Clinical Nursing Skills

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STANDARD PRACTICE FOR ALL PROCEDURES BEFORE THE PROCEDURE ✓

Check the patient’s chart both to identify the patient and to understand why procedure was ordered.

✓

Evaluate if the patient’s condition or history will affect how the procedure is performed.

✓ Wash your hands. ✓

Introduce yourself if the patient does not know you. Verify patient’s identity.

✓

Explain procedure to the patient and answer any questions.

✓

Close curtains or door to ensure privacy.

✓

Obtain and arrange supplies and equipment.

✓

Raise the bed to the appropriate height, raise side rails, and obtain assistance if necessary.

DURING THE PROCEDURE ✓

Wash your hands.

✓

Don gloves following standard precautions. Don eye protection and gown, if necessary.

✓

Execute procedure in accordance with standard practices.

AFTER THE PROCEDURE ✓

Dispose of sharps in appropriate container.

✓

Remove protective equipment.

✓

Wash your hands.

✓

Help the patient to a comfortable position.

✓

Lower the bed height.

✓

Wash your hands again before leaving the room.

✓

Document the procedure and report significant variations or results.

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Davis’s Guide to

Clinical Nursing Skills Jacqueline Rhoads, PhD, ACNP-BC, ANP-C, GNP, CCRN Professor Director of Primary Care in Community Health Public Health Nursing Louisiana State University Health Sciences Center School of Nursing New Orleans, Louisiana

Bonnie Juvé Meeker, DNS, RN Professor of Nursing Southeastern Louisiana University School of Nursing—Baton Rouge Center Baton Rouge, Louisiana

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F. A. Davis Company Copyright ©2008 by F. A. Davis Company. All rights reserved.This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Robert G. Martone Content Development Manager: Darlene D. Pedersen Project Editor: Padraic J. Maroney As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Rhoads, Jacqueline, 1948– Davis’s guide to clinical nursing skills / Jacqueline Rhoads, Bonnie Juvé Meeker. p. ; cm. ISBN-13: 978–0–8036–1164–1 ISBN-10: 0–8036-1164–1 1. Nursing—Handbooks, manuals, etc. I. Meeker, Bonnie Juvé. II. Title. III. Title: Guide to clinical nursing skills. [DNLM: 1. Nursing Care—methods—Handbooks. WY 49 R474d 2007] RT41.D3844 2007 610.73—dc22 2006034029 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1164-1/07 1 $.10.

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Contributors Michael Adams, RN, MN, CRNA Louisiana State University Health Sciences Center Lake Chartes, Louisiana

Jennifer Eileen Badeaux, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Marie Billings, RN, MN Southeastern Louisiana University Hammond, Louisiana

Suzanne Robbins Blumer, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Daniel M. Castell, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Chris Davis, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

William Davis, MN, APRN, CRNA, CCRN Louisiana State University Health Sciences Center New Orleans, Louisiana

Claudine Dufrene, RN, C, APRN, BC, MSN University of Texas Medical Branch Galveston, Texas

Carol Foster, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Deborah Delaney Garbee, PhD, APRN, BC Louisiana State University Health Sciences Center New Orleans, Louisiana

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iv Contributors

Kathleen Harris, RN, CWOCN Wound, Ostomy, Continence Society Baton Rouge, Louisiana

Denise Hart, MSN, APRN, BC, CWOCN Southeastern Louisana University Baton Rouge, Louisiana

Alison Hepting, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Barbara Hyde, EdD, APRN, FNP–BC Southeastern Louisiana University Baton Rouge, Louisiana

Scott Larson, PT, OCS BRPT Lake Rehabilitation Centers Baton Rouge, Louisiana

Cynthia Logan, PhD, APRN Southeastern Louisiana University Baton Rouge, Louisiana

Jamie May, MN, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Karen B. Moody, PhD, RNC Southeastern Louisiana University Baton Rouge, Louisiana

Harold S. Mustin III, MN, APRN, CRNA

Judith L. Mysing RN, APRN, CRNA Ochsner New Orleans, Louisiana

Lynn Pennington, FNP-C, BC-ADM, CWOCN Stanacola Medical Center Baton Rouge, Louisiana

Demetrius Porche, DNS, APRN Louisiana State University Health Sciences Center New Orleans, Louisiana

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Contributors v

Susan Pryor, DNS, RN Southeastern Louisiana University Baton Rouge, Louisiana

Marcy Ruello, APRN, CRNA Louisiana State University Health Sciences Center New Orleans, Louisiana

Ruth Rolling, RN, MSN Southeastern Louisiana University Baton Rouge, Louisiana

Jerilyn Schaller, MN, APRN Louisiana State University Health Sciences Center New Orleans, Louisiana

Karen Silady, RN, MN, CEN, APRN Louisiana State University Health Sciences Center New Orleans, Louisiana

Wanda Spurlock, DNS, RN, BC, CNS Southern University and A&M College Baton Rouge, Louisiana

Francise Thomas, MN, CCRN Louisiana State University Health Sciences Center New Orleans, Louisiana

Yolanda Jean Urick, MN, RN Southeastern Louisiana University Hammond, Louisiana

Sonja Washington, MN, CNS Louisiana State University Health Sciences Center New Orleans, Louisiana

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Contents

U N I T

1

Basic Care C H A P T E R

1.1 1.2 1.3 1.4

C H A P T E R

2.1 2.2 2.3 2.4 2.5

1

2

C H A P T E R

Vital Signs

Assessing Body Temperature, 30 Assessing Heart Rate, 38 Assessing Respiratory Rate, 44 Assessing Blood Pressure, 47

C H A P T E R

vi

20

2

Assessment 3

4.1 4.2 4.3 4.4

Infection Control

Handwashing, 18 Donning Isolation Gown and Gloves, Droplet Precautions, 22 Contact Precautions, 24 Airborne Precautions, 26 U N I T

3.1 3.2 3.3 3.4

Hygiene

Giving a Complete Bed Bath, 2 Providing Mouth Care, 5 Performing Foot Care, 10 Making an Occupied Bed, 12

4

Physical Assessment

Assessing the Eyes, 54 Assessing the Ears, 61 Assessing the Nose and Sinuses, Assessing the Mouth and Pharynx,

67 71

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4.5 4.6 4.7 4.8 4.9 4.10 4.11

Assessing the Neck, 75 Assessing the Thorax and Lungs, 78 Assessing the Heart and Vascular System, 86 Assessing the Musculoskeletal System, 96 Assessing the Abdomen, 100 Assessing the Neurologic System, 105 Assessing the Skin, Hair and Scalp, and Nails, 115

3

U N I T

Medication Administration 5 Oral and Topical Medications C H A P T E R

5.1 5.2 5.3 5.4 5.5 5.6 5.7

Administering Oral Medications, 120 Helping Patients with Self-Medication, 126 Applying Medications to the Skin, 130 Administering Eye Drops and Ointments, 134 Instilling Medications into the Ear, 139 Administering Medications via Metered-Dose Inhaler, 142 Administering Medications via Rectal Suppositories, 145

C H A P T E R

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9

6

Parenteral Medications

Administering Subcutaneous Injections, 150 Administering Intramuscular Injections, 155 Administering Intramuscular Injections by the Z-Track Method, 161 Administering Intradermal Injections, 164 Administering Intravenous Medications by Intermittent Infusion Sets or Mini-Infusion Pumps, Administering Medications by Intravenous Bolus, Teaching Patients How to Administer Self-Injections, 183 Mixing Two Types of Insulin, 188 Using Patient-Controlled Analgesia (PCA) Infusion Devices, 191

169 178

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4

U N I T

Respiratory 7 C H A P T E R

7.1 7.2

Performing Postural Drainage, 198 Teaching Controlled Coughing Techniques,

C H A P T E R

8.1 8.2

9.2 9.3 9.4 9.5 9.6 9.7

8

203

Oxygen Therapy

Administering Oxygen Therapy, 208 Administering Oxygen Therapy to the Patient with an Artificial Airway, 213

C H A P T E R

9.1

Noninvasive Pulmonary Hygiene

9

Ventilation Support

Managing Continuous Positive Airway Pressure (CPAP), 220 Managing Intermittent Positive Pressure Ventilation, 223 Managing Mechanical Ventilation (MV), 225 Using an Ambu Manual Ventilator, 229 Performing Endotracheal Tube Care, 232 Performing Tracheostomy Care, 235 Managing a Cuffed Endotracheal or Tracheostomy Tube, 240

C H A P T E R

10

Airway Suctioning

10.1 Inserting an Oral or Nasal Airway, 244 10.2 Performing Oropharyngeal (Yankauer) Suctioning, 249 10.3 Performing Nasopharyngeal and Nasotracheal Suctioning, 252 10.4 Performing Endotracheal or Tracheostomy Tube Suctioning, 257 C H A P T E R

11

Lung Re-Expansion or Chest Drainage

11.1 Managing Chest Tube and Drainage Systems, 11.2 Assisting with Chest Tube Removal, 271

264

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U N I T

5

Cardiovascular 12 Intravenous Fluid Therapy C H A P T E R

12.1 Inserting a Short-Term Intravenous Catheter, 276 12.2 Inserting Peripheral Midline and Central Catheters (PICC), 285 12.3 Calculating and Regulating Intavenous Flow Rate, 293 12.4 Changing Intravenous Site Dressings (Peripheral and Central), 296 12.5 Assisting with Percutaneous Central Line Placement, 299 C H A P T E R

13.1 13.2 13.3 13.4

13

Circulatory Maintenance

Caring for Vascular Access Devices, 308 Applying Sequential Compression Devices, 311 Applying Antiembolic Hose, 313 Teaching Postoperative Leg Exercises, 315

C H A P T E R

14

Blood Transfusion Therapy

14.1 Transfusing Blood Products, 320 14.2 Assisting with Autotransfusion, 324 U N I T

6

Nutritional and Digestive 15 Oral and Enteric Nutrition C H A P T E R

15.1 Administering Nasogastric, Nasoenteric, and Enteric Tube Feedings, 330 15.2 Administering Medications Through a Feeding Tube, 335 C H A P T E R

16

Parenteral Nutrition

16.1 Administering Total Parenteral Nutrition (TPN), 340 16.2 Administering Peripheral Partial Nutrition, 343 16.3 Administering a Fat Emulsion (Lipids), 346

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C H A P T E R

17

Gastrointestinal Intubation

17.1 Inserting a Nasogastric Tube, 352 17.2 Advancing a Nasoenteric Decompression Tube, C H A P T E R

18

Bowel Elimination

18.1 Administering an Enema, 18.2 Managing a Rectal Tube, 18.3 Managing Ostomy Care, U N I T

356

360 366 370

7

Renal and Urinary 19 Urinary Elimination C H A P T E R

19.1 Inserting a Straight or Indwelling Catheter (Male and Female), 378 19.2 Performing Catheter Care, 385 19.3 Applying a Urinary Incontinence Collection Device, 388 19.4 Teaching Clean Intermittent Self-Catheterization, C H A P T E R

20

Bladder Irrigation and Function

20.1 Performing and Managing Bladder Irrigation Through a Three-Way Foley Catheter, 396 20.2 Obtaining a Post-Void Residual Urine Volume, U N I T

391

400

8

Musculoskeletal 21 Body Alignment and Mechanics C H A P T E R

21.1 Maintaining Proper Body Alignment, 21.2 Performing Correct Lifting Techniques, C H A P T E R

22

406 411

Exercise and Ambulation

22.1 Performing Passive Range-of-Motion (ROM) Exercises, 418 22.2 Teaching Isometric Exercises, 422

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22.3 Teaching the Patient to Crutch Walk or Use a Walker, 425 C H A P T E R

23

Transfer and Positioning

23.1 Moving and Positioning the Patient in Bed, 432 23.2 Transferring a Patient from Bed to Wheelchair, 437 23.3 Teaching Hip Precautions, 439 C H A P T E R

24.1 24.2 24.3 24.4 24.5

24

Orthopedic Interventions

Providing Cast Care, 444 Applying Skin Traction, 448 Managing Skeletal Traction, 453 Applying a Moist Compress, 456 Applying an Ice Bag, Ice Pack, or Collar,

C H A P T E R

25

459

Beds, Frames, and Mattresses

25.1 Placing the Patient on a Specialty Surface, 25.2 Placing the Patient on an Air-Suspension or Air-Fluidized Bed, 467 U N I T

464

9

Integumentary System and Wound Care 26 Pressure Ulcers C H A P T E R

26.1 Assessing Pressure Ulcer Risk, 472 26.2 Implementing Pressure-Ulcer Prevention Strategies, 477 26.3 Assessing Wounds and Staging Pressure Ulcers, C H A P T E R

27

480

Wound Care

27.1 27.2 27.3 27.4 27.5

Applying a Pressure Bandage, 488 Administering a Sitz Bath, 490 Performing Wound Irrigation, 493 Managing Wound Drainage, 495 Teaching Self-Management of Wound-Drainage Devices, 498 27.6 Applying Wound Dressings, 501 27.7 Applying and Managing a V.A.C. ATS™ System,

506

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U N I T

10

Specimen Collection 28 Collecting Blood Samples C H A P T E R

28.1 Performing Venipuncture, 512 28.2 Obtaining a Blood Glucose Level by Finger Stick, 28.3 Obtaining a Specimen for Arterial Blood Gas Analysis, 520 C H A P T E R

29

517

Collecting Urine Samples

29.1 Collecting a Midstream Urine Specimen, 526 29.2 Collecting a Timed (24-Hour) Urine Specimen, 528 29.3 Collecting a Sterile Urine Specimen from an Indwelling Catheter, 531 29.4 Measuring Specific Gravity of Urine, 533 C H A P T E R

30

Collecting Other Specimens

30.1 Collecting a Nose or Throat Specimen for Culture, 30.2 Collecting a Sputum Specimen, 541 30.3 Obtaining a Wound Drainage Specimen, 545

References,

549

Illustration Credits, Index,

555

552

538

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U N I T

C H A P T E R

Basic Care

1 Hygiene 1.1 1.2 1.3 1.4

Giving a Complete Bed Bath, 2 Providing Mouth Care, 5 Performing Foot Care, 10 Making an Occupied Bed, 12

1

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2 C h a p t e r 1 Hygiene

PROCEDURE 1.1 Giving a Complete Bed Bath OVERVIEW

Ensures cleanliness of patients who cannot bathe themselves. Promotes circulation. ● Provides comfort. ● Maintains muscle tone and joint mobility through active and passive movement. ● Provides an opportunity for thorough assessment. ● ●

P R E PA R AT I O N

Assess patient’s ability to perform his or her own care. Discuss patient preferences for bathing. ● Provide privacy. ● Avoid chilling the patient. ● Wash your hands; wear gloves if you will come in contact with body fluids or handle a bedpan. ● Gather all supplies in room before you begin. ● Ask patient if he or she needs to use the bedpan ● Check to see if patient is allergic or sensitive to soap. ● ●

Special Considerations • Patients who need a complete bed bath are usually dependent in other ways also. They may need to be fed, be incontinent, or have devices such as IVs, feeding tubes, or multiple dressings in place. The nurse needs to be comfortable manipulating these devices when giving the bath and ensuring patency and cleanliness of these devices. • It is always preferable to have the patient assist with the bath as much as possible, particularly with perineal care. • The bed bath is a good time to establish rapport and expand the nurse–patient relationship. • During and after the bath, the bed linen is changed, and the two activities are usually combined. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired bed mobility Bathing/hygiene self-care deficit ● Risk for disuse syndrome ● ●

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P r o c e d u r e 1 . 1 Giving a Complete Bed Bath 3 EXPECTED OUTCOMES

Patient expresses comfort and relaxation Skin is clean and dry ● Patient participates in the procedure as much as possible ● ●

E Q U I P M E N T/S U P P L I E S

Basin of warm water Soap and soap dish ● Towels and washcloths (two or three of each, if possible) ● Laundry bag or hamper ● Clean gown ● Clean gloves ● ●

I M P L E M E N TAT I O N ➧ Discuss procedure with patient and ensure privacy. Promotes cooperation and decreases anxiety. ➧ Place all supplies within reach. Organizes task and prevents unnecessary steps. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Position bed at comfortable height. Reduces nurse’s back strain. ➧ Fill basin with warm water, and test temperature on wrist. Testing temperature helps prevent accidental scalding. ➧ Help patient to side of bed closest to you, and lower side rail. Provides access to patient, and reduces back strain of nurse. ➧ Remove patient’s clothes while providing warmth and privacy with

a covering such as a bed blanket. Provides access to body parts; provides modesty and warmth. ➧ Take washcloth and wrap the cloth around your hand tightly, form-

ing a mitt. Prevents splashing water on patient and bedclothes. ➧ Be careful of the patient’s eyes. Use clear water to clean them, start-

ing from the inner canthus to the outer canthus. If patient is not sensitive to soap, lather washcloth and gently wash the patient’s face, starting from the forehead down. Some patients are sensitive to soap or have very dry skin, and soap could increase dryness and lead to irritation and skin breakdown. Bathe from

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4 C h a p t e r 1 Hygiene cleanest area and work downward toward feet, going from areas of cleanest to dirtiest. Attention to the eyes prevents eye irritation and infection. ➧ Bathe ears and front and back of neck. Perspiration accumulates on the back of the neck when patients lie in bed for long periods. ➧ Bathe upper body and extremities, stroking arms from wrist to

shoulder. Include axillary area. Stimulates circulation. ➧ Soak hands in basin if indicated. Dirt accumulates under fingernails, especially in incontinent patients. ➧ Keep chest covered with towel and wash under breasts on female

patients. Apply powder if patient desires. This area stays moist on many females and can lead to skin excoriation. ➧ Bathe abdomen using side-to-side strokes on skin folds. Moisture and debris can accumulate in skin folds leading to irritation. ➧ Bathe legs and feet, being sure perineal area is draped. Prevents unnecessary exposure. ➧ Soak feet in basin if indicated, and if patient is able to hold leg in

position. Soaking will soften rough skin and facilitate cleaning toenails. ➧ Change bath water if necessary. Bath water may be cool or dirty. ➧ Assist patient to side-lying position and wash back. Give backrub. Side-lying position gives access to patients back for backrub. ➧ Put on clean gloves and bathe perineal area. Dry thoroughly. Prevents cross contamination of organisms. Excess moisture contributes to skin breakdown. ➧ Remove gloves and assist patient to put on clean gown. Promotes dignity and reduces exposure. ➧ Conduct other personal hygiene activities as needed. Promotes patient’s body image. ➧ Lower bed, raise side rails, put call bell in reach, and dispose of used

equipment and linen. Provides safety. ➧ Wash your hands. Reduces transmission of microorganisms.

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P r o c e d u r e 1 . 2 Providing Mouth Care 5 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Ask if patient is comfortable and feels refreshed Make sure bed is in low position, side rails are up, and call bell is within reach ● Replace all supplies, and put equipment where it belongs ● ●

KEY POINTS ● ●

FOR

REPORTING

AND

RECORDING

Level of assistance the patient required. Condition of skin and any significant findings, such as decreased skin turgor, or areas of redness, swelling, or breakdown.

PROCEDURE 1.2 Providing Mouth Care OVERVIEW

Removes plaque and bacteria-producing agents from the oral cavity, and removes unpleasant tastes and odors. ● Teaches proper oral hygiene. ● Assesses oral mucosa, teeth and throat at this time. ● Procedure includes: • Brushing the teeth. • Flossing. • If the patient wears dentures, brushing dentures. • If patient is unconscious, providing complete mouth care. ●

P R E PA R AT I O N

Determine if the patient wears dentures. Assess whether the patient can perform his or her own mouth care. ● Inquire about oral hygiene practices. ● ●

Special Considerations • Patients who will need frequent oral hygiene are those with an oral airway, NG tube, or tube feeding, and patients who are receiving oxygen.

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6 C h a p t e r 1 Hygiene

• Anyone who has not eaten for 12 hours or more should receive oral care. • Check for personal preference prior to providing mouth care even if the patient is unconscious—asking the patient’s family will allow you to give the type of oral care most acceptable to the patient. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired dentition Impaired oral mucous membrane EXPECTED OUTCOMES

Oral mucosa, teeth, and throat have been inspected by the nurse Food particles and plaque are removed without complication ● Unpleasant odors and tastes are removed ● Patient expresses comfort and satisfaction ● ●

E Q U I P M E N T/S U P P L I E S

Toothbrush Dental floss Cup of water Emesis basin Towel Clean gloves I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Gather all equipment. Promotes efficiency. ➧ Discuss procedure with patient. Discover hygiene preferences. ➧ Put on clean gloves. Prevents contact with microorganisms or body fluids. ➧ Assess oral mucosa, teeth, and throat. Determines status of oral cavity and patient’s need for care and teaching. ➧ Hold emesis basin beneath chin. Catches spilled water and irrigation water.

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P r o c e d u r e 1 . 2 Providing Mouth Care 7 ➧ Taking the soft toothbrush in hand, brush the teeth starting from the

top front and moving to the back molars. Do not brush in a circular motion, but begin at the gum line and sweep toward teeth. Brush gently. Stimulates gums and removes food particles from gum line. With various disease states, gums become sensitive and easily fragile making them more susceptible to micro tears. ➧ Lightly brush the tongue. Improves the breath, cleans the tongue of coated food particles and sputum. ➧ Allow patient to rinse his or her mouth and expectorate into emesis

basin. Irrigation removes food particles. ➧ Ask the patient if he or she uses dental floss. If acceptable to

the patient, floss between each tooth, using approximately 12–15 inches of easy-glide floss, taking care not to get floss lodged between teeth. Removes particles caught between teeth that was not removed by brushing. ➧ Allow patient to rinse his or her mouth and expectorate into emesis

basin. Removes food particles. ➧ Remove equipment. Proper disposal of equipment prevents spread of infection. ➧ Remove gloves and wash hands. Reduces spread of microorganisms. ➧ Check to see if patient is comfortable. Verifies comfort status. EQUIPMENT/SUPPLIES FOR PROVIDING DENTURE CARE

Toothbrush Denture cup Denture cleanser Clean gloves I M P L E M E N TAT I O N F O R P R O V I D I N G D E N T U R E C A R E ➧ Wash hands, and put on clean gloves. Reduces transmission of microorganisms, and prevents contact with body fluids.

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8 C h a p t e r 1 Hygiene ➧ Help patient remove dentures or remove them by placing your

finger on the upper denture and gently pressing downward. Breaks the seal at the roof of the mouth and allows the upper denture to slide out. Lowers usually lift out easily. ➧ Place a washcloth on the bottom of the sink, if washing dentures

over the sink. Prevents dentures from breaking in case they are dropped in sink. ➧ Take the patient’s soft toothbrush and gently brush the dentures

with toothpaste and rinse under running water. Removes food particles and bacteria. ➧ Replace dentures in patient’s mouth or store in denture cup full

of water. Dentures need to be kept in a wet area to avoid warping. ➧ Remove gloves and wash hands. Reduces transmission of microorganisms. E Q U I P M E N T/S U P P L I E S F O R P R O V I D I N G M O U T H C A R E F O R U N C O N S C I O U S PAT I E N T S

Lemon-Glycerin or other mouth swabs (optional) Toothbrush or sponge toothettes Tongue blade Emesis basin Towel Clean gloves 20-mL syringe I M P L E M E N TAT I O N F O R P R O V I D I N G M O U T H C A R E F O R U N C O N S C I O U S PAT I E N T S ➧ Gather equipment listed above. Promotes efficiency. ➧ Wash hands, and put on clean gloves. Reduces transmission of microorganisms and prevents contact with body fluids. ➧ Place the patient in a side-lying position or, if patient does not have

any head or neck injury, turn the head to the side. Allows fluid to drain from mouth and prevents aspiration. ➧ Place clean towel under the patient’s mouth. Keeps bedclothes dry and free from debris.

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P r o c e d u r e 1 . 2 Providing Mouth Care 9 ➧ Brush teeth and tongue with brush or sponge toothettes, using

tongue blade to move cheek and lips to allow visibility of area. Removes food particles and bacteria. ➧ Rinse with very small amount of water using a 20-mL syringe and

gently irrigating the teeth and sides of the mouth, catching water in emesis basin. Large amounts of water can increase the patient’s chances for aspiration. ➧ Repeat this step if patient’s mouth has dried sputum/saliva to loosen

dried debris gently. Repeated gentle irrigation will loosen dried debris and prevent mucosal breakdown. ➧ Lubricate lips and tongue with lip protector lubricant. Provides moisture and helps with control of halitosis. ➧ Remove emesis basin and towel from under patient’s chin, ensuring

that the patient is dry and free from wetness. Reduces transmission of microorganisms. ➧ Reposition patient as necessary. Frequent checks ensure correct body alignment. ➧ Remove gloves and wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Condition of oral mucosa, teeth, and throat have been assessed by nurse ● Unpleasant odors and tastes have been eliminated ● Excess secretions have been removed ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Findings of assessment of oral mucosa, teeth, and throat. Oral care given. ● Patient’s comfort level during the procedure. ● Any abnormalities noted on assessment. ●

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10 C h a p t e r 1 Hygiene

PROCEDURE 1.3 Performing Foot Care OVERVIEW

Prevents infection and injury to soft tissues. Patients with peripheral vascular disease or diabetes mellitus need to be referred to a specialist, such as a podiatrist. ● Many institutions do not allow staff to perform foot care especially with diabetic patients—toenail clipping should be referred to a podiatrist but check with institution’s policy before doing so. ● ●

P R E PA R AT I O N

Assess the ability of the patient to perform his or her own nail care before intervening. ● Assess condition of feet, toes, and toenails. ● Inspect all surfaces of the nails. ● Assess color, pulses, and temperature of toes and feet. ● Check water temperature. ●

Special Considerations Patients with Diabetes or Circulatory Disorders • Many diabetic patients lack sensation in their feet, which can allow abrasions of the skin to go unnoticed and become infected. • Diabetic patients have an altered ability to fight infection. • It is usually permissible to file the nails of diabetic patients or those with circulatory disorders. Check your institution’s policy first. • Teach patients the importance of proper foot care: • Inspect feet daily, including soles, heels, and areas between toes. If necessary, use a mirror to inspect the soles and toes. • Always wear clean socks or stockings daily. • Check for holes or lumps in stockings or socks, which can contribute to skin breakdown. • Do not walk barefoot. • Wear properly-fitting shoes. • Dry feet completely, especially between toes. • Check inside of shoes for stones, tears, or foreign objects before putting them on. • Apply lotion if feet are exceptionally dry and flaky. • Do not cut corns or calluses. Instead, alert the health-care provider.

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P r o c e d u r e 1 . 3 Performing Foot Care 11 R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to impaired blood flow Risk for impaired skin integrity EXPECTED OUTCOMES

● ●

Clean, manicured nails Patient is able to verbalize correct nail care E Q U I P M E N T/S U P P L I E S

Basin Nail clippers Emery board or nail file Disposable gloves Towel Orange stick I M P L E M E N TAT I O N ➧ Inspect all surfaces of each foot. Check in between toes and around

nail bed to detect early skin breakdown. Check pulse, skin color, and temperature, and compare to other foot. Early detection of break in skin integrity. Identify circulatory problems. ➧ Soak feet in basin filled with warm, soapy water before trimming the

toenails. Gently wash each foot, between nails, and all surfaces. Soaking softens the nails and allows them to be trimmed and cleaned easily. Washing removes dirt. ➧ Thoroughly dry each foot. Be careful to dry in between toes. Excess moisture leads to skin breakdown, possible fungal infections. ➧ Perform nail care if allowed given facility policy and patient risks. Improperly performed nail care can lead to nonhealing injuries, including the potential for amputation in patients with impaired circulation. ➧ Push cuticle gently back with orange stick. Reduces incidence of irritated, cracked, loose fragmented cuticles. ➧ After soaking the nails and if appropriate (if nails are not thick), use a

toenail clipper and clip nail straight across. Take care not to trim the nail too short. Cutting straight across prevents formation of sharp nail spikes that can irritate nail margins.

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12 C h a p t e r 1 Hygiene ➧ Slowly trim all toenails as previously described. Take time to trim slowly, avoiding cutting toenails at corners, which may damage tissues. ➧ After all nails have been trimmed, lightly apply lotion to feet. To lubricate dry skin and retain moisture. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess color, pulses, and temperature of toes, feet, and/or fingers Assess condition of cuticles and surrounding skin after nail care EXPECTED OUTCOMES

● ●

Patient verbalizes comfort and satisfaction with nail care Nails are smooth, no breaks in skin integrity

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Procedure performed and any abnormalities seen. of color, pulses, and temperature of toes, feet, and/or fingers. ● Any skin breaks or ulcerations observed. ● Color, pulses, and temperature of toes, feet, and/or fingers. ● Assessment

PROCEDURE 1.4 Making an Occupied Bed OVERVIEW ●

Promotes patient comfort. P R E PA R AT I O N

Determine need for assistance in rolling the patient from side to side. ● Determine if the patient is incontinent or has drainage from any source, and obtain absorbent linen protectors, if necessary. ●

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P r o c e d u r e 1 . 4 Making an Occupied Bed 13

Special Considerations • Determine patient’s need for pain medication to make the process of changing the bed easier. • Refusal to have bed changed: Nurse needs to determine the reason that the patient refuses to have the bed changed. If, for example, the patient is in pain, providing pain medication 15 minutes before assisting the patient out of bed may help the patient move easier. Explain to the patient the importance of moving. Elderly Patient • Determine elderly patient’s skin condition during each linen change. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired bed mobility Risk for Impaired Skin Integrity EXPECTED OUTCOMES

Bed linens will be clean, dry, wrinkle free Patient will verbalize comfort after the bed has been changed ● Patient will experience minimal discomfort while the bed is being made ● ●

E Q U I P M E N T/S U P P L I E S

Bottom sheet (fitted if available) Mattress cover Draw sheet Top sheet Gloves and gown if there is presence of bodily fluids or wet bed clothes or if patient is in isolation Pillowcases for each pillow I M P L E M E N TAT I O N ➧ Explain to the patient how you plan to change the bed. Patient will know what to expect and can assist as much as possible. ➧ Put on gloves and gown if there will be contact with body fluids or if

the patient has been placed on contact isolation. Reduces transmission of infectious organisms.

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14 C h a p t e r 1 Hygiene ➧ Roll the patient to one side, opposite you. Make sure that if the

patient is not able to assist in turning, assistance is available to help turn the patient safely and efficiently. Prevents injury to the health-care provider and unnecessary strain and pressure on the patient. ➧ Once the patient is safely on his side, loosen the old linen from that

side closest to you. ➧ Roll the dirty linen up close to the patient’s back. ➧ Tuck the old linen close to the patient’s body. ➧ If the mattress is wet from bodily excretions, wash the mattress with

a germicidal agent. Reduces transmission of infectious organisms. ➧ If the bottom sheet is fitted, apply it smoothly and evenly to that

side. ➧ If the bottom sheet is a flat sheet, apply it as evenly as possible, leav-

ing at least 2 in. or less hanging over the top and bottom edge. ➧ Place a bed protector 2 feet down from the top of the bed, and

place a draw sheet over the bed protector, if needed for patient positioning. Helps protect bottom sheet. Allows moving the patient up in bed. ➧ Roll the clean linen lengthwise, and tuck it under the rolled dirty

linen. ➧ Protect the new linen from the old linen by adding a barrier such as

a Chucks pad between the soiled and new linen. Prevents soiling clean sheets. ➧ Raise side rail and move to opposite side of bed if making the bed

unassisted. ➧ Roll the patient back over the roll of linen to the opposite side. ➧ Loosen the old linen, gather, and place in pillowcase or linen bag,

keeping the soiled linen away from your body.

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P r o c e d u r e 1 . 4 Making an Occupied Bed 15 ➧ If the mattress is wet from bodily excretions, wash the mattress with

a germicidal agent. Reduces transmission of infectious organisms. ➧ Remove gown and gloves, and wash your hands. Reduces transmission of infectious organisms. ➧ Pull clean sheets, and tuck smoothly. Ensures tight fit of bottom sheet, thereby preventing skin wrinkling and skin breakdown. ➧ Tuck the sheet at the top, and square the corners. Keeps the sheets and blankets secure and in place for patient comfort and safety. ➧ Move along each side of the bed and tuck in the sheet, pulling it

securely so the sheet is tight fitting and there are no wrinkles. Ensures smooth base free of wrinkles that could cause patient discomfort and possible skin irritation ➧ Once the bottom sheet is secure, place the draw sheet or pull sheet

on the bed 2 feet from the top of the mattress. Tuck the draw sheet in securely and tightly. Assists in repositioning the patient. ➧ The top sheet should be placed over the bed making sure the top

of the sheet is at least 2 in. over the top of the mattress. The top sheet can be tucked in or left loose, depending on patient or nursing preference. A blanket can be placed on top of the top sheet if the patient desires. ➧ Tuck in the bottom of the top sheet and blanket, if used. Square the

corners. Allow a 2-in. fold or pleat at the bottom of the top sheet so patient can move feet freely. Prevents too-tight sheets, which can contribute to foot drop and impaired skin integrity. ➧ Place a clean pillowcase on each pillow in the room, whether the

patient is using them or not. Allows the easy use of clean pillows for positioning if needed.

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16 C h a p t e r 1 Hygiene E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Bed linens are clean, dry, wrinkle free Patient verbalizes comfort in the clean bed

KEY POINTS ●

FOR

REPORTING

AND

RECODING

Document linen change and note if linens were wet secondary to perspiration or episodes of incontinence.

C H A P T E R

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2 Infection Control 2.1 2.2 2.3 2.4 2.5

Handwashing, 18 Donning Isolation Gown and Gloves, 20 Droplet Precautions, 22 Contact Precautions, 24 Airborne Precautions, 26

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18 C h a p t e r 2 Infection Control

PROCEDURE 2.1 Handwashing OVERVIEW

Promotes asepsis. Prevents the transmission of infections. ● Removes transient organisms. ● Handwashing is recommended: • After contact with blood and/or body fluids, mucous membranes, soiled linen, waste or contaminated equipment. • Immediately after removing gloves. • Before and after aseptic and sterile procedures. • Between tasks at different body sites. • Between patient contacts. • Before and after eating, drinking, smoking, applying cosmetics, or preparing food. • Upon arrival at work and prior to departing the work setting. ● Alcohol-based hand rinses are not a substitute for handwashing. ● ●

P R E PA R AT I O N ●

Remove jewelry and watches.

Special Considerations • Alcohol-based rinses can be used when soap is not readily available, but hands should be washed as soon as possible after using alcoholbased rinses. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for infection EXPECTED OUTCOMES

●

Organisms are not transmitted to other patients or health-care workers EQUIPMENT/SUPPLIES

Running water Antimicrobial soap

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P r o c e d u r e 2 . 1 Handwashing 19 I M P L E M E N TAT I O N ➧ Remove jewelry and watch. Provides access to skin surfaces for cleaning. Permits thorough cleansing of skin. ➧ Rinse hands and wrist with running water. Running water removes microorganisms. Provides effective soap distribution. ➧ Apply soap. Detergents promote degradation of organisms. Lather facilitates removal of microorganisms. ➧ Use friction to wash hands for at least 10 to 15 seconds. Clean

between fingers, palms, back of hands, wrist, forearms, and skin creases (knuckles). More time may be required for visibly soiled hands. Friction physically removes any transient organisms and soil. ➧ Rinse with hands in a down position with elbows straight. Rinse in

direction of forearm to wrist to fingers. Downward flow of water rinses away dirt and microorganisms. ➧ Blot hand and forearms; dry thoroughly. Dry in direction of fingers to

wrist to forearms. Blotting reduces chapping of skin. Dry in an upward direction from most clean to least clean area. ➧ Turn off water faucet with clean, dry paper towel. Prevents contamination of clean hands. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

No evidence of soil or contaminants on hands Hands are free of soap and dry

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Handwashing should be documented for aseptic and sterile procedures.

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20 C h a p t e r 2 Infection Control

PROCEDURE 2.2 Donning Isolation Gown and Gloves OVERVIEW

To protect patient from organisms or to prevent transmission of infectious organisms to other patients or staff. ● Isolation gown and gloves create a physical barrier between the patient and health-care professional or visitor that reduces the risk for infectious exposure. ●

P R E PA R AT I O N ●

Gown and gloves should be impermeable.

Special Considerations • Isolation equipment should be discarded upon exiting patient’s room to prevent transmission of microorganisms. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for infection EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted to other patients or health-care workers ● Health-care professionals do not transmit infections to patients ● Gown and gloves are donned correctly ●

EQUIPMENT/SUPPLIES

Isolation sign Disposable gown, gloves, and masks ● Impermeable bags ● ●

I M P L E M E N TAT I O N ➧ Remove jewelry, lab coat, and other items not necessary during

patient care. Decreases spread of resident and transient microorganisms. ➧ Wash hands. Removes transient microorganisms. ➧ Apply cap to cover hair and ears completely. Cap protects hair from contamination and prevents transmission of microorganisms from hair to patient.

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P r o c e d u r e 2 . 2 Donning Isolation Gown and Gloves 21 ➧ Don gown.

Hold gown in front of the body while placing arms through sleeves. Pull sleeves to wrist level. ● Tie gown securely around neck and waist. ● ●

Disposable gown acts as a barrier between the health-care professional and patient. ➧ Don gloves. Pull gloves to cover gown’s cuff. Gloves act as a barrier between the health-care professional and patient ➧ Apply mask.

Place the top of the mask over the nasal bridge and pinch the metal strip to fit snugly against your nose. ● Tie mask in place. ●

Mask acts as a barrier between the health-care professional and patient for any potential splashes or airborne/droplet precautions. ➧ Exiting isolation room.

Untie gown at waist. Remove one glove by grasping the cuff and pulling down so that the glove turns inside out. Dispose of glove. ● With ungloved hand, slip your finger inside the cuff of the other glove, pull the glove off, inside out, and dispose of it. ● Grasp and release the ties of the mask, dispose of mask. ● Release neck ties of the gown allowing the gown to fall forward. ● Place fingers of dominant hand inside cuff of other hand, and pull gown sleeve over other hand. ● With gowned covered hand, pull gown down over the dominant hand, folding the gown together as it is pulled down, remove entire gown and dispose of gown. ● Remove cap by slipping fingers under the cap and removing from the back and dispose of cap. ● ●

Gloves are removed inside out to avoid contact with skin. Gown is removed and folded with hands touching only outer edge of gown to reduce contamination. ➧ Wash hands. Removes resident and transient microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Health-care professionals and visitors wear gloves upon entering patient’s room

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22 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Patient diagnosis, infecting microorganisms, antimicrobial therapy. ● Isolation precautions implemented. ● Maintenance of proper technique for donning gown and gloves. ● Date, time, and precautions implemented.

PROCEDURE 2.3 Droplet Precautions OVERVIEW ●

To prevent the transmission of microorganisms transmitted by droplets that are larger than 5 microns in size generated by patient coughing, sneezing, or talking. P R E PA R AT I O N

Place patient in private room. If private room is not available, infected patients can be roomed with patients having the same infection. ● Contact precautions should be used with standard precautions. ● Maintain at least 3 feet spatial separation between infected patient and health-care professional or visitors. ● Door may remain open. ●

Special Considerations • Isolation signs are a method for communicating isolation precautions to other health-care professionals and visitors. • Patient diagnosis should not be included on the isolation signs. • Patient transportation should be limited. • If a patient must be transported within the health-care environment, the patient should wear a mask during transport. • Isolation precautions can be discontinued if the microorganism is determined not to be communicable.

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P r o c e d u r e 2 . 3 Droplet Precautions 23 R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for infection Social isolation related to isolation EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted to other patients or health-care workers ● Health-care professionals do not transmit infections to patients ●

EQUIPMENT/SUPPLIES

Masks Droplet isolation sign I M P L E M E N TAT I O N ➧ Instruct patient on droplet precautions. Patient education about droplet precautions may decrease feelings of anxiety, fear, stigma, and loneliness. ➧ Place patient in private room or with another patient with the same

infection. Decreases exposure of other patients to infectious microorganisms. ➧ Don a mask when entering the room. Masks should be worn when

within 3 feet of the patient. Maintain standard precautions. Microorganisms of 5 microns or larger are heavy and do not remain dispersed in the air, nor do these microorganisms travel more than 3 feet in the air when dispersed. ➧ Remove masks and other personal protective equipment prior to

leaving patient’s room. Prevents further contamination and spread of infectious microorganisms. Keeps any potential microorganisms in the patient’s environment. ➧ Wash hands. Removes any potential contamination and glove powder. Removes transient organisms. Promotes asepsis. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Health-care professionals and visitors wear masks when within 3 feet of patient

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24 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Patient diagnosis, infecting microorganism, antimicrobial therapy. ● Isolation precautions implemented. ● Maintenance of droplet precautions. ● Date, time, and precautions implemented when patient transported.

PROCEDURE 2.4 Contact Precautions OVERVIEW ●

To prevent the transmission of microorganisms transmitted via direct contact (hand-to-skin contact) or indirect contact (touching inanimate objects or contaminated environmental surfaces). P R E PA R AT I O N

Place patient in private room. If a private room is not available, infected patients can be roomed together. ● Dedicate the use of noncritical patient care equipment to a single patient. Avoid sharing between patients. If sharing of equipment is unavoidable, the equipment must be thoroughly cleaned between patient use ●

Special Considerations • Isolation signs are a method of communicating isolation precautions to other health-care professionals and visitors. • Patient diagnosis should not be included on the isolation signs. • Patient transportation should be limited. • If a patient must be transported within the health-care environment, the patient should wear gloves or site of infection must be concealed with an impermeable barrier during transport. • Isolation precautions can be discontinued when the offending microorganism is determined not to be communicable.

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P r o c e d u r e 2 . 4 Contact Precautions 25 R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for infection Social isolation related to isolation EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted to other patients or health-care workers ● Health-care professionals do not transmit infections to patients ●

EQUIPMENT/SUPPLIES

Gloves Contact isolation sign I M P L E M E N TAT I O N ➧ Instruct patient on contact precautions. Patient education about contact precautions may decrease feelings of anxiety, fear, stigma, and loneliness. ➧ Place patient in a private room. Keep door closed. Decreases exposure of other patients to infectious microorganisms. Closed door assists with maintaining negative pressure room. ➧ Don gloves (clean, nonsterile gloves are adequate) when entering

the room. Change gloves during patient contact if gloves become soiled or contaminated. Gloves provide a barrier between health-care professional and infected patient. Avoids skin contact with infected patient. ➧ Remove gloves immediately upon exiting the room. Prevents further contamination and spread of infectious microorganisms. Keeps any potential microorganisms in the patient’s environment. ➧ Wash hands. Removes any potential contamination and glove powder. Removes transient organisms. Promotes asepsis. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Health-care professionals and visitors wear gloves upon entering patient’s room

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26 C h a p t e r 2 Infection Control

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Patient diagnosis, infecting microorganisms, antimicrobial therapy. ● Isolation precautions implemented. ● Maintenance of contact precautions. ● Date, time, and precautions implemented when patient transported.

PROCEDURE 2.5 Airborne Precautions OVERVIEW ●

To prevent the transmission of microorganisms transmitted by droplets with nuclei smaller than 5 microns in size. These microorganisms are lighter and remain suspended in the air with the potential of wide air dispersion. P R E PA R AT I O N

Place patient in private room. If a private room is not available, infected patients can be cohorts. ● Keep door to room closed. ● Monitor negative air pressure in room. ● Ensure that room has 6 to 12 air exchanges per hour. ● Ensure appropriate discharge of air outdoors or ensure that a highefficiency filter is in place for room air that is recirculated. ●

Special Considerations • Isolation signs are a method of communicating isolation precautions to other health-care professionals and visitors. • Patient diagnosis should not be included on the isolation signs. • Patient transportation should be limited. • If a patient must be transported within the health-care environment, he or she should wear a mask during transport. • Isolation precautions can be discontinued when the offending microorganism is determined not to be communicable.

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P r o c e d u r e 2 . 5 Airborne Precautions 27 R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for infection Social isolation related to isolation EXPECTED OUTCOMES

Community-acquired and nosocomial infections are not transmitted to other patients or health-care workers ● Health-care professionals do not transmit infections to patients ● Nosocomial infections do not occur ● Masks worn upon entrance to patient’s room ●

EQUIPMENT/SUPPLIES

Masks Airborne isolation sign I M P L E M E N TAT I O N ➧ Instruct patient on airborne precautions. Patient education about airborne precautions may decrease feelings of anxiety, fear, stigma, and loneliness. ➧ Place patient in a private room or cohort. Keep door closed. Decreases exposure of other patients to infectious microorganisms. Closed door assists with maintaining negative pressure room. ➧ Don mask prior to entering patient’s room. Microorganisms of 5 microns or smaller are light and are considered to be dispersed throughout the patient’s room. ➧ Remove masks and other personal protective equipment prior to

leaving patient’s room. Prevents further contamination and spread of infectious microorganisms. Keeps any potential microorganisms in the patient’s environment. ➧ Wash hands. Removes any potential contamination and glove powder. Removes transient organisms. Promotes asepsis. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Health-care professionals and visitors wear a mask upon entering patient’s room

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28 C h a p t e r 2 Infection Control

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient diagnosis, infecting microorganism, antimicrobial therapy. ● Isolation precautions implemented. ● Maintenance of airborne precautions. ● Date, time, and precautions implemented when patient transported.

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U N I T

C H A P T E R

Assessment

3 Vital Signs 3.1 3.2 3.3 3.4

Assessing Body Temperature, 30 Assessing Heart Rate, 38 Assessing Respiratory Rate, 44 Assessing Blood Pressure, 47

2

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30 C h a p t e r 3 Vital Signs

PROCEDURE 3.1 Assessing Body Temperature OVERVIEW

Establish baseline data. Determine if core temperature is within normal range. ● Determine changes in core temperature in response to specific therapies (e.g., antipyretic medication, immunosuppressive therapy, invasive procedures). ● Monitor patients who are at risk for temperature alterations (those exposed to extreme temperatures; patients at risk for or with a diagnosis of infection; patients with a leukocyte count below 5000 or above 12,000). ● Most common sites for measuring body temperature are sublingual, rectal, axillary, and tympanic. ● Site most often used for body temperature measurement is sublingual. ● ●

P R E PA R AT I O N

Assess patient to determine appropriate method to obtain body temperature. ● For an oral temperature, obtain reading 15 to 30 minutes after ingestion of hot or cold food or fluids or smoking. ● Oral route is contraindicated if patient is unable to hold thermometer properly or if there is a risk that patient may bite thermometer. ● Rectal thermometer must be held securely in place and never left unattended. ●

TABLE 3.1 Comparing Fahrenheit and Centigrade Temperatures FAHRENHEIT (ºF)

CENTIGRADE (ºC)

96.8 97.7 98.6 99.5 100.4 101.0 102.2 103.1 104.0 To convert degrees F to degrees C subtract 32, then multiply by 5/9. To convert degrees C to degrees F multiply by 9/5, then add 32.

36.0 36.5 37.0 37.5 38.0 38.3 39.0 39.5 40.0

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P r o c e d u r e 3 . 1 Assessing Body Temperature 31

Special Considerations Pediatric Patients • Oral temperature measurement is not used on infants or small children. • Rectal temperature measurement is contraindicated in newborns. • Prevent infants and young children from kicking their legs or rolling to their side while the thermometer is in place. • Tympanic membrane thermometers quickly obtain a child’s temperature and may provide less of a threat to the child. Elderly Patients • Disturbances in temperature regulation that normally occur with aging can cause the older adult to have a lower-than-normal body temperature. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Ineffective thermoregulation Risk for altered body temperature EXPECTED OUTCOMES

● ●

Correct method for temperature assessment is performed Accurate temperature data is obtained E Q U I P M E N T/S U P P L I E S

Oral, rectal, axillary, or tympanic thermometer Probe covers if electronic thermometer is used Lubricant and tissue if rectal site is used Towel if axillary site is used Disposable gloves

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32 C h a p t e r 3 Vital Signs

FIGURE 3.1 Types of thermometers. (A) Glass thermometer.

(B) Electronic thermometer. (C) Tympanic-membrane thermometer (infrared). (D) Tape or other chemical/paper thermometer. I M P L E M E N TAT I O N ➧ Wash hands and apply disposable gloves. Reduces transmission of microorganisms. ➧ Explain procedure to patient. Reduces anxiety and promotes cooperation.

Variation 1: Oral Temperature Assessment Sublingual Temperature Using a Glass Thermometer ➧ Hold color-coded end of glass thermometer between fingertips. Prevents contamination of bulb to be inserted into patient’s mouth. ➧ Slowly rotate thermometer at eye level to read mercury level. Mercury is to be below 96⬚F (35.5⬚C). Thermometer reading must be below patient’s actual temperature before use. ➧ If mercury is higher than desired level, shake thermometer down-

ward. Hold upper end of thermometer securely between thumb and forefinger and stand away from solid objects. Sharply flick wrist downward until mercury is at appropriate level. Brisk shaking lowers mercury level in the glass tube. Standing in an open area away from objects prevents the breakage of the thermometer. ➧ Place thermometer in a plastic sheath according to agency policy. Prevents spread of microorganisms.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 33 ➧ Ask patient to open mouth and gently place thermometer at the

base of the tongue to the right or left of the frenulum, in the posterior sublingual pocket. Reflects the core temperature of the blood in the larger blood vessels. ➧ Ask patient to close the lips, not the teeth, around the thermometer. Maintains the proper position of the thermometer. Biting could cause the thermometer to break and can injure the oral mucosa and cause mercury poisoning. ➧ Leave the thermometer in place for 3 minutes or according to

agency policy. Minimum amount of time recommended obtaining an accurate reading with this type of thermometer. ➧ Carefully remove thermometer, discard plastic sheath, and read

results at eye level. Gentle handling prevents discomfort to patient and ensures an accurate reading.

Variation 2: Rectal Temperature Assessment Rectal Temperature ➧ Draw curtains around the patient’s bed and/or close the door. Keep

the patient’s upper body and lower extremities covered. This maintains privacy for the patient and minimizes patient embarrassment. ➧ Assist patient into Sims’ position, with the upper leg flexed to expose

anal area. Children may be placed in a prone position. This provides for optimal exposure of the anal area for correct placement of the thermometer. ➧ Squeeze a liberal amount of water-soluble lubricant onto a tissue.

Apply lubricant to the thermometer. Insertion of the thermometer into the lubricant container would contaminate contents of the container. Use of lubrication minimizes trauma to the rectal mucosa during insertion. ➧ With the nondominant hand, raise the patient’s upper buttock to

expose the anus. Full retraction of the buttocks completely exposes anus. ➧ Gently insert the thermometer into the anus in the direction of the

umbilicus. Insert the thermometer 11/2 in. (3.5 cm) for adults and 1/2 in. (1.2 cm) for infants or children. Do not force the thermometer. Ask the patient to take a deep breath and blow out. Insert the thermometer as the

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34 C h a p t e r 3 Vital Signs

patient takes in a breath. If resistance is felt, immediately remove the thermometer. Proper insertion of the thermometer ensures adequate exposure to the blood vessels in the rectal wall. Gentle insertion prevents trauma to the mucosa or the breakage of the thermometer. Having the patient take a deep breath helps to relax the anal sphincter. ➧ Hold the thermometer in place for a minimum of 2 minutes or

according to agency policy. It may be necessary to hold patient’s legs. Holding the thermometer in place prevents injury to the patient.

Variation 3: Axillary Temperature Axillary Temperature ➧ Draw curtains around the bed and/or close the door. Provides privacy and minimizes embarrassment for the patient. ➧ Assist the patient into a supine or sitting position. Move clothing away

from the patient’s shoulder and arm. Be sure the axillary area is dry. Provides optimal exposure of the patient’s axilla. ➧ Place the thermometer into the center of the patient’s axilla, lower

the arm over the thermometer, and place the patient’s forearm across the chest. Maintains the proper position of the thermometer against the blood vessels in the axilla. ➧ Hold the thermometer in place for; 5 to 10 minutes or according to

agency policy. The recommended time varies among agencies; 5 minutes is the time most often recommended for children. ➧ Remain with the patient and hold the thermometer in place if the

patient is unable to do so. Prevents injury to the patient. ➧ Remove the thermometer, remove plastic sheath, and read results

at eye level. Wash the thermometer in tepid, soapy water, rinse in cold water, and dry. Shake down the thermometer and return it to its container. Cleaning the thermometer after use reduces the spread of infection.

Variation 4 : Electronic Oral Temperature Assessment Electronic Thermometer: Oral Temperature ➧ Attach the oral probe (blue tip) to the electronic display unit. Grasp

the top of the stem, using caution not to apply pressure to the eject button. Ejection button releases the plastic cover from the probe.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 35 ➧ Slide a clean disposable plastic cover over the temperature probe

until it locks in place. The soft plastic cover will not break in the patient’s mouth and it prevents transmission of microorganisms between patients. ➧ Ask the patient to open mouth and gently place the probe under

the tongue, on either side of the frenulum. This ensures accurate reading. Use of correct techniques prevents injury to the patient. ➧ Have patient keep the probe in place until the alarm on the elec-

tronic thermometer sounds and the temperature reading appears on the digital display. Electronic units register the body temperature within seconds. ➧ Remove the probe from under the patient’s tongue, then push the

eject button on the thermometer probe to discard the plastic probe cover into the proper receptacle. This reduces the spread of infection. ➧ Replace probe in electronic unit. The battery unit is rechargeable.

Electronic Thermometer : Rectal Temperature ➧ Attach the rectal probe (red tip) to the electronic display unit, using

care not to apply pressure to the eject button. The ejection button releases the plastic cover from the probe. ➧ Slide the clean disposable plastic cover over the temperature probe

until it locks into place. This prevents the transmission of microorganisms. ➧ With the nondominant hand, raise the patient’s upper buttock to

expose the anus. This fully retracts the buttocks to expose the anus. ➧ Apply lubricant to the probe end of the thermometer. Lubricant minimizes trauma to the rectal mucosa during insertion of the thermometer. ➧ Gently insert the lubricated thermometer as previously described. Proper insertion of the thermometer ensures adequate exposure to blood vessels in the rectal wall. Gentle insertion prevents trauma to the mucosa, while deep breaths help to relax the anal sphincter. ➧ Hold the electronic probe in place until the electronic unit’s alarm

sounds and the temperature reading appears on the digital display. Electronic units register body temperature within seconds.

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36 C h a p t e r 3 Vital Signs ➧ Carefully remove the probe from the patient’s rectum. This avoids trauma to the rectal mucosa. ➧ Push eject button on the thermometer probe and discard the plastic

probe cover into the proper receptacle. This reduces the spread of infection. ➧ Replace the probe in the electronic unit. The battery unit is rechargeable.

Electronic Thermometer: Axillary Temperature ➧ Attach the rectal probe (red tip) to the electronic display unit as

instructed in the rectal thermometer. The ejection button releases the plastic cover from the probe. ➧ Slide the clean disposable plastic cover over the temperature probe

until it locks in place. This prevents transmission of microorganisms. ➧ Insert the probe into the center of the axilla, lower the patient’s arm

over the thermometer, and place the arm across the patient’s chest. Maintains the proper position of the thermometer against the blood vessels in the axilla. ➧ Hold the electronic probe in place until the electronic unit alarm

sounds and the temperature reading appears on the digital display. Electronic units measure the body temperature within seconds. ➧ Carefully remove the probe from the patient’s axilla and push the

eject button on the thermometer probe to discard the plastic probe cover into the proper receptacle. This reduces the spread of microorganisms between patients. ➧ Replace the probe in the electronic unit. The battery unit is rechargeable.

Electronic Thermometer: Tympanic Temperature ➧ Attach a disposable probe cover to the thermometer unit.

Different size sheaths fit adults and children. This reduces the spread of microorganisms. ➧ Select the ear opposite the side on which the patient has been lying. The ear lying against a surface can build up heat. ➧ Use the right hand to hold the thermometer when using the

patient’s right ear, the left hand for the left ear. This helps to achieve the proper angle for a good seal.

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P r o c e d u r e 3 . 1 Assessing Body Temperature 37 ➧ Gently pull the pinna upward and back for children older than age 3

and adults; straight back for children younger than age 3. This straightens the ear canal. ➧ Center the probe and gently advance into the ear canal to make a

firm seal, directing the probe toward the tympanic membrane. The pressure close to the tympanic membrane seals the ear canal and allows an accurate reading. ➧ Press and hold the temperature switch until the green light flashes

and the temperature reading is displayed. This method records core body temperature. ➧ Remove the thermometer and discard the probe cover. This reduces the spread of infection. ➧ Return the thermometer to its home base or storage unit for

recharge. The unit is rechargeable. ➧ Assist the patient to return to a comfortable position. This will restore the patient’s comfort. ➧ Record the patient’s temperature in the proper chart or flow sheet.

Signify rectal reading by a capital R and an axillary reading by a lower case a. Vital signs should be recorded immediately after measurement. R and a prevents later confusion with oral measurements. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare body temperature measurement with previous and baseline data ● Determine if measurement is within normal range for the patient ● Determine relationship to other vital signs ● Notify physician of abnormal findings ●

KEY POINTS ● ●

FOR

REPORTING

AND

RECORDING

Note the method of temperature measurement. Report abnormal temperature variations to the physician.

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38 C h a p t e r 3 Vital Signs

PROCEDURE 3.2 Assessing Heart Rate OVERVIEW

Provides valuable data regarding the integrity of the cardiovascular system. ● The most common sites of heart rate measurement are the apical and radial pulses. ● Other sites include temporal, carotid, brachial, femoral, popliteal, posterior tibial, and pedal pulses. ● The pulse is assessed for rate, rhythm, strength, and equality. ●

Temporal

Carotid

Brachial

Radial Ulnar

Femoral

Popliteal

Posterior tibial Dorsalis pedis

FIGURE 3.2A Sites commonly used for

assessing radial pulse.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 39 P R E PA R AT I O N

Patient should be resting for measurement. Factors such as exercise, anxiety, pain, and postural change should be controlled to obtain an accurate measurement of heart rate. ● Heart rate is affected by certain medications and disease processes. ● ●

Special Considerations Pediatric Patients • The most accurate site for pulse assessment in infants and small children is the apical site. Manubrium of sternum

Clavicle Angle of Louis

Midsternal line

Midclavicular line

Anterior axillary line Apical pulse before age 4 Apical pulse at ages 4 to 6

Body of sternum

Apical pulse in adult

FIGURE 3.2B Location of apical pulses for adults and children.

• Resting heart range for newborns ranges from 80 to 180 beats per minute. • Children 1 to 3 years of age have a resting heart rate that ranges from 80 to 140 beats per minute. Children 6 to 8 year olds have a resting heart rate that ranges from 75 to 120 beats per minute. • By 10 years of age, children have a resting heart rate that ranges from 50 to 90 beats per minute.

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40 C h a p t e r 3 Vital Signs

Elderly Patients • The resting heart rate should range between 60 and 100 beats per minute in the healthy older adult. • The healthy older adult has a normal cardiac rate and rhythm. • Older adults with cardiovascular, pulmonary, or other chronic illnesses are at risk for rapid, slow, or irregular heart rate and rhythms, and their heart rates should be assessed with an apical pulse. R E L E VA N T N U R S I N G D I A G N O S E S ●

Altered tissue perfusion related to cardiovascular disease EXPECTED OUTCOMES

● ●

Accurate assessment of heart rate Circulatory status is determined EQUIPMENT/SUPPLIES

Wristwatch with second hand or digital display Stethoscope (for apical heart rate) Pen, pencil, and flow sheet or record form I M P L E M E N TAT I O N

Assessing Radial Pulse ➧ Wash hands. Reduces transmission of microorganisms. ➧ Explain purpose and method of assessment to the patient. If the

patient was recently active, wait 5 to 10 minutes. This relieves patient anxiety and promotes cooperation. Activity and anxiety may increase patient’s heart rate. ➧ Have the patient get into a sitting or supine position. If in a

supine position, place the patient’s arm across lower chest with the wrist extended and palm down. If sitting, bend patient’s elbow 90 degrees and support the lower arm on a chair or your arm. Extend the patient’s wrist with the palm down. Proper positioning of the arm fully exposes the radial artery for palpation. ➧ Place the tips of the first two or three fingers of your hand over the

groove along the radial or thumb side of the patient’s inner wrist. The fingertips are the most sensitive parts of the hand to palpate arterial pulsations. Avoid use of the thumb because it has pulsation and may interfere with accuracy.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 41 ➧ Lightly compress your fingers against the radius, initially obliterate

pulse, and then relax the pressure so that the pulse becomes easily palpable. The pulse is assessed more accurately with moderate pressure. Too much pressure occludes the pulse and impairs the blood flow. ➧ When the pulse can be felt regularly, use a watch’s second hand or

seconds elapsed display and begin to count the rate, starting with 0, then 1, etc. The rate is accurately determined only after the assessor is certain that a pulse can be palpated. Timing should begin with 0 and the count of 1 is the first beat that is felt after the timing begins. ➧ If the pulse is regular, count for 30 seconds and multiply by 2. A 30-second pulse check is the most accurate for rapid pulse rates. ➧ If the pulse is irregular, count for 1 full minute. Counting for a full minute ensures an accurate count. ➧ Assess regularity and frequency of any dysrhythmia. Inefficient contraction of the heart fails to transmit a pulse wave and can interfere with cardiac output. ➧ Determine the strength of the pulse. Note whether the thrust of the

pulse against the fingertips is bounding, strong, weak, or thready. The strength of the pulse reflects the volume of the blood that is ejected against the arterial wall with each contraction of the heart. ➧ Assist patient to return to a comfortable position. Promotes comfort. ➧ Record characteristics of the pulse in the medical record or the flow

sheet. Report any abnormalities to the physician. This provides data for monitoring of changes in the patient’s condition. Detection of abnormalities may determine the need for medical intervention.

Assessing Apical Pulse ➧ Clean the earpieces and the diaphragm of the stethoscope with an

alcohol swab. This controls the transmission of microorganisms when nurses share a stethoscope. ➧ Wash hands. This reduces the spread of microorganisms. ➧ Explain procedure to patient. If patient was recently active, wait 10 to

15 minutes before obtaining measurement.

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42 C h a p t e r 3 Vital Signs This relieves anxiety and promotes patient cooperation. Activity and anxiety may increase the patient’s heart rate. ➧ Close the room door and/or draw curtains around the patient’s bed. This maintains patient privacy. ➧ With the patient in a supine or sitting position, remove patient’s

upper garments to expose the sternum and left side of the chest. This exposes the portion of the chest for selection of the auscultatory site. ➧ Palpate the point of maximal impulse (PMI), located at the fifth inter-

costal space to the left of the sternum at the midclavicular line. The use of anatomic landmarks allows the correct placement of the stethoscope over the apex of the heart. This position enhances the ability to hear heart sounds clearly. The PMI is located over the apex of the heart. ➧ Place the diaphragm of the stethoscope in the palm of your hand

for 5 to 10 seconds. This warms the diaphragm and reduces the risk for startling the patient. ➧ Place the diaphragm of the stethoscope over the PMI, and auscultate

for normal S1 and S2 (lub, dub) heart sounds. Heart sounds are the result of blood moving through the valves of the heart. ➧ When S1 and S2 sounds are heard with regularity, observe the

watch’s second hand and count one sound (lub) for 30 seconds, then multiply the number by 2. An accurate rate is determined only after the nurse is able to clearly auscultate the sounds. ➧ If the heart rate is irregular or the patient is on cardiovascular med-

ications, count for 1 full minute. The rate is determined more accurately when heard over a longer period. ➧ Replace patient’s garments. Provides comfort and privacy to the patient. ➧ Record characteristics of the pulse on the flow sheet. Report any

abnormalities to the physician. This provides data to monitor changes in the patient’s condition. Abnormalities may require medical intervention.

Assessing an Apical-Radial Pulse: Two-Nurse Technique ➧ Explain the procedure to the patient. This decreases the patient’s anxiety. ➧ Assist the patient into a supine position, and expose the chest area. This exposes the portion of the chest wall for the site of the apical pulse.

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P r o c e d u r e 3 . 2 Assessing Heart Rate 43 ➧ Place a watch where it will be seen by both nurses. This facilitates accuracy in the beginning and the ending. ➧ Position one nurse to take the radial pulse. Locates the radial pulse. ➧ The second nurse places the stethoscope on the patient’s chest at

the fifth intercostal space to the left of the sternum at the midclavicular line. Locates the apical pulse. ➧ The nurse taking the radial pulse states “Start” when ready to begin

and “Stop” when completed. This ensures that both counts are done simultaneously. ➧ Both nurses count the pulse for 1 full minute at the same time. Counting for 1 full minute is necessary for an accurate assessment of any discrepancies that may exist between the two sites. ➧ Compare the rates obtained. If a difference is noted between the

rates, subtract the radial rate from the apical rate. This determines if a pulse deficit exists. A pulse deficit represents the number of ineffective or nonperfused heartbeats. ➧ Replace the patient’s clothing, and place patient in position of

comfort. This restores patient’s privacy. ➧ Notify the physician if a pulse deficit was noted. Provides prompt medical intervention. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Monitor patient’s response to activity, and note any abnormalities Determine if external factors such as exercise, anxiety, pain, and postural change may have affected measurements ● Report any abnormal findings to physician ● ●

KEY POINTS ●

FOR

REPORTING

Pulse rate, rhythm, and strength. Patient’s condition. ● Any change in patient’s condition. ●

AND

RECORDING

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44 C h a p t e r 3 Vital Signs

PROCEDURE 3.3 Assessing Respiratory Rate OVERVIEW

Establish baseline data. Monitor respiratory rate, depth, and rhythm. ● Assess patient for presence of dyspnea or cyanosis. ● Assess for abnormal lung sounds, such as rales, rhonchi, or wheezes. ● Note respiratory rate, rhythm, and depth. ● Note labored, difficult, or noisy respirations or cyanosis. ● Identify alterations in respiratory pattern resulting from disease conditions. ● Assess if accessory muscles are used for breathing. ● ●

P R E PA R AT I O N

Assess rate when patient is at rest. Special Considerations Pediatric Patients • Respirations range from 30 to 80 per minute in newborns. Children 1 to 3 years of age have a normal respiratory range of 20 to 40 breaths per minute. Children 6 to 8 years olds have respiratory rates that range from 15 to 25 breaths per minute, as do 10-year-old children. Elderly Patients • Chronic illness in the older population can affect respiratory patterns. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired gas exchange Ineffective breathing pattern EXPECTED OUTCOMES

● ●

Accurate respiratory data are obtained Patient exhibits regular rate, depth, and rhythm of respirations EQUIPMENT/SUPPLIES

A watch with a second hand

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P r o c e d u r e 3 . 3 Assessing Respiratory Rate 45 I M P L E M E N TAT I O N ➧ Place the patient in a position of comfort, preferably sitting. Discomfort can cause the patient to breathe more rapidly. ➧ Place the patient’s arm in a relaxed position across the abdomen or

lower chest, or place your hand directly over the patient’s upper abdomen. This is the same position used during the assessment of the pulse. Both the patient’s and the nurse’s hands rise and fall during the respiratory cycle. Measurement of the respirations is done immediately after the pulse assessment and is not perceived by the patient. ➧ Observe the complete respiratory cycle (consists of one inspiration

and one expiration). This ensures that the count will begin with a normal respiratory cycle. ➧ Once a cycle is observed, monitor the watch’s second hand and

begin to count the rate of respirations. When the second hand reaches a number on the dial, count “one” to begin the first cycle. Timing of the respirations begins with a count of 1. Respirations occur more slowly than the pulse; therefore, the count begins with 1. ➧ For adults, count the number of respirations in 30 seconds, then

multiply by 2. For infants or young children, count the respirations for 1 full minute. The respiratory rate is equivalent to the number of respirations per minute. ➧ If an adult’s respirations have an irregular rhythm or they are

abnormally fast or slow, count for 1 full minute. This ensures an accurate measurement. ➧ While counting, note whether the depth of respirations is shallow,

normal, or deep and whether the rhythm is regular or altered. The character of ventilatory movements may indicate specific alterations in respirations or disease states. ➧ Record the results in the chart or the flow sheet. Report any signs

of respiratory alterations to the physician. This provides data to monitor for changes in the patient’s condition. Abnormalities require medical intervention.

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46 C h a p t e r 3 Vital Signs

TABLE 3.3 Respiratory Rates and Rhythms TYPE

DESCRIPTION

ILLUSTRATION

Respirations that are regular but abnormally deep and increase in rate Biot’s respira- Periods of respiration of equal depth, altertion nating with periods of apnea (absence of breathing) Cheyne-Stokes Gradual increase in depth of respirations, respiration followed by gradual decrease and then a period of apnea Absence of breathing Apnea Kussmaul’s respiration

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess the patient’s respiratory status, and compare to baseline Compare the respiratory rate with the pulse and blood pressure measurements

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Respiratory rate, depth, and rhythm. Use of accessory muscles. ● Abnormal breath sounds. ● Respiratory status. ● Alterations from baseline respiratory patterns. ●

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 47

PROCEDURE 3.4 Assessing Blood Pressure OVERVIEW

Establish a baseline measurement of arterial blood pressure for subsequent evaluation. ● Determine the patient’s hemodynamic status (e.g., stroke volume of the heart and blood vessel resistance). ● Identify and monitor changes in blood pressure resulting from a disease process and medical therapy (e.g., presence or history of cardiovascular disease, renal disease, circulatory shock, or acute pain; rapid infusion of fluids of blood products). ●

P R E PA R AT I O N

Readings reflecting a 20-mm Hg change in blood pressure should be reported. ● Although a diastolic pressure can be obtained by palpation, frequent errors occur in obtaining results. ● If the patient has had a mastectomy or has a hemodialysis shunt or IV infusion, avoid taking blood pressure in the affected extremity. ●

Special Considerations Pediatric Patients • Newborns have a mean systolic pressure of about 75 mm Hg. • The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat. • One quick way to determine the normal systolic blood pressure of a child is to use the following formula: Normal systolic BP ⫽ 80 ⫹ (2 ⫻ child’s age in years). Elderly Patients • In older people, elasticity of the arteries is decreased—the arteries are more rigid and less yielding to the pressure of the blood. • This produces an elevated systolic pressure. • Because the walls no longer retract as flexibly with decreased pressure, the diastolic pressure is also higher. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Decreased cardiac output related to low blood pressure Excess fluid volume

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48 C h a p t e r 3 Vital Signs EXPECTED OUTCOMES

Blood pressure is accurately assessed within normal range for the individual patient. ● Severely altered blood pressure readings are rechecked with different equipment or validated by another nurse. ● Alterations in blood pressure are identified early, and appropriate treatment is initiated. ●

E Q U I P M E N T/S U P P L I E S

Sphygmomanometer with proper-size cuff Stethoscope I M P L E M E N TAT I O N ➧ Check to determine if patient smoked or had caffeine prior to blood

pressure assessment. This allows the nurse to assess blood pressure accurately and to identify significant changes. ➧ Instruct patient to refrain from both prior to measurement. ➧ Determine the proper cuff size for the patient. The bladder should

completely encircle the arm without overlapping. The cuff should be long enough to encircle the arm several times. Proper cuff size is required for the correct amount of pressure to be applied over the artery. ➧ Determine the best site for the

cuff placement. Application of pressure from an inflated cuff can temporarily impair blood flow and compromise patient’s circulation.

FIGURE 3.4 Site for blood

pressure cuff placement.

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 49 ➧ Explain the purpose of the procedure to the patient. This reduces anxiety. ➧ Wash hands. Reduces spread of microorganisms. ➧ Assist the patient to a comfortable sitting position, with the upper

arm slightly flexed, the forearm supported at heart level, and the palm turned up. Placing the arm above the level of the heart produces false-low readings. This position facilitates cuff application. ➧ Fully expose the patient’s upper arm. This ensures proper cuff placement. ➧ Palpate the brachial artery (on the lower medial side of the biceps

muscle) and position the cuff 1 in. (2.5 cm) above the pulsations. The stethoscope will be placed over the artery without touching the cuff. ➧ Center the arrows marked on the cuff over the brachial artery. Inflating the bladder directly over the brachial artery ensures that proper pressure is applied during inflation of the cuff. ➧ With the cuff fully deflated, wrap it evenly and snugly around the

upper arm. A loose-fitting cuff will cause a false elevation in the blood pressure measurement. ➧ Keep manometer at eye level.

The nurse should be no more than approximately 1 yard away. This ensures accurate reading of the mercury level. ➧ Palpate the brachial or radial artery while rapidly inflating the cuff.

Inflate to a pressure 30 mm Hg above the point at which the pulse disappears. Slowly deflate the cuff, and notice when the pulse reappears. This identifies the patient’s approximate systolic pressure and determines the maximal inflation point for an accurate reading. It also prevents an auscultatory gap. ➧ Place the stethoscope earpieces in the ears, and be sure that sounds

are clear, not muffled. Each earpiece should follow the angle of the ear canal to facilitate hearing.

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50 C h a p t e r 3 Vital Signs ➧ Deflate the cuff, and wait 30 seconds. Prevents venous congestion and false-high readings. ➧ Relocate the brachial artery, and place the diaphragm of the stetho-

scope over it. Ensures optimal reception of sound. ➧ Close the valve of the pressure bulb by turning it clockwise until

tight. Prevents air leaking during inflation. ➧ Inflate the cuff to 30 mm Hg above the patient’s palpated systolic

level. This ensures an accurate pressure measurement. ➧ Slowly open the valve and allow the mercury to fall at a rate of 2 to

3 mm Hg per second. A decline in mercury that is too fast or too slow may lead to an inaccurate measurement. ➧ Note the point on the manometer when the first clear sound is

heard. The first Korotkoff sound indicates the systolic pressure. ➧ Continue to deflate the cuff gradually making note when the muf-

fled or dampened sound appears, and the point on the manometer when the sound disappears in adults. (Note the pressure to the nearest 2 mm Hg.) A fourth Korotkoff sound may be detected as a diastolic pressure in adults with hypertension. ➧ Continue to deflate the cuff, noticing the point to the nearest 2 mm

Hg when the sound disappears. The fifth Korotkoff sound is recommended as the diastolic reading in an adult. ➧ Deflate the cuff rapidly and remove from the patient’s arm, unless

the measurement needs to be repeated. Continuous inflation causes arterial occlusion, which will result in numbness and tingling of the patient’s arm. ➧ If the procedure needs to be repeated, wait 30 seconds. This prevents venous congestion and a false-high reading. ➧ Fold the cuff and store it in its proper place. Proper maintenance of the equipment contributes to the accuracy of the instrument.

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P r o c e d u r e 3 . 4 Assessing Blood Pressure 51 ➧ Assist the patient to a comfortable position and cover upper arm. Promotes comfort. ➧ Record findings on the medical record or the flow sheet. This documents the procedure and the patient’s status.

Blood Pressure by Palpation ➧ Explain the procedure to the patient This decreases anxiety and promotes patient cooperation. ➧ Wash hands. Prevents transmission of microorganisms. ➧ Locate the patient’s brachial or radial pulse. This locates the pulse that offers the best palpable volume for the procedure. ➧ Place the cuff on the patient’s arm. This will position the cuff for inflation. ➧ Palpate again for the pulse. When the pulse is felt, continue to

palpate. This relocates the pulse for the procedure. ➧ Inflate the cuff until unable to palpate the pulse. This occludes the arterial blood flow. ➧ Inflate the cuff until the measurement gauge is 20 mm Hg past the

point at which the pulse was lost on palpation. This identifies the point of pulse return. ➧ Slowly deflate the cuff at a rate of 2 to 3 mm Hg per second. This prevents the nurse from missing the first palpable beat. ➧ Note the reading on the measurement gauge when the pulse

returns. Remove cuff from the patient’s arm. This identifies the systolic blood pressure reading. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare blood pressure measurement to baseline Note if blood pressure measurement is appropriate for age and health status ● Note the relationship of the blood pressure measurement to pulse and respirations ● ●

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52 C h a p t e r 3 Vital Signs

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Document blood pressure measurement on appropriate form. Report significant change in the patient’s blood pressure to physician. ● Method of blood pressure measurement. ● Patient’s condition. ●

C H A P T E R

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4 Physical Assessment 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11

Assessing the Eyes, 54 Assessing the Ears, 61 Assessing the Nose and Sinuses, 67 Assessing the Mouth and Pharynx, 71 Assessing the Neck, 75 Assessing the Thorax and Lungs, 78 Assessing the Heart and Vascular System, 86 Assessing the Musculoskeletal System, 96 Assessing the Abdomen, 100 Assessing the Neurologic System, 105 Assessing the Skin, Hair and Scalp, and Nails, 115

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54 C h a p t e r 4 Physical Assessment

PROCEDURE 4.1 Assessing the Eyes OVERVIEW

The eyes are the sensory organ of vision. They allow humans to be an integral part of the world. ● Careful assessment of the eyes and vision is essential for promoting health and well-being. ●

P R E PA R AT I O N ●

Review related history including • Vision difficulty, photophobia. • Eye pain; external eye problems, such as excessive tearing; discharge; entropion; and ectropion. • Glaucoma. • Use of glasses or contact lenses.

Special Considerations Pediatric Patient • Special accommodations must be made for the evaluation of visual acuity in children, adults who cannot read, and those patients who do not speak English. Often, the Snellen E chart can be used, and the patient can point a finger in the direction that the legs are facing. Picture cards can also be used. A translator or family member can translate directions. • In examining the eyes of infants and children, it is important to remember that a child does not achieve 20/20 vision until the age of 6 or 7. Color vision should be tested once between the ages of 4 and 8. Testing for strabismus is an important screening to perform in early childhood, to receive the best prognosis. A funduscopic examination is difficult to perform on infants, but the red reflex and pupillary response to light should be checked. School-age children’s funduscopic examinations can be performed using the same procedure as that for adults. Elderly Patient • The loss of elasticity in the skin may make the lids appear heavier and the eyes appear sunken. • Decreased tear production causes the eye to look and feel dry. • Central acuity and peripheral vision may decrease as well. • Cataract formation, glaucoma, and macular degeneration are more prevalent in the aging population. • Careful assessment is imperative to maintain adequate vision in these populations.

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P r o c e d u r e 4 . 1 Assessing the Eyes 55 EXPECTED OUTCOMES

Completion of the eye examination while maintaining the patient’s comfort ● Examination adjusted for age, and developmental and educational levels ●

R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible disturbed sensory perception: visual EQUIPMENT/SUPPLIES

Snellen eye chart Near-vision card (Jaeger card) or newsprint Opaque cover card Penlight Ophthalmoscope

FIGURE 4.1 Ophthalmoscope.

I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Explain procedure to patient. Careful explanation reduces the patient’s anxiety. ➧ To test visual acuity. ●

Check distance vision using the Snellen eye chart.

●

Position the patient exactly 20 feet from the chart.

●

If patient wears corrective lenses, conduct the test with them on.

This is the most common and accurate measure of visual acuity. Ensures accurate measurement of visual acuity.

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56 C h a p t e r 4 Physical Assessment Only remove reading glasses because they will blur the patient’s far vision. Record results and make sure to state the results were with corrective lenses in place. ●

Direct patient to cover one eye with the opaque card and read the smallest line possible. Record the result as 20 (distance from the chart) over the number beside the smallest line of print the patient can read with at least half the numbers correct.

●

Repeat for opposite eye.

●

Check near vision in patients who are older than 40 years or in those complaining of reading difficulty.

Evaluates each eye separately.

Near vision is most commonly impaired in people who are older than 40 years. Use near vision card or newsprint to evaluate near-vision acuity. ●

Place the Jaeger card 14 inches in front of the patient’s face.

●

If patient wears corrective lenses, conduct the test with them on.

●

Direct patient to cover one eye with the opaque card and read the smallest line possible.

●

Repeat for opposite eye.

●

Have patient hold and read from newsprint at a comfortable distance.

Ensures accurate measurement of visual acuity. Allows evaluation of corrected vision.

Record the results as J1 through J12 as indicated on the chart. Evaluates each eye separately.

Record the type of reading material and the distance held from the face. ➧ Test visual fields by performing the confrontation test. This test is a gross measure of peripheral vision. It compares the patient’s peripheral with the examiner’s. ●

Position yourself at eye level and about 2 feet away from the patient.

●

Direct the patient to cover one eye with the opaque card and to look straight at you with his or her left eye. Cover your eye opposite to the patient’s covered one.

●

Hold a raised finger or pen midline between you and the patient and slowly advance it from the periphery in several directions (temporal, nasal, superior, and inferior).

Allows the patient and examiner to have the same field of vision.

Allows the patient and examiner to have the same field of vision.

Provides a focus target; tests all peripheral vision fields except the temporal in which the object should come from slightly behind the patient’s head. ●

Have the patient say “now” as the target is first seen; this should be just about the time that you see the object also. Compares the patient’s peripheral vision to your own.

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P r o c e d u r e 4 . 1 Assessing the Eyes 57 ●

Repeat the entire procedure for the opposite eye. Tests peripheral vision of both eyes.

➧ Test extraocular muscle function. ➧ Check corneal light reflex. Assesses the parallel alignment of the eyes.

Instruct the patient to stare straight ahead while you shine a light into his or her eyes from 30 cm (12 inches) away. ● Note the location of the light reflection on the corneas; it should be in exactly the same spot in each eye. ●

Allows detection of any deviation in alignment due to eye muscle weakness or paralysis. ➧ Check for coordinated movement of the eyes. Elicits any eye muscle weakness during movement. ●

Direct patient to hold head still and follow your finger only with his or her eyes as it moves.

●

Hold your finger about 30 cm (12 inches) in front of the patient.

●

Slowly move your finger from the center out to each of the six cardinal fields of gaze, hold it momentarily, and then move it back to center.

Encourages eye movement only. Allows the patient to focus comfortably on the object.

Allows detection of any eye movement that is not parallel. Also detects nystagmus and lid lag. ●

Observe for a normal response, which is parallel tracking of the finger with both eyes. An abnormal response indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

➧ Check for convergence. Elicits any eye muscle weakness during movement. ●

Have the patient watch your finger as it is moved from in front of the eyes to the bridge of the nose.

●

Observe for medial movement of both eyes.

Encourages a focal point of vision. Elicits an asymmetric response if abnormal. ➧ Inspect the external eye structures. ●

Note eyelids and lashes. Note any visible sclera above the iris, closure, or lesions. Note distribution and direction of lashes.

●

Note the position of the globe. Protrusion may be indicative of thyroid disorder; sunken eyes may be indicative of dehydration or wasting illness.

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58 C h a p t e r 4 Physical Assessment ●

Note the conjunctiva and sclera.

●

Note the lacrimal gland.

Indicative of local infection, hemorrhage, or jaundice. Redness, swelling or excessive tearing may indicate blockage of the nasolacrimal duct. ➧ Inspect the anterior eye structures. Provides an evaluation of the anatomic structures involved in sight. ●

Check the clarity of the cornea by shining a light from the side onto each eye. This oblique view allows detection of any irregularities in the corneal surface such as opacities or irregular ridges in the reflected light.These findings may be indicative of fluid accumulation or a corneal abrasion, respectively.

●

Note the shape and coloration of the irises. Compare the irises bilaterally. May indicate infection, glaucoma, or abnormalities in the pupils.

➧ Inspect the pupils for color, size, and equality. Abnormalities may indicate cataracts or neurologic problems. ➧ Test the pupillary response to light. Abnormalities may indicate neurologic problems. ●

Have the patient look into the distance, then shine a light on each pupil in turn. Make sure to advance the light from the side to directly in front of the pupil. Bringing the light in from the side will elicit a true light reflex. If the light is advanced from the front, the eyes will constrict to accommodate for near vision.

●

Observe for constriction of the pupil into which the light was shown (direct response) and for the simultaneous constriction of the other pupil (consensual response). These responses provide information on the central nervous system and the effect of certain drugs, including narcotics and anticholinergics.

➧ Test for accommodation. Elicits vision problems or eye muscle weakness. ●

Direct the patient to focus on an object in the distance, then have the person focus on your finger held 8 to 10 cm (3–4 inches) from the nose. Focusing on distant objects dilates the pupils, whereas focusing on near objects constricts the pupils.

●

Observe the patient for pupillary constriction and convergence. Absence of constriction or convergence indicates a problem with vision and/or eye muscle weakness.

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P r o c e d u r e 4 . 1 Assessing the Eyes 59 ➧ Examine the ocular fundus (retina, optic disk, macula, and retinal

vessels) in a darkened room using an ophthalmoscope. Perform this examination to view the inner structures of the eye. This is the only place in the body where you can directly view the blood vessels that are affected in systemic diseases, namely hypertension. ●

Remove eyeglasses worn by either the patient or you. Eyeglasses obstruct close movement, and you can adjust the diopter setting to correct your vision.

●

Select a large, round aperture with white light for routine examination. The light used should have maximum brightness to facilitate an adequate examination.

●

Hold the ophthalmoscope in your right hand up to your right eye to examine the patient’s right eye while placing your free hand on the patient’s forehead. This position allows you to gain close proximity to your patient while your free hand helps to orient you and secure the patient’s upper lid to help prevent blinking.

●

Have the patient focus on a distant fixed object. Staring at a distant object helps to dilate the pupils and hold the retinal structures still.

●

Begin the examination about 10 inches from the patient slightly lateral to the patient’s field of vision; note the red reflex and steadily move closer to the eye. The red reflex is caused by the reflection of the light of the ophthalmoscope off the retina; any variations such as dark or black spots may indicate cataracts.

●

Continue moving in along a 15-degree lateral line to locate the optic disk, which is to the nasal side of the retina; it can also be found by following a blood vessel as it enlarges.

●

Focus on the optic disk, and note its color, shape, margins, and cupdisk ratio.

The larger retinal vessels converge at the optic disk.

The disk should be creamy yellow-orange to pink, round or oval, with distinct margins. The cup-disk ratio may vary, but is normally not greater than one half the disk diameter. Variations in color and margins may indicate pallor or differences in pigmentation. ●

Note the retinal arterioles and veins (darker and larger than arterioles). Observe their branching pattern, contour, and integrity. Many systemic diseases that affect the vascular system show signs in the retinal vessels. Narrowed, discolored, and/or nicked vessels are some of the most significant evidence of hypertension and arteriosclerosis.

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60 C h a p t e r 4 Physical Assessment ●

Examine the general background of the fundus. Color should be consistent with the patient’s skin color; look for lesions, exudates, or microaneurysms.

●

Last, locate the macula, which should be 2 disc diameters (DD) temporal to the disc. Examine this structure last, because it may cause watering and discomfort. Clumped pigment in the macula may indicate trauma or retinal detachment. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

● ●

Compare assessment findings to normal Refer patient to optometrist or ophthalmologist as needed for evaluation of abnormal findings

KEY POINTS ● Visual

FOR

REPORTING

AND

RECORDING

acuity results for the left eye (O.S.) and right eye (O.D.) separately. For Snellen chart, record the result as 20 over the number beside the smallest line of print the patient can read with at least half the numbers correct. For the Jaeger chart, record the results as J1 through J12 as indicated. ● Results of visual confrontation test, extraocular movements, normal or abnormal findings. ● Symmetry of corneal light reflex, eyelids. ● Color of conjunctiva and sclera, and any abnormal findings during the external eye examination. ● Pupillary findings: if normal, may chart PERRLA (pupils equal, round, reactive to light, and accommodation); if abnormal, chart findings. ● Fundi findings—shape, margins, vessels, ability to see macula. Document any abnormal findings in the fundus by noting the clock position and relation to the optic disk in terms of size and distance. Example: Noted at 2 o’clock 3 DD from the disk. ● Visual acuity results. ● Patient’s use of corrective lenses or glasses and vision with “corrected” noted.

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P r o c e d u r e 4 . 2 Assessing the Ears 61

PROCEDURE 4.2 Assessing the Ears OVERVIEW

Plays an important role in the function of the ear as the sensory organ for hearing and maintaining equilibrium. ● Can help determine if hearing, equilibrium, or even speech problems stem from the ear, or if the neurologic system may be involved. ●

P R E PA R AT I O N

Review related history that would give the examiner information (past and present) regarding patient’s hearing and general ear condition, including earaches, infections, tinnitus, vertigo, and speechdevelopment problems. ● Ask about the intake of ototoxic drugs such as aspirin, furosemide, quinine, and aminoglycosides (gentamycin, vancomycin). ● Observe for signs of hearing loss during all interactions with the patient. ● Adjust your examination for the developmental and cultural needs of the patient. ●

Special Considerations • Never insert a speculum if a foreign object is seen in the external auditory canal. Pediatric Patient • In infants and children, otoscopic examination is best done at the end of the complete assessment, because children tend to protest. Make sure the child is securely restrained, preferably in the caretaker’s lap, to prevent head movement during the examination. Remember to pull the pinna straight down and back in children younger than 3 years old to match the direction of the ear canal. The tympanic membranes of a child may appear reddened and swollen, especially after crying. A pneumatic bulb may be used in children to introduce air into the canal and examine the mobility of the tympanic membrane. • Use developmental milestones to assess hearing in an infant. Loud, sudden sound should produce: • Newborn—startle reflex, acoustic blink reflex • 3–4 months—acoustic blink reflex, infant stops movement • 6–8 months—turns head toward sound, responds to own name • Delayed speech development can indicate a hearing problem in children.

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62 C h a p t e r 4 Physical Assessment

Elderly Patient • Elderly patients may have more pendulous earlobes; men may have coarse hairs present at the opening of the ear canal; the eardrum may appear whiter, thicker, and more opaque than in younger patients. • Presbycusis, the hearing loss that occurs with aging, affects the highfrequency tones. • This condition may become apparent in the whispered test and in difficulty hearing consonants during conversation. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible disturbed sensory perception: auditory EXPECTED OUTCOMES

Completion of the assessment, including examination of the external ear, internal ear, hearing, and equilibrium while maintaining patient comfort and safety ● Examination performed appropriately for age, and developmental and educational levels ●

EQUIPMENT/SUPPLIES

Otoscope with bright white light Pneumatic bulb attachment (optional) Tuning fork (512 or 1024 Hz)

FIGURE 4.2A Otoscope.

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P r o c e d u r e 4 . 2 Assessing the Ears 63

FIGURE 4.2B Tuning fork.

I M P L E M E N TAT I O N ➧ Inspect the external ear. Provides information and evidence of infection, deformities, trauma, or systemic problems. ●

Note placement, size, shape, symmetry of placement, and skin color. Abnormal size or placement of ears is associated with some genetic disorders; reddened ears may indicate inflammation, whereas red-blue color indicates frostbite. Ecchymosis behind the ear (Battle’s sign) may indicate basilar skull fracture.

●

Observe for drainage, swelling, lumps, and lesions. These signs are often found in infection, dermatitis, or carcinoma.

➧ Palpate the external ear for nodules and tenderness. Uncovers abnormalities that cannot be seen. ●

Move the pinna, push on the tragus, and press on the mastoid process. These maneuvers elicit pain and tenderness with otitis externa, mastoiditis, or trauma.

➧ Inspect the external auditory meatus noting the size of the opening,

any redness, swelling, or discharge Cerumen may be present, but other discharge may indicate infection. ➧ Examine the ear canal and eardrum using the otoscope. Provides a thorough examination of the ear that cannot be examined with the naked eye ●

Choose the largest speculum that will fit comfortably in the ear canal. Slightly tilt the patient’s head to the opposite shoulder of the ear that is being examined This will provide the best view of the eardrum.

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64 C h a p t e r 4 Physical Assessment ●

Pull the pinna up and back in an adult using your nondominant hand. Maintain this position until the otoscope is removed. Pulling the pinna up and back in the adult helps to straighten the ear canal.

●

Hold the otoscope in your dominant hand in an upsidedown position with the back of your hand braced on the patient’s cheek. This position helps to prevent forceful insertion and also stabilizes your hand in case the patient’s head moves.

●

FIGURE 4.2C Otoscope in sertion. Insert the speculum slowly, avoiding the medial wall, which is sensitive to pain. Observe the canal for redness, swelling, discharge, foreign bodies, and lesions.

Redness, swelling, and purulent discharge suggests otitis externa or otitis media with a ruptured eardrum. Frank blood or clear, watery fluid following trauma is associated with basal skull fracture. ●

Inspect the eardrum, noting the color, contour, and integrity of the eardrum. Normally the eardrum is shiny, translucent, pearl-gray. Other colors indicate infection, or the accumulation of serous fluid behind the eardrum. A perforated eardrum presents as a dark oval area or a larger opening on the drum.

●

Observe the umbo, the handle of the malleus, and the cone of light (noted at 5 o’clock in the right drum and at 7 o’clock in the left drum. Absent or distorted landmarks indicate fluid accumulation or a ruptured eardrum.

pars flaccida malleous umbo pars tensa

cone of light FIGURE 4.2D Eardrum.

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P r o c e d u r e 4 . 2 Assessing the Ears 65 ➧ Clean off any discharge or change the speculum, and repeat the

procedure for the other ear. Helps to prevent contamination of the other ear with possibly infectious material. ➧ Test hearing acuity. Tests conductive hearing as well as cranial nerve VIII. ➧ Voice Test (Whisper Test) Tests gross acuity of hearing. ●

Direct patient to occlude one ear by placing his or her finger on the tragus and rapidly push it in and out of the auditory meatus.

●

Have the patient repeat each word after you say it.

●

Repeat for the other ear.

This will mask the hearing in that ear while hearing is tested in the other ear. Verifies that the patient correctly heard the whispered word. Tests gross acuity in both ears. ➧ Weber Test Tests lateralization of sound. ●

Gently strike the tines of a tuning fork against your other hand.

●

Place the vibrating tuning fork on the midline of the patient’s skull. Ask the patient where the tone is heard: left ear, right ear, or both.

Sets the tuning fork vibrating.

Tests bone conduction through the skull; it should sound equally loud in both ears.

FIGURE 4.2E Weber test.

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66 C h a p t e r 4 Physical Assessment ➧ Rinne Test Compares air conduction and bone conduction of sound. ●

Place the base of a vibrating tuning fork on the patient’s mastoid process; have the person signal when the sound is no longer heard. Determines the length of bone conduction.

●

When the tone is no longer FIGURE 4.2F Rinne test. heard, quickly move the fork so that the tines are near the ear canal. Ask the patient if the tone is heard, and direct him or her to signal when it ends.

●

Compare the time of bone conduction to the time of air conduction.

Determines the length of air conduction.

Normally, air conduction is twice as long as bone conduction; variations from normal may indicate a conductive or sensorineural hearing loss. ➧ Perform the Romberg test. Tests the ability of the vestibular apparatus in the inner ear to help maintain standing balance. ●

Direct the patient to stand with feet together and arms at the sides, then have the person close his or her eyes and hold the position. Normally, the patient is able to maintain this position without swaying or falling for at least 20 seconds. A positive Romberg test (loss of balance) may indicate inner-ear problems or a problem with the cerebellum. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

● ●

Compare assessment findings to normal Refer patient to an audiologist or physician for further testing and evaluation of abnormal findings if needed

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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 67

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Abnormal

findings in assessment, including the use of a hearing aid. ● Symmetry of external ears; redness, scaling, discharge, masses, or tenderness noted on examination of the external ear and canals. ● Characteristics of the tympanic membrane, such as color, ability to see landmarks, integrity of the membrane. ● Whispered words repeated correctly or incorrectly. ● Results of Weber test—normally tone heard midline without lateralization ● Results of Rinne test—normally AC (air conduction) ⬎ BC (bone conduction) 2:1. ● Results of Romberg test—normally negative (no swaying). ● Use of hearing-aid device. ● Any consultations recommended.

PROCEDURE 4.3 Assessing the Nose and Sinuses OVERVIEW

The nose is the first segment of the respiratory system and is multifunctional. • As inspired air passes through the nasal mucosa, nasal turbinates, and nasal hairs, it is heated, humidified, and filtered. • The nose is also the sensory organ for smell. ● The sinuses lighten the skull, serve as resonators for sound, and provide mucus, which drains into the nasal cavity. ● Assessment of these areas offers insight to respiratory complaints as well as problems involving the ears, throat, and even headaches. ●

P R E PA R AT I O N ●

Review related history that would give the examiner information (past and present) regarding patient’s sense of smell and general information regarding the nose and sinuses, including allergies, epistaxis, nasal discharge, frequent colds, trauma or surgery, and sinus pain.

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68 C h a p t e r 4 Physical Assessment

Ask about the use of nasal sprays and intranasal use of cocaine or amphetamines. ● Cranial nerve I is usually not tested in a routine examination. If the sense of smell is tested, it can be performed while assessing the nose or while assessing the neurologic system. ●

Special Considerations Pediatric Patient • Most newborns are obligate nose breathers, and, therefore, special attention must be given to the patency of the nares. Often, nasal flaring is a sign of respiratory distress. • Avoid the nasal speculum in infants and young children; simply push the tip of the nose up and shine the light into the nares. • Only palpate the sinuses in children 8 and older; in younger children the sinuses are too small for palpation. • In toddlers, pay special attention to the possibility of foreign bodies lodged in the nasal cavity. Pregnant Patient • Nasal stuffiness and epistaxis may occur during pregnancy because of the increased vascularity in the upper respiratory tract. Elderly Patient • In older patients, the nose may appear larger, with the growth of especially coarse nasal hairs. The sense of smell may be diminished, and the nasal mucosa may become drier, making these patients more prone to nosebleeds. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Possible disturbed sensory perception: olfactory Possible ineffective airway clearance EXPECTED OUTCOMES

Completion of the examination while maintaining the patient’s comfort ● Examination performed appropriately for age, and developmental and educational level ●

EQUIPMENT/SUPPLIES

Otoscope with short, wide nasal tip or nasal speculum and penlight Small samples of familiar odors

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P r o c e d u r e 4 . 3 Assessing the Nose and Sinuses 69 I M P L E M E N TAT I O N ➧ Inspect the external aspect of the nose. Exposes any asymmetry, deformity, inflammation, or skin lesions. ➧ Palpate the nose gently. Uncovers pain, any breaks in the contour of the nose, or minute masses. ➧ Test the patency of each nostril by having the patient close the

mouth, then occlude one nostril and sniff inward through the other naris. Reveals any obstruction of the nares, such as nasal polyps or rhinitis. ➧ Inspect the nasal cavity using

either the otoscope with the nasal tip or a nasal speculum and penlight. This allows a more thorough examination of the nasal cavity. ●

Tilt the patient’s head back, stabilize the instrument, and gently insert the speculum approximately 1 cm while avoiding the nasal septum.

FIGURE 4.3A Inspect nasal cavity.

Provides maximum exposure while maintaining patient safety and comfort; the nasal septum is highly vascular and may bleed if irritated by the speculum. ●

Note the color and characteristics of the mucosa. Exposes any swelling, discharge, or bogginess, which are indicative of rhinitis, sinusitis, or chronic allergies.

●

Note the inferior and middle turbinates (the superior will not be in your view).

●

Note any deviation of the nasal septum.

Exposes nasal polyps or foreign bodies. A deviated septum is common and does not present a problem unless airflow is obstructed (if found in a hospitalized patient, document the findings in case the person requires a nasogastric tube or nasal suctioning).

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70 C h a p t e r 4 Physical Assessment ➧ Palpate the sinuses. Tenderness is elicited by palpation of sinuses in persons with chronic allergies and sinusitis. ●

Frontal sinuses by pressing with your thumbs up from under the medial aspect of the eyebrows. Pressure but not pain should be felt; be careful not to press on the eyeballs.

●

Maxillary sinuses by pressing up and in from under the cheekbones. Pressure but not pain should be felt. FIGURE 4.3B Palpate sinuses.

➧ Test cranial nerve I: olfactory. Evaluates the patient’s sense of smell; abnormalities can indicate a neurologic or a local problem. ●

Direct the patient to close eyes and occlude one naris. Ensures that the patient is not identifying the substance by sight and that he or she is not compensating by using the other naris.

●

Hold a substance with a familiar odor under the other naris and have the patient identify the odor.

●

Repeat for the other side.

Allows easy detection if the sense of smell is intact. Tests the sense of smell in each naris. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Inspect and ensure that if any bleeding occurred during the examination, it has stopped ● Compare assessment findings to normal ● Refer patient to an ear, nose, and throat specialist for further testing and evaluation of abnormal findings, if necessary ●

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P r o c e d u r e 4 . 4 Assessing the Mouth and Pharynx 71

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Abnormal

findings noted in the assessment. Deformities or tenderness noted as well as location and description. ● Patency of nares. ● Color, character of mucosa, including any lesions and their location. ● Position of septum (midline or side of deviation). ● Results of palpation of sinuses (note tenderness/no tenderness and which sinus). ● Sinus tenderness. ●

PROCEDURE 4.4 Assessing the Mouth and Pharynx OVERVIEW

The mouth and pharynx are the first segments of the respiratory and digestive systems. ● The structures included in this region are important for speech formation and the sense of taste, and contain a large amount of lymphatic tissue. ● Assessment of this area provides clues to local and systemic problems, such as nutritional status, hydration, and infection. ●

P R E PA R AT I O N

Review related history that would give the examiner information (past and present) regarding the general state of the patient’s mouth and pharynx, including sore throat, lesions, toothache, voice changes, difficulty swallowing, and self-care behaviors. ● Observe the patient with dentures to inspect the fit, but have the patient remove the dentures during the examination. ● Note the use and type of tobacco products (how much, how often, how long). ● Cranial nerve X and XII are usually tested during the assessment of the neurologic system, but such testing can be performed while assessing the mouth and pharynx as well. ●

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72 C h a p t e r 4 Physical Assessment

Special Considerations Pediatric Patient • In the infant or young child, save the oral examination until near the end of the complete examination; but, if a crying episode occurs before, take that opportunity to examine the mouth while it is open; Have the caretaker hold and restrain the child if necessary. • Only use the tongue blade when necessary because many people have an active gag reflex; have a child “roar like lion” or “ pant like a dog” to encourage him or her to open the mouth wide. • Normal variations in infants include Epstein’s pearls, sucking tubercle, no tonsillar tissue, and a slightly large tongue. • In children 10 years and under, the tonsils are normally large (⫹1 or ⫹2). • Eruption of teeth varies widely. As a general guide: for children under 2 years, the child’s age in months minus 6 should equal the number of teeth; normally all 20 deciduous teeth are present by 21/2 years. Elderly Patient • In elderly patients, the teeth may appear yellow, gum margins may recede, teeth may become looser, and the tongue may appear smoother. Check for proper fit of dentures if worn (no rough spots or ulcerations caused by the dentures); tonsils will normally shrink with age. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Possible disturbed sensory perception: gustatory Possible ineffective airway clearance EXPECTED OUTCOMES

Completion of the examination while maintaining the patient’s comfort ● Examination performed appropriately for age, and developmental and educational level ●

EQUIPMENT/SUPPLIES

Light Tongue blade Gauze square Clean gloves

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P r o c e d u r e 4 . 4 Assessing the Mouth and Pharynx 73 I M P L E M E N TAT I O N ➧ Inspect the outer and inner surface of the lips noting color, moisture,

lesions, and cracking. Variations from the normally pink, moist lips such as cyanosis, pallor, and cracking may indicate poor nutrition, dehydration, or hypoxia. Lesions may indicate herpes simplex. ➧ Inspect the buccal mucosa; ask patient to remove dentures if worn.

Use a tongue blade and good light. Careful inspection can reveal nodules, lesions, and the first signs of mumps (red Stensen’s ducts) and measles (Koplik’s spots). ➧ Inspect the teeth and gums for discoloration and diseased or miss-

ing teeth. Check gums for pink color, swelling, bleeding, or lesions. Teeth can be used as an index of a person’s general health. Abnormalities may indicate tobacco use, dental caries, or gingivitis. ➧ Inspect the roof of the mouth for color and structure. Reveals any deformities in the hard/ soft palate, jaundice, or pallor. ➧ Inspect all surfaces of the

tongue and the floor of the mouth. Reveals lesions, color, texture, size of the tongue. Normally the tongue is pink, the dorsal surface is roughened from the papillae, and a white coating may be present. Abnormalities may indicate poor nutrition, neurologic problems, or dehydration ●

FIGURE 4.4 Inspecting the pharynx.

Direct the patient to touch the tongue to the roof of the mouth and examine the ventral surface and the floor of the mouth carefully. Normally this surface should appear pink, smooth. Veins and saliva should be present. Oral malignancies are likely to develop in the area under the tongue; look for lesions, patches, or nodules.

●

Palpate the area under the tongue.

●

Have the patient stick out the tongue, and grasp it using a gloved hand and a piece of gauze. Pull the tongue to the left and examine it, then do the same to the other side.

Elicits tenderness and/or nodules not revealed by inspection alone.

Reveals lesions or patches on the sides and under the tongue where malignancies are common.

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74 C h a p t e r 4 Physical Assessment ➧ Inspect the throat by depressing the middle of the tongue with a

tongue blade and using a light. Note color, ulcerations, exudate, and enlargement of the tonsils. Tonsils that are swollen, bright red, or have exudate may have infection. ➧ Test cranial nerve X (vagus). Provides motor innervation to the palate, pharynx, and larynx. ●

Have the patient say “ah,” and watch for the rise of the soft palate and the uvula (it should be in the midline). Any deviation to the side or absence of movement indicates nerve damage.

➧ Test cranial nerve XII (hypoglossal). Provides motor innervation to the tongue. ●

Ask the person to stick out the tongue; observe for symmetry. Deviation will be toward the paralyzed side; tremors may be associated with conditions such as hyperthyroidism or cerebral palsy. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

● ●

Compare assessment findings to normal Refer patient to a dentist or an ear, nose, and throat specialist for evaluation of abnormal findings if necessary

KEY POINTS ● Abnormal

FOR

REPORTING

AND

RECORDING

findings noted in the assessment. Color and character of lips, mucosa and gingivae, including any lesions, bleeding, cracking, and the location; color of pharynx, lesions noted and location. ● Any abnormalities noted on the teeth or gums. ● Symmetry of tongue, tongue midline, or deviated when protruded, any tremors noted. ● Tonsillar size (graded ⫹1 thru ⫹4), exudate on tonsils. ● Midline rise or deviation of uvula on phonation. ● Dental abnormalities, especially loose teeth. ●

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P r o c e d u r e 4 . 5 Assessing the Neck 75

PROCEDURE 4.5 Assessing the Neck OVERVIEW

The neck is a channel for the passage of many structures including vessels, muscles, nerves, lymphatics, and viscera of the respiratory and digestive system. ● It is also the home of the thyroid gland. ● By assessing the structures in the neck, information concerning all of these systems is gained. ●

P R E PA R AT I O N ●

Review related history that would give the examiner information (past and present) regarding the neck, thyroid, and lymphatic system including pain, injury, difficulty swallowing, change in voice, lumps or swelling, thyroid disease or surgery, weight change, temperature intolerance, or change in activity tolerance.

Special Considerations Pediatric Patient • Infants have a short neck that can be more easily assessed by supporting the infant’s shoulders and tilting the head back slightly. The cervical lymph nodes and thyroid gland of an infant are not usually palpable. • Children can be assessed in the same manner as adults; their lymph nodes will feel more prominent until puberty when the lymphoid tissue begins to atrophy. Pregnant Patient • During pregnancy, the thyroid gland enlarges slightly due to hyperplasia of the tissue and increased vascularity. Elderly Patient • In elderly patients, the neck may show signs of kyphosis; ask them to perform range of motion slowly. Older patients may also have prolapse of the submandibular glands, which can be mistaken for a tumor. However, prolapsed glands will feel soft and symmetric. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Possible impaired neck mobility Possible Impaired swallowing

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76 C h a p t e r 4 Physical Assessment EXPECTED OUTCOMES

Completion of the examination while maintaining the patient’s comfort ● Exam performed appropriately for age, developmental, and educational level ●

EQUIPMENT/SUPPLIES

Stethoscope Glass of drinking water I M P L E M E N TAT I O N ➧ Inspect the neck for appearance and position while the patient is

sitting upright. The head should be erect and still; the neck and accessory neck muscles should be symmetric. ➧ Check the range of motion of the neck, note any pain or limited

movement. Stiffness or pain with movement may indicate arthritis or inflammation of the neck muscles. ●

Have the patient flex, extend neck, turn neck to the right and left, and touch each ear to the corresponding shoulder. Examines range of motion of the neck.

➧ Inspect the carotid artery and the jugular vein; note any obvious

pulsations. Normally there are no pulsations; if pulsations are present, the person may have an elevated blood pressure or fluid volume overload. ➧ Palpate for cervical lymph nodes using a gentle circular motion of

your fingerpads with light pressure; palpate both sides of the neck simultaneously. Use gentle pressure because strong pressure could push the nodes into the muscle; by palpating both sides simultaneously, the two sides can be compared. ●

Begin in front of the ear, and work systematically.

●

When palpating the submental node, palpate with only one hand, and use the other to position the head.

Establishes a sequence so that no nodes are missed.

This gland is easier to explore with only one hand. ➧ Inspect and palpate the trachea for deviation from the midline

position. Abnormalities may indicate cardiac, vascular, or pulmonary problems. ●

Place your index finger along one side of the trachea. Note the space between it and the sternocleidomastoid muscle.

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P r o c e d u r e 4 . 5 Assessing the Neck 77 Provides a method of measurement of the space between the trachea and the sternocleidomastoid muscle. ●

Repeat the procedure on the opposite side and compare the spaces. The two sides should be symmetric if the trachea is midline.

➧ Inspect the neck for the thyroid gland while the patient extends the

neck; have the patient swallow a sip of water in this position. Ability to view the thyroid gland is difficult; thyroid tissue moves up with a swallow. If thyroid tissue is seen, look for symmetry. ➧ Palpate the thyroid (the pos-

terior approach is described because it is easier for beginning practitioners). An enlarged thyroid is a good indication of hyperthyroidism. ●

Stand behind the patient and have the person bend the head slightly forward and to the right.

●

Using the fingers of your left hand, push the trachea slightly to the right while curving your right fingers between the trachea and the sternocleidomastoid muscle pulling back slightly.

This will relax the neck muscles.

The left hand pushes the boarder of the thyroid gland over while FIGURE 4.5 Palpating the the right hand retracts the sternthyroid. ocleidomastoid muscle slightly. This makes the thyroid gland easier to feel. ●

Direct the patient to take a sip of water and feel for the rise of the thyroid as the person swallows. Water facilitates swallowing for the patient, and swallowing facilitates palpation of the thyroid. Usually the normal thyroid gland cannot be palpated; abnormalities include enlarged lobes that are easily palpated before swallowing.

●

Reverse the procedure for the left side. Evaluates both sides of the thyroid gland.

➧ Auscultate any enlarged thyroid with the bell of the stethoscope. A bruit will be heard with accelerated or turbulent blood flow indicating hyperplasia of the thyroid.

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78 C h a p t e r 4 Physical Assessment E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to normal Refer patient to an internist or endocrinologist for evaluation of abnormal findings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Abnormal

observations of the neck including lesions, nodules, swelling, asymmetry, or tenderness. ● If nodes are palpated, note their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness. ● Position of the trachea (midline or direction of deviation) and direction of tracheal deviation if present. ● Ability to palpate thyroid, tenderness; if enlarged, which lobes are palpable, auscultation of a bruit. ● Presence of jugular-vein distention noting the degree of elevation of the head. ● Limitation of range of motion and in which position.

PROCEDURE 4.6 Assessing the Thorax and Lungs OVERVIEW

To determine functional status and to detect any alteration in physiologic process. ● A complete physical assessment of the chest and lungs, together with the history, will provide the examiner with important clues to diagnose and treat various pathologic conditions. ●

P R E PA R AT I O N

Provide privacy during assessment. Interview patient prior to assessment focusing on any history of cough, sputum production, allergies, dyspnea at rest or on exertion, chest pain, asthma, bronchitis, emphysema, tuberculosis, cyanosis, pallor, exposure to environmental irritants, or smoking. ● A specific sequence should be used when assessing the chest and lungs—inspection, palpation, percussion, and auscultation. ● ●

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 79

Special Considerations Pediatric Patient • There are special considerations when assessing the thorax and lungs of an infant. The anterior-posterior diameter noted on inspection of an infant is equal to the lateral or transverse diameter (1:1). The lateral diameter increases in proportion to the anteroposterior diameter. • The chest wall is thin, and the rib cage is soft and pliant. • Respiratory rate will vary with age. • Hyperresonance will be demonstrated upon auscultation throughout the lungs owing to the thin chest wall. • The bell of the stethoscope or small diaphragm should be used to localize findings. • Wheezes and rhonchi occur more frequently in infants and young children. • See Table 4.6A for respiratory rates for children. TABLE 4.6 Respiratory Rates for Children AGE

RATE

Newborn–5 months 5–23 months 24 months–12 years 12 years–19 years

30–50 20–30 20–30 12–20

Elderly Patient • Chest expansion is often decreased owing to muscle weakness, physical disability, or calcification of the rib articulations. • Bony prominences are marked, and there is a loss of subcutaneous tissue. • The dorsal curve of the thoracic spine may be pronounced (kyphosis), along with flattening of the lumbar curve. • The anterior-posterior diameter is increased in relation to the lateral diameter. • The pace of the physical examination should be adapted to the individual need. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Possible impaired tissue perfusion due to disease Impaired gas exchange related to infection

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80 C h a p t e r 4 Physical Assessment EXPECTED OUTCOMES

The outcome of assessing the thorax and lungs will include the following: ● Inspection of symmetry of movement on expansion, anteriorposterior to lateral diameter, and the use of accessory muscles ● Palpation of tactile fremitus ● Percussion for diaphragmatic excursion, resonance notes ● Auscultation of vesicular, bronchovesicular, bronchial, and adventitious breath sounds EQUIPMENT/SUPPLIES

Stethoscope Tape measure Drapes Marking pencil I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning an assessment enhances efficiency. ➧ Explain assessment to patient. Careful explanation reduces the patient’s anxiety. ➧ Expose anterior, posterior, and lateral chest with patient in sitting

position. Exposure of the chest in the sitting position facilitates easy access for inspection, palpation, percussion, and auscultation of the area.

Inspection ➧ Inspect anterior, posterior, and lateral thorax for the following: Inspection will enable the examiner to assess the general appearance of the thorax. Inspection is important before palpation, percussion, and auscultation as the latter are more invasive. ●

Color Color should be pink without pallor or cyanosis.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 81 ●

Intercostal spaces The intercostal spaces should be even and relaxed, without bulging or retracting.

●

Chest symmetry

●

Costal angle

Both sides of the chest should be equal. The costal angle is formed by the blending together of the costal margins at the sternum. It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles. ●

Respirations

●

Anterior-posterior to lateral diameter

Respirations should be even, 12–20/min, unlabored. Normal is a 1:2 ratio (anterior-posterior diameter is approximately one half the lateral diameter). This information will provide the examiner with shape and symmetry of the chest. A barrel chest, which results from compromised respiration, chronic obstructive pulmonary disease (COPD), for example, will demonstrate an increase in the anteroposterior diameter. ●

Shape and position of sternum Sternum should be level with the ribs. Two structural variations of the sternum are pigeon chest (pectus carinatum), a prominent sternal protrusion, and funnel chest (pectus excavatum), which is an indentation of the lower sternum above the xiphoid process.

●

Position of trachea

●

Chest expansion

Trachea should be midline without deviation to either side. Chest should expand approximately 3 inches upon inspiration.

Palpation ➧ Drape anterior chest. Use finger pads or palm of hands to palpate

posterior chest. Have patient lean forward and fold arms across chest. Palpation of the chest will enable the examiner to assess the thoracic muscles and skeleton, and to feel for pulsations, areas of tenderness, bulges, depressions, and unusual movements. The anterior chest should be draped while you are assessing the posterior chest to ensure privacy. Leaning forward increases the area of the lungs. Palpation, percussion, and auscultation of the posterior lungs will be done while the patient remains in the sitting position.

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82 C h a p t e r 4 Physical Assessment ➧ Palpate upper, middle, and lower thorax for sensation. No pain or tenderness should be present.

Palpating anterior chest excursion at apex

Palpating anterior chest excursion at base

FIGURE 4.6A Example of chest palpation.

➧ Palpate upper, middle, and lower thorax for vocal fremitus. Have the

patient say “99” while palpating. Vibration should be decreased over the periphery of the lungs and increased over the major airways. Vibration will be increased over areas of consolidation and decreased over airway with obstruction. ➧ Palpate the thorax for expansion. Place hands at level of 10th rib on

the posterior thorax, and have patient take a deep breath. Observe thumb movement. 2- to 3-inch symmetric expansion should be noted upon inspiration. ➧ Place hands on the lower sternum anteriorly and have patient take

a deep breath. Observe thumb movement. Symmetric expansion of 2 to 3 inches should be noted.

Percussion ➧ Percuss over shoulder apices and at posterior, anterior, and lateral

intercostal spaces moving from apex to base of lungs.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 83 Percussion will provide the examiner with information concerning areas of the thorax and lungs that are air-filled or that may have consolidation (fluidfilled). The impact of the examiner’s finger produces a vibration against the underlying tissue, and percussion tones can be heard (resonance). Resonance, a loud, low-pitched, hollow sound is percussed in healthy lungs. The more dense the medium, as in fluid or masses, for example, the quieter (dullness) the percussion tone. The percussion tone over air-filled lungs is loud, lowpitched, and has a boomlike quality (hyperresonance), as in emphysema.

FIGURE 4.6B Percussion sequence.

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84 C h a p t e r 4 Physical Assessment ➧ Percuss for diaphragmatic excursions bilaterally.

Ask patient to inhale deeply and hold. Percuss along the scapular line until you locate the lower border (noted by a change from resonance to dullness). ● Mark the point with a pencil and have the patient breathe. ● Ask the patient to exhale as much as possible and hold. ● Percuss up from the marked point and mark where the change from dullness to resonance occurred. Have the patient breathe. ● Measure and record the distance in centimeters. ● ●

The excursion distance of the diaphragm is usually 3 to 5 cm. The descent of the diaphragm may be limited by emphysema, ascites, tumor, or pain.

Auscultation ➧ Instruct patient to take slow, deep breaths through his mouth while

you auscultate the intercostal spaces with the diaphragm of the stethoscope. Auscultate over the following areas:

FIGURE 4.6C Auscultation sequence.

Auscultation of the chest provides the examiner with important clues to the condition of the lungs. Listen for two full breaths while comparing each side of the thorax moving the stethoscope from the apex of the lungs to the base. ●

Trachea Bronchial (tubular)/ tracheal breath sounds are heard over the trachea. They are high-pitched, loud, with the expiratory phase of respiration often longer than the inspiratory phase.

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P r o c e d u r e 4 . 6 Assessing the Thorax and Lungs 85 ●

Bronchial airway, including below clavicles and between scapulae Bronchovesicular breath sounds, medium in pitch, are heard over the main bronchus area and over the upper-right posterior lung field. The inspiratory phase should equal expiratory phase.

●

Lung periphery Vesicular (soft, breezy) breath sounds, low in pitch, are heard over lung periphery. The inspiratory phase should be longer than the expiratory phase.

➧ Auscultate breath sounds for adventitious sounds, including

wheezes, rales, and rhonchi. Lungs should be clear to auscultation on inspiration and expiration. If abnormal sounds are heard, ask patient to cough and note if adventitious sound is still present. ➧ Auscultate for altered voice sounds over lung periphery where any

previous lung abnormality was noted. ● Bronchophony patient says “99” while examiner auscultates. ● Whispered pectoriloquy patient whispers “one, two, three” while examiner auscultates. ● Egophony patient says “eee” while examiner auscultates. Auscultation for altered voice sounds will provide the examiner with clues regarding the presence of consolidation in the lung tissue. The voice vibrates and transmits sounds through the lung fields. The sounds should be muffled in healthy lungs, but may be loud and clear in any condition that consolidates lung tissue. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to normal findings Record and report normal and abnormal findings

KEY POINTS ●A

FOR

REPORTING

AND

RECORDING

history of any condition reported in the interview (subjective data) such as a history of cough, sputum production, allergies, dyspnea at rest or on exertion, chest pain, asthma, bronchitis, emphysema, tuberculosis, cyanosis, pallor, exposure to environmental irritants, or smoking. ● Assessment findings (objective data) to include • Size and shape of chest, anteroposterior versus lateral diameter, symmetry of movement with respiration • Presence of retractions or use of accessory muscles

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86 C h a p t e r 4 Physical Assessment

• Diaphragmatic excursion • Respiratory rate, depth, regularity, and ease of respiration • Symmetry and quality of tactile fremitus • Symmetry and quality of percussion notes • Characteristics of breath sounds including location and phase of respiration where abnormal sounds are auscultated • Characteristics of cough • Presence of vocal resonance

PROCEDURE 4.7 Assessing the Heart and Vascular System OVERVIEW

The heart and the blood vessels are complex, integrated systems. Findings from examinations of other systems, besides the cardiovascular, have a significant impact on judgments that will be made about the cardiovascular system. ● Performing a successful examination requires an ability to integrate and interpret findings in relation to the cardiac events they reflect. ● ●

P R E PA R AT I O N

The parts of the physical examination should be performed in a sequence that is comfortable for the examiner, with assessment of the heart following the traditional inspection, palpation, percussion, and then auscultation. ● These systems cannot be appropriately evaluated unless a complete examination is performed. ● Interview the patient for any history of the following: chest pain, irregular heartbeats, hypertension, diabetes, rheumatic fever, stroke, or smoking. Ask about pain in calves, feet, buttocks, or legs, including the type of pain and what aggravates or relieves the pain. Is there a history of coldness, cyanosis, edema, varicosities, paresthesia, or tingling in the extremities? ●

Special Considerations Pediatric Patient • There are a few variations that occur normally in children. • The presence of an S3 and S4 in children and young adults is common, but an increase in the intensity should be suspect.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 87

• Sinus arrhythmia is a physiologic event during childhood because the heart rate varies in a cyclic pattern, usually faster on inspiration and slower on expiration. • The heart rates in children vary from those of adults. The location of the apex of the heart also varies in infants and young children, as compared to adults. Elderly Patient • Variations that are usually noted in the assessment of elderly patients include the following: • Occasional ectopic beats and the presence of an S4, which may indicate decreased left ventricular compliance. • Early, soft, physiologic murmurs may be heard due to aortic lengthening, tortuosity, and sclerotic changes. • The dorsalis pedis and posterior tibial pulses may be difficult to detect without a Doppler. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired tissue perfusion related to injury Airway clearance, ineffective related to infection EXPECTED OUTCOMES

The outcome of assessing the cardiovascular system will include the following: ● Thorough observation and palpation of the pulses, as compared with the contralateral pulse and comparing pulses in the upper extremities with those in the lower extremities ● Complete inspection of the veins, especially the jugular venous veins ● Accurate measurement of blood pressure in both upper extremities with the patient sitting, standing, and supine ● Complete inspection, palpation, percussion, and auscultation of the heart EQUIPMENT/SUPPLIES

Stethoscope with a bell and diaphragm The bell of the stethoscope transmits low-pitched sounds when very light pressure is applied. The diaphragm of the stethoscope screens out low-pitched sounds and best transmits high-pitched sounds with firm pressure applied.

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88 C h a p t e r 4 Physical Assessment

Sphygmomanometer with appropriately sized cuff Cuffs are available in a number of sizes; the appropriate size is determined by the size of the patient’s limb. For adults, choose a width that is one third to one half the circumference of the limb. The length of the bladder should be twice the width (about 80% of the limb circumference), not quite enough to completely encircle the limb. For children, the cuff width should cover approximately two thirds of the upper arm or thigh. A cuff that is too wide will underestimate blood pressure, and those that are too narrow will give an artificially high measurement. Using the correct size cuff ensures that equal pressure is exerted on the artery, resulting in an accurate measurement. I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning the assessment enhances efficiency. ➧ Explain the process of heart and vascular assessment to patient. Careful explanation reduces the patient’s anxiety. ➧ Have the patient assume the supine position, and expose the ante-

rior chest providing privacy with drapes. A thorough examination of the heart requires the patient to assume several positions—supine, sitting erect, and leaning forward, and being in the left lateral recumbent position.

Inspection ➧ Inspect the chest for landmarks, including point of maximal impulse

(PMI) and any abnormal pulsations. Identifying the landmarks will aid in assessment of the heart. The point at which the apical pulse is most readily seen or felt is called the point of maximal impulse (PMI). It should be visible at the midclavicular line in the fifth intercostal space (ICS). The PMI is most visible when the patient is in the supine position because the heart is brought closer to the chest.

Palpation ➧ (Examiner should stand on the patient’s right side with the patient in

the supine position.) Palpate using the fingertips and palmar surfaces of the hands gently in an organized fashion, beginning in the aortic area and moving down the chest toward the tricuspid area.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 89 Palpation allows the examiner to feel the apical pulse and identify its location by intercostal space and distance from the midsternal line. Palpation over each valvular area will assist the examiner in detecting abnormal pulsations or vibrations. It is always best to be methodical in your examination. A suggested sequence is to begin at the apex, move to the left sternal border and then to the base, going down to the right sternal border. Touch gently and let movements rise to your hand, because sensation will decrease as you increase pressure.

BASE Base right (aortic) Base left (pulmonic) Erb’s point Left lateral sternal border (tricuspid) Apex (mitral) Xiphoid APEX

1 2

FIGURE 4.7A (1) Sites for cardiac assessment; (2) Palpating the mitral

valve area; (3) Palpating the pulmonic area.

3

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90 C h a p t e r 4 Physical Assessment ➧ A. Aortic area

Palpate second ICS at right sternal border. A. Palpation in the aortic area will allow the examiner to detect abnormal pulsations or vibrations. No vibrations or pulsations should be palpated. A pulsation or vibration generally indicates a disruption of the expected blood flow. ➧ B. Pulmonic area

Palpate second ICS at left sternal border. B. Palpation at the pulmonic valve area will allow the examiner to detect abnormal pulsations or vibrations. No vibrations or pulsations should be palpated. ➧ C. Erb’s point

Palpate third ICS at left sternal border. C. Palpation at Erb’s point will disclose possible dysfunction of the aortic valve during diastole (when the ventricles are filling). No vibrations or pulsations should be palpated. ➧ D. Tricuspid area

Palpate fifth ICS at lower left sternal border. D. Palpation at the tricuspid valve area will allow the examiner to detect abnormal pulsations or vibrations. No vibrations or pulsations should be palpated. ➧ E. Mitral area

Palpate fifth ICS at the left midclavicular line. This is also called the PMI. E. Palpation at the mitral valve area will allow the examiner to feel the PMI and determine if there are any vibrations present. A pulsation about the size of a nickel should be felt. No vibration should be present.

Percussion ➧ Percussion is an unreliable method in determining the borders of

the heart or determining its size. Percussion allows the examiner to determine borders of the heart and its approximate size, but has been found to be an unreliable method because the shape of the chest is relatively rigid and can make the more malleable heart conform. Size of the heart can be more accurately determined by chest radiograph.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 91

Auscultation ➧ A. With the patient in the supine position, auscultate in an orderly,

systematic fashion beginning in the aortic area and moving across and down the chest through the pulmonic, tricuspid, and mitral areas. Auscultate each area with the diaphragm of the stethoscope applied firmly to the chest and then repeat the sequence with the bell of the stethoscope applied lightly to the chest. Auscultate each sound and pause individually, focusing on one sound at a time. Identify the first heart sound (S1) or “lub” with the diaphragm of the stethoscope. Identify the second heart sound (S2) or “dub” with the diaphragm of the stethoscope. A. Auscultation allows the examiner to assess the heart sounds. Heart sounds are of relatively low frequency and are transmitted in the direction of blood flow. Specific heart sounds are best heard over areas where blood flows after it passes through a valve. Take the time to isolate each sound and each pause in the cycle listening separately for as many beats as necessary to evaluate the sounds. Avoid “jumping” the stethoscope from one point to another; instead, “inch” the endpiece along the route. This prevents missing important sounds, especially more widely transmitted abnormal sounds. S1 is a crisp, distinct sound that follows the long diastolic pause (filling of the right and left ventricles) and corresponds with ejection of the blood from the ventricles. Its sound is caused by the closure of the tricuspid and mitral valves (atrioventricular valves). S1 should also correlate with the carotid pulse because blood that is ejected from the left ventricle into the aorta travels to the carotid artery causing a pulsation. It should be heard in each area (aortic, pulmonic, tricuspid, and mitral), but should be loudest at the mitral and tricuspid areas. S1 may become louder with inspiration. S2 is a crisp, distinct sound heard loudest at the aortic and pulmonic areas and is caused by closure of the aortic and pulmonic valves (semilunar valves). It follows the short systolic pause (ejection of the blood from the ventricles into pulmonic and systemic circulation) of the cardiac cycle and corresponds with filling of the ventricles after the closure of the aortic and pulmonic valves. ➧ B. Assist the patient to the left lateral position and auscultate over

the apex (mitral area) with the bell of the stethoscope for a third heart sound (S3). B. Auscultation over the mitral area will allow the examiner to assess normal heart sounds (S1 and S2 or “lub” and “dub”) and also to detect extra heart sounds. A third heart sound is caused by rapid ventricular filling that occurs in the diastole phase of the cardiac cycle, or the ventricular filling phase. External influences that may cause a third heart sound are exercise, fast heart rates, elevation of the legs, and in increase in the venous return to the

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92 C h a p t e r 4 Physical Assessment heart. If a third heart sound is detected, it should be relatively quiet and difficult to hear. The left lateral position is the best position for detecting these low-pitched filling sounds. ➧ C. Assist the patient to a sitting position and auscultate each area

(aortic, pulmonic, tricuspid, and mitral) with the diaphragm of the stethoscope. C. Auscultation over each of the valvular areas of the heart will allow the examiner to assess for S1 and S2 and extra heart sounds. The supine position is the best position to hear relatively high-pitched murmurs (abnormal sounds). ➧ D. Auscultate systolic pause phase:

Heard between S1 and S2. D. Should hear a silent pause; distinct end of S1 and beginning of S2 with nothing heard in between. A murmur is an abnormal swishing sound heard at the beginning, middle, or end of systolic phase. (Note intensity, pitch, and quality.) A click is an abnormal sharp, high-pitched snapping sound heard immediately after S1 or in the middle of the systolic pause. ➧ E. Auscultate diastolic pause phase:

Space heard between S2 and the next S1. E. Should hear a silent pause; distinct end of S2 and distinct beginning of S2. Note the presence of murmurs or clicks during the beginning, middle, or end of the diastolic phase. ➧ F. Auscultate for rate and rhythm. F. Normal heart rate is between 60 and 100 beats per minute with a regular rhythm. Bradycardia is a heart rate ⬍ 60, and tachycardia is a heart rate ⬎100. An irregular rhythm should be noted as abnormal. ➧ G. Auscultate for S4. G. During diastole, the ventricles fill in two steps: an early passive flow of blood from the atria followed by a more vigorous atrial ejection. S4 is caused by the second phase of ventricle filling, which causes vibration in the valves, papillae, and ventricular walls. S4 is a soft, low-pitched sound that occurs late in diastole (ventricular filling) and should be quiet and difficult to hear. ➧ H. Have the patient lean forward and exhale while you listen over the

aortic area with the diaphragm of the stethescope. H. Auscultation over the aortic area, while the patient is leaning forward, will enable the examiner to assess the normal S1 and S2 heart sounds and detect extra high-pitched sounds, which may be associated with disruptions in the blood flow at the aortic valve. This is the best position to hear relatively highpitched murmurs (abnormal sounds).

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 93 ➧ Inspection, palpation, and auscultation of circulation to arms and

neck are performed together while the patient remains in the sitting position. A systematic assessment of circulation provides a thorough, organized approach to ensure efficiency. ➧ A. Palpate brachial artery and auscultate blood pressure in both arms

(patient remains in the sitting position). A. Normal systolic pressure is between 95 to 140 mm Hg with a diastolic pressure between 60 and 90. May be a difference of 5 to 10 mm Hg between the two arms. Deviations from normal are systolic ⬍ 95 mm Hg or ⬎ 140 mm Hg, a diastolic ⬍ 60 mm Hg or ⬎ 90 mm Hg, or more than a 10–mm Hg difference in pressure between the two arms. ➧ B. Palpate brachial artery and auscultate blood pressure in both arms

while the patient is standing. B. The difference between systolic pressure in both arms should be 15 mm Hg or less and a diastolic difference of 5 mm Hg or less. ➧ C. Palpate each carotid artery alternately for rate, rhythm, symmetry,

strength, and elasticity. NEVER palpate both sides simultaneously. C. Rate should correlate with apical pulse consisting of a regular rhythm, equal, strong, and elastic bilaterally. Palpating both sides simultaneously may stimulate the carotid sinus reflex and slow the pulse, drop the blood pressure, and compromise blood flow to the brain. ➧ D. Auscultate the carotid arteries with the bell of the stethoscope

while the patient holds breath. D. No sound should be heard. A bruit (murmur or unexpected sound) over an artery is a swishing, low-pitched sound that is relatively hard to hear. Holding the breath aids in detecting the abnormal sound. ➧ E. Inspect and palpate the upper extremities for the following. E. A continuous, systematic approach during the assessment ensures efficiency. ●

Color

●

Temperature

●

Mobility

●

Radial and ulnar pulses

Color should be pink. Should be warm to touch. Should be mobile. Bilateral pulses should be strong and equal.

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94 C h a p t e r 4 Physical Assessment ➧ Allen’s test ● ●

This is performed if the patient has weak radial or ulnar pulses. Procedure: Ask patient to make a fist. Compress radial and ulnar arteries. Ask patient to open hand. Release ulnar artery. Repeat with release of radial artery. The entire palm of hand should return to pink with the release of radial or ulnar artery. An abnormal finding is when only one half of the palm returns to pink with the release of the ulnar or radial artery and the other half remains whitish.

➧ F. Inspect jugular veins with the patient in the supine position and

the head elevated 45 degrees. Identify the highest point of venous wave in relation to the sternal angle and measure in centimeters. F. The pulsation height should be ⱕ 3 cm.

External jugular vein Internal jugular vein Carotid Artery Angle of Louis (sternal angle) Level of right atrium

FIGURE 4.7B Location of jugular veins.

➧ G. Inspect and palpate the legs for the following. ●

Color

●

Temperature

●

Mobility

Color should be pink (white skin) and dark brown (black skin). Temperature should be warm. Legs should be mobile.

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P r o c e d u r e 4 . 7 Assessing the Heart and Vascular System 95 ●

Superficial veins There should be slight venous distention with standing or lowering the extremity below the level of the heart and collapse with elevation.

●

Edema

●

Femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

●

Capillary refill

No edema should be present. Pulses should be strong and equal bilaterally. Compress nail beds of fingers and toes, and observe return of blood to capillaries. Color should return to pink in ⬍ 2 seconds. ➧ H. Check for deep phlebitis by quickly squeezing calf muscle against

the tibia. H. No calf pain should be present. ➧ I. Check for Homan’s sign by extending leg and dorsiflexing

foot. I. No calf soreness or pain should be present. ➧ J. Check for arterial deficiency if leg pulses are weak.

Support patient’s legs 12 inches above the level of the heart while the patient remains in the supine position. ● Ask patient to sit up and dangle legs in a dependent position. ●

J. Feet should be pink to slight pale with elevation of the legs, and pink color should return to tips of toes in 10 seconds with lowering of the legs. ➧ K. Auscultate over the following arteries: aorta, renal, iliac, and

femoral. K. No sound should be heard. Note the presence of a bruit if auscultated. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to normal findings Report and record normal and abnormal findings

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96 C h a p t e r 4 Physical Assessment

KEY POINTS

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REPORTING

AND

RECORDING

●A

history of any condition reported in the interview (subjective data) such as chest pain, irregular heartbeats, hypertension, diabetes, rheumatic fever, stroke, or smoking. Also include a history of pain in the calves, feet, buttocks, or legs, including the type of pain, what aggravates the pain, and what relieves the pain. Note a history of coldness, cyanosis, edema, varicosities, parethesis, or tingling in the extremities. Heart ● Assessment findings (objective data) to include • Anatomic location of apical impulse. • Heart rate, rhythm, and symmetry of apical pulse and pulse in extremities. • Palpation findings: pulsations, thrills. • Auscultation findings: characteristics of S1 and S2 (location, intensity, pitch, timing, systole, and diastole). • Presence of murmurs, clicks, S3 or S4 (description by timing, location, radiation, intensity, pitch, quality, variation with respiration). Blood Vessels ● Assessment findings (objective data) to include • Amplitude, symmetry of pulses in extremities. • Jugular vein pulsations and distention, pressure measurement. • Presence of bruits over carotid, renal, iliac, femoral arteries, and aorta. • Temperature, color nail beds of lower extremities. • Presence of edema, swelling, vein distention, varicosities, Homan’s sign, tenderness of lower extremities.

PROCEDURE 4.8 Assessing the Musculoskeletal System OVERVIEW ●

The assessment of the musculoskeletal function focuses on determining range of motion, muscle strength and tone, and joint and muscle condition.

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P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 97 P R E PA R AT I O N

Depending on the muscle or joint group assessed, the patient may be standing, sitting, supine, or prone. ● Joints vary in degrees of movement. ●

Special Considerations • When assessing range of motion, do not force a joint into a painful position. It is good practice to know the joint’s normal range and the extent to which it can be moved. Elderly Patient • Note: in older adults, a loss of muscle mass may cause bilateral weakness. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for injury due to immobility Self-care deficit due to injury EXPECTED OUTCOMES

Assessment completed while maintaining patient’s privacy and comfort ● Awareness of cultural and traditional health practices ●

EQUIPMENT/SUPPLIES

Marking pen or pencil Goniometer Tape measure Reflex hammer I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Explain each procedure to patient. Careful explanation reduces the patient’s anxiety. ➧ Fully expose area and be able to freely move body parts. Adequate exposure is necessary for a thorough examination.

General Inspection ➧ General inspection. The nurse inspects patient’s body and observes physical features and gait and posture.

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98 C h a p t e r 4 Physical Assessment ●

Observe gait and posture as the patient walks into the room. Note any foot dragging, limping, shuffling, and note the position of the trunk in relation to the legs. The patient is unaware of your assessment and is likely to walk naturally.

●

Note standing posture. Note the normal cervical, thoracic, and lumbar curves. Normal standing posture is upright with parallel alignment of the hips and shoulders, and the head is erect. Abnormalities include: Kyphosis—hunchback Lordosis—swayback Scoliosis—lateral spinal curvature Osteoporosis—height loss occurring in trunk

●

Note symmetry of joints, muscles, and extremity length, and look for obvious deformities. Asymmetric joints, muscles, and extremity lengths are abnormal and should be reported.

Palpation ➧ Palpation. The nurse uses the hands and sense of touch to gather data. Palpation is used to detect tenderness, temperature, texture, pulsations, and masses, and other changes in structural integrity. ●

Palpate all muscles, joints, bones while noting any tenderness, swelling, crepitus, and resistance to pressure. Provides information regarding any abnormalities in joints, muscles, and bones.

Range of Motion ➧ Range of joint motion. Assessment of patient mobility and range of joint motion allows the nurse to determine the amount of work or exercise tolerance a person is able to perform. ➧ Measure the precise degree of motion in a joint with the goniometer. This is usually done only when you suspect a reduction in joint movement. ●

Ask the patient to put each joint through its full range of motion while you gently support the extremity. The same body parts are compared for equality in movement. If patient is weak or ill, nurse may do passive ROM by gently supporting and moving the extremities through their range of movement.

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P r o c e d u r e 4 . 8 Assessing the Musculoskeletal System 99 Note: Swelling Stiffness Instability Deformity Tenderness Crepitus (a crackling sensation and noise caused by rubbing of bone fragments) Normal joints are nontender and move freely; in the elderly you may see stiffness with reduced ROM.

Muscle Tone and Strength ➧ Muscle tone and strength. The muscle tone and strength are assessed bilaterally to compare to opposite muscle. Differences in bilateral muscle tone or strength may indicate a pathologic diagnosis.

The nurse may assess muscle strength and tone during range of motion. Note: tone is the muscular resistance felt. ● You must know each joint’s normal range. ● Do not force a joint into a painful position. ●

Hypertonicity and movement will be met with resistance. Hypotonicity feels flabby and may hang loosely in a position determined by gravity.

Apply gradual increase in pressure to a muscle group, and have the patient resist the pressure to measure strength of the muscle. ● Neck: Place hand firmly against patient’s upper jaw and ask patient to turn head laterally against resistance. ● Shoulder: Place hand over midline of patient’s shoulder, exerting pressure. Have patient raise shoulders against resistance. ● Elbow: Pull down on forearm as patient attempts to flex arm, as patient’s arm is flexed, apply pressure against forearm. Ask patient to straighten arm. ● Hip: With patient in sitting position, apply downward pressure to thigh. Ask patient to raise leg up from table. ● Gastrocnemius: With patient sitting, hold shin of flexed leg. Ask patient to straighten leg against resistance. ●

If weakness is identified, the muscle size is compared to opposite muscle with a measuring tape.

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100 C h a p t e r 4 Physical Assessment E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to the normal Pursue more specific tests and assessments regarding abnormal findings if warranted

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Gait and posture and symmetry of joints, muscles, and extremity length. ● Note the joint’s range of motion and the extent to which it can be moved. Record and report any abnormalities found. ● Note in the patient’s record the muscle tone and strength that were observed and report any abnormalities found.

PROCEDURE 4.9 Assessing the Abdomen OVERVIEW

The abdominal assessment is routine in a physical examination and is performed on patients of all ages. ● The abdominal cavity contains several of the body’s vital organs and can provide valuable clues as to the patient’s diagnosis and condition. ●

P R E PA R AT I O N

Landmarks help the nurse map out the abdominal region. Assessment involves examination of organs and tissues anteriorly and posteriorly. ● Patients must be relaxed, warm, and provided privacy for the examination. ● Adequate light is essential for inspection and visualization during examination. ● Nurse must begin with inspection then follow with auscultation. ● ●

Special Considerations • The nurse must begin with inspection and then follow with auscultation.

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P r o c e d u r e 4 . 9 Assessing the Abdomen 101

• Palpation and percussion may alter the frequency and character of bowel sounds. • During auscultation, the nurse asks the patient to refrain from talking. If the patient has a nasogastric tube or an orogastric tube connected to suction, it should be turned off so that the sound from the suction will not obscure the bowel sounds. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Nutrition, altered related to infection Pain related to injury EXPECTED OUTCOMES

Assessment completed while maintaining patient’s privacy and comfort ● Awareness of cultural and traditional health practices ●

EQUIPMENT/SUPPLIES

Stethoscope Ruler or nonstretchable measuring tape Marking pen I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Explain procedure to patient. Explanation reduces the patient’s anxiety. ➧ Position the patient supine with arms down at sides, and place a

small pillow beneath the knees. Supine position facilitates the examination of the entire abdomen. Pillow supports the patient’s back. ➧ Provide adequate cover for the patient. This helps to reserve the patient’s privacy and provide warmth before proceeding with rest of the assessment. ➧ The nurse must stand on the patient’s right side and sit in a position

to look across the abdomen’s surface. Standing helps detect abnormal shadows and movement. Sitting position provides horizontal view that allows detection of abnormal protuberances and contours. ➧ Divide the abdomen into four quadrants. Landmarks help the nurse map out the abdominal regions.

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102 C h a p t e r 4 Physical Assessment

Inspection ➧ Inspection. Examiner needs to make sure the patient is disrobed and provide privacy with adequate covers and warmth of the examination room. ➧ Inspection of skin. The location of scars, venous patterns, rashes, lesions, pigmentation changes, and stretch marks are noted. This can help identify previous surgeries or trauma and show if skin has been stretched from obesity or pregnancy. Striations can also signal possible adrenal problems. ➧ Inspection of umbilicus. Normally the umbilicus is flat. You may notice a different shape or color, which could indicate pathology. Underlying masses may displace the umbilicus, and an everted umbilicus indicates distention. Watch for umbilical discharge; this is an abnormal sign. ➧ Inspect contour and symmetry. The presence of a mass or masses on one side may indicate a problem. Intestinal gas, tumor, or fluid in the abdomen may cause distention. Do not confuse distention with obesity. ●

Observe the abdomen while asking the patient to take a deep breath. This moves the diaphragm downward and decreases the size of the abdominal cavity; any enlarged organs may cause a bulge.

●

Observe the abdomen while the patient raises his or her hands over the head. This helps to evaluate the abdominal musculature. Any hernias, masses, and muscle separation will become more apparent.

➧ Inspect for movement and pulsations. With pain, respiratory movement is diminished, and the patient may guard against the pain by tightening the abdominal muscles. (Women breathe costally, and men breath more abdominally.) Looking across the abdomen, the nurse may see peristaltic movement and aortic pulsations (midline, above the umbilicus).

Auscultation ➧ Auscultation. Auscultation comes next in the physical examination. The examiner should listen to bowel sounds before palpating or percussing. These actions will stimulate bowel action and provide unreliable data for the examiner.

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P r o c e d u r e 4 . 9 Assessing the Abdomen 103 ➧ Warm the diaphragm of the stethoscope, and with light pressure

auscultate in all four quadrants to detect normal, high-pitched bowel sounds. Sounds are normally described as Normal Audible Absent—absence of gastrointestinal motility and a late stage of bowel obstruction Hyperactive or hypoactive—Hyperactive sounds indicate hypermotility caused by inflammation of the bowel, anxiety, diarrhea, bleeding, excess ingestion of laxatives, and reaction of the intestine to certain foods. You must listen 5 to 15 seconds in each quadrant. ➧ Place the bell of the stethoscope diaphragm over the epigastrium

to auscultate for bruits, which manifests as a whooshing or blowing sound. Renal-artery bruits can be heard by placing the stethoscope over each upper quadrant anteriorly or over the costovertebral angle posteriorly. If a bruit is heard, it is not normal and should be reported to a physician immediately. ➧ Place bell of the stethoscope above the liver and spleen and listen

for a friction rub. An inflamed liver or spleen may rub against the peritoneum during inspiration, creating a grating sound.

Percussion ➧ Percussion. Percussion allows the examiner to determine borders of the spleen, liver, and other major organs in the abdomen. It also provides information regarding presence of fluid in the abdominal cavity. ➧ Systematically percuss each quadrant to assess areas of tympany

and dullness. Tympany is percussed when there is air in the stomach or intestine. Dull percussion is heard over solid masses as in an enlarged liver, spleen, tumor, or a full bladder. ➧ Percuss to identify the liver border by starting at the iliac crest and

proceeding upward on the right midclavicular line. As you percuss upward, the percussion note changes from tympanic to dull at the liver’s lower border. (Mark the point.) The upper border is found by percussing downward from the nipple along the midclavicular line. When the note changes from resonance to dull, make a mark. The distance between the points should be 6 to 12 cm.

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104 C h a p t e r 4 Physical Assessment Percussion allows the nurse to identify borders of the liver and to detect any organ enlargement. Diseases such as cirrhosis, cancer, and hepatitis can cause this liver enlargement. ➧ Percuss for the gastric air bubble in the left lower anterior rib cage

and left epigastric area. Note: The tympany heard when percussing the gastric bubble is lower in pitch than the tympany of the intestines. ➧ Have the patient sit or stand erect to assess for kidney inflammation.

With the ulnar surface of a partially closed fist, percuss the costovertebral angle at the scapular line. If the kidneys are inflamed, the patient will feel tenderness during percussion.

Palpation ➧ Palpation. Palpation is the last process of the abdominal examination and provides the examiner with data concerning areas of tenderness and presence of fluid, masses. ➧ Hold the palm of your hand and forearm horizontally and lightly

palpate each quadrant.

FIGURE 4.9 Light palpation. ● ●

Superficial palpation (1 cm) Deep palpation (2.5 to 7.5 cm). If you are experienced, you may do this. You are palpating for muscular resistance, distention, tenderness, and superficial organs or masses.

➧ Wash hands. Reduces transmission of microorganisms, which could cause infection.

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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 105 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to normal Pursue more specific tests and assessment regarding abnormal findings if warranted

KEY POINTS

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REPORTING

AND

RECORDING

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If patient has abdominal or lower back pain, record the pain in detail (location, onset, frequency, severity, precipitating factors, aggravating factors). ● Assess normal bowel habits and any history of changes. ● Determine if patient has had abdominal surgery or trauma to the abdomen in the past. ● Assess for difficulty swallowing, heartburn, black or tarry stools, diarrhea, or constipation. ● Determine if patient is pregnant, and note last menstrual period. ● Ask patient about history of alcohol or aspirin intake.

PROCEDURE 4.10 Assessing the Neurologic System OVERVIEW

To determine alteration in neurologic functions such as initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory. ● To determine a cause for level of consciousness (LOC), mental/emotional status, and to determine if there are any alterations in central or peripheral nervous system. Identification of specific patterns may aid in the diagnosis of a pathologic condition. ●

P R E PA R AT I O N

Neurologic assessment can be time consuming, and the examiner must not rush through the assessment process. ● An efficient nurse can integrate neurologic measurements with other parts of a physical examination. Example: While taking the history, the nurse can note the patient’s mental and emotional status. ●

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106 C h a p t e r 4 Physical Assessment

Special Considerations • A patient’s level of consciousness influences the ability to follow directions. • General physical well-being may influence tolerance to assessment. • Chief complaint helps determine the need for a more thorough examination. • Complaint of headache or recent loss of function in an extremity may warrant a complete neurologic examination. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Confusion related to fluid volume deficit Self-care deficit due to immobility EXPECTED OUTCOMES

Assessment completed while maintaining the patient’s privacy and comfort ● Awareness of patient’s cultural and traditional health practices ●

EQUIPMENT/SUPPLIES

Reading materials Safety pin Penlight Tongue blade Hot and cold water Cotton balls Tuning fork Reflex hammer I M P L E M E N TAT I O N

Mental and Emotional Status ➧ Mental and emotional status. An observation made by the nurse to assess the appropriateness of emotions and mental status.

Levels of Consciousness ➧ Level of consciousness. Assess whether the patient will be able to follow with you during the examination. If a patient is not fully awake and alert, the neurologic assessment may be difficult. ●

Note LOC from fully awake, alertness, and cooperation to unresponsiveness to any form of stimuli.

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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 107 ●

Note if patient is oriented to person, time, and place. A fully conscious patient responds to questions spontaneously. As patient’s LOC lowers, you may see irritability, shorter attention span, and uncooperativeness.

●

Exert pressure on supraorbital ridge of nailbed.

●

Pinch Achilles tendon.

Normally, patient will try to stop or pull away from painful stimuli. If not responding properly, the patient may assume Decorticate posturing— (legs extended; feet extended with plantar flexion; arms internally rotated and flexed on chest) may be due to lesion of corticospinal tract near cerebral hemisphere. A. Decorticate posturing Wrists and fingers flexed

Feet plantar flexed

Legs internally rotated

Elbows flexed

Arms adducted

B. Decerebrate posturing

Feet plantar flexed

Wrists and fingers flexed Forearms pronated

Arms adducted Elbows extended

FIGURE 4.10 Decorticate (A) and decerebrate (B) posturing.

Decerebrate posturing— (arms stiffly extended and hands turned outward and flexed; legs extended with plantar flexion) may be due to lesion in diencephalons, pons, or midbrain. Flaccid posturing— (no motor response) may be due to extreme brain injury to motor area of brain. Abnormal involuntary movements Choreiform—(jerky and quick). Athetoid—(twisting and slow) present in cerebral palsy.

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108 C h a p t e r 4 Physical Assessment Tremors—hyperthyroidism, cerebellar ataxia, parkinsonism. Spasms—cord injury. Seizures—brain injury, heat stroke, electrolyte imbalance. Asterixis—metabolic encephalopathy due to liver or kidney failure.

Behavior and Appearance ➧ Behavior and appearance. Patient’s behavior and appearance initially show how they view themselves. This will often alert the nurse to a more thorough examination. ●

Note the patient’s behavior, mood, hygiene, and choice of dress. Appearance reflects how one feels about oneself. An unkempt appearance can mean a variety of things, such as: Poor self-image. Inability to keep clothes clean. Inability to perform grooming.

Language ➧ Language. When communication is altered, the assessment may be difficult, but also may indicate a pathologic diagnosis. ➧ Assess language when communication with the patient is

ineffective. ● Have the patient name an object you point to. ● Have the patient follow simple written commands like “sit down.” ● Have the patient read simple sentences aloud. If the patient is unable to understand spoken words or written words and to express the self through writing or gestures, there may be an injury to the cerebral cortex, which is called aphasia: Receptive—cannot understand written or verbal speech. Motor—can understand written and verbal speech but cannot return communication. Global—unable to understand speech or express the self.

Intellectual Function ➧ Intellectual function. Alerts the nurse of possible pathologic diagnosis.

Memory ➧ Memory. Many conditions can alter a patient’s memory.

Test for memory by assessing immediate recall and recent remote memory. ● Have patient repeat a series of numbers. ●

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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 109 ● ●

Have patient recall events occurring during the same day. Have patient recall medical history or family history or ask about birthdays or anniversaries. Sudden confusion may be caused by acute conditions such as dehydration, infection, drug toxicity, or hypoglycemia. In elderly, confusion and forgetfulness are common, but gradual, progressive deterioration in mental function may indicate Alzheimer’s disease.

Abstract Thinking ➧ Abstract thinking. Any type of altered mentation may prevent the patient from explaining an abstract idea. ➧ Test by asking the patient to explain “a stitch in time saves nine.” If the explanations are relevant and concrete, altered mentation is not suspected. A patient with altered mentation may interpret the phrase literally or just repeat the phrase.

Pupil Assessment ➧ Pupil assessment. When a beam of light is shone through the pupil and onto the retina, the third cranial nerve is stimulated and innervates the muscles of the iris to contract. Any abnormality along the nerve pathway from the retina to the iris alters the ability of the pupil to react to light. ➧ Size of pupil (holding eyelids open).

Shape of pupil. Unilateral dilation—third cranial nerve involvement. Bilateral dilation—upper brainstem damage. Unilateral and nonreactive—increased ICP or CNIII compression. Fixed and dilated—midbrain involvement. Pinpoint and fixed—a sign of pontine involvement or opiate effects. ➧ Equality of pupil. Unequal denotes that parasympathetic and sympathetic nervous systems are not synchronized. ➧ Reaction to light—In darkened room, open eyelid being tested

(cover opposite eye) and move penlight toward patient’s eye from side position. Sluggish reaction is an early warning of deteriorating condition. If pupil does not constrict, the connection between the brainstem and pupil is not intact.

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110 C h a p t e r 4 Physical Assessment ➧ Light reflex—hold both eyes open and shine light into one eye while

observing the reaction of the opposite pupil. Note— light reflex is the most important sign differentiating structural (cranial involvement) from metabolic coma due to extracranial cause (diabetic coma), which does not alter light reflex.

Motor Function ➧ Motor function. An assessment of motor function includes the same measurements made during the musculoskeletal examination. In addition, cerebellar function is assessed.

Muscle Strength ➧ Have patient squeeze your fingers bilaterally.

Test arm strength by having patient close eyes and hold arms out in front with palm side up. Lack of or diminished muscle function on one side may be a sign of: Hemiplegia (paralysis on one side of the body). Hemiparesis (weakness on one side of the body). Paraplegia (paralysis of the legs or lower body) . Tetraplegia or quadriplegia (paralysis of arms and legs).

Flexion and Extension ➧ Stand in front of patient and ask patient to push your hands away.

Have patient pull upward after placing your hand on patient’s forearm. Place patient’s knee in flexed position and ask patient to keep foot down while you extend the leg. Have patient straighten leg as you apply resistant force to knee and ankle with each hand. 1. Increased resistance is a sign of increased muscle rigidity or spasticity, and decreased resistance to leg extension and arm flexion may be assign of cerebrovascular accident (CVA). 2. Weakness may indicate cerebellar lesion.

Muscle Tone ➧ Flex and extend patient’s upper extremities to assess how well

patient resists your movements. Flex and extend patient’s lower extremities to assess resistance.

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Coordination ➧ Coordination. The nurse must observe the smoothness and balance of movements. Uncoordinated movements may be from cerebellar involvement or basal ganglia involvement.

Hand ➧ Hand.

While patient is seated, have the patient pat both thighs as rapidly as possible. ● Have the patient turn hands over in rapid succession. ● Ask the patient to touch thumb with each finger in rapid succession—repeat with other hand. Foot ●

➧ Foot.

Place your hands close to patient’s feet and ask the patient to tap your hands alternately with the balls of the feet. Hand Positioning ●

➧ Hand positioning.

Ask the patient to alternately touch his own nose and your index finger of one hand. ● Repeat test with patient’s eyes closed. ●

Inability to perform task with eyes closed: may be due to loss of positioning sense.

Leg Positioning ➧ Leg positioning. ●

Have patient run the heel of one foot down the shin or tibia of the other leg.

Reflexes ➧ Reflexes. Eliciting reflex reactions allows the nurse to assess the integrity of sensory and motor pathways of the reflex arc and specific spinal cord segments.

Blink ➧ Blink. ●

Have patient look up and away from you, as you approach from the side. Lightly touch the cornea with a cotton wisp. Absence of a blink response may indicate fifth or seventh cranial nerve involvement.

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112 C h a p t e r 4 Physical Assessment

Gag and Swallow ➧ Gag and swallow. ● ●

Open patient’s mouth and hold tongue down with tongue blade. Touch back of pharynx on each side with cotton applicator stick. Absence of gag and swallow may indicate ninth or tenth cranial nerve involvement.

Plantar Response ➧ Plantar response. ●

Run a pointed object on the lateral side of foot, from heel to ball, then curve medially across the ball of the foot. Babinski response—great toe dorsiflexes; others fan on foot of paralyzed side (CVA), and bilaterally in spinal cord injury (SCI).

Deep Tendon ➧ Deep tendon. ●

Patient must be relaxed. Position the limb with slight tension on the tendon to be tapped. Briskly tap tendon. • Biceps—flex at elbow and contract bicep • Triceps—extend at elbow and contract triceps • Knee—extend knee and contract quadriceps Absent or diminished bicep reflex—C5 or C6 involvement. Absent, diminished triceps—C7 or C8 involvement. Absent or diminished knee—L2–3 or L3–4 involvement.

Sensory Function ➧ Sensory function. The sensory pathways of the central nervous system conduct sensations of pain, temperature, touch, and position.

Pain ➧ Pain. ●

Stroke or touch skin with safety pin, alternate dull and sharp end—ask patient to distinguish the two. Alteration in pain or temperature sensations may indicate a lesion in posterior horn or spinal cord. Analgesia ⫽ absence of sense of pain. Hypoalgesia ⫽ decrease pain sensation. Hyperalgesia ⫽ exaggerated sensitivity to pain.

Temperature ➧ Temperature. ●

With patient’s eyes closed, have patient distinguish between a hot and cold item.

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Touch ➧ Touch. ●

Have patient close eyes. Touch skin lightly and have patient point or tell you the area when sensation is felt. Anesthesia ⫽ loss of light touch.

Positioning ➧ Positioning.

Have patient close eyes; grasp finger with your thumb and index finger. ● Move patient’s finger up and down. ● Have patient identify direction of movement. ●

Inability to identify correct direction of movement may indicate injury to posterior column or peripheral nerve disease.

Vital Signs Respirations ➧ Respirations. ● ●

Assess rate and pattern of breathing. If respiratory imbalance noted, monitor arterial blood gases. Cheyne-Stokes—rhythmic increase in depth of breathing followed by a period of apnea may indicate a cerebellar lesion or condition altering cerebral profusion. Hyperventilation—upper brain stem involvement. Ataxic—irregular, unpredictable breathing due to lower brain stem involvement. Alterations in pH and Pco2 values indicate respiratory imbalance. Normal: pH: 7.35–7.45. Pco2: 35–45 mm Hg. HCO3: 22–26 mEq/L. pH ⬍7.35 and Pco2⬎ 45 ⫽ Respiratory acidosis (hypoventilation). pH ⬎7.45 and Pco2 ⬍35 ⫽ Respiratory alkalosis (hyperventilation). HCO3 ⬎26 indicates metabolic compensation for chronic respiratory acidosis (hypoventilation).

Apical and Radial Pulse ➧ Apical and radial pulse.

Note character of pulses. Count heart rate. ● Count radial pulse rate. ● ●

Fast heart rate—decreased blood volume, arrhythmia, heart failure. Irregular rhythm with premature beats—hypoxia, cardiac irritability, or electrolyte imbalance.

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114 C h a p t e r 4 Physical Assessment

Temperature ➧ Temperature. ●

Take rectal or tympanic temperature if patient is semiresponsive. Inability to maintain normal temperature may indicate damage to hypothalamus.

Blood Pressure ➧ Blood pressure. ●

Position neurologic patients in low to semi-Fowler’s position. Systolic pressure rise without a rise in diastolic (widening pulse pressure) may indicate increased ICP. B/P ⬎140/90 mm Hg ⫽ hypertension. B/P ⬍95/60 mm Hg ⫽ hypotension. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

● ●

Compare assessment findings to normal Pursue more specific tests and assessment regarding abnormal findings if warranted

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Mental and emotional status. Intellectual function. ● Pupil size and reaction. ● Motor coordination. ● Reflexes. • Use grading scale: 4⫹ Hyperactive or exaggerated 3⫹ More brisk than usual but not indicative of disease state 2⫹ Average or normal 1⫹ Slightly diminished, low normal 0 No response ● Sensory. ● Vital signs. ●

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P r o c e d u r e 4 . 1 1 Assessing the Skin, Hair and Scalp, Nails 115

PROCEDURE 4.11 Assessing the Skin, Hair and Scalp, and Nails OVERVIEW

Skin, hair, and nails provide a self-regenerating protective covering for the body. ● Assessment of the skin not only provides information about the integumentary system but also provides data on the body’s circulation, nutritional status, and signs of systemic disease. ●

P R E PA R AT I O N

Review related history that would give the examiner information (past and present) regarding patient’s skin, hair, scalp, and nail conditions (i.e., skin cancer, eczema, change in mole, hair or nails, excessive bruising, rash or lesion). ● Integrate this assessment throughout the examination as each body part is examined. ● Observe symmetry of skin markings and pigmentation. ● Separate all skin folds and inspect thoroughly—front and back. ●

Special Considerations Pediatric Patient • Several pigmentation differences are found in the assessment of infants. The mongolian spot, a blue-black macular area at the sacrum or buttocks is more commonly found in Asian, Native American, and Hispanic newborns, as are café au lait spots. • Newborns may also have acrocyanosis, a bluish color around the lips, hands, and feet as well as transient mottling when exposed to cool temperatures. Physiologic jaundice is also seen in approximately half of all newborns. Lanugo, a covering of fine hair over the body is often found, especially in premature infants. • Turgor is tested over the abdomen in an infant. Pregnant Patient • In the assessment of a pregnant woman, striae or “stretch marks” are often found as well as the linea nigra, a brownish black line down the midline of the abdomen. Chloasma, the “mask of pregnancy,” is an irregular patch of hyperpigmentation on the face. Vascular spiders are found in about two thirds of pregnancies in white women. Elderly Patient • Elderly patients have special considerations as well.

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• The skin is thin and dry, with decreased turgor, and the nails become more brittle and yellowed. • Hair growth decreases, although in men, the hair becomes thick and coarse at the eyebrows, nose, and ears. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired tissue integrity related to infection Risk for infection related to injury EXPECTED OUTCOMES

Assessment completed while maintaining patient’s privacy and comfort ● Awareness of cultural and traditional health practices ●

EQUIPMENT/SUPPLIES

Strong, direct lighting Clear, flexible centimeter ruler Penlight I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Explain procedure to patient. Careful explanation reduces the patient’s anxiety. ➧ Fully expose area to be examined. Adequate exposure is necessary for a thorough examination. ➧ Inspect and palpate under strong, direct light. Weak, indirect lighting can distort colors and mask jaundice.

Skin ➧ Note general color as well as local variations. Color should be consistent with genetic background; look for pallor, cyanosis, jaundice. ➧ Note temperature using backs of hands, and compare bilaterally. Provides insight to circulatory status, infection, or trauma. ➧ Note moisture and texture using pads of fingers. Provides information regarding metabolic activity and fever.

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P r o c e d u r e 4 . 1 1 Assessing the Skin, Hair and Scalp, Nails 117 ➧ Note mobility and turgor using skin under the clavicle. Provides data on fluid status, weight gain/loss. ➧ Check for edema by pressing firmly over bony area of tibia or ankle. Provides information on fluid status, indicative of possible congestive heart failure, kidney failure, or local problem (especially if unilateral). ➧ Note lesions; identify color, shape, size, location, distribution, eleva-

tion, and any exudate (color/odor). May be indicative of traumatic or pathologic changes.

Hair and Scalp ➧ Note color of hair. Consistent with genetic background and signs of premature gray. ➧ Note texture of hair. Indicative of nutritional and endocrine status. ➧ Note distribution of hair. Indicative of endocrine and nutritional status. ➧ Note scalp abnormalities by parting and lifting hair—pay special

attention to occipital area and behind the ears. Provides information of presence of ringworm, lice, dandruff, lesions, or trauma.

Nails ➧ Note color. Provides information on perfusion and oxygenation status (pallor/cyanosis). ➧ Note capillary refill time—normal ⬍ 1–2 seconds. Cyanotic or sluggish color return may suggest cardiovascular or respiratory dysfunction. ➧ Note consistency—smoothness, thickness, adherence to nail bed. Indicative of nutritional, cardiovascular, or respiratory condition. ➧ Note shape and contour. Angle at nail base ⬍160 degrees with spongy nail base indicative of chronic cyanotic condition such as emphysema or chronic bronchitis. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Compare assessment findings to normal findings Pursue more specific tests and assessment regarding abnormal findings if warranted

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KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Skin color, integrity, texture, temperature, turgor, hygiene, scars (location). ● Edema. • Location. • Degree: 1⫹ Mild, 2⫹ Moderate, 3⫹ Deep pitting, 4⫹ Very deep pitting. • Unilateral/bilateral. ● Excessive perspiration, unusual odor. ● Presence and description of lesions. • Size, shape, location, distribution. • Color, blanching, tenderness, elevation. • Exudate—color/odor. ● Presence and description of decubitus. • Stage I—Reddened area of intact skin that will not blanch. • Stage II—Partial thickness wound involving the epidermis and/or dermis. Presents as a blister, abrasion, or shallow crater. • Stage III—Full-thickness wound extending into the subcutaneous tissue. Presents as a deep crater. • Stage IV—Full-thickness wound with extensive destruction of tissue, necrosis, and/or damage to muscle or bone. ● Trauma—location and description. ● Hair texture, distribution, parasites. ● Nail color, capillary refill time, nail base angle, adherence to nail bed.

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U N I T

C H A P T E R

Medication Administration

5 Oral and Topical Medications 5.1 5.2 5.3 5.4

Administering Oral Medications, 120 Helping Patients with Self-Medication, 126 Applying Medications to the Skin, 130 Administering Eye Drops and Ointments, 134 5.5 Instilling Medications into the Ear, 139 5.6 Administering Medications via Metered-Dose Inhaler, 142 5.7 Administering Medications via Rectal Suppository, 145

3

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PROCEDURE 5.1 Administering Oral Medications OVERVIEW ●

Safe medication administration involves accurate dose calculation, of the correct medication, given to the intended recipient, by the appropriate route, at the right time (the 5 rights). P R E PA R AT I O N

Calculation of Medications There are numerous methods for calculating medications. A few examples are listed. • Desired Dose (mg) ⫻ Available Vehicle (mL, tab, etc.) Correct Dose ᎏᎏᎏᎏᎏᎏ ⫽ (mL, tab) Available Dose (mg) • Available Vehicle Amount (mL, tab) ⫻ Desired Dose (mg) Correct ᎏᎏᎏᎏᎏᎏᎏ ⫽ Dose Available Dose (mg) (mL, tab) Special Considerations • A medication order must include the patient’s full name, the date and time the order was written, the name of the medication, the dose, the route, the frequency, and the signature of the person writing the order. • Medications must be checked for the five rights with each administration: right patient, right medication, right dose, right route, and right time. • Allergies should be checked prior to each medication administration. • The timing of the medication can affect the speed with which it is absorbed and acts. • In general, oral medications are absorbed better on an empty stomach if the patient can tolerate the medication. Many medications cause gastrointestinal distress. • Circadian rhythm also will affect absorption. • Check with references or the pharmacy before crushing any medication. Alert the prescriber if a liquid form is needed. • Do not crush an enteric-coated tablet, as they are not designed to be absorbed immediately. • Do not crush sustained-release tablets, as the delay in release of the drug will be lost, and more of the drug will be absorbed immediately. • Some medications, such as liquid iron preparations, will stain the teeth.

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• Some medications have special administration instructions, such as the patient must remain upright after administration. • If a medication falls on the floor, discard it and replace it to prevent contamination. • If the patient is scheduled for a test or procedure, check with the prescriber regarding medication administration, especially if the patient is ordered to have nothing by mouth. • Many medications have similar names. If an order is unclear, check with the prescriber before administration. • Many medications are made by more than one company. • The nurse needs to know the trade as well as the generic name of the medications being administered. Pediatric Patient • Do not refer to medications as candy. • In administering liquid medications to children, use a calibrated syringe or spoon readily available at drug stores and supermarkets to ensure correct dosing. • For infants, a syringe or dropper is best. • Place syringe alongside the tongue to prevent gagging and expulsion of medication. • To prevent choking, position the infant in a semi-reclining position and administer in small aliquots. • If using a spoon, collect and re-feed any expelled medication. • Do not mix medication into a large volume, as the child may not be able to drink the entire amount. • Play techniques may help elicit the child’s cooperation. • For children taking sweetened medications, especially on a longterm basis, follow medication administration with oral hygiene to assist in decreasing dental caries. Elderly Patient • The elderly are often on multiple medications from various physicians. • Look for possible drug interactions as well as prescriptions for more than one drug from the same class (such as beta-blockers). • At home, memory aides such as charts, daily-pill dispensers, and calendars can assist in ensuring that medications are taken correctly, especially for those on complex regimens. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible Knowledge Deficit related to safe medication administration

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122 C h a p t e r 5 Oral and Topical Medications EXPECTED OUTCOMES ●

The correct person will receive the correct medication and the correct dose, by the correct route, at the correct time, without injury or incident EQUIPMENT/SUPPLIES

Order Sheet Medication Administration Record (MAR) Medication Cart/Automated medication-dispensing system Medication to be administered (pills, capsules, liquids) Disposable medication cups or syringes as indicated Glass of water or other liquid and drinking straw Pill-crushing devise, if indicated I M P L E M E N TAT I O N ➧ Check MAR against order sheet, including checking for patient aller-

gies and order-expiry dates. Notify prescriber/supervisor of discrepancies and correct as necessary. Promotes safety, prevents errors, and prevents patient injury and unnecessary allergic reactions. ➧ Wash hands. Reduces transfer of infections. ➧ Assemble equipment. Improves efficiency. ➧ Obtain appropriate medications. Pour correct amount. Begin at the

top of the MAR. Check each against bottle label and MAR when pulled from the shelf or machine, as it is poured, and as bottle is replaced or drawer closed. Calculations should be made using standard formulas according to institutional policy when required. To ensure no medications are missed and the correct medication and dose are poured. ➧ For tablets or capsules: pour into cap of bottle then into medication

cup without touching the tablets/capsules. To prevent contamination. ➧ Unit dose: leave in packages until at the bedside. Keeps the medication clean and facilitates identification at the bedside ➧ Breaking tablets: Only scored tablets should be broken. Use a cutting

device as needed. The rest of the unused tablet should be discarded according to agency policy. To ensure correct amount is given and that safety is maintained.

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P r o c e d u r e 5 . 1 Administering Oral Medications 123 ➧ Crushing tablets: Place tablet between two medicine cups then

crush with pill crusher until a fine powder. Mix at bedside with small amount soft food or liquid. Fine powders mix better. To assist patients who have difficulty swallowing whole pills. ➧ Pouring liquids: Gently mix liquid by inverting bottle a few times. Many liquids settle while on the shelf. ➧ Set the cap upside down on the counter. To avoid contamination. ➧ Pour liquid away from label. To prevent destruction of label. ➧ Pour liquid medication into cup set on a firm surface, and read at the

lowest level of the meniscus. Ensures the most accurate dose. ➧ Wipe bottle before replacing cap. To keep cap from sticking. ➧ Controlled substances: The dose must be signed out on the narcotics

sheet with the patient’s name, medication, dose, date, time, and your name as the administering nurse. For those with automated dispensing machines, this is done automatically when the medication is removed. To comply with federal regulations. ➧ Obtain assessment data. To determine whether any medications need to be withheld for safety ➧ Take medication to bedside with liquid for swallowing. In preparation for administration. ➧ Assist the patient into a semi-Fowler’s position. To decrease risk for aspiration. ➧ Don gloves if exposure to saliva is possible. Protects nurse from infection. ➧ Recheck patient’s identity using armband and bar code, and asking

patient’s name. Explain procedure and medications. To ensure correct medication is being given to the correct patient. To enlist cooperation. ➧ If patient questions any medication, hold the medication and

recheck order. To ensure safety. Unfamiliar medications may signal a previously unidentified discrepancy.

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124 C h a p t e r 5 Oral and Topical Medications ➧ If a medication has a bad taste, sucking on ice before taking the

medication, giving it in a small amount of juice, or following it with a small amount of juice is permitted. Facilitate compliance by decreasing the bad taste. ➧ Open unit dose packets and place one at a time into a medication

cup. ➧ Give tablet or capsule medications to patient. Ask patient to take

one medication at a time and drink plenty of water. To ensure medication is swallowed and not lodged in throat or esophagus. ➧ Liquid medications should be taken after capsules and tablets are

taken. Ask the patient to finish the liquid medication. Follow with a small amount of water. Some liquids should not be further diluted. ➧ Stay with the patient until all medications are taken. Check patient’s

mouth if there is any question that the medication has been swallowed. Ensures all of the medications are taken and not retained in mouth or cheek. ➧ Reposition patient, lift side rails if lowered, and place call light within

reach. Instruct patient to call nurse for any deleterious side effects or symptoms of allergic reaction. Facilitates comfort. Ensures safety. ➧ Discard trash and remove any medications not ingested. Maintain safe environment. ➧ If patient refused medication or wishes to take it later, do not leave

at bedside. Maintain a safe environment. ➧ Remove medication and restore to shelf or machine only if in

unopened unit-dose packet. Allows nurse to administer later. ➧ All open pills and open unit-dose packets must be discarded accord-

ing to facility policy. Witness is needed for controlled substances. To comply with federal regulations. ➧ Wash hands Prevent spread of infection. ➧ Document administration. Serves as legal record of medication administration, and prevents inadvertent double dosing.

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P r o c e d u r e 5 . 1 Administering Oral Medications 125 ➧ Check patient 30 to 60 minutes later. To detect effectiveness of medication and/or any adverse or side effects. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Many medications have side effects; the patient should be carefully assessed for side effects and adverse reactions

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Routine medications are documented on the MAR. record should be clearly labeled with the person’s name. It should include the medication name, dose, route, frequency, and the time medication was administered. ● Any assessment data pertinent to the medication should be easily accessible, such as blood pressure measurement and heart rate for certain cardiovascular agents. ● For controlled substances, the dose must be signed out on the narcotics sheet with the patient’s name, medication, dose, date, time, and name of the administering nurse to comply with federal regulations. ● In automated dispensing machines, this is done automatically when the medication is removed. ● If the patient refuses a medication, document which medication is being refused and the reason and that the medication was withheld. ● Also document the notification of the prescriber. ● For medications administered on an as-needed basis (PRN), the assessment data pertinent to the medication, the reason the medication was given, the effects of the medication (Did it help?), and any teaching done should be recorded in the patient care record. ● Side effects from medications should be documented in the patient record. ● In shift report, it is assumed that all routine medications were given on time unless otherwise specified. ● Any problems, such as with swallowing, gastric distress, refused medications, or any changes in the routine should be reported. ● Any PRN medications, including results, should be reported. ● The

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126 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.2 Helping Patients with Self-Medication OVERVIEW ●

To assist the patient in managing home medication regimens. P R E PA R AT I O N

When teaching about medications, the essential nature and reason for that particular medication must be stressed. Perception of the helpfulness of treatment will affect the patient’s understanding and thus help promote understanding and compliance. ● Return demonstration for more difficult psychomotor skills such as inhalers, nebulizers, eye drops, ear drops, and insulin injections allows the nurse the best opportunity to assess patient performance. ● Common errors made include forgetting a medication, refusing to take a medication because of side effects, taking out-of-date medications, failing to understand instructions, taking medications prescribed for someone else, failing to obtain needed lab work to monitor medication dosing, and being unable to afford the medication prescribed. ● Addiction to prescription medications can occur. Assessment for signs of possible addiction and concomitant alcohol use should be assessed during routine visits using standardized formats, especially when patient is taking controlled substances. ● Especially in complex medicine regimens and when working with the elderly, it is helpful to use a daily medication chart upon which marks can be made or stickers placed as medications are taken. ●

TABLE 5.2 Medication Chart

●

MEDICATION

MON

Aspirin 325 mg Digoxin 0.125 mg Labetalol 200 mg

X

TUES

WED

THURS

FRI

SAT

SUN

AM PM

AM PM

AM PM

AM PM

AM PM

AM PM

X AM X PM

For those with poor reading skills, pictures or sketches can be used. A clock face, picture of a meal, or picture of a bed for nighttime

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P r o c e d u r e 5 . 2 Helping Patients with Self-Medication 127

medications can be placed on the chart for time. A picture of the medication can be placed in the medication list. ● The medication bottles can be color-coded corresponding to a line on the chart to ensure medications are taken correctly. Pill cases with sections for days and/or times can be used. ● If the pocket is empty, the patient knows the medication was taken for that day. These ′′pill minders′′ can be filled by part-time caretakers to increase the patient’s independence and sense of self-esteem. ● Some drug companies have special programs for low-income patients to assist in obtaining needed medications. Special Considerations Pediatric Patient • The parent or child care provider needs to be an integral part of the teaching/learning process. Children are generally quick learners; however, they have little life experience in which to couch new learning. • The consequences of their actions may not be understood. Simple developmental level–appropriate language must be used in teaching to facilitate understanding. Using a game format often facilitates learning in children. • Even very young children can be taught to use various medical equipment, such as nebulizers; however, usually an adult is required to supervise treatments and medication administration, especially for time management. • Children fear needles because of the pain. Teaching needs to include the sensations involved as well as the reason for the medication. Elderly Patient • In the elderly, anxiety and distraction decrease learning. The time needed to learn is increased. Sensory-perceptual and motor deficits require modified teaching techniques and make it more difficult to read labels and perform motor skills involved with self-medication administration. • Age-related physiologic changes alter the absorption and effects of medications. Many dosing regimens need to be decreased. Many elderly patients are on multiple medications, which increases the likelihood of interactions and side effects. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible knowledge deficit related to complex medication schedules and administration

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128 C h a p t e r 5 Oral and Topical Medications EXPECTED OUTCOMES ●

The patient will correctly and safely administer own medications according to schedule on a routine basis at home EQUIPMENT/SUPPLIES

Medications and administration equipment needed Chart for medication administration, calendar, list of medications Pill-minder boxes Clock, timer Pens, markers, stickers I M P L E M E N TAT I O N ➧ Assess patient’s ability to read, write, and any cognitive or psychomo-

tor impairment. Identify any other barriers to self-medication. To design a plan that is appropriate for that patient. If the patient cannot read or write, another avenue should be considered or adaptations made (see special considerations section). Many medications are very expensive, and patients cannot afford them. ➧ Gather all necessary equipment to be used by this patient. Obtain

placebo equipment, if needed, such as inhalers or saline for injection to teach insulin self-administration. For organization and to facilitate return demonstration for learning. ➧ Set up a mutually agreeable date and time to meet with the patient

and family or others involved in care. If the date and time is not agreeable, the patient will not be able to attend. ➧ Have patient bring all medications to teaching/learning session. To identify all medications the patient is taking, including over-the-counter and herbal medications, for possible interactions, double or incorrect dosing, missed medications, and expired medications. ➧ Review each medication with the patient—its purpose, effect, and

common side effects along with any special instructions. This will help the patient understand correct administration, and help prevent the patient from taking a medication for too long or not long enough; allows home assessment of effectiveness of treatment and opportunity to notify the health-care provider of problems. ➧ Encourage the use of one pharmacy for all medications. Using the same pharmacy will help ensure oversight of multiple medication regimens for possible drug interactions or other problems.

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P r o c e d u r e 5 . 2 Helping Patients with Self-Medication 129 ➧ Develop with the patient the chart or pill-minder system to be used. Improves compliance, and ensures that the patient can perform the plan. ➧ Teach psychomotor skill, then have the patient perform return

demonstrations until the patient is able to perform the skill correctly. Ask patient to verbally explain and to demonstrate steps of skill. To ensure correct performance and understanding of step. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Having the patient bring medications and charts or pill minders to routine visits helps reinforce learning and identify specific problems the patient may be having ● Return demonstrations for skills should be assessed periodically to correct poor habits that may have developed and to positively reinforce correct performance and previous learning ● Alternative plans can be made if needed to better meet the patient’s needs ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

In the patient’s chart, a note should be made regarding persons taught, content taught, the plan developed, any tools used (such as a chart), the patient’s response, and any return demonstration performed. ● Any problems identified (such as “the patient cannot see without his glasses, which are at home”) should be documented with actions taken in attempting to solve the problem. ● Plans for follow-up care should be recorded. ● In report, persons taught, content taught, the plan developed, any tools used (such as a chart), the patient’s response, and any return demonstration performed should be discussed with those involved in the patient’s care (such as other nurses, physicians, and social workers). ● Plans for follow-up care should also be discussed.

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130 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.3 Applying Medications to the Skin OVERVIEW

To create systemic and/or local effects when absorbed through the skin. ● These applications, such as lotions, powders, aerosol sprays, patches, pastes, and ointments, can be used to • Maintain skin hydration. • Protect skin surfaces. • Reduce local skin irritation. • Create local anesthesia. • Treat infections or medical conditions. ●

P R E PA R AT I O N

Topical medications should not be administered if skin integrity is altered, unless otherwise indicated. ● The skin must be cleaned thoroughly before applying topical medication to allow proper assessment of the skin surface and to ensure beneficial therapeutic outcomes (skin encrustations can harbor microorganisms and cause local infections as well as impede contact of medication to treatment area). ●

Special Considerations Pediatric Patient • A dry dressing to cover the affected area is usually necessary when applying topical agents to young children to prevent them from rubbing the medication off. Elderly Patient • Carefully apply topical agents and use tape sparingly when caring for an elderly patient. • Their skin can be thin and fragile. • Tape can cause bruising of the skin. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for impaired skin integrity related to topical medication Risk for noncompliance related to misunderstanding topical regimen

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P r o c e d u r e 5 . 3 Applying Medications to the Skin 131 EXPECTED OUTCOMES

Skin surfaces protected and hydrated Medication is properly administered ● Therapeutic effect is achieved ● ●

EQUIPMENT/SUPPLIES

Medication Administration Record (MAR) or chart (see Chapter 8) Ordered topical agent Clean and/or sterile disposable gloves (if required) Cotton-tipped applicators or tongue blades Sterile or nonsterile dressing, tape (if required) Cleaning solution to wash area if indicated I M P L E M E N TAT I O N ➧ Review physician’s order for drug name, strength, time of adminis-

tration, and site of application. Compare the label on the medication container with the MAR and check the expiration. (See Procedure 5.1) Ensures drug will be administered accurately and safely. ➧ Wash hands, observe appropriate infection control technique, and

organize the patient’s supplies at bedside. Prepare clean (intact skin) or sterile gloves (open noninfectious skin). Reduces transmission of microorganisms. Ensures an efficient, methodical procedure. Topical skin applications are usually not measured in the medication room. ➧ Close door to room or pull room curtain around bed; check patient’s

identification by asking patient’s name and checking it against ID bracelet; explain procedure, and position the patient comfortably. Provides privacy for patient, promotes comfort, and ensures that the right patient receives the right medication. Decreases anxiety and promotes patient cooperation. ➧ Expose area to be treated, inspect the condition of the skin and wash

affected area with a mild, nondrying soap, if indicated. Provides easy access to treatment area; provides a baseline to determine skin changes following therapy. Skin should be clean to conduct a proper assessment. Cleaning removes encrustations and debris and enhances penetration of the topical agent through the skin. ➧ Gently pat skin dry or let air dry. If skin is excessively dry and flaking,

apply topical agent to damp skin. Excessive moisture can prevent even application of topical agent. Applying agent over damp skin retains moisture within the skin layers.

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132 C h a p t e r 5 Oral and Topical Medications ➧ Don gloves, and apply topical agent. Disposable gloves prevent cross-contamination of infected lesions and protect the nurse from medication effects.

Applying Creams, Pastes, Ointments, and Oil-Based Lotions ➧ Using gloved hands, warm and soften medication by rubbing briskly

between hands or place a small amount of cream on tongue blade. Softening a topical agent makes it easy to spread on skin. ➧ Spread medication evenly over skin following the direction of hair

growth. Ensures even distribution of medication and prevents irritation of hair follicles. ➧ Explain to the patient that the skin may feel greasy after application. Ointments often contain oils.

Applying Nitroglycerin (in Antianginal) Ointment ➧ Remove previous dose paper. Wipe off residual medication with

tissue. Apply desired number of inches of ointment over papermeasuring guide. Removal of previous dose paper prevents overdose. Ensures correct dose of medication. Antianginal ointments are usually ordered in inches. ➧ Rotate site with each application. Apply ointment to skin surface

by holding edge or back of paper wrapper, and place ointment and wrapper directly on skin. Do not rub or massage ointment into skin Prevents skin irritation. Decreases the chance of ointment touching nurse’s hands. Massaging may increase absorption of medication. ➧ Date, time, and initial paper. Prevents missed doses. ➧ Secure ointment and paper with plastic wrap and tape (optional). Prevents medication from being removed and clothing from being stained.

Applying a Transdermal Patch ➧ Choose a clean, dry, hairless area recommended by the manufac-

turer. Placing the patch over hair or scar tissue may decrease the absorption. ➧ Carefully remove the patch from its protective covering. Holding

the patch without touching the adhesive edges, apply the patch by pressing firmly with the palm of one hand for approximately 10 seconds. Make sure edges stick well.

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P r o c e d u r e 5 . 3 Applying Medications to the Skin 133 Touching the adhesive edges may interfere with adherence of patch and medication dose. ➧ Date, time, and initial patch. Prevents missed doses. ➧ When the next dose is due, remove the patch and fold it so that the

medication side is covered before disposal. Choose a different site with each change. Wait at least 1 week before applying the patch to a previously used site. Proper disposal protects against accidental exposure of medication to others. Rotation of patch decreases skin irritations from medication and adhesive.

Applying Aerosolized Medication (Spray) ➧ Shake container vigorously, and hold the container at the recom-

mended distance (usually 6–12 inches). A mixture of contents and propellant ensures distribution of fine, even spray. Holding container too close results in thin, watery distribution. ➧ Spray medication evenly over affected area. If neck or upper chest

areas are to be sprayed, have patient turn face away from spray or briefly cover face with towel. Entire affected area should be covered with a fine, thin spray. Avoiding facial area prevents inhalation of spray.

Applying a Powder ➧ Dry the skin surface thoroughly. Spread apart any skin folds and dust

skin lightly with dispenser until area is covered with a fine, thin layer of powder. Decreases caking and crusting of powder. Skin is fully exposed for application. Slight lubricating properties are achieved in a thin layer of powder, reducing friction and promoting drying.

Applying Suspension-Based Lotion ➧ Shake container vigorously, and apply a small amount of lotion to

gauze dressing or pad. Apply to the skin by evenly stroking the lotion in the direction of hair growth. Explain to the patient that the skin may feel cool and dry. Mixture of powder and liquid forms well-mixed suspension. After water base of suspension dries, a protective film of powder is left on the skin. Technique prevents irritation of hair follicles. Water evaporates, leaving a thin layer of powder.

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134 C h a p t e r 5 Oral and Topical Medications ➧ Cover skin with dressing if ordered by physician; assist patient to

comfortable position and cover exposed area. May prevent agent from being rubbed off and staining clothing. Provides sense of well-being for patient. ➧ Remove gloves, dispose of supplies in proper receptacle, and wash

hands. Reduces transmission of microorganisms and/or residual medication to others. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s response to medication Rotate sites for application of transdermal medications ● Assess skin around wound or lesions, if applicable, for maceration from medications and moisture ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

findings before and after application of medication. ● Description of lesion and/or secretions. ● Patient’s tolerance of the procedure. ● Time medication was applied; site used. ● Cardiac status. ● Healing process of affected area.

PROCEDURE 5.4 Administering Eye Drops and Ointments OVERVIEW ●

To treat medical conditions (e.g., glaucoma) and infectious and inflammatory processes, dilate or vasoconstrict pupils for eye examinations, relieve pain, and prevent drying of delicate eye structures.

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P r o c e d u r e 5 . 4 Administering Eye Drops and Ointments 135 P R E PA R AT I O N

Avoid instilling medication directly onto the cornea. The wrong concentration of an ophthalmic drug may cause local irritation and systemic effects, and can prolong adverse side effects, such as blurred vision. ● Instill eye drops at room temperature to decrease irritation due to cold solution. ● When drops and ointment are ordered, place drops in first and wait 3 minutes before administering the ointment to allow time for the drops to be absorbed. ● ●

Special Considerations Pediatric Patient • Infants and young children may require immobilization of head and distraction. • Older children will only need explanation and direction. • If an infant clenches the eyes tight, place drops at the nasal corner where the lids meet. • The eye medication will flow into the child’s eye when it opens. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for injury related to impaired visual acuity EXPECTED OUTCOMES

Desired effect is achieved Patient denies discomfort ● Patient experiences no side effects, and symptoms are relieved ● ●

EQUIPMENT/SUPPLIES

MAR (Medication Administration Record) Medication bottle, ointment tube, or medicated intraocular disk Cotton balls and absorbent sponge (use sterile products if indicated) Wash basin filled with warm water or sterile solution Eye patch and tape (if indicated) Clean gloves

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136 C h a p t e r 5 Oral and Topical Medications I M P L E M E N TAT I O N ➧ Review physician’s order for correct drug name, drug concentration,

time of administration, and eye (right, O.D.; left O.S.; both O.U.). Compare the label on the medication container with the MAR, and check the expiration. Ensures drug will be administered accurately and safely. ➧ Wash hands, observe appropriate infection control technique, and

organize the patient’s supplies at bedside. Reduces transmission of microorganisms. Ensures an efficient, methodical procedure. ➧ Check patient’s identification by asking patient’s name and checking

it against ID bracelet. Explain procedure and purpose of medication. Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation. ➧ Position patient in a supine or a sitting position with the head ex-

tended. (Do not hyperextend the neck if there is cervical spine injury.) Positioning facilitates correct placement of medication and reduction of medication drainage through tear duct. ➧ Clean eyelids and eyelashes Removes microorganisms, and facilitates medication absorption through mucous membranes.

• Don clean gloves Inhibits exposure to eye secretions.

• Using moistened cotton balls, wipe eye from inner to outer canthus. Prevents cross-contamination and entrance of microorganisms into lacrimal duct.

• Let moistened cotton balls remain over eye for a few minutes to remove crust. (Do not use the same cotton ball for both eyes.) Soaking allows easy removal of crust and prevents direct eye pressure. Prevents cross-contamination. ➧ Administer eye medications: ●

Hold or give patient a dry cotton ball or absorbent sponge. Rationales for eye medications: Absorbs medication that may run off.

●

Instruct patient to look toward the ceiling.

●

Place thumb or fingers of nondominant hand on the patient’s cheekbone just below the eye, and gently draw the skin down on the cheek to expose the conjunctival sac.

Reduces the likelihood that the patient will blink if looking upward.

Reduces the risk for touching the cornea and putting pressure on the eyeball. Prevents the patient from blinking or squinting.

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P r o c e d u r e 5 . 4 Administering Eye Drops and Ointments 137

Eye Drops ➧ Rest the dominant hand on

the forehead. Approaching the eye from the side, instill the correct number of drops onto the outer third of the lower conjunctival sac. The dropper should be held about 1 to 2 cm above the sac. The side approach minimizes the blink response. Instilling drops into the conjunctival sac will eliminate harm to the cornea. The cornea may be FIGURE 5.4A Instilling eye drops. harmed if drops fall directly on the cornea. Do not let dropper touch sac or cornea. ➧ Instruct patient to gently close eyelids. Allows the medication to spread over eyeball. Squeezing the eye could cause harm to the eye and force the medication out. ➧ Press firmly or instruct patient to press firmly on the nasolacrimal

duct for approximately 30 to 60 seconds. Prevents drainage of medication out of the eye and to the nasopharynx. Prevents bad taste of drug.

Eye Ointment ➧ Discard the first bead. The first bead is considered to be contaminated.

FIGURE 5.4B Instilling eye ointment.

➧ Hold the tube above the lower conjunctival sac; apply a thin ribbon

of ointment from tube onto the inner edge of the lower lid from inner to outer canthus. Instruct patient to gently close eyelid, and, using a circular motion, lightly rub lid with absorbent sponge. Allows for medication to be evenly distributed across the eye and lid margin without causing harm to the eye.

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138 C h a p t e r 5 Oral and Topical Medications

Intraocular Disk Procedure ➧ Remove disk from packaging. Adhere disk to finger by lightly pressing your fingertip against disk. (Note: You may have to moisten your gloved finger with sterile saline.) Position the convex side of disk on fingertip. Ensures that there is no damage or deformity to disk. Prepares disk for correct administration. ➧ Gently pull the patient’s lower eyelid away from eye using the non-

dominant hand. Instruct patient to look toward the ceiling. Place the disk in the conjunctival sac; the disk should float on the sclera between the iris and lower eyelid. Exposes conjunctival sac to receive medicated disk. ➧ Pull the patient’s lower lid out and over the disk. Ensures medication delivery. ➧ To remove the disk, lightly pull the patient’s lower eyelid to expose

disk using your nondominant hand. Pinch the disk and lift it out of the patient’s eye using the forefinger and thumb of your opposite hand. Exposes the disk for removal without causing harm to the eye. ➧ Gently remove excess medication by wiping the eye from the inner

to outer canthus. Prevents cross-contamination. ➧ If patient requires an eye patch, apply clean patch by placing it over

the affected eye, covering the eye completely. Tape patch securely without applying pressure to eye. A clean patch minimizes the opportunity for infection. ➧ Remove gloves, dispose of dirty supplies in the appropriate recepta-

cle, and wash hands. Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe patient’s response to instillation Note if any discomfort is felt ● Assess visual changes, and note any side effects; if blurring of vision occurs, assist patient to bed if in chair, and instruct patient to remain in bed until clear vision returns; raise side rails and place call button within reach. ● ●

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P r o c e d u r e 5 . 5 Instilling Medications Into the Ear 139

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Drug name, concentration, and time administered. Patient’s response to instillation. ● Any discomfort or side effects. ● Patient’s visual status. ● Whether pain medication was required. ●

PROCEDURE 5.5 Instilling Medications Into the Ear OVERVIEW ●

To treat inflammation and infection and soften cerumen for easy removal. P R E PA R AT I O N

Solution must be at room temperature to avoid vertigo or nausea. Do not force solution into ear. ● Do not occlude ear canal with dropper; pressure can rise during instillation causing injury to ear drum. ● ●

Special Considerations • Pediatric patients may require a second person (preferably a caretaker) to assist by holding the child in a position as to avoid causing damage to the ear during administration of ear drops. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible disturbed sensory perception (hearing) related to infection or disease process EXPECTED OUTCOMES

Patient states there is no discomfort or pain during procedure Patient reports that pain is relieved or eliminated ● Affected ear shows no evidence of wax buildup, redness, swelling, or drainage ● Patient shows improvement in hearing acuity ● ●

EQUIPMENT/SUPPLIES

Medication Administration Record (MAR) (See Procedure 5.1) Medication to be administered

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140 C h a p t e r 5 Oral and Topical Medications

Clean gloves Small basin of warm water Soap Washcloth Small, dry towel I M P L E M E N TAT I O N ➧ Review physician’s order for correct drug name, number of drops

to instill, time of administration, and ear (right, A.D.; left A.S.; both A.U.). Compare the label on the medication container with the MAR, and check the expiration. Ensures drug will be administered accurately and safely. ➧ Wash hands, observe appropriate infection control technique, and

organize the patient’s supplies at bedside. Reduces transmission of microorganisms. Ensures an efficient, methodical procedure. ➧ Check patient’s identification by asking patient’s name and checking

it against ID bracelet. Explain procedure and purpose of medication, and close room curtain or door for patient privacy. Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation. ➧ Don gloves and wash ear if excess wax or drainage is observed. Reduces the risk for exposure to ear secretions. Cerumen and drainage can harbor microorganisms and inhibit the distribution of medication. ➧ Position patient in a side-lying, sitting, or high Fowler’s position with

affected ear facing up (if in a sitting position, patient will have to tilt head toward the opposite side). Helps to channel medication into ear canal. ➧ Gently pull the auricle of the

ear up and back using the nondominant hand (in children younger than 3 years old, pull the auricle down and back). This technique straightens the ear canal for proper channeling of medication.

FIGURE 5.5A (1) Method for instill-

ing ear medications in an adult.

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P r o c e d u r e 5 . 5 Instilling Medications Into the Ear 141

FIGURE 5.5A (2) Method for instill-

ing ear medications in a child. ➧ Instill drops as ordered holding the dropper about 1/2 inch above

ear canal. Accidental injury of eardrum is prevented; medication is delivered; and contamination of remaining solution in bottle is reduced. ➧ Request that patient remain in position for 5–10 minutes. Use

gentle massage or pressure to tragus of ear. Allows complete distribution and absorption. Helps to move medication toward the inside of ear. ➧ Remove gloves, dispose of dirty supplies in the appropriate recep-

tacle, and wash hands. Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s comfort level during procedure Assess amount, color, character, and odor of drainage if indicated ● Assess patient’s pain level using a pain scale; determine if pain medication is indicated ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Medication name and time administered. Patient’s tolerance to procedure. ● Amount, color, character, and odor of drainage if indicated. ● Swelling or redness in ear canal. ● Type of test used to assess patient’s auditory acuity. ● Irrigation solution used. ●

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142 C h a p t e r 5 Oral and Topical Medications

PROCEDURE 5.6 Administering Medications via Metered-Dose Inhaler (MDI) OVERVIEW

Metered-dose inhalers (MDI) are used for medications administered by means of the inhaled route and are usually intended to produce local effects. ● Because inhaled medications are absorbed rapidly through pulmonary circulation, systemic effects may occur. ●

P R E PA R AT I O N

The canister must be pressed at the same time the breath is taken. The inhaler must be shaken prior to delivering the medication. ● Wait 1 minute between inhalations. ● Clean the valve frequently. ● Observe a test spray before administering medication. ● Overuse may result in tolerance to medication and serious side effects. ● ●

Special Considerations Pediatric Patient • Infants and young children requiring inhaled medications use a nebulizer machine to deliver medications. • School-aged children through adolescence and elderly patients usually require a spacer device. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible impaired gas exchange related to disease process EXPECTED OUTCOMES

Medication is administered correctly Patient experiences improved breathing patterns and less restricted airways ● Patient has adequate gas exchange ● ●

EQUIPMENT/SUPPLIES

MAR (see Procedure 5.1) MDI with medication canister Stethoscope Spacer device (if indicated)

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P r o c e d u r e 5 . 6 Administering Medication via MDI 143

Drug canister Spacer

Metered-dose inhaler

FIGURE 5.6 Metered-dose inhaler.

I M P L E M E N TAT I O N ➧ Review physician’s order for correct drug name, drug concentration,

time of administration, and route (mouth or naris). Compare the label on the medication container with the MAR and check the expiration. Ensures drug will be administered accurately and safely. ➧ Wash hands, observe appropriate infection-control technique, and

organize the patient’s supplies at bedside. Reduces transmission of microorganisms. Ensures an efficient, methodical procedure. ➧ Check patient’s identification by asking patient’s name and check-

ing it against ID bracelet. Explain procedure and purpose of medication. Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation. ➧ Explain and demonstrate steps for administering medications via

an MDI: • Remove cover from the MDI mouthpiece. Using simple step-by-step explanations along with demonstration facilitates patient participation.

• Shake inhaler effectively for about 2–5 seconds. Ensures mixture of medication and propellant.

• Maintain inhaler in an upside-down position. Prepares patient’s airway to accept medication.

• Instruct patient to take several slow deep breaths exhaling deeply through the nose. Guides aerosol spray toward airway. Holding the mouthpiece 1–2 inches from mouth opening is the preferred delivery position without use of spacer device.

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144 C h a p t e r 5 Oral and Topical Medications

• Place the mouthpiece of the inhaler into the mouth with the opening pointed at the throat, or hold the mouthpiece 1–2 inches from the opening of the mouth. • Hold one naris closed, and place the nosepiece at the entrance of the other naris for nasal instillation. Repeat for other naris. Allows medication to be effectively distributed to airways during inhalation.

• With head slightly tilted back, inhale slowly and deeply through the mouth (or naris for nasal instillation) while pressing down on the medication canister to release the medication dose. Allows aerosol spray to get into deeper airways. Controlling exhalation allows the small airways to remain open during exhalation.

• Hold the breath for a count of 10 (approximately 10 seconds), and slowly exhale through pursed lips or nose. Waiting allows the first dose to begin working so that the following dose can reach deeper into the airways.

• If a second dose is ordered, wait 1 minute between puffs. ➧ Explain and demonstrate use of MDI with spacer device: Using simple step-by-step explanations along with demonstration facilitates patient participation.

• Remove mouthpiece covers from MDI and spacer device. MDI is inserted into the end of the spacer device. MDI fits into the end of spacer device.

• Shake inhaler effectively for 2–5 minutes. Ensures mixture of medication and propellant.

• Close lips around the spacer device mouthpiece and breathe normally. Do not cover exhalation slots with lips. Medication should not seep from mouth. Normal breathing allows patient to relax prior to medication delivery.

• Spray one puff into spacer device. Medication from MDI is trapped in spacer device.

• Inhale slowly and completely for about 5 seconds; hold breath for a count of 5–10 seconds. Prepares patient’s airway to accept medication. Allows aerosol spray to get into deeper airways. ➧ Rinse the mouth following delivery of medication. Medication from MDI has an unpleasant taste. ➧ Explain to patient that medication droplets on the pharynx or

tongue may elicit a gag response. Incorrectly inhaled medication produces a gag response. ➧ Remove medication canister, and clean inhaler with warm water. Medication can accumulate around mouthpiece and prevent correct distribution during use.

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P r o c e d u r e 5 . 7 Administrating Medications via Rectal Suppository 145 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe patient’s breathing patterns Assess patient’s respiratory status, and compare to pretreatment status ● Assess patient’s oxygen saturation ● If respiratory status shows no improvement, or if serious side effects develop, contact physician ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Drug name, concentration, and time administered. signs before and after treatment including oxygen saturation. ● Respiratory status. ● Need for oxygen. ● Cardiac monitor (if indicated). ● Vital

PROCEDURE 5.7 Administrating Medications via Rectal Suppository OVERVIEW

Various medications are delivered via rectum and absorbed through mucous membranes of rectum. ● This approach is convenient and safe. ● Medications delivered rectally are used to produce systemic effects or a local effect on gastrointestinal mucosa. ●

P R E PA R AT I O N

Improper placement can cause the suppository to be released prior to the medication being absorbed into the mucosa. ● The suppository should never be forced into a mass of fecal matter. ● Do not divide suppository into smaller sections; incorrect dosing may occur. ● Rectal suppositories should not be administered to patients with rectal surgery or active rectal bleeding. ●

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Special Considerations Pediatric Patient • In pediatric patients, it may be necessary to gently hold the buttocks for 5 to 10 minutes. • Pressure on the anal sphincter is relieved until the urge to expel the suppository has ended. Elderly Patient • Elderly patients may have difficulty retaining suppository due to poor sphincter control. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for constipation or diarrhea related to suppository use EXPECTED OUTCOMES

Patient’s symptoms for which medication is ordered are relieved or reduced ● Patient experiences no discomfort during procedure ●

EQUIPMENT/SUPPLIES

Medication administration record (MAR) (see Procedure 5.1) Rectal suppository Water-soluble lubrication jelly Clean gloves Tissues Drape I M P L E M E N TAT I O N ➧ Review physician’s order for correct drug name, drug strength, and

time of administration. Compare the label on the medication container with the MAR, and check the expiration. Ensures drug will be administered accurately and safely. ➧ Wash hands, observe appropriate infection control technique, and

organize the patient’s supplies at bedside. Reduces transmission of microorganisms. Ensures an efficient, methodical procedure ➧ Check patient’s identification by asking patient’s name and checking

it against ID bracelet. Explain procedure and purpose of medication, and close room curtain or door for patient privacy. Ensures that the right patient receives the right medication. Decreases anxiety, and promotes patient cooperation.

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P r o c e d u r e 5 . 7 Administrating Medications via Rectal Suppository 147 ➧ Position patient prone or in the left side-lying Sims’ position. Flex

upper right leg. Keep patient covered with drape, and expose only the anal area. Sims’ position aids in relaxing the external anal sphincter. Lying on the left side reduces the likelihood that the suppository or feces will be released. ➧ Don gloves and examine the condition of the anus. Inhibits exposure to feces. Allows observation of hemorrhoids, active bleeding, or rectal irritation. ➧ Remove the suppository from foil wrapper, and apply lubricant to

gloved index finger of dominant hand and to the smooth, rounded end of suppository. (Gently rub tip of suppository until smooth and slightly rounded if edge is sharp.) Water-soluble lubrication decreases friction as suppository is introduced into the rectal canal. ➧ Using the nondominant hand, spread the buttocks and instruct

patient to breathe slowly and deeply through mouth. Relaxes anal sphincter. Pushing a suppository through a constricted sphincter produces pain. ➧ Ask patient to bear down to identify anal opening (if indicated) and

insert suppository using your gloved dominant hand into the rectum beyond internal sphincter and against the rectal wall, approximately 4 inches. Absorption and therapeutic effects are achieved when the suppository is placed against the rectal mucosa.

FIGURE 5.7 Inserting a rectal suppository.

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148 C h a p t e r 5 Oral and Topical Medications ➧ Remove finger and wipe patient’s anal area. Maintains patient comfort. ➧ Ask patient to squeeze buttocks together for 3–5 minutes and

remain flat or on side for about 15–20 minutes. Raise side rails and place call light and bedpan within reach (if laxative is administered). Decreases the likelihood of expulsion of suppository. Allows time for medication to be distributed and absorbed. ➧ Remove gloves, dispose of dirty supplies in the appropriate recepta-

cle, and wash hands. Maintains a neat and clean environment for the patient. Reduces transmission of microorganisms to others. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Determine if suppository was released; reinsertion may be required Assess patient’s comfort level during insertion ● Assess for therapeutic effects ● Assess for rectal pain using a pain scale; determine if pain medication is required ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Medication name and time administered. Rectal pain. ● Unrelieved symptoms or therapeutic effects. ●

C H A P T E R

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6 Parenteral Medications 6.1 Administering Subcutaneous Injections, 150 6.2 Administering Intramuscular Injections, 155 6.3 Administering Intramuscular Injections by Z-Track Method, 161 6.4 Administering Intradermal Injections, 164 6.5 Administering Intravenous Medications by Intermittent Infusion Sets or Mini-Infusion Pumps, 169 6.6 Administering Medications by Intravenous Bolus, 178 6.7 Teaching Patients How to Administer Self-Injections, 183 6.8 Mixing Two Types of Insulin, 188 6.9 Using Patient-Controlled Analgesia (PCA) Infusion Devices, 191

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150 C h a p t e r 6 Parenteral Medications

PROCEDURE 6.1 Administering Subcutaneous Injections OVERVIEW

To deposit medication into the subcutaneous tissue layers safely, avoiding injury to the patient, while ensuring proper drug absorption after injection. ● Reasons medications are given parenterally are • To prevent irritation to the gastrointestinal tract. • To prevent destruction of the medication by first-pass hepatic effect or gastric juices. • To anesthetize specific areas of the body. • To achieve a rapid effect. • When the physical or mental state of the patient prohibits the use of other routes. ●

P R E PA R AT I O N

Review the medication order for patient’s name, drug name, dosage, and time and route of administration. ● Know information specific to drug that is ordered: action, purpose, time of onset and peak action, dosage, side effects, and nursing implications. ● Review patient’s allergy, medical, and medication history. ● Know reasons for giving medication by this route and if subcutaneous injection is contraindicated (circulatory shock or reduced local tissue perfusion). ●

Special Considerations • Subcutaneous injection is an effective method of drug delivery that is used quite frequently in nursing. • However, some “rules of thumb” must be kept in mind for the nurse using this method. • First, a well-lighted area should be used to assess the site of injection. • Second, when giving repeated doses on a regular basis, the use of a site rotation chart should be instituted and kept on the Medication Administration Record (MAR). • Third, avoiding exposing the needle in the patient’s line of vision decreases level of anxiety. • Additionally, keep in mind the anatomy of the patients receiving the medication: obesity requires the use of a longer needle, and

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P r o c e d u r e 6 . 1 Administering Subcutaneous Injections 151

elderly people have less subcutaneous tissue stores and less skin elasticity. • Insulin is routinely delivered by the subcutaneous injection route. • Reference should be made to the section on insulin for added information. • Efficient teaching to diabetic patients is beneficial because most of these patients will be self-administering these medications at home. • Heparin is another medication that is commonly administered by subcutaneous injection. • Some special considerations for heparin, owing to its anticoagulant effects, are • Site of choice is the abdomen, because the layer of subcutaneous tissue here does not lie over any major muscles, leading to decreased chance of hematoma formation and movement. • Use of a 1/2-inch, 25- to 27-gauge needle is a common choice. • Changing the needle once the medication is drawn up to prevent heparin from remaining in needle, which could lead to inadvertent delivering of the medication into the intradermal tissue. • Controversial views on aspirating prior to injection (review agency policy on this issue). • Massaging the site after injection can increase incidence of bruising. • Rotation of sites around abdomen to decrease irritation to tissue. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for impaired skin integrity EXPECTED OUTCOMES

Mild burning/stinging sensation at site of injection Patient explains purpose and effects of medication ● No allergies or unwanted effects from medication ● ●

EQUIPMENT/SUPPLIES

MAR Alcohol swabs Gloves (nonsterile) Adhesive bandage 1- to 2-mL syringe (insulin syringe may be appropriate) Needle (1/2- to 1-inch, 25- to 27-gauge; dependent on patient’s size) Medication to be administered

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152 C h a p t e r 6 Parenteral Medications I M P L E M E N TAT I O N ➧ Wash hands. Decreases transfer of microorganisms. ➧ Preparation of medication following the five rights of drug adminis-

tration. Decreases the chance of making a drug error. ➧ Properly identify the patient from the identification bracelet and by

asking his name. Ensures that medication not given to wrong patient. ➧ Give explanation of procedure and reason for giving drug in a calm,

confident manner. Decreases patient anxiety level. Explanation helps patient to anticipate nurse’s actions. ➧ Verify allergies on MAR with patient. Reduces chance of adverse reactions. ➧ Provide privacy. Lessens embarrassment. ➧ Don gloves. Prevents direct contact with body fluids. ➧ Perform or teach patient on the following steps of procedure. If patient is to self-administration at home. ➧ Selection of injection site.

FIGURE 6.1A Subcutaneous injection sites.

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P r o c e d u r e 6 . 1 Administering Subcutaneous Injections 153 ●

Common sites are abdomen and upper arm.

●

Heparin should be injected into abdomen.

Easy for self-administration. Recommended site.

Use alternative site if scarring, tissue irritation, or bulky dressings present. ● Rotation of sites, note on chart. ●

Prevents repeated and permanent damage to tissue. ➧ Position patient; cleanse site with alcohol swabs. Provides access to site. Decreases microorganism transmission. ➧ With needle exposed, hold

approximately 1 inch of fatty tissue between thumb and forefinger of nondominant hand. Elevates subcutaneous tissue. ●

(NOTE: Grab skin gently with minimal manipulation if giving heparin injection.)

Skinfold thickness

2 inches: Use a 90° angle 1 inch: Use a 45° angle

Prevents tissue trauma.

FIGURE 6.1B Pinch tissue between thumb and forefinger.

➧ With dominant hand, insert needle at a 45-degree angle in one

quick, smooth motion while holding syringe between thumb and forefinger. Use a 90-degree angle on a larger person. Quick, smooth insertion decreases discomfort. Angle prevents insertion into muscle layer. Obese people have larger layer of subcutaneous tissue.

90°

45° Skin Subcutaneous tissue Muscle

FIGURE 6.1C Insert needle at a 45-degree or 90-degree angle.

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154 C h a p t e r 6 Parenteral Medications ➧ On release of skinfold, aspirate plunger, looking for blood return in

the syringe. Presence of blood return indicates intravenous placement. ➧ If no blood return is noted, give drug slowly. Slow administration of drug reduces discomfort and trauma. ➧ If blood return is present:

Withdraw needle. Apply pressure until bleeding stops. ● Assess for presence of hematoma/bruising. ● Apply bandage, if needed. ● Begin again from step 1. ● ●

Prevents injection of drug intravenously. Subcutaneous medications are usually not indicated for intravenous absorption. ➧ Withdraw needle at the same angle as insertion, Prevents additional trauma to tissue. ➧ Wipe site with another alcohol swab while lightly massag-

ing site. ● DO NOT massage after heparin injection. Massage stimulates circulation, improving distribution and absorption of drug. Massage after heparin injection may cause bruising. ➧ Place bandage, if needed. Decreases amount of bleeding from site. ➧ Discard all equipment in proper manner. Prevents accidental needle sticks, and keeps work environment clean. ➧ Wash hands. Reduces transmission of infection. ➧ Document administration on MAR. Required for legal purposes, and makes others aware that drug has been administered.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 155 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

After a short period of time, ask patient if there is acute pain, burning sensation, tingling, and/or numbness at site of injection ● Check for a response to the medication approximately 30 minutes after injection ● Assess that patient has an understanding for the purpose of the drug administered ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Name, dose, injection site, and administration route of drug, as well as date and signature in MAR. ● Any teaching that was done with patient during task. ● Any adverse reactions from drug administration. ● Any as-needed (PRN) or one-time orders for medications should be charted in nurse’s notes—once at time of administration and another entry within 1 hour of patient’s response to medication. ● Report any unwanted side effects of medication to physician and charge nurse.

PROCEDURE 6.2 Administering Intramuscular Injections OVERVIEW

To administer ordered medication to the patient. This method provides rapid drug absorption because muscle tissue is highly vascular. ● Muscle is less sensitive to irritating and viscous medications. ● ●

P R E PA R AT I O N ● ●

Identify anatomic landmarks for injection Ventrogluteal Muscle • Situated away from all major nerves and blood vessels. • Safe for all patients and the preferred site for anyone older than 7 months old.

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156 C h a p t e r 6 Parenteral Medications

• Locate muscle by placing heal of hand over the greater trochanter of the patient’s hip with wrist perpendicular to femur. Use right hand for the left hip and left hand for the right hip. The index finger, middle finger, and the iliac crest form a “V”-shaped triangle. Inject into the center of the triangle. Anterior superior iliac spine

Iliac crest

Injection site

FIGURE 6.2A Locating the ventrogluteal

site. ●

Vastus Lateralis Muscle • Well-developed muscle. • Preferred site for infants. • Located on the anteriorlateral aspect of thigh, one hand-breadth below the trochanter and above the knee. • Injection should be into the middle third of the muscle.

FIGURE 6.2B Locating the vastus lateralis injection site.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 157

Dorsogluteal Muscle • Traditional site for intramuscular (IM) injections but should be last choice because of risk for striking the sciatic nerve or major Inject here blood vessels. • Avoid this site in small children until they are walking; adequate musculature may FIGURE 6.2C Locating the not have developed. dorsogluteal injection site. • Have the patient assume a prone position with toes inward. This produces inward rotation of the hips, which relaxes the muscle, making injection less painful. • Locate posterior superior iliac spine and the greater trochanter of the femur. Draw an imaginary line between the two landmarks, and inject above and lateral to the line. Avoid the sciatic nerve that runs parallel and below the line. ● Deltoid Muscle • Easily accessible but not well developed in many adults. • Use only for small volumes of medication (0.5–1.0 mL). • Locate the acromion process. The injection site is 2 inches below the acromion process in the center of the muscle. • Correct needle length is important to avoid subcutaneous injection. FIGURE 6.2D Locating the deltoid • 11/2-inch is usually long injection site. enough to penetrate the muscle in an adult. • 2- to 3-inch will be needed in the obese patient to avoid subcutaneous injection. • 1 inch is usually long enough to penetrate muscle in a child or emaciated adult. • A tuberculin syringe is usually adequate for injections in a small ●

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158 C h a p t e r 6 Parenteral Medications

child or infant. • Gauge (diameter) of the needle should be based on the viscosity of the fluid that is injected. • If the medication is irritating to the tissues, change to a new needle before injection. • If medication has been ordered in multiple routes (oral, parenteral, or rectal), determine the patient’s preference before medication preparation. • If medication has been ordered for pain, ask the patient to rate the pain using an approved pain scale. Special Considerations • Consider the volume of medication to be delivered to the patient; if volume exceeds 5 mL in an adult or 3 mL in a child, two separate injections should be given at different sites. • The deltoid muscles are limited to a volume of 1 mL. If the medication is irritating to the tissues, use the Z-track method. (See Procedure 6.3.)

R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for injury related to intramuscular injection EXPECTED OUTCOMES

●

Atraumatic delivery of medication to a muscle mass via appropriate injection site EQUIPMENT/SUPPLIES

Alcohol swabs Syringe Needles 1- to 11/2-gauge (2) Band-Aid Gauze MAR I M P L E M E N TAT I O N ➧ Prepare medication adhering to the five rights of administration. Decreases chance of drug error. ➧ Identify patient by name and identification bracelet. Confirms identify of patient.

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P r o c e d u r e 6 . 2 Administering Intramuscular Injections 159 ➧ Explain procedure and purpose of drug to patient/family. Reduces patient anxiety, and promotes cooperation. ➧ Verify allergies listed in medical record. Avoids possibility of drug reaction. ➧ Don gloves. Prevents contact with body fluids. ➧ Position patient according to selected injection site appropriate for

age and size located by anatomical landmarks. Facilitates visualization and access to muscle mass of selected injection site. (See Figs. 6.2A, B, C, and D.) ➧ Ask patient to relax the extremity planned for injection. Minimizes trauma and discomfort upon injection. ➧ Clean Injection site with alcohol, and remove needle cap. Provide air

lock. Maintains asepsis. ➧ Pull skin taut at insertion area. Facilitates complete needle insertion into muscle. ➧ Place thumb and index finger of nondominant hand over injection

site (avoid cleaned area) to form a “V.” ➧ Pull thumb and index finger in opposite directions, about 3 inches

apart. ➧ Rapidly insert needle at a 90-degree angle with dominant hand

using a darting motion. Reduces pain from needle insertion. This angle facilitates the medication reaching the muscle. ➧ Move thumb and index finger of nondominant hand to support bar-

rel of syringe (avoid obstructing view of barrel with fingers; you will need to visualize contents upon aspiration). Prevents needle movement and tearing injury to tissues. ➧ Pull back on plunger observing for blood return in barrel of syringe. Establishes if the needle is in a blood vessel or in a muscle. ➧ If blood present: remove needle, apply pressure to site, and repeat

steps 7 to 13. Prevents unintentional intravenous injection.

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160 C h a p t e r 6 Parenteral Medications ➧ If no blood present, slowly and steadily push the plunger down;

encourage patient to talk. Medication delivery that allows time for dispersal through the tissues. Reduces patient anxiety. ➧ Remove needle using the same angle as that of insertion. Prevents unnecessary tearing of tissues. ➧ Clean and massage insertion area with a second alcohol pad (if con-

traindicated for drug use firm pressure). Apply Band-Aid if needed. Prevents seepage of drug into subcutaneous tissues. ➧ Do not recap needle; place in sharps container; remove gloves. Averts accidental needle stick and spread of infection. ➧ Reposition patient; raise side rails, and position with call bell within

reach. Maintains safety, comfort, and communication. ➧ Wash hands. Prevents spread of microorganisms. ➧ Document administration on medication record. Serves as a legal record, and avoids inadvertent re-medication. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess infection site for bleeding, hematoma, and local reactions Assess for medication effects (i.e., allergic reactions and/or relief of pain/nausea)

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient’s tolerance to injection. Location and condition of injection site. ● Effect of medication. ● Time of injection. ● Status of side rail. ● Pain score (if appropriate). ● Adverse reactions to medication should be reported to physician and charge nurse. ●

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P r o c e d u r e 6 . 3 Administering Intramuscular Injections 161

PROCEDURE 6.3 Administering Intramuscular Injections by the Z-Track Method OVERVIEW ●

To contain irritating medication in the muscle and prevent seepage to the surrounding subcutaneous tissues. P R E PA R AT I O N

Appropriate injection sites for this method of medication administration include dorsogluteal, ventrogluteal, and vastus lateralis areas. ● Needle length should be 2 inches to prevent medication delivery to subcutaneous tissue. ● Viscosity of the solution should be considered when selecting gauge of needle. ● Consider consulting physician to obtain an alternative route in the patient who is emaciated or has muscle atrophy ●

Special Considerations • Incorrect administration of iron preparations can cause skin staining. • Incorrect administration of other medications may cause irritation to subcutaneous tissue. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for injury related to IM injection and irritating medications EXPECTED OUTCOMES

Patient is without extreme pain after medication delivery via Z- track method ● Skin surrounding injection site should be intact without bruising or hematoma ● Mild burning or irritation upon injection; extreme pain is an unexpected outcome ●

EQUIPMENT/SUPPLIES

Syringe 2 needles (one 2-inch needle) Alcohol pads Medication

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162 C h a p t e r 6 Parenteral Medications I M P L E M E N TAT I O N ➧ Wash hands. Prevents transmission of microorganisms. ➧ Prepare syringe with ordered medication adhering to the five rights

of drug administration. Reduces risk of drug error. Proper preparation of drug. ➧ Change needle after medication has been drawn up, and pull

plunger back 0.3 mL. Prevents irritation and staining of skin and subcutaneous tissues when needle is inserted into skin; airlock prevents back seepage of medication through the tissues. ➧ Identify patient by reading identification bracelet and addressing

patient by name. Confirms identity of the patient. ➧ Explain procedure and purpose of medication to be given. Decreases anxiety and promotes cooperation. ➧ Verify allergies listed on medication record. Alerts nurse to possible allergic reactions. ➧ Provide privacy. Reduces embarrassment. ➧ Don gloves. Prevents contact with body fluids. ➧ Assist patient into the prone position. Prone position facilitates identification of anatomic landmarks and promotes relaxation of gluteal muscles. ➧ Outline injection site by identification of anatomical landmarks of

dorsogluteal site (see Fig. 6.2C for important factors for acceptable sites), and information on locating anatomical landmarks). Prevents nerve injury. ➧ Clean skin with alcohol, and remove needle cap. Prevents transfer of microorganisms. ➧ Pull skin 1 to 1/2 inches laterally away from midline with nondomi-

nant hand, and rest the heel of the hand on the skin while maintaining traction. Retracts the skin and subcutaneous tissue from muscle, forming a tract that prevents back seepage of medication into subcutaneous tissues.

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P r o c e d u r e 6 . 3 Administering Intramuscular Injections 163 Allows fingers to support syringe barrel to provide stability of needle while aspirating.

Skin Subcutaneous tissue Muscle Medication FIGURE 6.3A Applying traction.

➧ Observe for the rise of the air bubble to the top of syringe and

quickly insert needle at 90-degree angle. Minimizes pain upon needle insertion, facilitates needle entering muscle mass, and ensures that air clears the needle to seal drug in muscle tissue. ➧ Pull plunger back to aspirate for blood return. Determines if inadvertent insertion into blood vessel has occurred. ➧ If blood returns, remove the needle, assess and clean site with alco-

hol pad, apply Band-Aid, and discard medication. Repeat steps 1–14. If no blood, return slowly inject medication, and hold needle in place for 10 seconds. Blood return indicates intravascular injection. Medication contaminated with blood must be discarded. Provides adequate absorption time, and prevents leakage of medication back into subcutaneous tissues. ➧ Release the skin while removing needle at the same angle of

insertion. Avoids a direct track between muscle and subcutaneous tissue and skin that would allow the drug to be displaced causing irritation and pain. Skin Subcutaneous tissue Muscle Medication FIGURE 6.3B Medication is sealed

in the muscle.

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164 C h a p t e r 6 Parenteral Medications ➧ Dispose of needle in sharps container; do not recap. Prevents accidental needle stick. ➧ Do not massage the insertion area; may place alcohol pad or Band-

Aid over the site. Massage will increase the possibility of drug displacement into the tissues. ➧ Reposition patient, raise side rails, and lower bed. Place call bell

within reach. Maintains safety, comfort, and communication. ➧ Wash hands Prevents transfer of microorganisms. ➧ Document administration on medication record. Prevents accidental re-medication, and serves as a legal record. ➧ Re-check site in 15 to 30 minutes. Verifies that no seepage of drug has occurred. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Reassessment of site after injection is important to ascertain whether seepage has occurred ● Notify physician if subcutaneous seepage is suspected ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Reporting should include all the information under IM injections with the following additions: method (Z-track), pain after injection, and presence of skin stain. ● Extreme pain upon injection. ● Skin stain. ● Physician notification.

PROCEDURE 6.4 Administering Intradermal Injections OVERVIEW ●

Serves as a method of diagnostic testing for exposure to specific diseases or as a method of diagnostic testing for allergens.

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P r o c e d u r e 6 . 4 Administering Intradermal Injections 165 P R E PA R AT I O N

Caution patient to avoid use of new products on skin (i.e., soap or perfumes) or covering injection site with a bandage as these actions may produce false-positive test results. ● Assess the patient’s skin before administration, and note presence of redness, swelling, lesions, abrasions, excoriations, and excessive hair. If present, avoid administration in these areas. ●

Special Considerations • The patient is at risk for injury related to allergen sensitivity. • Have appropriate antidotal medications (usually epinephrine hydrochloride, a bronchodilator, and an antihistamine) available on the unit before the start of the procedure. • Know the location of resuscitation equipment (artificial airway, Ambu-bag, and code cart); reactions can be fatal. Should reaction occur: • Maintain airway. • Notify physician immediately. • Administer medications as ordered or per protocol. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for tissue damage related to intradermal injection EXPECTED OUTCOMES

The patient will be free of local or systemic reactions Small bleb forms at the site of injection that gradually disappears ● Minimal bruising may develop at the site of injection ● ●

EQUIPMENT/SUPPLIES

Medication record Two alcohol pads Pen (ink or felt) Gloves (nonsterile) Medication and tray 1-mL syringe with 26- to 28-gauge needle

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166 C h a p t e r 6 Parenteral Medications I M P L E M E N TAT I O N ➧ Wash hands. Decreases microorganism transfer. ➧ Prepare medication according to the five rights of administration. Reduces possibility of drug error. ➧ Identify patient by reading identification bracelet and addressing

the patient by name. Verifies identity of the patient. ➧ Explain the purpose of medication and the administration

procedure. Lessens anxiety, and encourages cooperation. ➧ Verify allergies listed on the medical record. Alerts the nurse to possibility of allergic reactions. ➧ Don gloves. Prevents direct contact with body fluids. ➧ Select injection site on the forearm if no other site is required by

doctor’s order or agency policy. Sites for intradermal administration are determined via areas where subcutaneous fat is less likely to interfere with administration and absorption. ●

If forearm unsuitable for use, select an alternative site. Forearm is the standard initial starting point and has the least amount of subcutaneous tissue.

FIGURE 6.4A Locations for intradermal injections.

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P r o c e d u r e 6 . 4 Administering Intradermal Injections 167 ➧ Position patient with forearm supinated. Allows assessment of injection area. ➧ Clean site area with alcohol and remove needle cap. Decreases microorganism transfer. ➧ Place nondominant thumb approximately 1 inch below insertion

site, and pull skin toward the hand. Taut skin facilitates needle entry. ➧ Insert needle just below the skin at a 10- to 15-degree angle with

dominant hand. Facilitates needle placement just below epidermis.

Epidermis Dermis

Subcutaneous tissue

FIGURE 6.4B Angle of needle for insertion.

➧ Advance needle another 1/8 inch after entering skin surface. Prevents back leakage of medication. ➧ Inject medication slowly and steadily while observing for bleb (a

raised welt) formation. Slow administration allows time to terminate injection should systemic reaction occur. Bleb formation confirms proper drug administration.

FIGURE 6.4C Bleb formation.

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168 C h a p t e r 6 Parenteral Medications ➧ Remove needle at the same angle of insertion. Prevents tissue trauma. ➧ If blood is present remove by dabbing with a second alcohol swab.

Do not rub area. Rubbing causes the drug to leak out. ➧ Observe skin for local redness and swelling.

If an allergy test was performed, observe patient for signs of systemic reaction (i.e., respiratory distress, hypotension, diaphoresis, nausea, vomiting, and cyanosis). Provides a visual assessment of local or systemic reaction. ➧ Place needle in sharps container. Prevents accidental needle sticks. ➧ Draw a 1-inch circle around the bleb. Aids in reassessment of site. ➧ Reposition patient; instruct not to rub, cover or apply new products

to area. Prevents inaccurate test results. ➧ Discard equipment, and wash hands. Promotes clean environment, and reduces microorganism transmission. ➧ Document administration on patient’s medication record. Prevents accidental re-medication, and serves as a legal record. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Reassess patient at 5 and 15 minutes after administration as subsequent reactions may occur ● Read site within 48 to 72 hours of injection ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Documentation of patient’s response to administration. Date and time medication given. ● Site of administration. ● Reassessment of findings. ● Documentation of lot numbers (check with agency). ● Undesirable side effects to the medication effects to physician or charge nurse. ●

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 169

PROCEDURE 6.5 Administering Intravenous Medications by Intermittent Infusion Sets or Mini-Infusion Pumps OVERVIEW

To lessen the risk for sudden drug side effects caused by rapid administration of medications. ● This method also avoids infusing large fluid volumes in patients with fluid restrictions. ●

P R E PA R AT I O N

Maintenance intravenous (IV) line must be functioning properly to: • Ensure proper drug administration. • Prevent drug extravasation. ● Medication may be delivered via intravenous piggyback (IVPB), Buretrol (plastic graduated container that is part of the main line that separates the IV fluid bag from the infusion tubing; also called a vulture) or mini-infusion pump (a battery powered, portable, automated delivery device). ● If the medication is to be given through a secondary line or vulture, the primary infusion rate may have to be changed to administer the medication over the proper amount of time (usually 30–60 minutes). ● Expiration dates of tubing should be monitored to decrease the possibility of contamination and infection. ● Know the drop factor (drops per milliliter [gtts/mL]) of the infusion sets in use by your agency. • Microdrip: 60 gtts/mL • Macrodrip: 10 or 15 gtts/mL ● Know the conversion formula to calculate drops per minute: mL/hr ⫻ drop factor/60 minutes ⫽ drops/minute. ● Infusion pumps use positive pressure rather than gravity to control flow; infiltration is more likely when using a pump because flow will continue even in the presence of increased resistance. Although pumps have pressure limits that activate an alarm, tissue damage may occur before the alarm will sound. ●

Special Considerations Pediatric Patient • When administering intermittent infusion medications to pediatric patients, always use a volume-controlled chamber such as a Buretrol,

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170 C h a p t e r 6 Parenteral Medications

Buretrol, Volutrol or an electronic infusion device such as an IV pump or controller to prevent accidental fluid overload and increased infusion rates. • Pediatric patients receive smaller doses with less volume than adults; therefore, it is important when using Buretrol or Volutrol to make sure that the patient receives all of the medication contained within the chamber and tubing. Elderly Patient • Elderly patients often have fragile veins that may easily rupture and cause infiltration of IV fluids infiltrate. • Periodic assessment of the infusion site should be done with any intermittent drug infusion. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for impaired skin integrity related to invasive line EXPECTED OUTCOMES

Medication will be delivered at a continual, steady rate over a specified period of time ● Medication will be delivered without contamination, adverse reaction, discomfort, or irritation to site ●

EQUIPMENT/SUPPLIES

Gloves Alcohol swabs Needleless connection device Medication record Watch with second hand IVPB Method: Medication prepared in a 50 to 100 mL infusion bag Main IV fluid line Short secondary tubing set Buretrol Method: Syringe with prepared medication Volutrol Infusion-Pump Method: Infusion pump Compatible IV tubing

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 171

Mini-infusion–Pump Method: Medication Syringe to draw up medication Syringe (3–60 mL) large enough to hold medication and diluents Diluent (if needed) to form desired concentration of medication Extension tubing Needleless adapter (See Fig. 6.5A) I M P L E M E N TAT I O N ➧ Wash hands. Reduces microorganism transfer. ➧ Prepare medication adhering to the five rights of administration. Decreases the possibility of drug error. ➧ Calculate the infusion flow rate. Determines the accuracy of the infusion rate. ➧ Identify the patient by reading the identification bracelet and

addressing the patient by name. Verifies identity of patient. ➧ Explain the purpose of medication and the administration proce-

dure. Reduces anxiety and promotes cooperation. ➧ Verify allergies listed on the medication record. Reduces the possibility of an allergic reaction. ➧ Don gloves Decreases exposure to body fluids. ➧ Assess patency of IV catheter. Verifies the IV access is viable. ➧ Clean rubber port with alcohol. Decreases microorganisms.

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172 C h a p t e r 6 Parenteral Medications ➧ Hold the port with the thumb and first finger of nondominant hand

while inserting the needle, or, if using a needleless system, needleless adapter of a sterile saline syringe into the port. Stabilizes catheter and prevents accidental removal.

FIGURE 6.5A Needleless adapter con-

nection with saline flush.

FIGURE 6.5B Insertion of needle/ needleless adapter into heparin lock.

➧ Pull back on the plunger, and observe for blood return. Aspiration of blood determines if catheter is functional. ●

If no blood return, reposition that extremity, and reassess site for redness, edema, and/or pain.

●

Discontinue IV lock and restart if unable to see blood return.

●

If positive blood return, insert saline.

Verifies if the problem is related to positioning, infiltration, or phlebitis. Removes nonfunctional catheter and reestablishes a functional IV site. Flushes catheter.

The medication may be administered IVPB, by a mini-infusion pump, or in a Volutrol.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 173

Primary Line and Secondary Line ➧ Clean rubber port with alcohol. Decreases microorganism transmission. ➧ Insert needle/needleless

adapter of syringe containing sterile saline into port nearest the catheter insertion site.

Primary

Secondary

Port nearest the insertion site allows easy visualization of blood return upon aspiration. Clamp

Piggyback port Primary line Secondary line

Secondary port

To patient

FIGURE 6.5C Use port closer to insertion site.

➧ Clamp or pinch IV tubing just above the port. Permits one-way flow during aspiration. ➧ Observe for blood return in the tubing by pulling back on syringe

plunger or by lowering the IV fluid bag and tubing below the level of the extremity for 1 to 2 minutes: Aspiration of blood return indicates a functional IV line. ●

If no blood returns, reposition the arm and reassess for redness, edema or pain.

➧ If positive blood return, instill saline. Determines catheter placement and checks for problems associated with positioning, phlebitis, and infiltration.

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174 C h a p t e r 6 Parenteral Medications

Use of the Volutrol ➧ Verify infusion rate of IV line.

Fill chamber (Volutrol) with 50 to 100 mL or desired amount of mL by opening up the clamp between the Volutrol and the main IV bag; clamp off IV bag with roller clamp above Volutrol. Determines patency of system. Maintains volume status. Dilutes medication with small amount of fluid, and reduces the risk of rapid dose infusion. Avoids accidental excess fluid infusion, and prevents inaccurate drug dosage.

Medication bag

Primary bag Clamp

Fluid

Clamp

To patient

FIGURE 6.5D Intravenous medication administration using a Buretrol-type setup.

➧ Clean injection port on Volutrol, and unclamp vent. Decreases infection, and unclamping of vent prevents a negative pressure buildup within the Volutrol. ➧ Insert syringe/adapter into port on Volutrol, and inject medication.

Gently rotate the Volutrol between hands. Mixes medication within the Volutrol for even distribution.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 175

Infusion Pumps/Controllers ➧ Close regulating clamp; spike and prime the tubing, filling the drip

chamber halfway full. This allows the medication or fluid to be sensed. Allows visualization of flow. ➧ Hang the bag on the IV pole approximately 36 inches from infusion

site (for controller). This height provides enough gravity for flow of solution. ➧ Turn machine on, and insert tubing into pump following manufac-

turer’s directions. Failure to follow the manufacturer’s directions may lead to mechanical failure and incorrect dosing. ➧ Place the drip sensor on the drip chamber (if required). Allows certain machines to determine flow. ➧ Set the pump at the prescribed rate and mode (mL/hr, mg/hr, ␮g/kg/

hr or ␮g/kg/min; intermittent or continuous, and set the volume to be infused.

Determines the proper amount of medication to be delivered to the patient. ➧ Press the start button and observe the drip chamber for flow;

recheck settings 15 minutes after the start of the infusion. Permits visualization of proper machine function.

Mini-Infusion (Syringe) Pumps ➧ Select the proper size syringe according to manufacturer’s directions

and draw up fluid appropriate for dilution. Certain medications are caustic to veins and need further dilution. ➧ Attach the extension tubing to the Luer-Lok end of the syringe

(for administration via syringe pump through a Hep-Lock, a longer extension tubing will be necessary). Hold the syringe upside down and prime the tubing. Holding the syringe upside down allows expulsion of air without creating an air. ➧ Insert the syringe into the cradle of the pump, and squeeze clamp

to seat the plunger of syringe. Syringe must be seated correctly in the cradle of the pump in for proper mechanical function. ➧ Set the pump to the desired rate, mode, and volume to be infused

(follow manufacturer’s instructions). Delivers the correct amount of medication.

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176 C h a p t e r 6 Parenteral Medications ➧ Start the syringe pump, and check the infusion indicator. Verifies that pump is infusing. ➧ Clean the rubber stopper to be used for instillation with alcohol. Decreases microorganisms.

Administering the Medication ➧ Insert the needle or needleless adapter connected to the medication

tubing into the IV lock port; for IVPB, insert the port closest to top of primary tubing and secure with tape if needle used. Prevents needle dislodgment. ➧ For IVPB method, lower the

primary IV fluids about 6 inches lower than the secondary (medication) bag. Increased height creates more gravitational pull on secondary bag rather than on the primary infusion.

Secondary "Piggyback" Extension hook

Primary

Clamp

Piggyback line Primary line Primary Y port

Clamp

Secondary port To patient

FIGURE 6.5E For IVPB, use extender so primary IV bag hangs lower than secondary bag.

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P r o c e d u r e 6 . 5 Administering Intravenous Medications 177 ➧ Open the roller clamp on the secondary tubing slowly to adjust drip

rate. Prevents excessive infusion rate and associated drug reactions. ➧ Periodically assess patient during infusion. Allows monitoring of infusion and adverse drug reactions. ➧ For heparin lock and multiple IVPB medications with a primary line:

when infusion is complete and tubing is not expired, disconnect and recap needle/adapter. Otherwise leave tubing in port. Discard expired tubing. Allows greater mobility for the patient with a heparin lock. (Recapping needle or adaptor reduces microorganisms and prevents infection.) Reduces damage to primary tubing port. Prevents contamination of primary system. ➧ Insert needle/adapter of a second sterile saline syringe and Inject

into heparin lock; then flush with heparin if ordered. Clears medication and/or blood from catheter and confirms IV patency. ➧ Discard equipment and sharps appropriately. Promotes a clean and organized environment. Prevents accidental needle sticks. ➧ Wash hands. Decreases the spread of microorganisms. ➧ Document administration in medical record. Prevents accidental re-medication; serves as a legal record. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Readjust to previous IV flow rate (if needed) Reassess IV site every 2 hours if infusion controlled by gravity; reassess site every hour if infusion controlled by a pump ● Periodically assess rate of infusion, especially if medication is infusing via gravity; rates are altered by position changes of the extremity in which the IV is placed ● Report any drug reaction ● Compare the IV site pre- and post-infusion ● Assess IV patency post-infusion ● ●

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178 C h a p t e r 6 Parenteral Medications

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Dose of medication. Route of administration. ● Method of administration (IVP, IVPB, or infusion pump). ● Amount of diluent given. ● Time of administration. ● Adverse reactions. ● Condition of IV site. ● One-time medications ● Last dose (most important if medication levels need to be obtained). ●

PROCEDURE 6.6 Administering Medication by Intravenous Bolus OVERVIEW

To deliver a concentrated dose of medication directly into the systemic circulation (directly into vein or existing IV catheter), thus bypassing the absorption phase. ● IV bolus administration is used during emergencies, with critically unstable patients, and as a route when rapid and predictable responses are required. ●

P R E PA R AT I O N

Verify physician’s order for the type of medication, dosage, time, and route of administration. ● To increase safety, be aware of information about drug before administering it: • Drug’s action • Purpose • Side effects • Normal dosage • Time of peak onset • Nursing implications • Drug expiration date ● Verify allergies from MAR and patient. ● Assess IV catheter site for infiltration. Observe for redness, pain, swelling, patency of vein, and blood return. ●

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P r o c e d u r e 6 . 6 Administering Medication by Intravenous Bolus 179 ●

Check compatibility if other fluids are infusing at intended site for IV bolus.

Special Considerations • Giving IV bolus medications delivers a greater concentration of medication in a shorter period of time. This is beneficial when a rapid effect is desired. • By entering directly into the bloodstream, adverse reactions may be evident within seconds. • Of great importance is that the nurse must be aware not to administer the drug too quickly. • Knowing pertinent information about the drug beforehand allows the nurse to be better prepared if an adverse reaction occurs. • Elderly and pediatric patients’ veins are generally more fragile than other populations. Because of this, rapid or forceful administration of a drug can cause infiltration. R E L E VA N T N U R S I N G D I A G N O S E S ●

Potential for injury related to medication administration EXPECTED OUTCOMES

No adverse reactions occur after drug infusion IV site remains clear, absent of swelling ● No precipitation or clouding of medication during IV bolus ● ●

EQUIPMENT/SUPPLIES

IV existing line Medication in vial or ampule Syringe (3–5 mL) Sterile needles (21- and 25-gauge) Alcohol swabs A watch with ability to read seconds MAR IV intravenous lock (Hep-Lock) Medication in vial or ampule Syringe (3–5 mL) Syringes (1–3 mL) Vial of heparin flush solution (1 mL ⫽ 100 units, check agency policy, may be optional) or vial of normal saline Sterile needles (21- and 25-gauge) Alcohol swabs A watch with ability to read seconds

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180 C h a p t e r 6 Parenteral Medications I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Don gloves. ➧ Prepare ordered medication (aseptic technique) in adequate sized

syringe with small gauge needle, comparing dose to MAR, and reading package insert for correct IV dilution (reconstitute if necessary). Ensures medication is sterile. Ensures proper dose is drawn up. Ensures medication is administered correctly.

IV Push ➧ Existing line:

Explain procedure to patient while comparing identification with armband, MAR, and asking patient his name. (May look on MAR, if not done already, as well as asking patient). Decreases patient anxiety. Decreases chance of giving medication to wrong patient. Reactions from drug allergies may be fatal. The nurse is responsible for all medications given to the patient. ➧ Clean closest injection port to patient with alcohol swab. (Some

ports have a circle to indicate where to insert needle.) Decreases introduction of microorganisms during needle insertion. Using closest port permits easier aspiration to check for blood return. ➧ Insert the prepared syringe

with medication into center of port while clamping or pinching IV tubing just above port. ➧ Pull gently on plunger to check for blood return. (Assess IV site for infiltration.) Ports are self-sealing and designed for needle insertion in center. Ensures that medication is delivered to patient and not FIGURE 6.6A Clamp or pinch IV backward into IV tubing. tubing just above port. Blood return indicative of properly functioning IV catheter. Ensures safe drug administration.

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P r o c e d u r e 6 . 6 Administering Medication by Intravenous Bolus 181 ➧ After noting blood return, inject medication slowly in accordance

with directions on package. (Use watch to keep track of time.) Rapid administration of some drugs can be fatal. Infusion rates may be altered after IV bolus. ➧ Once medication has been delivered, release IV tubing, withdraw

syringe (dispose into sharps container), and recheck the infusion rate on existing fluid. Proper disposal reduces unwanted needle sticks. Checking for proper infusion rate decreases chance for circulatory overload.

Intravenous lock: ➧ Explain procedure to patient while verifying identification by com-

paring armband, MAR, and asking patient his name. (Check for drug allergies by checking MAR and asking patient.) Decreases patient anxiety. Ensures medication not given to wrong patient. Reactions from drug allergies may be fatal.

Using heparin flush method: ➧ Syringe and small gauge needle with 1 mL of heparin flush solution.

(*Note concentration is in accordance with agency policy.) Syringe and needle (25-gauge) with 1 mL of normal saline flush. The nurse is responsible for all medications given to the patient. Flush solution helps keep IV lock open after drug administration. Heparin comes in several different doses. Used to assess for blood return.

Using saline flush method: ➧ Two syringes with needles (25-gauge) each with 2 mL of normal

saline. Saline alone has been found effective in maintaining the patency of IV locks.

To administer medication: ➧ Wipe port with alcohol swab. Prevents introduction of microorganisms. ➧ Insert needle with syringe of normal saline into center of port,

pulling syringe plunger back gently checking for blood return. (Refer to Fig 6.6A.) Blood return indicates that IV catheter is within the vein. (Blood return is not always present with heparin lock even though IV lock is patent.)

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182 C h a p t e r 6 Parenteral Medications ➧ Flush with 1 mL of saline via syringe, and then remove syringe. Cleans needle and reservoir of blood. ➧ Wipe port again with alcohol swab. Prevents introduction of microorganisms. ➧ After inserting needle and

syringe with medication through the center of the port, slowly depress plunger over period of time according to recommendation on drug package insert. (Use watch to monitor time.) Using center of port eliminates leakage. Rapid IV bolus of a medication can prove to be fatal.

FIGURE 6.6B Administer medication in increments according to rate of infusion.

➧ Once IV push is complete, withdraw and dispose of needle properly

and wipe port once more with alcohol swab. Proper disposal decreases chance of needle stick and reduces incidence of microorganism transmission.

If using heparin flush: ➧ Insert needle connected to syringe with heparin flush into center of port. Maintains patency by inhibiting clots. Diluted heparin decreases chance of inadvertent anticoagulation. ➧ Instill 1 mL of heparin slowly while slowly removing needle. (Dispose

of needle properly.) Injecting while removing ensures catheter and hub contain heparin. Prevents accidental needle stick.

If using saline flush: ● Insert needle connected to saline syringe, inject 2 mL of saline, withdraw, and discard needle and syringe properly. Flushes medication out of IV catheter. Prevents needle stick. ➧ Wash hands. Decreases transmission of microorganisms.

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 183 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Orders should be checked for medication to be administered, dose, time, and route of administration ● Important to know about drug prior to giving: action, type of drug, onset, peak, duration, dose, side effects, and nursing considerations ● Observe IV insertion site for patency or infiltration ● Know patient medical, medication, and allergy history ● Review compatibility if giving with existing fluid infusion ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Documentation of drug, time, date, dose, route, and signature on MAR. ● If PRN or one-time order medication, document in nurse’s narrative at time medication is given and 1 hour later on patient’s response to medication. ● Report any adverse reactions to physician and charge nurse.

PROCEDURE 6.7 Teaching Patients How to Administer Self-Injections OVERVIEW ● ●

To facilitate self-care. The patient with knowledge of the disease process and treatment plan is more likely to comply with his or her health-care regimen. P R E PA R AT I O N

Assessment of the patient’s ability to learn • Language barriers • Cognitive barriers • Physical barriers ● Develop individual objectives for each patient’s teaching plan. ●

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184 C h a p t e r 6 Parenteral Medications

Special Considerations • Sensory changes related to diseases such as diabetes may cause decreases in tactile and visual acuity that could impede the learning process. • Alternative aids may be required to assist the patient with handling the syringe and medications. • Family members may be required to learn technique. • A family member or caretaker should be taught to care for the patient in times of illness when self-care is difficult. • If the patient wears glasses, instruct him or her to put them on before drawing up medication. • If visual acuity is reduced, consider a syringe magnifier. • If the patient is diabetic, make sure he or she can distinguish between a 0.5-mL syringe, which is marked off in 1-unit increments, and a 1.0-mL syringe that is marked off in 2-unit increments. • If the medication is heparin, the preferred site is the abdomen; this area has fewer capillaries and will bruise less easily. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Readiness for enhanced therapeutic regimen Risk for injury related to inappropriate technique EXPECTED OUTCOMES

Patient and/or caregiver should recognize the medication label and have increasing knowledge of medication and injection method via aseptic technique with each practice session ● State the importance of site rotation ● Ability to state the signs and symptoms of hypoglycemia and hyperglycemia (if the medication is insulin) ● Ability to recognize and manipulate syringe, draw up the ordered amount and type of medication, and to correctly inject it at the proper site while maintaining aseptic technique ●

EQUIPMENT/SUPPLIES

2 to 3 syringes (2 for practice and 1 to draw up medication) Alcohol swabs Bottle of normal saline (for practice) Chart of injection sites

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 185 I M P L E M E N TAT I O N ➧ Identify patient and verify the 5 rights of medication administration Confirms patient identity. ➧ Assemble equipment and teaching material and place orderly on a

table within easy reach in a quiet, comfortable environment. Organization and easy access to materials facilitate the learning process. ➧ Have patient wash hands. Prevents transfer of microorganisms and maintains aseptic technique. ➧ Have patient manipulate syringe and explain the parts that need to

remain sterile and those that can be touched. Familiarity with parts of the syringe increases safe administration. ➧ Discuss the ordered dose of the medication. Facilitates administration of correct dosage. ➧ Have the patient check the label and the expiration date on the

medication vial, and compare the dose of ordered medication to the markings on the syringe. Avoids delivery of precipitated or expired medication. ➧ If the medication is insulin, have the patient inspect the vial for

clumping or color change and allow to warm to room temperature. Reduces tissue trauma upon injection. ➧ Demonstrate the steps necessary to draw up the medication: ➧ Wipe off the top of the vial with alcohol. Prevents spread of microorganisms. ➧ Pull the plunger back to the same number of units to be removed

from the vial. This facilitates accurate medication withdrawal from vial. ➧ Push the plunger back into the vial. This prevents a vacuum. ➧ Hold the vial and the syringe together and turn both upside down.

With the other hand pull the plunger back to the number of units to be given making sure the needle stays under the fluid level of the vial. Do not touch the inside of the plunger. Facilitates the withdrawal of the correct amount of medication, and prevents withdrawing air in the syringe.

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186 C h a p t e r 6 Parenteral Medications ➧ Check for presence of air bubbles inside the syringe; if bubbles are

seen, re-inject the medication back into the syringe and slowly pull back to the correct dose. Repeat until no bubbles are seen. Maintains aseptic technique. Inclusion of air alters the dose of medication to be delivered to the patient. ➧ Remove syringe from vial and, without touching, recap the needle. Avoids unintentional needle stick. ➧ Show chart of injection sites and have patient find accessible sites

on his/her own body. Allows assessment of patient’s ability to recognize acceptable injection sites. ➧ Discuss importance of systematically rotating sites, using all of the

sites in one area before altering site location. Have the patient choose a site in the abdomen or thigh where demonstration is easily visible. Prevents the development of scar tissue that decreases drug absorption. Visualization of procedure enhances learning. ➧ Administer the injection concurrently, explaining each step in simple

terms; have the patient: Visualization and verbal explanation facilitate retention. ➧ Clean injection site with alcohol. Reduces microorganism transmission. ➧ Remove cover/sheath off of needle. ➧ Hold the syringe as if it were a pencil. Holding the barrel provides stability of the syringe upon injection. ➧ Grasp skin of injection site between thumb and fingers of nondomi-

nant hand to fold up skin. To inject posterior upper arm, press back of upper arm against wall or back of chair and rotate inward to push up the skin. Grasping the skin ensures that the injection is given into subcutaneous tissue. ➧ Insert needle at a 90-degree angle (45 degrees for children or thin

adults). A 90-degree angle may be too deep for thin or small individuals, and the medication could unintentionally be delivered intramuscularly.

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P r o c e d u r e 6 . 7 Teaching Patients How to Administer Self-Injections 187 ➧ Insert needle while holding onto skin, then let skin go and use free

hand to push the plunger. (Routine aspiration is no longer recommended for subcutaneous injections.) Be sure that all of the medication is administered. Routine aspiration may cause tissue damage. Administer the correct dose of medication. ➧ Place alcohol pad over injection site and quickly remove needle at

the same angle of insertion. Assess for leakage of medication. Leakage decreases the amount of medication delivered to the patient and can also cause tissue irritation. ➧ Discard uncapped needle in a sharps container. Prevents accidental needle sticks. ➧ Have patient indicate on record chart where injection was given. Documentation will assist the patient to correctly rotate injection sites. ➧ Give opportunity for patient to ask questions regarding procedure. Clarification and reinforcement enhance the patient’s knowledge base. ➧ Provide guidelines to patient with written literature and visual aids. Guidelines and aids reinforce the teaching plan. ➧ Document evaluation of the learning process: the ability of the

patient to correctly prepare and self-administer injections. Documentation provides continuity of the teaching plan and enables the nurse to determine if more instruction is needed. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

May need several practice sessions before independent insulin administration ● Assess the need for further teaching sessions ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Describe the content and/or skills taught with each session and the ability of the patient to perform (this provides continuity of the teaching plan and avoids needless repetition).

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188 C h a p t e r 6 Parenteral Medications

PROCEDURE 6.8 Mixing Two Types of Insulin OVERVIEW ●

To deliver the prescribed combination of insulin to the patient to control the blood glucose level without cross-contamination of medication. P R E PA R AT I O N

Regular insulin (unmodified insulin) is a rapid-acting, clear solution. Most other types of insulin are cloudy (modified) because of the addition of proteins, which slow the absorption of the drug, giving them an intermediate-to-long duration of action. ● Newer, long-acting insulins such as Lantus are clear but cannot be mixed with other insulins. ● Mixing guidelines: • Regular insulin can be mixed with any other type of insulin and should always be drawn up in the syringe first. • NPH (Neutral Protamine Hagedorn) insulin can only be mixed with regular insulin. • Different types of Lente insulin can be mixed together, and with regular insulin, but not with any other type of insulin. • Insulin syringes are calibrated in 50 or 100 units per milliliter. Care must be taken not to confuse the two, as each marking represents one unit on a 50-unit syringe and 2 units on a 100-unit syringe; that could lead to medication error. • Insulin can be kept at room temperature for approximately 1 month. Refrigeration is required for longer periods of time. Insulin should not be given cold, but should be allowed to warm to room temperature. ● ●

Special Considerations • Have D50W, sugar, orange juice, and glucagon available on unit. • If lispro (rapid acting) insulin is used, make sure meals are on unit; onset of action within 15 minutes. • Do not use insulin that has changed color or has become clumped or granular in appearance.

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P r o c e d u r e 6 . 8 Mixing Two Types of Insulin 189

• Regular and short-acting insulin should be clear; other types should be uniformly cloudy. • Store unused insulin in a cool area; use room temperature insulin for injection to limit irritation at injection site. • Mix insulin by gently rotating between palms. Do not shake; this creates air bubbles in the mixture and syringe thereby altering the dose delivered to the patient. • Commercial insulin concentrations of 100 or 500 U/mL are available. • 500 U/mL preparations are useful for the patient with insulin resistance who requires large doses, but should be stored separately to avoid an accidental overdose. R E L E VA N T N U R S I N G D I A G N O S E S ●

Potential for injury related to medication error EXPECTED OUTCOMES

●

The appropriate, prescribed combination of insulin will be drawn up in a single syringe without cross-contamination of insulin vials EQUIPMENT/SUPPLIES

Medication vials 2 alcohol pads Insulin syringe 2 needles (if applicable) I M P L E M E N TAT I O N ➧ Wash hands, rotate insulins in palms of hands for 1 minute (do not

shake); clean vial stoppers with alcohol. Decreases microorganism transmission. Rotating insulin resuspends the modified insulin and warms the medications. Shaking creates air bubbles that can alter dose. ➧ Aspirate volume of air equivalent to the dosage of the modified

(cloudy) insulin. Creates pressure to withdraw solution; avoids a vacuum that can cause cross-contamination.

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190 C h a p t e r 6 Parenteral Medications ➧ Inject the air into the modified (cloudy) vial; do not touch the med-

ication with the needle. [See Fig. 6-8A (1).] Prevents cross-contamination.

Regular

Lente

(1) Inject air

Lente

Regular

(2) Inject air

(3) Withdraw regular insulin

(4) Withdraw lente insulin; total dose now a mixture

FIGURE 6.8A (1–4) Mixing two kinds of insulin

in one syringe. ➧ Remove needle and syringe from vial and aspirate the amount of air

equivalent with the unmodified, regular (clear) insulin dosage. Creates pressure to withdraw the desired amount of medication in syringe. ➧ Insert the needle into the vial of unmodified, regular (clear) insulin

and inject the air; then pull back on plunger to fill syringe with prescribed insulin dosage. Remove needle from vial by the barrel and not the plunger. Verify the dosage. [See Fig. 6.8A (2) and (3).] Preparation of the first portion of insulin dosage. Prevents manipulation of plunger that may cause excess or loss of medication; ensures proper dosage prepared. ➧ Calculate the amount on the syringe what the combined units of

insulin should measure. Prevents inadvertent withdrawal of excess insulin from the second (cloudy) vial.

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P r o c e d u r e 6 . 9 Using Patient-Controlled Analgesia 191 ➧ Insert needle into the modified (cloudy) insulin vial. Use care not to

manipulate plunger and expel medication. Invert vial to withdraw desired amount of insulin in the syringe. [See Fig. 6.8A (4).] Syringe will fill, owing to positive pressure in the vial; no need to aspirate. ➧ Remove needle; expel excess air or fluid from the syringe. Air or insulin excess will incorrectly dose the patient. ➧ Discard needle in sharps container and wash hands. Reduces transfer of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

It is important to administer insulin mixture within 5 minutes of preparation. The action of regular insulin is reduced by its binding with NPH insulin

KEY POINTS ● Verification

FOR

REPORTING

AND

RECORDING

of dosage witnessed with a second nurse.

PROCEDURE 6.9 Using Patient-Controlled Analgesia (PCA) Infusion Devices OVERVIEW

To provide relief from acute or severe pain while providing a steadier drug serum level than that of IM and subcutaneous methods. ● PCA allows patients more self-control in their management of pain. ●

P R E PA R AT I O N

Most often used with postoperative patient population, although uses also include patients with advanced stages of cancer. ● Terms associated with PCA are: • Loading dose—the first dose of pain medication infused, normally more than doses that follow. • PCA dose—amount (mL) of drug to be administered with each infusion. • Lock-out interval—minimum ordered time in minutes in which the pain medication cannot be delivered. ●

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192 C h a p t e r 6 Parenteral Medications

• Basal rate—ordered dose per hour that can be infused at a continuous rate. • Maximum hourly limit—total amount of drug that can be infused over a certain time (usually 1–4 hours). • Bolus dose—loading dose can fall in this classification. An additional amount of drug other than PCA dose. An example is giving a bolus dose prior to a dressing change. • Attempts—the number of times a patient presses the button. • Injections—the number of times the drug is actually delivered. • Total dose—amount of drug delivered over a certain period of time Special Considerations • PCA can be a very effective tool in the prevention of pain for a large number of patients. • Not all patients are candidates for PCA use. • Patients who are mentally impaired, with a history of chronic obstructive pulmonary disease, a history of narcotic abuse, who are allergic to narcotics, or have septic profiles should not be prescribed PCA infusions. R E L E VA N T N U R S I N G D I A G N O S E S

Pain, acute related to injury Ineffective coping related to fear of unknown ● Risk for poisoning due to knowledge deficit ● ●

EXPECTED OUTCOMES

The patient is pain free and well rested Patient is able to move without excessive pain ● Patient is able to cough, turn, and deep breathe ● The patient does not excessively press the button more than actual delivery of medication ● The need for pain medication decreases over time ● ●

EQUIPMENT/SUPPLIES

PCA infusion device (including IV tubing, key, and IV pole) with manual on operation IV or epidural line that is patent Correct medication that is ordered Narcan 0.4 mg at bedside for patients with epidural infusion

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P r o c e d u r e 6 . 9 Using Patient-Controlled Analgesia 193 I M P L E M E N TAT I O N ➧ Review doctor’s order for drug, dose, route, bolus, lock-out interval,

and maximum dose to be administered. PCA infusions require a doctor’s order. ➧ Assess patient’s mental status, knowledge of PCA, and reason for

infusion before administering medication Allows the nurse to see if the patient is coherent/competent to participate in PCA operation. ➧ Observe IV for patency/infiltration. Infiltration can lead to serious tissue damage from medication. ➧ Set the primary fluid infusion rate specified in PCA orders. Primary fluid at a continuous rate ensures that the IV system will remain patent. ➧ Verify patient identification by comparing name on order sheet with

ID bracelet and asking patient his name. Avoids giving wrong medication. ➧ Compare medication in syringe to that on order sheet before prop-

erly inserting syringe into PCA device. Safety check to decrease risk for drug error. ➧ Connect plunger unit and medication vial by screwing together. Must be connected to deliver medication to patient. ➧ Prime the plunger unit by holding in vertical alignment with vial

below plunger. Push down gently to advance medication and expel air. This will decrease the risk for advancing air bubbles through tubing once infusion starts. ➧ Connect plunger unit (male end) to PCA tubing (female end). PCA tubing will deliver medication from the vial to the patient. ➧ Prime PCA tubing with medication up to the Y-branch in the tubing,

then clamp. This can be done manually before placing vial into PCA infusion pump OR by using the priming feature of the pump after the vial is loaded in place. Not priming past the Y-branch avoids giving too much medication or wasting medication when priming the rest of tubing. ➧ Load the vial/plunger unit into the PCA pump: ●

Unlock and open the door using the PCA key. Door must be unlocked to put medication vial in place.

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194 C h a p t e r 6 Parenteral Medications ●

Squeeze the two release levers on the top of the drive mechanism and slide it in an upward motion. This will allow the placement of a full medication vial. The plunger sticks out further when connected to a full vial.

●

Place the medication vial into the drive mechanism (should snap firmly into place).

●

Once in place, squeeze the release lever and slide in a downward motion until the flange on the plunger snaps firmly into the holder.

Assures proper placement.

Ensures proper placement of system. ➧ Connect PCA tubing and maintenance tubing to patient IV

connection. ● If maintenance fluid is not already infusing at this time, connect the maintenance tubing to the Y-tubing. Maintenance fluid that is infusing prior to setup must be turned off. Clamp the patient’s IV connection tubing and maintenance tubing and disconnect in a sterile fashion before connecting the two tubings (maintenance/PCA) together. Maintenance fluid is needed to keep IV patent since medication is delivered intermittently and in small quantities. Clamping will avoid bleeding from IV and maintenance fluid from leaking out. To prevent introduction of microorganisms into the patient’s bloodstream. ●

Use the roller clamp to finish priming the PCA tubing to the distal end, then clamp.

●

Connect distal PCA tubing to IV connection; release all clamps.

Adjust as needed to slowly prime tubing to keep from making a mess. Releasing clamps will allow fluids to be delivered to patient. ➧ Set the limits (loading dose, PCA dose, lockout interval, maximum

dose) specified in the PCA order. If unfamiliar with use of PCA, ask coworker to verify that settings are correct. Use instructions that come with PCA device. Ensures that PCA is used in a safe manner. ➧ Following the loading dose, provide patient with the injection but-

ton, making sure patient understands how to use PCA. The patient will take control of pain medication administration. ➧ Initially, the patient may be unable to press the button, in which a con-

tinuous dose may be administered. Keep reinforcing PCA instructions, assessing when patient will be able to participate in PCA delivery. Patients may be groggy following surgery due to anesthesia and other medications received. Patient must be alert enough to understand how to use PCA.

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P r o c e d u r e 6 . 9 Using Patient-Controlled Analgesia 195 ➧ Assess patient’s level of consciousness, pain level, and vital signs fre-

quently. Good indicators that patient is over- or undermedicated. ➧ Routinely check patency of IV line and that PCA is functioning prop-

erly. Ensures that patient is receiving medication in a safe manner. ➧ Document use of PCA on patient’s record and on controlled sub-

stance record. Documenting that nursing care is being provided as well as serving as a legal record. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare pain levels periodically on an institution-approved pain scale to determine if PCA infusion is effective ● Monitor for adverse reactions ● Routinely assess patency of IV line and proper functioning of PCA pump ● Observe for empty syringe and patient’s use of PCA (reinforce instructions as needed) ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Specifics about drug dose, beginning time, and delivery settings should be documented on proper record. ● Intermittent observations on patient should be documented and include: • Vital signs (BP, HR, RR, and pain level) • Patient’s level of consciousness • Patency of IV • Amount of solution infused and remaining • Amount of drug that patient received ● Report any adverse reactions to physician and charge nurse. ● Report to oncoming nurse should touch on PCA settings, drug,VS, LOC of patient, total dose, and patency of IV.

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U N I T

C H A P T E R

Respiratory

7 Noninvasive Pulmonary Hygiene 7.1 Performing Postural Drainage, 198 7.2 Teaching Controlled Coughing Techniques, 203

4

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198 C h a p t e r 7 Noninvasive Pulmonary Hygiene

PROCEDURE 7.1 Performing Postural Drainage OVERVIEW

To use the principles of gravity to assist in bronchial drainage whenever excessive fluid or mucus in the bronchi is not being removed by normal ciliary action and cough. ● There are 18 positions to facilitate drainage, each corresponding with one of the 18 segments of the lungs. ● The purpose of the various positions is to drain each segment toward the larger airways. ● This procedure is usually indicated in people with • Excessive bronchial secretions who have difficulty clearing secretions, with sputum production greater than 25 to 30 mL per day. • Evidence or suggestion of retained secretions in the presence of an artificial airway. • Lobar atelectasis caused by or suspected of being caused by mucus plugging. ● Loosens airway secretions. ● Uses gravity to drain and remove excessive secretions. ● Decreases accumulation of secretions in unconscious or weakened patients. ●

P R E PA R AT I O N

Positions are determined by areas of involved lung, which are assessed by chest radiograph, percussion, palpation, and auscultation. ● Chosen position is maintained for 5 to 15 minutes, although variations can be made if patient has trouble assuming various positions. ● Usually done 2 to 4 times per day. ●

Special Considerations • Aerosolized bronchodilators and hydration therapy are frequently administered before postural drainage. • It is important to remember to perform this procedure 1 hour before meals or 1 to 3 hours after meals. • Remember that the frequency and choice of positions depend on the location of retained secretions and patient tolerance to dependent positions. • The patient with chest trauma, hemoptysis, heart disease, or head injury should not be placed into Trendelenburg’s position.

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P r o c e d u r e 7 . 1 Performing Postural Drainage 199 R E L E VA N T N U R S I N G D I A G N O S E S ●

Impaired gas exchange related to excessive secretions EXPECTED OUTCOMES

Respirations, 14 to 20 per minute, of normal depth, smooth, and symmetric ● Breath sounds clear in target areas; chest radiograph reveals clear lung fields ● Arterial blood gases within normal limits for patient ● Sputum specimen within 1 hour after treatment ●

EQUIPMENT/SUPPLIES

Hospital bed or tilt board to place patient in Trendelenburg’s position (pillows, blocks, or books can also be used to help position patients) Tissues Container for sputum Mouthwash and emesis basin I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient and family. Careful explanation reduces the patient’s and family’s anxiety and facilitates cooperation. ➧ Administer bronchodilators, expectorants, or warm liquids if ordered. Loosens and liquefies secretions and facilitates drainage. ➧ Encourage patient to void. Prevents interruption of therapy. ➧ Loosen any tight clothing and auscultate breath sounds. Allows assessment of pulmonary to perform therapy in the correct anatomical place and assesses breath sounds prior to procedure. ➧ Position patient to drain upper lung segments/lobes: ●

Sitting upright in bed or chair—targets right and left chest.

●

Leaning forward in sitting position—targets back.

Drains anterior right and left apical segments. Drains posterior right and left apical segments.

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200 C h a p t e r 7 Noninvasive Pulmonary Hygiene ●

Lying flat on back—targets right and left chest.

●

Lying on abdomen, tilted to right or left side—targets right or left back.

Drains anterior segments.

Drains posterior segments.

FIGURE 7.1A Correct position to drain right

posterior segment. ➧ Position patient to drain middle lobe: ●

Lying on back, tilted to left side in Trendelenburg’s position— targets right chest. Drains middle posterior lobe.

FIGURE 7.1B Correct position to drain right

middle lobe. ●

Lying on abdomen, tilted to left side with hips elevated—targets right back. Drains middle posterior lobe.

➧ Position patient to drain basal/lower lobes: ●

Lying in Trendelenburg’s position on back—targets right and left chest. Drains anterior basal lobes.

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P r o c e d u r e 7 . 1 Performing Postural Drainage 201 ●

Lying in Trendelenburg’s position on abdomen—targets right and left back Drains posterior basal lobes.

FIGURE 7.1C Correct position to drain lower right

and left lobes. ●

On right or left side in Trendelenburg’s position—targets back.

●

Lying on abdomen—targets right and left back

Drains lateral basal lobes. Drains superior basal lobes.

FIGURE 7.1D Correct position to drain right

and left back. ➧ Maintain patient in position until chest percussion and vibration are

completed (approximately 5 minutes). Loosens secretions in target area and facilitates removal. ➧ Assist patient into position for coughing or for suctioning of trachea. Removes secretions from lungs that accumulate in the trachea. ➧ Auscultate chest areas for breath sounds. If breath sounds are clear, secretions are cleared; however, if crackles are present, secretions may not be cleared, and nurse may need to repeat process.

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202 C h a p t e r 7 Noninvasive Pulmonary Hygiene ➧ Continue until identified target areas have been drained. Completes drainage of congested lung fields. ➧ Auscultate breath sounds, and assist patient with mouth care. Assesses breath sounds after procedure, removes residual secretions from oral cavity, and freshens mouth. ➧ Position patient in bed with head of bed elevated 45 degrees or

more. Facilitates lung expansion and deep breathing. ➧ Turn patient to side with pillow at back. Facilitates movement of secretions. ➧ Raise side rails, and place call light within reach. Facilitates patient safety and communication with nurse. ➧ Wash hands. Reduces transmission of infection. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s respiratory status, and compare to baseline Note sputum characteristics and send to lab if ordered ● Assess how patient tolerated procedure, and write in nurse’s notes ● ●

KEY POINTS ● Vital

FOR

REPORTING

AND

RECORDING

signs. Rate and character of breath sounds, pulse. ● Which areas produced the most secretions. ● What areas sound the same before and after drainage upon auscultation. ● Description and amount of secretions. ● Patient’s tolerance of the procedure (which positions tolerated best). ● Patient’s acceptance and willingness to participate in procedure. ● Any unusual symptoms following procedure and what was done about symptoms. ● Replacement of oxygen source (if applicable). ● Time therapy was performed. ● Patient’s tolerance. ● Amount and characteristics of sputum. ● Respiratory status. ●

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P r o c e d u r e 7 . 2 Teaching Controlled Coughing Techniques 203

PROCEDURE 7.2 Teaching Controlled Coughing Techniques OVERVIEW

To clear the airways of sputum. It is important to teach the patient how to cough effectively after CPT. ● Removes secretions from large airways. ● ●

P R E PA R AT I O N

Have patient conserve as much energy as possible by teaching proper technique. ● Reduce patient fatigue by teaching proper technique. ● The patient with a surgical incision may need to be premedicated with pain medications and use a pillow as a splint over the incision. ●

Special Considerations • Effective coughing is the best means of removing secretions from the airways. • It is contraindicated for the patient who has had eye, ear, brain, or neck surgery. • The frequency of coughing should be determined based on need and patient tolerance of procedure. • Following abdominal or chest surgery, coughing could be performed hourly. • If the patient is unable to sit upright, positioning the patient in a side-lying position with hips and knees flexed or in a semi-Fowler’s position with the head and arms supported with pillows and knees flexed decreases abdominal tension and allows maximal movement of the diaphragm, thereby improving effectiveness of the cough. R E L E VA N T N U R S I N G D I A G N O S E S ●

Impaired gas exchange related to retained secretions EXPECTED OUTCOMES

Cleared airway secretions Patient states understanding of effective coughing techniques ● Arterial blood gases within normal limits for patient ● ●

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204 C h a p t e r 7 Noninvasive Pulmonary Hygiene EQUIPMENT/SUPPLIES

Straight chair or hospital bed in upright position Pillows for positioning and incisional support Tissues or emesis basin for secretions Protective gear: gloves, gown, goggles, and mask I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Premedicate patient if indicated. Reduces pain. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient and family. Careful explanation reduces the patient’s and family’s anxiety and facilitates cooperation. ➧ Put on protective gear. To protect self from bodily secretion. ➧ Place patient in upright position with upper body slightly forward,

and auscultate breath sounds. Assists patient to cough more effectively, and assesses breath sounds before procedure. ➧ Ask patient to take 2 to 3 slow, deep breaths, inhaling through the

nose and exhaling through the mouth. Adequately oxygenates patients and relaxes them. ➧ Instruct patient to inhale deeply and hold for 5 seconds, then lean

forward and cough rapidly using abdominal, thigh, and buttock muscles. Promotes forceful, effective cough. ➧ Instruct patients with pulmonary disease to exhale through pursed

lips and to cough early in exhalation. Helps prevent collapse of airways. ➧ Remember to support any incision with a pillow held tightly on top

of it. Supports incision and prevents strain. May encourage patient to take deeper breaths.

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P r o c e d u r e 7 . 2 Teaching Controlled Coughing Techniques 205 ➧ Encourage patient to keep coughing if cough is productive. Secretions left in airways promote bacterial growth and interfere with ventilation. ➧ Auscultate breath sounds, and ask if patient has any questions.

Be sure that he or she understands the importance of coughing effectively. Assesses breath sounds after coughing, facilitates rapport with patient, and educates patient. ➧ Reposition patient if in hospital bed (if indicated), raise side rails, and

place call light within reach. Promotes patient comfort, facilitates safety and communication with nurse. ➧ Discard protective gear. Reduces transmission of infection. ➧ Wash hands. Reduces transmission of infection. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s respiratory status, and compare to baseline Note sputum characteristics, and send to lab if ordered ● Assess how patient tolerated procedure, and write in nurse’s notes ● ●

KEY POINTS ● Vital

FOR

REPORTING

AND

RECORDING

signs. Rate and character of breath sounds, pulse. ● What areas sound like before and after coughing upon auscultation. ● Description and amount of secretions. ● Patient’s tolerance of the procedure. ● Patient’s acceptance and willingness to participate in coughing. ● Any unusual symptoms following procedure and what was done about symptoms. ● Replacement of oxygen source (if applicable). ● Time therapy was performed. ● Patient’s tolerance. ● Amount and characteristics of sputum. ● Respiratory status. ●

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C H A P T E R

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8 Oxygen Therapy 8.1 Administering Oxygen Therapy, 208 8.2 Administering Oxygen Therapy to the Patient with an Artificial Airway, 213

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208 C h a p t e r 8 Oxygen Therapy

PROCEDURE 8.1 Administering Oxygen Therapy OVERVIEW ● ●

Improves tissue oxygenation. There are several indications for oxygen therapy: • Hypoxia/hypoxemia. • Decreased cardiac output. • Increased oxygen demand. • Decreased oxygen carrying capacity. • Increased myocardial workload. • Procedures that may cause hypoxemia. P R E PA R AT I O N

●

The device for delivery of oxygen should be chosen based on the oxygen delivery needs of the patient.

FIGURE 8.1A Oxygen-delivery systems.

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P r o c e d u r e 8 . 1 Administering Oxygen Therapy 209

Low-flow devices do not provide the total inspired gas; the remainder of the inspired volume is from the surrounding room air. Lowflow devices include • Nasal cannula. • Simple face mask. • Partial rebreather mask. • Trach collar (used with tracheostomy). • T-piece (used with tracheostomy and endotracheal tube). ● High-flow devices provide the entire total inspired gas to the patient. High-flow devices include • Nonrebreather mask (used with nasal or oral airway). • Venturi mask (used with nasal or oral airway). • Mechanical ventilator (used with tracheostomy, endotracheal tube, nasotracheal tube). ●

Special Considerations Nasal Cannula • 1–6 L/min delivers 24% to 44% oxygen. • May cause pressure sores on ears—place gauze pads under cannula at tops of ears. • May cause dryness and pressure sores in nares—give nasal care every 8 hours, and check position of cannula to ensure that continuous pressure is not concentrated on one spot. Simple Face Mask • 6–10 L/min delivers 40% to 60% oxygen. • Hot, confining, and uncomfortable—clean face mask and wipe face every 4–8 hours. • Places pressure on bridge of nose and ears—pad with gauze pads to prevent pressure sores and necrosis. • Interferes with eating and drinking. Partial Rebreather Mask • 6–10 L/min delivers 35% to 60% oxygen. • Never let bag totally deflate because this may cause CO2 retention. • Places pressure on bridge of nose and ears—pad with gauze pads to prevent pressure sores and necrosis. • Interferes with eating and drinking. Nonrebreather Mask • 6–10 L/min delivers 60% to 100% oxygen. • Places pressure on bridge of nose and ears—pad with gauze pads to prevent pressure sores and necrosis. • Interferes with eating and drinking.

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210 C h a p t e r 8 Oxygen Therapy

Venturi Mask • 4 L/min delivers 24% to28% oxygen. • 8 L/min deliver 35% to 40% oxygen. • Places pressure on bridge of nose and ears—pad with gauze pads to prevent pressure sores and necrosis. • Interferes with eating and drinking. Safety and Toxicity Considerations • Some special safety considerations pertain to all types of oxygen therapy including keeping oxygen away from open flames and smoking, and using only water-soluble lubricants and creams with those receiving oxygen therapy. • Also make sure to observe patient for signs of oxygen toxicity such as substernal retractions, paresthesias in extremities, dry cough, dyspnea, anorexia, nausea, vomiting, fatigue, lethargy, malaise, restlessness, and progressive ventilatory difficulty. Hypoxic Patient • Patients who are hypoxic often become combative and may need to have constant supervision and alternative methods, including the possibility of restraints, to facilitate the continuation of oxygen therapy via an artificial airway. Elderly Patient • Older adults are at greater risk for skin breakdown; therefore, more frequent skin assessment may be necessary in these individuals. R E L E VA N T N U R S I N G D I A G N O S E S ●

Impaired gas exchange related to disease process EXPECTED OUTCOMES

Oxygenation saturation improves Tissue oxygenation improves ● Patient’s hemodynamics improve ● ●

EQUIPMENT/SUPPLIES ●

For all types of oxygen delivery, the following are needed: • Oxygen source • Oxygen flowmeter • Humidifier (if ordered) • Specific type of oxygen delivery system (nasal cannula, simple face mask, partial rebreather mask, nonrebreather mask, Venturi mask)

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P r o c e d u r e 8 . 1 Administering Oxygen Therapy 211 I M P L E M E N TAT I O N

Nasal Cannula ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning procedure enhances efficiency and patient safety. ➧ Explain procedure to patient. Ensures that patient is informed, and decreases patient anxiety. ➧ Prepare humidifier: Add distilled water if needed or remove prefilled

humidifier from package and screw enclosed spike cap to bottle. Delivers humidified oxygen to mucous membranes of airway. ➧ Connect humidifier to flow meter, and connect humidifier to tubing

attached to cannula. Controls flow of oxygen and connects humidification to oxygen delivery system. ➧ Turn oxygen flowmeter on until bubbling is noted in humidifier. Ensures connections are intact and that oxygen delivered will be humidified. ➧ Check order. ➧ Adjust flow of oxygen via flowmeter. Regulates oxygen flow delivery. ➧ Put on gloves. Reduces transmission of microorganisms. ➧ Place tips of cannula in patient’s nares; fit tubing over ears, tighten

tubing under chin, and adjust to proper fit. Ensures proper fit of nasal cannula. ➧ Position patient for comfort and ease of breathing with head of bed

elevated. Facilitates lung expansion for adequate gas exchange. ➧ Evaluate patient’s respirations and oxygen saturation. Determines adequacy of oxygen delivery system for patient.

Simple Face Mask, Partial Rebreather Mask, Nonrebreather Mask, Venturi Mask ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning procedure enhances efficiency and patient safety.

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212 C h a p t e r 8 Oxygen Therapy ➧ Explain procedure to patient. Ensures that patient is informed and decreases patient anxiety. ➧ Prepare humidifier: Add distilled water if needed or remove prefilled

humidifier from package and screw enclosed spike cap to bottle. Delivers humidified oxygen to mucous membranes of airway. ➧ Connect humidifier to flowmeter, and then connect humidifier to

mask tubing. Controls flow of oxygen and connects humidification to oxygen delivery system. ➧ Turn oxygen flow meter on until bubbling is noted in humidifier. Ensures connections are intact and that oxygen delivered will be humidified. ➧ Adjust flow of oxygen via flow-

Adjustable nose clip

meter (with Venturi mask, attach oxygen percentage regulator to oxygen mask and regulate flow as indicated).

30% 28% L3M 26% 24%

Regulates oxygen flow delivery. Oxygen regulator Venturi barrel

FIGURE 8.1B Oxygen percentage

regular. ➧ Put on gloves. Reduces transmission of microorganisms. ➧ Place mask over nose, mouth, and chin; adjust metal strip over

bridge of nose to fit securely; and pull elastic band around back of head and tighten to fit. Ensures proper fit of mask. ➧ Position patient for comfort and ease of breathing with head of

bed elevated. Facilitates lung expansion for adequate gas exchange. ➧ Evaluate patient’s respirations and oxygen saturation. Determines adequacy of oxygen-delivery system for patient.

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P r o c e d u r e 8 . 2 Administering Oxygen: Artificial Airway E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Assess the patient’s: • Oxygen saturation, and compare to baseline • Quality of and rate of respirations, and compare to baseline • Vital signs, and compare to baseline • Comfort level

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

of the patient’s respiratory status prior to initiation of oxygen therapy, including oxygen saturation and a description of respirations including rate. ● Type of oxygen-delivery method initiated. ● Time of initiation of oxygen-delivery method. ● Percentage of oxygen currently being given. ● Assessment of patient’s respiratory status after initiation of oxygen therapy to include oxygen saturation and a description of respirations, including rate.

PROCEDURE 8.2 Administering Oxygen Therapy to the Patient with an Artificial Airway OVERVIEW ● ●

Improves tissue oxygenation. There are several indications for oxygen therapy: • Hypoxia/hypoxemia. • Decreased cardiac output. • Increased oxygen demand. • Decreased oxygen carrying capacity. • Increased myocardial workload. • Procedures that may cause hypoxemia.

213

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214 C h a p t e r 8 Oxygen Therapy P R E PA R AT I O N The device for delivery of oxygen should be chosen based the oxygen-delivery needs of the patient. ●

Trach Collar • 21% to 70% oxygen delivery. • Possibility for condensation to collect in tubing and drain into patient’s airway upon turning—therefore, empty tubing frequently. • Does not pull on tracheostomy. • Elastic ties allow movement of collar away from trach without removing it.

FIGURE 8.2

Trach collar. ●

T-piece • 21% to 100% oxygen. • Possibility for condensation to collect in tubing and drain into patient’s airway upon turning—therefore, empty tubing frequently. • Possibility that weight of T-piece can pull on tracheostomy T-piece.

●

Mechanical ventilator • 21% to100% oxygen delivery. • Requires skilled personnel to manage (usually respiratory therapy). • Possibility that condensation could collect in the tubing and drain into the patient’s airway, especially during turning—therefore, frequent emptying of tubing condensation is indicated.

Special Considerations • High-flow systems that use heated humidifiers or aerosols are a common source of infection, particularly for the patient with an artificial airway. • Tubing should be changed every 48 hours in the hospital. R E L E VA N T N U R S I N G D I A G N O S E S ●

Impaired gas exchange related to disease process

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P r o c e d u r e 8 . 2 Administering Oxygen: Artificial Airway 215 EXPECTED OUTCOMES

Oxygenation saturation improves Tissue oxygenation improves ● Patient’s hemodynamics improve ● ●

EQUIPMENT/SUPPLIES

Oxygen source Oxygen flowmeter Humidifier (if ordered) Specific type of oxygen delivery system (trach collar, T-piece and tubing with reservoir bag, mechanical ventilator and circuit) I M P L E M E N TAT I O N

Trach Collar ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning procedure enhances efficiency and patient safety. ➧ Explain procedure to patient. Ensures that patient is informed and decreases patient anxiety. ➧ Prepare humidifier: Add distilled water if needed or remove prefilled

humidifier from package and screw enclosed spike cap to bottle. Delivers humidified oxygen to mucous membranes of airway. ➧ Connect humidifier. Controls flow of oxygen and connects humidification to oxygen delivery system. ➧ Turn oxygen flowmeter on until bubbling is noted in humidifier. Ensures connections are intact and that oxygen delivered will be humidified. ➧ Check order. ➧ Adjust flow of oxygen via flow meter. Regulates oxygen flow delivery. ➧ Put on gloves. Reduces transmission of microorganisms. ➧ Place collar around tracheostomy; adjust elastic band behind neck

and tighten to fit. Ensures proper fit of trach collar.

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216 C h a p t e r 8 Oxygen Therapy ➧ Position patient for comfort and ease of breathing with head of bed

elevated. Facilitates lung expansion for adequate gas exchange. ➧ Evaluate patient’s respirations and oxygen saturation. Determines adequacy of oxygen-delivery system for patient.

T-piece ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Organizing equipment before beginning procedure enhances efficiency and patient safety. ➧ Explain procedure to patient. Ensures that patient is informed, and decreases patient anxiety. ➧ Prepare humidifier: Add distilled water if needed or remove prefilled

humidifier from package and screw enclosed spike cap to bottle. Delivers humidified oxygen to mucous membranes of airway. ➧ Connect humidifier to flowmeter and connect humidifier to tubing

attached to T-piece. Controls flow of oxygen and connects humidification to oxygen delivery system. ➧ Turn oxygen flowmeter on until bubbling is noted in humidifier. Ensures connections are intact and that oxygen delivered will be humidified. ➧ Check order. ➧ Adjust flow of oxygen via flowmeter. Regulates oxygen flow delivery. ➧ Put on gloves. Reduces transmission of microorganisms. ➧ Place T-piece on end of tracheostomy or endotracheal tube. Ensures proper fit of T-piece. ➧ Place condensation tubing and reservoir bag dependently (lower

than the patient) to allow adequate collection of fluid within drainage bag, which is periodically emptied. Allows collection of fluid in drainage bag away from patient’s airway. ➧ Position patient for comfort and ease of breathing with head of bed

elevated. Facilitates lung expansion for adequate gas exchange.

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P r o c e d u r e 8 . 2 Administering Oxygen: Artificial Airway 217 ➧ Evaluate patient’s respirations and oxygen saturation. Determines adequacy of oxygen-delivery system for patient.

Mechanical Ventilator ➧ Wash hands. Reduces transmission of microorganisms. ➧ Equipment. Organizing equipment before beginning procedure enhances efficiency and patient safety. ➧ Explain procedure to patient. Ensures that patient is informed and decreases patient anxiety. ➧ Put on gloves. Reduces transmission of microorganisms. ➧ Attach ventilator circuit to tracheostomy, endotracheal tube, or naso-

tracheal tube, and ensure adequate seal. Ensures adequate attachment for the delivery of oxygen. ➧ Ventilator will be set by respiratory therapy. Monitor settings and

patient’s response. Ensures appropriate settings for the delivery of oxygen. ➧ Secure tubing to allow turning of patient’s head without

disconnection. Provides continuous oxygen delivery and guards against disconnection. ➧ Position patient for comfort and ease of breathing with head of bed

elevated. Facilitates lung expansion for adequate gas exchange. ➧ Evaluate patient’s respirations and oxygen saturation. Determines adequacy of oxygen delivery system for patient. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

Assess the patient’s: • Oxygen saturation, and compare to baseline • Quality and rate of respirations, and compare to baseline • Vital signs, and compare to baseline • Comfort level

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218 C h a p t e r 8 Oxygen Therapy

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

of the patient’s respiratory status before initiation of oxygen therapy, including oxygen saturation and a description of respirations including rate. ● Type of oxygen-delivery method initiated. ● Time of initiation of oxygen-delivery method. ● Percentage of oxygen currently being given. ● Assessment of patient’s respiratory status after initiation of oxygen therapy to include oxygen saturation and a description of respirations including rate.

C H A P T E R

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9 Ventilation Support 9.1 Managing Continuous Positive Airway Pressure, 220 9.2 Managing Intermittent Positive Pressure Ventilation, 223 9.3 Managing Mechanical Ventilation, 225 9.4 Using an Ambu Manual Ventilator, 229 9.5 Performing Endotracheal Tube Care, 232 9.6 Performing Tracheostomy Care, 235 9.7 Managing a Cuffed Endotracheal or Tracheostomy Tube, 240

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220 C h a p t e r 9 Ventilation Support

PROCEDURE 9.1 Managing Continuous Positive Airway Pressure (CPAP) OVERVIEW

To treat oxygen deficiency to maintain airway patency and prevent obstruction. ● CPAP mask maintains alveolar patency during expiration to prevent alveolar collapse. ●

P R E PA R AT I O N

Indicated for severely hypoxic patients such as those in early acute respiratory distress syndrome (ARDS). ● Proper seal of mask is of utmost importance in the delivery of CPAP. ● Contraindicated in hypovolemic patients and chronic obstructive pulmonary disease (COPD) patients because CPAP can increase intrathoracic pressure causing a further decrease in blood pressure, for COPD patients CPAP increases the work of breathing during the exhalation phase. ● Potential side effects include fluid retention, decreased cardiac output, pneumothorax, and gastric distention due to increased intrathoracic pressure and air entering the stomach. ●

Special Considerations • Patients are at increased risk for aspiration due to gastric distention caused by high pressure air entering the esophagus. CPAP should not be used with confused, agitated, or semicomatose patients. • In certain pathologies, alveolar collapse will occur within 1 hour of discontinuation. • Do not discontinue CPAP therapy unless urgent. • Patients require meticulous assessment of face every 2 hours for skin breakdown due to the increased pressure from the mask. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Ineffective breathing pattern Risk for aspiration

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P r o c e d u r e 9 . 1 Managing Continuous Positive Airway Pressure 221 EXPECTED OUTCOMES

Patient achieves target tidal volumes, promoting optimal lung expansion ● Absence of adventitious breath sounds ● Absence of copious secretions and pneumonia ● Achieves optimal oxygenation status as evidenced by PaO 60–100 2 mm Hg, capillary refill ⬍ 3 seconds, and pink nail beds ● Absence of atelectasis ●

EQUIPMENT/SUPPLIES

Appropriately sized CPAP mask (small, medium, and large) appropriate size mask must fit securely for therapy to be effective

FIGURE 9.1A CPAP mask.

Head strap Oxygen tubing, humidifier, and oxygen source Prescribed pressure adaptor Suctioning equipment I M P L E M E N TAT I O N ➧ Explain and give rationale for the use of CPAP. Reduces anxiety. ➧ Apply face mask and head strap to make an adequate seal. Adjust

head strap making sure no unnecessary pressure is applied to ear. Effective continuous positive pressure treatment is dependent on good seal. However, preventing skin breakdown is of utmost importance. ➧ Adjust oxygen concentration to ordered settings. Provides optimal oxygenation to patient.

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222 C h a p t e r 9 Ventilation Support ➧ Monitor patient for nausea caused by air entering the stomach

at frequent intervals and have suction equipment available. Patient’s risk for aspiration is markedly increased should vomiting occur with this type of mask. ➧ Provide communication devices, i.e., writing slates and call light. Enables patient to communicate needs without disruption of therapy. ➧ Evaluate ABGs and pulse oximetry as ordered every 4–7 hours. Establishes need for alternative interventions such as endotracheal tube intubation and mechanical ventilation. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess bilateral breath for decreased or absent breath sounds indicating the possibility of pneumothorax ● Evaluate pulse oximetry; make sure it is within the normal range ordered by the physician ● Evaluate patient’s ability to cough ● Evaluate patient’s tolerance to treatment ● Evaluate arterial blood gas analysis before, during, and after ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

oxygenation (skin color, capillary refill, and oxygen saturation) before and after treatment. ● FiO concentration used. 2 ● Color, consistency, and odor of secretions. ● Vital sign alterations before, during, and after therapy. ● Patient’s tolerance of treatment. ● Time of last treatment. ● Frequency of treatments ordered by the physician to ensure continuity of care. ● Results of treatment, i.e., improved respiratory status. ● Associated nausea and vomiting. ● Amount of pressure of CPAP mask ordered by physician. ● Episodes of hypotension because excessive CPAP pressure can decrease cardiac output. ● Episodes of hypotension may be an indication or reduction in CPAP pressure or change in therapy.

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P r o c e d u r e 9 . 2 Managing Intermittent Positive Pressure Ventilation 223

PROCEDURE 9.2 Managing Intermittent Positive Pressure Ventilation OVERVIEW

To improve oxygenation, lung expansion, and promote clearing of bronchial secretions. ● To prevent or relieve atelectasis. ●

P R E PA R AT I O N

Hyperinflation of the lungs is dependent on compliance of the chest wall and amount of positive pressure applied. ● Decreased compliance requires higher pressures to inflate the lungs. ● Intermittent positive pressure ventilation is useful in treating patients with respiratory weakness, chest wall deformity, and thoracic or abdominal incisions who are unable to deep breathe. ● Potential complications include nosocomial pneumonia, barotraumas, respiratory alkalosis, and psychological dependence in COPD patients. ●

Special Considerations • Intermittent positive pressure ventilation should not be used with confused, agitated, or semicomatose patients. • Because these patients are not able to cooperate, they are likely to swallow large volumes of air that leads to gastric distention and possible vomiting. Elderly Client • There is a great chance for barotraumas due to fragility of lung space. Pediatric Client • There is a tendency to overinflate pediatric clients, thereby increasing risk for barotraumas. R E L E VA N T N U R S I N G D I A G N O S E S ●

Potential impaired gas exchange EXPECTED OUTCOMES

Patient achieves target tidal volumes, promoting optimal lung expansion ● Absences of adventitious breath sounds ● Absences of copious secretions and pneumonia ● Achieved optimal oxygenation status ●

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224 C h a p t e r 9 Ventilation Support EQUIPMENT/SUPPLIES

Pressure controlled ventilator Appropriate-sized mouth piece Saline or prescribed medications Oxygen source

FIGURE 9.2A Pressurecontrolled noninvasive ventilator.

I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Assist patient into semi-Fowler’s or high Fowler’s position. These positions enhance intermittent positive pressure ventilation therapy and promote lung expansion. ➧ Demonstrate proper mouthpiece position, and emphasize that the

lips must completely cover mouthpiece. Demonstration is a reliable teaching technique to ensure proper technique. ➧ Ensure sensitivity setting is –1 or –2 cm H2O to trigger intermittent

positive pressure breathing (IPPB) cycling. Allows small respiratory effort to trigger ventilator cycle to assist patient with inspiration and adequate delivery of tidal volume and medication. ➧ Instruct patient to breathe with the machine until it cycles off, at

which time the patient should hold his or her breath for 3–5 seconds and exhale passively. Ensures adequate chest expansion with each inhalation and prevents forced exhalation, which can increase small airway obstruction. ➧ Encourage patient to cough and deep breathe during and after

treatment. Enhances removal of airway secretions. ➧ Wash hands. Reduces transmission of microorganisms.

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P r o c e d u r e 9 . 3 Managing Mechanical Ventilation (MV) 225 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess bilateral breath sounds for decreased or absent breath sounds indicating the possibility of pneumothorax ● Evaluate pulse oximetry if improvement with therapy ● Evaluate patient’s ability to clear secretions after postural drainage, controlled cough techniques and percussion by assessing bilateral breath sounds for adventitious or diminished breath ● Patient’s tolerance to treatment ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

of bilateral breath sounds before and after treatment. ● Type of ventilator and medication used to provide therapy, i.e., Bird Mark 1 ventilator or the Bennett Pressure Breathing Therapy Unit. ● Color, consistency, and odor of secretions suctioned or expectorated. ● Vital sign alterations before, during, and after therapy. ● Patient’s tolerance of treatment. ● Time of last treatment. ● Frequency of treatments to ensure continuity of care and primary care provider’s orders. ● Results of treatment, i.e., improved respiratory status.

PROCEDURE 9.3 Managing Mechanical Ventilation (MV) OVERVIEW

To maintain the patient’s arterial blood gas, which is achieved through keeping the PaO2, pH, and PaCO2 as close to normal limits as possible. ● Indicated for patients who cannot maintain adequate ventilation and/or unable to protect one’s own airway. ●

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226 C h a p t e r 9 Ventilation Support P R E PA R AT I O N

Ensure patient on a ventilator is carefully monitored and that the alarms are always on. ● Monitor the system at regular intervals to detect problems early. ● Anticipate problems and anticipate your response to the problems. ● Remember that machines fail and have a manual system in place, i.e., oxygen tank and Ambu bag. ●

FIGURE 9.3A Ambu bags, infant to

adult sizes.

Special Considerations • The psychosocial needs of the patient must be addressed. • The nutritional needs of the patient who is on an MV are of utmost importance. • Cardiac output may be decreased, which will affect end-organ perfusion. • Patients on MV are at high risk for the development of pneumothorax. • Repositioning of patient at least every 2 hours facilitates removal of pulmonary secretions and prevention of atelectasis. • Age of patient. • Coexistence of different pathologies. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired spontaneous ventilation Ineffective breathing pattern

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P r o c e d u r e 9 . 3 Managing Mechanical Ventilation (MV) 227 EXPECTED OUTCOMES

Improved patient oxygenation status Able to maintain airway reflexes ● Absence of adventitious breath sounds ● Normal respiratory rate ● Negative inspiratory flow of greater than–20 cm ● Vital capacity greater than 10 mL/kg ● PaO greater than 60 on FiO of less than 50% 2 2 ● Patient achieves target tidal volumes, promoting optimal lung expansion ● ●

EQUIPMENT/SUPPLIES

Oxygen and air source at 50 psi Spirometer Ventilator Humidifier Oxygen analyzer Distilled water Ambu bag Two endotracheal tubes and emergency equipment (sizes appropriate for patient). For women use 6.5 mm to 7.5 mm ETT and for men use 7.0 mm to 8.0 mm Connectors, adaptors, and ventilator circuit Monitors (blood pressure cuff, pulse oximetry, electrocardiogram) Stethoscope Suction equipment Communication device, i.e., magic slate, pen and paper Emergency airway equipment, such as oral airway, laryngoscope handle, and blades I M P L E M E N TAT I O N ➧ Wash hands. Reduces the transmission of microorganisms. ➧ Explain the rationale for therapy to patient and family. Establishes rapport, reduces anxiety, and promotes autonomy. ➧ Develop communication plan if time and condition permit. Enables patient to communicate needs. ➧ Address physical and psychological comfort measures. Reduces discomfort, and improves patient outcomes.

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228 C h a p t e r 9 Ventilation Support ➧ Administer pain and anxiety medication as prescribed. Reduces discomfort and anxiety related to therapy. ➧ Adjust alarm setting. Provides early detection of potential problems. Mechanical alarms are useful but patient assessment is vital. ➧ Provide client opportunity for position changes and mouth and

endotracheal tube care frequently. Promotes mobilization of secretions, and prevents oral cavity erosion. ➧ Preoxygenate by providing 100% oxygen and suction when indi-

cated. Promotes removal of pulmonary secretions and improved pulmonary function. ➧ Continuously evaluate ventilator settings, arterial blood gases

(ABGs), goals for therapy, and patient response. Improvement or deterioration in patient condition often requires changes in ventilator setting. ➧ Monitor patient’s ventilator pressure readings and breath sounds for

presence and quality. Barotrauma and pneumothorax associated with MV often present in an abrupt rise in peak inspiratory pressure or decreased breath sounds. ➧ Perform oral care and avoid triggers for gag reflex, such as deep

oropharyngeal suctioning. Contaminated oral secretions are often associated with nosocomial pneumonia. Gagging causes discomfort and increases intrathoracic and intracranial pressure. ➧ Elevate head of bed at least 30 degrees. Reduces the risk for aspiration and promotes lung expansion. ➧ Change ventilator tubing according to hospital policy to prevent

colonization of microorganisms. Warm, moist nature of ventilator equipment is a medium for bacterial growth, which makes patient prone to nosocomial infections. ➧ Make appropriate ventilator changes such as increasing or decreas-

ing rate and/or tidal volume and monitor for patient’s ability to be weaned from ventilator. Changes in ventilator setting facilitate spontaneous ventilation and selfsustained ventilation. ➧ Make referrals to dietitian to provide optimal nutrition. Provides holistic care to meet the individual needs of the patient. ➧ Wash hands. Reduces the transmission of microorganisms.

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P r o c e d u r e 9 . 4 Using an Ambu Manual Ventilator 229 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the initial reason for MV, and evaluate goals for therapy Anticipate duration of MV ● Know successful criteria for achievement of goals ● Detect patient problems early ● Evaluate arterial blood gas analysis ● Patient’s tolerance to treatment ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Size and depth of endotracheal tube used. Date of MV initiation. ● Ventilator settings at time of report. ● Patient’s response to ventilatory changes. ● Arterial blood gas analysis for the shift. ● Vital signs. ● Frequency of additional therapy, i.e., nebulizer treatments, chest postural treatment, suctioning. ● Amount, color, and consistency of secretions. ● Alarm limits. ● Ventilator settings ● Vital signs. ● Last treatments and suctioning. ● Patient’s tolerance. ● Neurological status of patient. ● Breath sounds. ●

PROCEDURE 9.4 Using an Ambu Manual Ventilator OVERVIEW

To hyperinflate the lung and increase minute ventilation. Useful in resuscitation efforts in which patients are unable to breathe adequately or ventilate. ● Used as a temporary means of assisting or total ventilation. ● ●

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230 C h a p t e r 9 Ventilation Support P R E PA R AT I O N

Designed primarily to be used in emergency situations. Useful in transporting mechanically ventilated patients. ● Useful in hyperventilation of the lungs to promote removal of secretions. ● Can deliver from 240 to 2000 mL. ● ●

Special Considerations • Hyperinflation of the lungs using an Ambu bag can result in gastric distention and increase the risk for aspiration. • Proper mask seal often requires an additional resuscitator assigned to mask placement. • Assisted ventilation should be timed and sequenced with patient’s inspiratory effort. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Impaired gas exchange Impaired spontaneous ventilation EXPECTED OUTCOMES

Secretions are loosened and easily removable Removable of mucus plugs by suctioning ● Normalizes respiratory rate and volumes ● Improved oxygen status and arterial blood gas analysis ● Restore artificial respirations ● ●

EQUIPMENT/SUPPLIES

Ambu bag with mask (see figure in Procedure 9.3) 15 mm adapter for endotracheal tube connection Endotracheal tube CO2 adapter Oxygen source and supply tubing Suction equipment I M P L E M E N TAT I O N ➧ Connect oxygen supply, and fill reservoir with 100% oxygen. Provides supplement oxygen. ➧ Prepare suction equipment. Suctioning is necessary to provide pulmonary toileting and prevent aspiration.

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P r o c e d u r e 9 . 4 Using an Ambu Manual Ventilator 231 ➧ If patient is intubated and you suspect mucus plugs, perform saline

lavage without preservative. Aids removal and loosening of secretions. ➧ Connect Ambu bag to endotracheal tube or place mask in proper

position on mouth and nose and create a good seal. Ensures supplemental ventilator support.

FIGURE 9.4A Create a good seal.

➧ Assess patient’s oxygen status, and, if necessary, perform suctioning. Removal of secretions improves oxygenation. ➧ Repeat steps if necessary, and monitor patient throughout procedure. Provides information about improvement or deterioration in patient’s status. ➧ If patient’s status improves, discontinue Ambu ventilation. If patient’s

respiratory status does not improve, place on mechanical ventilator and develop appropriate plan of care. Ambu ventilation is only for emergencies and temporary use; alternative ventilatory methods are often needed. ➧ Reposition patient. Different pathologies affect ventilator status; repositioning may improve ventilatory status and promote comfort. ➧ Wash hands. Reduces the transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess patient before and after use of Ambu bag Patient’s tolerance

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232 C h a p t e r 9 Ventilation Support

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

before and after bagging. Rate and duration of ventilation. ● Percentage of oxygen used. ● Color, consistency, and amount of secretions obtained during suctioning procedure. ● Patient’s tolerance and outcome. ● Last time of suctioning. ● Duration of apnea. ●

PROCEDURE 9.5 Performing Endotracheal Tube Care OVERVIEW

To provide oral hygiene. To prevent tracheal damage. ● To promote ventilation. ● To prevent endotracheal tube (ETT) complications. ● ●

P R E PA R AT I O N S

Important to maintain proper position of tube. Promote oral hygiene. ● Maintain tube patency. ● ●

Special Considerations • All patients with ETT require meticulous mouth care every 2 hours. • Repositioning and manipulation of ETT should only be done by experienced nurses or respiratory therapist to prevent accidental displacement of ETT. • Breath sounds should be assessed before, after, and during ETT care. • Confused patients who require ETT care will require more than one nursing professional to perform ETT care to prevent inadvertent displacement while tube is not secure. • Male patients may require shaving of beard and mustache to adequately secure ETT. • The risk for accidental extubation exists during ETT care; therefore, reintubation equipment should be readily available.

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P r o c e d u r e 9 . 5 Performing Endotracheal Tube Care 233 R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Ineffective airway clearance Potential impaired tissue integrity EXPECTED OUTCOMES

ETT is positioned on opposite side of mouth after tube care and retaping ● ETT depth is the same as when care started ● Tape is clean and secured to ETT and cheeks ● ETT patency is maintained, as evidenced by absences of high peak airway pressures, adequate oxygen saturation ●

EQUIPMENT/SUPPLIES

Bedside table Towel Wet washcloth Tincture of benzoin swab Peroxide/mouthwash swabs with suction adapter 1–1.5 inch tape Two pair of nonsterile gloves Endotracheal and oropharyngeal suction equipment Tongue depressor I M P L E M E N TAT I O N ➧ Wash hands and apply gloves. Prevents transmission of microorganisms. ➧ Perform oropharyngeal suctioning Removes secretions and decreases patient’s need to cough during the procedure. ➧ Prepare tape. Have an available assistant hold ETT tube securely. Allows nurse to have one hand secure to the ETT throughout the procedure. Prevents accidental extubation and maintains correct ETT position and depth. ➧ Carefully remove tape from endotracheal tube and patient’s face.

Use adhesive remover to remove extra adhesive; discard tape into proper receptacles. Promotes access to skin beneath tape for visualization and hygiene. ➧ Clean mouth, gums, and teeth on opposite side of tube with mouth-

wash swabs and solution. Move tube to opposite side and repeat cleaning. Allows access and complete visualization of the oral cavity. Promotes hygiene, and reduces oral cavity infections.

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234 C h a p t e r 9 Ventilation Support ➧ Clean face with soapy washcloth and towel dry. Use tincture of

benzoin swab on cheeks and chin. Allow to dry completely. Protects skin, and makes skin more receptive to skin taping. ➧ Pass tape under patient’s neck with adhesive side up. Careful not to

twist tape. Center tape. On one side of face, secure tape across cheek. Tear remaining tape in half lengthwise. Secure top half of tape above upper lip and bottom half around ETT. On other side of face firmly remove slack, and secure to face. Tear tape lengthwise. Secure bottom half to lip and top half to ETT. Secures tube to face, and positions tube at proper place and depth. ➧ Wash oral airway with hydrogen peroxide, and rinse with normal

saline. Prevents transmissions of microorganisms. ➧ Reinsert oral airway using tongue depressor to displace tongue inferi-

orly, allow proper positioning of oral airway, and prevent oral trauma. Prevents trauma to oral cavity and allows access for oropharyngeal airway. Prohibits patient from biting ETT. ➧ Check ETT cuff pressure. ➧ Discard soiled items, and wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for unequal breath sounds Assess for endotracheal tube depth (20–21 cm for the average adult female and 22–24 cm for the average adult male) ● Make sure tape is secure to cheek bone and jaw ● Check ETT cuff pressure using minimal leak technique ● ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

before and after ETT care. Supplies used to complete process. ● Patient’s tolerance to procedure. ● Frequency and extent of ETT care needed. ● Size and depth of ETT tube. ● Frequency of ETT care. ● The presence of ulceration. ● Type, consistency, color of secretions obtained. ●

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 235

PROCEDURE 9.6 Performing Tracheostomy Care OVERVIEW ●

To maintain airway patency, prevent infection, promote cleanliness, and prevent skin breakdown. P R E PA R AT I O N

One-way patency is achieved and maintained by suctioning and cleaning the inner cannula. ● Long-term tracheostomy patients and their family members should be taught proper tracheostomy care. ● Have extra tracheostomy tube of equal size at bedside in case of displacement and contamination. ●

Special Considerations • Patients with tracheal stomatitis, pneumonia, bronchitis, tracheitis, and short, fat neck may require more frequent tracheostomy care due to increased production and pooling of secretions with these disorders. • In addition, hydration and nutrition affect consistency of secretions and risk for infection. Adequate hydration promotes easily mobilized secretions. Adequate nutrition is necessary to maintain proper immune function to fight off infection. • Patients with tracheotomy may have decreased ability to cough and clear secretions, which may impede airway patency, thus requiring more suctioning and tracheostomy care. Meticulous attention to individualize a plan of care is important. • If long-term placement of tracheostomy tube is anticipated, the patient and family members should be educated and evaluated on performing tracheostomy care. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to infection Impaired gas exchange related to impaired tissue integrity

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236 C h a p t e r 9 Ventilation Support EXPECTED OUTCOMES

Maintenance of patent airway Device appropriate for patient, i.e., fenestrated for patients who can vocalize ● Inner cannula free of secretions ● Tracheostomy ties are clean and secure ● Stoma site is free of redness, mucoid secretions, and foul smelling and/or colored secretions ● ●

EQUIPMENT/SUPPLIES

Bedside table Tracheotomy suction supplies Sterile gloves Hydrogen peroxide Normal saline Sterile cotton-tipped swabs Tracheostomy ties Sterile basin Towel Sterile 4⫻4 gauze Small sterile brush Scissors Sterile tracheostomy care kit (if available) I M P L E M E N TAT I O N ➧ Wash hands. Prevents transmission of microorganisms. ➧ Perform tracheotomy suction. Removes secretion to prevent occlusion of outer cannula by secretions. ➧ Allow patient to reoxygenate by breathing 100% oxygen, and pour

the hydrogen peroxide and normal saline into sterile bowls. Place tracheotomy O2 collar over tracheotomy to ensure oxygen saturation. Allows efficient and organized completion of tracheotomy care. ➧ Don sterile gloves; remove soiled dressing with forceps and discard

in trash receptacle. Prevents transmission of microorganisms. ➧ Keeping dominant hand sterile, remove oxygen source and inner

cannula with nondominant hand; place cannula in hydrogen peroxide basin. Hydrogen peroxide loosens the secretions.

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 237 ➧ Place tracheotomy oxygen collar over outer cannula. Maintains oxygenation of patient. ➧ Clean inner cannula using small brush. Brush provides mechanical force to remove thick secretions.

FIGURE 9.6A Clean inner cannula with hydrogen peroxide and small brush.

➧ Rinse inner cannula with normal saline using nondominant non-

sterile hand to pour saline. Cleanses secretions and hydrogen peroxide from inner cannula. ➧ Replace inner cannula and secure locking mechanism. Reapply oxy-

gen source. Secures inner cannula and re-establishes oxygen supply. (Note: some tracheotomy devices do not have an inner cannula.) ➧ Cleanse outer cannula with a sterile cotton swab moistened with

hydrogen peroxide. Aseptically removes secretions from stoma site. ➧ Rinse stoma with cotton swab soaked in normal saline and dried

with sterile 4⫻4s.

FIGURE 9.6B Clean stoma with cotton-tipped swab.

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238 C h a p t e r 9 Ventilation Support Rinses hydrogen peroxide from surface and dries surface, prohibiting a moist medium for microorganisms. ➧ Do not release all tracheotomy ties at the same time. To prevent dislodgement of tracheotomy. ➧ Cut length adequate enough to wrap around the patient’s neck

twice and cut ends on diagonal. Insert end of tie through eye of faceplate and pull through ipsilateral eye. Slide tie around neck to other eyelet and insert through second eyelet. Bring one tie around back of neck until ends meet. Tie ends securely allowing one finger breath between neck and tie. Cutting ends on diagonal aids in insertion of tie through eyelet. One finger breath between neck and ties prevents ties from being too tight.

FIGURE 9.6C Securing face plate

with ties. ➧ Insert fresh tracheotomy dressing under clean ties and faceplate. Absorbs drainage.

FIGURE 9.6D Insert clean dressing under ties and face plate.

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P r o c e d u r e 9 . 6 Performing Tracheostomy Care 239 ➧ Position patient comfortably and assess respiratory status. Promotes comfort. Reassessment of airway patency and respiratory status ensures good patient outcomes and provides clues to whether further interventions are needed. ➧ Wash hands. Prevents transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess the patient’s respiratory status after procedure and compare to baseline ● Make sure tracheotomy is secure and ties are tight but not tight enough to constrict circulation ● Assess for stomatitis and pressure sores ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

findings such as airway patency, stoma condition before and after tracheostomy care. ● Size and type of tracheostomy tube. ● Description of secretions. ● Patient’s tolerance of the procedure. ● Supplies used. ● Special care of stoma. ● Frequency of tracheotomy care. ● Time tracheotomy care was completed to ensure continuity of care. ● Patient’s tolerance to tracheotomy care. ● Whether or not suctioning was needed to provide the caregiver with information on the frequency of suctioning. ● Respiratory status such as breath sounds, ease of respirations, and respiratory rate.

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240 C h a p t e r 9 Ventilation Support

PROCEDURE 9.7 Managing a Cuffed Endotracheal or Tracheostomy Tube OVERVIEW

To prevent cuff-related injuries such as tracheal stenosis, tracheal esophageal fistula, erosion of blood vessels, and tracheal malacia. ● To prevent accumulation of secretions above the cuff. ●

P R E PA R AT I O N

Detailed assessment to prevent complication. Three important techniques: Inflating the cuff; monitoring cuff pressure; and preventing pooling of secretions above the cuff. ● All complications of cuffed endotracheal tube and tracheostomy tube are preventable with proper cuff care. ● ●

Special Considerations • Patients who have cuffed endotracheal tube and tracheostomy tube require cuff care at least every 4 hours. • Patients who require frequent suctioning will require more frequent cuff care. • Patients who are not mechanically ventilated and are eating may only require cuff inflation during meals. • Measurement should be taken at end of expiration. • Patients who have undergone general anesthesia with N2O must have their cuff pressure measured immediately postoperatively because N2O diffuses readily into endotracheal cuffs. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Potential for tracheal injury related to ET tube Ineffective airway clearance EXPECTED OUTCOMES

Proper cuff inflation is equal to or less than 20–25 cm H2O or 14–17 mm Hg ● Absence of tracheal or blood vessel erosion ● Secretions above cuff are suctioned and removed ●

EQUIPMENT/SUPPLIES

Suction equipment 12- or 20-mL syringe Pressure manometer

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P r o c e d u r e 9 . 7 Managing a Cuffed Endotracheal 241 I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Attach pressure manometer to pilot balloon cuff, and measure cuff

pressure. Records cuff pressure, cuff pressure above 20 cm H2O may cause tracheal necrosis. ➧ If cuff pressure is greater than 20–25 cm H2O or 14–17 mm Hg, aspi-

rate air using syringe to appropriate pressure. High pressures obstruct tracheal capillary blood flow, which can cause necrotic injuries. ➧ If cuff pressure is less than 20–25 cm H2O or 14–17 mm Hg, inject air

using syringe to appropriate pressure. Pressures less than these values allow air to leak around cuff and prevent adequate ventilation of the lung. ➧ Perform endotracheal tube or tracheostomy tube suctioning. Removes secretions. ➧ Deflate cuff. Allows secretions above cuff to drain into a lower trachea to be suctioned. ➧ Repeat suctioning technique. Removes secretions. ➧ Reinflate cuff. Maintains integrity of airway and allows adequate ventilation of the lungs. ➧ Wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for excessive cuff pressure as evidenced by cuff manometer pressure greater than 25 cm H2O and remove excess air ● Assess for cuff rupture and leaking of air around the tube by monitoring pilot balloon pressure ● Assess for intratracheal bleeding as evidenced by blood-tinged sputum noted when suctioning endotracheal tube and oral pharynx ●

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242 C h a p t e r 9 Ventilation Support

KEY POINTS ● Amount

FOR

REPORTING

AND

RECORDING

of cuff pressure used. If excessive or low cuff pressure noted, record amount of air injected or removed, time and frequency of intervention. ● Color, consistency, and amount of secretions above the cuff that were removed when suctioning the oropharynx. (Oral secretions that leak around the cuff can frequently cause aspiration pneumonia.) ● Frequency and last time of cuff care performed. ● Patient’s tolerance of process. ● Technique used (i.e., measuring of cuff pressure and minimal leak technique). ● Amount of pressure in cuff after cuff care performed. ●

C H A P T E R

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10 Airway Suctioning 10.1 Inserting an Oral or Nasal Airway, 244 10.2 Performing Oropharyngeal (Yankauer) Suctioning, 249 10.3 Performing Nasopharyngeal and Nasotracheal Suctioning, 252 10.4 Performing Endotracheal or Tracheostomy Tube Suctioning, 257

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244 C h a p t e r 1 0 Airway Suctioning

PROCEDURE 10.1 Inserting an Oral or Nasal Airway OVERVIEW

To facilitate easy removal of secretions. To hold tongue forward and maintain open airway. ● To prevent biting of endotracheal or nasogastric tubes. ● ●

P R E PA R AT I O N

Oral Airway ● ●

Minimal flexibility of the airway. Airway extends from exterior mouth, over the tongue, to the pharynx.

FIGURE 10.1A Oropharyngeal airway

in place. ●

Proper size is needed for proper function. Sizes range from pediatric #000 to adult #9. Measure from mouth to meatus of the ear.

Nasal Airway ● ●

Correct size is important for proper fit and function. Extends from the naris and the back of the throat, to the pharynx in patients who need an airway but have a gag reflex or in whom an oropharyngeal airway cannot be placed or tolerated.

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P r o c e d u r e 1 0 . 1 Inserting an Oral or Nasal Airway 245

FIGURE 10.1B A nasopharyngeal airway in proper position.

Provides airway maintenance. Clearance of secretions. ● Nasal airways are flexible. ● ●

Special Considerations • The airway should be removed by gently pulling downward and outward following the normal curve of the nose/mouth. • This should be done at least every 4 hours. • Good nasal and mouth care should be administered before reinsertion. • Water-soluble lubricant should be applied to the lips to prevent cracking and breakdown from the pressure of the airway. • After lips and mouth are cleaned, reinsert the oral airway. • Before discontinuing the airway, ensure that the patient can follow commands and can swallow, and has regained gag and cough reflexes to prevent aspiration of airway secretions into the lungs. • If nasal airway cannot be inserted, consider the following: • Changing size of the tube. • Relubricating airway and attempt to reinsert. • Hyperextending the patient’s neck. • Inserting the tube at a different angle. • Inserting the oropharyngeal rather than nasopharyngeal airway. • Patients with nasal airways need to be assessed for suctioning, especially the elderly and children. • Keep materials for cleaning the nares and moisturizing the nasal mucosa close to the patient’s bedside. • Assess the patient’s nares and face around the nasal tube for skin breakdown, especially in elderly patients.

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246 C h a p t e r 1 0 Airway Suctioning

• Prior to removal, suction airway to remove secretions. • Rotate the airway to the other naris every 8 hours to prevent breakdown of nasal mucosa. R E L E VA N T N U R S I N G D I A G N O S E S ●

Potential impaired gas exchange related to retained respiratory secretions EXPECTED OUTCOMES

Airway placed atraumatically without damage to the nasal or oral airway or mucous membranes ● Airway properly secured ● Airway protected from obstruction ●

EQUIPMENT/SUPPLIES

Oral or flexible nasopharyngeal airway Equipment for suctioning Tape strips (one approximately 20 inches, one 16 inches) Tongue depressor Petroleum jelly Mouth moistener or swab with mouthwash Gloves, nonsterile I M P L E M E N TAT I O N ➧ Explain procedure to patient/family. Decreases anxiety and facilitates cooperation. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Gather equipment to the bedside, including an oral or nasal airway. Enhances efficiency and patient safety. ➧ Prepare and test suction system. To ensure prompt removal of secretions that increase risk for aspiration. ➧ Don nonsterile gloves. Reduces transmission of microorganisms. ➧ Rinse airway with cool water. Facilitates insertion; acts as a lubricant. ➧ Position patient in semi-Fowler’s or Fowler’s position; place a pillow

or shoulder roll under the shoulders to hyperextend the neck.

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P r o c e d u r e 1 0 . 1 Inserting an Oral or Nasal Airway 247 The semi-Fowler’s/Fowler’s position can facilitate removal of secretions, should patient vomit. Hyperextension of the neck opens the airway and helps keep the tongue from the pharynx. ➧ Determine if the patient needs an oral or a nasopharyngeal airway. An oral airway should only be placed on an unconscious or unresponsive patient or when nares are occluded.

Nasal Airway ➧ Select the naris that looks most patent by examining each side of

the nares with a flashlight to observe for occlusion. To facilitate easy insertion of nasal tube without trauma to the patient with multiple attempts of insertion. ➧ Select appropriate size nasal airway (should extend from tip of nares

to earlobe). For optimal fit, the lumen of airway should be narrower than patient’s nares airway. Choosing correct airway size will ensure adequate patency and facilitate easy removal of secretions. ➧ Wash hands, and don nonsterile gloves. Reduces transmission of microorganisms which could cause infection. ➧ Lubricate entire length of tube with water-soluble jelly or anesthetic

jelly. Check with patient’s physician to determine if anesthetic lubricant can be used. To prevent trauma to the airway and facilitate insertion. ➧ Insert the entire tube gently through the naris. Follow the anatomic

line of the nasal passage. If you feel resistance, the naris may be deviated or obstructed. Attempt placement via the other naris. ➧ Validate proper positioning by: ● ●

Feeling exhaled air with your hand through tube opening. Inspecting, with patient’s mouth open, for the tip of tube behind uvula. To ensure that the nasal tube is in the correct position and promoting respiratory function.

➧ Suction mouth and throat if needed. Removes accumulated or loosened secretions pooled in mouth and throat. ➧ Discard dirty gloves. Reduces transmission of infection. ➧ Wash hands. To prevent the spread of microorganisms.

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248 C h a p t e r 1 0 Airway Suctioning

Oral Airway ➧ Choose the correct size oral airway based on patient’s age, size, and

condition. To ensure adequate airway patency and ease of removal of secretions.

TABLE 10.1A Oral Airway Size in Children and Adults

Age Wt (kg)

PREMA- NEOTURE NATE INFANT

TODDLER

SMALL LARGE SMALL MEDIUM LARGE CHILD CHILD ADULT ADULT ADULT

0-1 mo 0.5–3

Oral 000Airway 00 (mm)

0–1 mo 3–5

1–12 mo 4–10

1–3 yr 8–16

3–8 yr 14–30

8–12 yr 25–50

00

0 (40)

1 (50)

2 (70)

3 (80)

13–18 yr above 50 3 (80)

Above 18 yr

Above 18 yr

4 (90)

5 (100)

➧ Hold oral airway with the curved end up. Makes insertion of airway easier. ➧ Slide oral airway in until tip is at the lower half of tongue. Ensure accurate placement. ➧ Tape airway securely to prevent injury to lips, teeth, tongue, and pos-

terior pharynx. Prevents expulsion of nasal airway.

Tape Nasal airway

Tape Airway

FIGURE 10.1C Taping the airway.

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P r o c e d u r e 1 0 . 2 Performing Oropharyngeal (Yankauer) Suctioning 249 ➧ Suction mouth and throat if needed. Removes accumulated or loosened secretions pooled in mouth and throat. ➧ Discard dirty gloves. Reduces transmission of infection. ➧ Wash hands. Prevents the spread of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s respiratory status, and compare to pre-insertion respiratory status ● If patient is attempting to remove or push airway out, consider that the airway may no longer be needed ● Assess for trauma to lips, teeth, tongue, and pharynx ● If the patient is gagging, consider a smaller airway ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

before/after insertion of airway. Size of airway used. ● Patient’s tolerance of procedure. ● If patient needed to be suctioned and what secretions looked like (bloody, clear, etc.). ● Any trauma from procedure. ● Time of insertion of airway. ● Patient’s tolerance of procedure. ● Respiratory status pre- and post-insertion. ● If suctioning was required, and what secretions looked like (bloody, clear, etc.). ● Any trauma from procedure. ●

PROCEDURE 10.2 Performing Oropharyngeal (Yankauer) Suctioning OVERVIEW ● ●

To clean oral airway of secretions. To facilitate breathing.

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250 C h a p t e r 1 0 Airway Suctioning P R E PA R AT I O N

Indications for suctioning include ineffective cough; thick, tenacious mucus; impaired pulmonary function; and pooled secretions in mouth and throat. ● Smaller Yankauer suctions are designed for pediatric patients. ●

Special Considerations • If adult or child is capable and wishes to manage suctioning independently, provide instruction in the use of the Yankauer catheter. • Suctioning of infants may require two people; parents may be helpful in assisting and allaying the infant’s fears. R E L E VA N T N U R S I N G D I A G N O S E S ●

Potential impaired gas exchange related to retained secretions EXPECTED OUTCOMES

Respirations of 14 to 20 breaths per minute Oral airway clear and free of secretions ● Easy respirations ● ●

EQUIPMENT/SUPPLIES

Portable or wall suction unit with connection tubing and Yankauer connector Large towel Yankauer (oral suction) catheter Nonsterile gloves Oral moisturizer swabs Sterile saline Mouthwash (optional) I M P L E M E N TAT I O N ➧ Explain procedure to the patient. Reduces anxiety, and increases cooperation. ➧ Wash hands. Reduces transmission of microorganisms.

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P r o c e d u r e 1 0 . 2 Performing Oropharyngeal (Yankauer) Suctioning 251 ➧ Gather equipment, including Yankauer and suction tubing. Enhances efficiency and patient safety.

FIGURE 10.2A Yankauer suction tube.

➧ Prepare and test suction system. Removes secretions during suctioning. ➧ Don nonsterile gloves. Reduces transmissions of microorganisms. ➧ Position patient in semi-Fowler’s or Fowler’s position. Facilitates forward draining of secretions in mouth. ➧ Place towel on pillow or under patient’s chin. Prevents soiling of bed linens or cloths from secretions. ➧ Select proper suction pressure and type of suction unit. Ensures safe negative pressure for patient’s age to prevent precipitate injury to mucosa.

TABLE 10.2A Vacuum and Suction Settings VACUUM SETTINGS Wall

Portable

Infants

60–100 mm Hg

3–5 inches Hg

Children

100–120 mm Hg

7–10 inches Hg

Adult

120–150 mm Hg

7–15 inches Hg

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252 C h a p t e r 1 0 Airway Suctioning ➧ Gently insert Yankauer catheter into one side of patient’s mouth, and

guide it to the oropharynx. Reduces stimulation of the gag reflex. ➧ Gently extract Yankauer catheter from mouth without excessive

force. Reduces injury to the mouth and the teeth. ➧ Flush Yankauer with sterile solution by placing it in solution and

applying suction. Removes secretions from Yankauer. ➧ Repeat step 9 (insert Yankauer) if all secretions are not cleared from

patient’s mouth. Ensures removal of all secretions from patient’s mouth. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess patient’s respiratory status Assess for trauma to mucous membrane of mouth

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

before/after suctioning. Patient tolerance. ● Trauma during procedure. ● Color, amount, and consistency of secretions. ● Time of last suctioning. ● If patient is suctioning self or nurse is suctioning. ● Patient’s tolerance to procedure. ● Any trauma from procedure. ● Respiratory status. ●

PROCEDURE 10.3 Performing Nasopharyngeal and Nasotracheal Suctioning OVERVIEW ● ●

To clean airway of secretions. To facilitate breathing and improve gas exchange.

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P r o c e d u r e 1 0 . 3 Nasopharyngeal & Nasotracheal Suctioning 253 P R E PA R AT I O N

Suction catheter sizes are adult, sizes 12 to 16 French; and pediatric, sizes 6 to 12 French. ● Limit suctioning to no more than 12 seconds to prevent hypoxia. ●

TABLE 10.3A Suction Catheter Sizes AGE Newborn Infant to 18 mo 18 mo 24 mo 2–4 yr 4–7 yr 7–12 yr Adults

CATHETER SIZE (FRENCH) 6–8 6–8 8–10 10 10–12 12 12–14 12–16

Special Considerations • Some patients may require more frequent but shorter-duration suctioning to hypoxia. Assess pulse oximetry readings during suctioning to determine patient’s level of tolerance. Pediatric Patient • Two people may be required to suction infants and children, one to calm and hold the child’s hands and one to suction. • Determine correct length of suction catheter by measuring from the tip of the child’s nose to the ear lobe, then to the midsternum. • The premeasured length should be used to prevent tracheal trauma instead of waiting for a cough to be induced. R E L E VA N T N U R S I N G D I A G N O S E S ●

Impaired gas exchange related to retained secretions EXPECTED OUTCOMES

Respirations of 14 to 20 breaths per minute, normal depth, easy and symmetrical ● Upper lung fields clear on auscultation ●

EQUIPMENT/SUPPLIES

Portable or wall suction unit with connecting tubing Large towel or linen saver Sterile irrigation saline or water Sterile gloves

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254 C h a p t e r 1 0 Airway Suctioning

Suction catheter Cotton-tip swabs Moist tissue/cotton swab Goggles and mask (optional) or face shield I M P L E M E N TAT I O N

General Procedure ➧ Explain the procedure to the patient. Reduces anxiety and increases cooperation. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Position patient in semi-Fowler’s during procedure. Facilitates maximal breathing during procedure. ➧ Don nonsterile gloves. Reduces transmission of microorganisms. ➧ Turn suction on. Place finger over end of tubing attached to suction

machine. Observe meter on suction head to make sure suction is working properly. Set suction to 60 mm Hg for children and 120 mm Hg for adults. Tests suction function. ➧ Open sterile irrigation solution, and pour solution into sterile cup. Allows sterile rinsing of catheter. ➧ Place towel under patient’s chin. Prevents soiling of sheets and clothes. ➧ Ask patient to breathe through one naris while the other is

occluded, then repeat with other naris. Determines patency of nasal passage. ➧ Provide skin care to nares if indicated. Remove and discard nonsterile

gloves. Clears nasal passage. ➧ Open sterile gloves, and suction package. Maintains aseptic procedure. ➧ Don sterile glove on dominant hand. Maintains sterile technique. ➧ Hold the suction catheter in sterile hand. Grasp the suction end and

the length of the tubing with the sterile hand. Attach suction control port end of the suction catheter to the tubing coming from the wall suction, which is held in the nonsterile hand. Maintains sterility while establishing suction.

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P r o c e d u r e 1 0 . 3 Nasopharyngeal & Nasotracheal Suctioning 255 ➧ Remove plastic sleeve from suction catheter if there is one. Using

sterile hand, grasp the suction catheter tubing closer to the fenestrated end. You can wrap tubing partially around hand. Hold suction control port end with nonsterile hand. Facilitates control of tubing. ➧ Lubricate 3 to 4 inches of catheter tip with irrigating solution. Prevents mucosal trauma when catheter is inserted. ➧ Ask patient to take several deep breaths with oxygen source before

suctioning. Provides additional oxygen to body tissues before suctioning.

Nasopharyngeal Suctioning ➧ Insert catheter into an unobstructed naris, using a slanted downward

motion. Facilitates unrestricted insertion of catheter. ➧ Observe the back of the throat to see if catheter is properly posi-

tioned or coiled in the mouth. If properly positioned, place thumb over suction port to apply suction. Assess position. Applies suction to the catheter for suctioning secretions. ➧ Withdraw catheter in circular motion, rotating it between thumb and

finger. Release suction every few seconds so that suction is on no more than a total of 10 seconds in the patient’s trachea. Removes secretions without removing oxygen. Protects mucosa from force of suction. ➧ Place tip of suction catheter in sterile solution, and apply suction for

1 to 2 seconds. Clears secretions from tubing. ➧ Have patient take several deep breaths. Assess lung sounds, espe-

cially over bronchi, and determine if secretions are still obstructing the airway. Determines if repeat suctioning is needed. ➧ Repeat one more time if secretions are still present when assessed. Promotes adequate clearing of airway. ➧ Disconnect suction catheter from suction tubing, and turn off suc-

tion machine. Properly dispose of suction catheter, gloves, and other supplies. Prevents spread of microorganisms.

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256 C h a p t e r 1 0 Airway Suctioning ➧ Wash hands. Removes microorganisms.

Nasotracheal Suctioning ➧ Ask patient to open mouth wide as catheter is inserted. Allows visibility of tip of catheter. ➧ Insert the catheter deeper when the patient pants or coughs. Decreases resistance to catheter insertion. ➧ Place thumb over suction port. Provides a suction to remove secretions. ➧ Encourage patient to cough. Facilitates loosening and removal of secretions. ➧ Withdraw catheter in circular motion, rotating it between thumb and

finger. Release suction every few seconds so that suction is on no more than a total of 10 seconds in the patient’s trachea. Removes secretions without depleting oxygen supply. ➧ Place tip of suction catheter in sterile solution, and apply suction for

1 to 2 seconds. Clears clogged tubing after suctioning. ➧ Have patient take several deep breaths. Auscultate bronchial area,

and assess if patient’s airway is clear. Determines if repeated suctioning is needed. ➧ Repeat if secretions are still present when assessed. Promotes adequate clearing of airway. ➧ Suction the mouth and pharynx. Clears secretions from oral airway. ➧ Disconnect suction catheter from suction tubing, and turn off suc-

tion machine. Properly dispose of or store equipment. Prevents spread of microorganisms. ➧ Wash hands. Removes microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess patient’s respiratory status Assess for trauma, including bleeding or cuts to mucous membranes of nares and mouth

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 257

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

before and after suctioning. Include work of breathing, frequency of cough, subjective feelings, if possible. ● Patient tolerance. Oximetry readings before and after suctioning. ● Trauma, including bleeding or tears in the mouth or nares during procedure ● Color, amount, and consistency of secretions ● Time of last suctioning ● Respiratory status

PROCEDURE 10.4 Performing Endotracheal or Tracheostomy Tube Suctioning OVERVIEW

To maintain a patent airway and prevent airway obstruction. To promote optimal respiratory exchange of oxygen and carbon dioxide into and out of the lungs. ● To prevent pneumonia that may result from accumulated secretions. ● ●

P R E PA R AT I O N

Indications for endotracheal or tracheostomy tube suctioning: ineffective cough; depressed level of consciousness; thick, tenacious mucus; impaired pulmonary function. ● To determine suction catheter size, multiply the artificial airway’s diameter times 2 (e.g., for 8-mm tube, use a 16 F suction catheter). ● Assess patient’s need for suctioning every 2 hours and as needed. ● Limit suctioning to no more than 10 seconds to prevent removal of excessive oxygen. ●

Special Considerations • Discontinue suction immediately if any of the following adverse reactions occur: • Hypoxia. • Cardiac arrhythmias (bradyarrhythmias). • Hypotension/hypertension. • Mucosal trauma.

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258 C h a p t e r 1 0 Airway Suctioning

• Laryngospasm/bronchospasm. • Cardiac/respiratory arrest. • Extreme anxiety/agitation. Pediatric Patient • Suction pressure should range from 80 to 100 mm Hg. • The suction catheter is inserted to 0.5 cm beyond or just to the end of the endotracheal or tracheostomy tube. Advancing the suction catheter until resistance is met may cause trauma to the tracheobronchial wall in children. Elderly Patient • Elderly patients have a decreased PaO2, resulting in increased oxygen demands between suctioning. R E L E VA N T N U R S I N G D I A G N O S E S

• Potential impaired gas exchange related to retained secretions EXPECTED OUTCOMES

Decreased or cleared secretions Improved breath sounds ● Improved oxygen saturation ● ●

EQUIPMENT/SUPPLIES

Ambu bag connected to 100% O2

FIGURE 10.4A Ambu bag connected

to 100% oxygen.

Sterile suction catheter kit (includes sterile catheter, gloves, and cup) Sterile normal saline Personal protective equipment—goggles, mask, and gown (if examiner will be exposed to any bodily secretions). Continuous suction source

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 259 I M P L E M E N TAT I O N ➧ Assess patient’s vital signs, breath sounds, and appearance prior to

suctioning. Establishes a baseline for comparison after suctioning. ➧ Obtain and organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient or significant other. Reduces anxiety, and promotes patient cooperation. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Put on personal protective equipment. Reduces transmission of microorganisms. ➧ Turn suction on between 80 mm Hg and 120 mm Hg. Adequate suction is needed to ensure clearance of the airway. ➧ Open suction catheter set. ➧ Don sterile gloves. Prevents contamination of field. ➧ Open sterile saline irrigation, and pour into sterile cup. Allows sterile rinsing of catheter after examiner has suctioned. ➧ Hold suction catheter

with dominant (sterile) hand while connecting suction source to suction catheter with nondominant (nonsterile) hand. Prevents contamination of sterile field and transmission of microorganisms.

Note: Throughout procedure continue to hold sterile suction catheter with dominant (sterile) hand.

FIGURE 10.4B

➧ Suction small amount of sterile saline by placing nondominant

(nonsterile) thumb over suction port. Determines that the suction equipment is working properly and lubricates the outside and the lumen of the catheter. Lubrication eases insertion and reduces tissue trauma during insertion.

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260 C h a p t e r 1 0 Airway Suctioning ➧ Connect Ambu bag to endotracheal tube or tracheostomy tube

adapter. Hyperoxygenate patient with 100% oxygen using Ambu bag or mechanical ventilator. Provides additional oxygen to body tissues before suctioning, preventing hypoxemia. Hyperventilation with Ambu bag is used to break up secretions and to hyperoxygenate patient. ➧ Insert suction catheter into endotracheal tube or tracheostomy tube

using a slanted, downward motion until resistance is felt or cough is elicited. Prevents trauma to membranes due to suction from catheter. ●

Note: Do not apply suction while inserting catheter.

➧ Apply intermittent suction with nonsterile (nondominant) thumb

while withdrawing catheter in a circular motion, rotating between thumb and finger of sterile (dominant) hand. Intermittent suction and catheter rotation prevents damage to mucosal lining during suctioning. ●

Note: Suction time is limited to 10 seconds or less. Minimizes oxygen loss.

➧ Replace oxygen delivery system between suctioning by reconnect-

ing to ventilator or connecting to oxygen source. Prevents hypoxemia. ●

Note: After catheter insertion, allow patient to return to baseline O2 saturation level or better before resuctioning.

➧ Place tip of suction catheter into sterile saline, and apply suction. Rinses suction catheter and removes secretions. ➧ Repeat suctioning procedure 2 or 3 times as necessary to remove

secretions. Promotes adequate clearing of airway. ➧ Reattach oxygen source to endotracheal tube or tracheostomy tube. Prevents hypoxemia. ➧ Disconnect suction catheter, wrap catheter around finger, and

remove glove over catheter. Discard suction equipment appropriately. ➧ Reassess patient’s vital signs, breath sounds, and oxygen saturation. Assesses patient status in comparison with patient’s baseline. ➧ Remove gloves and wash hands. Reduces transmission of infection.

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P r o c e d u r e 1 0 . 4 Endotracheal or Tracheostomy Tube Suctioning 261

If Specimen Is Needed ➧ Connect suction catheter to

rubber tubing of specimen container and tubing from suction source to suction adaptor on lid of specimen container. Places specimen container in the suction pathway so specimen collects in cup.

FIGURE 10.4C

➧ Suction patient per procedure. Secretions will collect in the specimen cup. ➧ When secretions are visible (about 2–3 mL) in Luki tube, stop suc-

tioning. Be careful to avoid suctioning for greater than 10 seconds. 2–3 mL of sputum is necessary for a sputum culture or Gram stain. ➧ Disconnect Luki tube, seal

the specimen container, reconnect suctioning tubing to suction catheter. Allows continuation of suctioning to clear airway and safe handling of body fluids.

FIGURE 10.4D Seal the speci-

men cup. ➧ Complete suctioning procedure as needed.

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262 C h a p t e r 1 0 Airway Suctioning E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess breath sounds Assess vital signs, oxygen saturation ● Assess patient comfort ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Date, time and procedure. Reason for suctioning. ● Patient’s tolerance, changes in breath sounds, etc. ● Color, consistency, and amount of secretions removed. ● Current MD suctioning orders. ● Time suctioned. ● Patient’s tolerance. ● Color, consistency, and amount of secretions removed. ●

C H A P T E R

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11 Lung Re-Expansion or Chest Drainage 11.1 Managing Chest Tube and Drainage Systems, 264 11.2 Assisting with Chest Tube Removal, 271

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264 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage

PROCEDURE 11.1 Managing Chest Tube and Drainage Systems OVERVIEW

To remove air, blood, or fluid from the intrapleural space. To facilitate removal of air and fluids while reestablishing normal intrapleural pressure and lung expansion. ● To remove air, chest tubes are placed through the second intercostal space (ICS) anteriorly. ● To remove blood or fluid, chest tubes are placed posteriorly through the eighth or ninth ICS. ● ●

P R E PA R AT I O N

36 French (F) is the most common adult size. Trocar chest tubes are available for emergency insertion and require a minimal number of instruments. ● Heimlich valves can be used for emergency transport until a chest drainage system is available. ● Chest tubes are connected to bottle systems or disposable chest drainage systems. ● Bottle systems have one, two, or three bottles, whereas disposable chest drainage systems have three chambers. ● Three-bottle or disposable chest drainage systems are used most often. ● The three bottles/chambers are: collection chamber, water seal chamber, and suction chamber. ● ●

Special Considerations • Milking and stripping of chest tubes is controversial and only performed with a physician’s order. Research shows that milking and stripping causes increased negative pressure. Always follow specific policy and procedures for these techniques and milk/strip away from the patient toward the drainage system. • If a chest tube becomes disconnected, instruct the patient to exhale fully, clamp the chest tube with two rubber-shod Kelly clamps closest to the patient; cleanse the ends with antiseptic; reconnect to drainage system; remove clamps; tape the connections; and assess the patient.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 265

• If a chest tube is accidentally removed, apply pressure with Vaseline gauze and a 4×4, tape the dressing, notify the physician, and continue to assess the patient for respiratory distress. • Other situations with potential risk for closed pneumothorax requiring a chest tube include injury from mechanical ventilation, insertion of a central venous catheter, perforation of the esophagus, and blunt trauma from motor vehicle accidents. • Tension pneumothorax is life threatening and requires immediate intervention. Intrathoracic pressure increases, the mediastinum shifts to the unaffected side, cardiac output is decreased, and jugular vein distention occurs. • Patients at risk for tension pneumothorax are those on mechanical ventilation, after resuscitation, or with an obstructed chest tube. Elderly Patient • Elderly patients may be at risk for pneumothorax following blunt trauma from falls or from ruptured blebs or bullae associated with chronic obstructive pulmonary disease (COPD). Pediatric Patient • Pediatric patients are also at increased risk for accidental injury. Although their bones are more flexible, internal injuries may exist without apparent external injuries. • Pediatric patients are more sensitive to changes in respiratory status. Hypoxia and respiratory arrest are the primary causes of cardiac arrest in children. • Drainage greater than 3 mL/kg/hr in a pediatric patient for 3 hours or more indicates possible hemorrhage. Whenever possible, use sedation for chest tube insertion and removal, such as local anesthetics, conscious sedation, or EMLA cream. • To reduce anxiety in children, show them pictures or an actual setup of equipment. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired gas exchange related to pneumothorax or hemothorax ● Pain related to presence of chest tube ●

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266 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage EXPECTED OUTCOMES

Air, fluid, and blood are removed from the intrapleural space Lungs re-expand producing improved breath sounds in all lobes, oxygen saturation between 95% and 100%, pink color, and stable vital signs ● Intrapleural pressure returns to normal ● No air leaks detected ● ●

EQUIPMENT/SUPPLIES

36 French chest tube (for adult) Chest drainage system (disposable or three-bottle) Sterile water 5 in 1 connector or Y connector (for 2 chest tubes) Sterile gloves and masks Dressing (Vaseline gauze, split drain sponge, 4×4s, 3-inch tape) Rubber shod Kelly clamps Chest tube–insertion tray (povidone-iodine, local anesthetic, syringe, needles, drapes, scalpel, suture) I M P L E M E N TAT I O N ➧ Assess patient; vital signs, respiratory and cardiac status, anxiety,

pain. Obtain baseline data. ➧ Explain procedure to patient/family. Reduce anxiety. ➧ Wash hands. Reduce transmission of microorganisms. ➧ Organize equipment. Enhance efficiency and patient safety. ➧ Prepare a chest drainage system, per physician preference,

using sterile technique to open packages, handle contents, and pour solutions. Don sterile gloves; recap connectors when finished. Facilitate rapid attachment of chest tube to water seal and suction. Maintain sterility of system and connections.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 267 ➧ One-bottle system: add sterile water to submerge water seal tube. Maintains water seal and fluid collection in one bottle.

Suction chamber

Water seal chamber

Drainage collection chamber

FIGURE 11.1A Bottle and disposable

chest drainage systems. ➧ Two-bottle system: add sterile water to submerge water-seal tube;

connect water-seal bottle to collection bottle. Provides separate bottles for fluid collection and water seal. ➧ Three-bottle system: add sterile water to submerge water-seal tube,

connect water-seal bottle to collection bottle, add sterile water to the suction bottle, ensure that long tube is submerged, connect suction bottle to water seal bottle then to suction regulator. Depth of long-tube submersion determines amount of negative pressure. ➧ Disposable system: swivel base of unit to stand upright, remove cap

on suction control chamber and add sterile water to 20-cm level, replace cap, remove cap on water-seal chamber tubing and use catheter tip syringe to add sterile water to 2-cm level, replace cap on tubing, inspect system for leaks or cracks. System is ready to provide water seal, suction, and fluid collection. Water seal prevents room air from entering pleural cavity. ➧ Assist physician as needed with chest tube insertion, maintain sterile

technique, don sterile gloves and mask. Monitor patient’s physical and emotional response to procedure. Assessment facilitates prompt interventions. ➧ Once chest tube is inserted, connect it to the long tube of collection

chamber of chest drainage system and remove rubber-shod Kelly. If

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268 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage

suction is ordered, attach short water-seal tubing to suction tubing and regulator. Keep unclamped if no suction has been ordered. Rubber-shod Kelly clamp prevents or reduces air entering chest during insertion. ➧ Apply dressing: Vaseline gauze, drain sponge, 4×4s, and tape. Tape

all connections. Reduces risk for air leak at insertion site and all connections.

FIGURE 11.1B(1) Apply occlusive

dressing.

FIGURE 11.1B(2) Tape connections.

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P r o c e d u r e 1 1 . 1 Managing Chest Tube and Drainage Systems 269 ➧ Adjust suction until gentle bubbling occurs in suction control

chamber. Unit is functioning properly. ➧ Ensure tubing is free of kinks and is loosely coiled or forms a straight

line to drainage system. Prevents obstruction and pooling of fluids in dependent loops.

FIGURE 11.1C

➧ Observe for air bubbles in water-seal chamber and fluctuations,

tidaling, with respiration. Continuous, constant bubbling in water-seal chamber indicates an air leak; intermittent bubbling is normal. Fluctuations, tidaling with respiration are normal—absence indicates lungs re-expanded or a blockage. ➧ Position chest drainage system upright and below level of chest.

Secure bottles in stand or disposable system to bed frame. Prevents fluid from draining back into chest. Secure position prevents overturning and loss of water seal.

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270 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage ➧ Order chest x-ray. Confirms chest tube placement and lung expansion. ➧ Mark fluid level on collection chamber and time of measurement.

Use tape if needed to write on. Accuracy of output. ➧ Encourage patient to breathe deeply, cough, and change positions. Facilitate drainage and lung expansion. ➧ Assess drainage and vital signs, notify physician for changes in

drainage quantity or character, especially change from serous to bloody. Identify and intervene based on changes in patient status. ➧ Keep rubber-shod Kelly clamps at bedside. Rapid availability in event of disconnection or break of drainage system. ➧ Document. Validates procedure and patient response. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s respiratory and cardiac status, vital signs, skin color, and compare to baseline. Assess for symmetric chest wall movement and subcutaneous emphysema ● Monitor water level in water seal and suction chambers; replace sterile water as needed ● Rule out suspected air leaks by first retaping connections, checking dressing, and/or momentarily clamping tubing with rubber-shod Kelly clamp, starting nearest patient and moving distal until bubbling ceases ● Report bleeding or drainage greater than 100 mL/hr ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

findings before, during, and after chest tube insertion. ● Physician performing procedure. ● Size of chest tube and placement. ● Local anesthetic injected and amount. ● Pre-medication or conscious sedation. ● Drainage system used and amount of suction.

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P r o c e d u r e 1 1 . 2 Assisting with Chest Tube Removal 271

●

Description of drainage. Patient’s tolerance of procedure. ● Dressings applied. ● Time chest tube inserted. ● Patient’s tolerance. ● Respiratory status and vital signs. ● Amount and characteristics of drainage. ● Type of drainage system and amount of suction. ●

PROCEDURE 11.2 Assisting with Chest Tube Removal OVERVIEW

When lungs are re-expanded and fluid drainage ceases, the chest tube is removed. ● Serial chest x-rays document progression of improvement, lung reexpansion. ●

P R E PA R AT I O N

Pain medication is given prior to chest tube removal. Sterile technique is used for removal. ● Respiratory distress or recurrent pneumothorax are possible. ● ●

Special Considerations • Some references recommend chest tube removal on full inspiration whereas others recommend removal on full expiration. • Check your facility’s policy and your physician’s preference. • If a purse-string suture is used at the time of chest tube placement, it is pulled tight after removal of the chest tube for closure. Elderly Patient • Elderly patients need encouragement to cough and deep breathe following chest tube removal. They may be reluctant to take pain medications, which would make these tasks easier. Pediatric Patient • Pediatric patients should be sedated to reduce their pain and fear. • Intravenous medication or EMLA cream applied 1 hour prior to removal and covered with an occlusive dressing, are effective to decrease pain of chest tube removal.

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272 C h a p t e r 1 1 Lung Re-Expansion or Chest Drainage R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to decreased oxygenation Impaired gas exchange related to infection EXPECTED OUTCOMES

Pleura will close Skin at chest tube site heals ● Intrapleural pressure remains normal ● No air leaks detected ● Lungs remain re-expanded ● Bilateral breath sounds clear, all lobes ● ●

EQUIPMENT/SUPPLIES

Sterile gloves Suture removal set Vaseline gauze 4×4 gauze Tape I M P L E M E N TAT I O N ➧ Medicate patient for pain 30 minutes before chest tube removal. Enhances comfort. ➧ Assemble equipment. Enhances efficiency. ➧ Explain procedure to patient/family. Reduces anxiety. ➧ Don gloves, remove dressing, discard in red biohazard bag. Reduces transmission of microorganisms. ➧ Assist physician as needed, don sterile gloves, cut suture on chest

tube, instruct patient to take a deep breath and hold, clamp chest tube, remove tube, tie purse-string suture (if present), apply sterile Vaseline gauze and 4×4, tape dressing. Facilitates airtight seal. ➧ Assess patients response; vital signs, breath sounds, anxiety, and

pain. Provides data for prompt interventions.

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P r o c e d u r e 1 1 . 2 Assisting with Chest Tube Removal 273 ➧ Assess breath sounds every hour for 4 hours. Verifies lung inflation. ➧ Discard chest tube and drainage system in biohazard containers. Prevents spread of microorganisms. ➧ Document procedure. Validates procedure and patient response. ➧ Order chest x-ray. Verifies lung re-expansion. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe dressing for wound drainage Reinforce dressing if needed ● Assess for signs and symptoms of respiratory distress, diminished or absent breath sounds, or tension pneumothorax ● Call for chest x-ray report ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Pain medication administered; type, dose, and route. Date and time of removal. ● Physician removing chest tube. ● Quantity and characteristic of drainage in collection chamber. ● Patient response, vital signs, breath sounds, anxiety and pain rating. ● Dressing applied, condition of dressing. ● Chest x-ray report and physician reading x-ray. ● Time chest tube removed. ● Patient’s tolerance. ● Assessment data since removal; vital signs, breath sounds, color, oxygen saturation. ●

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U N I T

C H A P T E R

Cardiovascular

12 Intravenous Fluid Therapy 12.1 Inserting a Short-Term Peripheral Intravenous Catheter, 276 12.2 Inserting Peripheral Midline and Central Catheters (PICC), 285 12.3 Calculating and Regulating Intravenous Flow Rate, 293 12.4 Changing Intravenous Dressings (Peripheral and Central), 296 12.5 Assisting with Central-Line Placement, 299

5

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276 C h a p t e r 1 2 Intravenous Fluid Therapy

PROCEDURE 12.1 Inserting a Short-Term Peripheral Intravenous Catheter OVERVIEW

To provide venous access for administration of fluids, electrolytes, blood, medications, or nutrients. ● Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic functions. ● Types of catheters used • Scalp or butterfly vein needles. • Over-the-needle catheters. • Through- or inside-the-needle catheters. • Neonates—26- to 24-gauge needles; children—24- to 22-gauge needles. ● Short peripheral catheters are not used to infuse vesicants, parenteral nutrition exceeding 10% dextrose, and/or 5% protein solutions. ● Site selection should be in accordance with diagnosis, age, condition of veins, previous venipuncture, and type and length of therapy required. ● All IV therapy should be accompanied by a physician’s order. ● IV therapy requires frequent monitoring. ● Documentation should include site, type of catheter, needle gauge and length, date and time of insertion, IV fluids or flush solution, absence of signs and symptoms of complications. ● All IV sites require care at least every 48 to 72 hours. ● Tubing change is usually every 48 to 72 hours. ● Avoid drawing blood from short catheters. ● Site should be carefully inspected at least every 2 hours while therapy is in progress. ●

P R E PA R AT I O N ●

Choose needle length and gauge appropriate for the solution. TABLE 12.1A Catheter Sizes and Uses SIZE

USED FOR

Small diameter (22–24 gauge)

Fluids and medications Pediatric patients Fragile veins (as in the elderly) Blood products Hypertonic solutions Large amounts of fluid Blood administration during surgery

Medium diameter (18–20 gauge) Large diameter (14–16 gauge)

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P r o c e d u r e 1 2 . 1 Inserting a Short-Term Peripheral IV Catheter 277

Choose smallest gauge that will meet the patient’s specific need. Use lower distal veins first to avoid leakage if same vein is used later. ● Veins in the lower extremities should not be used routinely to avoid the increased risk for embolism and thrombophlebitis. ● Vein should be large enough for needle insertion and advancement. ● Avoid areas of flexion. ● Do not shave venipuncture site; clip hairy sites with scissors. Shaving increases chances of contamination. ● IV solution should be clear and outer wrap dry. ● Do not use felt tip pens to mark IV solution bag—it may migrate through plastic into solution. ● Cannulas must be maintained by flushing if IV fluids are not ordered. ● Protocol for use of local anesthetic should be in accordance with Nurse Practice Act and the institution’s policies. ● ●

Special Considerations • Patients with mastectomies need physician’s approval and written order to access veins in the extremity. Elderly • Elderly patients’ veins are often fragile; insertion may be done without tourniquet if vein is clearly visible. Pediatric • Scalp vein needles, and veins in the dorsum of the hand, forearm, and foot, are usually used in infants and children or for single-dose therapy, IVP medications, or blood drawing. • Candidates for infant peripheral IV therapy include those with diarrhea, dehydration, or serious infection. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for injury and infection related to invasive venous access device Risk for excess fluid volume related to IV fluid therapy EXPECTED OUTCOMES

Vein is cannulated successfully IV insertion site is clean, dry, and free of redness, swelling, or pain ● Catheter is secured safely ● Catheter aspirates blood and flushes easily ● Cannulation and IV intake are consistent with physician’s order ● ●

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278 C h a p t e r 1 2 Intravenous Fluid Therapy EQUIPMENT/SUPPLIES

Clean gloves Select catheter (over-the-needle, through-the-needle, or butterfly) that is appropriate for the patient, considering type of infusion and vein fragility IV fluid or IV lock, injection caps, IV tubing (vented or nonvented), IV pole, IV pump 0.9% sodium chloride (normal saline) flush (at least 2–3 mL) IV kit (if available) or Tourniquet Tape 1 or 2 inch (if patient has tape allergy, use paper tape) 70% alcohol wipes, 10% povidone-iodine swabs or wipes, tincture of iodine 2%, and chlorhexidine Dressing—2⫻2-inch gauze, transparent semipermeable occlusive dressing (Tegaderm, Opsite) Labels Plastic pad or towel I M P L E M E N TAT I O N

Prepare IV Fluids ➧ Verify physician’s order for IV therapy. A physician’s order is needed to initiate therapy. Order should include type of infusion, route, dosage of administration, volume to be infused, rate, and duration. ➧ Gather equipment: IV tubing, injection caps/needleless systems; type

of IV solution. Enhances efficiency. ➧ Wash hands. Reduces microorganisms and chances of cross-contamination. ➧ Remove container from outer wrap; inspect fluid, and check

expiration. Assess sterility of contents. ➧ Remove IV tubing and uncoil; do not let end become contaminated. Prevents contamination. ➧ Close roller clamp or flow regulator. Prevents accidental spillage of IV fluids. ➧ Remove protective cap from fluid container. Allows sterile tubing entry into container.

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P r o c e d u r e 1 2 . 1 Inserting a Short-Term Peripheral IV Catheter 279 ➧ Remove covering from spike of IV tubing. Permits entry of tubing into IV container. ➧ Insert spike into port of IV container with a quick twist. Prevents contamination from insertion. ➧ Hang fluid container on IV pole. ●

Squeeze drip chamber once or twice.

●

Open clamp or regulator slowly, allowing tubing to fill slowly.

●

Invert filters and medication ports/Y-sites to clear air.

●

Close clamp.

Creates suction effect; fluid enters drip chamber and prevents air entry. Starts fluid flow. Clears air. Prevents loss of fluid.

Insert Peripheral Catheter ➧ Check physician’s order. A physician’s order is needed to initiate therapy. ➧ Assemble and organize equipment. Enhances efficiency. ➧ Wash hands. Reduces microorganisms and chances of cross-contamination. ➧ Explain procedure. Decreases anxiety and evaluates patient’s psychological preparedness for the procedure. ➧ Tie tourniquet on arm 3 to 5 inches above projected insertion site. Promotes vein distention or dilation. ➧ Ask patient to open and close hand; use warm compress if the vein is

difficult to palpate, or ask the patient to let his or her arm hang down below the level of the heart. Increases blood flow to veins below tourniquet. ➧ Select vein. Use vein with few curves and largest diameter. Use non-

dominant hand/extremity or patient’s preference, if possible. Selecting the best and largest vein with few curves allows more chance at successful cannulation and toleration of IV therapy. ➧ Release tourniquet. Reestablishes blood flow; allows patient comfort while preparing for venipuncture.

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280 C h a p t e r 1 2 Intravenous Fluid Therapy ➧ Select appropriate catheter, and open IV kit or supplies. Selecting appropriate catheter size prevents irritation of vein lining, decreasing infiltration and phlebitis problems; opening supplies prevents interruption during insertion. ➧ Place patient’s extremity on top of pad or towel. Protects linen. ➧ Prime IV tubing and hang on pole or prepare saline flush for IV lock. Enhances efficiency and avoids delay after vein is cannulated. ➧ Tear tape 3 strips of 1/2 inch tape. Have tape ready for immediate stabilization of cannula after insertion. ➧ Don gloves and prep site. Reduces potential for infection and cross contamination. ●

Remove hair with scissors. Clip hair instead of shaving because of potential abrasive effect of a razor, which increases risk of infection.

●

Can use prep agents as single agent or in combination; 70% alcohol wipes can be used to defat skin prior to application of other antimicrobial agents.

●

Vigorously use circular motion at site from center outward for at least 30 seconds using povidone-iodine 10% or chlorhexidine.

Adhesive on tape sticks better if skin is defatted.

If patient is ALLERGIC to iodine or shellfish, use 70% alcohol for at least 30 seconds. Friction needed to remove microbes. ●

Alcohol should NOT be used after povidone.

●

Allow agent to completely air-dry.

Alcohol negates the effect of povidone. Fanning the area may transmit microorganisms.

Venipuncture ➧ Pull skin taut below puncture area (continuously). Stabilizes skin and prevents vein rolling.

FIGURE 12.1A Pulling skin taut.

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P r o c e d u r e 1 2 . 1 Inserting a Short-Term Peripheral IV Catheter 281 ●

With bevel up, insert needle at a 30- to 45-degree angle into skin. Allows backflow of blood.

30° 15°

FIGURE 12.1B Insert needle at correct

angle. ●

For winged-tip (butterfly or scalp) catheter, pinch wings together to insert needle.

●

For fragile or rolling veins, puncture directly over the vein.

Provides stabilization, and decreases pain during insertion. Greater chance for success if catheter is inserted and directed over a rolling vein. ●

For all other veins, insert alongside the vein distal to the selected puncture site. Allows full insertion of catheter.

➧ Gently insert into vein and advance tip into vein lumen (about 1/4

inch). Maintain alignment with vein, relocate vein, and reduce angle, if necessary. Reduces risk for going through vein, which causes a hematoma and immediate swelling at site. ➧ Observe for blood flashback in plastic hub of catheter. Indicates you are in vein. ➧ After catheter tip is in vein, advance plastic over-the-needle catheter

(not needle) forward off the needle into vein while maintaining skin taut.

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282 C h a p t e r 1 2 Intravenous Fluid Therapy Prevents accidental puncture of both walls of vein wall causing swelling or hematoma.

FIGURE 12.1C Advance the catheter.

➧ *DO NOT ATTEMPT to reinsert needle if backflow of blood subsides. Catheter tip may shear off, causing an embolus. ➧ *IF UNABLE to insert fully, DO NOT force: Attach catheter to IV fluid and

open clamp. Fluid may facilitate insertion by dilating and straightening small curves in veins. ➧ When catheter is in place, carefully place one 2⫻2 gauze under

catheter and needle. Absorbs blood. ➧ Release tourniquet. Prevents vein rupture from fluid flowing against closed vessel and restores circulation. ➧ Remove needle by holding hub with one hand and placing pressure

with fingertip above tip to occlude site. To slow blood flow.

FIGURE 12.1D Removing the needle.

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P r o c e d u r e 1 2 . 1 Inserting a Short-Term Peripheral Intravenous 283 ➧ Connect IV fluids or injector cap. For IV lock, flush with 1 to 2 mL of

normal saline. Prevents clot formation; clears tubing of blood. ➧ Open clamp on IV fluids, and observe flow at site. Check for patency and ease of flow. ➧ Clean site of moisture and blood. Removes medium for bacteria growth. ➧ Stabilize catheter by taping main hub or butterfly wings using

one of the methods below. Make sure insertion site can always be visualized. Maintains catheter’s position for long-term use. Allows site assessment for swelling, redness, or drainage.

U Method Place one piece of 1/2-inch tape below hub, adhesive side up. Bring tape ends over the wings of the catheter and secure to skin in a U-shape (both ends U Method parallel to the catheter). ● Place a sterile, occlusive, transparent dressing over site and partially over hub. ● ●

Stabilizes and secures catheter. Allows visualization of site.

FIGURE 12.1E

U Method.

Chevron Method Place one piece of 1/2-inch tape under the hub and criss-cross over each wing, forming an “x” over the hub, but not over insertion site. ● Place another small piece over the crossed tape at the hub to stabilize further, if necessary. ● Place a sterile, occlusive transparent, dressing over site and partially over hub. ●

Stabilizes and secures catheter. Allows visualization of site.

Chevron Method

FIGURE 12.1F

Chevron Method.

Transparent Film ●

The transparent film may also be used alone, without the adhesive tape.

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284 C h a p t e r 1 2 Intravenous Fluid Therapy ●

Place film over insertion site and up to catheter hub. Pinch the film around the catheter hub to secure. Stabilizes and secures catheter. Allows visualization of site.

FIGURE 12.1G Cover site with transpar-

ent film. ➧ Loop IV tubing and tape to arm or hand a short distance from site. ➧ *DO NOT loop so as to cause a kink in tubing. Keeps tubing from dangling. ➧ Label site with date, needle gauge, and initials on side of dressing or

across hub. Alerts others when inserted and type of needle used. ➧ Label tubing according to agency policy. Label all fluids with date,

time hung, medication additives, and initials. Alerts caregivers when tubing and fluid change is due. ➧ Dispose of all equipment. ➧ *DO NOT recap needle; dispose in needle container. Prevents accidental needle puncture. ➧ Document in nurse’s notes procedure and patient response. Contains information to identify infusion procedures and provides patient and caregiver protection. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Note skin above insertion site for swelling or redness. If present, discontinue IV and remove cannula ● If fluid does not infuse, try to flush again and hang bag higher. If catheter is determined to be clotted, remove peripheral short catheters ● Follow agency’s policy for site change, tubing change, and site/ dressing care ● For all peripherally placed catheters, do not use blood pressure cuffs or tourniquets on the same extremity as the catheter ●

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 285

If bright red blood is seen immediately in the tubing and IV bag, you may be in an artery. Stop the flow, remove the catheter, and place pressure on the site for 5 minutes ● Infusion therapy should be discontinued upon order of authorized prescriber or when complications of therapy are evident. Complications can include • Phlebitis or infiltration • Circulatory overload, especially in the elderly and very young • Infection at site • Extravasation • Thrombosis ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time of insertion. Catheter device with gauge and length. ● Location of insertion site. ● Fluid infusing and rate or if catheter is IV locked (heparin or saline lock). ● Infusion controlled by pump or gravity. ● Patient’s response to procedure and therapy including what instructions were given to patient. ● Condition of site and last time assessed. ● Any specific changes in therapy owing to, for example, volume, type of fluid, or rate change. ● Time current IV container was hung and how much is left to be infused. ●

PROCEDURE 12.2 Inserting Peripheral Midline and Central Catheters (PICC) OVERVIEW

To provide venous access for long-term administration of fluids, electrolytes, blood, medications, or nutrients. ● Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic functions. ●

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Peripherally Inserted Midline (short- to medium-term use: 2 to 4 weeks Do not use midlines for continuous vesicant chemotherapy, parenteral nutrition exceeding 10% dextrose, and/or 5% protein solutions. ● Avoid routine blood drawing. ● Midline catheters are 3 to 8 inches in length. ●

FIGURE 12.2A Midline catheter.

About 2 hours after insertion, the catheter becomes softer and will increase approximately 2 gauges in size. ● Peripherally inserted with tip in the proximal axillary vein. ● Need physician’s order to place catheter in arm of a patient with mastectomy or axillary node dissection. ● X-ray confirmation of placement necessary. ●

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 287

Peripherally Inserted Central Catheter (PICC) (long-term use: weeks to months) ●

PICCs are 20 to 24 inches in length, gauges range from 16 to 26 g.

A

B FIGURE 12.2B Peripheral intravenous central catheters (PICCs).

Select site in antecubital fossa. Distal tip should dwell in vena cava or subclavian vein. ● Previously damaged or sclerotic veins should be avoided. ● Need physician’s order to place catheter in arm of a patient with mastectomy or node dissection. ● Can deliver all types of therapy and be used for blood draws. ● X-ray confirmation of placement necessary. ● Most institutions require certification in IV therapy for insertion of PICC and midline catheters. ● Consent may be required for PICC and midline catheter insertion. Know and follow your agency’s policy. ● ●

P R E PA R AT I O N

Examine the package carefully before opening to confirm integrity and identify expiration date. Do not use if package is damaged, opened, or the expiration date has passed. ● Inspect kit for inclusion of all components. ● Flush the catheter with sterile normal saline prior to use. ●

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288 C h a p t e r 1 2 Intravenous Fluid Therapy ●

Identify the vein and insertion site; select site in region of antecubital fossa.

Special Considerations Geriatric • Veins in older adults may be sclerotic and/or very mobile, meaning that the vein has a tendency to be pushed away by the catheter needle rather than pierced by it. Warm compresses can help dilate veins, especially if the patient is cold. • Tourniquet pressure can damage the vein, especially if the patient is on an anticoagulant or a corticosteroid. Do not tie tourniquet too tightly. • Avoid overtaping the catheter or dressing; removing the tape can easily tear an elderly patient’s fragile skin. Pediatric • Small vessel size makes midline and PICC placement challenging in the pediatric population. • Palpation of vessels may be difficult, and ultrasound guidance is often not helpful because the child cannot remain still throughout the procedure. • Risk for piercing nerve bundles or arteries is higher in children due to stages of anatomic development. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for infection related to placement of invasive IV Risk for injury related to placement of invasive IV EXPECTED OUTCOMES

● ●

Line is placed atraumatically Correct placement is verified EQUIPMENT/SUPPLIES

Sterile gloves (2 pair), masks, sterile gown, and goggles PICC insertion kit if provided or Sterile gauze 2⫻2, and transparent semipermeable occlusive dressing Tape 1 or 2 inch and steri-strips IV fluid, one vial of 100 U/mL heparin flush, at least two 10-mL syringes of 0.9% normal saline, injection caps, IV tubing (vented or nonvented), IV pole, IV pump

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70% alcohol wipes, 10% povidone-iodine swabs or wipes, tincture of iodine 2%, and chlorhexidine 2 drapes Tourniquet, sterile forceps, and scissors 2 tape measures PICC or midline catheter (size depends on patient’s vein and type of infusion needed) Labels I M P L E M E N TAT I O N ➧ Verify physician’s order. A physician’s order is needed to initiate therapy. ➧ Gather equipment. Enhances efficiency. ➧ Wash hands. Reduces microorganisms and chances of cross-contamination. ➧ Apply tourniquet above projected insertion site. Assess antecubital

veins (basilic, cephalic median cubital veins); basilic vein is preferred. These veins are large and usually straight. ➧ Select a vein, and release tourniquet. ➧ Measure arm with tape measure from a fingerbreadth below antecu-

bital fossa to shoulder and across the shoulder to midclavicular line for subclavian placement (PICC only). For vena cava placement, continue to the sternal notch and down to the third intercostal space (PICC only). Determines length of catheter needed for insertion. ➧ Select a catheter insertion kit with smallest gauge and shortest

length that will coincide with therapy. ➧ Write down lot number and expiration date from PICC or midline

insertion kit. Needed for defects or returns. ➧ Wash hands with antibacterial agent for 60 seconds. Decreases chance of contamination. ➧ Set up supplies on sterile field. Decreases chance of contamination. ➧ Put on mask, and don sterile gloves. Prevents contamination of site and subsequent infection.

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290 C h a p t e r 1 2 Intravenous Fluid Therapy ➧ Flush catheter with 0.9% normal saline. Ensures patency, removes air, and detects leaks. ➧ Prepare site with 70% alcohol starting at insertion site cleaning in

a circular motion at least 8 to 10 inches in diameter. Repeat three times allow to dry. Decreases transmission of microorganisms. ➧ Repeat cleansing using povidone-iodine. Decreases transmission of microorganisms. ➧ Remove gloves. Gloves are contaminated; sterile gloves must be worn for insertion. ➧ Reapply tourniquet. Promotes venous distention. Tourniquet is no longer sterile, and, therefore, it should be put on before donning sterile garb. ➧ Put on second pair of sterile gloves and sterile gown according to

agency policies. Decreases chance of contamination. ➧ Drape patient’s arm with sterile towels or sheet, making sure a sterile

field is created. Provides a sterile field around site. ➧ Anesthetize the site using intradermal or topical lidocaine without

epinephrine (topical must be done before site prep).* Eliminate this step if local anesthesia is NOT used. Anesthesia should be used in accordance with agency policies and state standards of care. Anesthetic reduces pain. ➧ Perform venipuncture with dominant hand while holding the skin

taut with other hand. Stabilizes skin and prevents vein rolling. ➧ Verify blood return through the introducer/stylet or aspirate with

syringe. Ensures cannulation. ➧ Decrease the angle, and advance introducer 1/4 to 1/2 inch further into

vein. Allows further catheter advancement and prevents contamination. ➧ Different manufacturers have different designs. For kit with

guidewire, thread wire through needle and remove needle. Then thread catheter over guidewire and remove wire. Wire adds firmness to catheters and enhances advancement.

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P r o c e d u r e 1 2 . 2 Inserting Peripheral Midline and Central Catheters 291 ➧ Using sterile gauze to maintain your sterility, remove tourniquet.

(Midline catheter may be advanced slowly with tourniquet on while intermittently flushing with normal saline and aspirating for blood). Removal will decrease chance of catheter puncture. ➧ Remove stylet or needle. ➧ *Remove breakaway introducer if kit and catheter has this type. ➧ Slowly advance catheter about halfway of desired length through

the introducer (PICC). ● Have patient turn head toward insertion site with chin placed tucked down toward clavicle or chest (PICC). Position change will facilitate entry into vena cava or subclavian vein. ●

Use forceps to stabilize catheter or apply light pressure and then remove the introducer.

●

Continue to slowly advance catheter to desired length.

Ensures that catheter will not be removed with introducer. ➧ *If resistance is met, stop advancement. Never force catheter. ➧ *Attempt to flush or flush while continuing to thread catheter

If unsuccessful, you may need to use another vein. May enhance advancement if blood return is still good. ➧ *Do not force; guidewire could puncture catheter. Avoids puncture of catheter and vein wall. ➧ *Never withdraw catheter through introducer. May puncture vein or kink catheter. ➧ Prime and attach extension tubing and injection cap. Clears air from tubing. ➧ Flush with 0.5 mL of normal saline and then aspirate to check blood

return; note blood flow, color, and consistency. Helps verify patency and placement. ➧ Vigorously flush catheter with remaining normal saline followed by

heparinized saline. Clears catheter of blood, preventing clotting. ➧ Secure catheter with sterile tape, Steri-Strips, sutures, or stabilization

device. Maintains catheter’s position, and prevents catheter migration. ➧ Cover site with 2⫻2 gauze dressing and transparent dressing. Provides pressure on site for 24 hours to control oozing caused by large bore needle.

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292 C h a p t e r 1 2 Intravenous Fluid Therapy ➧ Obtain chest x-ray to assess for catheter tip placement. Verifies correct placement. ➧ Document procedure and patient response in the patient record. Communicates information about infusion procedure. Provides patient and caregiver protection and is a part of quality and risk management. ➧ After verification of placement, begin IV fluids if ordered. Avoids complications. Do not start IV fluids until placement is verified. ➧ Dispose of equipment appropriately. Avoids accidental needle sticks. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess for bleeding, oozing, ecchymosis, or pain around site. May apply pressure or use a pressure dressing for the first 24 hours for oozing. Change dressing if saturated. Notify nurse practitioner or physician if oozing does not stop ● Assess for tenderness, warmth, redness, cord-like feeling of vein. May treat with moist heat and arm elevation. Notify nurse practitioner or physician ● Monitor for infection or sepsis (fever, chills, drainage at site), cellulitis (diffuse redness at site, or thrombophlebitis (pain in arm, shoulder, and neck; edema of arm/shoulder) ● Flush catheter per protocol, and prepare for thrombolytic declotting ● Assess for air embolism (chest pain, confusion, lightheadedness, tachycardia, and hypotension) ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Date and time of insertion. Catheter device with gauge and length. ● Location of insertion. ● Fluid infusing and rate or if catheter is IV locked (heparin or saline lock). ● Infusion controlled by pump or gravity. ● Patient’s response to procedure and therapy, including the instructions that were given to patient. ● Condition of site and last time assessed. ●

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P r o c e d u r e 1 2 . 3 Calculating and Regulating Intravenous Flow Rate 293

PROCEDURE 12.3 Calculating and Regulating Intravenous Flow Rate OVERVIEW ● ●

Verifies correct drug dosage or fluid rate for the patient. Infusions must be checked and regulated frequently, especially in the elderly and very young. P R E PA R AT I O N

Calculations should be done twice for accuracy. All IV solutions with additives should be calculated for rate and amount of drug administered either per minute or per hour. ● A check of pharmacy calculation of IV solutions containing additives should be done prior to administration. ● Pay careful attention to tubing package to determine correct drop factor. ● ●

Special Considerations • Nurses should select one preferred method of calculation and consistently use that method. • Infusion controllers can malfunction. Compare amount of infused fluids to programmed rate to verify accuracy. • Double-check all machine flow rates for accuracy by calculating rates manually. Pediatric Patient • Pediatric patients should have precise volumes administered. • Large volumes and fast rates are not safe for children. • Use of an infusion pump is advised. Elderly Patient • Elderly patients are at risk for heart failure if IV fluids infuse too rapidly. • Careful intake and output documentation helps the nurse monitor fluid balance. • Use of an infusion pump is advised. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for imbalanced fluid volume related to rate/flow of IV fluids EXPECTED OUTCOMES

●

Correct fluid and/or medication are infused within designated time as ordered

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294 C h a p t e r 1 2 Intravenous Fluid Therapy EQUIPMENT/SUPPLIES

IV pole Primed IV fluid system IV pump, if indicated Calculator, pen or pencil, scratch pad Watch with second hand I M P L E M E N TAT I O N ➧ Obtain physician’s order. A physician’s order is needed to initiate therapy. ➧ Gather equipment. Enhances efficiency. ➧ Choose tubing and observe drop factor on package. Indicates drops per milliliter for drip rate calculation.

Drop factor is drops/mL. Microdrip ⫽ 60 gtt/mL. ● Macrodrip ⫽ 10, 15, or 20 gtt/mL. ● ●

Used for pediatric or very precise volumes. Used for all other infusions. ➧ Calculate mL per hour.

Example: Order is for 1000 mL over 24 hours. Total volume ⫼ administration time.

●

1000 mL ⫼ 24 hours ⫽ 41.6 (round) ⫽ 42 mL/hr. Determines volume that should be infused hourly.

➧ Calculate rate per minute. ● mL/hour ⫼ 60 minutes 42 mL/hr ⫼ 60 min ⫽ 0.7 mL/min. Determines volume that should be infused per minute. ➧ Calculate drops per minute. ● ●

Determine tubing drop factor, in this example, 10 gtt/mL. Total volume multiplied by drop factor ( total hour multiplied by 60 minutes. 1000 mL ⫻ 10 gtt/mL 24 hours ⫻ 60 minutes 1000 144 ⫽ 6.9 or 7 gtt/min ⫽

●

or use hourly rate of 42 mL/hr 42 mL ⫻ 10 gtt/mL 1hour ⫻ 60 minutes ⫽ 6.9 or 7 gtt/min Determines volume that should be infused in drops per minute.

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P r o c e d u r e 1 2 . 3 Calculating and Regulating Intravenous Flow Rate 295 ➧ If IV pump is used, enter rate in mL/hr ●

Insert tubing into pump according to manufacturer’s directions.

●

Set volumes in rate/hour.

●

Enter volume to be absorbed.

●

Start infusion.

Can regulate IV rate if properly used. Determines amount of fluid pump will deliver. Pump will let nurse know when volume has infused. ➧ If manually regulating IV, use second-hand watch, and count drops

over one minute. Determines correct drip rate.

Adjust roller clamp to increase or decrease speed. ● Check the rate hourly. ●

To detect changes in rate.

Calculating and Regulating Secondary IV Rates (IVPB) ➧ Obtain correct IVPB noting medication, date prepared, and patient

name. Decreases chance of medication error. ➧ Obtain secondary tubing. Tubing is for intermittent secondary infusion (IVPB). ➧ If using IV pump, enter mL/hour. Ensures accurate rate of delivery. ● ●

IVPB of 50 mL to be infused over 1 hour. Set pump on 50; the pump will deliver 50 mL over 1 hour.

➧ If manually regulating IVPB, calculate gtt/min. ●

IVPB 50 mL to be infused over 30 minutes total fluids ⫻ drop factor minutes 50 mL ⫻ 10 gtt/mL 30 min ⫽1.66 ⫻ 10 ⫽16.6 or 17 gtt/min

➧ Regulate IV rate using second-hand watch and counting drops

over 1 minute. Adjust roller clamp to increase or decrease speed. ➧ Place time tape or IV label on bag. Time taping gives visual cue to whether IV is infusing at set rate.

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296 C h a p t e r 1 2 Intravenous Fluid Therapy E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess site for signs of infiltration if IV is sluggish If an infusion pump is used, nurse should still monitor rate for at least 15 seconds and multiply by 4 to check rate ● Recheck manually regulated drips after 5 minutes and again in 15 minutes ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Time

of initiation of infusion. and volume of infusion. ● Manual control or pump controlled. ● Additives. ● Rate in mL/hr or mL/minute. ● Type

PROCEDURE 12.4 Changing Intravenous Site Dressings (Peripheral and Central) OVERVIEW

Reduces colonization of bacteria. Soiled, wet, or poorly taped dressings should be changed immediately. ● Cumulative incidence of infection rises with time. ● Direct observation of site should be done often for evidence of infection. ● Protects the site from contamination. ● Sites with gauze dressings require change every 24 to 48 hours on central lines and every 72 hours for peripheral sites. ● Transparent dressings allow direct visualization of site. ● The risk for infection increases if the site was not prepared well upon initial insertion. ● All patients require meticulous site care along with observing and assessing the site often. ● The dressing should be observed to ensure that it is intact, dry, and clean. ● If the dressing is damp, its integrity has been compromised and needs replacing. ● ●

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P r o c e d u r e 1 2 . 4 Changing Intravenous Site Dressings 297 P R E PA R AT I O N

Sites with transparent semi-permeable dressing: site care and dressing change should be done 72 hours. ● Antimicrobial ointments are of no proven benefit and should not be used. ● Care should be taken to maintain tape sterility; do not stick tape to contaminated bed rails or over bed tables. ● Anchor tape should be applied to cannula hub distal to insertion site. ●

Special Considerations • The elderly, very young, and immunosuppressed patients are at greatest risk for infection; systemic infections for these populations can be fatal. • Any complaint from the patient concerning burning, pain, or tenderness should be investigated immediately. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for infection related to invasive IV line EXPECTED OUTCOMES

Dressing clean and dry Gauze or transparent dressing is secure on all sides ● Skin integrity maintained ● Site free of swelling, redness, and drainage ● ●

EQUIPMENT/SUPPLIES

Nonsterile gloves Dressing change kit or Sterile gloves Povidone swabs or wipes Alcohol wipes or swabs Skin barrier Transparent dressing Tape 2⫻2 gauze Sterile barrier Mask(s) (central lines, percutaneous, PICCs, midlines, tunneled) Sterile Steri-Strips (PICCs)

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298 C h a p t e r 1 2 Intravenous Fluid Therapy I M P L E M E N TAT I O N ➧ Wash hands. Reduces microorganisms and chances of cross-contamination. ➧ Set up sterile field on sterile barrier; arrange and open supplies. Enhances efficiency and reduces chance of contamination. ➧ Check patient allergy to iodine/shellfish. May need to use just alcohol or other antimicrobial agent. ➧ Explain procedure. Reduces anxiety. ➧ Put on mask (central, PICCs, midlines, and tunneled catheters ONLY). ● ●

Second mask can be placed on patient (optional). If mask not used, have patient turn head in opposite direction from site. Protects IV site from airborne microbes.

➧ Don nonsterile gloves. Protects from potential contamination. ➧ Stabilize catheter while removing old dressing. Prevents accidental catheter dislodgement or migration. ➧ Assess site for redness, swelling, or drainage, and remove old gloves. Close observation for signs of infection. ➧ Don sterile gloves. Reduces chance of contamination of site. ➧ Cleanse site with alcohol swabs or pads using circular motion from

inside outward. Repeat this process again with new swab. Removes organisms away from the site. ➧ Cleanse hub, sutures (if applied), and catheter with new swab. Removes debris, old blood, and organisms from equipment. ➧ Cleanse insertion site with povidone swabs, repeating circular

motion as with alcohol. Repeat this process again. Removes organisms from the site. ➧ Allow to air dry without fanning. Fanning may transmit microorganisms. ➧ Apply skin barrier or skin prep (optional). Protects skin, and adhesive on dressings will stick better.

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 299 ➧ Tape catheter under hub or use Steri-Strips (PICCs). Secures catheter. ➧ Apply gauze or just transparent dressing over site, securing all edges. Protects site from contamination. Stabilizes and secures site. ➧ Label dressing with date, time, and nurse’s initials. Determines when next care is due. ➧ Document in record. Legal protection for nurse and patient. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient tolerance of procedure Dressing is intact and secure on all sides ● Catheter is stabilized ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Condition of site. site care done. ● Stabilization of catheter. ● Patient tolerance of procedure. ● Actual

PROCEDURE 12.5 Assisting with Percutaneous Central Line Placement OVERVIEW

Used when a patient needs support that a peripheral IV cannot give; for example, vesicant therapy, nutritional support, and high-volume hydration. ● Central venous catheter placement at the bedside is associated with serious complications including pneumothorax, hemothorax, cardiac tamponade, and air emboli. ● There are several types of central venous access devices, which have somewhat different uses. ●

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300 C h a p t e r 1 2 Intravenous Fluid Therapy ●

Percutaneous catheters or central venous catheters (CVC) are placed in the subclavian or jugular vein (sometimes femoral vein). They are: • Secured by suturing. • May be single, double, or triple lumen. • Require x-ray confirmation of placement.

Slide clamp

Proximal lumen port (18-gauge lumen) Distal lumen port (16-gauge lumen)

Medial lumen port (18-gauge lumen)

FIGURE 12.5A Injection

ports of a triple lumen catheter. ●

Tunneled catheters (Hickman, Broviac, and Groshong) are soft silicone catheters with a Dacron cuff for securing the device. They are “tunneled” under the skin to help prevent infection. The small Dacron cuff on the distal end of the catheter will be located just under the skin after insertion. Skin grows over this cuff, which helps keep the catheter in place. Tunneled catheters • Can be single, dual, triple, or quadruple lumen. • Are 20 to 30 inches long and have 22 to 17 gauge lumens. • Have an insertion site and an exit site. Cephalic vein Entrance site

Superior vena cava Right atrium

Basilic vein

Dacron cuff Subcutaneous tunnel

Exit site

FIGURE 12.5B Tunneled catheter.

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 301 ●

Ports are permanent vascular access devices implanted beneath the skin in the arm or chest. Ports are completely closed systems consisting of a catheter attached to a small drug reservoir. They are used when IV access is required intermittently over a long period of time. Ports are: • Surgically implanted. • Can deliver all types of therapy and be used for blood draws. • Must be accessed with a noncoring needle called a Huber needle (sizes from 19–24 gauge, 1–2 inches in length, curved or straight). • Can withstand up to 2000 needle punctures.

Hickman® Titanium Port

MRI® Port

Dome™ Port

MRI® Dual Port

FIGURE 12.5C Ports. ●

See Table 12.5A for a discussion of catheter types, their uses, advantages, and disadvantages TABLE 12.5A Types, Use, Advantages and Disadvantages of Central Catheters TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

Percutaneous Single, double or triple lumen catheter

• Any type of fluid • Short-term use up to a few weeks (follow agency’s guidelines for replacement) • Blood sampling insertion sites • Subclavian • Jugular • Femoral

• Access can be done at bedside • Can change catheter over a guidewire when needed

• Requires sterile dressing maintenance and heparin flushes at least daily or more if IV medications or blood sampling done • Mobility and comfort altered

(table continued on page 302)

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TABLE 12.5A Types, Use, Advantages and Disadvantages of Central Catheters (continued) TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

• Inserted at bedside by a trained nurse • Little chance of pneumothorax • Repair kits available for external tear in catheter

• Femoral sites are for short-term use only • Hard to maintain sterility of jugular site • Activity restriction • Risk of pneumothorax and cardiac tamponade from puncture of lungs or heart • Requires sterile dressing maintenance and routine heparin flushes or more if IV medications or blood sampling done via catheter • Activity restriction

• Can only be inserted by a physician • Requires consent

PICC Discussed in previous section

• Any type of fluid • Long-term use up to several months • May require consent

Tunneled Hickman Broviac

• Any type of fluid • Patient can be • Long-term use taught site care • Blood sampling • Once site healed requires consent can use clean • Can only be dressings instead inserted by a of sterile physician • Routine heparin flushes except catheter with Groshong valve • No activity restriction • Can be repaired externally

• Catheters can break and need repair or discontinuation • May need daily up to weekly site care • Catheter is visible under clothes and may be at least 6 to 8 inches long • Requires surgery for insertion

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 303

TYPE OF CATHETER

USE

ADVANTAGES

DISADVANTAGES

Implanted Ports

• Any type of fluid • Long-term use • Blood sampling requires consent • Can only be inserted by a physician

• Monthly heparin • Minor surgery • Requires a flushes noncoring needle • No activity for access called restriction Huber needle • No dressing changes required • Must have special training for • Monthly heparin accessing ports flushes • Much less risk for infection

P R E PA R AT I O N

Keep transparent dressing occluded at all edges. Clamp all lumens, and cap them when not in use. ● Patients with central lines require meticulous site care maintenance. ● ●

Special Considerations • Central line lumens also need to be maintained by flushing regularly with saline and heparinized saline. • Assess central line sites for signs of infection at least every shift or more often if warranted. R E L E VA N T N U R S I N G D I A G N O S E S

Risk for complications related to placement and ongoing presence of invasive central intravenous catheter ● Impaired skin integrity related to catheter insertion ●

EXPECTED OUTCOMES

Central catheter is placed atraumatically Catheter is properly secured ● No adverse effects such as pneumothorax or cardiac tamponade ● ●

EQUIPMENT/SUPPLIES

The following Equipment and Implementation sections are for percutaneous central line placement ONLY. See Procedure 12.2 for PICCs; all other central catheters require surgery. Sterile gloves (2–3 pair), face masks (at least two), and sterile gowns

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304 C h a p t e r 1 2 Intravenous Fluid Therapy

3 to 4 10-mL syringes filled with normal saline 3-mL syringes with heparinized saline (3–4) 2 to 3 syringes with 1 inch needle 2 to 35/8 inch , 1 inch, and 11/2 inch needles Central line introducer kit with: Introducer Betadine swabs Sterile drapes 10-mL syringe Xylocaine 1% or 2% without epinephrine Suture Sterile scissors and needle holder Single-lumen or multilumen kit I M P L E M E N TAT I O N ➧ Explain procedure, and assist with consent. Allays patient anxiety. ➧ Gather equipment, and arrange supplies on a clean tray. Enhances efficiency. ➧ Wash hands. Reduces risk of contamination. ➧ Position patient in Trendelenburg position with a towel rolled

between shoulders. Dilates neck vessels. ➧ Don mask, and prepare area opening trays. Reduces risk for contamination of equipment by air droplets. ➧ Offer physician mask, gown, and then sterile gloves after washing of

hands. Maximum barrier precautions required for central line placement. ➧ Nurse dons sterile gloves and mask. Reduces risk for contamination. ➧ Prepare site with 70% alcohol starting at insertion site cleaning in a

circular motion at least 8 to 10 inches in diameter. Repeat three times, then do the same with povidone detergent scrub for 2 minutes. ➧ Allow to air dry. Reduces microbes on skin. Removes organisms away from the site.

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P r o c e d u r e 1 2 . 5 Assisting with Percutaneous Central Line Placement 305 ➧ Drape insertion site, creating a wide sterile field, and have patient

turn head in opposite direction of insertion. Creates sterile field to decrease chance of contamination. ➧ Physician will: ●

Anesthetize area with lidocaine. Decreases pain and anxiety.

Perform venipuncture with insertion needle either in jugular site or subclavian site. ● *Femoral site used in emergency situations. ●

Allows accessing of site. ●

Attach syringe to needle, and aspirate for blood. Indicates that needle is in the vein.

Once there is good blood return, remove syringe from needle. ● Insert the guidewire through the needle. ●

Provides guide for catheter into the vein. ●

Remove needle slowly, and use dilator to enlarge hole, if needed.

●

Flush catheter and introducer with normal saline.

May need larger hole to accommodate catheter. Removes air and tests for leaks.

Thread catheter over wire. ● Insert introducer over wire, which can be left in as another access. ●

Adds another access site.

Insert catheter through introducer. ● Aspirate all air out of lumens and then flush with normal saline. ●

Decreases chance of air embolism ●

Place injection caps on each lumen.

●

Suture catheter.

Prevents blood loss and protects sterility of lumens. Stabilizes catheter. ➧ Nurse will: ●

Apply sterile transparent dressing over site. Maintains sterility, and site can be observed.

Assist with equipment disposal. ● Make patient comfortable. ● Auscultate lungs, and assess for respiratory distress. ●

Checks for pneumothorax or tamponade. ●

Obtain vital signs. Assess for complications.

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306 C h a p t e r 1 2 Intravenous Fluid Therapy ●

Obtain chest x-ray.

●

Document in record.

Verifies placement and absence of thorax and cardiac puncture. Records procedure done. Legal protection for nurse and patient. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Asses patient comfort Assess site for bleeding and other complications, including signs and symptoms of pneumothorax (shortness of breath, light-headedness, fainting, chest pain, feeling unable to take a deep breath) ● Assess for signs and symptoms of infection (fever, shaking chills, vomiting, lethargy, change in mental status) ● Assess line for mechanical problems (failure of fluids to infuse, difficulty injecting lumen(s), absence of blood return, pain with injection into lumen(s) ● After x-ray verification, flush with heparinized saline or hang IV if ordered ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Date and time of catheter insertion. Insertion site location and catheter size. ● Care and maintenance procedures performed at the times of insertion and immediately after. ● Patient tolerance of procedure. ● X-ray verification. ●

C H A P T E R

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13 Circulatory Maintenance 13.1 Caring for Vascular Access Devices, 308 13.2 Applying Sequential Compression Devices, 311 13.3 Applying Antiembolic Hose, 313 13.4 Teaching Postoperative Leg Exercises, 315

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308 C h a p t e r 1 3 Circulatory Maintenance

PROCEDURE 13.1 Caring for Vascular Access Devices OVERVIEW

To obtain a blood specimen from a vascular access device because there is no other peripheral venous access available and diagnostic studies requiring a blood sample are ordered. ● To change the port cap(s) at regular intervals prevents leakage from the catheter and creates a secure seal which prevents air from entering. ● To flush the catheter(s) of vascular access devices every shift or according to facility protocol ensures patency of the catheter. ●

P R E PA R AT I O N

Sterility must be maintained when obtaining a blood specimen, flushing, and changing port caps. ● Lumen should be clamped before withdrawing syringe from port to prevent aspiration of blood or air into lumen. ● Flushing lumen with positive pressure decreases catheter complications. ● Proximal lumen should be utilized to obtain blood sample. ●

Special Considerations • Wear protective equipment, (i.e., gloves, mask, gown, and goggles) when drawing blood from a patient who is in isolation, HIV positive, on neutropenic precautions, and so on. • Flush various catheters according to facility protocol. • Monitor for any adverse reactions during and after procedures, (e.g., air embolism). • Monitor for signs and symptoms of infection at the insertion site and sepsis. Newborn and Pediatric Patient • Insertion sites may vary from adult and geriatric according to age and physical development R E L E VA N T N U R S I N G D I A G N O S E S

Risk for infection related to altered tissue Impaired skin integrity related to an invasive surgical procedure of inserting a vascular access device ● Altered nutrition, less than body requirements related to anorexia or surgery ● Fluid volume deficit related to nausea and vomiting ● ●

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P r o c e d u r e 1 3 . 1 Caring for Vascular Access Devices 309 EXPECTED OUTCOMES

Procedure will be accomplished without untoward effects to patient Sterility will be maintained while procedures are done ● Patient remains free of air embolism and infection at the catheter site and systemically ● Patient maintains optimum body weight ● ●

EQUIPMENT/SUPPLIES

Mask and gown (if required per agency protocol) Clean gloves Gown (depending on patient diagnosis) Goggles (depending on patient diagnosis) 4×4 sponges Povidone-iodine Three 10-mL syringes with needleless tip (for blood draws) 0.9% sterile sodium chloride solution in 10-mL syringe for flushing and blood draws Heparin 100 units/mL in 10-mL syringe for flushing and blood draws I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure and how patient can

assist. Decreases anxiety; meets patient’s right to be informed; encourages cooperation and participation. ➧ Wash hands and don clean gloves. (Wear gown and goggles as

indicated.) Reduces transmission of infectious microorganisms. ➧ Prep cap of proximal lumen with povidone-iodine solution and allow

to dry. Reduces introduction of infectious microorganisms into blood stream. ➧ Insert needleless cannula of a 10-mL syringe containing 10 mL of

0.9% sodium chloride into proximal lumen port. Using proximal port decreases contamination of specimen from solutions infusing into other lumens of catheter. ➧ Unclamp lumen and briefly aspirate for blood. Return. Verifies patency of lumen. ➧ Attach an empty sterile 10-mL syringe to port. Empty syringe needed to withdraw blood.

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310 C h a p t e r 1 3 Circulatory Maintenance ➧ Aspirate 3 mL of blood and discard blood and syringe. Avoids infusion of clotted blood. ➧ Attach an empty sterile 20-mL syringe to port and aspirate blood

needed for sample; place in appropriate laboratory tubes. Minimizes transmission of organisms by using one syringe to obtain blood sample. ➧ Flush catheter with 10 mL of 0.9% sodium chloride solution. Clears lumen and port of blood. ➧ Use 2 mL of heparin 100 units/mL to flush heparin lock, or according

to agency protocol. Decreases clotting of lumen. ➧ Continue pressure on plunger as syringe is withdrawn. Maintains positive pressure in line. ➧ Clamp lumen before withdrawing syringe. Prevents aspiration of blood into lumen. ➧ Change the port cap(s): ●

Open sterile cap package.

●

Place patient in supine or modified Trendelenburg position.

●

Prime cap with sodium chloride solution with syringe with needleless cannula.

●

Make sure catheter is clamped.

●

Using aseptic technique, remove existing cap and insert new one.

Maintains aseptic technique. Prevents air entering catheter.

Prevents air in cap. Prevents air in cap. Prevents transmission of infectious microorganisms.

Continue with same procedure until all ports are changed. ● Discard contaminated equipment, remove gloves, and wash hands. ●

➧ Reposition patient, if necessary. Patient comfort. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood specimen was drawn, flushing was done, and port caps were changed correctly on the central venous catheter ● Patient did not experience discomfort or adverse reactions during or after procedures ●

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P r o c e d u r e 1 3 . 2 Applying Sequential Compression Devices 311

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time of collection of blood sample, flushing, and/or changing port caps as per protocol. ● Any problems with the catheter. ● Assessment of insertion site.

PROCEDURE 13.2 Applying Sequential Compression Devices OVERVIEW ● ●

To prevent postoperative complications, (i.e., thrombophlebitis). To promote comfort in lower extremities. P R E PA R AT I O N

Review history related to recent surgical procedure, peripheral vascular disease, and thrombophlebitis. ● Determine patient’s ability to understand, cooperate, and participate in the procedure. ●

Special Considerations • Any patient may need additional assistance, support, and teaching to understand the importance of using SCDs and keeping them on as prescribed. Elderly, Physically, and Mentally Challenged Patients • May require more assistance to apply SCDs. R E L E VA N T N U R S I N G D I A G N O S E S

At risk for altered peripheral tissue perfusion related to immobility Impaired gas exchange related to pulmonary embolus ● Impaired physical mobility related to injury and/or surgery ● Pain/discomfort related to injury and/or surgery ● ●

EXPECTED OUTCOMES

Patient will have improved circulation in lower extremities postoperatively and without developing thrombophlebitis ● Patient expresses increased comfort ●

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312 C h a p t e r 1 3 Circulatory Maintenance EQUIPMENT/SUPPLIES

Sequential compression stockings/hose and equipment Clean gloves Tape measure I M P L E M E N TAT I O N ➧ Check doctor’s order; identify patient; explain purpose, procedure,

and how patient can assist if indicated. Assess patient’s or family member’s ability to participate. Confirms order; meets patient’s right to be informed; encourages cooperation and participation. ➧ Wash hands and don clean gloves. Reduces transmission of infectious microorganisms. ➧ Measure around the largest part of the thigh. Ensures correct sizing of stockings/hose. ➧ Obtain equipment from central supply. It is not usually on the supply cart on the nursing unit. ➧ Gather equipment and place at bedside and adjust lighting. Enhances organization; ensures good visualization to apply stockings/hose. ➧ Position patient in bed in Fowler’s position. Patient comfort and easy access to lower extremities. ➧ Wrap stockings/hose around the leg, starting at the ankle, with the

opening over the patella. For correct positioning and optimal compression to promote circulation by sequentially compressing the legs from the ankle upward. ➧ Attach the stockings/hose to the insufflator, and make sure the inter-

mittent pressure is between 35 to 40 mm Hg. Ensures stockings/hose are correctly placed and a constant intermittent pressure is maintained for optimal circulation. ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms. ➧ Check stockings/hose and compressor equipment periodically. Ensures proper functioning of stockings/hose and equipment. ➧ Conduct patient and/or family teaching about removal and applica-

tion of stockings/hose as indicated. Promotes participation from patient and/or family in the use of these stockings/hose.

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P r o c e d u r e 1 3 . 3 Applying Antiembolic Hose 313 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate Sequential compression devices (SCDs) are applied correctly. ● Patient’s circulation is improved and without postoperative thrombophlebitis ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time SCDs were applied (as required). Patient/family participation and any teaching that was done (as required). ● Any problems patient has with SCDs. ●

PROCEDURE 13.3 Applying Antiembolic Hose OVERVIEW ● ●

To prevent postoperative complications, (i.e., thrombophlebitis). To promote comfort in lower extremities. P R E PA R AT I O N

Review history related to recent surgical procedure, peripheral vascular disease, and thrombophlebitis. ● Determine patient’s ability to understand, cooperate, and participate in the procedure. ●

Special Considerations • Any patient may need additional assistance, support, and teaching to understand importance of using TED hose and keeping them on as prescribed. Elderly, Physically, and Mentally Challenged Patients • May require more assistance to apply hose.

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314 C h a p t e r 1 3 Circulatory Maintenance R E L E VA N T N U R S I N G D I A G N O S E S

At risk for altered peripheral tissue perfusion related to immobility Impaired gas exchange related to pulmonary embolus ● Impaired physical mobility related to injury and/or surgery ● Pain/discomfort related to injury and/or surgery ● ●

EXPECTED OUTCOMES

Patient will have improved circulation in lower extremities postoperatively and without developing thrombophlebitis ● Patient expresses increased comfort ●

EQUIPMENT/SUPPLIES

A pair of TED hose Clean gloves Tape measure I M P L E M E N TAT I O N ➧ Check doctor’s order; identify patient; explain purpose, procedure

and how patient can assist if indicated. Assess patient’s or family member’s ability to participate. Confirms order; meets patient’s right to be informed; encourages cooperation and participation. ➧ Wash hands and don clean gloves. Reduces transmission of infectious microorganisms. ➧ After determining patient’s ability to stand with or without assis-

tance, measure while standing, from gluteal fold to the floor, circumference of largest part of the calf. If patient is unable to stand, measure patient in bed. Ensures correct sizing of stockings/hose. ➧ Obtain equipment from central supply. It is not usually on the supply cart on the nursing unit. ➧ Gather equipment and place at bedside and adjust lighting. Enhances organization; ensures good visualization to apply stockings/hose. ➧ Position patient in bed in Fowler’s position. Patient comfort and easy access to lower extremities. ➧ With patient lying in bed, invert the stocking and slip it over the foot. For correct positioning of stocking/hose.

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P r o c e d u r e 1 3 . 4 Teaching Postoperative Leg Exercises 315 ➧ With the foot raised, ease the stocking/hose snugly over entire the

leg and then apply the other one in the same way. Ensures stockings/hose are correctly placed and that compression of these snugly fitting stockings/hose promotes proper circulation during periods of immobilization. ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms. ➧ Check stockings/hose and periodically. Ensures proper functioning of stockings/hose and equipment. ➧ Conduct patient and/or family teaching about removal and applica-

tion of stockings/hose as indicated. Promotes participation from patient and/or family in the use of these stockings/hose. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate Antiembolic hose (TED hose) are applied correctly ● Patient’s circulation is improved and without postoperative thrombophlebitis ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time TED hose were applied and removed (as required). ● Patient/family participation and any teaching that was done (as required). ● Any problems patient has with TED hose.

PROCEDURE 13.4 Teaching Postoperative Leg Exercises OVERVIEW ● ●

To prevent postoperative complications, (i.e., thrombophlebitis). To promote optimal circulation in lower extremities.

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316 C h a p t e r 1 3 Circulatory Maintenance P R E PA R AT I O N

Review history related to recent surgical procedure(s), peripheral vascular disease, and/or thrombophlebitis. ● Assess for pain/discomfort before and during exercises. ● Determine patient’s ability to understand, cooperate, and participate in the procedure. ● Determine patient’s ability to perform exercises independently after initial instructions. ●

Special Considerations: Pediatric, Elderly, and Physically and Mentally Challenged Patients • May need additional assistance, support, and follow-up teaching to learn to perform the exercises independently and following a prescribed schedule. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Risk for altered tissue perfusion related to immobility Risk for impaired gas exchange related to pulmonary embolus EXPECTED OUTCOMES

●

Patient will have optimal circulation in lower extremities postoperatively and without developing thrombophlebitis EQUIPMENT/SUPPLIES

Clean gloves I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist in learning these exercises. Assess patient’s or family member’s ability to participate. Meets patient’s right to be informed that these exercises will prevent pooling of blood in the lower extremities after surgery and will prevent clot formation; encourages cooperation and participation. ➧ Wash hands and don clean gloves. Reduces transmission of infectious microorganisms. ➧ Place patient in supine or semi-Fowler’s position. Patient comfort. ➧ Instruct patient to bend knee, raise foot in air, and hold in this posi-

tion for 2–3 seconds. Circulates blood from lower extremities back to body.

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P r o c e d u r e 1 3 . 4 Teaching Postoperative Leg Exercises 317 ➧ Have patient extend leg and lower it to bed. Extends muscles and circulates blood from lower extremities to upper body. ➧ Repeat procedure with other leg. Ensures consistency of exercising both lower extremities. ➧ Complete sequence 5–10 times each hour while awake. Ensures consistent and constant optimal circulation to lower extremities. ➧ Instruct patient to extend toes (plantar flexion) toward bottom of

bed, then flex (dorsiflexion) toward head of bed. Optimizes blood circulation from feet to legs. ➧ Repeat foot extension and flexion with the other side. To be consistent for both lower extremities. ➧ Repeat sequence 5 times each hour while awake. Ensures consistent and optimal blood circulation to lower extremities. ➧ Instruct patient to make circles with the ankle moving first to the left

and then to the right. Promotes optimal blood circulation to the foot. ➧ Repeat sequence 5 times each hour while awake. Ensures consistent optimal blood circulation to lower extremities. ➧ If you used gloves to assist patient with leg exercises, remove them

and wash hands. Prevents transmission of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate/perform exercises ● Patient performed exercises correctly and consistently as instructed ● Patient’s circulation is improved and without postoperative thrombophlebitis ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Frequency of exercises as done by patient (as required). Family participation and any teaching that was done (as required). ● Any problems patient has with understanding or performing the exercises. ●

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C H A P T E R

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14 Blood Transfusion Therapy 14.1 Transfusing Blood Products, 320 14.2 Assisting with Autotransfusion, 324

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320 C h a p t e r 1 4 Blood Transfusion Therapy

PROCEDURE 14.1 Transfusing Blood Products OVERVIEW ●

To safely transfuse whole blood, packed erythrocytes (RBCs), platelets, fresh frozen plasma so that special deficiencies such as anemia and bleeding disorders can be corrected. P R E PA R AT I O N

An informed consent must be obtained before transfusing blood. Baseline vital signs must be obtained. ● The nurse should remain with patient during the first 15 minutes of blood transfusion to assess for adverse reaction. ● Blood must be verified by two nurses or a nurse and a physician prior to transfusion. ● Medications should never be administered via blood transfusion tubing. A separate IV site should be used to administer medications. ● Monitor for fluid overload and transfusion reactions. ● No more than two units of blood should be administered via one blood administration set and/or filter—see protocol. ● Stop transfusion if reaction occurs—change tubing and keep IV patent with 0.9% sodium chloride. ● Return blood container and tubing to blood bank if reaction occurs. ● Obtain first voided urine specimen after a transfusion reaction and send to lab. ● ●

Special Considerations Elderly Patient • Infuse blood at a slower rate for better tolerance and prevention of complications (i.e., circulatory overload, pulmonary edema, and congestive heart failure). Pediatric, Confused, Comatose, and Mentally Challenged Patients • Monitor closely and often for adverse reactions since they often cannot communicate effectively if problems occur. Home Health Patient • The registered nurse should stay with the patient throughout the entire process of blood transfusion and 1–2 hours post-transfusion to monitor for adverse reactions. An additional RN would be indi-

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P r o c e d u r e 1 4 . 1 Transfusing Blood Products 321

cated for this procedure to check blood and patient information prior to administration. Cultural Considerations • Some religious groups do not receive blood transfusions and blood products, (e.g., Jehovah’s Witness). R E L E VA N T N U R S I N G D I A G N O S E S

Fluid volume deficit related to hemorrhage from trauma, GI bleeding, and/or surgery ● Fluid volume excess related to rapid infusion of blood ● At risk for decreased cardiac output related to circulatory overload and/or transfusion reaction ●

EXPECTED OUTCOMES

Transfusion will be completed for time frame ordered and no longer than 4 hours ● Symptoms of an allergic reaction to blood will be recognized early and prompt intervention initiated ● Improvement in serum hemoglobin and hematocrit will be noted following transfusion ●

EQUIPMENT/SUPPLIES

Blood unit or other blood product Bag of 0.9% sodium chloride IV solution Y-set blood tubing with filter Antimicrobial swabs Clean gloves Infusion pump, if needed Blood warmer, if needed Protective clothing, if needed I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure and how patient can

assist. Decreases anxiety; meets patient’s right to be informed; encourages cooperation and participation. ➧ Obtain informed consent. An informed consent is an INS standard—the patient should be aware of what is involved in the procedure and his or her role in the procedure and should be made aware of symptoms indicating a reaction to the transfusion.

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322 C h a p t e r 1 4 Blood Transfusion Therapy ➧ Establish that patient has a patent large-bore IV catheter. Blood should be transfused via a minimum of a 20-gauge IV catheter to provide adequate flow rate and prevent lysis of RBCs. ➧ Prime blood administration tubing with 0.9 % sodium chloride

solution. IV solutions other than 0.9 % sodium chloride may result in damage to RBCs or precipitate clots. ➧ Obtain blood from agency blood bank. Blood should remain at properly stored temperature until time of transfusion. Blood should be returned to blood bank if the unit will not be given within 20–30 minutes—see protocol of agency. ➧ Wash hands. Reduces transmission of infectious microorganisms. ➧ Verify the following information with another nurse or a physician:

Patient’s name and identification number. Blood component blood type and Rh factor. ● Crossmatching numbers. ● Expiration date of blood. ● ●

Any blood product must be verified as to correct blood component, correct type, expiration date, and correct patient to receive this blood. ➧ Obtain vital signs—temperature, pulse, respiration, blood pressure

and record on transfusion flow form. Provides baseline of vital parameters. ➧ Spike the blood container on the blood administration tubing Y

opposite of the 0.9% sodium chloride solution container, pushing tip of tubing straight up into the blood bag entry port—make sure the “Y” leading to the sodium chloride solution is turned OFF prior to spiking the blood bag. Spiking the blood container in a straight motion prevents puncture to blood bag. Priming the blood set is an INS standard—see fourth item of this procedure. ➧ Prime the blood administration tubing with blood and then initiate

transfusion at 5 mL/min. for the first 15 minutes of the transfusion. Blood transfusion reactions are more common during the first 15 minutes of the transfusion thus the transfusion rate is slower initially. ➧ Monitor and record the temperature, pulse, respiration, and blood

pressure at 5-minute intervals for the first 15 minutes of transfusion. Diligent monitoring of the patient during blood transfusion is necessary to ascertain adverse effects of the transfusion and institute early intervention.

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P r o c e d u r e 1 4 . 1 Transfusing Blood Products 323 The patient is more susceptible to an adverse reaction within the first 15 minutes of transfusion. ➧ Monitor patient for any signs or symptoms of an adverse reaction to

the transfusion (itching, hives, rash, urticaria, pain in lumbar-sacral region, chest pain, or decreased blood pressure, increased pulse or respiratory distress) at 5-minute intervals and record on transfusion flow form. Diligent monitoring of the patient during blood transfusion is necessary to ascertain adverse effects of the transfusion and institute early intervention. ➧ If a reaction occurs, stop the transfusion, notify physician, and

change IV tubing and keep vein open with 0.9% sodium chloride solution. ➧ Prepare to administer medications, return blood and tubing to blood bank, and obtain blood and urine specimens. Continuing the transfusion may result in more severe reaction. An IV access must be maintained in the event that patient requires IV medication—not changing tubing will result in furthering transfusion reaction. Treat reaction and identify type of reaction. ➧ After the initial 15 minutes of transfusion, as long as there are no

signs of transfusion reaction, the rate of flow can be increased to complete the transfusion during the time indicated by the physician or agency policy. Rate of infusion is based on the blood volume, hemodynamic and cardiac status of the patient. The total transfusion must not exceed 4 hours (this includes the initial 15 minutes transfusion). ➧ The T, P, R, and BP and clinical status of the patient should continue

to be assessed and recorded every 15 minutes for the first hour and then every 30 minutes until completion of the transfusion. A transfusion reaction may occur at any time during the transfusion. ➧ At completion of the blood transfusion, turn off flow control on

“Y” section leading to blood bag and open the flow control to the 0.9% sodium chloride solution. Flush the blood administration tubing until a light pink fluid is noted. Flushing blood tubing with sodium chloride solution ensures that patient receives all of blood. ➧ If no further blood is to be transfused, change tubing or cap IV line

with prn adaptor. IV site can be maintained for further use. Blood tubing should be utilized only for transfusion of blood.

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324 C h a p t e r 1 4 Blood Transfusion Therapy ➧ Dispose of blood container and tubing according to agency protocol. Blood container should be returned to blood bank if transfusion reaction occurs, otherwise can be discarded in contaminated waste (check protocol of agency). ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms. ➧ Reposition patient as needed. Promotes patient comfort. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood was transfused correctly Patient did not experience any adverse reactions ● Patient’s blood count has improved ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Notification of adverse reactions, if occurred, and report to physician and orders indicated ● Date and time of completion of transfusion

PROCEDURE 14.2 Assisting with Autotransfusion OVERVIEW ● ●

To collect, filter, and reinfuse the patient’s own blood. Indications for autologous transfusion include: • Elective surgery (blood donated by the recipient over time). Patient works with hospital or outpatient blood bank facility to donate blood as needed and follows that facility’s established protocol and will receive his own blood when indicated. • Nonelective surgery (blood drawn immediately before surgery). • Perioperative and emergency blood salvage during and after thoracic, cardiovascular, hip, or knee surgery. • Perioperative and emergency blood salvage for traumatic injury to major organs (i.e., lungs, liver, heart, and major blood vessels).

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P r o c e d u r e 1 4 . 2 Assisting with Autotransfusion 325 P R E PA R AT I O N

Autologous blood transfusion eliminates allergic reactions and eliminates the risk of exposure to blood-borne infectious agents. ● This type of transfusion provides more viable RBCs and has increased oxygen-carrying capacity than banked blood. ● Approval from the recipient’s physician/prescriber as well as the medical administrator of the blood bank is needed prior to autologous blood collection. ● Medications should never be administered via blood reinfusion tubing. A separate IV site should be used to administer. ● Each unit of blood should be administered with one blood administration set that is discarded when finished. ● Before reinfusion, identify the patient and make sure that the collection bag is clearly labeled with name, ID number, and an autologous blood label. ● Check patient’s appropriate lab data before reinfusion and compare to beginning baseline—that is, coagulation profile, hemoglobin, hematocrit, and so on. ●

Special Considerations • Contraindicated in patients: • Taking antibiotics. • When blood becomes contaminated by bowel contents. • When the hemoglobin is less than 11g/dL. • With a bacterial infection. • With unstable vital signs. • With unstable angina, severe aortic stenosis, and/or severe coronary artery disease. • With recent weight loss due to illness or malnutrition. Cultural Considerations • This type of transfusion provides and option for patients whose religious beliefs prohibit homologous transfusion. Elderly Patients • Infuse blood at a slower rate for better tolerance and prevention of complications (i.e., circulatory overload, pulmonary edema, and congestive heart failure). R E L E VA N T N U R S I N G D I A G N O S E S

Fluid volume deficit related to surgery Fluid volume excess related to rapid infusion ● Risk for decreased cardiac output related to circulatory overload ● ●

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326 C h a p t e r 1 4 Blood Transfusion Therapy EXPECTED OUTCOMES

Blood will be available when needed and the transfusion will be completed in a timely manner ● Symptoms of an allergic reaction to blood will not occur ● Improvement in serum hemoglobin and hematocrit will be noted following transfusion ●

EQUIPMENT/SUPPLIES

Autologous transfusion system, such as the Davol or Pleur-evac system ACD or CPD Collection bags Vacuum source regulator Suction tubing 18-gauge needle Blood administration set with in-line filter 500 mL of normal saline solution Optional: Hemovac and another autologous transfusion system I M P L E M E N TAT I O N

Perioperative Blood Donation ➧ Identify patient; explain purpose and procedure. If you know that the

patient will leave surgery with a drain to the autologous device, tell him this beforehand. Decreases anxiety; meets patient’s right to be informed; encourages cooperation and participation.

Perioperative Blood Donation Using a Davol System ➧ Open the transfusion unit onto the sterile field. The physician/

prescriber inserts the drain tube from the patient to the connecting tube of the unit. Follows protocol. ➧ The physician/prescriber injects 25 to 35 mL of ACD or CPD into the

injection port on top of the filter and wets the filter with anticoagulant. To prime tubing and keep the blood from clotting. ➧ Label the collection bag with the patient’s name and the time the

infusion was started. Ensures the reinfusion time is within standardized guidelines.

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P r o c e d u r e 1 4 . 2 Assisting with Autotransfusion 327 ➧ After the patient arrives on the nursing unit, note the amount of blood

in the bag on the appropriate document. Establishes and maintains an accurate record of blood collection. ➧ Attach the tube from the suction source to the port on the suction

control module and adjust to between 80 and 100 mm Hg on the wall regulator. Higher suction can cause problems, such as the collection bag to collapse, causing lysis of blood cells and unsafe to reinfuse. Lower than 80 mm Hg suction results in no blood collection. ➧ If less than 200 mL is collected in 4 hours, record on the appropriate

document, discard, and switch from the collection container to a closed-wound suction unit, such as a Hemovac. Because only 200 mL was collected within the 4-hour period, the proportion of anticoagulant (inserted in the operating room) to blood is too great to infuse. ➧ If 500 or more mL of blood is collected in the first 4 hours, connect a

new autologous transfusion unit to the patient, then reconnect to suction, monitor patient, and record. Enough blood is collected within 4 hours to reinfuse to the patient, if ordered by the doctor.

Blood Reinfusion ➧ Prime the blood filter with 500 mL of normal saline solution. Priming the blood set is an INS standard procedure. ➧ Twist the suction control module to remove it. It is not needed for blood reinfusion. ➧ Remove the hanger assembly from the collection bag; pull the clear

cap from the top of the bag and discard the cap and filter. Removing unnecessary equipment to prepare for reinfusion. ➧ Insert a spike adapter into the large port on top of the bottle. To prepare for reinfusion. ➧ Remove the protective seal to expose the filtered vent. To follow protocol. ➧ Attach the blood to the Y-connector of the blood filter; invert the

bag and hang it Ensures correct equipment is used to reinfuse blood. ➧ Obtain vital signs and document them. Establishes a baseline to compare to later. ➧ Begin the infusion, following your facility’s policy and procedure. This

will include that the T, P, R, and BP and clinical status of the patient

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328 C h a p t e r 1 4 Blood Transfusion Therapy

should continue to be assessed and recorded every 15 minutes for the first hour and then every 30 minutes until completion of the transfusion To compare to baseline vital signs and pre-infusion clinical status. ➧ Be sure to complete the infusion within 2 hours. At completion of

the blood transfusion, turn off flow control on “Y” section leading to blood bag and open the flow control to the 0.9% sodium chloride solution. Flush the blood administration tubing until a light pink fluid is noted. Follows standard time for blood reinfusion. Flushing blood tubing with sodium chloride solution ensures that patient receives all of blood. ➧ If no further blood is to be transfused, change tubing or cap IV line

with prn adaptor. IV site can be maintained for further use. Blood tubing should be utilized only for transfusion of blood. ➧ Dispose of blood container and tubing according to agency protocol. Blood container can be discarded in contaminated waste (check protocol of agency). ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms. ➧ Reposition patient as needed. Patient comfort. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Blood was reinfused correctly Patient did not experience any adverse reactions ● Patient’s blood count has improved ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Baseline vital signs prior to initiating reinfusion. Informed consent was obtained. ● Date and time of initiating blood reinfusion and time completed. ● Any adverse reactions experienced by the patient, notification to physician/prescriber, and actions taken. ●

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U N I T

C H A P T E R

Nutritional and Digestive

15 Oral and Enteric Nutrition 15.1 Administering Nasogastric, Nasoenteric, and Enteric Tube Feedings, 330 15.2 Administering Medications Through a Feeding Tube, 335

6

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330 C h a p t e r 1 5 Oral and Enteric Nutrition

PROCEDURE 15.1 Administering Nasogastric, Nasoenteric, and Enteric Tube Feedings OVERVIEW

To provide an alternative route for the administration of liquid nutrients to the patient who cannot take anything by mouth and has a nasogastric, nasoenteric, or gastrostomy (PEG) tube in place. ● To restore and/or maintain the patient’s nutritional status. ●

P R E PA R AT I O N

Assess for nasogastric or gastric tube placement (see Chapter 17). If the equipment, such as the catheter tip syringe, is to be reused, clean it thoroughly after each use. ● Do not allow feeding formula to hang more than 8 hours, and change reservoir bag and administration set with addition of feeding according to protocol. ● Gastrostomy or PEG tube site care and dressings should be done at least once per shift or as needed if soiled and according to facility protocol. ● Assess the site for signs of tube migration, dislodgment, infection, or skin breakdown at least every 8 hours, prn, and according to facility protocol. ● Follow prescriber and facility protocol related the use of blue tinting of the formula for detection of aspiration. ● Review appropriate blood work that may be critical for optimum nutritional replacement and management (i.e., complete blood count [CBC] and renal function studies). ● ●

Special Considerations • Monitor patient often for coughing, movement, or attempts to remove the nasogastric (NG) tube, which can cause tracheobronchial aspiration during enteral feedings. • If the patient is on a pump, monitor often and do not exceed 40 psi because excessive pressure can cause the tubing to rupture. • In patients with endotracheal or tracheostomy tubes, check cuff inflation. If deflated, inflate and maintain at least 30 to 60 minutes after feeding to prevent aspiration. Elderly Patient • Check level of consciousness. • Check for aspiration.

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P r o c e d u r e 1 5 . 1 Administering Nasogastric, Nasoenteric, & Enteric 331

• Place in Fowler’s position (30–45 degrees) before and after feeding, to prevent aspiration. Pediatric Patient • Make sure children are in high Fowler’s or upright position during and after feeding to prevent aspiration. • Hold and rock the infants and children if possible during the feeding. • Give a pacifier to an infant during the feeding to meet developmental needs. • Burp or bubble infants at intervals during the feeding and after. • Position an infant in a prone or side-lying position for at least an hour following the feeding to prevent aspiration. R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to anorexia, failure to thrive, or surgery ● Ineffective infant feeding pattern related to premature birth and underdevelopment of major body systems ● Self-care deficit related to dysphagia and impaired physical mobility ● Risk for aspiration related to impaired swallowing ●

EXPECTED OUTCOMES

Tube feeding is administered safely Desired fluid volume achieved without signs of fluid volume excess or deficit ● Patient’s pre- and post-therapy nutrition status (e.g., blood urea nitrogen [BUN], creatinine, serum albumin, and blood sugar) is within normal range ● ●

EQUIPMENT/SUPPLIES

Prescribed amount of nutrition formula/product Graduated container for measuring the feeding Irrigating syringe (60 mL) with catheter tip for bolus feeding or calibrated plastic feeding bag with tubing Feeding pump if required Calibrated container of water for flushing Water for diluting and flushing Clean gloves Alcohol swabs

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332 C h a p t e r 1 5 Oral and Enteric Nutrition I M P L E M E N TAT I O N ➧ Check the expiration date, and swab unopened formula container

top with alcohol. Reduces transmission of microorganisms. ➧ Date and refrigerate opened formula can. Discard unused formula after 24 hours and change formula delivery syringe daily to reduce the transmission of microorganisms. ➧ Warm refrigerated formula to room temperature. Excessively cold feedings may cause cramping. ➧ Prepare the patient for the feeding. This process of feeding should not cause discomfort, but the patient may have a sensation of fullness. ➧ Don nonsterile gloves. Reduces transmission of microorganisms. ➧ Elevate the head of the bed to a Fowler’s position in bed or a sitting

position in a chair. These positions facilitate gravitational flow of the feeding and prevent aspiration of feeding in the lungs. ➧ Assess patient’s abdomen, and verify the presence of bowel

sounds. Absence of bowel sounds indicates lack of peristalsis; gastric feeding should not be given in the case. ➧ Check tube placement by two methods: aspiration of gastric con-

tents, checking pH of gastric contents, air insufflation with 20 to 30 mL of air, or radiographic confirmation. Gastric contents may vary from clear to yellow or green. Medical diagnosis may also affect color. Usually pH of 0 to 4 ensures that tube is correctly placed in the stomach. Air insufflation while auscultating over the epigastrium assists in determining proper placement. NOTE: Radiographic determination of placement is most accurate but is costly and may not be feasible in all situations. ➧ If the feeding is being given through a gastrostomy tube, assess the

migration or change of length of the exposed tube, which is usually 1/2 inch. Changes in the length of the exposed tube may indicate tube displacement.

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P r o c e d u r e 1 5 . 1 Administering Nasogastric, Nasoenteric, & Enteric 333 ➧ Aspirate and measure gastric contents to determine residual

volume. If residual volume is greater than half the volume previously delivered or greater than 100 mL, hold feeding and recheck in 1 hour. ➧ Return aspirated contents to stomach. Secretions contain electrolytes that, if removed, may cause an electrolyte imbalance. ➧ For continuous tube feed-

ings, connect administration tubing to formula bag, thread tubing through pump per manufacturer’s instructions, connect the feeding tube to the nasoenteric tube or the jejunostomy tube, and start feeding at a slow, constant infusion rate (25 to 50 mL/hr). Priming the tube according to manufacturer’s instructions prevents administration difficulties, and incremental increases in rate may be better tolerated (maximum rate is usually 100 to 150 mL/hr).

FIGURE 15.1A Continuous

tube feeding administered by enteral pump. ➧ For intermittent tube feedings, remove the plunger from the

syringe and connect the empty syringe barrel to a pinched or clamped NG tube. Pinching or clamping the NG tube prevents excess air from entering the stomach. ➧ Holding the syringe no higher than 18 inches above the patient’s

stomach, administer 30 mL of water to flush the tubing; clamp tubing by folding before syringe empties. Prevents administering air into the patient’s stomach.

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334 C h a p t e r 1 5 Oral and Enteric Nutrition ➧ Pour feeding into the syringe

barrel and allow to flow slowly by gravity over 15 minutes. Rapid or forced delivery of feeding increases the risk for cramping, nausea, or vomiting.

FIGURE 15.1B Intermittent feeding

by gravity. ➧ Clamp tubing before the syringe empties, and continuously fill

syringe before it completely empties. If the syringe empties and fills with air, the additional formula will move this air into the patient’s stomach and increase the risk for vomiting. ➧ Flush the tubing with 30 mL of water following the intermittent

feeding or every 4 hours during a continuous feeding. Prevents the tube from clogging. ➧ Clamp the feeding tube before all the water is instilled. Clamping prevents leakage and air from entering the tube. ➧ Keep the head of the bed elevated for 2 hours following intermittent

feeding or at all times during a continuous feeding. This position facilitates digestion and movement of the feeding from the stomach along the alimentary tract and prevents potential aspiration of the feeding into the lungs.

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P r o c e d u r e 1 5 . 2 Administering Medications Through a Feeding 335 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate the patient’s tolerance of the feeding such as regurgitation, abdominal distention, or feelings of fullness, gagging, coughing, or verbal expressions of gastric discomfort ● Evaluate weight gain or loss daily ● Evaluate fecal elimination changes such as diarrhea, flatulence, or constipation ● Evaluate post-therapy nutrition status (e.g., BUN, creatinine, serum albumin, and blood sugar) to determine it is within normal range ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● The

date, time, type, rate, and amount of feeding administered and the next scheduled feeding. ● Quantity and character of the residual volumes obtained. ● Abdominal assessment findings. ● Type of infusion pump if applicable. ● Patient’s elevated position post bolus feeding or patient’s continuous elevated positioning for continuous feeding. ● Patient’s response to feeding and tolerance. ● Assessment characteristics of tube insertion site. ● Type and frequency of tube site dressing changes, if appropriate. ● Type and frequency of oral hygiene provided. ● The patient’s residual volumes prior to feedings. ● Any changes in the insertion site. ● Any obstructive issues occurring during the administration. ● Any signs of aspiration. ● Record intake and output as indicated.

PROCEDURE 15.2 Administering Medications Through a Feeding Tube OVERVIEW ●

To provide an alternative route for administration of medications to the patient who cannot take anything by mouth and has a nasogastric, nasoenteric, or gastrostomy tube in place.

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336 C h a p t e r 1 5 Oral and Enteric Nutrition P R E PA R AT I O N

Check prescriber’s order to verify medication orders. Use the five “rights” of drug administration. ● Check with the pharmacist to see if the patient’s medication comes in a liquid form, because these are less likely to cause tube obstruction. ● Determine if the nasogastric tube or gastric tube is in place (see Chapter 17). ● ●

Special Considerations Elderly Patient • Check level of consciousness. • Check for aspiration. • Place in Fowler’s position (30 to 45 degrees) before and after feeding to prevent aspiration. Pediatric Patient • Because of the small size of the feeding tube, use only medications that come in a liquid preparation to prevent occlusion. • Be sure children are in a high Fowler’s or upright position to prevent aspiration during administration. • Position an infant in a prone or side-lying position for 30 minutes to 1 hour following medication administration. R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to anorexia and/or failure to thrive ● Self-care deficit related to impaired swallowing and physical mobility ● Ineffective infant feeding pattern related to premature birth and underdeveloped sucking reflex ●

EXPECTED OUTCOMES

Medications will be administered safely and on time according to physician’s order ● Desired effects from the medication (e.g., relief or pain or decrease in body temperature) will occur ● The feeding tube will remain patent ●

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P r o c e d u r e 1 5 . 2 Administering Medications Through a Feeding 337 EQUIPMENT/SUPPLIES

Medication prepared and ready for insertion through the feeding tube according to physician’s orders Water for diluting and flushing the feeding tube 60-mL catheter-tip syringe Clean gloves I M P L E M E N TAT I O N ➧ Review prescriber’s orders. Determine medications and route to be administered to patient. ➧ Gather all equipment before administering the medications. Saves time and allows efficiency in the medication administration. ➧ Stop the tube feeding if medication is to be given on an empty

stomach. Some medications are not absorbed if taken with food or other medications. ➧ Prepare each medication separately. Maintains discrete identity of each medication. If, for some reason, a medication must be withheld, it can be easily identified. ➧ Check to determine if medications can be crushed. Enteric-coated, sustained-action, buccal, and sublingual medications should never be crushed, as doing so alters the absorbability of the medication or yields a toxic dose of the medication. ➧ Dilute crushed tablet or powder from a capsule in 30-mL warm

water. Facilitates easier flow of medications through the tube, and cold water may cause patient discomfort. ➧ Don nonsterile gloves. Reduces transmission of microorganisms. ➧ Always check and confirm NG tube placement before administering

the medications. Tube must be placed in the correct position to avoid aspiration. ➧ Check residual volume, return residual, and flush NG tube. Validates gastric capacity for receiving medications and flush solution. ➧ Flush the tube with 15 to 30 mL of water before administering med-

ications. Determines tube patency and reduces the risk for obstructing the feeding tube.

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338 C h a p t e r 1 5 Oral and Enteric Nutrition ➧ Disconnect NG tube from the feeding tube, maintaining asepsis of

the connecting adapter. Reduces transmission of infectious organisms. ➧ If several medications are being given, administer each one

separately using gravity. Allows identification of each medication given. ➧ Flush tube with 15 to 30 mL water after each medication. Reduces risk for tube obstruction. ➧ Restart tube feeding. Continues nutrition feeding. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Note if patient gags or coughs Patient verbalizes no gastric discomfort ● Patient will exhibit desired effects from the medication ● The NG tube remains patent ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Date, time, medication, dosage, and route of administration for each medication given. ● Documentation of the patient’s pre-administration and postadministration assessment data for medication administration. ● Reason for patient’s refusal or nurse’s decision not to administer medication. ● Any difficulty with the administration of medications through the feeding tube. ● Any PRN medications received and the evaluation of their effectiveness.

C H A P T E R

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16 Parenteral Nutrition 16.1 Administering Total Parenteral Nutrition (TPN), 340 16.2 Administering Peripheral Partial Nutrition, 343 16.3 Administering a Fat Emulsion (Lipids), 346

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340 C h a p t e r 1 6 Parenteral Nutrition

PROCEDURE 16.1 Administering Total Parenteral Nutrition (TPN) OVERVIEW

To provide a nutrition source for patients who are unable to process nutrients normally; nutrients for patients requiring bypass of the gastrointestinal tract; and increased calories for patients in a catabolic state. ● To prevent or correct a deficiency of essential fatty acids. ●

P R E PA R AT I O N

Determine patient’s ability to understand purpose of TPN therapy. Assess patient’s nutrition status. ● Assess nutrition needs of patients who are unable to process nutrients normally (gastrointestinally). ● Check prescriber’s orders for correct additives in each hyperalimentation bottle, bag, or other type of container. ● Check rate of infusion according to prescriber’s orders, and monitor closely. ● Check facility policy and procedure. Many require tubing and filter change with every bottle/bag. ● Monitor patient’s blood glucose level regularly. ● Keep family informed of therapy procedure, possible complications, and patient tolerance if patient has difficulty understanding information. ● Store TPN solution in the refrigerator until 30 minutes before use. (Some pharmacies deliver the solution before each infusion. Make sure TPN was mixed within 24 hours of infusion.) ● ●

Special Considerations Elderly and Pediatric Patients • Monitor elderly patients and children closely for signs of overload and hyperglycemia, and notify prescriber. R E L E VA N T N U R S I N G D I A G N O S E S ●

Altered nutrition: less than body requirements related to nausea, vomiting, anorexia, and/or surgery

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P r o c e d u r e 1 6 . 1 Administering Total Parenteral Nutrition (TPN) 341 EXPECTED OUTCOMES

TPN is infused at prescribed flow rate and tolerated by patient Dressing at catheter insertion site remains dry and intact ● Catheter insertion site remains free of infection and inflammation ● Patient receives nutrients necessary for tissue repair ● Patient’s blood glucose level is maintained within normal parameters ● ●

EQUIPMENT/SUPPLIES

Hyperalimentation solution (TPN) (refrigerated) Clean gloves (optional) Intravenous tubing, filter, and infusion pump Extension tubing Blood glucose testing monitor (e.g., Accucheck) Intake and output (I & O) record I M P L E M E N TAT I O N ➧ Identify patient; explain procedure and its purpose. Meets patient’s right to be informed, and encourages cooperation. ➧ Gather equipment, and place at bedside. Enhances organization and provides optimal lighting environment. ➧ Wash hands, and don clean gloves Reduces transmission of infectious microorganisms. ➧ Position in bed in supine position. Provides patient comfort. ➧ Obtain TPN bag after allowing it to warm to room temperature. Solution is refrigerated to prevent growth of organisms, but should be left at room temperature for 30 minutes to 1 hour before use. ➧ Check the bag for leaks, cloudiness, or floating particles. Do not use

if any of these are present. Reduces chances of adverse events and contamination. ➧ Check bag for patient’s name, correct bag number, expiration date,

and any additives. Compare with original order. Ensures that correct infusion is administered.

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342 C h a p t e r 1 6 Parenteral Nutrition ➧ Connect IV tubing and filter to TPN solution container. Ensure tubing and container are properly connected; changing filter and tubing every 24 hours or with each bottle/bag prevents growth of microorganisms that can cause infection. ➧ Prime IV tubing to clear air. Prevents air from entering patient’s bloodstream, which will cause air embolism. ➧ Place IV tubing through infusion pump. Set pump to correct rate. Infusion pump controls rate and prevents complications associated with too-rapid infusion. ➧ Using sterile technique, connect IV tubing to lumen of

central catheter. Make sure the lumen is dedicated to TPN administration. Reduces risk from contamination and line sepsis. ➧ After TPN and tubing are changed and infusion pump is started

at prescribed rate, remove gloves and discard, then wash hands. Ensures solution has begun without complications; prevents transmission of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance Assess vital signs; notify prescriber if temperature is elevated ● Assess blood glucose every 6 hours. Administer regular insulin according to sliding scale, if indicated ● Monitor serum electrolytes for potential imbalances ● Monitor and maintain an accurate intake and output record ● Weigh patient daily or at least three times per week to assess for fluid overload ● Assess for TPN therapy complications—that is, air embolus, hyperglycemia, osmotic diuresis, infiltration, or sepsis ● Change filter daily ● Change TPN tubing and needleless access cap every 24 hours for TPN with lipids and every 48 hours for TPN without lipids. Check facility policy ● Monitor and change dressing using sterile technique at IV (central line) catheter insertion site every 72 hours ● ●

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P r o c e d u r e 1 6 . 2 Administering Peripheral Partial Nutrition 343

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Record date and time of TPN bottle/bag hung, flow rate, and tubing change.A special TPN form may be used for documentation for this procedure. ● Results of finger-stick blood glucose checks. ● If insulin is required, type, amount, and site administered. ● Condition of catheter (central line) insertion site; status of dressing and if changed. ● Patient’s weight. ● I & O. ● Any problems the patient has with TPN therapy.

PROCEDURE 16.2 Administering Peripheral Partial Nutrition OVERVIEW

To provide a nutrition source for patients who are unable to process nutrients normally, such as patients requiring bypass of the gastrointestinal tract. ● Provides increased calories for patients in a catabolic state. ● These solutions/medications will often include: potassium or magnesium supplements and amino acids. ● To prevent or correct a deficiency of essential electrolytes. ●

P R E PA R AT I O N

Determine patient’s ability to understand the purpose of peripheral partial nutrition therapy. ● Assess patient’s current diet (nothing by mouth [NPO] or diet type, percutaneous endoscopic gastrostomy [PEG], or feeding tube). ● Assess nutrition needs of patient related to electrolyte imbalance or amino acid deficiency. ● Check prescriber’s orders for correct additives for each bottle or bag. ● Check rate of infusion according to physician’s orders, and monitor closely. ● Monitor patient’s electrolyte, blood glucose, and amino acid blood values. ●

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344 C h a p t e r 1 6 Parenteral Nutrition ●

Keep family informed of therapy procedure, possible complications, and patient’s tolerance of IV solution.

Special Considerations Elderly and Pediatric Patients • Monitor closely for signs of circulatory overload and hyperglycemia. Notify prescriber as needed. R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements related to nausea, vomiting, anorexia, and/or surgery ● Risk for decreased cardiac output related to circulatory overload ● Risk for electrolyte imbalance related to intolerance of IV solution mixture ●

EXPECTED OUTCOMES

Peripheral partial nutrition therapy is infused at prescribed flow rate and tolerated by patient ● IV site remains dry, intact, and free of infection and inflammation ● Patient’s electrolytes are maintained within normal parameters ●

EQUIPMENT/SUPPLIES

Solution and/or medication to be administered IV (may be refrigerated or not, depending upon the solution/medication) Clean gloves (optional) IV tubing, filter (if indicated), and infusion pump Extension tubing I & O record I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, and procedure. Prevents administration error. Meets patient’s right to be informed and encourages cooperation. ➧ Gather equipment and place at bedside. Enhances organization and provides optimal lighting environment. ➧ Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms.

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P r o c e d u r e 1 6 . 2 Administering Peripheral Partial Nutrition 345 ➧ Position in bed in supine position or sitting up in a chair at the bed-

side, depending on patient’s activity status. Patient comfort. ➧ Obtain the prescribed IV solution/medication. Allow bag to warm

to room temperature by removing it from the refrigerator approximately 30 minutes before use. Solution is refrigerated to prevent growth of organisms, but should be left at room temperature for 30 minutes to 1 hour prior to use. ➧ Connect IV tubing and solution container. Check facility policy and

procedure manual for frequency of changing tubing. Ensures that tubing and container are properly connected; ensures adherence to policy and procedure of changing tubing. ➧ Prime IV tubing to clear air. Prevents air entering patient’s blood stream and causing an air embolism. ➧ Place IV tubing through infusion pump and connect to primary

IV line. Controls rate of infusion and prevents fluid overload from too-rapid administration. ➧ Remove gloves and discard, then wash hands. Ensures solution has begun without complications; prevents transmission of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance Monitor appropriate blood studies—that is, electrolytes and amino acids ● Monitor and maintain an accurate intake and record ● Assess IV for complications (air embolus, infiltration) ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Record date and time that solution is hung and flow rate. Results of appropriate blood studies—that is, electrolytes. ● Condition of IV site; status of dressing, and if changed. ● Patient’s tolerance of procedure and any problems that occurred. ● Patient’s most recent body weight. ● I & O. ●

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346 C h a p t e r 1 6 Parenteral Nutrition

PROCEDURE 16.3 Administering a Fat Emulsion (Lipids) OVERVIEW

To spare protein in the critically ill patient. To provide a contamination-free mode of delivering lipids. ● To prevent or correct a deficiency of essential fatty acids. ● To provide a source of energy for patients with deficient protein intake. ● ●

P R E PA R AT I O N

Determine patient’s ability to understand purpose of receiving lipids. Assess patient for signs of essential fatty acid deficits; rash; eczema; dry, scaly skin; poor wound healing; and sparse hair. ● Assess patient for predisposing factors that could promote fat emboli, such as anemia, coagulation disorders, abnormal liver, pancreatic, or respiratory function. ● Check IV site of vascular access device for patency, erythema, and edema before infusing solution. ● Check rate of infusion according to prescriber’s orders, and monitor closely. ● Take patient’s vital signs to establish baseline. ● Keep family informed of therapy procedure, possible complications, and any problems related to patient understanding the procedure. ● ●

Special Considerations Elderly and Pediatric Patients • Monitor closely for adverse reactions, and notify prescriber as needed. R E L E VA N T N U R S I N G D I A G N O S E S ●

Altered nutrition: less than body requirements related to a deficiency in protein and essential fatty acid intake EXPECTED OUTCOMES

Lipids are infused at the prescribed flow rate and tolerated by patient Dressing at the IV or vascular access catheter insertion site remains dry and intact ● IV site remains free of infection and inflammation ● Adequate calories, protein, and essential fatty acids are provided to patients who are unable to ingest them ● ●

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P r o c e d u r e 1 6 . 3 Administering a Fat Emulsion (Lipids) 347 EQUIPMENT/SUPPLIES

IV fat solution (lipids) (not refrigerated) Special IV tubing infusion set for lipids (to prevent pooling of fat in IV tubing) and infusion pump Needleless cannula Iodophor sponges Alcohol swabs Clean gloves (optional) I M P L E M E N TAT I O N ➧ Review prescriber’s orders; identify patient; explain purpose and pro-

cedure. Confirms that lipids have been ordered; meets patient’s right to be informed and encourages cooperation. ➧ Gather equipment and place at bedside; adjust lighting as needed. Enhances organization and provides optimal lighting environment. ➧ Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms. ➧ Position in bed in supine position. Patient comfort. ➧ Make sure lipids are room temperature. Prevents discomfort when infusing. ➧ Examine bottle for separation of emulsion into layers or fat globules

or for accumulation of froth. Prevents infusion of lipids that are contaminated. ➧ Label bottle with patient’s name, room number, date, time, flow rate,

and start and stop times. Ensures proper identification. ➧ Take vital signs for baseline assessment. Baseline vital signs are needed because an immediate reaction to the lipid solution can occur. ➧ Swab stopper on IV bottle with iodophor sponge or alcohol swab

and allow to dry. Cleans stopper and prepares for spiking bottle. ➧ Connect special IV tubing to bottle, twisting the spike to prevent

particles from the stopper falling into the lipids. New tubing is

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348 C h a p t e r 1 6 Parenteral Nutrition

changed with each bottle. Because lipid particles are large, a filter is not used with infusion. Ensures that tubing and container are properly connected; changing tubing with each bottle prevents growth of microorganisms that can cause infection. ➧ Hang IV bottle at least 30 inches above IV site. Because of the solution viscosity, lipids need to be at a height to prevent backing up into infusion tubing. ➧ Fill drip chamber two-thirds full, gradually open clamp on the tub-

ing, and prime the tubing slowly. Reduces the chance of air bubble formation in the solution by priming the tubing slowly, and removes air in the tubing, preventing air from entering the patient. ➧ Attach the primed tubing to the IV site. Allows the start of infusion. ➧ If piggybacking lipids into hyperalimentation (TPN), use the port

closest to the patient, below tubing filter. Lipids are compatible with TPN and can be piggybacked into the same tubing as long as it is below the filter because the particles are large and will not go through a filter. ➧ Ideally, infuse lipids slowly at first; 1.0 mL/minute for adults and

0.1 mL/minute for children. Allows time to see if the body is going to have an adverse reaction to the solution. ➧ Monitor vital signs every 10 minutes for the first 30 minutes and

observe for side effects, such as chills, fever, flushing, dyspnea, nausea/vomiting, and allergic reaction. If any of these occurs, stop the infusion, follow protocol, and notify the prescriber. Alerts nurse to patient tolerating or not tolerating the lipid solution and allows decisions concerning emergency measures. ➧ If no reactions occur, adjust to prescribed flow rate and continue to

monitor according to protocol. Patient is tolerating the solution without complications, and monitoring follows facility protocol for administering lipids. ➧ If ordered by prescriber, monitor serum lipids 4 hours after discontin-

uing the infusion. Incorrect blood values will result if a blood sample is drawn too soon after the infusion is discontinued.

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P r o c e d u r e 1 6 . 3 Administering a Fat Emulsion (Lipids) 349 ➧ Discard partially used bottles. Prevents contamination. ➧ Discard bottle and used IV administration set after each use in the

proper trash receptacle. Prevents transmission of infectious microorganisms. ➧ Remove gloves (if used), and wash hands before leaving the room. Prevents transmission of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and tolerance Assess nutrition status ● Monitor for adverse events and complications ● Monitor IV site for infiltration and inflammation ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Record date and time lipids were hung and flow rate. Results of post-infusion blood tests, if ordered. ● Condition of IV site; status of dressing and if changed. ● Patient’s tolerance of procedure and any problems encountered and reported. ● Most recent body weight, if ordered. ● I & O. ●

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C H A P T E R

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17 Gastrointestinal Intubation 17.1 Inserting a Nasogastric Tube, 352 17.2 Advancing a Nasoenteric Decompression Tube, 356

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352 C h a p t e r 1 7 Gastrointestinal Intubation

PROCEDURE 17.1 Inserting a Nasogastric Tube OVERVIEW

To remove stomach contents and/or decompress the bowel when peristalsis is absent or malfunctioning. ● To introduce fluids into the stomach to provide nutrition. ● Patients who require insertion of a nasogastric (NG) tube may: • Be unable to swallow or eat normally. • Be bleeding from the gastrointestinal (GI) tract. • Have ingested poison or other dangerous substances, requiring evacuation of stomach contents. ●

P R E PA R AT I O N

The right naris is usually larger and facilitates easier insertion. Assessment prior to insertion of an NG tube should include careful history of any nasal injuries or anatomy-related problems. ● Severe coughing or cyanosis during the procedure may mean that the tube has slid into the trachea. Remove at once, allow the patient time to recover, and attempt again. ● ●

Special Considerations Pediatric Patient • Often requires a smaller bore tube. • Parents should be allowed to comfort infants and children and participate in care. • May require restraints to prevent dislodging of the tube because they are too young to understand explanations of procedure. Elderly, Disoriented, or Confused Patient • May require restraints to prevent dislodging of the tube and may require more frequent monitoring for complications, such as aspiration, because they are unable to communicate problems with the tube. R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to nausea, vomiting, anorexia, and/or surgery ● Risk for fluid volume deficit related to vomiting and/or surgery ●

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P r o c e d u r e 1 7 . 1 Inserting a Nasogastric Tube 353 EXPECTED OUTCOMES

Nasogastric tube is placed atraumatically Tube is properly secured ● Proper placement is confirmed ● ●

EQUIPMENT/SUPPLIES

Correct size NG tube: Usually a #16 or #18 for adults and size varies with infants and children Feeding tubes may be smaller and may have a weighted end Nonsterile gloves Ice or water, if patient can swallow voluntarily Water-soluble lubricant Tape or device for securing tube Large syringe (catheter tip or needle tip, depending on type of tube) for aspirating stomach contents pH paper Towel Emesis basin I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient/family. Reduces anxiety. ➧ Place patient in semi-Fowler’s position with neck slightly flexed. Facilitates insertion of the tube into the esophagus. Flexion narrows upper airway slightly. ➧ Don nonsterile gloves. Reduces transmission of microorganisms.

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354 C h a p t e r 1 7 Gastrointestinal Intubation ➧ Estimate the required length

by holding the distal end at the end of the nose, curving toward the ear, and then to a point approximately one quarter to one half the distance between the lower end of the sternum and the umbilicus. Mark this point with a marker or tape. Proper length and diameter of the tube facilitates insertion of the nasogastric tube. FIGURE 17.1A Measuring tube

for placement. ➧ Determine patency of nares before choosing an acceptable naris. Facilitates identification of obstruction. ➧ Lubricate the tube. Facilitates advancing the tube, and decreases patient discomfort. ➧ Insert tube into the more

patent nostril, and advance with gentle pressure. Anatomic problems, such as deviated septum, can interfere with insertion.

FIGURE 17.1B

➧ Rotate the tube when resistance felt. Resistance as the tube is advanced can be overcome usually by changing the direction of the tip of the tube slightly.

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P r o c e d u r e 1 7 . 1 Inserting a Nasogastric Tube 355 ➧ Ask the patient to swallow sip of water, if able, and continue to

advance the tube until it reaches the marked point. Facilitates advancing the tube through the esophagus, avoiding advancing into the trachea. ➧ Secure the tube. Prevents displacement of tube.

FIGURE 17.1C Secure tube

with tape. ➧ Check tube placement by at least two of the following methods:

Aspiration of gastric contents. Checking pH of aspirate (usually pH of 0 to 4 ensures that tube is correctly placed in the stomach). ● Auscultate with insufflation of 20 to 30 mL of air. ● Radiographic confirmation. ● ●

Ensure that tube is in the stomach and not in trachea. NOTE: Radiographic determination of placement is most accurate but is costly and may not be feasible in all situations. ➧ Connect to suction or feeding, if required. Suction facilitates removal of gastric contents. An NG feeding tube allows introduction of nutrition into the stomach. ➧ Assess patient’s comfort status, and answer any questions. Reinforces nurse–patient relationship and allows patient time to voice concerns or problems.

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356 C h a p t e r 1 7 Gastrointestinal Intubation E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess characteristics of gastric drainage Assess respiratory status and comfort level ● Answer any questions from patient and/or family ● Determine effectiveness of connected equipment ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Assessment

findings before and after insertion of NG tube. Size of NG tube. ● Characteristics of drainage. ● Method for checking placement and findings. ● Patient’s tolerance of procedure. ● Time NG tube was inserted. ● Respiratory status. ●

PROCEDURE 17.2 Advancing a Nasoenteric Decompression Tube OVERVIEW

To remove fluids from the small intestine. To relieve abdominal distention. ● To allow the return of intestinal peristalsis. ● ●

P R E PA R AT I O N

A nasoenteric tube is inserted following the same steps used in nasogastric tube insertion. (Refer to Procedure 17.1 on Inserting a Nasogastric Tube for a detailed explanation.) ● Approximately 3 to 4 cm of additional tubing are inserted to allow adequate length for passage of the tube through the pylorus into the small intestine. ● Passage of the tube from the stomach through the pylorus may take up to 24 hours. ● Surgery may be required if this treatment is ineffective. ●

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P r o c e d u r e 1 7 . 2 Advancing a Nasoenteric Decompression Tube 357

Special Considerations Pediatric Patient • Parents should be allowed to comfort infants and children and participate in care. • Use age-appropriate explanations. • May require restraints to prevent dislodging of the tube. • May require adaptation of play activities to remain in proper position. Elderly, Disoriented, or Confused Patient • May require restraints to prevent dislodging of the tube and may require more frequent monitoring for complications, such as aspiration because they may be unable to communicate problems with the tube. R E L E VA N T N U R S I N G D I A G N O S E S

Altered nutrition: less than body requirements, related to nausea, vomiting, anorexia, and/or surgery ● Risk for trauma to intestinal mucosa related to migration of the advanced tube ●

EXPECTED OUTCOMES

Nasoenteric tube is placed and advanced atraumatically Tube is secured properly ● Proper placement is confirmed ● ●

EQUIPMENT/SUPPLIES

Tape or permanent pen Nonsterile gloves Large syringe for aspirating intestinal contents pH paper I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Mark the tube with tape or permanent pen at a point 3 to 4 cm

past the point of insertion of an NG tube. Allows adequate tubing to reach and move through the pylorus.

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358 C h a p t e r 1 7 Gastrointestinal Intubation ➧ Following insertion of the tube, place the patient on his or her

right side. Facilitates movement of the tube through the pylorus. ➧ Check the pH of the aspirate. pH of intestinal contents is 6 or above. ➧ Confirm tube placement by x-ray. Most accurate method for determining placement. ➧ Secure the tube once placement has been confirmed. Maintains proper placement. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess characteristics of gastric/intestinal drainage Assess respiratory and comfort level ● Note progress of the nasoenteric tube ● Answer any questions from patient and/or family ● Determine effectiveness of connected equipment ● ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

findings during the advancement of the tube. Characteristics of the drainage. ● Method for checking placement and findings. ● Progress of advancement. ● Patient’s tolerance of procedure. ● Respiratory status. ●

C H A P T E R

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18 Bowel Elimination 18.1 Administering an Enema, 360 18.2 Managing a Rectal Tube, 366 18.3 Managing Ostomy Care, 370

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360 C h a p t e r 1 8 Bowel Elimination

PROCEDURE 18.1 Administering an Enema OVERVIEW ● ●

To evacuate the bowel of stool caused by constipation. To cleanse the bowel prior to surgery or other procedures for which the bowel, colon, and rectum are visualized. P R E PA R AT I O N

● ●

Determine patient’s ability to understand procedure. Assess patient’s ability to participate in procedure, such as holding contents when administered.

Special Considerations • Patients who have had recent surgery, or who have arthritis, a cast, lower limb amputations, or fractured pelvis may need additional time for the procedure, owing to limited physical mobility. • Patients with cardiac history or spinal cord injury may be at risk for complications from vagal stimulation. Elderly and Physically and Mentally Challenged Patients • May need more time and instruction of the procedure for optimal participation and results. Pediatric Patient • Care should be taken in insertion of the enema tube and instillation of the solution to prevent injury to anus and colon during the procedure. • Parents should be allowed to comfort infants and children and participate in the procedure. R E L E VA N T N U R S I N G D I A G N O S E S

Constipation related to decreased peristalsis Chronic pain related to abdominal discomfort and distention from bowel malfunction ● Potential for injury related to abdominal distention and trauma to the anus and colon during the procedure ● ●

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P r o c e d u r e 1 8 . 1 Administering an Enema 361 EXPECTED OUTCOMES

Patient will return to an optimal bowel elimination pattern Patient is able to assist/participate ● Patient will be able to evacuate feces from rectum and colon after the enema ● Patient experiences minimal discomfort during procedure and no injury to the colon and/or anus ● Patient experiences relief and comfort after procedure ● ●

EQUIPMENT/SUPPLIES

Regular bedpan, fracture pan, or bedside commode Water-soluble lubricant Clean gloves Toilet paper Disposable, absorbent bed pads Skin care items (i.e., soap or skin cleanser, water, towels) IV pole Enema container with tubing, normal saline, tap water, soap solution, or commercially prepared enema. I M P L E M E N TAT I O N ➧ Check prescriber’s order; identify patient; explain purpose, pro-

cedure, and how patient can assist. Assess patient’s ability to participate. Confirms order; meets patient’s right to be informed; encourages cooperation and participation. ➧ Gather all equipment and place in an easy to access area in patient’s

room; adjust lighting as needed. Promotes organization of equipment; saves time; and adjusted lighting enhances visualization for procedure. ➧ Explain to the patient the benefits of relaxing and taking periodic

deep breaths. Reduces anxiety and promotes comfort. ➧ Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms, and prevents contact with urine and/or feces.

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362 C h a p t e r 1 8 Bowel Elimination ➧ After determining patient’s ability to assist, place disposable

waterproof pad under patient. Have patient lift hips or roll from side to side. Bed pad protects against soiling of linens. ➧ Place patient in a left side-lying position with knees flexed. To facilitate flow of solution using contour of the bowel. ➧ Place bedpan next to patient. For easy access in case patient cannot hold enema solution.

Enema Bag (For Cleansing Enemas Using Soap Suds, Tap Water, or Saline) ➧ Fill enema container with 750 mL to 1000 mL of warm solution

and check temperature by dripping some solution on inner wrist. If too warm, empty container and refill. Add soap solution if ordered. This amount of solution is the standard volume unless a specific amount is ordered by the physician. This amount is normally what is tolerated; solutions that are too hot or too cold can cause cramping, damage to the rectal mucosa, or extreme shock. ➧ Allow the solution to run through the tubing to clear out the air;

clamp tubing and hang on an IV pole approximately 12 to 18 inches above the patient’s buttocks. Aids in removing air from the tubing that could cause abdominal cramping if instilled into the colon during the procedure; 18 inches is considered a high height, and 12 inches is considered a low height. The higher the pole, the faster the solution will enter the colon. ➧ Lubricate tip of tubing with generous amount of water-soluble

lubricant. Facilitates easier insertion of tubing into the rectum. ➧ Spread the buttocks, and gently insert the tip of the tubing 3

to 4 inches while the patient is instructed to take slow deep breaths. 3 to 4 inches is the correct placement of tubing in the rectum to allow solution to enter the colon without leakage; slow, deep breaths aids in relaxation of the rectal sphincter.

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P r o c e d u r e 1 8 . 1 Administering an Enema 363

FIGURE 18.1A

➧ Open the regulating clamp and allow the solution to flow slowly. When the solution is instilled slowly, less cramping is experienced by the patient, and the patient will be able to tolerate more volume of the solution. ➧ Hold the tubing in place in the patient’s rectum at all times, and

keep the bedpan nearby. The tubing will slip out easily if not held in place; the patient may need to expel contents before expected. ➧ Lower the solution container or clamp tubing if the patient com-

plains of cramping, then resume after a few minutes. Lowering the container will slow down the flow of solution and aid in decreasing cramps. ➧ After solution is instill, clamp tubing and gently remove. Prevents siphoning out enema solution as tube is removed.

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364 C h a p t e r 1 8 Bowel Elimination ➧ Instruct the patient to hold the solution about 10 to 15 minutes or

longer as tolerated. The longer the solution is retained, the more effective the results. ➧ Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces. ➧ Instruct patients with cardiovascular disease not to strain when

expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest. ➧ Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms. ➧ Assist patient back to bed as needed and into a comfortable position. Patient comfort. ➧ Dispose of enema equipment and clean bedpan or bedside com-

mode as needed. Prevents transmission of infectious microorganisms. ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms.

Commercially Prepared Enema (Fleet’s, Oil, or Medicated) ➧ Prepare patient and environment as described in first section.

Lubricate tip of enema container as needed (most are prelubricated). Facilitates easier insertion into the rectum. ➧ Spread buttocks and insert

the tip into the rectum. Gently squeeze entire contents of the container. Aids in optimal results if all solution is instilled.

FIGURE 18.1B

➧ Remove the tip while continuing to squeeze the container. To prevent the solution from being siphoned back into the container.

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P r o c e d u r e 1 8 . 1 Administering an Enema 365 ➧ Instruct the patient to hold the solution at least 5 to 7 minutes. To ensure optimal results. ➧ Provide bedpan or assist to commode as needed. Aids in evacuation of solution and feces. ➧ Instruct patients with cardiovascular disease not to strain when

expelling contents. Avoids creating the Valsalva maneuver, which can lead to sudden cardiac arrest. ➧ Assist patient with personal hygiene as needed. Provides patient comfort, and reduces transmission of infectious microorganisms. ➧ Assist patient back to bed as needed and into a comfortable position. Patient comfort. ➧ Dispose of enema equipment, and clean bedpan or bedside com-

mode as needed. Prevents transmission of infectious microorganisms. ➧ Remove gloves and wash hands. Prevents transmission of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to tolerate procedure Administration of an enema is done correctly, safely, and successfully ● An optimal pattern of elimination is maintained or restored ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Record date, time, type, and results of enema administration, as well as amount and other important characteristics of stool (as required in the designated area on the patient record). ● Record patient’s tolerance of procedure and any complications that occurred. ● Report patient teaching about prevention of constipation, such as, adequate hydration and dietary adjustments.

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366 C h a p t e r 1 8 Bowel Elimination

PROCEDURE 18.2 Managing a Rectal Tube OVERVIEW ●

To alleviate abdominal distention and discomfort from flatus. P R E PA R AT I O N

Determine patient’s ability to understand procedure. Assess patient’s history of cardiac disease, because insertion of a rectal tube can cause vagal stimulation, which causes bradycardia. ● Determine degree of abdominal distention by palpating the patient’s abdomen. ● Assess discomfort caused by flatulence. ● Assess quality and rate of pulse and respirations. ● Assess condition of perianal tissues. ● ●

Special Considerations • Patients who have had recent surgery, or have arthritis, a cast, lower limb amputations, or a fractured pelvis may need additional time for the procedure, owing to limited physical mobility. • Patients with cardiac history or spinal cord injury may be at risk for complications from vagal stimulation. • If the patient experiences seepage of liquid fecal material after this procedure, contact the prescriber, because an enema may be needed to remove stool in the rectum and dietary adjustments may be indicated, such as increased fluid and fiber. Elderly and Physically and Mentally Challenged Patients • May need more time and instruction of the procedure for optimal participation and learning about preventing constipation. Pediatric Patient • Extra care must be taken when inserting the rectal tube to prevent injury to anal sphincters and/or rectum. • Parents should be allowed to comfort infants and children and participate in the procedure. R E L E VA N T N U R S I N G D I A G N O S E S

Constipation related to decreased peristalsis Pain related to abdominal discomfort and distention from bowel malfunction ● Potential for injury related to abdominal distention and trauma to the anal sphincters and/or rectum during the procedure ● ●

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P r o c e d u r e 1 8 . 2 Managing a Rectal Tube 367 EXPECTED OUTCOMES

Patient will experience greater comfort from relief of abdominal distention ● Patient experiences minimal discomfort ● Respirations remain within normal limits after procedure if flatulence has caused respiratory distress ● Flatulence is removed from lower gastrointestinal tract ●

EQUIPMENT/SUPPLIES

Rectal tube: size 22 to 30 straight French for adults, and size 12 to 18 French for children Water-soluble lubricant Clean gloves Toilet paper Disposable, absorbent bed pad Skin care items (i.e., soap or skin cleanser, water, towels) Small plastic bag or stool specimen container Hypoallergenic paper tape I M P L E M E N TAT I O N ➧ Check prescriber’s order; identify patient; explain purpose, proce-

dure, and how patient can assist. Assess patient’s or family member’s ability to participate in education of prevention. Confirms order; meets patient’s right to be informed; encourages cooperation and participation. ➧ Gather all equipment, place in an easy-to-access area in patient’s

room, and adjust lighting as needed. Promotes organization of equipment; saves time; and adjusted lighting enhances visualization for procedure. ➧ Obtain baseline vital signs and record. This procedure can cause bradycardia and hypotension due to vagus nerve stimulation. Therefore, baseline vital signs are necessary for comparison post-procedure or if the patient develops abnormal vital signs during the procedure. ➧ Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms and prevents contact with urine and/or feces. ➧ After determining patient’s ability to assist, place disposable water-

proof pad under patient. Have patient lift hips or roll from side to side. Bed pad protects against soiling of linens

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368 C h a p t e r 1 8 Bowel Elimination ➧ Place patient in a left side-lying position. Facilitates insertion of tube following the normal curve of rectum and sigmoid colon. ➧ Tape the plastic bag around the distal end of the rectal tube or insert

the tube into the stool specimen container. To collect tiny pieces of stool if expelled with flatus. ➧ Vent the upper side of the plastic bag. Prevents inflation of flatus and bursting of the bag. ➧ Lubricate the proximal end of the rectal tube with water-soluble

lubricant. Aids in easier insertion of rectal tube. ➧ While separating the buttocks, ask the patient to take a deep

breath. Gently insert the tube into the rectum, past the external and internal anal sphincters (4–6 inches in adults and 2–4 inches in children). Taking deep breaths relaxes the anal sphincter and prevents tissue trauma during tube insertion. ➧ With adults, tape the tube in place, using hypoallergenic paper tape.

With children, hold the tube in place manually. Keeps the tube securely in place in order to function properly. ➧ Assess patient’s tolerance of procedure by checking heart rate

and respirations. If any untoward symptoms occur, stop procedure, notify physician immediately, and take appropriate actions, including monitoring vital signs. To monitor for adverse reactions caused by vagus nerve stimulation. ➧ Leave the tube in place no longer than 20 minutes. Prolonged presence of the catheter may cause pressure necrosis of the mucosa, and prolonged stimulation of the anal sphincter may result in loss of the neuromuscular response. ➧ After removal of the tube, wipe buttocks with tissue and assist with

cleaning of rectal area as needed. Prevents transmission of infectious microorganisms from feces and promotes patient comfort. ➧ Help the patient to resume a comfortable position in bed. Promotes comfort.

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P r o c e d u r e 1 8 . 2 Managing a Rectal Tube 369 ➧ Clean equipment if it is to be reused, and discard equipment not

being reused. Prevents transmission of infectious microorganisms, and provides clean equipment for next use. ➧ Instruct patient that chewing gum, sucking on candy, using a

straw, drinking carbonated beverages, and smoking should be avoided. This increases the chance of swallowing air and increases abdominal distention. ➧ Remove your gloves and wash hands. Prevents transmission of infectious microorganisms. ➧ Discuss with patient and/or family factors that promote normal

bowel functioning—for example, activity, increased fluid intake as tolerated, and dietary habits. Promotes patient/family understanding and cooperation of preventing future problems of constipation and fecal impaction. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient’s compliance and ability to tolerate procedure Assess degree of abdominal distention ● Assess for complications ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Record date, time, and size of tube inserted and characteristics of feces collected. ● Change or no change of abdominal distention. ● Pulse and respiratory rates before, during, and after procedure. ● Record patient’s tolerance of procedure and any complications that occurred. ● Report patient/family teaching about prevention of constipation and fecal impaction, such as, adequate hydration and dietary adjustments.

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370 C h a p t e r 1 8 Bowel Elimination

PROCEDURE 18.3 Managing Ostomy Care OVERVIEW ●

To provide the skills necessary to manage an ostomy including: • The application of an ostomy pouch. • Emptying a pouch and preventing skin breakdown associated with pouch leakage or an ill-fitting pouch. • Teaching the patient and/or caregiver to perform ostomy care. • Instructing the patient and/or caregiver about potential problems, such as skin irritation, pouch leakage, stomal irritation, stomal necrosis, or stenosis. • Giving useful tips to promote optimal adjustment and rehabilitation for the patient with an ostomy. P R E PA R AT I O N

Assess patient’s and/or caregiver’s knowledge about care of the ostomy. ● Assess the colostomy or ileostomy opening or stoma for a moist, pink appearance and notify the prescriber immediately if the stoma has any change in color. Deep purple or black coloring is a sign of necrosis and usually will require surgical intervention to revise the stoma. ● Assess ostomy for flatus as the first output after surgery and soft or liquid stool, until a regular diet is resumed. ● Assess for bleeding from the stoma, because it is never a normal finding, and notify the prescriber immediately, because this may represent gastrointestinal hemorrhage. ● Assess the stoma for retraction or separation, and notify the prescriber as needed. ● Assess the stoma for pain, which should be absent unless there is skin irritation from stool leakage. ● Assess the stoma location and shape, amount of output, patient dexterity, and personal preference. This and cost will determine the type of pouch used (a one-piece or two-piece). ●

Special Considerations • Provide simple instructions, and answer every question. • Allow the patient time to adjust to the change in body image.

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 371

• The patient may suffer depression and may need to work through the loss of a body part and normal bowel function. • Reinforce all learning, and remind the patient that adjustment and learning are individual. • Brief, frequent teaching sessions are helpful and less overwhelming for the patient and caregiver. • Provide age-appropriate teaching to the patient and/or caregiver about diet, medications, and activity specific to the type of ostomy. • Provide resource numbers, including the United Ostomy Association (UOA) and the local Ostomy Support meetings for additional information and patient/family support TABLE 18.3A Support Groups for People with Ostomies American Cancer Society (ACS) 1599 Clifton Road NE Atlanta, GA 30329 1-800-ACS-2345 www.cancer.org Crohn’s & Colitis Foundation of America, Inc. (CCFA) 386 Park Avenue South New York, NY 10016-8804 1-800-343-3637 1-212-685-3440 for NY www.ccfa.org National Family Caregivers Association 10605 Concord Street, Suite 501 Kensington, MD 20895-2504 1-800-896-3650 www.nfcacares.org

Great Comebacks Awards Program P. O. Box 9922 Rancho Santa Fe, CA 92067 www.greatcombacks.com United Ostomy Association (UOA) 19772 MacArthur Blvd., Suite 200 Irvine, CA 92612-2405 1-800-826-0826 www.uoa.org

Wound, Ostomy and Continence Nurses Society (WOCN) 1550 S. Coast Highway, Suite 201 Laguna Beach, CA 92651 1-888-224-WOCN or 1-888-4-WOCNCB www.wocn.org

Pediatric, Elderly, or Physically Challenged Patient • May have difficulty learning to manage the ostomy and need additional training. Home Health Patient • Arrange for a home health nurse if additional instruction or supervision is needed. Provide ostomy supplies, and arrange for the patient to get necessary supplies for home use.

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372 C h a p t e r 1 8 Bowel Elimination R E L E VA N T N U R S I N G D I A G N O S E S

Body image disturbance related to the ostomy Ineffective individual coping related to a change in bowel elimination and lifestyle ● Risk for impaired skin integrity related to increased contact of fecal matter around stoma ● Risk for knowledge deficit related to lack of understanding about ostomy care ● Risk for caregiver role strain related to added responsibility of caring for an ostomy ● ●

EXPECTED OUTCOMES

The ostomy stoma remains viable and begins normal function as expected postoperatively ● The stoma remains intact, without necrosis or retraction ● The patient and/or caregiver is taught to manage the ostomy at home by performing these skills independently and gives return demonstration before discharge to home ● Supplies are accessible to the patient ● The patient achieves a satisfactory adjustment to the ostomy, evidenced by achieving self-care and resumption of everyday activities ●

EQUIPMENT/SUPPLIES

Gloves Washcloths, moistened with cool tap water (never hot water to avoid trauma to the stoma) Towel or waterproof pad Adhesive remover wipes Skin prep wipes Colostomy pouch (one-piece adhesive pouch with cut-to-fit starter hole) Pouch clamp Scissors Measuring template for sizing the stoma Deodorizing liquid (Banish)* Liquid detergent cleanser (Uniwash)* Plastic squeeze bottle for pouch rinsing Toilet tissue Plastic bag to dispose of used equipment Hy-tape (pink waterproof tape) (optional) Stomahesive powder (optional) Stomahesive paste (optional)

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 373 I M P L E M E N TAT I O N ➧ Gather supplies and explain the procedure to the patient. Ask if

there is anyone else that the patient would prefer to have included in learning to perform the procedure (e.g., spouse). Reduces anxiety. Supplies at hand promote a relaxed learning environment. Respect the patient’s privacy. ➧ Position the patient comfortably in bed or chair; drape a towel or

waterproof pad under the colostomy pouch. Provides clear vision of the abdomen so that the patient can begin to learn self-care. A mirror may be helpful as well. Padding the bed avoids unpleasant leakage. ➧ Gently remove the ostomy

pouch using the adhesive remover wipes. Have the moist washcloth handy, once the pouch is removed. Gently cleanse the stoma and the skin with the washcloth. Use only cool tap water. Discard the pouch, unless there is a two-piece system in place; the pouch may be rinsed and FIGURE 18.3A Remove old wafer snapped back on the flange from the skin. if using a two-piece system. Remember to save the pouch clamp for reuse. Adhesive remover protects the skin from “stripping” and promotes patient comfort. Plain, cool tap water is used to clean the stoma and peristomal skin. Hot or warm water may stimulate the bowel to act. Hot water could burn the stoma also. Soap is not advisable. It may leave a residue and interfere with pouch adhesion. ➧ Leave the moist washcloth in place over the stoma while preparing

the new pouch. The colostomy may expel flatus or stool; the skin must be protected from stool.

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374 C h a p t e r 1 8 Bowel Elimination ➧ Use the stoma measuring

guide that is with the box of pouches to cut the opening in the pouch. Trace the pattern on the pouch barrier, and cut the hole. Save the “pattern” for the next pouch change. Expect some shrinkage in the stoma size over several weeks postoperatively. Note: Pouches FIGURE 18.3B with “pre-cut” holes also available for later when stoma reaches mature size. The pouch should fit with no more than 1/8 inch of skin around the stoma exposed; the stoma expands when expelling stool; a tight pouch could traumatize the stomal mucosa; a large opening causes skin irritation. ➧ Apply Skin Prep wipe to peristomal skin, and allow to air-dry for a

few seconds. Skin Prep “degreases” the skin and prepares the skin for the pouch. ➧ Close end of pouch with pouch clamp; use a few drops of Banish

deodorizer or mouthwash into the pouch. Put a few drops of Uniwash into the pouch or a tiny drop of dishwashing liquid to help with cleansing and emptying the pouch. Deodorizer and detergent help prevent odor and allow ease in rinsing and emptying the pouch. A small squirt bottle is useful for rinsing the pouch. A few drops of cooking oil or “Pam” cooking spray also allow ease in emptying the pouch. ➧ Place one edge of the pouch

on the skin, rolling it up and over the stoma, while pressing all around the stoma. Use one hand to gently stretch the skin as the other hand places the pouch. If using a two-piece system, center the wafer over the stoma and press down gently. Angle the pouch to the side if the FIGURE 18.3C Center the wafer over patient is inactive or bedridthe stoma. den. If the patient is ambulatory, the pouch should be placed with the clamped end pointing down, toward the feet. Frame the pouch with waterproof tape (optional).

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P r o c e d u r e 1 8 . 3 Managing Ostomy Care 375 Good adhesion prevents leakage and skin irritation and promotes overall well-being for the patient. Angling the pouch downward allows ease of rinsing and emptying the pouch. Waterproof tape provides added security. ➧ Chart the procedure, and notify the prescriber of any unusual

findings. Documentation is essential. Bleeding from the stoma, stomal separation, or retraction is an unusual finding. ➧ Advise the patient to sit quietly for a few minutes after the pouch

change to ensure good pouch adhesion. Decreases the chance of leakage. ➧ Teach the patient and/or caregiver to practice rinsing and emptying

the pouch while the patient is wearing it; this will be done 3–4 times a day or when the pouch is about one-third full. The pouch change is done every 3 to 5 days. An empty pouch is lighter; the patient will develop an emptying routine once usual bowel function resumes. Pouch wear time is dependent on adherence of the pouch and patient comfort and preference. ➧ Apply Skin-Prep wipe to the skin around the stoma, and wait

about 10 seconds for this to dry. Stretch the skin with one hand while applying the wafer to the skin. Press gently to adhere to the skin. Place the pouch clamp on the bottom of the pouch and add a drop of deodorizer and liquid detergent to the pouch. Snap the pouch onto the flange. Run a fingertip around the rim to ensure a tight seal. Picture-frame the wafer with waterproof tape (optional). Skin-Prep degreases the skin and prepares the skin for the wafer. Deodorizer and detergent reduce odors and allow ease in emptying the pouch. Checking the flange or rim for a tight seal prevents leakage. Waterproof tape provides added security. ➧ Record the pouch change procedure, how the patient toler-

ated the procedure, and notify the prescriber of any unusual findings. Documentation is essential for proper care of the ostomy.

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376 C h a p t e r 1 8 Bowel Elimination E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess periostomal skin for breakdown or irritation Assess stoma for change in color, which can indicate lack of blood supply ● Assess that bag remains secure ● Teach patient about ostomy supplies and community resources ● Teach the patient to empty the pouch either by removing the clamp and squirting water into the pouch or by snapping the pouch off of the flange for rinsing and emptying ● Change the adhesive wafer every 5 to 7 days or sooner if there is leakage ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Condition of stoma and skin; characteristics of output. Complications such as bleeding, stomal necrosis, retraction, or stomal separation, and that prescriber was notified. ● Time and date of ostomy change. ● Patient’s response to altered anatomy. ● Patient’s ability to participate in care of ostomy. ● Patient and family teaching. ● Discharge plans, including obtaining supplies and community resources are initiated. ●

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U N I T

C H A P T E R

Renal and Urinary

19 Urinary Elimination 19.1 Inserting a Straight or Indwelling Catheter (Male and Female), 378 19.2 Performing Catheter Care, 385 19.3 Applying a Urinary Incontinence Collection Device, 388 19.4 Teaching Clean Intermittent SelfCatheterization, 391

7

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378 C h a p t e r 1 9 Urinary Elimination

PROCEDURE 19.1 Inserting a Straight or Indwelling Catheter (Male and Female) OVERVIEW ●

To drain the bladder of urine due to an obstruction or incontinence. • A straight or in-and-out catheter facilitates intermittent bladder drainage. • An indwelling catheter allows continuous flow of urine in patients with poor or absent bladder control. P R E PA R AT I O N

Check prescriber’s order to ensure that the procedure specifies a straight or indwelling catheter. ● Determine if the patient is unconscious, hard of hearing, blind, or if there are any restrictive devices attached, such as restraints, traction, or casts. ● Note on lab form if patient is having a menstrual period if specimen is obtained for diagnostic study. ●

Special Considerations Female Patient • Because the urethra is close to the anus in female patients, thorough and careful cleaning of the perineum is very important before catheter insertion to reduce the incidence of infection. • For postpartum or post-gynecologic surgery, the perineum and labia may be swollen and tender; therefore, handle gently to minimize discomfort. Elderly and Physically Challenged Patients • Will require additional time and careful handling, especially if lower extremities are contracted, to prevent damage to muscle and bone. Pediatric Patient • Provide age-appropriate instructions to decrease anxiety and facilitate cooperation. • For infants and children, allow parents to participate in comforting patient. Home Health Patient • Patients may need careful monitoring and additional education about catheter care for indwelling and straight catheterization to prevent urinary tract infection.

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 379 EXPECTED OUTCOMES

Patient will experience increased comfort related to decreased bladder distention or urinary incontinence ● Bed linen and patient’s clothing will remain clean and dry for a longer period of time ● Ensures more accurate measurement of urinary output ●

R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery, and/or neuromuscular dysfunction ● Pain related to bladder distention or edema in perineum ● Potential for infection related to possible introduction of microorganisms in urethra from repeated catheterizations with in-and-out or poor catheter care with indwelling ●

EQUIPMENT/SUPPLIES

Appropriate disposable sterile catheterization tray for straight or indwelling procedure Additional sterile catheter if the physician orders a special type or size (age appropriate) Closed drainage set, if for an indwelling catheter and not included in kit Additional lighting as needed Towels and washcloths for cleaning and drying perineum Clean gloves Tape or catheter secure device if indwelling catheter, as per facility policy Completed specimen identification label and laboratory requisition form if specimen is ordered I M P L E M E N TAT I O N ➧ Review prescriber’s order; identify patient; explain purpose, proce-

dure, and how patient can assist, depending upon patient’s mental status. Confirms type and size of catheter to be inserted; meets patient’s right to be informed; encourages cooperation and participation. ➧ Gather all equipment and place on bedside table. Provides organization and saves time. ➧ Wash hands, and don clean gloves. Reduces transmission of infectious microorganisms.

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380 C h a p t e r 1 9 Urinary Elimination ➧ Adjust bed to a workable height, and lower side rail. Creates a comfortable working position while decreasing strain on back and arms. ➧ Assist/place patient to a supine position with knees flexed. (Use

assistance from other personnel as necessary.) Provides good access to and visualization of perineum. ➧ Drape patient with blanket or sheet covering abdomen and lower

legs. For male: Cover patient’s upper body with a blanket, and fold bed sheets down to expose penis. For female: Cover patient’s body with a blanket or sheet. Cover each leg with separate sheet crisscrossing sheets over the patient’s abdomen. When it is time to examine the female genitalia, only the perineum is exposed affording the patient the privacy necessary for the exam. Provides comfort and privacy.

FIGURE 19.1A

➧ Cleanse perineal area with appropriate antibacterial solution, rinse

well, and dry. Reduces presence of microorganisms near urethra.

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 381 ➧ Remove clean gloves, discard, and wash hands. Reduces transmission of infectious microorganisms. ➧ Open sterile package, and place plastic package container at the foot

of the bed. Facilitates for waste disposal. ➧ Place catheter tray on the bed between the patient’s legs. Allows easy access to equipment. ➧ Fold back blanket/sheet to expose perineum. Helps to clearly identify urinary meatus. ➧ Open white outer wrapping away from sterile package with last turn

toward patient. To maintain sterile field. ➧ Position white package wrap under patient’s buttocks. To protect bed linens. ➧ Remove sterile absorbent pad and place under patient’s buttocks.

If he or she is able, have patient lift buttocks. Maintains clean area. ➧ Don sterile gloves, remove sterile equipment from catheter tray, and

arrange for use. Provides easy access to equipment during procedure. ➧ Pour antiseptic or Betadine solution over cotton balls (use a different

solution if patient is allergic to Betadine). Cleanses. ➧ Uncap syringe filled with lubricant, or tear open package; lubricate

catheter tip generously. Leave catheter tip in sterile lubricant on sterile field until used. Provides easier catheter insertion. ➧ If specimen is ordered, uncap sterile container and place nearby on

the sterile field. Saves time and provides easier access when needed. ➧ If a straight/in-and-out catheterization is being done, place the urine

collection container close to the patient. Prevents urine from spilling onto working surface and bed. ➧ If an indwelling catheterization is being done, place drainage bag on

sterile field. Provides easier access after catheter is inserted and in place. ➧ For Male: Place the fenestrated drape (with the hole in the middle)

over the penis, exposing the urinary meatus.

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382 C h a p t e r 1 9 Urinary Elimination

For Female: Place the fenestrated drape (with the hole in the middle) over the perineum exposing the urinary meatus. Provides a clean working area near the catheter insertion site. ➧ For Male: Hold the penis upright with your nondominant hand. If

uncircumcised, retract foreskin. Hold glans of penis to prevent closing of urethra. Allows easy access when catheter is inserted. ➧ To cleanse urinary meatus and insert catheter:

With dominant, sterile, gloved hand, use forceps to pick up a cotton ball saturated with antiseptic or Betadine solution. ● Move in a circular motion from the meatus down to base of glans. ●

Reduces microorganisms at meatus and moves from least contaminated to most contaminated area.

FIGURE 19.1B ●

Discard each cotton ball after use. Prevents contamination after cleaning meatus.

Repeat cleaning at least 2 to 3 more times. ● Discard forceps, and with dominant, sterile, gloved hand, pick up lubricated catheter about 3 to 4 inches from the tip. ● Lift penis to a 90-degree angle (perpendicular to body) and exert slight traction by pulling upward. ●

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P r o c e d u r e 1 9 . 1 Inserting a Straight or Indwelling Catheter 383 ●

Insert catheter into urinary meatus about 7 to 9 inches in an adult (less in an infant or child) or until urine begins to flow. When urine appears, advance the catheter another 1–2 inches. Hold in place. Straightens the urethra for easier insertion of the catheter. Also, further advancement of the catheter ensures proper placement.

FIGURE 19.1C

➧ For Female: Carefully retract labia to fully expose urinary meatus

with nondominant hand. Allows easier access when catheter is inserted. ➧ To cleanse urinary meatus and insert catheter: ●

With dominant, sterile, gloved hand, use forceps to pick up a cotton ball saturated with antiseptic or Betadine solution and cleanse the urinary meatus with one downward stroke each time, one on each side and then down the middle. Reduces microorganisms at meatus and moves from least contaminated to most contaminated area.

FIGURE 19.1D

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384 C h a p t e r 1 9 Urinary Elimination ●

Discard each cotton ball after use. Prevents contamination after cleaning meatus.

Repeat cleaning at least 2 to 3 times. ● With dominant hand, continue to hold labia apart. ● Discard forceps and with dominant, sterile, gloved hand, pick up lubricated catheter about 3 to 4 inches from tip. ● Insert the catheter into the urinary meatus about 2 to 3 inches (less with infants and children) or until urine begins to flow. Hold in place. ●

Ensures catheter is in the bladder.

FIGURE 19.1E

➧ If a straight/in-and-out catheterization is being done, and a urine

specimen is needed, collect about 30 mL of urine in the sterile specimen container by placing the container under the drainage end of the catheter. To collect a urine specimen and drain bladder without spillage of urine. ➧ If an indwelling catheter is being inserted, follow steps for insertion;

then, with the dominant hand, fill the 10-mL balloon with approximately 8 mL of water. Gently pull back the catheter to make sure it is in place. Ensures catheter is in place and balloon is intact and adequately inflated. Decreases the incidence of catheter dislodging. ➧ For an indwelling catheter, after the balloon is filled with water and

catheter is intact in the bladder, secure catheter to patient’s upper leg with tape or a Catheter Secure Device, unless contraindicated by facility policy. Secure bag to bed rail. To ensure catheter is securely attached to patient and to reduce risk for dislodging with normal movement.

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P r o c e d u r e 1 9 . 2 Performing Catheter Care 385 ➧ Remove drapes, used catheter equipment, and dry perineum. Patient comfort. ➧ Position patient for comfort, side rails up, and in low position,

depending on patient’s activity status. Patient comfort and safety. ➧ Measure and record urine as indicated/ordered. To maintain an accurate I & O record. ➧ Discard gloves and used equipment in the proper waste disposal

and wash hands. To prevent transfer of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance; assess level of comfort Observe characteristics of urine and signs of urinary infection ● Inform prescriber of abnormal findings, and discuss any need for additional or change in therapy ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Document and report date and time of catheterization and specimen collected if ordered. ● Characteristics of urine and signs of possible urinary infection. ● Disposition of specimen if ordered.

PROCEDURE 19.2 Performing Catheter Care OVERVIEW ●

To prevent the introduction of infectious microorganisms into the urethra and bladder to cause bladder and kidney infections. P R E PA R AT I O N

Determine patient’s ability to understand and cooperate in the procedure. ● Assess for signs and symptoms of urinary infection. ● Determine an appropriate time for catheter care. ●

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386 C h a p t e r 1 9 Urinary Elimination

Special Considerations • Catheter care is most beneficial if performed after defecation if patient is incontinent. Female Patient • In females, note if patient is having menstrual period or vaginal discharge and, because the urethra is close to the anus, thorough and careful cleaning of the perineum is very important. • For postpartum or post–gynecologic surgery, the perineum and labia may be swollen and tender, therefore, handle gently to minimize discomfort. Pediatric Patient • Provide age-appropriate instructions to decrease anxiety and facilitate cooperation. • For infants and children, allow parents to participate by comforting patient. Home Health and Physically and/or Mentally Challenged Patients • Patients and/or caregivers may need careful monitoring and additional education about catheter care to prevent the occurrence of urinary tract infection. R E L E VA N T N U R S I N G D I A G N O S E S

At risk for infection related to bacterial invasion into urinary meatus from indwelling catheter ● At risk for injury related to possible renal involvement from urinary tract infection ● Pain related to urinary and/or renal infection ●

EXPECTED OUTCOMES ● ●

Patient will not develop a urinary tract infection Patency of catheter will be maintained EQUIPMENT/SUPPLIES

Wash cloth, soap, and towels Sterile catheter care kit or Sterile cotton balls or 2×2 gauze pads Antiseptic solution Clean gloves Plastic bag for garbage

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P r o c e d u r e 1 9 . 2 Performing Catheter Care 387 I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist. Decreases anxiety; meets patient’s right to be informed; encourages cooperation and participation. ➧ Wash hands. Reduces transmission of infectious microorganisms. ➧ Provide privacy. Encourage patient’s participation as appropriate. ➧ Raise bed and lower side rail on working side. Provides a comfortable working level. ➧ Place patient in supine position, and expose perineal area. To easily visualize urinary meatus. ➧ Don clean gloves and wash the urinary meatus and the proximal

catheter with soap and water; rinse, and gently dry with towel. Reduces transmission of infectious microorganisms. ➧ After removing contaminated gloves and washing hands, open

catheter care kit or assemble equipment on over-bed table and remove tape if used to secure catheter to patient’s upper thigh. Reduces transmission of infectious microorganisms and organizes equipment within easy reach while maintaining a clean working area. ➧ Don clean gloves and cleanse urinary meatus using a circular motion

moving from middle toward outside with antiseptic-soaked cotton ball or swab. Dispose of cotton ball/swab in trash bag. This motion prevents bacteria from entering the urinary meatus. Also, proper disposal of contaminated materials prevents the transmission of infectious microorganisms. ➧ Gently pull catheter taut and cleanse with a new cotton ball/swab

from catheter insertion site down catheter tubing about 4 to 5 inches toward drainage bag. Dispose of used cotton ball/swab. Cleans catheter and prevents bacterial growth. ➧ Dispose of all cleaning materials in proper waste container. Prevents transmission of infectious microorganisms. ➧ Remove gloves and re-tape catheter (as per facility policy). Prevents additional pull/strain on catheter by securing it to upper leg. ➧ Position patient for comfort, lower bed, and raise side rail. Provides comfort and safety measures. ➧ Wash hands Prevents transmission of infectious microorganisms.

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388 C h a p t e r 1 9 Urinary Elimination E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient comfort Observe characteristics of urine and signs of urinary infection ● Check test results and inform physician of abnormal findings ● Discuss appropriate therapy with prescriber ● ●

KEY POINTS ● ●

FOR

REPORTING

AND

RECORDING

Characteristics of urine and signs of urinary infection. Document date and time catheter care was done and participation of patient and/or caregiver.

PROCEDURE 19.3 Applying a Urinary Incontinence Collection Device OVERVIEW

To allow the patient to be able to collect urine for diagnostic studies and I & O. ● To prevent skin breakdown from urinary incontinence. ● To follow prescriber’s orders to apply collection device. ●

P R E PA R AT I O N

Determine patient’s ability to understand and cooperate in the procedure. ● Assess for signs and symptoms of urinary infection. ●

Special Considerations • Determine if the patient is unconscious, hard of hearing, blind, or if there are any restrictive devices attached, such as restraints, traction, and casts. • For postpartum or post-gynecologic surgery, the perineum and labia may be swollen and tender; therefore, handle gently to minimize discomfort. • If contaminated during defecation, remove device and reapply.

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P r o c e d u r e 1 9 . 3 Applying a Urinary Incontinence Collection Device 389

Pediatric Patient • Provide age-appropriate instructions to decrease anxiety and facilitate cooperation. • For infants and children, allow parents to participate by comforting patient. Elderly and Physically Challenged Patients • Will require additional time and careful handling, especially if lower extremities are contracted, to prevent damage to muscle and bone. Home-Health Patient • Patients and/or caregivers may need careful monitoring and additional education about application and maintenance of this type of catheter to prevent urinary tract infection. R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery, and/or neuromuscular dysfunction. ● Pain related to bladder distention, edema in perineum, or infection. ● At risk for infection related to bacterial invasion into urinary meatus from this type of catheter and length of time applied. ●

EXPECTED OUTCOMES

Urine output can be monitored, and a specimen can be collected for diagnostic studies as needed. ● Bed linens will remain dry for longer periods of time and patient will be more comfortable. ● Patient will not develop a urinary-tract infection. ● Patency of catheter will be maintained. ●

EQUIPMENT/SUPPLIES

Clean gloves Soap, water, towels, and washcloth Gender- and age-specific commercial urinary incontinence collection device Container for urine to be measured (keep in the patient’s bathroom) I M P L E M E N TAT I O N ➧ Check provider’s orders; identify patient; explain purpose, procedure,

and how patient can assist. Confirms order for urinary incontinence collection device; meets patient’s right to be informed; encourages cooperation and participation.

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390 C h a p t e r 1 9 Urinary Elimination ➧ Gather equipment and wash hands. Promotes organization; reduces transmission of infectious microorganisms. ➧ Provide privacy. Encourage patient’s participation. ➧ Raise bed and lower side rail on working side. Provides a comfortable working level. ➧ Don clean gloves, wash genital area with soap and water, and dry

thoroughly. Prevents transmission of infectious microorganisms. ➧ Peel off paper from both sides of the adhesive liner that accompa-

nies the commercial product. So device will adhere securely to the skin surface. ➧ In males, place penis inside

urinary incontinence collection device, unroll the condom along the shaft and secure. Ensures device will stay in place.

FIGURE 19.3A

➧ In females, secure device over urethra area, which may extend over

the vaginal area. Ensures device will stay in place. ➧ Lower bed, and raise side rail as indicated by patient’s activity regi-

men. Promotes patient safety. ➧ Instruct patient and/or caregiver about application and maintenance

of this device. Decreases anxiety and promotes cooperation by patient and/or caregiver. ➧ Remove gloves and wash hands. Prevents transmission of infectious organisms. ➧ Check catheter in 15 to 30 minutes to ensure it is in place, and moni-

tor periodically. Prevents complications and dislodging of device.

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P r o c e d u r e 1 9 . 4 Teaching Clean Intermittent Self-Catheterization 391 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and/or participation Observe characteristics of urine ● Inform provider of abnormal findings, and discuss any need for additional or change in therapy ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Document date and time of application of collection device. Specimen collected and disposition if ordered. ● Characteristics of urine and signs of possible urinary infection. ● Absence/presence of complications. ●

PROCEDURE 19.4 Teaching Clean Intermittent Self-Catheterization OVERVIEW

To provide the patient and/or caregiver with means of intermittently draining the bladder due to urinary retention. ● To prevent complications of bladder distention and urinary-tract infection. ●

P R E PA R AT I O N

Determine patient’s and/or caregiver’s ability to understand and perform the procedure. ● Determine patient’s mobility and independence in performing the procedure. ●

Special Considerations • Note any physical or mental deficits that may prevent this procedure being preformed by patient. • Teach caregiver to perform procedure as needed. • If specimen is ordered for a diagnostic test, note and document on container/lab form if patient is having menstrual period. Home Health Patient • Patients and/or caregivers may need careful monitoring and additional education regarding performing this procedure.

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392 C h a p t e r 1 9 Urinary Elimination R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery, and/or neuromuscular dysfunction ● Pain related to bladder distention ● Potential for infection related to possible introduction of microorganisms in urethra from repeated catheterizations and irritation to urethral mucosa ●

EXPECTED OUTCOMES ●

Patient will experience increased comfort related to decreased bladder distention and/or urinary-tract infections EQUIPMENT/SUPPLIES

Appropriate disposable sterile catheterization tray Cleansing towelette Povidone-iodine solution (if patient is not allergic) Sterile container for specimen, if ordered Clean gloves Bedpan, urinal, or commode Specimen hat if all urine must be measured I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient will

proceed. If a caregiver will be performing this procedure, explain procedure and assess ability to perform. Meets patient’s or caregiver’s right to be informed; encourages cooperation and participation. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Provide privacy. Encourage patient’s participation. ➧ Instruct patient to open disposable catheterization tray and put at a

convenient and close location. Convenience of equipment for patient use. ➧ (Refer to Procedure 19.1 “Inserting a Straight or Indwelling

Catheter [Male and Female”]). Instruct female patient to put on clean gloves. Wash and dry genital and perineal areas with soap and water. Remove soiled gloves; wash

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P r o c e d u r e 1 9 . 4 Teaching Clean Intermittent Self-Catheterization 393

hands, put on sterile gloves, and prepare equipment in a sterile tray for catheterization. Reduces transmission of microorganisms and reduces contamination of specimen with transient bacteria. ➧ Female patient: Spread the labia with fingers of nondominant hand. ➧ Cleanse each side of labia with cotton ball/swab with antiseptic solu-

tion on it and down the middle over urinary meatus using one stroke and one swab. Clean from area of least contamination to greatest contamination; decreases bacterial levels on the area. ➧ Discard towelette.

Male patient: Instruct male patient to put on sterile gloves, retract foreskin if not circumcised, use a clean towelette in a circular motion from the urinary meatus and several inches on the shaft of the penis. ➧ Show patient how to use sterile cotton ball/swab soaked with anti-

septic/Betadine solution, in a circular motion from urinary meatus and several inches on the shaft of the penis. Clean from least contaminated to greatest contamination to reduce bacteria on the area. ➧ Instruct patient to discard cotton balls/swabs and with the dominant

sterile gloved hand, pick up the lubricated catheter about 3 to 4 inches from tip and insert into the urinary meatus until urine begins to flow. (The male urethra is longer than that of the female—instruct on depth of insertion.). Reduces transmission of infectious microorganisms. ➧ Instruct patient to place open end of catheter in drainage container.

If specimen is needed, instruct patient to drain urine into the sterile urine specimen container. Prevent spillage of urine. ➧ After bladder is emptied and urine flow stops, instruct patient to

slowly remove catheter. Provides patient comfort. ➧ Instruct patient to remove and dispose of all equipment. Prevents the transmission of infectious microorganisms. ➧ Instruct patient to wash and dry perineal area, remove and discard

gloves, and wash hands. Prevents transmission of infectious microorganisms.

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394 C h a p t e r 1 9 Urinary Elimination ➧ If a specimen is collected, instruct patient to tightly close the con-

tainer, touching only the outside of container and cap. Prevents contamination of the specimen. ➧ Instruct patient to clean outside of the container if contaminated

with urine. Prevents transfer of microorganisms to others. ➧ Instruct patient to label container with name, etc. Ensures accurate patient identification. ➧ Refrigerate specimen if it cannot be transported immediately. Prevents deterioration of urine from bacterial contamination when left at room temperature. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient or caregiver (if indicated) compliance and ability to perform procedure ● Instruct patient to observe characteristics of urine and signs of urinary infection, and report to prescriber ● If a specimen was collected and sent to a lab for analysis, instruct the patient to contact the prescriber for the results ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Note date and time of specimen collection, if applicable. Characteristics of urine and signs of urinary infection. ● Disposition of specimen, if ordered. ● Teaching procedure to patient or caregiver if indicated. ●

C H A P T E R

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20 Bladder Irrigation and Function 20.1 Performing and Managing Bladder Irrigation Through a Three-Way Foley Catheter, 396 20.2 Obtaining a Post-Void Residual Urine Volume, 400

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396 C h a p t e r 2 0 Bladder Irrigation and Function

PROCEDURE 20.1 Performing and Managing Bladder Irrigation Through a Three-Way Foley Catheter OVERVIEW

To flush or “wash out” the bladder (intermittent or continuous) using a closed system. ● To maintain or restore catheter patency. ●

P R E PA R AT I O N

Use strict aseptic technique if intermittent irrigation is ordered. Medications may be added to irrigation solution. ● Isotonic irrigation solutions are used. ● Check prescriber’s order to determine if it is a continuous or intermittent irrigation. ● ●

Special Considerations • Assess bladder for distention, because clots can occur. • Assess patient for lower abdominal pain and/or cramping. • Perform manual irrigation as needed to remove clots and reestablish irrigation flow. • If resistance is met during manual irrigation, do not force irrigation fluid, notify prescriber. Pediatric, Elderly, and Mentally Challenged Patients • May need closer monitoring because they may not be able to communicate problems. R E L E VA N T N U R S I N G D I A G N O S E S

Pain or discomfort related to blood clots obstructing normal irrigation flow ● Potential for injury related to blood clots in bladder and/or urethra and causing distention ●

EXPECTED OUTCOMES

All irrigation solution and debris from bladder drains into catheter drainage bag ● Continuous: Flow rate of irrigant remains constant at prescribed rate, and bags of irrigation solution are added as needed ● Catheter and drainage bag tubing remain patent ● Urinary output is accurately assessed ● Patient experiences no discomfort during or following procedure ● Patient’s questions and concerns are adequately addressed ●

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P r o c e d u r e 2 0 . 1 Performing and Managing Bladder Irrigation 397 EQUIPMENT/SUPPLIES

Clean gloves Three-way Foley catheter with drainage bag in place Warmed or room temperature sterile irrigation solution Sterile infusion tubing IV pole tel

n d 01 o 0

e

e ti c

FIGURE 20.1A Triple lumen catheter.

Irrigation bag

Drip chamber Clamp Tubing to irrigate port Bladder

Inflation Triple port lumen catheter Drainage tubing Drainage bag FIGURE 20.1B Setup for continuous bladder irrigation.

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398 C h a p t e r 2 0 Bladder Irrigation and Function I M P L E M E N TAT I O N ➧ Review prescriber’s orders and obtain prescribed irrigation solution

from pharmacy (unless solution is already in place at bedside). Determines type, strength, and amount of irrigation solution, as well as frequency and timing of procedure. ➧ Place label on irrigation bag if not labeled; include patient’s initials,

date, time, room number, type of solution, and any additives. Provides safety and continuity of care. ➧ Gather all equipment. Enhances efficiency and patient safety. ➧ Check patient’s identification band. Ensures patient safety. ➧ Explain procedure and its purpose to patient, and provide privacy. Clear explanations reduce patient’s anxiety and increase cooperation with procedure. Maintains patient’s dignity. ➧ Organize equipment within easy reach and drape patient, exposing

access to irrigation port on catheter only. Enhances efficiency and patient safety. ➧ Don clean gloves, and empty and measure urine present in drainage

bag; discard urine and gloves in appropriate receptacles. Decreases transmission of microorganisms, provides pertinent data regarding patient’s urine output, and provides empty drainage bag for accurate measurements following procedure. ➧ Wash hands. Decreases transmission of microorganisms.

Infusion Tubing and Irrigation Solution Already in Place Continuous Irrigation ➧ Ascertain that solution is correct as prescribed. Ensures that the irrigation solution already hanging and connected to infusion tubing is the prescribed solution. ➧ Open flow clamp on urinary drainage tubing and on infusion tubing. Opening drainage bag flow clamp allows infused irrigation solution to flow from bladder into drainage bag. ➧ Adjust flow rate to prescribed hourly rate. Ensures that flow rate is continuous.

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P r o c e d u r e 2 0 . 1 Performing and Managing Bladder Irrigation 399

Intermittent Irrigation ➧ Ascertain that solution is correct as prescribed. Ensures that prescribed solution is in place. ➧ Open flow clamp to urinary drainage bag and to infusion tubing. Allows irrigation solution to flow into bladder, then into drainage bag. ➧ Allow prescribed amount of irrigation solution to infuse into bladder

and then clamp infusion tubing. Ensures that only prescribed amount is instilled into bladder.

Irrigation Solution and Infusion Tubing Not in Place ➧ Hang irrigation solution bag on IV pole 24 to 36 inches above

bladder. Ensures correct height for effective flow. ➧ Connect infusion tubing to irrigation solution, prime drip chamber,

and flush tubing with solution. Flushing infusion tubing with irrigation solution prevents air from entering patient’s bladder and causing discomfort. ➧ Close infusion tube clamp and connect infusion tubing to irrigation

port on three-way Foley. Closing infusion clamp allows only prescribed amount of irrigant to be infused. ➧ Open flow clamp on urinary drainage bag. Opening drainage bag flow clamp allows instilled irrigation solution to flow from bladder into drainage bag. ➧ Intermittent: Open flow clamp on infusion tubing, allowing pre-

scribed amount of irrigation solution to infuse into bladder; clamp tubing. Opening infusion flow clamp allows prescribed volume of irrigant to be infused. Clamping infusion tubing ensures that only prescribed amount of solution is instilled. ➧ Continuous: Open flow clamp on infusion tubing and adjust the

prescribed hourly rate. Change or add irrigation solution as needed, maintaining aseptic technique. Ensures continuous flow of solution. Ensures continuous irrigation and change in solution when prescribed. ➧ Change infusion tubing every 24 to 48 hours or per facility protocol. Reduces incidence of urinary tract infection.

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400 C h a p t e r 2 0 Bladder Irrigation and Function ➧ Monitor urine output hourly or as ordered, subtracting the amount

of irrigant from the total output from drainage bag. Provides pertinent information about bladder and kidney function and need for additional or change in plan of care. ➧ Assess drainage bag frequently and empty as needed. Bag can fill more quickly with irrigation and often needs more frequent emptying. ➧ Assess color, clarity, odor, and other characteristics of urinary output

during irrigation process and each time drainage bag is emptied. Provides pertinent information about bladder and kidney function and need for intervention. ➧ Discard gloves and urine in appropriate receptacles. Reduces transmission of organisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess amount, color, clarity, odor, and character of fluid in drainage bag, noting clots, tissue prior to and following irrigation ● Assess accurately urine volume and irrigant volume ● Assess patient’s comfort level during and after procedure ● Address patient’s questions and concerns ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Time

of procedure. Irrigation solution type and amount. ● Amount, color, clarity, odor, and character of contents of urinary bag (including urine and irrigant volumes) pre- and postprocedure. ● Patient’s tolerance of procedure. ●

PROCEDURE 20.2 Obtaining a Post-Void Residual Urine Volume OVERVIEW ●

To assess bladder function related to urine retained after voiding.

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P r o c e d u r e 2 0 . 2 Obtaining a Post-Void Residual Urine Volume 401 P R E PA R AT I O N

Assess patient’s and/or caregiver’s understanding and ability to participate in the procedure. ● Make sure patient understands that catheterization occurs immediately post-void and bladder will be drained. ● Determine if specimen is needed. ● Voided and residual urine volumes are attained. ●

Special Considerations • Patients who have had recent gynecologic surgery need careful handling because the perineum may still be in the healing process. Elderly, Physically, or Mentally Challenged Patients • May need more assistance for procedure. Pediatric Patient • Explanation of procedure should be appropriate for age/developmental level and involve parents as much as possible. R E L E VA N T N U R S I N G D I A G N O S E S

Altered urinary elimination related to bladder trauma, surgery, and/or neuromuscular dysfunction ● Pain related to bladder distention or edema in perineum ● Potential for Infection related to increased microorganism growth due to urinary retention ●

EXPECTED OUTCOMES

Obtained residual urine volume is accurate Patient expresses minimal discomfort during and following procedure ● Patient will not develop a urinary tract infection ● Patient’s concerns and questions are adequately addressed ● ●

EQUIPMENT/SUPPLIES

Clean gloves Bedside commode or bedpan as needed Toilet collection pan (“hat”) Straight catheterization kit Exam light or lamp Bladder scanner (if used by facility)

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402 C h a p t e r 2 0 Bladder Irrigation and Function I M P L E M E N TAT I O N ➧ Review prescriber’s orders. Determines if patient can ambulate, and frequency of residual urine volume measurement. ➧ Explain procedure and its purpose to patient; provide privacy.

Include caregiver when indicated. Clear explanations reduce patient anxiety and facilitate patient/caregiver cooperation and understanding of procedure. Maintains patient’s dignity. ➧ Gather all equipment. Enhances organization and patient safety. ➧ Wash hands and don clean gloves. Reduces transmission of organisms. ➧ Insert “hat” into toilet or bedside commode and assist patient to

bathroom or bedside commode, or with bedpan/urinal if needed, and have patient void. To collect voided urine for measurement. Facilitates voiding in manner most comfortable or necessary for patient. ➧ Have patient lay flat and use the bladder scanner to check for

residual urine (if indicated by facility protocol). Facilitates performance of procedure and justifies bladder is not empty. ➧ If there is a significant residual, prepare to catheterize the patient. Empty bladder and determine amount of residual urine. ➧ Wash hands. Reduces transmission of organisms. ➧ Perform straight catheterization, maintaining aseptic technique and

being careful to completely empty bladder. Reduces transmission of organisms. Ensures accurate residual urine volume measurement. ➧ Clean and dry perineum and assist patient to a comfortable position. Reduces transmission of organisms and promotes patient comfort. ➧ Measure voided and residual urine. Provides pertinent information regarding bladder status. ➧ Obtain a specimen, if ordered, and then dispose of urine. Dispose of

contaminated equipment in appropriate receptacles. A specimen may be ordered to monitor for urinary-tract infection. Reduces transmission of organisms.

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P r o c e d u r e 2 0 . 2 Obtaining a Post-Void Residual Urine Volume 403 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess accurately both voided and residual urine volumes Assess color, clarity, odor, and character of both voided and residual urine ● Assess patient’s comfort level during and following procedure ● Address patient’s questions and concerns ● ●

KEY POINTS ● Time ●

FOR

REPORTING

AND

RECORDING

of procedure and patient’s tolerance. Report any unusual findings to prescriber that may need additional follow-up and change in therapy.

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U N I T

C H A P T E R

Musculoskeletal

21 Body Alignment and Mechanics 21.1 Maintaining Proper Body Alignment, 406 21.2 Performing Correct Lifting Techniques, 411

8

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406 C h a p t e r 2 1 Body Alignment and Mechanics

PROCEDURE 21.1 Maintaining Proper Body Alignment OVERVIEW ●

To provide the patient with proper body alignment, thus promoting comfort and preventing bone, joint, muscular, skin, neural, lymphatic, circulatory, or tissue damage. P R E PA R AT I O N

Check prescriber’s order to ensure that patient can be moved to various positions. ● Determine need to assist the patient to various positions. ● Determine presence of IV equipment, surgical wounds, drains, or mechanical equipment. ● Determine need for extra pillows and covers, level and position of bed. ● Before beginning, assess skin surfaces for signs of pressure areas, such as blanched or reddened areas. ● Assess patient’s diet (e.g., high protein, high calorie, diabetic, cardiac) ● Avoid serving foods that cause alkaline ash and residue, such as tomato or grapefruit juices. Encourage an adequate amount of vitamin C foods that acidify patient’s urine. ● Monitor patient’s urine for sediment. ●

Special Considerations • Most patients require frequent repositioning, but this will vary with each patient and situation. • Repositioning will require a complete and thorough assessment of the patient to optimize patient comfort and proper alignment. • Provide intellectual stimulation. Suggest receiving visitors; working crossword puzzles; reading newspapers, books, magazines; and playing computer games. Elderly and Physically and/or Mentally Challenged Patients • Will often require more time for communication and understanding of positioning techniques. • Provide more time for moving and exercising activities. Pediatric Patient • Involve parents in procedure and mobility activities to reduce anxiety and enhance cooperation of infants and children.

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P r o c e d u r e 2 1 . 1 Maintaining Proper Body Alignment 407 R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or growth deficit ● Pain/discomfort related to inability to cope with body movements and prescribed alignment plan ●

EXPECTED OUTCOMES

Proper body alignment will be maintained at all times Patient will verbalize comfort in prescribed positions ● Patient will experience minimal discomfort in attaining proper body alignment for proper body posture ● ●

EQUIPMENT/SUPPLIES

Pillows Blankets Sheets Foot-drop stop Splints Heel and elbow protectors Floating mattress Air or water mattress Egg crates Trochanter rolls Lumbar roll Chair or positional bed I M P L E M E N TAT I O N ➧ Review prescriber’s order. Determine what is to be done and ability of patient to move. ➧ Gather all equipment before moving the patient. Saves time and allows patient to prepare for movement in/out of bed. ➧ Explain procedure and purpose to the patient/caregiver. Knowledge of procedure allows the patient to prepare for the procedure. Decreases dependency, disorientation, decreased motivation, and insomnia. Promotes relaxation. ➧ Don gloves and gown as necessary. Reduces transmission of infectious organisms. ➧ Assist patient to desired position for proper body alignment (use

assistance of another health-care provider if patient is unable to assist). Allows the position of comfort with correct alignment for the patient.

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408 C h a p t e r 2 1 Body Alignment and Mechanics ➧ Use the draw sheet or pull sheet to assist the patient in movement in

bed (use assistance of another health-care provider if patient is unable to assist). Another health-care provider may be needed to assist the patient to a chair or to stand. Assists in repositioning the patient. ➧ Place pillows, foot-drop stops,

splints, trochanter (sheet roll or blanket) between legs, under legs, or behind back as appropriate for comfort and positioning. Maintains position of comfort with correct alignment of the patient. Decreases back pain and/or discomfort. Ensures that joints and muscles are properly supported.

FIGURE 21.1A A footboard is placed

at the end of the bed to prevent foot drop.

Greater trochanter FIGURE 21.1B Trochanter roll prevents external rota-

tion. ➧ Assess all skin surfaces for pressure signs, such as blanched or red-

dened areas. Prevents tissue damage in areas of bony prominences, heavy tissue, or surgical-site areas.

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P r o c e d u r e 2 1 . 1 Maintaining Proper Body Alignment 409 ➧ Gently massage around (never on) pressure areas. Massage increases circulation to the area to prevent painful, reddened areas and decubitus ulcers. Prevents venous stasis, thrombus formation, and orthostatic hypotension. ➧ Perform complete range of motion at least three times per day. Maintains or increases muscle tone and prevents muscle atrophy. Prevents contractures; promotes relaxation and enhances flexibility. ➧ Turn and position patient frequently according to individual needs.

Elevate areas as needed. Prevents contractures, pressure points, thrombus formation, and decubitus ulcers. Prevents backaches and osteoporosis from disuse. Reduces edema.

FIGURE 21.1C The oblique position.

➧ Alternate use of chair, bed, or

standing as appropriate for individual patient. Promotes independence in choices of care. Eliminates the feeling of loss of control and deficient state of wellness.

FIGURE 21.1D Assisting patient to chair using a transfer belt.

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410 C h a p t e r 2 1 Body Alignment and Mechanics ➧ Provide instructions for and encourage coughing and deep

breathing in all positions. Prevents pooling of respiratory secretions thus restricting respiratory infections, hypostatic pneumonia, atelectasis, respiratory acidosis, and pulmonary emboli. ➧ When positioning is complete, return patient to comfortable

position. Patient comfort. ➧ Remove gloves (if used), discard, and wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient comfort and body alignment position Assess for complications such as contractures, decreased muscle tone, muscle atrophy, backaches, or osteoporosis ● Make sure supportive devices are correctly positioned and maintained ● Assess patient’s skin for signs of pressure, such as blanched or reddened areas ● Assess status of the respiratory and circulatory systems for venous stasis, thrombus formation, orthostatic hypotension, pooling of secretions, respiratory infections, atelectasis, respiratory acidosis, or pulmonary emboli ● Assess complications associated with immobility such as anorexia, constipation, renal calculi, urinary retention, or urinary tract infections ● ●

KEY POINTS ●

FOR

REPORTING

Position of patient. Patient’s response to change. ● Any tissue deviation or damage. ●

AND

RECORDING

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 411

PROCEDURE 21.2 Performing Correct Lifting Techniques OVERVIEW ●

To provide the patient and health-care provider with knowledge to perform correct lifting techniques, thus preventing stress, fatigue, trauma, and injury to promote comfort and prevent bone, joint, muscular, skin, or neural damage. P R E PA R AT I O N

Check prescriber’s order to appraise the amount of lifting the patient can perform. ● Determine need to assist the patient in the process of lifting. ● Assess the knowledge the patient has about the process of lifting. ● Determine need for any equipment to assist patient in the lifting process, proper body alignment, and correct body mechanics. ●

Special Considerations • Some patients require frequent re-educating about correct lifting positions. • The ability to perform lifting procedures may vary with each situation. Elderly and Physically Challenged Patients • May take longer to perform techniques due to limited mobility. R E L E VA N T N U R S I N G D I A G N O S E S

Pain/discomfort related to inability to perform correct lifting techniques due to limited mobility from poor muscle tone ● Risk for injury related to improper lifting techniques ●

EXPECTED OUTCOMES

Position will be comfortable and enhance proper body alignment at all times while performing the lifting process ● Patient will experience minimal discomfort in attaining proper body posture for lifting ● Patient will demonstrate proper lifting techniques in all performances ● Patient will express the value to his present and future health from the utilization of proper body alignment during the lifting process ●

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412 C h a p t e r 2 1 Body Alignment and Mechanics EQUIPMENT/SUPPLIES

Any positional aids such as pillows or blankets I M P L E M E N TAT I O N ➧ Review prescriber’s order. Determine ability of patient to lift. ➧ Gather all materials/equipment before approaching the patient. Saves time and allows patient to prepare for learning the lifting maneuvers. ➧ Explain procedures and purposes to the patient and/or caregiver. Knowledge of procedure allows the patient to prepare for the procedure. Decreases dependency, disorientation, decreased motivation, and trauma from improper techniques. ➧ Don gloves and gown if necessary. Reduces transmission of infectious organisms. ➧ Assist patient to desired position for proper body alignment (use

assistance of another health-care provider if patient is unable to assist). Teach patient to use proper body mechanics. Allows the position of comfort with correct alignment for the patient. Proper body mechanics can prevent back injury, help speed up recovery if injured, and prevent further injury after back is healed. ➧ Begin teaching the various lifting techniques. Use assistance of

another health-care provider if patient has difficulty in standing alone. Knowledge of the actual techniques will increase the patient’s selfconfidence and ensure future health. ➧ Have the patient test the weight of the load. Ascertain that the

patient can lift the weight safely. If not, use an assistive device. Safety at a task reduces trauma, pain, discomfort, and future injury. Ensures that joints and muscles are properly positioned. ➧ Keep the back in its natural curve by bending at the hips and/or

knees with the low back erect. Position allows for safe distribution of the forces. ➧ Maintain a wide base of support with feet. A solid and wide base of support reduces the possibility of slipping.

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 413

FIGURE 21.2 Wide stance lowers the center of gravity and is more stable.

➧ Hold objects as close to the body as possible. A wide base of support reduces stress to the muscles, ligaments, skeletal structure, and tissue of the back. ➧ Avoid twisting motion when lifting and carrying the object. Moving or changing the direction with the feet decreases the stress and load on the structures of the back. ➧ Tighten stomach muscles when lifting. Assisting with the abdomen reduces strain on the back during the lifting process. ➧ Plan the lift before beginning the process. Previous planning decreases the chance of damage to the body. ➧ Lift with the large muscle group of the legs. Use of the large muscle groups of the legs diminishes the forces on the low back. ➧ Make certain that the pathway is clear prior to beginning the move. A clear pathway eliminates slipping or falling. ➧ To squat-lift something of moderate size and weight: ●

Stand close to the object to be lifted.

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414 C h a p t e r 2 1 Body Alignment and Mechanics

Squat down, keeping the back straight, and firmly grasp the container. ● Pick up the container and hold it close to the body. ● Tighten the abdominal muscles and stand up slowly and smoothly letting the large leg muscles do the work. ●

Firm abdominal muscles strengthen the back. Use of the large muscle groups of the legs reduces the strain on the structures of the back. ➧ The half-kneel lift may be helpful with things that have an irregular

shape or may tend to move when lifted (e.g., pets, children). Stand close to the object, and squat down onto one knee. ● Keep the back straight; pick up the object and slide it up onto thigh and then cradle the object against the body. ● Tighten stomach muscles and slowly stand, using the strong leg muscles. ●

Use of the large muscle groups of the legs reduces the strain on the structures of the back. Proper body mechanics reduces trauma to the various body parts. ➧ The overhead lift is used when lifting objects down from a high sur-

face. A stepstool should be used when the object is higher than the head. ● Move close to the object. ● Place one leg in front of the other. ● Shift weight slightly to the front leg. ● Reach up and firmly grasp the object in both hands while keeping the back straight. ● Slowly lift the object off the shelf and shift equal weight back onto both feet. ● Carefully lower the object down to the chest. Maintaining proper body mechanics ensures stress and trauma reduction. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient comfort and body alignment position Teach patient about all aspects of lifting ● Assess for complications such as contractures, decreased muscle tone, muscle atrophy, backaches, or osteoporosis ● Supportive devices, if needed, are correctly positioned and maintained ● Monitor that patient assumes correct body mechanics for each lifting procedure ● Assess for injury in the lifting procedure ● ●

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P r o c e d u r e 2 1 . 2 Performing Correct Lifting Techniques 415

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Position of patient when lifting. Patient’s responses to lifting procedures. ● Any injury or damage the patient might experience. ●

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C H A P T E R

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22 Exercise and Ambulation 22.1 Performing Passive Range-of-Motion (ROM) Exercises, 418 22.2 Teaching Isometric Exercises, 422 22.3 Teaching the Patient to Crutch Walk or Use a Walker, 425

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418 C h a p t e r 2 2 Exercise and Ambulation

PROCEDURE 22.1 Performing Passive Range-of-Motion (ROM) Exercises OVERVIEW ●

To enhance/maintain joint ROM and soft tissue integrity, assist circulation and synovial nutrition, decrease formation of contractures, reduce or inhibit pain, and facilitate active ROM. P R E PA R AT I O N

Check prescriber’s orders to ensure passive ROM can be performed. Passive ROM is not the same as stretching. ● Movements should be performed in a pain-free ROM. ● Passive motion does not take the place of active motion. ● Will not prevent muscle atrophy. ● Will not increase strength or endurance. ● ●

Special Considerations • Careful handling needs to be done any time there is a surgical site, and this includes ROM restrictions or contraindications. Elderly, Pediatric, Unconscious, or Confused Patient • May take more time and communication to complete correctly. • Assess skin condition before beginning, and use gentle handling. • Include caregiver as much as possible because they may be participating when the patient goes home. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to cope with extremity movements ● Potential for injury related to improper ROM techniques used, such as extra force on a joint ●

EXPECTED OUTCOMES

Patient will experience comfort Maintenance or enhancement of ROM ● Assist in circulation and healing ● ●

EQUIPMENT/SUPPLIES

Gloves

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P r o c e d u r e 2 2 . 1 Performing Passive Range-of-Motion (ROM) 419 I M P L E M E N TAT I O N ➧ Review prescriber’s order. Determine if patient can be moved and any limitation of movement. ➧ Explain procedure to patient and/or caregiver. Enhances relaxation, understanding, and cooperation. ➧ Don gloves and gown. Reduces transmission of infectious organisms. ➧ Adjust bed to appropriate height for provider. Ensures proper mechanics and decreases strain. ➧ Assess placement of IVs, catheters, etc. Determine if any device will restrict motion. ➧ Lower side rails. Allows easier access to patient and allows good mechanics. ➧ Expose body part/extremity where ROM exercises will be performed,

and drape patient appropriately. Allows free motion of patient while providing privacy. ➧ Hold area to be moved close to joint (hand and wrist, hip, knee). Supports affected joint. ➧ Provide support of remaining extremity or injured site. Provides patient comfort and encourages relaxation. ➧ Move extremity through pain-free ROM (PROM) 5 to 10 times.

Follow anatomical planes or line of muscle. Accomplishes goals of PROM.

Neck

FIGURE 22.1

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420 C h a p t e r 2 2 Exercise and Ambulation

Wrist/hand

Shoulder

Hip

Elbow

Knee

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P r o c e d u r e 2 2 . 1 Performing Passive Range-of-Motion (ROM) 421

Foot

FIGURE 22.1 (continued)

➧ Monitor patient’s response to treatment, including facial

reactions, subjective reports, tissue response, vital signs, and ROM. Provides information regarding accomplishment of treatment and adjustments in speed and ROM if necessary. ➧ Reposition patient’s extremity and cover appropriately. Promotes comfort. ➧ Raise and secure side rails and other protective devices

in use. Patient safety. ➧ Document treatment. As required by facility. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Patient appears relaxed and correctly positioned Patient verbalizes comfort after treatment

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient’s response to treatment, including subjective and body response. ● Procedure performed, including direction and repetitions. ● Any limitations felt during motions. ● Report and discuss with prescriber any unusual findings, such as skin breakdown, increased pain after therapy.

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422 C h a p t e r 2 2 Exercise and Ambulation

PROCEDURE 22.2 Teaching Isometric Exercises OVERVIEW ●

To assist the patient to decrease pain, increase circulation when little resistance is applied, and increase strength, endurance, and circulation when adequate resistance (60%–80% maximum capacity) is applied. P R E PA R AT I O N

Check prescriber’s orders to ensure that isometric exercises can be initiated. ● Multiple angles may need to be performed, because strength gains are accomplished at the position performed. ● Site of application of resistance is usually distal to the segment desired to be strengthened. ● Force is applied opposite the desired direction of movement. ● There is no change in joint position during application. ●

Special Considerations • Gentle handling may be necessary for a patient with a surgical site, including ROM, muscle contraction, healing restrictions, and contraindications to prevent injury. • Determine need to educate caregivers about procedure. Elderly and Physically Challenged Patients • Determine and give consideration to patient’s physical conditioning and cognitive status. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to cope with body movements ● At risk for injury related to improper use of isometric exercises ●

EXPECTED OUTCOMES

Patient will increase strength in extremities Increase circulation to applied area ● Patient will experience an increase in comfort and healing time ● ●

EQUIPMENT/SUPPLIES

Gloves

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P r o c e d u r e 2 2 . 2 Teaching Isometric Exercises 423 I M P L E M E N TAT I O N ➧ Review prescriber’s orders. Determine if patient can be moved and any limitation or contraindication to treatment. ➧ Explain procedure to patient and caregiver as indicated. Enhances patient/caregiver understanding, participation, and relaxation. ➧ Don clean gloves. Reduces transmission of infectious organisms. ➧ Evaluate patient’s motion and strength. Determines how much resistance and ROM for isometric contraction to be performed. ➧ Place patient in comfortable position. Promotes relaxation. ➧ Position yourself so that you can use good body mechanics. Ensures provider safety. ➧ Assess placement of IVs, and catheters. Determine if devices will restrict techniques. ➧ Expose body part to be exercised. Ensures no restriction from clothing. ➧ Drape patient appropriately. Promotes patient privacy. ➧ Place extremity in desired position. To prevent possible injury. ➧ Stabilize extremity by holding in place. Helps prevent substitution from other muscle groups. ➧ Demonstrate movement by taking extremity through passive

ROM. Enhances patient’s understanding of motions. ➧ At desired angle, instruct patient to hold against resistance. Allows proper and safe movements. ➧ Advance slowly to movements that are maximum and pain-free

that the patient can tolerate. Provides maximum effect of exercise without pain and/or injury. ➧ Allow resistance to build from minimum to maximum. Allows patient understanding of movements and optimal muscle contraction.

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424 C h a p t e r 2 2 Exercise and Ambulation ➧ Hold contraction 10 seconds. Allows physiological changes to occur. ➧ Reassess patient’s status related to strength, pain, and

substitution. Allows adjustments in resistance, joint angle, and patient position. ➧ Repeat 10 times and then consider different angles for strengthen-

ing entire muscle. Allows treatment effects to entire muscle length. ➧ Adjust resistance, ROM, patient position. Ensures pain-free but maximum performance. ➧ Monitor patient’s response to treatment, including facial reactions,

subjective reports, tissue response, vital signs, and ROM. Provides information regarding accomplishment of treatment and adjustments in speed and ROM if necessary. ➧ Reposition patient’s extremity and cover/drape appropriately. Promotes patient comfort. ➧ Raise side rails and replace any other protective devices in use. Patient safety. ➧ Document treatment. As required by facility. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s ability to perform exercises Assess patient’s compliance with exercise schedule ● Assess muscle tone ● Assess for complications of bedrest, including thrombophlebitis, atelectasis, renal calculi, pressure ulcers, joint deformity ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient’s response to treatment, including subjective and body response. ● Procedure performed, including body part, direction, resistance, and repetitions. ● Any limitations/restrictions to treatment. ● Patient response/tolerance to treatment.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 425

PROCEDURE 22.3 Teaching the Patient to Crutch Walk or Use a Walker OVERVIEW ●

To allow patients to resume daily transfers, improve self ADLs, and increase household and community ambulation following deconditioning and/or surgery. P R E PA R AT I O N

Always use gait belt for patient safety. For safety considerations, ensure patient understands procedures. ● Check prescriber’s orders regarding teaching crutch walking and/or using a walker. ● ●

Special Considerations • For post-op patients, consideration has to be given to weightbearing precautions, contraindications, and deconditioning • Determine need to educate caregivers about the procedure and importance of safety measures Elderly Patient • Most often will require instruction on a walker versus crutches due to decreased physical fitness. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, and/or neuromuscular dysfunction ● Pain/discomfort related to inability to cope with extremity movements ● Potential for injury related to improper movements with crutches or a walker ●

EXPECTED OUTCOMES

Patient will be able perform self ADLs with minimal or no assistance or discomfort ● Patient will be able to ambulate independently while following precautions ● Patient will be able to assist in self-reconditioning ●

EQUIPMENT/SUPPLIES

Axillary crutches/walker Gait belt

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426 C h a p t e r 2 2 Exercise and Ambulation I M P L E M E N TAT I O N ➧ Review prescriber’s orders regarding the use of crutches or a walker. Determine if patient can be ambulated, and note any precautions or weightbearing restrictions. ➧ Don clean gloves. Reduces transmission of infectious organisms. ➧ Assess patient’s mental status. Determines if patient can follow explanations to ensure safety. ➧ Assess patient’s upper-extremity and lower-extremity strength. Ensures strength is adequate for gait training. ➧ Assess patient’s balance. Helps in selection of assistive device. ➧ Determine appropriate gait pattern and assistive device based on

physical and mental assessment, and record review. Ensures safety for patient. Follow surgical precautions.

TABLE 22.3A Different Types of Gait Patterns Four-point pattern

• Most stable pattern. • Requires bilateral ambulation device (crutches, cane). • Alternate pattern (i.e., left crutch advances and then right foot advances, right crutch advances and then left foot advances, etc.). • Slow gait pattern.

Two-point pattern

• Requires bilateral ambulation device (crutches, canes) • Faster than four-point. • Requires increased balance and coordination. • Reciprocal motion (i.e., right foot and left crutch together, then left foot and right crutch, etc.).

Three-point • Used with crutches or walkers. pattern • Used when patient requires non–weight-bearing status • Less stable pattern. • Requires good upper-extremity strength and coordination. • Assistive device and non–weight-bearing extremity advanced and then patient steps up to or through with full weight-bearing extremity. • Crutches or walker. Modified three-point • Use when allowed only partial weight-bearing. • Progress assistive device and partial weight-bearing extremity simulpattern taneously, and then progress full weight-bearing lower extremity. • More stable, than three-point gait pattern.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 427

2-Point Gait

3-Point Gait

4-Point Gait

• Partial weight bearing, both feet: faster, but less support than a 4-point gait.

• Non-weight bearing; faster than a 4-point gait; can be used with walker

• Partial weight bearing, both feet; patient must shift weight constantly

4. Advance right foot and left crutch

4. Advance right foot

4. Advance right foot

3. Advance left foot and right crutch

3. Advance left foot and both crutches

3. Advance left crutch

2. Advance right foot and left crutch

2. Advance right foot

2. Advance left foot

1. Advance left foot and right crutch

1. Advance left foot and both crutches

1. Advance right crutch

Tripod postition

Tripod postition

Tripod postition

FIGURE 22.3

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428 C h a p t e r 2 2 Exercise and Ambulation ➧ Assess for IVs, catheters, etc. Determine if any device will restrict and/or interfere with selected gait pattern. ➧ Assess walking area for hazards and/or barriers. Ensure safe walking environment. ➧ Check crutches/walker for safety (i.e., bolts tight, rubber caps not

worn). Ensure equipment safety. ➧ If necessary, transfer patient to seated position. Allow patient to watch demonstration of gait pattern. ➧ Apply gait belt. Ensure patient’s safety. ➧ Demonstrate selected gait pattern. Educate patient on correct procedure. ➧ Have patient explain procedure to you. Ensures patient understanding of techniques. ➧ If performing four-point pattern:

Instruct patient to move one crutch, then opposite foot. Maintain grip on gait belt. ● Continue with opposite crutch, then opposite foot. ● Repeat. ● ●

For use with unstable patient. ➧ If performing two-point pattern:

Instruct patient to move one crutch and opposite foot simultaneously. ● Repeat with other side. ●

For use when safety remains a concern. ➧ If performing three-point pattern:

Instruct patient to move crutches/walker forward, advance non–weight-bearing lower extremity. ● Instruct patient to advance uninvolved extremity placing weight through upper extremity. ● Maintain grip on gait belt. ●

For use with non–weight-bearing lower extremity, a walker is more stable. Patient safety. ➧ If performing modified three-point pattern: ●

Instruct patient to progress assistive device and partial weightbearing lower extremity.

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P r o c e d u r e 2 2 . 3 Teaching the Patient to Crutch Walk & Use a Walker 429

Instruct patient to advance uninvolved lower extremity to or through placing weight through upper extremity and partial weight-bearing lower extremity. ● Maintain grip on gait belt. ●

Patient safety. ➧ Walk at least 20 feet. Ensures patient performance safety and understanding.

Ascending (if non–weight-bearing lower extremity) ➧ With crutches: Patient pushes through crutches to raise unin-

volved lower extremity to next step. ➧ With walker: Place up onto curb first and then raise uninvolved

lower extremity by pushing through walker. To allow clearance to step. ➧ With crutches and walker:

Hold non–weight-bearing knee in flexion. Step up and advance crutches or walker. ● Repeat. ● ●

Descending ➧ When full weight-bearing allowed with crutches:

Lower crutches/walker and weak lower extremity down to next surface while bending/controlling with strong lower extremity. ● Step down with strong lower extremity placing weight through walker or crutches. ●

Allows control of weak lower extremity with strong lower extremity. ➧ When non–weight-bearing on lower extremity: ● ●

Place non–weight-bearing lower extremity in front of body. Place crutches/walker on surface below. Allows control with weight-bearing lower extremity and protects non–weight-bearing extremity.

●

Lower down to next level by bending strong leg and placing weight through crutches/walker.

●

Maintain grip on gait belt.

Ensures patient safety.

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430 C h a p t e r 2 2 Exercise and Ambulation

All Patients ➧ Monitor patient’s response to treatment including difficulties, safety

concerns, subjective reports, and visual signs. Provides information regarding appropriateness of device selection and modification, if needed. ➧ Return patient to sitting or lying position with call button. Provides patient comfort. ➧ Document treatment including any equipment needs for discharge. Communication and facilitation of patient care. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess patient’s ability to ambulate with assistive device Assess patient’s tolerance of activity, distance he or she can ambulate, proper technique

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient’s response to treatment including subjective, body response, and safety. ● Assistive device, gait pattern, assistance required, and for what length/time of ambulation. ● Any safety concerns for patient and other caregivers.

C H A P T E R

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23 Transfer and Positioning 23.1 Moving and Positioning the Patient in Bed, 432 23.2 Transferring a Patient from Bed to Wheelchair, 437 23.3 Teaching Hip Precautions, 439

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432 C h a p t e r 2 3 Transfer and Positioning

PROCEDURE 23.1 Moving and Positioning the Patient in Bed OVERVIEW ●

To facilitate and maintain correct body alignment, reduce discomfort, and promote normal tissue integrity. P R E PA R AT I O N

Check prescriber’s orders for specific restrictions. Assess patient’s ability to assist with moving. ● Determine patient’s and/or caregiver’s ability to understand and follow instructions. ● Assess patient’s activity tolerance. ● Determine comfort level of patient. ● ●

Special Considerations • Be sure that IV and/or drainage tubing is positioned to prevent tension or tangling during procedure. • If the patient is in isolation or if there is presence of body fluids or wet bed/clothing, wear gloves, gown, and any other personal protective equipment as indicated. Elderly and Physically Challenged Patients • Often have fragile skin; be careful not to drag the patient across the sheets, because it could cause skin sheering or tearing. • May take more time due to contractures and fragile bones. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to tolerate body movements ● Impaired skin integrity related to limited mobility and prolonged pressure on bony prominences ● Self-care deficit related to mental and/or physical impairment ●

EXPECTED OUTCOMES

Patient will be moved and positioned in bed without injury or discomfort ● Patient will maintain proper skin integrity with positioning regimen ●

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P r o c e d u r e 2 3 . 1 Moving and Positioning the Patient in Bed 433 EQUIPMENT/SUPPLIES

Hospital bed with side rails Pillows Trapeze if indicated Turn sheet or draw sheet Clean gloves Personal protective equipment (if indicated) I M P L E M E N TAT I O N

Moving Patient Up in Bed (One Nurse) ➧ Wash hands and don gloves and any other personal protective

equipment, if indicated. Reduces transmission of microorganisms. ➧ Explain procedure to patient and/or caregiver as indicated, and

how to assist if able. Reduces anxiety. Increases comprehension and cooperation. Promotes patient autonomy. ➧ Raise bed to your thigh level. Place patient on back with head of

bed in flat position. Lower side rails on side nearest you. Lock bed wheels. Lessens strain on nurse’s back muscles. Reduces gravity’s pull on patient’s upper body. Promotes patient safety. ➧ Remove pillow and place against the headboard. Prevents striking patient’s head against head of bed. ➧ Have patient fold arms across chest. Prevents injuring the patient’s arms during the move. ➧ If available, have patient hold on to overhead trapeze. Allows patient to assist with move, thus promoting patient’s autonomy. ➧ Have patient flex knees, and place feet flat on bed. Allows patient to assist with move. ➧ Stand at an angle to the head of the bed, feet apart, knees bent,

and feet toward the head of bed. Promotes good body mechanics. ➧ Place one hand and arm under patient’s shoulder, and the other

under patient’s thigh. Distributes patient’s weight more evenly. Supports shoulder and hip joints.

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434 C h a p t e r 2 3 Transfer and Positioning ➧ Rock forward toward the head of the bed, lifting patient with

you while having patient push with his/her legs. Note: If trapeze available, have patient pull up holding onto trapeze as you move patient upward in bed. Allows a smooth motion to lift patient. Assistance from patient reduces strain on nurse’s back muscles. Promotes patient autonomy. ➧ Replace patient’s pillow under the head. Elevate head of bed to

position tolerated by patient. Promotes patient comfort. Facilitates activities such as eating and drinking. ➧ Repeat steps if necessary until patient is high enough in bed. Heavy or immobile patients are often not moved far enough in one step. ➧ Raise side rails. Lower bed. Promotes patient safety. ➧ Wash hands. Reduces transmission of microorganisms.

Moving Patient Up in Bed (Two Nurses) ➧ With two nurses on opposite sides of bed, lower side rails. Lock

the wheels on the bed. Promotes patient safety. ➧ Remove pillow and place against headboard. Prevents striking patient’s head against top of bed. ➧ Place draw sheet on bed under patient’s midsection. Supports patient’s weight and reduces friction during move. ➧ Roll or bunch sheet so edges are close to patient’s body and

grasp firmly next to patient’s shoulders and hips. Provides support under heavy parts of the body and places the nurse’s hands close to the weight to be moved. ➧ If able to assist, have patient flex knees and place feet flat on

bed. Allows patient to assist with move.

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P r o c e d u r e 2 3 . 1 Moving and Positioning the Patient in Bed 435 ➧ Facing head of bed, the nurses stand on either side of the

patient’s center with knees flexed and feet apart in a broad stance. Increases stability and provides balance. Promotes good body mechanics. ➧ On signal, rock and shift weight

from back to front leg, moving patient upward in bed in one smooth motion. If possible, patient can assist with this move by pushing with his or her legs. Repeat the move if necessary. Provides additional force of body weight, reduces force needed to move load and decreases work of muscles during movement. Patient’s assistance lessens strain on nurse’s back muscles and promotes patient autonomy. FIGURE 23.1A

➧ After each positioning, realign patient, replace pillows and

other positioning aids. Replace bed to safe position; remove gloves and other protective equipment; wash hands. Promotes patient comfort. Maintains correct body alignment. Reduces transmission of microorganisms.

Turning a Patient in Bed ➧ Position patient near far side of bed in supine position. Provides room for patient to safely turn to side. ➧ Position patient’s near arm across the chest. Slightly abduct

the patient’s far shoulder from the side of the body. Place the patient’s near ankle and foot across the far ankle and foot. Prevents injury to patient’s arm. Facilitates movement during roll.

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436 C h a p t e r 2 3 Transfer and Positioning ➧ Place your hands on patient’s

far shoulder and hip and roll patient toward you. If drawsheet is in place, grasp it near patient’s shoulder and hip instead. Maintains proper body alignment. Drawsheet provides continuous support for patient’s back and should be used when available.

FIGURE 23.1B

➧ Stand opposite patient’s center with feet in wide stance and one

foot ahead of the other. Tighten abdominal and gluteal muscles, and flex your knees. Promotes good body mechanics. Wide stance provides a stable base of support. Increases stability and provides balance. ➧ Position patient with pillows and other positioning aids; raise side

rails; lower bed; remove gloves and other protective equipment; wash hands. Promotes safety and reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Patient was repositioned without injury and reports comfort Patient will maintain adequate skin integrity after moving and positioning therapy

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient’s body alignment and position, and comfort level. change in skin condition.

● Any

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P r o c e d u r e 2 3 . 2 Transferring a Patient from Bed to Wheelchair 437

PROCEDURE 23.2 Transferring a Patient from Bed to Wheelchair OVERVIEW ●

To promote safety, prevent injury, and maintain correct body alignment. P R E PA R AT I O N

Check prescriber’s orders for specific restrictions regarding patient activity and positioning. ● Assess patient’s ability and motivation to assist. ● Determine patient’s and/or caregiver’s ability to understand and follow instructions. ● Assess joint mobility and muscle strength of extremities. ● Determine presence and location of any equipment and tubing. ●

Special Considerations • Some patients may need analgesic medication to enhance comfort prior to moving. Elderly, Pediatric, Confused, and Physically or Mentally Challenged Patients • May require more time, teaching, and assistance. • Involve family and/or caregiver in teaching of this procedure. • Monitor activity while in wheelchair. • Use seat belts/special restraint devices that fasten behind the wheelchair to protect from sliding down and falling. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to tolerate moving, sitting, and/or standing ● Self-care deficit related to mental and/or physical impairment ●

EXPECTED OUTCOMES

Patient will be transferred from bed to wheelchair without injury and with minimal or no discomfort ● Patient and/or caregiver will be able to assist with the procedure ●

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438 C h a p t e r 2 3 Transfer and Positioning EQUIPMENT/SUPPLIES

Wheelchair Clean gloves Any other personal protective equipment as needed I M P L E M E N TAT I O N ➧ Explain procedure to patient and significant others. Reduces anxiety and enhances participation. ➧ Wash hands and don gloves. Reduces spread of microorganisms. ➧ Close door or curtain. Provides for privacy. ➧ Assist patient to put on robe and non-slippers or shoes. Promotes safety by reducing the risk for falls and injury. ➧ Place bed in lowest position. Facilitates transfer to wheelchair. ➧ Position the wheelchair as close as possible to the bedside facing the

foot of the bed. When sitting at side of bed, patient should be able to steady self by using the hand on the unaffected side to grasp the arm of the wheelchair. Facilitates use of stronger side to provide balance and improve stability during transfer. ➧ Lock wheels of bed and wheelchair. Raise foot pedals on wheelchair. Promotes patient safety. ➧ Raise head of bed to highest position. Decreased expenditure of energy. ➧ Assist patient to sitting position on side of bed by supporting

patient’s head and neck while moving patient’s legs over edge of the bed to dangle. Steady patient in this position for a few minutes. Facilitates transfer to the wheelchair and allows circulatory system to adjust to change in position (reduces risk for postural hypotension). ➧ To assist patient to standing position, face patient and brace your

feet and knees against the patient (especially against the patient’s affected extremity). Promotes stability and use of unaffected extremities to facilitate movement. ➧ Pivot the patient (on unaffected limb if applicable) toward seat

of chair with legs positioned against the chair. Enhances patient’s sense of security and ensures proper position before sitting.

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P r o c e d u r e 2 3 . 3 Teaching Hip Precautions 439 ➧ The patient may use one arm (the unaffected limb if applicable)

to place on the arm of the wheelchair while slowly easing self to sitting position in wheelchair. Ability to use own arm provides support and stability for patient. ➧ Continue to brace patient’s knees with your knees and flex your

hips and knees when lowering patient to sitting position. Reduces potential for strain on the nurse’s back. ➧ Adjust or support patient’s position with pillows where necessary. Promotes proper body alignment and comfort. ➧ Place call light within reach. Promotes patient safety. ➧ Remove gloves and other protective equipment, and wash hands. Reduces spread of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s tolerance of activity Assess patient’s ability to transfer safely ● Reinforce teaching ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Patient tolerance of procedure and length of time in wheelchair. ● Ability to assist with transfer. ● Patient’s level of comfort during transfer and while sitting in wheelchair.

PROCEDURE 23.3 Teaching Hip Precautions OVERVIEW ●

To facilitate postoperative recovery and prevent artificial hip dislocation.

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440 C h a p t e r 2 3 Transfer and Positioning P R E PA R AT I O N

Check prescriber’s orders for specific restrictions regarding patient activity and positioning. ● Assess patient’s readiness and ability to learn. ●

Special Considerations • Some patients may need analgesic medication to enhance comfort prior to moving. Elderly, Pediatric, Confused, and Physically or Mentally Challenged Patients • May require more time, teaching, and assistance. • Involve family and/or caregiver in teaching of this procedure. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to tolerate moving ● Self-care deficit related to mental or physical impairment ● Risk for injury related to improper use of positioning techniques ●

EXPECTED OUTCOMES ● ●

Patient will be free of complications from hip replacement Patient will use and maintain proper positioning for optimum comfort EQUIPMENT/SUPPLIES

Wedge or pillow I M P L E M E N TAT I O N ➧ Teach patient to avoid:

Adduction of legs by using abduction pillow or bed pillow between legs. ● Hip flexion, external rotation. ● Crossing leg (either in bed or seated). ● Bending hip past 90 degrees. ● Turning or rolling foot of operated leg inward. ● Lying on operated hip. ●

Maintains proper position and reduces risk for hip dislocation.

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P r o c e d u r e 2 3 . 3 Teaching Hip Precautions 441

FIGURE 23.3A Abductor pillow prevents

hip adduction. ➧ Instruct patient to keep the abduction wedge or pillow between

knees/legs when in bed. Prevents patient from crossing legs. Correct hip flexion

90 °

FIGURE 23.3B

Incorrect hip flexion

90°

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442 C h a p t e r 2 3 Transfer and Positioning ➧ Instruct patient to keep the toe of affected leg pointed forward

when standing, sitting, or lying. Also, instruct patient not to stand pigeon toed. Maintains proper position and reduces risk for hip dislocation. ➧ Instruct patient on signs and symptoms of dislocated hip (begins

with popping or slipping sensation; patient will not be able to bear weight on affected limb and may experience a fair amount of pain and discomfort). If signs and symptoms are experienced, notify prescriber immediately. The earlier complications are identified and treated, the less permanent the damage that will occur. ➧ Instruct patient on looking after hip joint:

Look for signs and symptoms of infection in the hip including pain, redness, swelling, or increased warmth. ● Follow all instructions regarding any activity or positioning limitations or restrictions. ●

The earlier complications are identified and treated, the less permanent the damage that will occur. ●

Assist patient or have patient perform leg exercises as ordered by prescriber. Reduces risk for blood clots forming in legs and possibly traveling to lungs. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s understanding of hip precautions Monitor patient’s position to maintain hip abduction and leg in neutral position ● Provide written instructions for discharge activities and positioning ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Patient/caregiver understanding and willingness to follow hip precautions. ● Patient’s self-care capabilities. ● Patient’s level of comfort and response to positioning and pain management.

C H A P T E R

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24 Orthopedic Interventions 24.1 24.2 24.3 24.4 24.5

Providing Cast Care, 444 Managing Skin Traction, 448 Managing Skeletal Traction, 453 Applying a Moist Compress, 456 Applying an Ice Bag, Ice Pack, or Collar, 459

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444 C h a p t e r 2 4 Orthopedic Interventions

PROCEDURE 24.1 Providing Cast Care OVERVIEW

To immobilize an injured structure that needs to maintain anatomical position. ● Used chiefly for fractures after they have been realigned. ●

P R E PA R AT I O N

Maintaining the cast—preventing cracks, exposure to dirt, wetness; keeping it clean. ● Evaluation of extremity in the cast—swelling, circulation. ● Detecting and evaluating bleeding. ●

Special Considerations • If the patient has had a compound fracture that required internal fixation or open reduction, the nurse should watch the cast for signs of bleeding for the first 24 to 48 hours. Elderly Patient • Elderly patients, due to trauma and pain medication, can easily become disoriented and lose balance or have difficulty with unbalanced gait. Pediatric Patient • With pediatric patients, it is especially important to instruct the family in recognizing signs of infection and drainage, and in the need to discourage children from scratching under the cast. • Instruct on ways to keep cast dry, especially when patient needs to be bathed. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Alteration in comfort related to trauma Impaired tissue perfusion related to trauma EXPECTED OUTCOMES

Patient will not experience pain, discoloration, or sensory or motor impairment of affected extremity ● Extremity in the cast will have good capillary refill ●

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P r o c e d u r e 2 4 . 1 Providing Cast Care 445

Patient will be able to ambulate and perform active range-of-motion (ROM) and isometric exercises as ordered by physician ● No evidence of neurovascular impairment in extremity in the cast ● No evidence of infection ●

EQUIPMENT/SUPPLIES

Thermometer (to monitor for signs of infection) Pillows Bed linens Towels Washcloths Alcohol pads I M P L E M E N TAT I O N ➧ Explain to the patient that you will be assessing the status of the

cast and extremity every 1 to 2 hours. Understanding promotes acceptance. ➧ Remove any cast residue that might be around the cast and on the

skin. This residue can be irritating to the patient’s skin. Removing it can prevent rashes or skin irritation. ➧ Elevate the extremity in the cast. Determine that each distal joint is

higher than the preceding one. Elevation promotes venous return and decreases swelling that could increase pressure and compromise neurovascular integrity. ➧ Ice bags can be placed next to a cast, especially next to an incision

if physician warrants its use. This controls swelling and bleeding. ➧ Expose cast directly to the air—do not cover the cast with blankets

or sheets. A cast produces heat as it dries, and if it is covered up, moisture can accumulate and delay the drying process. ➧ Ensure that nothing rests or lays on a wet cast. Pillows are to be used

under the cast to allow the cast to dry on a soft surface. Handle the cast only if necessary and use only the palms of your hands,

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446 C h a p t e r 2 4 Orthopedic Interventions Heavy objects or pressure from fingers that are placed on a wet cast can cause indentation and pressure points. This can result in neurovascular compromise.

FIGURE 24.1 Handle wet cast with palms

only. ➧ Footboards or cradles can be used to keep the patient covered but

off wet cast. Linen can be supported on these cradles or footboards to provide warmth and protect patient’s privacy. This will still allow air to circulate for the cast to dry. ➧ Turn patient to a different position every 2 hours. Repositioning helps to expose the cast to air and allows the cast to dry evenly. ➧ Assess for signs and symptoms of excess swelling and pressure

on the casted extremity every 30 minutes initially, then every 1 to 2 hours, if the assessment has been normal: ● Inspect and palpate to test for swelling, paleness, cyanosis, coolness of the skin. ● Check for capillary refill by putting pressure on the nail bed and releasing to determine return of blood flow to nail bed. ● Take pulses distal to casted areas. ● Determine degree of sensation in the extremity, and take note of any change. ● Ask patient to alert you to any areas of numbness or tingling. ● Check temperature of the skin above and below the casted extremity. ● Ask the patient to move his or her fingers or toes (whatever applicable) to check ability for movement. The cast is a rigid object that cannot expand when the tissue under it expands or swells. When the extremity does swell, neurovascular integrity can be compromised. Frequent assessments help to identify problems before they occur.

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P r o c e d u r e 2 4 . 1 Providing Cast Care 447 ➧ Watch for signs of drainage or bleeding on the cast. Bleeding can occur especially with compound fractures and open reduction. Venous blood turns brown and stops in a short time; arterial bleeding is bright red and continues to spread on the cast. ➧ Draw a ring around the drainage and add date, time, and initials.

Infection will produce drainage that may produce an odor. The color of the drainage will be tan or light brown. Determine degree of bleeding or discharge. ➧ Change a patient’s position every 1 to 2 hours. Mobility can decrease incidence of venous stasis, which could lead to vein thrombosis and pressure spots, leading to skin breakdown. ➧ Encourage ROM exercises for all extremities. Isometric exercises can

be used for the cast extremity. Exercise promotes circulation and muscle tone and prevents atrophy of casted muscles. ➧ Inspect the edges of the cast for rough edges or chipping plaster.

Cover rough edges with tape. Rough edges or chipped areas can cause skin abrasion and subsequent breakdown. Pieces of chipped plaster can become lodged inside the cast and further compromise skin integrity. ➧ Instruct patient not to insert objects into casted extremity, such as

straws and tooth brushes, when skin itches. Skin becomes dry and itchy under cast. Keeping skin lubricated by using lotion can help with dry itchy skin. Objects inserted inside cast can increase chance for skin abrasion and further skin breakdown. ➧ Periodically remove dry, flaked skin debris or chipped plaster from

inside the cast with vacuum cleaner or hair dryer hose using cool settings. Air can blow out debris keeping area free of debris. ➧ Protect the cast from wetness, especially when patient needs to

bathe. Cover the cast with plastic wrap and tape securely whenever patient needs to perform personal hygiene. Wet plaster softens and is not as strong as it needs to be to be an effective immobilizer. Plastic wrap can be taped securely and is waterproof if applied correctly. ➧ Instruct patient on avoiding overstrenuous activities that may dis-

lodge or misalign extremity or cast. Patient may dislodge or misalign extremity or cast and cause trauma to injured extremity.

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448 C h a p t e r 2 4 Orthopedic Interventions E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Casted extremity should be assessed every 30 minutes for 1 to 2 hours and, if assessment is within normal limits, then every hour for 24 hours and, if assessment is within normal limits, every 4 hours from that time on ● Check cast daily for odor, drainage, bleeding, cracks, crumbling plaster ● Neurovascular checks: temperature, color, capillary refill, edema, numbness, tingling sensation every 30 minutes for 1 to 2 hours and, if assessment is within normal limits, every hour for 24 hours and, if assessment is within normal limits, every 4 hours from that time on ● Instruct patient on avoiding overstrenuous activities that may dislodge or misalign extremity or cast ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Neurovascular assessment findings. Patient’s complaints and nursing responses. ● Presence of any drainage. ● Patient’s acceptance of cast. ● Type of cast applied if applied on your shift. ● Patient’s complaints and nursing responses. ●

PROCEDURE 24.2 Managing Skin Traction OVERVIEW

To provide pull and counterpull on a particular area of an extremity. ● To provide correct alignment of bony ends. ●

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P r o c e d u r e 2 4 . 2 Managing Skin Traction 449 P R E PA R AT I O N

Applied directly to the skeletal system by attaching weight to the skin. ● Comes in various types, such as Buck’s traction or Russell’s traction. ●

FIGURE 24.2A Buck’s traction.

Overbed frame

Trapeze

Russell’s traction

FIGURE 24.2B Russell’s traction.

Usually applied while patient is in bed. The pull is achieved by using weights in the form of sandbags, freeweight discs; counterpull is produced by patient’s own weight. ● Traction is possible through use of slings, ropes, pulleys, and weights. ● ●

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450 C h a p t e r 2 4 Orthopedic Interventions

Special Considerations • Patients with previous compromised neurovascular status need extra assessment. Nurse should check patient’s status every 30 minutes to ensure that no further loss of integrity is noted. Elderly Patient • Elderly patient has increased chance for venous stasis. Extra care needs to be taken to ensure the patient is free of thrombosis and emboli. • Constipation is another concern due to decreased motility, poor appetite, and decreased intake of fluids. Nurse needs to determine patient’s bowel habits and provide measures to ensure adequate elimination. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to impaired blood flow Risk for infection related to diabetes EXPECTED OUTCOMES

Extremity is maintained in correct position Bone ends are aligned and do not override ● Skin of affected extremity remains intact ● Patient maintains good body alignment ● ●

EQUIPMENT/SUPPLIES

Ropes, pulleys, and weights Tape Foam rubber or plastic sheeting Metal block spreader Traction foam boot Elastic bandage Sheepskin pad Shock blocks I M P L E M E N TAT I O N ➧ Review the physician’s order and ensure that you have correct trac-

tion equipment available. There are different types of traction. Making sure you are setting up for the correct, prescribed type will prevent injury to the patient. ➧ Explain the procedure to the patient. Understanding promotes acceptance.

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P r o c e d u r e 2 4 . 2 Managing Skin Traction 451 ➧ Most hospitals have an orthopedic technician who sets up the trac-

tion. If the hospital does not have a technician, review the procedure with other nurses who may have experience in setting up traction. Call the orthopedic technician and provide him with copy of physician’s order for traction. ➧ If you anticipate that the patient will have pain or discomfort during

the procedure, consider premedicating the patient as ordered by physician. Providing premedication will lessen the pain and discomfort when applying skin traction or assessing the traction effectiveness. Make sure there is a physician order; if there is not one, call physician and explain your desire to provide the patient with pain relief. ➧ Lay out all equipment. Facilitates procedure, ensures safe efficient care of patient. ➧ Place bed in semi-Trendelenburg position. Make sure this position

will not compromise patient’s condition—verify with physician before moving patient to this position. Trendelenburg position helps keep the traction intact, but in some cases patients cannot tolerate this position without compromise in respiratory status. ➧ Inspect skin for any signs of abrasion or lesions that could be

disturbed when skin traction is applied. Make sure skin is clean and dry. Skin traction (tape and pressure) placed over abraded areas could aggravate skin condition. ➧ Assess neurovascular status of patient’s extremities, and document

findings for referral later. Sets a baseline for later comparison. ➧ Position the patient in the center of the bed in good body

alignment. Ensures effective counterpull without compromising neurovascular status. ➧ Have a second person support the affected extremity so that you

can apply the elastic bandage and foam boot. Ensures that the affected extremity remains in alignment; reduces discomfort; allows the nurse the ability to apply the foot boot and elastic bandage (from the ankle up to knee). ➧ Place leg in foam boot, making sure to adjust the heel of the foot

snugly into boot. Prevents neurovascular compromise.

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452 C h a p t e r 2 4 Orthopedic Interventions ➧ Secure Velcro bootstraps, but avoid bony prominences. Prevents skin abrasion and breakdown. ➧ Apply metal spreader to allow the nurse to attach ropes and weights

as directed by physician. Spreads the ropes to equal distance so that traction is equally distributed. ➧ Apply weights, making sure they are not touching the bed, frame, or

floor. Weights should be free for adequate counterpull. ➧ Check with physician to determine the need for thromboembolic

disease stockings (TEDS) to other extremity. Prophylaxis against venous stasis. ➧ Assess neurovascular status of patient’s extremities and document

findings every 30 minutes when first applied; if there is no change, check status every 1 to 2 hours. This ensures adequate neurovascular integrity. Changes can be quickly noted. ➧ Check patient’s position every 1 to 2 hours to ensure that the patient

is in proper position to allow adequate counterpull of traction. Allows adequate counterpull of traction. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Determine that patient is in good body alignment Check to make sure elastic bandage and foot boot are in proper position ● Check that traction is equally distributed ● Determine if patient is warm and free of discomfort ● Assess neurovascular status ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Neurovascular status before and after traction applied. is maintained. ● Patient comfort. ● Skin integrity. ● Traction

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P r o c e d u r e 2 4 . 3 Managing Skeletal Traction 453

PROCEDURE 24.3 Managing Skeletal Traction OVERVIEW ● ●

To provide pull and counterpull on a particular area of an extremity. To provide correct alignment of bony ends.

FIGURE 24.3A Balanced suspension and skeletal traction for femur.

P R E PA R AT I O N

Applied directly to the skeletal system by attaching weight to the bone. ● Usually applied in the operating room and maintained while patient is in bed. ● The pull is achieved by using weights in the form of sandbags and free-weight discs; counterpull is produced by patient’s own weight. ● Traction is possible through use of slings, ropes, pulleys, and weights. ●

Special Considerations Elderly Patient • Skin is fragile and needs extra protection—take care to protect bony prominences to prevent skin breakdown. • Encourage range-of-motion (ROM) exercises to prevent venous stasis. • Encourage the patient to decorate his or her room to feel more at home.

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454 C h a p t e r 2 4 Orthopedic Interventions

• Encourage visitors. • Encourage self-care activities. Pediatric Patient • Check patient’s position—the child is small and can change position, making traction inadequate or harmful to neurovascular integrity. • Check to make sure patient has “safe toys” to play with. • Take precautions when child eats in the supine position—avoid aspiration. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to impaired blood flow Risk for infection related to trauma EXPECTED OUTCOMES

Extremity is maintained in correct position Bone ends are aligned and do not override ● Skin of affected extremity remains intact with no signs of infection ● Patient maintains good body alignment ● ●

EQUIPMENT/SUPPLIES

Slings, ropes, pulleys, and weights Tape Sterile cotton tip applicators Hydrogen peroxide Normal saline solution Foam rubber or plastic I M P L E M E N TAT I O N ➧ Traction is usually applied in the operating room under aseptic

technique. Procedure is painful and requires bone alignment and perforation of skin. General anesthesia is usually required to allow the surgeon to manipulate the fracture and align it correctly. ➧ When patient returns to his or her room, the nurse should inspect

the traction and other equipment to make sure weights and traction equipment are applied correctly. Ensures proper functioning of equipment, preventing injury. ➧ Make sure the patient’s bed has trapeze attached to bed frame. This will allow patient to move safely and perform ROM exercises, keeping muscles from atrophy.

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P r o c e d u r e 2 4 . 3 Managing Skeletal Traction 455 ➧ Regularly check to make sure patient is in center of bed. Good body alignment ⫽ adequate counterpull of traction. ➧ Avoid tucking in bed clothes. Tucking in bed clothes can impede traction. ➧ Instruct patient and family regarding ROM and body positions. Patient needs to be reminded not to turn to the side, because it disrupts traction integrity. ➧ Allow patient to do as much self care as possible—personal hygiene,

etc. Self-care activities can help a patient feel confident and useful. ➧ Clean back and buttocks and provide lotion and extra padding to

body prominences each day. Helps the patient feel clean; keeps skin from breakdown. ➧ Apply sheepskin or egg-crate mattress to patient’s bed to protect

skin from abrasion and pressure, especially to heels, back, pelvis, and elbows. Avoids skin breakdown and provides comfort for patient. ➧ Avoid using more than two pillows under patient’s head. Pillows can disrupt counterpull of traction. ➧ Use fracture bedpan for patient’s elimination needs. Facilitates elimination and ensures counterpull of traction. ➧ Encourage ROM exercises—isometric and isotonic exercises—and

frequent dorsiflexion of extremities. Facilitates circulation and prevents venous stasis. ➧ Inspect skin areas around traction attachment, checking for redness

and swelling. Keeps skin from infection and further breakdown. ➧ Clean skeletal attachment areas as directed by physician. Keeps skin from infection and further breakdown. ➧ Cover sharp edges or points with gauze or tape. Prevents possible injury to patient, family, or caregiver. ➧ Assess neurovascular status as directed by physician. Ensures proper circulation and nerve integrity. ➧ Allow patient to schedule personal activities and decorate room. Encourages self-control; prevents social isolation.

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456 C h a p t e r 2 4 Orthopedic Interventions E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Neurovascular state of extremity checked often to ensure adequate circulation and nerve function ● Frequent encouragement of patient to perform ROM exercises and set times for the patient to perform that are understandable to nurse and patient ● Vital signs taken as ordered ● Patient’s mental status will remain normal ● Integrity of the skin maintained ● Integrity of traction maintained ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Neurovascular state of extremity in traction. Patient’s ability to perform ROM exercises and times performed. ● Vital signs. ● Patient’s mental status. ● Integrity of the skin. ● Integrity of traction. ● Bowel and bladder integrity. ● Intake and output. ●

PROCEDURE 24.4 Applying a Moist Compress OVERVIEW ●

Local applications of moisture to an area to reduce pain, swelling, and temperature. P R E PA R AT I O N

May be hot or cold applications depending on desired purpose. Several layers of moist cloths may be used. ● Application of heat is generally more concentrated than cold. ● Duration of use longer than a soak. ● Application of hot or cold moist compresses will depend on patient’s tolerance. ● ●

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P r o c e d u r e 2 4 . 4 Applying a Moist Compress 457

Special Considerations • With elderly and pediatric patients, do not use too hot or too cold compresses due to fragility of skin. • Protect bed linens from wetness, which could further compromise skin integrity. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to impaired blood flow Risk for infection related to diabetes EXPECTED OUTCOMES

Reduced swelling Reduced bleeding ● Keeps area lubricated ● Decreased pain ● ●

EQUIPMENT/SUPPLIES

Clean basin Clean washcloths Tape Plastic wrap/bag Linen saver/chucks Disposable gloves Gauze pads Hot water, or Ice water I M P L E M E N TAT I O N ➧ Check physician’s order for application of moist compresses:

check to see if order calls for hot or cold applications. Ensures that correct process is followed as ordered by attending physician. ➧ Gather all equipment to the bedside. Facilitates procedure, saves time. ➧ Explain process to the patient. Understanding promotes acceptance. ➧ Prepare moist compress by soaking gauze pads in selected solution

(hot/cold).

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458 C h a p t e r 2 4 Orthopedic Interventions Make sure gauze pads are big enough and plentiful enough to cover area desired. Make sure they are thoroughly soaked before applying to area. ➧ Don gloves. Prevents transfer of microorganisms. ➧ Cover with dry covering, preferably a plastic bag or linen saver,

and mold it to the body area. Insulates the heat or cold application and concentrates it on the desired area. ➧ Check area every 15 minutes to ensure heat is not “cool” and cold

is not “warm.” Keeps temperature even to area that needs the application of moist compress. ➧ Apply moist compress for approximately 15 to 30 minutes four to

five times per day (check physician order). Avoid overexposure to moist compress, which may impair skin integrity. ➧ Keep the patient as dry as possible—check to make sure you have

dried area after moist compress has been completed. Promotes comfort. ➧ Assess the effects of the application of moist compresses. Report and record the positive and negative effects of the application— this may require the nurse to adjust plan of care if the treatment is not favorable or if the patient does not tolerate the procedure. ➧ Dispose of gloves and all contaminated equipment. Prevents transfer of microorganisms. ➧ Reposition patient in comfortable position. Promotes comfort. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess area every 4 to 6 hours to determine effectiveness of treatment ● Ask patient to evaluate effectiveness of the treatment ● Patient will have reduced pain, swelling, and redness of area ●

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P r o c e d u r e 2 4 . 5 Applying an Ice Bag, Ice Pack, or Collar 459

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Patient’s tolerance to treatment. times and duration. ● Physical effects of the application of moist compresses. ● Treatment

PROCEDURE 24.5 Applying an Ice Bag, Ice Pack, or Collar OVERVIEW

To reduce swelling and pain. To control bleeding by constricting blood vessels. ● To reduce body temperature and body’s metabolic rate. ● To produce an anesthetic effect. ● ●

P R E PA R AT I O N

No one optimum temperature can be documented for cold applications. ● Selection of temperature depends on duration of application, method of application, condition of the patient, and condition and sensitivity of the skin. ● It is considered dangerous to expose skin to extreme cold temperatures. ●

R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Altered tissue perfusion related to impaired blood flow Risk for infection related to impaired tissue integrity

Special Considerations • Very cold temperatures should be avoided in skin disease. • Avoid use of cold applications in patients with circulatory or heart disease. • Always consider patient’s age and condition of the skin before application of cold therapy. • Check elderly and pediatric patients’ skin and effects of cold treatment on their fragile skin. • Watch for possible sharp edges on ice that could abrade skin.

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460 C h a p t e r 2 4 Orthopedic Interventions EXPECTED OUTCOMES

Reduction of edema at trauma site Decreased pain sensation ● No alteration in skin integrity ● ●

EQUIPMENT/SUPPLIES

Ice bag, collar, plastic bag Bed protection (plastic diaper or chucks) Cold solution or crushed ice Tape Towels (2) I M P L E M E N TAT I O N ➧ Check physician’s order for cold application and determine what

equipment is necessary. Promotes effective use of time. ➧ Gather equipment to bedside. Promotes effective use of time. ➧ Explain procedure to the patient. Understanding promotes acceptance. ➧ Fill bag/collar with ice. If using a commercial ice pack, make sure

pack is not leaking; chemicals could cause damage to skin. Provides the main cold application. ➧ Squeeze excess air from bag or collar.

Commercial ice pack will already be free of air but will need to be shaken to distribute inner contents. Allows the bag/collar to lie flat and ice to evenly lay around collar. ➧ Tape/secure bag/collar. Make sure ice does not leak out and wet the patient’s clothes or bed linen. ➧ Cover the bag/collar with towel, and secure with tape. Provides smooth soft covering to prevent direct contact of plastic to skin, which could impair skin integrity. ➧ If the patient has an open wound or drainage, don gloves. Remove

old dressing or cold packs from area, noting amount and quality of drainage. Remove gloves and don new pair. Reduces transmission of microorganisms.

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P r o c e d u r e 2 4 . 5 Applying an Ice Bag, Ice Pack, or Collar 461 ➧ Place covered ice bag/collar/pack on affected area. Allows the transfer of cold to area affected. ➧ Assess patient’s tolerance to cold application. If patient cannot toler-

ate sensation of cold, apply a second towel over the bag/collar/pack. Assessing skin and patient’s tolerance of cold will allow better treatment of area and better patient compliance. ➧ After 30 minutes, terminate cold treatment, and gently dry area

treated. Allows the nurse to assess for redness and how well the treatment affected edema/swelling. ➧ If dressing is needed, follow guidelines for application of dressing. Decreases chances for infection and promotes wound healing. ➧ Remove all soiled equipment, and reposition patient as he desires. Eliminates chances for cross contamination and provides patient comfort. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Patient verbalizes positive effects of treatment Decreased edema ● No complications evidenced from treatment ● Decreased pain ● ●

KEY POINTS ● Treatment

FOR

REPORTING

AND

area before and after therapy. Duration of treatment. ● Patient’s tolerance to the treatment. ● Effects of treatment. ● Date and times treatment used. ● Where cold treatment was applied. ●

RECORDING

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C H A P T E R

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25 Beds, Frames, and Mattresses 25.1 Placing the Patient on a Specialty Surface, 464 25.2 Placing the Patient on an Air-Suspension or Air-Fluidized Bed, 467

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464 C h a p t e r 2 5 Beds, Frames, and Mattresses

PROCEDURE 25.1 Placing the Patient on a Specialty Surface OVERVIEW

To reduce pressure on tissues underlying bony prominences. To be used as a replacement mattress or used as an overlay that rests on top of an existing mattress. ● To promote optimal comfort and body alignment. ● ●

P R E PA R AT I O N

Determine patient’s ability to understand procedure. Determine patient’s ability to participate. ● Assess patient’s skin for erythema, induration, and blistering, especially over bony prominences. ● Assess patient’s level of comfort and presence of pain. ● ●

Special Considerations • Depending on medical condition, some patients may need analgesic medication to enhance comfort before moving. Elderly, Pediatric, Confused, and Physically or Mentally Challenged Patients • May take more time to complete procedure, especially if patient is immobile. • Involve family/caregiver if indicated. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to tolerate moving ● Impaired skin integrity related to prolonged pressure on joints and bony prominences ●

EXPECTED OUTCOMES

Patient’s skin remains intact without evidence of abnormal reactive hyperemia or mottling ● Existing pressure ulcers show evidence of healing by formation of granulation tissue ● Patient exhibits signs of comfort after specialty surface is in place ●

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P r o c e d u r e 2 5 . 1 Placing the Patient on a Specialty Surface 465 EQUIPMENT/SUPPLIES

Mattress support surface of: Foam or air overlay Foam or air mattress Clean gloves Sheets for bed and mattress I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure and how patient

can assist if indicated. Assess patient’s ability to move if on bed rest. Confirm type of support surface to be used with prescriber. Meets patient’s right to be informed; encourages cooperation and participation; identifies type of support surface most beneficial to the patient. ➧ Gather equipment and place at bedside; adjust lighting as

needed. Enhances organization; ensures good visualization to prepare bedding. ➧ Wash hands and don clean gloves. Reduces transmission of infectious microorganisms. ➧ Apply support surface to bed (bed may be occupied or

unoccupied). (See Chapter 1). Ensures correct application of the surface support whether the bed is occupied or unoccupied.

Applying a Foam-Mattress Replacement ➧ Remove the mattress and replace with foam mattress.

Remove cushions as needed in areas of high risk for skin breakdown, such as elbows and heels. Apply sheet, and avoid wrinkles. To reduce pressure in direct contact with skin surfaces.

Applying a Foam-Mattress Overlay ➧ Apply foam overlay directly on hospital mattress.

Leave thin, protective covering in place. Apply sheet. Avoid wrinkles. Foam egg-crate surface is primarily for comfort. It reduces pressure in direct contact with the skin.

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466 C h a p t e r 2 5 Beds, Frames, and Mattresses

FIGURE 25.1 Egg-crate mattress.

Applying an Air-Mattress Replacement ➧ Remove standard hospital mattress and replace with air mattress.

Use blower to inflate to the appropriate pressure. Apply sheet, and avoid wrinkles. Limit the use of incontinent pads. Air pressure is used to distribute patient’s weight. A company representative usually participates in the setup of this device.

Applying an Air-Mattress Overlay ➧ Apply deflated overlay directly over the bed mattress. Use supplied

flaps or clips to secure mattress. Use blower or other continuous inflation device to inflate mattress to the desired pressure. Apply sheet, and avoid wrinkles. Check cycling on continuous-cycling unit. Avoid use of sharp objects near mattress. Intermittent cycling inflates portions of the mattress at a time, which alternates pressure against the skin; checking cycling on the unit ensures proper functioning; avoiding use of sharp objects near the mattress ensures that the mattress material will not be punctured.

With Any Support Surface ➧ Reposition patient over support surface as frequently as condition

allows to minimize pressure (see Chapter 23). Perform range-ofmotion (ROM) exercises every shift as tolerated (see Chapter 22). Enhances patient comfort, relieves pressure, and facilitates removal of secretions from the airways. Range-of-motion (ROM) exercises are necessary to prevent contractures and promote good circulation. ➧ Remove gloves and wash hands before leaving patient’s room. Prevents transmission of infectious microorganisms.

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P r o c e d u r e 2 5 . 2 Placing the Patient on an Air-Suspension Bed 467 E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate in procedure Inspect skin condition every 2 hours ● Monitor turning schedule and assess effectiveness of the support mattress ● Inspect any existing pressure ulcers for evidence of granulation tissue ● Assess patient’s comfort level at least every 2 hours or PRN ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time support surface was applied. Patient’s overall skin condition. ● Patient participation in moving and turning schedule. ●

PROCEDURE 25.2 Placing the Patient on an Air-Suspension or Air-Fluidized Bed OVERVIEW

To reduce pressure on tissues underlying bony prominences. To promote optimal skin integrity in the immobile or bedridden patient. ● To promote optimal comfort and body alignment by cushioning support and redistributing weight. ● To reduce the effects of shear, friction, maceration, and pressure. ● ●

P R E PA R AT I O N

Determine patient’s ability to understand the purpose of using an air-suspension or air-fluidized bed. ● Determine patient’s ability to participate. ● Assess patient’s skin for erythema, induration, and blistering, especially over bony prominences (risk for pressure-ulcer formation). ● Assess patient’s level of comfort and presence of pain. ●

Special Considerations • Depending on medical condition, some patients may require analgesic medication to enhance comfort before moving.

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468 C h a p t e r 2 5 Beds, Frames, and Mattresses

Elderly, Pediatric, Confused, and Physically or Mentally Challenged Patients • May take more time to complete procedure, especially if patient is immobile. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired physical mobility related to trauma, surgery, or neuromuscular deficit ● Pain/discomfort related to inability to tolerate moving ● Impaired skin integrity related to prolonged pressure on joints and bony prominences ●

EXPECTED OUTCOMES

Patient’s skin remains intact without evidence of abnormal reactive hyperemia or mottling ● Existing pressure ulcers show evidence of healing by formation of granulation tissue ● Patient exhibits signs of comfort after being placed on specialty bed ●

EQUIPMENT/SUPPLIES

Air-suspension or air-fluidized bed (as ordered/indicated) Gortex sheet (supplied by distributor) Clean gloves Disposable bed pads, if indicated I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist if indicated. Assess patient’s ability to move if on bed rest. Meets patient’s right to be informed; encourages cooperation and participation. ➧ Have bed placed in patient’s room. Gather all other equipment

needed and place at bedside, and adjust lighting as needed. Enhances organization; ensures good visualization to prepare bedding. ➧ Wash hands and don clean gloves. Reduces transmission of infectious microorganisms. ➧ After applying Gortex sheet and disposable pads (if needed), transfer

patient onto air-suspension bed using appropriate transfer techniques (see Chapter 23). Ensures correct transfer techniques and reduces the risk for injury.

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P r o c e d u r e 2 5 . 2 Placing the Patient on an Air-Suspension Bed 469 ➧ Turn bed on by depressing switch. Activates air action of bed operation. ➧ Position patient. Promotes patient comfort and maintains proper body alignment. ➧ Establish and maintain a turning schedule, as indicated by patient’s

plan of care, diagnosis, and mobility status. Frequent turning is necessary to prevent skin breakdown and facilitate removal of secretions from the airways. ➧ Establish a schedule and perform ROM exercises as indicated by

patient’s plan of care, diagnosis, and mobility status (see Chapter 22). Frequent and consistent exercising is necessary to prevent joint deformity, contractures, and skin breakdown. ➧ Activate maximum inflation switch for turning, positioning, use of

bedpan, or other procedures. Release maximum inflation when procedure concluded. Maximum inflation hardens the bed, thereby eliminating pressure relief. A firm surface is necessary for turning and various other procedures. ➧ Leave patient in a comfortable position with side rails up. To ensure patient comfort and safety. ➧ Remove gloves and wash hands. To prevent transmission of infectious microorganisms.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance and ability to participate in procedure Inspect skin condition every 2 hours or according to turning schedule and PRN to determine any changes and assessing effectiveness of the air-suspension or air-fluidized bed ● Inspect any existing pressure ulcers for evidence of granulation tissue ● Assess patient’s comfort level at least every 2 hours and PRN ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Date and time air-suspension or air-fluidized bed was applied. Patient participation in moving and turning schedule. ● Overall skin condition and any problems patient has with the air-suspension or air-fluidized bed. ●

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U N I T

C H A P T E R

Integumentary System and Wound Care

26 Pressure Ulcers 26.1 Assessing Pressure Ulcer Risk, 472 26.2 Implementing Pressure-Ulcer Prevention Strategies, 477 26.3 Assessing Wounds and Staging Pressure Ulcers, 480

9

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472 C h a p t e r 2 6 Pressure Ulcers

PROCEDURE 26.1 Assessing Pressure Ulcer Risk OVERVIEW

To provide a method for evaluating a patient for the presence of risk factors that could lead to the development of a pressure ulcer. ● To determine the presence of risk factors, provide a rationale for implementing preventive measures to avoid pressure ulcers, and maintain skin integrity. ● To perform a skin assessment for the presence of any lesions, ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture, or dryness. ●

P R E PA R AT I O N

Screen all patients on admission to determine the presence of risk factors that may result in a pressure ulcer. Note whether there is any history of a pressure ulcer or skin problem. ● Use a risk assessment tool to identify risk factors: immobility, inactivity, incontinence, malnutrition, friction, and shear. ● Perform a head-to-toe skin assessment to determine any abnormal skin findings: lesions, ulcers, blisters, rashes, warmth, redness, bruising, scaling, moisture, or dryness. ● Document all findings, be specific in describing any problems, and illustrate findings on the skin assessment form. (Forms vary according to facility.) ● Identify the patient at risk for developing a pressure ulcer, according to the Norton Scale, the Braden Scale, or the preferred risk assessment scale in the facility. ● Institute the protocol for prevention of pressure ulcers based on the risk assessment. ● Obtain specific skin care orders when there is a problem. ● Determine if there are other factors that may place the patient at risk for a pressure ulcer, such as altered mental status, unstable vital signs. ● Reassess every patient at least every 48 hours and perform risk assessment at any time when there has been a significant change in the patient’s condition to prevent skin breakdown. ● Continue to monitor and document the skin condition and report any change in skin integrity promptly to prevent a pressure ulcer. ● Always document any special protocols, including skin or ulcer care or special pressure-reduction mattresses or beds. ●

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Physical Condition 4 3 2 1

Alert Apathetic Confused Stupor

Activity 4 3 2 1

Ambulant Walk/help Chair-bound Bed

Mobility 4 3 2 1

Full Slightly limited Very limited Immobile

Incontinent 4 3 2 1

Not Occasional Usually/urine Doubly

4 3 2 1

Total Score

Name/Date

The Norton Scale uses five criteria to assess patients' risk for pressure ulcers. Scores of 14 or less indicate liability to ulcers; scores of <12 indicate very high risk. Norton, D., McLaren, R. & Exton-Smith, A. N. (1975). An investigation of geriatric nursing problems in hospitals. Edinburgh, UK: Churchill Livingstone. Used with permission.

FIGURE 26.1A Norton scale for assessing risk of pressure ulcers.

Page 473

Good Fair Poor Very bad

Mental Condition

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Norton Scale for Assessing Risk of Pressure Ulcers

473

4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE Degree to which skin is exposed to moisture

1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist Skin usually dry, linen only requires changing at routine intervals.

ACTIVITY degree of physical activity

1. Bedfast Confined to bed.

2. Chairfast Ability to walk severly limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.

MOBILITY ability to change and control body position

1. Completely Immobile Does not make even slight changes in body or extremity position without assistance.

2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.

4. No Limitation Makes major and frequent changes in position without assistance.

NUTRITION usual food intake pattern

1. Very Poor Never eats a complete meal. Rarely eats more than 1/2 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear fluids or IVs for more than 5 days.

2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.

3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most nutritional needs.

4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

FRICTION & SHEAR

1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets in impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spastic, contractures or agitation leads to almost constant friction.

2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair..

Total Score

FIGURE 26.1B The Braden scale for predicting pressure sore risk.

Page 474

3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

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2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.

5/3/07

1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body.

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Date of Assessment

SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort

474 C h a p t e r 2 6 Pressure Ulcers

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Evaluator’s Name

Patient’s Name

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P r o c e d u r e 2 6 . 1 Assessing Pressure Ulcer Risk 475

Special Considerations • Patients who have had surgery, life-threatening illnesses, chronic debilitating disease, immune-compromised illnesses, or any sudden change in condition, such as cardiac arrest, are at increased risk for skin breakdown and need skin assessment every shift to help avoid skin breakdown. Elderly and Physically Challenged Patients • May have several risk factors on admission; therefore, the risk category will require immediate initiation of the prevention protocol to avoid pressure ulcer development. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Physical Mobility related to trauma, surgery, or neuromuscular deficit ● Impaired Skin Integrity related to prolonged pressure on joints and bony prominences ● Ineffective Communication related to illness ●

EXPECTED OUTCOMES

Factors that place a patient at risk for developing a pressure ulcer will be recognized, reported, and documented ● Patient will be assessed for pressure ulcer risk in a timely manner, and a prevention plan will be instituted ● Patient will maintain optimal skin integrity ●

EQUIPMENT/SUPPLIES

Risk assessment tool (Norton Scale, Braden Scale, or specific risk assessment tool for facility) Standard facility admission form for documentation of skin assessment Nursing record or flow sheet for ongoing skin assessment Adequate lighting to perform thorough skin assessment Measuring device to document size of skin lesion, ulcer, or other abnormal finding Sheet or appropriate drape for patient comfort during the skin assessment Any Personal Protective Equipment (PPE), such as gloves, mask, gown, goggles, as indicated by patient’s diagnosis

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476 C h a p t e r 2 6 Pressure Ulcers I M P L E M E N TAT I O N ➧ Perform skin assessment on admission, and complete admission

assessment form. Explain procedure to patient and/or caregiver. Use clean gloves and/or any other PPE if indicated. Determines whether skin is intact or if there is a pressure ulcer or skin problem at time of admission. Provides baseline documentation of skin condition. Provides explanation to patient and/or caregiver. Reduces transmission of microorganisms. ➧ Assess risk with risk assessment scale. Determines risk category and potential for skin breakdown. ➧ Initiate prevention protocol based on risk assessment and risk fac-

tors identified. Check on prevention protocol and strategies. Prevention strategies decrease the risk for developing a pressure ulcer. Consistent turning, skin care, and incontinence management increase the potential for maintaining skin integrity. ➧ Document all preventive care or wound care if there is a skin

problem. Documentation ensures that care was provided. Flow sheets provide adequate documentation; record additional description as needed in the narrative and nurse’s notes. ➧ Communicate all skin care with nursing staff, and promptly notify

the patient’s prescriber when there is a change in the skin condition. Prompt notification ensures that any necessary change will be made to reduce risk for further skin damage. ➧ Continue to assess the patient’s skin for changes: nonblanching

erythema, swelling, moisture may increase risk for a pressure ulcer. Skin assessment must be included in the head-to-toe assessment; regular skin assessment ensures that any change will be noted and prevention methods will be initiated. ➧ After completing assessment, remove gloves and PPE, and wash

hands. Reduces transmission of infectious organisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Skin assessment is completed on every new admission Risk assessment and risk category are established for every patient ● Preventive skin care measures are instituted according to the risk category of every patient ● Routine skin assessment is performed each shift, or according to the established standards of the facility, and documented ● ●

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P r o c e d u r e 2 6 . 2 Implementing Pressure-Ulcer Strategies 477 ● ●

Patient maintains optimal skin integrity Any change in skin integrity is documented and communicated promptly, and appropriate preventive or treatment measures are instituted

KEY POINTS

FOR

REPORTING

AND

RECORDING

● An

admission skin assessment was performed, and the risk category for the patient is established. ● A prevention protocol was initiated. ● A routine skin assessment was done as per the facility’s standard of care. ● Prescriber was notified of any change in skin integrity.

PROCEDURE 26.2 Implementing Pressure-Ulcer Prevention Strategies OVERVIEW ●

To decrease the incidence of pressure ulcers and maintain skin integrity for the patient at risk for a pressure ulcer. P R E PA R AT I O N

Skin assessment and determining the risk category are essential steps in the process of implementing strategies for pressure ulcer prevention. ● The risk assessment (Norton Scale, Braden Scale; see Procedure 26.1) provides the caregiver with an overall risk category. The assessment also identifies the specific areas of concern that contribute to the patient’s risk score (mental status, mobility, moisture, activity, nutrition, friction, shear). ● Reassessment is essential for determining changes in the skin; assessment intervals should be at least every 48 hours; any critical change in the patient’s condition requires a reassessment. ● Prevention strategies must be consistent; the nurse implements the prevention protocol according to the facility’s standard of care: ●

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478 C h a p t e r 2 6 Pressure Ulcers

turning schedules, moisture barriers for the skin, pressure reduction mattresses or beds, nutritional interventions, and shear and friction reduction techniques. ● Documentation of all pressure-ulcer prevention strategies is essential. Special Considerations • Some patients may require heel-propping and turning; skin barrier products provide important preventive measures to promote maintenance of skin integrity. • Patients who are critically ill, postoperative, immunocompromised, or with chronic debilitating disease need careful monitoring of vital signs, sedation, immunosuppression, and nutrition status because these are important risk factors that may lead to skin breakdown. Elderly, Confused, and Physically Challenged Patients • Need frequent skin assessment for signs of erythema, excess moisture, or dryness. • Use protective measures for incontinence. • Note mental status and mobility. • Require specific turning schedule and careful handling. R E L AT E D N U R S I N G D I A G N O S E S

Altered nutrition-related inability to swallow or poor appetite due to stroke or debilitating illness ● Impaired skin integrity related to prolonged pressure on joints and bony prominences ● Impaired mobility related to trauma, surgery, or chronic debilitating illness ●

EXPECTED OUTCOMES

Pressure-ulcer prevention strategies will be implemented according to the risk assessment and risk category ● Pressure-ulcer prevention strategies are implemented and revised if there is a change in the skin condition ● Each risk assessment point is addressed with a nursing intervention to promote skin integrity and prevent a pressure ulcer ● Skin assessment and preventive strategies are documented ● Patient will maintain optimal skin integrity ● The nurse recognizes actual and potential skin problems, communicates the problem, and implements the prevention strategies in a timely manner ●

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P r o c e d u r e 2 6 . 2 Implementing Pressure-Ulcer Strategies 479 EQUIPMENT/SUPPLIES

Pressure ulcer prevention protocol Risk assessment form Admission skin assessment form Clean gloves and Personal Protective Equipment (PPE), such as gloves, mask, gown, and goggles (as indicated) I M P L E M E N TAT I O N ➧ Perform skin assessment on admission and at recommended inter-

vals according to facility standards. Provides baseline data to determine the need for implementing pressureulcer prevention strategies. ➧ Wear PPE as indicated by patient diagnosis. Reduces transmission of infectious microorganisms. ➧ Identify patients who are at risk for pressure ulcer. Determines the degree of risk and provides rationale for implementing preventive measures. ➧ Implement necessary preventive measures according to the risk

factors identified with the risk assessment. Preventive measures maintain skin integrity and reduce risk for developing a pressure ulcer. ➧ Explain to the patient and caregiver the process of preventive

skin care. Patient and caregiver will recognize risk factors. They can assist with preventive measures. ➧ Communicate and document all preventive strategies according to

the facility standard of care. Promotes continuity of care; reduces risk for pressure ulcer; enhances healing of actual skin breakdown. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Pressure ulcer incidence rate is decreased Staff awareness is increased to prevent skin breakdown ● Actual skin problems are managed appropriately ● Patient and caregiver education promotes pressure-ulcer prevention and improves quality of life for patients who are at risk for pressure ulcer ● ●

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480 C h a p t e r 2 6 Pressure Ulcers

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Skin assessment has been done and the prevention strategy is initiated according to the risk category and facility protocol. ● Patient’s response to the prevention strategy. ● If there has been a change in the health status, the patient’s risk category has changed. ● If there is actual skin breakdown, treatment measures are initiated. ● Patient and/or caregiver education is ongoing.

PROCEDURE 26.3 Assessing Wounds and Staging Pressure Ulcers OVERVIEW

Wound Assessment ●

To obtain baseline data to measure wound healing. Wound assessment includes: • Obtaining information relating to patient history. • Identifying the etiology of the wound, the patient environment, and caregiver support. • Noting wound characteristics. • Identifying other conditions that may effect wound healing.

Staging Pressure Ulcers To classify the ulcer by defining the depth of tissue destruction. Staging is determined at the initial assessment by the level of deepest tissue involvement. ● Staging is a factor in determining treatment. ● ●

P R E PA R AT I O N

Wound Assessment ● Screen all patients on admission and perform a head-to-toe assessment to identify wounds using assessment tools, such as, Norton or Braden scale. ● Document findings on forms specific to wound care as used per facility protocol. ● Collaborate with prescriber regarding plan of care, such as wound care, activity, and nutrition therapy. ● Reassess wounds according to plan of care, and monitor progress.

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P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 481

Staging Pressure Ulcers Staging a pressure ulcer is determined at the initial assessment. The exception is the presence of eschar (hard, black, leathery surface); it is impossible to declare the stage of a pressure ulcer covered with eschar. ● The stage of the ulcer is determined by the level of tissue destruction. Stages are defined as follows: ●

Epidermis Dermis Fat Muscle Bone

Stage I

Stage II

Stage III

Stage IV

FIGURE 26.3 Pressure sore stages.

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482 C h a p t e r 2 6 Pressure Ulcers

• Stage I: nonblanchable erythema of intact skin; often the early warning of tissue destruction; dark-skinned patients may have purple discoloration, warmth, or induration. • Stage II: partial thickness skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as a blister or abrasion. • Stage III: full thickness tissue destruction of the subcutaneous tissue that may extend down to but not through the underlying fascia. The ulcer appears as a deep crater with or without undermining. • Stage IV: full-thickness skin loss with extensive tissue destruction or damage to muscle, bone, or other structures, such as the joint capsule. There may be undermining and sinus tracts as well. ● Describe a pressure ulcer by its stage, and document the wound size, drainage, odor, granulation tissue, contraction, epithelialization, and peri-ulcer skin condition. Special Considerations • Skin assessment may not always be simple on patients with a cast, compression wrap, anti-embolism hose, or a brace; therefore, more time must be devoted to their assessment and treatment. Be alert to complaints of pain, and remove these items for a more thorough assessment. • Stage I ulcers may not be accurately or reliably assessed in patients with dark skin; therefore, assessment findings of warmth, induration, or purplish discoloration may be the only indication of a stage 1 ulcer in this population. Elderly and Critically Ill Patients, and Those with Circulatory Compromise • Are priority for immediate identification and treatment of pressure ulcers. RELEVENT NURSING DIAGNOSES

Impaired skin Integrity related to prolonged pressure on joints and bony prominences ● Impaired physical mobility related to trauma, surgery, or chronic debilitating disease ● At risk for infection related to invasion of microorganisms into open wounds and/or ulcers ●

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P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 483 EXPECTED OUTCOMES

Patient will be screened immediately, and causative factors of wounds or ulcers will be identified ● A treatment plan will be initiated immediately, including wound care and nutrition ● Monitoring wound and pressure-ulcer healing will be ongoing, and the patient will maintain optimal wound healing ●

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves and other Personal Protective Equipment (PPE), such as gown, mask, and goggles, as indicated Measuring apparatus: paper or plastic ruler Sterile cotton-tipped applicator Pen or pencil and paper Documentation form to record pressure-ulcer stage I M P L E M E N TAT I O N ➧ Review prescriber’s order. Determines if wound dressing can be removed. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient/caregiver. Decreases anxiety. ➧ Position patient so that wound is accessible. Facilitates access to the wound. ➧ Don gloves and/or other PPE as indicated. Reduces transmission of microorganisms. ➧ Remove soiled dressing; observe dressing for exudate characteristics

(color, consistency, odor, and amount). Provides information about the status of the wound. ➧ Discard soiled dressing according to institutional policy. Don sterile

gloves, if indicated. Reduces transmission of infection and microorganisms.

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484 C h a p t e r 2 6 Pressure Ulcers ➧ Identify the anatomical location of wound or pressure ulcer. Use

descriptors of bony prominences, if appropriate. Facilitates communication between health-care providers; identifies healing potential. ➧ Observe wound for extent of tissue damage (full or partial thick-

ness). If pressure related, can stage I–IV. Provides a baseline for further evaluation; enhances communication between health-care providers. ➧ Observe the wound-bed color and appearance. Note presence of

devitalized tissue or slough, eschar, granulation, or epithelial tissue. Observe the wound margins. Record amount of granulation tissue, slough, eschar, and epithelial tissue in percentages. Provides information about the status of the wound. ➧ Gently probe the wound/pressure ulcer using a sterile, cotton-tipped

applicator for any tunnels, sinus tracts, and undermining. Measure tunnels or undermining depth of wound cavity by placing cotton tip at deepest part of cavity or tract and then marking the applicator at skin level. Next, place it next to a measuring guide calibrated in centimeters. Provides information about the status of the wound. ➧ Observe the wound for exudate; note color, amount, consistency, and

presence of odor. Provides information about the status of the wound. ➧ Observe and palpate the skin around the wound/pressure ulcer

(peri-wound area). Note: color, condition of the area, warmth, pain, and any presence of induration or edema. Provides information about the status of the wound. ➧ Measure the wound/pressure ulcer by gently placing a sterile, cot-

ton-tipped applicator in the wound finding the greatest length (head to toe), mark the applicator with a finger and place it next to a measuring guide calibrated in centimeters. Repeat above for width (side to side) and depth. Provides information as to what to expect during the wound healing process. Follow-up measurements quantify changes in wound size and predict wound healing. ➧ Implement prescribed treatment measures for wound/pressure

ulcer. Follows protocol and prescriber’s orders and provides consistent care that promotes timely healing.

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P r o c e d u r e 2 6 . 3 Assessing Wounds and Staging Pressure Ulcers 485 ➧ Discard soiled gloves, cotton-tipped applicators, and measuring

devices in appropriate receptacles. Reduces transmission of infectious microorganisms. ➧ Wash hands. Reduces transmission of infection. ➧ Document appropriate information according to protocol about

wound care or pressure-ulcer staging and care. Follows prescriber’s orders and established protocol, and enhances communication among members of the health-care team. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Skin problems are correctly identified and treatment is initiated, monitored, and maintained ● Documentation is consistent in the patient record ● Staff awareness is increased so that skin care is consistent ●

KEY POINTS

FOR

● Wound/pressure

REPORTING

AND

RECORDING

ulcer location, appearance, and extent of tissue damage. ● Dimensions of wound or staging of pressure ulcer. ● Exudate, including characteristics. ● Prescriber notified of skin condition and any complications. ● Treatment initiated or in progress.

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C H A P T E R

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27 Wound Care 27.1 27.2 27.3 27.4 27.5

Applying a Pressure Bandage, 488 Administering a Sitz Bath, 490 Performing Wound Irrigation, 493 Managing Wound Drainage, 495 Teaching Self-Management of Wound-Drainage Devices, 498 27.6 Applying Wound Dressings, 501 27.7 Applying and Managing a V.A.C. ATS™ System, 506

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488 C h a p t e r 2 7 Wound Care

PROCEDURE 27.1 Applying a Pressure Bandage OVERVIEW ●

To control or eliminate bleeding from a surgical or a traumatic wound. P R E PA R AT I O N

Assess wound immediately, and take action as indicated because bleeding could range from “oozing” (capillary), to “steady flow” (venous), to “gushing or pulsing” (arterial), which could be lifethreatening. ● Assess limbs for impaired circulation. ●

Special Considerations • If bleeding is severe (arterial), sterile supplies are not necessary, because speed is more critical. If dressings are not available, strips of clothing may be used. Elderly and Pediatric Patients • Will require careful handling when applying pressure on body parts and are more at risk for complications from extensive blood loss. R E L E VA N T N U R S I N G D I A G N O S E S

Fluid Volume Deficit related to severe bleeding from surgery or traumatic event to a body part ● Impaired Tissue Integrity related to trauma to skin and blood vessels ●

EXPECTED OUTCOMES

Bleeding is controlled or stopped Circulation is not affected ● Patient sustains minimal blood loss ● Wound does not get infected ● ●

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves Rolled gauze Gauze 4 ⫻ 4’s Surgipad Elastic-type rolled bandage (Ace wrap) Silk or foam-type tape Strips of fabric, if in an emergency setting

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P r o c e d u r e 2 7 . 1 Applying a Pressure Bandage 489 I M P L E M E N TAT I O N ➧ If bleeding is severe (arterial), alert staff to contact prescriber and

assist in applying a pressure dressing. Enhances efficiency and patient safety. ➧ Wash hands, if time or situation allows. Reduces transmission of microorganisms. ➧ Organize equipment, if time allows. Enhances efficiency and patient safety. ➧ Don nonsterile gloves, if time allows; in a nonclinical setting, create

a barrier with clothing or plastic, if possible. Reduces transmission of microorganisms. ➧ Place patient in supine position and elevate affected extremity

above heart level, if possible. Reduces blood flow to affected extremity. ➧ Select appropriate size and number of gauze pads or surgipads

depending on the severity of the bleeding to be controlled. Fold gauze in half or quarters for increased pressure; use pressure when applying to the affected area. Absorbs excess blood, reduces transmission of microorganisms, aids in blood clotting, and compresses the open blood vessel. ➧ Apply direct pressure to affected area using palm of gloved hand

directly over the dressing for 5 to 10 minutes. Aids in blood clotting and compresses the open blood vessel. ➧ Continue applying pressure when securing the dressing with either

a bandage or a tape product. ● Trunk wounds—secure dressing occlusively with tape product. ● Extremity wounds—secure dressing by wrapping extremity in a circular fashion with rolled elastic bandage. Aids in blood clotting and compresses the open blood vessel. ➧ After the bandage is in place, check the pulse to the affected

extremity. Ensures that circulation is not interrupted. ➧ If bleeding continues, apply additional dressing material directly

over previous dressing, with direct pressure over the bleeding site. Aids in blood clotting and compresses the open blood vessel.

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490 C h a p t e r 2 7 Wound Care ➧ Once bleeding has stopped, observe dressing for any strike-through

bleeding requiring additional dressings. Observe extremity for any bluish discoloration, coolness, or lack of pulse. Provides information about the status of the bleeding and possible impaired circulation, if the bandage is too tight. ➧ Remove soiled gloves and discard in appropriate container; wash

hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s response, level of consciousness, and vital signs Evaluate dressing/bandage for any additional bleeding ● Assess for impaired circulation if extremity is affected ● Notify prescriber of patient’s condition ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Location of the bleeding. and type of dressings applied. ● Time required for the bleeding to stop. ● How the patient tolerated the procedure and current condition. ● When the prescriber was notified. ● Amount

PROCEDURE 27.2 Administering a Sitz Bath OVERVIEW

To relieve pain from surgery in the rectal or genital areas. To ease discomfort and reduce inflammation in the area of the rectum and perineum. ● Indicated for hemorrhoids, uterine cramps, prostatitis, and infections of bladder, prostate, or vagina. ● ●

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P r o c e d u r e 2 7 . 2 Administering a Sitz Bath 491 P R E PA R AT I O N

Check prescriber’s orders for any additives to the water. Check water temperature with a thermometer; it should be 100⬚F to 102⬚F. ● Determine patient/caregiver understanding and assistance with procedure. ● Check patient record to determine if an infection is present. ● ●

Special Considerations • Depending on medical condition, some patients may need frequent monitoring or an attendant. Elderly and Pediatric Patients • May need warm water temperature owing to fragile and sensitive skin. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Skin Integrity related to surgery and/or inflammation to the rectum and/or perineum ● Pain/Discomfort related inflammation of the rectum and/or perineum ●

EXPECTED OUTCOMES

Patient will experience relief of discomfort in the affected area Patient will experience a decrease in inflammation to the area ● Patient will experience optimal healing at the affected site ● ●

EQUIPMENT/SUPPLIES

Tub or portable device for use on toilet Thermometer Towels Clean gloves, other Personal Protective Equipment (PPE), such as gown, goggles, and mask, as indicated by patient’s diagnosis. I M P L E M E N TAT I O N ➧ Identify patient; explain procedure and include family/caregiver,

if indicated; assess ability to participate. Reduces anxiety; encourages participation. ➧ Wash hands and don gloves and/or other PPE. Reduces transmission of microorganisms.

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492 C h a p t e r 2 7 Wound Care ➧ Make certain that the tub is clean or set up portable equipment that

fits on a standard toilet. Reduces transmission of microorganisms ➧ Place towel in tub for patient to sit on. Promotes comfort. ➧ Fill tub with 3 to 4 inches water. Use appropriate amount for

portable device. Only the buttocks and genital area are to be soaked. ➧ Check temperature of water. Temperature should be 100⬚F to 102⬚F,

or follow facility protocol. Provides for patient safety and comfort. ➧ Patient sits in the tub or on portable device for 10 to 15 minutes or

time according to policy. Remove any dressings prior to the sitz bath. Relieves discomfort, reduces inflammation. ➧ On exiting the tub or portable unit, the area should be carefully

patted dry and, if ordered, clean dressings applied. Protects wound and promotes healing. ➧ Assist patient back to bed or chair. Ensures safety and comfort. ➧ Clean equipment; remove gloves; wash hands. Reduces transmission of infectious organisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Evaluate skin integrity and report to prescriber Assess patient’s response to sitz bath and any complications

KEY POINTS ● Temperature

FOR

REPORTING

AND

RECORDING

of the water. of the wound or the genital area. ● Date and time of sitz bath and patient’s tolerance. ● Appearance

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P r o c e d u r e 2 7 . 3 Performing Wound Irrigation 493

PROCEDURE 27.3 Performing Wound Irrigation OVERVIEW ● ●

To cleanse the wound of all devitalized tissue. To decrease bacterial contamination and promote optimal wound healing. P R E PA R AT I O N

Wound cleansers should not be toxic to tissue, but could cause local irritation. ● Self-contained, sterile systems for wound irrigation are available that deliver fluid at elevated pressures with varying spray patterns. ● Antiseptics should be used only if necessary to control bacterial overgrowth. ● Review patient record to determine if infection is documented. ●

Special Considerations • Some patients may have an allergy or sensitivity to certain wound cleansers or antimicrobial solutions. Pediatric Patient • Allow parents to stay with infant or child to provide comfort. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to surgery or trauma Risk for infection related to invasion of infectious microorganisms into an open wound ● Pain/discomfort related to manipulation of impaired tissue and/or sensitivity to irrigant ● ●

EXPECTED OUTCOMES

Devitalized tissue will be removed Wound will exhibit signs of healing, such as decreased erythema, edema, and exudates ● Patient will experience increased comfort as healing progresses ● Wound infection will subside ● ●

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494 C h a p t e r 2 7 Wound Care EQUIPMENT/SUPPLIES

35-mL syringe and 19-gauge needle Clean gloves, other Personal Protective Equipment (PPE), such as gown, goggles, and mask, as indicated Wound cleanser Bag for soiled dressings Towels or drapes to drape the wound Gauze, absorbent pads, and tape to redress the wound I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Identify patient; explain procedure to patient/family/caregiver as

indicated. Reduces anxiety, reinforces teaching. ➧ Position patient for access to wound. Facilitates procedure and enhances comfort. ➧ Don gloves; remove dressing and place in bag for disposal. Reduces transmission of microorganisms. ➧ Drape wound with towels/drapes. Confines irrigant solution to wound area and reduces spread of infection. ➧ Draw wound solution into

syringe; direct stream of irrigant to all areas of the wound, using gauze to absorb solution or emesis basin to collect solution. Removes necrotic debris; promotes wound healing.

FIGURE 27.3 Direct stream of irrig-

ant to all areas of the wound.

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P r o c e d u r e 2 7 . 3 Performing Wound Irrigation 495 ➧ Assess wound for healing. Wound assessment identifies healing or deterioration and contributes to decision making for subsequent care. ➧ Redress wound as indicated/ordered. Protects wound, promotes healing. ➧ Remove towel/drape; remove gloves and dispose in trash container;

wash hands. Reduces spread of infectious microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ●

When the wound is clean and free of debris, irrigation can be discontinued, and the wound can then be gently cleansed at each dressing change

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Wound

assessment parameters, such as size, edema, erythema, and exudates. ● Complications, such as infection. ● Patient’s tolerance of the procedure and participation.

PROCEDURE 27.4 Managing Wound Drainage OVERVIEW ●

To contain the drainage, protect the skin, and control odor. P R E PA R AT I O N

Draining wounds may be a result of trauma, surgery, or disease. Fluid and electrolyte problems and disruptions in skin integrity may occur. ● Appropriate management increases patient comfort and can reduce complications and facilitate healing. ● Equipment will be chosen depending on type and quantity of drainage: • Copious: over 50 mL per day can best be managed with pouching, especially if the effluent is harmful to the skin. ● ●

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496 C h a p t e r 2 7 Wound Care

• Less copious: under 50 mL per day and not harmful to the skin can be managed with absorbent dressings and skin sealants to protect the peri-wound skin. Special Considerations • Provide teaching of wound care and pouching to client and/or caregiver before discharge. Geriatric and Pediatric Patients • Take extra time and care because skin is fragile. • Involve parent/caregiver in wound drainage management. Home Health Patient • During discharge planning, make arrangements for home health to follow, and monitor patient and/or caregiver compliance and skill with wound-drainage management. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to trauma or surgery Potential for infection related to invasion of infectious microorganisms into wound ● Pain/discomfort related to impaired tissue and irritation of wound drainage ● ●

EXPECTED OUTCOMES

Skin will be protected against excessive drainage Patient will experience increased comfort due to drainage containment and odor control ● Drainage can be measured accurately ● ●

EQUIPMENT/SUPPLIES

Wound drainage pouch Nonsterile gloves, gauze, wound cleanser, bag for disposal of soiled dressings Skin sealant, drainage collector, paste, adhesive tape I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety.

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P r o c e d u r e 2 7 . 4 Managing Wound Drainage 497 ➧ Explain procedure to patient/family. Reduces anxiety, reinforces teaching. ➧ Position patient for access to wound. Facilitates procedure. ➧ Don nonsterile gloves, remove dressing and place in bag for

disposal. Reduces transmission of microorganisms. ➧ Gently flush wound with wound cleanser. Removes necrotic debris, reduces spread of infection. ➧ Assess wound for healing. Assessment of wound identifies healing or deterioration and contributes to decision-making for subsequent care. ➧ Dry periwound area by patting gently. Allows application of skin sealant and wound-drainage device.

Pouching procedure: ➧ Trace pattern on back of pouch cut opening 1/8- to 1/4-inch larger

than opening on skin. Too large an opening will expose skin to harmful drainage. Too small an opening will cause leakage and decrease wear time. ➧ Apply paste around wound opening to fill in uneven spaces and

cover exposed skin. Protects exposed skin from drainage and extends wear time by preventing leakage under the edge of the pouch. ➧ Apply pouch, centering pouch opening over wound opening. Provides for proper location of pouch, collection of drainage, and protection of the skin. ➧ Apply tape to picture-frame edges of pouch. Promotes increased wear time. ➧ Connect pouch to drainage bag. Draining effluent away from pouch increases wear time, prevents leakage onto skin, and aids in measurement of drainage. ➧ Remove gloves and discard into disposal bag. Reduces spread of infection. ➧ Wash hands. Reduces spread of infection.

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498 C h a p t e r 2 7 Wound Care E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Reassess efficacy of wound management system at each change Assess patient’s tolerance of the wound management system

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Wound

assessment parameters and changes in the wound. Patient’s tolerance of the procedure. ● Effectiveness of the procedure, such as skin protection, odor control, and containment of drainage. ●

PROCEDURE 27.5 Teaching Self-Management of Wound-Drainage Devices OVERVIEW

To assist the patient with the transition process from hospital to home. ● To maintain function of the device while preventing complications. ●

P R E PA R AT I O N

Determine patient/caregiver’s basic knowledge about the wounddrainage device. ● Prepare and initiate a teaching plan, including the purpose, function, and routine care of the device, and present to patient and/or caregiver. ● Assess patient/caregiver’s basic knowledge about signs and symptoms of complications or problems and appropriate intervention. ●

Special Considerations • Provide teaching of self-management of wound-drainage devices to patient/caregiver/family before discharge. • Teaching should be based on individual needs and abilities. Home Health Patient • During discharge planning, make arrangements for home health to follow and monitor progress and/or complications with selfmanagement of wound-drainage devices.

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P r o c e d u r e 2 7 . 5 Teaching Self-Management of Wound-Drainage 499 R E L E VA N T N U R S I N G D I A G N O S E S

Deficient knowledge related to managing wound drainage devices Ineffective individual and/or family coping related to stress of dealing with wound-drainage and care ● Noncompliance related to fear/depression of dealing with wounddrainage devices ● ●

EXPECTED OUTCOMES

Patient/caregiver can accurately apply the device Drainage, odor, and protection of skin will be managed ● Complications of using the devices will be prevented ● ●

EQUIPMENT/SUPPLIES

Wound drainage device Nonsterile gloves, gauze, wound cleanser, bag for disposal of soiled dressing Written instructions for patient/caregiver Anatomical chart or diagram I M P L E M E N TAT I O N ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Explain procedure to patient/caregiver. Reduces anxiety, reinforces teaching. ➧ Position patient for access to wound. Facilitates dressing change. ➧ Don nonsterile gloves; remove dressing and place in bag for

disposal. Reduces transmission of microorganisms. ➧ Gently flush wound with wound cleanser. Removes necrotic debris, reduces spread of infection. ➧ Assess wound for healing. Assessment of wound identifies healing or deterioration and contributes to decision-making for subsequent care.

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500 C h a p t e r 2 7 Wound Care ➧ Dry periwound area by patting

gently. Allows for application of skin barrier and/or adhesive backing of wound-drainage device.

FIGURE 27.5 Teach patient to carefully dry periwound edges.

➧ Explain and demonstrate procedure to patient/caregiver. Contributes to patient/caregiver understanding and builds confidence ➧ Allow patient/caregiver to return demonstration if time allows, or do

a return demonstration at the next procedure. Contributes to patient/caregiver understanding and builds confidence. ➧ Review procedure with patient/caregiver at each teaching session,

allowing patient/caregiver to do more each time. Builds confidence and gradually shifts responsibility to patient/caregiver. ➧ Remove gloves and discard into disposal bag. Reduces spread of infection. ➧ Wash hands. Reduces spread of infection. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient/caregiver understanding and ability at each teaching session ● Provide written instructions and arrange for acquisition of supplies at discharge ● Allow time to teach and for patient/caregiver to return demonstrate ● Follow-up practice sessions should be provided ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Procedure as taught. Patient/caregiver understanding and ability. ● Plans for follow-up teaching. ●

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 501

PROCEDURE 27.6 Applying Wound Dressings OVERVIEW

Wet-to-Dry Dressings are appropriate for surgical wounds, full thickness wounds, pressure ulcers, and vascular ulcers. ● Hydrogel Dressings are to help maintain a moist wound environment and may be used on stage I through stage IV wounds. They are available in amorphous and sheet forms, as well as packing strips impregnated with the gel. ● Transparent Film Dressings are thin, transparent polyurethane sheets with one side coated with an adhesive. They are appropriate for partial thickness wounds, skin tears, and stage I and II pressure ulcers and are used as primary or secondary dressings. ● Hydrocolloid Dressings are combinations of gels and adhesives that form a gel when in contact with wound fluid. The adhesive side will adhere to most moist surfaces, but not to the wound base. They are appropriate for partial thickness wounds, skin tears, shallow fullthickness wounds, venous stasis ulcers, and stage I through III pressure ulcers. ●

P R E PA R AT I O N ●

Check prescriber’s order for specific type of dressing ordered for wound.

Wet-to-Dry Dressings Easy and inexpensive. May cause bleeding of wound bed on removal if dry (mechanical débridement). ● May cause maceration of periwound if gauze is too wet or there are large amounts of exudates. ● ●

Hydrogels Prevent desiccation. Easy to use and relatively inexpensive. ● May cause maceration of periwound skin (also with Transparent Film and Hydrocolloid Dressings). ● ●

Transparent Film and Hydrocolloid Dressings ● ●

The dressing should overlap onto intact skin approximately 1 inch. May cause epidermal stripping to periwound skin on removal.

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502 C h a p t e r 2 7 Wound Care

Contraindicated in arterial, infected, puncture, stage III and IV pressure ulcers, third-degree burns, and draining wounds. ● Edges of hydrocolloid dressings may roll up in sacral areas; consider taping all edges down or select a product with a border. ●

Special Considerations • Conduct patient/caregiver teaching as indicated for type and application of wound dressing. Elderly and Pediatric Patients • May require more time to apply to fragile skin. • For elderly patients, use skin sealant for skin protection. Home Health Patient • During discharge planning, arrange for home health to follow and assist in additional teaching of wound dressings as needed. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired Skin Integrity related to surgery or trauma Potential for Infection related to invasion of infectious microorganisms into an open wound ● Pain/Discomfort related to cleaning wound and applying dressing ● ●

EXPECTED OUTCOMES

Removal of necrotic tissue by promoting mechanical débridement and supporting autolytic débridement ● Prevention of infection ● Wound healing ●

EQUIPMENT/SUPPLIES

Sterile or nonsterile gloves Gauze sponges Rolled cotton gauze and scissors (for wet-to-dry) 0.9% saline solution, unless physician order specifies a different solution Secondary dressing supplies: surgipad, additional gauze, and tape or island dressing with tape border Specialty dressing as ordered/indicated: hydrogel, transparent film, or hydrocolloid

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 503 I M P L E M E N TAT I O N ➧ Review prescriber’s order. Determines appropriate treatment and dressing for patient. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment according to type of dressing to be used. Enhances efficiency and patient safety. ➧ Position patient so that wound is accessible. Facilitates access to the wound. ➧ Don nonsterile gloves, remove soiled dressings, and dispose

dressings and soiled gloves in appropriate bag. Reduces transmission of infection and microorganisms. ➧ Don nonsterile or sterile gloves (if sterile dressing change). Reduces transmission of microorganisms. ➧ Gently cleanse wound with 0.9% saline solution or other wound

cleansers as indicated. Removes necrotic debris. ➧ Assess wound (including periwound as indicated). Provides information about the status of a wound; contributes to decisions for subsequent care. ➧ Using gauze sponge, dry periwound or ulcer area by patting or

gently wiping away from wound. Dries and maintains integrity of periwound without contaminating the wound with skin flora.

For Wet-to-Dry Dressing ➧ Moisten gauze sponges or

rolled gauze with appropriate solution, wring out excess (gauze is to be damp, not dripping), open gauze sponges, and gently fill cavity of wound ensuring moist dressing is not on the surrounding skin. Note: Use rolled gauze if size of wound requires more than one gauze sponge.

FIGURE 27.6A Place moistened

gauze in wound cavity while avoidProvides a moist environment, obliterates dead space, absorbs ing wound edges. exudate, adheres to the necrotic tissue when allowed to completely dry.

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504 C h a p t e r 2 7 Wound Care ➧ Apply and secure secondary dressing if indicated. Use Montgomery

straps, if indicated, depending on type and location of wound, and frequency of dressing changes. Remove gloves and discard according to institutional policy. Protects wound and decreases transmission of microorganisms. ➧ Wash hands. Reduces transmission of microorganisms.

For Hydrogel Dressing ➧ Follow initial steps for applying a wet-to-dry dressing up to and

including drying the periwound edge: Apply dressing in size appropriate to cover the wound. If using amorphous hydrogel, apply to wound and cover with gauze or composite dressing, loosely packing if necessary. Remove gloves and discard according to institutional policy. Absorbs exudates, eliminates dead space, promotes moist healing, and prevents epidural stripping. Reduces spread of infection. ➧ Wash hands. Reduces transmission of microorganisms.

For Transparent Dressing ➧ Follow initial steps for apply-

ing a wet-to-dry dressing up to and including drying the periwound edge: Apply dressing with adhesive side towards patient taking care to avoid any creases or skin folds beneath the dressing. Tape edges of transparent film if dressing is in a highly mobile area. Remove gloves and discard according to institutional FIGURE 27.6B Take care to avoid policy. creasing film. Provides a moist environment, facilitates autolytic débridement, protects wound from bacterial invasion, and protects periwound margins from exudates. ➧ Wash hands. Reduces transmission of microorganisms.

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P r o c e d u r e 2 7 . 6 Applying Wound Dressings 505

For Hydrocolloid Dressing ➧ Follow initial steps for applying

a wet-to-dry dressing up to and including drying the periwound edge: Apply adhesive side toward patient, taking care to avoid forming any creases or skin folds beneath the dressing. Warm the dressing by placing palm of hand directly over dressing for 30 to 60 seconds. May apply tape to all edges if FIGURE 27.6C Apply hydrocolloid in sacral region. dressing. Remove gloves and discard according to institutional policy. Provides a moist environment, facilitates autolytic débridement, absorbs a small-to-moderate amount of exudates, protects wound from bacterial invasion, protects periwound margins from exudates, protects vulnerable skin from friction, and prevents edges from rolling up. ➧ Wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Assess patient’s response and tolerance of dressing change Assess wound at each dressing change

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

of wound: location, extent of tissue damage, wound appearance including periwound, dimensions, characteristics of exudate. ● Patient’s tolerance of dressing change. ● Changes in the wound.

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506 C h a p t e r 2 7 Wound Care

PROCEDURE 27.7 Applying and Managing a V.A.C. ATSTM System OVERVIEW

To promote granulation tissue formation. To promote wound contraction. ● To provide moist wound healing. ● To remove infectious material. ● To remove excess wound exudate or edema. ● To stabilize new skin grafts or flaps. ● V.A.C. ATS System is a vacuum-assisted closure device using the T.R.A.C.® technology for pressure sensing. V.A.C. systems are appropriate for patients who would benefit from negative pressure, such as those with stage III and stage IV pressure ulcers, open chronic wounds, neuropathic ulcers, acute and traumatic wounds, skin grafts and flaps, and dehisced wounds. ● ●

P R E PA R AT I O N

A thin wound covering such as Adaptic® (Johnson & Johnson Inc., New Brunswick, NJ), Mepitel® (Mölnlycke Health Care AB, Gothenborg, Sweden) or Drynet™ Wound Veil (Smith & Nephew, Inc., London, England) may be indicated over fragile wound beds to prevent adherence or to protect blood vessels or organs in deep or open cavity wounds. ● Careful use in patients with active bleeding, irradiated, sutured blood vessels or organs, currently taking anticoagulants. ● Certified Wound, Ostomy, and Continence Nurses may assist in appropriate sponge dressing selection and application. ● Contraindicated in malignancy in the wound, necrotic tissue with eschar, untreated osteomyelitis, in direct contact with exposed blood vessels or organs, nonenteric and unexplored fistulas. ●

Special Considerations • Some patients may require additional preventative measures in conjunction with the V.A.C. System, such as heel-propping and skin-barrier products. • Patients who are critically ill, postoperative, immunocompromised, or with chronic debilitating disease need careful monitoring of vital signs, sedation, immunosuppression, and nutrition status that may prolong adequate wound healing.

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P r o c e d u r e 2 7 . 7 Applying and Managing a V.A.C. ATSTM System 507

• Dressings require changing in approximately 48 hours to two to three times a week. • Assess and premedicate with pain medication as ordered. Elderly, Pediatric, Confused, and Physically Challenged Patients • Need a specific skin assessment and turning schedule. • Use protective measures for incontinence. • Note mental status and mobility. R E L E VA N T N U R S I N G D I A G N O S E S

Impaired skin integrity related to surgery or trauma Potential for infection related to invasion of infectious microorganisms into an open wound ● Pain/discomfort related to cleaning wound and applying V.A.C. System ● ●

EXPECTED OUTCOMES

Formation of granulation tissue (some adherence is expected when using the black V.A.C. GranuFoam® Dressing) (KCI Medical Ltd., San Antonio, TX) ● Wound contraction ● Decreased edema ● Wound healing ●

EQUIPMENT/SUPPLIES

Nonsterile gloves Sterile gloves Wound cleanser or 0.9% saline solution, unless physician order specifies a different solution V.A.C. ATS System V.A.C. GranuFoam Dressing (black sponge) or V.A.C. Vers-Foam™ (sterile water premoistened white sponge) (KCI Medical Ltd., San Antonio, TX)

FIGURE 27.7A Foam sponge,

drapes, and suction wafer

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508 C h a p t e r 2 7 Wound Care

Gauze sponges T.R.A.C. Pad ® and V.A.C. Drape® dressing (KCI Medical Ltd., San Antonio, TX) 1000-mL canister Sterile scissors I M P L E M E N TAT I O N ➧ Review physician’s order. Determines appropriate treatment. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Organize equipment. Enhances efficiency and patient safety. ➧ Position patient so wound is accessible. Facilitates access to the wound. ➧ Don nonsterile gloves. Gently remove the dressing in the direction

of the hair growth while supporting the surrounding skin; dispose dressing and soiled gloves in appropriate bag. Decreases discomfort, reduces epidermal stripping, reduces transmission of infection and microorganisms. ➧ Don sterile gloves. Reduces transmission of microorganisms. ➧ Gently cleanse wound with wound cleanser, 0.9% saline solution,

or prescribed solution using sterile gauze sponges. Removes necrotic debris. ➧ Assess wound including periwound. Provides information about the status of a wound, contributes to decisions for subsequent care. ➧ Using gauze sponge, dry periwound area by patting or gently wiping

away from wound. Dries and maintains integrity of periwound without contaminating the wound with skin flora.

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P r o c e d u r e 2 7 . 7 Applying and Managing a V.A.C. ATSTM System 509 ➧ Cut desired foam the size and

shape of the wound. May require the use of more than one piece of sponge. Keep in mind the sponges need to touch to provide negative pressure. Sizing the foam appropriately prevents periwound maceration.

FIGURE 27.7B Cut foam to fit into the wound bed.

➧ Apply wound protective layer against wound, if indicated. Protects fragile wound bed from adherence. ➧ Apply or pack the cavity with

the “cut to fit” foam, apply the drape film dressing taking care not to pinch intact skin and ensuring the film is adhering to at least 3 to 5 cm of intact skin, cut an opening in the drape dressing over the sponge area, apply the T.R.A.C. Pad over the cutout opening and connect to the canister, turn the V.A.C. ATS System on; general settings include continuous suction of 125 mm Hg for adult patients, observe for the “pruning” of the foam dressing.

FIGURE 27.7C Cut hole in drape

film over the foam sponge.

Applies negative pressure, removes excess wound exudate away from wound; protects wound from bacterial invasion and trauma.

FIGURE 27.7D Apply T.R.A.C. over the cutout, opening in the drape.

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510 C h a p t e r 2 7 Wound Care

FIGURE 27.7E Observe “pruning” of the foam, and drape dressing after suction is applied.

➧ Remove gloves and discard in appropriate bag. Reduces transmission of microorganisms. ➧ Wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess patient’s response and tolerance of dressing change Assess the sponge for “pruning” (a compression of the sponge) ● Assess wound at each dressing change ● ●

KEY POINTS ● Assessment

FOR

REPORTING

AND

RECORDING

of wound: location, extent of tissue damage, wound appearance including periwound, dimensions, characteristics of exudate. ● Patient’s tolerance of dressing change. ● Settings of the V.A.C.ATS System. ● Type of sponge used. ● Compression of the sponge, called “pruning.”

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U N I T

C H A P T E R

Specimen Collection

10

28 Collecting Blood Samples 28.1 Performing Venipuncture, 512 28.2 Obtaining a Blood Glucose Level by Finger Stick, 517 28.3 Obtaining a Specimen for Arterial Blood Gas Analysis, 520

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512 C h a p t e r 2 8 Collecting Blood Samples

PROCEDURE 28.1 Performing Venipuncture OVERVIEW ●

To collect a venous blood specimen for laboratory examination. P R E PA R AT I O N

Determine agency policy regarding personnel certified to perform venipuncture. ● Determine method of collection—syringe or Vacutainer. ● Determine special conditions, such as fasting, specified collection time, and/or administration of drugs before or after collection. ● Determine if bleeding and/or clotting time may be increased due to medication or pathologic condition; determine contraindications for venipuncture of a specific site. ● Determine patient’s ability to understand, cooperate, and assist in the procedure. ●

Special Considerations • For patients needing blood cultures, collect from two different sites; inoculate anaerobic culture first, then aerobic. • Do not collect sample from an extremity where blood or IV fluids are infusing or from lower extremity. Elderly and Pediatric Patients • Apply warm compresses and use small-bore catheters to promote optimal conditions for collection. • Allow parents to hold children and infants for comfort, if possible. R E L E VA N T N U R S I N G D I A G N O S E S

Potential for injury related to trauma to blood vessel during venipuncture ● Risk for infection related to invasion of microorganisms at the venipuncture site ●

EXPECTED OUTCOMES

Venipuncture site shows no evidence of bleeding, hematoma, or infection ● Sterile specimen is collected in proper container ●

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P r o c e d u r e 2 8 . 1 Performing Venipuncture 513 EQUIPMENT/SUPPLIES

Alcohol or povidone-iodine swab Disposable, clean gloves Small pillow or folded towel Sterile 2⫻2 gauze pads Rubber tourniquet Tape or Band-Aid Completed identification label Completed laboratory requisition Plastic bags for specimen transport Needle/equipment disposal container; blood tubes Syringe Method Sterile needles: 20–21 gauge (adult): 23–25 gauge (children and older adults) Sterile syringe (volume determined by amount of blood sample needed) Vacutainer Method Vacutainer tube with needle holder Sterile double-ended needles: 20–21 gauge (adults): 23–25 gauge (children and older adults) Blood Culture Sterile needle: 20–21 gauge (adult): 23–25 gauge (children and older adults) Anaerobic and aerobic culture bottles I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist. Ensures accurate testing; meets patient’s right to be informed; encourages cooperation and participation. ➧ Determine that special test-related conditions have been met. Test may require fasting, specified time, or administration of medicines before or after the test. ➧ Determine risks for increased bleeding or clotting time. Patient may have bleeding disorder or be on anticoagulant therapy. ➧ Determine contraindications for a venipuncture site. Venipuncture is avoided in areas of an infusion, hematoma, arteriovenous shunt, or in the same arm as mastectomy. ➧ Wash hands, provide privacy, and raise bed to working height. Reduces spread of microorganisms; provides comfort and safety to patient and nurse.

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514 C h a p t e r 2 8 Collecting Blood Samples ➧ Place patient in supine or semi-Fowler’s position with arm extended;

support upper arm with pillow or towel. Stabilizes extremity and facilitates access to site. ➧ Don nonsterile gloves. Reduces exposure to blood-borne pathogens. ➧ Wrap tourniquet around extremity 5–10 cm (2–4 inches) above site. Tourniquet obstructs venous return to the heart and dilates vein facilitating palpation or visualization. ➧ Palpate distal pulse below the tourniquet; reapply less tightly if pulse

is not palpable. Arterial blood circulation will be interrupted by a tourniquet that is applied too tightly. ➧ Instruct patient to pump fist several times. Promotes distention of veins. ➧ Inspect extremity, select straight, easily visualized vein; palpate to

assess elasticity. Apply warm compresses if vein is not visible or easily palpated. Facilitates venipuncture; rigid veins are more difficult to puncture. Warmth dilates blood vessels. ➧ Remove tourniquet within one minute. Wait additional minute

before reapplying or selecting another site. Prolonged pressure will alter blood circulation and cause patient discomfort.

Syringe Method ➧ Select proper-size syringe and needle. Size depends on test to be performed and patient age and/or physical characteristics. ➧ Clean site with alcohol or povidone-iodine swab using a circular

motion from site outward to an area of 5 cm (2 inches); allow area to dry. Reduces bacteria on skin surface from invading puncture site; drying of site reduces sting of venipuncture and supports antimicrobial effect. ➧ Remove needle cover; inform patient to expect a stick. Meets patient need to be informed, and assists in controlling patient anxiety. ➧ Pull skin taut 2.5 cm (1 inch) below proposed venipuncture site with

thumb or forefinger of nondominant hand to stabilize vein. Prevents rolling of vein during insertion of needle.

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P r o c e d u r e 2 8 . 1 Performing Venipuncture 515 ➧ With bevel up, slowly insert needle at 5- to 30-degree angle into

vein; may feel a “pop” as needle enters vein. Reduces vein injury and penetration of both sides of vein. ➧ Pull back gently on plunger of syringe and observe for blood return. Creates vacuum necessary to aspirate the blood into the syringe. Validates that needle is in vein. ➧ Withdraw volume of blood required for test. Ensures accurate test results. ➧ Release tourniquet. Minimizes bleeding when needle is removed from site. ➧ Place 2 ⫻ 2 gauze or alcohol swab over site; withdraw needle and

apply pressure. Reduces patient discomfort and vein injury. ➧ Transfer specimen to blood tubes using one hand to insert needle

into blood tube stopper; allow vacuum to fill tube. Prevents damage to red blood cells; prevents needle-stick injury. ➧ Gently rotate blood in tube back and forth 8 to 10 times. Mixes additives in tube with blood to prevent clotting.

Vacutainer Method ➧ Place double-ended needle on Vacutainer tube. Double-end long needle used to puncture vein and short needle to puncture blood tube stopper. ➧ Place correctly colored blood tube inside Vacutainer without punc-

turing rubber stopper. Ensures accurate test results. ➧ Remove needle from Vacutainer; inform patient to expect a stick. Meets patient need to be informed and assists in controlling patient anxiety. ➧ Pull skin taut 2.5 cm (1 inch) below site with thumb or forefinger of

nondominant hand to stabilize vein. Prevents rolling of vein during insertion of needle. ➧ Hold Vacutainer needle with bevel up at 15- to 30-degree angle.

Insert slowly into vein. Reduces vein injury and penetration of both sides of vein. ➧ Hold Vacutainer firmly, and push blood tube into needle of holder. Puncturing stopper allows blood to flow into tube.

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516 C h a p t e r 2 8 Collecting Blood Samples ➧ Observe blood flow into tube. Validates vacuum is present and needle is in vein. ➧ Holding Vacutainer securely in place, remove tube when filled, and

add additional tubes to vacutainer as necessary. Prevents needle from penetrating vein or dislodging from vein. ➧ Release tourniquet, apply 2⫻2 gauze over puncture site, and with-

draw needle from Vacutainer. Minimizes bleeding at site, vein trauma, and patient discomfort. ➧ Apply pressure to site for 2 to 3 minutes or until bleeding stops; tape

gauze securely. Reduces bleeding and hematoma formation. ➧ Clean tubes with alcohol if outside is contaminated with blood. Prevents transmission of blood-borne pathogens to others. ➧ Label each tube, and attach lab requisitions. Ensures accurate reporting of patient’s test results and appropriate therapy. ➧ Dispose of contaminated needles, syringes, and equipment into

sharps container and/or appropriate container. Prevents transmission of blood-borne pathogens. ➧ Put specimens in appropriate container for transport to laboratory;

remove gloves and wash hands. Prevents transfer of microorganisms; fresh specimen ensures accurate patient results and appropriate therapy. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe venipuncture site for bleeding, hematoma, or signs of infection ● Check test results, and inform prescriber of abnormal findings ●

KEY POINTS ●

FOR

REPORTING

Date, time of specimen collection of site ● Disposition of specimen ● Test results ● Assessment

AND

RECORDING

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P r o c e d u r e 2 8 . 2 Obtaining a Blood Glucose Level by Finger Stick 517

PROCEDURE 28.2 Obtaining a Blood Glucose Level by Finger Stick OVERVIEW ● ●

To measure the amount of glucose in the blood. A drop of capillary blood is obtained by skin puncture on the finger by a single lancet or a device that holds a lancet and then is applied to a reagent test strip that is placed in a glucose monitor to be read. P R E PA R AT I O N

Sterile asepsis and standard precautions are used throughout the procedure. ● Make sure enough blood is obtained to ensure accurate test results. ● Assess patient/caregiver understanding about procedure and provide teaching. ●

Special Considerations • Patients who have had repeated sticks over time may have calloused fingers. • Blood sugar level should be checked before meals or as ordered to determine insulin dosages. • Hold the hand in a dependent position before the stick to increase blood flow to the area. Elderly Patient • Possible visual impairment reduces ability to read meter accurately; assistance with sticks may be necessary. • May be necessary to warm fingertips to produce vasodilation to obtain blood sample. Pediatric Patient • Heel and great-toe sticks can be used, especially on infants; warming the area with a warm cloth will increase blood flow. • Allow children to choose puncture site if feasible, and incorporate use of play therapy. EXPECTED OUTCOMES

Normal blood glucose level No tissue damage or infection to puncture site ● Adequate amount of blood obtained to get accurate results ● Patient is educated about proper technique and normal blood glucose level ● ●

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518 C h a p t e r 2 8 Collecting Blood Samples EQUIPMENT/SUPPLIES

Sterile single lancet or automatic lancet Capillary tube Glucose reagent test strip Antiseptic swab Cotton ball or gauze pad Soap and water Clean gloves Glucose meter Biohazard bag Sharps container I M P L E M E N TAT I O N ➧ Check prescriber’s order for frequency of glucose status. Identify

patient and explain procedure; provide privacy. Frequency is based on patient’s glucose status; ensures accurate testing; enhances cooperation and understanding; allays embarrassment. ➧ Gather equipment, and wash hands. Organization promotes successful and time-efficient collection; decreases spread of microorganisms. ➧ Don clean gloves. Provides protective barrier. ➧ Assess area for puncture site. The most vascular areas with fewer nerve endings are the outer aspect of heel and toes, sides of fingers. Heels and toes are more frequently used for infants. ➧ Choose site for finger stick and massage toward puncture

site. Increases blood flow to site. ➧ Cleanse with soap and water or alcohol swab; allow to dry. Warm water increases blood flow. Reduces bacteria on skin surface from invading puncture site; drying reduces sting of puncture and supports antimicrobial effect. ➧ Uncover lancet or activate the automated lancet twisting. Preparation promotes success.

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P r o c e d u r e 2 8 . 2 Obtaining a Blood Glucose Level by Finger Stick 519 ➧ Place automated lancet firmly

against side of finger, and gently press the activating button. Hold the single lancet perpendicular to site. Ensures correct position.

FIGURE 28.2A Proper position

of lancet. ➧ Wipe away the first drop of blood with gauze or cotton ball. Contains more serum, which can dilute blood specimen and alter results. ➧ Stroke from base of finger, toe, or heel to puncture site. Do not

squeeze puncture site. Stroking in a massaging motion will increase blood flow; squeezing will increase serum and dilute specimen. ➧ Fill capillary tube with blood

by placing tip of tube at base of drop of blood; or if using reagent strip, place next to blood drop, making sure that enough blood is absorbed by the strip for accurate results. Ensures accuracy of testing. FIGURE 28.2B Apply blood drop to

reagent. ➧ Apply pressure to puncture site for 15 to 30 seconds with gauze

to stop bleeding. Direct pressure reduces bleeding. ➧ If using a glucose meter, allow blood to stay on strip for specified

time and then place in meter for digital readout. Ensures accurate testing.

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520 C h a p t e r 2 8 Collecting Blood Samples ➧ Discard used equipment into biohazard bags or sharps container,

remove gloves and wash hands. Decreases spread of blood-borne pathogens. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Compare patient’s value with normal lab values, and inform prescriber of abnormal findings ● Inspect puncture site for further bleeding ● Administer drug therapy, if ordered, for abnormal glucose level ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

● Time

and site of stick Patient’s glucose level ● If any drug therapy was administered—type, amount, location of injection ● Any teaching provided ●

PROCEDURE 28.3 Obtaining a Specimen for Arterial Blood Gas Analysis OVERVIEW

To provide assessment of a patient’s ventilation and oxygenation status and acid–base balance. ● Parameters include: • Arterial oxygen saturation. • Arterial blood pH. • Partial pressure of oxygen. • Partial pressure of carbon dioxide. ●

P R E PA R AT I O N

Dyspnea, increase in respiratory rate, unequal respiratory pattern, abnormal breath sounds, and alteration in level of consciousness may indicate need for arterial blood gas (ABG) analysis. ● Prepare patient that procedure is painful. ●

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P r o c e d u r e 2 8 . 3 Obtaining a Specimen for Arterial Blood Gas 521 ●

Factors that may influence results of ABG include use or nonuse of oxygen, any recent change in amount of oxygen being delivered, use of tracheal suctioning before obtaining ABG.

Special Considerations • Some patients may require additional instruction about procedure. Pediatric, Confused, and Combative Patients • May require more than one person to obtain sample. R E L E VA N T N U R S I N G D I A G N O S E S

Pain/discomfort related to needle insertion depth into skin and artery ● Risk for injury related to improperly done procedure ●

EXPECTED OUTCOMES ● ●

Sample is appropriate for blood gas analysis Neurovascular checks to involved extremity will reveal a warm extremity with pulses and capillary refill of less than 3 seconds EQUIPMENT/SUPPLIES

3-mL heparinized syringe 23- or 25-gauge 1-inch needle 2 alcohol swabs 2 ⫻ 2 gauze Clean gloves Tape Plastic bag with crushed ice Goggles Requisition and identification labels 1:1000 heparin solution, if needed I M P L E M E N TAT I O N ➧ Check prescriber’s order. Identifies specimen ordered, ensuring correct collection methodology. ➧ Identify patient, and explain procedure. Ensures accurate testing; promotes cooperation and understanding. ➧ Wash hands, and gather equipment. Decreases spread of microorganisms; organization promotes successful and time-efficient collection.

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522 C h a p t e r 2 8 Collecting Blood Samples ➧ Prepare heparinized syringe if agency does not have preprepared

syringe. Heparin prevents blood specimen from clotting. ➧ Aspirate 0.5 mL of the 1:1000 heparin solution into syringe, after

wiping top of vial with alcohol swab. Withdraw the plunger to the end of the syringe so that the heparin coats all sides of the syringe. Eject the heparin into the sink. Preparation of syringe for accurate testing. ➧ Don clean gloves and goggles. Serve as protective barriers for the nurse. ➧ Inspect and palpate radial site. Perform Allen’s Test to determine col-

lateral circulation. Have patient make fist and nurse applies pressure over ulnar and radial arteries using index and middle fingers. Have patient open and close fist several times. Release pressure over ulnar artery and watch for flushing of palm and fingers within 15 seconds. If collateral circulation is present, the hand will flush upon releasing the ulnar artery. If there is no flushing, do not use that radial artery. Assess the other hand. ➧ Hyperextend the selected wrist. Decreases mobility of the artery. ➧ Cleanse site with alcohol swab using circular motions. Application of bacteriostatic agent and use of friction from clean to dirty area decreases number of microorganisms. ➧ Feel for radial pulse with index finger of nondominant hand; as you

hold needle at a 45-degree angle, insert needle bevel up into site of pulsation. Angle enhances arterial collection. ➧ Once blood enters syringe, do not advance syringe further into

artery. Arterial pulsations will fill the syringe, reducing presence of air bubbles that may alter test results. ➧ Place alcohol swab next to needle site, and withdraw needle. Stabilizes skin as needle is withdrawn. ➧ Apply pressure over the puncture site with gauze sponges for 5 to

10 minutes. May apply pressure dressing with gauze and tape for an additional 5 minutes for patients with anticoagulant therapy. Promotes coagulation at site.

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P r o c e d u r e 2 8 . 3 Obtaining a Specimen for Arterial Blood Gas 523 ➧ Continue to monitor site for bleeding. Arterial puncture sites require continuing monitoring. ➧ Assess pulse and neurovascular status. Denotes change in arterial flow. ➧ Expel air from syringe; apply protective needle cap per agency

policy. Air can elevate arterial oxygen pressure and decrease arterial carbon dioxide pressure. ➧ Attach requisition to syringe, documenting percentage of oxygen

therapy patient is receiving; place syringe in plastic bag with ice, and send specimen to lab. Oxygen administration alters test results; coldness decreases metabolism within cell. ➧ Remove gloves and wash hands. Decreases spread of blood-borne pathogens. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe site for bleeding or extremity for vascular complications Compare patient’s results with normal ranges, and notify prescriber of abnormal findings ● Continue respiratory and neurologic assessment ● Discuss appropriate therapy ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Record date and time specimen collected and sent to lab. State site used to collect specimen. ● Neurovascular assessment of site before and after puncture and any complications. ● Respiratory/neurologic assessment.

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C H A P T E R

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29 Collecting Urine Samples 29.1 Collecting a Midstream Urine Specimen, 526 29.2 Collecting a Timed (24-Hour) Urine Specimen, 528 29.3 Collecting a Sterile Urine Specimen from an Indwelling Catheter, 531 29.4 Measuring Specific Gravity of Urine, 533

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526 C h a p t e r 2 9 Collecting Urine Samples

PROCEDURE 29.1 Collecting a Midstream Urine Specimen OVERVIEW ●

To obtain a urine specimen for culture and sensitivity testing. This will determine the types of microorganisms present and the antibiotics to which the microorganisms are sensitive. Results are determined at 24 and 48 hours after collection. P R E PA R AT I O N

Determine patient’s ability to understand and cooperate in the procedure. ● Determine signs and symptoms of urinary infection. ● Determine patient’s mobility and independence in collecting a midstream specimen while voiding. ●

Special Considerations • Avoid collecting specimen during defecation. • Note if patient is having menstrual period. Elderly, Pediatric, and Physically Challenged Patients • Determine if they can assist or need assistance. • Have parent stay with children. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible urinary tract infection EXPECTED OUTCOMES

● ●

Collection of an uncontaminated urine specimen Test results reveal no abnormalities of urine EQUIPMENT/SUPPLIES

Kit for clean-voided urine Sterile cotton balls or 2⫻2 gauze pads Cleansing towelette Povidone-iodine solution Sterile container Clean gloves Bedpan, urinal, or commode Specimen hat if all urine must be measured Potty chair for child Completed specimen identification label Completed laboratory requisition form

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P r o c e d u r e 2 9 . 1 Collecting a Midstream Urine Specimen 527 I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist. Ensures accurate testing; meets patient’s right to be informed; encourages cooperation and participation. ➧ Wash hands. Reduces transmission of microorganisms. ➧ Provide privacy. ➧ If patient is unable to use bathroom and collect specimen independ-

ently, provide a commode, bedpan, or urinal. ➧ Open clean catch kit without contaminating it. If patient is obtaining

the specimen independently, tell him or her how to open without contaminating the specimen container. Prevents contamination of the specimen. ➧ Instruct ambulatory female patient to put on clean gloves the spread

the labia with fingers of nondominant hand. Tell patient to use the towelette and clean urinary meatus wiping from front to back once. (For the patient requiring assistance, put on clean gloves and clean the patient as described.) Reduces transmission of microorganisms and reduces contamination of specimen with transient bacteria. Cleans from area of least contamination to greatest contamination; decreases bacterial levels on the area. ➧ Instruct male patient to put on clean gloves and hold penis with

nondominant hand, retracting foreskin if not circumcised. Tell patient to use the towelette and clean the urinary meatus in a circular motion. (For the patient requiring assistance, put on clean gloves and clean the patient as described above.) Decreases microorganisms. ➧ Instruct female patient to hold labia open, void for a few seconds,

then place container into stream of urine and collect specimen without touching container to perineum. Instruct male patient to collect specimen without the penis touching the specimen cup. Clears bacteria from the distal urethra and meatus; prevents contamination of the specimen. ➧ Collect 30–60 mL of urine. Remove container before the flow of urine

stops and before letting go of the labia or penis. Prevents contamination of the specimen.

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528 C h a p t e r 2 9 Collecting Urine Samples ➧ Tightly close the container, touching only the outside of container

and cap. Prevents contamination of the specimen. ➧ Clean outside of the container if contaminated with urine. Prevents transfer of microorganisms to others. ➧ Label container, attach lab requisition. Note on lab requisition if

patient is on antibiotic therapy or if patient is menstruating. Ensures accurate reporting of patient’s test results and appropriate therapy. ➧ Refrigerate specimen if it cannot be transported immediately. Prevents deterioration of urine from bacterial contamination when left at room temperature. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Evaluate patient compliance Observe characteristics of urine and signs of urinary infection ● Check test results, and inform prescriber of abnormal findings ● Discuss appropriate therapy with prescriber ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time of specimen collection. Characteristics of urine and signs of urinary infection. ● Disposition of specimen. ●

PROCEDURE 29.2 Collecting a Timed (24-Hour) Urine Specimen OVERVIEW

To measure the amounts of substances, such as adrenocorticosteroids, hormones, glucose, proteins, electrolytes, or creatinine in the urine. ● To measure the dilution or concentration of the urine. ●

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P r o c e d u r e 2 9 . 2 Collecting a Timed (24-Hour) Urine Specimen 529 P R E PA R AT I O N

Determine patient’s ability to understand, cooperate, and assist in the procedure. ● Discard first-voided specimen of the morning. ● Begin test at time first specimen is discarded. ● Collect all specimens until the time period ends, transferring each specimen immediately into a large collection bottle. ● Repeat the test if a specimen is lost. ● Store collection bottle in ice. Use preservatives as indicated. ● Collect last specimen as close to the end of the collection period as possible. ● Determine if any fluid/dietary requirements or medications are associated with the testing. ●

Special Considerations Elderly and Pediatric Patients • Use pediatric bags as indicated. • Remind older adults and children regarding collection of specimen. R E L E VA N T N U R S I N G D I A G N O S E S ●

Deficient knowledge related to unfamiliar procedure EXPECTED OUTCOMES

Collection of all of the patient’s urine specimens in the test period ● Urine collection is not contaminated by feces, blood, or toilet tissue ● Test results reveal no abnormalities of urine ●

EQUIPMENT/SUPPLIES

Large capped collection bottle with preservative as ordered; basin with ice Bedpan, urinal, commode, specimen hat, or potty chair Graduated measuring cup Completed specimen identification label Completed laboratory requisition Instruction sign to remind patient/staff to save urine specimens Clean gloves

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530 C h a p t e r 2 9 Collecting Urine Samples I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist. Explain that specimens must be free of feces, blood, and toilet tissue. Ensures accurate testing; meets patient’s right to be informed; encourages cooperation and participation. Ensures accurate lab results. ➧ Instruct patient regarding fluid/dietary requirements or medication

administration. Specific tests may have special requirements. ➧ Post instruction signs on door and bathroom; inform staff or other

departments if necessary. Informed personnel prevents loss of specimen. ➧ Add preservative to container if ordered. Fill basin with ice or refrig-

erate specimen, if requested by lab. Maintains urine integrity. ➧ If patient is unable to collect specimen in bathroom independently,

obtain a commode, bedpan, or urinal. ➧ Discard first morning specimen. Note the time, as this constitutes the

beginning of the collection period. Note time on lab requisition. Collection period begins with empty bladder. ➧ Collect all urine specimens for the next 24 hours (or duration of test,

if other than 24-hour test) and empty into the large collection bottle. Ensures accuracy of lab results. ➧ Instruct patient to drink two glasses of water 1 hour prior to the end

of the collection period, unless restricted. Facilitates patient’s ability to void at end of test period. ➧ Instruct patient to void within the last 15 minutes of the test. Ensures timely completion of test. ➧ Label collection bottle and transport to lab with attached requisition. Ensures accurate reporting of patient’s test results and appropriate therapy. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe characteristics and amount of urine Check test results and inform prescriber of abnormal findings ● Discuss appropriate therapy with prescriber ● ●

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P r o c e d u r e 2 9 . 3 Indwelling Catheters 531

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date, starting and ending time of specimen collection. medication, fluid, or dietary requirements. ● Disposition of specimen. ● Any

PROCEDURE 29.3 Collecting a Sterile Urine Specimen from an Indwelling Catheter OVERVIEW ●

To obtain a sterile specimen for examination of the composition of urine or for culture. P R E PA R AT I O N

Determine patient’s ability to understand, cooperate, and assist in the procedure. ● Determine signs and symptoms of urinary infection. ● Determine if urinary closed system has sampling port. ● Use strict aseptic technique in the specimen collection. ● Determine amount of urine needed. ●

Special Considerations • Maintain sterility of closed system drainage. R E L E VA N T N U R S I N G D I A G N O S E S ●

Risk for infection related to break in a sterile system EXPECTED OUTCOMES

Collection of uncontaminated urine specimen Urinary drainage system remains intact ● Test results reveal no abnormalities of the urine ● ●

EQUIPMENT/SUPPLIES

3-mL syringe with 21-gauge 1-inch needle for culture; 20-mL syringe with 21-gauge 1-inch needle for routine urinalysis Metal clamp or rubber band Alcohol or povidone-iodine swab Clean gloves

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532 C h a p t e r 2 9 Collecting Urine Samples I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist. Ensures accurate testing; meets patient’s right to be informed; encourages cooperation and participation. ➧ Clamp urine tubing below the port for 15 to 30 minutes unless con-

traindicated by agency. Ensures adequate amount of urine to be collected. ➧ Wash hands, put on gloves. Reduces transfer of microorganisms. ➧ Position patient for easy access to aspiration port; cleanse port with

antiseptic swab. Ensures collection; reduces transmission of microorganisms. ➧ Insert needle with appropri-

ate syringe at a 30–45 degree angle into port. Facilitates sealing of the port after insertion.

FIGURE 29.3 Obtaining a sterile

urine specimen from an indwelling catheter. ➧ Aspirate sample by gently pulling on syringe plunger. Provides ample urine specimen for collection. ➧ Remove needle from port, and wipe port with antiseptic swab. Reduces transmission of microorganisms. ➧ Remove clamp, and allow urine to drain. Restores urinary drainage system. ➧ Transfer urine to sterile urine specimen container without contami-

nating the container. Tightly close cap. Ensures sterility of specimen. ➧ Remove and discard gloves and soiled supplies. Wash hands. Reduces transmission of microorganisms.

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P r o c e d u r e 2 9 . 4 Measuring Specific Gravity of Urine 533 ➧ Label specimen container and transport to lab with attached

requisition. Ensures accurate reporting of patient’s test results and appropriate therapy. ➧ Refrigerate specimen if it cannot be transported immediately. Prevents deterioration of urine from bacterial contamination when left at room temperature. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Check test results and inform physician of abnormal findings Discuss appropriate therapy with provider ● Observe urinary drainage system to ensure that it is intact and patent ● Assess urine for signs of infection ● ●

KEY POINTS

FOR

REPORTING

AND

RECORDING

●

Date and time of sterile specimen collection per closed urinary system port. ● Characteristics of urine and signs of urinary infection. ● Note restoration of closed urinary system drainage. ● Disposition of specimen.

PROCEDURE 29.4 Measuring Specific Gravity of Urine OVERVIEW ●

To determine the patient’s kidney function, hydration status, and requirement for fluid intake. P R E PA R AT I O N

Determine patient’s ability to understand, cooperate, and assist in the procedure. ● Assess patient’s signs of hydration, especially skin turgor, mucous membranes, intake and output, and fontanels in infants. ● Determine patient history of renal disease. ●

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534 C h a p t e r 2 9 Collecting Urine Samples

Special Considerations • Medications or fluid restrictions may affect test results. • Report test results in relation to age of patient. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible imbalanced fluid volume related to disease process EXPECTED OUTCOMES

● ●

Collection of uncontaminated urine specimen. Test results reveal no abnormalities of urine. EQUIPMENT/SUPPLIES

Calibrated urinometer Multistix reagent test strips Refractometer Clean, dry, glass cylinder Medicine dropper Clean gloves Slide I M P L E M E N TAT I O N ➧ Identify patient; explain purpose, procedure, and how patient can

assist, as indicated. Ensures accurate testing; meets patient’s right to be informed; encourages cooperation and participation. ➧ Explain that specimen must be free of feces, blood, and toilet tissue. Ensures accurate test results. ➧ Wash hands and put on gloves. Reduces transmission of microorganisms. ➧ Collect fresh specimen of urine. Ensures accurate test results.

Urinometer Method ➧ Pour urine to fill 2/3 to 3/4 of glass cylinder, and twirl stem gently. Urinometer floats when cylinder is 2/3 full; twirling keeps urinometer from touching sides of cylinder. ➧ When urinometer stops bobbing, hold urinometer scale at eye level

and read point where urine level touches lowest point of meniscus of the calibrated scale.

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P r o c e d u r e 2 9 . 4 Measuring Specific Gravity of Urine 535 The depth the urinometer floats is in relation to the concentration of dissolved solutes in urine. ➧ Discard urine; wash cylinder in cool water. Warm water coagulates protein on glass surface. ➧ Wash hands. Reduces transmission of microorganisms.

Multistix Reagent Strip Method ➧ Place end of strip into urine sample. Activates chemical reagent strip. ➧ Wait designated time, read color of strip, and compare to color chart

on bottle. Time exposure measures specific gravity. ➧ Discard urine and strip; wash hands. Reduces transmission of microorganisms.

Refractometer Method ➧ Place 1 drop of urine on slide, and view through refractometer. Refractometer visualizes the density of urine on a calibrated scale. ➧ Discard urine and slide; rinse dropper in cool water; wash hands. Reduces transmission of microorganisms. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S ● ●

Check test results and inform provider of abnormal findings. Discuss appropriate therapy with provider

KEY POINTS ● ●

FOR

REPORTING

AND

RECORDING

Date, time, and result of test. Notification to provider of abnormal findings.

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C H A P T E R

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30 Collecting Other Specimens 30.1 Collecting a Nose or Throat Specimen for Culture, 538 30.2 Collecting a Sputum Specimen, 541 30.3 Obtaining a Wound Drainage Specimen, 545

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538 C h a p t e r 3 0 Collecting Other Specimens

PROCEDURE 30.1 Collecting a Nose or Throat Specimen for Culture OVERVIEW ●

To determine the presence of pathogenic microorganisms. P R E PA R AT I O N

Specimen collection may cause gagging or mucosal discomfort. Nurse may need assistance in obtaining specimens from children and confused or combative patients. ● Always read directions on commercially prepared culture tubes to ensure correct collection and transport of specimen. ● ●

Special Considerations • Specimen collection may cause gagging or mucosal discomfort; therefore, extra time may be necessary if the patient gags. Pediatric, Confused, and Combative Patients ● May need more than one person to collect specimen. R E L E VA N T N U R S I N G D I A G N O S E S ● ●

Possible infection Potential for injury related to movement during procedure causing nasal mucosa irritation EXPECTED OUTCOMES

Collected specimen is not contaminated Specimen is transported to lab in required time frame and in appropriate collection tube ● Specimen contains no pathogenic microorganisms ● No trauma to throat/nasal mucosa ● ●

EQUIPMENT/SUPPLIES

Tongue depressor Clean gloves Culture tubes with culture swabs Emesis basin Tissues Light source Laboratory requisitions and identification labels Penlight

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P r o c e d u r e 3 0 . 1 Collecting a Nose or Throat Specimen for Culture 539 I M P L E M E N TAT I O N ➧ Check prescriber’s orders. Identifies type of culture ordered, ensuring identification of the appropriate container and time frame needed to send culture to lab. ➧ Identify patient and assess functional ability. Ensures accurate testing; determines amount of assistance needed. ➧ Wash hands, and gather equipment. Decreases spread of microorganisms; organization promotes successful and time-efficient collection. ➧ Explain purpose and procedure of test; provide privacy. Enhances cooperation and understanding; allays embarrassment.

Collection of Throat Specimen ➧ Place patient in semi-Fowler’s position with head tilted back; use

light source; provide emesis basin. Allows easy visualization and access to oral structures; stimulation of gag reflex may induce vomiting. ➧ Don clean gloves. Provides protective barrier. ➧ Loosen sterile culture swab from culture tube. Allows easy removal of swab. ➧ Have patient open mouth, and depress tongue with tongue

depressor. Depressing tongue prevents contamination of swab by oral mucosa; depression of the anterior portion of tongue decreases gag reflex. ➧ Insert swab without touching any oral structures. Prevents contamination with resident bacteria. ➧ Gently swab throat at tonsillar area, contacting purulent/inflamed

area. Permits exposure to sites with pathogenic microorganisms. ➧ Remove culture swab without touching oral structures and place in

culture tube, crushing ampule until culture medium saturates end of swab. Preserves bacteria sample until testing.

Collection of Nasal Specimen ➧ Position patient with head back and check nasal passages for

patency with a penlight. Ensures larger access to obtain specimen.

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540 C h a p t e r 3 0 Collecting Other Specimens ➧ Insert culture swab into nasal passage to inflamed area, being careful

not to touch other nasal structures. Prevents contamination of swab prior to collection of specimen. ➧ Gently and rapidly rotate swab at site and move from nasal passage

without touching sides of nasal passage. Prevents contamination of collected specimen by resident bacteria. ➧ Offer patient tissues to blow nose. Promotes comfort. ➧ Securely place top on culture tube and discard tongue depressor

into trash. Prevents spread of microorganisms. ➧ Position patient comfortably. Enhances comfort. ➧ Wash hands. Prevents spread of microorganisms. ➧ Attach completed identification label and lab requisition to culture

tube. Send to lab immediately. Ensures accurate reporting of patient’s test results and appropriate therapy; fresh specimen enhances accurate test results. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Check patient’s nasal/throat passage for evidence of trauma, such as bleeding ● Check test results and inform prescriber of abnormal finding ● Discuss appropriate therapy with prescriber ●

KEY POINTS ● Assessment

FOR

REPORTING

of nasal/oral mucosa. Date, time, and type of culture. ● Describe any exudates. ● Patient’s tolerance of procedure. ● Time sent to laboratory. ●

AND

RECORDING

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P r o c e d u r e 3 0 . 2 Collecting a Sputum Specimen 541

PROCEDURE 30.2 Collecting a Sputum Specimen OVERVIEW ●

To aid in diagnosis of respiratory conditions. P R E PA R AT I O N

Early-morning specimen provides an adequate amount and more easily expectorated specimen. ● Assess patient’s knowledge about and ability to effectively cough to facilitate sputum expectoration. ● Adhere to rigid aseptic technique to avoid specimen contamination. ● If unable to obtain specimen, collecting of sputum may have to be done through suctioning of secretions, or enhanced through the use of bronchodilators, nebulization treatments, or chest physiotherapy. ●

Special Considerations • If patient develops respiratory distress during procedure, it may be necessary to stop and provide oxygen until breathing is improved. • Some patients may need additional instruction on how to effectively cough to facilitate sputum expectoration. • Postoperative patients may require splinting of surgical site to effectively cough and prevent injury. R E L E VA N T N U R S I N G D I A G N O S E S ●

Possible respiratory tract infection EXPECTED OUTCOMES

Obtain an uncontaminated sputum specimen Test results do not reveal abnormal cells or pathogenic microorganisms ● No respiratory distress experienced by patient during or after procedure ● No injury experienced to abdominal area during coughing (if incision is present) ● ●

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542 C h a p t e r 3 0 Collecting Other Specimens

EQUIPMENT/SUPPLIES

Sterile specimen container Tissues Clean gloves Gown, goggles, and mask, if indicated Small lab transport container as indicated by agency Identification and requisition labels Additional equipment needed for suction: Suction device Sterile suction catheter Sterile gloves Sterile sputum trap—Lufkin’s Oxygen, if indicated I M P L E M E N TAT I O N ➧ Check prescriber’s orders. Ensures collection of correct type of specimen. ➧ Identify patient and explain procedure, assessing patient’s ability to

cough. Enhances cooperation and understanding; a deep cough produces sputum from the tracheobronchial tree ensuring accurate specimen analysis. ➧ Assess respiratory status. Provides a baseline assessment. ➧ Gather equipment and wash your hands. Preparation promotes success; decreases spread of microorganisms. ➧ Provide privacy. Allays embarrassment.

Expectorated Specimen ➧ Don clean gloves. If indicated, don gown, goggles, and mask. Prevents cross-contamination from patient secretions. ➧ Place patient in upright position and provide specimen container. Facilitates lung expansion and coughing. ➧ Splint an abdominal incision with your hands or a pillow. Minimizes muscle use and discomfort, encouraging a deeper cough. ➧ Instruct patient to take several breaths without exhaling completely,

then cough deeply, expectorating sputum with an intense cough into the specimen container.

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P r o c e d u r e 3 0 . 2 Collecting a Sputum Specimen 543 Opens airways, loosens secretions, mobilizes secretions into larger airways, and forcefully expels secretions. ➧ Obtain 5–10 mL of sputum and cap container; place in appropriate

container per agency policy. Ensures accurate testing.

Suctioned Specimen ➧ Set up suction equipment. Preparation promotes success. ➧ Connect sputum trap to

suction tube. Allows suction to the trap.

FIGURE 30.2A Attach suction tube

to specimen container. ➧ Apply sterile glove to dominant hand and connect sterile suction

catheter to sputum trap. Tracheobronchial tree is sterile environment. ➧ Insert the sterile catheter tube into the respiratory tract (nasophar-

ynx or tracheostomy) without applying suction. Decreases trauma to respiratory tract during insertion of catheter. ➧ Apply suction intermittently as patient coughs and while withdraw-

ing catheter. Do not apply suction longer than 10 to 15 seconds at a time to prevent an alteration in respiratory status.

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544 C h a p t e r 3 0 Collecting Other Specimens ➧ Detach catheter from trap

and dispose in trash bin. Cap trap and place in appropriate agency container. Reduces spread of microorganisms.

FIGURE 30.2B Obtaining a sterile urine specimen from an indwelling catheter.

➧ Wash hands. Decreases spread of microorganisms. ➧ Label and send specimen to lab immediately. Ensures accurate lab results and appropriate therapy; bacteria count increases quickly in room temperature. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Observe respiratory status during entire procedure Check test results and inform prescriber of abnormal findings ● Discuss appropriate therapy with prescriber ● Observe character of sputum, making sure that specimen is not saliva. ● Observe patient’s tolerance of procedure. ● ●

KEY POINTS ●

FOR

REPORTING

AND

RECORDING

Describe amount, color and consistency of sputum. Patient’s tolerance of procedure. ● Respiratory status throughout procedure. ● Method of collection ● Time specimen collected and sent to lab ●

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P r o c e d u r e 3 0 . 3 Obtaining a Wound Drainage Specimen 545

PROCEDURE 30.3 Obtaining a Wound Drainage Specimen OVERVIEW ●

To identify the type and number of pathogenic organisms present. P R E PA R AT I O N

Often will be obtained during dressing-change procedure. Collect specimen from wound, not from skin around wound, unless ordered. Do not collect from old exudate. ● A large wound may need to have several cultures taken from different areas of wound. ● ●

Special Considerations • Some patients may require analgesic medication at least 15 to 30 minutes prior to specimen collection. Pediatric, Confused, and Combative Patients • May need more than one person to collect specimen. • Have parent stay with infant or child when possible, to comfort. R E L E VA N T N U R S I N G D I A G N O S E S ●

Pain/discomfort related to tissue manipulation during specimen collection EXPECTED OUTCOMES

No bacterial growth Wound culture is not contaminated by superficial skin microbes ● Specimen is transported to lab in required time frame and in appropriate collection container ● No discomfort for patient ● ●

EQUIPMENT/SUPPLIES

Clean gloves—2 pair Sterile gloves—1 pair Plastic disposable bag Dressing materials Appropriate culture tube with swabs and transport medium Identification and requisition labels Gown, goggles, and mask, if indicated Transport container as indicated by agency

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546 C h a p t e r 3 0 Collecting Other Specimens I M P L E M E N TAT I O N ➧ Check prescriber’s orders. Ensures correct type of culture, anaerobic or aerobic, and site of culture. ➧ Identify patient and explain procedure. Ensures accurate testing; promotes cooperation and understanding. ➧ Give analgesic if indicated. Decreases discomfort. ➧ Provide privacy; gather equipment, and wash hands. Promotes relaxation and allays undue embarrassment; preparation promotes successful and time-efficient collection; decreases spread of microorganisms. ➧ Open any sterile items, and place in easy reach. Provides an accessible sterile field. ➧ Don clean gloves. Provides barrier to patient’s microorganisms. ➧ Remove soiled dressings and discard in plastic disposable bag. Decreases spread of microorganisms. ➧ Remove gloves, and don clean gloves. Provides barrier to patient microorganisms. ➧ Obtain culture swab from

culture tube and place tip into wound, rotating tip in drainage. Remove from wound and place swab into culture tube. Crush end of tube, activating medium, and push tip of swab into medium. Ensures needed medium to keep organisms viable until growth of culture. FIGURE 30.3 Rotate cotton swab in

wound drainage. ➧ Place specimen in agency-appropriate transport container; remove

gloves and wash hands. Decreases spread of microorganisms.

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P r o c e d u r e 3 0 . 3 Obtaining a Wound Drainage Specimen 547 ➧ Label specimen with requisition and identification and send to lab

immediately. Note on label any current antibiotic or antifungal therapy. Ensures accurate testing; ensures microorganism viability for correct analysis results. Drug therapy may lead to false-negative lab results. ➧ Don sterile gloves, and replace dressings using sterile technique. Prevents wound contamination. ➧ Remove gloves and wash hands. Decreases spread of microorganisms. ➧ Place patient in comfortable position. Promotes comfort and well-being. E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S

Assess wound and drainage characteristics Assess and control pain level post-procedure if indicated ● Check test results and notify prescriber of abnormal findings ● Discuss appropriate therapy with prescriber ● ●

KEY POINTS ● Describe

FOR

REPORTING

AND

RECORDING

wound and drainage, including unusual characteristics. ● Type of culture done. ● Area from which culture is taken. ● Time specimen collected and sent to lab. ● Patient toleration of procedure.

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References 551 Smith-Temple, J., & Johnson, J. (2002). Nurse’s guide to clinical procedures (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Smith-Temple, J., & Johnson, J. (2006). Nurse’s guide to clinical procedures (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Sussman, C., & Bates-Jensen, B. (2004). Wound care: A collaborative practice manual for physical therapists and nurses (2nd ed.). Gaithersburg, MD: Aspen Publications. Taylor, C., Lillis, C., & LeMone, P. (2004). Fundamentals of nursing: The art and science of nursing care (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Thompson, J. M., McFarland, G. K., Hirsch, J. E., & Tucker, S. M. (2002). Mosby’s clinical nursing (5th ed.). St. Louis: Mosby. Turnbull, G. (2003). The ostomy files:The convexity controversy. Ostomy/wound Management 49(1), 16–17. Weenig, R. H., Davis, M. D. P., Dahl, P.R., & Su, W. P. D. (2002). Skin ulcers misdiagnosed as pyoderma gangrenosum. New England Journal of Medicine, 347, 1412. Whittington, K., Patrick, M., & Roberts, J. L. (2000). A national study of pressure ulcer prevalence and incidence in acute care hospitals. Journal of Wound, Ostomy and Continence Nursing, 27(4), 209–215.

Other Handbook of Nursing Procedures (2001). Springhouse, PA: Springhouse Corporation.

Website references: http://www.kcil.com/products/VAC/index.asp http://www.medicalmultimediagroup.com/pated/joints/hip/hip_pre.html http://www.nursing.uiowa.edu/sites/chronicwound/!de2.htm http://www.eakin.co.uk/products/items/?title_id⫽4&Image_ID⫽3.gif

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C R E D I T S

Chapter 3 Pages 32–48: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 4 Pages 55–63: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company. Pages 64–104: From Dillon, P. (2007). Nursing Health Assessment, 2/e. Philadelphia, PA: FA Davis Company. Page 107: From Williams, L and Hopper, P. (2007). Understanding Medical Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 5 Pages 137, 140, 141, 147: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company. Page 143: From Williams, L and Hopper, P. (2007). Understanding Medical Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 6 Pages 152–167, 173–190: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 7 Pages 200–201: From Kisner, C, Colby L. (2002). Therapeutic Exercise: Foundations and Techniques, 4/e. Philadelphia, PA: FA Davis Company.

Chapter 8 Pages 208–214: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 9 Pages 237–238: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 10 Pages 244–261: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 11 Pages 267–269: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 12 Pages 280–284, 300–301: From Phillips, L. (2006). IV Therapy Notes. Philadelphia, PA: FA Davis Company.

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Illustration Credits 553 Pages 286–287: From Phillips, L. (2006). Manual of IV Therapeutics. Philadelphia, PA: FA Davis Company

Chapter 15 Pages 334–335: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 17 Pages 354–355: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 18 Pages 363–374: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 19 Pages 380–390: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 20 Page 397: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 21 Pages 408–413: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 22 Pages 419–427: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 23 Pages 435–436: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company. Page 441: From Williams, L and Hopper, P. (2007). Understanding Medical Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 24 Pages 449–453: From Williams, L and Hopper, P. (2007). Understanding Medical Surgical Nursing, 3/e. Philadelphia, PA: FA Davis Company.

Chapter 25 Pages 453–466: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

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Chapter 26 Page 473: From Norton, D., McLaren, R., & Exton-Smith, A.N. (1975). An investigation of geriatric nursing problems in hospitals. Edinburgh, UK: Churchill Livingstone. Page 474: From U.S. Department of Health and Human Services. (1992). Clinical Practice Guideline. Pressure ulcers in adults: Prediction and prevention. PPPPUA Publication No. 92–0047. Rockville, MD: Public Health Service, pp. 16–17. Copyright Barbara Braden and Nancy Bergstrom, 1988. Page 481: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 27 Pages 494–505: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company. Page 504: From Davis’s Drug Guide Wound Care Tutorial Figure.

Chapter 28 Page 519: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 29 Page 532: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

Chapter 30 Pages 543–546: From Wilkinson, J, Van Leuven, K. (2007). Fundamentals of Nursing. Philadelphia, PA: FA Davis Company.

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Page 555

I N D E X A Abdomen assessments, 100–105 Abstract thinking, 109 Accommodation, 58–59 Acoustic blink reflex, 61 Acrocyanosis, 115 Administration of medications. See Medication administration Aerosolized medications, 133 Air mattress, 466 Airborne precautions, 26–28 Air-fluidized bed, 467–469 Air-suspension bed, 467–469 Airway suctioning. See also Artificial airway catheter sizes for, 253t endotracheal tube, 257–262 nasopharyngeal, 252–257 nasotracheal, 252–257 oropharyngeal, 249–252 tracheostomy tube, 257–262 Alcohol-based rinses, 18 Allen’s test, 94, 522 Ambu manual ventilator, 229–232 Analgesia definition of, 112 patient-controlled, 191–195 Angle of Louis, 39f Anterior axillary line, 39f Antiembolic hose, 313–315 Aortic area, 90 Apical pulse, 39f, 41–42, 113–114 Apical-radial pulse, 42–43 Apnea, 46t Arterial blood gas analysis, 520–523 Artificial airway mechanical ventilator, 214 oxygen therapy administration in patients with, 213–218 T-piece, 214, 216–217 trach collar, 214–216 As-needed basis, 125 Assessments abdomen, 100–105 blood pressure, 47–52 body temperature. See Body temperature ear. See Ear assessments eye. See Eye assessments heart. See Heart assessment mouth, 71–74

musculoskeletal, 96–100 neck, 75–78 neurologic system. See Neurologic system assessments nose, 67–71 pharynx, 71–74 pulse. See Pulse assessment respiratory rate, 44–46 sinuses, 67–71 skin, 115–118 Asterixis, 108 Ataxic breathing, 113 Athetoid movements, 108 Auscultation of abdomen, 101–103 of heart, 91–95 of thorax, 84–85 Autotransfusion, 324–328 Axillary body temperature assessment, 34, 36 Axillary line, 39f

B Bed air-fluidized, 467–469 with air-mattress, 466 air-suspension, 467–469 with foam-mattress overlay, 465 moving and positioning the patient in, 432–436 occupied, 12–15 specialty surface, 464–467 transferring patient from, to wheelchair, 437–439 turning patients in, 435–436 Bed bath, 2–5 Biot’s respirations, 46t Bladder irrigation, using three-way Foley catheter, 396–400 Bleb formation, 167 Blink reflex, 111 Blood donation, 326–327 Blood glucose level, fingerstick method for obtaining, 517–520 Blood pressure, 47–52, 93, 114 Blood reinfusion, 327–328 Blood specimen for arterial blood gas analysis, 520–523 finger stick method, 517–520 venipuncture for, 512–516

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556 Index Blood transfusion autotransfusion, 324–328 blood products, 320–324 Blood vessel assessments, 94, 96 Body alignment, 406–410 Body positioning assessments, 113 Body temperature assessment of, 112 axillary, 34, 36 in elderly patients, 31 electronic methods of, 34–37 oral, 32–37 overview of, 30 in pediatric patients, 31 preparation, 30 rectal, 33–36 thermometers, 32f, 32–37 tympanic, 36–37 Bolus, intravenous, 178–183 Bowel elimination enema, 360–365 ostomy care, 370–376 rectal tube, 366–369 Brachial artery, 49–50, 93 Braden scale, 474f Bronchophony, 85 Broviac catheter, 302t Buck’s traction, 449 Buretrol, 169–170, 173–174

C Carotid artery, 93 Cast care, 444–448 Catheters central, 299–306 indwelling care of, 385–388 insertion of, 378–385 urine specimen collected from, 531–533 percutaneous, 300, 301t–302t peripherally inserted midline and central dressing changes, 296–299 insertion technique for, 285–292 short-term peripheral intravenous. See Short-term peripheral intravenous catheter insertion straight care of, 385–388 insertion of, 378–385 triple lumen, 397f

tunneled, 300 urinary, 378–388 Centigrade conversions, 31t Central catheters, 299–306 Central line placement, 299–306 Cervical lymph nodes, 76 Chest auscultation of, 84–85 inspection of, 80–81 palpation of, 81–82 percussion of, 82–84 Chest tubes in elderly patients, 265 management of, 264–271 milking of, 264 in pediatric patients, 265 removal of, 271–273 stripping of, 264 Chevron method, of taping, 283 Cheyne-Stokes respiration, 46t, 113 Children. See Newborns; Pediatric patients Chloasma, 115 Choreiform movements, 107 Clean intermittent self-catheterization, 391–394 Collar, 459–461 Color vision, 54 Compress, moist, 456–459 Confrontation test, 56–57 Constipation, 450 Contact precautions, 24–26 Continuous positive airway pressure, 220–222 Continuous tube feedings, 333 Controlled coughing, 203–205 Convergence, 57 Coordination, 111 Corneal light reflex, 57 Costal angle, 81 Coughing, controlled, 203–205 Creams, 132 Crutch walk, 425–430 Cuffed endotracheal/tracheostomy tube, 240–242

D Decerebrate posturing, 107 Decorticate posturing, 107 Decubitus, 118 Deep tendon reflexes, 112 Deltoid muscle injections, 157–158

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Index 557 Dental floss, 7 Denture care, 7–8 Diabetes mellitus, foot care in, 10 Diastolic pause, 92 Dorsogluteal muscle injections, 157 Drainage chest, 264–271 postural, 198–202 wound. See Wound drainage Dressings hydrocolloid, 501–502, 505 hydrogel, 501, 504 occlusive, 268 peripherally inserted midline and central catheter, 296–299 transparent film, 501–502, 504–505 wet-to-dry, 501, 503–504 wound, 501–505 Drop factor, 170 Droplet precautions, 22–24 Dull percussion, 103

E Ear assessments ear canal, 63–65 eardrum, 63–65 in elderly patients, 62 external ear, 63 otoscope used in, 62f in pediatric patients, 61 Rinne test, 66–67 Romberg test, 66–67 Weber test, 65, 67 whisper test, 65 Ear medications, 139–141 Egg-crate mattress, 466f Egophony, 85 Elbow muscle tone and strength assessments, 99 range-of-motion exercises, 420 Elderly patients assessments body temperature, 31 ears, 62 eyes, 54 heart, 87 mouth, 72 neck, 75 nose, 68 pulse, 40 sinus, 68

skin, 115–116 thorax, 79 blood pressure in, 47 blood transfusion in, 320, 325 body alignment in, 406 cast care in, 444 chest tubes in, 265, 271 endotracheal tube suctioning in, 258 enema in, 360 finger stick method for obtaining blood glucose level in, 517 intermittent positive pressure ventilation in, 223 intravenous fluid therapy in flow rate considerations, 293 peripherally inserted midline and central catheters, 288 medication administration in feeding tubes, 336 intravenous medications, 170 oral medications, 121 rectal suppository, 146 self-medication, 127 to skin, 130 moving and positioning patients in bed, 432 nasoenteric tube advancement in, 357 nasogastric tube insertion in, 352 oxygen therapy in, 210 pressure ulcers in, 475, 478 skeletal traction in, 453–454 skin traction in, 450 total parenteral nutrition in, 340 tracheostomy tube suctioning in, 258 tube feedings in, 330–331, 336 urinary incontinence collection device in, 389 urine specimen collection in, 526, 529 walker use by, 425–430 wounds in drainage of, 496 dressings for, 502 Endotracheal tube care of, 232–234 cuffed, 240–242 suctioning of, 257–262 Enema, 360–365 Enema bag, 362–364 Enteric tube feedings, 330–335 Exercises isometric, 422–424 passive range-of-motion, 418–421

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558 Index External ear, 63 Eye assessments accommodation, 58–59 convergence, 57 corneal light reflex, 57 in elderly patients, 54 eye movements, 57 ocular fundus, 59–60 ophthalmoscope used in, 55f in pediatric patients, 54 pupillary response to light, 58 visual acuity, 55–56, 60 visual fields, 56–57 Eye care, 3–4 Eye drops, 134–139 Eye ointment, 134–139

F Fahrenheit conversions, 31t Fat emulsion, 346–349 Feeding tubes feedings using, 330–335 medications administered through, 335–338 Feet care of, 10–12 range-of-motion exercises, 420 Finger stick method, for obtaining blood glucose level, 517–520 First heart sound, 91 Flaccid posturing, 107 Foam mattress, 465 Foley catheter, three-way, 396–400 Footboard, 408f Four-point gait pattern, 426t, 427f, 428 Fundus, 59–60 Funduscopic examination, 54

G Gag reflex, 112 Gait patterns, 426t, 427f, 428 Gastrocnemius, 99 Gloves, isolation, 20–22 Gown, isolation, 20–22

H Hair, 117 Half-kneel lift, 414 Hand range-of-motion exercises, 420 Handwashing, 18–19 Heart assessment

auscultation, 91–95 in elderly patients, 87 equipment, 87–88 palpation, 88–90 in pediatric patients, 86–87 percussion, 90 preparation, 86 Heart rate, 38–43 Heart sounds, 91–92 Heparin, 151, 153–154 Heparin flush, 181–182 Heparin lock, 172 Hickman catheter, 302t Hip artificial, precautions for, 439–442 muscle tone and strength assessments, 99 range-of-motion exercises, 420 Homan’s sign, 95 Home health patients blood transfusion in, 320–321 indwelling catheters in, 378 ostomy care for, 371 straight catheters in, 378 urinary incontinence collection device in, 389 wound drainage, 496, 498 wound dressings, 502 Hydrocolloid dressings, 501–502, 505 Hydrogel dressings, 501, 504 Hygiene bed bath, 2–5 foot care, 10–12 mouth care, 5–9 Hyperanalgesia, 112 Hypertension, 114 Hyperventilation, 113 Hypoanalgesia, 112 Hypoglossal nerve testing, 74 Hypotension, 114

I Ice bag, 459–461 Ice pack, 459–461 Implanted ports, 301, 303t Indwelling catheter care of, 385–388 insertion of, 378–385 urine specimen collected from, 531–533 Infection control airborne precautions, 26–28

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Page 559

Index 559 contact precautions, 24–26 droplet precautions, 22–24 handwashing, 18–19 isolation gown and gloves, 20–22 Infusion intermittent infusion sets, 169–178 patient-controlled analgesia, 191–195 Inhaler. See Metered-dose inhaler Injections insulin mixing, 188–191 intradermal, 164–168 intramuscular. See Intramuscular injections self-injections, 183–187 subcutaneous, 150–155 Inspection of abdomen, 102 of chest, 80–81, 88 Insulin mixing of, 188–191 subcutaneous injection of, 151 types of, 188 Intellectual function, 108–109 Intermittent infusion sets, 169–178 Intermittent positive pressure ventilation, 223–225 Intermittent self-catheterization, 391–394 Intermittent tube feedings, 334 Intradermal injections, 164–168 Intramuscular injections standard administration of, 155–160 Z-track method for, 161–164 Intraocular disk, 138 Intravenous fluid therapy central catheters, 299–306 flow rate calculations and regulation, 293–296 percutaneous catheters, 300, 301t–302t peripherally inserted midline and central catheters dressing changes, 296–299 insertion technique for, 285–292 summary of, 302t ports, 301, 303t short-term peripheral intravenous catheter insertion. See Short-term peripheral intravenous catheter insertion Intravenous lock, 181

Intravenous medications bolus, 178–183 Buretrol set-up for, 169–170, 173–174 intermittent infusion sets for, 169–178 mini-infusion pumps for, 169–178 in pediatric patients, 169–170 Intravenous piggyback description of, 169–170, 176 flow rate calculations, 295 Intravenous push, 180–181 Irrigation bladder, 396–400 wound, 493–495 Isolation gown and gloves, 20–22 Isolation precautions airborne, 26–28 contact, 24–26 droplets, 22–24 Isolation room, 21 Isometric exercises, 422–424

J Jugular veins, 94

K Knee range-of-motion exercises, 420 Kussmaul’s respirations, 46t Kyphosis, 79, 98

L Language, 108 Lanugo, 115 Leg(s) assessment of, 94–95 postoperative exercises for, 315–317 Level of consciousness, 106–108 Lifting techniques, 411–415 Light reflex, 110 Linea nigra, 115 Lipids, 346–349 Lordosis, 98 Lotions, 132–134 Lung assessments auscultation, 84–85 in elderly patients, 79 inspection, 80–81 palpation, 81–82 Lung assessments (Continued) in pediatric patients, 79 percussion, 82–84 preparation, 78

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Page 560

560 Index M Macrodrip, 170 Mask continuous positive airway pressure, 221 nonrebreather, 209, 211–212 partial rebreather, 209, 211–212 simple face, 209, 211–212 Venturi, 210–212 Mechanical ventilation Ambu manual ventilator, 229–232 continuous positive airway pressure, 220–222 intermittent positive pressure ventilation, 223–225 management of, 225–229 Mechanical ventilator, 217 Medication administration aerosolized medications, 133 as-needed basis, 125 calculations, 120 creams, 132 to ear, 139–141 eye drops, 134–139 eye ointment, 134–139 feeding tubes for, 335–338 injections intradermal, 164–168 intramuscular. See Intramuscular injections intravenous. See Intravenous medications self-injections, 183–187 subcutaneous injection, 150–155 intraocular disk, 138 metered-dose inhaler, 142–145 nitroglycerin ointment, 132 ointments, 132 oral medications, 120–125 pastes, 132 patient-controlled analgesia, 191–195 powders, 133 rectal suppository, 145–148 self-medication, 125–129 to skin, 130–134 suspension-based lotion, 133–134 transdermal patch, 132–133 Medication administration record, 122 Memory, 108–109 Men intermittent self-catheterization teaching for, 393

midstream urine specimen collection in, 527 straight or indwelling catheter insertion in, 380–383 urinary incontinence collection device in, 390 Mental status assessments, 106 Metered-dose inhaler, 142–145 Microdrip, 170 Midclavicular line, 39f Midsternal line, 39f Midstream urine specimen, 526–528 Mini-infusion pumps, 169–178 Mitral valve area, 89f, 90 Moist compress, 456–459 Mongolian spot, 115 Mouth assessment of, 71–74 care of, 5–9 Moving of patients in bed, 432 Multistix reagent strip method, 535 Muscle tone and strength, 99, 110 Musculoskeletal assessments, 96–100

N Nails, 117 Nasal cannula, 209, 211 Nasal septum deviation, 69 Nasal specimen, 538–540 Nasoenteric tube advancing of, 356–358 feedings using, 330–335 Nasogastric tube feedings using, 330–335 insertion of, 352–356 Nasopharyngeal airway insertion of, 244–249 suctioning of, 252–257 Nasotracheal airway insertion of, 244–249 suctioning of, 252–257 Neck assessment of, 75–78 muscle tone and strength evaluations, 99 passive range-of-motion exercises, 419 Neurologic system assessments behavior and appearance, 108 coordination, 111 intellectual function, 108–109 language, 108 level of consciousness, 106–108

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Index 561 mental status, 106 motor function, 110 overview of, 105 preparation, 105 pupils, 109–110 reflexes, 111–112 sensory function, 112–113 vital signs, 113–114 Newborns pulse assessment in, 39 respiratory rate in, 44 skin assessments in, 115 Nitroglycerin ointment, 132 Nonrebreather mask, 209, 211–212 Norton scale, 473f Nose assessment of, 67–71 specimen collection from, 538–540 Nutrition. See also Feeding tubes peripheral partial, 343–345 total parenteral, 340–343

O Oblique body position, 409f Occlusive dressing, 268 Occupied bed, 12–15 Ocular fundus, 59–60 Oil-based lotions, 132 Ointments in eyes, 134–139 topical, 132 Olfactory nerve testing, 70 Ophthalmoscope, 55f Optic disk, 59 Oral body temperature assessment, 32–37 Oral medications administration of, 120–125 calculation of, 120 Oropharyngeal airway insertion of, 244–249 in pediatric patients, 248, 251 suctioning of, 249–252 Osteoporosis, 98 Ostomy care, 370–376 Otoscope, 62f Otoscopic examination, 61 Overhead lift, 414 Oxygen therapy administration delivery methods, 208 in elderly patients, 210 nasal cannula, 209, 211

nonrebreather mask for, 209, 211–212 partial rebreather mask for, 209, 211–212 in patient with artificial airway, 213–218 simple face mask for, 209, 211–212 standard approach to, 208–213 Venturi mask for, 210–212

P Pain, 112 Palpation blood pressure by, 51 heart assessments, 88–90 of abdomen, 104 of chest, 81–82 of musculoskeletal system, 98 Parenteral nutrition fat emulsion, 346–349 total, 340–343 Partial rebreather mask, 209, 211–212 Passive range-of-motion exercises, 418–421 Pastes, 132 Patient-controlled analgesia, 191–195 Pediatric patients. See also Newborns assessments body temperature, 31 ear, 61 eyes, 54 heart, 86–87 mouth, 72 neck, 75 nose, 68 pulse, 39 sinus, 68 skin, 115 thorax, 79 blood pressure in, 47 blood transfusion in, 320 body alignment in, 406 cast care in, 444 chest tubes in, 265, 271 endotracheal tube suctioning in, 258 enema in, 360 fingerstick method for obtaining blood glucose level in, 517 indwelling catheters in, 378 intermittent positive pressure ventilation in, 223 intravenous fluid therapy in

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Page 562

562 Index Pediatric patients (Continued) flow rate considerations, 293 short-term peripheral intravenous catheter insertion, 277 medication administration in ear medications, 139 eye drops and ointments, 135 feeding tubes, 336 intravenous medications, 169–170 metered-dose inhaler, 142 oral medications, 121 rectal suppository, 146 self-medication, 127 to skin, 130 nasal airway suctioning in, 253 nasoenteric tube advancement in, 357 nasogastric tube insertion in, 352 oropharyngeal airway in, 248, 251 rectal tube in, 366 respiratory rate in, 44, 79t skeletal traction in, 454 straight catheters in, 378 total parenteral nutrition in, 340 tracheostomy tube suctioning in, 258 tube feedings in, 331, 336 urinary catheters in, 386 urinary incontinence collection device in, 389 wound drainage, 496 wound dressings, 502 Percussion of abdomen, 103–104 of heart, 90 of thorax, 82–84 Percutaneous catheters, 300, 301t–302t Peripheral intravenous catheter, shortterm. See Short-term peripheral intravenous catheter insertion Peripheral partial nutrition, 343–345 Peripherally inserted central catheter dressing changes, 296–299 insertion technique for, 285–292 summary of, 302t Peripherally inserted midline catheter dressing changes, 296–299 insertion technique for, 285–292 summary of, 302t Pharynx assessment, 71–74 Phlebitis, 95 Plantar response reflex, 112 Point of maximal impulse, 88 Ports, 301, 303t

Positioning of patients in bed, 432 Postoperative leg exercises, 315–317 Postural drainage, 198–202 Post-void residual urine volume, 400–403 Pouching procedure, for wound drainage, 497 Powders, 133 Pregnancy neck assessments during, 75 nose assessments during, 68 skin assessments during, 115 Presbycusis, 62 Pressure bandage, 488–490 Pressure ulcers Braden scale for, 474f in elderly patients, 475 Norton scale for, 473f prevention of, 477–480 risk assessments, 472–477 staging of, 480–485 Pulmonic area, 89f, 90 Pulse assessment apical pulse, 39f, 41–42, 113–114 apical-radial pulse, 42–43 in elderly patients, 40 in pediatric patients, 39 radial pulse, 40–41, 113–114 sites for, 38f Pupil(s) assessment of, 109–110 response to light, 58, 109

R Radial pulse, 40–41, 113–114 Range of motion assessment of, 98–99 passive, 418–421 Rectal body temperature assessment, 33–36 Rectal suppository, 145–148 Rectal tube, 366–369 Red reflex, 59 Reflexes, 111–112 Refractometer method, 535 Residual urine volume, post-void, 400–403 Respiratory acidosis, 113 Respiratory alkalosis, 113 Respiratory rate, 44–46, 79t, 113 Rinne test, 66–67 Romberg test, 66–67 Russell’s traction, 449

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Index 563 S Saline flush, 181–182 Scalp, 117 Scoliosis, 98 Second heart sound, 91 Seizures, 108 Self-catheterization, 391–394 Self-injections, 183–187 Self-medication, 125–129 Sensory function, 112–113 Sequential compression devices, 311–313 Short-term peripheral intravenous catheter insertion catheter sizes and uses, 276t in elderly patients, 277 evaluation, 284–285 fluid preparation, 278–279 overview of, 276 in pediatric patients, 277 taping methods, 283 technique, 279–280 transparent film over site, 283–284 venipuncture, 280–283 Shoulder muscle tone and strength assessments, 99 range-of-motion exercises, 420 Simple face mask, 209, 211–212 Sinus assessments, 67–71 Sitz bath, 490–492 Skeletal traction, 453–456 Skin assessment of, 115–118 medication administration to, 130–134 pressure ulcers. See Pressure ulcers Skin traction, 448–452 Spasms, 108 Specific gravity of urine, 533–535 Specimen collection blood. See Blood specimen endotracheal tube, 261 nose, 538–540 sputum, 541–544 throat, 538–540 tracheostomy tube, 261 urine. See Urine specimen wound drainage, 545–547 Sphygmomanometer, 88 Sputum specimen, 541–544 Squat-lift, 413–414 Startle reflex, 61 Sternum, 81

Stethoscope abdomen assessments using, 103 heart assessments using, 87 Strabismus, 54 Straight catheter care of, 385–388 insertion of, 378–385 Subcutaneous injections, 150–155 Suctioning of airway. See Airway suctioning sputum specimen obtained by, 543–544 Suppository, rectal, 145–148 Suspension-based lotion, 133–134 Swallow reflex, 112 Systolic pause, 92

T Tablets, 122–123 Teeth care of, 7 eruption of, 72 Temperature. See Body temperature Tension pneumothorax, 265 Thermometers, 32f, 32–37 Thorax assessment auscultation, 84–85 in elderly patients, 79 inspection, 80–81 palpation, 81–82 Thorax assessment (Continued) in pediatric patients, 79 percussion, 82–84 preparation, 78 Three-point gait pattern, 426t, 427f, 428 Throat specimen, 538–540 Thyroid gland, 77 Timed (24-hour) urine specimen, 528–531 Tongue, 7 Total parenteral nutrition, 340–343 Touch assessments, 113 T-piece, 214, 216–217 Trach collar, 214–216 Trachea, 76–77 Tracheostomy tube care of, 235–239 cuffed, 240–242 suctioning of, 257–262 Traction skeletal, 453–456 skin, 448–452

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564 Index Transdermal patch, 132–133 Transfer belt, 409f Transferring patient from bed to wheelchair, 437–439 Transparent film dressings, 501–502, 504–505 Tremors, 108 Trendelenburg’s position, 198, 200–201, 451 Tricuspid area, 90 Triple lumen catheter, 397f Trochanter roll, 408f Tube feedings, 330–335 Tuning fork, 63f Tunneled catheters, 300 Two-point gait pattern, 426t, 427f, 428 Tympanic membrane assessment of, 61 body temperature assessment using, 36–37 Tympany, 103

U U method, of taping, 283 Umbilicus, 102 Unconscious patients, mouth care in, 8–9 Urinary catheters, 378–388 Urinary incontinence collection device, 388–391 Urine residual volume of, after voiding, 400–403 specific gravity of, 533–535 Urine specimen from indwelling catheter, 531–533 midstream, 526–528 timed (24-hour), 528–531 Urinometer method, 534–535

V V.A.C. ATS System, 506–510 Vagus nerve testing, 74 Vascular access devices, 308–311 Vastus lateralis muscle injections, 156 Venipuncture equipment/supplies, 513 preparation, 512 for short-term peripheral intravenous catheter insertion, 280–283 syringe method, 514–515 vacutainer method, 515–516

Ventilation. See Mechanical ventilation Ventrogluteal muscle injections, 155–156 Venturi mask, 210–212 Visual acuity, 55–56, 60 Visual fields, 56–57 Vital signs assessment of, 113–114 blood pressure, 47–52 body temperature. See Body temperature heart rate, 38–43 respiratory rate, 44–46, 79t Voiding, residual urine volume after, 400–403

W Walker, 425–430 Weber test, 65, 67 Wet-to-dry dressings, 501, 503–504 Wheelchair transfers from bed, 437–439 Whisper test, 65 Winged-tip catheter, 281 Women intermittent self-catheterization teaching for, 392–393 midstream urine specimen collection in, 527 straight or indwelling catheter insertion in, 382–385 urinary incontinence collection device in, 390 Wound assessment of, 480, 482–485 dressings for, 501–505 irrigation of, 493–495 pressure bandage for, 488–490 sitz bath for, 490–492 V.A.C. ATS System for, 506–510 Wound drainage devices for, 498–500 management of, 495–498 specimen collection, 545–547 Wrist range-of-motion exercises, 420

Y Yankauer suctioning, 249–252

Z Z-track method, for intramuscular injections, 161–164

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NURSING DIAGNOSES Activity Intolerance [specify level] Activity Intolerance, risk for Airway Clearance, ineffective Allergy Response, latex Allergy response, latex, risk for Anxiety [specify level] Anxiety, death Aspiration, risk for Attachment, risk for impaired parent/infant/child Autonomic Dysreflexia Autonomic Dysreflexia, risk for Blood Sugar, risk for unstable Body Image, disturbed Body Temperature, risk for imbalanced Bowel Incontinence Breastfeeding, effective Breastfeeding, ineffective Breastfeeding, interrupted Breathing Pattern, ineffective Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Conflict, parental role Confusion, acute Confusion, risk for acute Confusion, chronic Constipation Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, defensive Coping, ineffective Coping, readiness for enhanced Coping, ineffective community Coping, readiness for enhanced community Coping, compromised family Coping, disabled family Coping, readiness for enhanced family Death Syndrome, risk for sudden infant Decisional Conflict (specify) Denial, ineffective Dentition, impaired Decision-Making, readiness for enhanced Development, risk for delayed Diarrhea Disuse Syndrome, risk for Diversional Activity, deficient Energy Field, disturbed (revised) Environmental Interpretation Syndrome, impaired Failure to Thrive, adult Falls, risk for Family Processes: alcoholism, dysfunctional Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear (specify focus) Fluid Balance, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume risk for imbalanced Gas Exchange, impaired Glucose, risk for unstable level Grieving Grieving, complicated

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Accepted for Use and Research (2007–2008) Grieving, risk for complicated Growth, risk for disproportionate Growth & Development, delayed Health Behavior, risk prone Health Maintenance, ineffective Health-Seeking Behaviors (specify) Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Hyperthermia Hypothermia Identify, disturbed personal Immunization Status, readiness for enhanced Infant Behavior, disorganized Infant Behavior, organized, readiness for enhanced Infant Behavior, risk for disorganized Infant Feeding Pattern, ineffective Infection, risk for Injury, risk for Injury, risk for perioperative positioning Insomnia Intracranial Adaptive Capacity, decreased Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Lifestyle, sedentary Liver Function, risk for impaired Loneliness, risk for Memory, impaired Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Moral Distress Nausea Noncompliance, [Adherence, ineffective] [specify] Nutrition, less than body requirements, imbalanced Nutrition, more than body requirements, imbalanced Nutrition, readiness for enhanced Nutrition, more than body requirements, risk for imbalanced Oral Mucous Membrane, impaired Pain, acute Pain, chronic Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perioperative Positioning, risk for Peripheral Neurovascular Dysfunction, risk for Poisoning, risk for Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level] Powerlessness, risk for Protection, ineffective Rape-Trauma Syndrome Rape-Trauma Syndrome: compound reaction Rape-Trauma Syndrome: silent reaction Religiosity, impaired Religiosity, risk for impaired Religiosity, readiness for enhanced Relocation Stress Syndrome

Relocation Stress Syndrome, risk for Role Performance, ineffective Self-Care Deficit: bathing/hygiene, Self-Care Deficit: dressing/grooming, Self-Care Deficit: feeding Self-Care Deficit: toileting Self-Care, readiness for enhanced Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, situational low Self-Esteem, risk for situational low Self-Mutilation Self-Mutilation, risk for Sensory Perception, disturbed: (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Sexual Dysfunction Sexuality Pattern, ineffective Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation Social Interaction, impaired Social Isolation Sorrow, chronic Spiritual Distress Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced Stress Overload Suffocation, risk for Suicide, risk for Surgical Recovery, delayed Swallowing, impaired Therapeutic Regimen Management, effective Therapeutic Regimen Management, ineffective Therapeutic Regimen Management, ineffective community Therapeutic Regimen Management, ineffective family Therapeutic Regimen Management, readiness for enhanced Thermoregulation, ineffective Thought Processes, disturbed Tissue Integrity, impaired Tissue Perfusion, ineffective (specify type: cerebral, cardiopulmonary, renal, gastrointestinal, peripheral) Transfer Ability, impaired Trauma, risk for Unilateral Neglect Syndrome Urinary Elimination, impaired Urinary Elimination, readiness for enhanced Urinary Incontinence, functional Urinary Incontinence, overflow Urinary Incontinence, reflex Urinary Incontinence, stress Urinary Incontinence, total Urinary Incontinence, urge Urinary Incontinence, risk for urge Urinary Retention [acute/chronic] Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional Violence, [actual/] risk for other-directed Violence, [actual/] risk for self-directed Walking, impaired Wandering [specify sporadic or continual] [ ] author recommendations Used with permission from NANDA International: Definitions and Classification, 2007–2008. NANDA, Philadelphia, PA 2007