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