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Procedure of Urinary Catheters Care and Removal

Procedure of Urinary Catheters Care and Removal

Routine Catheter Care
■ Use standard precautions.
■ Keep bag below level of Pt’s bladder at all times.
■ Check frequently to be sure there are no kinks or loops in the tubing and that the Pt is not lying on the tubing.
■ Do not pull or tug on the catheter.
■ Wash around the catheter entry site with soap and water twice each day and after each bowel movement.
■ Do not use powder around the catheter entry site.
■ Periodically check skin around the catheter entry site for signs of irritation, redness, tenderness, swelling, or drainage.
■ Offer fluids frequently (if not contraindicated by health status), especially water or cranberry juice.
■ Record urine output every shift or per physician orders.
■ Empty collection bag each shift; note quantity, color, clarity, odor, and presence of sediment.

■ Notify physician of any of the following:
■ Blood, cloudiness, or foul odor.
■ Decreased urine output (<30 mL/hour) order a bladder scan.
■ Irritation, redness, tenderness, swelling, or drainage or leaking around the catheter entry site.
■ Fever, or abdominal or flank pain.

Procedure for Removal
■ Don gloves and observe Standard Precautions.
■ Use a 10-mL syringe to withdraw all water from balloon. Some catheter balloons are overinflated or have up to a 30-mL balloon; withdraw and discard water until no more water can be removed.
■ Hold a clean 4x4 at the meatus in the nondominant hand. With dominant hand, gently pull catheter. If you meet resistance, stop and reassess if balloon is completely
deflated. If balloon appears to be deflated and catheter cannot be removed easily, notify physician.
■ Wrap tip in clean 4x4 as it is withdrawn to prevent leakage of urine. If a culture of the catheter tip is desired, wrap tip in a sterile 4 4 as it is withdrawn.
■ Note time that catheter was discontinued.
■ Provide bedpan, urinal, or assistance to bathroom as needed.
■ Document time of removal and how Pt tolerated the procedure.
■ Document amount and time of spontaneous void.
■ If Pt does not void within 8 hours, palpate bladder and notify physician. Catheter may need to be reinserted.
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Urinary Catheters

Urinary Catheters

Straight Catheter
■ Also called a red rubber catheter or “straight cath.” Straight catheters have only a single lumen and do not have a balloon near the tip. Straight catheters are inserted for only as much time as it takes to drain the bladder or obtain a urine specimen.

Indwelling Catheter
■ Also called a Foley or retention catheter. Indwelling catheters have two lumens, one for urine drainage and the other for inflation of the balloon near the tip. Three Way Foley catheters are used for continuous or intermittent bladder irrigation. They have a third lumen for irrigation.

Procedure for Insertion
■ Prepare Pt: Explain procedure and provide privacy.
■ Collect the appropriate equipment.
■ Place Pt in the supine position (Female: knees up, legs apart; Male: legs flat, slightly apart).
■ Open and set up catheter kit using sterile technique.
■ Don sterile gloves and set up sterile field.
■ If placing indwelling catheter, check for leaks and proper inflation of balloon by filling with 5 mL of sterile water. Remove water.
■ Lubricate end of catheter.
■ Saturate cotton balls with cleansing solution (assess Pt allergies).
■ With nondominant hand (now contaminated); Female: hold labia apart; use dominant (sterile) hand to hold swabs with sterile forceps and swab from front to back, in the following order: (1) labia farthest from you, (2) labia nearest to you, (3) center of the meatus between each labia. Use one swab per swipe. Male: retract foreskin; use dominant (sterile) hand to hold swabs with sterile forceps and swab in a circular motion from the meatus outward. Repeat three times, using a different swab each time. Ensure that foreskin is NOT left retracted once procedure is completed.
■ Gently insert catheter (about 2–3 inches for females and 6–9 inches for males) until the return of urine is noted.
■ For straight catheters: Obtain specimen or drain bladder and then remove and discard catheter.
■ For indwelling catheters: Insert an additional inch and then inflate balloon.
■ Attach catheter to drainage bag using sterile technique.
■ Secure catheter to Pt’s leg according to hospital policy.
■ Hang drainage bag on bed frame below level of the bladder.
■ Document type and size of catheter, amount and appearance of urine, and how Pt tolerated the procedure.
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Ostomy Care

Ostomy Care

Types of Ostomies
■ Colostomy: May be permanent or temporary. Used when only part of the large intestine is removed. Commonly placed in the sigmoid colon, the stoma is made from the large intestine and is larger in appearance than an ileostomy. Contents range from firm to fully formed, depending on the amount of remaining colon.

■ Ileostomy: May be permanent or temporary. Used when the entire large intestine must be removed. The stoma is made from small intestine and is therefore smaller than that of a colostomy. Contents range from paste-like to watery.

■ Urostomy: Used when the urinary bladder is either bypassed or must be removed altogether.

Procedure for Changing an Ostomy Bag
■ Explain procedure to Pt.
■ Gather supplies.
■ Place Pt in a supine position.
■ Wash hands and observe standard precautions (don gloves).
■ Remove old pouch by gently pulling away from skin.
■ Discard gloves, wash hands, and don a new pair of gloves.
■ Gently wash area around stoma with warm, soapy water and then dry skin thoroughly.
■ Inspect the appearance of the stoma, the condition of the skin, and note the amount, color, consistency of contents, and presence of unusual odor.
■ Cover the exposed stoma with a gauze pad to absorb any drainage during ostomy care.
■ Apply skin prep in a circular motion and allow to air dry for approximately 30 seconds.
■ Apply skin barrier in a circular motion.
■ Measure stoma using a stoma guide and cut ring to size.
■ Remove paper backing from adhesive-backed ring and, using gentle pressure, center the ring over the stoma and press it to the skin.
■ Smooth out any wrinkles to prevent seepage of effluent.
■ Center faceplate of bag over stoma and gently press down until completely closed.
■ Document appearance of the stoma, the condition of the skin, amount, color, and consistency of contents, and presence of any unusual odor.
■ Discard soiled items per hospital policy using standard precautions.
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Tube Feeding Complications

Tube Feeding Complications

Problem
Possible Causes and Interventions
Nausea,
vomiting,
& bloating
■ Large residuals: Withhold or decrease
feedings.
■ Medication: Review meds and consult
physician.
■ Rapid infusion rate: Decrease rate.
Diarrhea
■ Too rapid administration: Reduce rate.
■ Refrigerated TF (too cold): Administer at room
temp.
■ Tube migration into duodenum: Retract tube to
reposition in the stomach and reconfirm
placement.
Constipation
■ Decreased fluid intake: Provide adequate
hydration.
■ Decreased dietary fiber: Use formula with
fiber.
Aspiration and
gastric reflux
■ Improper tube placement: Verify placement.
■ Delayed gastric emptying: Check residuals.
■ Position of patient: Keep HOB elevated 30–45.
Occluded tube
■ Inadequate flushing: Flush more routinely.
■ Use of crushed meds: Switch to liquid meds.
Displaced tube
■ Improperly secured tube: Retape tube.
■ Confused patient: Follow hospital protocol.

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Procedure of NG Tube Feedings

Procedure of NG Tube Feedings

■ Confirm placement prior to using: (1) using a 20-mL syringe, inject a 20-mL bolus of air into the feeding tube while auscultating the abdomen. Loud gurgling indicates proper placement. DO NOT attempt this with water! (2) Use a 20-mL syringe and gently aspirate gastric content. Dip litmus paper into gastric aspirate a pH of 1–3 suggests proper placement.

■ Maintenance: Flush with 30 mL of water every 4 to 6 hours and before and after administering tube feedings, checking for residuals, and administering medications.

■ Medication: Dilute liquid medications with 20–30 mL of water. Obtain all medications in liquid form. If liquid form is not available, check with pharmacy to see if medication can be crushed. Administer each medication separately and flush with 5–10 mL of water between each medication. Do not mix medications with feeding formula!

■ Residuals: Check before bolus feeding, administration of medication, or every 4 hours for continuous feeding. Hold feeding if greater than 100 mL and recheck in 1 hour. If residuals are still high after 1 hour, notify physician.

Types of Tube Feedings
■ Initial tube feedings: Advance as tolerated by 10–25 mL/hour every 8–12 hours until goal rate is reached.
■ Intermittent feedings: Infusions of 200–400 mL of enteral formulas several times per day infused over a 30-minute period.
■ Continuous feedings: Feedings that are initiated over 24 hours with the use of an infusion pump.

Checking Residuals
■ Using a 60-mL syringe, withdraw from the gastric feeding tube any residual formula that may remain in the stomach.
■ The volume of this formula is noted, and if it is greater than a predetermined amount the stomach is not emptying properly and the next feeding dose is withheld.
■ This process can indicate gastroparesis and intolerance to the advancement to a higher volume of formula.
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Procedure of NG Tube Care and Removal

Procedure of NG Tube Care and Removal

Patient Care
■ Reassess placement of tube prior to administering bolus feedings, fluids, or meds and q shift for continuous feedings.
■ Flush tube with 30 mL of water after each feeding and after each administration of medication.
■ Assess for skin irritation or breakdown. Retape daily and alternate sites to avoid constant pressure on one area of the nose. Gently wash around nose with soap and water and dry before replacing tape. Provide nasal hygiene daily and p.r.n.
■ Provide good oral hygiene every 2 hours and p.r.n. (mouthwash, water, toothettes → clean tongue, teeth, gums, cheeks, and mucous membranes). If Pt is performing oral hygiene, remind him or her not to swallow any water.

Removal
■ Explain procedure to Pt. Observe standard precautions.
■ Remove tape from nose and face.
■ Clamp or plug tube (prevents aspiration), instruct Pt to hold breath, and remove tube in one gentle but swift motion.
■ Assess for signs of aspiration.
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NG (Nasogastric) Tube Insertion

NG (Nasogastric) Tube Insertion

■ Explain the procedure to the Pt and offer reassurance.
■ Auscultate abdomen for positive bowel sounds if NG tube is to be used for administration of feedings or medication.
■ Position the Pt upright in high-Fowler’s position. Instruct the Pt to keep a chin-to-chest posture during insertion. This helps to prevent accidental insertion into the trachea.
■ Measure the tube from the tip of the nose to the ear lobe, then down to the xyphoid. Mark this point on the tube with tape.
■ Lubricate the tube by applying water-soluble lubricant to the tube. Never use petroleum-based jelly, which degrades PVC tubing.
■ Insert the tube through the nostril until you reach the previously marked point on the tube. Instruct the Pt to take small sips of water during insertion to help facilitate passing of the tube.
■ Secure the tube to Pt’s nose using tape. Be careful not to block the nostril. Tape tube 12–18 inches below insertion line and then pin tape to Pt’s gown. Allow slack for movement.
■ Position HOB at 30–45 to minimize risk of aspiration.
■ Confirm proper location of NG tube:
■ Pull back on plunger* of a 20-mL syringe to aspirate stomach contents. Typically, gastric aspirates are cloudy and green, or tan, off-white, bloody, or brown. Gastric aspirate can look like respiratory secretions so it is best to also check pH.
■ Dip litmus paper into gastric aspirate. A reading of a pH of 1–3 suggests placement in the stomach.
■ An alternative method, but less reliable, is to inject 20 mL of air into the tube while auscultating the abdomen. Hearing a loud gurgle of air suggests placement in the stomach. If no bubbling is heard, remove tube and reattempt. Withdraw tube immediately if the Pt becomes cyanotic or develops breathing problems.
■ An inability to speak also suggests intubation of the trachea instead of the stomach. *Note: small-bore NI (nasointestinal) tubes (e.g., Dobhoff) may collapse under pressure and initial confirmation of placement is obtained with x-ray.
■ Assemble equipment (wall suction, feeding pump, etc.) per manufacturer guidelines.
■ Document the type and size of NG tube, which nostril, and how the Pt tolerated the procedure. Document how tube placement was confirmed and whether tubing was left clamped or attached to feeding pump or suction.
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Troubleshooting Chest Tubes

Troubleshooting Chest Tubes

Air Leak
Continuous bubbling in the water seal chamber suggests that there is an air leak, either in the Pt or in the drainage system. Possible causes include a disconnection or break in the drainage system, an incomplete seal around the tube at the insertion site, or an improperly inserted tube. Notify the MD, and check the Pt and system for the source of the air leak:

■ Briefly occlude the tube manually by pinching the tubing close to the chest wall. A cessation of bubbling suggests that the air leak is within the Pt at the insertion site. Notify the physician.
■ If bubbling continues, assess to see if air might be entering at the insertion site around the wound. Using both hands, apply pressure around insertion site. If bubbling stops or decreases with pressure, notify physician and discuss replacing dressing with another pressure dressing. A suture may be required around tube.
■ If neither measure decreases bubbling, the air leak may be in the tubing and/or connections. Secure and retape all connections.
■ If air leak is still present, change out drainage system.

The Chest Tube Has Become
Completely separated from the Pt.
■ Assess Pt for respiratory distress and notify physician stat.
■ Apply occlusive dressing to insertion site (taped on three sides to allow air to escape, but not enter the chest).* Partially pulled out of the insertion site, exposing the drainage opening, but the end of the chest tube still remains in the Pt.
■ Assess Pt for respiratory distress and notify physician stat.
■ Remove dressing at insertion site and wrap chest tube (covering the drainage opening) with an occlusive dressing.* *Be prepared to assist with reinsertion of new chest tube.

Chest tube has become disconnected from drainage unit
■ Do one of three things while preparing to reattach tubes: (1) Leave the tube open to air, (2) Submerge the distal end of the chest tube under 1–2 inches of sterile water or normal saline (essentially, a water seal), or (3) Attach a one-way (Heimlich) valve.
■ Clean both exposed ends with Betadine swabs for 30 seconds and let air dry for 30 seconds. Reconnect drainage system and retape with fresh waterproof tape.
■ If tube connections have been grossly contaminated (i.e., with feces, urine, etc.), a new drainage system including sterile connector must be attached. This must be done as quickly as possible to prevent respiratory distress due to possible pneumothorax.
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Suctioning a Patient on the Ventilator

Suctioning a Patient on the Ventilator

Preparation
■ Prepare the patient: Explain procedure offer reassurance.
■ Gather supplies: Sterile gloves, sterile suction catheter and tubing, sterile normal saline, sterile basin, bag-valve mask connected to a supplemental oxygen source, suction source.
■ Equipment: Ensure that wall or portable suction is turned on (no higher than 120 mm Hg) and position supplies and the suction tubing so that they are easily accessible.
■ Wash hands: Follow standard precautions.

Preprocedure
■ Setup: Using sterile technique, open and position supplies so that they are within easy reach. Fill sterile basin with sterile normal saline and open sterile gloves close by so that they are easy to reach.
■ Position yourself: Stand at the Pt’s bedside so that your nondominant hand is toward the Pt’s head.
■ Preoxygenate: Manually ventilate Pt with 100% O2 for several deep breaths.

Technique
■ Don sterile gloves.
■ Wrap the sterile suction catheter around your dominant hand and connect it to the suction tubing. Wrapping the catheter around your hand prevents it from dangling and minimizes risk of contamination. Be careful not to touch your dominant hand with the end of the suction tubing.
■ Note:Your nondominant hand is no longer sterile and must not touch any part of the catheter or your dominant hand.
■ Insert suction catheter just far enough to stimulate a cough reflex.
■ Apply intermittent suction while withdrawing catheter and rotating 360 for no longer than 10–15 seconds to prevent hypoxia.
■ Manually ventilate with 100% O2 for several deep breaths.
■ Repeat until the Pt’s airway is clear.
■ Suction oropharynx after suctioning of airway is complete.
■ Rinse catheter in basin with sterile saline in between suction attempts (apply suction while holding tip in the saline).
■ Rinse suction tubing when done and discard soiled supplies.



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Troubleshooting Ventilator Alarms

Troubleshooting Ventilator Alarms

■ When the ventilator alarms: Check the Pt first. If Pt is in no apparent distress, check ventilator to determine source of problem.
■ If patient is showing signs of distress (“fighting the vent”): Try to calm the Pt. If unsuccessful, immediately disconnect Pt from vent and manually ventilate with 100% oxygen using a BVM. Notify the physician and RT immediately.

Alarm
Intervention
Low-Pressure:
Usually caused
by system
disconnections
or leaks.
■ Reconnect Pt to ventilator.
■ Evaluate cuff and reinflate if needed (if ruptured, tube will need to be replaced).
■ Evaluate connections and tighten or replace as needed.
■ Check ET tube placement (auscultate lung fields and assess for equal, bilateral breath sounds).
High-Pressure:
Usually caused by
resistance within
the system. Can
be kink or water
in tubing, Pt biting
the tube, copious
secretions, or
plugged endotracheal
tube.
■ Suction Pt if secretions are suspected.
■ Insert bite block to prevent Pt from biting tube.
■ Reposition Pt’s head and neck, or reposition tube.
■ Sedation may be required to prevent a Pt from fighting the vent, but only after
careful assessment excludes a physical or mechanical cause.
High Respiratory
Rate:
Can be caused by
anxiety or pain,
secretions in
ETT/airway, or
hypoxia.
■ Suction Pt.
■ Look for source of anxiety (e.g., pain, environmental stimuli, inability to communicate, restlessness, etc.).
■ Evaluate oxygenation.
Low Exhaled
Volume:
Usually caused
by tubing disconnection
or
inadequate seal.
■ Evaluate/reinflate cuff; if ruptured, ETT must be replaced.
■ Evaluate connections; tighten or replace as needed; check ETT placement,
reconnect to ventilator.


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Pulse Oximeters

 Pulse Oximeters 
Finding
Intervention
SpO2 > 95%
■ Considered normal and requires no intervention.
■ Continue routine monitoring of Pt.
SpO2
91%–94%
■ Considered acceptable.
■ Assess probe placement and adjust if necessary.
■ Continue to monitor Pt.
SpO2
85%–90%
■ Raise head of bed (HOB) and stimulate Pt to breathe deeply.
■ Assess airway and encourage coughing.
■ Suction airway if needed.
■ Administer oxygen and titrate to SpO2 > 90%.
■ Notify physician and respiratory therapist (RT) if SpO2 fails to improve after a few minutes.
SpO2
< 85%
■ Administer 100% oxygen, position Pt to facilitate breathing, suction airway if needed, and notify physician and RT immediately.
■ Check medication record and consider naloxone or flumazenil for medicationinduced respiratory depression.
■ Be prepared to manually ventilate or aid in intubation if condition worsens or fails to improve.


Caution: Consider readings within the overall context of the Pt’s medical history and physical exam. The reliability of pulse oximeters is sometimes questionable and many conditions can produce false readings. Assess the Pt’s skin signs, respiratory rate (RR), and heart rate (HR). Ask how the Pt is feeling. Repositioning the probe to a different location (ears, toes, or a different finger) may help correct a suspected false reading.

Conditions That May Produce False Readings
Anemia
false high
Carbon monoxide (CO) poisoning
false high
Hypovolemia
false high
Pt movement
erratic readings
Cool extremities
false low
Dark pigment
false low
Nail polish
false low
Medication (peripheral vasoconstrictors)
false low
Poor peripheral circulation
false low
Raynaud’s disease
false low
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Procedure of Artificial Airways

Procedure of Artificial Airways

Oropharyngeal Airway
Oropharyngeal Airway (OPA):
■ Indicated for unconscious Pts who do not have a gag reflex
■ Measure from the corner of the Pt’s mouth to the earlobe
■ Rotate airway 180 while inserting into oropharynx
Nasopharyngeal Airway
Nasopharyngeal Airway (NPA):
■ Indicated for Pts with a gag reflex, or comatose with spontaneous respirations
■ Measure from the tip of the Pt’s nose to the earlobe
■ The diameter should match the Pt’s smallest finger
■ NEVER insert in the presence of facial trauma!
Endotracheal Tube
Endotracheal Tube (ETT):
■ Indicated for apnea, airway obstruction, respiratory failure, risk of aspiration, or therapeutic hyperventilation
■ Can be inserted through the mouth or nose
■ Inflated cuff protects Pt from aspiration
Laryngeal Mask Airway
Laryngeal Mask Airway (LMA):
■ Often used in noncomplicated surgeries and by EMS
■ Direct visualization not needed for proper placement
■ When cuff is inflated, the mask conforms to the hypopharynx, occluding the esophagus and protecting the glottic opening


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Procedure of Oxygen Delivery Equipment

Procedure of Oxygen Delivery Equipment

Nasal Cannula
Nasal Cannula
■ Indicated for low flow, low percentage supplemental oxygen
■ Flow rate of 1–6 L/min
■ Delivers 22%–44% oxygen
■ Pt can eat, drink, and talk
■ Extended use can be very drying; use with a humidifier
Simple Face Mask
Simple Face Mask
■ Indicated for higher percentage supplemental oxygen
■ Flow rate of 6–10 L/min
■ Delivers 35%–60% oxygen
■ Lateral perforations permit exhaled CO2 to escape
■ Permits humidification
Nonrebreather (NRB) Mask
Nonrebreather (NRB) Mask
■ Indicated for high percentage supplemental oxygen
■ Flow rate of up to 15 L/min
■ Delivers up to 100% oxygen
■ One-way flaps open and close with respiration, resulting in a high concentration of delivered oxygen and minimal to no CO2 rebreathed by the Pt
Venturi Mask (venti-mask)
Venturi Mask (venti-mask)
■ Indicated for precise titration of percentage of oxygen
■ Flow rate of 4–8 L/min
■ Delivers 24%–40% oxygen
■ Accurate delivery of O2 is accomplished with a graduated dial which is set to the desired percentage of oxygen to be delivered
Bag Valve Mask (BVM)
Bag-Valve-Mask (BVM)
■ Indicated for manual ventilation of a Pt who has no or ineffective respirations
■ Can deliver up to 100% O2 when connected to O2 source
■ Appropriate mask size and fit are essential to create a good seal and prevent injury
■ To create seal, hold mask with thumb and index finger and grasp underneath the ridge of the jaw with remaining three fingers
Humidified Systems
Humidified Systems
■ Indicated for Pts requiring long-term oxygen therapy to prevent drying of mucous membranes
■ Setup may vary between brands. Fill canister with sterile water to recommended level, attach to oxygen source, and attach mask or cannula to humidifier
■ Adjust flow rate
Transtracheal Oxygenation
Transtracheal Oxygenation
■ Indicated for Pts with a tracheostomy who require longterm oxygen therapy and/or intermittent, transtracheal aerosol treatment
■ Ensure proper placement (over stoma, tracheal tube)
■ Assess for and clear secretions as needed
■ Assess skin for signs of irritation
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Safety Restraints

Safety Restraints

General Information
■ Restraints are any physical or pharmacological means used to restrict a Pt’s movement, activity, or access to his/her body.
■ Restraints are used only as a last alternative after all other methods of control have been attempted prior to application.
■ Restraints can only be used to prevent Pts from harming themselves or others, or interfering with medical treatment.
■ Restraints may never be used for staff convenience or discipline.
■ The application of restraints requires a written physician order specifying the clinical necessity, type of restraint, frequency of assessment, and duration restraint is to be used.
■ Use of restraints should not exceed 24 hours. Note: Always refer to specific agency’s policy and procedure when using restraints.

Procedure (Physical Restraints)
■ Informed consent should be obtained from Pt or family.
■ Obtain a written physician order must be renewed every 24 hours.
■ Always use the least restrictive form of restraint available.
■ Assess skin and circulation, sensation, and motion (CSM) of area to be restrained prior to application.
■ Pt should be restrained in an anatomically correct position with all bony prominences adequately padded and protected to prevent the development of pressure sores.
■ Follow manufacturer’s instructions when applying restraints.
■ Apply loosely enough for two fingers to fit under the restraints.
■ Restraints must not interfere with medical devices or treatment.
■ Restraints should be secured to chair or bed frame (Never to side rails) using quick-release knots. For adjustable beds, secure to the parts of the bed frame that move with the Pt.
■ A call bell must be easily accessible to the Pt.
■ Assess restraint sites (skin, distal circulation, etc.) q 15 min.
■ Remove restraints every 2 hours if possible. For aggressive Pts, remove only one restraint at a time.
■ Document findings and interventions after each assessment.

Alternatives to Restraints
■ Provide regular orientation to reality and diversional activities.
■ Encourage family to be involved with diversion and supervision.
■ Allow ample opportunity for supervised ambulation and toileting.
■ Move Pt closer to nurse’s station. Monitor more frequently and respond to call lights promptly.
■ Utilize pressure-sensitive alarms in beds and chairs or sitters.
■ Conceal tubes and lines with pajamas or scrubs.
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Nursing Communication

Nursing Communication

Lifespan Considerations
■ Approach children at their eye level. Address them by name often and use language appropriate to their developmental level.
■ Be aware of cognitive impairment, but never assume that a Pt is cognitively impaired simply because of advanced age.
■ Be considerate of generational and gender differences.

Cultural Considerations
■ Be aware that culture has a strong influence on an individual’s interpretation of and responses to health care.
■ An interpreter may help ease the anxieties of a language barrier.
■ Be sensitive to cultural influence on nonverbal communication, i.e., touching or eye contact may be perceived as disrespectful.



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Nosocomial Infection

Nosocomial Infection

■ Definition: A hospital-acquired infection that can be fatal to an immunosuppressed Pt. Nosocomial infections are transmitted by either accidental or deliberate disregard for standard precautions designed to minimize transmission from Pt to Pt or from health-care provider to Pt.

■ Common Organisms: Clostridium difficile (C-diff), methicillinresistant Staph. aureus (MRSA), vancomycin-resistant Staph. aureus (VRSA), vancomycin-resistant Enterococcus (VRE).

■ Likely Access: Indwelling catheters, vascular access devices, endotracheal (ET) tubes, nasogastric (NG) and gastric tubes, and surgical wound sites.

■ Prevention: Use Standard Precautions during Pt contact.

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Standard (Universal) Precautions

Standard (Universal) Precautions

■ Indications: Recommended for the care of all Pts, regardless of their diagnosis or presumed infection status.
■ Purpose: Designed to provide a barrier precaution for all health-care providers prevent the spread of infectious disease.
■ Application: Applies to blood, other bodily fluids, secretions, excretions, nonintact skin, and mucous membranes.

Types of Standard Precautions
■ Hand washing:The single most important means of preventing the spread of disease. Perform before and after every Pt contact, and after contact with blood, bodily fluids, or contaminated equipment.
■ Gloves: Nonlatex gloves should be worn whenever contact with bodily fluids is possible. Note: lotions may degrade gloves.
■ Mask and eye protection:Worn whenever there exists the potential for getting splashed by bodily fluids.
■ Gown:Worn whenever exposed skin or clothing is likely to become soiled during Pt contact.
■ Disposal of sharps: Sharp instruments and needles are disposed of in a properly labeled, puncture-resistant container. NEVER recap needles at any time.
■ Containment: Soiled linen should be placed in a leak-proof bag. Grossly contaminated refuse is placed in a red biohazard bag and placed in appropriate receptacle.
■ Decontamination: Contaminated equipment should be properly disinfected per facility guidelines. Single-use equipment must be properly disposed of after use.

Transmission-Based Precautions
Airborne: In addition to Standard Precautions, use Airborne
Precautions for Pts known or suspected to have serious illnesses transmitted by airborne droplet nuclei.
■ Particulate Size: Droplet nuclei smaller than 5 microns
■ Common Etiology: Measles, chickenpox, disseminated varicella zoster, TB (tuberculosis)
■ Specific Precautions: Private room, negative airflow (at least six changes per hour), and a mask for the health-care provider. The Pt may be required to wear a mask if coughing is excessive. Droplet: In addition to Standard Precautions, use Droplet Precautions for Pts known or suspected to have serious illnesses transmitted by large particle droplets.
■ Particulate Size: Droplet nuclei larger than 5 microns
■ Common Etiology: Haemophilus influenzae type-B, (meningitis, pneumonia, epiglottitis, and sepsis), Neisseria meningitidis (meningitis, pneumonia, and sepsis), diphtheria, pertussis, mycoplasma pneumonia, pneumonic plague, streptococcal (group A) pharyngitis, pneumonia, scarlet fever in children, adenoviruses, mumps, parvovirus B19, rubella, and chicken pox
■ Specific Precautions: Private room and a mask for the healthcare provider are required. The Pt may be required to wear a mask if coughing is excessive. Contact: In addition to Standard Precautions, use Contact
Precautions for Pts known or suspected to have serious illnesses transmitted by direct Pt contact or by contact with items in the Pt’s environment.
■ Common Etiology: GI, respiratory, skin, or wound colonization or infection with drug-resistant bacteria. Other pathogens include Clostridium difficile (C-diff), Escherichia coli, (E-coli), Shigella, hepatitis, rotavirus, respiratory syncytial virus (RSV), diphtheria, herpes simplex, impetigo, pediculosis, scabies, chicken pox, and viral hemorrhagic infections, such as Ebola.
■ Specific Precautions: Private room for the Pt, and gloves and gown for the health-care provider. The Pt may be required to wear a mask if coughing is excessive.
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Applying Sequential Compression Devices

Applying Sequential Compression Devices

Equipment
■ Compression pump, motor, or machine.
■ Connecting tubing, if applicable. (In some devices, the tubing is preconnected to the sleeves.)
■ Compression sleeve (knee-high or thigh-high, depending on the prescription and the type of device).
■ Elastic stockings (if prescribed).
■ Washcloth and towel as needed to cleanse the lower extremities.
■ Measuring tape.

Assessment
■ Assess signs and symptoms of severe peripheral arterial disease (e.g., weak or absent pulses, discoloration, cyanosis, or gangrene).
■ Assess the condition of the skin: note lesions, dermatitis, or major edema, as evidenced by shiny, taut skin.
■ Be Safe! Assess cognitive level and level of consciousness. Patients with altered cognition may be at higher risk for falls related to the presence of the connecting tubing and attachment to the compression pump. Patients who are unconscious will not be able to report a device that is creating too much pressure.
■ Be Smart! Increased compression of vessels by the sequential device may further impede arterial flow. If skin is overstretched by edema, the SCD may irritate or worsen skin conditions and cause skin breakdown.

Post-Procedure Reassessment
■ Assess inflation and deflation of the sleeve to be sure the device is working.
■ Monitor for kinking or pinching of the connecting tubing.
■ Monitor circulation, sensation, and motion of the foot, including:
■ Skin color.
■ Pulses.
■ Temperature.
■ Capillary refill.
■ Motion and sensation.
■ Patient comfort.
■ Skin condition.
■ Signs and symptoms of deep vein thrombosis.
■ Be Safe! Remove the compression sleeves at intervals so that you can inspect skin and evaluate the adequacy of circulation. Note: If elastic stockings are being used in conjunction with SCD, follow the recommendations in Procedure 37-2.

Key Points
■ Determine whether elastic stockings are to be used concurrently with the SCD. If so, apply them.
■ Place the regulating pump for the sequential compression in a location that will ensure patient safety.
■ Place the patient in a supine position.
■ If you are using SCDS or PAS brand thigh-high compression sleeves, measure the thigh.
■ Place the lower extremity on the open sleeve, ensuring that the compression chambers are located over the correct anatomical structure (e.g., knee opening is at the level of the joint).
■ Leave one to two fingerbreadths between the sleeve and the extremity.
■ Set the regulating pump to the correct pressure, as prescribed.
■ Be Safe! Instruct the patient to call for assistance in disconnecting the tubing from the sleeve.

Documentation
■ Document the date and time you applied the device.
■ Note the type and size (if applicable) of the compression sleeve used.
■ Document the skin condition, including any abnormalities.

Sequential compression sleeves
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Procedure of Applying Antiembolism Stockings

Procedure of Applying Antiembolism Stockings

Equipment
■ Measuring tape.
■ Antiembolism stockings.
■ Washcloth and towel (if needed to cleanse legs).
■ Talcum powder (optional check manufacturer’s recommendations).

Assessment
■ Assess:
■ Level of consciousness and cognitive ability.
■ Skin condition.
■ Be Safe! Assess for and symptoms of severe peripheral arterial disease, such as weak or absent pulses, discoloration or cyanosis, or gangrene. Antiembolism stockings may further impede arterial flow and should not be used in patients with any of these findings.
■ Be Safe! Assess the condition of the skin (lesions, dermatitis, or major edema, as evidenced by shiny, taut skin). Antiembolism stockings may irritate or worsen skin conditions and cause skin breakdown.

Post-Procedure Reassessment
■ Evaluate patient comfort and ability to ambulate. Remeasure legs regularly to assess for edema and weight gain.
■ Be Safe! Remove the stockings for 20 to 30 minutes every 8 to 12 hours and monitor skin condition. Check the stockings for wrinkles and/or rolling down at the top, especially when sitting.

Key Points
■ Be Smart! Measure the patient’s leg(s) to ensure that you select stockings of the correct size. Measure thigh and calf circumference at widest section.
■ Thigh-high: Measure distance from gluteal fold to base of the heel.
■ Knee-high: Measure distance from the middle of the knee joint to the base of the heel.
■ Be Smart! Place the patient supine for at least 15 minutes before stocking application. This prevents trapping of pooled venous blood.
■ Elevate the patient’s legs for at least 15 minutes before applying stockings.
■ Cleanse legs and feet if necessary; dry well. Dust with powder if recommended by the manufacturer.
■ Insert your dominant hand to the heel, grasp heel and turn stocking inside out to the level of the heel with your other hand.
■ Insert patient’s foot, toes pointed, into stocking. Gradually pull the remaining portion of the stocking up and over the leg.
■ Keep knee-high stockings 2.5 to 5 cm (1 to 2 in.) below the joint.
■ Be Safe! Do not apply thigh-high stockings if the thigh circumference is greater than 100 cm (25 in.).
■ Make sure the stocking is free of wrinkles and is not rolled at the top or bunched.
■ Be Smart! Launder stockings every 3 days.

Documentation
■ Document:
■ Leg measurements and size of the stockings used.
■ Time and date applied.
■ Condition of the skin, including any abnormalities.

Measure the circumference at the widest part of the calf
Grasp the heel with your hand inside the stocking
Gradually pull the stocking up and over the leg
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Teaching a Patient to Deep Breathe, Cough, Move in Bed, and Perform Leg Exercises

Teaching a Patient to Deep Breathe, Cough, Move in Bed, and Perform Leg Exercises

Equipment
For Teaching Deep Breathing and Coughing:
■ Folded blanket or a pillow (if teaching will include splinting of a surgical incision site).
■ Tissues.

For Moving in Bed:
■ Small pillow or folded blanket.
■ Pillows.

Assessment
■ Assess cognitive level, level of consciousness, and pain level.
■ Assess the patient’s belief about the ability of the surgical incision to remain intact.
■ Determine whether the surgical procedure or a physical disability will limit the patient’s participation.
■ Determine whether the surgical procedure may entail special exercises or equipment.
■ Assess whether special equipment (e.g., braces, slings, or abductor wedges) may be needed when turning a patient in bed.
■ Be Safe! For orthopedic surgeries, consult the surgeon before teaching the patient any leg exercises.
■ Be Safe! Identify postoperative restrictions on movement (e.g., some spinal surgeries require the patient to logroll [move from head to toe as one unit]; some neurological procedures require limiting the amount of time the patient’s head of bed is above 30°).
■ Be Safe! Coughing and deep-breathing exercises are contraindicated for a patient who has had nasal, ophthalmic, or neurological surgery.

Post-Procedure Reassessment
■ Make sure that the patient performs correctly a return demonstration of the procedures taught.

Key Points
■ Assess the patient’s readiness to learn.

Deep Breathing and Coughing
■ Demonstrate how to splint a chest or abdominal incision.
■ Use pillows to support the patient who is unable to maintain a side-lying position.
■ Ensure that the patient is clear about the difference between coughing and merely clearing her throat. Turning in Bed
■ To turn to the left side: Start in supine position, bend the right leg, grasp the siderail with the right hand, and pull on the rail while
pushing with the right foot. To turn to the right, repeat the process using the opposite limbs.

Leg Exercises:
■ Teach the patient to alternately flex and extend her knees.
■ Teach the patient to alternately dorsiflex and plantar flex her feet.
■ Teach the patient to rotate her ankles in a complete circle.

Documentation
■ Checklists and charts often have special areas in which to document patient teaching.
■ Identify:
■ The person who completed the teaching.
■ The person to whom the procedures were taught.
■ What procedures were taught.
■ Whether the patient understood the teaching.
■ Also include the name and type of any printed materials given.

Turning to the left side
Performing ankle circles
Performing leg exercises
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Performing Cardiac Monitoring

Performing Cardiac Monitoring

Equipment
■ Alcohol pads.
■ Gauze pads.
■ Washcloth.
■ Shaving supplies or scissors, if necessary.
■ Disposable electrodes.
■ For hardwire monitoring, add: cardiac monitor; cable with lead wires; safety pin; 1-in. tape.
■ For telemetry, add: transmitter with lead wires (with a new battery inserted before each use); pouch to carry transmitter.

Assessment
■ Check for history of dysrhythmias.
■ Assess cardiovascular status, including:
■ Heart sounds.
■ Pulse rate.
■ BP.
■ Check for the presence of pain.
■ Be Smart! Assess skin integrity of the chest before applying electrodes.
■ Skin lesions contraindicate the application of leads to the affected area.

Post-Procedure Reassessment
■ Evaluate changes in the patient’s cardiac rhythm.
■ Check skin integrity, and replace the electrodes at least every 24 hours.

Key Points
■ Plug in the monitor and turn it on. Connect the cable with lead wires into the monitor.
■ Identify electrode sites based on the monitoring system and the patient’s anatomy.
■ Gently rub the placement sites with a gauze pad until the skin reddens slightly.
■ Use an alcohol pad to clean the areas for electrode placement; allow to dry.
■ Connect lead wires to the electrodes.
■ Be Smart! If the patient’s chest is very hairy, shave small areas for the electrodes.
■ Apply the electrodes, pressing firmly.
■ Check the ECG tracing on the monitor. If necessary, adjust the gain to increase the waveform size.
■ Be Safe! Set the upper and lower heart rate alarm limits and turn them on.
■ Obtain a rhythm strip by pressing the “record” button.
■ Be Smart! If you are not getting a good reading, recheck the leads, replace leads, or move leads if necessary.

Documentation
■ Chart the date and time monitoring was instituted and the monitoring lead selected.
■ Document a rhythm strip every 8 hours and with changes in the patient’s condition according to agency policy.
■ Label the rhythm strip (if the monitor does not label it for you) with the date, time, patient’s name, and room number.
■ Indicate on the strip when symptoms and treatment interventions occurred.
■ Document the patient’s response to treatment.

The monitoring system specifies lead placement
Evaluate the cardiac rhythm
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