converting Enzyume); SACE. Used to test severity ofor response to therapy for diagnosed sarcoidosis.Normal test resultsvalues range from 23 to 57 U/ml (units - nanomoles/min). Elevatedlevels of ACE may indicate sarcoidosis. Other conditions that maycause a higher result than normal may be Gaucher's disease (a rarefamilial disorder of fat metabolism), leprosy, alcoholic cirrhosis, ac-tive histoplasmosis, tuberculosis, Hodgkin's disease, myeloma, scle-roderma, pulmonary embolism, and idiopathic pulmonary fibrosis.Lower than normal levels may be expected with sarcoidosis treatedwith prednisone.ASO Titer (Antistreptolysin O Titer). This is used in the diagnosis ofstreptococcal infections such as rheumatic fever, scarlet fever, bacte-rial endocarditis and glomerulonephritis. Elevated ASO usually indi-cates a recent infection with group A betahemolytic streptococcus.Normal values range (less than) <160 Todd units/ml for adults, new-born similar to mother's value, (less than) <50 Todd units/ml for 6months to 2 year olds, (less than) <160 Todd units/ml for 2 to 4 yearolds, (less than) <200 Todd units/mo for 5 to 12 year olds.Plasma Renin Activity. This test is used to measure plasma aldosteronelevel for a differential diagnosis of hyperaldosteronism. It is alsoused to detect essential, renal or renovascular hypertension. Normalvalues range from 2.9 to 24 ng/ml/h in a 20 to 39 years old adulttaken from an upright position, sodium depleted peripheral vein or2.9 to 10.8 ng/ml/h in a (greater than) >40 years old. Results varyfor a sodium replete Normal adult value range from 0.1 to 4.3 ng/ml/h age 20 to 39 years old taken in an upright position from aperipheral vein or 0.1 to 3ng/ml/h in a (greater than) >40 years old.An Increased results in aldosterone accompany with a decreased re-nin level may indicate aldosteronism (Conn's syndrome) or primaryhyperaldosteronism. Pregnancy and several drugs (e.g., oral contra-ceptives, antihypertensives, vasodilators) and certain foods (e.g., lico-rice) affect renin levels. Elevated renin levels may indicate essentialhypertension, malignant or renovascular hypertension, Addison's dis-ease, cirrhosis, hypokalemia, hemorrhage, and reni-producing renaltumors (Bartter's syndrome). Decreased levels could be associatedwith salt-retaining steroid therapy and antidiuretic hormone therapy.

Specimen Collection

228


BUN (Blood Urea Nitrogen). Part of a renal function test BUN levelsindicate primary renal disease (e.g., glomerulonephritis, pyelonephri-tis, acute tubular necrosis and urinary obstrction from tumor or stones).Normal value ranges from 5 to 20mg/dl. An elevated level my indi-cate the kidneys are overwhelmed by excessive amounts of proteinfor hepatic catabolism and so are unable to excrete the sudden loadof urea. BUN level may increase in gastrointestinal (GI) bleedingdisorders. Decreased BUN levels can occur from toxins (e.g., gen-tamicin, tobromycin, myoglbin and free hemoglobin), overhydrationor dehydration, shock, congestive heart failure, liver failure, negativenitrogen balance and pregnancy.CREA (Creatinine). Normal values range from 0.7 to 1.5 mg/dl. El-evated results may indicate renal disorders (e.g., glomerulonephritis,pyelonephritis, acute tubular necrosis and urinary obstructions).Bun-Creatinine ratio may be used to assess kidney function. A normalvalue would expect a 20 (BUN) to 1 (Createnine) ratio (some sourcesuse 15:1). When BUN level is elevated out of proportion to thecreatinine level this may indicate dehydration, gastrointestinal bleed-ing or malnutrition. When BUN level decreased out of proprtion tothe creatinine level, then low protein intake, overhydration or severeliver failure is indicated. If both levels are elevated this may be due tokidney failure or disease.Creatinine Clearance. This is used to assess renal function. Normal urinesample value ranges from 95 to 104 ml/min for men and 95 to 125ml/min for women. Lower than normal results may indicate renalartery atherosclerosis, dehydration or shock. Most primary renal dis-eases (e.g., glomerulonephritis and acute tubular necrosis) cause adecrease in creatinine clearance level. Long standing obstruction tourinary outflow can cause decreased levels.

Other Urinary Tests24-hr Urine Test for Vanillylmandelic Acid (VMA) and Catecholamines. Di-agnose hypertension secondary to pheochromocytoma. NormalValues range from 1 to 9 mg/24°. Catecholamines’ Epinephrinerange from 5 to 40ug/24°, Norepinephrine range from 10 to 80ug/24°, Metanephrine range from 24 to 96 ug/24° and

229

Normetanephrime ranges from 75 to 375 ug/24°. One or all resultsin excessive quanities in a 24-hour collection of urine may indicatepheochromocytoma. Elevated VMA and catecholamine levels alsoappear in neuroblastomas, ganglioneuromas, and ganglioblastomas.Severe stress, strenuous exercise and acute anxiety can cause elevatedcatecholamine results.Reagent strip method (dipstick) is the most commonly employed methodto test for proteinuria. It tests mainly for albumin, is sensitive to 10-30 mg/dl and is read out by a color change. The intensity of thecolor change is proportional to the concentration of protein, withtrace = 10-30 mg/dl, 1 + = 30 mg/ dl, 2 + = 100 mg/dl, 3 + = 500mg/dl, and 4 + >1000 mg/dl. Highly concentrated or alkaline(pH>8) specimens may give a false positive reaction, while very di-lute urine and globulins may give a false negative reaction.

Materials Required Perineal care materials (mild hypo-allegenic soap with tap water) Sterile specimen bottle Disposable gloves

Procedures for Collecting Midstream (Clean-Voided) Urine Specimen & Rationale

Evaluate status of patient.RATIONALE: Assesses patient's bladder for fullness, ability to cooperate and

level of assistance needed.Set up equipment and supplies.RATIONALE: Facilitates easy access to materials. Maintains sterility. Orga-

nizes nurse's working environment and saves time.Give procedure details to patient.RATIONALE: Improves patient's understanding of procedure. Reduces anxiety

and promotes cooperation.Unless contraindicated, give fluids 30 mins before specimen col-lection.RATIONALE: Encourages urination.

Specimen Collection

230


Wash hands.RATIONALE: Reduces transmission of microorganisms.Give privacy.RATIONALE: Reduces patient embarrassment.Assist or allow patient to cleanse perineal site.RATIONALE: Encourages patient independence.Set up sterile kit and prepare properly.RATIONALE: Maintains sterile field, controls spread of infection.Wear sterile gloves.RATIONALE: Prevents spread of infection.Open specimen container by placing cap with inside area facingup.RATIONALE: Prevents contamination of cap.Apply antiseptic to gauze or cotton balls.RATIONALE: To be used for further cleansing of the urethra.Let patient cleanse perineal site or assist in the process and collectspecimen:RATIONALE: Enhances patient's self-esteem and independence.For male patient, cleanse penis of patient and rinse. Pass con-tainer into stream after patient starts to urinate and gather 30-60ml of urine.For female patient, cleanse perineal area of patient and rinse.Pass container into stream after patient starts to urinate and gather30-60 ml of urine.RATIONALE: Decreases bacterial levels. Container will hold specimen collected.Before urine flow ends, remove container.RATIONALE: Prevents urine contamination by skin flora.Cover container with cap.RATIONALE: Maintains specimen sterility.Wipe off excess urine outside of container.

231

RATIONALE: Prevents spread of microorganisms from specimenPut container in a plastic specimen bag.RATIONALE: Additional infection control measure.If applicable, remove bedpan and help patient assume a com-fortable position.RATIONALE: Restores patient comfort.Properly label specimen; attach laboratory requisition slip.RATIONALE: Ensures proper identification of specimen donor and diagnosis.Take off and discard gloves. Wash hands.RATIONALE: Prevents bacterial growth in the specimen. Ensures accurate analysis.Either immediately bring specimen to laboratory within 15 minsor put in refrigerator.RATIONALE: Refrigeration preserves specimen integrity.Document time and date specimen collection.RATIONALE: Documentation facilitates communication with other health team


8.2. Insertion of a Straight or Indwelling CatheterA urinary catheter is any tube system placed in the body to drain andcollect urine from the bladder. A Foley catheter is a soft plastic orrubber tube that is inserted into the bladder to drain the urine. Uri-nary catheters are sometimes recommended as way to manage uri-nary incontinence and urinary retention in both men and women.

Urinary CathetersUrinary catheters may be used to drain the bladder. This is often alast resort because of the possible complications associated with con-tinuous catheter usage. Complications of catheter use may include:urinary tract and/or kidney infections, blood infections (septicemia),urethral injury, skin breakdown, bladder stones, and blood in the

Specimen Collection

232


urine (hematuria). After many years of catheter use, bladder cancermay also develop.Your health care provider may recommend use of a catheter forshort term use or long term use (indwelling). The catheter may beleft in place during this time or you may be instructed on a procedurefor placing a catheter just long enough to empty the bladder and thenremove it (clean intermittent self catheterization).Catheters come in a large variety of sizes (12 Fr., 14 Fr.,... 30 Fr.),materials (latex, silicone, Teflon) and types (Foley catheter, straightcatheter, coude tip catheter). It is recommended that you use thesmallest size of catheter, if possible. Commonly, a size 14 Fr. or size16 Fr. catheter is used. Some people may require larger catheters tocontrol leakage of urine around the catheter or if the urine is thickand bloody or contains large amounts of sediment. Be aware thatlarger catheters are more likely to cause damage to the urethra. Somepeople have developed allergies or sensitivity to latex after long termlatex catheter use; these people should use the silicone or Teflon cath-eters.

Long Term (Indwelling) Urethral CathetersA catheter that is left in place for a period of time may be attached toa drainage bag to collect the urine. There are two types of drainagebags. One type is a leg bag, which is a smaller drainage device thatattaches by elastic bands to the leg. A leg bag is usually worn duringthe day since it fits discreetly under pants or skirts, and is easily emp-tied into the toilet. The other type of drainage bag is a larger drainagedevice (down drain) that may be used during the night. This device isusually hung on the bed or placed on the floor.

ImportanceInsertion of this device is required in order to:

• Prevent or relieve over distention owing to patient's inability tourinate

• Empty the bladder as:- prior to instillation, irrigation, operation or delivery

233

- prevention of complication when voluntary urination iscontraindicated

• Secure urine for analysis and culture• Remove residual urine• Manage incontinence when all other measures have failed• Provide for intermittent or continuous bladder drainage and

irrigation.• Prevent urine from contacting an incision after perineal surgery• Facilitate an accurate measurement of urinary output.• Empty the bladder completely prior to surgery to prevent

inadvertent injury to adjacent organs.

Factors Affecting Urinary Catheterization• Site of Insertion• Type of catheter

Assessment SitesUrethral meatus and surrounding area should be assessed for colorand foul smelling odor. The nurse should inspect for the presence ofsore and ulcers, lump or mass and fistula. Upon insertion, if resis-tance is encountered, do not attempt to insert the catheter forcefully.

Materials Required• Perineal care materials• Catheter (straight or indwelling)

female : french 10-12male : french 14-18child : 5-10

• Sterile and disposable gloves• KY Jelly• Kidney basin• Cotton balls

Specimen Collection

234


• Anti-septic solutions• Clamp• 10 cc syringe• Sterile saline solution

Procedures for Insertion of a Straight orIndwelling Catheter & Rationale

Evaluate status of patient.RATIONALE: Provides baseline data for nursing care management.Assess medical record of patient.RATIONALE: Determines patient diagnosis and existing care management.Evaluate knowledge of patient of catheterization's purpose. Giveprocedure details to patient.RATIONALE: Provides opportunity for health teaching. Improves patient's un-

derstanding of procedure. Reduces anxiety and enhances coopera-tion.

If needed, make arrangements for assistance.RATIONALE: Prevents muscle strain/injury on part of the nurse.Start intake and output monitoring.RATIONALE: Determines function of the kidneys.Wash hands.RATIONALE: Reduces transmission of microorganisms.Give privacy.RATIONALE: Reduces patient embarrassment.Elevate bed to proper working level. If right-handed, stand onbed's left side, if left-handed, stand on right side. Clear bedsidetable and prepare equipment.RATIONALE: Good body alignment is maintained. Provides for good organiza-

tion during performance of procedure.Elevate side rail located on bed's opposite side. Bring down siderail on working side.

235

RATIONALE: Prevents patient injury from falling.Put under patient the waterproof pad.RATIONALE: Prevents soiling of linen.Put patient to proper position:For female patient, help patient to dorsal recumbent position.Request patient to relax thighs to enable external rotation of hipjoints. If patient cannot be placed in supine position, put patientin side-lying position with upper leg flexed at knee and hip.For male patient, help patient to supine position with slightly ab-ducted thighs.RATIONALE: Exposes perineal area.Drape patient:For female patient, diamond drape patient.For male patient, drape upper trunk of patient using bath blan-ket. Cover lower extremities using bed sheets, leaving genitaliaexposed.RATIONALE: Prevents unnecessary exposure of patient's private body parts.Wear disposable gloves.RATIONALE: Reduces risk of infection.As needed, cleanse perineal area of patient using soap and waterand completely dry area.RATIONALE: Prevents growth of infectious microorganisms and promotes pa-

tient comfort.Take gloves off.RATIONALE: Facilitates ease in carrying out procedure.To illuminate perineal area, position light.RATIONALE: Provides a better view of perineum.After opening draining system package, put drainage bag on topof edge of bed frame's bottom. Position drainage tube up be-tween mattress and side rail (indwelling catheter only). As perinstructions, open catheterization kit, maintaining container's bot-tom sterile. Wear sterile gloves. Prepare supplies on sterile field.

Specimen Collection

236


Open inner sterile package containing catheter. Apply sterile anti-septic solution to the appropriate compartment containing ster-ile cotton balls and open packet containing lubricant. Take speci-men container off (lid must be loosely put above) and pre-filledsyringe from tray's collection compartment. Put them aside onsterile field.RATIONALE: Contamination is avoided. Risk of infection is reduced.Try balloon. Inject fluid from prefilled syringe into balloon port.RATIONALE: Product is tested for defects.For female patients, lubricate 2.5-5 cm of catheter. For male pa-tients, lubricate 12.5-17.5 cm.RATIONALE: Facilitates easier and smoother insertion. Male patients require

more lubrication owing to length of the male urethra.Put sterile drape:For female patient, let drapes' top edges to form cuff aboveboth hands. Put down drape on bed between the thighs of pa-tient. Slip cuffed edge a little below buttocks of patient. Liftfenestrated sterile drape and let it unfold without contacting anunsterile object. Put drape over perineum of patient, with labiaexposed.For male patient: Using the first method, place drape over thighsof patient and below penis without totally opening fenestrateddrape. Using the second method, place drape over thighs ofpatient slightly under penis. Lift fenestrated sterile drape, let itunfold, and drape it on penis, with fenestrated slit placed overpenis.RATIONALE: Prevents unnecessary exposure of patient's private parts, while

maintaining sterility. Reduces patient anxiety.Put sterile tray and content on sterile drape between the thighs ofpatient and open specimen container.RATIONALE: Sterility is maintained.Cleanse urethral meatus:For female patient, retract labia of patient using nondominanthand to completely expose urethral meatus and sustain

237

nondominant hand's position throughout the process. Pick upantiseptic solution-saturated cotton balls using forceps and cleanperineal area wiping front to back, from clitoris to anus. Includewiping far labial fold, near labial fold, and center of urethralmeatus.For male patient, use nondominant hand to retract foreskin ofthe penis of patient and hold penis at shaft slightly under glans.Retract urethral meatus between thumb and forefinger and sus-tain nondominant hand's position throughout the process. Pickup antiseptic solution-saturated cotton balls using forceps andclean penis. In circular motion, move cotton ball starting fromurethral meatus toward glans' base. Repeat procedure three moretimes using a new cotton ball for each instance.RATIONALE: Ensures sterility of procedure.Using gloved dominant hand, pick up catheter 7.5-10 cm fromcatheter tip. Hold catheter's end loosely coiled in dominant hand'spalm.Facilitates insertion without contamination.Insert catheter:For female patient: As if voiding urine, have patient gently beardown. through urethral meatus, insert catheter slowly.RATIONALE: Provides a better view of urinary miatus expansion.Move catheter 5-7.5 cm in adult or until the time urine oozes outof the end of catheter. Without forcing, move catheter another2.5-5 cm as urine appears. Put catheter's end in urine tray recep-tacle.RATIONALE: Determines length of urinary miatus while catching urinary

output.Let labia off and, with dominant hand, firmly hold catheter andinflate retention catheter's balloon.RATIONALE: Anchors catheter in the bladder.For male patient: Raise penis of patient to a perpendicular posi-tion to his body and put light traction.RATIONALE: Eases catheter insertion by straightening urethral passage.As if voiding urine, have patient gently bear down. Throughurethral meatus, insert catheter slowly.

Specimen Collection

CatheterizationChapter Nine

9.1. Care of Indwelling Catheter

9.2. Irrigation of Closed and Open Catheter

9.3. Condom Catheter Application

240


9.1. Care of Indwelling Catheter[For lecture, please refer to 8.2]

Materials Required• Perineal care materials• Catheter (straight or indwelling)• female : french 10-12• male : french 14-18• child : 5-10• Sterile and disposable gloves• KY Jelly• Kidney basin• Cotton balls• Anti-septic solutions• Clamp• 10 cc syringe• Sterile saline solution

Procedures for Care of Indwelling Catheter &Rationale

Evaluate bowel incontinence or discomfort of patient at inser-tion site of catheter.RATIONALE: Accumulation of secretions or feces causes irritation to perineal

tissues and acts as a source of bacterial growth.Set up equipment and supplies.RATIONALE: Right preparation conserves time and energy for the nurse and

provides comfort for the patient.Give procedure details to patient. Give privacy.RATIONALE: Information promotes patient's cooperation and reduces anxiety.

Reduces embarrassment for the patient and providing privacy isone of the patient's rights.

Wash hands.RATIONALE: Reduces spread of microorganisms.

241

Properly position patient. Put waterproof pad under patient.RATIONALE: Ensures easy access to perineal tissues. Prevents soiling of linen.Drape patient. Wear disposable gloves.RATIONALE: Prevents unnecessary exposure of urethral areas. Reduces spread

of microorganisms.Unfasten anchor tapes to free tubing of catheter.RATIONALE: For easy manipulation of catheter tube and facilitates tasks.Expose and examine urethral meatus of patient.RATIONALE: Determines presence of local infection and status of hygiene.Wash perineal tissues of patient with soap and water.RATIONALE: Promotes perineal hygiene.For female patient, wash labia minora and labium majora, clean-ing toward anus. Put catheter down.RATIONALE: Provides full visualization of urethral meatus. Full retraction

prevents contamination during cleansing.For male patient, first wash around catheter, going toward glansand meatus in circular manner.RATIONALE: Accidental dropping of penis during cleansing requires repeat of

procedure.Reevaluate meatus of patient for discharge.RATIONALE: Determines presence of local infection and status of hygiene.In a circular motion, wipe using soap and water around 10 cmbelow catheter's length.RATIONALE: Reduces presence of secretion or drainage on exterior of catheter

surface.If ordered, administer antibiotic ointment along catheter and onmeatus.RATIONALE: Further reduces growth of microorganism at insertion site.

Catheterization

242


Remove gloves and supplies. Wash hands.RATIONALE: Reduces spread of microorganism and risk nosocomial infection.Document and report status of patient's catheter.RATIONALE: Documentation facilitates communication with other health team


9.2. Irrigation of Closed & Open Catheter

Materials Required• Perineal care materials• Catheter (straight or indwelling)• female : french 10-12• male : french 14-18• child : 5-10• Sterile and disposable gloves• KY Jelly• Kidney basin• Cotton balls• Anti-septic solutions• Clamp• 10 cc syringe• Sterile saline solution

Procedures for the Irrigation of Closed & OpenCatheter and Rationale

Check order of prescriber.RATIONALE: RATIONALE: Catheter irrigation is an invasive procedure and a

dependent nursing procedure therefore needs doctor's order.Examine amount and appearance of urine of client and typecatheter used.RATIONALE: Urine characteristics and quantity is a good indicator of kidney

function. This can also be affected by the type of catheter used.

243

Establish catheter patency.RATIONALE: Out put quantity and quality may be affected by any tubing

obstruction.Measure urine in drainage bag.RATIONALE: Intake and out put should be commensurate, alteration in the

balance affects homeostatsis.Give procedure details to client.RATIONALE: Any procedure that is to be done is a primary patient concern, its

an illustration of respect to patient's privacy.Wash hands.RATIONALE: Ensures infection control.Wear disposable gloves for closed method (see below).RATIONALE: Maintains sterility and protects nurse from urine contamination.Give privacy.RATIONALE: Avoids unnecessary exposure minimizes client's discomfort.Examine if client has bladder distention.RATIONALE: Distention may be a sign of obstructed or dislodged tubing.Properly position client.RATIONALE: Obstruction or kinking may also be related to posture.CLOSED INTERMITTENT IRRIGATION

Set up solution and inject into syringe.RATIONALE: Usage of syringe will accurately administer medication internally

without spillage.Attach indwelling catheter under injection port.RATIONALE: Seals the syringe tip towards the catheter administration port.Use swab to cleanse port.RATIONALE: Ensures infection control.Draw syringe at 30° angle.RATIONALE: Enhances gravitational pull of syringe fluid.

Catheterization

244


Inject fluid gradually into bladder and catheter.RATIONALE: So as not to cause discomfort and trauma to bladder.Remove syringe, take off clamp, and let solution to drain intobag.RATIONALE: Ends the irrigation of fluid, avoids backflow of irrigating solu-

tion to syringe.CLOSED CONTINUOUS IRRIGATION

Observing aseptic method, draw irrigation tubing's tip into bagcontaining solution.RATIONALE: Gravitational pull facilitates irrigation.Close tubing clamp and put solution on IV pole.RATIONALE: Facilitates higher (Bag on the pole) to lower (patient's catheter)

movement of fluid .Open clamp to let solution flow through tubing and then closeclamp.RATIONALE: Opens the flow tube, initiating irrigation.Using a triple lumen catheter or Y connector, securely attach irri-gation tubing to double lumen catheter.RATIONALE: Ensures closed system, eliminates entrance of pathogens from the

surrounding.Intermittent flow:Clamp tubing on drainage and open irrigation tubing. Let pre-scribed amount to go into bladder. Afterwards, close irrigationclamp and open drainage clamp.RATIONALE: Avoids excessive amount to enter into the bladder that would

cause trauma, irritation or discomfort.Continuous irrigation:Measure drip rate and adjust tubing clamp. Determine patencyand security of system.RATIONALE: The physician have already anticipated the bladder's capacity to

hold continous irrigation, removing solid particles inside such asblood clots.

245

Open irrigation:RATIONALE: Time to relieve the bladder from fluid volume and flush solid

sediments inside.Set up sterile supplies.RATIONALE: Ensures aseptic field to prevent infection.Wear sterile gloves and position waterproof drape.RATIONALE: Ensures infection control and avoids spillage of irrigation on bed.Aspirate 30 ml of solution into sterile irrigating syringe.RATIONALE: Flushes out solid particles from the bladder by initiating negative

pressure.Detach catheter from drainage tubing. Let urine flow into basin.Cover tubing's open end with sterile cap. Assist pressure to drawfluid volume from the inside of the bladder. Inject syringe, slowlyinstill solution, then withdraw syringe.RATIONALE: Creates a cycle of introduction of irrigating solution and with-

drawal to achieve purpose of flushing and , softening obstructiveparticles.

Let solution flow into basin. Repeat procedure until drainage isempty.RATIONALE: Limits the irrigation process until therapeutic level based on

doctor's order.When irrigation is finished, initiate closed drainage system.RATIONALE: Prevents entrance of pathogens into the tubing to the bladder.Either change client position or gently aspirate solution if solu-tion does not come back.RATIONALE: Moving client from one position to another aids in gravitational

pull of irrigating solution from the inside of the bladder.Anchor back catheter to client.RATIONALE: Avoids disconnection by pulling.Help client assume comfortable position.

Catheterization

246


RATIONALE: Changing position may to drain irrigating fluid may cause toassume uncontrollable position.

If indicated, bring down bed and elevate side rails.RATIONALE: Ensures safety from injury such as fall.Discard supplies.RATIONALE: Avoids contamination.Take off and discard gloves.RATIONALE: Aseptic measures.Wash hands.RATIONALE: The best method to avoid infection.Measure usage of irrigation fluid then subtract from total drain-age.RATIONALE: Ensures balance of input and output, avoids retention that may

harm patient.Document and report amount and type of irrigation, drainagecharacter, and any abnormal findings.RATIONALE: Documentation facilitates communication with other health team


9.3. Condom Catheter Application

Condom CatheterThe systems for men usually consist of a pouch or condom likedevice that is securely placed around the penis. This is often called acondom catheter. A drainage tube is attached at the tip of the deviceto remove urine. The drainage tube then empties into a storage bag,which can be emptied directly into the toilet. Condom catheters aremost effective when applied to a clean, dry penis. It is sometimeshelpful to trim excess pubic hair from the area, because excess hairmay prevent the appliance from securely attaching to the penis. Thesedevices must be changed at least every other day, to protect the skin

247

of the penis and prevent urinary tract infections. Make sure the con-dom device fits snugly but not too tightly, as this may cause skinbreakdown.

Materials Required• Perineal care materials• Sterile and disposable gloves• Condom catheter

Procedures for Condom Catheter Application andRationale

Examine urinary status of patient.RATIONALE: Assessment provides baseline data for nursing care.Evaluate mental status of patient.RATIONALE: Invasive procedures needs client's permission, abnormal mental

status prevents the client to decide for himself.Study the penis condition of patient.RATIONALE: Assess for redness prior to procedure which can be mistaken as

contact irritation.Determine knowledge of patient on the aim of using condomcatheter. Give procedure details to patient.RATIONALE: Awareness minimizes fears, resistance to cooperate and promotes

self esteem.Coordinate for assistance if moving dependent patient.RATIONALE: Over exertion during lifting procedures can strain or injure nurse's

back.Wash hands.RATIONALE: Ensures asepsis.Give privacy.RATIONALE: Assures respect to client.Elevate bed to proper working level. Lift up side rail on bed'sopposite then bring down side rail on working side.

Catheterization

248


RATIONALE: To ensure safety from fall through nurse's opposite side.Help patient assume a supine position then cover patient's uppertorso with bath blanket. Since only genitalia must be exposed,fold sheets.RATIONALE: Ensures privacy and unnecessary exposures.Set up urinary drainage collection tubing and bag. Clamp offport of drainage bag and secure collection bag to bed frame.Carry drainage tubing up via side rails and onto bed. If needed,leg bag for connection to condom catheter.RATIONALE: To avoid spillage of urine from the bag caused by accidental

rupture or disconnection from tubing.Wear disposable gloves.RATIONALE: Ensure infection control.Cleanse perineal area of patient and dry completely.RATIONALE: Ensures dryness, comfort and prevents growth of microorganisms

since wetness encourages bacterial growth.Trim hair at base of penis of patient.RATIONALE: Avoid hindrance during adhesive or snap application.Administer skin preparation to penis of patient and let it dry.RATIONALE: Ensures infection control.Bring foreskin back to normal position if patient is uncircum-cised hile use dominant hand to hold condom sheath and penistip, then gradually roll sheath onto patient's penis.RATIONALE: Avoids discomfort and provides stability of the organ during

application.Using strip of elastic adhesive, spiral wrap penile shaft of pa-tient. Avoid using tape since it may prevent circulation.RATIONALE: Absence of tape's elasticity results to tight which impedes circula-

tion.Attach drainage tubing to condom catheter's end. It is possibleto attach catheter to large volume bag or leg bag.RATIONALE: Facilitates collection of urine into the bag.Put tubing's excess coiling on bed and secure to sheet's bottom.RATIONALE: Avoids accidental pulling of excess tubings.

Special TherapeuticProcedures

Chapter Ten

10.1. Elastic Stockings Application

10.2. Positioning Clients in Bed

10.3. Transfer Techniques

10.4. Assessing for Risk of Pressure Ulcer

Development

10.5. Pressure Ulcer Treatment

10.6. Performing Wound Irrigations

10.7. Applying an Abdominal, T, or Breast Binder

10.8. Elastic Bandage Application

10.9. Moist Hot Compress Application

10.10. Postoperative Exercises Demonstration

10.11. Crutches

250


10.1. Elastic Stockings Application (Anti-embolicstockings)

Anatomy and PhysiologyCirculatory SystemThe purpose of the circulatory system is to deliver oxygen and nutri-ents throughout the body and to remove waste products. Your ar-teries are muscular tubes that vary in size and extend into all parts ofyour body. They carry oxygen and nutrient enriched blood to yourmuscles and organs. Veins are collapsible tubes that carry waste prod-ucts and deoxygenated blood from your muscles and organs backto the heart and lungs.

Peripheral Circulation/Venous ValvesThere are three primary parts to the peripheral venous system. Thedeep venous system, superficial venous system and the perforator/communicator veins. All of these systems return blood back fromyour arms and legs to your heart. When you breath and move yourarms and legs blood is propelled toward your heart. Valves insideyour veins help prevent your blood from flowing backward intoyour arms and legs. Sometimes these valves become damaged andcan no longer prevent the backward flow of blood into your armsand leg. This is called venous valvular incompetence and may causevaricose veins and or swelling in the affected extremity.Deep Venous System. The deep veins are well supported by muscletissue and protected by the bones in your body. These veins have adirect route back to your heart and lungs.Superficial Venous System. The superficial veins lie close to the skin andare not as well protected or supported. These veins do not have adirect route back to the heart. They lead back to the heart by eitherconnecting to the deep veins or by connecting through a perforator/communicator veins.

Risk Factors Changes in medications

251

History of venous thrombosis Obesity Pregnancy Prolonged bed rest or immobilization Surgery Trauma to blood vessel Peripheral Venous Examination

AssessmentThis test is to provide information about blood clots that can forminside your veins. By placing a special probe (a microphone-like de-vice) on your arms/legs, the vascular technologist examines the veinsusing ultrasound, which can help physicians determine if you have ablood clot. Using this information, your medical caregiver can makespecific recommendation about any further testing or proceduresthat may follow the examination. You will be asked to lie down on atable and exposing your arms or legs. The technician will then place awater based gel on the areas that he/she will need to examine. Thetime the exam takes is different for each person, but you can expectabout 45 minutes for the exam. There are several reasons your medi-cal care giver may request this examination. The following are ex-amples of these symptoms:

Swelling Difficulty Breathing Chest Pain Pain in your legs or arms Ulcers Inflammation of the skin

Peripheral Venous ExaminationDuplex Imaging and Physiological Testing (Doppler) of the Deep &Superficial Venous System examines the different parts of the fol-lowing:Lower Extremities

Deep Venous System

Special Therapeutic Procedures

252


Common Femoral Vein Superficial Femoral Vein Proximal Deep Profunda Vein Popliteal Vein Posterior Tibial Veins Peroneal Veins Deep Muscular Calf Veins Superficial Venous System Greater Saphenous Vein Lesser Saphenous Vein Varicosities Communicator/Perforator Veins (When Indicated)

Upper Extremities

Deep Venous System Internal Jugular Vein Subclavian Vein Axillary Vein Brachial Vein Radial Vein Ulnar Vein

Superficial Venous System Basilic Vein Cephalic Vein

Dependent on a properly-functioning cardiovascular system, adequateperfusion is necessary for oxygenation and nutrition of body tissues.Various factors control sufficient blood flow, such as efficient pumpingaction of the heart, patent and responsive blood vessels, and an ad-equate circulating blood volume. Likewise, activity of the nervoussystem, viscosity of blood, and the metabolic requirements of tis-sues influence the rate of blood flow and thus the adequacy of bloodflow.Venous insufficiency is often accompanied by edema and decreasedoxygen and nutrient composites in tissue. Since Iymph drainage canbe augmented by external pressure, proximal venous flow also ben-efits from external compression. use of pneumatic compression de-vices to treat venous insufficiency has proven highly successful. Pump-ing promotes cutaneous circulation, which in turn, increases the oxy-

253

gen content of tissues.

The Elastic Stockings (Anti-embolic )The wearing of anti-embolic stockings is prescribed to improve thecirculation; prevent blood clots from forming in the legs (due to areduction in physical activity); and to reduce ankle swelling whichhelps your wounds to heal. These help increase venous return. Elasticstockings should be worn during the day and taken off and washedat night until the first post-operative appointment with your visitingmedical practitioner or as otherwise prescribed by the visiting medi-cal practitioner. The stockings are left insitu except for bathing andare not routinely taken off at night and replaced in the morning.These stockings are designed to reduce the risk of thrombo-embolicdisease caused by immobilization. Compression stockings are animportant part of the management of chronic venous ulcers, vari-cose eczema, and edema. They are graded according to the level ofankle pressure they exert. DVA supports a full assessment includingdoppler, before their application to exclude any contraindicationsfor use, particularly to exclude arterial insufficiency. A trained fittershould measure the individual to ensure correct fit. Below knee com-pression stockings are adequate in most situations and promote higherdegrees of compliance and independence in the entitled person. It isnecessary to take these stockings off at night and replace them in themorning ideally before getting out of bed so that there is no oppor-tunity for dependent edema to accumulate.

Importance To provide firm support to the soft tissues Prevent venous blood from pooling Prevent blood clots from developing in the deep veins To maintain venous return To provide adequate and equal pressure without impairing bloodflow

Factors Affecting Application of Elastic Stockings Age and size of patient Size of anti-embolic stockings Compliance with the treatment


254


Medical history and present health conditions Skin condition Environment and climate Treatment duration Virchow's triad (Rudolf Ludwig Karl Virchow)

Hypercoagulability: all patients with clotting disorders, fever ordehydration; during patency and first 6 weeks postpartum if thewoman was confined to bed; and with oral contraceptive use(especially if patient smokes)

Venous wall abnormalities: local trauma, orthopedic surgeries, majorabdominal surgery, varicose veins, atherosclerosis.

Blood stasis: immobility, obesity, pregnancy.

Assessment SitesIt is important that extremities be assessed for cyanosis, sores andulcer, pressure sites and inflammation signs. If on maintained stock-ings, observe for capillary refill, impaired blood flow and compart-ment syndrome.

Materials Required Correct size of anti-embolic stockings

Procedures for Elastic Stockings Application &Rationale

Determine patient's need for elastic stockings.RATIONALE: Patient must have at least one of the alterations based on Vinchow's

triad.Assess for signs/conditions that might be contraindicated to theuse of elastic stockings.RATIONALE: Skin lesions, skin graft and disproportionately large thighs are

contraindicated to this procedure.Review prescriber's order.RATIONALE: Ensures that correct procedure is performed on the correct pa-

tient.Assess patient's understanding of elastic stockings application.

255

RATIONALE: Provides opportunity for health teaching. Reduces patient anxietyand promotes cooperation.

Assess and record condition of patient's skin and legs circulation.Explain to patient the procedure and reasons for applying stock-ings.RATIONALE: Provides baseline data on circulatory and integumentary condi-

tion needed for care management.Measure patient's legs to determine proper size of stockings tobe applied.RATIONALE: Appropriate stocking size prevents excessive compression and

injury to skin and blood vessels.Wash hands.RATIONALE: Reduces transmission of microorganisms.Assist patient to establish supine position.RATIONALE: Eases stockings application and promotes even distribution of

blood.Clean patient's legs and apply a small amount of talcum powderif not contraindicated.RATIONALE: Eases application of stockings as powder reduces friction.Stockings application:Turn stockings inside out.RATIONALE: Facilitates easier application of stockings.Position patient's toes into foot of stocking. Make sure that sockis smooth.RATIONALE: Circulation can be impeded by wrinkles in stockings.Slide remaining parts of stocking into patient's foot. Check cov-ering of toes and position of heel.RATIONALE: Toes must be covered to avoid constrictionSlide stocking up to patient's calf until totally extended andsmooth.RATIONALE: Ridges can obstruct venous return.


256


Caution patient against partially rolling stocking down.RATIONALE: Rolling stockings down can cause constricting action.Assist patient to comfortable position.RATIONALE: Restores patient comfort.Wash hands.RATIONALE: Reduces transmission of microorganisms.Examine stocking, making sure there are no wrinkles.RATIONALE: Circulation can be impeded by wrinkles in stockings.Observe patient's reaction to stockings.RATIONALE: Determines presence of discomfort or adaptation to applied stock-

ings.Stockings should be removed at least once every 8 hrs, assessskin and circulation of legs.RATIONALE: Ensures good skin circulation.Record procedure and report skin condition and circulatory as-sessment.RATIONALE: Documentation facilitates communication with other health team


10.2. Positioning Patients in Bed

Anatomy and PhysiologyBody mechanics is the process by which the body moves and main-tains balance via the most efficient utilization of all body parts toavoid harm to other body parts. It is also the efficient coordinationand safe use of the body to produce motion and maintenance ofbalance during any activity. Proper movement optimizes body func-tioning of the musculoskeletal system. Structure reduces the energynecessary for movement and maintaining balance, thus reducing fa-tigue.

257

Body alignment is the arrangement of body parts in relation to eachother. Sound body alignment promotes maximum balance and bodyfunctioning in whatever position the patient assumes, whether lyingdown, sitting or standing. Good body alignment and good postureare synonymous in context.

ImportanceProvision of comfort is the intervention that covers the promotive,curative, preventive, rehabilitative, and palliative aspects of care. Toprovide safety and comfort to both patients and health care pro-vider, the nurse must be knowledgeable and competent in applyingthe body mechanics principles.

Factors Affecting Positioning and TransferringPatients

Medical history and present health condition Age, weight, height and size of patient Compliance with the procedure Skill and strength of health care provider Mental status Muscle strength and endurance of the patient

Assessment SitesThe nurse must take into account the affected, injured or problemarea of the patients. Presence of bed sores should also be checked.Most importantly, the nurse must assess the muscle tone, strength,endurance of the patient and recovery or improvement.

Materials Required Turning team Linen Mattress Drape Supportive tool such as overhead trapeze, bars, canes etc.

Procedures for Positioning Patients in Bed &Rationale


258


With patient lying down, assess patient's body alignment andcomfort level.RATIONALE: Alignment and position is determined when patient is lying down.

Provides baseline data for evaluation of procedure's effectiveness.Assess patient's physical capacity to aid in moving and mobility.RATIONALE: Encourages patient independenceRaise bed to achieve comfortable height.RATIONALE: Promotes proper body mechanics and avoids lifting-related inju-

ries.Remove pillows or any devices used in previous position.RATIONALE: Removes interference during movement.Ask for assistance if necessary.RATIONALE: Ensures nurse and patient safety.Explain procedure to patient.RATIONALE: Reduces patient anxiety and promotes cooperation.PATIENT POSITIONING IN BED

Move immobile patient in bed (single nurse):Have patient lie on back with head of bed in a flat position.RATIONALE: Minimizes gravitational pull on patient's upper extremeties which

may hinder the procedure.Remove pillow from under patient's head and place it at headof bed.RATIONALE: Prevents patient from accidentally bumping head on board.Start with patient's feet. Face bed's foot at a 45? angle. Place feetapart with foot nearest bed's head behind other foot. If needed,flex knees and hips to bring arms level with patient's legs. Shiftweight from front to back leg. Slide patient's legs diagonally to-ward bed's head.RATIONALE: These parts can move by following the upper extremeties because

they are lighter. Ensures proper balance when nurse is facing the

259

direction of movement. Shifting weight from one leg to the otherdecreases force exerted to move load. Diagonal movement allowspull on the direction of force. Flexing knees lowers nurse's centerof gravity, thigh muscles are utilized instead of back muscles.

Move parallel to patient's hips. Flex knees and hips (if needed) tobring arms level with hips of patient.RATIONALE: Maintains nurse's proper body alignment. Flexed knees lowers

center of gravity and uses thigh muscles instead of back muscles.Diagonally, slide patient's hips toward bed's head.RATIONALE: Facilitates alignment of patient's feet and hips.Move parallel to patient's head and shoulders. Flex knees andhips (if needed) to bring arms level with patient's body.RATIONALE: Body alignment is maintained. Brings nurse closer to patient's

body. The center of gravityis lowered. Prevents usage of backmuscles, thigh muscles are used instead.

Slide arm nearest to head of bed underneath patient's neck. Reachhand under patient to support patient's shoulders.RATIONALE: Prevents injury during movement by supporting the head and

neck. Maintains alignment of body parts.Put other arm under upper portion of patient's back.RATIONALE: Reduces friction during movement while patient's body weight is

supported.Diagonally slide patient's trunk, shoulders, head, and neck to-ward head of bed.RATIONALE: Patient's body is re-aligned on one side of bed.Repeat procedure while alternating sides until patient reachesappropriate position in bed.RATIONALE: Organizes positioning steps.Assisting patient in moving up in bed (one or twonurses):Have patient lie on back with bed head flat.RATIONALE: Minimizes pull of gravity on patient's upper extremities.


260


Remove pillow from beneath patient's head and shoulders. Putpillow at head of bed.RATIONALE: Prevents accidental bumping of patient's head on board.Face head of bed.RATIONALE: Maintains proper alignment.Put one arm under patient's shoulder and the other beneath thethighs. Alternative position: One nurse should be positioned atpatient's upper body. The nurse will put arm closest to head ofbed beneath patient's head and opposite shoulder. The other arm(nurse) should be placed under patient's nearest arm and shoul-der. Another nurse will be positioned at patient's lower torso.This nurse will put arms under patient's lower back/torso.RATIONALE: Evenly distributes support to patient's musculoskeletal system.Place feet apart, with foot closest to head of bed behind otherfoot.RATIONALE: Ensures nurse's balance.Flex knees/hips. Weight should be shifted from front to backleg. Move patient and drawsheet/pullsheet to appropriate posi-tion in bed.RATIONALE: Ensures proper balance when shifting weight. Focuses strain on

thigh muscles instead of back muscles, thereby preventing injury.Position patient in Fowler's position (supported):Bed should be elevated 45-60 degrees. Have patient rest headagainst a mattress or pillow.RATIONALE: Cervical vertebrae contracture is prevented.If patient doesn't have control of arms and hands, support themusing pillows.RATIONALE: Prevents shoulder dislocation from unsupported arms. Prevents

venous pooling.Place pillow at lower back of patient.RATIONALE: Supports the spine to maintain alignment.Put a small pillow or roll under patient's thigh. Do the same for

261

patient's ankles.RATIONALE: Prevents pressure on heels from mattress.Positioning a hemiplegic patient in Fowler's position(supported):Head of bed must be elevated 45-60 degrees. Assist patient to asitting position as straight as possible and support patient's af-fected shoulder.RATIONALE: Decreases intracranial pressure, avoids patient's tendency to slump

forward. Prevents danger of aspiration.Position patient's head on small pillow. Chin should be slightlyforward, taking care to avoid hyperextension of the neck.RATIONALE: Too many pillows may result in hyperextended neck flexion con-

tracture.Support patient's involved arm and hand using overbed table.Put arm away from patient's side and use pillow to support theelbow.RATIONALE: Edema, sublaxation of shoulder and pain may occur from failure

of the paralyzed muscle to voluntarily resist gravity.Position patient's flaccid hand in normal resting position withwrist slightly extended. Maintain arches of hand and partially flexfingers. Clasp patient's hands together.RATIONALE: Prevents contracture of the hands and maintains their functional-

ity.Position spastic hand with wrist in neutral position or slightlyextended.RATIONALE: Prevents flexor spasticity of the hands, maintains functional level.Place pillow or folded blanket under patient's knees to flexpatient's knees and hips.RATIONALE: Joint mobility may result without proper alignment and hyperex-

tension of the knees and hips.Use a firm pillow, footboard or high-top sneakers to supportpatient's feet in dorsiflexion.


262


RATIONALE: Prevents foot drop.Positioning patient in supine position:Have patient lie on back with head of bed flat.RATIONALE: Position is important in preparation for assuming supine position.Put a small rolled towel underneath patient's lumbar area.RATIONALE: Protects the lumbar spine from disalignment.Put a pillow under patient's upper shoulders, neck or head.RATIONALE: Prevents cervical lumbar spine flexion contractures.Put trochanter rolls or sandbags parallel to lateral surface ofpatient's thighs.RATIONALE: Prevents external hip rotation.Elevate patient heels by putting a small pillow/roll under patient'sankles.RATIONALE: Prevents pressure sores.Put foot board or firm pillows against bottom of patient's feet.Put high-top sneakers on patient's feet.RATIONALE: Prevents foot drop.Put pillows under patient's pronated forearms taking care to keeppatient's upper arms parallel to the body.RATIONALE: Maintains correct body alignment. Minimizes internal rotation

of shoulder. Prevents extension of elbows.Put hand rolls in patient's hands.RATIONALE: Extension and abduction of thumb are reduced. Keeps thumb

slightly abducted and in opposition to fingers.Positioning a hemiplegic patient in supine position:Have patient lie on back with head of bed flat.RATIONALE: Allows patient to be put in a supine position.Put folded towel/small pillow under patient's shoulder or af-fected side.RATIONALE: Pain, joint contracture and sublaxation will be reduced. Mobility

263

of shoulder muscles is maintained.Affected arm should be kept away from patient's body, withelbow extended and palm up.RATIONALE: Mobility of arm, joints and shoulders are maintained.Put a folded towel underneath patient's hip on involved side.RATIONALE: Spasticity of leg is diminished by maintaining proper hip position.Support patient's affected knee using a pillow/folded blanket toflex knee 30?.RATIONALE: Maintains leg alignment, preventing internal rotation of hips.Use soft pillow to support patient's feet at right angle to leg.RATIONALE: Prevents foot drop.Position patient in prone position:Roll patient over arm with one arm positioned near patient'sbody, elbow straight, and hand under hip. Have patient lie onabdomen in center of bed.RATIONALE: Proper alignment prevents contractures.Turn patient's head to one side. Use a small pillow to supporthead.RATIONALE: Cervical vertebrae hyperextension/flexion.Put a small pillow under patient's abdomen, below diaphragmlevel.RATIONALE: Pain and discomfort from weight pressure on female breast are

prevented.Support patient's arms in flexed position level at the shoulders.RATIONALE: Reduces risk for joint dislocation.Support patient's lower legs. Use pillows to elevate toes.RATIONALE: Pressure on toes is minimized. External rotation of legs is pre-

vented.Positioning hemiplegic patient in prone position:Have patient move toward unaffected side.RATIONALE: Patient is rolled onto center of bed while maintaining proper body

alignment.


264


Roll patient onto side and place pillow on patient's abdomen.RATIONALE: Reduces lower back strain caused by hyperextension of lumbar

vertebrae.Help patient roll onto abdomen by positioning involved armclose to patient's body with elbow straight and hand under hip.RATIONALE: Prevents injury to paralyzed body part.Turn patient's head toward involved side and position involvedarm out to side. Elbow should be bend and hand toward headof the bed. If possible, extend patient's fingers.RATIONALE: Neck and truck extension is promoted, which are vital when

standing and walking.Slightly flex patient's knees by placing pillow under legs (fromknees to ankles).RATIONALE: Prevents joint immobility due to prolonged hyperextension.Patient's feet should be kept at right angles to legs. use a pillowhigh enough, keeping toes off the mattress.RATIONALE: Ensures dorsiflexion and prevents foot drop.Position patient in lateral position:Lower bed's head or as low as patient can tolerate.RATIONALE: Relieves pressure on bony prominences. Restores patient comfort.Position patient on side of bed.RATIONALE: Provides patient with room to turn to side.Turn patient onto side and roll patient toward you.RATIONALE: Protects patient against injury from fall.Put a pillow under patient's head and neck.RATIONALE: Prevents lateral neck flexion. Prevents strain on sternocleidomas-

toid muscle.Move patient's shoulder blade forward.RATIONALE: Prevents patient's weight from resting directly on shoulder joints.Position both arms in slightly flexed position. support upper armby pillow level and other arm by mattress.

265

RATIONALE: Prevents internal rotation abduction of shoulders.Put tuck-back pillow behind patient's back.RATIONALE: Maintains patient on side.Support semi-flexed upper leg with a pillow.RATIONALE: Prevents hyperextension of leg.Place sandbag parallel to plantar surface of patient's dependentfoot. Put high-top sneakers on patient's feet.RATIONALE: Prevents foot drop. Maintains foot dorsiflexion.Position patient in Sim's position:Completely lower head of the bed.RATIONALE: Facilitates proper body alignment while patient is lying down.Have patient establish supine position.RATIONALE: Prepares patient for position change.Position patient in a lateral position, partially lying on abdomen.RATIONALE: Patient is rolled partially on abdomen.Put a small under patient's head.RATIONALE: Prevents lateral neck flexion.Support arm on level with shoulder by putting a pillow underpatient's flexed upper arm.RATIONALE: Internal rotation of shoulder is prevented.Support leg on level with hip by putting a pillow under patient'sflexed upper legs.RATIONALE: Internal rotation of hip and abduction of leg is prevented.Put sandbags parallel to plantar surface of patient's feet. Put high-top sneakers on patient's feet.RATIONALE: Prevents foot drop.Wash hands.RATIONALE: Reduces transmission of microorganisms.Position bed to desired height.


266


RATIONALE: Ensures patient's comfort and safety.Observe body alignment, position, and level of comfort of pa-tient.RATIONALE: Evaluates effectiveness of positioning. Additional support such as

pillows and trochanter may be added.Assess patient for areas of erythema or skin breakdown.RATIONALE: Anticipates any complication that may arise due to immobility.Record each change in position including amount of assistancerequired and patient's response and tolerance. Record/report anysigns of redness (e.g., areas over bony prominences).RATIONALE: Documentation facilitates communication with other health team


10.3. Transfer Techniques

Materials Required Transfer team Linen Mattress Drape Supportive tool such as overhead trapeze, bars, canes etc.

Procedures for Transfer Techniques & RationaleAssess patient's status and identify risks for problems with trans-fer.RATIONALE: Furnishes the nurse with information such as patient's physical

status, level of consciousness and comprehension.Explain procedure to patient.RATIONALE: Improves patient's understanding of procedure. Reduces patient

anxiety and promotes cooperation.Provide needed privacy.

267

RATIONALE: Reduces patient embarrassment.Wash hands.RATIONALE: Reduces transmission of microorganisms.TRANFER PATIENT

Assist patient to establishing sitting position (bed).RATIONALE: Allows for diaphragmatic expansion. Improves oxygenation.Put patient in a supine position.RATIONALE: Allows nurse to examine appropriateness of body alignment.Face head of bed and remove pillows.RATIONALE: Proper body alignment decreases nurse's risk for back injury.Place feet apart with foot closer to bed behind other foot.RATIONALE: Facilitates center of gravity. Improves balance and maintains

body mechanics.Place hand farther from patient under patient's shoulders. Sup-port patient's head and cervical vertebrae.RATIONALE: Supports head and back of patient, preventing cervical injury.Put hand on surface of bed.RATIONALE: Provides additional balance and support.Shift weight from front to back leg to raise patient to a sittingposition.RATIONALE: Overcomes inertia and shifts patient's weight to direction of move-

ment.Using arm on bed surface, push against bed.RATIONALE: Bracing provides additional support and balance. Prevents back

injury.Assist patient to a sitting position on side of bed (bed inlow position):Raise head of bed 30°.RATIONALE: Reduces effort required to lift patient to sitting position.Turn patient to side of bed where he/she will be sitting.


268


RATIONALE: Protects patient against injury from falling. Prepares him/her tomovement to side of bed.

Stand opposite patient's hips and turn diagonally. You should befacing patient and far corner of foot of bed.RATIONALE: Center of gravity is shifted proximally to patient. Avoids twist-

ing of nurse's body, which may cause back injury.Place feet apart with foot closer to bed head in front of theother foot.RATIONALE: Facilitates center of gravity. Improves balance and maintains

body mechanics.Put arm closer head of bed under patient's shoulder to supporthis/her head and neck. Place other arm closer to head and neck.RATIONALE: Supports head and back of patient, preventing cervical injury.Move patient's lower legs and feet over side of bed. pivot to-ward rear leg and allow patient's upper legs to swing down-ward.RATIONALE: Quickens pace of patient's movement from one surface to another.Shift weight to rear leg and elevate patient at the same time.RATIONALE: Facilitates shifting of patient's weight to direction of motion.Stay in front of patient until he/she regains balance.RATIONALE: Prevents injury. Anticipates need for support.Transfer patient from bed to chair (bed in low position):Assist patient to establishing a sitting position on side of bed.RATIONALE: Provides easy access to chair during transfer.If needed, apply transfer belt or other transfer aid to patient.RATIONALE: Ensures physical stability of patient during transfer.Make sure that the patient has stable, non-skid shoes. put strongleg forward and weak leg back.RATIONALE: Prevents injury.Spread feet apart and flex hips and knees. Align knees with patient'sknees.

269

RATIONALE: Wide base of support provides balance.Grasp transfer belt (if present) or reach through patient's axillaeand put hands on patient's scapulas.RATIONALE: Reduces pressure on axillae.On count of three, rock patient up to a standing position whilestraightening hips and legs. Keep knees slightly flexed. If patientis able, instruct him/her to push up using hands.Provides patient's body with momentum and muscular effort to lift patient.Use knee to maintain stability of patient's weak/paralyzed leg.RATIONALE: Prevents loss of balance.Use foot farther from chair to pivot.RATIONALE: Provides ample space for movement. Speeds up movement.Ask patient to use chair's armrests for support. Ease patient intochair.RATIONALE: Reinforces patient stability.Assess patient for proper alignment for sitting position. Para-lyzed extremities should be supported. For flaccid arms, use alap board. Support legs using bath blanket or pillow.RATIONALE: Poor body alignment may cause patient injury.Acknowledge patient's progress, effort, and performance.RATIONALE: Acknowledges patient's efforts.Perform three-person carry from bed to stretcher (bedat stretcher level):With two other nurses, stand side by side facing patient's bed.RATIONALE: Facilitates proper body mechanics.Each nurse should assume responsibility for the head and shoul-ders, hips, and thigh and ankle areas.RATIONALE: Evenly distributes patient's body weight.Lifting nurses will put arms under the three areas, securing fin-gers around patient's body.RATIONALE: Delegates weight on forearms of lifter.


270


Lifters will roll patient toward them. Lift patient and hold againstchest on count of three.RATIONALE: Distributes body weight over lifter's base of support.Lifters will step back and pivot toward stretcher on second countof three.RATIONALE: Shifts patient's weight towards stretcher.Lifters will lower patient onto stretcher's center by flexing kneesand hips until elbows are level with stretcher's edge.RATIONALE: Keeps alignment (lifters') to prevent patient injury.Assess body alignment of patient.RATIONALE: Evaluates effectiveness of procedure and determines need for modi-

fications.Wash hands and assess patient's tolerance.RATIONALE: Reduces transmission of microorganisms.Record each transfer/position change and response and toler-ance of patient. Record/report any signs of redness.RATIONALE: Documentation facilitates communication with other health team


10.4. Assessing Patients for Risk of Developmentof Pressure Ulcer

Anatomy and PhysiologyThe integumentary system, consisting of the skin, hair and nails, act asa barrier to protect the body from the outside world. It also func-tions to retain body fluids, protect against disease, eliminate wasteproducts, and regulate body temperature. The word integumentcomes from a latin word that means to "cover", hence the mostimportant function of the integumentary system is protection. Thefive main functions of the integumentary system are: serving as a

271

barrier against infection and injury, helping to regulate body tem-perature, removing waste products from the body, providing pro-tection against ultraviolet radiation from the sun and producing vita-min D.The skin is the largest organ of the body and is indispensable forhuman life. This organ forms a barrier between the internal organsand the external environment as well as participates in many vitalfunctions of the body. The skin is continuous, composed of themucous membranes at the external openings of the digestive, respi-ratory and urogenital systems. Because the skin contains several typesof sensory receptors, it serves as the gateway through which sensa-tions such as pressure, heat, cold and pain are transmitted to thenervous system. The skin is composed of two main layers - theepidermis and dermis.The outer most layer of skin is known as the epidermis. It is composedof many sheets of flattened, scaly epithelial cells. This is a thin outerlayer of skin. Its layers are made of mostly dead cells. Most of thecells of the epidermis undergo rapid cell division (mitosis). As newcells are produced, they push older cells to the surface of the skin.The older cells become flattened, lose their cellular contents and be-gin making keratin, a tough fibrous protein and forms the basicstructure of hair, nails and calluses. Eventually, the keratin-producingcells (keratincytes) die and form a tough, flexible waterproof cover-ing on the surface of the skin. Our thickest epidermis in on the palmsand soles. This outer layer of dead cells is shed or washed away onceevery 14 to 28 days.The epidermis contains melanocytes, cells thatproduce melanin, a dark brown pigment.. Melanin is important forprotection, by absorption of ultraviolet radiation from the sun. Allpeople, but especially people with Light Skin, need to minimize ex-posure to the sun and protect themselves from its ultraviolet radia-tion, which can damage DNA in skin cells and lead to deadly formsof skin cancer. There are no blood vessels in the epidermis that iswhy a small scratch will not cause bleeding.The dermis is the innermost thick layer of the skin composed ofliving cells. The dermis lies beneath the epidermis and contains bloodvessels, nerve endings, glands, sense organs, smooth muscles and hair


272


follicles. The dermis helps us to control our body temperature. On acold day when the body needs to conserve heat, the blood vessels inthe dermis narrow. On hot days, the blood vessels widen, warmingthe skin and increasing heat loss. Tiny muscle fibers attach to hairfollicles contract and pull hair upright when you are cold or afraid,producing what is commonly called goose bumps. Beneath the der-mis is the hypodermis, the subcutaneous layer of the skin whichcontains fato and loose connective tissue that insulates the body andacts as an energy reserve. The dermis contains two major types ofglands: sweat glands and sebaceous or oil glands. These glands passthrough the epidermis and release their products at the surface ofthe skin. Sweat glands produce the watery secretions known as sweatwhich contains salt, water and other compund. These secretions arestimulated by nerve impulses that cause the production of sweatwhen the temperature of the body is raised. They help to cool thebody. Sebaceous glands (oil glands) produce oily secretions knownas sebum that spreads out along the surface of the skin and keeps thekeratin rich epidermis flexible and waterproof. The production ofsebum is controlled by hormones. Oil glands are usually connectedby tiny ducts (exocrine glands) to hair follicles. Sebum coats thesurface of the skin and the shafts of hair, preventing excess waterloss and lubricating and softening the skin and hair. Sebum is mildlytoxic to some bacteria. When the skin is put on pressure, the skin ofthe foot may be subject to friction. This will separate layers of epi-dermis or separate the epidermis from the dermis, and tissue fluidmay collect, causing a blister or ulcers sores. If the skin is subjected topressure, the rate of mitosis will increase and create a thicker epider-mis; we call this a callus.

Characteristics of Normal SkinThis is the least common skin type, many people could have almostperfect skin, but never completely. The goal of skin care is to get theskin's condition as close a possible to normal. Usually the combina-tions are normal to dry, normal and mature or normal and dehy-drated. Main skin care goal is to Protect the skin. The following arecharacteristics of normal skin:

Texture of skin is smooth Complexion is even; no redness blotchy spots, oiliness, no overly

273

shiny T-Zone Pores are barely visible The skin has a spongy feel when touched The skin layers are not deficient of any nutrients and minerals

Pressure UlcerA pressure ulcer is an area of skin and tissue that becomes injured orbroken down. Generally, pressure ulcers occur when a person is in asitting or lying position for too long without shifting his or her weight.The constant pressure against the skin causes a decreased blood sup-ply to that area. Without a blood supply, the area cannot survive andthe affected tissue dies.The most common places for pressure ulcers are over bony promi-nences (bones close to the skin), such as the elbow, heels, hips, ankles,shoulders, back, and the back of the head.While it is more common for people to get pressure ulcers if theyspend most of their time in bed or use a wheelchair, people who canwalk can also get pressure ulcers when they are bedridden as a resultof an acute illness or injury.

CausesFactors which increase risk for pressure ulcers include:

Age -- elderly people are at higher risk Inability to move certain parts of the body without assistance,such as with spinal or brain injury patients, and patients withneuromuscular diseases

Malnourishment Being bedridden or in a wheelchair Having a chronic condition, such as diabetes or artery disease,that prevents areas of the body from receiving proper bloodflow and nutrition

Urinary incontinence or bowel incontinence (moisture next tothe skin for long periods of time can cause skin irritation thatmay lead to skin breakdown)

Fragile skin Mental disability from conditions, such as Alzheimer's (some


274


patients may not be capable of taking the proper steps towardprevention and may not seek appropriate treatment when anulcer has formed)

Symptoms & SignsThe National Pressure Ulcer Advisory Panel (NPUAP) in the UnitedStates created a process for evaluating pressure sores based on astaging system from Stage I (earliest signs) to Stage IV (worst):

Stage I: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressureulcer is starting to develop.

Stage II: The skin blisters or forms an open sore. The area aroundthe sore may be red and irritated.

Stage III: The skin breakdown now looks like a crater wherethere is damage to the tissue below the skin.

Stage IV: The pressure ulcer has become so deep that there isdamage to the muscle and bone, and sometimes tendons andjoints.

ImportanceThe nurse is responsible for the assessment of patient risk for devel-oping pressure ulcer, being the most common complications of de-bilitating condition, as a preventive approach to avoid the occur-rence of other serious health problems. If these complications hap-pen as a result of patient's severe condition, the nurse is in charge ofcurative and rehabilitative aspects of care.

Factors that Contribute to Pressure Ulcer Development Immobility, compromised mobility and debilitation Prolonged pressure on tissue Loss of protective reflexes, sensory deficit or loss Poor skin or tissue perfusion Malnutrition, decreased nutritional status Friction, shearing forces and trauma Altered skin moisture (excessively dry or moist) Incontinence of urine or feces Age and gerantologic conditions Equipments: casts, traction, restraints, etc.

275

Environment Types of linen and mattress Poor continuous monitoring by the health care provider

Assessment SitesIn examining a patient for pressure ulcer for potential or actual prob-lem, the nurse should first take into account the factors that contrib-ute to pressure ulcer development. For every shift, the nurse mustconduct total skin condition assessment, inspect every pressure siteand bony prominences for necrosis, skin breaks, inflammation, edema,blisters, sores, mottled skin, blanching response, erythema, and othersigns of infection. Color and odor discharges must also be assessed,together with the size and location. The nurse may use a gradingsystem to describe its severity.

Materials Required Grading system of pressure ulcer Ballpen and charts for documentation Powder Sterile cotton balls and gauze Antiseptic solutions Solutions as ordered to treat the type of infection or invadingmicroorganism

Antibiotic pads and plaster Sterile water or saline solution Applicator Irrigating syringe or tube Forceps Sterile gloves Mask and gown

Procedure for Assessing Patient for Risk ofDeveloping Pressure Ulcer & Rationale

Identify general risk of patient developing pressure ulcer.RATIONALE: Evaluates need for additional nursing interventions such as appli-

cation of topical agents.


276


Assess skin condition over areas of pressure.RATIONALE: May indicate/locate source of pressure such as catheters, linen,

etc.Assess patient for regions of possible pressure.RATIONALE: Multiple sites of necrosis should be located during physical assess-

ment to be able to implement appropriate nursing care.Observe patient's preferred positions when in bed/chair.RATIONALE: Promotes patient comfort.Observe mobility and ability of patient to start and assist withposition changes.RATIONALE: Enhances patient participation and self-esteem.Patient should be assisted in establishing any of the followingpositions: supine, prone or 30-degree lateral.RATIONALE: Exposure to friction worsens when patient is totally dependent in

changing positions.Palpate any discolored or mottled region of patient's skin.RATIONALE: Early interventions could minimize complications.Monitor length of period that any discoloration may persist.RATIONALE: Redness usually lasts for half of the time when hypoxia occurred.Obtain patient's nutritional assessment data.RATIONALE: Poor nutrition contributes to skin susceptibility to pressure trauma.Assess patient/family's knowledge of risk for pressure ulcers.RATIONALE: Provides opportunity for patient health education.Observe patient's tolerance for position change. Record/reportpatient's risk assessment and preventive measures used if any.RATIONALE: Documentation facilitates communication with other health team


10.5. Pressure Ulcer Treatment

277

Materials Required Grading system of pressure ulcer Ballpen and charts for documentation Powder Sterile cotton balls and gauze Antiseptic solutions Solutions as ordered to treat the type of infection or invadingmicroorganism

Antibiotic pads and plaster Sterile water or saline solution Applicator Irrigating syringe or tube Forceps Sterile gloves Mask and gown

Procedures for Pressure Ulcer Treatment &Rationale

Assess patient's comfort level and need for pain medication.RATIONALE: Pain assessment is needed prior to dressing change to achieve better

tolerance and illicit patient cooperation.Determine if patient is allergic to topical agents.RATIONALE: Skin reactions may be caused by allergy to topical agents such as

povidone iodine.Review physician's order for topical agent/dressing.RATIONALE: Confirms appropriate medication and treatment.Wash hands. Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Position patient for removal of dressing.RATIONALE: Provides easy access to affected area.Assess pressure ulcer and surrounding area of skin to determinestage of the ulcer:RATIONALE: Note color, moisture, and appearance of skin around ulcer and


278


the ulcer itself.Use sterile cotton swab to measure pressure ulcer depth. Tomeasure depth of skin undermined by tissue necrosis, use sterilecotton swab to measure and probe beneath skin edges gently.RATIONALE: Comprehensive assessment of presence of ulcer determines the type

of care management to be carried out.Use warm water to gently wash skin around ulcer. Rinse areathoroughly with water.RATIONALE: Water may eradicate resident bacteria. Do not use soap as it may

irritate skin.Gently pat skin with a towel to dry skin.RATIONALE: Moisture worsens maceration of affected tissue.Use normal saline/cleansing agent to thoroughly cleanse ulcer.for deep ulcers, use irrigating syringe.RATIONALE: Solution removes debris. Application of soaked dressing removes

previously applied enzymes.FOLLOW PRESCRIPTION IN THE APPLICATION OF TOPICAL AGENTS

Enzymes:Limit application of thin layer of ointment over ulcers necroticareas.RATIONALE: Thin layer is absorbs easily and effectively while excessive amounts

can irritate surrounding tissue.Apply gauze dressing directly over ulcer. Securely tape dressingin place.RATIONALE: Protects wound from bacteria.Gel agents:Use applicator/gloved hand to cover ulcer surface with gel agents.RATIONALE: When used as applicator, glove maintains sterility.Completely cover ulcer by applying dry gauze or transparentdressing over gel.RATIONALE: Dressing holds gel on wound surface.

279

Calcium alginates:Use applicator/gloved hand to pack wound with alginate.RATIONALE: When used as applicator, glove maintains sterility.Apply dry gauze over alginate.RATIONALE: Gauze holds alginate on wound surface.Assist patient to comfortable position.RATIONALE: Restores patient comfort.Remove and dispose of gloves. Discard soiled supplies and washhands.RATIONALE: Reduces transmission of microorganisms.Observe ulcer's surrounding skin for inflammation, edema, andtenderness.RATIONALE: Evaluates efficiency of procedure for purpose of comparison in the

assessment of patient prognosis.Monitor patient for signs of infection.

RATIONALE: Early detection ensures early management.Record and report procedure and ulcer appearance.RATIONALE: Documentation facilitates communication with other health team


10.6. Performing Wound Irrigations

Anatomy and PhysiologyWound is resulted from any breaks in the continuity of the skin.Wound healing is a complex and dynamic process of restoring cellu-lar structures and tissue layers. The human adult wound healing pro-cess can be divided into 3 distinct phases: the inflammatory phase,the proliferative phase, and the remodeling phase. Within these 3broad phases is a complex and coordinated series of events thatincludes chemotaxis, phagocytosis, neocollagenesis, collagen degra-


280


dation, and collagen remodeling. In addition, angiogenesis, epithe-lization, and the production of new glycosaminoglycans (GAGs) andproteoglycans are vital to the wound healing milieu. The culminationof these biological processes results in the replacement of normalskin structures with fibroblastic mediated scar tissue.This process can go awry and produce an exuberance of fibroblasticproliferation with a resultant hypertrophic scar, which by definition isconfined to the wound site. Further exuberance can result in keloidformation where scar production extends beyond the area of theoriginal insult. Conversely, insufficient healing can result in atrophicscar formation.

Categories of Wound HealingAlthough various categories of wound healing have been described,the ultimate outcome of any healing process is repair of a tissuedefect. Primary healing, delayed primary healing, and healing by sec-ondary intention are the 3 main categories of wound healing. Eventhough different categories exist, the interactions of cellular and ex-tracellular constituents are similar.Category 1. Primary wound healing or healing by first intention occurswithin hours of repairing a full-thickness surgical incision. This surgi-cal insult results in the mortality of a minimal number of cellularconstituents.Category 2. If the wound edges are not reapproximated immediately,delayed primary wound healing transpires. This type of healing maybe desired in the case of contaminated wounds. By the fourth day,phagocytosis of contaminated tissues is well underway, and the pro-cesses of epithelization, collagen deposition, and maturation are oc-curring. Foreign materials are walled off by macrophages that maymetamorphose into epithelioid cells, which are encircled by mono-nuclear leukocytes, forming granulomas. Usually the wound is closedsurgically at this juncture, and if the "cleansing" of the wound isincomplete, chronic inflammation can ensue, resulting in prominentscarring.Category 3. A third type of healing is known as secondary healing orhealing by secondary intention. In this type of healing, a full-thickness

281

wound is allowed to close and heal. Secondary healing results in aninflammatory response that is more intense than with primary woundhealing. In addition, a larger quantity of granulomatous tissue is fab-ricated because of the need for wound closure. Secondary healingresults in pronounced contraction of wounds. Fibroblastic differen-tiation into myofibroblasts, which resemble contractile smooth muscle,is believed to contribute to wound contraction. These myofibroblastsare maximally present in the wound from the 10th-21st days.Category 4. Epithelization is the process by which epithelial cells mi-grate and replicate via mitoses and traverse the wound. This occursas part of the phases of wound healing, which are discussed in Se-quence of Events in Wound Healing. In wounds that are partial thick-ness, involving only the epidermis and superficial dermis, epitheliza-tion is the predominant method by which healing occurs. Woundcontracture is not a common component of this process if only theepidermis or epidermis and superficial dermis are involved.

Overview of Wound HealingThe amalgam of coordinated events that constitute the process ofwound healing is quite complex. The steps in the procession of woundhealing include inflammation, the fibroblastic phase, scar maturation,and wound contracture (Tanenbaum, 1995; Cahill, 1993). Woundcontracture is a process that occurs throughout the healing process,commencing in the fibroblastic stage (Tanenbaum, 1995).The inflammatory phase occurs immediately following the injury andlasts approximately 6 days. The fibroblastic phase occurs at the ter-mination of the inflammatory phase and can last up to 4 weeks. Scarmaturation begins at the fourth week and can last for years(Tanenbaum, 1995). An analogous system depicts the 4 phases ashemostasis, inflammation, granulation, and remodeling in a continu-ous symbiotic process (Cho, 1998).

Phases of Wound HealingFollowing tissue injury via an incision, the initial response is usuallybleeding. The cascade of vasoconstriction and coagulation commenceswith clotted blood immediately impregnating the wound, leading to


282


hemostasis, and with dehydration, a scab forms. An influx of in-flammatory cells follows, with the release of cellular substances andmediators. Angiogenesis and re-epithelization occur and the deposi-tion of new cellular and extracellular components ensues.Initial phase - Hemostasis. Following vasoconstriction, platelets adhereto damaged endothelium and discharge adenosine diphosphate(ADP), promoting thrombocyte clumping, which dams the wound.The inflammatory phase is initiated by the release of numerouscytokines by platelets. Alpha granules liberate platelet-derived growthfactor (PDGF), platelet factor IV, and transforming growth factorbeta (TGF-b), while vasoactive amines such as histamine and seroto-nin are released from dense bodies found in thrombocytes. PDGF ischemotactic for fibroblasts and along with TGF-b is a potent modu-lator of fibroblastic mitosis, leading to prolific collagen fibril con-struction in later phases. Fibrinogen is cleaved into fibrin and theframework for completion of the coagulation process is formed.Fibrin provides the structural support for cellular constituents ofinflammation. This process starts immediately after the insult andmay continue for a few days.Second phase - Inflammation. Within the first 6-8 hours, the next phaseof the healing process is underway, with polymorphonuclear leuko-cytes (PMNs) engorging the wound. TGF-b facilitates PMN migra-tion from surrounding blood vessels where they extrude themselvesfrom these vessels. These cells "cleanse" the wound, clearing it ofdebris. The PMNs attain their maximal numbers in 24-48 hours andcommence their departure by hour Other chemotactic agents arereleased, including fibroblastic growth factor (FGF), transforminggrowth factors (TGF-b and TGF-a), PDGF, and plasma-activatedcomplements C3a and C5a (anaphylactic toxins). They are seques-tered by macrophages or interred within the scab or eschar (Habif,1996). As the process continues, monocytes also exude from thevessels. These are termed macrophages. The macrophages continuethe cleansing process and manufacture various growth factors dur-ing days 3-4. The macrophages orchestrate the multiplication of en-dothelial cells with the sprouting of new blood vessels, the duplica-tion of smooth muscle cells, and the creation of the milieu createdby the fibroblast. Many factors influencing the wound healing pro-

283

cess are secreted by macrophages. These include TGFs, cytokinesand interleukin-1 (IL-1), tumor necrosis factor (TNF), and PDGF.Third phase - Granulation. This phase consists of different subphases.These subphases do not happen in discrete time frames but consti-tute an overall and ongoing process. The subphases are "fibroplasia,matrix deposition, angiogenesis and re-epithelialization" (Cho, 1998).In days 5-7, fibroblasts have migrated into the wound, laying downnew collagen of the subtypes I and III. Early in normal woundhealing, type III collagen predominates but is later replaced by type Icollagen. Tropocollagen is the precursor of all collagen types and istransformed within the cell's rough endoplasmic reticulum, whereproline and lysine are hydroxylated. Disulfide bonds are established,allowing 3 tropocollagen strands to form a triple left-handed triplehelix, termed procollagen. As the procollagen is secreted into theextracellular space, peptidases in the cell wall cleave terminal peptidechains, creating true collagen fibrils. The wound is suffused with GAGsand fibronectin produced by fibroblasts. These GAGs include heparansulfate, hyaluronic acid, chondroitin sulfate, and keratan sulfate.Proteoglycans are GAGs that are bonded covalently to a proteincore and contribute to matrix deposition. Angiogenesis is the prod-uct of parent vessel offshoots. The formation of new vasculaturerequires extracellular matrix and basement membrane degradationfollowed by migration, mitosis, and maturation of endothelial cells.Basic FGF and vascular endothelial growth factor are believed tomodulate angiogenesis. Re-epithelization occurs with the migrationof cells from the periphery of the wound and adnexal structures.This process commences with the spreading of cells within 24 hours.Division of peripheral cells occurs in hours 48-72, resulting in a thinepithelial cell layer, which bridges the wound. Epidermal growthfactors are believed to play a key role in this aspect of wound heal-ing. This succession of subphases can last up to 4 weeks in the cleanand uncontaminated wound.Fourth phase - Remodeling. After the third week, the wound undergoesconstant alterations, known as remodeling, which can last for yearsafter the initial injury occurred. Collagen is degraded and depositedin an equilibrium-producing fashion, resulting in no change in the


284


amount of collagen present in the wound. The collagen depositionin normal wound healing reaches a peak by the third week after thewound is created. Contraction of the wound is an ongoing processresulting in part from the proliferation of the specialized fibroblaststermed myofibroblasts, which resemble contractile smooth musclecells. Wound contraction occurs to a greater extent with secondaryhealing than with primary healing. Maximal tensile strength of thewound is achieved by the 12th week, and the ultimate resultant scarhas only four fifths or 80%, of the tensile strength of the original skinthat it has replaced.The process of wound healing constitutes an array of interrelatedand concomitant events, culminating in the development of scar tis-sue to replace the tissue that has been injured or lost.

ImportanceThe nurse's main goal for taking good care of patients with woundis the prevention of infection and the rise of resulting complications.Thus, proper knowledge and skills in the handling and managementof wound is imperative. Actually, correct care of wound enhancesthe curative aspect of care.

Factors Affecting the Healing of Wound Nutritional status Medical history and present health conditions Age and gerantologic conditions Size, deepness and severity of the wound Cause of the wound Compliance to pharmacological regimen Personal hygiene Skin integrity Blood circulation Altered skin moisture Presence of equipments: cast, traction, bead, implants, etc. Environment

Assessment SitesThe nurse is responsible for the assessment of signs and symptoms

285

of inflammation. Presence and characteristics of discharges must beobserved. Level of healing must also be evaluated, together with therise of complications. Presence of microorganism must be inspectedand the difference of healthy wound from gangrene.

Materials Required Ordered pain relievers and analgesics Prescribed solutions Antiseptic solutions Irrigating tube and syringe Sterile forceps Sterile gloves Mask and gown Sterile scissors Sterile bowl Sterile gauze Micropore tape Basin or bed pan

Procedures for Performing Wound Irrigation &Rationale

Assess patient's level of pain.RATIONALE: Discomfort may be related directly to wound or indirectly to

muscle tension or immobility.Review prescriber's order for open wound irrigation.RATIONALE: Open wound irrigation requires medical order, including type of

solutions use.Assess signs/symptoms related to open wound.RATIONALE: Data are used as baseline to indicate change in condition of

wound. May indicate response to infection. Amount will decreaseas healing takes place. Strong odor indicates infectious process.Leukocytes produce thick drainage. Determines stage of healing.

Explain procedure to patient.RATIONALE: Information will reduce patient's anxiety.


286


Prescribed analgesic should be administered 30-45 mins beforebeginning procedure.RATIONALE: Increased comfort level permits patient to move more easily and be

positioned to facilitate wound irrigation.Assist patient to a comfortable position. Make sure of irrigationsolution's gravitational flow into wound.RATIONALE: Directing solution from top to bottom of wound and from clean to

contaminated area prevents further infection. Positioning patientduring planning stage provides bed surfaces for later preparationof equipment.

Warm irrigation to body temperature.RATIONALE: Warmed solution increases comfort and reduces vascular constric-

tion response in tissues.Wash hands.RATIONALE: Reduces transmission of microorganisms.Form cuff on waterproof bag and place near bed.RATIONALE: Cuffing helps to maintain large opening, thereby permitting place-

ment of contaminated dressing without touching refuse bag itself.Provide needed privacy.RATIONALE: Reduces embarrassment for the patient and providing privacy is

one of the patient's rights.If necessary, apply gown/goggles.RATIONALE: Protects nurse from splashes or sprays of blood and body fluids.Wear disposable gloves.RATIONALE: Remove soiled wound dressing and properly discard.Remove and dispose of gloves.RATIONALE: Reduces transmission of microorganisms.Prepare needed supplies.RATIONALE: Right preparation conserves time and energy for the nurse and

provides comfort for the patient.Apply sterile gown.

287

RATIONALE: Observes aseptic technique.Irrigate wound:For wound with wide opening:Fill syringe with irrigating solution.RATIONALE: Flushing wound helps remove debris and facilitates healing by

secondary intention.Attach 19-gauge needle/angiocatheter to syringe.RATIONALE: Provides ideal pressure of cleansing and removal of debris.Hold syringe tip about 2.5 cm over wound's upper end overarea to be cleansed.RATIONALE: Prevents syringe contamination. Careful placement of the syringe

prevents unsafe pressure of the following solution.Use continuous pressure to flush wound. Repeat steps until drainedsolution becomes clear.RATIONALE: Clear indicates that all debris has been removed.For deep wound with small opening:Attach soft angiocatheter to filled syringe.RATIONALE: Catheter permits direct flow of irrigant into wound. Expect

wound to take longer to empty when opening is small.Use irrigating solution to lubricate catheter tip. gently insert cath-eter tip and pull out about 1 cm.RATIONALE: Removes tip from fragile inner wall of wound.Use slow continuous pressure to flush wound.RATIONALE: Clear indicates that all debris has been removed.Pinch off catheter below syringe while keeping catheter in place.RATIONALE: Avoids contamination of sterile solution.Remove syringe and refill. Reattach to catheter and repeat proce-dure until drained solution becomes clear.RATIONALE: Clear indicates that all debris has been removed.Cleanse wound with non-bacteriostatic saline and if necessary,


288


obtain cultures.RATIONALE: Routine cultures of open wounds is not recommended in the

AHCPR guidelines (1994). They recommend using quantitativebacterial cultures (tissue biopsy or wound fluid by needle aspira-tion) rather than swab cultures, which often detect only surfacebacterial contaminants.

Use gauze to dry wound edges.RATIONALE: Prevents maceration of surrounding tissue from excess moisture.Apply dressing.RATIONALE: Maintains protective barrier and healing environment for wound.Remove gloves.RATIONALE: Prevents transfer of microorganisms.Assist patient to comfortable position.RATIONALE: Promotes comfort.Dispose of equipment and soiled supplies properly. Wash hands.RATIONALE: Reduces transmission of microorganisms.Periodically inspect dressing.RATIONALE: Identifies wound-healing progress and determines type of wound

cleansing needed. Determines patient's response to wound irriga-tion and need to modify plan of care.

Examine skin integrity.RATIONALE: Determines if extension of wound has occurred.Observe patient for any sign of discomfort.RATIONALE: Patient's pain should not increase as a result of wound irrigation.Record procedure and patient response.RATIONALE: Documentation facilitates communication with other health team


Immediately report any fresh bleeding, increase in pain, irrigantretention or signs of shock to attending physician.RATIONALE: Patient's pain should not increase as a result of wound irrigation.

289

10.7. Application of an Abdominal, T or BreastBinder

ImportanceSome of the great nursing roles that should never be underminedare the provision of comfort, alleviation of pain, and prevention ofcomplications. Binders and bandages are applied to promote com-fort as well as immobilize, protect, and provide pressure, warmth,and support to the affected body parts.

Factors Affecting the Application of Abdominal, Tor Breast Binder

Age and size of patient Size and types or binder or bandage Size of affected sites Sites of application Reason for the application of binder or bandage Compliance with the treatment Medical history and present health condition Skin condition and integrity Environment and climate Duration of treatment

Assessment SitesAffected sites should be assessed for wound, fracture, severity oftrauma, pressure sites, cyanosis, sores and ulcer, and signs of inflam-mation/infection. Thorough observation for capillary refill, impairedblood flow and compartment syndrome must be conducted. Effec-tiveness of treatment should also be monitored.

Materials Required Binder or bandages Disposable gloves


290


Dressing tray (as needed)

Procedure for Applying Abdominal, T or BreastBinder & Rationale

Assess patient's need for support of thorax/abdomen. Observepatient's ability to breathe deeply and cough effectively.RATIONALE: Provides baseline data for determining patient's coughing and

breathing. Alteration in coughing/breathing can lead to inad-equate oxygenation.

Review patient's record for use of prescribed binder.RATIONALE: Application of abdominal, T or breast binder is an independent

nursing intervention. In some cases, physician insight is required.Inspect patient's skin integrity.RATIONALE: Binder may cause additional pressure, excoriation or worsen skin

condition..Inspect for any present surgical dressing.RATIONALE: Any binder application can be done after change of dressing or

reinforcementAssess patient's level of comfort.RATIONALE: Data will determine effectiveness of binder placement.Assess patient for kind of binder to be applied.RATIONALE: Proper fit of binder is ensured.Explain procedure to patient.RATIONALE: Promotes patient's understanding of procedure, relieves anxiety

and enhances cooperation.Educate patient/caregiver on procedure.RATIONALE: Ensures continuity of care after discharge.Wash hands. Wear disposable gloves.RATIONALE: Reduces transmission of microorganisms.Provide needed privacy.RATIONALE: Reduces patient embarrassment.

291

APPLY BINDER

Abdominal binder:Place patient in supine position. Slightly elevate head with kneesslightly flexed.RATIONALE: Relaxes muscles including abdominal organ.Fanfold binder's far side toward binder's midline.RATIONALE: Prepares support for abdominal organs. Reduces period of time

in which patient is in uncomfortable position.Help patient roll away from you while firmly supporting ab-dominal incision and dressing with hands.RATIONALE: Reduces patient pain and discomfort.Place fan-folded ends beneath patient.RATIONALE: Permits placement and placement of binder with minimal discom-

fort.Assist patient in rolling over onto folded ends. Smoothly unfoldand stretch ends out on bed's far side.RATIONALE: Ensures wrinkle-free binding avoids disruption of skin integrity

and comfort.Ask patient to roll back to supine position.When binder is closed, it facilitates support of incision site. Boosts patient's

confidence to cough.Center patient over binder by adjusting binder using symphysispubis and costal margins as lower and upper landmarks.Ensures centered support of binder for affected side which reduces lung ex-

pansion.Close binder. Pull one end over middle of patient's abdomen.While tension on that end is maintained, pull opposite end overcenter, secure with Valero closure tabs, metal fasteners or safetypins.Ensures full support of affected area. Improves comfort.Assess patient's comfort level.Evaluates effectiveness of procedure.


292


Adjust binder as deemed appropriate.Prevents impeding of circulation. Promotes lung expansion and patient com-

fort.Single T and double T-binders:Assist patient in establishing dorsal recumbent position. Slightlyflex lower extremities with hips slightly rotated outward.Relaxes muscles in perineal organs.Ask patient to raise hips and put horizontal band around patient'swaist. Vertical tails should be extended past patient's buttocks.Overlap waistband in front and secure using safety pins.Allows binder to be inserted, running through buttock area.Complete binder application:Single-T binder: Put remaining vertical strip over perineal dressingworking up and below center horizontal band's front. Bring endsover waistband. Secure all thicknesses using safety pins. Double-Tbinder: Bring remaining vertical strips over perineal/suprapubicdressing with each tail supporting one side of the scrotum pro-ceeding upward on either side of penis Continue drawing endsbehind and downward in front of horizontal band. Secure thick-nesses using safety pin.RATIONALE: Provides perineal muscle and organ support. Ensures proper

placement of perineal muscle and suprapubic dressing.Assess patient's level of comfort. If necessary, adjust front pinsand tails ensuring that tails are not too tight. If any area rubsagainst surrounding tissue, increase padding.RATIONALE: Evaluates effectiveness of procedure.Ask patient regarding binder removal before urinating/defecat-ing. Inform patient that binder needs to be replaced after per-forming the said bodily functions.RATIONALE: Prevents soiling of binder. Reduces risk of infection.Breast binder:Assist patient in putting arms through armholes of binder.RATIONALE: Arm holes serve as access to support breast weight.

293

Assist patient in establishing supine position in bed.RATIONALE: Ensures proper placement of perineal muscle and suprapubic

dressing.Area under patient's breast should be padded if needed.RATIONALE: Prevents excoriation or irritation due to contact between skin and

undersurface.Secure binder beginning at the nipple level. Close binder aboveand then below nipple line until binder is closed.RATIONALE: Uneven pressure is prevented by horizontal placement of safety

pins.Adjust binder as needed.RATIONALE: Facilitates proper breathing.Remove and dispose of gloves. Wash hands.RATIONALE: Prevents cross infections.Observe skin integrity, circulation and characteristic around woundsite.RATIONALE: Determines that binder has not resulted in complication to skin,

wound or underlying germs.Assess patient's ventilation.RATIONALE: dentifies any impaired ventilation and potential pulmonary com-

plications.Record and report procedure.RATIONALE: Documentation facilitates communication with other health team


Report ineffective lung expansion (if any) to physician immedi-ately.RATIONALE: Ineffective lung expansion results from tight application of binder.

10.8. Elastic Bandage Application


294


Materials Required Binder or bandages Disposable gloves Dressing tray (as needed)

Procedures for Elastic Bandage Application &Rationale

Examine patient's skin integrity.RATIONALE: Altered skin integrity contraindicates to use of elastic bandages.Assess patient's surgical dressing.RATIONALE: Surgical dressing replacement or reinforcement precedes applica-

tion of any bandage.Observe circulation distal to bandage.RATIONALE: Comparison of area before and after application of bandage is

necessary to ensure continued adequate circulation. Impairment ofcirculation may result in coolness to touch when compared withopposite side of body, cyanosis or pallor of skin, diminished orabsent pulses, edema or localized pooling, and numbness or tin-gling of part.

Review patient's record for specific orders related to elastic ban-dage application.RATIONALE: Specific prescription may direct procedure, including factors such

as extent of application (e.g., toe to knee, toe to groin) and dura-tion of treatment.

Identify patient/caregiver's knowledge level and skill in elasticbandage application.RATIONALE: Ensures that planning and teaching are individualized.Explain procedure to patient.RATIONALE: Increased knowledge promotes cooperation and reduces anxieties.Wash hands. If drainage is present, wear disposable gloves.RATIONALE: Reduces spread of microorganisms.Provide needed privacy.

295

RATIONALE: Maintains patient's comfort and dignity.Assist patient to a comfortable position.RATIONALE: Maintains alignment. Prevents muscoskeletal deformity.Use dominant hand to hold roll of elastic bandage, use otherhand to hold bandage beginning at distal body part. Transfer rollto dominant hand in wrapping bandage.RATIONALE: Maintains appropriate and consistent bandage tension.Bandage should be applied from distal point toward proximalboundary. Use a variety of turns to cover various shapes ofbody parts.RATIONALE: Bandage is applied in manner that conforms evenly to body part

and promotes venous return.Unroll and slightly stretch bandage.RATIONALE: Maintains uniform bandage tension.Overlap turns by ½-2/3 width of bandage roll.RATIONALE: Prevents uneven bandage tension and circulatory impairment.Use clip/tape to secure first bandage before applying additionalrolls. Do not leave uncovered skin surface in applying additionalrolls. Secure final bandage.RATIONALE: Prevents wrinkling or loose ends.Remove and dispose of gloves. Wash hands.RATIONALE: Reduces transmission of microorganisms.Assess patient's distal circulation upon completion of bandageapplication or at least twice every 8 hrs.RATIONALE: Early detection and management of circulatory impairment en-

sures healthy neurovascular status. Neurovascular changes indi-cate impaired venous return. Determines if bandage is too tight,which restricts movement or determines if joint immobility is at-tained.

Record and report condition of patient's wound, dressing integ-rity, bandage application, circulation and comfort level of pa-tient.


296



10.9. Moist Hot Compress Application to anOpen Wound

ImportanceSince heat primarily promotes blood vessel dilation and opens poresand stoma, it enables good blood flow and circulation. Its comforteffect is also remarkable. Application of its therapeutic effect causeschanges in the circulation of a local or remote site, thus, heat:

Relieves pain and congestion Hastens suppuration Relaxes muscles, and Increases metabolism.

Factors Affecting the Application of Moist Hot Compress to an OpenWound

Temperature and environment Reasons for treatment Types of solutions Types, sites, size, characteristics, severity and cause of wound Nutritional status Medical history and present health conditions Age and gerontologic condition Compliance to pharmacological regimen Personal hygiene Skin integrity Blood circulation Altered skin moisture Presence of equipments: cast, traction, bead, implants, dressings,bandages, etc.

Assessment Sites

297

Assessment for signs and symptoms of infection must be conducted.Presence and characteristics of discharges must be observed. Levelof healing must also be evaluated, together with the rise of compli-cations. Presence of microorganism must be inspected and the dif-ference of healthy wound from gangrene.

Materials Required Heating equipment Sterile towel Sterile gauze Solutions as ordered Sterile container Sterile gloves Sterile dressing materials Sterile basin Sterile forceps

Procedures for Moist Hot Compress Application toan Open Wound & Rationale

Re-check patient's record for hot compress order.RATIONALE: Ensures safe and correct application.Assess condition of patient's exposed skin/wound on whichcompress is to be applied.RATIONALE: Provides baseline data to determine changes in skin dur-

ing heat application.Assess patient's extremities for sensitivity to temperature and pain.RATIONALE: Patients insensitive to heat or cold sensations must be monitored

closely during treatment.To identify any systemic contraindications to application of heat,refer to patient's record.RATIONALE: Heat causes vasodilation, which aggravates active bleeding. Heat

applied to localized area of acute inflammation or tumor maycause rupture or activate cell growth.

Prepare necessary equipment/supplies.


298


RATIONALE: Organization of supplies prevents unnecessary delays in the pro-cedure.

Explain procedure and expected sensations. Explain precautionsto prevent burning.RATIONALE: Minimizes patient's anxiety and promotes cooperation during the

procedure.Provide needed privacy.RATIONALE: Decreases drafts, thus decreasing the transmission of microorgan-

isms. Provides for patient privacy.Assist patient to establishing comfortable position. Put water-proof pad under body part to be treated.RATIONALE: Compress remains in place for several minutes. Limited mobility

in uncomfortable position causes muscular stress. Pad preventssoiling of linen.

Expose body part to be covered by compress. Use bath blanketto drape rest of patient's body.RATIONALE: Prevents unnecessary cooling and exposure of body part.Wash hands.RATIONALE: Reduces transmission of microorganisms.COMPRESS PREPARATION

RATIONALE: Ensures orderly procedure.Pour solution into sterile container. Open sterile packages anddrop gauze into container. Adjust temperature.RATIONALE: Compresses must retain warmth for therapeutic benefit.Wear disposable gloves.RATIONALE: Remove soiled dressing from wound.Dispose of gloves/soiled dressing properly.Reduces transmission of microorganisms.Assess wound's condition and surrounding skin.RATIONALE: Provides baseline to determine skin changes following compress

299

application.Wear sterile gloves.RATIONALE: Allows nurse to manipulate sterile dressing and touch open wound.Pick-up a layer of sterile gauze and wring out excess solution.lightly apply gauze to wound.RATIONALE: Excess moisture macerates skin and increases risks of burns and

infection. Skin is sensitive to sudden change in temperature.Lift edge to assess for redness after a few seconds.RATIONALE: Increased redness indicates burn.If compress is tolerated, snugly pack gauze against wound. Allwound surfaces should be covered by compress.RATIONALE: Packing of compress prevents rapid cooling from underlying air

currents.Cover compress with dry sterile dressing and bath towel. pin/tieto secure if needed.RATIONALE: Dry sterile dressing will prevent transfer of microorganisms to

wound via capillary action caused by moist compress. Towel insu-lates compress to prevent heat loss.

Remove sterile gloves.RATIONALE: Reduces transmission of microorganisms.Hot compress should be changed every 5 mins or as prescribed.RATIONALE: Prevents cooling and maintains therapeutic benefit of compress.After appropriated time, wear disposable gloves and removepad, towel, and compress. Re-assess wound and skin condition.Replace dry sterile dressing.RATIONALE: Continues exposure to moisture will macerate skin. Prevents

entrance of microorganisms into wound site.Assist patient to a comfortable position.RATIONALE: Maintains patient's comfort.


300


Properly dispose of equipment and soiled supplies. Wash hands.RATIONALE: Reduces transmission of microorganisms.Examine area covered with compress every 5-10 mins.RATIONALE: Assists in determining effects of application.Ask patient for any unusual burning sensation not felt beforeapplication.RATIONALE: It may be difficult to assess burn merely by color changes if wound

is inflamed or drainage is present.Record procedure and condition of wound/skin, treatment, andpatient's response to compress.RATIONALE: Documentation facilitates communication with other health team


10.10. Post-operative Exercises Demonstration

Anatomy and PhysiologyStress is a collective term for a number of psychologic and physi-ologic factors that cause neurochemical changes inside the body. Thesefactors include tissue damage, pain, immobilization, anesthesia, bloodloss and fever. By combining both psychologic and physiologic fac-tors, the stressful stimuli imposed by surgery encourage the stressresponse.

ImportanceOne of the foremost impact of sickness, both benign or malignant,is the impairment of physical mobility, particularly in patients whohave undergone operative procedures. Early recovery can be greatlyfacilitated by effective demonstration and patient's compliance topost-operative exercises. Range of motion maintains muscle toneand joint mobility as well as promotes blood circulation. Likewise,good breathing exercises encourage effective pulmonary function.Above all, sound post-operative exercises help prevent postopera-

301

tive complications. Executing these maneuvers normally help patientnot to undergo lengthy rehabilitation.

Factors Affecting Compliance to PostoperativeExercises

Effectiveness of the nurse education Medical history and present health condition Mental status of the patient Environment Support system Age and size of the patient Kinds of operation the patient has undergone Therapy and treatment Contraptions Patient's knowledge and anticipation about medical condition

Assessment SitesThe nurse's primary considerations before starting postoperative ex-ercises include the vital signs, wound and drainage, cardiovascularstatus, neurologic status, respiratory status, tubes and contraptions.Patient's capability and understanding about the procedures mustalso be assessed. The nurse must also be skilled/knowledgeable aboutpost-operative exercise indications and contraindications.

Materials Required Turning team Exercising materials Support tools such as bars, canes, trapeze, etc. Spirometry or pulmonary function test gadget

Procedures for Post-operative ExercisesDemonstration & Rationale

Assess patient for any risk of post-operative complications.RATIONALE: Exercise may also cause post operative injury, assessment prevents

injury.Explain to patient purpose and importance of exercises.RATIONALE: Immobility is often a problem 20 to pain, proper explanation

develops client's determination to move.


References

304


305

(no author). (1989). Mosby’s patient teaching guides. St. Louis: Mosby.(no author). (2003). Competencies essentials for nursing. Manila: Educational

Publishing House.Altman, J.B. (n.d.). Delmar’s Fundamental and Advanced Nursing Skills.

(2nd Ed.).Altman, J.B. (n.d.). Delmar’s Fundamental and Advanced Nursing Skills.

Checklist.Benenson, A.S. (1995). Control of communicable diseases manual.

Washington, DC: American Public Health Association.Centers for Disease Control and Prevention. (1994). Guideline for

preventing the transmission of myobacterium tuberculosisin healthcare facilities. Federal Register 59, 208, 54242.

Cox, C. L. and McGrath, A. (1999) Respiratory assessment in criticalcare units. Intensive & Critical Care Nursing 15(4): 226-234.

Ellis, J. et al. (1992). Modules for basic nursing skills. (5th Ed.) Manila:Educational Publishing House.

Ellis, J. et al. (1992). Modules for basic nursing skills. (6th Ed.). Manila:C&E Publishing.

Endacott, R. and Jenks, C. (1997) RCN: continuing education.Respiratory assessment in A&E. Emergency Nurse 5(4): 31-38.

Finesilver, C. (1992) Respiratory assessment. RN 55(2): 22-30.Fritz, D. J. (1997) Fine tune your physical assessment of the lungs

and respiratory system. Home Care Provider 2(6): 299-305.Gumban, J. et al. (2004). Basic Nursing Procedures Performance Checklist

for Level 2. Wiseman Books.Jackson, N. (1994) Vital signs. in Perry, A. G. and Potter, P. A. Clinical

Nursing Skills and Techniques St Louis: Mosby. Ch.11 pp 196-239.

306


Mallett, J. and Dougherty, L. (2000) Observations. Manual of ClinicalNursing Procedures Oxford: Blackwell Science. Ch.28 pp 402-432.

Marchese, T. W. and Diamond, F. B. (1995) Primary care for women:comprehensive assessment of the respiratory system. Journalof Nurse-Midwifery 40(2): 150-162.

Owen, A. (1998) Respiratory assessment revisited. Nursing 28(4): 48-49.

Pereira, L.J. et. al. (1990). The effect of surgical handwashing routineson the microbial counts of operating room nurses. AmericanJournal of Infection Control, 18, 354.

Potter, P.A. (2001). Fundamentals of nursing: Singapore: Harcourt Asia.Stevens, S. and Becker, K. L. (1988) How to perform picture-perfect

respiratory assessment. Nursing 18(1): 57-63.Thompson, J.M. et al. (1989). Mosby’s manual of clinical nursing. (2nd

ed.). St. Louis: Mosby.Thompson, J.M. et. al. (1999). Whaley and Wong’s nursing care of infants

and children. (6th ed.). St. Louis: Mosby.Torrance, C. and Elley, K. (1997) Practical procedures for nurses.

Respiration: technique and observation - 2... no. 4.2. NursingTimes 93(44): insert-Nov.

Torrance, C. and Elley, K. (1997) Practical procedures for nurses.Respiration: technique and observation - 1... no. 4.1. NursingTimes 93(43): insert-28.

Udan, Q.J. (n.d.). Mastering fundamentals of nursing. Manila: Jade BookStore.

Weinstein, S.A. et. al. (1989). Bacterial surface contamination of patient’slinen: isolation precautions versus standard care. AmericanJournal of Infection Control, 17, (5), 264.

Woodrow, P. (2002) Assessing respiratory function in older people.Nursing Older People.

Companion 2 Nursing Body Final2pdf

Documents

Transcript of Companion 2 Nursing Body Final2pdf