Nursing: Application of Restraint

Nursing: Application of Restraint

Equipments:
Restraint

Nursing Actions:

1. Explain the rationale of the restraint application
2. Select the proper type of restraint
3. Assess skin for any irritation
4. Apply restraint to the patient assuring some movement of body part. One to two fingers should slide between restraints and patient’s skin.
5. Tie straps with clove hitch knot securely
6. To make a clove hitch, make a figure-eight
7. Pick up the loops and put the limb through the loops and secure
8. Pad bony prominences
9. Secure restraints to the bed frame and do not tie the straps to the side rail
10. Assess skin integrity and restraints q 30 minutes and release it at least every 2 hours
11. The restraints should be assessed continually at least every 8 hours

Postoperative Exercise

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

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

Splinting and Coughing

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


6. Slowly bend forward and exhale slowly through pursed lips
7. Repeat breathing two or three times
8. 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
9. 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.
10. Have a tissue ready

Using an Incentive Spirometer

1. Instruct the patient on the use of an incentive spirometer:
2. Have a volume-oriented incentive spirometer upright
3. 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
4. The patient simultaneously measures the amount of inspired air volume on the calibrated plastic tube
5. Remove the mouthpiece, and exhale normally
6. Take several normal breaths
7. Repeat the procedure 4-5 times
8. Ask the patient to cough after the incentive effort
9. Ask the patient to clean mouthpiece under running water

Leg and Foot Exercises

1. Explains the leg and foot exercises
2. Ask the patient to demonstrate in bed:
3. 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
4. With heels on the bed, lift and circle both ankles: first to the right and then to the left, repeat three times then relax
5. Flex and extend each knee alternately, sliding foot up along the bed then relax

Turn in Bed and Get Out of Bed

1. 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:
2. Flex the knees
3. With the right hand splint the incision with hand or small pillow
4. 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
5. 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
6. Reverse procedure as using left side instead of right for the patient with a right-sided incision
7. Instruct patient with orthopedic surgery ho to use a trapeze bar

Administering a Vaginal Suppository

Administering a Vaginal Suppository

Equipments:

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

Nursing Actions:

1. Identify any allergies or medical condition that contraindicate the use of drug
2. Obtain necessary equipment
3. Check the written order on MAR
4. Wash hands
5. Follow the five rights of medication administration
6. Instruct patient to void
7. 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


8. Don non-sterile gloves
9. Explain briefly the procedure to the patient and provide privacy
10. Assess perineal area and inspect vaginal orifice. Note if there is any odor, discharge from vagina or any problems such as itching or discomfort
11. Cleanse the perineal area with soap and water if there is any secretion or discharge
12. 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.
13. 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
14. Wipe the perineum area with a clean dry tissue
15. Ask the patient to remain in bed for 15 minutes
16. Wash applicator under cool running water
17. Remove glove and wash hand
18. Record the drug’s name, dosage, rout, date and time of administration on MAR
19. Observe the patient in 15 minutes to ensure that the suppository did not slip out
20. Identify the effectiveness of the medication

Rectal Suppository Administration

Medical Equipments:

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

Nursing Procedures:

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

Administering a Metered Dose Inhaler (self administration)

Equipments:

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

Nursing Actions:

1. Check any allergies that patient has or any medical condition that is contraindicated with the use of thd drug
2. Obtain all equipments
3. Check the written order on MAR
4. Wash hands
5. Follow the five right of medication administration
6. Check the patient identification
7. Allow the patient o hold and manipulate the canister and explain how the canister fits into the inhaler.
8. Have the patient demonstrate the insertion of the canister
9. Discuss the metered-dose concept and frequency of dose to the patient
10. Explain that the inhaler should be shaken before each use
11. 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
12. Instruct the patient to exhale, place the mouthpiece into the mouth and tighten the lips (seal) around the mouthpieces
13. Ask the patient to firmly push the cylinder down against the mouthpiece only once, while slowly inhaling until the lungs feel full
14. Instruct the patient to remove the mouthpiece while holding the breath for about 10 seconds then exhale slowly through pursed lips
15. Repeat the doses as prescribed and waiting 1 minute between puffs
16. A mouthwash can be use by the patient to remove the taste of the medication
17. Demonstrate to the patient how to wash the mouthpiece under tepid running water to remove secretions
18. If two or more inhaler medication are prescribed, wait 5-10 minutes between inhalations or as specifically ordered by physician
19. Record all the drug’s name, dose, date, and time for medication on MAR
20. Observe for effectiveness of medication and relief of the patient’s symptoms

Administering Nose Drops

Medical Equipments:

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

Nursing Actions:

1. Check the allergies that patient may have
2. Determine the written order on MAR
3. Wash hands
4. Check patient’s identification armband
5. Explain the procedures to the patient and provide privacy
6. Ask patient to blow nose unless contraindicated
7. 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
8. 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
9. Instruct the patient to breathe through mouth
10. Squeeze medications into the dropper
11. Insert the nasal drops about 3/8 inch into nostril and keep the tip of the dropper away from the sides of the nares.
12. Instill the medication as prescribed and observe for signs and discomforts
13. Ask the patient to maintain supine position for 5 minutes
14. Discard any unused medication remaining in the bottle
15. 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
16. Remove gloves and wash hands
17. Record the medication given, doses, and time on MAR
18. Observe the patient for side effects for 30 minutes after administration

Administering Ear Medication

Medical Equipments:

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

Nursing Procedures:

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

Administering Eye Medication Disk

Medical Equipments:

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

Nursing Procedures:

1. Assess the patient and the cart for any allergies
2. Check the written orders on MAR
3. Obtains the necessary equipments
4. Follow the five rights of drug administration
5. Determine the identification armband
6. Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops
7. Wash hand and don non-sterile gloves
8. 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)
9. 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

Medical Equipments:

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

Nursing Procedures:

1. Assess the patient and the cart for any allergies


2. Check the written orders on MAR


3. Obtains the necessary equipments


4. Follow the five rights of drug administration


5. Determine the identification armband


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


7. Wash hand and don non-sterile gloves


8. 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)


9. Position patient in a supine position with the head slightly hyperextented
10. For Lower Lid:
1. 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
2. Instruct the patient to look up
3. Apply eye ointment along inside edge of the entire lower eyelid, from inner to outer canthus
11. For Upper Lid:
1. Instruct patient to look down
2. 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
3. Apply ointment along upper lid starting at inner chantus

Administering Eye Drops

Medical Equipments:

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

Nursing Procedures:

1. Assess the patient and the cart for any allergies
2. Check the written orders on MAR
3. Obtains the necessary equipments
4. Follow the five rights of drug administration
5. Determine the identification armband
6. Explain the procedure to the patient and ask if he or she wants to instill his or her own eye drops
7. Wash hand and don non-sterile gloves
8. 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)
9. Position patient in a supine position with the head slightly hyperextented
10. Remove cap from eye bottle and place cap on its side
11. Squeeze the amount of medication as prescribed into the eyedropper
12. Put a tissue below the lower lid
13. With dominant hand, hold eyedropper ½ to ¾ inch above the eyeball, the rest hand is on patient forehead to stabilize
14. Place nondominant hand on cheekbone and expose lower conjunctival sac by pulling on cheek while applying slight pressure to the inner chantus
15. Instruct the patient to look up and drop the drops into center of conjunctival sac
16. Do not instill medication drops directly into the cornea
17. If the patient blinks and the drops land on the outer lid or eyelash, repeat the procedure
18. Instruct patient to close and move eyes gently
19. Remove gloves and wash hands
20. Record the route, site, and time administered on the MAR

Administering Medications by IV Piggyback to an Existing IV

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:

1. Gather all of prepared equipments
2. Wash your hand
3. Check patient identification or arm-band
4. Explain the procedures to the patient
5. Observe the puncture site for redness and puffiness then palpate for tenderness
6. Observe fluid infusing and check the patency of infusion site
7. Remove IV container from the pole and lower the container below the level of infusion site
8. Observe for backflow of blood into the hub of the venous access device and replace container on IV hole
9. Secure the medication bag and check the prescription and the MAR
10. Check patient's chart for allergies and drug compability
11. Hang the secondary bag on IV hole
12. Add the administration set to the secondary bag and prime the tubing
13. Affix a needle-less locking cannula to the end of tubing
14. Cleanse needle-less Y-site injection port of primary IV tubing closest to infusion site with an alcohol swab and allow to dry
15. Insert needle-less locking cannula of secondary bag set into Y-site injection port of primary set ans secure in place with tape
16. 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
17. Open clamp of secondary tubing and adjust drip rate to desired infusion rate
18. Observe patient for any signs or adverse reaction to the medication
19. 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
20. Record medication infusion on the MAR and note any patient's responses

Administering an Intramuscular Injection

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:

1. Identify the patient's allergies to any known medication
2. Wash your hands
3. Follow the rule of five rights
4. Obtain the medication from an ampule or vial
5. Check the patient identification or arm band
6. Position patient in an appropriate position to expose the site of injection
7. For deltoid area: sitting position
8. 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
9. Don non-sterile gloves
10. Assess the skin for redness, scarring, breaks and palpate for lumps or nodules
11. Select using the anatomic landmarks
12. The area for injection is cleansed by an alcohol swab from inside outward using friction and wait 30 seconds to allow to dry
13. Remove the needle cap by pulling it straight off and expel any air bubbles from the syringe
14. Pull the skin down or to one side (Z-track technique) with non-dominant hand
15. Administer in deltoid: quickly insert the needle with a cart-like motion at 90 degrees angle
16. 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
17. Aspirate it by pulling back the plunger and observe for blood
18. If blood is appeared, remove the needle and discard
19. If blood is not appeared, inject the medication slowly about 10 sec per ml
20. Wait 10 seconds after the medication has been injected, then smoothly withdraw the needle at the same angle of insertion
21. 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
22. Discard the syringe and needle in sharps box container and never recap the needle
23. Place the patient in comfort position and encourage him/her to perform leg exercises (flexion and extension) after receiving ventrogluteal injection
24. Remove gloves and wash your hands
25. Record on the medication administration report the dosage, route, site and time or injection
26. Observe the injection site within 2-4 hours and evaluate the patient's responses

Administering an Subcutaneous Injection

Medical Equipments:

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

Nursing Procedures:

1. Identify patient's allergies to any known medication
2. Wash your hands
3. Follow the five rights of drug administrations
4. Prepare medication from an ampule or vial and place them on a clean surface in the patient's room
5. Check the patient's identification card or armband
6. Inform patient about the procedure
7. Place patient in a comfortable position and provide for privacy
8. Don non-sterile gloves
9. Assess and observe the skins for bruises, redness, hard tissue, or broken skin
10. Cleanse the site for injection with an alcohol swab from inside to outside
11. Prepare the injection by removing the needle guard and expressing any air bubbles from the syringes, and check the dosage in the syringes
12. With dominant hand, hold the syringe between thumb and forefinger
13. 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
14. Insert the needle quickly at 45 or 90 degrees angle



15. Release the subcutaneous tissue and grasp the barrel of the syringe with non-dominant hand
16. With dominant dominant hand, aspirate by pulling back on the plunger gently, except when administering an anticoagulant injection
17. If blood appears, remove needle and discard in a sharps box container
18. Inject medication slowly if there is no blood present
19. Remove the needle quickly and lightly massage area with alcohol swab, do not massage the injection site after an anticoagulant injection
20. Do not recap needle, discard the needle in a sharps box container
21. Place patient in comfort position
22. Remove glove and wash hands
23. Record the route, site, and time of injection on the medication administration record
24. Observe any side or adverse effects and assess the effectiveness of the medication at the appropriate time

Administer Intradermal Injection

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:

1. Check the patient's allergies to any known medication
2. Wash your hands
3. Follow the five rights drug administrations
4. Prepare the medication from an ampule or vial and take the medication to the client's room and put on a clean surface
5. Check the patient's identification card or arm band
6. Inform the patient about the procedure
7. Position the patient as comfortable as possible and provide for privacy
8. Wash hands and don non sterile gloves
9. Assess the skin for bruises, redness, or broken tissue
10. Select an appropriate site using appropriate anatomic landmarks
11. Cleanse the site with an alcohol swab in a firm circular motion, cleanse from inside to outside, and allow alcohol to dry
12. Obtain the syringe for injection
13. Remove the needle guard
14. Remove any air bubbles from the syringe
15. Check the amount of solution in the syringe
16. Hold the syringe in dominant hand
17. With non dominant hand grasp the patient's dorsal forearm and gently pull the skin SEE PICTURE
    
18. 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
19. Push the medication slowly and observe the development of a bleb (large flaccid vesicle). If it does not appear, withdraw the needle slightly
20. Withdraw the needle
21. Gently part area with a dray 2x2 sterile gauze pad
22. Avoid massage the area after removing the needle
23. The needle and syringes are discharged in a sharps box container
24. Remove glove and wash hand
25. Observe for signs of allergic reaction
26. Draw a circle around the perimeter of the bleb with a pen
27. Record the procedure and site of injection on medication administration record

Mixing Insulin in One Syringe

Medical Equipments:

• Medication administration record
• Insulin vials
• Alcohol swab
• Insulin syringe

Nursing Procedures:

1. Assess patient's allergies or medical condition that would contraindicate in administrating the drug
2. Gather necessary equipment
3. Check the medication administration record against medication order
4. Wash your hands
5. Follow the five rights of medication administration and check the patient's identification band
6. Remove insulin vial cap
7. Rotate each bottle of insulin slowly but never shake them. Make sure suspensions are thoroughly mixed
8. Clean the rubber stopper of the vial with an alcohol swab
9. 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
10. 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
11. 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.
12. Remove the needle
13. 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.
14. Remove the needle
15. Have another nurse check the prescribed dose
16. Store insulin vials according to your agency policy
17. Wash your hand

Withdrawing Medication from a Vial

Medical Equipments:

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

Nursing Procedures:

1. Wash your hands
2. Prepare the vial
3. Open the alcohol swab
4. For new vial: remove metal cap from vial and cleanse the rubber top of vial
5. For used vial: cleanse the rubber top of the vial
6. Choose a syringe of appropriate size
7. Grasp needle and turn barrel of syringe to the right
8. 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
9. Insert the needle into the center of the upright vial and inject air into the vial
10. 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
11. Remove air from the syringe while needle remains within the inverted vial by tapping the syringe side by your finger
12. Check the amount of medication in the syringe
13. Turn vial upright and remove the needle
14. Replace the needle cap and replace with new needle. Remove used needle and dispose it in the sharps container
15. Attaché the new needle to the syringe by turning the barrel to the right
16. Compare the medication in the syringes with the prescribed dosage

Withdrawing Medication from an Ampule

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:

1. Wash your hands
2. Hold the ampule and tap the top chamber quickly and lightly until all fluid flows into the bottom chamber
3. Place a sterile gauze or alcohol swab around the neck of the ampule
4. 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
5. Withdraw the medication from the ampule while maintaining the sterile technique
6. Check the connection of needle to syringe turning barrel to right while the needle guard is held
7. Use a filter needle if recommended
8. Remove needle guard and hold syringes in domain hand
9. With non dominant hand, grasp ampule and turn upside down, or stabilize ampoule on a flat surface
10. 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
11. Keep needle tip below level of meniscus
12. Aspirate the medication by pulling on the plunger
13. 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
14. Remove excess air from the syringe and check the dosage of medication in the syringes. Recap
15. Discard any unused portion of the medication, and dispose of the ampule top in a suitable container after comparing with medical administration record
16. Change needle discard used needle properly. Secure needle to syringes by turning the barrel to right while holding the needle guard
17. Wash hands

Administering Oral Medication

Medical Equipments:

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

Nursing Procedures:

1. Identify the patient's potential problem such ach absence of a gag reflex
2. Check the MAR against the written orders
3. Identify for drug allergies
4. Wash your hand
5. Prepare the medication for one patient at a time
6. Select the correct medication and double-check against MAR
7. Calculate the medication doses if necessary and double-check for accuracy
8. 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
9. For liquid medication: place the label side of the medicine bottle against your palm and pour the liquid at eye level


10. Recheck the medication with MAR
11. Check again MAR and make sure that all medications to be administered have been prepared
12. Place on the tray or medication cart
13. Check patient's armband before giving medication
14. Do any assessment required before the drug administration such ach apical pulse rate before digoxin administration
15. Place patient on sitting position
16. Provide liquids before and during ingestion and encourage patient to drink 5-6 oz of water
17. 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
18. If a drug / medication falls on the floor, discard it and start over
19. Remain with the patient until all medications have been swallowed
20. Wash your hand
21. Record the administered drug on the Medical Administration Record
22. Observe the side effects or adverse reaction that might be happened to the patient

Urine Collection: Clean Catch, Female

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:

1. Check patient's identification band
2. Gather the equipments
3. Wash your hand and don glove
4. Provide privacy for patient
5. 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
6. Instruct female patient to use thumb and forefinger to separate labia
7. 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
8. 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
9. Position sterile lid back onto the container, close tightly, label it, and send it to laboratory

Urine Collection: Closed Drainage System

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:

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

Venipuncture

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:

1. Check patient identification band
2. Wash hands
3. Inform and explain the procedure to patient
4. Position patient in a sitting or supine position and lower side rail
5. Prepare supplies: open sterile packages and label specimen tubes with the patient's data
6. Place arm straight or in dependent position if possible
7. Tourniquet is applied 6-10 cm above the elbow and should only obstruct venous blood flow, not arterial flow
8. Select a dilated vein. SEE PICTURE.
9. 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
10. Palpate vein for size and pliancy and make sure it is well seated
11. Release the tourniquet



12. 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.
13. Store equipment in easy reach and position yourself to access the puncture site
14. Apply the tourniquet again (should not exceed 3 minutes)
15. Don glove
16. Perform venipuncture
17. Remove cap from 20- or 21-gauge needle.
18. With nondominant hand, stabilize the vein by holding the skin taut over the puncture site (apply downward tension on the forearm with your thumb).
19. With dominant hand, hold the needle bevel facing upward at an approximate 30° angle to the arm
    
20. 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.)
21. 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.)
22. The tourniquet is removed when blood is flowing into the tube or syringes then collect specimens
23. 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
24. Let patient maintain pressure on the puncture site
25. Apply a sterile bandage or adhesive bandage to the puncture site
26. If using a needle and syringes, transfer the blood into test tube under moderate pressure
27. Dispose the needle or syringes into a sharp box container
28. Remove glove and wash your hands

Assessment: Blood Pressure

Medical Equipments:

• Alcohol swabs
• Stethoscope
• Sphygmomanometer

Nursing Procedures:

1. 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
2. Select a cuff size to completely encircle upper without overlapping
3. Move clothing away from upper arm
4. Position arm at heart level, extend elbow with palm turned upward
5. Make sure bladder cuff is fully deflated and pump valve move freely
6. Identify brachial artery in the antecubital space
7. Apply cuff snugly and smoothly over upper arm about 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery
8. Connect bladder rubbing to manometer tubing or if a portable mercury-filled manometer is used, position vertically at eye level
9. 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.
10. Slowly deflate cuff and noting reading when pulse is felt again.
11. Insert earpiece of stethoscope in ears with a forward tilt and ensure that the diaphragm hangs freely
12. 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
    
13. 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
14. 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)
15. Deflate cuff rapidly and completely
16. Remove cuff or wait 2 minutes before taking a second reading
17. Record and inform patient about result
18. Put all equipment and store in proper place
19. Wash hands
20. Document the result in patient's medical record and compare with patient's baseline data and normal range for age group
21. If there are abnormal result, measure again and report abnormal result to instructor or nurse in charge

Assessment: Respiration

Equipments:
Watch with a second hand


Nursing Procedures:

1. Assess patient's respiration before replacing gown from auscultating heart sounds
2. Place your hand over patient's wrist and observe one complete respiratory cycle
3. 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
4. Assess the depth of respiration by degree of chess wall movement and rhythm of cycle
5. Replace client's gown
6. Record rate and character of respirations

Assessment: Respiration

Equipments:

• Watch with a second hand

Nursing Procedures:

1. Assess patient's respiration before replacing gown from auscultating heart sounds
2. Place your hand over patient's wrist and observe one complete respiratory cycle
3. 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
4. Assess the depth of respiration by degree of chess wall movement and rhythm of cycle
5. Replace client's gown
6. Record rate and character of respirations

Assessment: Pulse Rate – Apical Pulse

Equipments:

• Watch with a second hand
• Alcohol swab
• Stethoscope
  

Nursing Procedures:

1. Raise patient's gown to expose sternum and left side of chest
2. Cleanse earpiece and diaphragm of stethoscope with an alcohol swab
3. Put stethoscope around your neck
4. Position patient on left side and locate suprasternal notch
5. Palpate second intercostals space to left of sternum
6. Place index finger in intercostals space and counting downward until fifth intercostals space is located
7. 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
8. Keep index finger of nondominant hand on the PMI
9. Inform the patient that you are going to listen to his/her heart and instruct him/her to remain silent
10. 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
11. Place diaphragm of stethoscope over the PMI and auscultate for S1 and S2 to hear lub-dub sound, see picture
12. Identify the regularity of rhythm
13. 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
14. Record by site the rate, rhythm and number of irregular beats

Assessment: Pulse Rate – Radial Pulse

Equipments:

1. Watch with a second hand
2. Alcohol swab
3. Stethoscope

Nursing Procedures:

1. Inform patient the site at which the pulse will be measured
2. Flex patient's elbow and place lower part of arm across the chest
3. Support patient's wrist by grasping outer aspect with thumb
4. 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
5. Identify the rhythm of pulse
6. Identify pulse volume
7. 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

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

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

Assessment: Body Temperature – Disposable (chemical strips) Thermometer

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

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

Assessment: Body Temperature – Axillary Temperature

Nursing Procedures:

1. Remove patient's arm and shoulder from one sleeve of gown but avoid expose chest
2. Make sure that the axillary skin is dry or pat if necessary
3. Remove thermometer from storage container and cleanse under cool water
4. Wipe thermometer dry with a tissue from bulb's end toward fingertips
5. 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
6. 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
7. Remove the thermometer and read the result the inform it to patient
8. Remove thermometer and wipe it with a tissue away from fingers toward the bulb's end
9. Shake the thermometer down and cleanse it with soapy water, rinse under cold water and return it to the storage container
10. Assist patient with replacing gown
11. Record the result and indicate site as "AT"

Assessment: Body Temperature – Rectal Temperature

Nursing Procedures:

1. Place patient in the "sims" position with upper knee is flexed.
2. Adjust sheet to expose only anal area
3. Place tissues near patient and easy to reach
4. Don gloves
5. Remove rectal thermometer from storage container and cleanse under cool water
6. Wipe rectal thermometer dry with a tissue from bulb's end toward fingertips
7. Lubricate tip of rectal thermometer or probe
8. Grasp the thermometer with dominant hand and separate buttocks to expose anus with non-dominant hand
9. 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
10. Leave the thermometer in place as specified by agency policy that usually 3-5 minutes
11. Wipe secretion off glass thermometer with tissue and dispose the tissue in a receptacle
12. Read the result and inform it to patient
13. 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
14. Cleanse thermometer by shaking the thermometer down and cleanse glass thermometer with soapy water, rinse under cold water, and return it to storage container
15. Remove and dispose of glove in receptacle, then wash hand
16. Record the result and indicate site as "RT"

Body Temperature – Electronic Oral Temperature

Nursing Procedure:

1. Place disposable protective sheath over probe.
2. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button.
3. 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
4. Instruct client to keep the mouth closed around thermometer.
5. Thermometer will signal (beep) when a constant temperature registers.
6. Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well.
7. Inform client of temperature reading.
8. Remove gloves and wash hands.
9. Record reading and indicate site “OT.”
10. Return electronic thermometer unit to charging base.

Body Temperature – Glass Oral Temperature

Nursing Procedure:

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

Body Temperature Measuring – General

Nursing Equipments:

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

Nursing Action:

1. Review medical record for baseline data and factors that influence vital signs
2. Explain to the patient that vital signs will be assessed and encourage them to remain still and refrain from drinking, eating, or smoking
3. Assess patient’s toileting needs and proceed as appropriate
4. Obtain equipment as indicated
5. Provide privacy
6. Wash hands and don gloves
7. 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
8. 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)