Nursing Procedures

Nursing: Application of Restraint

2009-06-09T13:31:00.000-07:00

Nursing: Application of Restraint

Equipments:
Restraint

Nursing Actions:

Explain the rationale of the restraint application
Select the proper type of restraint
Assess skin for any irritation
Apply restraint to the patient assuring some movement of body part. One to two fingers should slide between restraints and patient’s skin.

Tie straps with clove hitch knot securely

To make a clove hitch, make a figure-eight

Pick up the loops and put the limb through the loops and secure

Pad bony prominences

Secure restraints to the bed frame and do not tie the straps to the side rail

Assess skin integrity and restraints q 30 minutes and release it at least every 2 hours

The restraints should be assessed continually at least every 8 hours

Postoperative Exercise

2009-06-05T03:16:00.000-07:00

Postoperative Exercise

Med Equipments:

Educational materials
Tissue
Disposal volume oriented incentive spirometer
Pillow
Non-sterile gloves

Nursing Interventions:

Wash hand and obtain equipments
Check the patient’s identification
Place patient in a sitting position
Then follow these procedures:

Deep Breathing

Demonstrate deep breathing exercise
Ask the patient to return demonstrate deep breathing
Place on hand on abdomen (umbilical area) during inhalation
Expand the abdomen and rib cage on inspiration
Slowly inhale through your nose until you achieve maximum chest expansion
Hold breath for 2-3 seconds
Exhale slowly through your mouth until maximum chest contraction has been achieved
Repeat the exercise three or four times and allow the patient to rest

Splinting and Coughing

Demonstrate splinting and coughing
Don gloves
Place the patient in a sitting position with the head is slightly flexed, shoulders relaxed and slightly forward, and feed supported on the floor
Instruct the patient to re-demonstrate splinting and coughing:
Slowly raise head and sniff the air

Slowly bend forward and exhale slowly through pursed lips

Repeat breathing two or three times

When ready to cough, ask the patient to place a folded pillow against the abdomen and grasp the pillow against the abdomen with clasped hands

Instruct patient to take a deep breath and begin coughing immediately after inspiration is completed by bending forward slightly and producing a series of soft and staccato coughs.

Have a tissue ready

Using an Incentive Spirometer

Instruct the patient on the use of an incentive spirometer:
Have a volume-oriented incentive spirometer upright
Take a normal breath and exhale then seal lips tightly around the mouthpiece, take slow, deep breath to elevate the balls in the plastic tube and hold the inspiration for at least 3 seconds
The patient simultaneously measures the amount of inspired air volume on the calibrated plastic tube
Remove the mouthpiece, and exhale normally
Take several normal breaths
Repeat the procedure 4-5 times
Ask the patient to cough after the incentive effort
Ask the patient to clean mouthpiece under running water

Leg and Foot Exercises

Explains the leg and foot exercises
Ask the patient to demonstrate in bed:
With heels on bed, push the toes of both feet toward the foot of the bed until the calf muscles tighten then relax feet. Pull the toes toward the chin until calf muscles tighten then relax feet
With heels on the bed, lift and circle both ankles: first to the right and then to the left, repeat three times then relax
Flex and extend each knee alternately, sliding foot up along the bed then relax

Turn in Bed and Get Out of Bed

Instruct the patient who will have a left-sided abdominal or ches incision to turn to the right side of bed and sit up as follows:
Flex the knees
With the right hand splint the incision with hand or small pillow
Turn toward right side by pushing with the left foot and grasping the shoulder of the nurseor partial foot rail of the bed with the left hand
Raise up to a sitting position on the side of the bed by using the left arm and hand to push down against the mattrees
Reverse procedure as using left side instead of right for the patient with a right-sided incision
Instruct patient with orthopedic surgery ho to use a trapeze bar

Administering a Vaginal Suppository

2009-06-04T21:04:00.001-07:00

Administering a Vaginal Suppository

Equipments:

Medication Administration Record (MAR)
Prescribed vaginal suppository
Disposable applicator
Non-sterile gloves
Water soluble lubricant
Tissue

Nursing Actions:

Identify any allergies or medical condition that contraindicate the use of drug
Obtain necessary equipment
Check the written order on MAR
Wash hands
Follow the five rights of medication administration
Instruct patient to void
Place patient in a dorsal recumbent position with knees flexed and hips rotated laterally on in a Sims’ position if the patient cannot maintain the dorsal recumbent position

Don non-sterile gloves

Explain briefly the procedure to the patient and provide privacy

Assess perineal area and inspect vaginal orifice. Note if there is any odor, discharge from vagina or any problems such as itching or discomfort

Cleanse the perineal area with soap and water if there is any secretion or discharge

Remove suppository from the foil wrapper and insert into applicator tip if any. Put a small amount of lubricant to rounded tip of the suppository.

With non-dominant hand, spread labial folds and insert the suppository into the vaginal canal at least 2 inches along the posterior wall of the vagina or as far as it will go. If you use an applicator, insert it as described above and depress plunger to release suppository

Wipe the perineum area with a clean dry tissue

Ask the patient to remain in bed for 15 minutes

Wash applicator under cool running water

Remove glove and wash hand

Record the drug’s name, dosage, rout, date and time of administration on MAR

Observe the patient in 15 minutes to ensure that the suppository did not slip out

Identify the effectiveness of the medication

Rectal Suppository Administration

2009-06-03T11:58:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Prescribed Rectal suppository
Water Soluble Lubricant (K-Y Jelly)
Non-sterile Gloves
Tissue
Bedpan (as optional)

Nursing Procedures:

Identify any allergies that patient has
Gather necessary equipments
Determine the written order on MAR
Wash your hands
Check the patient’s identification
As patient if she or he wants to void
Explain the procedure to the patient briefly
Don non sterile gloves
Place patient in the Sim’s left lateral position with the upper leg flexed
Open the package of lubricant and remove the foil wrapper from the suppository
Apply a small amount of lubricant to the smooth rounded end of the suppository
Lubricate the gloved index finger
Ask the patient to breathe through the mouth
Insert the suppository into the rectal canal beyond the internal sphincter about 4 inches for an adult and 2 inches for a child
Avoid inserting the suppository into feces
Withdraw the finger and wipe the anal area with tissue
Ask patient to remain in bed for 15 minutes and to resist urge to defecate
Remove glove and wash hand
Record the name of the drug, dosage, route, and time of administration on MAR
Observe the effectiveness of medication

Administering a Metered Dose Inhaler (self administration)

2009-06-03T11:39:00.000-07:00

Equipments:

Medication Administration Record (MAR)
Inhaler
Non-sterile Gloves
Wash basin or sink to rinse mouth
Tissue (optional)

Nursing Actions:

Check any allergies that patient has or any medical condition that is contraindicated with the use of thd drug
Obtain all equipments
Check the written order on MAR
Wash hands
Follow the five right of medication administration
Check the patient identification
Allow the patient o hold and manipulate the canister and explain how the canister fits into the inhaler.
Have the patient demonstrate the insertion of the canister
Discuss the metered-dose concept and frequency of dose to the patient
Explain that the inhaler should be shaken before each use
Remove the mouthpiece and cap from the bottle and insert the stem into the small hole on the flattened portion of the mouthpiece. The patient should grasp the inhaler with thumb and first two fingers
Instruct the patient to exhale, place the mouthpiece into the mouth and tighten the lips (seal) around the mouthpieces
Ask the patient to firmly push the cylinder down against the mouthpiece only once, while slowly inhaling until the lungs feel full
Instruct the patient to remove the mouthpiece while holding the breath for about 10 seconds then exhale slowly through pursed lips
Repeat the doses as prescribed and waiting 1 minute between puffs
A mouthwash can be use by the patient to remove the taste of the medication
Demonstrate to the patient how to wash the mouthpiece under tepid running water to remove secretions
If two or more inhaler medication are prescribed, wait 5-10 minutes between inhalations or as specifically ordered by physician
Record all the drug’s name, dose, date, and time for medication on MAR
Observe for effectiveness of medication and relief of the patient’s symptoms

Administering Nose Drops

2009-06-02T10:47:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Medication with Dropper
Emesis Basin (optional)
Non-sterile Gloves
Tissue

Nursing Actions:

Check the allergies that patient may have
Determine the written order on MAR
Wash hands
Check patient’s identification armband
Explain the procedures to the patient and provide privacy
Ask patient to blow nose unless contraindicated
Inform the patient that he/she may feel a burning sensation to the mucosa or a choking sensation, or both, as the drop trickles back into the throat
Place patient in a supine position and hyperextend the neck and position the head to the site that facilitates the drop reaching the expected site
Instruct the patient to breathe through mouth
Squeeze medications into the dropper
Insert the nasal drops about 3/8 inch into nostril and keep the tip of the dropper away from the sides of the nares.
Instill the medication as prescribed and observe for signs and discomforts
Ask the patient to maintain supine position for 5 minutes
Discard any unused medication remaining in the bottle
Position the patient to a comfortable position and proved the patient with the emesis basin and tissue to expectorate any medication and flows in to the oropharynx and mouth
Remove gloves and wash hands
Record the medication given, doses, and time on MAR
Observe the patient for side effects for 30 minutes after administration

Administering Ear Medication

2009-06-02T10:35:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Cotton-tipped Applicator
Cotton Balls
Medications
Non-sterile gloves
Tissue

Nursing Procedures:

Determine the allergies for any medication
Check the written order on MAR
Wash hand
Calculate the dose
Identify patient’s armband
Explain the procedure to the patient
Place patient in a side lying position with the affected ear facing up
Don non-sterile gloves
Straighten the ear canal by pulling the pinna down and back for children or upward and outward for adults
The drops are instilled into the ear canal by holding the dropper at least ½ inch above the ear canal
Instruct patient to maintain the position for 2-3 minutes
Place a cotton ball n the outermost part of the canal
Wash hand
Record the drug, number of drops, time administered, and medication on MAR

Administering Eye Medication Disk

2009-06-02T09:35:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Tissue or cotton ball
Eye Medication (medication disk)
Nonsterile gloves

Nursing Procedures:

Assess the patient and the cart for any allergies
Check the written orders on MAR
Obtains the necessary equipments
Follow the five rights of drug administration
Determine the identification armband
Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops
Wash hand and don non-sterile gloves
Gently wash the eye if there is crust or drainage along the margins of inner canthus. (always wipe from the innter canthus to the outer and use warm soaks to soften material if necessary)
Position patient in a supine position with the head slightly hyperextented

To Insert Medication Disk:

Open sterile package and pres dominant, gloved finger against the oval disk so it lies lengthwise across fingertip
Instruct patient to look up
With non-dominant hand, gently pull the lower eyelid down and place the disk horizontally in the conjunctival sac. The disk should float on the sclera between the iris and the lower eyelid
Pull the lower eyelid out, up and over the disk
Instruct patient to blink several times
If disk is still visible, repeat the steps
When the disk is in place, instruct patient to press his fingers against his closed lid but do not rub eyes or move the disk across the cornea
If the disk falls out, rinse it under cool water and reinsert it

To Remove Medication Disk:

With non-dominant hand, invert the lower eyelid and identify the disk
If the disk is located in the upper eye, instruct patient to close the eye and place your finger on closed eyelid. Apply gentle, long, circular strokes and instruct patient to open the eye. Disk then should be located in the corner of eye. With your fingertip, slide the disk to the lower lid, then proceed
With dominant hand, use the forefinger to slide the disk onto the lid and out the patient’s eye
Remove gloves and wash hands
Record it on the MAR

Administering Eye Ointment

2009-06-02T08:47:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Tissue or cotton ball
Eye Medication (ointment)
Nonsterile gloves

Nursing Procedures:

Assess the patient and the cart for any allergies

Check the written orders on MAR

Obtains the necessary equipments

Follow the five rights of drug administration

Determine the identification armband

Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops

Wash hand and don non-sterile gloves

Gently wash the eye if there is crust or drainage along the margins of inner canthus. (always wipe from the innter canthus to the outer and use warm soaks to soften material if necessary)

Position patient in a supine position with the head slightly hyperextented
For Lower Lid:

With non-dominant hand, separate eyelids with thumb and finger, and grasp lower lid near margin immediately below the lashes, exert pressure downward over the bony prominence of the cheek
Instruct the patient to look up
Apply eye ointment along inside edge of the entire lower eyelid, from inner to outer canthus

For Upper Lid:

Instruct patient to look down
With non-dominant hand, gently grasp patient’s lashes near center of upper lid with thum and index finger, and draw lid up and away from eyeball
Apply ointment along upper lid starting at inner chantus

Administering Eye Drops

2009-06-02T08:35:00.000-07:00

Medical Equipments:

Medication Administration Record (MAR)
Tissue or cotton ball
Eye Medication (drops)
Nonsterile gloves

Nursing Procedures:

Assess the patient and the cart for any allergies
Check the written orders on MAR
Obtains the necessary equipments
Follow the five rights of drug administration
Determine the identification armband
Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops
Wash hand and don non-sterile gloves
Gently wash the eye if there is crust or drainage along the margins of inner canthus. (always wipe from the innter canthus to the outer and use warm soaks to soften material if necessary)
Position patient in a supine position with the head slightly hyperextented
Remove cap from eye bottle and place cap on its side
Squeeze the amount of medication as prescribed into the eyedropper
Put a tissue below the lower lid
With dominant hand, hold eyedropper ½ to ¾ inch above the eyeball, the rest hand is on patient forehead to stabilize
Place nondominant hand on cheekbone and expose lower conjunctival sac by pulling on cheek while applying slight pressure to the inner chantus
Instruct the patient to look up and drop the drops into center of conjunctival sac
Do not instill medication drops directly into the cornea
If the patient blinks and the drops land on the outer lid or eyelash, repeat the procedure
Instruct patient to close and move eyes gently
Remove gloves and wash hands
Record the route, site, and time administered on the MAR

Administering Medications by IV Piggyback to an Existing IV

2009-03-29T23:29:00.000-07:00

Medical Equipments:

Medication administration record (MAR)
Prepared and labeled medication 50 ml solution bag from pharmacy
Alcohol swab
Secondary administration set
Needle-less locking cannula

Nursing Procedures:

Gather all of prepared equipments
Wash your hand
Check patient identification or arm-band
Explain the procedures to the patient
Observe the puncture site for redness and puffiness then palpate for tenderness
Observe fluid infusing and check the patency of infusion site
Remove IV container from the pole and lower the container below the level of infusion site
Observe for backflow of blood into the hub of the venous access device and replace container on IV hole
Secure the medication bag and check the prescription and the MAR
Check patient's chart for allergies and drug compability
Hang the secondary bag on IV hole

Add the administration set to the secondary bag and prime the tubing

Affix a needle-less locking cannula to the end of tubing

Cleanse needle-less Y-site injection port of primary IV tubing closest to infusion site with an alcohol swab and allow to dry

Insert needle-less locking cannula of secondary bag set into Y-site injection port of primary set ans secure in place with tape

Affix the extension hook to the primary bag on the IV pole so that the primary bag hangs below the level of the secondary bag

Open clamp of secondary tubing and adjust drip rate to desired infusion rate

Observe patient for any signs or adverse reaction to the medication

When secondary bag and drip chamber are empty, close the clamp on secondary system, readjust drip of primary solution as indicated and remove the secondary system

Record medication infusion on the MAR and note any patient's responses

Administering an Intramuscular Injection

2009-03-29T23:23:00.000-07:00

Medical Equipments:

Medication administration report (MAR)
Sterile 3-ml syringe and long bevel 33 to 22 gauge
Medication as prescribed
Alcohol swab
Non-sterile gloves
Sterile 2 x 2 gauze pad

Nursing Procedures:

Identify the patient's allergies to any known medication
Wash your hands
Follow the rule of five rights
Obtain the medication from an ampule or vial
Check the patient identification or arm band
Position patient in an appropriate position to expose the site of injection
For deltoid area: sitting position
For ventrogluteal area: side-lying, flex the knee, pivot the leg forward the hip about 20 degrees so it can rest on the bed; supine position, flex the knee on injection site; or prone position, point toes inward toward each other to internally rotate the femur
Don non-sterile gloves
Assess the skin for redness, scarring, breaks and palpate for lumps or nodules
Select using the anatomic landmarks
The area for injection is cleansed by an alcohol swab from inside outward using friction and wait 30 seconds to allow to dry
Remove the needle cap by pulling it straight off and expel any air bubbles from the syringe

Pull the skin down or to one side (Z-track technique) with non-dominant hand

Administer in deltoid: quickly insert the needle with a cart-like motion at 90 degrees angle

Administer in ventrogluteal: quickly insert the needle using a dart-like motion and steady pressure at 90 degrees angle to the iliac crest in the middle of the V

Aspirate it by pulling back the plunger and observe for blood

If blood is appeared, remove the needle and discard

If blood is not appeared, inject the medication slowly about 10 sec per ml

Wait 10 seconds after the medication has been injected, then smoothly withdraw the needle at the same angle of insertion

Gently pressure is applied at the site with a dry sterile 2 x 2 gauze and do not massage the injection site. Swab using gentle pressure

Discard the syringe and needle in sharps box container and never recap the needle

Place the patient in comfort position and encourage him/her to perform leg exercises (flexion and extension) after receiving ventrogluteal injection

Remove gloves and wash your hands

Record on the medication administration report the dosage, route, site and time or injection

Observe the injection site within 2-4 hours and evaluate the patient's responses

Administering an Subcutaneous Injection

2009-03-24T02:17:00.000-07:00

Medical Equipments:

Medication administration record (MAR)
Sterile syringe and 5/8 inch needle
Disposable gloves
Two alcohol swabs
Medication as prescribed

Nursing Procedures:

Identify patient's allergies to any known medication
Wash your hands
Follow the five rights of drug administrations
Prepare medication from an ampule or vial and place them on a clean surface in the patient's room
Check the patient's identification card or armband
Inform patient about the procedure
Place patient in a comfortable position and provide for privacy
Don non-sterile gloves
Assess and observe the skins for bruises, redness, hard tissue, or broken skin
Cleanse the site for injection with an alcohol swab from inside to outside
Prepare the injection by removing the needle guard and expressing any air bubbles from the syringes, and check the dosage in the syringes
With dominant hand, hold the syringe between thumb and forefinger
With non-dominant hand, pinch the subcutaneous tissue between the thumb and forefinger, or spread the tissue taut if the patient has substantial subcutaneous tissue
Insert the needle quickly at 45 or 90 degrees angle

Release the subcutaneous tissue and grasp the barrel of the syringe with non-dominant hand

With dominant dominant hand, aspirate by pulling back on the plunger gently, except when administering an anticoagulant injection

If blood appears, remove needle and discard in a sharps box container

Inject medication slowly if there is no blood present

Remove the needle quickly and lightly massage area with alcohol swab, do not massage the injection site after an anticoagulant injection

Do not recap needle, discard the needle in a sharps box container

Place patient in comfort position

Remove glove and wash hands

Record the route, site, and time of injection on the medication administration record

Observe any side or adverse effects and assess the effectiveness of the medication at the appropriate time

Administer Intradermal Injection

2009-03-24T02:12:00.000-07:00

Medical Equipments:

Medication administration record (MAR)
Sterile tuberculin syringes and short bevel, 25-27 gauge, 3/8-1/2 inch needle
Drug / medication
Alcohol swab and sterile 2 x 2 gauze pad
Disposable glove

Nursing Procedures:

Check the patient's allergies to any known medication
Wash your hands
Follow the five rights drug administrations
Prepare the medication from an ampule or vial and take the medication to the client's room and put on a clean surface
Check the patient's identification card or arm band
Inform the patient about the procedure
Position the patient as comfortable as possible and provide for privacy
Wash hands and don non sterile gloves
Assess the skin for bruises, redness, or broken tissue
Select an appropriate site using appropriate anatomic landmarks
Cleanse the site with an alcohol swab in a firm circular motion, cleanse from inside to outside, and allow alcohol to dry
Obtain the syringe for injection
Remove the needle guard
Remove any air bubbles from the syringe
Check the amount of solution in the syringe
Hold the syringe in dominant hand
With non dominant hand grasp the patient's dorsal forearm and gently pull the skin SEE PICTURE
Place the needle close to the skin with bevel side up. Insert the needle at a 10-15 degrees angle until resistance is felt, and advance the needle approximately 3 mm below the skin surface. The needle's tip should be visible under the skin
Push the medication slowly and observe the development of a bleb (large flaccid vesicle). If it does not appear, withdraw the needle slightly
Withdraw the needle
Gently part area with a dray 2x2 sterile gauze pad
Avoid massage the area after removing the needle
The needle and syringes are discharged in a sharps box container
Remove glove and wash hand
Observe for signs of allergic reaction
Draw a circle around the perimeter of the bleb with a pen
Record the procedure and site of injection on medication administration record

Mixing Insulin in One Syringe

2009-03-24T02:08:00.000-07:00

Medical Equipments:

Medication administration record
Insulin vials
Alcohol swab
Insulin syringe

Nursing Procedures:

Assess patient's allergies or medical condition that would contraindicate in administrating the drug
Gather necessary equipment
Check the medication administration record against medication order
Wash your hands
Follow the five rights of medication administration and check the patient's identification band
Remove insulin vial cap
Rotate each bottle of insulin slowly but never shake them. Make sure suspensions are thoroughly mixed
Clean the rubber stopper of the vial with an alcohol swab
Remove cap from the needle. Draw air into the syringes equal to the doses of insulin to be given. Insert needle into vial of the suspension, not to touch the needle to the medication in the vial. Inject the air into the vial and remove the needle. Do not withdrawal any insulin yet
Fill syringes with air equal to dose of regular insulin. Insert needle into bottle and inject air into vial. Invert bottle and pull plunger down to withdraw the appropriate dose of insuline
With needle in the bottle, hold it up to the light and look for air bubbles. Remove air bubble if any by taping or flicking the syringe with your finger to cause air to rise and then push plunger to push air and some insulin back into the vial. Pull back to get the appropriate dose of insulin free of air.
Remove the needle
Again insert needle into the vial of longer-acting insulin and make sure that the tip of the needle is below the surface of the fluid level. Invert the bottle and slowly draw back to dose of insulin prescribed.
Remove the needle
Have another nurse check the prescribed dose
Store insulin vials according to your agency policy
Wash your hand

Withdrawing Medication from a Vial

2009-03-24T02:05:00.000-07:00

Medical Equipments:

Medication administration record (MAR)
Sterile syringes and needle
Alcohol swab
Medication vial
Sterile needle

Nursing Procedures:

Wash your hands
Prepare the vial
Open the alcohol swab
For new vial: remove metal cap from vial and cleanse the rubber top of vial
For used vial: cleanse the rubber top of the vial
Choose a syringe of appropriate size
Grasp needle and turn barrel of syringe to the right
Remove the needle cap and pull back on plunger to fill syringes with an amount of air as much as the amount of solution to be withdrawn from the vial
Insert the needle into the center of the upright vial and inject air into the vial
Invert the vial and keep it at the eye level and the needle's bevel below the fluid level, and remove the exact amount of medication while touching only the syringe barrel and plunger tip SEE PICTURE
Remove air from the syringe while needle remains within the inverted vial by tapping the syringe side by your finger
Check the amount of medication in the syringe
Turn vial upright and remove the needle
Replace the needle cap and replace with new needle. Remove used needle and dispose it in the sharps container
Attaché the new needle to the syringe by turning the barrel to the right
Compare the medication in the syringes with the prescribed dosage

Withdrawing Medication from an Ampule

2009-03-24T01:58:00.000-07:00

Medical Equipments:

Medical administration record (MAR)
Sterile syringe and needle
Extra needle of proper gauge and length according to the site of injection
Ampule of prescribed medication
Sterile gauze or alcohol swab
Filter needle

Nursing Procedures:

Wash your hands
Hold the ampule and tap the top chamber quickly and lightly until all fluid flows into the bottom chamber
Place a sterile gauze or alcohol swab around the neck of the ampule
Firmly grasp the neck of the ampule and quickly snap the top off away from your body, and put the ampule on a flat surface
Withdraw the medication from the ampule while maintaining the sterile technique
Check the connection of needle to syringe turning barrel to right while the needle guard is held
Use a filter needle if recommended
Remove needle guard and hold syringes in domain hand
With non dominant hand, grasp ampule and turn upside down, or stabilize ampoule on a flat surface
Insert the needle into the center of the ampule and do not allow the needle tip or shaft to touch the rim of the ampule SEE PICTURE
Keep needle tip below level of meniscus
Aspirate the medication by pulling on the plunger
If air bubbles are aspirated, remove the needle from the ampule, hold syringes with needle pointing up and tap sides of the syringes. Draw back slightly on plunger, and gently push the plunger upward to eject air. Reinsert the needle in the middle of the ampule and continue withdraw the medication
Remove excess air from the syringe and check the dosage of medication in the syringes. Recap
Discard any unused portion of the medication, and dispose of the ampule top in a suitable container after comparing with medical administration record
Change needle discard used needle properly. Secure needle to syringes by turning the barrel to right while holding the needle guard
Wash hands

Administering Oral Medication

2009-03-24T01:51:00.000-07:00

Medical Equipments:

Medication administration record (MAR)
Medication cart or tray
Glass of water of juice
Medication cup
Medication properly labeled
Straw

Nursing Procedures:

Identify the patient's potential problem such ach absence of a gag reflex
Check the MAR against the written orders
Identify for drug allergies
Wash your hand
Prepare the medication for one patient at a time
Select the correct medication and double-check against MAR
Calculate the medication doses if necessary and double-check for accuracy
Do not touch the drug while pouring in cup or leave the drug in the wrapper if unit-dose is available until at the bedside
For liquid medication: place the label side of the medicine bottle against your palm and pour the liquid at eye level

Recheck the medication with MAR
Check again MAR and make sure that all medications to be administered have been prepared
Place on the tray or medication cart
Check patient's armband before giving medication
Do any assessment required before the drug administration such ach apical pulse rate before digoxin administration
Place patient on sitting position
Provide liquids before and during ingestion and encourage patient to drink 5-6 oz of water
If the patient is unable to hold the medication cup, assist him/her by using medication cup to introduce the pills to the person's mouth one at time
If a drug / medication falls on the floor, discard it and start over
Remain with the patient until all medications have been swallowed
Wash your hand
Record the administered drug on the Medical Administration Record
Observe the side effects or adverse reaction that might be happened to the patient

Urine Collection: Clean Catch, Female

2009-03-11T01:43:00.000-07:00

Equipments:

Examinations glove
Sterile collection container, lid, and label
Sterile midstream kit
Three antiseptic towelettes or 3 cotton balls saturate with an antiseptic solution

Nursing Procedures:

Check patient's identification band
Gather the equipments
Wash your hand and don glove
Provide privacy for patient
Instruct female patient to sit with legs separated on the toilet, open the sterile container and place the lid up on a firm surface in easy reach
Instruct female patient to use thumb and forefinger to separate labia
With the labia separated, instruct female patient to cleanse one side of the labia with the towelette, discard the towelette, repeat procedure on the other side with the second towelette. Make sure the labia stay separated throughout the procedures
Instruct her to urinate into the toilet, place the collection cup unter the stream of urine after a good flow of urine has been started. Fill the container just half-way with urine
Position sterile lid back onto the container, close tightly, label it, and send it to laboratory

Urine Collection: Closed Drainage System

2009-03-11T01:41:00.000-07:00

Equipments:

Rubber band or catheter clamp
Tape and sign
Examination gloves
Sterile specimen container and label
Sterile packages of 70% isopropanol or povidone-iodine
Sterile 10 cc syringes with 23- or 25-gauge needle

Nursing Procedures:

Check patient's identification band
Gather equipments
Inform and explain procedure to patient
Manipulate the drainage tubing so that the urine in the tubing goes into the bag
Clamp the drainage tubing below the aspiration port, leave clamped 10-15 minutes
Tape a sign over the client's bed that the foley catheter's drainage tubing is temporarily clamped for a specimen
Wash your hand and don gloves
Provide privacy for patient
Cleanse the aspiration port at a 45 degrees angle, aspirate 10 ml from port and remove needle
Place urine into sterile labeled container, secure lid on container, then place container in a biohazard bag
Store needle and syringe unit into sharp box container and never recap a contaminated needle
Remove the notice from above the bed
Send specimen to laboratory
Remove and dispose the gloves and wash your hands

Venipuncture

2009-03-11T01:34:00.000-07:00

Equipment:

Sterile packages of 70% isopropanol (antiseptic) and povidone-iodine (topical anti-infectant)
Sterile needle and syringe or vacutainer system (20- or 21-gauge needle for cubital vein puncture on an adult)
Sterile 2 x 2 cotton gauze and povidone-iodine
Tourniquet
Nonsterile gloves
Bandage or sterile adhesive bandage
Collecting tube

Nursing Procedures:

Check patient identification band
Wash hands
Inform and explain the procedure to patient
Position patient in a sitting or supine position and lower side rail
Prepare supplies: open sterile packages and label specimen tubes with the patient's data
Place arm straight or in dependent position if possible
Tourniquet is applied 6-10 cm above the elbow and should only obstruct venous blood flow, not arterial flow
Select a dilated vein. SEE PICTURE.
If a vein is not visible, encourage patient to pen and close his / her fist, or stroke extremity from proximal to distal, tap lightly over a vein, apply warmth
Palpate vein for size and pliancy and make sure it is well seated
Release the tourniquet

Cleanse puncture site with isopropanol, let it dries and cleanse it with povidone-iodine, let dry or wipe with sterile gauze. Do not touch site after cleansing.

Store equipment in easy reach and position yourself to access the puncture site

Apply the tourniquet again (should not exceed 3 minutes)

Don glove

Perform venipuncture

Remove cap from 20- or 21-gauge needle.

With nondominant hand, stabilize the vein by holding the skin taut over the puncture site (apply downward tension on the forearm with your thumb).

With dominant hand, hold the needle bevel facing upward at an approximate 30° angle to the arm

Puncture the skin into the straightest part of vein with a steady, moderately fast movement. (When the vein is entered you will feel a slight give and can see blood at the needle’s hub.)

Apply moderate negative pressure by puncturing the vacuum tube or by gently retracting the syringe plunger. (When first performing a venipuncture, use a syringe. It takes greater dexterity to puncture the vacuum tube with a two-sided needle; if you apply too much pressure you will go through the vein.)

The tourniquet is removed when blood is flowing into the tube or syringes then collect specimens

Remove the needle and apply pressure to site immediately for 2-3 minutes or 5-10 minutes if patient is in under anticoagulant treatment. Keep the arm straight

Let patient maintain pressure on the puncture site

Apply a sterile bandage or adhesive bandage to the puncture site

If using a needle and syringes, transfer the blood into test tube under moderate pressure

Dispose the needle or syringes into a sharp box container

Remove glove and wash your hands

Assessment: Blood Pressure

2009-03-11T01:30:00.000-07:00

Medical Equipments:

Alcohol swabs
Stethoscope
Sphygmomanometer

Nursing Procedures:

Identify the extremity that is most appropriate for reading. Furthermore do not take blood pressure reading on an injured or painful extremity or on in which an intravenous line is running
Select a cuff size to completely encircle upper without overlapping
Move clothing away from upper arm
Position arm at heart level, extend elbow with palm turned upward
Make sure bladder cuff is fully deflated and pump valve move freely
Identify brachial artery in the antecubital space
Apply cuff snugly and smoothly over upper arm about 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery
Connect bladder rubbing to manometer tubing or if a portable mercury-filled manometer is used, position vertically at eye level
Palpate brachial artery, then turn valve clockwise to close and compress bulb to inflate cuff to 30 mg Hg above point where palpated pulse disappears.
Slowly deflate cuff and noting reading when pulse is felt again.
Insert earpiece of stethoscope in ears with a forward tilt and ensure that the diaphragm hangs freely
Relocate brachial pulse with your non-dominant hand and place bell or diaphragm chestpiece directly over pulse. The chestpiece of stethoscope should be in direct contact with skin and not touch cuff. see picture
Close the valve with dominant hand by turning it clockwise then compress pump to inflate cuff until manometer reach 30 mm Hg above diminished pulse point
Turn valve counterclockwise slowly so the mercury falls at 2-3 mm Hg per second. Listen for five phase of Korotkoff's sounds while noting manometer reading. A fain, clear tapping sound appear and increase in intensity (phase I), sound swishes (phase II), sound intense (phase III), abrupt and distinctive muffled sounds (phase IV), and sound disappears (phase V)
Deflate cuff rapidly and completely
Remove cuff or wait 2 minutes before taking a second reading
Record and inform patient about result
Put all equipment and store in proper place
Wash hands
Document the result in patient's medical record and compare with patient's baseline data and normal range for age group
If there are abnormal result, measure again and report abnormal result to instructor or nurse in charge

Assessment: Respiration

2009-03-11T01:27:00.000-07:00

Equipments:
Watch with a second hand

Nursing Procedures:

Assess patient's respiration before replacing gown from auscultating heart sounds
Place your hand over patient's wrist and observe one complete respiratory cycle
Start count with first inspiration while looking at second hand weep of watch. For infants and children, count it a full minute. For adult, count it for 30 second then multiply by 2 if regular rate or count it for a full minute if irregular
Assess the depth of respiration by degree of chess wall movement and rhythm of cycle
Replace client's gown
Record rate and character of respirations

Assessment: Respiration

2009-03-08T12:27:00.000-07:00

Equipments:

Watch with a second hand

Nursing Procedures:

Assess patient's respiration before replacing gown from auscultating heart sounds
Place your hand over patient's wrist and observe one complete respiratory cycle
Start count with first inspiration while looking at second hand weep of watch. For infants and children, count it a full minute. For adult, count it for 30 second then multiply by 2 if regular rate or count it for a full minute if irregular
Assess the depth of respiration by degree of chess wall movement and rhythm of cycle
Replace client's gown
Record rate and character of respirations

Assessment: Pulse Rate – Apical Pulse

2009-03-08T12:20:00.000-07:00

Equipments:

Watch with a second hand
Alcohol swab
Stethoscope

Nursing Procedures:

Raise patient's gown to expose sternum and left side of chest
Cleanse earpiece and diaphragm of stethoscope with an alcohol swab
Put stethoscope around your neck
Position patient on left side and locate suprasternal notch
Palpate second intercostals space to left of sternum
Place index finger in intercostals space and counting downward until fifth intercostals space is located
Move index finger along fourth intercostals space left of the sternal border and to the fifth intercostals space, left of the midclavicular line to palpate the point of maximal impulse, see picture
Keep index finger of nondominant hand on the PMI
Inform the patient that you are going to listen to his/her heart and instruct him/her to remain silent
Put earpiece of the stethoscope in your ears with dominant handa and grasp diaphragm of the stethoscope in palm of your hand for 5-10 second
Place diaphragm of stethoscope over the PMI and auscultate for S1 and S2 to hear lub-dub sound, see picture
Identify the regularity of rhythm
Count lub-dub sound as one beat while looking at second hand of watch. For a regular rhythm count rate for 60 seconds, while for an irregular count it for a full minute and noting number of irregular beats
Record by site the rate, rhythm and number of irregular beats

Assessment: Pulse Rate – Radial Pulse

2009-03-08T12:17:00.002-07:00

Equipments:

Watch with a second hand
Alcohol swab
Stethoscope

Nursing Procedures:

Inform patient the site at which the pulse will be measured
Flex patient's elbow and place lower part of arm across the chest
Support patient's wrist by grasping outer aspect with thumb
Place your index and middle finger on inner aspect of patient's wrist over the radial artery and apply light but firm pressure until pulse is palpated
Identify the rhythm of pulse
Identify pulse volume
Count pulse rate by using second hand on a watch. For regular rhythm, count number of beats for 30 seconds and multiply by 2, while for an irregular rhythm, count it for a full minute and noting number of irregular beats

Assessment: Body Temperature – Tympanic Temperature

2009-03-08T12:17:00.001-07:00

Follow this step when using tympanic temperature (infrared thermometer) in measuring body temperature:

Place patient in "sims" position
Remove the probe from container and attach it cover to tympanic thermometer unit
Turn patient's head to one side. For an adult: pull pinna upward and back. For a child: pull down and back.
Insert probe gently with firm pressure into ear canal
Remove prove after reading is displayed on digital unit. It usually needs 2 seconds
Return tympanic thermometer to storage unit
Record the result and indicate site as "ET"

Assessment: Body Temperature – Disposable (chemical strips) Thermometer

2009-03-08T12:15:00.000-07:00

When measuring body temperature by using the disposable (chemical strips) thermometer, follow this procedure here:

Apply tape to appropriate skin area (usually on forehead)
Observe the color changes on tape
Record the result and indicate method

Assessment: Body Temperature – Axillary Temperature

2009-03-08T12:08:00.000-07:00

Nursing Procedures:

Remove patient's arm and shoulder from one sleeve of gown but avoid expose chest
Make sure that the axillary skin is dry or pat if necessary
Remove thermometer from storage container and cleanse under cool water
Wipe thermometer dry with a tissue from bulb's end toward fingertips
Place thermometer or probe into center of axilla, fold patient's upper arm straight down and place the arm across patient's chest, see the picture
Leave the glass thermometer in place as specified by agency policy that usually 6-8 minutes, or leave the electronic thermometer in place until signal (beep) is heard
Remove the thermometer and read the result the inform it to patient
Remove thermometer and wipe it with a tissue away from fingers toward the bulb's end
Shake the thermometer down and cleanse it with soapy water, rinse under cold water and return it to the storage container
Assist patient with replacing gown
Record the result and indicate site as "AT"

Assessment: Body Temperature – Rectal Temperature

2009-03-08T12:03:00.000-07:00

Nursing Procedures:

Place patient in the "sims" position with upper knee is flexed.
Adjust sheet to expose only anal area
Place tissues near patient and easy to reach
Don gloves
Remove rectal thermometer from storage container and cleanse under cool water
Wipe rectal thermometer dry with a tissue from bulb's end toward fingertips
Lubricate tip of rectal thermometer or probe
Grasp the thermometer with dominant hand and separate buttocks to expose anus with non-dominant hand
Instruct patient to take a deep breath then insert thermometer or probe gently into anus (infant 0.5 inch, adult 3.5 inch) and if there is a resistance, do not force insertion
Leave the thermometer in place as specified by agency policy that usually 3-5 minutes
Wipe secretion off glass thermometer with tissue and dispose the tissue in a receptacle
Read the result and inform it to patient
Hold glass thermometer in one hand, wipe anal area with tissue to remove lubricant or feces with other hand and dispose of soiled tissue, then cover patient
Cleanse thermometer by shaking the thermometer down and cleanse glass thermometer with soapy water, rinse under cold water, and return it to storage container
Remove and dispose of glove in receptacle, then wash hand
Record the result and indicate site as "RT"

Body Temperature – Electronic Oral Temperature

2009-03-07T12:17:00.001-08:00

Nursing Procedure:

Place disposable protective sheath over probe.
Grasp top of the probe’s stem. Avoid placing pressure on the ejection button.
Place tip of thermometer under the client’s tongue and along the gum line to the posterior sublingual pocket lateral to center of lower jaw
Instruct client to keep the mouth closed around thermometer.
Thermometer will signal (beep) when a constant temperature registers.
Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well.
Inform client of temperature reading.
Remove gloves and wash hands.
Record reading and indicate site “OT.”
Return electronic thermometer unit to charging base.

Body Temperature – Glass Oral Temperature

2009-03-07T11:54:00.000-08:00

Nursing Procedure:

Select correct color tip of thermometer from patient’s bedside container
Remove thermometer from storage container and cleanse under cool water
Wipe thermometer dry with a tissue from bulb’s end toward fingertips.
Read thermometer by locating mercury level. It should read 35.5°C (96°F).
If thermometer is not below a normal body temperature reading, grasp thermometer with
thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal.
Place thermometer in mouth under the tongue and along the gumline to the posterior sublingual pocket. Instruct client to hold lips closed.
Leave in place as specified by agency policy, usually 3–5 minutes.
Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end.
Read at eye level and rotate slowly until mercury level is visualized.
Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container.
Remove and dispose of gloves in receptacle,
Wash hands.
Record reading and indicate site as “OT.”

Body Temperature Measuring – General

2009-03-07T05:15:00.000-08:00

Nursing Equipments:

Thermometer: glass; electronic and disposable protective sheath; disposable (chemical); tympanic.
Lubricant (rectal, glass thermometer)
Two pairs of nonsterile gloves
Tissues

Nursing Action:

Review medical record for baseline data and factors that influence vital signs
Explain to the patient that vital signs will be assessed and encourage them to remain still and refrain from drinking, eating, or smoking
Assess patient’s toileting needs and proceed as appropriate
Obtain equipment as indicated
Provide privacy
Wash hands and don gloves
Keep the patient in a sitting or lying position with the head of the bed is elevated 45 – 60 degrees to measure all vital signs except those designated otherwise
Follow next nursing action for body temperature measurement with oral temperature (glass and electronic thermometer), rectal temperature, axillary temperature, disposable (chemical strip) thermometer, and tympanic temperature (infrared thermometer)