HANDWASHING

⮚ Purpose – to prevent infection & spread of disease

⮚ Major components:
1. running water
2. friction
3. cleansing agent – 5 mL

⮚ Types:
1. medical handwashing
- after rinsing, hands should be held below the elbows
- clean technique
- 20 to 30 secs., happy birthday song
-
2. surgical handwashing

- after rinsing, hands should be held above the elbows

- sterile technique
- 3 to 5 mins
- 2 happy birthday songs

OXYGEN THERAPY

⮚ Purpose – to improve tissue oxygenation

⮚ CO2 – respiratory/hypoxic drive (stimulus for breathing)

⮚ Major Characteristics:

a. Dry gas

1. Humidify the gas with sterile water

2. Perform oral care
3. Lubricate with water based
 b. Supports combustion

1. Place no smoking sign

2. Check electrical devices
3. Use cotton fabric
- X wool & silk (static electricity)

c. Colorless

1. Prone to leakage

⮚ Methods of O2 delivery devices:

1. Nasal cannula or Nasal Prongs

- 24 to 40%
- most commonly used
2. Simple Face Mask
- 40 to 60%
3. Non-rebreather mask
- 95 to 100%
- highest delivery
- Best to manage CO poisoning
- CO is light; it settles in higher areas
- CO easily attaches to RBCs; it can cross BBB
4. Venturi mask
- 24 to 40%
- most accurate
- Used with COPD

pO2 – 80 to 100% 🡪 ABG analysis

O2 sat – 95 to 100% 🡪 Pulse Oximeter

a. Fingers/toes
b. Bridge of nose
c. Earlobe
d. Forehead
⮚ Nursing Considerations:

1. Asses for hypoxia

Early Late
Pulse Restlessness Cyanosis
Respiration
Tachy Brady
Blood
pressure

2. Verify the Doctor’s order

a. 2 to 3 L/m (independent)
b. More than 3 L/m (dependent)

3. Position: Fowler’s

4. Regulate O2 flow accurately.

Oxygen

🡪 Retrolental Fibroplasia
- retinal damage leading to irreversible blindness as a result of excessive
O2 administration

⮚ Tank colors:
a. green – O2
b. gray – CO2
c. brown – helium
d. yellow – compressed air
e. blue – laughing gas/nitrous oxide
f. red – fire extinguisher (check exp. date)
CHEST PHYSIOTHERAPY
a.k.a. Bronchopulmonary Hygiene

⮚ Purpose – to remove & loosen excessive bronchial secretions

⮚ To mobilize secretion: DEEP BREATHING EXERCISE (DBE)

⮚ To liquefy secretion: INCREASE OFI

⮚ To remove & loosen secretion: CPT

⮚ Methods:

1. Percussion
- A.k.a. clapping
- Cupped hands
- Striking motion
- Performed with both hands (done alternately)
2. Vibration
- Flat hands (on top of the other)
- Shaking
- Performed with both hands (done @ the same time)
3. Postural drainage
- By gravity
- 1st thing to do

⮚ Nursing Considerations:

1. Check the Doctor’s order

2. Auscultate for Breath Sounds (CRACKLES)

3. Before postural drainage, give:

a. Bronchodilators (Aminophylline)
 b. Nebulization therapy
- Give if already given bronchodilators
4. Best time for postural drainage:
a. Before meals – to prevent aspiration (after meals: 2 to 3O after)
b. Early morning
c. At bedtime
5. Each position (postural drainage): 10 to 15 mins
- Maximum time: 30 mins
- To prevent exhaustion
6. Perform oral care
7. Auscultate for breath sounds
- Bronchovesicular breath sounds, compelling 7 normal breath sounds

⮚ Breath sounds:

1. Normal Lung Sounds:

a. Bronchial
b. Vesicular
c. Bronchovesicular
2. Abnormal
a. Crackles – secretions
b. Wheezing
c. Ronchi
d. Stridor
e. Friction rub

SUCTIONING

⮚ Purpose - to maintain airway patency

⮚ Nursing Considerations:

1. Auscultate for breath sounds (crackles)

2. Position:
a. UNCONCIOUS: Side-lying
b. CONSCIOUS: Semi Fowlers

3. SIZE of suction catheters:

 a. Adult: FR 12 to 18
b. Child: 8 to 10
c. Infant: 5 to 8

4. PRESSURE of suction machine:

Wall Portable
Adult 100 to 120 10 to 15
Child 95 to 110 5 to 10
Infant 50 to 95 2 to 5

5. Hyper-oxygenate (100%)

6. Wear sterile gloves

7. Lubricate:

a. Nasopharyngeal: water-based

b. Oropharyngeal: PNSS

8. length of insertion: nose to earlobe (5” or 5 to 10 cm)

9. introduced suction catheter without suction

10. Time of suction:

a. NORMAL: 5 to 10 secs
b. INTERVAL: 20 to 30 secs
c. MAXIMUM: 3 to 5 mins

11.Withdraw the suction catheter in a rotating motion.

 12.Perform oral care

13. Hyper-oxygenate (100%)

14.Auscultate for breath sounds (bronchovesicular breath sounds)

TRACHEOSTOMY

⮚ Purpose: to provide long-term airway support

⮚ Basic Parts:

1. Outer cannula

- Serves as an artificial airway

- Directly inserted @ trachea
- It also serves as an artificial airway during trach care and removal of the
inner cannula; it is then connected to the mech vent.

2. Inner cannula

- Serves as an artificial airway

- Directly inserted @ outer cannula

3. Obturator

- Serves as guide
- Used to insert both cannulas into the respiratory tract
- Should be kept @ bedside
- Removes dislodgement

4. Flange

- Located @ the distal portion of the cannula

- Secured with tape & ties

⮚ Nursing Considerations:

1. Provide privacy
 2. Position Semi Fowler’s
3. Prepare & open the sterile kit
4. Wear sterile gloves
5. Organize the sterile kit:
a. Container 1: hydrogen peroxide (half strength)
b. Container 2: PNSS
6. Remove the inner cannula only (counterclockwise)
a. Soak: hydrogen peroxide (half strength)
b. Clean: PNSS
7. Remove the soiled dressing @ the back of the flange
8. Wear another sterile glove (double gloving)
9. Suction outer cannula
10.Insert inner cannula (clockwise)
11.Clean flange & site
a. Sterile gauze
b. PNSS
12.Apply sterile gauze @ the back of the flange
a. Size: 4” x 4”
b. Appearance: V-shape
13.Change the ties
a. Apply new ties first, then remove old ties (square knot)
b. Distance: 1 or 1 to 2 fingerbreadths
14.Tracheostomy Care is done every day

NASOGASTRIC TUBE

⮚ Purpose:

1. GAVAGE – entry food & promote nutrition – FEEDING

2. LAVAGE – exit of substance from the stomach – GASTRIC DECOMPRESSION
& ASPIRATION
3. To administer MEDICATION.
- Enteric-coated drugs are NEVER given via NGT.

⮚ Before using NGT, stimulate appetite first by giving HIS FAVORITE FOOD.

⮚ Insertion:
 1. Position in High Fowler’s
2. Wear clean or sterile gloves
3. Lubricate with water-based (2”)
4. Length of insertion:
NEX – nose to earlobe to xiphoid process (12 to 18”)
5. Upon insertion: Hyperextend the neck of the patient
6. Upon reaching the Oropharynx, Tilt the pt.’s head forward
7. Offer Sips of water
8. Allow DBE

9. Check for PATENCY:

A AUSCULTATION (wheezing, bubbling, gurgling sounds)

S UBMERSION (without bubbles)
A SPIRATION (Lithmus Paper Test, Nitrazine Paper Test)
X-RAY (Confirmation)

10.Tape @ the Bridge of the Nose

⮚ Feeding:

1. Position in Semi Fowler’s

2. Check for PATENCY
3. Aspirate for Residual Contents
- More than 100 mL – WITHHOLD THE FEEDING (Indigestion) – Notify the
physician
- Less than 100 mL – CONTINUE THE FEEDING (Digestion)
4. Instill Water 30 to 60 mL
5. Average distance: 12”
- Less than 12” (too slow)
- More than 12” (too rapid) – DUMPING SYNDROME – rapid gastric
emptying
6. Instill Water: 30 to 60 mL
7. Before Clamping, retain some water in the tube – to prevent the introduction of
air.
8. Position in Semi Fowler’s (30 mins)
9. Replace every 3 to 5 DAYS

TOTAL PARENTERAL NUTRITION

a.k.a. Intravenous Hyperalimentation

⮚ Purpose – to promote nourishment intravenously

⮚ Prepared by PHARMACIST

⮚ Nursing Considerations:

1. Route: Intravenous
2. Site: Subclavian (or Jugular)
3. Contents:
a. Amino Acids
b. Vitamins
c. Minerals
d. GLUCOSE

4. Storage:

a. Before: Refrigerator
- Before administration: 30 mins (room temp.)

b. After: Discard (open or with leak)

5. Complications:

a. Hyperglycemia/Hypoglycemia
b. Sepsis

6. Monitor:
a. Blood glucose
b. Body temperature
c. Intake & Output
d. Weight

⮚ Types of Nutrients:

1. Macronutrients
a. Carbohydrates – 1g is 4 calories, the chief source of energy
b. Protein – 1g is 4 calories, tissue growth & repair
c. Fats – 1g is 9 calories, most concentrated source of energy
 2. Micronutrients
a. Vitamins
1. Fat-soluble – ADEK
2. Water soluble – B Complexes & Vit C
b. Minerals – iron, iodine, phosphorus
⮚ SANGKAP PINOY – program of DOH
- Problems of nutrients in Vit A, Iron & Iodine

⮚ Lithmus or Nitrazine Paper Test

- Red – Acidic
- Blue – Alkaline

COLOSTOMY

⮚ Purpose – to DIVERT & DRAIN fecal matter

- Bowel Diversion/Conduit

Mouth

Stomach
(Food Digestion)

Small Intestine
(Absorption of Nutrients)
Duodenum
Jejunum
Ileum

Large Intestine
(Absorption of Water)
Ascending
Transverse
Descending
Sigmoid
⮚ Enzymes: Digestive Enzymes
1. Amylase
2. Lipase
3. Trypsin

⮚ Status:

1. Temporary
a. Trauma
b. Inflammatory Bowel Disease (IBD) – Chron’s Disease, Ulcerative Colitis

2. Permanent
a. Terminal – Bowel CA, Colon CA, Colorectal CA
b. Congenital Abnormalities – Hirschsprung’s Disease

⮚ Locations:

1. Ileostomy
- If Large Intestine has a problem
- Liquid stool
⮚ Effluent – stool containing digestive enzyme
2. Ascending Colostomy
- Liquid stool
⮚ Effluent – stool containing digestive enzyme
3. Transverse Colostomy
- Mushy stool
4. Descending Colostomy
- Semi-solid stool
5. Sigmoid Colostomy
- Solid stool/well-formed

⮚ Nursing Considerations:

1. Provide PRIVACY
 2. Position: Sitting / Standing
3. Wear Clean Gloves
4. Empty the APPLIANCE (bedpan)
a. Amount: 1/3 to ½ FULL
b. Clean: VINEGAR (acetic acid)
5. Clean the STOMA:
a. Use water & cotton balls (mild soap is optional)
6. Insert back the APPLIANCE:
a. Site: dried thoroughly
b. Effluent: K ARAYA
c. Minimize ODOR: CITRUS FRUITS & YOGHURT
d. Bag: CHARCOAL
7. Replace: 6 to 7 days

⮚ Typical Characteristics of STOMA:

a. Color: Pinkish Red

b. Status: SLIGHT protrusion
c. Appearance: SLIGHT bleeding

⮚ A person with a Colostomy bag can swim in the swimming pool, but empty the bag
first & dry the stoma.

ENEMA ADMINISTRATION

⮚ Purpose:

1. To CLEAN the colon and EVACUATE fecal matter.

- CLEANSING ENEMA:
a. Low Flow – sigmoid colon (500 mL)
b. High Flow – entire colon (1000 mL)

2. To expel FLATUS

- CARMINATIVE ENEMA
- Oil-based (60 to 80 mL)
 - RETURN-FLOW ENEMA
- Evacuates fecal matter
- Expels flatus
- 300 to 500 mL
- Outflow: CLEAR (5 to 6 times)

3. To relieve CONSTIPATION

- RETENTION ENEMA
- Oil-based
- Max retention time: 1 to 3

⮚ Nursing Consideration:

1. Check Doctor’s Order

2. Provide PRIVACY
3. Position: Left Side Lying (Sims Lateral)
4. Wear Clean Gloves

5. SIZE of rectal catheters:

a. Adult: FR 22 to 32
b. Child: 14 to 18
c. Infant: 12

6. Allow the solution to flow into the catheter

7. Lubricate: water-based
8. Allow DBE
9. Length of insertion: 3 to 4”
10.Average height: 12 to 18”
a. Less than 12” (too slow)
b. More than 12” (too rapid)
- Abdominal cramping (temporarily stop until it subsides & lower
height)

CATHETERIZATION
⮚ Purpose – to empty the bladder when the patient is NO longer capable

⮚ Stimulate voiding first before catheterization:

a. Provide privacy
b. Make a running water sound
c. Open the faucet
d. Gently massage pubic area

⮚ Insertion:

1. Check Doctor’s Order

2. Provide PRIVACY
3. Position:
a. Male: SUPINE
b. Female: DORSAL RECUMBENT
4. Perform PERINEAL CARE
a. Male: glands to the shaft
b. Female: meatus to anus
5. Wear Sterile gloves
6. SIZE of Catheter:
a. Male
FR 16 to 18
b. Females 12 to 14
7. Lubricate: water-based
8. Allow DBE
9. Length of insertion:
a. Male: 6 to 9”
b. Female: 3 to 4”
10.Observe BACKFLOW OF URINE
11.Advance the catheter further: 1 to 3”
12.Inflate the balloon: 5 to 10 cc (sterile water)
13.Tape:
a. Male: Lower Abdomen (prevent Penoscrotal pressure)
b. Female: Inner Thigh

⮚ Removal:

1. Check Doctor’s Order

2. Before removal: BLADDER TRAINING
 - To prevent a sense of urgency
- Prevents Urinary Incontinence
a. CLAMP for 2O
b. RELEASE for 30 minutes
3. Wear Clean gloves
4. Deflates the balloon COMPLETELY
5. Allow DBE
6. Perform PERINEAL CARE
7. Normal voiding: 4 to 6 degrees

⮚ Replace:
a. Foley Catheter: 3 to 5 days
b. Straight Catheter: single-use
c. Condom Catheter: 2-3 days

CONDOM CATHETER

⮚ Nursing Consideration:

1. Gender: MALE
2. Problem: Urinary Incontinence
3. Position (penis): PERPENDICULAR
4. Tape: Spiral
5. Complication: UTI