THERAPEUTIC PROCEDURES

SELECTED TOPICS ON COMMON NURSING PROCEDURES

UNIVERSAL PRECAUTIONS

HANDWASHINGBARRIER METHODSTERILIZATION AND DISINFECTION IMMUNIZATIONENVIRONMENTAL CONTROL AND

SANITATION ISOLATION

SURGICAL ASEPSIS

MAINTENANCE OF STERILE FIELD

MEDICAL AND SURGICAL ASEPTIC TECHNIQUES

THERAPEUTIC EXERCISES

ISOMETRIC ISOTONIC

ROM

CHEST PHYSIOTHERAPY

BREATHINGCOUGHING\POSTURAL DRAINANGEPERCUSSION AND VIBRATION INCENTIVE SPIROMETERSUCTIONINGTRACHEOSTOMY CAREOXYGEN THERAPY

Chest Physiotherapy It is the combination of percussion, vibration, and

postural drainage Percussion is done for 1-2 minutes. If the patient has

tenacious secretions, this can be performed for 3-5 minutes

Vibration is done during 5 exhalations Postural drainage is done for 15-20 minutes usually

performed 3-4 times a day. Instruct the client to increase fluid intake to liquefy

secretions This procedure should not be performed in clients who

are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.

This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy Indicated to clients who needs additional

oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.

Humidify the oxygen first before you administer.

Check for bubbles in the humidifier to promote adequate flow of oxygen

Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking:

Oxygen is in used” Instruct the client not to use woolen blankets

as this may create static electricity

pulmonary function tests tidal volume- 500 residual volume- 1200 expiratory reserve volume –1200 inspiratory reserve volume – 3100

Vital Capacity- tidal volume + IRV + ERV = 4800

Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000

Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H

endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly

visualization – X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray +

post Procedural

Tracheostomy Care tie new trache tie before removing the

old tie to prevent accidental dislodgement

use precut gauze and perform care OD at least.

soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well

suction prn, oral care prn

Oxygen Delivery Equipment cannula – 2-6 LPM – 24-45% Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask –

2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%

Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: Hyperoxygenate the patient before and after the procedure. Apply intermittent suction on withdrawal of the catheter. Do not suction the patient for more than 15 seconds. Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. NURSING ALERT: Check the consent. Position: Sitting on the side of the bed with feet on a chair, leaning

over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder.

Instruct the patient not to cough, breath deeply or move during the procedure.

After the procedure: Position the patient on the unaffected side/puncture site up.

Check for bleeding at the puncture site and monitor the respiratory function.

Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.

ENEMA

They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.

Enemas serve the following purpose: Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic

procedures Administration of medications

ENEMA Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches Position: adult- left lateral; infants and

children- dorsal recumbent Administration- administer the enema in a

minimum of 15 minutes duration. Conatainer’s Height- 12 inches above the

rectum Temperature- 42°C or less

types: carminative – expel flatus – 60 –180 ml. retention oil – 1 –3 hours(LUBRICANTS) BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI wetting/stool softeners- Colace(days) Chemical hypertonic irritant-increases peristalsis-

castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN

Saline- Epson salts, milk of mg(rapid)/mg citrate return flow – haris flushing , colon irrigation fleet – commercial

oil 1-3 H retention others – 5 to 10 mins.

cleansing- irritating( hypertonic osmotic)) high 1000 ml low 500 ml

T = 40-43 ‘ C ( 105 – 110 ‘ F CHILDREN 37.7 ( 100 ‘ F) APPROXIMATELY 30 CM ( 12 INCHES) BUT

HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.

INSERT 7 – 10 CM ( 3-4 INCH)-ADULT 5 – 7.5 CM. –CHILD 2.5 – 3.5 – INFANT

IF FEELING OF FULLNESS – CLAMP – 30 SECS

amount 18 mos – 50-200 ml 18 mos – 5 y – 200-300 ml 5 – 12 years – 300 – 500 ml 12 – above – 500 – 1000 ml.

rectal tubes infants-10-12F toddler – 14 –16F school age – 16-18F adult – 22 – 30F

ENEMAS- PRESCRIBED AMOUNT AND TIMEHYPERTONIC – 5-10MINS – VARIESHYPOTONIC(TAP)-15-20MIN – 500-

1000ML ISOTONIC(SALINE)-15-20MIN- 50MLSOAP SUDS- 10-15MIN- + 3-5 ML.

SOAPoil( MINERAL/COTTONSEED) – 30-60

MIN- 90-120ML.

COLOSTOMY CAREostomy – divert and drain fecal material

temporary ( trauma / inflammatory condition)

permanent ( Cancer / congenital or Birth defects

stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

parts: periostomal seal adhesive square –

solid wafer disk skin barrier

liquid skin sealant drainable end pouch ( Can be washable) pouch belt face plate

ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full

colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation

avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended

dry skin before applying appliancekaraya – barrier to prevent

contamination with excretaappliance can be up to 2 weeksbroadwell 48 – 72 hours to check for

periostomal skin24-48 hours if eroded / ulcerated refer to enterostomal therapy nursewith deodorant ( Charcoal filter Disk)

Catheterization, urinary

PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.

NURSING ALERT:      Know the necessary facts:

Principles Male Female Position Supine Dorsal recumbent Length of tube 40 cm./ 15.75 in. 22cm./ 8.66

in. French number or Circumference #14- 16 #18 Length of tube to be inserted 2-3 in. 6-9 in. Balloon size 5-10 ml. (30 ml 5-10 ml Can be used to achieve hemostasis of the prostatic area following prostatectomy Place to secure lower abdomen Inner thigh

      The procedure is sterile      Maintain a close system      The draining bag must always be

below the bladder       The catheter bag should not be

allowed to lie on the floor      Do not allow the drainage spout to

touch the collection receptacle or on the toilet bowl when draining it

CATHETER CHANGE

PLASTIC – 1 WEEKLATEX – 2-3 WEEKSSILICONE – 2-3 MOS.PVC – 4-6 WEEKS

CLOSED INTERMITTENT IRRIGATION

ASPIRATE FROM PORTCBI -3 WAY FOLEY CAHETERCATHETER IRRIGATION ONLY – 200

ML.BLADDER IRRIGATION – 1000MLCLAMPS ON BOTH SIDES –

ALTERNATELY RELEASED

URINARY DIVERSIONS-URINARY STOMA

ILEAL CONDUIT- EXTERNAL POUCHKOCK POUCH – SMALL DRESSING

OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN

SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS

NORMAL AMOUNT/ DAY

1-3 / 500-600ML3-5 / 600-700ML5-8 / 700-100OML8-14 / 800 – 1400ML14 – ADULT / 1500 – 2500

CAN HOLD 500 – 750 ML

Bladder training Q2 hours and 30 mins void(Trigerring, Credes

and valsalva)

NEUROGENIC BLADDERIntermitent Catheterization – 2-3 hours if

<150ml ----3-4 Hweaning-intermittent clampingDTV 1-4 hours after removal

for incontinence – kegels exercises

HEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR

CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR

BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM

SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-COMPLICATIONS

PERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETER WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY

OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V

PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION

TYPES: CAPD(4-6H INDWELLING), AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING

DRESSINGS PROTECT FROM INJURY , BACTERIAL

CONTAMINATION PROVIDE HUMIDITY INSULATION ABSORB DRAINAGE DEBRIDE THE WOUND PREVENT HEMORRHAGE SPLINT / IMMOBILIZE COMFORT

GUAZE, SYNTHETIC , SECURING, TEGADERM

TYPES OF DRESSINGS DRY TO DRY – TRAP NECROTIC DEBRIS

AND EXUDATE WET TO DRY ( SALINE AND ANTI

MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE

WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)

WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE

WOUND HEALING HEMOSTASIS---FIBRIN----

PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS

FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS

MATURATION(PHASE 21 DAYS – 2 YEARS)

pressure ulcer dressings

dry gauze stage II-IV tegaderm film/ hydrocolloid – SI - SIIAbsorptive Dressing IIIHydrogel – II - III

WOUND CARE PRIMARY SECONDARY- INCREASED INFECTION

INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)

TERTIARY- ABD. DRAINAGE

EXUDATES – SUPPURATION PUS – ABCESS( PYOGENIC BACTERIA)

SURGICAL DRAINS PENROSE – OPEN ENDS CLOSED WOUND DRAINAGE ( SUCTION) –

DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR

D/C 3-7 DAYS POST – OP PACKAGE – FACILITATE GRANULATION IRRIGATION LAVAGE - STERILE

CHEST TUBES AND DRAINAGE SYSTEMS 1-DRAINAGE 2-WATERSEAL 3-COLLECTION/SUCTION

SEALED PATENCY-AFTER 3 DAYS REEXPANDED

FLUCTUATIONS IN WATER SEAL CHAMBER

RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

NUTRITIONAL SUPPORT

NGT-GAVAGE AND LAVAGE

TPN

Nasogastric Tube Insertion Purposes:

Gastric Gavage- gastric feeding Gastric Lavage- stomach irrigation For decompression Medication and supplemental fluid administration

Principles: Position: High-Fowler’s position Length of tube to be inserted: measured from

the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.

Lubricate the tip of the tube by a water soluble lubricant before insertion

Secure the NGT by taping to the bridge of the nose

Gastroenteral Feedings This is the administration of formula through a tube

placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall.

Remember these principles: Position: fowler’s or sitting position Prior to feeding, assess the bowel sounds and residual

content Assess for tube placement and patency:

Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated.

X-ray most accurate Aspirate gastric content Immerse the tip of the tube in water, no bubbles must be

produced. Height of feeding: 12 inches above the patient’s point

of insertion Instill 60 ml of water into the NGT after feeding to

cleanse the lumen of the tube

TOTAL PARENTERAL NUTRITION

peripheral< 2 weeks – phlebitisPIC – Basilic / cephalicPCC – subclavianTriple Lumen- infuse and draw

blood;TPN;MedicationsAtrial- Hickman/Biovac and Groshong;

Huber needle port

TOTAL PARENTERAL NUTRITION TPN-IV with bacterial filter(2-3L) TNA – 1 liter/D-no filter If no available solution D10W –ok –initial at

50ml/hr

hyperglycemia- hyperosmolar(HA, N and Vomiting,fever, chills, malaise)

Infection ( IV tubing and filter Q24 changed,solutions refrigerated and warmed just prior to administration

Pneumothorax

Heat and Cold Therapy An intervention the reduces inflammation Principles: Cold application is generally safer than heat

application. Heat application usually requires a doctor’s

order Cold application is done within 72 hours after

an injury, while heat application is done after 72 hours.

The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes)

Check the area applications are done every 15 minutes.

Anti-embolism Stocking Helps prevents thrombophlebitis by promoting

venous return from the legs It usually requires a doctor’s order The client’s extremeties must be properly

measured to assure therapeutic effect Apply stockings before getting out of bed. If

the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes

The stockings must be removed every 8 hours for 20-30 minutes

Assess the skin integrity

DOSAGES AND CALCULATION CONVERSIONS MEDICATION DOSAGES

D/A X V = Q INFUSIONS

TOTAL VOLUME X DROP FACTORTIME IN HOUR ( 60 MIN.)

THERAPEUTIC DOSE CLARKS RULE BSA COMPUTATION IV INFUSION FOR BURNS

MEDICATION ADMINISTRATION

RIGHT DRUGRIGHT DOSAGERIGHT ROUTERIGHT TIMERIGHT PATIENTRIGHT ATTITUDE RIGHT DOCUMENTATION

PARENTERAL ADMINISTRATION• IM – G 18-21 ; 1 1/2 INCH, Z-TRACK ( RETRACT) SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO

NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN)

• INTRADERMAL- 10-15’; G26-27;1\2 INCH BEVEL UP

• INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW

IV THERAPY

backflow means patent linesolutions for specific diseases and

contraindications of certain solutionsmanagement and troubleshootingcheck for phlebitis and infiltrationchange line everydaykeep site sterile

BLOOD TRANSFUSION line – PNSS vital signs – baseline then Q15 x 4; Q30 x 2;

then q h 4 –6 hours blood typing and crossmatching watch out for blood transfusion reactions

hemolytic anaphylactic febrile hypervolemic septic

Hygiene and comfort measures

BEDMAKING- ODPERINEAL CARE – FRONT TO BACK

OUTER TO INNER, ONE COTTONBALL PER STROKE

BEDBATHING AND ND SHAMPOOFOOT, HAIR , SKIN AND NAIL CAREORAL CAREEYE AND EAR CARE

THERAPEUTIC BATH SALINE – 4 ML- 500 ML OATMEAL/AVENO – SOOTHES SKIN

IRRITATION, LUBRICATES CORNSTARCH- IN COLD WATER –

SOOTHES IRRITATION Na CHO3 – 4 ml. – 500 ml H2O

cooling / relieves irritation KMnO4 – tablets dissolved in H2O – clears and

disinfects

Rotating Tourniquet GET MEAN APPLY PRESSURE TO 3 LIMBS ONE AT A

TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES

DO NOT RELEASE SIMULTANEOUSLY PATIENT IN ORTHOPNEIC / FOWLERS

POSITION

CPR and ACPLS Protocols 0-1 MINUTE ; CARDIAC IRRITABILITY 0-4 MINUTES; BRAIN DAMAGE NOT

LIKELY 4-6 MINUTES; BRAIN DAMAGE POSSIBLE 6-10 MINUTES; BRAIN DAMAGE LIKELY 10 MINUTES-IRREVERSIBLE BRAIN

DAMAGE

INFANTS HTCL MANEUVER, JAW THRUST IF

SPINAL INJURY IS SUSPECTED INITIAL BREATHS – 2 – 1 1/2 SECS SUBSEQUENT BREATHS 1 B/3 SECS; 20

BPM USE 2 OR 3 FINGERS DEPTH:1/2 TO 1 INCH COMPRESSION AT LEAST 100/MIN RATIO 5:1; CHECK AFTER 20 CYCLES FOREIGN BODY OBSTRUCTIONS:

BACKBLOWS AND CHEST THRUST

CHILDREN HTCL / JAW THRUST 2 BREATHS INITIAL DURATION OF 1- 1 ½

SECS SUBSEQUENT 1 BREATH EVERY 3

SECONDS 20 BREATHS/ MIN CAROTID ARTERY HEEL OF HAND 1 TO 1 1\2 INCH 100 BPM; CHECK AFTER 12 CYCLES ABDOMINAL THRUST- FOR AIRWAY

OBSTRUCTION

ADULTSHTCL / JAW THRUST INITIAL 2 BREATHS AT LEAST 2

SECS EACHDEPRESS 1 ½ - 2 INCHES; RATE 60

TO 100RATIO 5:1AFTER 4 CYCLES ;RECHECK FOR 10

SECS

ERGONOMICS

TRANSFER TECHNIQUESBODY POSITIONING BODY MECHANICS