Sumalinog, Tiffany Marie L.

BSN 2B

NCM 109 REVIEWER

(RLE)  Ballard’s Chart- Commonly used to assess

gestational age
ASSESSMENT OF HIGH-RISK INFANTS
 Term Infant- born between weeks 38 and 42
of pregnancy.
 Pre-term Infant (premature)- born before
their due date of prematurely born
children (prior to the start of the 38th week
of pregnancy)
 Post term infant (postdate) - born after a
woman’s 41st week of pregnancy meaning
one that extends beyond 42
 Appropriate for gestational age (AGA)-
infants who fall between the 10th and 90th
percentiles of weight for their gestational
age, whether they are preterm, term, or post
term
 Small for gestational age (SGA)- Infants
who fall below the 10th percentile of weight
for Based on gestational age, neonates are classified as
their age Premature: <34 weeks gestation
 Large for gestational age (LGA)- Those who Late pre-term: 34-<37 weeks
fall above the 90th percentile in weight Early term: 37 0/7 weeks through 38 6/7 weeks
DIFFERENT TYPES OF ASSESSMENT TOOLS Full term: 39 0/7 weeks through 40 6/7 weeks
Late term: 41 0/7 weeks through 41 6/7 weeks
 APGAR SCORING Postterm: 42 0/7 weeks and beyond
- quick assessment tool to assess the status Postmature: >42 weeks
of newborn baby 1 minute and 5 minutes
after birth  Silverman-Andersen index
A - APPEARANCE/COLOR - Assessed by physical examination
P - PULSE/HEART RATE - within 1 hr of birth
G - GRIMACE/REFLEX IRRITABILITY - to predict need for escalation of respiratory
A - ACTIVITY/MUSCLE TONE support and facilitate decision making for
R – RESPIRATION transfer in low-resource settings

10: severe respiratory distress

> 7: impending respiratory failure
INTERVENTIONS BASED ON APGAR SCORE 0: no respiratory distress

0-3: need full resuscitation  Brazelton Neonatal Behavioral Assessment

4-6 : some resuscitation assistance required; re-assess Scale- Assess the newborn’s neurological
every 5 mins until normal
development, reflexes, and reactions to
7-10: no interventions, baby doing good, just need
people and objects during the first month of
routine post-delivery care
life
 - it is a rating scale of six different categories
of behavior: habituation, social interaction,
motor system, state organization, state
regulation, autonomic system,
supplementary items, reflexes
 habituation - decreased reaction to repeated
presentations of auditory and visual
 stimuli- lower scores are more optimal
 social-interactive - response to inanimate
and animate visual and auditory stimuli and
the quality of overall alertness - higher
scores are optimal
 motor system - when infant has good tone
when handled but relaxed in between
handlings. there are normal reflexes, and the
activity level is moderate. the infant shows
coordinated motor activity by smooth
movements, some head control, and hand-to-
mouth or other directed movements.
 state organization - examines the infant’s
ability to achieve and maintain an alert state,
control irritability, and habituation to
(shutting out of) disturbing stimuli.
 state regulation - ability to organize motor
activity and state during the examination and
respond to cuddling, consoling, and negative
stimuli - higher scores are optimal
 autonomic system - poor performance is one
in which the infant shows profound skin
color change and slow recovery of good
color, and is frequently startled or tremulous
even when alert. lesser reactions are
considered average
 supplementary items - designed to evaluate
the infant’s ability to cope with the
examination and maintain an alert state.
 reflexes - a scale where a record of the
number for any abnormal reflexes
THE INITIAL ASSESSMENT OF A NORMAL
AND A HIGH-RISK INFANT
High-risk infant
An infant that appears well but has a much greater
chance than most infants of developing a clinical
problem
An infant that appears well but has any of the
following features should be regarded as high risk
and, therefore, likely to develop a problem during
the newborn period:
1. Infants that are born preterm or postterm
2. All low-birth-weight infants
3. Infants who are underweight or overweight for
gestational age
4. Wasted infants
5. Infants who have a low 1-minute apgar score
6. Infants who are born to mothers with a
complicated pregnancy, labor, or delivery
7. Infants who have had one or more clinical
problems since delivery
8. Infants who were sick but have now recovered
NORMAL INFANT
● the vitals are normal
● pregnancy labor and delivery were normal
● infant born at term
Healthy Response to Birth
● If the infant is pink, the arms and legs are actively
pulled toward the body, the baby is crying and does
not have retractions or nasal flaring, the infant may
be placed skin-to-skin on the mother's chest
At Risk Response to Birth
● If the infant is not breathing or has not cried,
neonatal resuscitation will be needed.
 This begins with stimulation of the infant
and oxygen by mask
NORMAL VALUES
● The infant's normal heart rate is 120-160 BPM
● respiration normal rate is 30 to 60 CPM
● normal axillary temperature is 36.5 to 37.2 C
● born at 40 weeks gestation (normal pregnancy)
●weighing >2500 g and < 4000 g is considered
AGA or appropriate for gestational age.
● The average head circumference (HC) is 33-
37cm.
● chest circumference average is 30 to 33 cm and
should be 2-3 cm LESS THAN head circumference.
● The normal length is 45 to 55 cm.
IMPORTANT CHARACTERISTICS OF BODY
SYSTEMS BEFORE AND AFTER BIRTH
Cardiovascular system
● the lungs are in control of oxygenation blood that
was previously supplied by the placenta after birth.
● Blood pressure in the pulmonary artery drops
after the first breath. the ductus arteriosus, the fetal
shunt between the pulmonary artery and the aorta,
begins to shut as it lowers.
● as a result of the pressure against the lip of the
structure, increasing blood circulation to the left
side of the heart leads the foramen ovale to shut.
● blood within veins clots and closes as the
surviving fetal circulatory systems no longer get
blood from the placenta, and vessels atrophy during
the next few weeks
Respiratory system
● The first breath is a big deal since it takes a great
deal of pressure for a newborn to expand alveoli for
its first time.
● Because fluid eases the surface tension on
alveolar walls and permits alveoli to inflate more
easily than if the lungs were dry, a newborn's first
breath is made possible by some fluid present in the
lungs from intrauterine life.
● The baby's breathing becomes much easier when
the alveoli have been inflated for the first time,
requiring only 6-9 cm h20 pressure.
● Most babies have established easy respirations
and a good residual volume within 10 minutes of
birth.
● Vital capacity reaches newborn proportions at
Gastrointestinal System
● bacteria can be cultured from the gastrointestinal
tract in most newborns within 5 hours after birth
and from all babies within 24 hours of life, even
though the tract is generally sterile at birth. most of
all the bacteria reach the tract through the newborn's
mouth from airborne sources, while some may
emerge from vaginal secretions at birth, hospital
bed linen, or breast interaction.
● since the pancreatic enzymes, lipase, and amylase
are insufficient for the first few months of life, a
newborn has limited capability to absorb everything
taken in, including fat and starch10-10 hours of age.
Urinary system
● The newborn will normally urinate within the first
24 hours of life after birth. The kidneys gain the
ability to keep the body's fluid and electrolyte
balance in check. After birth and over the first two
weeks of life, the rate at which blood filters through
the kidneys (glomerular filtration rate) increases
dramatically.
● Female should create a constant stream, not just
continual dribbling, whereas male should void with
enough force to produce a tiny projected arc.
Immune system
● Because newborns cannot manufacture antibodies
until they are roughly 2 months old, they have poor
immunologic protection at birth.
● Newborn babies' immunity is very transient, and
it begins to wane after a few weeks or months.
Breast milk also contains antibodies, which means
that breastfed newborns have longer-lasting passive
immunity.
● The placenta provides the majority of maternal
immunoglobulins (Ig), primarily immunoglobulin G
(IgG), to human newborns. The transmission of
maternal antibodies to the fetus begins as early as
the 13th week of pregnancy.
Neuromuscular system
● Neuromuscular development is shown in term
newborns. They try to move their extremities in
order to function, control head movement,
exhibiting a strong cry and displaying the reflexes
of a newborn.
● The sensory development of a newborn infant is
impressive, as is his or her ability to self-organize in
social relationships.
● Newborn reflexes can be tested with consistency
by using a number of simple maneuvers.
DIFFERENT NEONATAL REFLEXES
 Babinski reflex
 Blink reflex
 Palmar grasp reflex
 Magnet Reflex
 Trunk Incurvation Reflex
 Landau Reflex
 Moro Reflex
 Tonic Neck reflex
 Plantar Grasp Reflex
 Placing Reflex
 Walk-in-place reflex
 Extrusion Reflex
 Swallowing Reflex
 Sucking Reflex
 Rooting reflex
OXYGEN THERAPY
 Respiration - is the act of breathing or the
overall exchange of gases between the
atmosphere, the blood, and the cells.
 Oxygen Therapy-are interventions used to
improve oxygenation, tissue perfusion and at
the same time, reduce the burden of the
cardiovascular and hematologic systems.
  Humidifier- is a device that adds moisture to
the air supplied to the patient and is used for
symptomatic relief of dry mucous
membranes and many common illnesses.
 Hypoxia-decreased tissue oxygenation.
 Dyspnea-shortness or labored breathing
 Hypoventilation-refers to very shallow
respirations.
 Hyperventilation-refers to very rapid, deep
respirations.
(at 6 L/min)
2. Simple Face Mask
- is used to deliver oxygen concentrations of
40% to 60% for short-term oxygen therapy or
in an emergency.
3. Partial Rebreather Mask
- provides oxygen concentrations of 60% to 75%,
with flow rates of 6 to 11 L/min
- is a mask with a reservoir bag but no flaps

4. Non-rebreather Mask
- provides the highest oxygen level of the
low-flow devices and can deliver a fraction of
PURPOSE OF OXYGEN THERAPY inspired oxygen greater than 90%, depending on
the client’s breathing pattern.
● Used to relief of hypoxemia and hypoxia.
- is often used with clients whose respiratory
● To maintain adequate oxygenation.
status is unstable and who may require
● To increase the amount of oxygen in the lungs.
intubation
● To alleviate anoxia.
● To reduce feeling of breathlessness.
High-flow Oxygen Delivery Devices
● To improve exercise tolerance.
1. Venturi Mask
- “venti mask”
INDICATIONS
- delivers the most accurate oxygen concentration
● Clients with hypoxia - for the client with chronic lung disease because it
● Clients who experience delivers a precise oxygen concentration
dyspnea
● Client with severe 2. Face Tent
anemia or blood loss - fits over the chin, with the top extending halfway
● Clients with Chronic across the face
Obstructive - oxygen level delivered varies
Pulmonary Disease
● During major surgery 3. Aerosol Mask
- is used when high humidity is needed after
CONTRAINDICATIONS extubation or Upper airway surgery, or for thick
secretions.
● Depression of
ventilation 4. Tracheostomy Collar
● Absorption - is used to deliver high humidity and the desired
Atelectasis oxygen to the client with a tracheostomy
● Emphysema
● Oxygen Toxicity 5. T-piece
- is used to deliver the desired fraction of inspired
oxygen to the client with a tracheostomy,
DELIVERY SERVICES FOR OXYGEN laryngectomy, or endotrachealtube
THERAPY

Low-flow Oxygen Delivery Services

SAFETY MEASURES OR PRECAUTIONS FOR
1. Nasal Cannula OXYGEN THERAPY ADMINISTRATION
- is used at flow rates of 1 to 6 L/min.
● For home oxygen use or when the facility permits
- used for clients with chronic lung disease & any
smoking, teach family members and roommates to
client requiring long-term oxygen therapy.
smoke only outside or in provided smoking rooms
- oxygen concentrations of 24% (at 1 L/min) to
away from the client and oxygen equipment.
44%
● Place cautionary signs reading “No Smoking:
Oxygen in Use” on the oxygen equipment.
● Instruct the client and visitors about the hazard
of smoking with oxygen in use.
● Make sure that electric devices (such as razors,
hearing aids, radios, television, and heating pads)
are in good working orders to prevent the
occurrence of short-circuit sparks.
● Avoid materials that generate static electricity,
such as woolen blankets, and synthetic fabrics.
Cotton blankets should be used, and client and
caregivers should be advised to wear cotton fabrics.
● Avoid the use of volatile, flammable materials,
such as oils, greases alcohol, ether, and acetone
(e.g., nail remover), near the clients receiving
oxygen.
● Be sure that electric monitor equipment, suction
machines and portable diagnostic machines are
electrically grounded.
● Make known the location of fire extinguishers,
and make sure personnel are trained in their use.
NURSING RESPONSIBILITIES BEFORE,
DURING AND AFTER OXYGEN THERAPY
Before:
● Determine the need for oxygen therapy, and
verify the order for the therapy.
● Prepare the client and support people.
● Explain to the client what you are going to do,
why it is necessary, and how he or she can
participate.
● Perform hand hygiene and observe other
appropriate infection prevention procedures.
During
● Provide client's privacy, if appropriate.
● Assist the client to a semi-Fowler's position if
possible.
● Set up the oxygen equipment and the humidifier.
● Turn on the oxygen at the prescribed rate and
ensure proper functioning.
● Apply the appropriate oxygen delivery device.
After
● Assess the client regularly to know the patient's
condition.
● Client's vital signs, level of anxiety, color.
● Assess for clinical signs of hypoxia, tachycardia,
confusion, dyspnea, restlessness, and cyanosis.
● Inspect the equipment on a regular basis.
● Document findings in the client record using
forms or checklists and supplemented by narrative
notes when appropriate
ASSISTING IN INTRAVENOUS FLUID (IVF)
INSERTION
 intravenous fluid- or IV solutions contain
dextrose or electrolytes mixed in various
proportions with water.
 intravenous administration- is performed in
the hospital, outpatient diagnostic and
surgical settings, clinics, and home to
replace fluids, administer medications, and
provide nutrients when no other route is
available.
 venipuncture site- The site chosen for
venipuncture varies with the client’s age,
length of time an infusion is to run, the type
of solution used, and the condition of veins.
For adults, veins in the arm are commonly
used; for infants, veins in the scalp and
dorsal foot veins are often used.
 Tourniquet- a device (such as a band of
rubber) that checks bleeding or blood flow
by compressing blood vessels.
 IV push-Intravenous push (IVP) or bolus is
the intravenous administration of an
undiluted drug directly into the systemic
circulation
PURPOSES OF IV THERAPY
 To treat dehydration and electrolyte
imbalances
 To transport nutrients and nutritional
supplements
 To administer medications or emergency
medications
 To administer blood or blood products
RISK OF PERIPHERAL IV THERAPY
Infection
Phlebitis
Infiltration
Extravasation
Fluid overload
Hypersensitivity
Air Embolism
Hemorrhage/hematoma
FACTORS INFLUENCING FLOW RATES OF IV
SOLUTIONS
The position of the forearm. Sometimes a change -can contain a single or multiple channels (lumens)
in the position of the client's arm decreases flow.
Indications:
Slight pronation, supination, extension, or elevation
of the forearm on a pillow can increase flow  Nutritional support
 Administration of caustic medications (eg,
The position and patency of the tubing. Tubing
vasopressors)
can be obstructive by the client's weight, a kink, or a
 CVP monitoring.
clamp closed too tightly. The flow rate also
 Hemodialysis.
diminishes when part of the tubing dangles below
the puncture site. Contraindications:
The height of the infusion bottle. Elevating the  Obstructed vein (eg. clot)
height of the infusion bottle a few inches can speed  Stenosis of the vein
the flow by creating more pressure  Contaminated site
Possible infiltration or fluid leakage. Swelling, a  Traumatized site (eg. clavicle fracture and
feeling of coldness, and tenderness at the subclavian line)
venipuncture sire may indicate infiltration  Burned site

Relationship of the size of the angiocath to the
vein. A catheter that is too large may impede the
infusion flow.
Implanted Vascular Access Device (IVAD)
- a small port and catheter that allows
medication to be administered directly into
the large central vein
- used for clients in chronic illness who
require long term therapy.
- this type of device is designed to provide
repeated access to the central venous system,
avoiding the trauma and complications of
multiple venipunctures.

THE DIFFERENT KINDS OF VENOUS ACCESS

DEVICE OR IV NEEDLE CANNULA cannula
is a small flexible plastic tube inserted into a vein.
Peripherally Inserted Central Venous Catheter The cannula is to give you medication or fluids that
(PICC) you are unable to take by mouth or that need to
enter your blood stream directly.
-inserted in the basilic or cephalic vein just above or
below the antecubital space of the right arm
-the tip of the catheter is in superior vena cava
-these catheters frequently are used for long –term
iv access when the client will be managing IV
therapy at home
Indication:
 IV Therapy
Contraindications:
 Burns, trauma, skin infections, radiation,
history of venous thrombosis at insertion site
 Active bacteremia
 Chronic renal failure, end-stage renal
disease (veins should be preserved for
potential dialysis catheter placement)
Central Venous Access Device (CVAD)
- thin, soft, flexible tube that is inserted into a large
vein leading to the heart.

Macroset
A collection of sterile devices designed to conduct
fluids from an intravenous (IV) fluid container to a
patient's venous system; used for gravitational
intravenous administration.
Microset
A microset is an infusion set used when you are
supposed to give the patient 60 drops per minute, or
about 100 mL per hour. This is ideal for pedia or
infant use.
IV Tubings
IV Pumps
 Select a vein that is:
a) Easily palpated and feels soft and full
b) Naturally splinted by bone
c) Large enough to allow adequate
circulation around the catheter
 Avoid using veins that are:
a) In areas of flexion
b) Highly visible, because they tend to roll
away from the needle
c) Damaged by previous use, phlebitis,
infiltration, or sclerosis
d) Continually distended with blood , or
knotted or tortuous
e) In a surgically compromised or injured
extremity, because of possible impaired
circulation and discomfort for the client.
METHODS OF TAPING A VENOUS ACCESS
SITE
 Chevron Method
 U method
 H method
EXAMPLES OF COMMONLY INFUSED
DRUGS THROUGH INTRAVENOUS TUBING

Large volume infusion pump that helps in  Hydralazine hydrochloride (anti-

administering medications hypertensive)
 Chemotherapy drugs (doxorubicin,
Piggyback Infusion vincristine, cisplatin, and paclitaxel.
a secondary IV setup that connects a second  Antibiotics (vancomycin, meropenem,
container to the tubing of a primary container at the gentamicin)
upper port. Used solely for intermittent drug  Antifungal (micafungin and amphotericin)
administration.  Pain Medications (hydromorphone and
morphine)
Arm Splint
Splints stabilize injuries by decreasing movement
and providing support, thus preventing further
damage. Splinting also alleviates extremity pain and
DIFFERENT TYPES OF IVF SOLUTIONS AND
edema and promotes soft-tissue and bone healing
ITS NURSING IMPLICATION
DIFFERENT VENIPUNCTURE SITES
ISOTONIC SOLUTIONS
Upper extremities:
0.9% NaCl (normal saline )
- Metacarpal
Lactated Ringer's ( a balance electrolyte solution)
- Basilic, and;
- Cephalic veins 5% dextrose in water ( D5W)
Lower extremities: NURSING IMPLICATIONS
- Femoral vein Isotonic solutions such as normal saline (NS) and
- Dorsal vein lactated Ringer's initially remain in the vascular
compartment , expanding vascular volume. Assess
GUIDELINES IN VEIN SELECTION
clients carefully for signs of hypervolemia such as
 Use distal veins of the arm first; subsequent bounding pulse and shortness of breath .
IV starts should be proximal to the previous
site.
 Use the client's nondominant arm wherever D5W is isotonic on initial administration byt
possible provides free water when dextrose is metabolized ,
expanding intracellular and extracellular fluid
volumes. D5W is avoided in clients at risk for
increased intracranial pressure (IICP) because it can
increase cerebral edema.
HYPOTONIC SOLUTIONS
0.45% NaCl ( half normal saline )
0.33% NaCl ( one - third normal saline
NURSING IMPLICATIONS
HYPotonic solutions are used to provide free water
and treat cellular dehydration . These solutions
promote waste elimination by the kidneys . Do not
administer to clients at risk for IICP or third -space
fluid
HYPERTONIC SOLUTIONS
5% dextrose in normal saline ( D5NS)
5% dextrose in 0.45% NaCl ( D5½NS)
5% dextrose in lactated Ringer's (D5LR shift)
NURSING IMPLICATIONS
HYPERtonic solutions draw fluid out of the
intracellular and interstitial compartments into the
vascular compartment, expanding vascular volume.
Do not administer to clients with kidney or heart
disease or clients who are dehydrated . Watch for
signs of hypervolemia.
CALCULATE THE FLOW RATE OF IV
SOLUTIONS
PARENTERAL MEDICATIONS
 Parenteral Administration- means any route
other than the gastrointestinal (GI) tract.
 Syringe- Is used for irrigations, withdrawing
fluids from the body, and intravenous
injections and etc.
 Vials- Glass container sealed at the top by a
rubber stopper to enhance sterility of the
contents. Contents may be a solution or a
powdered drug that needs to be
reconstituted. Vials may be multiple dose or
unit dose.
 Ampules- An ampule is a glass container
usually designed to hold a single dose of a
drug. It is made of clear glass and has a
distinctive shape with a constricted neck.
 Reconstitution- The powder (dry particles of
drugs) itself cannot be injected. It must be
mixed with a sterile diluting solution (sterile
water or saline solution) to render an
injectable solution
DIFFERENT ROUTES OF ADMINISTRATION,
ITS ADVANTAGES AND DISADVANTAGES
AND COMMON SITES INDICATED FOR EACH
ROUTE
a) Intradermal (ID): Injection into the dermis
just under the epidermis
b) Subcutaneous: Injection into tissues just
below the dermis of the skin
c) Intramuscular (IM): Injection into a muscle
d) Intravenous (IV): Injection into a vein
1. INTRADERMAL INJECTIONS
- is the administration of a drug into the
dermal layer of the skin just beneath the
epidermis. It is frequently used for allergy
testing and tuberculosis (TB) screening.
Common sites for intradermal injections are the
inner lower arm, the upper chest, and the back
beneath the scapulae.
2. SUBCUTANEOUS INJECTIONS
- Involve placing medications into the loose
connective tissue under the dermis
- This may be the route of choice for drugs
that should not be absorbed as rapidly as
through the IV or IM routes.
Common sites for subcutaneous injections are the
outer aspect of the upper arms and the anterior
aspect of the thighs. Other areas that can be used are
the abdomen, the scapular areas of the upper back,
and the upper ventrogluteal and dorsogluteal areas.
3. INTRAMUSCULAR INJECTIONS
- are administered deep into large muscles.
- The length of the needle varies with the size
of the patient.
- Absorption is more rapid because the muscle
tissue is more vascular.
There are five recommended sites: Dorsogluteal,
Ventrogluteal, Deltoid, Vastus lateralis, Rectus
femoris
a. DORSOGLUTEAL SITE
 - Injection site is in the upper outer quadrant
of the buttock, gluteus maximus (preferred
site for adults)
- Position the patient flat on the stomach
(prone) with the toes pointed inward or on
the side with the upper leg flexed
b. VENTROGLUTEAL SITE
- The ventrogluteal site is in the gluteus
medius muscle, which lies over the gluteus
minimus. Can be used for all patients
- The client position for the injection can be a
back, prone, or side-lying position. The side-
lying position, however, helps locate the
ventrogluteal site more easily.
c. DELTOID SITE
- The deltoid muscle is found on the lateral
aspect of the upper arm.
- It is not used often for intramuscular
injections because it is a relatively small
muscle and is very close to the radial nerve
and radial artery.
- This site is recommended for the
administration of hepatitis B vaccine in
adults.
d. VASTUS LATERALIS SITE
- Located on the anterior lateral thigh, the
preferred site for infants (The middle third
of the muscle is suggested as the site), since
these muscles are the most developed for
children under the age of three years.
- The client can assume a back-lying or a
sitting position for an injection into this site.
e. RECTUS FEMORIS SITE
- The rectus femoris muscle, which belongs to
the quadriceps muscle group. Is situated on
the anterior aspect of the thigh
- Used only occasionally for intramuscular
injections. It is the preferred site for self-
injection because of its accessibility.
4. INTRAVENOUS INJECTIONS
- Injected directly into a vein.
- IVs are administered by a physician,
registered nurse, or paramedic.
- IV is the best route for treatment of
emergencies because of the speed of action.
- Types of intravenous injections include: IV
push, IV infusion or IV drip, IV piggyback
(IVPB)
a. IV PUSH
IV push, a small volume of drug (bolus) injected
into a peripheral saline lock (PRN adapter), attached
to a vein. An IV push medication can also be
injected into a port on a primary (continuous)
injection line.
b. IV INFUSION
IV infusion or IV drip, a large volume of fluids,
often with drugs added, that infuses continually into
a vein
c. IV PIGGYBACK
IV piggyback (IVPB), a drug diluted in moderate
volume (50–100 mL) of fluid for intermittent
infusion at specified intervals, usually q6–8h; the
diluted solution is infused (piggyback) into a port
on the main IV tubing or into a rubber adapter on
the IV catheter.
OTHER PARENTERAL SITES RELATED TO
PHYSICIANS:
 INTRACARDIAC- Medication given directly
into the cardiac tissue
 INTRAARTICULAR- Medication given in the
joint
 INTRAPERITONEAL- Medications are
administered to the peritoneal cavity
 INTRAPLEURAL- Injection through the chest
wall and directly into the pleural space
 INTRAARTERIAL- Administered to the
arteries.
 Co EPIDURAL- Are administered in the
epidural space via cathetersmmon for clients
who have arterial clot
 INTRATHECAL- One ventricles of the brain
 INTRAOSSEOUS- Infusion of medication
directly to the bone marrow
PARTS OF A SYRINGE
1. Tip - which connects with the needle
2. Barrel - outside part on which the scales are
printed
3. Plunger - this fits inside the barrel and
pushes the medication out
4. Calibration - are marks on quantity
graduations used for measuring the desired
amount of medication
TYPES OF SYRINGES
• Hypodermic syringe
- comes in 3- and 5-mL sizes.
- two scales marked on them: the minim and
the milliliter
• Insulin syringe
- is similar to a hypodermic syringe, but the
scale is specially designed for insulin: a 100-
unit calibrated scale intended for use with U-
100 insulin.
- should be used to administer insulin.
• Tuberculin syringe
- was originally designed to administer
tuberculin solution. It is a narrow syringe,
calibrated in tenths and hundredths of a
milliliter (up to 1 mL) on one scale and in
sixteenths of a minim (up to 1 minim) on the
other scale.
NEEDLE GAUGES TO BE USED FOR EACH
PARENTERAL ROUTE

DRUG CALCULATION
CLEANSING ENEMA
 Enema- an enema is an introduction of fluid into
the lower bowel through the rectum for the
5. Products of digestion
purpose of cleansing or to introduce medication
or nourishment. These products are flatus and feces which is transported
 Peristalsis - wavelike movement produced by by the colon through the anal canal.
the circular and longitudinal muscle fibers of the
6. Reaction of anal canal
intestinal walls; it propels the intestinal contents
forward. When the feces move into the rectum, the sensory
 Haustra- Small segmented pouches to the large nerves are stimulated which gives awareness with the
intestine need to defecate, and this is where the internal anal
 Constipation may be defined as fewer than three sphincter relaxes.
bowel movements per week. This infers the
7. Expulsion of feces
passage of dry, hard stool or the passage of no
stool. With the assistance of the contraction of abdominal
 Fecal Impaction- Is a mass or collection of muscles and diaphragm, defecation is achieved.
hardened feces in the folds of the rectum
8. Normal Defecation
 Fecal Incontinence- refers to the loss of
voluntary ability to control fecal and gaseous This is facilitated by:
discharges through the anal sphincter.
● Thigh flexion - increases pressure within the abdomen
 Feces- The excreted waste products are referred
● Sitting position - increases downward pressure on the
to as feces or stool
rectum
 Defecation- Is the expulsion of feces from the
anus and rectum. It is also called a bowel
movement.
PURPOSE AND IMPORTANCE OF
 Chyme- The waste products leaving the stomach
ADMINISTERING ENEMA
through the small intestine and then passing
through the ileocecal valve are called chyme To achieve one or more of the following actions:
cleansing, carminative, retention, or return-flow
· To stimulate defecation & to treat constipation
PHYSIOLOGY OF PROCESS OF DEFECATION · To soften hard fecal matter
1. Ingestion to the colon · To administer medication
The contents of the colon normally contains foods · To relieve the gaseous distention
ingested over the previous 4 days.

2. Colon in action
Its main functions are:
 Absorption of water and nutrients
 Mucoid protection of intestinal wall
 Fecal elimination
3. 1,500 ml chyme
As much as 1,500 ml of chyme passes into the large
intestine daily, and all but 100 ml is reabsorbed in the
colon, which is excreted as feces
4. Mucous secretion
DIFFERENT CLASSIFICATION OF ENEMA
Carminative Enema
- A Carminative enema is given primarily to expel flatus.
The solution instilled into the rectum releases gas,
which in turn distends the rectum and the colon, thus
stimulating peristalsis.
Retention enema
A retention enema introduces oil or medication into the
rectum and sigmoid colon. It acts to soften the feces
and to lubricate the rectum and anal canal, thus
facilitating passage of the feces.

In extreme stimulation, large amounts of mucous are Return-Flow Enema

secreted which results in the passage of stringy mucus
A return-flow enema, also called a Harris flush, is
with little or no feces. Thus, mucus serves as protection
occasionally used to expel flatus. Alternating flow of
from trauma by acids formed in feces and holds them
fluid into and out of the rectum and sigmoid colon
together; as well as protection of intestinal wall from
stimulates peristalsis.
bacteria

FACTORS THAT AFFECT DEFECATION
 Development
 Diet
 Fluid intake and output
 Activity
 Psychological Factors
 Defecation habits
 Medications
 Diagnostic procedures
 Anesthesia and Surgery
 Pathological conditions
INDICATIONS IN ADMINISTERING ENEMA
 Patients who will undergo bowel surgery
 Patients with a certain diagnostic test such as
x-ray or Visualization test (eg. Colonoscopy/
sigmoidoscopy)
 Patients with constipation or impaction
CONTRAINDICATIONS IN ADMINISTERING
ENEMA
 Patient with increased sodium in the blood
and high amount of phosphate in blood
 Patient with renal failure and acute/chronic
kidney disease
 Patient with dehydration
 Patient with history of cardiac disease and/or
dysrhythmia
 Patient with inflamed large intestine
EQUIPMENT USED IN ENEMA
ADMINISTRATION
- Disposable linen-saver pad
- Clean gloves
- Bath blanket
- Bedpan or commode
- Water-soluble lubricant if tubing not
prelubricated
- Paper towel
- Large-volume enema
- Small- volume enema
URINARY CATHETERIZATION
Catheter- a hollow flexible tube that Can be inserted
into a vessel/cavity of the body to withdraw or to instill
fluids, directly monitor various types of information and
visualize a vessel or cavity.
Micturition- the process of emptying the bladder; also
called micturition or voiding
Urinary retention- the accumulation of urine in the
bladder and inability of the bladder to empty itself
Urinary Catheterization- is the introduction of a
catheter into the urinary bladder.
Urgency in urination- the feeling that one must urinate
Urinary Incontinence- involuntary leakage of urine
or loss of bladder control, is a health symptom, not a
disease. It is normal in infants
Residual Volume- the amount of urine remaining in
the bladder after a person voids
PHYSIOLOGY OF URINE FORMATION
1st step: Glomerular Filtration
Water, salts, nutrient molecules, and waste molecules
move from the glomerulus to the inside of the
glomerular capsule. These small molecules are called
the GLOMERULAR FILTRATION.
2nd step: Tubular Reabsorption
Nutrient and salt molecules are actively reabsorbed
from the proximal convoluted tubule into the
peritubular capillary network, and water flows
passively.
3rd step: Tubular Secretion
Certain molecules are actively secreted from the
peritubular capillary network into the distal convoluted
tubule

VARIOUS TYPES OF ALTERATIONS IN
URINARY ELIMINATION
PURPOSE OF URINARY
CATHETERIZATION
 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
 To prevent urine from contacting an incision
after perineal surgery
INDICATIONS OF URINARY
CATHETERIZATION
INTERMITTENT CATHERIZATION
• Relieving discomfort of bladder distention, providing
decompression
• Obtaining sterile urine specimen when cleancatch
specimen is unobtainable
• Assessing residual urine after urination
• Managing patients with spinal cord injuries,
neuromuscular degeneration, or incompetent bladders
long term
SHORT-TERM INDWELLING CATHERIZATION
• Obstruction to urine outflow (e.g., prostate
enlargement)
• Surgical repair of bladder, urethra, and surrounding
structures
• Prevention of urethral obstruction from blood clots
after genitourinary surgery
• Measurement of urinary output in critically ill patients
• Continuous or intermittent bladder irrigations
LONG-TERM INDWELLING CATHERIZATION
• Severe urinary retention with recurrent episodes of
UTI
• Skin rashes, ulcers, or wounds irritated by contact
with urine
• Terminal illness when bed linen changes are painful
for patient
CONTRAINDICATIONS OF URINARY
CATHETERIZATION
•Traumatic urethral injury - performed with the double lumen indwelling
catheter.
•Colonic Obstruction
MALE AND FEMALE METHODS
•Following gastrointestinal and gynecological surgery
•Bowel inflammation and ulcerative conditions of the OF CATHETERIZATION
large colon

TYPES OF CATHETER AND METHODS OF

CATHETERIZATION

STRAIGHT CATHETER

- is a single-lumen tube with a small eye or

opening about 1.25 cm (0.5 in.) from the
insertion tip.
- a catheter that is used to drain urine
temporarily or to obtain a urine specimen

INDWELLING CATHETER

- if the catheter remains in place for continuous

drainage.
- It is also called retention or foley catheter.

THREE WAY CATHETER

- catheter with three ports: one for the inflation

of the retention balloon, one for urine
drainage, and one for infusing irrigant.

SUPRAPUBIC CATHETER

- Occasionally used for continuous drainage.

- This type of catheter is surgically inserted
through a small incision above the pubic area

COUDÉ CATHETER

- used on male client who may have OPERATING ROOM TECHNIQUE

enlarged/hypertrophied prostates that partly
obstruct the urethra.
CONDOM CATHETER
- also referred to as a “ urinary sheath” or “
external catheter ”.
- Attached to a urinary drainage system is
commonly prescribed for incontinent males
METHODS OF URINARY IRRIGATION
CLOSED METHOD
- is performed without disruption of the close
drainage system using a triple lumen indwelling
urethral catheter.
- The catheter and drainage tube remains
connected to decrease the risk of entry of
microorganisms into the system which could
cause infection.
OPEN METHOD
 Peri-operative nursing- Is the delivery of nursing
care provided to surgical patients through the
framework of the nursing process.
Nursing Care provided to surgical patient
during the entire in-patient from admission
to discharge.
Three Phases of Peri-operative Nursing
 Pre-operative Phase Begins: decision to have
surgery is made; ends: client is transferred to the
operating table.
 Intra-operative Phase Begins: client is transferred
to the operating table ends: client is admitted to the
post anesthesia care unit (PACU).
 Post-operative Phase Begins: admission of the
client to the post anesthesia area ends: healing is
complete. This is the most critical period (varies on
the patient and what kind of surgery)
----
 Surgery- Is a branch of medicine that is concerned isolated by doors from the main hospital corridor
with the treatment of injuries, diseases, and other and elevators and from other areas of the surgical
disorders by manual and instrumental means. suite. It serves as an outside-to-inside access area
(i.e., a transition zone)
 Surgical Conscience Is an awareness that develops
from the knowledge based on the importance of the Semi-restricted zone
strict adherence to principles of aseptic technique Traffic is limited to properly attired, authorized
and sterile technique. personnel.
 Analgesia- Reduces or decreases awareness of
pain.
 Anesthesia- Loss of feeling or sensation
especially loss of the sensation of pain with loss Restricted zone
of protective reflexes. A result of anesthetic. Where scrub clothes, shoe covers, caps, and masks
 Antiseptic- An agent that inhibits the growth of are worn. The surgeon and other
some microorganisms. surgical team members wear additional sterile
 Asepsis- Is the freedom from disease causing clothing and protective devices during
microorganisms. surgery.
 Surgical Asepsis- Refers to those practices that
keep an area or object free from all III. Attire
microorganism it includes practices that ● Two-piece pantsuit
destroys all microorganisms and spores. Refers ● Head cover
to sterile technique ● Goggles
 Medical Asepsis- Includes procedures used to ● Mask
reduce the number of organisms present and ● Shoe cover
prevent the transfer of organisms. A.K.A Clean ● Sterile gown, apron & gloves
technique
 Consent- Consent to treatment means a person
must give permission before they receive any type Personal protective equipment (PPE) such as
of medical treatment, test or examination. eyewear and other protective items are worn by
 Resident Bacteria- Microorganisms that normally personnel as appropriate for anticipated exposure
reside on the skin and mucous membrane, and to blood and body fluid.
inside the respiratory and gastrointestinal tracts. IV. Set-up
 Transient Bacteria- Refers to the microorganisms
that transiently colonize the skin.
 Disinfection- Describes a process that eliminates
many or all pathogenic microorganisms, except
bacterial spores, on inanimate objects.
 Homeostasis- The tendency of the body to maintain
a state of balance or equilibrium while continually
changing.
 Sterilization A process that destroys all
microorganisms including spores and viruses.
 Sterile Microorganisms free area

I. PERSONNEL
 Patient
 Unsterile team
 Circulating nurse
 anesthesiologist and CRNA Basic Rules of Surgical Asepsis
 Sterile team ● All materials in contact with the surgical wound or
 Surgeon used within the sterile fields must be sterile.
 Surgical assistant ● Gowns of the surgical team are considered sterile in
 Scrub nurse front from the chest to the level of the sterile field.
● Sterile drapes are used to create a sterile field. Only
II. Physical lay-out the top surface of a drape is considered sterile. During
draping of a table or patient, the sterile drape is held
Unrestricted zone
well above the surface to be covered and is positioned - is used for appendectomy, hernia surgery, inguinal
from front to back hernia repair, cholecystectomy
● Items are dispensed to a sterile field by methods that
2. Lateral Thoracoabdominal Skin Preparation
preserve the sterility of the items and the integrity of
the sterile field. - is used in selected cases requiring maximal surgical
● The movements of the surgical team are from sterile exposure, such as radical left/right nephrectomy,
to a sterile area and from non-sterile to non-sterile splenectomy, distal pancreatectomy
areas.
● Movement around a sterile field must not cause
contamination of the field. Sterile areas must be kept in 3. Chest and Breast Antiseptic Skin Preparation
view during movement around the area. - used for augmentation/reduction mammoplasty,
● Whenever a sterile barrier is breached, the area must mastectomy, breast lumpectomy,
be considered contaminated. A tear or puncture of the
drape permitting access to a non-sterile surface 4. Rectoperineal and vaginal antiseptic skin
underneath renders the area non sterile. Such a drape preparation
must be replaced. - area includes the pubis, external genitalia, perineum
● Every sterile field is constantly monitored and and anus, and inner aspects of the thighs
maintained.
● The routine administration of hyperoxia (high levels of - The anus is prepped last.
oxygen) is not recommended to reduce surgical site
5. Knee and Lower Leg Antiseptic Skin Preparation
infections.
- is used for arthroscopy, knee arthroplasty, knee
osteotomy, knee revision surgery, lower extremity
OPERATIVE POSITIONS
bypass surgery
1. Supine (Dorsal position)
- natural position for the body at rest
- used for procedures on the anterior surface of the ● MAJOR AND MINOR PACKS
body, such as abdominal, abdominothoracic, and some
Major Pack:
lower extremity procedures.
 1 wrapper
2. Trendelenburg’s Position  1 table cover
- used for procedures in the lower abdomen or pelvis  12 towels
when shifting the abdominal viscera cephalad away  20 sponges, radiopaque
from the pelvic area for better exposure  2 single sheets
 1 mayo stand cover
3. Semi-Fowler’s Position  2 gowns
- used for shoulder, nasopharyngeal, facial, and breast  2 handtowels
reconstruction procedures
Minor pack:
4.Lithotomy Position
 1 wrapper
- Is used for perineal, vaginal, urologic, rectal
 1 table cover
procedures, cystoscopy exams, childbirth and
 1 double sheet
surgery in the pelvic area.
 8 towels
 1 single sheet
5.Prone Position
- Used for all procedures with a dorsal or  10 sponges, radiopaque
posterior approach  1 mayo stand cover
- a common position used for access to the posterior  2 gowns
head, neck, and spine during spinal surgery  2 hand towels

BASIC INSTRUMENTS FOUND IN THE BASIC SET

6.Lateral Position
-Is when the patient is positioned with the non-  Grasping Instruments
operative side placed on the surgical surface.
Cheatle Forceps

- used to remove sterilised instruments from

SITES FOR SKIN PREPARATION
boilers and formalin cabinets
1. Abdominal antiseptic skin preparation
Babcock Forceps
 - are surgical instruments used for securely - used to cut bandages, dressings and a variety of
grasping intestinal tissues other materials

Allis Forceps
 Retracting and Exposing Instruments
- a surgical instrument with sharp teeth, used to
Army Navy Retractor Army- Navy
hold or grasp heavy tissue
- Used to retract shallow or superficial incisions.
Sponge Forceps
From small wounds to abdominal operation
- is used to grasp and hold sponges and swabs
during surgical procedures and examinations

Towel Clamp

- is a surgical instrument which is used to secure

towels and surgical draping during a medical Richardson Retractor
procedure
- retract abdominal or chest incisions. Used for
Tissue forcep with teeth holding back multiple layers of deep tissue. This
is one of the most common general retractors
- Used when a strong and long forceps is needed,
both to occlude blood vessels and to lift or Malleable Retractors
retract organs
- These retractors are made from malleable
Tissue forcep without teeth stainless steel, allowing for easy modification of
retractor angle and shape
- used by compression between your thumb and
forefinger and are used for grasping, holding or Hooks Retractor
manipulating body tissue
- Retractors are used during open surgical
Kelly Forceps (can be curved or straight) procedures to hold open a wound by pulling at
the edges of an incision
- are surgical tools used to control bleeding by
clamping and holding blood vessels so Self-Retaining Retractor
cauterization or ligation can be performed
- have locking mechanisms that keep the blades
Needle Holder Forceps apart and in place while spreading the edges of
the incision and holding other tissue in place,
- is made from stainless steel and is used to hold
thus freeing the surgeon's and assistant's hands
a suturing needle during surgical procedures
for other tasks
Brown Adson Tissue Forceps
CLASSIFCATIONS OF SURGERY
- used for holding dressing materials such as
 Major surgery
cotton and gauze during surgical procedures,
 Minor surgery
holding and manipulating delicate tissues etc.
Reason for surgery:
 Dissecting/Cutting Instruments
- Facilitationg a diagnosis
Scalpel Handle - Cure
- Repair
- used “for making skin incisions, tissue
- Reconstructivr/cosmetic
dissections, and a variety of surgical approaches
- Palliative
since the onset of 'modern' surgery.”
Categories of surgery base on urgency:
Curve Sharp Scissors
I. Emergent
- is suitable for several surgical procedures. It
II. Urgent
features sharp and blunt ends with curved
III. Required
blades to ensure precise cutting
IV. Elective
Suture Scissors V. Optional

- are often called “Suture Scissors.” Common abdominal incision

- Metzenbaum scissors or “Metz” are used for
fine dissection and cutting

Lister Bandage Scissors


1. Kocher incision
- for open exposure of the gallbladder and biliary
tree
- used for: open cholecystectomy
2. Midline incision
- “laparotomy incision, or celiotomy”
- Used for =: diagnostic laparotomy
3. Battle Incision
- for dealing with acute appendicitis and
pathologies in the right lower quadrant of the
abdomen.
- USED FOR: appendectomy
4. McBurney Incision (Gridiron Incision)
- for performing open appendectomies
- USED FOR: appendectomy, bladder for renal
transplantation, colonic resection, caecostomy
or sigmoid colostomy
5. Lanz incision
- for open appendectomies.
- USED FOR: open appendectomy
6. Paramedian
- USED FOR: laparotomies
7. Transverse Incision
- removal of appendix because it gives a better
cosmetic scar on healing
8. Rutherford Morrison Incision
- also used for kidney transplantation.
9. Pfannenstiel (Pubic incision)
- This approach is most frequently used for
urologic, orthopedic, pelvic, and cesarean
sections.
- USED FOR: hysterectomy, cesarean birth,
prostatic surgery
ASA CLASSIFICATION
ASA I- a normal healthy patient
ASA II- a patient with mild systemic disease
ASA III- a patient with severe systemic disease
ASA IV- a patient with severe systemic disease that is
constant threat to life
ASA V- a moribund patients who is not expected to
survive without operation
ASA VI- a declared brain-dead patient whose organs are
being removed for donor purposes.
DIFFERENT TYPES AND LEVELS OF ANESTHESIA
I. General Anesthesia
Patients under general anesthesia are
 not arousable, not even to painful stimuli.
 they lose the ability to maintain ventilatory
function
 require assistance in maintaining a patent
airway.
 Cardiovascular function may be impaired as
well.
4 Stages of General Anesthesia
i. Beginning anesthesia
ii. Excitement
iii. Surgical anesthesia
4 planes of stage iii
1. Light anesthesia
2. Medium anesthesia
3. Surgical anesthesia
4. Deep anesthesia
iv. Medullary depression
2. Regional Anesthesia
- an anesthetic agent is injected around nerves so that
the region supplied by these nerves is anesthetized.
-The patient receiving regional anesthesia is awake and
aware of their surroundings unless medications are
given to produce mild sedation or to relieve anxiety.
Epidural Anesthesia
- involves injection of a local anesthetic into the
epidural space via a thoracic or lumbar
approach.
- The anesthetic agent does not enter the
cerebrospinal fluid but binds to nerve roots as
they enter and exit the spinal cord.
- Sensation is blocked at the level of the
diaphragm without the loss of consciousness.
- is often used in obstetrics (c-section), vascular
procedures involving the lower extremities, lung
resections, and renal and mid-abdominal
surgeries.
Spinal Anesthesia
-involves the injection of a local anesthetic into the
cerebrospinal fluid in the subarachnoid space, usually
below the level of L2.
-The local anesthetic mixes with cerebrospinal fluid
- may be used for procedures involving the extremities
(e.g., joint replacements) and lower gastrointestinal,
prostate, and gynecologic surgeries. It is also used for
appendectomies.
- Become encapsulated in the tissue during the
healing process and remain in the tissue unless
they are removed.
- These sutures are made of silk, cotton, steel,
nylon, polyester, or other synthetic material.
- Non-absorbable sutures are used for connecting
blood vessels, “wiring” the sternum together
after open heart surgery, and closing external
wounds.

3. Moderate Sedation (IV sedation) Examples:

- involves the IV administration of sedatives or ● Polyester (Mersilene)

analgesic medications to reduce patient anxiety ● Polymerized Caprolactum
and control pain during diagnostic or ● Polyamide Nylon
therapeutic procedures. ● Polybutester
- It is being used increasingly for specific short-
term surgical procedures in hospitals and TWO CLASSIFICATIONS OF SUTURE MATERIALS
ambulatory care centers
Monofilament suture:

4.Local Anesthesia - single threadlike

- injection of a solution containing the anesthetic agent
into the tissues at the planned incision site.
- It is given directly to the surgical field, and the
circulating nurse observes and monitors the patient for
possible side effects
Advantages:
● It is simple, economical, and nonexplosive.
● Equipment needed is minimal.
● Postoperative recovery is brief. Undesirable effects of
general anesthesia are avoided.
- less traumatic when pulled through tissue
- The smooth surface glides easily without
catching on tissue.
Multifilament suture:
- made of more than one threadlike structure
held together by braiding or twisting
- has a rougher surface and can be somewhat
traumatic as it is pulled through tissue layers.
STERILIZATION

Moist heat: steam under pressure

It is ideal for short and minor surgical procedures.
Usually used for minor surgeries such as: Gas: Ethylene oxide gas

● Circumcision ● Suturing ● Debribement Boiling water: Boiling a minimum of 15 minutes

Radiation: Both ionizing and nonionizing (uv light)

radiation are used
TWO TYPES OF SUTURES

Absorbable sutures

- are digested over time by body enzymes.

- Catgut suture:
“Plain gut” and “chromic gut”
- Other absorbable sutures are made of synthetic
- absorption time: usually about 2 weeks.

Examples:

● Polyglactin 910 (Vicryl)

● Polycaprolate (Dexon II)
● Poliglecaprone 25 (Monocryl)
● Polysorb Polydioxanone (PDS II)
● Polytrimethylene carbonate (Maxon)
● V-Loc
● Polyglytone 621 (Caprosyn)

Non-absorbable sutures