RLE PROCEDURE:

INSERTION OF CATHETER

Why urinary catheters are used

A urinary catheter is usually used in people who have difficulty passing urine naturally. It can also be used to empty the
bladder before or after surgery and to help perform certain tests. Specific reasons include:

 to allow urine to drain if you have an obstruction in the tube that carries urine out of the bladder (urethra) – for
example, because of scarring or prostate enlargement
 to allow you to urinate if you have bladder weakness or nerve damage which affects your ability to pee
 to drain your bladder during childbirth, if you have an epidural anaesthetic
 to drain your bladder before, during and/or after some types of surgery, such as operations on the womb,
ovaries or bowels
 to deliver medication directly into the bladder, such as during chemotherapy for bladder cancer
 as a treatment for urinary incontinence when other types of treatment haven’t worked
MALE CATHETERIZATION INSERTION

1. Gather the Supplies

Indwelling Foley Catheter Tray with a 10 cc balloon (size 16fr is a common size used for adults.) The tray comes with
all the needed supplies

Syringe to deflate the balloon of the existing catheter (if there is one already in the bladder)

Soapy wash cloth and wet wash cloth

2. Wash hands with soap and water

3. Prepare all needed supplies

4. Lie flat on back with legs flat

5. If there is already a catheter in place, remove it by deflating the balloon.

Attach the syringe to the end of the "Y" pigtail (side port).

Withdraw the plunger of the syringe. This will deflate the balloon on the catheter inside the bladder.

You will know it is completely deflated when you are unable to pull anymore water into the syringe.

6. Gently pull the catheter out from the bladder.

Wash the penis with the soapy cloth and rinse with the wet cloth. Dry well.

7. Wash penis

Wash with the soapy cloth and rinse with the wet cloth. Dry well.

8. Wash hands again.

9. Open the Indwelling Catheter Tray carefully. Set up the supplies.

Place paper pad under hips.

Put on the gloves if this is not a self catheterization.

Pour the Betadine onto the cotton balls

Remove the plastic cover from the catheter (be careful not to touch the catheter tube) & squirt the lubricating jelly
onto the catheter.

Remove the rubber cap from the syringe with the water in it.

Connect the end of the catheter to the drainage bag

10. Choose your "clean" and "dirty" hand.

Whatever hand comes in contact with the body, the one that holds the penis, is dirty. The one that touches the
catheter supplies is clean. Never mix clean and dirty hands in regard to the catheter supplies. It is important that this
procedure stay "super clean" so as not to allow germs to enter the bladder.

11. Hold the penis.

Remember, the hand touching the body will now be the dirty hand.

12. Clean urinary opening on penis

Use clean hand to touch items in the kit

Clean penis with the cotton balls soaked in Betadine.

Use 1 cotton ball per wipe.

Always wipe from the tip of the penis toward the shaft of the penis.

Never re-use a cotton ball.

Insert the catheter slowly and gently into the urinary opening on the penis.13. Insert the catheter slowly and gently
into the urinary opening on the penis.
 14. See the urine flow into the catheter

Continue to insert the catheter until the "Y" pigtail section of the catheter becomes very close to the end of the
penis.

While holding the catheter in place, attach the pre-filled syringe in the kit to the Y pigtail port and insert all of the
water from the syringe.

15. Blow up the balloon

While holding the catheter in place, attach the pre-filled syringe in the kit to the "Y" pigtail port and insert all of the
water from the syringe.

If it is easier, you can attach the syringe before you insert the catheter so it is ready when you need it. Do not blow
up the balloon until the catheter is in and you see urine flowing.

Below is a picture of a catheter with an inflated balloon...this is what it would look like inside the bladder

16. Wash off the extra Betadine from the penis.Always hang/attach the drainage bag to chair/bed frame below the
level of the penis.

17. Always hang/attach the drainage bag to chair/bed frame below the level of the penis.

This will allow for the best drainage.

18. Consider wearing a leg strap.

The leg strap attaches the catheter to the inner thigh. It helps to keep the catheter secure.

19. If wearing a leg bag, always wear it below the knee.

Urinary Catheterization is the introduction of a catheter through the urethra into the bladder for the purpose of
withdrawing urine.

Purposes:

 To relieve urinary retention

 To obtain a sterile urine specimen from a woman

 To measure the amount of residual urine in the bladder

 To obtain a urine specimen when a specimen cannot secure satisfactory by other means

 To empty bladder before and during surgery and before certain diagnostic examinations

Necessary Equipment for Catheterization

 Catheters are graded on the French scale according to the size of the lumen.

 For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not
necessary and the size of the lumen is also so small that it increases the length of time necessary for emptying the
bladder.

 Larger catheter distends the urethra and tends to increase the discomfort of the procedure.

 For male adult, No.18 and No. 20 French catheters usually used, but if this appears to be too large, smaller catheter
should be used.

 No. 8 and No. 10 French catheters are commonly used for children.
 INDICATIONS FOR NGT FEEDING:

 To decompress the stomach and gastrointestinal (GI) tract (ie, to relieve distention due to obstruction, ileus,
or atony)
 To empty the stomach, for example, in patients who are intubated to prevent aspiration or in patients with
GI bleeding to remove blood and clots
 To obtain a sample of gastric contents to assess bleeding, volume, or acid content
 To remove ingested toxins (rare)
 To give antidotes such as activated charcoal
 To give oral radiopaque contrast agents
 To provide feeding of nutrients into stomach or feeding directly into small intestine with a long, thin, flexible
enteral feeding tube

EQUIPMENTS:

 Protective gown, gloves, and face shield

 Nasogastric tube for decompression such as a Levin tube (single lumen) or Salem sump tube (double
lumen such that second lumen vents to atmosphere)
 If small intestine feeding planned, a long, thin, intestinal feeding tube (nasoenteric tube) for long-term
enteral feeding (use with a stiffening wire or stylet)
 Topical anesthetic spray such as benzocaine or lidocaine
 Vasoconstrictor spray such as phenylephrine or oxymetazoline
 Cup of water and straw
 60-mL catheter-tipped syringe
 Lubricant
 Emesis basin
 Towel or blue pad
 Stethoscope
 Tape and benzoin
 Suction (wall or mobile device)

Steps in Inserting a Nasogastric Tube

Listed below are the step-by-step procedure in inserting a nasogastric tube.

1. Review the physician’s order and know the type, size, and purpose of the NG tube. It is widely acceptable to use a size
16 or 18 French for adults while sizes suitable for children vary from a very small size 5 French for children to size 12
French for older children.

2. Check the client’s identification band. Just like in administering medications, it is very important to be sure that the
procedure is being carried out on the right client.

3. Gather equipment, set up tube-feeding equipment or suction equipment mentioned above. This is to make sure that
the equipment is functioning properly before using it on the client.

4. Briefly explain the procedure to the client and assess his capability to participate. It is not advisable to explain the
procedure too far in advance because the client’s anxiety about the procedure may interfere with its success. It is
important that the client relax, swallow, and cooperate during the procedure.

5. Observe proper hand washing and don non-sterile gloves. Clean, not sterile, technique is necessary because the
gastrointestinal (GI) tract is not sterile.

6. Position client upright or in full Fowler’s position if possible. Place a clean towel over the client’s chest. Full Fowler’s
position assists the client to swallow, for optimal neck-stomach alignment and promotes peristalsis. A towel is used as a
covering to protect bed linens and the client’s gown.

7. Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the
navel. Mark this spot with a small piece of temporary tape or note the distance. Each client will have a slightly different
terminal insertion point. Measurements must be made for each individual’s anatomy.

8. Wipe the client’s face and nose with a wet towel. Wipe down the exterior of the nose with an alcohol swab. The NG
tube will stay more secure if taped on a clean, non oily nose. If the nose has been cleaned with an alcohol swab, the tape
will stay more secure and the tube will not move in the throat—causing gagging or discomfort later.
9. Cover the client’s eyes with a cloth. This protects the client’s eyes from any alcohol fumes from the alcohol swab.

10. Examine nostrils for deformity or obstruction by closing one nostril and then the other and asking the client to
breathe through the nose for each attempt. If the client has difficulty breathing out of one nostril, try to insert the NG
tube in that one. The client may breathe more comfortably if the “good” nostril remains patent.The blocked nasal
passage may not be totally occluded and thus you may still be able to pass an NG tube. It may be necessary to use the
more patent nostril for insertion.

11. Lubricate 4 to 8 inches of the tub with a water-soluble lubricant. The NG intubation is very uncomfortable for many
patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate
the discomfort.

12. Flex the client’s head forward, tilt the tip of the nose upward and pass the tube gently into the nose to as far as the
back of the throat. Guide the tube straight back. Flexing the head aids in the anatomic insertion of the tube.The tube is
less likely to pass into the trachea.

Nasogastric-Intubation

13. Once the tube reaches the nasopharynx, allow the client lower his head slightly. Ask the assistant to hold the glass of
water. Ready the emesis basin and tissues. The positioning helps the passage of the NG to follow anatomic landmarks.
Swallowing water, if allowed, helps the passage of the NG tube.

14. Instruct the client to swallow as the tube advances. Advance the tube until the correct marked position on the tube is
reached. Encourage the client to breathe through his mouth. Swallowing of small sips of water may enhance passage of
tube into the stomach rather than the trachea.

15. If changes occur in patient’s respiratory status, if tube coils in mouth, if the patient begins to cough or turns cyanotic,
withdraw the tube immediately. The tube may be in the trachea.

16. If obstruction is felt, pull out the tube and try the other nostril. The client’s nostril may deflect the NG into an
inappropriate position. Let the client rest a moment and retry on the other side.

17. Advance the tube as far as the marked insertion point. Place a temporary piece of tape across the nose and tube. In
this way, you can check for placement before securing the tube. The tube may move out of position if not secured before
checking for placement.

18. Check the back of the client’s throat to make sure that the tube is not curled in the back of the throat. On instance,
the NG will curl up in the back of the throat instead of passing down to the stomach. Visual inspection is needed in this
situation. Withdraw the entire tube and start again if such thing occurred.

19. Check tube placement with these methods. Check the tube for correct placement by at least two and preferably
three of the following methods:

 A. Aspirate stomach contents. Stomach aspirate will appear cloudy, green, tan, off-white, bloody, or brown. It is not
always visually possible to distinguish between stomach and respiratory aspirates. Special note: The small diameters
of some NG tubes make aspiration problematic. The tubes themselves collapse when suction is applied via the
syringe. Thus, contents cannot be aspirated.

 B. Check pH of aspirate. Measuring the pH of stomach aspirate is considered more accurate than visual inspection.
Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4. The aspirate of respiratory contents is
generally more alkaline, with a pH of 7 or more.

 C. Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh” of air into the stomach. The
small diameter of some NG tubes may make it difficult to hear air entering the stomach.

 D. Confirm by x-ray placement. X-ray visualization is the only method that is considered positive.

20. Secure the tube with tape or commercially prepared tube holder once stomach placement has been confirmed. It
is very important to ensure that the NG tube is in its correct place within the stomach because, if by accident the NG
is within the trachea, serious complications in relation to the lungs would appear. Securing the tube in place will
prevent peristaltic movement from advancing the tube or from the tube unintentionally being pulled out.
Definition

Nebulization is the process of medication administration via inhalation. It utilizes a nebulizer which transports
medications to the lungs by means of mist inhalation.

Indication

Nebulization therapy is used to deliver medications along the respiratory tract and is indicated to various respiratory
problems and diseases such as:

 Bronchospasms

 Chest tightness

 Excessive and thick mucus secretions

 Respiratory congestions

 Pneumonia

 Atelectasis

 Asthma

Contraindications

In some cases, nebulization is restricted or avoided due to possible untoward results or rather decreased effectiveness
such as:

 Patients with unstable and increased blood pressure

 Individuals with cardiac irritability (may result to dysrhythmias)

 Persons with increased pulses

 Unconscious patients (inhalation may be done via mask but the therapeutic effect may be significantly low)

Equipments

 Nebulizer and nebulizer connecting tubes

 Compressor oxygen tank

 Mouthpiece/mask

 Respiratory medication to be administered

 Normal saline solution

Procedure

 Position the patient appropriately, allowing optimal ventilation.

 Assess and record breath sounds, respiratory status, pulse rate and other significant respiratory functions.

 Teach patient the proper way of inhalation:

 Slow inhalation through the mouth via the mouthpiece

 Short pause after the inspiration

 Slow and complete exhalation

 Some resting breaths before another deep inhalation

 Prepare equipments at hand

 Check doctor’s orders for the medication, prepare thereafter

 Place the medication in the nebulizer while adding the amount of saline solution ordered.

 Attach the nebulizer to the compressed gas source

 Attach the connecting tubes and mouthpiece to the nebulizer

 Turn the machine on (notice the mist produced by the nebulizer)

 Offer the nebulizer to the patient, offer assistance until he is able to perform proper inhalation (if unable to hold the
nebulizer [pediatric/geriatric/special cases], replace the mouthpiece with mask

 Continue until medication is consumed

 Reassess patient status from breath sounds, respiratory status, pulse rate and other significant respiratory functions
needed. Compare and record significant changes and improvement. Refer if necessary

 Attend to possible side effects and inhalation reactions

What is the Purpose of a Tracheostomy?

A tracheostomy may be performed when an airway is restricted. This can be done
during an emergency when your airway is blocked, or if a disease makes normal
breathing impossible.

Common reasons for a tracheostomy:

 Anaphylaxis
 Birth defects of the airway
 Burns in the airway from inhalation of corrosive material
 Cancer in the neck
 Chronic lung disease
 Coma
 Diaphragm dysfunction
 Facial burns or surgery
 Infection
 Injury to the larynx or laryngectomy
 Injury to the chest wall
 Need for prolonged respiratory or ventilator support
 Obstruction of the airway by a foreign body
 Obstructive sleep apnea
 Paralysis of the muscles used in swallowing
 Severe neck or mouth injuries
 Tumors
 Vocal cord paralysis

Tracheostomy Prep
Before you do anything, assess the following for your patient:

 Respiratory status (ease of breathing, rate, rhythm, depth, lung

sounds, and oxygen saturation level)
 Pulse rate
 Secretions from the tracheostomy site (i.e. character and amount)
 Presence of drainage on tracheostomy dressing or ties
 Appearance of incision (i.e. redness, swelling, weeping discharge,
or odor)
Necessary Equipment for Tracheostomy
Care

The suggested supplies for tracheostomy care may include the following:

 Sterile/disposable tracheostomy cleaning kit or supplies (i.e. sterile

containers, sterile nylon brush or pipe cleaners, sterile applicators,
gauze squares, etc.)
 Suction catheter kit
 Saline
 Medical gloves
 Towels
 Moisture-proof bag
 Tracheostomy dressing or sterile gauze dressing
 Cotton twill ties
 Sterilized scissors
Tracheostomy Steps
Here are some of the general guidelines from Kozier & Erb’s Fundamentals of
Nursing that you should follow when administering trach care in a controlled
setting.

1. Introduce yourself and verify the patient’s identity. Explain

everything that you need to do, why it is necessary, and how they can
cooperate. For instance, they could blink their eyes or raise a finger
to indicate pain or distress.
2. Ensure that infection-control procedures are in place (i.e. hand
hygiene).
3. Ensure the patient’s privacy.
4. Prepare the patient and your equipment.
 Help the patient to a Semi-Fowler’s or Fowler’s position.
 Open the tracheostomy kit or sterile basins.
 Pour the soaking solution and sterile normal saline into
separate containers.
 Establish the sterile field.
 Open other sterile supplies as needed, such as sterile
applicators, suction kit, and tracheostomy dressing.
5. If needed, suction the tracheostomy tube.
 Put on a pair of sterile gloves.
 Suction the full length of the tracheostomy tube to remove
secretions and reinforce the airway.
 Rinse the suction catheter, wrap the catheter around your
hand, and peel the glove off so that it turns inside out over the
catheter.
 Unlock the inner cannula with the gloved hand.
 Remove it by gently pulling toward you in line with its
curvature.
 Place it in the soaking solution.
 Remove the soiled tracheostomy dressing.
 Place the dressing in your gloved hand and peel the glove
off so that it turns inside out over the dressing.
 Discard the glove and the dressing.
 Put on sterile gloves. Make sure your dominant hand is sterile
during the procedure.
6. Clean the inner cannula.
 Remove the inner cannula from the soaking solution.
 Clean the lumen and entire inner cannula thoroughly using the
brush or pipe cleaners moistened with sterile normal saline.
 Inspect the cannula for cleanliness by holding it at eye
level and looking through it into the light.
 Rinse the inner cannula thoroughly in the sterile normal saline.
 Tap the cannula against the inside edge of the sterile saline
container.
  Use a pipe cleaner folded in half to dry only the inside of the
cannula; do not dry the outside.
7. Replace the inner cannula and secure it.
 Insert the inner cannula by grasping the outer flange and
inserting the cannula in the direction of its curvature.
 Lock the cannula in place by turning the lock (if applicable)
into position. This will secure the flange of the inner cannula to
the outer cannula.
8. Clean the incision site as well as the tube flange.
 Clean the incision site using sterile applicators or gauze
dressings that have been moistened with normal saline.
 Remember to handle the sterile supplies with your
dominant hand.
 Use each applicator or gauze dressing only once and then
discard.
 Hydrogen peroxide can typically be used in a half-strength
solution—mix it with sterile normal saline—in order to remove
crusty secretions (check hospital policy).
 Thoroughly rinse the cleaned area using gauze squares
moistened with sterile normal saline.
 Clean the flange of the tube in the same manner.
 Thoroughly dry the patient’s skin and tube flanges with dry
gauze squares.
9. Apply a sterile dressing.
 Use a commercially prepared tracheostomy dressing of non-
raveling material. Alternatively, you can open and refold a 4-in. x 4-
in. gauze dressing into a V shape.
 Tip: Avoid using cotton-filled gauze squares or cutting the
4-in. x 4-in. gauze.
 Place the dressing under the flange of the tracheostomy tube.
 While applying the dressing, make sure that the tracheostomy
tube is firmly supported.
10. Change the tracheostomy ties.
 Change as needed to keep the skin dry and clean.
 Twill tape and specially manufactured Velcro ties are available.
 Twill tape is inexpensive and available; however, it’s easily
soiled and can trap moisture that often leads to skin irritation.
 Velcro ties are wider, more comfortable, and cause fewer
abrasions.
11. Tape and pad the tie knot. Place a folded 4-in. x. 4-in. gauze
square under the tie knot and apply tape over the knot.
12. Check the tightness of the ties. Regularly check the tightness
of the tracheostomy ties as well as the position of the tube.
 13. Document relevant information. Record suctioning,
tracheostomy care, and the dressing change.

Stages of Bed Sores:

Pressure sores develop in four stages:

1. The skin feels warm to the touch. There may be a color change, such as redness, and the area may be itchy.

2. A painful open sore or blister develops, with discolored skin around it.

3. The lesion develops a crater-like appearance, due to tissue damage below the skin’s surface.

4. There is severe damage to the skin and tissue, possibly with an infection. The muscles, bones, and tendons may be visible.

Note: An infected sore takes longer to heal. The infection can spread elsewhere in the body and cause significant harm.

Prevention

Tips for reducing the risk of pressure sores include:

 changing positions frequently, between every 15 minutes to every 2 hours, depending on a person’s needs

 inspecting the skin every day

 keeping the skin clean and dry

 maintaining good nutrition

 quitting smoking and avoiding secondhand smoke

 doing exercises, even while in bed, to encourage circulation

Risk factors

The following can increase the chances that sores develop:

 being unable to move unaided

 older age, as the skin becomes thinner and more fragile

 incontinence, which increases the risk of skin damage and infection

 a low or high body mass index, or BMI, either of which can increase pressure

 a low body weight, which leads to less padding around the bones

 a condition, such as diabetes, that reduces feelings of pain

 prolongedTrusted Source wound healing, as can also happen with diabetes

 poor blood circulation

 reduced mental awareness