General Medical Surgical

(Clinical )

Prepared by
Staff of

Adult Nursing Department

Faculty of Nursing

Aswan University

2023

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 List of content

Content Page

 IV infusion

 Venous blood sample

 Blood transfusion

 Supplying Oxygen Inhalation

 Chest Physiotherapy

 Incentive Spirometers

 Surgical dressing

1. Close

2. Open

 Nursing care for drain

 Suture removal

 Inserting a Nasogastric tube

 Removing an NG Tube

 Gastric gavage

 Gastric lavage

 Ostomy Care (Ileostomy or Colostomy)

 Paracentasis

 Port catheter care

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 Intravenous infusion
I. Definition

It is the collection of blood via various methods with the purpose of testing and
analyzing the components of the blood

II. Indications for IV Therapy

1. Fluid and Electrolyte maintenance and balance.

2. Maintain or correct a patient's nutritional state.

3. Replacement therapy in Hemorrhage, low platelets, persistent vomiting and

diarrhea.
4. Restoration therapy in Burns , nasogastric tubes and abdominal wounds.

III. Preparation for administration

Before preparing the solution, inspects the container and determine that:

1. The solution is the one prescribed by the physician.

2. The solution is clear and transparent.

3. The expiration date has not elapsed.

4. No leaks are apparent.

5. A separate label is attached, identifying the type and amount of other drugs
added to the commercial solution.
I. How To Calculate Flow Rate:-
a. To find the number of milliliters to be given per hour:
Total solution
= –––––––——––––––––– ═ mL hour
No. of hours to run

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 b. To find drops per minute:
mL /hr × drop factor
= ––––––––––––––––––––– ═ d/minute
60 minutes

N.B 20 drops\minute 60 drop\m 10 drop\m

IV. Equipment
1. IV solution in a bag ( fig 1).

2. Medication administration record

3. Gloves

4. IV tubing ( fig ,2)

5. The spike (see fig 3)

6. The drip chamber ( fig, 4)

7. Roller clamps(fig, 5)
( fig 1)

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 (fig, 2) (fig, 3)

(fig, 5)
(fig, 4)

V. Procedure
Steps Rational

- Reduces the transmission

1. Wash hands apply gloves
microorganisms
2. Removing protective cover from the bag.

3. Inspect the bag for leaks, tears, or cracks - Prevents infusing contaminated or
inspect the fluid for clarity and color. outdated solution.
Check expiration date.

4. Prepare a label for the IV bag: on the label

- To prevent mistaks.
( date, time, and initials) .

5. Remove gloves and wash hands.

- Prevent infection.

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6. Hanging the prepared IV (fig,6).

(fig,6)

7. Wash hands. - To prevent infection

8. Check patients identification arm band . - To ensures IV solution is given to the

correct patient.

9. Make sure the clamp on the tubing is - To decrease rapid flow of solution
closed . grasp the port of the IV bag with without air bubbles.
non-dominant hand remove the plastic tab
covering the port and insert the full length
of the spike into the bag's port(fig,7).

(fig,7)
10. Compress drip chamber to fill halfway. -prevent air of IV line

11.Open roller clamp, and flush tubing - To remove air from tubing.
with solution.

12. Close roller clamp. - To prevent fluid from leaking and

maintain sterility of needle.
13. Remove the cap protector from the tubing
attach the IV tubing to venipuncture
catheter.
14.Open clamp and regulate flow rate.
15. Wash hands .

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 Venous Blood Sample

I. Definition
Collect sample of blood usually collected from an appropriate vein for laboratory
examination.
II. Indications

1. To help in making diagnosis.

2. To confirm diagnosis.

3. To follow the prognosis of diagnosis.

III. Equipments

1. Dry sterile syringe.

2. Tourniquet.

3. Gloves.

4. Alcohol sponge and dry cotton sponge.

5. Sterile or clean, colored and coded test tube.

6. laboratory request form (fig,1).

(fig,1)

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IV. Procedure

Steps Rational

1. Check doctor order. - To confirm the order.

2. Hand washing. - To control infection.

3. Collect and prepare equipment. label - To safe time &effort.

all collection tube with the patient and
room number, date and time of
collection and signature.

4. Explain procedures to patient. - To ensure his cooperation.

5. Inspect patient hands and forearm and - To avoid pain and harming to patient.
select the site for venipuncture.

6. Apply tourniquet 10-15cm (4-6 inch)

above the selected site & should be
tight enough to impede venous return
but not occlude arterial flow (fig,2).

(fig,2).

- To facilitates observation and puncture

of distended veins.

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7. Examine the selected vein by putting - When it is distended it will feel spongy.
your index finger lightly against it.

8. Promote venous distention by

instructing the patient to open and
close the fist several.

9. Put on gloves.

10.Cleanse site with alcohol swab in a

circular out ward for 2 inches allow the - To control infection.
area to dry.

- To smooth insertion of the needle or

11.Stretch skin and stabilize vein with non
cannula and decrease patient
dominant hand.
discomfort.

12.Insert with bevel up at 10 to 30 degree

angle then decreases the angle of the
catheter (fig,3).

(fig,3)

13.When blood return is obtained

decreases the angle of the catheter and - To ensure that the needle in correct site.
very carefully advances the needle

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 To avoid destruction of RBCs.
14.Withdraw required amount of blood
(fig,4).

(fig,4)

15. Remove tourniquet. -To decrease pressure at site of sampling.

16. Slowly remove needle and apply -To prevent bleeding.

gentle pressure.

17. Transfer sample to collection tubes, -To prevent hemolysis.

gently rotate each tube to help mix
additives with sample (fig,5).

-
(fig,5)

18. Send specimen to lab. -For examination.

19.Remove equipment and dispose of -To prevent infection.

sharp container.
-To provide an accurate reflection of nursing
20. Record procedures. assessment.

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 Blood Transfusion
I. Definition
Blood transfusion is the IV administration of a component of blood or whole
blood. Component frequently transfused include fresh or frozen plasma, Red blood
cells or packed red blood cells and platelet.

II. Indications
1. Major surgical operations

2. Anaemia.

3. Accidents.

4. Severe burn victims.

5. Women in childbirth and newborn babies in certain cases.

III. Purpose

1. Restore blood volume after hemorrhage.

2. Maintain hemoglobin levels in severe anemia..

3. Replace specific blood component.

IV. Equipment

1. Blood administration set and filters (fig,1).

2. Intravenous solution of 0.9% sodium chloride (normal saline).

3. Disposable gloves.

4. Tape.

5. Blood warmer, if needed.

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  N.B –the blood must be given within 4h after getting from lab.
- The time of transfusion 1-3 h .
- Double check is important before the blood transfusion.
6. Blood warmer, if needed.

(fig,1)
V. Procedure

Steps Rationale

1. Verify the physicians order for the transfusion. - Blood must be ordered by a physician
or qualified practitioner.

2. Explain procedure to the client. - Ensures that client understands

procedure and decreases anxiety.
- Prompt reporting of a side effect will
3. Review side effects (dyspnea, chills, headache,
lead to earlier discontinuation of
chest pain, itching) with client and ask them to
transfusion and minimize the
report to the nurse.
reaction.

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4. Prompt reporting of a side effect will lead to - Some hospitals or agencies
earlier discontinuation of transfusion and require the client to sign a consent
minimize the reaction and have the client sign form.
consent forms.

5. Obtain baseline vital sign. - Allows detection of a reaction by any

change in vital signs during the
transfusion.

6. Obtain the blood product from the blood bank - To prevents bacterial growth and
within 30 minutes of initiation (fig,2). destruction of red blood cells. (fig,2).

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7. Verify and record the blood product and identify the - Strict verification procedures will
client with another nurse (fig,3,4) reduce the risk of administering
blood products to the wrong client.

(fig.3)

A. Clients name, blood group, Rh type.

(fig.4)
B. Cross-match compatibility.

C. Donor blood group and Rh type.

D. Unit and hospital number.

E. Expiration date and time on blood bag.

F. Type of blood product compared with physicians

order

G. Presence of clots in blood.

8. Instruct client to empty the bladder. - A urine specimen after initiation of

the transfusion will be needed if a
transfusion reaction occurs.

9. Wash hands and put on gloves. - Reduces risk of transmission of

blood borne bacteria.

10. Open blood administration kit and move roller

clamps to ―off position

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11. For Y-tubing set:
A. Spike the normal saline bag and open the roller A. The Y-tubing allows the nurse
clamp on the Y-tubing connected to the bag. to switch from infusing normal
B. Close clamp on unused tubing. saline to blood.
C. Squeeze sides of drip chamber and allow filter to
B. Correctly filled drip chamber
partially fill. (fig.5 )
enables an accurate drip count.

C. Removes all air from tubing

system

D. Prevents waste of IV fluid.

D. Open lower roller clamp and allow tubing to fill
Equal distribution of cells
with normal saline to the hub.
prevents clumping, which can
E. Close lower clamp.
lead to clotting of cells.
F. Invert blood bag once or twice. Spike blood bag,
open clamps on inlet tube to allow blood to cover E. Prevents blood from flowing
the filter completely (fig.6) . until tubing is attached to
G. Close lower clamp. venous catheter.

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12. For single-tubing set:
A. Attaches tubing to blood unit.
A. Spike blood unit.
B. Correctly filled drip chamber
B. Squeeze drip chamber and allow the filter to
enables an accurate drip count.
fill with blood (fig.7).
(fig.7)
C. Open roller clamp and allow tubing to fill
with blood to the hub (fig.8).

(fig.8)

13. Attach tubing to venous catheter using - Allows the blood product to be
sterile precautions and open lower clamp. infused into the clients vein.

14. Infuse the blood at a rate of 2–5 ml/min - Packed red blood cells usually run
according to the physicians order. over 11/2–2 hours; whole blood runs
over 2–3 hours.

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15. Remain with client for first 15–30 minutes, - If a reaction occurs, it generally
monitoring vital signs every 5 minutes for 15 happens during the first 15–30
minutes, then every 15 minutes for 1 hour, minutes. Changes in vital signs can
then hourly until 1 hour after the infusion is warn of a transfusion reaction.
completed (fig,9).

16. After blood has infused, allow the tubing to - The client will receive all of the blood
clear with normal saline. that is left in the tubing.

17. Appropriately dispose of bag, - Reduces transmission of

tubing, and gloves. microorganisms.

18. Wash hands.

19. Document the procedure.

Blood transfusion reaction

Transfusion reactions are adverse events associated with the transfusion of

whole blood or one of its components. They range in severity from minor to life-
threatening . Reactions can occur during the transfusion (acute transfusion reactions)
or days to weeks later (delayed transfusion reactions).

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 I. Types of transfusion reactions

A. Acute Transfusion Reactions

1. Mild allergic.

2. Anaphylactic reaction.
3. Febrile non-hemolytic.
4. Septic
5. Acute hemolytic transfusion reactions
6. Transfusion-associated circulatory overload
7. Transfusion-related acute lung injury
B. Delayed Transfusion Reactions

II. Common signs and symptoms of transfusion reaction

1. Urticaria /Itching
2. flushed skin
3. vomiting
4. Diarrhea
5. Fever/Chills
6. Dyspnea
7. Hypotension
8. Hypothermia

III. Nursing management for transfusion reaction

1. Stop the transfusion. Maintain the intravenous line with normal saline
solution through new intravenous tubing, administered at a slow rate.
2. Asses the patient carefully, compare the vital sign with those from thebase
line assessment.
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3. Notify the physician of the assessment findings and implement any order
obtained.
4. Notify the blood bank that a suspected transfusion reaction has occurred.
Send the blood container and tubing to the blood bank for repeat typing
and culture, the identifying tag and number are verified.

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 Oxygen therapy
I. Definition
Method by which oxygen is supplemented at higher percentages than what is
available in atmospheric air.
II. Purpose

1. To relieve dyspnea.

2. To reduce or prevent hypoxemia and hypoxia.

3. To alleviate associated with struggle to breathe.
III. Sources of Oxygen
Therapeutic oxygen is available from two sources.
1. Wall Outlets (Central supply).
2. Oxygen cylinders.

IV.Oxygen devices

Device Advantages Disadvantages Figure

Nasal cannula
- Comfortable and well - Can cause drying and
tolerated. irritation of airways
when higher flow rates
- Patient can eat, drink and
are used.
communicate easily.

- No risk of rebreathing
carbon dioxide.
Simple face-
- Generally well tolerated - Can cause build-up of
mask
when used for a short carbon dioxide when
period of time (hours used at a flow rate of
rather than days). <5 L/min.

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Reservoir mask
- Provides a high - Not suitable for
(non
rebreathing concentration of oxygen weaning oxygen flow
mask)
to critically unwell or concentration.
patients in an emergency
situation.
Venturi mask
- Safe to use for patients at - Patients may find the
risk of hypercapnic mask claustrophobic
respiratory failure.

- Accurate delivery of
prescribed/desired oxygen
concentration.

- Suitable for patients with

a respiratory rate above
30 breaths per minute .
Tracheostomy
- Provides oxygen at - Oxygen concentration
mask
varying concentrations. delivery can vary
(depending on the
- Placed directly over the
patient’s rate and depth
tracheostomy tube.
of breathing).

- If required for
prolonged periods, the
oxygen should be
humidified and ideally
warmed, as upper
airways are by passed.

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V. Oxygen safety

Oxygen is not a flammable gas but it does support combustion (rapid burning)
,due to this the following rules should be followed:

1. Do not smoke in the vicinity of oxygen equipment.

2. Do not use aerosol sprays in the same room as the oxygen equipment.
3. Turn off oxygen immediately when not in use. Oxygen is heavier than air and
will pool in fabric making the material more flammable. Therefore, never leave
the nasal prongs or mask under or on bed coverings or cushions whilst the
oxygen is being supplied.
4. Oxygen cylinders should be secured safely to avoid injury.
5. Do not store oxygen cylinders in hot places.
6. Keep the oxygen equipment out of reach of children.
7. Do not use any petroleum products or petroleum byproducts e.g. petroleum
jelly/Vaseline whilst using oxygen.

VI. Equipment ( fig 1).

1. Stethoscope.
2. Oxygen connecting tube.
3. Oxygen Flow meter.
4. Humidifier filled with sterile water.
5. Oxygen source: Wall Outlets or Oxygen cylinder.
6. Oxygen delivery device: nasal cannula, mask, tent or T-tube with adapter
for artificial airway.

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 (fig.1)

IV. Procedure

Steps Rationale
1. Check client's identification band.
2. Explain procedure before beginning. 2. To gain cooperation.
3. Wash hands. 3. Reduce transmission of microorganism.
4. Verify the health care provider's 4. Ensure correct dosage and route.
order.
Remind clients who smoke of thereasons Increases compliance with
for not smoking while O2 is in procedures.
use.

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6. If using humidity fill humidifier to fill 6. Prevents drying of the client's airway and
line with distilled water and close thins any secretions
container. (fig.4)

(Fig.4)
7. Attach humidifier to oxygen flow 7. Allows the oxygen to pass
meter. through the water and become
humidified.
8. Insert humidifier and flow meterinto 8. Give access to oxygen .Reduces
oxygen source in wall or portable possibility of inserting into wrong
unit. outlet.

9. For nasal cannula : 9. Rates above 6L/min are not

- Attach the oxygen tubing and nasal efficacious and can dry the nasal
cannula to the flow meter and turn it mucosa.
on to the prescribed flow rate .
- Place the nasal prongs in the -Dry membrane s are moreprone
clients nostrils. to breakdown by friction or
-Secure the cannula. pressure from nasal cannula.
-Assess client's nostril every 8
-If client complains of dryness
hours.
or has signs of irritation.

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 9. Mask (fig,5).
-To ensure the mask is correctly fitted and
-For oxygen mask : placing the mask
is comfortable for the patient.
over the patient’s mouth and nose, then
pull the elastic strap over the head and
adjust the strap on both sides to secure
the mask in a position that seals it
against the face. (fig,5)
-For a reservoir mask, first cover the
one-way valve with fingers until the
reservoir bag is fully inflated. Then
apply the mask as described above
(fig,6).

(fig,6)

- Place the mask on the -Prevents loss of oxygen fromthe sides of

client's ears, and tighten until themask the mask.
fits snugly.
- Assess client's face and ears for -Provides client comfort andprevents
skin breakdown
pressure from the mask and use
padding as needed.

10.Check for proper flow rate every 4 -Ensures that client receives proper
dose.
hours and when the client return from
the procedure.
14.Monitor vital signs, oxygen saturation, 14. Detects any untoward effectsfrom
and client condition every4 to 8 hours therapy.
for signs and symptoms
of hypoxia.

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15. Wean client from oxygen as soon 15. Oxygen is not without sideeffects
as possible using standard protocol. and should be used only as
needed.

16. Documentation:

Nurses ‘Notes

- Record O2 rate.

- Note method of oxygen delivery.

- Document client’s assessment

parameters and response to
treatment.

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 Chest Physiotherapy

I. Definition
Is a group of therapies used in combination to mobilize pulmonary
secretions
II. Types
A. Postural drainage
B. Chest percussion.
C. Vibration.
III. Guide lines for chest physiotherapy
1. Know the client's normal range of vital signs.
2. Know the client's medication.
3. Know the client's medical history.
4. Be aware of the client's exercise tolerance.
A. Postural drainage
Definition
Uses positioning technique to draw secretions from specific segment of
the lung and bronchi into the trachea.
Objectives
1. Maintain a patient airway.
2. Increase respiratory gas exchange.
3. Decrease the incidence of respiratory infection.
Indication

1. Patients with chronic obstructive pulmonary disease (COPD).

2. Patients with bronchostasis.

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 3. Lung abscess.
Contra indication
1. Massive hemorrhage.
2. Hypertensive patients.
3. Increase intracranial pressure
4. Neurological patient as head injury.
5. Rib fracture ,with or without flail chest
Various postural drainage positions are used to mobilize secretionsfrom
specific lobes and segments of the lung (fig,1).

(fig,1)
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 B. Chest percussion
Definition
Rhythmical clapping on the chest wall over area that being drained by striking
the chest wall at different speeds, with cupped hands .
C. Chest vibration
Definition
Involve the compression of the chest, or is fines shaking pressure applied
to the chest wall only during exhalation (while you are breathing out).

IV. Equipment
1. Stethoscope.
2. Small covered emesis basin.
3. Tissue paper.
4. Pillow
5. Paper bag for used tissue paper.
V. Procedure

Steps Rationale
1. Verify the order. 1. Verification of order prevents
potential errors.
2. Confirm the client's ID. Compare the 2. Checking identification ensures
name with the name on the client's ID. client safety through concept of
correct procedure for correct client.

3. Provide privacy and explain the 3. Explanation protects client's rights

procedure to the client. and encourages participation in care.

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4. Wash your hands, don gloves, a face
shield, and a gown, and follow standard
precautions.
5. Auscultate the client's lungs.
6. Position the client as doctor order.
4. Reduce transfer of microorgan-
isms and protect nurse.
5. Determines baseline respiratory
status.

7. Instruct the client to remain in each

7. Percussion and vibration loosen
position for 10 to 15 minutes. Duringthis
secretions in target areas.
time, perform percussion andvibration, as
ordered.
A. To perform percussion, instructs the
client to breathe slowly and deeply,
using the diaphragm, to promote
relaxation.
B. Hold your hands in a cupped shape, with
fingers flexed and thumbs pressed ( fig.2)
tightly against your index fingers.
Percuss each segment for 1 to2 minutes
by alternating your hands against the
client in a rhythmic manner ( fig.2).

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C. To perform vibration, ask the client to
inhale deeply and then exhale slowly
through pursed lips.
D. During exhalation, firmly press your
fingers and the palms of your hands
against the chest wall (fig,3).

(fig,3)

8. Coughing removes secretions

8. After postural drainage, percussion, or
that have accumulated in trachea.
vibration, tell the client to inhale
deeply through the nose and then exhale
in three short huffs then instruct the
client to cough to remove loosened
secretions.
9. Have the client perform coughing 9. Scheduling chest physiotherapy
exercises for about 1 minute and then before bed will help maximize
rest for 2 minutes. client's oxygenation while sleeping.

10. If the client's cough is ineffective, 10. Suction removes secretions that
suction the client. have accumulated in trachea.
11. Provide oral hygiene.

12. Auscultate the client's lungs .

13. Record:

A. Date and time

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B. Which chest segments were percussed

C. Client's response to the treatment.

D. The color, amount, odor, and

viscosity of any secretions produced
andthe presence of any blood.

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 Incentive Spirometers

I. Definition
It is a method of encouraging voluntary deep breathing by providing visual
feedback about inspiratory volume. Using a specially designed spirometer.

II. Purpose
1. To encourage clients to sustain deep voluntary breathing and maximum
inspiration
2. To open airways, encourage coughing.
3. To prevent or reduce atelectasis.
III. Indication
1. Postoperative clients
2. Chest trauma victims.
3. Clients with respiratory disorders.
4. Clients who have had abdominal or thoracic surgery
5. Elderly clients are especially at risk for atelectasis and consolidation.
IV. Assessment
1. Assess need for incentive spirometry. Clients who are post-surgery, or
clients with pneumonia or post-chest trauma are at increased risk for
respiratory complications.
2. Assess the client’s respiratory status by general observation, auscultation
of breath sounds, and percussion of thorax to be able to compare future
assessments with a baseline evaluation.
3. Review medical record for recent arterial blood gases to determine need
for using incentive spirometer.

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V. Equipment (fig.1)
1. Stethoscope
2. Incentive spirometer with appropriate mouthpiece
a. Flow-oriented
b. Volume-oriented
3. Tissue paper
4. Emesis basin
5. Pillow if needed

(fig,1)
VI. Procedure

Steps
1. Wash hands.
2. Check chart for previous respiratory
3. Gather equipment.
4. Explain procedure to client.
5. Demonstrate deep, sustained
inspiration.
6. Instruct client to assume a semi-
Fowler’s or high-Fowler’s position.
7. Set pointer on IS at appropriate level
or point to level where disk or ball
should reach.
Rationale
1. Reduces the transmission of
microorganisms.
2. Establishes a baseline for
comparison.
3. Ensures preparation.
4. Encourages client’s cooperation.
5. Demonstration is a reliable
Teaching
6. Promotes optimal lung expansion.
7. Encourages client to reach
appropriate goal.

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8. Use incentive spirometer:
A. Promotes clearing of secretions
A. Have client breathe in and exhale
before using the IS.
completely before using IS.
B. Prevents ineffective use of the
B. Hold unit upright.
spirometer.
C. Allows gauge to register effective
C. Have client seal lips around
inspiration.
mouthpiece and inhale slowly and
deeply until desired volume is
attained. (fig.2).

(fig.2)
D. Sustain inspiration for at least 3 D. Allows the alveolar sacs to openand
remain open
seconds (fig.3).
E. Exhale slowly.

(fig,3)

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9. Repeat 10–20 times every 1–2 hours
While awake for 72 hours.
10. Teach client to perform IS every
hour.
11. Dispose of soiled equipment or
tissues and wash hand
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9. Ensures airways remain open and
Prevents atelectasis.
10. Encourages clients to take
responsibility for their health care.
11. Reduces the transmission of
microorganisms.
 Surgical Dressing

I. Definition
Sterile dressing covering applied to a wound or incision using aseptic technique with
or without medication.

II. Purpose
1. To promote wound granulation and healing process.

2. To prevent undue contamination of wound.

3. Maintain rigid sterile technique.

4. Provide physical and mental comfort.

III. To decrease purulent wound drainage .

IV. Types of wound
1. Closed wound (fig,1).

(fig,1)

2. Open wound (fig,2).

(fig,2)

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3. Wound with drainage (fig,3).

(fig,3)

V. Types of Dressing
1. Transparent dressing : Are often applied to wounds including ulcerated or
burned skin areas (fig,4).

(fig,4)
2. Hydrocolloid dressing : Are frequently used over pressure ulcers (fig,5).

(fig,5)
3. Securing dressing : The nurse tapes the dressing over the wound , ensuring
that the dressing covers the entire wound and dose not become dislodged.
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VI. General instructions for the wound dressing
1. Practice strict aseptic technique to prevent cross infection to the wound and
from the wound.
2. All articles should be disinfected thoroughly too make sure that they are free
from pathogens.
3. Instruments used for one dressing cannot be used for another until they have
been re-sterilized.
4. Dressings are not changed for at least 15 minutes after the room has been
swept or cleaned.
5. Avoid talking , coughing and sneezing when the wound is opened.
6. Create a sterile field around the wound by spreading sterile towels.
7. When dressing the wound , keep the wound edges are near as possible to
promote healing.
8. Give an analgesic prior to the painful dressing.

VII. Equipment (fig,6).

1. Variety of gauze, dressing, and sterile package.

2. Cleansing solution and sterile solution.

3. Kidney basin.

4. Clean, disposable gloves .

5. Sterile gloves.

6. Tape, ties or bandage as needed 7-Waterproof bag.

7. Rubber sheet.

8. 9- Anti-biotic ointment .

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(fig,6)

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VIII. Procedure

A. Procedures for applying sterile dressing on closed wound

Steps
1. Check order for dressing procedure.
2. Perform hand washing.
3. Explain procedures to patient, and
instruct him not to touch wound area
or sterile supplies.
4. Identify the patient.
5. Prepare the environment:
a. Close room and windows.
b. Pull the drape and draw the curtain
around the bed.
Rational
- To indicate types of dressing that will use.
-To reduce transmission of infection.
-To obtain patient co-operation, decrease
his fear and anxiety, and prevent
contamination of wound and supplies.
-To perform the procedures to the correct
patient.
-Provide privacy.
-To prevent contamination of supplies.
-Ensure easy disposal of soiled dressing.
-Provide access to minimize unnecessary
exposure.

c. Make sure your work surface is

clean and dry.

d. d- Place disposable bag within

reach of work area.
- To avoid back strain.
6. Adjust the bed to safe working
height.
-To reduce stress on suture line or wound
7. Position patient comfortably.
edges.

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8. Remove tape: pull parallel to skin,
pull toward dressing, and remove
adhesive from skin in direction of
hair growth (fig,7).

(fig,7)
-To control microorganism.
9. Disinfect hands; ensure your hands
are completely dry before
proceeding.
-To control microorganism.
10.Put on clean disposable gloves and
remove tape, bandage or ties.

11.With gloved hand, carefully remove

gauze dressing one layer at time
(fig,8).

(fig,8)
-To detect any abnormality.
12.Observe character and amount of
drainage on dressing and appearance
of wound (wounds edges presence of
inflammation, edema, and odor of
drainage).

42
13.Fold dressing, and remove gloves
inside out with small dressing,
removes gloves inside out over
dressing (fig,9).

- Dispose of gloves and solid dressing

in disposable bag.
(fig,9)
-To reduce transmission of
14.Perform hand washing.
microorganisms.
-To assess condition of wound & indicate
15. Open sterile dressing tray, and
the amount of drainage when nurse chart.
arrange the sterile equipment.
-To reduce transmission of infection&
prevent contact of nurse’s hands with
material on gloves.
-To prevent transmission of infection.
16.Pour ordered solution into sterile
container.
-To prevent contamination of previously
17.Clean wound with antiseptic
cleaned area.
solution, using each swab only once,
clean 2-3 time (clean from least
contaminated area to most
contaminated area.
Different ways of cleaning wound.

a. Circular way (fig,10).

(fig,10)

43
 b. longitudinal way (fig,11).

(fig,11)
c. Transverse way (fig,12).

(fig,12)
-To keep dressing in place, and prevent
18.Dry surrounding skin:
skin irritation.

-To ensure proper healing.

19. After cleaning suture line swap a
generous amount of antibiotic
ointment on sponge, and spread the
ointment on the suture line according
to physician order.
-To ensure proper healing.
20.Apply dressing, sterile dry
dressing covering wound.
-Support wound and ensure placement and
21.Secure the dressing with tape
stability of dressing.
(fig,12).

44
 (fig,13)
-Reduce transmission of
22.Remove gloves and disposes it in
microorganism.
bag.
-Reduce transmission of microorganism.
23.Dispose of supplies and perform
hand hygiene.
-Promote patient's sense of well being.
24.Readjusts the bed to safe height and
assist patient to comfortable position.

25.Documentation

B. Surgical dressing for open wound Cleansing and irrigation

I.Wound irrigation

 Definition: An irrigation ( lavage) is the washing or flushing out of an area. It is

sterile technique is required for a wound irrigation because there is a break in the skin
integrity.

 Purpose
1. To clean the area.
2. To apply heat and hasten the healing process.
3. To apply an antimicrobial solution.

II.Bandage

 Definition: Is a strip of material used mainly to support and immobilize a part of the
body.
45
III.Bandaging

 Definition: Is the process of covering a wound or injured part using various materials
such as gauze, cotton, elasticized knit, flannel.

 Purpose
1. To support wound .
2. To secure dressing.
3. To maintain splints in position.
4. To maintain direct pressure over a body part or dressing to control bleeding.

IV.Equipment

1. Cleansing solution and antiseptic solution.

2. Irrigation delivery system depending on amount of pressure desired (35 ml syringe).

3. Clean and sterile gloves.

4. Waterproof under pad.

5. Dressing supplies.

6. Personal protective items.

7. Catheter and 2 Tommy syringe.

8. Kidney basin.

9. 2 towels.

46
 V.Procedures for open wound

Steps Rational
-To decrease pain, enhance comfort that
1. Assess patient pain level and
increase patient mobility and make patient
administer prescribed analgesic before
easily.
procedures 30-45 min.
-Open wound irrigation requires medical
2. Review medical record for physician
order.
for irrigation.
-To indicated changes in condition of
3. Assess recent recording signs related
wound.
to client open wound including:
-May indicate response to infection.
- Correlation of wound and skin. - A strong odor refers to infection.
- Elevation of body temp.

- Drainage of wound (amount – odor

consistency).

- Wound size (depth –length- width).

-To reduce patient anxiety.
4. Explain procedure to patient.
-To control infection.
5. Hand washing.
-Direct solution from top to bottom of
6. Position patient comfortably to permit
wound.
gravitational flow of drainage solution
through wound.
-To increase comfort and reduce vascular
7. Warm irrigation solution to
constriction.
approximately body temperature.
-To keep privacy.
8. Prepare environment as described
previously.

47
 -To protect nurse from splashes and body
9. Apply personnel protective measures as
fluids.
needed.
-Help to remove outer secretions.
10. Put on clean gloves and remove
soiled dressing and discard in water
proof bag and discard gloves as
described previously.

11.Using 2 towels and squeezing

the wound.

12.Prepare equipment and open

sterile supplies.

13.Put on sterile gloves.

14.To irrigate wound with wide

Opening (fig,14):

a. Fill 35 ml syringe with irrigation

b. Hold syringe tip 2.5 cm (1 inch)

above upper end of wound and

over area being cleaned.

c. Using continuous pressure,

flush wound, and repeat the step

(fig,14)
until solution drainage into
bushing is clear.

48
15.To irrigate wound with very
small opening (fig,15):

a. Attach soft catheter to filled

irrigating syringe.

b. Lubricating tip of catheter with

irrigating solution then gently

insert tip of catheter and pull out

about (1cm).
(fig,15)
c. Using slow and continuous

pressure and flush wound.

d. Continue irrigating until the

solution becomes clear (no exudate
is present) .

16.Dry wound edges with gauze.

17.Apply appropriate dressing.

18.Remove gloves , dispose equipment,

soiled supplies, and perform hand
washing.
- To determine patient response to wound
19. Assist patient to comfortable position
irrigation
& inspect dressing periodically

49
 Nursing care for drain

I.Definition
Surgical drains are tubes placed near surgical incisions in the post-operative patient, to
remove pus, blood or other fluid, preventing it from accumulating in the body.
- Drains are available in different size.
- may be hooked to wall suction, a portable suction device , or they may be left to
drain by gravity.

II.Indications
1. To help eliminate dead space.
2. To prevent the potential accumulation of fluid.
3. To evacuate existing accumulation of fluid , to remove pus , blood , serous exudates
or bile.
4. Decrease infection rate.

III.Classification of drains:

1. Open drain : Include corrugated rubber or plastic sheets e.g. penrose drain (fig,1).

(fig,1)

2. Closed drain : Consist of tubes draining into a bag or bottle e.g jackson-pratt drain
(fig,2).

50
 (fig,2)

3. Active drains : Are maintained under suction e.g hemovac drain and sump drain (fig
3,4).

(fig 3,4)

4. Passive drains : Drains have no suction e.g Foleys catheter and corrugated drain (fig
5).

(fig 5)
51
IV. Equipment

1. Clean exam gloves.

2. Container for collecting and measuring the drain output.

3. Iodine swabs.

4. Approved cleaning solution.

5. Normal saline.

6. Sterile 4 x 4 gauze pads or split drain dressings.

7. Sterile cotton-tip applicators.

8. Tape.

V. Procedure

Steps Rational

1. Review order of physician or - To check for an agency/institutional

qualified practitioner. policy or the physician’s orders.
2. Gather supplies.
- To ensures that all supplies are ready
and
prevents interruption during the
procedure.
3. Provide privacy; draw curtains; close
- To maintains client comfort and privacy
door.
while body is exposed during procedure.
4. Explain procedure to client/family.
- To provides information about the
procedure that helps alleviate client
anxiety and promotes cooperation.
5. Wash hands, and set up
- To reduces the transmission of
supplies.
microorganisms
52
6. Apply clean exam gloves.
- To provides infection control and
protection from body fluids.
7. Unpin drain tube from gown or
- To allow for ease of removal of the old
clothing. Remove old dressing and
dressing. Dressings soiled with body
dispose in appropriate waste location.
fluids are considered contaminated and
subject to biohazard disposal in the
correct manner per institution protocol.
8. Assess site.
- To checks for signs of infection;
ascertains that the sutures that secure
tube to skin are intact; checks the
placement of the drain and that tubing is
not kinked.
9. Cleanse around drain with approved
- If there are crusts, this is an effective
cleaning solution using sterile cotton-
removal technique. This step may be
tip applicator, using gentle rolling
omitted if crusts are not present.
motion of the applicator around the
wound edge (fig,6).

(fig,6)

10. Cleanse away from the drain exit

- To reduces the transmission of
site. Do not roll one applicator more
microorganisms.
than halfway around the exit site. Use

53
as many applicators as needed to clean
the site. Dry with dry applicators.

12. Apply a single folded 4 x 4 under

- To collects potential drainage and
drain and another folded 4x 4 on top
protects site.
and tape in place.
13. Secure drain tube to dressing
- To minimizes the potential for
dislodging the drain.
14.
For A Jackson-Pratt drain (fig,7):

- Remove stopper plug from on top of

bulb to empty ,do not touch drain
port

- Turn bulb upside down and squeeze

fluid out into measuring cup (fig,7)

For hemovac drain(fig,8) :

- Lift the stopper.

- Turn the drain upside down.
- Drain the fluid into a measuring cup.

(fig,8)

15. Close the cork stopper device.

16.Discard drain fluid into toilet

17.Remove and properly dispose of To promotes clean technique, and

gloves and wash hands. reduces the transmission of
microorganisms.
18.documentation
54
VI.Complications of drains
1. Inefficient drainage

- Obstruction

- Poor drain selection.

2. Incision dehiscence :

- Poor placement.

- Accumulation of fluid .

3. Infection

- Ascending of bacterial invasion

- Foreign body reaction

- Poor postoperative management

4. Discomfort & pain .

55
 Suture removal
I.Definition
Sutures and staples are a surgical means of closing a wound by sewing, wiring, or stapling
the edges of the wound together , its generally removed 7–10 days after surgery, depending on
where the wound is located and how well it is healing.

(fig,1)
II. Common methods of suturing:-
1. Intermittent stitches: - Are formed by placing the suture in such a manner that each
stitch is placed separately and tied independently of the other stitches.
2. Continuous suture: - Each stitch follows one after the other without interruption,
and only the first and the last are tied.
3. Purse-string suture: - When a continuous stitch is placed around an aperture to
create a closure , such as before the removal of an organ (eg. The appendix ,
gallbladder , or urinary bladder) , it is referred to as a purse-string technique. Once
the suture is in place , the end is drawn closed causing the opening to close tightly.

56
 4. Retention or stay sutures: - Retention sutures provide a secondary suture line.
These sutures placed at a distance from the primary suture line, relieve undue
pressure and help to remove dead space.
III. Time of suture removal depends on :-
1. Shape &size and location of the sutured incision.
2. The absence of inflammation , drainage and infection .
3. Patients general condition.
4. Sutures should be removed:

– Face : 3-4 days

– Scalp: 5 days
– Trunk : 7 days
– Limb: 7-10 days
– Foot : 10-14 days

IV. Equipment needed for removing sutures

1. Good light source.

2. Sterile curve-tipped suture scissors & tray.

3. Clean gloves.

4. Sterile gauze pads.

5. Sterile forceps.

6. -Bag for solids.

7. If the wound is dressed sterile gloves.

8. Normal saline solution &antiseptic cleaning solution.

57
V. Procedure

Steps Rational

1. Wash your hands. - To reduces the transmission of

microorganisms.

2. Assess the wound to determine - To check healing process.

whether the edges of the wound are
well-approximated and healing has
occurred .

3. Gather the equipment you will need. - To save time and effort and doing
( suture removal kits and staple procedure efficiently.
removers) & check sterility of suture
removal package.

4. Identify the patient and explain - To avoid patient anxiety and gain his
procedure. cooperation.

5. Help the patient to assume - To facilitates removal of the sutures

comfortable position with easy access and allows for careful observation of
and visibility of suture line. suture line.

6. Drape the client so that only the - To provide the privacy

suture area is exposed

7. Apply clean gloves to remove the old - To control infection.

dressing and place it in a disposable
bag

58
 - To facilitates removal of the sutures
8. Open the suture removal kit, and
assemble any supplies needed within
easy access on a clean surface.

9. Remove gloves and rewash hands. - To providing infection control.

10. Put on sterile gloves and cleans the

- To reduces the transmission of
incision with saline-soaked gauze
microorganism.
pads or antiseptic solution (fig,2).

(fig,2)

11. To remove an intermittent suture;

hold the stitch- remover scissors in
the dominant hand and the forceps in
the other hand to Grasp one of the
suture „tails‟ with forceps and (fig,3)
elevate (fig,3).

59
12. To remove an intermittent suture;
hold the stitch- remover scissors in
the dominant hand and the forceps in
the other hand to Grasp one of the
suture „tails‟ with forceps and
elevate (fig,3).

(fig,3)

12. Slip the curved edges of the scissor

under the suture at or near the knot
the tip of the scissors under the
suture and cut close to the skin edge

13. Cut between the knot and the skin

- To minimize the length of
and then gently pull out the cut
contaminated suture that will be pulled
stitch. Ensure that no piece of the
through the wound
stitch is left in the wound as this may
form a wound sinus.

60
14. For continuous stitches:-
- To facilitates suture removal without

- Hold the stitch-scissor in the traumatizing the incision line.

dominant hand and the forceps in

the other hand to lift gently the
knot.

- Cut between the knot and the

skin of one end ; then grasp the
knot at the other end of the suture
line and pull gently away from the
wound to remove the total suture
intact.

- To decrease the transmission of

15. Discard the suture onto the gauze
microorganisms.
squares in the disposable bag.

16. Assess the suture line to ensure - To detect early signs of dehiscence.
that the edges remain approximated Ensures that sutures do not remain
and that all sutures have been in the skin when they are no longer
removed. needed.
17. Apply adhesive strips or butterfly
tape adhesive strips across the
suture line to secure the edges
(fig,4).

(fig,4)

- To reduces odors in the client’s

18. Dispose of the soiled equipment. room and reduces the transmission
of microorganisms.

61
 - To reduces the transmission of
19. Remove gloves and wash hands.
microorganisms.
20. Documentation :-

‐ Document procedure and findings at

wound site, such as redness, pain,
or drainage.

‐ Document the time sutures were

removed.

62
 Nasogastric tube

I. Definition

It is a flexible plastic tube inserted through the nostrils, down the

nasopharynx, and into the stomach or the upper portion of the small intestine.
Placement of NG tubes is always confirmed with an X-ray prior to use

II. Purposes
1. To provide nutrition when the client is comatose, semiconscious or unable to
consume sufficient nutrition orally.

2. Nasogastric suction tubes are used for decompression of gastric content after
gastrointestinal surgery.

3. Obtain gastric specimens for diagnosis of peptic ulcer.

4. Nasogastric tube is used for irrigation to clean and flush the stomach after oral
ingestion of poisonous substances.

5. Nasogastric tube is used to document the presence of blood in the stomach,

monitor the amount of bleeding from the stomach, and identify the recurrence of
bleeding in the stomach.

III. Equipment

1. Nasogastric tube 2. Syringe10ml

3. Lubricant 4. Cotton balls

5. Kidney tray 6. Disposable gloves

7. Adhesive tape 8. Stethoscope

9. Clamp 10. Marker pen

11. Steel Tray

63
A : Insertion of nasogastric tube
Procedures:
Step Rational

1. Review client’s medical history. - To assess for any nostril surgery

and abnormal bleeding.

2. Assess client’s consciousness, - To decreases anxiety and

ability to understand and explain the promotes cooperation.
procedure to patient.

3. Prepare the equipment, putting - To facilitates an efficient

tissues, a cup of water, and an procedure.
emesis basin nearby .

4. Prepare the environment; raise the - To facilitates insertion and

bed and place it in a high Fowler’s prevents back strain .
position (45 to 60 degrees). Cover
the chest with a towel.

5. Wash hands and then put on gloves. - To practices clean technique.

6. Use a penlight to view the client’s - To choosing the more patent

nostrils. Assess client’s nostrils with nostril for insertion decreases
penlight and have the client blow discomfort and unnecessary
her nose one nostril at a time . trauma.

64
7. Place a towel on the patients chest - Nasal and oral secretions may
and provide facial tissues and an beevident during the procedure.
emesis basin.

8. Provide patient with drinking water - Sipping water through a straw

and a straw if the patient is not fluid helpsto initiate the swallowing
restricted. reflex andfacilitate passing of
NG tube.

9. Stand on patients right side if youare - The nurse will use the dominant
right-handed and the left side ifyou hand to insert the tube.
are left-handed.

10.Measure distance of the tube from

the tip of the nose, to the earlobe, to
the xiphoid process and then mark
the tube at this point ( fig1,2).

(fig 1,2)

11.Lubricate NG tube tip according to

your agency policy(fig,3).

(fig,3)

12.Apply clean non-sterile gloves(fig

4).

(fig 4)

65
 - Curling the NG tube around
13.Curve 10 to 15 cm of the end of the
your finger helps it conform to
NG tube around your gloved finger,
the normalcurve of the
and then release it(fig 5).
nasopharynx.

(fig 5)
- Dropping the head forward
14.Have patient drop head forward and
closes the trachea and opens the
breathe through themouth.
esophagus, which allows the
NG tube to pass moreeasily
through the nasopharynx and
into the stomach.

- This follows the natural

15.1nsert NG tube tip slowly into the
anatomicalalignment of the
patients nostril and advance it
nasopharynx.
steadily, in a downward direction,
along the bottom of the nasal
passage, with the curved end
pointing downward in the direction
of the ear on the same side as the
nostril (fig, 6). (fig, 6)

66
 - It is common for the patient to
16.You may feel slight resistance asyou
feel discomfort, and this may be
advance along the nasal passage.
expressed with light coughing
Twist the tube slightly, apply
and gagging. Moreaggressive
downward pressure, and
coughing and gagging may
continue trying to advance the tube.
indicate that the tube has
If significant resistance is felt,
entered the airways, in which
remove the tube and allow the
case you should withdraw the
patient to rest before trying again in
NG tube.
the other nostril.

- If patient continues to gag or

17.If there is difficulty in passing the
cough, check that the tube is not
NG tube, you may ask the patient to
coiled in the back of the mouth,
sip water slowly through a straw
using a tongue blade and a
unless oral fluids are
flashlight to check the backof
contraindicated. If oral fluids are not
the mouth. If tube is coiled,
allowed, ask the patient to try dry
withdraw the tube until only the
swallowing while you advancethe
tip of the tube is seen in the
tube (fig,7).
back of the mouth. Then try
advancing the tube again while
patient tries to swallow.

(fig,7)

67
 - This ensures accurate
18.Continue to advance NG tube until
placement.
you reach the mark/tape you had
placed for measurement.

- This prevents displacement of

19.Temporarily anchor the tube to
the NGtube while checking
patients cheek with a piece of tape
placement.
until you can check for correct
placement(fig ,8).

(fig,8)

20.Verify tube placement according to - To ensures correct placement.

agency policy.
A. Color-coded pH paper is usually
used, as an initial and interim
check, to confirm that acidic
contents are present.
B. Then an X-ray is taken to
confirmplacement prior to using
NG tubefor feeding.

68
21.Secure the tube to the patient’s - This keeps the NG tube in
gown with a safety pin, allowing place. Secure the tube to the
enough tube length for comfortable patient’s gownwith a safety pin
head movement (fig,9).

(fig,9)

22. Remove gloves, dispose of - To implements the principles of

contaminated materials in proper infection control.
container, and wash hands.

23. Position client comfortably and - To decreases client’s anxiety

place the call light in easy reach and provides access to help if
needed.

24. Document the procedure - Timely and accurate

accordingto agency policy, and documentation promotes patient
report any unexpected findings to the safety.
appropriate health care provider.

69
B : Removing an NG tube

Procedures

Steps Rational

1. Verify health care provider’s - An order is required to remove an

NG tube.
orders to remove NG tube.

2. Collect supplies. - Supplies include waterproof pads, 20

ml syringe, tissues, non-sterile
gloves,and garbage bag.

3. Verify patient using two - Follow agency policy for proper

identifiers. Explain procedure to patient identification.
patient and place patient in high
fowler’s position.

4. Perform hand hygiene. Place

waterproof pad on patient’s chest
(fig ,11).

(fig ,11)

5. Disconnect tube from feed if - This prevents risk of aspiration of

present (fig,12). tube feed.

(fig,12)

70
6. Remove tape or securement - This allows for the tube to be easily
device from nose(fig ,12). removed.

(fig12)

7. Unclip NG tube from patient’s - This allows for tube to be easily

gown. removed.

8. Clear NG tube by inserting 10 - This prevents aspiration of tube feed

to 20 ml of air into tube falling out of tube.

( fig,14).

(fig ,14)

9. Instruct patient to take a deep - This prevents any residual feed from

breath and hold it(fig ,15). flowing out of tube upon removal.

71
 ( fig ,15).

10.Kink the NG tube near the - Wrap tube in glove and dispose .
naris and gently pull out tube
in a swift, steady motion,
wrappingit in your hand as it
is being pulled out. Dispose of
tube in garbage bag (fig ,16).
(fig ,16)

11. Offer tissue or clean the nares - This clears the nares/nasal passages
for the patient and offer mouth ofany remaining secretions.
care as required (fig,17).

(fig ,17).

12.Remove gloves and perform - To prevent transmission of

hand hygiene. microorganisms.

13.Document procedure - Document removal of NG tube and

patient response to the removal.
according to agency policy.

72
 Gavage feeding

I. Definition
Gastric Gavage is a means of supplying nutritional substance via a small
plastictube direct to the stomach, tube feedings are given to meet nutritional
requirements when oral intake is inadequate or not possible and the GI tract is
functioning normally.

II. Indications
1. Preoperative bowel preparation.
2. Gastrointestinal problems.
3. Cancer therapy.
4. Coma, semi consciousness.

5. Alcoholism, chronic depression, anorexia nervosa.

6. cervical surgery.

7. Oropharyngeal or esophageal paralysis.

8. Gastrointestinal diseases and surgery.

9. Hyper metabolic states (burns, multiple trauma ,sepsis, cancer).

10. Certain neurologic disorders (stroke and coma).

11.following certain types of surgery (head and neck, esophagus).

III. Contraindication

1. (Absent bowel sounds )Tube feedings are contraindicated to patients

without bowel sounds.
2. Administration of feeding solution to an improperly placed tube may
cause aspiration into the lungs.

73
IV. Equipment

1. Tube feeding at room temperature.

2. Rubber band.

3. IV pole.
4. Feeding bag or prefilled tube feeding set clamp (Hoffman or butterfly)
5. Disposable pad or towel.
6. Stethoscope.
7. Enteral feeding pump (if ordered).
8. Sterile gauze.
9. Feeding formula.
10. Calibrated drinking glass.
11. Bowl.
12. Acepto syringe Medicine.
13. Glass with tap water.
V. Procedure

Steps Rationale

1. Explain procedure to client. - Facilitates cooperation and

provides reassurance for client.

2. Assemble equipment. Check amount, - Provide for organized approached

to task.
concentration, type and frequency tube
feeding on client’s chart.
3. Wash your hands. - Hand washing deters the spread of
microorganisms.

74
4. Position client with the head of bead
elevated at least 30 degrees angel .
5. Unpin tube from client’s gown and
check to see that the gastric tube is
properly located in the stomach.
6. Aspirate all gastric contents with
syringe and measure. Return
immediately through tube and proceed
with feeding if amount of residual
doesnot exceed policy of agency or
physician’s guidelines. Disconnect
syringe from tubing.
75
- Minimize possibility of aspiration
into trachea.
- The instillation of water or
nourishment could lead to serious
respiratory problems if a gastric
tube is in the trachea or a
bronchus, rather than in a
stomach.
- A residual of more than 50% of
theprevious hour’s intake is
significantand must be reported to
physician.
7. Giving feeding
When using Asepto syringe or Toomey
syringe:
A. The syringe acts to receive the
A. Remove plunger or bulb from
nourishment. Introducing the
syringe and attach syringe to
nourishment slowly gives the
nasogastrictube which has been
stomach time to accommodate
pinched with fingerand introduce
the fluid and decreases
the prescribed amount slowly.
gastrointestinaldistress.
B. Hold the syringe approximately 12
B. Nourishment enters the stomach
inches above the stomach. Allow
by gravity when gastric gavage
solution to run in by gravity. Raise
is used.
the syringe to increase the rate of
flow, andlower the syringe to
decrease the rate offlow.
C. This technique prevents air from
C. Do not let the syringe empty while
introducing the nourishment.

D. Introduce 30ml – 60mL) of water

D. Being forced into the stomach
into the tube after the nourishment
whenthe syringe is refilled.
is introduced.

E. Clamp the gastric tube immediately

E. Washing the gastric tube with
after nourishment and water are
water forces remaining
instilled. Disconnect the syringe
nourishmentin the tube into the
and cover end of tubing with gauze
stomach .
secured with rubber band
introducing the nourishment.

76
When using a feeding bag:
A. Hang bag on IV pole and adjust to A.Formula displaces air in the
about 12 inches above the stomach. tubing
Clamp tubing and pour formula into
B. Introducing the formula at a slow,
thebag. Release clamp enough to
regular rate allow the stomach
allow formula to run through
to accommodate the feeding
tubing. Close clamp.
and decreases gastrointestinal
B. Attach tubing to nasogastric tube, distress.
open clamp and regulate drip
C. Water rinse the feeding from the
accordingto physician’s order.
tube and helps to keep it
C. Add 30 ml – 60 ml of water to patent.
feeding bag when feeding is almost
completed and allow to run through
tube.
D. Clamp the tubing immediately after
D. Clamping the tube prevents air.
E. water has been instilled. Disconnect
from nasogastric tube and cover gauze
secured with a rubber bad.
8.Have client remain in upright position
- Pain may lead to
for at least 30 minutes after feeding.
Vomiting.

10. Wash and clean equipment or replace

- This position minimizes risk of
according to agency policy. Wash your
backflow and discourage
hands.
aspiration should any vomiting
occurs.
11. Record type and amount of feeding
- Prevents contamination and deters
and client’s response.
spread of microorganisms.

77
VI. Complications of Enteral Therapy
A-Gastrointestinal
- Diarrhea (most common)

- Nausea/vomiting

- Constipation

B-Mechanical
- Aspiration pneumonia
- Tube displacement

- Tube obstruction

- Nasopharyngeal irritation

C-Metabolic
- Dehydration and azotemia(excessive urea in the blood)

78
 Gastric lavage

I. Definition:

Gastric lavage, also called stomach pumping or gastric irrigation, is the

process of cleaning out the contents of the stomach by using rubber tube is
inserted into the mouth or nose of a conscious or unconscious patient until it
reaches the stomach where the unwanted contents are present .

II. Indications:

1. With patient has ingested a potentially life-threatening amount of a

poison and the procedure can be undertaken within 60 minutes of
ingestion.
2. Cleaning the stomach before an upper endoscopy in someone who has
been vomiting blood.
3. Collecting stomach acid for tests.
4. Relieving pressure in someone with a blockage in the intestines.

III. Contraindications :

1. Loss of airway protective reflexes, such as in a patient with a depressed

state of consciousness.
2. Ingestion of a corrosive substance such as a strong acid or alkali.
3. Patients who are at risk of hemorrhage or gastrointestinal perforation due
to pathology, recent surgery, or other medical condition.
4. Insignificant overdose.

IV. Equipments (fig,1):

1. Nasogastric insertion equipments.

2. Lavage fluid – Nacl or other prescribed solution.

3. Syringe 20ml for aspiration and 50ml for lavage.

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4. Specimen container with lab request form.

5. Kidney dish as receiver.

6. Measuring jug.

7. Protective sheet.

8. Clinical waste.

9. Domestic waste.

(fig,1)

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V. Procedure

Steps Rational

1. Verify Doctor order. - To ensure correct patient and

correct procedure.

2. Asses patient level of consciousness. - To decreases anxiety and

promotes cooperation.

3. Greet patient and explain procedure. - To decreases anxiety

4. Provide privacy - To keep patient dignity.

5. Remove dental appliances and - To ensure safety to patient.

inspect oral cavity for loose teeth.

6. Position patient in Semi-Fowlers. - To promotes comfort to the

patient.

7. Insert NG tube as per procedure

handout.

8. Check placement of tube in stomach - To ensures correct placement.

( 3 times check).

9. Aspirate stomach contents before - To keep specimen in container

instilling water or antidote (fig,2). for analysis.

(fig,2

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10.Remove 20ml syringe and attach - To prepare solution for wash
with 50ml syringe to pour lavage the stomach.
solution into NG tube or attach with
50ml syringe barrel.

11.inject slowly 20ml solution and wait

for 1 minute (fig,3).

(fig,3)

12.Aspirate (if use syringe) or siphon (if

use barrel) gastric contents and
discard it in kidney dish (fig,4).

(fig,4)

13.Record input and output throughout - To ensure all entered solution

procedures. will out.

14.Repeat step 10-14 until returns are - To ensure that the stomach
clear. Usually requires a total volume content is clear.
of 2 liters.

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 15.Remove NG tube as per procedure
handout.

16.Make patient comfortable.

17.Label specimens and send it to lab

immediately.

18.Clean and clear the equipments.

19.Record and report findings.

VI. Complications

1. Aspiration pneumonia.
2. Laryngospasm.
3. Hypoxia and hypercapnia.
4. Mechanical injury to the throat, esophagus, and stomach.
5. Fluid and electrolyte imbalance.

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 Ostomy Care (Ileostomy or Colostomy)
I. Definition
An ostomy is a surgically created opening from the urinary tract or
intestines, where effluent (fecal matter, urine, or mucous) is rerouted to the
outside of the body using an artificially created opening called a stoma.
II. Classifications of ostomies
1. Urostomies are for drainage of urine.
2. Colostomies are for drainage of stool from the large bowel.
3. Ileostomies are for drainage of stool from the small bowel.

III. Types of ostomies

1. Temporary colostomies: Certain lower bowel problems are treated by
giving part of the bowel a rest, so that the bowel can heal. This healing
process may take a few weeks, months, or even years. In time, the
colostomy will be reversed (removed) and the bowel will work like it did
before – the stool will exit from the anus again.
2. Permanent colostomies: When part of the colon or the rectum becomes
diseased, a long-term (permanent) colostomy must be made. In this case,
the colostomy is not expected to be closed in the future.
3. Transverse colostomies: This type of colostomy allows the stool to
leave the body before it reaches the descending colon.

IV. Purpose
1. To provide means of fecal evacuation.
2. To maintain the integrity of the stoma and peristomal area.
3. To prevent lesions, ulceration, excoriation, and other skin breakdown
caused by fecal contaminants.
4. To promote general comfort and positive self-image.

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V. Assessment
1. Inspect the stoma for color and texture. Allows the nurse to determine the
viability and turgor of the stoma.
2. Inspect the condition of the skin surrounding the stoma. Alterations in
skin integrity will prohibit a closed drainage system from adhering to the
skin.
3. Measure the dimensions of the stoma prior to obtaining an ostomy
appliance system from central supply. Alleviates the problem of obtaining
the wrong size equipment.

(fig,1)
VI. Safety considerations
1. Pouching system should be changed every 4 to 7 days, depending on the
patient and type of pouch.
2. Always consult a wound care specialist or equivalent if there is skin
breakdown, if the pouch leaks, or if there are other concerns related to the
pouching system.
3. Patients should participate in the care of their ostomy, and health care
providers should promote patient and family involvement.
4. Encourage the patient to empty the pouch when it is one-quarter to one-
half full of urine, gas, or feces.

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 5. Ostomy product choices are based on the patients’ needs and preference.
6. Follow all post-operative assessments for new ostomies according
to agency policy.
7. Medications and diet may need adjusting for new ileostomies/
colostomies.
8. An ostomy belt may be used to help hold the ostomy pouch in place.
9. Factors that affect the pouching system include sweating, high heat, moist
or oily skin, and physical exercise.
10.Always treat minor skin irritations right away. Skin that is sore, wet, or
red is difficult to seal with a flange for a proper leak-proof fit.

VII. Equipment (fig,2)

- Flange.
- Ostomy bag and clip,
- Scissors,
- Stoma measuring guide,
- Waterproof pad,
- Pencil, adhesive remover for
skin.

(fig,2)

- Stoma adhesive paste or powder,

- Wet cloth,
- Non-sterile gloves, and additional cloths.

VIII. Procedures

Rational
Nursing action
1. Perform hand hygiene.
- This prevents the spread of
microorganisms.
2. Gather supplies.
- Encouraging patients to participate

86
 helps them adjust to having an ostomy.
3. Identify the patient and review the
- Encourage the patient to participate as
procedure.
much as possible.

4. Create privacy. Place waterproof

- The pad prevents the spilling of
pad under pouch.
effluent on patient and bed sheets.

5. Apply gloves. Remove ostomy

bag, and measure and empty
contents. Place old pouching
system in garbage bag (fig,3).

(fig,3)

6. Remove flange by gently pulling

- Gentle removal helps prevent skin
it toward the stoma. Support the
tears. An adhesive remover may be
skin with your other hand. An
used to decrease skin and hair
adhesive remover may be used
stripping.
(fig,4).

(fig,4)
7. Clean stoma gently by wiping with
- Aggressive cleaning can cause
warm water. Do not use soap.
bleeding.
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8. Assess stoma and peristomal skin
- A stoma should be pink to red in
(fig,5).
colour, raised above skin level, and
moist.

(fig ,5)
9. Measure the stoma diameter using
the measuring guide (tracing
template) and cut out stoma hole
(fig,6).

(fig,6)
10.Trace diameter of the measuring
guide onto the flange, and cut on
the outside of the pen marking
(fig,7).

(fig,7)
11.Prepare skin and apply accessory
- Wet skin will prevent the flange from
products as required or according
adhering to the skin.
to agency policy.

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12.Remove inner backing on flange
and apply flange over stoma.
Leave the border tape on (fig,8).

(fig,8)

13.Hold in place for 1 minute to

warm the flange to meld to
patient‟s body. Then remove outer
border backing and press gently to
create seal (fig,9).

(fig,9)

14.Apply the ostomy bag. Attach the

- This step prevents the effluent from
clip to the bottom of the bag
soiling the patient or bed.
(fig,9).

(fig,10)
15.Hold palm of hand over ostomy
- The flange is heat activated
pouch for 2 minutes to assist with
appliance adhering to skin.

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 16.Clean up supplies, and place
- Removing garbage helps decrease
patient in a comfortable position.
odor.
Remove garbage from patients
room.
17.Perform hand hygiene.
- This minimizes the transmission of
microorganisms.

18.Document procedure.
- Follow agency policy for
documentation.

IX. Special Considerations

1. When patients are discharged from an acute care facility, ensure they are
able to empty their pouch system independently or with assistance from a
caregiver, have spare supplies, and know the signs and symptoms of
complications and where to seek help.
2. The ostomy bag may become filled with gas from the intestine. Patients
may “burp” the bag through the opening at the top in a two-piece system
by opening a corner of the ostomy pouch from the flange to let the air out.
3. Dietary restrictions may also help decrease the amount of gas produced
by the intestines

90
 Paracentesis Care

I. Definition
Paracentesis is a procedure in which a needle or catheter is inserted into the
peritoneal cavity to obtain ascetic fluid for diagnostic or therapeutic purposes.

(fig,1)

II. Indication

1. To relieve abdominal pressure from ascites .

2. To diagnose spontaneous bacterial peritonitis and other infections.

3. To diagnose metastatic cancer .

4. To diagnose blood in peritoneal cavity in trauma .

III. Contra-indication

1. Pregnancy .

2. Distended urinary bladder.

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 3. Distended bowel .

4. Abdominal wall cellulitis .

5. Intra-abdominal adhesions .
IV. Assessment

1. Identify the purpose for the abdominal paracentesis.

2. Check allergies to medications or anesthetic, bleeding problems,

medications currently using including aspirin ,this will decrease the
chance of complication during the abdominal paracentesis.

3. Assess client’s knowledge regarding the abdominal paracentesis.

4. Assess the client for bleeding tendencies to determine the risk of bleeding
during and after the procedure.

V. Equipment

1. Disposable paracentesis tray or 16-gauge 3.5-inch aspiration needle.

2. Ampule of 1% lidocaine, 5 ml.

3. Needles for local anesthetic, 25 gauge, 5⁄8 inch.

4. Needle, 21 gauge 1.5 inches.

5. Syringe, 5 ml.

6. Syringe, 50 ml.

7. Prep tray.

8. Prep applicators.

9. Sterile drapes.

10. Sponges.

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 11. Two-way valve.

12. Specimen tubes.

13. Drainage bag or bottles.

14. Adhesive bandage.

15. Sterile gloves.

VI. Procedure:.

Steps Rationale

1. Wash hands. - Reduces the transmission of

microorganisms.
2. Gather equipment. - Ensures preparation.

3. Explain procedure to client. - Encourages clients cooperation.

4. Assist in preparing the equipment and - Provides a sterile field to decrease

risk for infection.
sterile field.

5. Assist the physician or nurse - Reduces risk for infection.

practitioner to cleanse insertion site with
antiseptic solution .

6. Assist the physician or advanced - Provides sterile field to decrease

risk for infection.
practice nurse with the application of
sterile gloves, gown, and mask as well
as sterile drapes to outline the area to
be tapped.

7. Assist the physician or advanced - Local anesthesia minimizes pain

and discomfort.
practice nurse to draw up local
anesthetic.

93
8. Assist in collection of peritoneal fluid
for laboratory analysis.

9. Assist the physician or advanced - Initiates therapy

practice nurse in attaching syringes or
stopcock and tubing and aspirating or
siphoning fluid via gravity or vacuum
into the collection device.

10.After the fluid and catheter are - Keeps the insertion site clean.
Reduces the risk for infection.
removed, apply pressure to the
wound. If the wound is still leaking
fluid after 5 minutes of direct
pressure, the physician or advanced
practice nurse may suture the
puncture site.

11.Assist with applying a sterile dressing - Provides a barrier to infection and

to the wound site. collects fluid that may leak from
wound site.

12.Remove PE and sterile equipment - Standard Precautions.

used during the procedure & wash
hands.

13.Patient Monitoring and Care

- Evaluate changes in abdominal girth.

- Monitor for changes in the respiratory

status.
- Monitor for potential complications,

94
 including bowel or bladder perforation,
bleeding, and intravascular volume loss.
- Monitor vital signs, temperature, and
insertion site for drainage or evidence
of infection.
- Monitor intake and output.

14.Documentation

- The amount and characteristics of fluid

removed.
- Specimens sent for laboratory analysis.

- Post-procedure vital signs, respiratory

status.
- Abdominal girth.

VII. Complication

- Perforation of bowel, bladder or stomach.

- Lacerations of major vessels (mesenteric, iliac, aorta).

- Abdominal wall hematomas.

- Laceration of catheter and loss in peritoneal cavity.

- Incisional hernias.

- Local or systemic infection.

- Hypovolemia, hypotension, shock

- Bleeding from insertion site.

95
 Port catheter care

I.Definition
An implanted port is a type of central line. A central line (also called a
central venous catheter) is like an intravenous (IV) line. But it is much longer than
a regular IV and goes all the way up to a vein near the heart or just inside the heart.

II. Purpose

1. Good aesthetics and intact body image.

2. Patients can resume regular activities after the pocket is healed, including

swimming, exercise and sports (contact sports, however, should be avoided).

3. Ports require less maintenance, flushing and dressing changes. When a port is
not in use it only needs heparin flushing every 4 - 6 weeks.

4. Ports are not exposed to environmental or cutaneous contamination, therefore,

it is theorized that the subcutaneous position prevents infection from skin
bacteria leading to a lower risk of infection. Many articles have been written
to support this.

III. Indication

1. The infusion of all types of medication and solutions .

2. The administration of blood /blood products.

3. For blood sampling.

4. For IV contrast via pressure injectable port.

96
IV. Type of port catheter (fig,1)

A. Double-chamber plastic port.

B. Single metal port.

(fig,1)

V. A port consists of two parts:

1. The first part is the port itself. This is a small chamber made of metal, with a
soft silicone top.
2. The second part is a long, soft, thin, flexible tube called a catheter. One end
of the catheter is attached to the port and the other end is inserted into one of
the large veins that leads to the heart (fig 2,3).

(fig, 2) (fig ,3)

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VI. Equipment (fig,4)

1. Chlorhexidine solution.
2. Non-coring gripper needle .
3. Extension set and positive displacement luer lock cap.
4. 10 mL NS pre-filled syringe .
5. Face mask.
6. Sterile gloves and dressing tray

)Fig,4)

98
VII. Procedure

Steps Rational

1. Verify Doctor order. - Reduces the transmission of

microorganisms.
2. Explain procedure to client. - Encourages clients cooperation.

3. Perform hand hygiene and apply clean - Provides a sterile field to decrease risk
gloves. for infection.

4. Place a mask on the patient and nurse. - To control infection.

5. Gather equipment through prepare - Prime extension set and gripper

needle with sterile NS to prevent air
dressing tray, adding chlorhexidine and
embolism when device is attached to
gripper needle, sterile syringe, extension
port (fig,5).
set and luer lock cap and 10 mL NS
syringe. Prime extension set and gripper
needle with NS. Leave syringe attached

(fig,5)

6. Perform hand hygiene again. - Reduces the transmission of

microorganisms.

7. Cleanse a 10 to 13 cm area of skin over - To prevent microorganisms from

port area with chlorhexidine soaked entering the central line
gauze using a scrubbing motion for 60
- Drying time prevents bacterial growth
seconds and allow to air dry completely
and prevents skin breakdown
(up to 2 min).

99
8. With non-dominant hand stabilize the - Stabilizing the port allows for ease
port using thumb and first two fingers and accuracy of insertion of gripper
forming a “C” around the port. needle into the center of the septum.

9. With dominant hand grasp gripper

needle and hold at a 90 degree angle.
Firmly insert the needle in a continuous
motion, through the skin and septum of
port device.)fig,6,7).

(fig,6)

)fig,7)

10. Pull back on syringe and gently - To ensures all heparin is removed
aspirate 5 mL blood. Remove syringe and does not get into patient’s circulation
and discard waste in biohazard or alter lab sample results.
container .

11. If blood return is not apparent, - If no blood return, begin

troubleshoot for blockage. Try a gentle troubleshooting for mechanical
push/pull technique to aspirate blood. If versus thrombotic occlusion.

100
 still unsuccessful, try gently advancing
needle further into the septum. Attempt
aspiration of blood. If still unsuccessful,
obtain new supplies and try reinserting a
new gripper needle

12. obtaining lab samples if required. If - Turbulent 20 mL NS flush ensures

initiating a medication or fluid infusion, the port is patent.
flush the port with 20 mL NS and then
connect infusion to extension set (fig,8).

(fig,8)

13. If gripper is being left in place for - To prevent accidental dislodgement

infusion, secure gripper needle with a during infusion.
translucent opaque dressing (fig,9).

(fig,9)

14. Once infusion is complete, flush port - To ensure continued patency of the
with 20 mL NS using turbulent, pulsing Line.
technique.

15. Gather a syringe with 3-5 mL of - To prevent back up of blood into the

101
 heparin 100 u/mL, in a 10 mL syringe: device.

- Obtain a second nurse or ask patient to

assist with removal of gripper needle by
securing the port with a “C” clamp
technique.

- Inject the heparin into the port through

the extension set and gripper needle.

- The patient or second nurse stabilizes

the port while the gripper needle is
withdrawn and the last 0.5 mL of
heparin is injected.

- Dry the site with sterile.

- A dressing may be required following

gripper removal .

16. Document the following:

- Flushing and patency of port .

- Specimen(s) collected.

- IV infusion, blood or medication

delivered .

- Heparinizing of port post-

procedure.

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103