FEMALE CATHETERIZATION

I. KNOWLEDGE

1. State the purpose of Female Catheterization

● To prevent and relieve over distention of the bladder owing to the inability to urinate.
● To empty the bladder as a measure, preparatory to instillation, irrigation or operation or when
obstetrical or post-operative condition contraindicates a voluntary urination in the normal way.
● To obtain a urine specimen.
● To assess the amount of residual urine if the bladder empties incompletely.
● To provide for intermittent or continuous bladder drainage and irrigation.
● To manage incontinence when other measures have failed.

2. Enumerate the indications of Female Catheterization

● Relief of acute or chronic urinary retention, such as due to urethral obstruction (obstructive uropathy) or neurogenic bladder
● Treatment of urinary incontinence
● Monitoring of urine output
● Measurement of postvoid residual urine volume
● Collection of sterile urine for culture
● Diagnostic studies of the lower genitourinary tract
● Bladder irrigation or instillation of medication

3. Explain the Rationale of each suggested action.

4. Enumerate the materials used.

● Blanket
● Flushing tray
● Bedpan
● Rubber sheet
● Disposable gloves
● Catheterization tray with the following:
○ Catheter
○ Sterile gloves
○ Flashlight
○ Antiseptic cleaning solution
○ Forceps
○ Syringe with sterile water
○ Lubricant
○ Kidney basin
○ Specimen bottle
○ Cotton balls
○ Safety pin or tape
○ Receptacle or basin

II. SKILLS

1. Assemble equipment. Prepare a sterile catheterization set.

- Ensure smooth flow of procedure.

2. Wash hands.
- Reduces transmission of microorganisms. Infection is common after Catheterization.

3. Provide for privacy and explain procedures to clients.

* Good morning, Ma’am! I am Jade, your nurse for today. May I know your name? So ma’am, maglalagay po tayo ngayon ng catheter para
ma-monitor po natin ang inyong urine out. Sa procedure na ito, kailangan ko po ang inyong cooperation.*
- Ensures cooperation and aids in relaxation during procedure

4. Position client into dorsal recumbent or side-lying position.

- Legs may be supported with pillows to reduce muscle tension and promote comfort.

5. Drape client: place blanket in a diamond fashion.

- Avoids unnecessary exposure of body parts and maintains client‟s comfort.

6. Apply gloves.

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 - Reduce transmission of microorganisms

7. Wash the perineal area and dry.

- Reduces microorganisms near urethral meatus and allows further opportunity to visualize perineum landmarks.

8. Remove gloves and wash hands.

- Reduces the transmission of microorganisms, since hands and gloves are already contaminated.

9. Open the catheterization kit. Use a wrapper to establish a sterile field.

- Prevents transmission of microorganisms from table or work area to sterile supplies

10. Apply sterile gloves.

- Reduce transmission of microorganisms

11. Lubricate the catheter for about 1 to 2 inches being careful not to fill the eyes of the catheter.
- Eases insertion of catheter through urethral canal, and prevents urethral trauma and discomfort.

12. Cleanse urethral meatus, retract labia, pick up cotton balls with antiseptic solution and wipe from front to back.
- Full visualization of urethral meatus is provided. Full rtraction prevents contamination of urethral meatus during cleansing.

13. Pick up the catheter with your dominant hand. Ask the client to bear down gently and insert a catheter through the urethral
meatus.
- Relaxation of external sphincter aids in insertion of catheter.

14. Advance catheter a total of 2 to 3 inches, when urine appears advance another 1 to 2 inches. Do not force against resistance.
- Female urethra is short. Presence of urine indicates that the catheter tip is in the bladder or lower urethra. Advancement of
catheter ensures bladder placement.

15. Place the end of the catheter in the urine receptacle.

- Prevent the spillage of urine.

16. Collect urine specimens as needed.

- Allows sterile specimens to be obtained for culture analysis.

17. When urine flow starts to decrease, withdraw catheter slowly about 1 cm at a time till urine barely drips, then withdraw
- Ensures complete bladder emptying.

INDWELLING WITH RETENTION BALLOON

18. Reattach the water-filled syringe to the inflation port.

- Inflates the balloon, size of balloon is marked on the catheter port.

19. Inflate the retention balloon by injecting the required amount of solution
- Inflation of balloon anchors catheter tip in place above bladder outlet to prevent removal of catheter. A 5 ml balloon is
commonly used. Do not over inflate or under inflate the balloon..

20. If the client experiences pain during balloon inflation, deflate the balloon and insert the catheter
further.
- The balloon may not be entirely in the bladder

21. Once inflated, gently pull the catheter until the retention balloon is resting against the bladder neck.
- Anchoring the catheter reduces pressure on the urethra, thus reducing the possibility of tissue injury.

22. Tape the catheter to the inner thigh.

- It avoids pulling the urinary catheter.

23. Place the drainage bag below the level of the bladder.
- Helps to keep urine from flowing back into your bladder.

24. Remove gloves, dispose of materials

- Reduces transmission of microorganism

25. Help clients adjust position.

- Maintains comfort and security.

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 26. Wash hands.
- Reduces transmission of microorganism

27. Document
- Note all the output of the patient, and record it on the chart.

MALE URINARY CATHETERIZATION

I. KNOWLEDGE

1. State the purpose of Male Catheterization

● To prevent and relieve over distention of the bladder owing to the inability to urinate.
● To empty the bladder as a measure, preparatory to instillation, irrigation or operation or when
obstetrical or post-operative condition contraindicates a voluntary urination in the normal way.
● To obtain a urine specimen.
● To assess the amount of residual urine if the bladder empties incompletely.
● To provide for intermittent or continuous bladder drainage and irrigation.
● To manage incontinence when other measures have failed.

2. Enumerate the indications of Male Catheterization

● Relief of acute or chronic urinary retention, such as due to urethral obstruction (obstructive uropathy) or neurogenic bladder
● Treatment of urinary incontinence
● Monitoring of urine output
● Measurement of postvoid residual urine volume
● Collection of sterile urine for culture
● Diagnostic studies of the lower genitourinary tract
● Bladder irrigation or instillation of medication

3. Explain the Rationale of each suggested action.

5. Enumerate the materials used.

● Blanket
● Flushing tray
● Bedpan
● Rubber sheet
● Disposable gloves
● Catheterization tray with the following:
○ Catheter
○ Sterile gloves
○ Flashlight
○ Antiseptic cleaning solution
○ Forceps
○ Syringe with sterile water
○ Lubricant
○ Kidney basin
○ Specimen bottle
○ Cotton balls
○ Safety pin or tape
○ Receptacle or basin

II. SKILLS

1. Assemble equipment. Prepare a sterile catheterization set.

- Ensure smooth flow of procedure.

2. Wash hands Reduces transmission of microorganisms.

- Infection is common after Catheterization.

3. Provide for privacy and explain procedures to clients.

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* Good morning, Sir! I am Jade, your nurse for today. May I know your name? So ma’am, maglalagay po tayo ngayon ng catheter para
ma-monitor po natin ang inyong urine out. Sa procedure na ito, kailangan ko po ang inyong cooperation.*
- Ensures cooperation and aids in relaxation during procedure

4. Position client into supine position with thighs slightly abducted.

- A comfortable position for clients that aids in visualization.

5. Drape client: drape upper trunk with bath blanket and cover lower extremities with bed sheets.
- Avoids unnecessary exposure of body parts and maintains client‟s comfort.

6. Apply gloves
- Reduce transmission of microorganisms

7. Wash perineal area and dry.

- Reduces microorganisms near urethral meatus

8. Remove gloves and wash hands.

- Reduces transmission of microorganism

9. Open the catheterization kit. Use a wrapper to establish a sterile field.

- Prevents transmission of microorganisms from table or work area to sterile supplies

10. Apply sterile gloves.

- Allows nurses to handle sterile supplies without contamination.

11. Lubricate the catheter for about 6 to 7 inches

- Eases insertion of catheter through urethral canal.

12. Lift penis with one hand, cleanse area of meatus with cotton ball in a circular motion. Move from meatus toward the base of the
penis.
- Reduces the number of microorganisms at urethral meatus and moves from areas of least to most contamination. Dominant
hand remains sterile
*Retract foreskin in the uncircumcised male client
- Accidental release of foreskin or dropping of penis requires the process to be repeated because the area has been contaminated.

13. Lift penis perpendicular to the body, steadily insert catheter into the meatus.
- Straightens urethral canal to ease catheter insertion.

14. Ask the client to breathe deeply and rotate the catheter gently if slight resistance is met, advance the catheter for about 7 to 9
inches.
- The adult male urethra is long. It is normal to meet resistance at the prostatic sphincter, just hold the catheter firmly against the
sphincter without forcing the catheter. After a few seconds, the sphincter relaxes and the catheter is advanced.

15. Hold the catheter securely while the bladder empties into a sterile receptacles
- Collection of urine prevents soiling and provides output measurement.

16. When urine flows starts to decrease, withdraw the catheter slowly about 1 cm at a time till urine barely drips, then withdraw.
- Ensures complete bladder emptying.

INDWELLING WITH RETENTION BALLOON.

17. Continue insertion for another 1-3 inches.

18. Reattach the water-filled syringe to the inflation port.

- Inflates the balloon, size of balloon is marked on the catheter port.

19. Inflate the retention balloon

- Inflation of balloon anchors catheter tip in place above bladder outlet to prevent removal of catheter. A 5 ml balloon is
commonly used. Do not over inflate or under inflate the balloon.

20. If the client experiences pain during balloon inflation, deflate the balloon and insert the catheter further.
- The balloon may not be entirely in the bladder.

21. Once inflated, gently pull the catheter until the retention balloon is resting against the bladder neck.
- Moving the catheter back into the bladder will avoid placing pressure on the bladder neck.

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22. Tape the catheter to the abdomen or thigh.
- Anchoring the catheter reduces pressure on the urethra, thus reducing the possibility of tissue injury.

23. Place the drainage bag below the level of the bladder.
- Helps to keep urine from flowing back into your bladder.

24. Remove gloves, dispose of materials & wash hands

- Reduces transmission of microorganisms

25. Help clients adjust position.

- Maintains comfort and security.

26. Document.
- Note all the output of the patient, and record it on the chart.

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 ELECTROCARDIOGRAM LEAD PLACEMENT

I. KNOWLEDGE

1. State the purpose of electrocardiogram.

● It helps to diagnose certain heart conditions, including abnormal heart rhythms and coronary heart disease (heart attack and
angina).
● To determine f blocked or narrowed arteries in the heart (coronary artery disease) are causing chest pain or a heart attack
● To know whether you have had a previous heart attack
● To know well certain heart disease treatments, such as a pacemaker, are working

2. Enumerate the special considerations in obtaining electrocardiogram.

● Small areas of hair on the client's chest or extremities may be clipped; clipping usually is not necessary.
● If the client's skin is exceptionally oily, scaly, or diaphoretic, rub the electrode site with a dry 4" × 4" gauze pad or washcloth
before applying the electrode to help reduce interference in the tracing. During the procedure, ask the client to breathe
normally. If the respirations distort the recording, ask the client to hold his breath briefly to reduce baseline wander in the
tracing.
● If the client has a pacemaker, you can perform an ECG with or without a magnet, according to the physician's orders. Be sure
to note the presence of a pacemaker and the use of a magnet on the strip.

3. Explain the rationale of each suggested action.

4. Enumerate the equipments used.

● ECG machine
● Recording paper
● Disposable pre-gelled electrodes
● 4" × 4" gauze pads or washcloth
● Clippers, marking pen

II. SKILLS

1. Verify the order for an ECG on the patient's chart

- Verification of order prevents potential errors.

2. Assemble equipment and supplies

- Ensure smooth flow of procedure.

3. Explain procedure to the client

*Good morning Ma’am! I am Jade, your nurse for today. May I know your name and your birthday? So ngayon po ma’am, maglalagay po ako ng
electrocardiogram sa inyong dibdib para malaman po natin ang kondisyon ng inyong puso. Sa procedure na ito, kailangan ko po ang inyong
kooperasyon.*
- Ensures cooperation and aids in relaxation during procedure

4. Wash hands
- Reduces the transmission of microorganisms.

5. Provide for client privacy

- Minimizes embarrassment.

6. Place the ECG machine close to the patient’s bed, and plug the power cord into the wall outlet.
- Moving electrodes and keeping client away from electrical fixtures and power cords will minimize electrical interference on
ECG tracing.

7. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver
- Provide comfort to the patient throughout the procedure.

8. Have the patient lie supine in the center of the bed with the arms at the sides. Raise the head of the bed if necessary to promote
comfort.
- This position increases client comfort. Relaxing arms and legs reduces trembling and creates a better tracing.

9. Select flat, fleshy areas on which to place the electrodes. Avoid muscular and bony areas.
- Tissue conducts current more effectively than bone, which produces a better tracing.

10. If an area is excessively hairy, clip the hair. Do not shave hair. Clean excess oil or other substances from the skin with soap and
water and dry it completely.

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 - Do not shave hair; shaving causes microabrasion on skin.

11. Apply the limb lead electrodes. Position the disposable electrodes on the legs with the lead connection pointing superiorly.
- Positioning lead connections superiorly guarantees best connection to lead wire

12. Connect the limb lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright.

13. Expose the patient’s chest. Apply the precordial lead electrodes. The brown or V1 to V6 leads are applied to the chest.
- Proper lead placement ensures accurate test results.

14. Connect the precordial lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright.
- Proper setup ensures proper functioning.

15. After the application of all the leads, make sure the paper-speed selector is set to the standard 25 m/second and that the machine
is set to full voltage.

16. If necessary, enter the appropriate patient identification data into the machine.
- Ensures the correct result will be given to the right patient.

17. Ask the patient to relax and breathe normally. Instruct the patient to lie still and not to talk while you record the ECG.
- Having clients relax and remain still will produce a better tracing.

18. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically,
recording 3 consecutive leads simultaneously.
- Note any adjustments made during tracing to ensure accurate interpretation of results.

19. When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the patient’s skin

20. After disconnecting the lead wires from the electrodes, dispose all of the electrodes. Return the patient to a comfortable position.
- Proper disposal reduces the spread of microorganisms. Repositioning of bed promotes client safety.

21. Document significant assessment findings, the date and time that the ECG was obtained, and the patient’s response to the
procedure.
- Document in your notes the test's date and time and significant responses by the client. Verify the date, time, client's name, and
assigned ID number on the ECG itself. Note any appropriate clinical information on the ECG.

BLOOD TRANSFUSION

I. KNOWLEDGE

1. State the purposes of Blood Transfusion

● To restore intravascular volume with whole blood or albumin.
● To restore the oxygen-carrying capacity of blood by replacing red blood cells (RBC‘s).
● To replace clotting factors and/or replace platelets to reverse coagulopathy.
● To replace white blood cells in neutropenic clients.

2. Enumerate the indications of Blood transfusion

● Anemia.
● Major Surgical Operation.
● Accidents resulting in considerable blood loss.
● Cancer patients requiring therapy.
● Women in childbirth and newborn babies in certain cases.
● Patients of hereditary disorders like Haemophilia and Thalassaemia.
● Severe burn victims.

3. Explain the Rationale of each suggested action

4. Enumerate the materials used

● Unit of blood or packed RBCs
● Blood administration set
● 0.9% NaCl IV solution
● Alcohol wipes
● Disposable, clean gloves
● Tape

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 ● Tourniquet
● Blood pressure cuff and stethoscope
● Thermometer
● Signed transfusion consent form

II. SKILLS

PRE-ADMINISTRATION

1. Verify Doctor‘s order and make a treatment card.

- A physician order must be present before transfusing a blood product

2. Check Identity of client.

- Strict adherence to verification procedures before administration of blood reduces risk of administering the wrong blood to
clients.

3. Explain the procedure to clients and significant others and secure consent.
*Good morning Ma’am! I am Jade, your nurse for today. May I know your name and your birthday? So ngayon po ma’am, magblo-blood
transfusion po tayo kasi marami pong dugo na-nawala sa inyo nung na accidente kayo. Kailangan ko po ng kooperasyon niyo sa buong therapy.*
- Client consent must be obtained for the protection of the client and health team.
Get the patient's history regarding previous blood transfusion.
*Ma’am, nag blood transfusion na po ba kayo dati? Kung oo, kelan po ito? May reaction po ba yung katawan niyo during or pagkatapos ng
transfusion?*
- Identifies client‟s prior response to transfusion of blood components.

4. Verify that the component received from the blood bank is a component ordered by the physician.
- Ensures clients receive correct therapy.

5. Warm blood at room temperature, wrap it with towel.

- To avoid hypothermia and the resultant undesirable physiological consequences

6. Have Two nurses compare and validate the following information with the medical record, patient
identification band, and the label of the blood product:
- To determine any discrepancy in the procedure.
a. Medical order for transfusion of blood product
b. Informed consent
c. Patient identification number
d. Patient name
e. Blood group, type and serial number of blood
f. Expiration date
g. Inspection of blood product for clots

ADMINISTRATION

7. Get baseline vital signs BP; CR, Temperature before transfusion; refer if elevated.
- Change from vital signs will alert nurses to a potential transfusion reaction or adverse effect of therapy.

8. Give pre-med 30 minutes before transfusion as ordered by the doctor.

- Avoid altering the blood transfusion reaction of the patient.

9. Wash hands.
- Reduces risk for transmission of microorganisms.

10. Prepare compatible administration set, blood components, etc.

- Ensure smooth flow of procedure.

11. Open Y-tubing blood administration set and spike blood aseptically and carefully; prime tubing.
- Priming tubing removes air from the system.

12. Close roller clamp when tubing is filled with blood.

- Minimizes wasting any component.

13. Initiate an appropriate IV catheter with plain NSS; disinfect the Y-injection port of IV tubing.
- Saline should be readily available in case of transfusion reaction.

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14. Close IV fluid of Plain NSS or regulate to KVO (based on Doctor‘s order) while transfusion is going on.
- This will prevent blood from backing up into saline bag.

15. Transfuse the blood via the Y-injection port at 10-15 gtt, initially for 15 minutes and regulate it at
ordered rate (use g. 19 needle).
- Maintaining the prescribed rate of flow decreases risk of fluid volume excess while restoring vascular volume.

16. Observe client on an on-going basis; for any untoward signs and symptoms like flushed skin, chills, elevated temperature,
itchiness, urticaria and dyspnea; Stop transfusion, notify physician immediately; open IV line with plain NSS.
- Most transfusion reactions occur within the first 5 to 15 minutes of a transfusion. Infusing a small amount of blood component
initially minimizes the volume of blood to which the client is exposed, thereby minimizing the severity of reaction

17. Swirl the blood bag periodically to mix the solid and liquid blood elements.
- This will equally distribute cells throughout the preservative solution.

18. If blood is consumed, close the roller clamp of BT set then disconnect from IV lines then regulate the IVF as ordered.
- Infusing IV saline solution infuses remainder of blood in IV tubing and keeps IV line patent for supportive measures in case of
a transfusion reaction.

19. Continue to observe patients, for delayed reactions could still occur.
- Monitor VS and reassure patients. Frequent monitoring of vital signs will help to quickly alert nurses to a transfusion reaction.

20. Follow post-blood transfusion order such as re-checking of Hgb and Hct, bleeding time, serial platelet count, etc.
- Aid in determining whether goals of therapy have been reached or if further blood component therapy will be required.

21. Discard blood bags and BT sets according to hospital policy.

- Standard precautions during a transfusion reduce transmission of microorganisms

22. Wash hands.

- Reduces risk for transmission of microorganisms.

23. Document observation and nursing intervention and endorse the incoming shift.
- Ensures correct intervention will be given to the patient by the next shift nurse.

24. Continue to observe client as blood and/or components transfusion

- Untoward signs and symptoms can happen even after transfusion.

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