ADMITTING A PATIENT IN THE HOSPITAL

Definition: It is the admission of a client in a health care facility courteously and

professionally to establish a therapeutic relationship with the client.

Purposes:
1. To provide immediate care for the patient entering the hospital.
2. To ensure that the patient receives a courteous welcome in the hospital.
3. To provide safe and efficient handling of the patient's clothing and valuables.

Equipments:
thermometer in a thermometer tray drinking glass and water in tray
bath towel silver spoon and fork, teaspoon
2 bedsheets pillow and a pillow case
patient's gown or pajama bath soap in a soap case
bathroom tissue weighing scale
sphygmomanometer and stethoscope basin of warm water
tape measure

Assessment: Assess for patient's condition to know if the patient requires immediate attention.

Procedure:
1. Greet patient upon entering the admitting section to reduce patient's anxiety and get
admission order.
2. Assemble all necessary equipment for admitting a patient to save time and effort.
3. Put patient on bed if necessary or make comfortable on a chair.
4. Accomplish case record form and fill in the patient's data. Let the patient sign the
Consent for Admission Form. If a patient is a minor or very ill, let a responsible relative
or companion sign on his behalf. Interpret to the patient or to the person who will sign
the consent what are written on the consent form to avoid confusion.
5. Take the patient's complaints or the reason for seeking admission from patient himself
or his companion . Obtain nursing history organized by standards of nursing care
adopted by hospital for proper assessment Ask for the duration and nature of the
illness stated and document on the chart.
6. Take patient's vital signs like TPR and blood pressure and record to provide baseline
measurement to compare future findings. Note also the time of admission and
condition of the patient upon admission.
7. Notify the resident-on- duty about the admission for preliminary orders. Afterwards,
notify the attending physician.
8. Usher patient to room of choice, taking into consideration the agency's policy for room
assignment. Usually, a patient who requires frequent monitoring should be placed near
the nurse's station.
9. Orient patient to the unit and hospital personnel to help client recognize caregivers,
including the agency's policies in orientation for knowledge of hospital policies assists
client in adapting to the health care environment.
10. Give admission bath according to hospital's policy. Usually, a bed bath for patients
who are bed-ridden and a shower for ambulatory patients to make patient comfortable
and promote well-being. Patients with skin eruptions or rashes are not bathed until
seen and examined by the doctor. Change patient's clothes into a hospital gown. Fix
hair and cut nails if necessary.
11. Provide patient with necessary bedside accessories,bath towel, wash cloth, soap dish

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 with soap, hand bell or signal light, drinking glass and a bottle of water.
12. Make patient comfortable on bed.
13. List all valuables the patient has for proper placement and prevents loss. If the patient
wishes to retain his valuables under his keeping then he must be notified that it is at his
own risk and the hospital will not assume responsibility for any damage or loss of his
valuables. The list of valuables must be checked with the patient and signed by him. If
the patient cannot sign the list, a second nurse must serve as a witness and sign the
list. All valuables must be deposited in the business office together with the signed list,
leaving a copy to the patient. Secure receipt from the cashier or his representative who
received it.
14. Complete all records to provide complete data. Carry out all doctor's orders to prevent
delay which may cause deterioration of client's condition and show chart to head
nurse. Notify also the dietitian so that appropriate diet could be provided to the patient.

Admitting Patient To A Private Ward

1. Make sure that the patient's companion has already made an arrangement with the
cashier's office and information clerk regarding the patient's admission to avoid
confusion.
2. Bring the patient directly to his room of choice and put him on bed or chair depending
on his condition to provide comfort.
3. Change patient's clothes into hospital gown or he may use his own pajamas or
nightgowns for patient's comfort.
4. Clothings and patient's valuables may not be deposited if patient prefers them,
however, he should be told that he is responsible for them.

Admitting Patient To Obstetrical Ward

1. Notify obstetrician-on-duty and prepare patient for internal and physical examination in
the examining room.
2. If patient is on advanced labor, take her directly to the delivery room. Ask the patient
for her 1st day of Last Menstrual Period to know her Expected Date of Confinement.

Admitting Patient To Pediatrics Ward (Children not more than 12 years old)

1. Do the same procedure in admitting a patient.

2. Take the patient's height and weight then record.
3. Ask the patient's companion for the kind of feeding used for infants admitted.

Admitting Patient To Gynecology Ward

1. Notify gynecologist-on-duty.
2. Prepare patient for physical and internal examination.
3. If ordered for admission, proceed to same admission routine.

Charting And Documentation

Document the time of admission, manner of arrival, (whether the patient is ambulatory,
on wheelchair or stretcher) physical condition, chief complaints, vital signs and
other pertinent data and affix your signature as the admitting nurse.

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 DISCHARGING A PATIENT FROM THE HOSPITAL

Definition: Is a process which guarantee a prompt and well-coordinated discharge from

acute care to ensure that adequate care is continued either in the client's home
or in a restorative care setting.

Purposes
1. To provide patient with necessary information regarding his condition before leaving
the hospital.
2. To provide patient with necessary instructions regarding his return and follow-up visit
to the hospital.
3. To protect the hospital and the patient against misunderstanding and difficulties related
to patient's release.

Assessment:
1. From time of admission, assess clients health care needs for discharge using nursing
history and care plan; focus on ongoing assessments on physical health, functional
status, psychosocial support system, financial resources,health values, cultural and
ethnic background, level of education, and barriers to care to assist client achieve
maximal functioning.
2. Assess client's and family's need for health teaching related to how to perform home
therapies, use of home medical equipment, restrictions resulting from health
alterations, and possible complications to improve understanding of health care needs
and ability to achieve self-care at home.
3. Assess with client and family any environmental factors within home that might
interfere with self-care and pose risks to safety as a result of limitation created by
illness .
4. Collaborate with physician and staff in other disciplines in assessing need for referral
for skilled home health care services,to be confined at home, under physician's care
and require skilled nursing care on intermittent basis or extended care facility .

Preparation For Discharge:

1. Secure doctor's order for discharge to attend to any last minute treatments or
procedures well before discharge and give patient return slip for follow-up visit.
2. It is the duty of the head nurse to inform the family of the patient a day before release
so that arrangements can be made and bills could be settled.
3. Prepare a detailed instructions regarding medications and treatment that need to be
continued at home to provide feedback to determine client's success in learning about
medications and treatments.

Procedure:
1. As soon as there is an order for discharge, inform the family so that bills could be
settled.
2. Check with the accounting office if patient has paid for his bills.
3. Help the patient get dressed and prepare his things.
4. Check all the things of the hospital that have been used by the patient.
5. Inspect the patient's package and obtain copy of valuable list signed by the client and
have appropriate administrator deliver valuables to client. Client's signature verifies
receipt of items and relieves nursing department of liability for losses.

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 6. Give instructions pertaining home medications and next visit. Offer a final review of any
information needed to facilitate safe medication self-administration.
7. A minor, weak and irrational patient must be accompanied by a relative during
discharge for safe transport. Using a wheelchair is indicated for patients who are
unable to walk.
8. Bill the discharge slip in duplicate, send one to the information, the other is left in the
chart for documentation purposes.

9. Accompany patient until she gets her ride.

10. Complete the chart to be filled up when the patient has left the hospital, the condition of
the patient, his companion, and the time of departure. Indicate if the patient was
*Discharged Against Medical Advice*. Inspect for completeness of chart and enter into
discharge.

*If patient insists on going home without doctor's order,let him sign a note that he is releasing
the hospital of any responsibility if anything happens to him.

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 ADMINISTRATION OF ORAL MEDICATIONS

Definition: The administration of medications by mouth or per orem for the absorption in the
stomach and small intestine.

Purposes:
1. To give medication conveniently and less expensively.
2. It is safe, does not break skin barrier.
3. Does not cause stress during administration.

Materials:
medication in a disposable cup or oral syringe
liquid with straw if not contraindicated
medication cart or tray
medication Kardex or MAR (medication administration record

Assessment:
1. Assess for the patient's ability to swallow- if patient cannot swallow, is on NPO,or is
experiencing nausea and vomiting, the medication should be withheld, the physician
notified, and proper documentation completed.
2. Assess the patient's knowledge of the medication- if patient has knowledge deficit
about the medication, this may be the appropriate time to begin education about the
medication
3. Assess vital signs before administration- some medications affect the patient's vital
signs
4. If medication is for pain relief, assess the patient's pain level before and after
administration

Procedure:
1. Arrange MAR or medication Kardex.
2. Compare label on medication with MAR and physician's order and check the ten rights
of medication administration. Clarify any inconsistencies, this comparison helps to
identify errors that may have occurred when orders were transcribed.
3. Check the patient's chart for allergies.
4. Know the actions, special nursing considerations, safe dose ranges, purpose of
administration, and adverse effects of the medications to be administered.
5. Calculate the correct dosage to prevent error.
6. Wash hands to prevent the spread of microorganisms
7. Prepare medications for only one client at a time to prevent error in medication
administration.
A. Unit Dosage: Place packaged medications directly into medicine cup or lay on
tray without unwrapping for the label is needed for an additional safety
check. Unwrap only at patient's bedside.
B. Medication From A Multi-dose Bottle: Pour tablets or capsules into the
container lid and transfer into medicine cup without touching the
medication to prevent contamination. Pouring medication into the lid
allows for easy return of excess medications to bottle. Break only scored
tablets, if necessary, to obtain proper dosage.
C. Medications From A Bingo Card: Snap the bubble containing the correct

5
 medication directly over the medication cup. Do not touch medications
Pouring tablets or capsules into the nurse's hands is unsanitary.
Liquid Medications: Remove cap and place on counter top inside up. Hold medication
bottle with the label against the palm of the hand. Use the appropriate measuring
device when pouring liquids,hold medication cup at eye level, and fill until bottom of the
meniscus.

8. Accuracy is possible when the appropriate measuring device is used and then read
accurately. Wipe the lip of the bottle with a paper towel. Liquid that may drip onto the
label makes the label difficult to read. Discard excess poured liquid from cup into sink.
9. Recheck each medication package or preparation with the order as it is poured. This is
a second check to guard against a medication error.
10. When all medications for one patient has been prepared, recheck once again with the
medication order before taking them to the patient. This is a third check to ensure
accuracy and to prevent errors.
11. Transport medications to the patient's bedside carefully, and keep the medications in
sight at all times. Careful handling and close observation prevent accidental or
deliberate disarrangement of medications.
12. See that the patient receives the medications at the correct time. Check agency policy,
which may allow for administration within a period of 30 minutes before and 30 minutes
after designated time.
13. Identify the patient carefully by doing these three correct ways:
a) check the name on the patient's identification band- this is the most reliable
method. Replace the identification band if it is missing or inaccurate in any way.
b) ask the patient to state his or her name- this requires a response from the patient,
but illness and strange surroundings often cause patients to be confused.
c) verify the patient's identification with a staff member who knows the patient- this is
another way to double- check identity.
14. Complete necessary assessments before administering medications like taking of vital
signs to assess patient's status.
15. Explain the purpose and action of medication to client.
16. Assist the patient to an upward or lateral position. This facilitates proper positioning. An
upright or side-lying position protects the patient from aspiration.
17. Administer medications:
a) offer water or other permitted fluids with pills, capsules, tablets, and some liquid
medications to facilitate easy swallowing of solid drugs. In cases that some liquid
medications are intended to adhere to the pharyngeal area, do not offer liquids.
b) ask whether the patient prefers to take the medications by hand or in a cup and
one at a time or all at once to encourage patient's participation in taking the
medications.
c) if a tablet or capsule falls to the floor, discard it and administer a new one to
prevent contamination.

6
 d) record any fluid intake if intake and output measurement is ordered to provide
proper documentation.
18. Remain with the patient until medication is swallowed for the drug to be recorded as
administered and do not leave medication at bedside unless ordered by the physician.
19. Perform hand hygiene to prevent spread of microorganisms.
20. Record each medication given on the medication chart or record using the required
format to prevent repeating accidentally the administration of the drug.
a) record in the appropriate area of medication record if drug is omitted or refused and
notify the physician to verify the reason why medication is omitted and ensures
physician's awareness of the patient's condition.
b) recording of administration of a narcotic drug may require additional documentation
on a narcotic record, stating drug count and other specific information because
controlled substance laws necessitate careful recording of narcotic use.
21. Check patient to verify response to medication within 30 minutes after administration.

SUBLINGUAL ADMINISTRATION BUCCAL ADMINISTRATION

7
 APPLICATION OF TRANSDERMAL PATCH

Definition: The application of a patch to the skin that contains medication intended
for daily use or for longer intervals.

Purpose: To deliver hormones, narcotic analgesics and nicotine

Equipment: medication
scissors (optional)
gloves
washcloth, soap and water
medication Kardex or MAR (Medication Administration Record)

Assessment:
1. Assess patient for allergies.
2. Assess the skin for the location of the patch. This should not be placed on irritated or
broken skin. Check the manufacturer’s instructions for location of the patch to avoid
error.
3. Assess for any old patches on the patient’s skin. A new one should not be applied if
the old patch is not completely removed.
4. Asses the patient’s knowledge about the medication to know if there’s knowledge
deficit so that patient education about the medication could be done.

Procedure:
1. Bring equipment to patient’s bedside to save time and facilitates performance of task.
Check for medication order against physician’s order to ensure that the patient will
receive the correct medication at the correct time and in the right manner.
2. Identify patient by checking identification band on the wrist and ask patient his or her
name to ensure that the medication is given to the right person. Ask patient about any
allergies.
3. Explain procedure to the patient to allay patient’s anxiety.
4. Perform hand hygiene to deter the spread of microorganisms and don gloves to protect
yourself when handling the medication on the transdermal patch.
5. Assess patient’s skin where patch is to be placed, observing for any sign of irritation or
breakdown. Transdermal patch should not be placed on irritated or broken skin. Find a
place that does not have a large amount of hair because this can prevent the patch
from sticking to the skin. If patient has a large amount of hair especially on chest or
back, use scissors to trim the hair and do not shave the area. Shaving has been known
to cause small cuts on the skin’s surface that may lead to infection.
6. Remove any old transdermal patch from the patient’s skin because leaving old patches
on patient while applying new ones may lead to delivery of a toxic level of drug. Gently
wash the area with soap and water where the old patch was to remove all traces of
medication in that area.
7. Remove cover of patch without touching adhesive side to avoid altering the amount of
medication on the patch. Put the patch on the patient’s skin by pressing it firmly with
the palm of the hand for 10 seconds. This ensures that the patch stays on the patient’s
skin.
8. Write your initials, date and time on the transdermal patch to prevent medication errors
by ensuring that old patches are removed.
9. Remove gloves and perform hand hygiene.
10. Chart site of patch administration for accurate documentation to prevent medication
error.

8
 11. Assess for patient’s response to medication within appropriate time frame to ensure
that patch is delivering drug appropriately and that patient is not experiencing any
adverse effects.
INSTILLATION OF EYE MEDICATIONS

Definition: It is the administration of medications in the conjunctival sac for their local
effects.

Purposes:
1. to dilate or constrict the pupil during eye examination
2. for treating an infection
3. to help control intraocular pressure for patients with glaucoma

Materials: gloves
medication ( eye drop or ointment )
tissue or washcloth
medication Kardex or MAR ( Medication Administration Record )

Assessment:
1. Assess the patient for allergies to prevent untoward reactions to the medication.
2. Assess the affected eye for any drainage, erythema, or swelling.
3. Assess the patient's knowledge of medication, if the patient has a knowledge deficit,
this may be the appropriate time to begin education about the medication.

Procedure:
1. Bring equipments to patient's bedside after checking the medication order. This saves
time and effort and ensures that the patient receives the right medication.
2. Identify patient by checking identification band on patient's wrist or ask patient his
name to ensure that medication is given to the right person. Ask patient about any
allergies.
3. Explain procedure to the patient to allay anxiety.
4. Perform hand hygiene to deter microorganisms and don gloves to protect your hand
from any drainage from eyes.
5. Assist client to sit in an upright position with the head hyperextended for patients
comfort and to easily instill the medication.
6. Provide client with the tissue to blot any medication or tears that spill from the eye
during the instillation to save time in getting a clean or sterile cloth to wipe off excess
medication from the eye.
7. Cleanse the eyelids and eyelashes of any drainage with a washcloth moistened with
normal saline solution starting from the inner canthus to the outer canthus using each
area of the washcloth only once. This is to kept debris away from the lacrimal duct.
8. Tilt the patient's head back slightly to make it easier for the medication to reach the
conjunctival sac or turned slightly to the affected side to prevent solution or tears from
flowing to the opposite eye. However, this should be avoided if the patient has a
cervical spine injury.
9. Ask client to look up to the ceiling.
10. Remove the cap of the medication drop or ointment carefully so as not to touch the
inner side of the cap to prevent contamination.
11. Place 2 fingers or thumb on lower eyelid and gently hold the lower lid down to expose

9
 the conjunctival sac. This is to instill the medication in the conjunctival sac and not on
the eyeball.

12. With other hand resting on the clients forehead, instill the required number of drops or
the ointment on the lower conjunctival sac, starting from the inner to outer canthus
without touching the eyelids or lashes to prevent contamination of the medication
container and prevent patient from startling causing the patient to blink which could
injure the eye.

13. Occlude the lacrimal duct for approximately 1 minute to prevent systemic absorption.
14. Avoid dropping a solution onto the cornea directly to prevent injury.
15. Release the lower lid, and allow the client to close eye to distribute medication over
the entire eye.
16.If the client blinks and the medication is not instilled, repeat the above steps.

10
 INSTILLATION OF NOSE DROPS

Definition: The instillation of medications through the nose.

Purposes:
1. To treat allergies,sinus infections, and nasal congestions.
2. To instill medications with systemic effects like vasopressin.

Equipment: medication
gloves
tissue
medication Kardex or Medication Administration Record

Assessment:
1. Assess patient for allergies to prevent untoward reactions.
2. Assess the patient's knowledge of medication to begin education if patient has
knowledge deficit.
3. Assess the nares for drainage or broken skin for these interfere with drug absorption..
4. Assess client's history of hypertension,heart disease, diabetes, and hyperthyroidism for
these conditions can contraindicate use of decongestants that stimulates the
CNS,resulting to transient hypertension, tachycardia,palpitations,and headache may
occur.

Procedure:
1. Perform hand hygiene to reduce transmission of microorganisms.
2. Arrange supplies and medication at bedside to ensure smooth and orderly procedure.
3. Instruct client to clear or blow nose gently unless contraindicated to remove mucus and
secretions that can block distribution of medication. Blowing the nose is
contraindicated when there is increased intracranial pressure or nosebleeds.
4. Assist client to supine position and position head properly to provide access to specific
nasal passages.
Access To Posterior Pharynx: tilt client's head backward

Access To Ethmoid or Sphenoid Sinus: tilt Access To Frontal and Maxillary Sinus:
head back over edge of bed or place small tilt head back over edge of bed or pillow
pillow under client's shoulder and tilt head with head turned toward side to be

11
back treated.

5. Support client's head with non-dominant hand to prevent straining of the neck muscles.
6. Instruct client to breath through mouth to reduce chance of aspirating nasal drops into
the trachea and lungs.
7. Hold dropper 1 cm (½ inch) above nares to avoid contamination of dropper and instill
prescribed number of drops toward midline of ethmoid bone to facilitate distribution of
medication over nasal mucosa.
8. Instruct client to remain in supine position for 5minutes to prevent premature loss of
medication through nares.
9. Offer facial tissue to blot runny nose but caution client against blowing nose for several
minutes to allow maximal amount of medication to be absorbed.
10. Assist client to a position of comfort after medication is absorbed to restore comfort.
11. Dispose of soiled supplies in proper container to maintain neat and orderly
environment and perform hand hygiene to reduce spread of microorganisms.
12. Document medication administration and any drainage noted from the nose to provide
accurate documentation and prevent medication errors.
13. Observe client for side effects 15 to 30 minutes after administration.

12
 INSTILLATION OF EARDROPS

Definition: It is the instillation of drugs in the external auditory canal for their local effects

Purposes:
1. To instill ear medications accurately and safely
2. To soften impacted ear wax
3. To relieve pain, apply local anesthesia, destroy organisms or destroy an insect lodged
in the canal

Materials:
ear drop ( warmed to body temperature )
tissue
cotton ball (optional)
gloves (optional)
washcloth (optional)
medication Kardex or MAR (Medication Administration Record)

Assessment:
1. Assess the affected ear for drainage or tenderness.
2. Assess the patient for allergies to prevent untoward signs and symptoms.
3. Assess the patient's knowledge of medication to give appropriate education if there's
knowledge deficit

Procedure:

1. Bring equipments to patient's bedside to save time and effort.

2. Check physician's order to ensure that the patient receives the right medication at the
right time and in the right manner.

3. Identify patient by checking identification band on the patient's wrist and asking the
patients name to ensure that the medication is given to the right person. Ask patient
regarding allergies to medications.

4. Explain procedure to the patient to allay anxiety.

5. Perform hand-washing. Don gloves if drainage is present to protect self from

microorganisms.

6. Offer tissue to patient to be used when solution spills from the ear toward the eye.

7. Have client sit or lie with head turned to unaffected side to prevent drops from
escaping from the ear.

8. Using cotton ball or washcloth moistened with normal saline solution, clean the
external ear because drainage and some debris prevent some medication from
entering the ear canal.

9. Draw up exact amount of solution needed in a dropper. Excess should not be returned
to stock bottle to prevent the risk of contamination.

10. Straighten the auditory canal by gently pulling the pinna (cartilaginous portion of

13
 the outer ear) up and back in older children and adults, and down and back for
infants and children younger than 3 years.

11. Hold dropper in ear with its tip above auditory canal so that majority of the medication
will enter the ear canal. For an infant or an irrational or confuse patient, protect
dropper with a piece of soft tubing to help prevent injury to ear.

12.Instill eardrops on side of the auditory canal to allow the drops not to fall directly on the
tympanic membrane for this is very uncomfortable to the patient.

13. Release the pinna, and gently massage tragus of the ear.to allow medication to move
toward tympanic membrane. Have patient maintain the position for at least 5 minutes
to prevent the escape of medication.

14. If permitted, place a cotton ball or wick in the outer ear to keep medication in the
canal.

15. If drops required in the opposite ear, wait a few minutes, and repeat the procedure in
that ear.

16. Remove gloves and perform hand hygiene.

17. Document medication administration and any drainage from ear noted to provide
accurate documentation.

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 INSERTING VAGINAL SUPPOSITORY OR CREAM

Definition: It is the application of creams and tablets intravaginally using a narrow, tubular
applicator with an attached plunger or the manual insertion of vaginal
suppositories that melt when exposed to body heat with gloved hands.

Purpose:
1. For topical application of anti-infective agents for female clients with vaginal infections.
2. To augment labor Zytotec).

Equipments: medication (vaginal cream, jelly, tablet, or suppository)

applicator (if needed)
disposable gloves
tissues
drape
water-soluble lubricants
Medication Administration Record
Assessment:
1. Review prescriber’s order including client’ name, drug name, form, route, dosage, and
time of administration to ensure safe and correct administration of medication.
2. Review pertinent information related to medication, including action, purpose, side
effects, and nursing implications to administer drug properly and to monitor client’s
response.
3. Ask if client is experiencing any symptoms of pruritus, burning, or discomfort to assess
for symptoms of vaginal irritation.
4. Have client void to empty bladder and promotes comfort during insertion.
5. Assess client’s ability to manipulate applicator or suppository and to properly position
self to insert medication for mobility restrictions indicates level of assistance required
from the nurse.
6. Review client’s knowledge of purpose for drug therapy and interest in self-
administering medication for this may indicate need for health teaching and client’s
understanding influences compliance with therapy.
Procedure:

1. Perform hand hygiene to deter the spread of microorganisms.

2. Arrange supplies at bedside to help nurse perform the procedure smoothly.

3. Put on clean gloves to protect the nurse’s hands from microorganisms.

4. Close room curtain or door to provide privacy.

5. Assist client to lie in a dorsal recumbent position to provide easy access to and good
exposure of vaginal canal. Clients with restricted mobility in knees or hips may lie
supine with legs abducted.

6. Keep abdomen and lower extremities draped .to minimize client’s embarrassment by
limiting exposure.

7. Be sure vaginal orifice is well-illuminated by room light for proper insertion, otherwise,
position portable goose neck lamp.

15
8. Inspect condition of external genitalia and vaginal canal to provide baseline to monitor
effect of medication.

For Suppository Insertion:

1. Remove suppository from wrapper and apply liberal amount of water-soluble
lubricant to smooth or rounded end to reduce friction against mucosal surface
during insertion. Lubricate gloved index finger of dominant hand.
2. With non-dominant gloved hand, gently separate labial folds, in the front-to-back
direction to expose the vaginal orifice.
3. Insert rounded end of suppository along posterior wall of vaginal canal entire
length of finger (7.5 to 10 cm. or 3-4 inches) for proper placement that ensures
equal distribution of medication along walls of vaginal cavity.
4. Withdraw finger and wipe away remaining lubricant from around orifice and labia
to maintain patient’s comfort.

For Application of Cream:

1. Fill cream applicator following package directions for proper dosage.
2. With non-dominant gloved hand, gently separate labial folds to expose vaginal
orifice.
3. With dominant gloved hand, insert applicator approximately 5 to 7.5 cm. (2 to
3inches) to allow equal distribution of medication along vaginal walls. Push
applicator plunger to deposit medication into vagina.
4. Withdraw applicator and place on paper towel for this may contain
microorganisms.. Wipe off residual cream from labia or vaginal orifice to
maintain patient’s comfort.

APPLICATION OF VAGINAL CREAM USING APPLICATOR

9. Instruct client to remain on her back for at least 10 minutes to allow melting and
spreading of the medication throughout vaginal cavity and prevents loss through the
orifice.

10. If applicator is used, wash with soap and warm water, and rinse to remove residual
cream and bacteria, and store for future use.

11. Offer perineal pad when patient resumes ambulation to promote comfort.

12. Discard gloves by turning them inside out, and dispose of gloves and other soiled
equipment in appropriate receptacle, then perform hand hygiene to reduce
transmission of microorganisms.

16
 13. Do charting for proper documentation.

ADMINISTERING RECTAL SUPPOSITORIES

Definition: Administration of a drug through the rectum for local or systemic effects.

Purposes:
1. For local effect on the GI mucosa, such as promoting defecation.
2. To exert systemic effect, such as relieving nausea or providing analgesia.

Equipment: rectal suppository tissue

lubricating jelly (water soluble) drape
clean gloves Medication Administration Record

Assessment:
1. Review prescriber’s order, including client’s name, drug name. dosage, form route, and
time of administration to ensure safe and correct administration of medication.
2. Review pertinent information related to medication, including action, purpose, side
effects, and nursing implications for proper drug administration and to monitor client’s
response.
3. Review medical record for history of rectal surgery or bleeding for these conditions
contraindicate use of suppository.
4. Review any presenting signs and symptoms of GI alterations like constipation or
diarrhea. These conditions indicate use of suppository.
5. Assess client’s ability to hold suppository and to position self to insert medication.
6. Review client’s knowledge of purpose of drug therapy and interest in self-
administering suppository.

Procedure:
1. Perform hand hygiene, arrange supplies at bedside, and apply gloves to reduce
transfer of microorganisms and helps nurse perform procedure smoothly.
2. Close room curtain or door to maintain privacy and minimizes embarrassment.
3. Assist client in assuming a left side- lying Sim’s position with upper leg flexed upward
to expose anus and helps client to relax external anal sphincter. Left side lessens the
likelihood of the suppository or feces being expelled. If the client has mobility
impairment that prevents a left side lying Sim’s position, assist client to a left lateral
position. Obtain assistance from another health care provider to help client turn, and
use pillows under client’s upper arm and leg for support and comfort.
4. Keep client draped with only anal are exposed to maintain privacy and facilitates
relaxation.
5. Examine condition of anus externally to determine active rectal bleeding. Suppository
is contraindicated in this condition, as well as in cases wherein patient is having
diarrhea. Palpate rectal walls as needed to determine whether rectum is filled with
feces which may interfere with suppository placement. Palpation is contraindicated if
client has had rectal surgery. Dispose of gloves by turning them inside out and placing
them in proper receptacle to reduce transmission of microorganisms.
6. Apply new pair of disposable gloves to minimize contact with fecal material to reduce
transmission of infection.
7. Remove suppository from foil wrapper and lubricate rounded end with water- soluble

17
 lubricant to reduce friction as suppository enters rectal canal. Lubricate gloved index
finger of dominant hand. If client has hemorrhoids, use liberal amount of lubricant and
handle area gently.
8. Ask client to take slow deep breaths through mouth and to relax anal sphincter to
prevent constriction of sphincter that may cause pain.
9. Retract client’s buttocks with non-dominant hand. With gloved index finger of dominant
hand, insert suppository gently through anus, past internal sphincter, and against rectal
wall, 10 cm or 4 inches, to place suppository against rectal mucosa for eventual
absorption and therapeutic action. It should not be inserted into a mass of fecal
material for this reduces the effectiveness of medication.

10. Withdraw finger and wipe client’s anal area to provide comfort.
11. Discard gloves by turning them inside out, and dispose of in appropriate receptacle to
reduce transfer of microorganisms.
12. Ask client to remain flat or on side for 5 minutes to prevent expulsion of suppository.
13. If suppository contains laxative or fecal softener, place call light within reach so client
can obtain assistance to reach bedpan or toilet.
14. Perform hand hygiene and dispose of gloves and other equipment to reduce risk of
transfer of infection.
15. Return within 5 minutes to determine if suppository was expelled and if reinsertion is
necessary.
16. Do charting for proper documentation.

18
19
PARTS OF SYRINGE

PARTS OF NEEDLE

20
Protect yourself – follow hospital, state, and national recommendations:

NEVER RECAP NEEDLES

ADMINISTERING AN INTRADERMAL INJECTIONS

Definition: The administration of a drug into the dermal layer of the skin just beneath the
epidermis.

Purposes:
1. For diagnostic purposes such as allergy and tuberculin testing
2. For vaccination

Equipment: medication
tuberculin syringe
withdrawal needle (for withdrawing drug from a vial)
sterile water for injection
antimicrobial swab
disposable gloves
acetone and 2x2 sterile gauze square (optional)
medication Kardex or medication administration record (MAR)

Assessment
1. Assess the patient for any allergies.
2. Assess the site on the patient where the injection is to be given; it should not be given
in broken or open skin. Avoid areas that are highly pigmented and hairy.
3. Assess the patient’s knowledge of reason for injection. This may provide an opportune
time for patient education.

Procedure:
1. Check the physician’s order. This ensures that the patient receives the right medication
at the right time by the proper route. Many intradermal drugs are potent allergens and
may cause a significant reaction if given in an incorrect dose.
2. Assemble all needed equipment to save time and effort.
3. Identify patient to avoid error.

21
4. Explain the procedure to the patient. Explanation encourages cooperation and reduces
apprehension.
5. Perform hand hygiene. Don disposable gloves. Hand hygiene deters the spread of
micro organisms. Gloves act as a barrier and protect the nurse’s hands from accidental
exposure to blood during the injection procedure.
6. If necessary, withdraw 0. 9 cc of distilled water and 0.1 cc of drug from an ampule or
vial. Use a withdrawal needle if drug is to be withdrawn from a vial so that the needle
on a T-syringe will not become dull when introduce to the skin. Recap the needle to
protect it from contact with micro-organisms.
7. Select an area on the inner aspect of the forearm that is not heavily pigmented or
covered with hair. The forearm is a convenient and easy location for introducing an
agent intradermally. The upper chest and upper back beneath the scapulae also are
sites for intradermal injections.
8. Cleanse the area with antimicrobial swab while wiping with a firm, circular motion and
moving outward from the injection site. Allow the skin to dry. For oily skin, clean the
area with a pledget moistened with acetone. This is effective for removing oily
substances from the skin.
9. Remove the needle cap with the non-dominant hand by pulling it straight off. This
technique lessens the risk of an accidental needlestick.
10. Use the non-dominant hand to spread the skin taut over the injection site. Tauting the
skin provides an easy entrance into the intradermal tissue.
11. Place the needle almost flat against the patient’s skin, bevel side up, and insert the
needle into the skin so that the point of the needle can be seen through the skin. Insert
the needle only about 1/8” with entire bevel under the skin. Intradermal tissue is
entered when the needle is held as nearly parallel to the skin as possible and is
inserted about 1/8”.
12. Slowly inject the agent while watching for a small wheal or blister to appear. If none
appears, the needle is not in the intradermal tissue. Withdraw the needle to ensure
bevel is in intradermal tissue.
13. Once the medication has been injected, withdraw the needle quickly at the same
angle that it was inserted to minimize tissue damage and discomfort for the patient.
14. Do not massage area after removing the needle for this may interfere with test results
by spreading medication to underlying subcutaneous tissue. Tell patient not to rub or
scratch the site.
15. Mark around the edge of the wheal with a pen with black or blue ink, not red to easily
identify the site of the intradermal injection and allows careful observation of the exact
site.
16. Do not recap the used needle to prevent accidental puncture wounds. Discard the
needle and syringe in the appropriate receptacle.
17. Assist patient to a position of comfort. Remove gloves and dispose properly. Do hand
hygiene to deter the spread of micro-organisms.
18. Chart the administration of the medication as well as the site of administration.
19. Observe the area for signs of a reaction at ordered intervals (usually after 30 mins.).
Inform the client of this inspection

22
 ADMINISTERING SUBCUTANEOUS INJECTIONS

Definition: It is the introduction of small amount of liquid solution into the subcutaneous
tissues with a needle and syringe.

Purposes:
1. when immediate effect of the drug is desired.
2. when the drug losses its potency when acted upon by gastric juices.
3. when the effect of the drug is desired at the site of injection.

Equipment: medication
sterile syringe and needle (size depends on medication to be
administered and patient)
antimicrobial swabs
disposable gloves
medication kardex or Medication Administration Record
cotton balls or dry sponge (optional)l

Assessment:
1. Assess patient for allergies.
2. Assess patient’s knowledge of the medication to begin education about medication if
there’s knowledge deficit.
3. Assess areas where the injection is to be given. It should not be given to areas of the
skin that are broken or open.

23
Procedure:
1. Assemble equipment and check the medication order to ensure that the patient
receives the right medication at the right time by the proper route.
2. Explain procedure to client to encourage client’s cooperation and reduce client’s
apprehension.
3. Wash your hands to deter the spread of microorganisms.
4. Withdraw medication from vial or ampule.
5. Identify the patient carefully by checking the identification band on the patient’s wrist
and asking patient his or her name to guard against error.
6. Close the curtain to provide privacy.
7. Wear gloves to protect your hand from accidental exposure to blood during the
injection procedure.
8. Have the patient assume a position appropriate for the most commonly used sites like
outer aspect of upper arm; the patient’s arm should be relaxed and at the side of the
body to prevent discomfort, anterior thighs; the patient may lie or sit with the leg
relaxed, and abdomen; the patient may lie in a semi-recumbent position
9. Clean the area around the injection site with an antimicrobial swab using a firm,
circular motion because friction helps to clean the skin, while moving outward from the
injection site. Allow the area to dry.

24
10. Remove the needle cap with the non-dominant hand, pulling it straight off to prevent
accidental needle stick.
11. Grasp and bunch the area surrounding the injection site or spread the skin at the site
to provide easy, less painful entry into the subcutaneous tissue. Pinching or spreading
tissue of the injection site depends on the size of the patient. For thin patients,
bunching the skin is necessary to create a skin fold.

12. Hold the syringe in the dominant hand between the thumb and forefinger. Inject the
needle quickly to cause less pain to the patient at an angle of 45 to 90 degrees,
depending on the amount and turgor of the tissue and the length of the needle.
Subcutaneous tissue is abundant in a well-nourished, well- hydrated people and spare
in emaciated, dehydrated or very thin person where it is best to insert the needle at 45-
degree angle.
13. After the needle is in place, release the tissue to prevent compression resulting to
pressure against nerve fibers and creates discomfort. If you have a large skin fold
pinched up, ensure that the needle stays in place as the skin is released to prevent
skin from retracting away from the needle. Immediately move your non-dominant hand
to steady the lower end of the syringe. Slide your dominant hand to the tip of the barrel.
14. Aspirate, if recommended, by pulling back gently on the plunger of the syringe to
determine whether the needle is in a blood vessel. If blood appears, the needle should
be withdrawn to prevent possible serious reaction if a drug intended for subcutaneous
use is injected into a vein.

25
 15. Discard the medication and the needle. A new syringe with new medication should be
prepared. Do not aspirate when giving insulin or any form of heparin, which is an
anticoagulant for this may cause bruising if aspirated.
16. If no blood appears, inject the solution slowly to prevent pressure in the tissues due to
rapid injection of the solution,causing discomfort to the patient.
17. Withdraw the needle quickly at the same angle at which it was inserted to prevent
pulling of tissues and discomfort due to slow withdrawal of the needle.
18. Massage the area gently with cotton ball or dry swab to distribute the solution and
hastens its absorption. Do not massage a subcutaneous heparin or insulin injection
site to prevent bruising. Apply a small bandage if needed.
19. Do not recap the needle to prevent accidental needlestick. Discard needle and syringe
in appropriate receptacle.
20. Assist patient to a comfortable position.
21. Remove gloves and dispose properly. Do hand hygiene to prevent the spread of
microorganisms.
22. Chart the administration of the medication, including the site of administration to
provide accurate documentation and prevent error.

23. Evaluate the response of the patient to the medication within an appropriate time
frame, usually 15 to 20 minutes after injection.
ADMINISTRATION OF INTRAMUSCULAR INJECTIONS

Definition: It is the introduction of small amount of liquid solution into the muscle with a
needle and syringe especially for drugs that are irritating because there are few
nerve endings in deep muscle tissue.

Purposes:
1. to administer irritating drugs that would produce unnecessary pain if given
subcutaneously.
2. to obtain a more rapid action than by subcutaneous route.

Equipments: medication
disposable gloves
syringe of suitable sizes
tray lined w/ sterile towel
needles G 20 – 21, or 1 – 2 ½ in length
antimicrobial swab
depending upon the thickness of
dry sponge
the muscle to be injected
medication Kardex or computer- generated Medication Administration Record

Procedure:

26
1. Check medication order to ensure that the patient receives the right medication at the
right time by the proper route and assemble equipment to save time and effort.
2. Explain procedure to patient to encourage cooperation and alleviates apprehension.
3. Perform hand hygiene to deter the spread of microorganisms.
4. Withdraw medication from a vial or ampule.
5. Do not add air to the syringe for this is potentially dangerous and may result in air
embolism.
6. Identify the patient carefully by checking the name of the patient on the identification
band, which is the most accurate, asking the patient his or her name, and verify the
patient's identification with a staff member who knows the patient. By doing all these,
you are guarding self against error.
7. Provide privacy. Have the patient assume a position appropriate for the site selected,
and encourage the patient to relax for injection into a tense muscle causes discomfort.

Ventrogluteal muscle: the patient ,may lie on the back or side with the hip and knee
flexed

Vastus lateralis muscle: patient may lie on the back or may assume a sitting
position

Deltoid muscle: the patient may sit or lie with arm relaxed

27
 Dorsogluteal muscle: the patient may lie prone with toes pointing inward or on the
side with upper leg flexed and placed in front of the lower leg

8. Locate the site of choice. Ensure that the area is non tender and free of lumps and
nodules for this may indicate a previous injection site where absorption was
inadequate.

9. Clean the area thoroughly with an antimicrobial swab, using friction and allow to dry.

10. Remove the needle cap by pulling it straight off to lessen the risk of accidental needle
stick and also prevents inadvertently unscrewing the needle from the barrel of the
syringe.

11. Displace the skin in a Z-track manner by pulling to one side or spread the skin at the
site using your non dominant hand to make the tissue taut and minimizes discomfort.

28
12. Hold the syringe in the dominant hand between the thumb and forefinger then quickly
dart the needle into the tissue at a 90-degree angle to make the injection less painful
and facilitates entry into muscle tissue.

13. As soon as the needle is in place, using the non dominant hand, hold the lower end of
the syringe to steady it.

14. Aspirate slowly for at least 5 seconds by pulling back on the plunger to determine
whether the needle is in a blood vessel. If blood is aspirated, discard the needle,
syringe, and medication for a possible serious reaction may occur if a drug intended for
intramuscular use is injected into a vein. Prepare a new sterile set up and inject into
another site.

15. If no blood is aspirated, inject the solution slowly, at least 10 seconds per ml of
medication to reduce discomfort by allowing time for solution to disperse in the tissues
muscle. Release displaced tissue if Z-track technique was used to seal medication in
16. Apply gentle pressure at the site with light pressure for less trauma and irritation to the
tissues using a small,dry sponge or cotton ball.

17. Do not recap used needle to avoid accidental puncture wounds. Discard needle and
syringe in appropriate receptacle.

18. Assist patient to position of comfort. Encourage exercise of extremity used for injection
to promote absorption of medication, if possible.

19. Remove gloves and dispose properly. Perform hand hygiene to deter the spread of
microorganisms.

29
 20. Chart the administration of medication,including the site of administration for proper
documentation and prevent error.
21. Evaluate patient's response to medication within an appropriate time frame to assess
reaction to medication which is a possibility. Assess also site of injection within 2 to 4
hours after administration for any untoward effects.

IM INJECTION IN CHILDREN
ASSISTING IN INTRAVENOUS INFUSION

Definition: Intravenous infusion is the administration of intravenous fluids to correct or

prevent fluid and electrolyte disturbances in clients who are or may become
acutely ill.

Purposes: 1. For burn clients with third-degree burns or over 40% of the body to
prevent severe fluid and electrolyte imbalances.
2. For NPO clients,usually after surgery
3. To provide IV access for intermittent or emergency medication
administration

Equipments:
IV solution
towel or disposable pad
non-allergenic tape
IV infusion set
gauze or transparent dressing
electronic infusion device (if available and ordered)
IV tubing
tourniquet
time tape or label (for IV container)
arm board (if needed)
cleansing swabs (alcohol, povidone-iodine)

30
 disposable gloves
IV pole
anesthetic cream (if ordered)
IV catheter (Abbo-cath or Angiocath)

Assessment:
1. Assess vital signs for baseline data.
2. Assess arms and hands for potential sites for initiating the IV. The site should not be
over a joint to prevent occlusion every time the patient moves the extremity. Inspect
the area, looking for a vein that is straight in an area approximately 5 cm long.
3. Determine the type of IV catheter to use
4. Ascertain which extremity is the patient's dominant arm, and try to use the non-
dominant arm for the patient's comfort.

Procedure:
1. Assemble equipment and bring to bedside to save time and facilitates accomplishment
of task.
2. Check the doctor's order to ensure that the patient receives the ordered IV solution.
Read label on fluid reservoir carefully.
3. Check fluid reservoir for expiration date and cloudy solution to prevent untoward
reactions.
4. Explain the need for IV and procedure to the patient to allay anxiety.
5. Perform hand hygiene to deter the spread of microorganisms.
6. Apply anesthetic cream to a few potential insertion sites, if anesthetic cream is
ordered. This is to decrease the amount of pain felt at the insertion site. Usually,
numbing creams take an hour to become effective.
7. Prepare IV solution and tubing.
a) maintain aseptic technique when opening sterile packages and IV solution to
prevent contamination.
b) clamp tubing, uncap spike, and insert into entry site on bag depending on
manufacturer's instructions to puncture the seal of the IV bag.
c) squeeze drip chamber to allow fluid to drip into it and fill it at least halfway. This
prevents air from moving down the tubing.
d) Remove cap at the end of tubing,release clamp,and allow fluid to move through
tubing. Allow fluid to flow until all air bubbles have disappeared because air in
larger amounts could cause an embolism. Close clamp and recap end of
tubing,maintaining sterility of setup.
e) if using an electronic device, follow manufacturer's instructions for inserting tubing
and setting infusion rate for correct flow rate and proper use of equipment.
f) apply label if medication was added to container for administration of correct
solution with prescribed medication or additive. Label tubing with date and time the
tubing was hung.
g) place time-tape on container for immediate evaluation of IV according to schedule
and hang IV on pole.

8. Place patient in a low Fowler's position on bed because supine position permits either
arm to be used and allows good body alignment. Place protective towel or pad under
patient's arm.
9. Select an appropriate site and palpate accessible veins to decrease discomfort for the
patient and reduce the risk for damage to body tissues.
10. If the site is hairy, clip a 2” area around the intended site of entry depending on the
agency policy, because hair can harbor microorganisms.
11. Apply tourniquet 5” to 6” above the venipuncture site to obstruct venous blood flow and
distend the vein for distended veins are easy to see,palpate, and enter. Direct the ends
of the tourniquet away from the site of entry to avoid contamination of the area of
insertion.
12. Instruct patient to open and close fist while observing and palpating for a suitable vein

31
 to contract the muscles of the forearms to force blood into the veins to distend them
further.
13. Try the following techniques if a vein cannot be felt:
a) release tourniquet and have patient lower arm below heart level to fill the veins,
reapply tourniquet and gently tap over intended vein to help distend it.
b) remove tourniquet and place warm moist compresses over intended vein for 10 to
15 minutes to help dilate the blood vessels.
14. Don clean gloves to protect hands against transmission of HIV and other blood-borne
infections.
15. If numbing cream was used, wipe cream off from insertion site. Cleanse site with an
antiseptic solution (alcohol swab) followed by antimicrobial solution like povidone-
iodine according to agency policy to prevent introduction of microorganisms into the
tissues or blood stream with the needle. Use circular motion to move from the center
outward for several inches.
16. Assist the physician in IV insertion after offering clean gloves.
To be performed by the physician:
a) using the non-dominant hand to hold the skin taut against the vein, place about 1”
or 2” below the entry site to apply pressure to prevent movement of the vein as the
catheter or needle is being inserted, avoiding touching the prepared site to keep it
free from contamination.
b) enter the skin gently, holding the catheter by the hub in the dominant hand, bevel
side up, at a10- to 30- degree angle. Catheter may be inserted from directly over
the vein or the side of the vein. This allows needle or catheter to enter vein with
minimal trauma. While following the course of the vein, advance the needle or
catheter into the vein. A sensation of “give” can be felt when the needle enters the
vein.
c) when blood returns to the lumen of the needle or the flashback chamber of the
catheter,advance either device 1/8 “ to ¼” farther into the vein. A catheter needs
to be advanced until the hub is at the venipuncture site to prevent dislodgement,
but the exact technique depends on the type of device used.
d) Release the tourniquet while quickly removing the protective cap from the IV
tubing and attach the tubing to the catheter or needle to minimize bleeding and
maintain the patency of the vein. Stabilize the needle or catheter with non-dominat
hand.
17. Start the flow of the solution promptly by releasing the clamp on the tubing to prevent
blood clots from forming if IV flow is not maintained. Examine the tissue around the
insertion site for signs of infiltration cause by accidental slip of the catheter out of the
vein.
18. Secure the catheter with narrow non-allergenic tape (1/2”) placed sticky side up under
the hub and crossed over the top of the hub to prevent from pulling it out of the vein
cause by the weight of the tubing.
19. Place sterile dressing over venipuncture site. Depending on the agency policy, the
nurse may use gauze dressing or transparent dressing. Though transparent dressing
allows easy visualization of site but it may place the patient at increased risk for
infection. Gauze dressing absorbs drainage and may have a decreased infection rate.
Loop the tube near the site of entry and anchor to dressing.
20. Mark the date, time,site, and type and size of the catheter used for the infusion on the
tape anchoring the tubing so that other personnel working with the infusion will know
what type of device is being used, the site,and when it was inserted.
21. Remove all equipment and dispose properly. Remove gloves and perform hand-
washing to deter the spread of microorganisms.
22. Use arm board and anchor arm for support if necessary to prevent the position of the
catheter in the vein from changing.
23. Adjust the flow rate according to the amount prescribed by the physician, or follow
manufacturer's direction for adjusting flow rate on infusion pump.
24. Document procedure and patient's response including the time, site, device used and

32
 solution to provide accurate documentation and ensures continuity of care.
25. Return after 30 minutes to check the flow rate and observe for infiltration and to assess
the patient's response to infusion.

33
 ADDING MEDICATIONS TO AN
INTRAVENOUS SOLUTION CONTAINER

Definition: Addition of medication to an IV fluid for direct venous circulation causing

rapid effect.

Purposes: For rapid effect of the medication.

Equipment: medication prepared in a syringe with a 19-to 21- gauge needle

IV fluid container (bag or bottle)
antimicrobial swab
label to be attached to the IV container
Medication Kardex or Medication Administration Record

Assessment:
1. Asses for compatibility of the medications when more than one medication is to be
added to IV solution for this often becomes apparent when drugs are mixed together
resulting to clouding or crystallization of IV fluids. Check institutional reference for drug
compatibility list.
2. Assess client's systemic fluid balance as reflected by skin turgor and hydration, body
weight, pulse,blood pressure and electrolyte laboratory values, for danger of
continuous IV infusions, especially in older adults or children may occur due to rapid
infusion causing circulatory overload.
3. Assess client's history of drug allergies, for intravenous administration of drugs causes

34
 rapid effects and allergic reactions can be immediate.
4. Assess IV insertion site for signs of infiltration or phlebitis to ensure that medication
could be given safely. Presence of complication will require IV to be restarted.

Procedure:
1. Check medication order with the physician's order to ensure that the patient receives
the correct medication at the correct time and in the right manner.
2. Check if the medication is compatible with the IV fluid to prevent complications.
3. Gather all equipment and take to patient's bedside to save time and facilitates
performance of the task.
4. Perform hand hygiene to deter the spread of microorganisms.
5. Identify patient by checking identification band on patient's wrist or asking patient his or
her name to ensure that medication is given to the right person.
6. Explain procedure to the patient to allay patient's anxiety.
7. Add the medication to the IV solution.
Adding The Medications To An Infusing IV Solution:
a) Check that the volume in the bag or bottle is adequate to dilute the drug.
b) Close the IV clamp to prevent back flow directly to the patient of improperly diluted
medication.
c) Clean the medication port with an antimicrobial swab to deter entry of
microorganisms when the port is punctured.
d) Steady the container and uncap the needle and insert it into the port, ensuring that
the needle enters the container, and inject the medication to disperse it into the
solution.
e) Remove the container from the IV pole and gently rotate the solution to mix it with
the medication.
f) Rehang the container, open the clamp, and readjust the flow rate to ensure the
infusion of the IV with the medication is at the prescribed rate.
g) Attach the label to the container so that the dose of the medication that has been
added is apparent to confirm that the prescribed dose of medication has been
added to the IV solution.

Adding Medication To The IV Solution Before The Infusion:

a) Carefully remove any protective cover and locate the injection port and clean with
an antimicrobial swab to deter entry of microorganisms when the needle punctures
the port.

b) Uncap the needle and insert into the port to ensure that the needle enters the

35
 container and inject the medication to disperse it into the solution.

c) Withdraw and insert the spike into the proper entry site on the bag or bottle to
puncture the seal.
d) With tubing clamped, gently rotate the IV solution in the bag or bottle to mix the
medication with the solution. Hang the IV.
e) Attach the label to the container so that the dose of medication that has been
added is apparent to confirm that the prescribed dose of medication has been
added to the IV solution.

8. Dispose of equipment according to agency policy to prevent inadvertent injury from the
equipment
9. Chart the addition of medication to the IV solution for proper documentation to prevent
medication error.
10. Evaluate the patient's response to medication within the appropriate time frame for
careful observation because medication given by IV route has a rapid effect.
ASSISTING IN BLOOD TRANSFUSION ADMINISTRATION

Definition: Blood transfusion is the infusion of whole blood or blood components such as
plasma, red blood cells, or platelets into a patient’s venous circulation.

Purposes:
1. To restore blood volume after a severe hemorrhage
2. To restore the capacity of blood to carry oxygen

Equipment:
blood product
blood administration set (tubing with in-line filter)
0.9% normal saline
IV pole
IV catheter (20 gauge or larger)
large-bore needle 18 or 19 gauge
disposable gloves
tape or plaster

Assessment:

36
 1. Assess patient thoroughly, including heart and lung sounds and urinary output. Review
recent laboratory values.
2. Ask patient about any previous transfusions, including the number he or she has had
and any reactions experienced during a transfusion.
3. Inspect the IV transfusion site and check the type of solution being given.

Procedure:
1. Check physician’s order to avoid error and to know if there’s an order for a pre-
medication before blood transfusion so that it could be administered right away.
2. Obtain blood product from the laboratory. It must be stored at a carefully controlled
temperature of 4 degrees Celsius. Do not store blood in the unit refrigerator because
its temperature is not precisely regulated and the blood may be damaged.
3. Warm blood before transfusion at room temperature for not longer than 30 mins. Never
warm blood in a microwave Red blood cells deteriorate and lose their effectiveness
after 2 hours at room temperature. Hemolysis releases potassium into the blood
stream causing hyperkalemia.
4. Carefully identify the blood before transfusion. Check for:
5. identification number- unit numbers should match
6. blood group and type- ABO group& type are the same
7. expiration date- after 35 days, RBC's deteriorate
8. patient’s name- never administered without proper identification
9. blood clots- if present, must be returned to blood bank
10. Perform hand hygiene to deter the spread of microorganism.
11. Gather necessary equipment to save time and effort.
12. Identify the patient. Determine whether patient knows reason for transfusion to direct
teaching before transfusion. Ask if the patient has had a transfusion or a transfusion
reaction in the past.
13. Explain the procedure to the patient to allay anxiety, the product to be administered,
how long the blood transfusion will take and tell patient to report for any blood
transfusion reactions.
14. Take patient’s vital signs for baseline data. Any change in vital signs during the
transfusion may indicate a reaction..
15. Wear clean gloves to protect hands from accidental exposure to the patient’s blood
and hang the container of 0.9 normal saline with an IV administration set on the IV
stand to initiate IV infusion and follow administration of blood.
16. Assist the physician in IV insertion using an IV catheter with 18 or 19 gauge if not
already present. A large bore- needle or catheter is necessary for the infusion of blood
products so that lumen must be large enough so as not to cause damage to red blood
cells. Keep IV open by starting flow of normal saline. Dextrose and other IV solutions
may cause clumping of red blood cells and hemolysis.
17. Start infusion of the blood product:
a) Prime in-line filter with blood. This is necessary for blood to flow properly. Fill the
drip chamber half full and open clamp, allowing blood to flow until it reaches on
the tip of the tubing with a large-bore needle attached to it, thus removing air
from the tubing.
b) Attach the blood set to the Y-tubing (piggy-back) of the IV line flowing with 0.9%
normal saline and secure properly with a plaster or tape. Close the clamp of the
IV tubing that serves as the mainline.
c) Start administration slowly (not more than 25 to 50 ml for
the 1st 15 minutes) to minimize the volume of blood infused to prevent cardiac
arrhythmias due to rapid infusion especially with cold blood.. Stay with the
patient for the 1st 5-15 minutes. of transfusion because transfusion reactions
usually occur during this period.
d) Check vital signs at least every 15 minutes. for the 1 st half-hour. If there’s no
adverse effect during this time, the infusion rate is increased. If complications
occur, they can be observed and transfusion can be stopped immediately.

37
 Follow institution’s recommendations for taking vital signs during the remainder
of the transfusion.
18. Observe patient for flushing, dyspnea, itching, hives or rash. These are early
symptoms of a transfusion reaction.
19. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the
patient’s overall condition, keeping in mind the outer limits for safe administration.
Assess frequently for any transfusion reaction. Stop transfusion if a reaction is
suspected. Notify physician at once.
20. When transfusion is complete, clamp off blood and begin to infuse 0.9% normal saline.
Saline prevents hemolysis of RBC's and clears remainder of blood in IV line.
21. Record blood administration and patient’s reaction as ordered by agency for accurate
documentation of patient’s response to the transfusion.

CATHETERIZATION

Catheterization of the bladder involves introducing a rubber or plastic tube through the
urethra and into the bladder .The catheter provides for a continuous flow of urine in clients
unable to control micturition or in those with obstruction to urine outflow. An indwelling or
Foley catheter may remain in place for an extended period. It may be necessary to change an
indwelling catheter periodically .
Intermittent catheterization, in which an a straight catheter is used , can be repeated as
necessary ,IC is a proven alternative for management of incontinence in many clients with
spinal cord disease.

PURPOSE:
1. To relieve bladder distention
2. To obtain sterile urine specimen
3. To empty the bladder before surgery where general and spinal anesthesia are used
4. To check and or remove residual urine
5. To prevent voiding when there are wounds in the genitourinary tract or other conditions
which make it important that the area be kept clean and dry.

POINTS TO REMEMBER :
1. Never catheterize without a written order

38
 2. Rigid aseptic technique should be practiced
3. Never use force in pushing catheter .Lubricate it well before use.
4. Determine allergy to antiseptic ,tape, or betadine or latex

MATERIALS:
Sterile catheter indwelling or intermittent
sterile gloves(extra pair optional)
sterile drape
water soluble lubricant
antiseptic cleansing solution
cotton balls
forceps
syringe filled with 5 to 8 ml sterile water to inflate balloon of indwelling catheter
sterile drainage tubing with collection bag
tape
basin/receptacle
specimen container
flashlight/ goose neck lamp or other appropriate additional light as needed

ASSESSMENT
1. Assess status of client :
1. time of last urination by asking client , checking (I&O) flow sheet-indicates
likelihood of bladder fullness.
2. level of awareness or developmental stage – reveals clients ability to cooperate
and level of explanation needed
3. mobility and physical limitations of client- affects way that the nurse positions
client
4. client's gender and age-determines catheter size : 8 to 10 French is generally used
for children, 14 to 16 Fr. Is indicated for women , 16 to 18 Fr is used for male
clients unless larger size is ordered by the physician
2. Determine if client has distended bladder:bladder is palpable above symphysis pubis;
palpation cause urge to urinate-causes pain . Can indicate need to insert catheter if
client is unable to void independently.
3. Assess for perineal anatomical landmarks , erythema , drainage and odor.- determines
condition of perineum.
4. Assess for any pathological condition that may impair passage of catheter (e.g.
Enlarge prostate gland in men)
5. Review clients medical record , including physician's order and nurses notes.-
determine purpose of inserting catheter:preparation for surgery, urinary irrigations,
collection of sterile urine specimen, or measurement of residual urine. Assess for
previous catheterization, including catheter size, response of client, and time of last
cathterization. Catheters may range in size from 6 Fr to 30 Fr.
6. Assess client's knowledge of the purpose for catheterization- Reveal need for client
instruction.

PROCEDURES/IMPLEMENTATION
1. Perform hand hygiene.- Reduces transmission of microorganisms. Infection is common
after catheterization. Foley catheter systems are often colonized with bacteria within 48
hours of catheterization.
2. Close curtain or door.- Offers privacy, reduces embarrassment, and aids in relaxation
during the procedure.
3. Raise bed to appropriate working height.- Promotes use of proper body mechanics.
4. Facing client, stand on left side of bed if right-handed (on right side if left handed).
Clear bedside table and arrange equipment.- successful catheter insertion requires

39
 nurse to assume comfortable position with all equipment easily accessible.

5. Raise side rail on opposite side of bed, and put side rail down on working side.-
Promotes client safety.
6. Place waterproof pad under client.-prevents soiling of bed linen.
7. Position client:
a. Female client:

i. Assist to dorsal recumbent position (supine with knees flexed). Ask client to
relax thighs so the hip joints can be externally rotated.- Legs may be supported
with pillows to reduce muscle tension and promote comfort.
ii. Position female client in side-lying (sims') position with upper leg flexed at knee
and hip if unable to be supine. If this position is used, nurse must take extra
precautions to cover rectal area with drape during procedure to reduce chance
of cross contamination.- This alternate position is used if client cannot abduct
leg at hip joint(e.g., if client has arthritic joints). Also, this position may be more
comfortable for client. Support client with pillows if necessary to maintain
position.

b. Male client:

i. Assist to supine position with thighs slightly abducted.- Comfortable position

for clients that aids in visualization.

8. Drape client:- avoids unnecessary exposure of body parts and maintains client's
comfort.
a. Female client:
(1) Drape with bath blanket. Place blanket diamond fashion over client, with one
corner at client's neck, side corners over each arm and side, and last corner

40
 over perineum.
b. Male client:
(1) Drape with bath blanket and cover lower extremities with bedsheets, exposing
only genitalia.

9. Wearing disposable gloves, wash perineal area with soap and water as needed; dry.-
Reduces microorganisms near urethral meatus and allows further opportunity to
visualize perineum and landmarks.
10. Position lamp to illuminate perineal area. (when using flashlight, have assistant hold
it) - Permits accurate identification and good visualization of urethral meatus.
11. Open package containing drainage system; place drainage bag over edge of bottom
bed frame and bring drainage tube up between side rail and mattress.- Prepares bag
for attachment to catheter.
12. Open catheterization kit according to directions, keeping bottom of container sterile.-
Prevents transmission of microorganisms from table or work area to sterile supplies.
The materials in the kit are ordered in sequence of use.
13. Place plastic bag that contains kit within reach of work area to use as waterproof bag
to dispose of used supplies.

14. Apply sterile gloves.- allows nurse to handle sterile supplies without contamination.

15. Organize supplies on sterile field. Open inner sterile package containing catheter.
Pour sterile antiseptic solution into correct compartment containing sterile cotton balls.
Open packet containing lubricant. Remove specimen container (lid should be loosely
placed on top) and pre-filled syringe from collection compartment of tray and set them
aside on sterile field if needed.- Maintains principles of surgical asepsis and
organized work area.

16. Before inserting indwelling catheter,m a common practice is to test balloon by

injecting fluid from pre-filled syringe into balloon port.- Checks integrity of balloon. Do
not use the catheter if the balloon does not inflate or leaks. This is a controversial
step. Follow manufacturer's recommendations. Checking the balloon in this way may
stretch the balloon and cause increased trauma on insertion.

17. Lubricate catheter 2.5 to 5 cm (1 to 2 inches) for women and 12.5 to 17.5 cm (5 to 7
inches) for men. NOTE: some catheter kits will have a plastic sheet over the catheter
that must be removed prior to lubrication. (option: physician may order use of lubricant
containing local anesthetic.)- Eases insertion of catheter through urethral canal.

18. Apply sterile drape, keeping gloves sterile:

a. Female client:
(1) allow top edge of drape to form cuff over both hands. Place drape down on bed
between client's thighs. Slip cuffed edge just under buttocks, taking care not to
touch contaminated surface with gloves.- Outer surface of drape covering hands
remains sterile. Sterile drape against sterile gloves is sterile.
(2) Pick up fenestrated sterile drape and allow it to unfold without touching an
unsterile object. Apply drape over perineum, exposing labia and being sure not
to touch contaminated surface.-maintains sterility of work surface.

b. Male client: Two methods are used for draping, depending on preference.-
maintains sterility of work surface.
(1) First method: Apply drape over thighs and under penis without completely
opening fenestrated drape.
(2) Second method: Apply drape over thighs just below penis. Pick up fenestrated

41
 sterile drape, allow it to unfold, and drape it over penis with fenestrated slit
resting over penis.

19. Place sterile tray and contents on sterile drape between legs. Open specimen
container. NOTE: client's size and positioning will dictate exact placement . This
method works best with flexible, average-size clients.- provides easy access to
supplies during catheter insertion. Maintain aseptic technique during procedure.

20. Cleanse urethral meatus.

a. Female client:
(1) With non dominant hand, carefully retract labia to fully expose urethral meatus.
Maintain position of non dominant hand throughout the procedure.- Full
visualization of urethral meatus is provided. Full retraction prevents
contamination of urethral meatus during cleansing.
(2) Using forceps is sterile dominant hand, pick up cotton ball saturated with
antiseptic solution and clean perineal area, wiping front to back from client
towards anus. Using a new cotton ball for each area, wipe along the far labial
fold, near labial fold, and directly over center of urethral meatus.- Cleansing
reduces number of microorganisms at urethral meatus. Use of single cotton ball
for each wipe prevents transfer of microorganisms. Preparation moves from
area of least contamination to that of most contamination. Dominant hand
remains sterile.

b. Male client:
(1) If client is not circumcised, retract foreskin with non dominant hand. Grasp penis
and shaft just below glans . Retract urethral meatus between thumb and
forefinger . Maintain nondominant hand in this position throughout procedure.-
Accidental release of foreskin or dropping of penis during cleansing requires
process to be repeated because area has become contaminated.
(2) With dominant hand, pick up cotton ball with forceps and clean penis. Move it in
circular motion from urethral meatus down to base of glans. Repeat cleansing
three or more times, using clean cotton ball each time.- Reduces number of
microorganisms at urethral meatus and moves from areas of least to most
contamination. Dominant hand remains sterile.
21. Pick up catheter with gloved dominant hand 7.5 to 10 cm (3 to 4 inches) from catheter
tip. Hold end of catheter loosely coiled in palm of dominant hand (Optional:may grasp
catheter with forceps). Place distal end of catheter in urine tray receptacle if straight
catheterization is being done.

22. Insert catheter:

a. Female client:
(1) Ask client to bear down gently as if to void and slowly insert catheter through
urethral meatus- Relaxation of external sphincter aids in insertion of catheter.
(2) Advanced catheter a total of 5 to 7.5 cm (2 to 3 inches) in adult or until urine
flows out catheter's end. When urine appears, advanced catheter another 2.5 to
5 cm (1 to 2 inches). Do not force against resistance. Place end of catheter in
urine tray receptacle.- Female urethra is short. Appearance of urine indicates
that catheter tip is in bladder or lower urethra. Advancement of catheter ensures
bladder placement.
(3) Release labia and hold catheter securely with non-dominant hand. Inflate
balloon if retention catheter is used.- Bladder or sphincter contraction may
cause accidental expulsion of catheter.

b. Male client:
(1) Lift penis to position perpendicular to client's body and apply light traction.-

42
 Straightens urethral canal to ease catheter insertion.
(2) Ask client to bear down as if to void and slowly insert catheter through urethral
meatus.- Relaxation of external sphincter aids in insertion of catheter.
(3) Advanced catheter 17 to 22.5 cm (7 to 9 inches) in adult or until urine flows out
catheter's end. If resistance is felt, withdraw catheter; do not force through
urethra. When urine appears, advance catheter another 2.5 to 5 cm (1 to 2
inches). Do not use force to insert catheter.- The adult male urethra is long. It
is normal to meet resistance at the prostatic sphincter. When resistance is met,
nurse should hold catheter firmly against sphincter without forcing catheter. After
few seconds, sphincter relaxes and catheter is advanced. Appearance of urine
indicates catheter tip is in bladder or urethra. Farther advancement of catheter
ensures proper placement.
(4) Lower penis and hold catheter securely in non-dominant hand. Place end of
catheter in urine tray receptacle. Inflate balloon if retention catheter is used.-
Catheter may be accidentally expelled by bladder or urethral contraction.
Collection of urine prevents soiling and provides output measurement.
(5) Reduce (or reposition) the foreskin.- Paraphimosis (retraction and constriction of
the foreskin behind the glans penis), secondary to catheterization may occur if
foreskin is not reduced.
23. Collect urine specimen as needed. Fill specimen cup or jar to desired level (20 to 30
ml) by holding end of catheter in dominant hand over cup.- Allows sterile specimen to
be obtained for culture analysis.
24. Allow bladder to empty fully unless institution policy restricts maximal volume of urine
drain with each catheterization (about 800 to 1000 ml).- Retained urine may serve as
reservoir for growth of microorganism.
25. Inflate balloon fully per manufacturer's recommendations, and then release catheter
with non dominant hand and pull gently to feel resistance.- Inflation of balloon anchors
catheter tip in place above bladder outlet to prevent removal of catheter. Note the size
of balloon on the catheter. Most commonly a 5-ml balloon is used, but a 30-ml balloon
may be ordered. A pre-filled syringe may be included with the kit; use only the amount
included. Do not over inflate or under inflate the balloon.

26. Attach end of catheter to collecting tube of drainage system. Drainage bag must be
below level of bladder; do not place bag on side rails of bed.- Establishes closed
system for urine drainage.

27. Anchor catheter:

a. Female client:
(1) Secure catheter tubing to inner thigh with strip of non-allergenic tape
(commercial multipurpose tube holders with a Velcro strap are available). Allow
for slack so movement of thigh does not create tension on catheter.- Anchoring
catheter to inner thigh reduces pressure on urethra, thus reducing possibility of
tissue injury in this area.

b. Male client:
(1) Secure catheter tubing to top of thigh lower abdomen (with penis directed
toward chest). Allow slack in catheter so movement does not create tension on
catheter.- Anchoring catheter to lower abdomen reduces pressure on urethra at
junction of penis and scrotum, thus reducing possibility of tissue injury in this
area.

28. Assist client to comfortable position. Wash and dry perineal area as needed.-
Maintains comfort and security.

43
 29. Remove gloves and dispose of equipment, drapes, and urine in proper receptacles.-
Reduces transmission of microorganisms.

30. Perform hand hygiene.- Reduces spread of microorganisms.

APPLICATION OF BINDERS
ABDOMINAL BINDERS AND BREAST BINDERS

DEFINITION
Binders are indicated for the support of underlying muscles and large incisions
The muscles and the viscera surrounding an operative site may require support during
the postoperative period to reduce trauma and edema . This promotes healing and
permits a client to move more freely without additional discomfort.

Abdominal binders – the basic shape is a rectangle that is wide enough to extend from groin
to the waistline and long enough to encircle the abdomen with an overlap for closure .

Breast binders – are made in the form of tight-fitting vest/tight fitting binders

PURPOSE
1. To provide support and comfort to the patients
2. To apply pressure
3. To hold dressings, medicinal applications and splints in place

44
POINTS TO REMEMBER
1. The patient should not be exposed unnecessarily.
2. The binder should not be snug but not too tight.
3. Abdominal binders should be brought down over the hips but not so as to interfere
with the use of the bed pan .
4. Binders should not be pinned directly over the incision site or over bony prominences
5. Safety pins should be used in securing binders
6. Poorly applied binders are worst than none.

ASSESSMENT
1. For client who needs support of abdomen, observe ability to breathe deeply , cough
effectively , and turn or move independently .-Baseline assessment determines client's
ability to breathe and cough. Impaired ventilation can lead to alveolar atelectasis .
2. Inspect skin for actual or potential alterations in integrity -actual impairments in skin
can be worsened with application of a binder. Binder can cause pressure and
excoriation.
3. Inspect any surgical dressing for intactness, presence of drainage , and coverage of
incision . Change any soiled dressing before applying binder- dressing replacement or
reinforcement precedes application of any binder . If left uncovered , a wound can be
damaged from rubbing of binder.
4. Gather necessary data regarding size of client and appropriate binder to use- ensures
proper fit of binder.

MATERIALS :
Type of binders indicated
Safety pins
gloves if wound drainage is present

PROCEDURES/ IMPLEMENTATIONS
1. Close curtain or room door-- Maintains client's comfort and dignity
2. Perform hand hygiene and apply gloves(if likely to contact wound drainage) -reduces
transmission of microorganisms.
3. APPLICATION OF ABDOMINAL BINDERS:
a) position client in supine position with head slightly elevated and knees slightly
flexed- minimizes muscular tension on abdominal organs
b) assist client in rolling on side away from the nurse toward raised side rail while
firmly supporting abdominal incision and dressing with hands – reduces pain
and discomfort
c) place binder flat on bed , right side up . Fanfold far side of binder toward midline
of binder (for a scultetus binder , be sure tails are smoothly placed against
client's side as far side is folded – gathers binders together so client can roll
over with minimal effort.
d) place fan folded ends of binder under client.- permits placement and centering
of binder with minimal discomfort
e) instruct or assist client in rolling over folder binder-position client over binder.
f) unfold and stretch ends out smoothly on far side of bed .then stretch out ends
on
g) near side of bed.- smooth , even binder maintains skin integrity and comfort .
h) instruct client to roll back into supine position .- facilitates an even application of
binder over abdomen .
i) adjust binder so that supine client is centered over binder , using symphysis
pubis and costal margins as lower and upper landmarks .- centers support from
binder over abdominal structures,which reduces incidence of decreased lung

45
 expansion while ensuring adequate wound support .
j) If client is very thin, pad iliac prominences with gauze bandage- reduces
pressure on the bony prominences
k) close binder . Pull one end binder over center of client's abdomen .while
maintaining tension on that end of binder, pull opposite end of binder over
center and secure safety pins or metal fasteners- provides continuous wound
support and comfort.
l) assess client's comfort level – helps determine effectiveness of binder
placement
m) adjust binder as necessary – promotes comfort and chest expansion .

4. APPLICATION OF BREAST BINDERS :

a) have client lie supine with head elevated 45 degrees – facilitates normal
anatomical position of breast and eases application of binder.
b) thoroughly wash and dry under pendulous breast before applying a breast
binder -reduces risk of growth of microorganisms
c) assist client's in placing arms through binders armholes- eases binder
placement
d) lightly pad area under under breast with 4 x 4 gauze dressing if necessary .-
prevents skin contact with under surfactant.
e) horizontally placed safety pins , secure binder at nipple level first . Continue
closure process above and then below the nipple line until entire binder is
closed- horizontal placement of pins may reduce risk of uneven pressure or
localized irritation . Applying support at nipple line ensures even alignment of
breast .
f) make appropriate adjustments , including individualized fit of shoulder straps
and pinning waistline darts to reduce binder size . -maintains support to clients
breast.
g) removes gloves and perform hand hygiene -prevents cross infection.

MEASURES TO REMOVE RESPIRATORY TRACY SECRETION

POSTURAL DRAINAGE

Gravity is used to drain secretions from the lungs. The person is positioned in a way that
promotes the drainage of secretions from smaller pulmonary branches into larger ones, where
they can be removed by drainage or coughing. Postural drainage is often preceded by
vibration, percussion, or both.

Purpose:
1. To loosen lung secretions.
2. To clear airways of pulmonary secretions.
3. To encourage a more effective coughing.
4. To improve pulmonary ventilation.

Nursing Consideration:
1. Postural drainage should be scheduled at least 30 minutes to 1 hour after the patient
has eaten in order to prevent nausea, vomiting, and possible aspiration.

46
 2. The nurse should encourage the patient to drink at least 8-12 glasses of fluids daily to
liquefy the pulmonary secretions.
3. Avoid percussing over the spine, liver, kidneys or spleen to prevent injuries to the spine
and internal organs.
4. Record the patient’s response, including lung and breath sounds, breathing pattern or
signs of dyspnea, before and after the procedure.
Each position is usually assumed for 10-15 minutes, although beginning treatments
may start with shorter time and gradually increases.

POSITIONING A PATIENT FOR POSTURAL DRAINAGE

To drain the posterior basal segments of the lower lobes, elevate the foot of the table
18” (46 cm) or 30 degrees, or change the elevation of the foot of the bed similarly. Position
the patient on his abdomen with head lowered. Place pillows as shown. Per cuss the lower
ribs on both sides of the spine.

To drain the lateral basal segments of the lower lobes elevate the foot of the table or
bed 18” or 30 degrees. Position the patient on his abdomen with head lowered and upper leg
flexed over a pillow for support. Have him rotate a quarter turn upward. Percuss the lower ribs
on the uppermost portion of the lateral chest wall.

To drain the anterior basal segments of the lower lobes, elevate the foot of the table or
bed 18” or 30 degrees. Position the patient on his side with his head lowered. Place pillows as
shown. Percuss with a slightly cupped hand over the lower ribs just beneath the axilla.

Note: If an acutely ill patient experiences breathing difficulty in this position, adjust the angle
of the table or bed to one he can tolerate. Then begin percussion.

47
To drain the superior segments of the lower lobes, keep the table or bed flat. Position the
patient abdomen, and place two pillows under his hips. Percuss on both sides of the spine at
the lower tip of the scapulae.

To drain the medial and lateral segments of the right middle lobe, elevate the foot of the table
or bed 14” (36 cm) or 15 degrees. Position the patient on his left side with his head lowered
and knees flexed. Then have him rotate a quarter turn backward. Place a pillow beneath him.
Percuss with the hand moderately cupped over the right nipple. For female patient, cup the
hand so its heel is under the armpit and fingers extend forward beneath the breast.

To drain the superior and inferior segments of the angular portion of the left upper lobe,
elevate the foot of the table or bed 14” or 15” degrees. Position the patient on his side with his
head lowered and knees flexed. Then have him rotate a quarter turn backward. Place a pillow
behind him from shoulders to hips. Percuss as above, but on the left side.

48
To drain the anterior segments of the upper lobes, keep the table or bed flat. Have the patient
lie on his back with a pillow folded under his knees. Then have him rotate slightly away from
the side being drained. Percuss between the clavicle and nipple.

To drain the apical segment of the right upper lobe and the apical sub segment of the left
upper lobe, have the patient sit on a flat table or bed. Standing behind the patient holding a
pillow at a 30 degree angle, percuss between the clavicle and the top of each scapulae.

To drain the posterior segment of the right upper lobe and the posterior sub segment of the
left upper lobe, have the patient sit and lean over a folded pillow at a 30 degree angle.
Standing behind him, percuss and clap the upper back on each side.

49
50
 CHEST PERCUSSION

Movement done by striking the chest walls in a rhythmic fashion with cupped hands or a
mechanical devise directly over the lung segment

Procedure:
1. Check the doctor’s order.
2. Explain procedure to the patient to elicit cooperation and determine level of
understanding.
3. Wash hands to remove and reduce transmission of microorganisms.
4. Instruct the patient to perform diaphragmatic breathing to help the patient relax.
5. Position the patient as prescribed in postural drainage. The spine should be straight to
allow rib cage expansion.
6. Ensure that the area to be percussed is covered by a gown or a towel.
7. Instruct the client to breathe slowly and deeply to promote relaxation and widening of
the airways.
8. Cup your hands and flex them slightly to form a cup as you would to scoop up water.
This hand position creates an air pocket that sends vibrations through the chest wall.
9. Relax your wrist and flex your elbows.
10. With both hands cupped, alternately flex and extend the wrist rapidly to slap the chest.
The hands must remain cupped because air in hand acts as cushion and painless.
11. Percuss each affected lung segment for 1-2 minutes from the lower back to shoulder,
and from the lower ribs to top of the chest at the front to dislodge mucus plugs and
mobilize secretions toward the main bronchi and trachea. Avoid clapping over the
spine, liver, kidney and spleen to prevent from injury.
12. Instruct the patient to inhale slowly and deeply for relaxation.
13. Document properly.
14. Record deep breathing and coughing results into the chart.
15. Repeat deep breathing and coughing hourly as needed.

Proper hand positioning for percussion.

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 CHEST VIBRATION

Chest vibration is a series of vigorous quivering produced by hands that are placed flat
against the client’s chest wall.

Procedure:
1. Explain procedure to the patient.

2. Place the flattened hand, one over the other.

3. Ask the client to breathe deeply through the mouth and exhale through the pursed lips
to make exhalation easier.

4. During exhalation, straight elbows and vibrate during 5 exhalations over one affected
lung segments to set up a vibration that carries through the chest wall and helps free
the mucus. Vibrate only during exhalation so as to follow the natural downward
movement of the rib cage.

5. Place one hand on top of the other over affected area or place one hand on each side
of the rib cage.

6. Tense the muscles of the hands and arms while applying moderate pressure and
vibrate hands and arms. This maneuver is performed in the direction in which the ribs
move on expiration.

7. Encourage the patient to cough and expectorate secretions onto the sputum container.
Coughing aids in the movement and expulsion of secretions.

8. Auscultate and compare with baseline data. The appearance of moist sounds
(crackles) indicates movement of air around mucus in the bronchi.

9. Document the amount, color and character of secretions. Inspection may also
determine if mucus is adequately thinned.

10. Recheck the rate, depth, chest expansion and respiration to determine effectiveness of
therapy.

11. Evaluate patient’s response in terms of fatigue and comfort.

Proper hand position for vibration.

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 STEAM INHALATION

Drawing in of plain steam or with a drug as prescribe, into the respiratory tract.

Equipment:
 Steam Inhalation
- electric steam inhalator
- extension spout
 Eye cover
 Prescribed drug

Procedure:
1. Explain patient response to treatment.

2. Check the water level according to apparatus indication.

3. Plug the apparatus to the appropriate electric outlet to avoid accidents and fire.

4. Protect the patient’s eye by covering with face towel.

5. Instruct patient to take slow deep breaths to promote relaxation.

6. Give the treatment for the prescribed length of time, usually 10-15 minutes.

7. Adjust the distance of the apparatus from the time to time, as needed. Take note for
complaints of too much heat.

8. Make the patient comfortable and encourage coughing after treatment.

9. Empty the container and clean the equipment.

10. Evaluate patient response to treatment.

11. Document treatment, time and duration.

53
 DIAPHRAGMATIC BREATHING

This is the mode of breathing in which dome of the diaphragm is flattened during
inspiration resulting in enlargement of the upper abdomen as air rushes into the chest.

Procedure:
1. Explain the procedure to the patient.

2. Have the patient assume a comfortable position either semi- Fowlers with knees flexed
or a supine position with one head pillow and knees flexed. This position allows
maximum chest expansion in bedridden and to relax the muscles of the abdomen.

3. Have the patient place one of both hands on the abdomen just below the ribs. This
helps the patient to become aware of the diaphragm and its function in breathing.

4. Instruct the patient to breathe deeply through the nose, keeping the mouth closed, stay
relaxed and avoid arching the back and concentrate on feeling the abdomen rise.
Slow inhalation provides ventilation and hyperinflation of the lungs.

5. If the patient has a difficulty in raising the abdomen, instruct to do a forceful and quick
inhalation through the nose.

6. Instruct the client to purse his lips as if about to whistle to breathe out slowly and
gently, making a slow whooshing sound to avoid coughing out of checks and to
concentrate the abdomen falling. This allows for gradual, controlled expulsion of air.
Count to 7 during exhalation.

7. If the patient has COPD, teach the double cough technique.

8. Instruct the patient to use diaphragmatic breathing exercise 5-10 minutes, 4 times a
day. Repetition of exercise reinforces learning. Regular deep breathing will also
prevent or minimize postoperative respiratory complications. This exercise, once
learned, can be performed when sitting upright, standing and walking.

54
 COUGHING EXERCISE

Definition:
Coughing is a natural defense mechanism that protects the lungs and airways from
inhaled particles, foreign bodies and excess secretions.

Procedure:
1. Place the patient in a semi-Fowlers position, leaning forward. Proper positioning
facilitates diaphragm excursion and enhances thorax and abdominal expansion.

2. Provide a pillow or folded bath blanket to use in splinting the incision. Splinting incision
with pillows or folded bath blankets provides firm support and reduces incisional pulling
and pain and prevents wound dehiscence.

3. Let the patient inhale and exhale deeply and slowly through the nose 3 times to
increase cough pressure.

4. Instruct the patient to take a deep breath and hold it for 3 seconds. “Hack” out for 3
short breaths. A deep breath expands lungs fully so that air moves behind mucus and
facilitates effective coughing. This technique helps keep airways open while moving
secretions up and out of the lungs.

5. Ask the patient to take a quick breath and let him cough once or twice to remove
secretions.

6. Repeat the exercise every 2 hours while awake. Try to avoid prolonged episodes of
coughing because these may cause fatique and hypoxia.

55
 INCENTIVE SPIROMETRY

An incentive spirometer helps increase lung volume and promotes inflation of the
alveoli. It is also referred to as Sustained Maximal Inspiration Devices (SMI’s).

Purpose: 1) To improve pulmonary ventilation

2) To counteract the effects of anesthesia or hypoventilation
3) To loosen respiratory secretions
4) To facilitate respiratory gaseous exchange
5) To expand collapsed alveoli

Procedure:
1. Assist patient into a position, preferable sitting position in bed or a chair. This position
facilitates maximum ventilation.
2. Hold or place the spirometer in an upright position. A tilted flow-oriented device
requires less effort to raise the balls or discs; a volume-oriented device will not function
correctly unless upright. Set the volume goal indicator on the spirometer.
3. Exhale normally.
4. Seal the lips tightly around the mouthpiece to create a seal.
5. Take in a slow, deep breath to elevate the balls or cylinder, and then hold the breath
for two seconds initially, increasing to six seconds (optimum), to keep the balls or
cylinder elevated if possible. The patient can observe progress toward the goal by
watching the balls or diaphragm of spirometer elevate or lights go on (depending on
equipment used).
6. For a flow-oriented device, avoid brisk, low-volume breaths that snap the balls to the
top of the chamber. Greater lung expansion is achieved with a very slow inspiration
that with a brisk, shallow breath, eventhough it may not elevate the balls or keep them
elevated while the patient holds his/her breath. Sustained elevation of the balls or
cylinder ensures adequate ventilation of the alveoli (lung air sacs).
7. If the patient has difficulty breathing only through the mouth, a nose clip can be used.
8. Remove the mouthpiece and exhale normally.
9. Instruct the patient to cough after the incentive effort. Deep ventilation may loosen
secretions, and coughing can facilitate their removal.
10. Encourage patient to relax and take several normal breaths before using the
spirometer again.
11. Repeat the procedure several times and then 4 or 5 times hourly while awake.
Practice increases inspiratory volume, maintain alveolar ventilation, and prevents
atelectasis (collapse of the air sacs).
12. Clean the mouthpiece with water and shake it dry.

56
 SUCTIONING

Definition: Suctioning is the aspiration of secretions through a catheter connected to a

suction machine or wall suction outlet.

Purposes: 1) To remove secretions that obstruct the airway

2) To facilitate ventilation.
3) To obtain secretions for diagnostic purposes.
4) To prevent infection that may result from accumulated secretions.

Assessment:
1. Assess for clinical signs indicating the need for suctioning: Restlessness
2. Gurgling sounds during respiration
3. Adventitious breath sounds when the client is auscultated
4. Oxygenation saturation level. Oxygen saturation usually decreases when a patient
needs to be suctioned.
5. Change in mental status
6. Skin color
7. Pulse rate and rhythm
8. Rate and pattern of respiration

Equipment Needed:
Portable or wall suction unit with tubing and collection receptacle
Sterile suction catheter with Y-port in appropriate size (for adults, 12 to 18 Fr; for
children, 8 to 10 Fr; for infants, 5 to 8 Fr) – if both the oropharynx and the
nasopharynx are to be suctioned, one sterile catheter is required for each)
Sterile water or saline
Sterile disposable container for fluids
Sterile gloves
Towel or moisture-resistant pad
Goggles or eye shield if splashing is likely
Sterile gauzes
Moisture-resistant disposable bag

Procedure:
1. Wash hands. Hand hygiene deters the spread of microorganisms.
2. Gather necessary equipment. This provides for organized approach.
3. Explain procedure to patient. This provides reassurance and promotes cooperation.
Explain to the client what you are going to do, why it is necessary, and how he/she can
cooperate. Inform the client that suctioning will relieve breathing difficulty and that the
procedure is painless but may be uncomfortable and stimulate the cough, gag, or

57
 sneeze reflex. Knowing that the procedure will relieve breathing problems is often
reassuring and enlists the client’s cooperation.
4. Provide adequate lighting for better visualization.
5. Position patient. Adjust bed to comfortable working position. Lower side rail closer to
you. If patient is conscious, place him/her in a semi-Fowler’s position. If patient is
unconscious, place him/her in the lateral position, facing you. A sitting position helps
the patient to cough and makes breathing easier. Gravity also facilitates catheter
insertion. The lateral position prevents the airway from becoming obstructed and
promotes drainage of secretions
6. .Place towel or waterproof pad across patient’s chest. This protects bed linens.
7. Open kit, maintaining sterile field.
8. Glove dominant hand that will handle the catheter and it must remain sterile, while the
non-dominant hand is considered clean rather than sterile. Handling the sterile
catheter using a sterile glove helps prevent introducing organisms into the respiratory
tract.
9. Keeping gloved hand sterile, attach end of catheter to tubing.
10. With clean hand, pour water into basin.
11. Turn on machine to appropriate pressure
* Wall Unit
Adult : 100 – 120 mmHg
Child : 95 – 110 mmHg
Infant: 50 – 95 mmHg

*Portable Unit
Adult: 10 – 15 mmHg
Child: 5 – 10 mmHg
Infant: 2 – 5 mmHg

12. Test by flushing with water.

13. Ask patient to take a deep breath or administer oxygen.
14. Insert catheter. Do not apply suction until catheter is in place. Using suction while
inserting the catheter can cause trauma to the mucosa and removes oxygen from the
respiratory tract.
a. Orally: Without placing thumb over control, insert catheter directly downward
toward the back of the throat
b. Nasopharyngeal: Insert catheter about 5 inches into nares
15. Place finger over control when in position for not more than 15 seconds. Suctioning for
longer than 10 – 15 seconds robs the respiratory tract of oxygen, which may result in
hypoxia.
16. If using oral route, suction carefully the cheeks. It may be necessary during
oropharyngeal suctioning to apply suction to secretions that collect in the vestibule of
the mouth and beneath the tongue.
17. Slowly remove catheter using a rotating motion. Turning the catheter as it is withdrawn
helps clean all surfaces of the respiratory passageway.
18. Flush tubing and catheter with water. Flushing clears catheter and lubricates it for next
insertion.
19. Briefly turn off suction and listen to patient’s breath sounds. Listening to chest and
breathing sounds helps determine whether the respiratory passageways are clear of
secretions.

58
20. Repeat procedure if necessary. Avoid repeating more than 3 times. Allow at least 20-
to 30-second interval if additional suctioning is needed. Encourage patient to cough
and deep breathe between suctioning. Normal breathing between suctioning helps
compensate for any hypoxia induced by suctioning.
21. Stop when breathing is clear.
22. Remove gloves inside out and dispose.
23. Detach and discard catheter.
24. Ask patient to breathe deeply.
25. Reposition patient. Assist the client to a position that facilitates breathing.
26. Wash hands. Hand hygiene prevents transmission of microorganisms.
27. Record procedure: the amount, consistency, color and odor of sputum (eg. foamy,
white mucus, thick, green-tinged mucus) and the client’s breathing status before and
after the procedure. Keeping records for nursing measures used helps assess,
evaluate, and coordinate care.
28. Offer oral hygiene after suctioning. Respiratory secretions that are allowed to
accumulate in the mouth are irritating to mucous membranes and unpleasant for the
patient.

59
 OXYGEN ADMINISTRATION

Oxygen is essential to life. An optimum level of oxygen must be maintained to sustain

mental functioning.
Oxygen can be delivered to the patient through a variety of devices. The device
selected is based on the patient’s condition and oxygen needs.

Purposes:
Cannula
1. To deliver a relatively low concentration of oxygen when only minimal oxygen support
is required.
2. To allow uninterrupted delivery of oxygen while the client ingests food or fluid.
Face Mask
1. To promote moderate oxygen support and a higher concentration of oxygen and/or
humidity than is provided by the cannula.
Face Tent
1. To provide high humidity
2. To provide oxygen when a mask is poorly tolerated
3. To provide a high flow of oxygen when attached to a venture system

Assess:
1. Skin and mucous membrane color: Note whether cyanosis is present
2. Breathing patterns: Note depth of respiration and presence of tachypnea, bradypnea,
orthopnea.
3. Chest movements: Note whether there are intercostals, substernal, suprasternal,
supraclavicular, or tracheal retraction during inspiration or expiration.
4. Chest wall configuration (eg. kyphosis)
5. Lung sounds audible by auscultating the chest and by ear.
6. Presence of clinical signs of hypovolemia: tachycardia, tachypnea, restlessness,
dyspnea, cyanosis and confusion. Tachycardia and tachypnea are often early signs.
Confusion is a later sign of sever oxygen deprivation.
7. Presence of clinical signs of hypercarbia (hypercapnia): restlessness, hypertension,
headache, lethargy, tremor.
8. Presence of clinical signs of oxygen toxicity: tracheal irritation and cough, dyspnea and
decreased pulmonary ventilation.

Equipment:
Cannula
1. oxygen supply with a flow meter and adapter
2. humidifier with distilled water or tap water according to agency protocol
3. nasal cannula and tubing
4. tape
5. padding for the elastic band
Face Mask
1. oxygen supply with a flow meter and adapter
2. humidifier with distilled water or tap water according to agency protocol
3. prescribed face mask of the appropriate size
4. padding for the elastic band
Face Tent
1. oxygen supply with a flow meter and adapter
2. humidifier with distilled water or tap water according to agency protocol

60
 3. face tent of the appropriate size

Procedure:
1. Check physician’s order to clarify the procedure.
2. Assess the patient’s immediate respiratory status including respiratory rate, effort and
lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring,
use of accessory muscles, or dyspnea. This provides a baseline to evaluate the
effectiveness of oxygen therapy.
3. Identify the type of oxygen equipment and oxygen source in your facility.
4. Wash hands to deter the spread of microorganisms.
5. Plan for any assistance needed.
6. Choose the appropriate equipment for the method of oxygen administration ordered.
7. Check the immediate environment carefully for any potential source of fire or sparks,
Place “NO SMOKING” signs in appropriate areas. Oxygen supports combustion.
8. Identify the patient to be sure you are performing the procedure to the right person.
9. Carefully and calmly explain what you are going to do and review safety precautions
necessary when oxygen is in use. Explain to the client what you are going to do, why it
is necessary and how he/she can cooperate. Explanation alleviates anxiety.
10. Attach the oxygen supply tube to the oxygen set-up (mask, catheter, tent, or cannula)
and humidification. Oxygen forced through a water reservoir is humidified before it is
delivered to the patient, thus preventing dehydration of the mucous membranes.
11. Turn on the oxygen, adjust the flow rate as ordered by the physician and test the flow.
Check that oxygen is flowing freely through the tubing. There should be no kinks in the
tubing, and the connections should be airtight. There should be bubbles in the
humidifier as the oxygen flows through. You should feel the oxygen at the outlets of
the cannula, mask, catheter or tent.

Nasal Cannula
1. Put the cannula over the client’s face, with the outlet prongs fitting into the nares
and the elastic band around the head. (Some models have a strap to adjust
under the chin)
2. If the cannula will not stay in place, tape it at the sides of the face.
3. Place gauzepads at ear beneath the tubing as necessary. Adjust cannula as
necessary. Pads reduce irritation and pressure and protect the skin. Correct
placement of the prongs and fastener facilitates oxygen administration and
patient comfort.
4. Encourage the client to breathe through his nose with mouth closed for optimal
delivery of oxygen.

Face Mask
1. Guide the mask toward the client’s face, and apply it from the nose downward.
2. Fit the mask to the contours of the client’s face. The mask should mold to the
face, so that very little oxygen escapes into the eyes or around he cheek and
chin.
3. Secure the elastic band around the client’s head so that the mask is comfortable
but snug.
4. Pad the band behind the ears and over bony prominences. Padding will prevent
irritation from the mask and protect the skin.

Oxygen Tent
1. Place tent over crib or bed. Connect the humidifier to the oxygen source in the
wall. Insert oxygen tubing connected to the humidifier inside tent, out of patient’s
reach. Adjust flow rate as ordered by the physician. Check that oxygen is
flowing into tent. Oxygen forced through a water reservoir is humidified before it
is delivered to the patient, thus preventing dehydration of the mucous
membranes.
2. Turn analyzer on. Place oxygen analyzer probe in tent, out of patient’s reach.

61
 The analyzer will give on accurate reading of the concentration of oxygen in the
crib or bed.
3. Adjust oxygen as necessary. Once oxygen levels reach the prescribed
amounts, place patient in the bed. Patient will receive oxygen one placed in the
tent.
4. Tuck ten edges under blanket rolls. The blanket helps keep the edges of the tent
flap from coming up and letting oxygen out.
5. Encourage patient and family members to keep tent flap closed. Every time the
tent flap is opened, oxygen is released.
6. Frequently check bedding and patient’s pajamas for moisture. The large
amount of humidification delivered in the oxygen tent quickly makes each cloth
moist, which would be uncomfortable for the patient.
7. Stay with the patient until you are sure the proper flow rte is maintained and the
patient is calm enough to be left alone safely.
8. Assess the patient’s breathing. Patient’s respiratory rate and pattern, color and
so forth indicate effectiveness of oxygen therapy.
9. Explain safety precautions to the patient and any family or visitors present.
Explain that oxygen is not dangerous when safety precautions are observed.
10. Wash your hands. Hand hygiene deters the spread of microorganisms.
11. Assess and chart client’s response to therapy. Document amount of oxygen
supplied, respiratory rate, oxygen saturation and lung sounds. Documentation
ensures continuity of care and ongoing assessment record.

Precautions for Handling Oxygen Cylinder:

1) No naked light, cigarette, mechanical toy which produces sparks must be allowed
anywhere near oxygen tent or especially when it is in use for patient.
2) No electrical bells, lights, or healing pads should be allowed near oxygen tent.
3) Grease must not be used on the valve or flow meter, There is a risk of explosion if
grease is used.
4) When the tent is used, the cylinder should be carefully watched and not allowed to be
empty as it may cause dangerous effect on the patient as oxygen supply fails.
5) The nozzle of cylinder must be cleaned before attaching the regulator.
6) Caution must be used when handling oxygen cylinder and regulator. It should be
transported carefully.
7) Place a sign that oxygen is in use displayed at patient’s bedside and door.
8) Avoid open flames in patient’s room. Although oxygen itself is not explosive, it supports
combustion.
9) Prominently display a “NO SMOKING” sign on the patient’s door, which cautions all
persons including the patient not to smoke.
10)Check to see that electrical equipment used in room in good working order to prevent
the occurrence of short-circuit sparks.
11)Avoid wearing and using synthetic fabrics which build up static electricity.
12)Avoid using oil, wearing clothing stained with oil in the area. Oil can ignite
spontaneously in the presence of oxygen.
13)Do not give electric or friction toys to children receiving oxygen in any form.

62
 Common oxygen delivery devices

Cannula Simple-oxygen mask

Venturi mask Reservoir mask

63
 ASSISTING IN THE THORACOSTOMY TUBE INSERTION

It is the insertion of one or more flexible tubes into the pleural space to evacuate air,
blood or fluid collections and to achieve full re- expansion of the lung. It also allows sclerosing
agents to be placed in the pleural cavity for the treatment of malignant effusions

Equipment:
1. Thoracostomy set
- syringe
- needle/trocar
- sponges
- scalpel
2. Sterile drape
3. Larger clamps (2)
4. Xylocaine 1%
5. Chest tube connector
6. Chest drainage system connecting tubes and tubing’s, collection bottles, suction
apparatus ( if needed)
7. Solution tray
8. Suture materials

Procedure:
1. Explain the procedure to the patient and secure a consent form. The presence of a
signed consent form indicates the patient has received a thorough explanation of the
procedure and understands the risks and the probability of successful outcome of an
invasive procedure.
2. See to it that chest X-ray films are at bedside to evaluate the extent of lung collapse or
amount of bleeding in pleural space.
3. Gather equipment at bedside.
4. Assemble drainage system as ordered.
5. Position the patient according to AP’s preference or place him on an affected side and
elevate the head of the bed 30-45 degrees.
6. Assist and anticipate needs of the surgeon during the procedure. The skin is prepared
over the area where surgeon indicates the needle will be inserted. The exact location
depends on the area where fluid/air is present.
7. Instruct patient to remain immobile during the procedure and to hold deep breath
during the insertion. A small incision is made through the skin and a chest tube is
inserted between the ribs and into the pleura. The distal end of the tube is clamped
and connected into the water seal system as prescribed.
8. Observe the drainage system for blood or air. Check for fluctuation in tube on
respiration. Fluctuation of the water level in the tube shows that there is effective
communication between the pleural space and the drainage bottle, thus an indication
of the patency of the drainage system. A chest X-ray is usually ordered after the
procedure to confirm correct chest tube placement and re- expansion of the lung.

9. Continue to monitor the vital signs during and after the procedure.
10. Inspect for bleeding, leakage of air and fluid around the tube.
11. Clean and position patient comfortably to promote comfort.
12. Clean and return equipment used.

64
 13. Record the procedure done, color, and amount of drainage obtained, patency of the
system, patient’s reactions and other relevant observations.
NURSING MANAGEMENT OF PATIENT WITH WATER-SEAL
CHEST DRAINAGE SYSTEM

Water-seal drainage is a crucial intervention for improving gas exchange and breathing.

Principles:
1. The water-seal mechanism operates on the principles of negative pressure.
2. When the chest has been opened, a vacuum must be applied to the to the chest to re-
established negative pressure.
3. Water acts as a seal and keeps air from being drawn back into the pleural space but
permits air and fluid to drain from chest.
4. An open-drainage system would allow air to be sucked back into the chest cavity and
collapses the lungs.

Purpose:
1. To maintain an air-tight system until the patient’s lungs re-expand and air or fluid is
removed from the pleural space.
2. To maintain patency of the chest tubes.
3. To maintain water-sealed system
4. To promote adequate gas exchange until normal respiration function returns.

Procedure:
1. Fill the water-seal chamber with sterile water to the level equaling 3 cm. water to keep
the air being drawn back into the pleural space.
2. Fill the suction control chamber with sterile water to 20 cm. level as prescribed to
determine the degree of suction applied ( if suction is used).
3. Attach the drainage catheter from the pleural space (the patient) to the tubing coming
from the collection chamber of the water-seal system. Tape securely.
4. Connect the suction control chamber tubing to the suction unit (if suction is used). Turn
on suction unit and increase pressure until bubbling appears in the suction control
chamber.
5. Mark the original fluid level with tape on the outside of the drainage unit hourly or every
shift to show the amount of fluid loss and how fast the liquid is collecting in the
drainage bottle.
6. Ensure that the tubing is not looping or interfering with the movements of the patient. It
can produce pressure which may possibly force drainage back onto the pleural space
or impede drainage from the pleural space.
7. Encourage the patient to assume position of comfort and to change position frequently
to promote drainage. The body should be kept in good alignment to prevent postural
deformities and contractures.
8. Put the arm and shoulder to the affected side through range of motion exercises
several times daily. Exercise helps to avoid ankylosis of the shoulder and assist in
lessening post operative pain and discomfort.
9. Milk the tubing in the direction of drainage chamber every 2 hours to prevent it from
becoming plugged with clots and fibrins. Constant attention to maintaining the patency
of the tube facilitates prompt expansion of the lung and minimizes complication.
10. Make sure there is fluctuation of the fluid level in the water-seal chamber. Fluctuation
of water level in the tube shows that there is effective communication between the

65
 pleural cavity and drainage bottle. This provides valuable indication of the patency of
the drainage system, and is a gauge of intra-pleural pressure.
11. Fluctuation in the fluid in the tubing will stop when the lung has re-expanded, the tubing
is obstructed with blood clots, a dependent loop has developed or suction motor or wall
is not working properly.
12. Watch for leaks of air in the drainage system as indicated by constant bubbling in the
water-seal chamber. Leaking and trapping of air in the pleural space can result in
tension pneumothorax. Report excessive bubbling in the water- seal chamber
immediately. Milking” of chest tubes in patients with air leaks should not only be done if
requested by the surgeon.
13. Encourage the patient to breath deeply and cough at frequent intervals. If there are
signs of incision pain, adequate pain medication in indicated. Deep breathing and
coughing help to raise the intra pleural pressure, which allows emptying of any
accumulation in the pleural space and removes secretions from the tracheobronchial
tree, so that the lung expands and atelectasis is prevented
14. Place the drainage system below the chest level if the patient has to be transported to
another are on a stretcher, if the tube becomes disconnected, cut off the contaminated
tips of the chest tube and tubing, and re attach to the drainage system. Otherwise, do
not clamp chest tube during transport. Drainage apparatus must be kept at a level
lower than the patient’s chest to prevent backflow of fluid into the pleural space.

66
 ASSISTING THORACENTESIS

Thoracentesis is the aspiration of fluid or air from the pleural space. It may be diagnostic or a
therapeutic procedure.

Purpose:
1. To remove fluid and air from the pleural cavity.
2. To obtain diagnostic aspiration of pleural fluid.
3. To obtain pleural biopsy.
4. To instill medication into the pleural space.

Equipment:
1. Thoracentesis set
- hemostat
- biopsy needle
- sterile gauze
- sterile towels and drape
- sterile specimen containers
- sterile eye sheet
2. Sterile gloves
3. Syringe: 5 cc, 10 cc, 50ml
4. Sterile disposable needle: gauge 19
5. 3-way stopcock
6. Venoset
7. Sterile bottle (1)
8. Xylocaine 1%
9. Solution tray: betadine,H202, cotton balls, forceps
10. Spinal needle/IV catheter g 14- 16 (AP’s choice)

Procedure:
1. Ascertain in advance if the chest X-ray and or other test have been prescribe and
completed. Localization of pleural fluid is accomplished by physical examination, chest
X-ray, ultrasound or fluoroscopic localization.
2. Explain the procedure to the patient and let him sign a consent form. The presence of
a signed consent form indicates the patient has received a thorough explanation of the
procedure and understands the risks and the probability of successful outcome of an
invasive procedure.
3. Determine if the patient is allergic to the local anesthetic agent to be used to decrease
the chances of complications. Give sedation if prescribed to relieve anxiety.
4. Inform the patient about the procedure and indicate how he can be helpful. An
explanation helps orient the patient to the procedure, assists him to mobilize his
resources, and gives him an opportunity to ask questions and verbalize anxiety.
Explain:
a. the nature of the procedure
b. the importance of remaining immobile
c. pressure sensations to be experienced
d. that no discomfort is anticipated after the procedure
5. Make the patient comfortable with adequate support. If possible place him upright, to
ensure that the diaphragm is most dependent and facilitates the removal of fluid that

67
 usually localizes at the base of the chest, or in one of the following positions:
a. Sitting on the edge of the bed with feet supported and head on a padded over the
bed table

b. Straddling a chair with his arms and head resting on the back of the chair.
c. Elevating the head of the bed 30-45 degrees or place him on unaffected side, if the
patient is unable to assume sitting position.

A B C

6. Support and provide reassurance to the patient during the procedure.

a) Prepare the patient for sensations of cold from skin germicide and for pressure and
sting infiltration of local anesthetic agent.
b) Encourage the patient to refrain from coughing. Sudden unexpected movement by
the patient can cause trauma to the visceral pleura with resultant trauma to the lung.

7. Expose the entire chest. The site for aspiration is determined from chest x-ray films
and by percussion.

8. This procedure is done under aseptic conditions. The physician and the assisting nurse
must follow strict sterile technique. Local anesthetic is injected slowly.

9. The physician advances the Thoracentesis needle with the syringe attached.

10. After the needle is withdrawn, apply pressure over the puncture site and a small sterile
dressing is fixed in place to prevent the entry of air into the pleural space after the
procedure.

11. Place the patient on bed rest and request for chest X-ray, if ordered after the
procedure. This will verify if there is no pneumothorax.

12. Check and record vital signs every 15 minutes for one hour to note possible
complications.

13. Administer oxygen as prescribed if patient has cardio-respiratory disease because

pulmonary gas exchange may worsen the Thoracentesis.
14. Record the total amount of fluid withdrawn and the nature of fluid, its color and

68
 viscosity. The fluid may be clear, serous, bloody, purulent, etc. If prescribed, prepare
samples of fluid for laboratory evaluation. A small amount of heparin may be needed
for several of the specimen containers with preservative may be needed if a pleural
biopsy is to be obtained.

15. Evaluate the patient at intervals for increasing respiration, faintness, vertigo, tightness
in the chest, uncontrollable cough, blood- tinged mucus and rapid pulse and signs of
hypoxemia.

69
 INSERTING A NASOGASTRIC TUBE

Definition: The nasogastric (NG) tube is passed through the nose and into the stomach.
This type of tube allows the use of the stomach as a natural reservoir for food.

Purposes: 1) To decompress or irrigate the stomach.

2) To drain fluid or air from the stomach.
3) To allow the intestinal tract to rest and promote healing after bowel surgery.
4) To monitor bleeding in the gastrointestinal tract or to help treat an intestinal
obstruction.
5) To prevent nausea, vomiting and gastric distention when gastrointestinal tract
motility is slow or absent.
6) To provide a route for delivering liquid enteral feedings (gavage) in clients
who cannot swallow or ingest adequate caloric intake.

Equipment: Nasogastric tube or appropriate size (8 – 18 French)

Stethoscope
Small basin filled with ice or warm water (optional)
Water-soluble lubricant
Disposable gloves
Tongue blade
Flashlight / Penlight
Glass of water with straw
Towel or drape to place across the client’s chest
Emesis basin
Asepto bulb syringe or Toomey syringe (20 – 50 ml)
Non allergenic tape (1” wide)
Suction apparatus (if ordered)

Assessment:
1. Assess the patency of the patient’s nares by asking the patient to occlude one nostril
and breathe normally through the other. Select the nostril through which air passes
more easily.

2. Auscultate bowel sounds and palpate the abdomen for distention and tenderness. If
the abdomen is distended, consider measuring the abdominal girth at the umbilicus to
establish a baseline.

3. Assess the patient’s history for any recent facial trauma or surgeries. Patients with
facial fractures or facial surgeries present a higher risk for misplacement into the brain.

Procedure:
1. Check patient’s chart for doctor’s order to clarify the procedure and the type of
equipment required.
2. Prepare all needed materials / equipment. This provides for organized approach to

70
task, to allow the nurse to work efficiently and to avoid repeated trips for supplies.
3. Explain the procedure to the client to facilitate patient cooperation.
4. Do hand-washing to deter the spread of microorganisms.
5. Prepare the client
a) Assist the client to a high-Fowler’s (head of the bed elevated 60 – 90 degrees)
position and support the head on a pillow. This is the best position to allow the
client to bring his head forward to swallow and protect against aspiration, if the
patient should vomit. If the position is contraindicated or the client is
unconscious, it may be necessary to keep him in recumbent position.
b) Place the infant in an infant seat, or position the infant with a rolled towel or
pillow under the head and shoulders.
c) Place the towel across the chest. A bib can be used for an infant. This prevents
patient’s gown from being soiled.

6. Assess the client’s nares

a) Ask the client to hyperextend the head.
b) Examine the nares for any obstructions or deformities by asking the client to
breathe through one nostril while occluding the other to determine which of the
client’s nostrils is most open. Repeat the process on the opposite side to
compare openness.
c) Select the nostril that has the greater airflow.
d) Obstruct one of the infant’s nares, and feel for air passage from the other.

7. Prepare the tube

a) If a rubber tube is being used, place in on ice to make it rigid and easier to pass.
b) If a plastic tube is being used, place it on warm water.

8. Determine how far to insert the tube.

a) Use the tube to mark off the distance from the tip of the client’s nose to the tip of
the earlobe and then from the tip of the earlobe to the tip of the sternum (xiphoid
process). Measurement ensures that tube will be long enough to enter patient’s
stomach.
b) For infants and young children, measure from the nose to the tip of the earlobe
and then to the point midway between the umbilicus and the xiphoid process.
c) Mark this length with adhesive tape if the tube does not have markings.

9. Insert the tube

a) Don disposable gloves to deter the spread of microorganisms.
b) Lubricate the tip of the tube (at least 1” to 2”) with water-soluble lubricant or
water to ease insertion. Lubrication reduces friction and facilitates passage of
the tube into the stomach. Water-soluble lubricant will not cause pneumonia if
tube accidentally enters the lungs. Apply topical analgesic to nostril and
oropharynx, if ordered, or ask patient to hold ice chips in mouth for several
minutes. Topical analgesics or ice acts as a local anesthetic, reducing
discomfort.
c) Insert the tube with the natural curve toward the client, into the selected nostril.
d) Ask the client to hyperextend the neck and gently advance the tube toward the
nasopharynx while directing tube upward and backward. Following the normal
contour of the nasal passage while inserting the tube reduces irritation and the
likelihood of mucosal injury.
e) Do not hyperextend or hyperflex an infant’s neck. Hyperextension or
hyperflexion of the neck could occlude the airway.
f) Direct the tube along the floor of the nostril and toward the ear on that side.
g) If the tube meets resistance, withdraw it, relubricate it, and insert it in the other
nostril.
h) Once the tube reaches the oropharynx (throat) the client will feel the tube in the

71
 throat and may gag or retch. Ask the client to tilt the head forward (touch chin to
chest) and encourage the client to sip through a straw and swallow (even if no
fluids are permitted). The gag reflex is readily stimulated by the tube. Bringing
the head forward helps close the trachea and open the esophagus. Swallowing
helps advance the tube, causes the epiglottis to cover the opening of the
trachea, and helps to eliminate gagging and coughing. Provide tissues for
tearing or watering of eyes. Tears are a natural response as the tube passes
into the nasopharynx.
i) If the client gags, stop passing the tube momentarily. Have the client rest, take a
few breaths, and take sips of water to calm the gag reflex.
j) In cooperating with the client, pass the tube 5 – 10 cm (2 – 4 inches) with each
swallow, until the indicated length is inserted.
k) If the client continues to gag and the tube does not advance with each swallow,
withdraw it slightly, and inspect the throat by checking the placement of tube
with tongue blade and flashlight. Excessive coughing and gagging may occur if
the tube has curled in the back of throat. Do not use force. Rotate tube if it
meets resistance. Forcing the tube may injure mucous membranes.

10. Ascertain correct placement of the tube

a) Attach syringe to end of tube and aspirate a small amount of stomach contents.
The tube is in the stomach if its contents can be aspirated: pH of aspirate can
then be tested to determine gastric placement.
b) Measure the pH of aspirated fluid using pH paper or a meter. The pH of gastric
contents is acidic (4 or less), compared with an average pH of 7.0 or greater for
respiratory fluid. Because pH of intestinal fluid also is slightly basic, this method
will not effectively differentiate between intestinal fluid and pleural fluid.
c) Visualize aspirated contents, checking for color and consistency. Gastric fluid
can be green with particles, brown if old blood is present, clear or straw-colored;
tracheobronchial fluid is usually off-white to tan; pleural fluid can be straw-
colored and is usually watery; intestinal fluid is usually light to dark golden-
yellow or brownish-green. A small amount of blood-tinged fluid may be seen
immediately after NG insertion.
d) If the signs do not indicate placement in the stomach, advance the tube 5 cm
(2 in) and repeat the tests.

11. Secure the tube by taping it to the bridge of the client’s nose. For infants or small
children, tape the tube to the area between the end of the nares and the upper lip,
as well as to the cheek.

12. Document the type of tube inserted, date and time of tube insertion. This facilitates
documentation and provides for comprehensive care. Also document a description
of gastric contents, including the pH, which naris is used, and the patient’s
response.

13. Do charting of relevant information.

14. Do after care of the equipment.
15. Remove disposable gloves and perform hand hygiene. Make
patient comfortable.

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 NASOGASTRIC / GAVAGE FEEDING
(ADMINISTERING A TUBE FEEDING)

Definition: A feeding through the Nasogastric tube (NGT).

Purposes: 1) To restore or maintain nutritional status.

2) To administer medications.

Equipment Needed:
Tube feeding at room temperature
Feeding bag or Prefilled tube feeding set
Stethoscope
Disposable gloves
Disposable pad or towel
Asepto or Toomey syringe
Emesis basin
Measuring container from which to pour the feeding (if using the open system)
Enteral feeding pump (if ordered)
Rubber band
Clamp (Hoffman or butterfly)
IV pole
Water for irrigation
20- to 20-ml syringe with an adapter
Large syringe with plunger

Assessment:
1. Assess for any clinical signs of malnutrition or dehydration.
2. Check for allergies to any food in the feeding.
3. Assess abdomen by auscultating for the presence of bowel sounds and palpating the
abdomen. If the abdomen is distended, consider measuring the abdominal girth at the
umbilicus.
4. Note any problems that suggest lack of tolerance of previous feedings (eg. Delayed
gastric emptying, abdominal distention, Dumping syndrome, constipation or
dehydration)

Procedure:
1. Check the physician’s order.
2. Read any observation about previous feedings noted on the patient’s chart.
3. Wash hands. Hand hygiene deters the spread of microorganisms.
4. Decide whether the patient is to fed using the reservoir, Asepto or prefilled method.
Checking ensures that correct feeding will be administered.
5. Gather any equipment you will need. This provides for organized approach tot ask.
Regardless of the method, you will need a stethoscope for checking the position of the
feeding tube and to assess bowel sounds. Presence of bowel sounds may indicate
functional GI tract.
6. Identify the patient to be sure you are carrying out the procedure for the correct patient.
7. Explain the procedure to the client. This facilitates cooperation and provides

73
 reassurance for patient. Inform the client that the feeding should not cause any
discomfort but may cause with feeling of fullness.
8. Place the patient in a semi-Fowler’s position. Position patient with head of bed
elevated at least 30 degrees or as near normal position for eating as possible. This
position enhances the gravitational flow of the solution and prevents aspiration of fluid
into the lungs.
9. Attach asepto syringe to the end of tube.
10. Hold funnel 12 to 6 inches or less above the patient. The higher the funnel is held, the
faster the formula flows. Do not push formula with syringe plunger.
11. Test the placement of the tube and for residual formula. Even when initially positioned
correctly, an NG tube left in place can become dislodged between feedings.
a) Listen over the epigastrium with a stethoscope as you introduce a small amount of
air (5 to 20 ml of air). Air injected into the stomach produces whooshing, gurgling,
or bubbling sounds over the epigastrium and the left upper quadrant.
b) Aspirate the gastric contents. This is done to evaluate the absorption of the last
feeding; that is, whether undigested formula from a previous feeding remains.

12. Depending on the equipment used, administer a small amount of water first, then any
medication ordered and the formula. Follow with the remainder of the water, which
rinses formula out of the tubing. Water rinses the feeding from the tube and helps to
keep it patent.
13. After the feeding, clamp the tube tightly or plug it. Clamping the tube prevents air from
entering the stomach and causing distention. Rinse tube with 30 – 60 ml of water.
Rinsing with water clears the gastric tube to prevent blockage and bacterial growth.
14. Reposition the patient in a low or semi-Fowler’s position. If the patient is comatose, the
head should be turned to one side. These positions facilitate digestion and movement
of the feeding from the stomach along the alimentary tract, and prevent the potential
aspiration of the feeding into the lungs.
15. Return to the patient approximately 30 minutes to make sure the feeding has been
retained.
16. Wash hands and clean equipment. This prevents contaminations and deters spread of
microorganisms.
17. Record on the medication sheet or progress notes the date, time, type of feeding,
amount of formula, amount of water and the patient’s response. This provides accurate
documentation of procedure.

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 ASSISTING IN GASTRIC LAVAGE

Definition: It is the aspiration of the stomach contents and washing out of the stomach by
means of gastric tube

Purposes:
1. To cleanse the stomach of undigested food, fermenting material, and toxic and
poisonous substances.
2. To relieve persistent vomiting.
3. To cleanse the stomach to prepare for gastric surgeries
4. To cleanse the stomach before endoscopic procedures
5. To relieve gastric distention, pain, congestion, and inflammation.
6. To analyze gastric function
7. To diagnose gastric hemorrhage and for the arrest of hemorrhage

Equipment: Large-bore orogastric tubes

Large irrigating syringe with adapter
Large plastic funnel with adapter to fit stomach tube
Water-soluble lubricant
Lavage fluid (warm saline or other prescribed solution)
Bucket for aspirate
Mouth gag; nasotracheal or endotracheal tubes with inflatable cuffs
Containers for specimens

Procedure:
1. Remove dental appliances and inspect oral cavity for loose teeth to prevent accidental
aspiration.

2. Measure the distance on the lavage tube between the bridge of the nose and the
xiphoid process. Mark with indelible pencil or tape. This is a rule-of-thumb
measurement of the distance the tube is passed to reach the stomach; avoids
curling/kinking of excess tubing.

3. Lubricate the tube with water-soluble lubricant.

4. If the patient is comatose, he is intubated with a cuffed nasotracheal or endotracheal

tube. A cuffed endotracheal tube prevents aspiration of gastric contents.

5. Place the unconscious patient in left lateral position with the head (lowered approx 15
degrees downward), neck and trunk forming a straight line. This position decreases
passage of gastric contents into the duodenum during lavage and minimizes the
possibility of aspiration into lungs.

6. Pass the tube via the oral (or nasal) route while keeping the head in a neutral position.
Pass the tube to the adhesive marking or about 50 cm (20 inches). After the lavage
tube is passed, the head of the table is lowered. Have standby suction available. The

75
 depth of insertion of the tube will vary with the height of the patient. If the tube enters
the larynx instead of the esophagus, the patient will experience coughing and dyspnea.
Submerge free end of the tube below water level at the moment of the patient's
exhalation or auscultate the stomach during injection of air with a syringe to confirm
gastric location. If tube is inadvertently in the lungs, the water will bubble with each
exhalation.
7. Aspirate the stomach contents with syringe attached to the tube before instilling water
or antidote. Save the specimen for analysis. Aspiration is carried out to remvoe the
stomach contents. Initial gastric aspirates are saved for toxicologic analysis.
8. Remove syringe. Attach funnel to the stomach tube or use 50 ml syringe to put lavage
solution in gastric tube. Volume of fluid placed in the stomach should be small.
Overfilling of the stomach may cause regurgitation and aspiration, or force the stomach
contents through the pylorus.
9. Elevate funnel above the patient's head and pour approximately 150-200 ml of solution
into funnel. The lavage fluid is left in place about 1 minute and then allowed to drain.

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 IRRIGATING A COLOSTOMY

DEFINITION:
A colostomy is an opening -- called a stoma -- that connects the colon to the surface of
the abdomen. This provides a new path for waste material and gas to leave the body after
part of the colon or rectum is removed because of disease or injury.
Colostomy irrigation is a way to regulate bowel movements by emptying the colon at a
scheduled time

PURPOSE
1. It is to establish a pattern of regular bowel elimination after ostomy surgery.
2. To cleanse the bowel of feces before tests or surgical procedures
3. To relieve constipation

ASSESSMENT
1. Assess frequency of defecation, character of stool, and placement of stoma as well as
client’s regular nutritional pattern.
May indicate a need to irrigate to stimulate eliminations functions; consistency of
stool varies along length of GI tract.
2. Assess time when client normally irrigate colostomy. In the case of a new ostomy,
confer with physician about whether and when irrigations can begin. Obtain written
order.
Irrigation helps to establish regular bowel emptying. Bowel must be totally
healed so irrigation fluid will not cause perforation. This usually occurs 3-7 days
after surgery.
3. Confer with client for best time to irrigate.
Irrigation can be planned to coincide with other hygiene with other hygiene
activities.
4. Assess client’s understanding of procedure and ability to perform techniques.
Determines level of participation to expect from the client, level of explanations nurses
should provide, and if client/caregiver is able to perform irrigation.

MATERIALS
Ostomy irrigation set that consists of an irrigation solution bag and tubing with a fluid
control clamp and cone tip
Irrigation sleeve (with belt tabs or stick-on ring and end close device)
Water –soluble lubricant
Ostomy pouch and skin barrier or stoma cap cover
Ostomy deodorant
Clean disposable gloves
Toilet facilities that include a flushable toilet, a hook or some device to hold the
irrigation container, toilet tissue, running water

For clients who are Bedridden:

Bedpan
Towels
Waterproof pad

PROCEDURES AND RATIONALES

1. Verify physician’s orders if skill is dependent or collaborative nursing intervention.

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 Independent nursing intervention may be verified with the nursing care plan or primary
nurse.
2. Identify the client name by checking the armband and having the client state name (if
able to do so). In many long care tem care settings, armbands are not used, however
pictures are available for identification.
3. Introduce yourself to client (family), including both your name and title or role.
4. Tell the client (family) what you plan to do to enhance cooperation and relieve anxiety.
5. Identify teaching needed and describe what the client can expect in terms the client
can understand.
6. Assess client to determine that the intervention is still appropriate.
7. Gather equipment needed and complete necessary charges according to agency
policy.
8. Perform hand hygiene to decrease transmission of microorganism.
9. Adjust the bed to the appropriate height. If a side rail is raised, it should not restrain the
client’s movement. Lower side rail on the side nearest you.
10. Provide privacy for client. Position and drape client as needed.
11. Summarize for client how procedure will be performed. Encourage questions as you
proceed
It helps client anticipate steps in procedure. Active dialogue during procedure
can enhance learning.
12. Wear clean disposable gloves. (Gloves are optional for client who is doing self-care).
13. Position client on toilet or in chair in front of toilet if ambulatory or on side with head
slightly elevated, if unable to be out of bed. Place bedpan nearby
It allows for placement of irrigation sleeve into toilet or bedpan.
14. For adult client, close clamp on irrigation bag, then fill bag with 500 to 1000 ml warm
irrigation solution. Open clamp to clear tubing of air. Close clamp
Volume will adequately distend colon and cause evacuation. Cold solution can
cause cramping and/or syncope; hot solution could injure mucosa. Air entering
colon can cause cramping.
15. Hang the irrigation bag on a hook so that the lower end of the bag is no higher than the
client’s shoulder height when sitting or 18 to 20 inches (45-50 cm) above stoma.
This position prevents too high water pressure and reduces possibility of bowel
damage.
16. Remove client’s pouch by gently pushing skin from adhesive and barrier; dispose of
according to hospital policy for standard precautions (save clamp if attached to pouch)
It prevents skin irritation, controls odor in room.
17. Place irrigation sleeve over client’s stoma. Angle sleeve for appropriate flow of fecal
returns (if client is using bedpan, place the irrigation sleeve at a 45-degree angle).
Know particular use of the selected irrigation equipment. Some irrigation sleeves
attach to flange of the two-piece skin barrier. Some sleeves require use of a belt. If so,
adjust belt so it fits comfortably and is not too tight or too loose.
Make sure irrigation sleeve is correctly attached. Angle of irrigation sleeve
facilitates flow of fecal returns. End of sleeve must be in toilet or bedpan to
prevent spillage of feces.
18. Lubricate tip of irrigating cone. Reach through the top of the irrigation sleeve and, using
gentle pressure, hold cone tip snugly against stoma opening. Do not force cone into
stoma.
It prevents trauma, tearing, bleeding and rupturing of stoma. Cone tip avoids
perforation of bowel.
19. While client is holding cone, open flow control clamp and allow solution to flow. Start
with 500 ml; this should take 5 to 10 minutes. Adjust the direction of the cone to
facilitate inflow of solution as needed.
Too rapid instillation of irrigation solution can cause cramping and risk bowel
perforation. Cone aids in retaining solution during inflow. Aiming flow of solution
toward direction of bowel aids inflow.
20. If cramping occurs, reduce or stop flow irrigation fluid.
Client’s complaint of abdominal cramps indicates need to stop irrigating and wait

78
 until cramps subside.
21. When all the irrigation fluid has been instilled into client’s stoma, close flow control
clamp and wait for 15 seconds before removing irrigation cone from the stoma. Close
top of irrigation sleeve using appropriate closure method. Discard gloves.
Avoids backflow of solution from stoma

22. Allow 15 to 20 minutes for initial evacuation of stool. Keep end of sleeve in toilet or
bedpan.
Keeps the device balanced and prevents injury from bumping against objects.
23. Wear gloves. After initial evacuation of stool is over, dry tip of irrigation sleeve and
close end with the clip or closure device. Leave in place 30-45 minutes while waiting
for the secondary evacuation. Client may get off toilet and may walk around, shower or
shave.
Exercise stimulates bowel.
24. Unclamp sleeve and empty any fecal contents into toilet and bedpan. Rinse sleeve by
pouring a small amount of water through the top, then remove sleeve. Rinse with liquid
cleanser and cool water. Hang sleeve to dry.
Maintains sleeve in clean condition for future use.
25. Wipe stoma with toilet tissue to remove any stool. Put an appropriate colostomy pouch
over stoma. If client is using a two-piece pouching system, place anew flange cap or
closed-end pouch onto skin barrier.
An appropriate pouch or cap may be worn to contain feces in case of elimination
between irrigations.
26. Assist client to a position of comfort and place needed items within reach. Be certain
client has a way to call for help and knows how to use it.
27. Raise the side rails and lower the bed to the lowest position.
28. Store or remove and dispose of supplies and equipment.
29. After client contact, remove gloves if used
30. Perform hand hygiene.
31. Document and report client’s response and unexpected outcomes

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Stomahesive wafer with flange An opaque or transparent drainable
(1 1/2”, 1 3/4”, 2 1/4”, 2 3/4”) can be pouch is position at desired angle
applied directly to the peristomal area over stoma
after it has been thoroughly clean & dry

pouch may be removed without removing stoma may be assessed without

wafer removing wafer

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 ASSISTING IN ABDOMINAL PARACENTESIS

DEFINITION
It is a sterile invasive procedure performed by the physician to obtained peritoneal fluid
from the peritoneal cavity through a small opening or puncture made through abdominal wall.

PURPOSES
1. Diagnostic analysis
a) Peritoneal fluid is analyzed to determine the presence of bacteria, blood,
glucose and protein.
b) For cytologic analysis to detect.

2. Palliative Measure
a) To provide temporary relief of respiratory and abdominal discomfort caused by
ascites or reduce intraabdominal pressure.

ASSESSMENT
1. Note for allergies of any medication
2. Note for bleeding problems
3. Check informed consent

MATERIALS
Antiseptic Aspirating set
Sponge’s receptacle for fluid
Fenestrated drape tubing
Small scalpel trocar
Specimen containers cannula
Big syringe (to aspirate)
Gloves and mask

PROCEDURE AND RATIONALE

NURSING RESPONSIBILITIES BEFORE THE PROCEDURE

1. Check the physician order to be sure of the exact procedure to be done and to identify
the purpose of the procedure.
2. Check whether patient has signed written informed consent for legal purposes.
3. Determine whether the patient has history of being uncooperative or has severe
coagulatory, intestinal obstruction.
These conditions contraindicate the procedure.
4. Determine whether the patient’s has history of allergies especially to local anesthesia.
5. Explain procedure to the client. To relieve anxiety and facilitates patient’s participation.
6. Obtain client’s vital signs especially blood pressure.
Baseline vital signs detect changes caused by complication by drainage of large fluid
volumes
7. Palpate patient’s bladder. Ask the patient to void prior to the procedure.
Chance of bladder trauma is decreased if bladder is not distended.

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8. Weigh patient and assess abdomen and measure abdominal girth in centimeters at
largest point of the abdomen.
Abdominal girth is measured in same place to accurately note abdominal size before
and after Paracentesis.
9. Assess patient’s respiratory rate, diaphragmatic excursion.
Excess peritoneal fluid can increased intra abdominal pressure which compromises
respiration.
NURSING RESPONSIBILITIES DURING THE PROCEDURE
1. Ensure patient’s comfort and assess for complication to detect adverse response to the
sudden removal of the abdominal pressure.
2. Observe client closely for signs of distress. Observe the client’s vital signs every 15
minutes.
3. Place a small sterile dressing over the site of incision after the cannula is withdrawn to
ensure hemostasis.

NURSING RESPONSIBILITIES AFTER THE PROCEDURE

1. Assess the client’s pulse rate, skin color and blood pressure every 15 minutes for 1
hour, every 30 minutes for 2 hours and every 4 hours until stable.
Hypotension/hypovolemic shock may result because of rapid shift of fluid from
circulation into the peritoneal cavity
2. Measure the abdominal girth, color, clarity and amount of drained fluid.
It determines change after fluid drainage.
3. Record the procedure on the client’s chart, including the date, time, name of the
physician, abdominal girth before and after the procedure; color, clarity and amount of
fluid drained.

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 ASSISTING LUMBAR PUNCTURE / SPINAL TAP

DEFINITION
It is also called spinal puncture or spinal tap involves the introduction of a needle into
the subarachnoid space of the spinal column.

PURPOSE:
1. To diagnose Meningitis (an infection of the meninges)
2. To remove fluid and relieve pressure (ICP)
3. To look for other diseases in the central nervous system
4. To place chemotherapeutic medications into the spinal fluid.
5. To instill dye or air into the spinal fluid.

ASSESSMENT
1. Assess client’s knowledge of procedure to determine level of teaching required.
2. Observe verbal and nonverbal behaviors to determine client’s anxiety.
3. Assess client’s ability to understand and follow directions.
Procedure requires client to follow direction closely and assume proper position.
The procedures may be contraindicated in clients who cannot cooperate or
remain still during the procedure
4. Assess musculoskeletal flexibility of client to assume a lateral decubitus (fetal)
position
To place spinal needle in proper position. (Severe arthritic patient and
orthopneic may be unable to assume this position)
5. Determine allergic reaction to medication (lidocaine)
To use alternative of the medication.
6. Check signed consent
Presence of signed consent form indicates the patient has received a thorough
explanation of the procedure and understanding the risks and probability of
successful outcome of the procedure
7. Obtain vital signs and neurological status of lower extremities
It includes movement, sensation and muscle strength
For baseline data comparison
8. Assess for bladder distension and determine last voiding
9. Weigh client, assess abdomen and measure abdominal girth at largest point. Mark
location.
10. Assess client’s coagulation status (use of anticoagulant, platelet count, protrombin
time) to determine factors that can increase bleeding.
11. Assess need for preprocedural pain medication.
Procedure may be painful and pain control helps client remain still throughout
procedure.

MATERIALS:
Lumbar Puncture Tray
 Antiseptic Solution ( povidone iodine)

83
  10 gauze sponges ( 4x4)
 3 spinal needles ( various sizes) with inner obturator (5-12.5 cm long; infants
need 5 cm needle
 Alcohol swabs
 Anesthetic agent (Lidocaine 1%)
 Syringes ( 3-5ml)
 2 rolled bath towels

 Sterile gloves ( check physician size)

 Glass or plastic manometer with 3 way stopcock
 4 test tubes
 Antiseptic ointment
 Band aids or 2x2 dressing

 Sterile towels
 Mask and goggles ( optional)
 Straight chair for physician

PROCEDURES AND RATIONALES:

1. Explain steps, of skin preparation, anesthetic, injection, needle insertion, and position
required.
Anticipation of expected sensation reduces anxiety
2. Explain procedure to client
Nurse tells the client in understandable terms about potential discomfort
associated with entry of needle
3. Have the client empty the bladder/ bowel before the procedure.
Avoid interruption of the test and prevent discomfort
4. Position client in Lateral Recumbent (Fetal) position with head and knee flexed.
Explain that client should remain still for entire procedure
Flexion of lumbar spine allows easy access to CSF in spinal canal, allows
maximal space between vertebrae.
5. Caution the client not to cough and to breathe slowly and deeply.
Coughing/ changes in breathing may result in injury and/ or inaccurate readings.
6. Explain step that may give discomfort.
Brief pain occurs when spinal needle penetrates/ anesthesia needle.
7. Set up sterile tray or open supplies to make accessible for physician.
Reduces risk of contamination of sterile field and promotes prompt completion
of procedure.
8. Physician cleanses site with antiseptic solution and drapes site with sterile drape.
9. Physician injects local anesthetic and waits for area to become numb.
Discomfort and pressure may still occur when deep tissues are disrupted.

PHYSICIAN RESPONSIBILITY
1. Before pressure reading, ask client to relax and straighten the legs
Relaxing and straightening the legs reduces intraabdominal pressure which
causes a normal CSF pressure
2. Apply gloves in preparation for assisting with filling test tubes with CSF.
Prevents transmission of microorganism
3. Properly label tubes with client information and name of test desired. Transport
specimens to Lab immediately.
Analysis must be performed promptly on freshly obtained specimens
“Test tube 1”-chemical and immunological analysis
“Test tube 2”- microbial analysis
“Test tube 3” – microscopic examination of cells

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4. Assist with placement of direct pressure and gauze dressing once needle is withdrawn.
Pressure helps minimize CSF loss and bleeding
5. Remove gloves; perform handwashing especially if tubes with CSF have been
handled.
Tubes might contain virulent microorganism.
6. Assist client in comfortable position. Maintain in supine or dorsal recumbent, usually 4-
12 hours. Do not raise head.
Maintaining this position helps prevent headache following lumbar puncture.
7. During and after the procedure, observe the client for:
RESPIRATORY STATUS AND V/S
 Indicates increase ICP

CHANGE LEVEL OF CONSCIOUSNESS

 Indicates ICP-maintain patent airway; notify the physician

EXCESSIVE DRAINAGE FROM INSERTION SITE

 Monitor v/s; assess insertion site, follow post procedure orders related to
findings

POST-PUNCTURE HEADACHE
 Instruct to lie flat in bed; fluid intake at least 1 glass/ hr (unless contraindicated);
analgesic as ordered

PAIN OR TINGLING SENSATION IN LOWER EXTREMETIES

 May result from spinal nerve irritation
 Compare to pre-procedure baseline assessment; continue to monitor; notify
physician.

8. Document/ Chart
Procedure; time, opening pressure, color of CSF, amount of drainage in dressing,
headache or tingling sensation on legs, specimen sent to laboratory.

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86
 ASSISTING BONE MARROW ASPIRATION

DEFINITION
A method of removing a small tissue sample from the body to have it examined undera
microscope and possibly analyzed by other tests.

PURPOSE
1. The test is done after abnormal types or numbers of red or white blood cells are found
in a complete blood count, or to evaluate whether other systemic diseases are present
in the bone marrow.
2. The examination may detect the cause of the abnormality, certain types of anemia (not
enough red blood cells), cancer in the marrow, and may be used to monitor the
response to therapy for some cancers.

ASSESSMENT
1. Note for allergies of any medication
2. Note for bleeding problems
3. Check informed consent

MATERIALS
Bone Marrow Aspiration Tray:
Marrow aspiration needle with stylet

Towels
No. 25 and 22 gauge needles
Two 20 or 10 mL, 5 ml syringes
Local anesthetic (1% procaine or xylocaine)

87
 Laboratory Equipment
Coverslips
Microscopic slides
Test tubes
Sterile Gloves,
Drape
Skin antiseptic
Scalpel blade and handle

PROCEDURE AND RATIONALE

Preparatory Phase done by the Nurse

1. Check doctor’s order – for verification purposes and to avoid some errors
2. Check consent
Procedure is invasive
3. Assess the client’s vital signs
Baseline vital signs detect changes
Provides baseline data
4. Determine any allergies in particular to local anesthetic
CNS and Respiratory depression, hypotension
5. Explain the procedure to the patient
To ease anxiety and ensure cooperation
6. Give pre-procedure medication (1%) xylocaine or meperidine
Used as an analgesic and sedative for apprehension
7. Place the patient in prone or supine position

Supine (Sternum)-dangerous
Prone or side lying with top knee flexed- (Iliac crest)
Posterior superior (preferred)
Anterior (if patient is obese)

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 Performance Phase done by the Physician
8. Iliac Crest Aspiration
The skin is prepared and drape. The marked area is infiltrated with local
anesthetic through the skin and the subcutaneous tissue to the periosteum of
the bone.

Tell the patient he will experience a needle prick followed by a burning

sensation.
The periosteum is the region of greatest sensitivity

A small incision may be made

The biopsy needle is large and it needs a small incision to facilitate insertion

The bone marrow needle with stylet in place is introduced through the incision.
The needle is pointed toward the anterior superior iliac spine and brought in
contact with the posterior iliac spine.

The needle is advanced and rotated by using firm and steady pressure. When
the needle is felt to enter the outer cortex of the bone marrow cavity, the stylet is
removed and the syringe attached.
There is usually decreased resistance when the bone marrow is entered

9. Sternal Aspiration done by the Physician

The skin is prepared and the site is infiltrated with procaine or xylocaine.
Tell the patient he will experience a needle prick followed by a burning
sensation.

The side selected is usually the midsternal line at the level of the 2 nd interspace
The sternum is thinner and marrow are more plenty between the sternal
interspaces
A small stab incision may be made before bone marrow needle insertion.
This technique avoids pushing the skin into the bone marrow.
The marrow needle with stylet in place is inserted through the cortex of the bone
with a slight rotating motion.
The sternal puncture is more dangerous than other sites because of its
proximity to vital structures in the mediastinum
The stylet is removed and a syringe attached to the hub of the needle. The
plunger is withdrawn slowly until marrow appears in the syringe and is
aspirated.
The marrow will appear as thick, dark reddish fluid
Warn the patient that he may feel a brief episode of sharp pain or pressure
The pain is caused by suction of the syringe and last only a few seconds
The syringe and needle are removed and passed to a technician for preparation
of smear
Smears of aspirated marrow are made; technique is similar to that of preparing

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 blood smears
Pressure is applied over the puncture site for a brief period of time ( 10-15
minutes)
To prevent further bleeding and to ensure hemostasis
A small dressing is applied with pressure over the puncture site.
To ensure hemostasis and prevent further bleeding
Remove dressing 24 hours and inspect the area for inflammation
If (+) inflammation, notify physician.

10. Follow up Phase done by the Nurse

Give mild analgesic as ordered PRN

Assess the patient for discomfort, continued bleeding and untoward symptoms
Arrange for the specimen with completed requisition and label to be transported to the
laboratory.
Record the procedure on the client’s chart including the date and time of the
procedure, the name of the physician and the assessment of the client.

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 CONTINUOUS BLADDER IRRIGATION

DEFINITION: It is a continuous infusion of a sterile solution into the bladder, usually using
three-way irrigation closed system with a triple –lumen catheter. One lumen goes to the
client to drain urine, one goes to the irrigation solution, an done is used to inflate the
catheter balloon.

PURPOSE
1. The primary use of CBI is following genitourinary surgery to use indwelling catheter to
keep the bladder clear and free from blood clots or sediment.
2. CBI is frequently ordered after bladder surgeries

ASSESSMENT
1. Assess client’s level of consciousness and ability to cooperate.
2. Palpate bladder for distention and tenderness.
Bladder distention indicates flow of urine may be blocked from draining.
3. Ask client to describe bladder pain or spasms.
It serves as baseline. Accumulation of blood clots can increase bladder spasms.
4. Observe urine for color, amount, clarity and presence of mucus, clots or sediment.
This indicates if client is bleeding or sloughing tissue and determines necessity
for increasing irrigation rate.
5. Review I&O record to verify that the hourly output into the drainage bag is in
appropriate proportion to the irrigating solution entering the bladder
It determines if system is obstructed. Expect more output than fluid instilled
because of urine production.
6. Assess client’s knowledge regarding purpose of performing catheter irrigation

EQUIPMENT
Clean gloves
Irrigation solution at room temperature as prescribed
Irrigation tubing with clamp to regulate irrigation flow rate
Y connector (optional) to connect irrigation tubing to double-lumen catheter
Intravenous (IV) pole
Antiseptic swab

PROCEDURE AND RATIONALE

1. Verify physician’s orders if skill is dependent or collaborative nursing intervention.
Independent nursing intervention may be verified with the nursing care plan or primary
nurse.
2. Identify the client name by checking the armband and having the client state name (if
able to do so). In many long care term care settings, armbands are not used, however
pictures are available for identification.
3. Introduce yourself to client (family), including both your name and title or role.
4. Tell the client (family) what you plan to do to enhance cooperation and relieve anxiety.
5. Identify teaching needed and describe what the client can expect in terms the client

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 can understand.
6. Assess client to determine that the intervention is still appropriate.
7. Gather equipment needed and complete necessary charges according to agency
policy.
8. Perform hand hygiene to decrease transmission of microorganism.
9. Adjust the bed to the appropriate height. If a side rail is raised, it should not restrain the
client’s movement. Lower side rail on the side nearest you.
10. Provide privacy for client. Position and drape client as needed.
11. Place label on irrigation solution bag with client’s name, room number, date and time,
type of solution and any additives. Clearly mark the bag for GU IRRIGATION ONLY.
Indicates fluid is not to be infused intravenously.
12. Hang bag on IV pole.
13. Using aseptic technique, insert (spike) tip of sterile irrigation tubing into bag containing
irrigation solution.
14. Close clamp on tubing, and fill the drip chamber one-half full by squeezing the
chamber. Open the clamp to completely fill tubing and remove air. Close the clamp
Air in the tubing may cause bladder fullness and spasms.
15. Wear clean gloves. Using aseptic technique, wipe off irrigation port of triple-lumen
catheter with antiseptic swab and connect to irrigation tubing
16. Calculate drip rate and adjust rate at roller clamp ( according to physician’s orders or
agency protocol)
17. If urine is bright red or has clots, increase irrigation rate until drainage appears pink.
Continuous drainage is expected and assists with prevention of clotting in the
presence of active bleeding in bladder and flushes clots out of bladder.
18. Replace bag of irrigation solution as needed.
19. Empty catheter drainage bag as needed.
Bag will fill rapidly and may need to be emptied every 1-2 hours.
20. Compare urine output with infusion of irrigation solution every hour.
21. Assist client to a position of comfort and place needed items within reach. Be certain
client has a way to call for help and knows how to use it.
22. Raise the side rails and lower the bed to the lowest position.
23. Store or remove and dispose of supplies and equipment.
24. After client contact, remove gloves if used
25. Perform hand hygiene.
26. Document and report client’s response and unexpected outcomes.

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 CENTRAL VENOUS PRESSURE MONITORING

DEFINITION
It refers to the measurement of right atrial pressure or the pressure of the great veins
within the thorax.

PURPOSE
1. To serve as a guide for fluid replacement.
2. To monitor pressure in the right atrium and central veins.
3. To administer blood products, TPN, and drug therapy contraindicated for peripheral
infusion.
4. To obtain venous pressure access when peripheral vein sites are inadequate.
5. To insert temporary pacemaker.
6. To obtain central venous blood samples.

MATERIALS
Venous pressure tray
Cut down tray
Infusion solution/ infusion set with CVP manometer
Heparin Flush system/ pressure bag
IV pole
Arm board
Sterile dressing
Gown, mask, caps and sterile gloves
ECG monitoring

PROCEDURE AND RATIONALE

PREPARATORY PHASE done by the Nurse

1. Assemble all the equipment according to the manufacturer’s direction.
2. Explain the procedure to the patient and obtain informed consent
a) Explain to the patient how to do valsava maneuver.
b) NPO for 6 hours prior to insertion.
3. Position patient appropriately
a) Place in supine position
1. Extend arm and secure on arm board
2. Place patient in trendelenburg positioned. Place a small rolled towel under
shoulders (subclavian approach)
4. Flush IV infusion set and manometer (measuring device) or prepare heparin flush for
use with transducer.
a) Attach manometer to IV pole. The zero point of the manometer should be on the
level with the patient’s right atrium.
b) Calibrate zero transducer and level port level with patient’s right atrium.
5. Place patient on ECG monitor.

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 INSERTION PHASE done by the Physician

1. Physician dons gown, cap and mask.

2. The CVP site is surgically cleansed.
3. Assist patient to remain motionless during insertion.
4. Monitor for dysrhythmias as catheter is threaded to great vein or right atrium.
5. Connect prime IV tubing/heparin flush system to catheter and allow IV solution to flow
at a minimum rate to keep vein open (25ml maximum).
6. The catheter should be sutured in place.
7. Place a sterile occlusive dressing over site.
8. Obtain a chest X-ray.

TO MEASURE THE CVP

1. Place the patient in a position of comfort. This is the baseline position used for
subsequent readings.
2. Position the zero point of the manometer at the level of the right atrium.
3. Turn on the stopcock so that IV solution flows into the manometer, filling to about the
20-25 cm level. Then turn stopcock so that solution in manometer flows into patient.
4. Observe the fall in the height of the column of fluid in manometer. Record the level at
which the solution stabilizes or stops moving downward. This is the CVP result. Record
CVP and the position of the patient.
5. The CVP catheter may be connected to a transducer and an electrical monitor with
either digital or calibrated CVP wave readout.
6. The CVP may range from 5-12 cm water or 2-6 mmHg.
7. Asses the patient’s clinical condition. Frequent changes in measurement will serve as
a guide to detect whether the heart can handle its fluid load and whether hypovolemia
or hypervolemia is present.
8. Turn the stopcock again to allow IV solution to flow from solution bottle into the
patient’s vein.

FOLLOW-UP PHASE
1. Observe for complications.
a) From catheter insertion: pneumothorax, hemothorax, air embolism and hematoma.
b) From indwelling catheter: infection and air embolism.
2. Carry out ongoing nursing surveillance of the insertion site and maintain aseptic
technique.
a) Inspect entry site twice for signs of local inflammation. Remove immediately if there
are any signs of infection.
b) Change dressings as prescribed.
c) Label to show date/time of change.
d) Send the catheter tip for any bacteriologic culture when it is removed.

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 VAGINAL INSTILLATION
AND VAGINAL IRRIGATION (DOUCHING)

DEFINITION
1. Vaginal Irrigation (douching) is the washing of vagina by a liquid at a low pressure.
2. Vaginal Instillation is instilling medications such creams, jellies, foams, or suppositories
to relieve infection and vaginal discomfort.

PURPOSE
1. It is used to prevent infection by applying antimicrobial solution that discourages the
growth of microorganism.
2. To remove an offensive or irritating discharge
3. To reduce the inflammation or to prevent hemorrhage by the application of heat or
cold.
4. To relieve vaginal discomfort.

ASSESSMENT
1. Assess any allergy to medications or irritating fluid.
2. Look for vaginal orifice for inflammation, amount, character and odor of vaginal
discharges.
3. Assess for complaints of vaginal discomfort (burning or itching).

MATERIALS

Vaginal Instillation Vaginal Irrigation

Drape Bedpan
Correct vaginal suppository Roll or pillow
Applicator for vaginal cream Moisture proof pad
Disposable gloves Moisture resistant drape
Lubricant for a suppository Vaginal Irrigation set
(Nozzle, tubing, clamp, solution container)
Disposable towel IV pole
Clean perineal pad and T-binder Irrigating solution
Or sanitary belt Gloves
Tissues
Clean perineal pad and T binder
or sanitary belt

PROCEDURE AND RATIONALE

1. Verify the medication or irrigation order.
2. Prepare the client to enhance cooperation and decrease anxiety.
3. Provide privacy and ask the client to void.
If the bladder is empty, the client will have less discomfort during the treatment and the
possibility of injuring the vaginal lining is decreased.

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4. Position and drape the client appropriately.

a) Instillation
Assist the client to a back-lying position with the knees flexed and the hips rotated
laterally. Drape the client appropriately
b) Irrigation
Assist the client to a back-lying position with the hips higher that the shoulders so
that the solution will flow into the posterior fornix of the vagina.
Position the client on a bedpan and provide comfortable support for the lumbar
region of the back with a roll or pillow
Place the waterproof pad under the bedpan to protect the beddings.
Provide a drape for the legs so that only the perineal area is exposed.
5. Prepare the equipment.
a) Instillation
Unwrap the suppository and put it on the opened wrapper or fill the applicator with
the prescribed cream, jelly, or foam. Directions are provided with the manufacturer’s
applicator
b) Irrigation
Clamp the tubing. Hang the irrigating container on the IV pole so that the base is
about 30 cm or (12 inches) above the vagina.
At this height the pressure of the solution should not be great enough to injure the
vaginal lining
Run fluid through the tubing and nozzle into the bedpan.
Fluid is run through the tubing to remove air and to moisten the nozzle
6. Assess and clean the perineal area.
Don gloves.
Gloves prevent contamination of the nurse’s hands from vaginal and perineal
microorganism
Inspect the vaginal orifice, note any odor or discharge from the vagina and ask about
any vaginal discomfort
Provide perineal care to remove microorganisms.
This decreases the chance of moving microorganism into the vagina.

7. Administer the vaginal suppository, cream, foam, jelly, or irrigation.

a) Suppository
1. Lubricate the rounded (smooth) end of the suppository, which is inserted first.
Lubrication facilitates insertion
2. Lubricate your gloved index finger
3. Expose the vaginal orifice by separating the labia with your nondominant hand.
4. Insert the suppository about 8 to 10 cm (3-4in) along the posterior wall of the
vagina or as far as it will go.

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 5. Withdraw the finger and remove the gloves, turning them inside out. Discard
appropriately.
Turning the gloves inside out prevents the spread of microorganisms.
6. Ask the client to remain lying in the supine position for 5-10 minutes following
insertion. The hips may also elevate on a pillow.
This position allows the medication to flow into the posterior fornix after it has
melted
7. Vaginal cream, jelly, or foam
8. Gently insert the applicator about 5 cm (2in).
9. Slowly push the plunger until the applicator is empty.
10. Remove the applicator and place it on the towel.
The applicator is put on the towel to prevent the spread microorganisms.
11. Discard the applicator if disposable or clean it according to the manufacturer’s
directions.
12. Remove the gloves, turning them inside out. Discard appropriately.
13. Ask the client to remain in bed in the supine position for 5-10 minutes following
the instillation.

b) Irrigation
1. Run some fluid over the perineal area then insert the nozzle carefully into the
vagina. Direct the nozzle toward the sacrum following the direction of the
vagina.
2. Insert the nozzle about 7-10 cm (3-4in) start the flow and rotate the nozzle
several times.
3. Rotating the nozzle irrigates all parts of the vagina.
4. Use all the irrigating solution, permitting it to flow out freely into the bedpan.
5. Obstructing the flow of the returns could result in injury to the tissues from
pressure.
6. Remove the nozzle from the vagina.
7. Assist the client to a sitting position on the bedpan.
Sitting on the bedpan will help drain the remaining fluid by gravity.

8. Ensure client comfort.

1. Dry the perineum with tissues as required
2. Remove the bedpan, in used.
3. Remove the moisture-resistant pad and the drape.

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 4. Apply a clean perineal pad and a T-binder if there is excessive drainage

9. Document all relevant information

1. Record the instillation and assessments as for other medications and
instillations.
2. When recording the administration of the irrigation, note when it was
administered; the amount, type, strength and temperature of the irrigating
solution and all nursing assessments.

10. Assess the client’s response.

OPERATING ROOM TECHNIQUE

Operating Room (OR), also called surgery center - is the unit of a hospital where surgical
procedures are performed.

Purpose:
An operating room may be designed and equipped to provide care to patients
with a range of conditions, or it may be designed and equipped to provide specialized
care to patients with specific conditions.

Operating Room Environment

Operating rooms are sterile environments, all personnel wear protective

clothing called scrubs. They also wear shoe covers, masks, caps, eye shields, and
other coverings to prevent the spread of germs.

The operating room is brightly lit and the temperature is very cool; operating
rooms are air-conditioned to help prevent infection.

The patient is brought to the operating room on a wheelchair or bed with wheels
(called a gurney). The patient is transferred from the gurney to the operating table,
which is narrow and has safety straps to keep him or her positioned correctly.

The monitoring equipment and anesthesia used during surgery are usually kept
at the head of the bed. The anesthesiologist sits here to monitor the patient's condition
during surgery.

Depending on the nature of the surgery, various forms of anesthesia or sedation

are administered. The surgical site is cleansed and surrounded by a sterile drape.

The instruments used during a surgical procedure are different for external and
internal treatment; the same tools are not used on the outside and inside of the body.
Once internal surgery is started, the surgeon uses smaller, more delicate devices.

Asepsis in the operating room

Aseptic technique is most strictly applied in the operating room because of the
direct and often extensive disruption of skin and underlying tissue. Aseptic technique
helps to prevent or minimize postoperative infection.

Principles that are applied to maintain surgical asepsis in the operating room

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15. All items in a sterile field must be sterile.
16. Sterile packages or fields are opened or created as close as possible to time of actual
use.
17. Moist areas are not considered sterile.
18. Contaminated items must be removed immediately from the sterile field.
19. Only areas that can be seen by the clinician are considered sterile (i.e., the back of the
clinician is not sterile).
20. Gowns are considered sterile only in the front, from chest to waist and from the hands
to slightly above the elbow.
21. Tables are considered sterile only at or above the level of the table.
22. Nonsterile items should not cross above a sterile field.
23. There should be no talking, laughing, coughing, or sneezing across a sterile field.
24. Personnel with colds should avoid working while ill or apply a double mask.
25. Edges of sterile areas or fields (generally the outer inch) are not considered sterile.
26. When in doubt about sterility, discard the potentially contaminated item and begin
again.
27. A safe space or margin of safety is maintained between sterile and nonsterile objects
and areas.
28. When pouring fluids, only the lip and inner cap of the pouring container is considered
sterile; the pouring container should not touch the receiving container, and splashing
should be avoided.
29. Tears in barriers and expired sterilization dates are considered breaks in sterility.

Gowns are considered sterile from waist to Circulating nurse pouring solution
into shoulder level in front and the sleeves. a sterile basin. Note that only the
tip of bottle is over the basin.

Sequence of one sterile person going around another.

A B

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 C

They pass each other back to back.

Classification of Surgical Procedures

Based on Urgency
15. Elective: Delay of surgery has no ill effects; can be scheduled in advance based on
patient's choice.
Purpose
14)To remove or repair a body part
15)To restore function
16)To improve health
17)To improve self – concept

Examples: Tonsillectomy, hernia repair, cataract extraction and lens implantation,

hemorrhoidectomy, hip prosthesis, scar revision, facelift, mammoplasty.

6. Urgent: Usually done within 24 – 48 hours

Purpose
4. To remove or repair a body part
5. To preserve or restore health
6. To restore function
7. To prevent further tissue damage

Examples: Removal of gall bladder, coronary artery bypass, surgical removal of a

malignant tumor, colon resection, amputation.

2. Emergency: Done immediately.

Purpose
7. To preserve life (plus purposes listed above)

Examples: Control of hemorrhage, repair of trauma, perforated ulcer, intestinal

obstruction, tracheostomy.

Based on Degree of Risk

7. Major: may be elective, urgent, or emergency. Extensive surgery that involves serious
risk and complications and blood loss.
Purpose
 To preserve life
 To remove or repair a body part
 To restore function
 To improve or maintain health

Examples: Carotidendarterectomy, cholecystectomy, nephrectomy, colostomy,

hysterectomy, radical mastectomy, amputation, trauma repair

8. Minor: Primarily elective. Surgery that involves minimal complications and minimal
blood loss.

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 Purpose
16. To restore function.
17. To remove skin lesions.
18. To correct deformities.
Examples: Teeth extraction, removal of warts, skin biopsy, dilation and curettage,
laparoscopy, cataract extraction, arthroscopy

Based on Purpose
 Diagnostic
Purpose
5. To make or confirm a diagnosis

Examples: Breast biopsy, laparoscopy, bronchoscopy, exploratory laparotomy

2. Curative
a. Ablative
Purpose
5. To remove a diseased body part.

Examples: Appendectomy, subtotal thyroidectomy, partial gastrectomy, colon

resection, amputation

b. Palliative
Purpose
d. To relieve or reduce intensity of an illness; is not curative.

Examples: Colostomy, nerve root resection, debridement of necrotic tissue,

balloon angioplasties, arthroscopy.

c. Reconstructive
Purpose:
▪ To restore function to traumatized or malfunctioning tissue.
▪ To improve self – concept.

Examples: Scar revision, plastic surgery, skin graft, internal fixation of a

fracture breast reconstruction

2. Transplantation
Purpose:
▪ To replace organs or structures that are diseased or malfunctioning.

Examples : Kidney, liver, cornea, heart, joints

3. Constructive
Purpose:
▪ To restore function in congenital anomalies

Examples: Cleft palate repair, closure of atrial – septal defect.

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 Positions for Surgery

Positioning is putting the patient in proper body alignment to expose the operative site
or area.

Supine Position Modified Trendelenburg Position

A B
Reverse modified Trendelenburg Position
A. For upper abdominal surgery B. For face and neck surgery

Lithotomy positions

Prone position Modified jackknife, used for rectal surgery

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 Lateral position. Modified Fowler’s Position
Generally used for operations on Used mostly in Neurosurgery
Kidneys, lungs and hips
SKIN PREPARATION

Lateral thoracoabdominal preparation Chest and breast preparation

Abdominal preparation Knee and lower leg preparation

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Rectoperineal and vaginal preparation Hip preparation
Layers of abdominal tissue from the outer most:

Skin

Subcutaneous

Fascia

Muscle

Peritonium

Parts of Organ commonly operated.

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 Common abdominal incisions.

Preoperative Patient Care:

The preoperative phase consists of the time from when it is decided that surgery is
needed until the patient arrives in the operating room. This is a time of assessment and
education.

1. Identify patients for whom surgery is a greater risk, including the following:

a. Very young and elderly patients

b. Obese or malnourished patients
c. Patients with fluid and electrolyte imbalances
d. Patients in poor general health from chronic disease and infectious processes
e. Patients taking certain medications (i,e anticoagulants, antibiotics, diuretics,
depressants, steroids)
f. Patients who are extremely anxious.

Identification of high risk status allows for recognition of patients who may be prone to
complications after surgery.
Review the nursing database, history, and physical examination. Check that the baseline
data are recorded; report those that are abnormal. Review identifies patients who are
surgical risks.

 Check that diagnostics testing has been completed and results are available; identify
and report abnormal results. This check may influence the type of surgery performed
and anesthetic used, as well as the timing of surgery or the need for additional
consultation.

 Promote optimal nutrition and hydration status as ordered. This promotes wound
healing.

 Identify learning needs of patient and family. This enhances surgical recovery and
allays anxiety by preparing patients for postoperative convalescence, discharge plans,
and self – care.

 Conduct preoperative teaching regarding coughing and deep – breathing exercises

with splinting if necessary.
Deep – breathing exercises improve lung expansion and volume, help expel anesthetic
gases and mucus from the airway, and facilitate the oxygenation of body tissues.
Coughing helps remove retained mucus from the respiratory tract.
Splinting minimizes pain while coughing or moving.

 Conduct preoperative teaching regarding respiratory therapy regiments such as

incentive spirometry. Incentive spirometry improves lung expansion, helps expel
anesthetic gases and mucus from the airway, and facilitates oxygenation of body
tissues.

 Conduct preoperative teaching regarding management of pain after surgery. Using

ordered analgesics to minimize pain helps prevent postoperative complications.

 Conduct preoperative teaching regarding leg exercises. Leg exercises promote venous
return and decrease complications related to venous stasis.

 Provide preoperative teaching regarding early ambulation and turning in bed.

Turning and moving in bed helps to minimize pain and prevent postoperative

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 complications.

 Provide preoperative teaching regarding postoperative equipment and monitoring

devices.

 Provide preoperative teaching regarding home care requirements.

 Document findings and instruction given. Documentation ensures communication and

continuity of care.
Day Before Surgery

 Provide emotional support. Answer questions realistically. Provide spiritual assistance

if requested. Include family when possible. This allays family and patient
misconceptions and fears.

 Follow preoperative fluid and food restrictions. This reduces risk for vomiting and
aspiration during surgery. Anesthetic agents temporarily depress gastrointestinal
function and processes.

 Prepare for elimination needs during and after surgery. Anesthetic agents and
abdominal surgery interfere with normal elimination function. A urinary catheter
inserted preoperatively minimizes risk for inadvertent trauma to bladder during surgery.

 Attend to patient’s special hygiene needs (i,e use of antiseptic cleaning agents to
prepare surgical site). This decreases risk for infection.

 Provide for adequate rest. Rest minimizes stress before surgery.

Day of surgery

 Check that proper identification band is on patient. Double – checking ensures identity
of patient.

 Check that preoperative consent forms are signed, witnessed, and correct, that
advance directives are in the medical record ( as applicable),and that the medical
record is in order. This fulfills legal requirement related to informed consent and
educates patient regarding advance directives.

 Check vital signs. Notify physician of any pertinent changes (i,e rise or drop in blood
pressure, elevated temperature, cough, symptoms of infection). This provides baseline
data for comparison.

 Provide hygiene and oral care. Remind patient of food and fluid restrictions before
surgery. This promotes comfort and prevents intraoperative complications during
anesthesia induction.

 Continue nutritional and hydration preparation. This prepares patient for operative
procedure.

 Remove cosmetics, jewelry, nail polish, and prostheses (eg, contact lenses, false
eyelashes , dentures, and so forth). Some facilities allow a wedding band to be left in
place depending on the type of surgery, provided it is secured to the finger with tape.
Reassess for loose teeth. These interfere with assessment during surgery.

 Place valuables in appropriate area. The hospital safe is most appropriate place for
valuables. They should not be placed in narcotics drawer. This ensures safety of

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 valuables and personal possessions.

 Have patient empty bladder and bowel before surgery. An empty bladder and bowel
minimize risk for injury or complications during and after surgery.

 Attend to any special preoperative orders. This prepares patient for operative
procedure.

 Complete preoperative checklist and record of patient's preoperative preparation. This

ensures accurate documentation and communication with perioperative nurse caring
for patient.

 Administer preoperative medication as prescribed by physician/anesthesia provider.

Medication reduces anxiety, provides sedation, and diminishes salivary and bronchial
secretions.

 Raise side rails of bed, place bed in lowest position. Instruct patient to remain in bed or
on stretcher. If necessary, a safety restraint may be used. These actions ensure the
patient's safety once the preoperative medication has been given.

 Help move the patient from the bed to the transport stretcher if necessary. Reconfirm
patient identification and ensure that all preoperative events and measures are
documented. Helping the patient move prevents injury. Reconfirming patient identity
helps to ensure that the correct patient is being transported to surgery.

 After the patient the patient leaves for the operating room, prepare the room and bed
for postoperative care. Anticipate any necessary equipment based on the type of
surgery and the patient's history. Preparing for the patient's return helps to promote
efficient care in the postoperative period.

Postoperative Care - When Patient Returns to Room

Postoperative care facilitates recovery from surgery and supports the patient in coping
with physical changes or alterations. Nursing interventions promote physical and
psychological health, prevent complications, and teach self – care skills for the patient to use
after the hospital stay. After surgery, patients spend time on the post anesthesia care unit
(PACU). From the PACU, they are transferred back to their rooms. At this time, nursing
interventions focus on actual problems and anticipated problems the patient is at risk for
developing.

2. When patient returns from the PACU, obtain a report from the PACU nurse and
review the operating room and PACU data. Check the patient's identification.
Perform hand hygiene. Place patient in safe position (semi – or high Fowler's or
side – lying ). Note level of consciousness. Obtaining report ensures accurate
communication and promotes continuity of care. A sitting position facilitates deep
breathing; the side – lying position with neck slightly extended prevents aspiration
and airway obstruction.

3. Monitor and record vital signs frequently. Assessment order may vary, but usual
frequency includes taking vital signs every 15 minutes the first hour, every 30
minutes the next 2 hours, every hour for 4 hours, and finally every 4 hours.
Comparison with baseline preoperative vital signs may indicate impending shock or
hemorrhage.

4. Provide for warmth, using blankets as necessary. Assess skin color and condition.

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 Hypothermia is uncomfortable and may lead to cardiac arrhythmias and impaired
would healing.

5. Check dressings for color, odor, and amount of drainage, and feel under the patient
for bleeding. Hemorrhage and shock are life – threatening complications of surgery.

6. Verify that all tubes and drains are patent and equipment is operative; note amount
of drainage in collection device. This ensures maintenance of vital functions.

7. Maintain I V infusion at correct rate. This prevents dehydration and electrolyte

imbalances.

8. Provide for a safe environment. Keep bed in low position with side rails up. Have
call bell within patient's reach. This prevents accidental injury.

9. Relieve pain by administering medications ordered by physician. Check record to

verify if analgesic medication was administered in the PACU. Analgesics are used
for relief of postoperative pain.

10. Record assessments and interventions on chart. This provide for accurate
documentation.

Ongoing Care

11. Promote optimal respiratory function:

a. Coughing and deep – breathing
b. Incentive spirometry
c. Early ambulation
d. Frequent position change
e. Administration of oxygen as ordered.

Anesthetic agents may depress respiratory function: patients who have existing
respiratory or cardiovascular disease or abdominal or chest incisions or who are obese
or elderly or in a poor state of nutrition are at greater risk for respiratory complications.

12. Maintain adequate circulation, including:

a. Frequent position changes
b. Early ambulation
c. Application for antiembolism stockings or pneumatic compression devices, if ordered
by physician
d. Leg and range – of – motion exercises if not contraindicated.

Preventive measures can improve venous return and circulatory status.

13. Assess urinary elimination status:

a. Promote voiding by offering bedpan at regular intervals
b. Monitor catheter drainage if present
c. Measure intake and output

Anesthetic and surgical manipulation in the area may temporarily depress bladder
tone and response.

13. Promote optimal nutrition status and return of gastrointestinal function:

a. Assess for return of peristalsis
b. Assist with diet progression
c. Encourage fluid intake
d. Monitor intake

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 e. Medicate for nausea and vomiting as ordered by physician.

Anesthetic agents and narcotics depress peristalsis and normal functioning of

gastrointestinal tract.

14. Promote wound healing by using surgical asepsis; assess condition of wound and any
drainage.

Alteration in nutritional, circulatory, and metabolic status may predispose patient to

infection and delayed healing.

(1) Provide for rest and comfort. This shortens recovery period and
facilitates return to normal function.

(2) Provide emotional and spiritual support. This facilitates individualized

care and patient's return to normal health.

(3) Document findings and interventions used. Documentation provides a

means of communication and facilitates continuity of care.

PREPARATION OF THE OPERATING ROOM FOR SURGERY

DUTIES OF THE OPERATING ROOM SPECIALIST AS A CIRCULATOR

GENERAL

1. Both the circulator and the scrub nurse must study the operating room schedule in
detail to enable them to carry out their duties effectively.

2. Preliminary preparation of the operating room is done before the patient enters.

3. To work efficiently during a surgical procedure, the circulator must be thoroughly

familiar with the established routine in the operating room suite. He must know
instruments, equipments, and supplies -- including the supplies needed for
positioning the patient – to enable him to provide the appropriate items. He must
also know their location to avoid loss of time in obtaining them.

PREPARATION OF THE OPERATING ROOM

4. The circulator should check the operating room schedule the day before surgery for any
changes that may have been made.

5. Personal cleanliness is extremely important for the operating room specialist. Before
performing the duties, the circulator should wash his hands thoroughly and don a surgical
hat. The surgical cap must cover the hair completely to prevent possible contamination of
the sterile area from falling hair or dandruff. Before entering a restricted area, the OR
specialist must don a surgical mask per local SOP. The mask protects the patient from
bacteria exhaled by operating room personnel. The mask must fit snugly around the nose
and mouth to filter air through it rather than around the sides of the mask. The mask
should be changed whenever it becomes damp and after each procedure.

6. Damp dust the operating room. Concurrent with dusting, check equipment, arrange
furniture, and restock supplies. After damp dusting with a cloth soaked with disinfectant
solution prescribed by local policy, wet vacuum the floor using a disinfectant prescribed by
local policy. Dry dusting and mopping is never done in the operating room because it
raises dust that contains bacteria.

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 (1) Damp dusting should be done before the first schedule incision time of
the day.

(2) Establish and follow a definite order when damp dusting furniture.
Start with the tallest equipment and work down since this method
helps the settling of airborne microorganisms. Damp dust the
operating room overhead light first, then the operating table. Work
from the center of the room to the perimeter (outer limits) and from the
tallest item to the lowest. If you are called from the room, leave the
damp dusting cloth on the item being dusted; this will serve as the
starting point when resuming dusting duties.

(3) As the damp dusting is accomplished, set up the equipment and

check each item for proper functioning. This will save time and
energy. This includes such things as:

1. Switch on the overhead light to ensure

proper functioning.
2. Check the operating table for proper
working order.
3. Check suction machine, the
electrosurgical unit, and other pieces of
equipment in the operating room whether
or not they are to be used.
4. Line the kick buckets with plastic bags.
5. Check the supply cabinets for stock.
Restock, if necessary.

d. Consult with the scrub on the arrangement of the furniture for the surgical
procedure. In general, the area chosen for the sterile set-up should be away from
doorways and traffic. It should be in the most close in area away from the cabinet
that are to be opened during the set-up. As damp-dusting continues, arrange the
furniture for the sterile set-up so that the scrub can work within the sterile field and
the circulator can work outside the field.
d. Check with the scrub for any special equipment he may need for the case.
e. If the instruments were not wrapped and sterilized on the preceding shift,
ensure that instrument sets are placed in the autoclave.
f. Check that all equipment needed to position the patient is in the room. If not,
get the necessary equipment.
g. Discuss with the scrub the sterile supplies needed for the case (be sure to
discuss the kind and amount of sutures needed) and then bring the supplies
to the room. The surgeon's preference card will list the types and sizes of
sutures needed for the procedure.
h. Place sterile goods on the tables or stands where they will be used to avoid
having to move them from one place to another. You should place the
various sterile items as indicated in (1) through (6) below.

5. The linen or drape pack on the large instrument table (back table).
6. The gown pack on the prep table.
7. The mayo tray on the mayo stand.
8. The sterile basin set in to the ring stand.
9. The prep set placed on the prep table. Only after the scrub dons the
gown and the wrapper is removed.
10. The instrument set on a ring stand or table.

i. Put sterile packages that the scrub will not need immediately (such as

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 suction tubing and culture tubes) on the utility table and open them after the
scrub has prepared a space for them. You may also place on the utility table
supplies needed form the sterile supply cabinet such as knife blades,
needles, etc.

j. Do not place sterile supplies on the operating table nor on the anesthetist's
equipment (the anesthesia apparatus and the anesthetist's table) because
these areas are for the use by the anesthetist only.

k. Open the sterile supplies. Before any sterile supplies are opened, however,
the integrity of every package is checked for tears, punctures, and
watermarks, expiration date, and the sterile pack indicate that the supplies
are unsafe to use. The sterilization indicator shows whether the pack has
been through the sterilization process. The date of expiration will tell you
whether it is too old for safe use. If the package is in any way compromised, it
must be discarded and a new pack secured.

l. Open the packs and sets in the order in which the scrub will need them.
Open the sterile gown first; the scrub will need this immediately upon entering
the room.
(1) Remove the tap from the packages, unwrap the item, and check the
indicator tape to ensure item has been through the sterilization
process. If the indicator tape shows no or incomplete sterilization
process, discard the package and secure a new one.
(2) After opening the pack containing the scrub’s gown, open the basin
set, the linen pack, the prep set, and the instrument set.

m. All sterile wrappers are to be removed in the same general manner. Open
the wrapper so that your hand and arm do not pass over any part of the
inside of the wrapper that has been exposed.
a. Position the package so that the flaps are on top
b. Using on hand lift the distal flap up and away from the package
c. Open the left flap
d. Open the right flap
e. Open the near flap

n. Larger sterile supplies can be opened using the wrappers to form a sterile
field and are to be opened in the following manner.
A. With hands on the outside of each wrapper in a folded cuff, always lift the wrapper
toward you to avoid contaminating the contents of the pack. The area touched by you
under the cuff falls below table level and the inside of the wrapper remains sterile.
B. Walk around the table as you remove each portion of the wrapper. Do not reach over
the inside of the sterile table cover or the contents of the pack.
C. Stand at arms length from the sterile pack as you lift the wrappers. If a sterile pack falls
to the floor, discard it, as it has now become contaminated.
D. Check the sterilization indicator. If the sterilization indicator in the pack is acceptable,
the circulator continues. If the indicator is not acceptable, the pack is discarded and a
new pack is opened.
E. The inside of the wrapper can now be used as a sterile field. The object that was
wrapped (such as the scrub’s gown, double basin set or back table surgical pack) is
now located within a sterile field.

o. Smaller sterile supplies are to be opened and added to the sterile field in the
following manner:
(1) Hold the sterile package in one hand with the flaps up. This is done
away from the sterile field.
(2) Grasp the outside edges of the sterile wrapper with your free hand.

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 This protects the sterility of the packages contents.
(3) Unwrap the sterile package. Be careful not to contaminate the inside
of the wrapper or the sterile object.
(4) Hold edges of sterile wrapper back around your wrist so they will not
accidentally drag across the sterile field and so the hand supporting
the sterile object is enclosed by the wrapper.
(5) Drop small sterile items directly into the sterile field.

Role and Responsibilities of a Registered Nurse First Assistant

The RNFA role is an expansion of the traditional perioperative nursing role and areas
of responsibility will overlap. Responsibilities specific to the practice of first assisting include:

1. Providing surgical exposure (assist in retraction of tissues and suctioning of surgical

fields)
2. Providing hemostasis (control of bleeding)
3. Handling tissue safely
4. Using surgical instruments and suturing
5. Performing wound closure
6. Applying human anatomical and physiological consideration in practice; recognizes
structure, function and location of tissues and organs; manipulates tissues accordingly
to avoid injury

Role of the Scrub Nurse

1. Assists circulating nurse in preparing OR, opening supplies

2. Performs surgical hand scrub and dons sterile gown and gloves
3. Sets up sterile field with procedure-appropriate supplies and instruments, verifying all
are in working order
4. Performs sponge, sharp, and instrument counts with circulating nurse before incision is
made
5. Gowns and gloves surgeons and assistants as they enter the OR
6. Assist surgeons with sterile draping of client
7. Keep sterile field orderly and monitors progress of procedure and any breaks in aseptic
technique
8. Passes instruments and supplies to surgeons and assistants
9. Handles surgical specimens per institutional policy
10. Constantly monitors location of all sponges and sharps in the field and performs
closing sponge, sharp, and instrument counts with circulating nurse.

Draping

Proper draping of the surgical area helps to maintain asepsis by creating a

sterile field, thus limiting exposure to microorganisms. Drapes are used to cover other
areas of the body, exposing only the incisional wound.

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 Draping the Mayo Stand Completing the draping of the Mayo Stand
(Scrub nurse’s hands are protected in cuff of the drape.)

Nurse unfold sterile drape. Basic prep set

Putting a scalpel blade on a knife handle. Passing an instrument. Tip is visible; hand is
free. Handle is placed directly into
waiting hand.

Role of the Circulating Nurse

1. Organizes and prepares OR before start of case; checks to see equipment works
property
2. Gathers supplies for case and opens sterile supplies for scrub nurse
3. Counts sponges, sharps, and instruments with scrub nurse before incision is made
4. Sends for client at appropriate time
5. Conducts preoperative client assessment, including the following:
6. Explains role and identifies client
7. Reviews medical record and verifies procedure and consents
8. Confirms dentures and prostheses removed
9. Confirms client's allergies, nothing by mouth (NPO) status, laboratory values,
electrocardiogram (ECG), x-ray films, skin condition, circulatory and pulmonary status
10. Safely transfers client to operating table and positions client according to surgeon
preference and procedure type
11. Applies return electrode pad to client if electrocautery used; may prepare client's

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 skin;may apply ECG electrodes for local case
12. Explains briefly to client what the circulating nurse and the scrub nurse are doing
13. Assists surgical team by typing gowns and arranging tables
14. Assists anesthesiologist during induction and extubation
15. Continuously monitors procedure for any breaks in aseptic technique or to anticipate
needs of the team; opens additional sterile supplies for scrub nurse; ensures standard
precautions maintained
16. Handles surgical specimens per institutional policy
17. Documents care on perioperative nurse's notes
18. Performs sponge, sharp, and instrument counts with scrub nurse at beginning of
wound closure.
Wound Closure

7. Sutures.
A material used to sew an incision together. Sutures can be either absorbable
or nonabsorbable
a. Absorbable sutures absorb into the skin, so that removal is not necessary.
eg. Catgut or chromic
b. Nonabsorbable sutures must be removed after the incision has healed.
eg. Synthetic nylon or polypropylene, silk

A B C
A. Intermittent B. Continuous C. Blanket

Removal of Intermittent suture. Nurse removes suture and never pulls

the contaminated stitch through tissues.

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8. Clips
Skin clips can also be used for incisional closure. Clips, which are larger than
staples and protrude up from the incision in a clamp-like fashion, are also made of
stainless steel. Clips approximate skin edges and are removed by pinching the top
of the clip together, releasing the section of the clip that approximates the skin
edges.

9. Staples
Skin staples are made of stainless steel and look like paper stables flat against
the skin. Skin staples are minimally reactive to the body as a foreign substance, and
therefore minimize the risk of infection.
A staple gun is used to place staples to close
the incision. The use of the skin staples also reduces tissue handling because staples
provide faster wound closure than sutures. Skin staples are usually removed using a
staple remover within the first week after surgery, after incisional healing has occurred.

Suture line secured with staples. Staple extractor placed under staples.

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 Method of cleansing suture line area.
SURGICAL HANDSCRUB

Definition: Process of removing as many microorganism as possible from the hands and
arms by mechanical washing and chemical antisepsis.

Purpose:
• To remove debris and transient microorganisms from the nails, hands and
forearms.
• To reduce the resident microbial count to a minimum.
• To inhibit rapid rebound growth of microorganism.

Equipment:
• Deep sink with foot or knee controls for dispensing water and soap (faucet should
be high enough for hands and forearms to fit comfortably).
• Antiseptic detergent
• Surgical scrub brush with plastic nail pick.
• Paper mask and cap or hood.
• Sterile towel
• Scrub suit attire
• Protective eyewear (glasses or goggles)

Assessment:
• Consult institutional policy regarding required length of time for hand wash.
• Be sure fingernails are short, clean and healthy.
• Inspect condition of cuticles, hands and forearms for presence of abrasions, cuts or
open lesions.

Length of Scrubbing

The length of the surgical scrub varies from one institution to another, as does
the scrub procedure. Variation in length may depend on frequency of scrubbing and
the agent used.

Surgical Scrub Procedure

A. Time method
B. Counted brush-stroke method

Time Method. Fingers, hands and arms are scrubbed by allotting a prescribed amount of
time to each anatomical area or each step of the procedure.

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 1. Complete scrub takes 5-7 minutes; this is done:
a. In the Morning before the first gowning and gloving.
b. Following a clean case if gloves have been removed inadvertently, before the gown.
c. Following a clean case, if gloves have had a hole between them.
d. Following a clean case if hands have been contaminated in any other way.
e. Before an emergency case at anytime.

2. Short Scrub takes 3 minutes, this is done following a clean case, if the hands and
arms have not been contaminated. It is done to remove bacteria that have emerge
from the pores and multiplied while the gloves were on.

Brush stroke method. A prescribed number of brush strokes, applied length-wise of the
brush or sponge, is used for each surface of the fingers, hand and arms. Scrub
the nails of one hand 30 strokes, all sides of each finger 20 strokes, the back of
the hand 20 strokes,the palm of the hand 20 strokes, the arms 20 strokes for
each third of the arm, to 3 inches above the elbow.

Procedure:

1. Apply surgical attire: shoe covers, cap or hood, face mask and protective
eyewear. Mask prevents escape into air of microorganisms that can
contaminate hands. Other protective wear prevents exposure to blood and body
fluid splashes during the procedure.

2. Turn on water using knee or foot controls and adjust to comfortable

temperature. Knee or foot controls prevent contamination of hands after
scrubbing.

3. Wet hands and arms under running lukewarm water with soap up to 2 inches
above elbows at all times. Keeping hands elevated allows water to flow from
least to most contaminated areas.

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4. Rinse hands and arms thoroughly under running water. Remember: keep
hands above elbows. Water runs by gravity from fingertips, to elbows. Rinsing
removes transient bacteria from fingers, hands and forearms.

5. Under running water, clean under nails of both hands with file. Discard after use.
Removes dirt and organic material that harbor large numbers of
microorganisms.

6. Pick one brush, wet brush and apply antimicrobial detergent under running
water. Scrub the nails of one hand with 15 strokes. Holding brush
perpendicular, scrub the palm, each side of the thumb, and fingers, and the
posterior side of the hand with 10 strokes each. The arm is mentally divided into
thirds, up to 3 inches above the elbow, and each third is scrubbed 10 times.
Entire scrub should last at least 2 to 3 minutes. Rinse brush and repeat the
sequence for the other arm.

7. Scrubbing loosens resident bacteria that adhere to skin surfaces.

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8. Drop or discard the brush and rinse hands and arms thoroughly. Turn off water
with foot or knee control. After touching the skin, brush is considered
contaminated. Rinsing removes resident bacteria.

9. Enter major room, holding hands up and in front of and away from the body.
This will prevent accidental contamination.

10. Bending slightly forward at the wait, pick a sterile hand towel at with one hand
without touching table cover and other contents therein, to dry hand thoroughly
moving from fingers to elbow. Dry in a rotating motion. Dry from the cleanest to
least clean area.

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 11. Repeat drying method for other hand, using a different area of the towel or a
new sterile towel. Drying prevents chapping and facilitates donning of gloves .

12. Discard the towel.

GOWN AND GLOVE TECHNIQUE

Purposes
e. To enable the nurse to work close to a sterile field and handle sterile object freely.
f. To protect clients from becoming contaminated with microorganisms on the nurse's
hands, arms, and clothing

Equipment
5. Sterile pack containing a sterile gown.
6. Sterile gloves

ASSESSMENT

Procedure
1. Perform surgical hand scrub.

2. Enter operating suite, keeping elbows bent away from scrub suit and hands above
waist. Prevents hands from touching contaminated object.

3. Dry hands with sterile towel. Prevents wetting scrubs with water.

4. Take hold of the gown below and neckline using one hand in lifting gown and avoiding
touching other parts of gown. The hands are not completely sterile.

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5. Lift gown from table and step back a few spaces for enough from non sterile objects to
give a wide margin safety, avoiding contamination of gown.

6. Allow lower end of gown to drop, keeping inside of gown toward body. Do not touch
outside of gown with bare hands. Outside of gown remains sterile.

7. Slip hands into perspective arm holes, Keep hands in extended position in front while
circulating nurse helps to bring gown over shoulders by reaching inside to arm seams.
Gown is pulled on, leaving sleeves covering hands. Careful application prevents
contamination. Gown covers hands to prepare for closed gloving.

8. Have circulating nurse securely tie back of gown at collar and waist. Gown must
completely enclose underlying garments.

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4. CLOSED GLOVE TECHNIQUE

1. With hands covered by gown sleeves, open inner sterile glove package. Hands remain
clean. Sterile gown cuff will touch sterile glove surface.

2. Slide hands into sleeves until cuff slams can be grasped between fingers and thumbs.

3. With protected left hand, under gown cuff pick up sterile right hand glove. Sterile gown
touches sterile gloves.

4. With glove palm facing down and fingers pointing towards the gowned elbow, place
glove over covered cuff in level with the middle half of the sleeve stockinette. Positions
glove for application over cuffed hand, keeping glove sterile.

5. Stretch cuff over opening of sleeve to cover gown wrist entirely and at the same time
grasp glove cuff and sleeve stockinette together and pull them towards the wrist.

6. Adjust to fit snugly and neatly. Ensures that nurse has full dexterity while using gloved
hand.

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 7. With gloved right and pick – up left hand glove and follow the same procedures for
gloving left hand. Sterile touches sterile.

8. Arrange table neatly:

a. discard use gloved envelops
b. Set aside sterile packs of powder until all of the scrub team have been
gloved.
c. Check on needed doctor's gloves.

B. ASSISTING DOCTOR WITH THE GOWN

1. Offer sterile hand towel to the doctor.

2. Insert gloved hand under the neckline with the gown rough edge facing you.
3. Lift gown from table and slightly shake it to loosen gown. Outside of gown
remains sterile.
4. Spread gown and extend to doctor.
5. Adjust sleeves so wrist cuff are well fitted.

C. ASSISTING DOCTOR WITH ON GLOVE

1. Open glove envelope. Gloves remains sterile in package.

2. Pick pack of powder on doctor's hands.
3. Remove right hand glove from envelope and inflate.
4. Serve glove to the doctor:
a. hold glove with the palm facing the doctor.

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 2. Insert fingers under folded cuff and extend thumbs out.

c. Stretch cuff sufficient for doctor to insert his/her hand.

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 Removing Gown

A B C

The gown is pulled downward from the shoulders, turning the

sleeves inside out as it is pulled off the arms.

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 ABBREVIATIONS

a before NJ Nasojejunal tube

A.D., ad right ear NPO Nothing Per Orem
aq water O.D.,od right eye
A.S., as left ear O.S.,os left eye
A.U., au both ears O.U., ou both eyes
c with p after
et and PO, p.o.,os by mouth, orally
GT gastrostomy tube p.r. Per rectum, rectally
I.M. Intramuscular q every
I.D intradermal ® right
I.V. intravenous s without
IV PB intravenous piggyback SC, subc,sc subcutaneous
KVO keep vein open SL, sl, subl sublingual
NGT nasogastric thru tubing TKO keep vein open
noct night

MEASUREMENTS AND DRUG FORMS

< lesser than ml milliliter

> greater than oz. ounce
cap capsule pt. pint
Cc cubic centimeter Q, qm, g, GM – gram
Dr dram qt. quart
Elix elixir SR sustained release
Fl dr fluir dram ss ½ or one half
Gr grain supp. suppository
gtt. Drops susp. suspension
Kg kilograms T, tbsp. tablespoon
L, l liter t, tsp teaspoon
m squared square meter T.O. telephone order
m, min minim tab tablet
mcg, ug microgram u unit
meq. Milliequivalent v.o. verbal order
mg. milligram

TIMES OF ADMINISTRATION

AC, ac before meals q.2h every 2 hours

Ad lib as desired , freely q.4h every 4 hours
b.i.d twice a day q.6h every 6 hours
C with q.8h every 8 hours
h hour Q.I.D., q.i.d. four times a day
hs hours of sleep, at bedtime q.o.d. every other day
min minute qd once a day, everyday

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noct at night OD once daily
NPO nothing by mouth qh every hour
PC, pc after meals s without
PRN, p.r.n. whenever necessary, SOS once if necessary;
as needed if there is a need
q every stat immediately, at once
q am every morning T.I.D., t.i.d three times a day

METRIC UNITS OF MEASUREMENTS

UNIT NAME & MEASUREMENTS
ABBREVIATIONS
Gram 1 kilogram (kg, Kg) 1000 g
(weight) 1 gram (g, gm, G, Gm) 1g
1 milligram (mg) 0.001 g
1 microgram ( , mcg) 0.000001 g
1 nanogram (ng) 0.000000001g

Liter 1 kiloliter (kl, KL) 1000 L

(volume) 1 liter (L, l) 1L
1 milliliter (ml) 0.001 L

Meter 1 kilometer (km) 1000 m

(length) 1 meter (m, M) 1m
1 centimeter (cm) 0.1 m
1 millimeter (mm) 0.001 m

NOTE: 1 ml (milliliter) = 1 cc (cubic centimeter): values are the same in drug &
fluid therapy.

APOTHECARY EQUIVALENTS IN WEIGHTS AND FLUID VOLUME

DRY WEIGHT FLUID VOLUME

Larger Units Smaller units Larger Units Smaller units
1 ounce (oz) = 480 grains (gr) 1 quart (qt) = 2 pints (pt)
1 ounce (oz) = 8 drams ( ) 1 pint (pt) = 16 fluid ounce (fl oz or fl)
1 dram ( ) = 60 grains (gr) 1 fluid ounce = 8 fluid dram (fl dr or fl )
1 scruple = 20 grains (gr) 1 fluid dram = 60 minims ( , min)
1 minim = 1 drop

HOUSEHOLD EQUIVALENTS IN FLUID VOLUME

1 measuring cup = 8 ounces (oz)
1 medium size glass = 8 ounces (oz)
(tumbler size)
1 coffee cup (c) = 6 ounces (oz) (varies with cup size)
1 ounce (oz) = 2 tablespoon (T)
1 tablespoon (T) = 3 teaspoon (t)
1 teaspoon (t) = 60 drops (gtt)*
1 drop (gt)* = 1 minim ( , min)

MANUFACTURER DROPS (GTT/ML)

MACRODRIP SET ( w/ large drops/ml )
Abbott 15
Cutter 20

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 McGraw 15
Travenol 10

MICRODRIP SET ( w/ small drops/ml )

Travenol 60
Minidrip sets

Abbreviation of Solutions

Intravenous Solution Abbreviations

5 % Dextrose in Water D5 W, 5 % D/W

10 % Dextrose in Water D10 W, 10% D/W
0.9 % Sodium Chloride, Normal 0.9 % NaCl, NSS
Saline
Solution 0.45 % NaCl, ½ NSS
0.45 % Sodium Chloride, ½ Normal
Saline D5 NSS, 5 % D / NSS, 5 % D / 0.9 % NaCl
Solution D5 / ½ NSS, 5 % D / ½ NSS
5 % Dextrose in 0.9 % Sodium 5 % Dextrose in ½ Normal Saline Solution
Chloride LR
5 % Dextrose in 0.45 % Sodium
Chloride

Lactated Ringer’s Solution

REFERENCES:

1. A Guide to Physical Examination by Barbara Bates, Lippincott

2. Clinical Nursing Skills and Technique – Perry and Potter 5 th Edition

3. Dosage Calculations 7th Edition – Gloria Pickar, Thomas Asian Edition

4. Fundamentals of Nursing 5th Edition by Kozier, Erb Blais, Wilkinson

5. Fundamentals of Nursing, 4th Edition by: Kozier, Erb, and Olivier

6. Nursing Interventions and Clinical Skills by Elkin, Perry, Potter 3 rd Edition Mosby

7. Taylor's Clinical Nursing Skills – Pamela Evans-Smith, Lippincott Williams and Wilkins

8. The Lippincott Manual of Nursing Practice, 7 th Edition

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