Fundamentals of Nursing  (sparks can trigger explosion)

3. Use: Cotton fabric

Date: 08/18 23  (wool and silk trigger static electricity)
Lecturer: Alvin Andrade
C. Colorless & Odorless
NURSING PROCEDURES 1. Prone: LEAKAGE (not visible)

HANDWASHING II. METHODS OF 02 DELIVERY DEVICES

Purpose: TO PREVENT INFECTION & SPREAD OF
DISEASES. 1. Nasal Canula - Nasal prongs
 (24-40%)
I. MAJOR COMPONENTS 2. Simple Face mask
1. Running water  (40-406)
2. Rubbing-Friction (MOST IMPORTANT COMPONENT) 3. Non-Rebreather - delivers the highest possible O2
3. Antimicrobial solution - Cleansing Agent  (95-100%)
4. Venturi mask- delivers the most accurate amount of
II. TYPES O2
 (24-40%)
1. Medical Handwashing-ordinary handwashing
PULSE OXIMETER -measures the amount of 02
 (CLEAN TECHNIQUE)  Pa02 - 80-100 mmHg (N)
 after rinsing hands should be held below the  O2 Sat - 95%-100% (N)
elbows. Others: (essential for arterial blood gas)
 20-30 seconds  pH (power of Hydrogen) -7.35-7.45 (N)
2. Surgical Handwashing  7.40 (Neutral point)
 (STERILE TECHNIQUE)  PCO2-35-45 (N)
 after rinsing, hands should bel held above the  HCO3-22-26 (N)
elbows.
 3-5 minutes NRSING CONSIDERATION WHEN ADMINGSTERING 02:
1 Assess for: HYPOXIA-phases
OXYGEN THERAPY Early: Late:
Purpose: TO IMPROVE TISSUE OXYGENATION • Pulse
Carbon Dioxide maintains HYPOXIC DRIVE- • Respiration
stimuli for breathing. • BP
• Acidic in nature (CO2) (Compensation) Restlessness Cyanosis
• Alkaline in nature (O2)
2. Verify doctors' order
COPD- (Respiratory Acidosis) • 2-7L/M (independent)
 ↑ CO2 counter out by: • more than 3L/M (dependent)
 O2 (alkaline)-2-3L/M 3. Position
• Fowlers
I. MAJOR CHARACTERISTICS
A. Dry Gas - to prevent dryness of mucus membrane: 4. Regulate 02 flow accurately
1. Humidifier: sterile H20  Excessive of administration may lead to:
2. Perform: Oral care • Decrease O2
3. Lubricant: water-based • Retrolental Fibroplasia- retinal damage
B. Supports Combustion (explodes) (Irreversible)
1. Place: NO SMOKING SIGN
2. Check: electrical devices
TANK COLORS: a) Soak: H202 (1/2 strength) -Container 1
 Green-Oxygen b) Clean: PNSSContainer 2
 Gray Carbon dioxide
 Brown-Helium 6. Remove: Soiled dressing (at the back of the flange)
 Yellow - Compressed Air 7. Wear: STERILE GLOVES (changing of gloves)
 Black – Nitrogen  Note: wear 2 gloves already on #3
 Blue-Inhaled anesthesia (DOUBLE GLOVING)
 Red-Fire extinguisher 8. Suction: Outer cannula
Check: Expiration date Types:
 Nasopharyngeal - secretions in the nasopharynx
TRACHEOSTOMY  Oropharyngeal - secretions in the oropharynx
 Tracheal- secretions on the outer cannula (not
Surgical opening in the trachea in the trachea)
9.Insert: Inner Cannula
Purpose: ESTABLISH AN AIRWAYProvide a long-term  CLOCKWISE
airway support  Note:
 Removal Counterclockwise
I.BASIC PARTS:  Insertion Clockwise
1 Outer Cannula 10. Clean: Flanged the site by the use of
 serves as an artificial airway directly inserted to a) Sterile OS (gauze)
the trachea b) PNSS
2. Inner Cannula  Note:
 inserted inside the outer cannula 11. Apply: Sterile dressing (#6)
3. Obturator a) Size: 4x4
 guide wire, used to directly insert both cannula b) Appearance: Y-shaped
in the respiratory tract
 must be kept BEDSIDE 12. Change: Ties (before removing the old ties, secure
4. Flange first the new ties)
 located at the distal portion of the cannula a) Apply new ties first
 Secured by tapes & ties b) Then, remove old ties (square knots)
c) Distance from neck: I finger breadth
II.NURSING CONSIDERATIONS WHEN PERFORMING
TRACHEOTOMY Tracheostomy care must be done EVERY DAY!
 Tracheostomy cutt - separates pre URT & LRT
1. Provide: PRIVACY (Avoid embarrassment)  mechanical Ventilator - emergency equipment.
2. Position: SEMI FOWLER'S (best)  Accidental removal- straighten the neck.
3. Wear: STERILE GLOVES (Sterile Procedure)
4. Open: Sterile Kit (must be available already at the
bedside) Wear: STERILE gines tracheal-secretions on the outer
a) Container 1: H2O2 (1/2 strength)-Hydrogen Cannula (not in the tracked)
peroxide.
b) Container 2: PNSS SUCTIONING
5.Cleaning:
 Remove only Inner cannula Purpose: To maintain airway patency.
 * outer cannula is my removed by the doctor  INDEPENDENT NEG ITV.
 In removing inner cannula by the use of
obturator
 Direction COUNTER CLOCKWISE
I. NURSING CONSIDERATIONS: Abnormal Lung Sounds
1. Auscultate: Breath sounds ✓Crackles a) Crackles
2. Position: b) Wheezing
 unconscious – SIDELYING c) Stridor
 Conscious- SEMI FOWLERS d) Rhonchi
SUCTION CATHETER: e) Friction Rus- (Epiglottitis)
3. Size: French (catheter) the bigger the size" the
bigger the catheter CHEST PHYSIOTHERAPY
a) Adult -12-18
b) Child-8-10 AKA: BRONCHOPULMONARY HYGIENE
c) Intart-5-8 Purpose: To REMOVE 2 LOOSEN EXCESSIVE BRONCHIAL
4. Pressure: mmHg "The younger, The weaker SECRETIONS
pressure”  DEPENDENT NEG. INTI.
Wall Portable
Adult 100-120 10-15 I.SEVERAL METHODS
Child 98-110 5-10 1. PERCUSSION:
Infant 50-95 2-5  cupped hands
 striking
5. Hyper oxygenate: 100% 02  both hands done alternately
6. Wear: Sterile gloves Other terms:
• Suctioning Sterile Procedure a) CHEST/BACK TAPPING
7. Lubricant: b) CLAPPING
a) Nasopharyngeal- water based 2. VIBRATION:
b) Oropharyngeal- PNSS/0.9% NaCl  Flat hands
 Shaking
8. Length of Insertion: NOSE EAR LOBE  Both hands done at the same time
(Approx 5 inches) 3. POSTURAL DRAINAGE:
Note: 1inch= 2.5cm  Principle of gravity
9. Introduce suction catheter: WITHOUT SUCTION  First and last method to be done
 suction while withdrawal
10. Normal time of suctioning: II. NURSING CONSIDERATIONS:
a) 5-10 secs. (best) - to minimize O2 suction a) Check Doctor's order
b) 10-15 secs. b) Auscultate for breath sound
c) Interval: 20-30 seconds c) Best time for Postural Drainage:
d) Maximum time: 3-5 mins to prevent hypoxia • Before meals - to prevent aspiration
11. Withdraw Suction Catheter: Rotating/Circular • If after meals: 2-3 hrs.
motion • Bed time / Early morning.
 To prevent mucus membrane damage d) Before performing Postural Drainage:
12. Perform: Oral Care Administer:
13. Hyper oxygenate: 100%  Bronchodilators-widen resp tract
14. Auscultate: Breadth sounds  Nebulization Therapy / Steam
 Determine effectiveness of suctioning Inhalationto liquify mucus
- Crackles= X e) Perform Postural Drainage:
- Normal: BRONCHO VESICULAR  Each position: 10-15 mins  to prevent
Notes: exhaustion
Normal Lung Sounds  Maximum: 30 MIN  all throughout The
a) Bronchial procedure
b) Vesicular f) Perform: Percussion & Vibration alternately
c) Broncho vesicular  each method: 1-2 Mis
  Maximum: 30 MIN entire procedure
g) After the procedure: Perform oral care
h) Auscultate: Breath sounds
Note: CPT is best done to condition of Cystic Fibrosis
(CPT-applied for problems in secretion)
-COPD is not applicable (obstruction)
Complication of CPT – HYPOXIA
Feeding: NORMAL - P.O
NUTRITION
How to promote appetite?
 LET THE PATIENT EAT HIS/HER OWN FOOD
(regardless of nutritional benefit)
NASOGASTRIC TUBE
Purpose:
1. GAVAGE
2. LAVAGE
3. TO ADMINSTER MEDICATIONS
(X Enteric-Coated) -drug that has specialized coating
which is designed to be dissolve in a highly acidic
environment (stomach)
Note: Stomach (parietal cells) produces 2 substances
necessary for digestion:
• HCL (digests all types of food)
• Intrinsic factor (digest Vitamin B12)
I. INSERTION
1. Position: HGH FOWLERS
2. Wear: CLEAN/ sterile gloves
3. Lubricant: Water-based
4. Length of Insertion: NOSE-EARS-XYPHOID
(Approx. 13-18 inches)
5. Upon Insertion: HYPER EXTEND the NECK of
the patient
6. Upon reaching the oropharynx:
o The patients head forward to ensure it
reaches the stomach, not in the lungs.
7. Promote swallowing: SIP OF WATER
8. Allow: DEEP BREATHING EXERCISES
9. Check for patency: Methods in checking next
for –
a) Aspiration-Assess for PH
 Lithmus gaper test
use of blue paper:
blue= Blue-Alkaline (lungs)
blue=Red-Acid (stomach)
b) Auscultate- Use of Stethoscope
 Whooshing, bubbling, gurgling sounds=
stomach
c) X-ray- confirmatory
10. Secure: Tape in the bridge of the nose
II. FEEDING
1. Position: SEMI FOWLER'S
2. Check for patches
3. Aspirate for: Residual content
1/2 of the amount of previous feeding
a) if more than the amount of feeding- withhold
b) if less than the amount of feeding.
ASSESS: PROPER DIGESTION
4. Flush: 30-60ml of water
5. Height: 12 inches (Normal)
 Virtue of gravity alters the speed of
administration.
 Too rapid administration will pre dispose to
DUMPING SYNDROME- rapid empting
• less than 12 inches - TOD SLOW
• more than 12 inches - TWO FAST
6. Flush: 30-60 ml of water
7. Before clamping: Retain some water in the
tubeTo prevent introduction of AIR
8. Position After feeding:
 SEMIFOWLERS'S (30 mins)
 TO PREVENT ASPIRATION
9. Change tubings: 3-5 days
PARENTERAL NUTRITION
Purpose: To promote nourishment intravenously
Note: Enteral Feeding - food directly to the stomach
Ex. NGT, PEG
Parenteral Feeding directly to the blood
I. STATUS
 Partial -no problems in the intestines, only
nutritional deficiency suck as Protein (kwashiorkor) &
fat/carbohydrate (Marasmus)
 Total- for GI disorders such as intestinal
disorders, ulcerative colitis or regional enteritis
NURSING CONSIDERATIONS: b) HIGH FLOW Entire Colon (1000ml)
1. Route: Intravenous 2. TO EXPEL FLATUS
2. Site: SUBCLAVIAN & JUGULAR VEIN (requires large (carminative Enema) - use of oil-based
vein) Lubricant-60-80ml
3. Contents: Return Flow Enema / Haris Flush
 Amino acids (Cleansing & carminative)
 Vitamins  evaluate fecal matter.
 Minerals  expel flatus
 Glucose  300-500ml
Outflow: CLEAR! (Repeated 5-6 times)
4. STORAGE: a 3. TO RELIEVE CONSTIPATION
a) Refrigerator (before) -body of ref. •Retention Enema - use of oil-based solution
b) Room temperature (prior to administration)  maximum retention time -(1-3 hour)/ at
ROOMTEMP for 30 mins. least 1 hr
c) DISCARD -(after)/ damage

5. Complications: NURSING CONSIDERATIONS

a) Glucose imbalances 1. Check doctors order
 too fast - HYPER GLYCEMIA 2. Provide: PRIVACY
 too slow HYPOGLYCEMIA 3. Position: LEFT SIDE LYING/SIMS LATERAL
b) Systemic infection – SEPSIS Note: Anal procedures = Left side lying
 glucose attracts bacteria in the insertion -Sigmoid corn is descenders to the Left.
site 4. Wear: Clean gloves
6. Monitor: 5. Use of Rectal Catheter: Size- (French)
a) Blood glucose - Glucometer a) Adult:22-32
Normal:80-120 mg/dl b) Child:14-18
Check: CBG/HGT c) Intant:12
Taken: Before breakfast (early morning) 6. Before Insertion of Catheter: Allow the solution
b) Vital signs to flow in the catheter - to prevent entry of air
 Body Temperature (signs of infection) 7. Lubricant: Water-based
c) Intake & out put 8. Allow: Deep Breathing Exercise-to prevent
d) Weight resistance
same: 9. Length of insertion: 3-4 inches
 Patient 10. Normal Height:
 Time a) High flow: 12-18 inches
 Clothes b) Others (Low flow): 12 inches
 weighing scale less than 12 inches: Too slow
more than 12 inches: Too fast = ABDOMINAL
ELIMINATION CRAMPING!
If abdominal cramping happens:
How to stimulate defecation:  stop the administration (temporarily)
 Provide privacy  Resume if the cramping subsided
 Increase OFI
 Fiber diet
ENEMA ADMINISTRATION

1. Purpose: To CLEAN THE COLON & EVACUATE

FECAL MATTER (Cleansing Enema)
a) LOW FLOW→ Sigmoid colon (500ml)
 COLOSTOMY Note: Patients with colostomy are allowed to
swimProvided empty the bag.
Surgical opening in the colon Appliance is used up to 6-4 days

Purpose: TO DIVERT & DRAIN FECAL MATTER

Other Term: Fecal Diversion/Bower

I. STATUS
1) Temporary to heal the colon; Trauma, IBDs
(Crohns, Ulcerative Colitis)
2) Permanentterminal conditions of the large
intestines (Bowel, colon & colorectal CA.) -
Congenital abnormalities (imperforated anus,
Hirshprungs dx)

II. LOCATIONS: Characteristic of Stools

1. Ileostomy- liquid/watery stool (Effluent)-stool
that contains enzymes
Note: WOF: Skin breakdown due to digestive enzymes
2. Ascending colostomy - liquid/watery (Effluent)
3. Transverse colostomy –mushy
4. Descending colostomy-semi-solid
5. Sigmoid Colostomy-solid/ well formed

NURSING CONSIDERATIONS:

1.
2.
3.
4. Empty the appliance → Bed pan
a) Amount: 43-1/2 full
b) Clean: Vinegar
5. Clean the stoma
a) use: water & cotton balls; PNSS
• (Do not use alcohol or soap because it
causes dryness; mild soap is optional)
b) Characteristics:
 Color: pinkish Red, BEEFY RED
 Status: Slight Protrusion
 Appearance: Slight bleeding
Note: Absence of the terms slight & minimal in
protrusion & bleeding is considered ABNORMAL
6. Apply Appliance
 Dry Thoroughly the SITE
 Effluent: Apply KARAYA Powder (skin
barrier)
 Minimize odor: Encourage patient to
consume citrus fruits
 Inside the bag: Put Charcoal