NURSING PROCEDURES

1. Steam Inhalation

it is a dependent nursing action

Place the spout 12 - 18 in away from the client's nose or adjust the distance as necessary.

2. Suctioning

Assess the lungs before the procedure for baseline information.

Position: conscious - semi-fowlers... unconscious - lateral position

Hyper oxygenate before and after procedure

observe sterile technique

Apply suction during withdrawal of the catheter

Time: adult - 10 sec to maximum of 15 sec... pedia - maximum of 10sec

3. Nasogastric Feeding (gastric gavage) insertion

clean procedure not sterile - rationale: not all things that we ingest through mouth are sterile.

From tip of the nose to tip of the earlobe to the xyphoid - adult

from tip of the earlobe to the tip of the nose to xyphoid - pedia

4. Tube Feeding

Semi - fowler's position

Assess tube placement by: x-ray(most reliable), by pH or by placing the tip to the basin of water, if bubbles occur, it is not in the right place.

Assess residual feeding: it should be empty after 2 - 3 hrs... report to physician if it is more than 100 ml.

Height of feeding is 12 in. above

Ask client to remain upright position for at least 30 min

Most common problem: Diarrhea due to lactose intolerance

5. Enema

Check foe MD's order

provide privacy

position is left lateral

Insert 3 - 4 in of rectal tube

If abdominal cramps occur, temporarily stop the flow until the cramp is gone.

height of enema - 18 in

discontinue if there is bleeding and report to MD.

6. Urinary Catheterization

Verify MD's order

Practice strict asepsis

Provide privacy

Perineal care before the procedure

Catheter size: male 14 -16 , female 12 -14

Lenght of catheter insertion: male - 6-9 in., female - 3-4 in

For Retention CatheterMale - anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure.Female - inner aspect of the thigh.

7. Bed Bath

Provide privacy

Expose, wash and dry one body part at a time

Use warm water (110 -115F) 43 - 45C

Wash from cleanest to dirtiest or distal to proximal to increase venous return.

8. Foot Care

Soaking the feet of diabetic patient is no longer recommended

Cut nail straight across

9. Oral Care for Unconscious client

Place in side lying position

Have the suction apparatus readily available - to drain extra secretion if necessary

10. Hair Shampoo

Place client diagonally in bed

Cover the eyes with wash cloth

Plug the ears with cotton balls

Massage the scalp with the fatpads of the fingers to promote circulation in the scalp

11. Restraints

Secure MD's order for each episode of restraints application

Check circulation every 15 min

Remove restraints at least every 2 hrs. for 30 mins