CARING FOR CLIENT IN ISOLATION

DefinitionIsolation technique is used in certain patients with infectious diseases to prevent

the spread of the disease to other people.

Purpose:- To prevent transmitting to the infectious microorganism from the patient to

other patients and members of the medical team.- To avoid contaminating the medical equipment. Such as thermometer and BP apparatus being use to monitor health status of the patient.

Principle:- Always do the medical hand washing before and after entering the patients

room.- Always clean the medical equipment before and after patient’s use.- Bear in mind the medical precaution.- Always clean the least contaminated to the most contaminated area.

Equipment:- BP apparatus- Stethoscope- Cotton balls with alcohol- Cotton balls with soap- Cotton balls with water- Dry cotton balls - Paper lining- Gown- Gloves- Mask

Rationale:1. To be able to determine the recommended type of isolation and to be familiar

with the things to observe with the particular type of isolation.2. Proper planning and gathering of the necessary equipment saves time and

energy. Wrapping the watch and open the with paper prevents the microorganisms from harboring on them.

3. Preparing the equipment saves the time and energy.4. For the patient and his significant others to take the necessary precautions in

avoiding possible infections.5. Hand washing is one way if preventing the spread of microorganisms.6. To protect oneself from harboring microorganism

a. The inside part of the gown is considered cleanb. For proper fitting of the gownc. To secure the gown to the body

7. Paper lining is necessary because anything in the patient’s room is considered dirty.

8. Taking vital signs assesses the health status of the patient.9. The stem is considered as the least contaminated part, wiping in circular

motion promotes better removal of the microorganisms from the thermometer.10. To get the most accurate reading.11. To prepare the thermometer for the next use.12. Wrapping the clients arms with gown prevents direct skin-to-skin contact

between the nurse and the patient.13. To take the blood pressure using the safest way in avoiding the transfer of the

microorganisms.14. To assess the patient’s hemodynamic status.15. Recording the reading immediately for record purposes.16. The outer portion is not considered contaminated; placing it on the rack for

the next use.17. To provide care for the patient.18. It should be discarded for it is considered contaminated.19. To make the patient feel at ease.20. Proper removal of gloves helps prevent spread of microorganisms21. The string of the mask is considered the least contaminated part.22. To facilitate the removal of the gown. The universal precaution.23. The outside part of the gown is considered contaminated.24. To avoid contaminating the inside part of the gown.25. To prevent the spread of microorganisms.26. Hand washing is the most single effective way of preventing the spread of

disease.27. For safe keeping and documentation purposes.

References:www.allrefer.com

BAG TECHNIQUE

Definition:A tool making use of a public health bag through which the nurse, during his/her

home visit, can perform nursing procedures with ease and defines, saving time and effort with the end and view of rendering effective nurse care.

To render effective nurse care due to clients and/or members of the family during home visits.Principle:

1. The use of the bag should minimize if not totally to prevent the spread of infection from individuals to families, hence, to the community.

2. Bag technique should save time and effort on the part of the nurse in the performance of the nursing procedures.

3. Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family.

4. Bag technique can be performed in a variety ways depending upon agency policies, actual home situation, etc., as long as principles of avoiding transfer of infection is carried out.

Equipment: Paper lining Extra paper for making bag for

waste materials (paper bag) Plastic/ linen lining Apron Hand towel in plastic bag Soap in soap dish Thermometers (one oral and one

for rectal) 2 pairs of scissors (surgical and

bandage) 2 pairs of forceps (curved and

straight) Syringes (5ml and 2ml) Hypodermic needles g

19, 22, 23, 25 Sterile dressing Sterile cord tie Adhesive plaster Alcohol lamp Tape measure Baby’s scale 1 pair of rubber gloves 2 test tubes Test tube holder Medicines

Betadine solution 70% alcohol Opthalmic ointment Zephiran solution Hydrogen peroxide Spirit of ammonia Acetic acid Benedict’s solution

Rationale:1. To protect the bag from contamination.2. To be used for washing. To protect the work field from being wet.3. To make a non-contaminated work field or area.4. To prepare for hand washing.5. Hand washing prevents possible infection from care provider to the client.6. To protect the nurse’s uniform. Keeping the crease creates aesthetic appearance.7. To make them readily accessible.8. To prevent contamination of clean area.9. To give comfort and security, maintain personal hygiene and hasten recovery.10. To prevent contamination of bag and contents.11. To protect care giver and prevent spread of infection to others.12. To avoid microbes.13. To keep it organized.14. To avoid contamination.15. To be used as reference for future visit.16. For follow up care.

Reference:Reyala, Jean, et.al., Community Health Nursing Services in The Philippines, 9th

Edition, Philippines, 2000 pp. 54-58.

Self Breast Examination

Definition: Breast self examination is a technique that women uses to asses themselves.

Purposes:1. To detect early changes in their breast.2. To detect lumps or any abnormalities in the breast.3. For early detection of disease resulting in a greater chance of cure and less

complex treatment.

Principles:1. Self breast examination should be done 1 week before after menstruation.2. Self breast examination should be done at least once a month.

Rationale:Female (In front of the mirror)

1. Inspection of breast in the front of the mirror aids in the visualization of the breast which can easily detect unusual changes of the breast.

2. Clasping the hands behind the head and pressing forward exposes breast and allows the breast to hang to detect for any unusualities. This examines the lateral and under surfaces of each breast.

3. Pressing the hands firmly on hips tightens the pectoral muscles. Contraction of the pectoral muscles exaggerates signs of retraction or skin flattening. Slight bowing allows the breast to hang freely.

4. Self Breast examination is done in the shower because soapy hands glides more easily over wet skin thus palpating the breast with ease.

5. Raising the arms exposes the breast further. Palpation of the breast from the outer to inner quadrant ensures that the whole breast is covered and proper examined. Careful palpation would easily detect any masses and lumps of the breast.

6. Squeezing the nipples detect for abnormal discharges.7. To examine the other breast.

(Supine position)8. Lying flat on bed distribute tissues evenly on chest. The folded towel exposes the

breast further for thorough examination of the breast.9. To examine the other breast.

Male1. To detect abnormalities.2. To detect abnormalities.

References:Medical – Surgical Nursing 6th edition by Black, Hokanson, Hawks and Keen. Pages 920–922.

CRUTCH WALKING

Definition:Crutches are artificial supports that assist who need aid in walking because of

disease, injury or birth defect.

Purpose:1. To assist client

Who cannot bear any weight on one leg. Who have full weight bearing in both legs.

2. Prevent further injury to client have difficulty ambulating.

Principles:1. Asses clients physical limitation to determine safety and comfort.2. Take time show patients how to walk with crutches first to give time to learn to

use crutches.3. Maintain proper body mechanics.

Nursing Diagnosis:1. Impaired Physical Mobility R/T.2. Risk for injury R/T.3. Deficient knowledge, related to using assistive devices for mobility.4. Risk for falls R/T.

Equipments: Gait belt Crutches Tape measure Sturdy footwear, properly fitted

Rationale

Crutch walking1. Reduces anxiety; helps increase comprehension and cooperation; promotes

clients independence.2. Helps determines the clients capabilities and amount of assistance required.3. Provides broad base of support for the client. Space between the crutch pad

and axilla prevents pressure on radical nerves. The elbow flexion allows for space between the crutch pad and axilla.

4. Allows the clients to set with on the floor for stability.5. Allows for stabilization of blood pressure, thus preventing orthostatic

hypotension.6. Increases clients comprehension and cooperation.7. Provides support; promotes safety.8. Standing for a few minutes with assists in preventing orthostatic hypotension.

Four-Point Gait

9. The four-point gait (used for partial or full weight bearing) provides greater stability. Weight bearing is on three points (two crutches and one foot or two feet and one crutch) at all times. The clients must be able to bear weight both legs.

Three-Point Gait10. The three-point gait (used for partial weight bearing) provides a strong base of

support. This gait can be used if the client has a weak for non weight-bearing leg.

Two-Point Gait11. The two-point gait (used for partial weight bearing) provides a strong base of

support. The client must be able to bear weight on both legs. This gait is faster than the four-point gait.

Walking Up Stairs12. Prevents weight bearing on the weaker leg.

Walking Down Stairs13. Prevents weight bearing on the weaker leg.14. Crutch walking takes up to 10 times the energy required for unassisted

ambulation.15. The physical therapist is the expert on the health care team for crutch-walking

techniques.16. Reduces the transmission of organisms.

Reference:Susan Roe 2005. Delmar’s Clinical Nursing Skills and Concept. 1st Thompson

Asian Edition Thompson Delmar Learning. Pages 662-666.

ADMINISTERING CARDIOPULMONARY RESUSITATION (CPR)

Definition:A life saving skills to maintain tissue oxygenation by providing external cardiac comprehension.

Purposes:1. Establish airway2. Initiate breathing 3. Maintain circulation4. Elevate suffering 5. Prolong life

Principles:1. Maintain proper body mechanics2. Chest comprehension board3. Body substance isolating items

Gloves Face shield Mask/CPR oral barrier

4. Ambu bag5. Oral airway6. Emergency resuscitation cart7. Documentation forms

Rationale:

1. Prevent injury to the client who is not experiencing cardiac or respiratory assist, also assisting the level of consciousness.

2. Activates assistance from the personnel trained in advanced support. Also one person cannot perform CPR indefinitely. If the rescuer is alone, provide 1 minute CPR before activating the emergency responses system to help the risk of brain damage.

3. Proper positioning of facilities assessment of the cardiac and respiratory status and successful internal cardiac massage. And to prevent further head and neck injury.

4. Prevent transmission of disease.5. Proper positioning prevents rescuer fatigue and facilities CPR by allowing the

rescuer to move from the chest compression to artificial breathing with minimal movements.

6. A patients airway is essential to successful artificial respiratory. The head tilt assist in preventing the tongue from blocking the airway. The jaw thrust is uses when the head or neck injury is suspected because it prevents extension and decrease the potential for further injury.

7. CPR should not be administering to a client with spontaneous respiratory or pulse due to potential risk for injury.

8. Pressing the nostrils and performing all over the clients mouth will prevent air leakage and provide full infiltration of the lungs. Excessive air volume and rapid

inspiration flow rate can create pharyngeal pressures that are greater than the esophageal and opening pressure. That will allow air into the stomach. Resulting in gastric distention and increase vomiting.

9. Visual assessment of the chest movement helps confirm an open airway. A volume of 800-1200ml is sufficient to make the chest rise in most adult.

10. Performing chest comprehension on the individual with a pulse could result in injury. Additionally, the carotid pulse may persist. Hyperventilation assists in maintaining blood oxygen level.

11. Irreversible brain and tissue damage can occur if a clients is hypoxia for over 4-6 minutes. Proper positioning is essential for the following reason:

Allow maximum compression of the heart between the sternum and vertebrae.

Comprehension over the xyphoid process can lacerate the liver. Keeping fingers of the chest during the compression reduce the risk of the rib

fracture.

12. Faster rates increases blood flow to the key organ tissue.13. Determine return of the spontaneous pulse and respiratory and the need to continue

CPR.14. Proper positioning allows 1 rescuer to perform artificial respiratory while other

administers chest compressions without getting each others way.15. Two rescuer are needed because one person cannot maintain CPR. When rescuer

becomes fatigued chest compression can be ineffective.

Reference:www.allrefer.com

POST MASTECTOMY EXERCISE

Definition:These are exercises done by patients who underwent mastectomy or the surgical

removal of one or both breasts.Purposes:

1. To increase blood circulation 2. To increase muscular strength 3. Prevents joints stiffness and contractures4. To restore full range of motion of the arms and shoulders.

Principles:

Check the doctor’s order To be perform three times a day for 20 minutes at a time Let patient shower with warm water prior to exercise Administer analgesic 30 minutes prior to exercise If patient has a graft, exercise may need to be prescribed and introduced gradually

Equipment: Rod or broom stick (1.5 – 2 meters long) Rope (1.5 – 2 meters long)

Rationale:1. To be sure that the exercise is not contraindicated to the patient.2. To gain patient’s cooperation also give time for her to prepare.3. Allow patient full range of motion.4. This does not strain the patient while preparing her for more strenuous exercise.5. This increase circulation the muscular strength, prevent elbow and shoulder joints

stiffness and contracture, and restore full range of motion of the shoulders and arm.

6. This will prevent joint stiffness that may result to the frozen shoulder as a result of the surgery.

7. To restore arms and shoulder joints full range of motion and muscle strength, prevents stiffness as well as increase blood circulation.

8. To restore arms and joints full range of motion restore elbow strength.9. To restore the abduction and adduction range of motion of the shoulder joints to

prevent the “frozen shoulder” syndrome.10. To support muscle in the affected side during chest expansion.11. Allowing patient to rest for the next sessions of post mastectomy exercises.12. Records allow nurse and therapies to adjust patient’s capability.

Reference: Smeltzer, Suzanne C. and Bare, Brenda G. (2004), Brunner & Suddarth’s Textbook of Medical-Surgical Vol. 2. Lippincott Williams & Wilkins, Philadelphia. Pp. 1472-1473

Testicular Examination

Definition: It is examination of the testes to determine any abnormalities.

Purposes:1. To determine if there are abnormalities such as tumors, epididymitis, large

discrepancy in size and shape of the testes.2. As diagnostic procedure to screen the testicular cancer.

Principle:1. Always check doctor’s order.2. Obtain patient’s consent.3. If possible, it should be done in the presence of patients significant others.4. Wash hand and Don Gloves.5. Provide privacy.6. Better done after a warm shower.

Rationale:1. This is done to ensure that if the nurse will be the one to do it to the patient, the

nurse has to be sure that it was ordered to right patient.2. This is very important since it is the private part of the patient that the nurse is

going to examine. Explaining the procedure to the patient will also win cooperation of the patient during examination.

3. This is to prevent the microbes from the nurse’s hands to the testicles of the patient. This will also provide precautionary measures for the nurse in case the patient has lesions or secretions.

4. This will provide the nurse better view when observing the scrotum’s general size and appearance.

5. Swelling, nodules, redness, ulceration and distended veins are all abnormal findings and should be referred to the attending physician immediately.

6. This will provide better assessment as to the symmetry and difference of the testes.

7. To determine any abnormality. The epididymis should feel soft, spongy, and slightly tender.

8. To check for any abnormality. The use of the thumb and first two fingers will give the nurse a better fell of the testes since the testes can be slightly padded by the two fingers while the thumb is used to palpate.

9. Abnormal findings should be documented and referred to the attending physician immediately.

10. Serous fluid causes light to show with a red glow, tissue or blood does not transluminate.

11. For patient’s comfort and well being.12. To prevent spread of microorganism.13. Ready for the next user and prevent the spread of microbes.14. For documentation purposes.

Reference:Medical-Surgical Nursing 6th edition by Black, Hawks and Keen.

TRACHEOSTOMY CARE

Definition:A care given with tracheostomy tube inserted directly into the trachea and the

level of the second or third tracheal ring through a surgically made incision.

Purposes:

1. Permits mechanics ventilation facilitates secretion removal.2. Can be for long term when ET intubation has been used more than 14 days.3. have extra tracheostomy tube obturator and hemostats at beside.

Equipment: Sterile towel Sterile gauze sponges 12 Track sparks Sterile cotton swabs Sterile gloves Face shield Hydrogen revoxide Sterile water Antiseptic solution and ointment (optimal) Tracheostomy the tape or commercially available tracheostomy securing

device.

Rational:1. To know if there is necessity of care.2. To alley anxiety and promote compliance and cooperation.3. To save time and effort.4. To promote self sense and privacy.5. Promotes proper positioning.6. Universal precaution in transmission of disease.7. Use of 100% oxygen will help hypoxemia. Make sure all equipment is functional

before sterile technique is institute to prevent interruption.8. To promote comfort.9. a.) provide sterile field.

b.) for removal of muscus and crust, which promotes bacterial growth.c.) Use for the removal of mucus.

10. The hand designates as sterile must remain uncontaminated so organisms are not introduce to the lungs. The contaminated hand must also be gloved to prevent sputum from contracting the nurse’s hand possibility resulting an infection of the nurse.

11. Prevents contamination of the connection.12. Because cannula is dirty when you remove it.13. Hydrogen proxide may help loosen dry crusted secretions.14. Suctioning on insertion would be unnecessarily decrease oxygen in the airway.15. Suctioning removes oxygen as well as secretion and may also cause vagal

stimulation.

16. Repeated suctioning of a patient in a short time interval predisposes to hypoxemia, as well as being tiring and traumatic to the patient.

17. To stop the suctioning.18. It is consider sterile once you clean it.19. To put it back in place.20. To clean it by using hydrogen peroxide.21. To maintain sterility.22. Soiled materials should discarded to avoid spread microorganisms.23. For patient comfort and maintain airway patency.24. For the next use.25. For cleanse equipment maybe for the next use.26. To ready for the next use.27. To evaluate the effectiveness and for legal documents.

Reference:Santa M. Netti, Lippincott Manual of Nursing Practice 7th Edition Vol. 1 pages

227-229, 218-221

ENDOTRACHEAL INTUBATION

Definition:A procedure done by the physician through the mouth and nose using flexing that

acts as an artificial airway.

Purposes:1. Allows for deep suction and removal of secretions.2. Permits mechanical ventilation.3. Inflated balloon seals off trachea so aspiration from the GI tract cannot occur.

Principle:1 Maintain aseptic technique.2 Assemble all materials.3 Explain procedure to the patient.

Equipment:- Laryngoscope with curve or straight blade and working light source- Endotracheal tube with low pressure cuff and adapter to connect tube to

ventilator or resuscitation bag- Stylet to guide the ET tube- Bite block to keep patient from biting into and occluding the ET tube adhesive

tape- Sterile anesthetic lubricant jelly- 10ml syringe- Suction source - Suction catheter- Gloves - Sterile towel - Face shield/Mask- Resuscitation bag connected to oxygen source

Rationale:1. Provides a baseline to estimate patient’s tolerance of procedure.2. May interfere with insertion. Will not be able to remove easily from patient

once intubated.3. a. Pt may require ventilatory assistance during procedure. Suction should be

functional, because gagging and emesis may occur during procedure.b. Ensure good light for clear visibility.c. Establish right ventilatory long requirement.d. Maintains sterility and prevent iatrogenic contamination of the distal end of the tube.e. Malfunction of the cuff must be ascertained before tube placement occurs.f. Aids in insertion.g. Stiffens the soft tube allowing to be more easily directed.

4. To check if NGT is in place.5. Provide alternative means of communication.6. Promote Pt safety & maintain sterile technique.

7. Prevents contract with pt’s oral secretions.8. Upper airway is open maximally in this position.9. Will decrease gagging.10. Decrease of possibility cardiac arrythmias or respiratory distress sec. to hypoxia.11. Leverage is improved by crossing the thumb and index fingers when the pt’s mouth.12. Rolling the lip away from the teeth prevents injury by being caught between teeth and blade.13. Do not use teeth as a fulcrum, this could lead to dental damage.14. This stretches the hypoepiglottis ligament folding the epiglottis upward and exposing the glottis.15. Do not use the wrist. Use the shoulder and arm to lift the epiglottis.16. Make sure that you don’t insert into esophagus, the esophageal mucosa in pink and the opening is horizontal rather than vertical.17. If vocal cords is in spasms (closed). Wait a few seconds before passing the tube.18. Advancing tube further may lead to its entry into mainstem bronchus (usually the right bronchus) causing collapse of the unventilated lung.19. For proper placement and procedure process.20. Listen over the cuff area with a stethoscope. Occlusion occurs when no air leak is heard during ventilator inspiration or compression of the resuscitation bag.21. This keeps the pt from biting down the tube and obstructing the airway.22. Observation and auscultation help in determining that the tube remains in position and has not slipped into the right mainstem bronchus.23. For detection of any later change in tube position.24. The tube must be fixed securely to ensure that it will not be dislodged. Dislodgement of a tube with an inflated cuff may result in damage to the vocal cords.25. To advance or remove several cm. for proper placement.

Reference:Lippincott Williams & Wilkins, Philadelphia

TAKING ELECTROCARDIGRAM

Definition:It is the graphical recording of the activities of the heart. It indicates alternations

of myocardial oxygenation.

Purposes:1. To diagnose recording of the electrical activities of the heart such as:

MI, Angina Pectoris Cardiac dysrythmias Cardiomegaly Electrolyte disturbances (K+ Ca+ Levels) Inflammatory disease of the heart Effects of drugs ( e.g Digoxin)

Principles:1. Place leads properly to accurate reading2. Explain procedure to the patient that procedure is painless and he will not

experience electrical shock3. Provide privacy

Equipment: ECG machine Cotton balls with alcohol

Rationale:1. To gain patients cooperation and reduce anxiety.2. To save time and effort.3. Provide privacy to the patient.4. Provide comfort to the patient and allow easy access to chest area.5. To expose area where electrodes will be placed.6. To gain accurate reading.7. To proper use and in order to accurate reading.8. For good electrical ground.9. To ensure correct reading.10. To start reading the activity of the heart.11. To prepare the machine for the next use.12. To identify patient and obtain baseline data for succeeding ECG reading result

comparison.13. For easy access/ reading of ECG results by physician.14. For proper interpretation and intervention.15. To prepare machine for the next use.

Reference:Sandra M. Nettina. Lippincott Manual of Nursing Practice.7th Philippine Edition.Pages 315-318

GLASSGOW COMA SCALE

Definition:It is an objective evaluation of the level of consciousness, motor and verbal

response of the patient.

Purposes: To assess the level of consciousness, motor and verbal response of the patient

especially comatose patient. To check progress of the patient LOC For diagnostic purposes.

Principle: Always explain the procedure to the patient or significant others. Wash hands before and after the procedure. Provide comfort and privacy.

Equipment: Penlight

Rationale:1. To gain patients cooperation.2. To prevent contamination.3. To check if patient will respond by calling his/her name4. To check if patient will respond to pain.5. To properly score the eye opening of the patient.6. To check if the patient is oriented to time and place.7. To properly score the verbal response of the patient.8. To assess patients capability to follow direction.9. To check if the patient respond to pain.10. To properly score the motor response of the patient.11. To sum up the total score for proper documentation purposes.12. For proper management.13. To provide comfort to the patient.

Reference:The Manual of Nursing Practice 7th Edition, page 446