1. Steam Inhalation
a. It is dependent nursing function.
b. Heat application requires physician’s order.
c. Place the spout 12-18 inches away from
... [Show More] the client’s nose or adjust the distance as necessary.
2. Suctioning
a. Assess the lungs before the procedure for baseline information.
b. Position: conscious – semi-Fowler’s
c. Unconscious – lateral position
d. Size of suction catheter- adult- fr 12-18
e. Hyper oxygenate before and after procedure
f. Observe sterile technique
g. Apply suction during withdrawal of the catheter
h. Maximum time per suctioning –15 sec
3. Nasogastric Feeding (gastric gavage)
Insertion:
a. Fowler’s position
b. Tip of the nose to tip of the earlobe to the xyphoid
Tube Feeding
a. Semi-Fowler’s position
b. Assess tube placement
c. Assess residual feeding
d. Height of feeding is 12 inches above the tube’s point of insertion
e. Ask client to remain upright position for at least 30 min.
f. Most common problem of tube feeding is Diarrhea due to lactose intolerance
4. Enema
a. Check MD’s order
b. Provide privacy
c. Position left lateral
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube
f. If abdominal cramps occur, temporarily stop the flow until cramps are gone.
g. Height of enema can – 18 inches
5. Urinary Catheterization
a. Verify MD’s order
b. Practice strict asepsis
c. Perineal care before the procedure
d. Catheter size: male-14-16 , female – 12 – 14
e. Length of catheter insertion
male – 6-9 inches ,female – 3-4 inches
For retention catheter:
Male –anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure
Female- inner aspect of the thigh
TYPES OF OSTOMIES
a. Ileostomy
➢ Liquid to semi-formed stool, dependent upon amount of bowel removed
➢ May skew fluid & electrolyte balance, especially potassium & sodium
➢ Digestive enzymes in stool irritate skinDo NOT give laxatives
➢ Ileostomy lavage may be done if needed to clear food blockage
➢ May not require appliance set; if continent ileal reservoir or Koch pouch
b. Colostomy
Ascending-must wear appliance--semi-liquid stool
Transverse-wear appliance--semi-formed stool
Loop stoma
✔ Proximal end-functioning stoma
✔ Distal end-drains mucous
✔ Plastic rod used to keep loop out
✔ Usually temporary
Double barrel
✔ Two stomas
✔ Similar to loop but bowel is surgically severed
______________________________________________________________
Sigmoid
✔ Formed stool
✔ Bowel can be regulated so appliance not needed
✔ May be irrigated
Stoma assessment
a. Color-should be same color as mucous membranes
(normal stoma color- Red not dusky or pale: sign of infection)
b. Edema-common after surgery. Bleeding-slight bleeding common after surgery
6. COLOSTOMY IRRIGATION
✔ Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are done to
promote evacuation of feces at a regular and convenient time
✔ Recommended with sigmoid colostomy
✔ Initiated 5 to 7 days postop
✔ Done in semi – Fowler’s position; then sitting on a toilet bowl once ambulatory.
✔ Use warm normal saline solution
✔ Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently
✔ Dilate stoma with lubricated gloved finger before insertion of catheter
✔ Lubricate catheter before insertion.
✔ Insert 3 to 4 inches of the catheter into the stoma
✔ Height of solution 12 inches above the stoma
✔ If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution
until peristalsis relaxes.
✔ Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then
remove catheter to drain for 15 to 20 minutes.
✔ Clean the stoma, apply new pouch
7 . Bed Bath
a. Provide privacy
b. Expose, wash and dry one body part a time
c. Use warm water (110-115 F)
d. Wash from cleanest to dirtiest
e. Wash, rinse, and dry the arms and leg using Long, firm strokes from distal to proximal area – to
increase venous return.
8. Foot Care
a. Soaking the feet of diabetic client is no longer recommended
b. Cut nail straight across
9. Mouth Care
a. Eat coarse, fibrous foods (cleansing foods) such as fresh fruits and raw vegetables
b. Dental check every 6 mounts
10. Oral care for unconscious client
a. Place in side lying position
b. Have the suction apparatus readily available
11. Hair Shampoo
c. Place client diagonally in bed
d. Cover the eyes with wash cloth
e. Plug the ears with cotton balls
f. Massage the scalp with the fatpads of the fingers to promote circulation in the scalp.
11. Restraints
✔ Secure MD’s order for each episode of restraints application.
✔ Check circulation every 15 min
✔ Remove restraints at least every 2 hours for 30 minutes
Types of Restraints
➢ Chemical – sedating antipsychotic drugs to manage or control behavior
➢ Physical – direct application of physical force to a client, with or without the client’s permission.
➢ Seclusion – involuntary confinement of a client in a locked room
Procedure:
✔ Ensure that face-to face assessment is completed on the client
✔ Ensure that the restraint orders are renewed every 24 hours or sooner according to hospital
policy.
✔ Tie the restraints using clove hitch
✔ Secure the tie in a non-movable part of the bed [Show Less]