FUNDAMENTALS OF NURSING PRACTICE
MIDTERMS SY. 2023-2024
Protective Devices
● Hand rolls and rubber balls (to prevent claw hand
deformity)
● Trochanter roll (to prevent external rotation of the
hips; apply from the hips to the upper third of the
thighs)
● Footboard and boot splints (to prevent footdrop)
Exercises
Purposes
1. To maintain a good body alignment
2. To improve muscle strength
3. To improve muscle tone
4. To improve circulation
5. To relieve muscle spasm
6. To relieve pain
7. To prevent or correct contracture deformities
8. To promote sense of wellbeing
Types of Exercises
1. Active Range Of Motion - done by client w/out
assistance; to increase muscle strength
2. Passive Range Of Motion - done for the client by
health care providers w/out assistance from the
patient; will not preserve muscle mass or bone
mineralization because there is no voluntary
contraction, lengthening of muscle or tension on
bones)
3. Active-Resistive Range Of Motion - done by the
client against a weight or force; pulling or pushing
against an opposing force
4. Active-Assistive Range Of Motion - done by with
assistance from the nurse; encourage normal
muscle function while the nurse supports the distal
joints; the stronger arm and leg to the weaker arm
and leg
5. Isotonic - involves change in muscle length and
tension; walking running, performing Activities of
Daily Living
6. Isometric - involves change in muscle tension only;
alternate tension and relaxation of group muscles;
while keeping the part in a fixed position; to
maintain muscle strength when a joint is
immobilized; full patient cooperation is required
Definition of Terms
★ Mobility – a person’s ability to move about freely
★ Immobility – the inability to move about freely
★ Bed rest – is an intervention that restricts patients
to bed for therapeutic reasons
★ Disuse atrophy – the tendency of cells and tissues
to reduce in size and function in response to
prolonged inactivity resulting from bed rest, trauma,
casting of a body part or nerve damage
★ Hypostatic pneumonia – inflammation of the lung
from stasis or pooling of secretions
★ Joint contracture – is an abnormal and possibly
permanent condition characterized by fixation of a
joint
★ Range of Motion (ROM) is the maximum amount
of movement available at a joint in one of the three
planes of the body (sagittal, transverse or frontal)
★ Gait – describes a particular manner or style of
walking
★ Exercise – is physical activity for conditioning the
body,improving health and maintaining fitness
★ Activity tolerance – is the type and amount of
exercise or work that a person is able to perform
without undue exertion or possible injury
Transport of Client
➢ Bed to Wheelchair
○ Position the stretcher parallel to the bed
○ Lock the wheels of the wheelchair
➢ Bed to Stretcher
○ Place the stretcher parallel to the bed
○ Lock the wheels of the bed and stretcher
○ Push the stretcher from the end where the
client’s head is positioned
○ When entering the elevator, maneuver the
stretcher so that the client’s head goes in
first
○ Always lock wheels on bed, stretcher or
wheelchair; unexpected movements may
result to injury
Assisting Clients in Ambulation
Purposes
1. To increase muscle strength and joint mobility
2. To prevent some potential problems of immobility
3. To increase the client’s sense of independence and
self-esteem
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If the client becomes dizzy or starts to fall, during CHARACTERISTICS OF A SAFE ENVIRONMENT
ambulation, slowly and gently lower him to the floor and call
for help; if the client is at high – risk for falls, two nurses 1. Adequate lighting
may be required to assist with ambulation - Night light as necessary, to prevent falls if the client
needs to go to the bathroom
Patient Safety and Security - To eliminate shadows. This would prevent
❖ The need of people to protect themselves and in unnecessary fear, especially among children and
some instances to be protected is always present confused clients
❖ The environment around us contains many 2. Neat and clean
hazards, both seen and unseen - Litter and clutter are removed to prevent accidents
❖ The need for safe environment relates to the - Spilled food and liquid are cleaned up to prevent
national concerns as well as to the community and slipping on the floor
to the immediate environment of a person - Furniture are in accustomed places
❖ A safe environment is one where the likelihood of a 3. Safe equipment
person becoming ill or injured because of factors in - Furniture/equipment is regularly maintained; broken
the environment is reduced to the lowest degree of equipment and furniture can cause accidents
possibility - Electrical equipment in good repair
❖ Safety, is often defined as freedom from 4. Noise level is comfortable
psychological and physical injury, is a basic human - Sound above 120 decibels is painful/damaging to
need the ears
❖ Health care provided in safe manner and a safe 5. Cleanliness
community environment is essential for a patient’s - Excessive dirt and microorganism cause infection
survival and well-being 6. Medication
❖ It is one in which people can function safely and - Kept separately in cupboards out of reach of
one in which they obtain a sense of security children to prevent poisoning
❖ A safe environment has a number of general 7. Temperature of environment 65-75 F (18.3-23.9
characteristics C))
❖ It means freedom from injury such as thermal, 8. Relative humidity 30-60%
mechanical, radiation, electrical, microbial, chemical 9. Free of pollution such as:
and psychologic ● Air pollution
● Land pollution
ENVIRONMENTAL SAFETY ● Water pollution
● Noise pollution
★ A patient’s environment includes physical and
psychological factors that influence or affect the life BASIC NEEDS
and survival of that patient ➢ Oxygen
★ A safe environment protects the staff as well, ➢ Nutrition
allowing them to function optimally ➢ Temperature
★ Vulnerable groups who often require help include
infants, children,older adults, the ill, the physically
and mentally disabled, the illiterate and the poor PHYSICAL HAZARDS
★ A safe environment includes meeting basic needs,
reducing physical hazards and the transmission of ● Motor Vehicle Accidents
pathogens, and controlling pollution ● Poison - is any substance that impairs health or
destroys life when ingested, inhaled, or absorbed
by the body; impair the function of every major
organ
● Falls
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● Fire RISKS IN THE HEALTH CARE AGENCY

● Disasters 1. Falls (this is the most common accident in the
TRANSMISSION OF PATHOGENS hospital)
2. Client-inherent accidents (ex. Altered level of
● Immunization consciousness, impaired sensation, and impaired vision)
● Pollution 3. Procedure-related accidents (ex. Use of hot water
● bag, steam inhalators, transport of clients)
FACTORS THAT AFFECT PEOPLE’S ABILITY TO 4. Equipment-related accidents (ex. broken
PROTECT THEMSELVES stretchers,wheelchairs)

➔ Age SAFETY PRECAUTIONS IN HEALTH

Infant, toddler, pre-schooler
- Injuries are leading causes of death (ex. poisoning
accidents, burns, falls and choking)
School-age
- Risk of injury from strangers (don’t accept candy,
food, gifts or rides from the strangers)
- Sports safety is stressed. Use helmet, knee-pads
and elbow pads as necessary
Adolescent
- Use of drugs or nicotine lead to health risks,
accidents (drowning, motor vehicle accidents)
Adult
- Lifestyle habits (alcohol, smoking, stress)
- Health risk, motor vehicle accidents
Older adult
- Falls, burns, car accidents are common
➔ Orientation and level of consciousness
- Unconscious/semiconscious
- Neurologic impairment
- Inability to communicate
- Paralyzed
- Confused
- Alcohol withdrawal
➔ Emotions
- Acute anxiety
- Depression
- Preoccupation with pain/illness
➔ Injury
- Ill, weak people are prone to accidents
➔ Sensory or communication impairment
- Unable to perceive potential danger or express
needs for assistance
➔ Information/Safety awareness
- Knowledge deficit on safety increase risk for various
types of accidents
Infants
- Although infants are completely dependent upon
others for personal care, they soon learn to roll from
side to side, to put anything within reach into their
mouth and to creep and walk
Some of the special precautions to be observed in the care
of the infants are as follows:
- Provide only toys that are soft and large and that do
not have parts that can be removed and swallowed
- Always have the sides of the crib up when the baby
is not being handled.
- The rails of the crib sides need to be close enough
together so that the baby cannot get his/her head
between them
- At feeding time, hold the baby. There is danger of
choking if he/she is propped up with a bottle
- Put pins, needles, buttons and nails out of reach of
the baby because infants like to put things in their
mouth
- Use guard rails at the top and bottom of the stairs
when the baby starts to crawl
- Cover electric outlets and install safety outlets if
possible. Babies like to explore by putting their
fingers in hole
- Do not leave a baby alone in the bath or in a bed or
table because the baby may roll off
Toddlers
- Toddlers are curious and like to feel and taste
everything they can reach. Toddlers like to climb
and explore, and many things such as garden pools
and busy street fascinate them
Some special precautions in toddlers are as follows:
- Knives and other sharp tools and matches need to
be kept safely away from the toddler’s reach
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- Pots on the stove need to be kept on the back
burners, away from the toddler’s reach
- Cleaning solutions and insecticides need to be kept
in locked cupboards
- All medicines need to be stored in a locked cup
board
- The play area outside should be free of deep
ditches, wells and pools
- Teach the toddler what “no” and “don’t” mean and
what these words are meant when they are spoken
at times of risk for the toddler or for others
Preschoolers
- Accident prevention includes teaching
them to observe and to act safely
School-age Children
- School-age children have the following needs to
protect themselves:
- School-age children need to learn to use equipment
such as the stove and garden equipment safely
- They will need to understand traffic rules before
bicycling
- They will still need help and supervision with much
equipment, and if they live in the country, they will
need to handle farm animals
Adolescents
- Adolescents spend much of their time away from
home with their peer groups. However, they still
need guidance from parents. The accident rate
involving adolescents is high and the major cause
involves automobiles
- Some safety measures that adolescents require in
order to prevent accidents are as follows:’
- Developing an inner discipline, which is necessary
to be a safe driver
- Wearing safety helmets when riding motorcycles
and similar vehicles
- Learning to swim and understanding water safety
- Understanding the dangers involved in the use of
drugs and alcohol
Adults
- Alcohol is a significant factor in accidents. Adults
need to learn not to drink if they are driving motor
vehicles or boating
Elderly
- Elderly people are particularly prone to accidents.
- They require safe environment. Toys need to be out
of the way, rugs need to be fastened so that they
will not slip. Hand railings in bathrooms and the
placement of dishes and frequently used supplies
within easy reach are a few of the precautions
which can assist in prevention of accidents
SAFETY PRECAUTIONS IN ILLNESS
Falls and Other Mechanical Trauma
● In hospitals and homes nurses need to be very
much aware of patients who may fall. A number of
safeguards are generally taken to try to prevent
these accidents
● Bedside tables and over bed tables are placed near
the bed or chair so that patients do not need to
overreach and consequently lose their balance
● Patients who have had surgery or have been in bed
for some time are advised to have assistance when
first getting out of bed
● Footstools are supplied with rubber feet, which do
not slip, and wheelchairs with locks on the wheel
● Floors have nonslip surfaces; rugs and carpeting
are fixed securely in place so that they will not slip
● The environment is kept tidy so that people do not
trip over light cords, toys or misplaced furniture
● Some hospitals provide ambulating patients with
● railings along the corridors and in the bathrooms
● Use of protective devices such as side rails and
restraints may be indicated in certain situations
● Siderails– sometimes referred to as cribsides, side
rails are attached to the side of the bed and when
elevated they can help prevent from falling out of
bed
● Restraints – these are used judiciously, and as a
last resort, to prevent falls or injury
GUIDELINES IN APPLICATION OF RESTRAINTS
1. Allow the patient as much freedom to move as
possible and at the same time serve the purpose of
the restraint
2. The patient’s circulation must not be occluded by
the restraint
3. Pad bony prominences under a restraint in order to
avoid skin abrasions; preferably, use soft restraints
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4. The restraint needs to permit the body to assume
its normal position (ex. slight flexion of the arms)
attach restraint to the bed frame, not to the side
rails to prevent trauma
5. Use at least conspicuous type of restraint possible;
even if the patient is not aware of the restraint,
visitors often find them disturbing
6. At the first indication of occluded peripheral
circulation(pallor, blueness, cold, tingling or pain)
the restraint needs to be loosened and the limb
exercised
7. Remove restraints at least every 2 hours for 30
minutes. Exercise the limb and provide skin care to
prevent skin abrasions
8. Restraints application requires doctor’s order
9. Secure doctor’s order for each episode of restraints
application. PRN orders for restraints application in
unacceptable
10. Ideally, application of restraints require consent
from relatives or significant others
Burns
- The possibility of burns is a continual problem.
- Patients who are ill may be unaware that they are
being burned. People can be accustomed to heat
that in fact is injurious to tissues
● Burns can be prevented in health care environment
by:
- Testing bath water for temperature when the client
has sensory impairment
- Checking heating pads, heat lamps, stem inhalator
and other electrical equipment to be sure they are
functioning properly
- Assisting clients when handling hot beverages as
needed
Chemical Trauma
● Accidents do occur as a result of the use of
chemicals. It is important that patients who will be
taking their own medications be provided with
assistance necessary to prevent accidents.
● Some of these are as follows:
○ Label the medication in enough print so that
the patient can read it, and write the
directions in understandable words
○ Parents with young children may need
cautioning to place the medicine out of
reach of the children
Patients who take their own medications while in the
hospital will need to have this recorded on their charts and
have the physician’s permission. This may prevent a double
dose of a medication from being taken by a patient
Radiation Injury
- Radiation has become a more recently recognized
cause of injury to people. Radiation can injure skin,
reproductive organs, bone marrow and other parts
of the body
Factors that directly affect the degree of exposure to
radiation are as follows:
- The longer the time that a person is in the presence
of radiation the greater the exposure
- The closer a person is to the source of the radiation
the greater the exposure
- Substances such as lead can be used to shield a
person from radiation
Safety of the client should always be given priority when
providing care. Safe nursing care environment is of utmost
consideration in every health care setting.
HYGIENE AND COMFORT
★ Hygiene is the science of health and its
maintenance
★ Maintenance and promotion of hygiene is very
important aspect of human physiological needs
★ Many kinds of disease or illness can be prevented
by maintaining personal hygiene
★ If hygiene is promoted and maintained, the
individual has a feeling of comfort, well-being,
safety and self-confidence
★ Personal hygiene is a self-care by which people
attend to such as functions as bathing, toileting,
general body
★ hygiene and grooming
★ Hygiene is determined by individual values and
practices
★ It involves the care of skin, hair, nails, teeth, oral
and nasal cavities, eye and perineal areas
ANATOMY AND PHYSIOLOGY OF THE SKIN
● It is the largest organ of the body
● The functions of the skin are as follows:
● It is the first line of defense against injury and
microorganism
● It maintains body temperature
● It is secretory organ. It secretes sebum (an oily
substance which lubricates the hair and the
 FUNDAMENTALS OF NURSING PRACTICE
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skin;prevents the hair from becoming brittle;
decreases water loss from the skin; lessens the
amount of heat lost from the skin and has
bactericidal action)
● It is a sensory organ. It has numerous nerve
receptors which are sensitive to pain, temperature,
touch and pressure
● produces and absorbs Vitamin D through the
action of ultraviolet rays from the sun which activate
TWO TYPES OF SWEAT GLANDS
1. Apocrine glands
● They are primarily located in the axilla and
anogenital areas
● They begin to function at puberty under the
influence of androgen
● The secretion of these glands is odourless, but may
become musky/unpleasant when acted upon by
microorganism
2. Eccrine glands
● They are found primarily on the palms of the hands,
the soles of the feet and forehead
● The sweat they produce cools the body through
evaporation
● The sweat is composed of water, sodium,
potassium, chloride, glucose, urea and lactate
HYGIENIC MEASURES
SKIN CARE
➢ Common Problems of the Skin
1. Abrasion
● Superficial layers of the skin are scraped or rubbed
away
● The area appears red, with localized bleeding or
serous weeping
Nursing Interventions
● Keep the wound clean and dry to prevent infection
● Lift instead of sliding, pulling or pushing the client
in bed
● Do not wear jewelries when performing procedures
to the client
2. Excessive dryness
● Skin is scaly and rough
Nursing Interventions
● Encourage to increase fluid intake (this is most
effective measure to relieve dryness of the skin)
● Apply cream or lotion to moisturize the skin and
prevent cracking
● Avoid use of alcohol on the skin
● Bathe the client less frequently, rinse skin
thoroughly
3. Acne
● An inflammatory condition of the skin which occurs
in and around sebaceous glands
● Characterized by papules, pustules and comedones
(black heads)
Nursing Interventions
● Encourage daily bath
● Keep the skin clean and dry
● Adequate rest, sleep and exercise
● Have exposure to natural sunlight
● Avoid foods with high carbohydrate and fat content
● Reduce emotional stress and anxiety
● Avoid picking or squeezing of pimples
● Use medications as prescribed:
- topical ointment
- systemic antibiotics
- estrogen with progesterone
4. Erythema
● Redness of the skin which may be associated with
rashes, exposure to sun, elevated body
temperature
Nursing Interventions
● Wash skin thoroughly to minimize microorganisms
● Apply antiseptic spray or lotion to relieve pruritus
● Promote healing and prevent impairment of the skin
integrity
5. Hirsutism
● Excessive growth of the hair among women
Nursing Interventions
● Shave excessive hair growth
● Use depilatory cream
● Enhance client’s self concept
6. Hyperhidrosis –is excessive perspiration
7. Bromhidrosis– is foul smelling perspiration
8. Vitiligo– are patches of hypopigmented skin
caused by destruction of melanocytes
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TYPES OF SKIN LESION
A. Primary Skin Lesion
● Macule– a flat, circumscribed area of color with no
elevation of its surface; 1mm to 1 cm (ex. freckle,
flat nevi [moles])
● Patch – same as macule but larger than 1 cm (ex.
port wine birth mark)
● Papule – a circumscribed, solid elevation of skin;
less than 1 cm (ex.warts, acne)
● Plaque– same as papule but larger than 1 cm
(ex.eczema)
● Nodule – a solid mass that extends deeper into the
dermis than that of a papule (ex. pigmented nevi)
● Tumor– a solid mass larger than a nodule (ex.
epithelioma)
● Vesicle – a circumscribed elevation containing
serous fluid or blood less than 1 cm (ex blister,
chicken pox)
● Bulla – a large fluid-filled sac
● Pustule – a vesicle or bulla filled with pus (ex acne
vulgaris, impetigo)
● Wheal – a relatively reddened, elevated localized
collection of edema fluid; irregular in shape
(ex.mosquito bite)
● Cyst – elevated, thick-walled lesion containing fluid
or semisolid matter
● Telangiectasia – dilated capillary; fine red lines
(ex.liver cirrhosis)
● Petechiae– pinpoint red spots
B. Secondary Skin Lesion
● Scale- thickened epidermal cells that take off
(ex.dandruff, psoriasis)
● Crust– dried serum or pus on the skin surface (ex.
impetigo)
● Fissure– a deep linear crack (ex. athlete’s foot)
● Erosion–loss of all or part of the epidermis; appears
moist demarcated depressed area (ex. ruptured
chicken pox vesicle)
● Excoriation– a superficial linear or hollowed out
crushed area exposing dermis (ex. scratch)
● Atrophy– a decreases in the volume of epidermis
(ex. striae, aged skin)
● Scar– a formation of connective tissue (ex healed
wound)
● Ulcer– an excavation extending into the dermis or
below (ex decubitus ulcer )
● Lichenification– (chronic atopic dermatitis )
GENERAL GUIDELINES FOR SKIN CARE
1. An intact, healthy skin is the body’s first line of
defense
2. The degree to which the skin protects the
underlying tissues from injury depends on the
amount of subcutaneous tissue and the dryness of
the skin
3. Moisture in contact with the skin can result in
increased bacterial growth and irritation
4. Body odors are caused by resident skin bacteria
acting on the body secretions (cleanliness is the
best deodorant)
5. Skin sensitivity to irritation and injury varies among
individuals and in accordance with their health
6. Agents used for skin care have selective actions
and purposes (ex. soap, detergent, bath oil, cream,
lotion, powder, deodorant and antiperspirant)
Methods of Bathing
● Tub bath
● Stand-up shower
● Sit-down shower with shower chair
● Bed bath
Clients who suffer dizziness, weakness or mental confusion
should not be allowed to take stand-up showers. Obese
clients may find it difficult to maneuver into a bathtub and
might risk falling. For these clients, a sit-down shower with
shower chair may be more appropriate
Purposes of Bed Bath
1. To remove microorganisms, body secretions and
excretions and dead skin cells
2. To improve circulation
3. To promote relaxation and comfort
4. To prevent or eliminate body odors and promote
self-esteem
5. To promote sense of wellbeing
6. To assess the client’s skin and body parts
7. To provide activity and exercise
Nursing Interventions
● Inform the client and explain purpose of the
procedure
 FUNDAMENTALS OF NURSING PRACTICE
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● Provide privacy by closing curtains around bed or
shut room door (this is to maintain client’s dignity)
● Close windows and doors (to prevent drafts)
● Turn –off electric fan or air conditioning unit (to
prevent chills)
● Encourage to void before start of the procedure (to
ensure comfort)
● Place the bed in flat position, if admissible (to
facilitate movement and change of position)
● Move the client to one side of the bed (to prevent
overreaching and prevent muscle strain)
● Remove the patient’s gown. Cover up to shoulder
level with the top sheet or bath blanket (to provide
comfort, warmth and privacy)
● Use warm water (110-115 F)
● Make bath mitt the washcloth (to retain heat and
water better than a loosely held washcloth and
prevent water from dripping on client)
● Wash the body parts as follows:
1. eyes, face, ears, neck
2. farther arm
3. nearer arm
4. hands
5. chest and abdomen
6. farther leg
7. nearer leg
8. feet
9. back and buttocks
10. perineum (“finishing the bath”)
● Exposure, wash and dry one body part a time (to
promote privacy and prevent chills)
● Rinse off soap thoroughly (to prevent skin irritation)
● May apply cream, lotion or powder on the skin
● Change gown. Do bed making
● Do after-care of equipment and articles
● Document relevant data
SPECIAL NURSING CONSIDERATIONS WHEN BATHING
A CLIENT IN BED
1. Cleanse eyes with water only, wiping from inner to
outer canthus; use separate corner of mitt for each
eye (washing eye from inner to outer canthus
prevents secretions from entering and irritating
nasolacrimal ducts; using separate corner for each
eye prevents transfer of microorganisms from one
eye to the other )
2. Determine if client would like to use soap on face;
consider individual preferences (soap can be drying
especially to the face; some clients use special
cleansing solution for their faces)
3. Wash, rinse and dry the arms and legs using long,
firm strokes from distal to proximal areas (stroking
from distal to proximal areas stimulates venous
blood return)
4. Assess bath water temperature and change water
as necessary (to ensure warm temperature of water
for comfort). Changing water as necessary ensures
cleanliness of the water used for bathing the client
To ensure asepsis, always wash from clean areas to dirty
areas when possible
Back Rub
● The back rub is a massage of the back with two
chief objectives
1. to relax and relieve muscle tension
2. to stimulate blood circulation to the tissues and
muscles
Types of Techniques that Can be Used in Back Rub
● Effleurage– is a smooth, long stroke, moving the
hands up and down the back; the hands are moved
lightly down the sides of the back, maintaining
contact with the skin but are moved firmly up the
back
● Tapotement– in here the little finger side of each
hand is used in a sharp hacking movement on the
back; care must be taken with this types of rub to
not hurt the patient (also called tapping)
● Petrissage– is a large pinch of the skin,
subcutaneous tissue and muscle quickly done; the
pinches are taken first up the vertebral column and
then over the entire back (also called kneading)
Nursing Interventions
● Help client to side-lying or prone position
● Expose back, shoulders, upper arms and sacral
area; cover remainder of the body with bath
blankets (this prevents unnecessary exposure and
chilling while maintaining dignity)
● Wash hand in warm water; warm lotion by holding
container under running warm water; warm hands
and lotion prevent startle response and muscle
tension from cold hands and lotion
● Pour small amount of lotion into palms; lubricating
palms reduces friction on skin during massage
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● Massages sacral area with circular motion; move
hands upwards to shoulders, massaging over
scapulae in smooth, firm strokes; without removing
hands from skin, continue in smooth strokes to
upper arms and down sides of back to iliac crest;
continue for 3 to 5 minutes; continuous, firm strokes
promote relaxation and stimulate circulation
● Use petrissage over shoulders and gluteal area and
tapotement up and down the spine
● End massage with long, continuous, stroking
movements;stroking is the most relaxing of the
massage movement
PERINEAL-GENITAL CARE
Purposes of Perineal-Genital Care
1. To remove normal perineal secretions and odor
2. To prevent infection
3. To promote comfort
Nursing Interventions
● Inform the client and explain purpose of the
procedure
● Provide privacy (to maintain client dignity)
● Position and drape the client as follows:
● Female : Dorsal recumbent position; drape the
client diagonally
● Male: Supine position
● For female clients, use forceps to hold cotton balls
for cleansing the perineum
● For male clients, wear clean gloves
● For female clients
○ Use anterior
○ Use one cotton ball for each stroke
○ Cleanse perineum with soap/antiseptic
solution; include the inner thigh
○ Rinse the area with copious amount of
water (to remove soap adequately and
prevent irritation of the perineal area)
○ Dry perineum thoroughly; moisture
supports microbial growth
● For male clients
○ Wash and dry penis using firm strokes (to
prevent erection of the penis)
○ Use circular motion, from the tip of glans
penis towards the penile shaft
○ If the client is uncircumcised, retract the
prepuce (foreskin) (this is to remove
smegma that collects under the foreskin
and facilitates bacterial growth)
○ Wash and dry the scrotum and buttocks
● For post delivery or menstruating females, apply a
perineal pad as needed from front to back (this
prevents contamination of urethra and vagina from
anal area)
● Keep the client comfortable
● Do after-care of equipment
● Document relevant data
FOOT CARE
● Wash the feet daily, and dry them well especially
the interdigital spaces
● Use warm water for foot soak, to soften the nails
and loosen debris under them
● Soaking the feet of diabetic clients is no longer
encouraged because excessive moisture can
contribute to skin breakdown
● Use cream or lotion to moisten the skin and soften
calluses
● Use deodorant sprays or foot powder to prevent or
control unpleasant odor
● File toenails straight across (to prevent nail splitting
and tissue injury around nail)
● Change socks or stocking daily
● Wear comfortable, well-fitted pair of shoes
● Do not go barefooted
● Exercise the feet to improve circulation
● Avoid using constricting clothing or round garters
which may decrease circulation
● Avoid crossing the legs
● Avoid self-treatment for corns or calluses
Common Foot Problems
1. Callus –painless, flat, thickened epidermis, a mass
of keratotic material; often caused by pressure from
the shoe on bony prominence
2. Corn – keratosis caused by friction and pressure
from a shoe; it commonly affects the fourth and fifth
toe; it appears circular and raised
3. Unpleasant odors – this results from perspiration
and its interaction with microorganisms
4. Plantar warts – caused by virus papova-virus
hominis; they appear on the sole of the foot and are
moderately contagious; they are painful and make
walking difficult
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5. Fissures – caused by dryness and cracking of the
skin
6. Tinea Pedis – characterized by scaling and
cracking of the skin, particularly between the toes,
caused by a fungus; there may be blisters (also
athlete’s foot, ringworm of the foot)
7. Ingrown Toenail – inward growth of the nail,
causing trauma into soft tissues; it is usually due to
trimming the lateral edges of the toenail
NAIL CARE
● Trim nails straight across or follow the contour of
the fingers
● File nails to have smooth edges
● Do not trim nails at the lateral corners to prevent
ingrowns
● Diabetic clients are advised against cutting
hangnails or cuticles
● Ingrown is also called unguis incarnate
● Separation of the nail from the nailbed is
onycholysis
● Inflammation of the skin fold at the nail margin is
paronychia
MOUTH CARE
Measures to Prevent Tooth Decay
● Brush the teeth thoroughly after meals and at
bedtime
● Floss the teeth daily
● Ensure adequate intake of food rich in calcium,
phosphorus, Vitamins A, C, and D and fluoride
● Avoid sweet foods and drinks between meals
● Eat coarse, fibrous foods (cleansing foods) such as
fresh fruits and raw vegetables
● Have dental check up every 6 months
● Have topical fluoride applications as prescribed by
the dentists
Brushing and Flossing the Teeth
● Purposes
a. To remove food particles from around and between
the teeth
b. To remove dental plaque
c. To enhance the client’s feelings of well-being
d. To prevent sordes and infection of the oral tissues
● Inform the client and explain purpose of the
procedure
● Provide privacy
● Assist in sitting or side-lying position
● Place towel under the client’s chin
● Moisten bristles of toothbrush and apply dentifrice
● Hold kidney basin under the chin
● Allow the client to brush his teeth, if possible
● Use downward strokes for upper front teeth; upward
strokes for lower front teeth; back and forth strokes
for the biting surfaces of the teeth;and hold the
brush against the teeth with bristles at 45 degrees
angle to penetrate and clean under the gingival
margins
● Rinse the mouth with adequate amount of water;
floss the teeth
● Keep the client comfortable
● Do after-care of equipment and articles
● Document relevant data
For Unconscious Client
● Place in side-lying position to prevent aspiration
● Have suction apparatus readily available
● Use padded tongue blade to open the mouth
● Brush teeth and gums, using toothbrush or soft
sponge – ended swab
● Apply thin layer of petroleum jelly to lips to prevent
drying or cracking (lemon glycerine swabs can be
drying to oral mucosa if used for extended periods)
Care of Artificial Dentures
● Wear gloves when handling and cleansing dentures
● Place a wash cloth in basin or bowl of the sink
when brushing dentures to prevent damage if the
dentures are dropped
● Store the dentures in a container with water
Common Problems of the Mouth
1. Plaque – an invisible soft film of bacteria,
saliva,epithelial cells and leukocytes that adhere to
the enamel surface of the teeth
2. Tartar – a visible, hard deposit of plaque and
bacteria that forms at the gum lines
3. Halitosis – bad breath
4. Glossitis – inflammation of the tongue
5. Gingivitis – inflammation of the gums
6. Stomatitis – inflammation and dryness of the oral
mucosa
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7. Parotitis – inflammation of the parotid salivary
glands (mumps)
8. Sordes– accumulation of foul matter (food,
microorganisms and epithelial elements) on the
gums and teeth
9. Periodontal Disease – gums appear spongy and
bleeding (pyorrhoea )
10. Cheilosis – cracking of the lips
11. Dental Caries – teeth have darkened area, may be
painful (cavities)
HAIR CARE
● The appearance of the hair may reflect a person’s
sense of well being and health status
● Brushing and combing the hair stimulate circulation
of blood in the scalp; distribute the oil along the hair
shaft; help to arrange the hair
Hair Shampoo
● Purposes
● To stimulate the circulation of the blood in the scalp
through massage
● To clean the hair and improve the client’s sense of
well-being
Nursing Considerations
● Determine if the institution requires doctor’s order
for hair shampoo
● Place client diagonally in bed
● Remove pins from hair; comb and brush hair
thoroughly(this is to remove tangle)
● Place Kelly pad under the head, with neck
hyperextended
● The trough of the Kelly pad should be directed to a
pail (to prevent spillage of water onto the floor)
● Cover the eyes with wash cloth (to protect them
from irritation)
● Plug the ears with cotton balls (to prevent entry of
water into the external auditory canal)
● Apply small amount of shampoo
● Massage the scalp with fat pads of the fingers and
make a rich lather; massage promotes circulation in
the scalp; rich lather ensures through cleaning of
the air
● Rinse the hair thoroughly (soap residue in hair may
cause irritation of the scalp and may dry hair)
● Dry the hair thoroughly
● Keep the client comfortable
● Do after-care of equipment
● Make relevant documentation
Common Hair and Scalp Problems
1. Dandruff – is a chronic diffuse scaling of the
scalp,with pruritus (seborrheic dermatitis)
2. Alopecia – hair loss or baldness
3. Pediculosis– infestation with lice
a. Pediculosis capitis – is head louse
b. Pediculosis corporis – is body louse
c. Pediculosis pubis – is crab louse
● The usual treatment for pediculosis is gamma
benzene hexachloride (Kwell), which comes in
lotion, cream and shampoo. Pubic lice are difficult
to remove, so the shampoo may be applied and left
on for 12 to 24 hours
● Linens and clothing used by clients should be
washed in hot water
4. Scabies – contagious skin infestation by the itch
mite. The characteristic of the lesion is the burrow
produced by the female mite as it penetrates the
skin. The burrows are short, wavy, brown or black
threadlike lesions
EYE CARE
Nursing Interventions
● Cleanse the eyes from the inner canthus to the
outer canthus. Use a new cotton ball for each wipe
(to prevent contamination of the nasolacrimal ducts)
● If the client is comatose, cover the eyes with sterile
moist compresses (to prevent dryness and irritation
of the cornea)
● Eyeglass should be cleansed with warm water and
soap; dried with soft tissue
● Clean contact lens as directed by the manufacturer
● To remove artificial eyes, wear clean gloves,
depress the client’s lower eyelid
● Hold the artificial eye with thumb and index finger
● Clean the artificial eye with warm normal saline,
then place in a container with water or saline
solution
● Eyeglass should be cleansed with warm water and
soap; dried with soft tissue
● Clean contact lens as directed by the manufacturer
● To remove artificial eyes, wear clean gloves,
depress the client’s lower eyelid
● Hold the artificial eye with thumb and index finger
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● Clean the artificial eye with warm normal saline,
then place in a container with water or saline
solution
EAR CARE
Nursing Considerations
● Cleanse the pinna with moist wash cloth
● Remove visible cerumen by retracting the ears
downward (if this is ineffective, irrigate the ear as
ordered)
● Do not use bobby pins, toothpicks or cotton-tipped
applicators to remove cerumen (these can rupture
tympanic membrane or traumatize the ear canal).
Cotton–tipped applicators can push wax into the ear
canal, which can cause blockage
NOSE CARE
Nursing Considerations
● Clean nasal secretions by blowing the nose gently
into the soft tissue
● Both nares should be open when blowing the nose
(to prevent forcing debris into the middle ear, via the
Eustachian tube)
● May use cotton-tipped applicator moistened with
saline or water to remove encrusted, dried
secretions. Insert only up to cotton tip
SUPPORTING A HYGIENIC ENVIRONMENT:
BED MAKING
Types of Bed
1. Closed bed – bed which is covered to the top
2. Open bed – bed with the top sheet fan folded,ready
for a newly admitted client
3. Postop bed – bed ready to admit a client
recovering from anesthesia
4. Occupied bed – bed which is made with the client
in it
Purposes of Bed Making
1. To promote comfort of the client
2. To provide clean, neat environment
3. To provide a smooth, wrinkle-free bed foundation and
remove sources of skin irritation
Special Considerations in Bed Making
1. Practice good body mechanics (to prevent muscle
strain and back injury)
2. Strip one bed linen/sheet at a time (to check if
client’s valuables are present )
3. Finish one side of the bed at a time
4. Avoid overreaching of the bed at a time
5. Avoid fanning of soiled linens (may cause
contamination of the environment)
6. Confine surface of bed linen that has been in direct
with the environment (to prevent spread of
microorganisms)
7. Place the soiled linens in a pillow case, to be
discarded into a linen hamper (to prevent
contamination of the environment)
8. Keep soiled linens away from the uniform (to
prevent contamination of uniform)
9. Apply bed sheets in the following order:
● Bottom sheet
● Rubber sheet
● Draw sheet
● Top sheet and blanket (blanket is optional)
● Pillow case
10. Make mitered corner to ensure neat bed
11. The smooth surface of the bed sheets should come
in contact with the client’s skin
12. For post op bed:
● Place pillow against the head part
● Place towel
● Placement of rubber sheet and draw sheet depends
on the type of surgery
● Prepare the following at the bedside: IV pole,
emesis, basin BP apparatus, suction apparatus,
suction apparatus, oxygen device
13. For occupied bed, maintain safety of the client.
Another nurse must stay on the other side of the
bed or put up the side rail on the that side to
prevent falls
14. Maintain privacy of the client during the entire
procedure
15. Wash hands thoroughly after the procedure (to
prevent contamination with microorganisms and
maintain a safe environment)
Asepsis is an important consideration in bed making.
Drainage onto used linens may contain microorganisms that
can be transmitted through the air when linens are shaken
or through contact with the nurse’s hands or clothing.
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Handle linens carefully without shaking them. Wear gloves
during bed making if linen soiling is likely. Avoid touching
your clothing and wash your hands after handling soiled
linens.
NEUROSURGERY FOR RELIEF OF PAIN
● Neurectomy – interrupts cranial or peripheral
nerves by an incision
● Rhizotomy – interruption of the anterior or posterior
nerve root area close to the spinal cord
● Cordotomy or Spino thalamic Tractotomy – the
surgical interruption of pain-conducting pathways
within the spinal cord; the incision is made in the
anterolateral pathway opposite the side on which
the pain is located’
● Tractotomy – surgical resection of the anterolateral
pathway in the brainstem
● Gyrectomy– removal of the postcentralgyrus (part
of the sensory cortex of the brain)
● Hypophysectomy– destroying of the pituitary gland
by injection with absolute alcohol
Pain Modulation
● Endogenous Oploids – chemical regulators that
may modify pain
● Enkephalins– they inhibit the relese of substance
P, a neurotransmitter which enhances transmission
of pain impulses
● Endorphins – they are more potent than the
enkephalins
● Dynorphins– they have analgesic effect, which is
50 times more potent than endorphins
Three Stages of Pain Response
1. Activation - begins with the perception of pain; the
body assumes a fight or flight reaction, initiated by
the sympathetic nervous system
2. Rebound – the pain experienced is intense but
brief; the parasympathetic nervous system
dominates
3. Adaptation – this may due to endorphins
counteracting the pain; this occurs when the pain
lasts hours or days
MEDICATION ADMINISTRATION
Definition of Terms
● Medication (Drug)–a substance administered for
diagnosis, cure, treatment, relief or prevention of
disease
● Prescription Name – the name given to a drug
before it becomes official
● Official Name - the name after which the drug is
listed in one of the official publications
● Chemical Name – the name which describes the
constituents of dugs precisely
● Brand Name (Trademark) – the name given to a
drug by the manufacturer
● Pharmacology – the study of the effects of drugs
on living organism
● Posology – the study of dosage or amount of drugs
given in the treatment of diseases
Types of Doctor’s Order
1. Standing Order – it is carried out until the specified
period of time or until it is discontinued by another
order
2. Single Order – it is carried out for one time only
3. STAT Order – it is carried out at once or
immediately
4. PRN Order – it is carried out as the patient requires
Effects of the Drugs
● Therapeutic Effect (Desired Effect)– the primary
effects intended, that is the reason the drug is
prescribed
● Side Effect (Secondary Effect) – the effect of the
drug that is unintended
● Drug Allergy – the immunologic reaction to the
drug
● Anaphylactic Reaction – a severe allergic reaction
which usually occurs immediately following
administration of the drug
● Drug Tolerance – a decreased physiologic
response to the repeated administration of a drug or
chemically related substance (excessive increase in
the dosage is required in order to maintain the
desired therapeutic effect
● Cumulative Effect – it is the increasing response
to the repeated doses of a drug that occurs when
the rate of administration exceeds the rate of
metabolism or excretion
● Idiosyncratic Effect – it is the unexpected peculiar
response to the drug; either over response, under
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response, different response than
expected,unpredictable or unexplained responses
● Drug Abuse – inappropriate intake of a substance,
either continually or periodically
● Drug Dependence – it is a person’s reliance to
take a drug or substance (intense physical or
emotional disturbance is produced if the drug is
withdrawn)
● Addiction (Physical Dependence) – it is due to
biochemical changes in body tissues, especially the
nervous systems (these tissues come to require the
substance for normal functioning)
● Habituation (Psychological Dependence) – it is
the emotional reliance on a drug to maintain a
sense of well being accompanied by feelings of
need or cravings for the drug
● Drug Interaction – effects of one drug are modified
by the prior or concurrent administration of another
drug, thereby increasing or decreasing the
pharmacological action
● Drug Antagonism – conjoint effect of two drugs is
less than the drugs acting separately
● Summation– the combined effect of two drugs
produces a result that equals the sum of the
individual effects of each agent
● Synergism – the combined effects of drugs is
greater than the sum of each individual agent acting
independently
● Potentiation – the concurrent administration of two
drugs in which one drug increases the effect of the
other drug
PRINCIPLES IN ADMINISTERING MEDICATIONS
A. Observe the “10 Rights” of Drug Administration
1. Administer the right drug
2. Administer the drug to the right patient
3. Administer the right dose
4. Administer the drug by the right route
5. Administer the drug at the right time
6. Teach the patient about the drugs they are
receiving
7. Take a complete patient drug history
8. Find out if the patient has any allergies
9. Be aware of the potential drug’ interaction
10. Document each drug administered
B. Practice asepsis – wash hands before and after
preparing medications
C. Nurses who administer medications are responsible for
their own actions. Questions any order that you consider
incorrect (may be unclear or inappropriate)
D. Be knowledgeable about the medications that you
administer
❑A fundamental rule of safe drug administration is:
“Never administer an unfamiliar medications”
E. Keep narcotics in locked place
F. Use only medications that are in clearly labelled
containers (relabeling of drugs is the responsibility of the
pharmacist)
G. Return liquid that are cloudy in color to the pharmacy
H. Before administering the medication, identify the client
correctly
I. Do not leave the medication at the bedside (stay with the
client until he actually takes the medications)
J. The nurse who prepares the drug administers it. Only the
nurse who prepared the drug knows what that drug is (do
not accept endorsement of medications)
K. If the client vomits after taking the medication, report this
to the nurse in charge or physician
L. Preoperative medications are usually discontinued during
the postoperative period unless ordered to be continued
M. When a medication is omitted for any reason, record the
fact together with the reason
N. When a medication error is made, report it immediately
to the nurse in charge or physician. To implement necessary
measures immediately (this may prevent any adverse
effects of the drug)
ROUTES OF DRUG ADMINISTRATION
1. ORAL
● Advantages
a. most convenient
b. usually less expensive
c. safe, does not break skin barrier
● Disadvantages
a. inappropriate for client with nausea and vomiting
b. drugs may have unpleasant taste or odor
c. inappropriate if client cannot swallow and if GIT has
reduce motility
d. drugs may discolour the teeth
e. drug may irritate gastric mucosa
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MIDTERMS SY. 2023-2024

f. drug may be aspirated by a serious ill patient ● Application of medication to a circumscribed area of
Drug Forms for Oral Administration the body
● Solid: tablet, capsule, pill, powder
● Liquid: syrup, suspension, emulsion, elixir, milk, or A. DERMATOLOGIC - includes lotions, liniments and
other alkaline substances ointments
● Syrup: sugar – based liquid medication
● Suspension: water- based liquid medication. Shake ● Wash and pat dry area well before application to
the bottle before use of medication to properly mix it facilitate absorption
● Emulsion: oil-based liquid medication ● Use surgical asepsis when open wound is present
● Elixir: alcohol-based liquid medication. ● Remove previous application before the next
● After administration of elixir, allow 30 minutes to application
elapse before giving water (this allows maximum ● Apply only thin layer of medication to prevent
absorption of the medication) systemic absorption
2. SUBLINGUAL
● A drug that is placed under the tongue, where it B. OPHTHALMIC – includes instillation and irrigations
dissolves. When a medication is in capsule and 1. Instillations (to provide an eye medication that the
ordered sublingually, the fluid must be aspirated client requires)
from the capsule and placed under the tongue 2. Irrigation (to clear the eye of noxious or other
● Advantages foreign material)
a. same as oral, plus - C. OTIC – includes instillations and irrigations
b. drug can be administered for local effect ● Instillations
c. drug is rapidly absorbed in the bloodstream 1. to soften earwax
● Disadvantages 2. to reduce inflammation and treat infection
a. if swallowed, drug may be inactivated by gastric 3. to relieve pain
juices
b. drug must remain under the tongue until dissolved ● Irrigations
and absorbed 1. to remove cerumen or pus
3. BUCCAL 2. to apply heat
● A medication is held in the mouth against the 3. to remove foreign body
mucous membranes of the cheek until the drug D. NASAL– nasal instillations usually are instilled for their
dissolves. The medication should not be chewed, astringent effect (to shrink swollen mucous membrane), to
swallowed, or placed under the tongue (ex loosen secretions and facilitates drainage or treat infections
sustained release nitroglycerine, opiates, of the nasal cavity or sinuses ( ex. decongestants, steroids,
antiemetics, tranquilizers, sedatives) calcitonin)
E. INHALATION – use nebulizers, metered-dose
● Advantages inhalers (MDI)
a. same as oral, plus - F. VAGINAL
b. drug can be administered for local effect ● Advantage
c. ensures greater potency because drug directly 1. provides local therapeutic effect
enters the blood and bypass the liver
● Disadvantages
● Disadvantage 1. has limited use
a. if swallowed, drug may be inactivated by gastric
juice ● Drug Forms: tablet, liquid (douches), cream, jelly,
foam and suppository
4. TOPICAL ● Use applicator or sterile gloves for vaginal
administration of medications
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● Vaginal Irrigation (douche)– is the washing of the
vagina by a liquid at low pressure
5. RECTAL
● Advantage
1. can be used when the drug has objectionable taste
or odor
● Disadvantage
1. dose absorbed is unpredictable
6. PARENTERAL – the administration of medication
by needle
a. Intradermal – under the epidermis (ID)
b. Subcutaneous – into the subcutaneous tissue (SC)
c. Intramuscular – into the muscle (IM)
d. Intravenous – into the vein
e. Intraarterial – into the artery
f. Intraosseous – into the bone
INTRADERMAL INJECTION
● the administration of a drug into the dermal layer of
the skin beneath the epidermis
● The sites are the inner lower arm, upper chest and
back, and beneath the scapulae
● Indicated for allergy and tuberculin testing and for
vaccinations
● Use left arm for tuberculin tests; use right arm for all
other tests
● Use the needle gauge 25, 26, 27; needle length
3/8”, 5/8” or ½”needle at 10 – 15 degree angle;
bevel up
● Inject a small amount of drug slowly over 3 to 5
seconds to form a wheal or bleb
● Do not massage the site of injection (to prevent
irritation of the site, and to prevent absorption of the
drug into the subcutaneous)
SUBCUTANEOUS
● Drugs administered subcutaneously are as follows:
a. vaccines
b. preoperative medications
c. narcotics
d. insulin
e. heparin
● The sites are the outer aspects of the upper arms,
anterior aspect of the thighs, abdomen, scapular
areas of the upper back and ventrogluteal and
dorsogluteal areas
● Only small doses of medication should be injected
via SC route (0.5 to 1ml)
● Rotate sites of injection (to minimize tissue
damage)
● Needle length for adults are the same as for
intradermal injections
● Use 5/8 needle for adults when the injection is
administered at 45 degree angle; ½ is used at a 90
degree angle
● For thin patients: 45 degree angle of needle
● For obese patients: 90 degree angle of needle
● For heparin injection: do not aspirate; do not
massage the injection site (to prevent hematoma
formation)
● For insulin injection: do not massage (to prevent
rapid absorption which may result to hypoglycaemic
reaction); always inject insulin at 90 degree angle to
administer the medication in the packet between
the subcutaneous and muscle layer; adjust the
length of the needle, depending on the size of the
client
● For other medications, aspirate before injection of
medication to check if blood vessel had been hit; if
blood appears on pulling back of the plunger of the
syringe, remove the needle and discard the
medication and equipment
INTRAMUSCULAR INJECTIONS
● Needle length is 1”, 1 ½”, 2” (to reach the muscle
layer)
● Use needle gauge 20, 21, 22, 23, depending on the
viscosity of medication
● Clean the injection site with alcoholised cotton ball
(to reduce microorganisms in the area )
● Inject the medication slowly (to allow the tissues to
accommodate volume)
Sites
Ventrogluteal Site (von Hochsteter’s Site)
● Uses gluteusmedius which lies over the
● Gluteus minimus muscle
● The area contains no large nerves, or blood vessels
and less fat; it is farther from the rectal area, so it
less contaminated
Dorsogluteal Site
● Uses the gluteus medius muscle
● Position of the client is similar to ventrogluteal site
 FUNDAMENTALS OF NURSING PRACTICE
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● The site should not be used for infants under 3
years,because the gluteal muscles are not
well-developed yet
Avoid hitting the sciatic nerve, major blood vessel or bone
by locating the site properly
Vastus Lateralis
● Recommended site of injection for infants
● Located at the middle third of the anterior lateral
aspect of the thigh
Rectus Femoris Site
● Located at the middle third, anterior aspect of the
thigh
Deltoid Site
● Not used often for IM injection because it is
relatively small muscle and is very close to the
radial nerve and radial artery
● To locate the site, palpate the lower edge of the
acromion process and the midpoint on the lateral
aspect of the arm that is in line with the axilla; this is
approximately 5 cm (2 inches) or 2 to
fingerbreadths below the acromion process
Variation of the IM injection: Z – tract technique
● Used for parenteral iron preparation (to seal the
drug deep into the muscles and prevent permanent
staining of the skin)
● Retract the skin laterally, inject the medication
slowly; hold retraction of skin until the needle is
withdrawn
● Do not massage the site of injection (to prevent
leakage into subcutaneous)
GENERAL PRINCIPLES IN PARENTERAL
ADMINISTRATION OF MEDICATIONS
1. Check the doctor’s order
2. Identify the client properly (this ensured that the
medication is administered to the right client)
3. Practice asepsis (to prevent infection)
4. Use appropriate needle size (to prevent hitting
nerves, blood vessels, bones)
5. Plot the site of injection properly (to prevent hitting
nerves, blood vessels, bones)
6. Use separate needles for aspiration and injection of
medications (to prevent irritation of tissues)
7. Introduce air into the vial before aspiration (to
create positive pressure within the vial and to allow
easy withdrawal of the medication)
8. Allow a small air bubble (0.2 ml) in the syringe to
push the medication that they may remain in the
hub and lumen of the needle
9. Introduce the needle in a quick thrust (to lessen
discomfort)
10. Either spread or pinch muscle when introducing the
medication (depending on the size of the client)
11. Minimize discomfort by applying cold compress
over the injection site before introduction of
medication to numb nerve endings; apply warm
compress to improve circulation in the area
12. Aspirate before introduction of medication (to check
if blood vessel had been hit)
13. Support the tissues with cotton swabs before
withdrawal of needle (to prevent discomfort of
pulling tissues as needle is withdrawn)
14. Massage the site of injection (to hasten absorption)
15. Apply pressure at the site for few minutes (to
prevent bleeding)
16. Evaluate effectiveness of the procedure and make
relevant documentation
COMPLICATIONS OF IV INFUSION
Infiltration– the needle is out of vein, and fluids
accumulates in the subcutaneous tissues
● Assessment
✓Pain
✓Swelling
✓Skin is cold ay needle site
✓Pallor of the site
✓Flow of IV rate decreases or stops
✓Absence of backflow of blood into the tubing as the IV
fluid is put down, or the tubing is kinked
Nursing Interventions
1. Change the site of needle
2. Apply cold compress (this will reabsorb edema
fluids and reduce swelling “cold to cold” [cold skin,
cold compress])
Circulatory Overload– results from
administration of excessive volume of IV fluids
• Assessment
✓Headache
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✓Flushed skin 3. Turn patient to left side in the Trendelenburg

✓Rapid pulse rate position (to allow air to rise in the right side of the
✓Increased BP heart; this prevents pulmonary embolism)
✓Weight gain
✓Syncope or faintness Nerve Damage- may result from tying the arm too tightly to
✓Pulmonary edema the splint
✓ Increased venous pressure ● Assessment
✓ Coughing ✓ Numbness
✓SOB (shortness of breath) Nursing Interventions
✓Tachypnea 1. Massage area and move shoulder through its ROM
✓Shock 2. Instruct the patient to open and close hand several
Nursing Interventions times each hour
1. Slow infusion to KVO (Keep Vein Open – 10 3. Physical therapy may be required
gtts/min) Apply splint with the fingers free to move
2. Place patient in high Fowler’s position (to ease
breathing) Speed Shock- may result from administration of IV push
3. Administer diuretic, bronchodilator as ordered medications rapidly
Superficial Thrombophlebitis- it is due to overuse of a ● To avoid speed shock, and possible cardiac arrest,
vein, irritating solutions or drugs, clot formation, large bore give most IV push medications over 3 to 5 minutes
catheters
● Assessment
✓Pain along the course of vein
✓Vein may feel hard and cordlike
✓Edema and redness at needle insertion site
✓Arm feels warmer than the other arm
Nursing Interventions
1. Change IV site every 72 hours
2. Use large veins for irritating fluids
3. Stabilize venipuncture at area of flexion
4. Apply warm compress immediately to relieve pain
and inflammation [“warm to warm” (warm skin,
warm compress)]
Do not irrigate IV because this could push clot into the
systemic circulation

Air Embolism- air manages to get into the circulatory

system; 5 ml of air or more causes air embolism
● Assessment
✓Chest, shoulder, or back pain
✓Hypotension
✓Dyspnea
✓Cyanosis
✓Tachycardia
✓Increased venous pressure
✓Loss of consciousness
Nursing Interventions
1. Do not allow IV bottle to “run dry”
2. “Prime” IV tubing before starting infusion