NURSING PROCEDURES

1. Steam Inhalation

• it is a dependent nursing action
• Place the spout 12 - 18 in away from the client's nose or adjust the distance as necessary.

2. Suctioning

• Assess the lungs before the procedure for baseline information.
• Position: conscious - semi-fowlers... unconscious - lateral position
• Hyper oxygenate before and after procedure
• observe sterile technique
• Apply suction during withdrawal of the catheter
• Time: adult - 10 sec to maximum of 15 sec... pedia - maximum of 10sec

3. Nasogastric Feeding (gastric gavage) insertion

• clean procedure not sterile - rationale: not all things that we ingest through mouth are sterile.
• From tip of the nose to tip of the earlobe to the xyphoid - adult
• from tip of the earlobe to the tip of the nose to xyphoid - pedia

4. Tube Feeding

• Semi - fowler's position
• Assess tube placement by: x-ray(most reliable), by pH or by placing the tip to the basin of water, if bubbles occur, it is not in the right place.
• Assess residual feeding: it should be empty after 2 - 3 hrs... report to physician if it is more than 100 ml.
• Height of feeding is 12 in. above
  
• Ask client to remain upright position for at least 30 min
• Most common problem: Diarrhea due to lactose intolerance
  

5. Enema

• Check foe MD's order
• provide privacy
• position is left lateral
• Insert 3 - 4 in of rectal tube
• If abdominal cramps occur, temporarily stop the flow until the cramp is gone.
• height of enema - 18 in
• discontinue if there is bleeding and report to MD.

6. Urinary Catheterization

• Verify MD's order
• Practice strict asepsis
• Provide privacy
  
• Perineal care before the procedure
• Catheter size: male 14 -16 , female 12 -14
• Lenght of catheter insertion: male - 6-9 in., female - 3-4 in

For Retention Catheter
Male - anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure.
Female - inner aspect of the thigh.

7. Bed Bath

• Provide privacy
• Expose, wash and dry one body part at a time
• Use warm water (110 -115F) 43 - 45C
• Wash from cleanest to dirtiest or distal to proximal to increase venous return.

8. Foot Care

• Soaking the feet of diabetic patient is no longer recommended
• Cut nail straight across

9. Oral Care for Unconscious client

• Place in side lying position
• Have the suction apparatus readily available - to drain extra secretion if necessary
  

10. Hair Shampoo

• Place client diagonally in bed
• Cover the eyes with wash cloth
• Plug the ears with cotton balls
• Massage the scalp with the fatpads of the fingers to promote circulation in the scalp

11. Restraints

• Secure MD's order for each episode of restraints application
• Check circulation every 15 min
• Remove restraints at least every 2 hrs. for 30 mins

Relates Posts:

• Laboratory Examination
• Barium Enema and Barium Swallow
• Chest X-ray, Cardiac and Urinary Catheterization
• CT Scan, CVP and Cytoscopy
• Electrocardiogram and Electroencephalogram
• FBS, Gastric Analysis, IVP and KUB
• Abdominal Assessment and Arterial Blood Gas Analysis
• Liver Biopsy and Lumbar Puncture
• Mammography, Mantoux and MRI
• Paracentesis and Rinne's Test
• Schilling, Sputum and Stool Analysis
• Thoracentesis and Tonometry
• Urinalysis, Weber and X-ray