ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021

RELATED LEARNING EXPERIENCE (NURSING ENRICHMENT PROGRAM)

Please study the following common procedures. State the rationale and/or importance of these
procedures:
1. Vital Signs including the Pulse Oximeter
 Vital signs reflect changes in body function that otherwise might not be observed.
 Body temperature is the balance between heat produced by and heat lost from the body.
 Pulse rate and volume reflect the stroke volume output, the compliance of the client’s
arteries, and the adequacy of blood flow.
 Normally a peripheral pulse reflects the client’s heartbeat, but it may differ from the
heartbeat in clients with certain cardiovascular diseases; in these instances, the nurse
takes an apical pulse and compares it to the peripheral pulse.
 Respirations are assessed by observing respiratory rate, depth, rhythm, quality, and
effectiveness. Blood pressure reflects the pumping action of the heart, peripheral vascular
resistance, blood volume, and blood viscosity.
 A pulse oximeter measures the percent of hemoglobin saturated with oxygen. A normal
result is 95% to 100%.
 Pulse oximeter sensors may be placed on the finger, toes, nose, earlobe, forehead, or
around the hand or foot of the neonate.

Assessing Body Temperature

 To establish baseline data for subsequent evaluation
 To identify whether the core temperature is within normal range
 To determine changes in the core temperature in response to specific therapies (e.g.,
antipyretic medication, immunosuppressive therapy, invasive procedure)
 To monitor clients at risk for imbalanced body temperature (e.g., clients at risk for
infection or diagnosis of infection; those who have been exposed to temperature
extremes)
Assessing a Peripheral Pulse
 To establish baseline data for subsequent evaluation
 To identify whether the pulse rate is within normal range
 To determine the pulse volume and whether the pulse rhythm is regular
 To determine the equality of corresponding peripheral pulses on each side of the body
 To monitor and assess changes in the client’s health status
 To monitor clients at risk for pulse alterations (e.g., those with a history of heart disease
or experiencing cardiac arrhythmias, hemorrhage, acute pain, infusion of large volumes
of fluids, or fever)
 To evaluate blood perfusion to the extremities
Assessing an apical pulse
 To obtain the heart rate of an adult with an irregular peripheral pulse
 To establish baseline data for subsequent evaluation
 To determine whether the cardiac rate is within normal range and the rhythm is regular
 To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to
improve heart action
Assessing an Apical-Radial Pulse
 To determine adequacy of peripheral circulation or presence of pulse deficit
Assessing Respirations
 To acquire baseline data against which future measurements can be compared
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021
 To monitor abnormal respirations and respiratory patterns and identify changes
 To monitor respirations before or after the administration of a general anesthetic or any
medication that influences respirations
 To monitor clients at risk for respiratory alterations (e.g., those with fever, pain, acute anxiety,
chronic obstructive pulmonary disease, asthma, respiratory infection, pulmonary edema or
emboli, chest trauma or constriction, brainstem injury)
Assessing Blood Pressure
 To obtain a baseline measurement of arterial blood pressure for subsequent evaluation
 To determine the client’s hemodynamic status (e.g., cardiac output: stroke volume of the
heart and blood vessel resistance)
 To identify and monitor changes in blood pressure resulting from a disease process or
medical therapy (e.g., presence or history of cardiovascular disease, renal disease, circulatory
shock, or acute pain; rapid infusion of fluids or blood products)
Measuring Oxygen Saturation
 To estimate the arterial blood oxygen saturation
 To detect the presence of hypoxemia before visible signs develop

2. Morning Care
 Early morning care is provided to clients as they awaken in the morning. This care
consists of providing a urinal or bedpan to the client confined to bed, washing the face
and hands, and giving oral care. Morning care is often provided after clients have
breakfast, although it may be provided before breakfast. It usually includes providing for
elimination needs, a bath or shower, perineal care, back massages, and oral, nail, and hair
care. Making the client’s bed is part of morning care. Hour of sleep or PM care is
provided to clients before they retire for the night. It usually involves providing for
elimination needs, washing face and hands, giving oral care, and giving a back massage.
As-needed (prn) care is provided as required by the client. For example, a client who is
diaphoretic (sweating profusely) may need more frequent bathing and a change of clothes
and linen.

3. Bed-Making
The technique of preparing different types of bed making patients/clients comfortable in his/ her
suitable position for a particular condition.
 To promote clients comfort.
 To provide a clean environment for the clients.
 To provide a smooth, wrinkle- free bed foundation, thus minimizing sources of skin
irritation.
 To conserve the clients energy and maintain current healthy status.
 To prevent or avoid microorganisms to come in contact with the patient which could
cause tribulations.

4. Administration of medication –
a. Oral- Oral administration is the most common, least expensive, and most convenient route for
most clients. In oral administration, the drug is swallowed. Because the skin is not broken as
it is for an injection, oral administration is also a safe method.
The major disadvantages can include an unpleasant taste of the drugs, irritation of the gastric
mucosa, irregular absorption from the GI tract, slow absorption, and, in some cases, harm to
the client’s teeth. For example, the liquid preparation of ferrous sulfate (iron) can stain the
teeth.
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021
b. Intradermal- To introduce medication through epidermis into dermis.

 The intradermal technique is used to inject small amounts (0.01-0.1 mL) of fluid for diagnostic
purposes, usually to determine sensitivity to various substances.
 Ventral forearm surface is usual site. Commonly used skin antigens are histoplasmin and
tuberculin purified protein derivative.
 Prior to tuberculin (TB) testing, obtain a negative history for mantoux reaction, BCG
immunization or symptoms of active TB. Immunocompromised patients may have a negative TB
purified protein derivative (PPD) test, yet have active TB infection
 A TB test is administered by Mantoux technique, that is, the intradermal injection of PPD.
 Allergy skin testing is usually not done in the home.
 For intradermal injections, select a 25- to 27-gauge needle with a short bevel. The needle length
can be 3/8-5/8 inches.
 Use at least 2 patient identifiers prior to administering medications.

c. Subcutaneous
 To provide a medication the client requires (see specific drug action)
 To allow slower absorption of a medication compared with either the intramuscular
or intravenous route
d. Intramuscular -are absorbed more quickly than subcutaneous injections because of the greater
blood supply to the body muscles. Muscles can also take a larger volume of fluid without
discomfort than subcutaneous tissues can, although the amount varies among individuals,
chiefly based on muscle size and condition and the site used. An adult with well developed
muscles can usually safely tolerate up to 3 mL of medication in the gluteus medius and
gluteus maximus muscles. A volume of 1 to 2 mL is usually recommended for adults with
less developed muscles. In the deltoid muscle, volumes of 0.5 to 1 mL are recommended.
e. Suppository - Insertion of medications into the rectum in the form of suppositories is a
frequent practice. Rectal administration is a convenient and safe method of giving certain
medications. Advantages include the following:
 It avoids irritation of the upper GI tract in clients who encounter this problem (e.g., in
clients who are nauseated or vomiting).
 It is advantageous when the medication has an objectionable taste or odor.
 The drug is released at a slow but steady rate.
 Rectal suppositories are thought to provide higher bloodstream levels (titers) of
medication because the venous blood from the lower rectum is not transported
through the liver.
f. Nebulization - Nebulizers deliver most medications administered through the inhaled route. A
nebulizer is used to deliver a fine spray (fog or mist) of medication or moisture to a client.
There are two kinds of nebulization: atomization and aerosolization. In atomization, a device
called an atomizer produces rather large droplets for inhalation. In aerosolization, the droplets
are suspended in a gas, such as oxygen. The smaller the droplets, the further they can be
inhaled into the respiratory tract. When a medication is intended for the nasal mucosa, it is
inhaled through the nose; when it is intended for the trachea, bronchi, and/or lungs, it is
inhaled through the mouth.
A large-volume nebulizer can provide a heated or cool mist. It is used for long-term therapy,
such as that following a tracheostomy. The ultrasonic nebulizer provides 100% humidity and
can provide particles small enough to be inhaled deeply into the respiratory tract.
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021

5. Intravenous Therapy –
a. Regulation
 rehydration after becoming dehydrated from illness or excessive activity
 treatment of an infection using antibiotics
 cancer treatment through chemotherapy drugs
 management of pain using certain medications
b. Follow up - help maintain a patient's hydration, electrolyte and blood sugar levels while
undergoing surgical procedures. Clinicians are also able to administer warmed IV fluids
directly into a patient's bloodstream, as it is common for a patient's body temperature to
decrease slowly while he or she is sedated.
c. Termination - it may be discontinued at any time for a number of reasons. The common
reasons to discontinue IV fluids are: the patient's fluid volume has returned to baseline; the
patient is being discharged from the facility; the IV catheter needs to be replaced; or the IV
site has become unfavorable due to infection, infiltration, extravasation, or phlebitis.
6. Nasogastric Feeding - Nasogastric tube feeding is defined as the delivery of nutrients from the
nasal route into the stomach via a feeding tube.
 Smaller size feeding tube improves patient comfort. Common complications associated
with the use of larger and stiffer tubes include nasopharyngeal erosions / necrosis,
sinusitis and otitis media.
 Polyurethane or silicone tubes are better for long-term (> 4-8 weeks) use because they are
more flexible and less irritating to tissues.
 PVC feeding tubes are used for short term duration (< 3 weeks) and they tend to harden
and become brittle with time and may cause tissue irritation or necrosis.
 For short-term usage, PVC feeding tubes have adequate efficacy and are more cost
effective.
7. Blood Transfusion - IV fluids can be effective in restoring intravascular (blood) volume;
however, they do not affect the oxygen-carrying capacity of the blood. When red or white blood
cells, platelets, or blood proteins are lost because of hemorrhage or disease, it may be necessary
to replace these components to restore the blood’s ability to transport oxygen and carbon dioxide,
clot, fight infection, and keep extracellular fluid within the intravascular compartment. A blood
transfusion is the introduction of whole blood or blood components into venous circulation.
8. Random Blood Sugar -
 To determine or monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia
 To promote blood glucose regulation by the client
 To evaluate the effectiveness of insulin administration
9. Catheterization- Urinary catheterization is frequently required for clients with urinary retention
but is only performed when all other measures to facilitate voiding fail. Sterile technique is
essential to prevent urinary infections.
a. Insertion
 To relieve discomfort due to bladder distention or to provide gradual decompression
of a distended bladder
 To assess the amount of residual urine if the bladder empties incompletely
 To obtain a sterile urine specimen
 To empty the bladder completely prior to surgery
 To facilitate accurate measurement of urinary output for critically ill clients whose
output needs to be monitored hourly
 To provide for intermittent or continuous bladder drainage and/ or irrigation
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021
 To prevent urine from contacting an incision after perineal surgery
b. Removal - It is important to understand the reason for removal and whether the catheter is
being removed permanently or in a planned or unplanned change due to prob- lems
encountered by the patient, such as a blocked catheter. The procedure differs depending on
whether the insertion site is urethral or suprapubic.
The removal of a urinary catheter should be a simple, uncomplicated procedure but there are
recognised competencies. Nurses removing a catheter must be aware of:
 Local policies and procedure;
 Anatomy and physiology of the genitourinary system
 Care of the patient before, during and after removal;
 What action to take if they encounter a problem;
 Infection prevention and control issues relating to catheter care;
 The balloon mechanism used to retain catheters in the bladder

Common Diagnostic Procedures. State the rationale and/or importance of these procedures:
1. Cardiac Enzymes Test - The protein troponin T is the key biomarker measured in a cardiac
enzyme test. This biomarker helps let your doctor know when your heart has been under stress. It
can also reveal if your heart muscle isn't getting enough oxygen. Keep reading to learn more
about the testing process and what the results may mean for you.
2. Complete Blood Count - Specimens of venous blood are taken for a complete blood count (CBC),
which includes hemoglobin and hematocrit measurements, erythrocyte (red blood cells) count,
red blood cell indices, leukocyte (white blood cell) count, and a differential white cell count. The
CBC is a basic screening test and one of the most frequently ordered blood tests.
 Hemoglobin (Hgb) is the main intracellular protein of erythrocytes. It is the iron-
containing protein in the red blood cells that transports oxygen through the body. The
hemoglobin test is a measure of the total amount of hemoglobin in the blood.
 The hematocrit (Hct) measures the percentage of RBCs in the total blood volume.
Normal values for both hemoglobin and hematocrit vary, with males having higher levels
than females. Hemoglobin and hematocrit are often ordered together and commonly
referred to as “H&H” when ordering laboratory tests.
 Hemoglobin and hematocrit increase with dehydration as the blood becomes more
concentrated, and decrease with hypervolemia and resulting hemodilution. Both the
hemoglobin and hematocrit are related to the red blood cell (RBC) count, which is the
number of RBCs per cubic millimeter of whole blood.
 Low RBC counts are indicative of anemia. Clients with chronic hypoxia may develop
higher than normal counts, a condition known as polycythemia. Red blood cell (RBC)
indices may be performed as part of the CBC to evaluate the size, weight, and
hemoglobin concentration of RBCs.
 The leukocyte or white blood cell (WBC) count determines the number of circulating
WBCs per cubic millimeter of whole blood. High WBC counts are often seen in the
presence of a bacterial infection; by contrast, WBC counts may be low if a viral infection
is present. In the WBC differential, leukocytes are identified by type, and the percentage
of each type is determined. This information is useful in diagnosing certain disorders that
have characteristic patterns of distribution.
3. CT Scan- Computed tomography (CT), also called CT scanning, computerized tomography, or
computerized axial tomography (CAT), is a painless, noninvasive x-ray procedure that has the
unique capability of distinguishing minor differences in the density of tissues. The CT produces a
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021
three-dimensional image of the organ or structure, making it more sensitive than the x-ray
machine.
4. ECG - provides a graphic recording of the heart’s electrical activity. Electrodes placed on the skin
transmit the electrical impulses to an oscilloscope or graphic recorder. With the wave forms
recorded, the electrocardiogram (ECG) can then be examined to detect dysrhythmias and
alterations in conduction indicative of myocardial damage, enlargement of the heart, or drug
effects.
5. Echocardiogram - an echocardiogram is a noninvasive test that uses ultrasound to visualize
structures of the heart and evaluate left ventricular function. Images are produced as ultrasound
waves are reflected back to a transducer after striking cardiac structures. The nurse should tell the
client that this test causes no discomfort, although the conductive gel used may be cold.
X-ray examination of the chest is done both to diagnose disease and to assess the progress of a
disease. For an x-ray examination, the nurse needs to inform the client that jewelry and clothing
from the waist up must be removed.
6. Holster monitoring - is used for this type of monitoring. It is usually applied in an office or clinic
setting, and the client wears the portable recorder for 24 hours. Other portable devices used for
recording episodic arrhythmias include cardiac event monitors. The client activates the device
during times when symptoms appear and then the recorded data can be transmitted to a central
location through a telephone.
7. Lipid Panel - When we measure cholesterol and blood fats, we're really talking about three
different numbers: HDL, LDL, and triglycerides. They combine to give you a "lipid profile"
score, but the three individual scores are most important. Here are the numbers to strive for: Total
cholesterol of 200 mg/dL or lower.
8. Liver Enzymes Test - can be used to: Screen for liver infections, such as hepatitis. Monitor the
progression of a disease, such as viral or alcoholic hepatitis, and determine how well a treatment
is working. Measure the severity of a disease, particularly scarring of the liver (cirrhosis)
9. Liver Function Test - can be used to: Screen for liver infections, such as hepatitis. Monitor the
progression of a disease, such as viral or alcoholic hepatitis, and determine how well a treatment
is working. Measure the severity of a disease, particularly scarring of the liver (cirrhosis)
10. Sputum Test - A sputum culture is most often used to: Find and diagnose bacteria or fungi that
may be causing an infection in the lungs or airways. See if a chronic illness of the lungs has
worsened. See if treatment for an infection is working.
11. Ultrasound - An ultrasound allows your doctor to see problems with organs, vessels, and tissues
without needing to make an incision. Unlike other imaging techniques, ultrasound uses no
radiation. For this reason, it's the preferred method for viewing a developing fetus during
pregnancy.
12. Urinalysis - A urinalysis is used to detect and manage a wide range of disorders, such as urinary
tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance,
concentration and content of urine. Abnormal urinalysis results may point to a disease or illness.
13. X-Ray - The most familiar use of x-rays is checking for fractures (broken bones), but x-rays are
also used in other ways. For example, chest x-rays can spot pneumonia. Mammograms use x-rays
to look for breast cancer. When you have an x-ray, you may wear a lead apron to protect certain
parts of your body.

Sources: Kozier Fudamental of Nursing 10th edition