SPAN OF

DUTY
REVISION

Guidelines for presenting your patient

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1.Name

2.Age with Developmental stage

3. Diagnosis and Date of admission

4.Why they were admitted (whether elective surgery or if emergency state chief complaints)

5.Social History (light, water, married or single, how much children, if a smoker or drinker, occupation, church)

6. Past Medical History (Sickness and how long ago)

7. Past surgical history (and how long)

8. Allergies (to food or meds)

9. Laboratory values and diagnostic tests

10. Current management of patient (why patient in hospital still example patient being managed for pain)

11. Medications (side effects, action, class, nursing implications etc)

12. Assessment of Patient (How you received them)

13. Nursing Diagnoses

14. Outcome

15. Interventions with Rationales

16. Evaluation

17. Legal and ethical Issues

18. Health Promotion Activity

DVELOPMENTAL STAGES
ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

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NB. Avoid saying according to Erikson, Patient X is going through intimacy vs isolation……. Instead, say
according to Erikson’s stages of psychosocial development, at the age of 25 the focus is on relationships. At this
age, the conflict is intimacy vs. isolation. Based on my assessment, Patient X is at the less favourable side, isolation.
This is evidenced by……

PATIENT’S HISTORY
 Chief Complaint: “Reason For Hospitalization”

The answer given to the question “What is troubling you?” or “Can you tell me the reason you came to the
hospital?”

Examples of chief complaints: Chest pain for 3 days, swollen ankles for 2 weeks, fever and headache for 24
hours or abdominal pains and PR bleeding 2 days.

*Must include why they decided to come to the hospital. E.g. Swollen ankles for 2 weeks but came to
emergency room 2 days ago as it got red and warm.

 Admitted for surgery (What type, when it was done, what type of anaesthesia)
 History of present illness (HPI)

Gather information relevant to the chief complaint, and the client's problem, including essential and relevant
data, and self-medical treatment.

 Social History

Light, water, married or single, how much children, if a smoker or drinker, occupation, church, etc.

 Family History

Ask questions about immediate family members and diseases listed in PMH to identify any illness of
environmental, genetic, or familial nature that might have implications for the client's health problems.

 Past Medical and Surgical History

This includes:

 Previous similar illness/es – details

 General health in the past
 Illnesses-include chronic illnesses-eg. Diabetes, hypertension, strokes, etc.

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  Childhood illness e.g. history of rheumatic fever.
 History of accidents and disabling injuries

 History of hospitalization (time of admission, date, admitting complaint, discharge diagnosis and follow up
care.)
 History of operations "how and why this done"

PHYSICAL ASSESSMENTS
Techniques

The following techniques are used in physical examination of each specific area of the body:

Inspection- visual examination; must be systematic; Describe what you see not what you think. (Ex: swollen joints,
not arthritis).

Palpation- examination using the sense of touch. Used to determine temperature, position (location), size, texture
(masses, fluids), vibration (joints), tenderness/pain, rate(pulse).Light (.5-1”) then deep (1.5-2”).

Percussion- method by which the body is struck indirectly to elicit sounds. Sounds produced: flatness (bone);
dullness (liver); resonance (lungs); hyper resonance (emphysema/lung); tympani (abdomen). May be performed
directly or indirectly.

Auscultation- Listening to sounds in body; direct (use of ear) or indirect with a stethoscope. The diaphragm (flat) is
used for high-pitched sounds (breath, normal heart sounds, bowel sounds). The bell is used for low-pitched sounds
(abnormal heart sounds, bruit). Tubing should be short; earpieces pointed toward nose.

**Physical exam always in order of: inspection, palpation, percussion, auscultation except on the abdomen; then
inspection auscultation before palpation and percussion.

 The Integument

Assessed by inspection and palpation.

Color: Pallor (decrease blood supply); cyanosis (bluish tint- decreased oxygenation); jaundice (yellow- due to
increased bilirubin); erythematous (inflammation or rashes).

Moisture: Excessive sweating (diaphoresis); excessive dryness (elderly).

Temperature: Hypothermia (fever); coolness- decreased circulation.

Turgor: Elasticity r/t hydration- assess on back of hand. Poor turgor: skin remains tented >3 sec.

Lesions/Rashes: Should be described in terms of size, color, type (primary or secondary) and location.

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Primary lesions (appear initially):

 Macule: flat up to 1 cm in size- freckle.

 Papule: elevated, solid; <1cm- pimple, wart
 Nodule: solid mass, deeper than papule.
 Vesicle: fluid filled, defined-blister; chickenpox.
 Bulla: large, elevated, fluid filled- hives.
 Pustule: pus filled, <1cm- acne, impetigo.
 Wheal: irregularly shaped fluid collection- hive
 Plaque: raised solid lesion.

Secondary Lesion (results from change in primary):

 Scale: dried fragments of cells- dandruff, psoriasis

 Scar: formation of fibrous tissue after healing
 Fissure: linear crack-athlete’s foot
 Ulcer: excavation of epidermis- stasis ulcer
 Crust: dried serum- impetigo
 Keloid: hypertrophied scar

Hair: Assesses for distribution (hirsutism); texture, infestation; fullness or loss (alopecia).

Nails: Assessed for shaped (clubbing) color (blanch test); texture (infection)

 Clubbing- angle between nail and nail bed is 180 degrees or > (normal is 160); indicates circ/resp. problem.
Seen in patients with prolonged/chronic hypoxia.
 Capillary Refill- blanch test- when nail is pressed color should return promptly (< 3 sec); may indicate
circulatory or respiratory problem.

 Head and Face

Assessed by inspection and palpation.

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  Inspect size (normocephalic); symmetry; note any deformities.

 Eyes and Vision

Assessment can include external structures, ocular movement, visual fields, visual acuity and fundus.

External Structures

 Eyelids: inspect for ability to blink; position (ptosis); lesions (hordeolum- stye).
 Conjunctiva: palpebral (lid)- color (pink) or lesions.
 Sclera: color- white, not red or yellow
 Cornea: assess for opacity or scratch
 Pupil: inspect for size, shape, reaction to light and accommodation. PERRLA normally, both are black,
round, equal in size and react to light and accommodation. Chart is used to measure size (1-10mm). Test
pupillary reaction to light: have client look at distant object (room should be dim); look for direct and
consensual. Accommodation refers to pupillary change for near and distance (look far off then at finger.
Eyes should converge and pupils contract).
 Extraocular Movement- evaluation of the movement of the eyes while the head remains still.
 8 cardinal fields of gaze, which are controlled by three cranial nerves (CN 3 oculomotor, 4 trochlear, 6
abducens). Watch for nystagmus.
 Visual Fields: How much a person can see at the periphery.
 Visual Acuity: Degree to which a person can discern an image. Normal is 20/20.
 Near vision: (general screening) have client read a paper; Far vision: (general screening) read something
across the room. Do one eye; then the other. Test wearing corrective lenses.
 Using Snellen Chart, have client stand 20’ from chart (numerator is 20). Take three readings, right, left,
both eyes. Record the smallest line person is able to read. The denominator is the number next to the line
on the chart that the person is able to read.20/200 client can read only very large # which a person with
normal vision could read at 200’. The larger the denominator, the worse the vision.

Internal Structures: Requires use of an ophthalmoscope to visualize the fundus (back part of internal eye).

 The Ears

Exam includes inspection/palpation of external parts; inspection of canal and drum with otoscope and auditory
acuity.

Auricle: Inspect for position (pinna level with corner of eye), compare each side; lesions.

Canal- Look for drainage. Tympanic membrane (eardrum) requires use of otoscope.

Auditory acuity: gross hearing may be assessed by client’s response to voice. Test one ear at a time, covering the
other. Start with a whisper. Use 2 syllable words such as “baseball.” A tuning fork may be used to perform tests
such as Rinne and Weber.

 The Nose and Sinuses

External nose: inspect for any deviations in shape, size, color, flaring or discharge. Check for patency Check for
sense of smell (olfactory nerve- CN I).

Frontal/Maxillary sinuses- palpate for tenderness.

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  The Mouth and Oropharynx

Lips: inspect for color, lesions (cancer or herpes).

Oral Mucosa: Using tongue blade, inspect for color, lesions; should be uniformly pink.

Teeth: (# and dentition); gums (bleeding, retraction).

Tongue: Inspect for position (center), color, and texture.

Tonsils: Lie between posterior and anterior tonsillar pillars. Normal: does not elevate above the tonsillar pillars.
Should be pink and smooth; note size, hypertrophy; exudates. Should have gag reflex.

 Neck

ROM

Palpate for lymph nodes—normally cannot feel any lymph nodes; document any enlarged or painful nodes.

Jugular venous distention—refers to distention of the Jugular vein and is an indication of increased central venous
pressure as found in Rt. heart failure or fluid overload. Patient should be at 30-45

Degree angle and note the level of neck vein distention.

 The Thorax and Lungs

Chest landmarks:

Anterior imaginary lines: Midsternal, midclavicular, anterior axillary.

Posterior imaginary lines: L or R scapular, vertebral.

Lateral: Posterior axillary, midaxillary and anterior axillary.

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2nd and 5th intercostals space (ICS).

To identify the 2nd ICS: Palpate the clavicle and follow it to the sternum; note the suprasternal notch and angle of
Louis. Place 3 fingers under the suprasternal notch and palpate the bony ridge below your fingers (angle of Louis);
move finger laterally to find the 2nd rib. (The 2nd rib is the first one felt since the 1st rib is beneath the clavicle).
The 2nd ICS is the space beneath the 2nd rib.

Posterior Thorax:

Inspect shape and look for deformities.

Note the anteroposterior diameter compared with transverse (1:2)- AP diameter is < transverse diameter. A barrel
chest is associated with pulmonary emphysema or normal aging.

Note any retraction of the interspaces during inspiration- found in emphysema, tracheal or laryngeal obstruction.
Seen in newborns.

Palpate – respiratory excursion. Place hands over lower thorax (10th rib) with thumbs adjacent to spine should
separate 1 ½” – method of determining equal expansion of the lungs

Percussion- advanced technique. Range: resonance (hollow); hyperresonance (booming); dullness (masses, fluid).

Anterior Thorax

Inspect/ count respiratory rate (15-20/min) and note rhythm. Note respiratory effort; use of neck muscles or
abdominal breathing. Observe intercostal spaces for retraction (obstruction) or bulging (emphysema).

Palpation- may palpate for masses or crackling feeling (crepitus subcutaneous air).

Auscultation: To assess breath sounds that occurs as a result of the movement of air through the trachea, bronchi and
alveoli. Use of diaphragm; have client breath through mouth, more deeply than usual. Avoid hyperventilation.
Remember the right lung is divided into 3 lobes, the left into 2 lobes. Try to visualize each lobe. Apex is at the top;
base at the bottom. Sounds are compared side-to-side, top to bottom; anterior and posterior. The middle lobe is best
assessed on the right side under the arm.

Normal Breath Sounds: depending on where you listen, sounds may be different. Sounds may be decreased when
client fails to breathe deeply or is obese.

 Vesicular- inspiration > expiration; soft, low, heard in periphery and base of lungs.

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  Bronchovesicular- inspiration = expiration; medium pitch, heard between scapula and anteriorly close to
sternum.
 Bronchial- expiration > inspiration; loud and harsh; heard over trachea. Abnormal when heard elsewhere
(pneumonia, tumor).

Adventitious (abnormal) breath sounds occur when air passes through narrowed airways filled with fluid or mucus;
superimposed over normal breath sounds.

 Crackles- fine, high pitched crackling sound; best heard on inspiration at the base caused by reinflation of
the alveoli.
 Rhonchi- low pitched, gurgling; moaning, snoring quality; heard between scapula and lateral to sternum;
clear with coughing.
 Wheeze- high pitched, squeaky; best heard on expiration; heard anywhere.

Documentation: Clear, if normal breath sounds are heard in all areas. Document: Clear breath sounds throughout all
lung fields. Otherwise, state the abnormal sounds you have heard and where you heard it.

 The Heart

Function can be assessed to a large degree by findings in the history: shortness of breath (SOB), edema of
ankles/legs, pain, pulse rate and rhythm; vital signs, signs and symptoms of oxygen deficit.

Location: Heart lies behind and to the left of the sternum. The upper portion or atria (BASE) lies to the back; the
ventricles (APEX) points forward, the apex of the left ventricle actually touches the anterior chest wall near the left
midclavicular line at or near the 5th left ICS. Known as point of maximal impulse (PMI) and is where apical beat is
assessed. Impulse is a good index of heart size.

Landmarks for assessment: The precordium is the area on the anterior chest overlying the heart. Hearts sounds are
heard throughout the precordium, but there are 4 major areas for examining heart sounds. Each area corresponds to
one of the hearts 4 valves.

 Aortic area- 2nd ICS to right of sternum (closure of the aortic valve loudest here).
 Pulmonic area- 2nd ICS to left of sternum (closure of the pulmonic valve loudest here).
 Tricuspid- 5th ICS left of sternal border (closure of tricuspid valve).
 Mitral- 5th ICS left of the sternum just medial to MCL (closure of mitral valve). When cardiac output is
increased as in anemia, anxiety, HTN, fever, the impulse may have greater force- inspect for lift or heave.

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Techniques of Assessment:

 Inspection- look for lift at apex.

 Auscultation- Client should be assessed in supine position with head up to 45 deg.; examiner stands at right
side. Use diaphragm for basic sounds; bell for murmurs and extra sounds.

Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral.

Heart Sounds

Review of A&P: Blood flows from R. atrium to R. ventricle through the atrioventricular valve, the tricuspid. Blood
flows from L. atrium to L. ventricle through the mitral valve. Blood passes from R. ventricle to pulmonary artery
through the pulmonic valve and from the left ventricle to aorta through the aortic valve (semilunar valves). Events
on the left side of the heart slightly precede those on the right.

There are 2 basic normal heart sounds and several abnormal ones.

Normal:

 S-1 (produced by closure of the atrioventricular valves, mitral and tricuspid)- at mitral area and tricuspid
area S1 is louder than S2. The sound is a dull, low pitched “lub.”
 S-2 (produced by closure of aortic and pulmonic valve) is higher pitched, shorter and is the “dub” sound.
Heard best at the base (aortic and pulmonic areas) where S-2 is louder than S-1

Systole begins with the 1st sound. As ventricles start to contract, pressure within exceeds the atria, shutting the
mitral and tricuspid valves. Blood is forced into the great vessels.

When the ventricles have emptied themselves, the pressure in the aorta and pulmonary arteries force the semilunar
valves shut (aortic/pulmonic), which is the 2nd sound and diastole (ventricular relaxation) begins.

Other heart sounds:

 S-3 – rapid filling of the ventricle with blood; heard following S-2. Can be normal in young adults and
children; pathologic in elderly.
 S-4 – atrial contraction and thought to result from stiffened left ventricle; directly precedes S-1. Heard in
elderly.

Extra sounds: snaps and clicks are associated with valves: aortic and mitral stenosis, prosthetic valves.

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Murmurs: S1 or S2 is a swishing or blowing sounds caused by

 Forward flow through a stenotic (narrowed) valve

 Increased flow through a normal valve
 Backward flow through a valve that fails to close (insufficiency).

Murmurs should be identified as systolic (S-1) or diastolic (S-2). Murmurs are common in children and occur often
in the elderly. Try to identify grade of murmur: Grade I (barely audible) to Grade VI (loud and may be heard with
the stethoscope not quite on the chest or barely touching the chest).

Documentation: Normally, you should be able to note that S-1, S-2 heard without extra sounds.

Peripheral Vascular System

Assessment of BP, peripheral pulses, jugular and peripheral vessels; and inspection of skin tissues to determine
perfusion to the extremities.

Inspect neck for pulsations and jugular veins for distention. JVD refers to jugular venous distention- index of
function of the right atrium.

Advanced practitioners would auscultate the carotid artery for a bruit (blowing or swishing sound) and palpate a
thrill (a vibrating sensation).

Inspect and palpate skin of hands, feet and legs for color, temperature and edema. Unilateral coolness may be
associated with decreased blood flow and should be correlated with pulse in that extremity.

Arterial insufficiency- cool extremity, dec. or absent pulse, color changes.

Venous insufficiency- normal temperature, normal pulses, color changes; skin changes.

Deep vein thrombosis (DVT)- Homan’s sign: Knee flexed- pain in calf with dorsiflexion of foot. Not performed if
pt. is dx’d with thrombus.

Edema- fluid accumulation in the tissues; assess by pressing firmly with the thumb- usually over shin or medial
malleolus of foot. Graded on scale of 1+ - 4+.

 The Abdomen

Description: Done by dividing the abdomen into quadrants or into 9 sections.

Quadrants- imaginary lines crossing at the umbilicus. RUQ, LUQ, LLQ, RLQ.

9 sections- terms most often used are epigastric, umbilical, right and left inguinal, suprapubic.

Visualize contents of each quadrant:

RUQ: liver, gall bladder, duodenum, colon, kidney, head of

pancreas.

LUQ: stomach, spleen, colon, kidney, pancreas.

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RLQ: appendix, ovary, urethra, colon, uterus.

LLQ: sigmoid colon, ovary, urethra, uterus.

Techniques of examination: Use of inspection, auscultation, palpation, and percussion. General guidelines:

 Client should not have full bladder. Should be supine with pillow under head; relaxed, flat. Arms at sides,
not overhead.
 Expose only abdomen from costal margin to pubis.
 Warm hands and stethoscope.
 Ask client to point to any area of discomfort.

Inspection:

Skin- look for scars (describe and note location); rashes, lesions, striate, vascularities.

Contour- is it flat, rounded; protuberant; scaphoid (concave); distended- the 6 F’s: flatus, fetus, fat, fluid, feces, and
fetal growth.

Pulsations- if found, usually the abdominal aorta.

Auscultation: To assess bowel sounds, vascular sound; in pregnancy, FHT’s are heard.

Frequency of bowels sounds approx 5-20/min; listen 3-5/min. before reporting that they are absent.

Describe what you hear as: audible- diminished- hypoactive- absent- hyperactive, borborygmi.

Percussion:

To identify organ size and detect fluid, gas or masses.

Palpation:

To detect tenderness, distention, ascities, flatus), presence of masses, bladder distention;

Light palpation- use fingertips with fingers together in a light dipping motion (1/2- 1” deep).

Deep palpation- advanced skill.

 The Musculoskeletal System

Approach: The completeness of the exam depends to a certain extent on the needs and problems of the client.

Muscles are inspected for strength, tone, size and symmetry. Muscle strength is graded on a 0-5 scale. Impaired
strength is called paresis; hemi paresis refers to weakness on one half of the body.

Bones for normalcy and form.

Joints for ROM, tenderness, swelling, crepitating and nodules.

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Inspection:

Total body- compare one side with the other- should be symmetrical; note any gross deformities.

Posture- head balanced midway between shoulders, shoulders aligned with hips, hips over ankles.

Back Contour- normally, the cervical spine is concave, the thoracic spine is convex, the lumbar spine concave. Note
any deformities: Kyphosis- convex curvature of the thoracic spine; Scoliosis- lateral deviation of spine; Lordosis-
exaggerated concavity of lumbar spine.

Gait- normal is balanced, coordinated walking movements.

Extremities-compare side-to-side, compare length, muscle condition. Look for atrophy (wasting away); hypertrophy
(increase in size). Note contractures.

Range of motion- establish for each joint as needed. Describe as adduction, abduction, ext. and int. rotation, flexion
and extension. In terms of foot; dorsiflexion is foot up; plantar flexion is foot down. Look for joint
swelling/inflammation.

Palpation:

Tone- slight residual tension- assessed by slight resistance to passive stretch.

Muscle Strength- level of active movement against resistance- grips or push/pull of elbow.

 The Neurological System:

Includes (1) mental status; (2) level of consciousness; (3) cranial nerves; (4) motor system; (5) sensory system; (6)
reflexes. Most of this is advanced work but you should have a general idea of what it covers.

 Level of consciousness—a continuum from alert to coma. Note if your patient is awake? Alert? Drowsy,
Lethargic? Responds to verbal stimuli? Comatose? Coma? Reacts to painful stimuli?
 Glasgow coma scale—uses objective numeral scale for measurement of consciousness in a patient in a
coma or who is comatose. Measures eye opening, verbal response and motor response. The higher the
score, the more normal the level of functioning.

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  Mental Status: reveals general cerebral function including cognitive (intellectual) and affective (emotional)
function.
 Cognitive function: Determine orientation- to person, place and time (0x3). Other measures of cognitive
function- intact memory, judgment, abstract thinking and knowledge, calculation. Are the client’s thought
processes logical, coherent and relevant?
 Speech/language: Should be clearly articulated, not slurred. Aphasia- defects in word formation or choice
of words.
 Mood and behavior: Attentive to examiner, cooperative, not distracted, irritable or hostile. Appearance
reflects how client feels about self- personal hygiene, choice of clothing- appropriate to setting.

Cranial Nerves:

Mnemonic Cranial Nerve Assessment

On I Olfactory Smell

Old II Optic Vision

Olympus III Oculomotor Eye movements, PERRLA, eyelids; III, IV,

VI assessed together

Towering IV Trochlear III, IV, VI assessed together

Top V Trigeminal Facial sensations, corneal reflex

A VI Abducens III, IV, VI assessed together

Finn VII Facial Taste, smile, frown, close eyes tightly

And VIII Acoustic Hearing

German IX Glossopharnxgeal Gag reflex, swallowing, taste

Viewed X Vagus Swallowing; the vagus nerve is sometimes

called the "wandering nerve" because it
wanders through the body. It is a
parasympathetic nerve therefore has a
cholinergic effect. Stimulation of the vagus
nerve can cause increased gastric secretion,
bradycardia. Giving an enema or taking a
rectal temperature can stimulate the vagus

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 nerve.

Some XI Spinal accessory Shrug shoulders, turn head against

resistance

Hops XII Hypoglossal Stick out tongue, move tongue side to side

Reflexes: Automatic response to stimulus- common one is knee jerk; biceps; triceps; reported in plusses. Babinski-
normal: toes down going (plantar flexion). Babinski positive: dorsiflexion of great toe with fanning of other toes
indicates upper motor neuron disease.

Motor Function: Motor pathways, corticospinal, extra pyramidal & cerebella maintain our equilibrium; mediate
muscle tone and voluntary movements.

Note gait and posture- erect; balanced, coordinated gain, arm swinging.

Inspect muscles for tremor (involuntary); flaccidity (weakness); Spasticity (sudden involuntary contraction);
contraction (rigidity).

Compare strength bilaterally. ('Squeeze my hands')

Move all extremities (MAE); pull and push against resistance,

Sensory Function: Sensory pathways, lateral spinothalamic, anterior spinothalamic, & posterior column, conveys
crude and fine touch, pain and temperature and position and vibration.

Simple assessment of client’s sensory ability: Does client complain of any numbness, tingling or any unusual feeling
in an extremity (parenthesis). Assess ability to feel light touch by touching lower extremities lightly; compare side to
side.

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 INTERPRETING VITAL SIGNS

Some vital sign findings may present as abnormal and indicate a significant patient pathology, whereas, other
findings that appear to be abnormal are indeed a normal response. Following is a discussion of some of these normal
and abnormal findings that may assist you in more accurately interpreting vital sign data obtained from patients.

 Respiration

When assessing respiration, it is important to determine not only respiratory rate, but also tidal volume. Respiratory
rate alone does not provide an indication of the adequacy of respiratory status. In order for a patient to be breathing
adequately, he must have a respiratory rate that is adequate and an adequate tidal volume. Thus, it is two
"adequates" (rate and tidal volume) that constitute adequate breathing. Only one "inadequate" establishes an
inadequate ventilatory status and requires immediate intervention with positive pressure ventilation.

Respiratory rate is determined by counting the number of respirations (one inhalation and one exhalation = one
respiration) in one minute. On average, adult patients breathe between 12 and 20 times per minute. A respiratory rate
outside of that average range may be considered abnormal. However, recognize that a patient can have a resting

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respiratory rate of less than 12 or greater than 20 and not be considered to have an abnormal respiratory rate. As an
example, if a patient has a resting respiratory rate of 10 per minute and displays no evidence of respiratory distress
or hypoxia; he is talking clearly and normally; and he is alert and oriented to person, place and time, a respiratory
rate of 10/minute in this patient would clearly not be considered abnormal.

On the other hand, elderly patients typically have higher resting respiratory rates due to decreases in tidal
volumes. It would not necessarily be abnormal for an elderly patient to have a resting respiratory rate of
20-22/minute. Once again, consider the respiratory rate in conjunction with other physical findings to make a
clinical judgment of normalcy.

Tachypnea (faster than normal respiratory rate) usually indicates cellular hypoxia, acidosis or conditions that
interfere with gas exchange, ventilation or perfusion, such as pulmonary edema, pneumonia and pulmonary
embolism. As perfusion of cells with oxygenated blood begins to decrease, cells may be forced to convert from
aerobic metabolism (metabolism of glucose with oxygen), where the byproduct of carbon dioxide and water is
produced, to anaerobic metabolism (glucose metabolism without oxygen), where lactic acid is a primary byproduct.
As the metabolic acid level increases within the body, the respiratory rate will increase in an attempt to reduce the
acid load. Thus, you can expect tachypnea as an early sign in the shock patient with poor tissue perfusion.

A patient who presents with tachypnea and exhibits no signs of distress, and has no evidence of any trauma that
would explain the etiology of the tachypnea or any other overt clinical reason for the fast respiratory rate, would be
described as having "quiet tachypnea." Quiet tachypnea is often a sign of metabolic acidosis.

Tachypnea can be a normal response to pain. Thus, in a patient whom you suspect is experiencing peritonitis with
severe abdominal pain, tachypnea may be a normal response associated with pain and anxiety and may not
necessarily be an indication of a hypoxia state. In this situation, it would be prudent to obtain a pulse oximeter
reading and look for any other clinical signs or symptoms of hypoxia. If none are found and the SpO2 is above 95%
while the patient is breathing room air, you can suspect the tachypnea may be related to pain and anxiety and less to
a hypoxic state. When obtaining pulse oximetry readings, it is important to document the reading based on the FiO2
(fraction of inspired oxygen) the patient is breathing. A patient breathing room air (21% oxygen) who has a SpO2
reading of 95% would not be of great concern; however, a patient who has been on a nonrebreather at 15 lpm for a
period of time and has a SpO2 reading of 95% may be of great concern. You would have to suspect in the latter
patient that when the nonrebreather mask is removed, the SpO2 reading will decrease well below 95%, reflecting
poor blood oxygen content. Removing the nonrebreather mask in this patient would precipitate a hypoxic state.

A patient who presents with a SpO2 reading near or at 100% while on room air but is severely hypoxic is the carbon
monoxide-poisoned patient. The pulse oximeter works by reading the color of hemoglobin. When oxygen is bonded
to hemoglobin it turns the hemoglobin molecule red. Thus, the pulse oximeter compares oxygenated hemoglobin
(red color) to unoxygenated hemoglobin to determine oxygen saturation. The result is a SpO2 percentage reading.
Carbon monoxide (CO) has a high affinity for hemoglobin. When CO binds with hemoglobin, it turns the
hemoglobin molecule a bright red color. Thus, the pulse oximeter is reading the hemoglobin as being highly
saturated with oxygen when it is really bonded with high amounts of CO. The SpO2 reading will be extremely high
even though the CO is producing severe cellular hypoxia. In this situation, the pulse oximeter reading will not match
the patient's signs and symptoms of hypoxia.

Bradypnea (slower than normal respiratory rate) may be an indication of head injury, stroke or toxic syndromes
involving central nervous system depressants. Bradypnea may also be an ominous sign of respiratory failure or
impending respiratory arrest.

 Pulse

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Pulse rate is simply determined by measuring the number of beats in one minute. This is typically translated into a
heart rate; however, be cautious when making the assumption that the pulse always directly correlates with the heart
rate. In some conditions, the heart contraction is not strong enough to produce a palpable pulse with each beat. A
good example of this may be the patient who is experiencing a supraventricular tachycardia (SVT). Due to the
excessively high heart rate, the ventricular diastolic filling time is drastically shortened, leading to a reduction in
preload, stroke volume and cardiac output. This may result in contractions that are not producing palpable pulses.
Thus, the EMS provider may document a heart rate based on the palpation of a peripheral pulse that is less than the
actual heart rate. If possible, attach the patient to a continuous ECG monitor and compare the palpable pulse rate to
the heart rate on the oscilloscope. If you are unable to apply a continuous ECG monitor, auscultate the apical pulse
with a stethoscope and compare it to the peripheral pulse to determine if there is a discrepancy in the heart
contraction and pulse wave production.

Bradycardia is a lower than normal heart rate. Bradycardia may be due to medical or trauma conditions such as a
cardiac conduction defect, central nervous system depressant drug use or overdose, Cushing's reflex in a head-
injured patient, poisoning, or an ominous sign of severe hypoxia and impending respiratory and cardiac arrest. There
are many other causes of bradycardia.

Once again, it is important to consider the bradycardia in relation to the whole patient. Extremely fit athletes and
individuals may have very low resting heart rates. They will not exhibit any evidence of hypoperfusion or
hemodynamic instability as a result of the low resting heart rate, as will sick individuals with abnormally low heart
rates. Assess the mental status, skin perfusion, work of breathing and blood pressure to gauge the patient's stability.

Be aware that patients on beta blockers and calcium channel blockers may not respond with tachycardia when
expected due to the blockade of the beta receptor sites and calcium ion movement, respectively. An example is a
patient who takes atenolol (a beta blocker) who is involved in a traumatic incident and is hemorrhaging. The
patient's skin is pale, cool and clammy; he is anxious and tachypneic; however, his heart rate remains less than 90
beats per minute. The heart rate does not match the typical shock presentation. Upon learning that the patient is
taking a beta blocker, it is evident that a high heart rate is not to be expected in this case and should not be used as
an effective gauge of the class of hemorrhage due to the beta receptor site blockade.

It is important to note that elderly patients may present with an elevated resting heart rate that is 90 beats per minute.
If you encounter a young or healthy individual who has experienced blunt trauma to the chest and has a sustained
tachycardia even after you have him past the acute stress reaction phase, suspect a possible myocardial contusion.
This is also true of a young or healthy individual with blunt trauma to the chest who presents with an irregular pulse.
Like tachypnea, tachycardia may be associated with the body's response to pain.

The quality of the pulse may provide some information about cardiac output. A strong peripheral pulse usually
indicates good left ventricular filling and contractility. A weak and thready pulse is usually an indication of an
increased systemic vascular resistance, poor left ventricular filling, or an ineffective left ventricular contractile force.
Thus, pulse quality can provide an indication of the effectiveness of cardiac contraction and blood volume.

Pulsusalternans, also known as mechanical alternans or pressure alternans, is identified by a variation in pulse
strength from contraction to contraction. The amplitude (strength) of the pulse varies from beat to beat, even though
the rhythm remains regular. One pulse wave may be strong and the next may be weak, followed again by a strong
pulse. The pulse amplitude basically alternates between strong and weak. This is usually an indication of severe left
ventricular dysfunction and is important to report to the receiving facility.

If you notice a change in amplitude while taking a pulse, continue to assess the pulse while watching the
respirations. If you notice a decrease in the pulse amplitude (it weakens or becomes absent) during inspiration, it
may be an indication of pulsusparadoxus. This may be a subtle finding that is hard to detect in the field; however, it

18
is a significant finding that may indicate severe increases in intrathoracic pressure (severe acute asthma attack and
obstructive lung disease), or other conditions such as pericardial tamponade, adhesive pericarditis, advanced
congestive heart failure and hypovolemia.

EMS personnel are frequently taught that pulse location (radial, brachial, femoral or carotid) correlates with the
estimated systolic blood pressure. It is postulated that a systolic blood pressure of 80-90 mmHg is needed to produce
radial pulses, a systolic blood pressure of 70 mmHg is needed to produce femoral and brachial pulses, and a systolic
blood pressure of 60 mmHg is needed to produce carotid pulses. Be careful when interpreting this finding. One
article found that trauma patients with a radial pulse had a mean systolic blood pressure (SBP) of 72.5 mmHg; 83%
of the trauma patients with a radial pulse had a SBP of less than 80 mmHg. Trauma patients with a femoral and
carotid pulse had a mean SBP of 66.4 mmHg; 83% of the trauma patients with a femoral or carotid pulse had a SBP
less than 70 mmHg. It is necessary to have a SBP of 60 mmHg to produce a carotid pulse.

 Skin

Assess the patient's skin color, temperature and condition. Abnormal skin color may include pallor, cyanosis,
flushing or redness, mottling or jaundice. Cyanosis is a late sign of hypoxia or poor perfusion states. Redness or
flushing is typically a result of peripheral vasodilation. Pallor is an early sign of hypoxia and is also seen in poor
perfusion states. Mottling occurs when blood stagnates in an area of poor perfusion and becomes deoxygenated.
Jaundice, a yellow coloring of the skin and sclera, is a sign of hepatic failure.

Abnormal skin temperatures may be cool, cold or hot. When assessing the skin, be sure to take into account the
ambient temperature. Hot skin temperature may be an indication of a significantly increased body core temperature.
Peripheral vasoconstriction will cause the warm red blood in the skin to be shunted to the core of the body, resulting
in cool skin temperature. Cold skin usually occurs as a result of a significant decrease in the body's core
temperature.

The moisture and dryness of the skin refers to condition. Skin is normally dry to touch. Moist skin may be a result of
discharge of the sympathetic nervous system and from the alpha properties' stimulation of the sweat glands from
circulating epinephrine and norepinephrine. Both hormones will also cause vasoconstriction, leading to cool, pale,
clammy skin.

Extremely dry skin may occur as a result of dehydration. Skin turgor is tested to determine the presence of
dehydration. Turgor is actually the speed at which the pinched or lifted fold of skin returns to its normal place. A
decrease in turgor is an indication of dehydration. One of the best places to assess for skin turgor is on the chest over
the sternum. Elderly patients undergo changes in the structure of the skin that make it less elastic. With the loss of
recoil, the skin will stay tented when pinched. Thus, skin turgor is not a good test to assess the dehydration status of
elderly patients. Suspect dehydration if the oral mucosa is dry, the tongue is furrowed and there is a lack of tear
formation.

Capillary refill is a useful test of hydration status in pediatric patients. The best place to test for capillary refill in
children is on the forearm or over the patella (kneecap).

 Blood Pressure

Auscultation of blood pressure can potentially provide more information than palpation. An auscultated blood
pressure provides both a systolic and diastolic value. Both are reported in even numbers in increments of 2 mmHg.
The normal range for a systolic blood pressure is 100 to 140 mmHg and 60 to 90 mmHg for diastolic.

19
Systolic blood pressure is a measure of left ventricular function. It is important to note that a diastolic blood pressure
represents more than just the relaxed phase of the cardiac cycle. Diastole is a direct measure of the degree of vessel
constriction or vascular resistance. If a patient is compensating for either an abnormally high or abnormally low
blood pressure, they may vasoconstrict or vasodilate, respectively, and the diastolic blood pressure value will reflect
the change. This may provide an indication of how well a patient is compensating for changes in cardiac output.

A pulse pressure is determined by subtracting diastolic blood pressure from systolic blood pressure. A normal
pulse pressure is often noted as 30 to 40 mmHg. More specifically, a narrow pulse pressure is one that is less than
25% of the systolic blood pressure. A narrow pulse pressure may be an indication of a decreasing cardiac output and
an increasing peripheral vascular resistance associated with systemic vasoconstriction. A wide pulse pressure is
greater than 50% of the systolic blood pressure. A wide pulse pressure may be seen in brain-injured patients
exhibiting Cushing's reflex where the systolic blood pressure drastically increases to maintain cerebral perfusion, but
the diastolic remains normal or low.

If fluid or blood loss is suspected in the medical patient, you may perform the "tilt test" or test for orthostatic vital
signs. You are actually testing for postural hypotension. To do so, place the patient in a supine position for
approximately two minutes or more. Assess the blood pressure and heart rate. Move the patient into a standing
position. This allows for 7 to 8 ml/kg of blood to be transferred to the lower extremities due to gravity. After two
minutes, reassess the blood pressure and heart rate with the patient in the standing position. A patient with a volume
deficit will experience a decrease in preload, stroke volume and cardiac output. Clinically, this will present as a
decrease in systolic blood pressure and an increase in heart rate. If the systolic blood pressure decreases greater than
20 mmHg or the heart rate increases by greater than 20 to 30 beats per minute from the supine to standing vital
signs, the patient is said to have orthostatic vital signs or postural hypotension. The increase in heart rate has been
found to be a more sensitive indicator of volume depletion.

Be cautious when interpreting a decrease in systolic blood pressure when performing the orthostatic tilt test,
especially on elderly patients. Approximately 10% of persons younger than age 65 and 11%-30% older than 65 who
have a normal blood volume will exhibit a decrease in systolic blood pressure of 20 mmHg or greater when moved
from a supine to standing position. Thus, an increased heart rate of greater than 20 beats per minute becomes a better
predictive indicator of volume depletion when performing this test.

If a sudden drop of greater than 10 mmHg in the systolic reading is found when assessing blood pressure, note
the phase of respiration when the drop is occurring. If a drop of greater than 10 mmHg of pressure is noted during
the inspiratory phase of respiration, it may be an indication of pulsusparadoxus, which can be seen in cardiac
tamponade, pericardial effusion, constrictive pericarditis, pulmonary embolism, cardiogenic shock, bronchial asthma
or tension pneumothorax. Another indication of pulsusparadoxus seen on physical examination is engorgement of
the jugular veins on inspiration. This is known as Kussmaul's sign.

When assessing a patient complaining of chest pain or midscapular pain, measure the blood pressure in both upper
arms and compare the systolic readings. If there is a difference of 10 to 20 mmHg in the systolic blood pressure
between both extremities, it may be an indication of an aortic dissection.

ACE inhibitors are drugs that cause blood vessels to dilate, thereby reducing the vascular resistance, which
results in a decrease in blood pressure. This lower vascular resistance reduces the myocardial workload and can
improve the function of a weakened heart. In the patient who presents with a low blood pressure, consider the
possibility of ACE inhibitor use.

 Pupils

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Assess the pupils for size, equality and reactivity. Pupil signs may provide some evidence as to the integrity of the
brainstem. Pupils may also provide a clue as to whether the coma patient has a structural lesion or if the condition is
of a metabolic etiology. Pupils that are unequal, fixed and dilated in a comatose patient indicate a structural etiology
or space-occupying lesion. If the coma or altered mental status is due to a metabolic cause such as hypoxia, drug
overdose or hypoglycemia, the pupils will remain equal and reactive to light; however, they may respond more
sluggishly. When encountering a patient with an unknown etiology of coma, pupil signs may provide a clue as to the
cause.

NURSING SKILLS
 Hand Washing for Medical Asepsis

Action Rationale

1. Gather the necessary equipment and supplies Removal of jewelry facilitates proper cleansing.
Microorganisms may accumulate in settings of jewelry.
2. Remove jewelry (watch, rings)

3. Stand in front of the sink. Do not allow clothing The sink is considered contaminated. Clothing may
to touch sink during the washing procedure. carry organisms from place to place.

4. Turn on water and adjust force. Regulate Water splashed from the contaminated sink will
temperature until water is warm. contaminate clothing. Warm water is more comfortable
and is less likely to open pores and remove oils from the
skin.

5. Wet hands and wrists thoroughly with water. Water should flow from the cleaner area toward the
Keep hands lower than elbows to allow water more contaminated area. Hands are more contaminated
to flow toward fingertips. than forearms.

6. Use soap to lather hands and wrists thoroughly.

(3 – 5 mL liquid soap/ rinse bar of soap, lather Rinsing the soap before and after use removes the lather,
thoroughly, then rinse bar of soap again before returning which may contain microorganisms.
it to the soap rack).

7. Using firm rubbing and circular motions, wash Friction caused by firm rubbing and circular motions
the palms and backs of the hands, each finger, helps to loosen dirt and microorganisms that can lodge
the areas between the fingers, and the knuckles, between the fingers, in skin crevices of the knuckles, on
wrists, and forearms. the palms and backs of the hands, and on the wrists and
forearms.
Wash at least 1 inch above area of visible contamination.

8. Continue this friction motion for at least 15

seconds. Length of time for handwashing is determined by the
degree of contamination.

9. Use fingernails of the opposing hand to clean Area under nails has a high microorganism count, and
under fingernails. they can remain under the nails where they can grow and

21
 be spread to other persons.

10. Rinse thoroughly with water flowing toward Running water rinses microorganisms and dirt into the
the fingertips. sink.

11. Pat dry hands with a paper towel, beginning Patting the skin dry prevents chapping.
with the fingers and moving upward towards
the forearms. Discard used paper towel Dry hands first because they are considered the cleanest
immediately. and the least contaminated area.

Use a clean paper towel to turn off the faucet. Discard Turning off the faucet with a clean paper towel protects
towel immediately without touching the other clean the clean hands from contact with a soiled surface
hand.

12. Use lotion on hands, if desired. Lotion helps to keep the skin soft and prevent chapping.

 Bed bath

Action Rationale

1. Review chart for limitations in physical Identifying limitations prevents patient discomfort and
activity. injury.

2. Bring necessary equipment to the bedside stand Bringing everything to the bed side conserves time and
or over bed table. energy. Arranging items nearby is convenient, saves
time, and avoids unnecessary stretching and twisting of
muscles on the part of the nurse.

3. Perform hand hygiene and put on gloves and/ Hand hygiene and PPE prevent the spread of
or other PPE, if indicated. microorganisms; PPE is required based on transmission
precautions.

4. Identify the patient. Discuss the procedure with Identification the patient ensures the right patient
the patient and assess his/her ability to assist in receives the intervention and helps prevent errors.
the bathing process, as well as personal hygiene Discussion promotes reassurance and provides
preferences. knowledge about the procedure. Dialogue encourages
patient participation and allows for individualized
nursing care.

22
 5. Close curtains around bed and close the door to This ensures patient’s privacy and lessens the risk for
the room if possible. Adjust the room loss of body heat during the bath.
temperature, if necessary.

6. Remove sequential compression devises and Most manufactures and agencies recommend removal of
ant embolism stockings from lower extremities these devices before the bath to allow for assessment.
according to agency protocol.

7. Offer the patient bedpan or urinal. Voiding or defecating before the bath lessens the
likelihood that the bath will be interrupted, because
warm bath water may stimulate the urge to void.

8. Remove gloves and perform hand hygiene. Hand hygiene deters the spread of microorganisms.

9. Adjust the bed to a comfortable working height, Having the bed at the proper height prevents back and
usually elbow height of the caregiver. muscle strain.

10. Put on gloves. Lower side rail nearer to you and Gloves prevent transmission of microorganisms. Having
assist patient side of bed where you will work. the patient positioned near the nurse and lowering the
Have patient lie on his/her back. side rail prevent unnecessary stretching and twisting of
muscles on the part of the nurse.

11. Loosen top covers and remove all except the The patient is not exposed unnecessarily, and warmth is
top sheet. Place bath blanket over the patient maintained. If a bath blanket is unavailable, the top sheet
and then remove the top sheet while the patient may be used in place of the bath blanket.
holds the bath blanket in place. If linen is to be
reused, fold it over a chair. Place soiled linen in
laundry bag. Take care to prevent linen from
coming in contact with your clothing.

12. Remove the patient’s gown and keep the bath This provides uncluttered access during the bath and
blanket in place. If the patient has an IV line maintains warmth of the patient. IV fluids must be
and is not wearing a gown with snap sleeves, maintained at the prescribed rate.
remove the gown from other arm first.

Lower the IV container and pass the gown over the

tubing and the container. Re-hang the container and
check the drip rate.

13. Raise the side rail. Fill basin with sufficient Side rails maintain patient safety. Warm water is
amount of comfortably warm water (1100 F to comfortable and relaxing for the patient. It also
1150 F). Add the skin cleanser, if appropriate stimulates circulation and provides for more effective
according to manufacturer’s directions. Change cleansing.
as necessary through the bath.
Lower side rail closer to you when you return
to the bed side to begin the bath.

14. Put on gloves, if necessary. Fold the washcloth Gloves are necessary if there is potential contact with
like a mitt on your hand so that there are no blood or body fluids. Having loose ends of cloth drag
loose ends. across the patient’s skin is uncomfortable. Loose ends

23
 cool quickly and feel cold to the patient.

15. Lay a towel across patient’s chest and on top of This prevents chilling and keeps the bath blanket dry.
bath blanket.

16. With no cleanser on the wash cloth, wipe on Soap is irritating to the eyes. Moving from the inner to
eye from the inner part of the eye, near the the outer aspect of the eye prevents carrying debris
nose, to the outer part. Rinse or turn the cloth toward the nasolacrimal duct. Rinsing or turning the
before washing the other eye. wash cloth prevents spreading organisms from one eye
to the other.

17. Bathe patient’s face, neck, and ears. Apply Use of emollient is recommended to restore and
appropriate emollient. maintain skin integrity.

18. Expose the patient’s far arm and place the The towel helps to keep the bed dry. Washing the far
towel length wise under it. Using firm strokes, side first eliminates contaminating a clean area once it is
wash hand, arm, and axial, lifting the arm as washed. Gentle friction stimulates circulation and
necessary to access axillary region. Rinse, if muscles and helps remove dirt, oil, and organisms.
necessary, and dry. Apply appropriate Long, firm strokes are relaxing and more comfortable
emollient. than short, uneven strokes. Rinsing is necessary when
using some cleansing products. Use of emollients is
recommended to restore and maintain skin integrity.

19. Place a folded towel on the bed next to the Placing the hand in the basin of water is an additional
patient’s hand and put basin on it. Soak the comfort measure for the patient. It facilitates through
patient’s hand in the basin. Wash, rinse if washing of the hands between fingers and aids in
necessary, and dry hand. Apply appropriate removing debris from under the skin. Use of emollients
emollient. is recommended to restore and maintain skin integrity.

20. Repeat actions 15 and 16 for the arm nearer

you. An option for the shorter nurse or one
susceptible to back strain might be to bathe one
side of the patient and move to the other side of
the bed to complete the bath.

21. Spread a towel across the patient’s chest. Exposing, washing, rinsing, and drying one part of the
Lower the bath blanket to the patient’s body at a time avoids unnecessary exposure and chilling.
umbilical area. Wash, rinse, if necessary, and Skin folds areas may be sources of odour and skin
dry chest. Keep chest covered with towel breakdown if not cleaned and dried properly.
between the wash and rinse. Pay special
attention to skin under the breast.

22. Lower the bath blanket to the perineal area. Keeping the bath blanket and towel in place avoids
Place a towel over the patient’s chest. exposure and chilling.

23. Wash, rinse, if necessary, and dry abdomen. Skin fold areas may be sources of odours and skin
Carefully inspect and clean the umbilical area breakdown if not cleaned and dried properly.
and any abdominal folds or creases.

24. Return the bath blanket to its original position The towel protects linens and prevents the patient from
and expose the far leg. Place towel under the feeling uncomfortable from a damp or wet bed. Washing

24
 far leg. Using firm strokes wash, rinse, if from ankle to groin with firm strokes promotes venous
necessary, and dry the leg from ankle to the return. Use of emollients is recommended to restore and
knee and knee to groin. Apply appropriate maintain skin integrity.
emollient.

25. Wash, rinse if necessary, and dry the foot. Pay Drying of the foot is important to prevent irritation,
particular attention to the areas between the possible skin breakdown, and infections. Use of
toes. Apply appropriate emollient. emollients is recommended to restore and maintain skin
integrity.

26. Repeat Actions 21 and 22 for the other leg and

foot.

27. Make sure the patient is covered with the bath The bath blanket maintains warmth and privacy. Clean,
blanket. Change water and wash cloth at this warm water prevents chilling and maintains patient
point, or earlier, if necessary. comfort.

28. Assist patient to prone or side-lying position. Positioning the towel and bath blanket protects the
Put on gloves, if not applied earlier. Position patient’s privacy and provides warmth. Gloves prevent
bath blanket and towel to expose only the back contact with body fluids.
and buttocks.

29. Wash, rinse if necessary, and dry back and Fecal material near the anus may be a source of
buttocks area. Pay particular attention to microorganisms. Prolonged pressure on the sacral area
cleansing between gluteal folds, and observe or other bony prominences may compromise circulation
for any redness or skin breakdown in the sacral and lead to development of decubitus ulcer.
area.

30. If not contraindicated, give patient a backrub. A backrub improves circulation to the tissues and is an
Back massage may be given also after perineal aid to relaxation. A backrub may be contraindicated in
care. Apply appropriate emollient and/or skin patients with cardiovascular disease or musculoskeletal
barrier product. injuries. Use of emollients is recommended to restore
and maintain skin integrity. Skin barriers protect the skin
from damage caused by excessive exposure to water and
irritants, such as urine and faeces.

31. Raise the side rail. Refill basin with clean The washcloth, towel, and water are contaminated after
water. Discard wash cloth and towel. Remove washing the patient’s gluteal area. Changing to clean
gloves and put on clean gloves. supplies decreases the spread of organisms from the anal
area to the genitals.

32. Clean perineal area or set up patient so that Providing perineal self care may decrease
he/she can complete perineal self care. If the embarrassment for the patient. Effective perineal care
patient is unable, lower the side rail and reduces odour and decreases the risk for infection
complete perineal care, following guidelines in through contamination. Skin barriers protect the skin
the accompanying skill variation. Apply skin from damage caused by excessive exposure to water and
barrier, as indicated. Raise side rail, remove irritants, such as urine and faeces.
gloves, and perform hand hygiene.

33. Help patient put on a clean gown and assist This provides the patient’s warmth and comfort.

25
 with the use of other personal toiletries, such as
deodorant or cosmetics.

34. Protect pillow with towel and groom patient’s

hair.

35. When finished, make sure the patient is Proper positioning with raised side rails and proper bed
comfortable, with the side rails up and the bed height provide for patient comfort and safety.
in the lowest position.

36. Change bed linens. Dispose of soiled linens Removing PPE properly reduces the risk for
according to agency policy. Remove gloves and transmission and contamination of other items. Hand
any other PPE, if used. Perform hand hygiene. hygiene prevents the spread of microorganisms.

37. Documentation

 Bed making (occupied bed)

Action Rationale

1. Check chart for limitations on the patient’s This facilitates patient cooperation, determines level of
physical activity. activity, and promotes patient safety .

2. Assemble equipment and arrange on bedside Organization facilitates performance of the task.
chair in the order the items will be used.

3. Perform hand washing. Put on PPE, as Hand hygiene and PPE prevent the spread of
indicated. microorganisms; PPE is required based on transmission
precautions.

4. Identify the patient. Explain the procedure you Patient identification validates the correct patient and
are about to perform. correct procedure. Discussion and explanation allay
anxiety and prepare the patient for what to expect.

5. Close curtains around bed and close the door to This ensures patient’s privacy.
the room if possible.

6. Adjust the bed to a comfortably working Having the bed at a proper height prevents back and
height. muscle strain.

7. Lower the rail near you, leaving the opposite Having the mattress flat makes it easier to prepare a
side rail up. Place bed in flat position unless wrinkle free bed.
contraindicated.

26
8. Put on gloves. Check bed linens for patient’s Gloves prevent the spread of microorganisms. It is costly
personals items. Disconnect the call bell, and inconvenient when personal items are lost.
tubes/drains from bed lines. Disconnecting tubes from linens prevents discomfort
and accidental dislodging of the tubes.

9. Place a bath blanket over the patient. Have The blanket provides warmth and privacy. Placing linens
patient hold on to bath blanket while you reach directly into the hamper helps prevent the spread of
under it and remove top linens. Leave the top microorganisms. The floor is heavily contaminated;
sheet in place if a bath blanket is not used. Fold soiled linen will further contaminate furniture. Soiled
linen that is to be reused over the back of a linen contaminates the nurse’s uniform, and this may
chair. Discard soiled linen in laundry or bag or spread organisms to another patients.
hamper. Do not place on the floor or furniture.
Do not hold soiled linens against your uniform.

10. If possible, and another person is available to This allows more foot room for the patient.
assist, grasp the mattress securely and shift it up
to the head of the bed.

11. Assist the patient to turn towards the opposite This allows the bed to be made on the vacant side.
side of the bed, and reposition the pillow under
the patient’s head.

12. Loosen all bottom linens from head, foot, and This facilitates removal of linens.
side of bed.

13. Fan-fold soiled linens as close to the patient as This makes it easier to remove linens when the patient
possible. turns to the other side.

14. Use clean linen and make the near side of the Opening linens on the bed reduces strain on the nurse’s
bed. Place the bottom sheet with its center fold arms and diminishes the spread of microorganisms.
in the center, positioning it under the old linens. centering the sheet ensures sufficient coverage for both
Pull the bottom sheet over the corners at the sides of the mattress. Positioning under the old linens
head and foot of the mattress. makes it easier to remove the linens.

15. If using, place the draw sheet with its center If the patient soils the bed, draw sheet and pad can be
fold in the center of the bed and positioned so it changed without the bottom and top linens on the bed. A
will be located under the patien’s midsection. draw sheet can aid moving the patient in bed.
Open the draw sheet and fan-fold to the center
of the mattress. Tuck the draw sheet securely
under the mattress. If a protective pad is used,
place it over the draw sheet in the proper area
and open to the center fold. Not all agencies use
draw sheets routinely. The nurse may decide to
use one.

16. Raise side rail. Assist to the roll over the folded This ensures patient safety. The movement allows the
linen in the middle of the bed toward you. bed to be made on the other side. The bath blanket
Reposition pillow and bath blanket or top sheet. provides warmth and privacy.
Move to the other side of the bed and lower the

27
 side rail.

17. Loosen and remove all bottom linen. Discard Placing linens directly into the hamper helps prevent the
soiled linen in laundry bag or hamper. Do not spread of microorganisms. The floor is heavily
place on floor or furniture. Do not hold soiled contaminated; soiled linen will further contaminate
linens against your uniform. furniture. Soiled linen contaminates the nurse’s uniform,
and this may spread organisms to another patient.

18. Ease clean linen from under the patient. Pull the This removes the wrinkles and creases in the linens,
bottom sheet taut and secure it at the corners of which are uncomfortable to lie on.
the head and foot of the mattress. Pull the draw
sheet tight and smooth. Tuck the draw sheet
securely under the mattress.

19. Assist the patient to turn back to the center of Opening linens by shaking them causes organisms to be
the bed. Remove pillow and change pillow carried on air currents.
case. Open each pillow case in the same
manner as you opened other linens. Gather the
pillow case toward the closed end. Grasp the
pillow with the hand inside the pillow case.
Keep a firm hold on the top of the pillow and
pull the cover on the pillow. Place the pillow
under the patient’s head.

20. Apply top linens, sheet and blanket, if desired, This allows bottom hems to be tucked securely under the
so that they are centered. Fold the top linens mattress and provides for privacy.
over at the patient’s shoulders to make a cuff.
Have the patient hold on to top linen and
remove the bath blanket from underneath.

21. Secure top linens under the foot of the mattress This provides for a neat appearance. loosening linens
and miter corners. Loosen top linens over the over the patient’s feet gives more room for movement.
patient’s feet by grasping them in the area of
the feet and pulling gently toward foot and
head.

22. Return the patient to a position of comfort. Promotes patient comfort and safety. Removing gloves
Remove your gloves. Raise side rail and lower properly reduces the risk for infection transmission and
the bed. Reattached call bell and tubes/drains. contamination of other items.

23. Dispose of soiled linens according to agency Deters the spread of microorganisms.
policy.

24. Remove any other PPE, if used. Perform hand Removing PPE properly reduces the risk for infection
hygiene. transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.

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  Oral Medication Administration

Action Rationale

1. Perform hand hygiene To prevent the spread of the microorganisms.

2. Gather Equipment

3. Check each medication order against the This comparison helps to prevent medication error.
original order

4. Check the patient’s chart for allergies.

5. Know the actions, special nursing To evaluate the therapeutic effect of the medication and
considerations, safe dose range and purpose of to educate the patient.
administration and adverse effects of the
medications to be administered.

6. Perform hand hygiene To prevent the spread of the microorganisms.

7. Prepare the medication in the medication area. Organization facilitates error free administration.

8. Prepare medications for one patient at a time. To prevent medication error.

9. Read the medication administration record and This is the first check of the label.
select the proper medications from the
medication drawer.

10. Check the label with the medication This is the second check of the label.
administration Record. Check expiration dates
and perform the calculations.

11. Prepare the required medications. The label is needed for an additional safety check.

o Place packaged dose medicines in a

disposable cup, without opening the
wrapper until at the bedside.

o Keep medications require special nursing Assessing vital signs and checking laboratory
assessments E.g. : Narcotics in a separate investigations results are vital safety measures for
container. administration of medications.

o Multi dose medication containers: Pour It allow for easy return of excess medication to bottle.
the necessary number into the bottle cap

29
 and then place the tablets in a medication
cup.

o Break only scored tablets, if necessary, to

obtain the proper dosage.

o Do not touch tablets with hands. Pouring tablets or capsules into the nurse’s hand in
unsanitary.

o Liquid medication in multi dose bottle: Liquid that may drop onto the label makes the label
When pouring liquid medication from a difficult to read.
multi dose bottle, hold the bottle so the
label against the palm. Use the appropriate
measuring device when pouring liquids.

o Read the amount of medication at the To administer correct dose of medication.

bottom of the meniscus at eye level. Wipe
the lip of the bottle with a paper towel.

12. When all medications are prepared, recheck the The third check to ensure accuracy and to prevent errors.
label with the medication administration record
before taking them to the patient.

13. Replace any multi dose containers in the To safeguards the patient’s medications supply.
patient’s drawer or medication cart. Lock the
medication cart before leaving it.

14. Transport medications to the patient’s bedside To prevent accidental or deliberate disarrangement of
carefully, and keeping the medications in sight medications.
at all times.

15. Ensure the patient receives the medications at Check agent policy, which may allow for administration
the correct time. with in a period of 30 minutes before or 30 minutes after
designated time.

16. Identify the patient. It ensures the right patient receives the medications and
helps prevent errors.

o Check the name and identification number

on the patient’s identification band. This is the most reliable method.

o Ask the patient to state his or her name.

o If the patient cannot identify him or

herself, verify the patient’s identification

30
 with the staff member who knows the This requires a response from the patient, but illness and
patient for the second source. strange surrounding often cause patients to be confused.

This is another way to double check identity.

17. Complete necessary assessments before Assessment is a prerequisite to administration of

administering medications. Check allergy medication.
bracelet or ask patient about allergies. Explain
the purpose and action of each medication to
the patient.

18. Assist the patient to an upright or lateral Swallowing is facilitated by proper positioning. The
position. above mentioned position prevents aspiration.

19. Administer medications. Liquid facilitates swallowing of solid drugs. ** Some

liquid medications are intended to adhere to the
o Offer water or other permitted fluids with pharyngeal area, in which case liquid is not offered with
pills, capsules, tablets and some liquid the medication.
medications.

o Ask whether the patient prefers to take the This encourages the patient participation.
medications by hand or cup.

o Remain with the patient until each The patient’s chart is legal record. Unless the nurse has
medication is swallowed. NEVER LEAVE seen the patient swallow the drug, the drug cannot be
THE MEDICATION AT THE recorded as administered.
PATIENT’S BEDSIDE.

o Perform Hand Hygiene. To prevents the spread of microorganisms.

20. Leave the patient in comfortable position.

21. Check on the patient within 30 minutes, or time This provides information for further documentation and
appropriate for drugs, to verify response to additional assessment of effectiveness of pain relief and
medication. adverse effects of medication.

31
 22. Document

 Using Personal Protective Equipment (PPE)

Action Rationale

1. Check medical record and nursing plan of care Mode of transmission of organism determines type of
for type of precautions in infection control precautions required.
manual

2. Plan nursing activities before entering patient’s Organization facilitates performance of task of task and
room. adherence to precautions.

3. Perform hand hygiene Hand hygiene prevents the spread of microorganisms.

4. Provide instruction about precautions to patient, Explanation encourages cooperation of patient and
family members, and visitors. family and reduces apprehension about precaution
procedures.

5. Put on gown, gloves, mask, and eyewear, based Use of PPE interrupts chain of infection and protects

32
 on the type of exposure anticipated and patient and nurse. Gown should protect entire uniform.
category of isolation precautions. Gloves protect hands and wrist from microorganisms.
Mask protects nurse or patient from droplet nuclei and
large-particule aerosols. Eyewear protects mucous
membranes in the eyes from splashes.

Gown should fully cover the torso from the neck to

knees, arms to the end of wrists, and wrap around the
a. Put on the gown, with the opening in back.
the back, Tie gown securely at neck
and waist.

Masks protect nurse or patient from droplet nuclei and

large particle aerosols. A mask must fit securely to
provide protection.

b. Put on the mask or respirator over

your nose, mouth, and chin. Secure
ties or elastic bands at the middle of
the head and neck. if respirator is used,
perform a fit check. Inhale; the
respirator should collapse. Exhale; air
should not leak out.
Eyewear protects mucous membrane in the eye from
splashes. Must fit securely to provide protection.

c. Put on goggles. Place over eyes and

adjust to fit. Alternatively, a face
shield could be use to take the place of
the mask and goggles.

Gloves protect hands and wrists from microorganisms.

d. Put on clean disposable gloves.
Extend gloves to cover the cuffs of the
gown.

6. Identify the patient. Explain the procedure to Patient identification validates the correct patient and the
the patient. Continue with patient care as correct procedure. Discussion and explanation help allay
appropriate. anxiety and prepare the patient for what to expect.

REMOVE PPE

7. Remove PPE: Except for respirator, remove Proper removal prevents contact with, and the spread of,

33
PPE at the doorway or in an anteroom. Remove microorganisms. Outside front of equipment is
respirator after leaving the patient’s room and considered contaminated. The inside, outside back, and
closing door. ties on head and back are considered clean, which are
areas of PPE that are not likely to have been in contact
with infectious organisms.

Front of gown, including waist strings, are

contaminated. If tied in front of body, the ties must be
a. If impervious gown has been tied in
untied before removing gloves.
front of the body at the waistline, untie
waist strings before removing gloves.

b. Grasp the outside of one glove with Outside of gloves are contaminated.
the opposite gloved hand and peel off,
turning the glove inside out as you pull
it off. Hold the removed glove in the
remaining gloved hand.

c. Slide fingers of ungloved hand under

the remaining glove at the wrist,
taking care not to touch the outer
surface of the glove.

Ungloved hand is clean and should not touch

contaminated areas.
d. Peel off the glove over the first glove,
containing the one glove inside the
other. Discard in appropriate
container.

e. To remove the goggles or face shield:

Handle by the headband or earpieces.
Lift away from the face. Place in Proper disposal prevents transmission of
designated receptacle for reprocessing microorganisms.
or in an appropriate waste container.

f. To remove gown: Unfasten ties, if at

the neck and back. Allow the gown to

34
 fall away from shoulders. Touching
only the inside of the gown, pull away
from the torso. Keeping hands on the Outside of goggles or face shield is contaminated.
inner surface of the gown pull from Handling by headband or earpieces and lifting away
arms. Turn gown inside out. Fold or from face prevents transmission of microorganisms.
roll into a bundle and discard. Proper disposal prevents transmission of
microorganisms.

g. To remove mask or respirator; Grasp

the neck ties or elastic, then top ties or
elastic and remove. Take c are to
Gown front and sleeves are contaminated. Touching
avoid touching front of mask or
only the inside of the gown and pulling
respirator. Discard in waste container.
If using a respirator, save for future
use in the designated area.

Front of mask or respirator is contaminated. Do not

touch. Not touching the front and proper disposal
prevent transmission of microorganisms.

8. Perform hand hygiene immediately after Hand hygiene prevents spread of microorganisms.
removing all PPE.

9. Documentation

 Administration of Intramuscular (IM) Medications

Intramuscular (IM) injections deliver medication through the skin and subcutaneous tissues into the muscles.
Muscles have larger and a greater number of blood vessels than does subcutaneous tissue, allowing faster onset of
action than with subcutaneous injections.

This route is used to administer drugs such as antibiotics, hormones, and vaccines (such as the Hepatitis vaccine).

35
IM Site Selection

It is important to be able to identify anatomic landmarks and to use accurate careful technique when administering
IM injections. If care is not taken, complications can arise. These include, abscesses; cellulitis; and injury to blood
vessels, bones and nerves.

Avoid using sites that are bruised, tender, hard, swollen, inflamed, or scarred.

Rotate the sites used to administer IM medications when therapy requires repeated injections.

Sites

 Ventrogluteal – involves the gluteus medius and gluteus minimus muscles in the hip area. The correct area
for injection can be determined in the following manner. Place the palm of the hand over the greater
trochanter of the femur with fingers pointing towards the patient's head. (The left hand is used for the right
hip and vice versa.) While keeping the palm of the hand over the greater trochanter and placing the index
finger on the anterosuperior iliac spine, stretch the middle finger dorsally palpating for the iliac crest. The
triangle formed by the iliac crest, the third finger and index finger forms the area suitable for intramuscular
injection. (Paediatric consideration: The gluteus maximus muscle [dorsal gluteal site] must not be
used until the child has been walking for at least 1 year).

 Vastuslateralis – involves the quadriceps femoris muscles and is located along the anterolateral aspect of
the thigh. This muscle is more commonly used as the site for IM injections as it is not located close to any
major arteries or nerves. It is also readily accessed. To locate the site, divide the thigh into thirds
horizontally and vertically and administer the injection in the outer middle third.( Paediatric
consideration: preferred site for young children)

 Deltoid – located in the lateral aspect of the upper arm. The deltoid muscle can be used readily for IM
injections if there is sufficient muscle mass to justify use of this site. The deltoid's close proximity to the
radial nerve and radial artery means that careful consideration and palpation of the muscle is required to
find a safe site for penetration of the needle. IM injections into the deltoid should be limited to 1mL of
solution. (Paediatric consideration: This muscle is rarely used in young children except for the small
amounts injected in some vaccines).

 Dorsogluteal – large muscle of the buttocks. Divide the buttock into quadrants. Administer IM in upper
outer quadrant.

General Paediatric considerations: Infants and toddlers need to be held securely and with only minimal
explanations understood. The preschooler and the young school-age child may often understand the reason for the
injection. Explain what it feels like. At the end of the procedure find something to praise the child for, example:
holding still (if he or she did).

Equipment

 Medication Kardex

 Prescribed medication (in vials, ampoules)

 Medication cart/tray

 Sterile syringes

36
  Sterile needles (of appropriate size and gauge.)

 Alcohol swabs

 Gauze squares

Assessment Guidelines:

1. Assess the patient for any allergies.

2. Check the expiration date before administering medication.

3. Assess the appropriateness of the drug for the patient.

4. Assess the patient’s knowledge of the medication.

5. Assess the site on the patient where the injection is to be given. (Avoid areas that are bruised, tender, hard,
swollen, inflamed or scarred.)

6. If the medication may affect the patient’s vital signs, assess them before administration.

Procedure

Action Rationale

1. Wash hands. This prevents the spread of microorganisms.

2. Gather equipment. Prepare Preparation promotes efficient time management and

medication cart/tray with the organized approach to the task.
necessary equipment and supplies.

3. Check the Kardex/medication order This helps to identify any errors.

for completeness and accuracy.

4. Select the appropriate medication This is the first check of the label.
from stock.

5. Compare the label with the order on

the Kardex. This is the second check of the label.

Check expiration dates and perform

calculations.
Verify calculations with another nurse.

6. Withdraw the medication from the

ampoule or vial. Change needle to
one of an appropriate size and
length.

7. Recheck label against Kardex.

This is the third check of the label.
8. Take the medication to the patient’s
Close observation prevent accidental or deliberate
bedside. Keep medications in sight

37
 at all times. disarrangement of medication.

9. Identify patient. This ensures the right patient receives the medications and
help prevents errors.
10. Provide privacy.

11. Perform necessary assessments. Assessment is a prerequisite to administration of

medications.
Explain the procedure and, the purpose and
action of the medication to the patient. Explanation provides rationale, increases knowledge and
reduces anxiety.

12. Select an appropriate administration Selecting the appropriate site prevents injury.
site.

Assist the patient to the appropriate position.

Expose only the site area to be used. Appropriate positioning for the site chosen prevents
injury.

13. Cleanse the area around the site with Prevents the introduction of pathogens into the tissues by
an alcohol swab. the needle.

Use firm circular motion while moving away Moving from the center outwards prevents contamination
from the injection site. of the site.

Allow area to dry. Allowing skin to dry prevents introducing alcohol into the
tissue, which can be irritating and uncomfortable.

14. Remove the needle cap by pulling it This technique lessens the risk of an accidental needle
straight off. stick and also prevents inadvertently unscrewing the
needle from the syringe.
Hold the syringe in dominant hand between
the thumb and forefinger.

15. With the non-dominant hand, pull This ensures that medication does not leak back along the
the skin down or to one side. needle track and into the subcutaneous tissue.

16. Quickly insert the needle into the A quick injection is less painful.
tissue at a 72 to 90 degree angle.
A 72 to 90 degree angle facilitates entry into muscle
tissue.

17. As soon as the needle is in place, use Provides stability to the syringe as moving it could cause
the thumb and forefinger of the non- damage to the tissues.
dominant hand to hold the lower end
of the syringe.

Move your dominant hand to the end of the

plunger and pull back on the plunger to check
Aspiration of blood indicates the needle has entered a
for blood.
blood vessel.
18. Inject the medication slowly.

38
 Rapid injection can cause pressure in the tissues and result
in discomfort.

19. Withdraw the needle smoothly and To minimize damage tissue damage.
steadily at the same angle at which it
was inserted.

20. Apply gentle pressure to the site with Light pressure cause less irritation to the tissues.
a dry gauze square. Do not massage
the site. Massaging can force medication into subcutaneous
tissues.

21. Discard the needle and syringe in the Proper disposal of the needle prevents injury.
appropriate receptacle.

Do not recap the used needle.

22. Assist patient to a comfortable This provides for the well-being of the patient.
position.

23. Wash hands.

24. Document Timely documentation helps to ensure patient safety.

25. Evaluate the patient’s response to the For therapeutic and adverse effects from the medications.
medication (within an appropriate
time frame)

 Administration of Subcutaneous (SQ) Medications

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. This
tissue has few blood vessels, so drugs administered here have a slow, sustained rate of absorption into the
capillaries. This route is used to administer drugs such as insulin and heparin.

Sites Selection

Various sites may be used for SQ injections.

Avoid sites that are bruised, tender, hard, swollen, inflamed, or scarred. These conditions can affect absorption or
cause discomfort and injury.

Sites

 Outer aspect of the upper arm

 Abdomen (from below the costal margin to the iliac crests)

 Anterior aspects of the thigh

39
  Upper back

 Upper ventral or dorsogluteal area

General Paediatric considerations: The site of the SC injection depends on the age of the child. Usually the
dorsum of the upper arm or the anterior thigh is used in newborns, infants, and toddlers. Infants and toddlers need to
be held securely and with only minimal explanations understood. The preschooler and the young school-age child
may often understand the reason for the injection. Explain what it feels like. At the end of the procedure find
something to praise the child for, example: holding still (if he or she did).

Equipment

 Medication Kardex

 Prescribed medication(s)

 Medication cart/tray

 Sterile syringes { appropriate size}

 Sterile needles {appropriate size and length}

 Alcohol swabs

 Gauze squares

 Equipment used for a SQ injection includes (a) syringe of appropriate volume for the amount of drug being
administered, (b) 25 to 30 gauge(G), 3/8” to 1” needle. Choose the needle length based on the amount of
subcutaneous tissue present. Usually no more than 1 mL of solution is given subcutaneously

Assessment Guidelines

1. Assess for any allergies.

2. Assess the appropriateness of the drug for the patient.

3. Assess the site on the patient where the injection is to be given.

4. Assess the patient’s knowledge of the medication.

5. If the medication affects the patient’s vital signs, assess them before administration.

Procedure

Action Rationale

1. Wash hands. This prevents the spread of microorganisms.

2. Gather equipment. Prepare medication cart/tray Preparation promotes efficient time management and
with the necessary equipment and supplies. organized approach to the task.

40
 3. Check the Kardex/medication order for This helps to identify any errors.
completeness and accuracy.

4. Select the appropriate medication from stock. This is the first check of the label.

5. Compare the label with the order on the

Kardex.
This is the second check of the label.
6. Check expiration dates and perform
calculations.

Verify calculations with another nurse.

7. Withdraw the medication from the ampoule or

vial. Change needle to one of an appropriate
size and length.

8. Recheck label against Kardex.

9. Take the medication to the patient’s bedside. This is the third check of the label.
Keep medications in sight at all times.
Close observation prevent accidental or deliberate
disarrangement of medication.

10. Identify patient. This ensures the right patient receives the medications
and help prevents errors.
Provide privacy.

11. Perform necessary assessments. Assessment is a prerequisite to administration of

medications.
Explain the procedure and, the purpose and action of the
medication to the patient. Explanation provides rationale, increases knowledge and
reduces anxiety.

12. Select an appropriate administration site. Selecting the appropriate site prevents injury.

13. Assist the patient to the appropriate position.

Expose only the site area to be used.
Appropriate positioning for the site chosen prevents
injury.

14. Cleanse the area around the site with an alcohol Prevents the introduction of pathogens into the tissues
swab. by the needle.

Use firm circular motion while moving away from the Moving from the center outwards prevents
injection site. contamination of the site.

Allow area to dry. Allowing skin to dry prevents introducing alcohol into
the tissue, which can be irritating and uncomfortable.

15. Remove the needle cap by pulling it straight This technique lessens the risk of an accidental
off. needlestick and also prevents inadvertently unscrewing
the needle from the syringe.

41
Hold the syringe in dominant hand between the thumb
and forefinger.

16. Grasp and bunch the area surrounding the Pinching is advised for thinner patients and when a
injection site or spread the skin taut at the site. longer needle is used, to lift the adipose tissue away
from underlying muscle.

17. Hold the syringe in dominant hand between the

thumb and forefinger.

18. Inject the needle quickly at a 45 to 90 degree

angle. A quick injection is less painful.

For persons with little subcutaneous tissue, it is best to

insert the needle at a 45-degree angle.

19. Release the tissue. Move your non-dominant Injecting the solution into compressed tissues results in
hand to steady the lower end of the syringe. pressure against nerve fibres and creates discomfort.

Move your dominant hand to the end of the plunger.

Avoid moving the syringe.

20. Inject the medication slowly. Rapid injection can cause pressure in the tissues and
result in discomfort

21. Withdraw the needle quickly at the same angle Slow withdrawal of the needle pulls the tissues and
at which it was inserted. causes discomfort.

22. Apply gentle pressure to the site with a dry Massaging the site is not necessary and can increase the
gauze square. Do not massage the site. absorption of the medication.

23. Discard the needle and syringe in the Proper disposal of the needle prevents injury.
appropriate receptacle.

Do not recap the used needle.

24. Assist patient to a comfortable position. This provides for the well-being of the patient.

25. Wash hands. Timely documentation helps to ensure patient safety.

26. Document.

27. Evaluate the patient’s response to the For therapeutic and adverse effects from the
medication (within an appropriate time frame) medications.

42
  Changing and Emptying an Ostomy Appliance

Overview

A colostomy is an opening surgically created from the ascending, transverse, or descending colon to the abdominal
wall. An ileostomy is an opening from the ileum to the abdominal wall. Colostomies and ileostomies function to
discharge waste (liquids, solids, and gases) to the outside of the body.

General Paediatric considerations: Infants and children may require an ostomy for several reasons, including
necrotizing enterocolitis, Hirshprung’s disease, imperforate anus, prune belly syndrome, inflammatory bowel
syndrome, spina bifida, tumor and trauma, In children and infants, ostomies pose special problems because of the
fragility of the skin. Care must be taken to prevent skin breakdown at the site.

Equipment:

 Basin with warm water

 Skin cleanser, towel, washcloth

 Gauze squares

 Skin protectant or barrier

 Ostomy appliance

 Stoma measuring guide

 Bedpan

 Toilet paper

 Scissors

 Disposable gloves

 Small plastic trash bag

 Waterproof disposable pad

Assessment Guidelines

1. Inspect the stoma for color and texture. This allows the nurse to determine the viability and turgor of the
stoma.

2. Inspect the condition of the skin surrounding the stoma. Alterations in skin integrity will prohibit a closed
drainage system from adhering to the skin.

3. Measure the dimensions of the stoma prior to obtaining an ostomy appliance system. Alleviate the problem
of obtaining the wrong size equipments.

Procedure

43
Action Evidence-Based Rationale

1. Identify the patient Proper identification of the patient ensures that the right
patient receives the right procedure as ordered which
helps to prevent errors.

2. Explain the procedure to the patient and Explanation encourages patient cooperation and reduces
encourage the patient to observe and participate apprehension. It also provides knowledge about the
if possible. procedure.

3. Gather the equipment This facilitates an organized and efficient procedure.

4. Wash hands Hand washing/Hand hygiene reduce the risk of

spreading micro-organisms.

5. Close the patient’s bedside curtain or door This provides privacy thereby improving patient’s
comfort and cooperation

6. Assist the patient to a comfortable sitting or Lying flat or sitting upright facilitates smooth
lying position. application of the appliance. Either position should
allow the patient to view the procedure in preparation
for learning to perform it independently

7. Put on disposable gloves. Remove clamp and Gloves prevent contact with body fluids and
fold end of pouch upwards like a cuff. microorganisms. Creating a cuff before emptying
prevents additional soilage and odor.

8. Empty contents into bedpan or measuring Rinsing the Inside provides cleaner appearance and
device. Rinse appliance or pouch with tepid minimizes odor. Some appliances don not need rinsing
water. as rinsing may reduce the appliance’s odor barrier.

9. Wipe the lower 2 inches of the pouch with toilet Drying the lower section removes any additional fecal
tissue. material, thus decreasing odor problem.

10. Uncuff edge of appliance or pouch and apply The edges of the appliance or pouch should remain
clip or clamp. Remove gloves. If appliance is clean. The clamp secures closure, Hand hygiene deters
not to be changed. Perform hand hygiene. microorganisms. Ensures patient comfort
Assist patient to a comfortable position.

Changing an Appliance

Action Evidence-Based Rationale

1. Place a disposable pad on the works surface. The pad protects the surface. Organisation facilitates
Setup the wash basin with warm water and the efficient performance of the procedure.
rest of the supplies. Place a trash bag/bin within
reach.

2. Put on gloves. Place waterproof pad under the The waterproof pad protects the patient and linen from
patient’s stoma site. Empty the appliance as moisture. Emptying the contents before removing

44
 previously outlined. prevents accidental spillage of fecal material.

3. Gently remove pouch faceplate from skin by This reduces irritation to the skin.
pushing skin from appliance rather than pulling
appliance from skin; starting at the top while The seal between the surface of the faceplate and the
keeping the abdominal skin taut. skin must be broken before the faceplate can be
removed. Harsh handling of the appliance can damage
the skin and impair the development of a secure seal in
the future.

4. Place the appliance in the trash bag/bin, if Appropriate disposal implements the principles of
disposable. If reusable, set aside to wash in infection control.
lukewarm water and allow to air dry after the
new appliance is in place.

5. Use toilet tissue to remove any excess stool Toilet tissue, used gently will not damage the stoma.
from stoma. Cover stoma with gauze pad. Clean The gauze absorbs any drainage from the stoma while
stoma with mild soap and water or a cleansing the skin is being prepared. Cleaning the skin removes
agent and a washcloth. Remove all old excretions, old adhesives and skin protectant. Excretions
Adhesive from the skin; do not apply lotion to or a buildup of other substances can irritate and damage
peristomal area. the skin. Lotion will prevent a tight adhesive seal.

6. Gently pat area dry. Ensure the skin around the Careful drying prevent trauma to skin and stoma. Proper
stoma is thoroughly dry. Assess stoma and drying facilitates a proper adhesive seal which will
condition of surrounding skin. protect the skin integrity from seepage.

A change in color and size of the stoma may indicate a

circulatory problem.

7. Lift the gauze squares for a moment and The appliance should fit snuggly around the stoma, with
measure the stoma opening, using the only 1/8 of an inch of skin visible around the opening. A
measuring guide. Replace the gauze. Trace the faceplate opening that is too small can cause trauma to
same size opening on the back center of the the stoma. If the opening is too large. Exposes skin will
appliance. Cut the opening 1/8 of an inch larger be irritated.
than the stoma size.

8. Remove the backing from the appliance. The appliance is effective only if it is properly
Quickly remove the gauze squares and ease the positioned and securely adhered.
appliance over the stoma. Gently press onto the
skin while smoothing over the surface. Apply
gentle pressure to appliance for 5 minutes.

9. Close bottom of appliance or pouch by folding A tightly sealed appliance will not leak and cause
the end upward and using clamp or clip that embarrassment and discomfort for the patient.
comes with the appliance.

10. Remove gloves. Assist the patient to a Provides warmth and promotes comfort and safety.
comfortable position. Cover the patient with
bed linens. Place the bed in lowest position.

11. Put on clean gloves. Remove or discard The patient’s response may indicate the need for further

45
 equipment and assess patient’s response to the interventions such as health teaching. Hand hygiene
procedure. Remove gloves and perform hand reduces transmission of microorganisms.
hygiene.

 Irrigation of Colostomy

Overview

The purpose of a colostomy irrigation is to empty the large colon of stool. The colostomy irrigation can be
performed at the bedside or in the bathroom. This process is similar to performing an enema.

Equipment

Top Shelf

 Bowl with funnel, tubing, connection and rectal catheter size 12-16 FG(medium), gate clip or clamp.

 Jug with normal saline (1000 mls) temp. 100oF standing in blow of water 105oF

 Bowl with clean gauze and cotton wool swabs

 Lubricant for catheter

Bottom Shelf

 Large kidney shape receiver

 Receptacle (pail) for retuned irrigation fluid

 Disposable gloves

 Paper bag in bowl of used colostomy bag and soiled dressing

 Incontinent pad

 Clean colostomy bag

 Bedpan and toilet paper

Assessment Guidelines

1. Assess patient’s attitude towards his/her the colostomy or ability to participate in the procedure.

2. Assess ostomy, ensuring that the diversion is a colostomy. Ileostomoies are never irrigated because the
fecal content is liquid and cannot be controlled. Note placement

3. Inspect the stoma for color and texture. This allows the nurse to determine the viability and turgor of the
stoma.

4. Inspect the condition of the skin surrounding the stoma. Alterations in skin integrity will prohibit a closed
drainage system from adhering to the skin.

46
 5. Determine the direction of the intestine by digitalization of the stoma. This allows the nurse to know the
direction of the intestinal tract prior to beginning the irrigation, which will prevent possible perforation of
the bowel.

6. Measure the dimensions of the stoma prior to obtaining an ostomy appliance system. Alleviates the
problem of obtaining the wrong size equipment.

Action Evidence-Based Rationale

1. Identify the patient Proper identification of the patient ensures that the right
patient receives the right procedure as ordered which
helps to prevent errors.

2. Explain the procedure to the patient and Explanation helps to minimize anxiety and promote
encourage the patient to observe and participate cooperation. It also provides knowledge about the
if possible. procedure.

3. Gather the equipment This facilitates an organized and efficient procedure.

4. Wash hands Hand washing/Hand hygiene reduce the risk of

spreading micro-organisms.

5. Close the patient’s bedside curtain or door This provides privacy thereby improving patient’s
comfort and cooperation

6. Assist patient onto bedpan, commode or toilet The patient cannot hold the irrigation fluid. A large
(if in the bathroom) immediate return of irrigation solution and stool usually
occurs.

7. Assemble irrigation kit: Attach cone or catheter Ensures that all equipment is ready to use.
to irrigation bag tubing.

8. Add irrigation solution to bag/container. This causes any air to be expelled from the tubing.
Release clamp and allow fluid to progress Allowing air to enter the intestine may cause further
through tube before reclamping. distension.

9. Hang container so that the bottom of the bag Gravity forces the solution to enter the intestine. The
will be at shoulder level when seated. amount of pressure determines the rate of flow and
pressure exerted on the intestinal wall.

10. Put on non-sterile gloves Prevents direct contact with body fluids

11. Remove ostomy appliance and attach irrigation The irrigation sleeve directs all irrigation fluid and stool
sleeve. Place drainage end into toilet bowl, into the toilet, commode or pail.
commode or pail. In the absence on irrigation
sleeve, place a large kidney dish under stoma

47
Action Evidence-Based Rationale

12. Lubricate end of the cone with water soluble Lubrication facilitates passage of the cone into the
lubricant. stoma and reduces the risk of irritating the mucosa.

13. Insert the cone/catheter 3-4 inches into the If the irrigation solution is instilled too quickly, the
stoma. Introduce solution slowly over a period patient may experience nausea and cramps. If cramping
of 5-6 minutes. Hold tubing (or of patient is should start, immediately stop and allow client to rest
able, allow patient to hold tubing) all the time for a few minutes.
that the solution is being instilled. Control rate
of flow by closing or opening clamp.

14. Hold cone in place for an additional 10 seconds This will allow a small amount of dwell time for the
after fluid is infused. irrigation solution.

15. Remove cone. Patient should remain seated on An immediate return of solution and stool usually occur,
toilet or bedside commode. followed by a return in spurts for up to 45 more minutes

16. After majority of the solution has returned, An immediate return of solution and stool usually occur,
allow patient to close bottom of irrigation followed by a return in spurts for up to 45 more minutes
sleeve and continue with activities of daily
living.

17. After solution has stopped flowing from stoma, Gloves prevent contact with body fluids. Peristomal skin
put on clean gloves, Remove irrigating sleeve must be clean and free of any liquid or stool before
and cleanse skin around stoma opening with application of new appliance.
mild soap and water. Gently pat peristomal skin
dry.

18. Attach new appliance to stoma or stoma cover. Some patients will not require an appliance, but may use
a stoma cover to protect the stoma.

19. Lift the gauze squares for a moment and The appliance should fit snuggly around the stoma, with
measure the stoma opening, using the only 1/8 of an inch of skin visible around the opening. A
measuring guide. Replace the gauze. Trace the faceplate opening that is too small can cause trauma to
same size opening on the back center of the the stoma. If the opening is too large. Exposes skin will
appliance. Cut the opening 1/8 of an inch larger be irritated.
than the stoma size.

20. Remove gloves. Assist patient to assume a Provides warmth and promotes comfort and safety.
comfortable position. Cover patient with bed Removing gloves prevents the spread of
linen. microorganisms.

21. Wash hands Proper hand hygiene reduces the risk of spreading
microorganisms.

 Inserting a Nasogastric (NG) Tube

48
A nasogastric (NG) tube is a clear, flexible, plastic tube with a single lumen and has holes at the tip and along the
distal side. It is inserted through the nose, into the oesophagus down into the stomach.

Purposes

Ng tubes serve both therapeutic and diagnostic purposes.

Therapeutic:-

 Nutrition – used for feeds

 Decompress/ drain unwanted fluid and air from the stomach

 Administer drugs and other agents such as activated charcoal to neutralize swallowed poisons

Diagnostic:-

 Monitor bleeding in the GI tract

 To take samples of the stomach contents for laboratory studies

General paediatric considerations: Tell the preschooler what will happen in simple terms. Offer the school-age
and adolescent a rationale for the procedure.Recommended sizes for NGT are as follows:

Preterm ………….…..5

Newborn and Infant…5-8

1-3years……………...10

4-6 years ……….……10-12

7-11years …….……..12-14

Adolescent……….…..14-18

Equipment

 Nasogastric tube (appropriate size)

 Nonsterile gloves

 Catheter tip irrigation 60 mL syringe

 Water soluble lubricant (KY jelly)

 Adhesive tape

 Drainage bag

 Glass of water

 Emesis basin

49
  Stethoscope

 Incopad

 Gauze squares/tissues

Assessment Guidelines

1. Check doctor’s order for insertion of NG tube.

2. Assess client’s understanding of the procedure.

3. Assess the need for assistance with the procedure.

4. Assess the patency of the client’s nares.

Action Rationale

1. Verify doctor’s order for insertion of NG tube. This ensures the right patient receives the correct
treatment.

2. Wash hands. This helps to prevent the spread of microorganisms.

3. Identify patient Identifying the patient ensures the right patient receives
the intervention and helps to prevent errors.
4. Explain procedure to the patient (include the
purpose of the tube and any associated Explanation encourages patient cooperation.
discomfort the patient may experience).

5. Gather equipment and take to the patient’s This provides for an organized approach to the task.
bedside.

6. Ensure privacy (close the curtains/drapes or This provides for patient’s privacy
close door to the patient’s room).

7. Raise bed to comfortable working height. This prevents back and muscle strain.

8. Assist patient to high Fowler’s position. This position is more natural for swallowing.

9. Drape the patient’s chest with the Incopad and Passage of the NG tube may stimulate the gag reflex as
have emesis bowl and gauze squares/tissues well as cause tearing of the eyes.
ready.

10. Determine the appropriate length for tube Measurement ensures that the tube will be long enough
insertion. Using the NG tube measure from the to enter the patient’s stomach.
tip of the nose to the ear lobe and then to the
xiphoid process. Mark this point on the tube
with tape.

11. Put on gloves. Lubricate the tip of the tube Lubrication reduces friction and facilitates passage of
the tube.
(at least 2 to 4 inches) with KY jelly.

50
 12. Ask patient to slightly flex head back. Gently Gently guiding the tube along the normal contour of the
insert tube into the nostril, directing it along the nasal passage reduces irritation and the likelihood of
floor of the nose. mucosal injury.

Ask patient to swallow (provide sip of water from the Swallowing helps advance the tube, causes the epiglottis
glass). to cover the opening of the trachea, and helps to
eliminate coughing and gagging.

13. Advance tube until taped mark is reached.

14. Loosely secure tube (with tape) to nose. This stabilizes the tube until placement/position is
determined.
Check placement of the tube (using at least two
methods)

a.) Inject 10 mL of air through tube while

listening with stethoscope over the
stomach for the rush of air.

b.) Aspirate for stomach contents

15. Spigot end of tube or attach to drainage bag.

Tape tube securely to the “bridge” of the nose and on the

cheek (check hospital’s policy).
Securing the tube prevents tension and tugging.

16. Dispose of equipment according to hospital’s

policy.

Remove gloves.
Removing gloves reduces the risk for infection
transmission and contamination of other items.

17. Assist patient to a position of comfort.

Raise side rails and return bed to its lowest position.

18. Document.

 Aseptic Dressing

A wound is a break or disruption in the normal integrity of the skin and tissues. Wounds are classified in many
different ways: intentional or unintentional (based on how they are acquired), open or closed, and acute or chronic.
Wounds may also be classified as partial-thickness, full thickness, or complex.

Wound healing is a process of tissue response to injury. Wound repair occurs by (a) primary intention (edges are
well approximated; example surgical incision), (b) secondary intention (edges are not well approximated; example

51
wounds from burns), or (c) tertiary intention (wounds left open for several days to allow edema or infection to
resolve or exudates to drain, and then are closed).

Phases of wound healing

Wound healing occurs in four phases. These phases systematically lead to repair of the injury: hemostasis,
inflammation, proliferation, and maturation.

Wound Assessment

Wound assessment includes inspection (sight and smell) and palpation for appearance, drainage, odor, and pain.
Wound assessment determines the status of the wound, identifies barriers to the healing process, and signs of
complications.

Note the location of the wound (described in relation to the nearest anatomical landmark).

Document the size of the wound (in centimeters or millimeters, measuring length, width, and depth).

Assess for approximation of the edges. Assess the color of the wound and surrounding area (note the presence of
tubes, drains, sutures).

Assess for the presence of odor, which can be indicative of certain types of bacteria.

Assess for wound drainage. The exudate is composed of fluid and cells that escape from blood vessels and are
deposited in or on tissue surfaces. This exudate can be described as serous, sanguineous, serosanguineous or
purulent (if infected).

Changing the Dressing

Prepare the patient for the dressing change before starting the procedure by explaining what will be done. The use of
aseptic techniques when changing the dressing is crucial. Be especially vigilant in performing thorough hand
washing before and after changing dressings.

Surgical wounds require the use of sterile technique. Pressure ulcers are not sterile wounds and non-sterile gloves
can be used for wound care.

General Paediatric consideration: Consider growth and development when providing explanations and reason for
performing wound care and dressing change. Infants and toddlers may need to be held in order to maintain their
position and protect sterility of the wound care equipment and wound. The skin of the infant is susceptible to tears
and blisters so care should be taken in removing and applying adhesive dressings or tape. Where pain is anticipated,
analgesics should be administered prior to the procedure.

Equipment

Dressing Trolley with:

Top Shelf BottomShelf

 Dressing set containing: Sterile gloves

 1 large tray Disposable gloves

 2 gallipots Incopad

52
  1 receiver/kidney dish Cleaning solution

 2 dressing forceps Additional gauze and cotton packs

 1 non-toothed dissecting forceps Receptacle for soiled dressings/waste

 Gauze squares and cotton swabs Adhesive tape and/or bandage

 1 fenestrated towel Scissors

Assessment Guidelines

1. Assess the situation to determine the need for wound cleaning and dressing change.

2. Assess the patient’s level of comfort and the need for analgesics before wound care.

3. Assess the current dressing (if it is intact, saturated, for drainage, bleeding)

4. Assess the wound and surrounding tissues (for appearance, approximation of the edges, color, presence of
sutures or staples). Note the stage of healing and the characteristics of any drainage.

Action Rationale

1. Verify the medical order for wound This ensures the right patient receives the right
care/dressing change. procedure.

2. Wash hands.

Gather necessary equipment and supplies. Promotes efficient time management and an organized
approach to the task.

3. Bring supplies to patient’s bedside.

Provide privacy.

4. Identify patient. To ensure the right patient receives the intervention.

Explanation relieves anxiety and facilitates cooperation.

Explain procedure and its purpose.

5. Assess the patient for the possible need for Wound care/dressing change may cause pain for some
analgesic. patients.

6. Adjust bed to a comfortable working height. Having the bed at the proper height prevents back and
muscle strain.
7. Assist patient to assume a comfortable position
that provides easy access to the wound site.
Expose the wound area only.

8. Place Incopad under the wound site.

9. Place waste receptacle at a convenient location Having a waste container handy means the soiled
for use during the procedure. dressings and other waste generated during the

53
 procedure may be discarded easily, without the spread of
microorganisms.

10. Put on clean, disposable gloves. Gloves protect the nurse from contaminated dressings
and prevent the spread of microorganisms.
Loosen the tape on the old dressing and carefully
remove the soiled dressing. Sterile saline moistens the dressing for easier removal
and minimizes damage and pain.
If dressing sticks to the wound, use a small amount of
sterile saline to help loosen and then remove.

Note the presence, amount, color, odor of any exudate The presence of drainage should be documented.
on the dressings.

Place soiled dressings in the waste receptacle. Remove

gloves and discard in waste receptacle. Proper disposal of soiled dressings and used gloves
prevents the spread of microorganisms.

11. Inspect wound for size, appearance and Wound healing or the presence of infection should be
drainage. documented.

12. Wash hands.

13. Using sterile techniques, prepare the dressing

tray on the top shelf. (Pouring sterile cleaning
solution, adding sterile items such as sterile
gloves and additional sterile gauze squares)

14. Don sterile gloves Use of sterile gloves maintains surgical asepsis and
reduces the risk for spreading microorganisms.
Drape wound site with the fenestrated towel.

Use the dressing forceps to pick up, moisten and remove

excess solution from gauze squares.

15. Clean the wound using a new gauze The use of a new gauze square for each wipe ensures
square/cotton swab for each wipe. Discard the that the previously cleaned area is not recontaminated.
used gauze in the waste receptacle.

For surgical wounds with approximated edges: Clean

from top to bottom, working outward from the incision,
in parallel lines. (Wipe from clean area toward less clean
Cleaning from top to bottom and from center to outside
area.)
ensures that cleaning occurs from the least to the most
For open wounds: Clean the wound in circles, beginning contaminated area.
in the center, working toward the outside a few inches
beyond the wound edges. Use a new gauze square/cotton
swab for each circle.

16. Once the wound is cleaned, dry the area using Moisture provides a medium for growth of
dry gauze squares in the same manner. microorganisms.

54
(apply ointment, cream or other treatment at this stage,
as ordered)

17. Apply dry sterile gauze squares in layer(s) over

the wound.

Dissecting forceps may be used to apply the dressing.

Use of forceps helps ensure that sterile technique is
maintained.

18. Remove and discard gloves. Proper disposal of used gloves prevents the spread of
microorganisms.
Cut strips of tape and apply, to secure the dressings.
Tape is easier to apply after gloves have been removed.

19. Dispose of equipment as per hospital’s policy.

Place patient in a comfortable position, with rails up and

the bed in the lowest position.
Proper patient and bed positioning promotes safety and
comfort.

20. Wash hands.

21. Document procedure.

 Administering Nasogastric Tube Feeding

While oral feeding is the preferred and most effective method of feeding patients, at times, he/she will be unable to
meet nutritional needs through oral intake of an adequate diet. An alternate feeding method may be necessary when
this circumstance arises. The enteral route is the next best method of feeding.

A nasogastric tube enables a nutritionally adequate diet to be delivered to the stomach bypassing the oral route. It is
the most common route for enteral feeding (Best, 2005).

Gastric feedings have the advantage of allowing the stomach to be used as a natural reservoir, regulating the amount
of foods and liquids released into the small intestine.

General paediatric consideration: consider age of child when carrying out procedure especially in regards to
simple explanations.

Equipment

 Clean trolley

 Prescribed feeding formula (at room temperature)

 Feeding bag

 60 mL syringe (catheter-tip irrigation)

55
  IV pole

 Nonsterile gloves

 Stethoscope

 Incopad

 Water for irrigation and hydration (as needed)

 Additional PPE (eg. gown), as needed.

Assessment Guidelines

1. Assess the patient’s abdomen (inspection, auscultation, palpation). If the abdomen is distended, measure
and record the girth.

2. Assess for the placement of the tube.

3. Consult with doctor (before administering feed) if the patient reports abdominal pain, nausea, or if there are
signs of firmness or rigidity of the abdomen.

4. Assess the patient’s understanding/knowledge of the rationale for tube feeding. Address any queries and
concerns.

5. Assess the patient’s response during and after tube feeding.

Contraindications

 Patients with a dysfunctional gag reflex

 Patients with a high risk of aspiration

 Patients with nasal injuries

 Patients with gastroesophageal reflux

Action Rationale

1. Check patient’s chart for medical order for tube This ensures that the correct feeding will be
feeding (amount, concentration, type and administered
frequency).

2. Wash hands. Hand washing prevents the spread of microorganisms.

3. Gather necessary equipment and supplies. This provides an organized approach to the procedure to
be performed.

Expired formula may be contaminated.

4. Check expiration date of the formula.

5. Identify patient. This ensures the right patient receives the intervention.
Helps to prevent errors.

56
 This helps to facilitate patient cooperation.

6. Explain the procedure to the patient.

7. Bring equipment to the bedside.

Close curtains (or close door to patient’s room) This provides for patient privacy.

Raise bed to a comfortable working position

This helps to prevent back and muscle strain (worker).

8. Perform abdominal assessment. Assessment is vital before initiating the intervention as

there may be changes in the patient’s condition since the
last feed.

9. Position patient with head of bed elevated to a This position minimizes the risk for aspiration.
45 degree angle.

10. Put on gloves Gloves prevent contact with body fluids.

Verify the position of the tube (check for taped mark at

the nostril).
This ensures that the tube has not been displaced.

11. Attach syringe to the end of the tube and The tube is in the stomach if its contents can be
aspirate a small amount of gastric contents. aspirated. (Another method of checking tube placement).

12. Visualize aspirated contents and note its color

and consistency.

13. Aspirate all gastric contents and measure to This is done to identify any delay in gastric emptying.
check for the residual amount.
This is done to avoid fluid and electrolyte imbalance.
Return the residual amount (based on hospital policy).

14. Flush the tube with 30 mL of water for Flushing the tube helps to prevent clogging/occlusion.
irrigation.

15. Administer the feeding:

Using the Feeding Bag

a) Label the bag with date and time. Hang the

bag to the IV pole and adjust the height of
the pole to about 12 inches above the The correct height ensures the feed is not administered
patient’s stomach. Ensure the clamp is too quickly.
closed.

b) Check expiration date of the formula

Cleanse top of the formula container before opening it.

Pour formula into the feeding bag and allow it to run

57
through the tubing (priming). Close clamp. Cleansing the top of the container minimizes the risk of
contaminants entering the feeding bag.
c) Attach to feeding tube, open clamp and
regulate flow according to the medical
order.

d) When feeding is almost completed, add 30

to 60 mL of water to the feeding bag and
allow it to run through the tube.
Introducing the formula at a desirable rate allows the
stomach to accommodate to the feeding and lessens GI
distress.

Water rinses feeding from the tube and helps to keep it

patent.

16. Using the Large Syringe method:

a) Remove the plunger from the 60 mL

syringe

b) Attach syringe to the NG tube, pour the

pre-measured amount into the syringe, Introducing the formula at a desirable rate allows the
open clamp/kink and allow the formula to stomach to accommodate to the feeding and lessens GI
flow through the tube at desired rate. distress.
(Regulate rate of flow by height of the
syringe)
The higher the syringe is held, the faster the flow of the
c) When feeding is almost completed, add 30
formula.
to 60 mL of water to the syringe and allow
it to run through the tube. Water rinses feeding from the tube and helps to keep it
patent.
d) When the syringe is empty, hold it high
and disconnect it from the tube. Cover the
end of the tube with cap/spigot.

Holding the tube high prevents the backflow of the

formula out of the tube and onto the patient.

Capping/spigoting the tube deters the entry of

microorganisms, as well as protects the patient and
linens from fluid leakage from the tube.

17. Allow patient to remain in an upright position This position minimizes the risk for backflow and
for at least one (1) hour after feeding. aspiration should reflux or vomiting occurs.

Return patient to a comfortable position.

Raise side rails and lower bed. This promotes patient comfort and safety.

18. Dispose of equipment according to hospital Hospital’s policy and guidelines will determine the

58
 policy. specifics on care of equipment used.

19. Remove gloves (and additional PPE)and wash

hands

20. Document the procedure.

Documentation

1. Document the type/size of NG tube present

2. Record the placement check performed to confirm the tube’s placement before feeding commenced.

3. Document the aspiration of stomach content. Note the color and consistency.

4. Record the pre-feed abdominal assessment, include the subjective data from the patient (eg; nausea)

5. Record the residual amount obtained.

6. Document the type and amount of feeding, and the method of feeding used.

7. Document the patient’s tolerance to the procedure.

8. Document any patient teaching done

 Suctioning of Tracheostomy

1. Place client in a semi-Fowlers position (Position may vary according to client’s conscious level or
diagnosis).

2. Move the overbed table close to your work area and raise to waist height.

3. Place towel/ waterproof pad across patient's chest.

4. Turn suction to appropriate pressure.

5. Put on a disposable glove and occlude the end of the connecting tubing to check suction pressure.

6. Open sterile suction package using aseptic technique.

7. Pour sterile water or saline in a sterile kidney dish.

8. . Don sterile gloves.

9. With dominant gloved hand pick up sterile catheter.

10. Connect sterile catheter to the suction tubing.

11. Using the dominant hand gently and quickly insert catheter into trachea.

59
12. Advance the catheter do not apply suction on insertion.

13. After insertion apply suction

14. Then gently rotate the catheter as its being withdrawn (do not suction for more than 10-15 seconds at
a time).

15. Flush catheter with saline.

16. Assess the effectiveness of suctioning and repeat as needed and according to patient's tolerance.

17. When suctioning is completed remove glove from dominant hand over the coiled catheter, pulling it
off inside out.

18. Remove gloves and dispose of gloves, catheter and container with sterile water.

19. Assist patient to a comfortable position.

20. Turn off suction an offer oral hygiene.

21. Perform Hand hygiene.

22. Document the procedure.

 Venipuncture for Intravenous Infusion

Equipment

 IV Cannula (appropriate size)

 IV Pole

 IV Infusion set/Buretrol

 Alcohol swabs

 Tourniquet

 Non-sterile gloves

 Tape

 IV Label

 Surgical scissors

 Protective pad (Incopad)

 Sharps container

 Trash receptacle

60
 Assessment Guidelines

 Assess arms and hands for potential sites for initiating the IV

 Determine the most desirable accessible vein (Cephalic vein, accessory cephalic vein, metacarpal, and basilic
vein)

 Either arm may be used for IV (but preferably the non-dominant)

 Do not use antecubital veins if other veins are available.

 Do not use veins in the legs, unless other sites are inaccessible

 Do not use veins in surgical areas

Procedure

Action Rationale

1. Check the doctor’s order for verification

2. Gather all equipment. Organization facilitates performance of the task.

3. Identify the patient. Explain the procedure you Patient identification validates the correct patient
are about to perform. Allow the patient to ask and correct procedure. Discussion and explanation
questions and advise that the procedure may be allay anxiety and prepare the patient for what to
uncomfortable. expect.

4. Provide privacy (close curtains/door).

5. Ensure good lighting.

6. Perform hand washing. Hand washing prevents the spread of

microorganisms.

7. Prepare the IV solution and administration set

(priming), maintaining asepsis.

8. Prepare tape to be used to secure/stabilize the

cannula. This saves time and facilitates accomplishment of
procedure.

9. Place protective pad under the patient’s arm. This protects underlying surface from blood
contamination.
10. Apply tourniquet, select and palpate for an
appropriate vein.

11. Release the tourniquet.

12. Put on gloves. Gloves prevent contact with blood and body fluids.

13. Clean the selected site with alcohol swab (allow

the area to dry)in a concentric circular motion

61
14. Reapply tourniquet (using enough pressure to
impede venous circulation) approximately 3 to
4 inches above the identified site. Interrupting blood flow causes the vein to distend.
Distended veins are easy to see, palpate and enter.
*Direct the ends of the tourniquet away from the
site of entry. The ends of the tourniquet could contaminate the
area of injection if directed toward the site of entry.

15. Hold the patient’s arm in a downward position

with your non-dominant hand.

Use the thumb or first finger to pull the skin taut

against the vein (just below the identified puncture Pressure on the vein and surrounding tissues helps
site). to prevent movement of the vein as the cannula is
being inserted.

16. Ask the patient to remain still while performing Patient movement may prevent proper technique.
the venipuncture.

17. Enter the skin gently, holding the cannula by This allows cannula to enter the vein with minimal
the hub in your dominant hand, bevel side up, trauma and deters passage of the needle through the
at a 10- to 15-degree angle vein.

18. Insert the cannula from directly over the vein or

from the side of the vein

19. Advance the needle until a sensation of “give”

can be felt when the needle enters the vein.

20. Observe for “flashback” blood to appear in the

cannula. The tourniquet causes increased venous pressure,
resulting in automatic backflow.

21. Partially withdraw the needle while advancing Placing the cannula well into the vein helps prevent
the cannula into the vein. dislodgement.

22. Release the tourniquet.

23. Compress the area of the skin over the tip of the This minimizes bleeding through the cannula.
cannula while removing the needle from the
cannula.

24. Connect the primed IV tubing to the hub of the

cannula and turn the roller clamp on to flush
through a bolus of solution. Assess for free
flow of the fluid.

25. Secure the cannula and tubing with the strips of This preserves the integrity of the device and
tape. prevents loss of the access.

26. Complete IV label and attach to site: Other personnel will know what type of cannula
used, the site and when it was inserted.

62
  Cannula size

 Date & Time of cannulation

 Name

27. Initiate flow of IV fluid at the desired rate and

observe the site for any possible complications

28. Discard used items according to agency

policies.

29. Remove and discard gloves.

30. Perform hand hygiene Hand hygiene prevents transmission of

microorganisms.
31. Document

 Date & Time

 Site
Continued monitoring is important to maintain
 Type and amount of IV fluid to be correct flow rate.
infused

 Flow rate

 Duration of infusion

 Any adverse reactions and measures

taken to correct them.

32. Return to check flow rate and observe IV site Early detection of problems ensures prompt
for infiltration. interventions.

Evaluation

 IV access is initiated on the first attempt

 Fluid flows easily into the vein without any signs of infiltration

 Patient verbalizes minimal discomfort related to insertion and demonstrates understanding of the
reasons for the IV.

IV FLUIDS
Fluids within the body are contained in two basic compartments, intracellular and extracellular. Cell membranes
and capillary walls separate the two fluid compartments. The intracellular fluid compartment, which consists of
fluid contained within all of our body cells, is the larger of the two compartments. The extracellular fluid
compartment contains all the fluids outside the cells and is further divided into two major subcomponents:

63
 intravascular fluid contained in blood vessels and interstitial fluid found in the tissue spaces. The intracellular,
intravascular, and interstitial spaces are the major fluid compartments in the body.A third category of the
extracellular fluid compartment is the transcellular compartment, which includes cerebrospinal fluid and fluid
contained in body spaces such as the pleural cavity and joint spaces. Because transcellular fluids don't normally
contribute significantly to fluid balance, they're beyond the scope of this article. The amount of water in the
body varies depending on age, gender, and body build. In nonobese adults, intracellular fluid constitutes
approximately 40% of body weight, and extracellular fluid, 20%.

Classification of fluids

The fluids used in intravenous fluid therapy are generally classified into the following three groups:

1. Whole blood and blood products

2. Colloids

3. Crystalloids.

 Whole blood and blood products

Whole blood is used in cases of:

 Severe haemorrhage
 Severe anemia
 Specific problems (e.g. Von Willebrand’s disease) where it isnecessary to provide platelets or clotting
factors.

 Colloids

Colloids are a group of fluids containing large molecules designed to remain in the intravenous space longer than
crystalloid fluids. Thismeans that colloids are able to expand and maintain the vascular volume more effectively.
Their osmotic potential is so great that colloids draw fluid out of the interstitial and intracellular spaces into the
plasma, hence colloids are commonly termed plasma expanders. Colloids are used in cases of shock where
cardiovascular function needs to be improved rapidly:

• Haemorrhage

• Shock

• Severe dehydration.

Following haemorrhage, colloids are sometimes administered rather than blood because obtaining a blood donor is
not always easy and they avoid the possibility of a blood transfusion reaction if cross-matching is not possible or
practical.

 Crystalloids

Crystalloids are a group of sodium-based electrolyte fluids. They enter the extracellular fluid (ECF) and from there
equilibrate with other fluid compartments in the body to restore fluid balance. The most commonly used crystalloids

64
are similar to plasma water in composition. In patients where renal function is normal, crystalloids will be excreted
in the urine.

PHARMACOLOGY
Major Classifications of Medications

1. Analgesic – relieves pain

2. Antacid – reduces or eliminates acids in the stomach

3. Antianxiety – decreases anxiety

4. Antiasthmatic– treats asthma

5. Antibacterial/Antibiotic – kills or slows the growth of bacteria

6. Anticoagulant – slows blood clotting

7. Anticonvulsant – prevents or stops seizures

8. Antidepressant – relieves depression

9. Antidiarrheal – stops or decreases diarrhea

10. Antidote – counteracts overdoses of medication or toxic substances

11. Antiemetic – controls nausea and vomiting

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12. Antifungal – treats fungal infections

13. Antihistamine – reduces symptoms of allergies

14. Antihypertensive – decreases high blood pressure

15. Antipsychotic – treats psychosis and controls behavior

16. Antipyretic – reduces fever

17. Antitussive – relieves cough

18. Antiulcer – treats heartburn and decreases secretion of stomach acid

19. Antiviral – manages or prevents viral infections

20. Bronchodilator – treats bronchospasm in asthma

21. Cardiovascular Agent – treats heart and circulatory disorders

22. Diuretic – increases urinary output

23. Expectorant – induces cough and movement of fluid from respiratory tract

24. Gastrointestinal Stimulant – stimulates motility of the upper GI tract and accelerates stomach emptying

25. Glucocorticoids – reduces inflammation or suppresses the immune system

26. Hormones – treats hormone deficiency including diabetes, hypothyroidism and menopause

27. Hypoglycemic Medication – treats and controls diabetes

28. Laxative – stimulates and loosens the bowels

29. Nonsteroidal Anti-Inflammatory Agents – control pain, fever and inflammatory conditions such as
muscle or joint pain

30. Over-the-Counter (OTC) – medications that do not require a prescription

31. Psychotropic – treats behavior/mental health issues

32. Sedative/Hypnotic – induces sleep

33. Skeletal Muscle Relaxants – stops muscle spasms and relieves painful musculoskeletal conditions

34. Stimulant - schedule II controlled substance which produces central nervous system stimulation

35. Topical Steroid – reduces inflammation of various skin conditions due to dermatitis, insect bites, poison
ivy, and the like

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 Common classification of medications

Note letters in medication name and look for those letters that identify a particular classification:

◊ Androgens: end with –terone: testosterone (Testoderm)

◊ ACE Inhibitors: end with –pril: enalapril (Vasotec)

◊ Antidiuretic hormones: end with –pressin: desmopressin (DDAVP)

◊ Antilipidemic: end with –statin: atorvastatin (Lipitor)

◊ Antiviral:contain -vir: ritonavir (Norvir)

 Benzodiazepines: include alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), estazolam

(ProSom), and triazolam (Halcion). Most others end with –pam: diazepam (Valium)

◊ Beta Blockers: end with –lol: atenolol (Tenormin)

◊ CCB: end with –pine: amlodipine (Norvasc); some exceptions include diltiazem (Cardizem), verapamil (Isoptin)

◊ Carbonic anhydrase inhibitors: end with –mide: acetazolamide (Diamox)

◊ Estrogens: contain est: conjugated estrogen (Premarin)

◊ Glucocorticoids and corticosteroids: end with –sone: prednisone (Deltasone)

◊ Histamine H2 receptor antagonists: end with –dine: cimetidine (Tagamet)

◊ Nitrates: contain nitr: nitroglycerin (Nitrostat)

◊ Pancreatic enzyme replacements: contain pancre: pancrelipase (Pancrease)

◊ Phenothiazines: end with –zine: chlorpromazine (Thorazine)

◊ Proton Pump Inhibitors: end with –zole: lansoprazole (Prevacid)

◊ Sulfonamides: include –sulf: sulfasalazine (Azulfidine)

◊ Thiazide diuretics: end with –zide: hydrochlorothiazide (HydroDIURIL)

◊ Thrombolytics: end with -ase: alteplase (Activase)

◊ Thyroid hormones: contain –thy: levothyroxine (Synthroid)

◊ Xanthine bronchodialators: end with –line: theophylline

Pharmocodynamics

1. This looks at how the drug changes the body, it looks at the mechanisms of drug action and the relationship

67
 between drug concentration and responses in the body.

Drug actions

 To replace or act as substitutes for missing chemicals

 To increase or stimulate certain cellular activities

 To depress or slow cellular activities

 To interfere with the functioning of foreign cells such as invading microorganisms or neoplasms.

2. Drugs are thought to act at specific areas on cell membrane called receptor sites, these sites react with certain
chemicals to cause an effect within the cell.

3. Some drugs interact directly with receptor sites to cause the same activity that natural chemicals would cause at
that site. These drugs are called agonists e.g. insulin.

4. Other drugs act to prevent the breakdown of natural chemicals that are stimulating the receptor site.

5. Other drugs act to prevent the breakdown of natural chemicals therefore the cell function is inhibited because
the drug occupies the receptor sites. These drugs are called antagonist.

6. Drugs can also cause their effects by interfering with the enzyme system that acts as catalysts for various
chemical reactions. If a single step in one of the many enzyme system is blocked, normal cell function is
disrupted. Acetazolamide (Diamox) is a diuretic that blocks the enzyme carbonic anhydrase, which
subsequently causes alterations in the hydrogen ion and water exchange system in the kidneys as well as in the
eye.

7. Some drugs have selective toxicity, in that the drug has the ability to attack only those systems found in foreign
cells. Penicillin, an antibiotic used to treat bacterial infections has selective toxicity as it only affects the enzyme
system unique to the bacteria causing bacterial cell death without disrupting normal human cell functioning.

8. However some drugs, while destroying foreign cells also destroy normal human cells.

Pharmacokinetics

1. Absorption – refers to what happens to a drug from the time it is introduced into the body until it reaches
circulating fluids and tissues.

 The length of time a drug takes to produce its effect is dependent on the absorption

 The more rapid the absorption the more rapid the onset of the drugs

 Drugs are absorbed into cells by passive diffusion and active transport

2. Distribution – transportation of the drug from the site of absorption to the site of action

 The amount blood flow to tissues determines the distribution of the drug

 The heart, liver, kidney and brain receive the most blood supply, while skin, bone and adipose tissue

68
 receive a lower blood supply

 The physical property of the drug also influences its distribution

 Lipid solubility determines how quickly a drug is distributed in the body

 Drugs that are not lipid soluble cannot cross the blood –brain barrier

 Some tissues have the ability to accumulate and store drugs after absorption, such as bone marrow,
teeth eyes and adipose tissue. These tissues are said to have an affinity for certain medications.
Therefore distribution is affected.

 Drugs that bind to protein molecules affect the distribution of the drug. the drug is unable to reach the
target tissue because the protein molecule is large and so the drug which is bound to protein cannot
cross capillary membrane for distribution

 Please read up on the blood-brain barrier and the fetal-placenta barrier

Metabolism (Biotransformation)

 This is the process of converting the drug into a new less active form and therefore more easily removed from
the body

 The liver is the primary site of drug metabolism in the liver is accomplished by the hepatic microsomal enzyme
system

 Changes in the function of this system can significantly impact on the metabolism of a drug and so if the liver
is not functioning properly then the drug will not be metabolized as it should be and toxic levels could develop

 Some drugs are totally biotransformed to an inactive form in the liver before they ever reach the general
circulation- first pass effect. A large number of oral drugs are rendered inactive by the hepatic reactions
therefore alternate routes of delivery that bypass the first pass effect must be considered for these drugs

Excretion

 The rate at which a drug is excreted from the body determines its concentration in the blood stream and
tissues

 Liver disease or renal failure often increases the duration of drug action in the body because the illness
interferes with the natural excretion mechanisms

 Clients with renal failure have a diminished capacity to excrete medications and so the drug is retained in
the body for an extended period

 Doses for these persons must be reduced to avoid toxicity, kidney function must be close monitored

 The acidity of urine plays an important role in excretion, some drugs are excreted more quickly in an acidic
urine and others in an alkaline urine.

 To speed up the excretion of an acidic drug e.g. aspirin (like in the case of aspirin over dose) the patient can
be given sodium bicarbonate which ionizes the aspirin and causes it to be excreted more readily

69
  To speed up the excretion of an alkaline drug e.g. diazepam (like in the case of an over dose) the patient can
be given ammonium chloride. This will acidify the filtrate and increase the excretion of the drug

Three checks for safe administration of medication

1. First check

Check patient’s docket, it will show the most recent medication order written for the patient and verify this with what is
written on the patient’s kardex

Read the medication kardex and remove the medication from the drawer or cabinet, verify client’s name and the
medication ordered

2. Second check

While preparing the medication e.g. pouring, drawing up etc

3. Third check

Just before administration check the kardex and medication containers you took out.

Rights of medication administration

1. Right medication

2. Right dose

3. Right time

4. Right route

5. Right client

6. Right client education

7. Right documentation

8. Right to refuse

9. Right assessment

10. Right evaluation

Medication can be given many different ways. Some examples include:

 Oral route: swallowed by mouth as a pill, liquid, tablet or lozenge

 Rectal route: suppository inserted into the rectum

 Intravenous route: injected into vein with a syringe or into intravenous (IV) line

 Infusion: injected into a vein with an IV line and slowly dripped in over time

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  Intramuscular route: injected into muscle through skin with a syringe

 Topical route: applied to skin

 Enteric: delivered directly into the stomach with a G-tube or J-tube

 Nasal: sprays or pumps that deliver drug into the nose

 Inhaled: inhaled through a tube or mask (e.g. lung medications)

 Otic: drops into the ear

 Ophthalmic: drops, gel or ointment for the eye

 Sublingual: under the tongue

 Buccal: held inside the cheek

 Transdermal: a patch on the skin

 Subcutaneous: injected just under the skin

Abbreviations used in pharmacology

before meals
a.c.
ad lib. use as much as one desires; freely
p.c. after meals
a.m. morning, before noon
amp ampule
amt amount

a.s. left ear

a.d. right ear

a.u. both ears
b.d./b.i.d. twice daily
cap., caps. c capsule
cc cubic centimetre)
comp. compound
cr., crm cream
D/C, discontinue
disp. dispersible or dispense
elix. elixir
emuls. emulsion
fl., fld. fluid
g gram
gr grain
gtt(s) drop(s)
h, hr hour

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h.s. at bedtime
ID intradermal
IM intramuscular (with respect to injections)
inj. injection
IP intraperitoneal
IV intravenous
ung. ointment
T.P.N. total parenteral nutrition
t.i.d. three times a day
t.d.s. three times a day
stat immediately
q.d. every day
q.i.d. four times a day
every other day
q.d.s. four times a day
q.h. every hour
q.h.s. every night at bedtime
q.1h every 1 hour; (can replace "1" with other numbers)
q.d. every day
mane in the morning
o.d. right eye
o.s. left eye
o.u. both eyes
p.c. after meals
PRN, prn as needed
p.o. by mouth or orally
p.r. by rectum
PV via the vagina or per vagina
stat immediately
SC, SQ subcutaneous

tsp teaspoon
t.i.d. three times a day
t.d.s. three times a day

ung. ointment
1/7 one day (can replace 1 with other numbers)

2/12 two months ( can replace 2 with other numbers)

4/52 four weeks (can replace 4 with other numbers)

System of measurement

Kg – kilogram To convert from grams to kilograms divide by 1000

g – grams To convert from kilogram to grams multiply by 1000

mg – milligram

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mcg – micrograms To convert from grams to milligram multiply by 1000

1 kg = 1000g To convert from milligram to grams divide by 1000

1gram – 1000mg

1mg = 1000mcg To convert from microgram to milligram divide by 1000

To convert from milligram to microgram multiply by 1000

L – litre

ml - milliliter / cc

1000ml / cubic centimeter = 1 litre

To convert from mlilitre to litre divide by 1000

1ml - 15 gtt To convert from litre to mililitre multiply by 1000

5mls - 1teaspoon(tsp)

15mls - 1tablespoon(Tbsp)

30mls - 1 ounce(oz) To convert from kilograms to pounds multiply by 2.2

500mls - 1 pint To convert from pounds to kilogram divide by 2.2

1000mls - 1 quart

4000mls - 1 gallon

60mg - 1grain (gr)

30grams -1 ounce

500grams – 1.1pounds(lb)

1000g (1kg) – 2.2 lb

Calculating IV drip rates

Example 1

800mls of fluid is to be given over 5 hours. The IV set delivers 15 drops/ml. calculate the amount of drops in the minute.

Volume X drop factor = rate(drops /min)

Time in minutes

800mls X 15drops/min =40 gtts/min

5hrs x 60

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Example 2

600mls of fluid is dripping at 20 drops/min. The IV set delivers 15gtt/ml. how long will it take for the patient to receive
all the fluid

Volume X gtts/ml = time in hours

gtt/min x 60

600ml x 15gtt/ml = 7 ½ hours

20gtt/min x 60

Example 3

500mls of fluid is to run over 8 hours, how many ml/hr of fluid will the patient receive

Volume = ml /hour

Time in hours

500ml = 62.5 ml/hour

8 hours

Example 4

600mls of fluid is to run over 4 hours. How many mls/min should the infusion run?

Volume =mls/min

Time in hours x 60

600ml = 2.5 mls/min

4 hrs x 60

COMMON DRUGS

1. Aspirin

2. Lanzoprazole

3. Augmentin

4. Amoxil

5. Ibuprofen

6. Digoxin

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7. Metformin

8. Federgel

9. Diazepam

10. Heparin

11. Insulin

12. Simvastatin

13. Voltaren

14. Enalapril

15. Buscopan

16. Propanalol

17. Gentamycin

18. Hydralazine

19. Dph

20. Panadol

21. Bactrim

22. Voltaren

23. Amikacin

24. Prednisone

25. Nifedipine

26. Erythromycin

27. Cefuroxime

28. Nitroglycerine

29. Ceftriaxone

30. Ventolin

31. Atrovent

32. Warfrin

33. Atenolol

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 34. Metronidazole

35. Lasix

Drugs for coagulation disorders and nursing considerations

1. Coagulation modifiers

 Anticoagulants

 Thrombolytics

 Haemostatics

 Antiplatelets

1A. Anticoagulants

 Prolong bleeding time thereby preventing blood clot formation ( primarily in veins)

 E.g. heparin and warfarin

 Warfarin

- An oral drug

- It interferes with Vit K dependent clotting factors in the liver

- Therefore it depletes the clotting factors and so prolong clotting time

- It is readily absorbed by GI tract, metabolized by the liver and excreted in urine and
faeces

- Onset is 2-7 days, duration 3-5 days

- The antidote is vitamin K as this reverses the action of warfarin

 Heparin

- Is given SQ or IV

- Blocks the conversion of prothrombin to thrombin resulting in blocking the conversion of

fibrinogen to fibrin

- Onset is 20 – 60 min, duration is 8 -12 hrs

- It does not cross the placenta nor enters breast milk

- Patients may be started on heparin for the acute stage of the illness then switched to
warfarin

Nursing considerations

- It is contraindicated in pregnant and lactating mothers, patients with bleeding disorders, severe hepatic and renal

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impairment, recent trauma and active bleeding

- assess for signs of bleeding i.e, nose bleeds, bruising, excessive menstrual flow, coffee ground emesis,

- assess for hypotension

- monitor lab values i.e. PTT ( normal 25-40 sec) PT(12-15 sec)

Do client teaching

-immediately report signs of bleeding, pain or swelling

- take warfarin same time each day

- avoid sudden increases in Vit K rich foods

- Limit intake of garlic

1B. Thrombolytics

a. Promote clot destruction i.e. fibrinolysis

b. This is done by converting plasminogen to plasmin

c. The end result is that the clot is dissolved

d. E.g. streptokinase , tenecteplase

Nursing considerations

- Assess patient for conditions that would predispose them to bleeding

- Base line coagulation tests/ lab values
- Cerebral haemorrhage is a major concern therefore assess for changes in the level of consciousness
- Monitor for dysrhythmias
- Giving by IM route is not encouraged

Do client teaching

-immediately report signs of bleeding, pain or swelling

- avoid activities that can cause bleeding injuries

1C. Haemostatics

a. Also called antifibrinolytics

b. Opposite action to anticoagulant therefore bleeding time is shortened

c. They prevent fibrin from dissolving so the clot is stabilized

d. Prevents excessive bleeding following surgery

e. Given by IV

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Nursing consideration

- Asses for changes in peripheral pulses, parasthesia

- Assess for prominence of peripheral veins, chest pain and SOB
- Muscle wasting

Do client teaching

-immediately report signs of bleeding, pain or swelling

- avoid activities that can cause bleeding injuries

- Avoid aspirin and any OTC containing aspirin

1D. Antiplatelets

 Prevents platelet aggregation

 Prevents clot formation in arteries

 E.g. aspirin, plavix, trental

Nursing consideration

 Asses for risk of bleeding

 Injection site or venepuncture sites will require prolong pressure to avoid bleeding

 Aspirin may causes GI bleeding

 Monitor V/S and lab values

Do client teaching

 immediately report signs of bleeding, pain or swelling

 avoid activities that can cause bleeding injuries

 Avoid OTC drugs containing aspirin

COMPLETE BLOOD COUNT WITH CLINICAL IMPLICATIONS

RED BLOOD CELL COUNT (RBC)

The red blood cells’ primary function is to carry oxygen in the bloodstream. If the total RBC count is below normal

78
levels, anemia may be present. This may lead to insufficient supply of oxygen to the body.

On the other hand, if the total RBC count is above normal, polycythemia vera may be present. Too many red blood cells
in the bloodstream tend to form clots and may cause blockage.

Normal range:

Male: 4.5–5.5 million cells per microliter

Female: 4.0–5.0 million cells per microliter

Children: 3.8–6.0 million cells per microliter

Newborn: 4.1–6.1 million cells per microliter

High Level: Dehydration, cigarette smoking, congenital heart disease, pulmonary fibrosis, renal cell carcinoma,
polycythemia vera.

Low Level: Bleeding, anemia, malnutrition, overhydration, hemolysis, erythropoietin deficiency, leukemia, multiple
myeloma, porphyria, thalassemia, sickle cell anemia.

Drugs that may increase RBC count: Methyldopa, gentamycin.

Drugs that may decrease RBC count: Quinidine, hydantoins, chloramphenicol, chemotherapeutic drugs.

HEMOGLOBIN (Hgb)

Hemoglobin is the protein component of red blood cells. It makes the blood look bright red as it is made with iron.

High hemoglobin levels are usually present among people living in high altitude levels and among smokers. It’s the
body’s compensatory mechanism in response to low supply of oxygen. On the other hand, low hemoglobin levels may be
present in a variety of blood diseases like sickle cell disease and thalassemia.

Normal range:

Male: 14.0–18.0 grams per deciliter (g/dL)

Female: 12.0–16.0 g/dL

Children: 9.5–20.5 g/dL

Newborn: 14.5–24.5 g/dL

High Level: Dehydration, cigarette smoking, polycythemia vera, tumors, erythropoietin abuse, lung diseases, blood
doping.

Low Level: Nutritional deficiencies, blood loss, renal problems, sickle cell anemia, bone marrow suppression, leukemia,
lead poisoning, Hodgkin’s lymphoma.

Drugs that may increase hemoglobin: Erythropoietin, iron supplements.

Drugs that may decrease hemoglobin: Aspirin, antibiotics, sulfonamides, trimethadione, anti-neoplastic drugs,

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indomethacin, doxapram, rifampin and primaquine.

HEMATOCRIT (Hct)

Hematocrit is also known as packed cell volume or PCV. It reflects the volume percentage of red blood cells in the whole
blood. The result is dependent on the size, structure and total number of red blood cells. Determining hematocrit is
helpful in diagnosing and assessing blood diseases, nutritional deficiencies and hydration status.

Normal range:

Male: 42% – 54%

Female: 38% – 46%

Children: 36% – 40%

Newborn: 55% – 68%

High Level: Dehydration, hypoxia, cigarette smoking, polycythemia vera, tumors, erythropoietin abuse, lung diseases,
blood doping, erythrocytosis, corpulmonale.

Low Level: Overhydration, nutritional deficiencies, blood loss, bone marrow suppression, leukemia, lead poisoning,
Hodgkin’s lymphoma, chemotherapy treatment.

Drugs that may increase hemoglobin: Erythropoietin, iron supplements.

Drugs that may decrease hemoglobin: Aspirin, antibiotics, anti-neoplastic drugs.

PLATELET COUNT

Platelets are also known as thrombocytes. They circulate in the bloodstream and bind together to form a clot over the
damaged blood vessel. Determining platelet count is vital in assessing patients for tendencies of bleeding and
thrombosis.A low platelet count is called thrombocytopenia. Thrombocytopenia can be caused by failure of the bone
marrow to produce enough platelets, or it can result from the destruction of platelets after they’re produced. A higher
than normal number of platelets is called thrombocytosis. This can be caused by chronic myelogenous leukemia (CML),
polycythemia vera, or primary thrombocytosis.

Normal range:

150,000 to 400,000 per microliter.

High Level: Cancer, allergic reactions, polycythemia vera, recent spleen removal, chronic myelogenous leukemia,
inflammation, secondary thombocytosis.

Low Level: Viral infection, aplastic anemia, leukemia, alcoholism, vitamin B12 and folic acid deficiency, systemic
lupus erythematosus, hemolytic uremic condition, HELLP syndrome, disseminated intravascular coagulopathy,
vasculitis, sepsis, splenic sequestration, cirrhosis.

Drugs that may increase platelet: Romiplostim, steroids, human IgG, immunosuppresants.

Drugs that may decrease platelet: Aspirin, hydroxyurea, anagrelide, chemotherapeutic drugs, statins, ranitidine,

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quinidine, tetracycline, vancomycin, valproic acid, sulfonamides, phenytoin, piperacillin, penicillin, pentoxifylline,
omeprazole, nitroglycerin.

Mean Platelet Volume (MPV)

The average size of platelets in the blood.

Normal Range: 5.0 – 15.0 femtoliters/fL — a femtoliter is one quadrillionth of a liter.

A low MPV is of no diagnostic relevance. The MPV should not be interpreted alone but in conjunction with the platelet
count.

WHITE BLOOD CELL COUNT

White blood cells, also known as leukocytes, defend the body against infections and other foreign bodies. In general,
there are five types of white blood cells – neutrophils, lymphocytes, monocytes, eosinophils and basophils (see
differential count). The total number of white blood cells is often used as indicator of bacterial and viral infections.

Normal range:

4,500-11,000 per microliter.

High Level: Infections, cigarette smoking, leukemia, inflammatory diseases, tissue damage, severe physical or mental
stress.

Low Level: Autoimmune disorders, bone marrow deficiencies, viral diseases, liver problems, spleen problems, severe
bacterial infections, radiation therapy.

Drugs that may increase white blood cells: Corticosteroids, heparin, beta adrenergic agonists, epinephrine, granulocyte
colony-stimulating factor, lithium.

Drugs that may decrease white blood cells: Diuretics, chemotherapeutic drugs, histamine-2 blockers, captopril,
anticonvulsants, antibiotics, antithyroid drugs, quinidine, chlorpromazine, terbinafine, clozapine, sulfonamides,
ticlopidine.

DIFFERENTIAL COUNT

The proportion of each of the five WBCs in a sample of 100 WBCs.

Neutrophils

Normal Range: 55%-70%

High Level: Stress, Acute infection

Low Level: Viral diseases, some drugs (e.g. chemotherapy, antibiotics such as nafcillin, penicillin, and cephalosporins),
radiation therapy.

Lymphocytes

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Normal Range: 20%-40%

High Level: Viral infection, mononucleosis, tuberculosis, chronic bacterial infections, lymphocytic leukemia.

Low Level: Adrenal corticosteroids and other immunosuppressive drugs, autoimmune diseases (e.g. lupus
erythematosus), severe malnutrition.

Monocytes

Normal Range: 2%-8%

High Level: Chronic inflammatory disorders, tuberculosis, protozoan infections (e.g. malaria, Rocky Mountain spotted
fever), chronic ulcerative colitis.

Low Level: Drug therapy (prednisone).

Eosinophils

Normal Range: 1%-4%

High Level: Allergic reactions (e.g. asthma, hay fever, or hypersensitivity to a drug), parasitic infections (e.g. round
worms).

Low Level: Corticosteroid therapy.

Basophils

Normal Range: 0%-2%

High Level: Leukemia.

Low Level: Acute allergic reaction, corticosteroids, acute infections.

RED BLOOD CELL INDICES (RBC indices)

Mean cell volume (MCV)

The mean or average size of an individual RBC.

Normal Range: Males (78-100 femtoliter/fL); Females (78-102 femtoliter/fL).

High Level: Liver disease, alcoholism, pernicious anemia.

Low Level: Iron deficiency anemia, lead poisoning.

Mean cell hemoglobin (MCH)

Amount of hemoglobin present in one cell.

Normal Range: 25-35 pg

High Level: Rarely Seen

Low Level: Iron deficiency anemia

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Mean cell hemoglobin concentration (MCHC)

The proportion of each cell occupied by hemoglobin.

Normal Range: 31-37%

High Level: Rarely Seen

Low Level: Iron deficiency anemia

Red cell Distribution Width

A parameter that measures variation in red blood cell size or red blood cell volume.

Normal Range: 11.5- 14.5%

High Level: Iron deficiency anemia, Folate and vitamin B12 deficiency anemia, recent hemorrhage.

Low Level: Rarely Seen

PROTHROMBIN TIME (PT) and PARTIAL THROMBOPLASTIN TIME (PTT)

The time it takes for the liquid portion (plasma) of the blood to clot.

PT or prothrombin time is derived from the prothrombin ratio along with the international normalized ratio to measure
the extrinsic coagulation pathway. PT measures the clotting factors I, II V VII and X. PT is also the indicator for
Warfarin levels in the body, as well as the vitamin K status.

Normal Ranges: 11-13.5 seconds

PTT, or the partial thromboplastin time, is the measurement of the intrinsic coagulation pathway and the common
coagulation pathway. This also measures the level of Heparin needed in the body if the patient is on anti-coagulation
therapy. Unlike PT, which gives us an idea of how much Warfarin to use, PTT measures Heparin. Clotting factors I, II,
V, VII, IX, XI and XII are measured by PTT.

Normal Ranges: 25-35 seconds

Interpretation:

High Level (Clots too slowly): Blood-thinning medications, such as warfarin (Coumadin) & heparin, Liver problems,
Inadequate levels of proteins (factors) that cause blood to clot, Vitamin K deficiency, Congenital factor deficiency,
Presence of coagulation factor inhibitors.

Low Level (Clots too fast): Supplements that contain vitamin K, High intake of foods that contain vitamin K such as
liver, broccoli, chickpeas, green tea, kale, turnip greens and products that contain soybeans, Estrogen-containing
medications such as birth control pills and hormone replacement therapy.

URINALYSIS
Urinalysis is usually done as part of routine diagnostic examinations. Although the result of urinalysis cannot directly
pinpoint the disease that may be present, it is often used as a supportive examination in diagnosing illnesses. A standard

83
urinalysis involves three stages – visual exam, dipstick test and microscopic exam.

Visual Exam

In visual examination, the urine sample is inspected for color, cloudiness and odor. Urine is usually clear but its color
may be affected by certain medications and foods. If cloudiness and unpleasant odor are present, there might be infection
in the urinary tract system. Here are some indications of different colors of urine:

 Clear to dark yellow – normal.

 Amber to honey yellow – dehydration.
 Orange – dehydration, intake of rifampicin, consumption of orange food dye.
 Brown ale – severe dehydration, liver disease.
 Pink to reddish – consumption of beets, rhubarb or blueberries, mercury poisoning, tumors, kidney diseases,
prostate problems, UTI.
 Blue or green – consumption of asparagus, genetic disorders, excess calcium, heartburn medications,
multivitamins.
 Deep purple – porphyria.
Dipstick Urine Test

The dipstick urine test is done by dipping a plastic strip into the urine sample. This strip has partitions impregnated by
different chemicals that correspond to certain substances present in the urine, so abnormalities will be detected. Once the
strip is dipped into the urine, there will be some changes in the color of the partitions. The following are the chemical
tests usually included in reagent strips:

 pH
The pH level of the urine is related to the acid-base balance maintained by the body. Therefore, consumption of acidic or
basic foods as well as the occurrence of any condition in the body that produces acids or bases will directly affect the pH
of the urine. In some circumstances, too acidic or basic urine produces crystals. When this phenomenon happens inside
the kidney, kidney stones can develop. Urine is normally slightly acidic, with an average pH of 6 (7 is neutral, less than 7
is acidic, greater than 7 is alkaline). Because the kidneys play an important role in regulating acid-base balance,
assessment of urine pH can be useful in determining whether the kidneys are responding appropriately to acid-base
imbalances. In metabolic acidosis, urine pH should decrease as the kidneys excrete hydrogen ions; in metabolic alkalosis,
the pH should increase.

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  Specific Gravity
Specific gravity reflects how concentrated the urine is. It can measure the proportion of solutes present in the urine when
compared to pure water. Determining specific gravity is useful when you want to detect a particular substance in the
urine sample. For example, if you suspect that a patient secretes small amounts of protein in the urine, the first morning-
void urine is the best sample because it has high specific gravity and appears concentrated. The specific gravity of
distilled water is 1.00; the specific gravity of urine normally ranges from 1.010 to 1.025. As urine becomes more
concentrated, its specific gravity increases. Excess fluid intake or diseases affecting the ability of the kidneys to
concentrate urine can result in low specific gravity readings. A high specific gravity may indicate fluid deficit or
dehydration, or excess solutes such as glucose in the urine.

 Protein
Albumin is usually the first type of protein compound excreted in the urine whenever there is a kidney problem. Other
types of protein compounds are not detectable in dip stick test and can be measured through a different urine protein test.
Conditions that usually produce high amounts of protein in the urine include preeclampsia, multiple myeloma,
inflammation, urinary tract injuries, malignancies and other disorders that destroy red blood cells.

 Glucose
Glucose should not be present in the urine. However, in some circumstances the renal threshold allows the excretion of
glucose in the urine when the blood glucose levels are too high. Individuals who have ingested large amounts of sugar
may show small amounts of glucose in their urine. Testing urine for glucose is not a measure of current blood glucose
levels and is considered an inadequate measurement. The conditions that can cause glucosuria are pregnancy, diabetes
mellitus, liver diseases and hormonal disorders.

 Ketones
Like glucose, ketones should not be present in the urine. Ketones are by-products of fat metabolism and they form
whenever there is not enough carbohydrates present for energy production. Ketones also form when insulin levels are not
enough to initiate carbohydrate metabolism so the body just uses fat in order to produce the energy needed for daily
activities. Other conditions that produce ketones in the urine are diabetes mellitus, frequent vomiting, strenuous exercise,
and high protein diet. Ketone testing with a reagent stick or dipstick is also used to evaluate ketoacidosis in clients who
are alcoholic, fasting, starving, or consuming high-protein diets.

 Blood
Normal urine is free from blood. When blood is present, it may be clearly visible or not visible (occult). The presence of
blood in the urine is called hematuria and this usually happens when there is an injury in the urinary tract. Other
conditions that may induce hematuria include cigarette smoking, strenuous exercise, kidney problems and trauma.

 Leukocyte Esterase
Leukocyte esterase is the enzyme produced by white blood cells. Normally, there are white blood cells present in the
urine, but they are so few that there is no leukocyte esterase detectable in dip stick test. On the other hand, when there are
many white blood cells present in the urine the leukocyte esterase level elevates and it could be detected in strips. White
blood cells in the urine increase in response to urinary tract infections.

 Bilirubin
Bilirubin is a part of bile which is the yellow fluid secreted into the intestines to aid in digestion. Bilirubin is a waste
product produced by the liver. It should not be present in a normal urine sample but once detected, it can reflect the
presence of liver diseases.

 Urobilinogen
Urobilinogen is formed from bilirubin. It is excreted in the urine in small amounts. High urobilinogen levels in the urine
can signify liver diseases and other conditions that can cause RBC destruction. For people with liver problems and

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obvious signs of liver dysfunction, the absence of urobilinogen may indicate the presence of hepatic or biliary
obstruction.

 Nitrite
When bacterial infection is present in the urinary tract, the bacterial flora can convert the urine’s nitrate compound to
nitrite. However, the detection of nitrite in the urine is not used as a sole basis for the determination of UTI as some
people can still have UTI with a negative nitrite result.

SERUM ELECTROLYTES

NORMAL ELECTROLYTE VALUES FOR ADULTS

Venous Blood

1. Sodium 135-145 mEq/L

2. Potassium 3.5-5.0 mEq/L

3. Chloride 95-105 mEq/L

4. Calcium (total) (ionized) 4.5-5.5 mEq/L or 8.5-10.5mg/dL

 Potassium
50% of total calcium (2.5 mEq/L or 4.0-5.0 mg/dL)
Potassium is critical in nerve
and muscle function.
5. Magnesium 1.5-2.5 mEq/L or 1.6-2.5 mg/dL
Nerves and muscles
communicate 6. Phosphate 1.8-2.6 mEq/L (phosphorus) impulses
through the help of
potassium in 7. Serum Osmolality 280-300 mOsm/kg water the blood. The
movement of nutrients into
the cell and the transport of waste products out of the cell are also mediated by potassium. Whenever potassium levels
are increased or decreased, the heart rhythms are affected as signified by EKG changes.

High Level: Infection, dehydration, Addison’s disease, injury to tissue, diabetes, acute or chronic kidney failure,
hypoaldosteronism.

Low Level: Anorexia nervosa, malnutrition, diarrhea, vomiting, poorly managed diabetes, hyperaldosteronism.

Drugs that may increase potassium: ACE inhibitors, beta blockers, NSAIDs, potassium-sparing diuretics.

Drugs that may decrease potassium: Amphotericin B, gentamicin, carbenicillin, corticosteroids, beta-adrenergic agonists,
potassium-wasting diuretics.

Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots,
celery).

Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac
contractility, ECG changes, reflexes.

 Sodium
Sodium reflects a part of renal function as kidneys are responsible for the elimination of sodium from the body. It also
plays a part in motor and nerve function. Patients are tested for serum sodium levels in cases of dehydration, edema,

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abnormal blood pressure levels and changes in motor functions.

High Level: Cushing syndrome, diabetes insipidus, excessive fluid loss, malnutrition, dehydration.

Low Level: Addison’s disease, renal diseases, cirrhosis, heart failure, ketonuria.

Drugs that may increase sodium: NSAIDs, laxatives, birth control pills, corticosteroids and lithium.

Drugs that may decrease sodium: Diuretics, morphine, and SSRI antidepressants.

Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids

Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution

 Chloride
Together with sodium, potassium and carbon dioxide, chloride maintains the normal acid-base balance of the body
through balancing body fluids. Abnormal changes in serum chloride levels usually reflect metabolic changes in the body.

High Level: Diarrhea, metabolic acidosis, compensated respiratory alkalosis, renal tubular acidosis, bromide poisoning,
kidney diseases, Cushing syndrome, hyperventilation.

Low Level: Vomiting, burns, excessive sweating, dehydration, gastric suction, chronic lung diseases, Addison’s
disease, Bartter syndrome, congestive heart failure, metabolic alkalosis, compensated respiratory acidosis,
hyperaldosteronism, syndrome of inappropriate diuretic hormone secretion (SIADH).

Drugs that may increase chloride: Carbonic anhydrase inhibitors.

Drugs that may decrease chloride: Diuretics.

 Calcium
Calcium is usually binded with protein in the blood. For this reason, a standard calcium test can be misleading and
determination of ionized calcium is recommended. The ionized calcium test measures the calcium that is not attached to
proteins. Determining serum calcium levels is important when there are existing nerve and motor dysfunctions.

High Level: Tuberculosis, fungal and mycobacterial infections, HIV/AIDS, hyperparathyroidism, metastatic bone
tumor, Paget’s disease, multiple myeloma, osteomalacia, sarcoidosis, hyperthyroidism.

Low Level: Malnutrition, vitamin D deficiency, hypoparathyroidism, low blood level of albumin, kidney failure,
magnesium deficiency, liver disease, osteomalacia, pancreatitis.

Drugs that may increase calcium: Lithium, tamoxifen, thiazides, calcium supplements, vitamin D supplements.

Drugs that may decrease calcium: No known drug.

Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor.

Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative
effect on CNS.

 Magnesium
Magnesium is important in muscle and nerve functions, blood pressure regulation and immune system. It also plays a
role in blood sugar regulation. Although half of magnesium in the body is stored in bones, magnesium can also be found
in cells of organs and body tissues. Magnesium levels are determined whenever there are changes in motor functions or

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when patients are suspected for metabolic diseases.

High Level: Oliguria, dehydration, Addison disease, chronic renal failure, diabetic acidosis.

Low Level: Chronic diarrhea, alcoholism, hemodialysis, ulcerative colitis, delirium tremens, hypoparathyroidism,
hyperaldosteronism, hepatic cirrhosis, pancreatitis, toxemia of pregnancy.

Drugs that may increase magnesium: Milk of magnesia, lithium carbonate.

Drugs that may decrease magnesium: Insulin, antiarrhythmic drugs, digoxin amiodarone, sotalol, quinidine, bretylium,
strophanthin, diuretics, isoproterenol.

HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity.

HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow
respirations, emergency.

 Phosphorus
Phosphorus is involved in the intracellular metabolism of proteins, fats and carbohydrates. It also participates in the
production of ATP which is the chemical compound that supplies energy to the cell. Phosphorus plays an important role
in acid-base balance of the body and in glycolysis. It also helps in the release of oxygen molecule from the hemoglobin
of the blood.

High Level: Hypoparathyroidism, diabetic ketoacidosis, liver disease, kidney failure.

Low Level: Poor nutrition, alcoholism, hyperparathyroidism, hypercalcemia .

Drugs that may increase phosphorous: Vitamin D, phosphate-containing laxatives.

Drugs that may decrease phosphorous: Antacids, diuretics, corticosteroids, anticonvulsants, ACE inhibitors, insulin.

 Serum Osmolality
A measure of the solute concentration of the blood. The particles included are sodium ions, glucose, and urea (BUN).
Serum osmolality can be estimated by doubling the serum sodium, because sodium and its associated chloride ions are
the major determinants of serum osmolality. Serum osmolality values are used primarily to evaluate fluid balance. An
increase indicates a fluid volume deficit; a decrease reflects a fluid volume excess.

LIVER FUNCTION TESTS

 ALT
Alanine transaminase (ALT) is an enzyme found in the highest amounts in the liver. It is also called SGPT (Serum
glutamate pyruvate transaminase). Injury to the liver results in release of the substance into the blood. It is a more
specific indicator of liver damage than AST.

Normal Range: Men (10-55 U/L); Women (7-30 U/L)

High Level: Increased levels of ALT often means that liver disease is present. Liver disease is even more likely when
levels of other liver blood tests are also increased. An increase in ALT levels may be due to cirrhosis (scarring of the
liver), death of liver tissue (liver necrosis), hepatitis, hemochromatosis, lack of blood flow to the liver (liver ischemia),
acute myocardial infarction, heart failure, liver tumor or cancer, medications that are toxic to the liver, mononucleosis
("mono"), pancreatitis (swollen and inflamed pancreas).

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Low Level: Not clinically significant.

 AST
AST (aspartate aminotransferase) is an enzyme found in high amounts in liver, heart, and muscle cells. It is also found in
lesser amounts in other tissues. It is also called Serum glutamic-oxaloacetic transaminase (SGOT).

Normal Range: Men (10-40 U/L); Women (9-25 U/L)

High Level: Increased AST levels are usually a sign of liver disease. Liver disease is even more likely if other liver-
related blood tests are abnormal. An increase in AST levels may be due to, cirrhosis (scarring of the liver), death of liver
tissue, heart attack, hemochromatosis, hepatitis, lack of blood flow to the liver (liver ischemia), liver cancer or tumor,
medicines that are toxic to the liver, mononucleosis ("mono"), muscle disease or trauma, pancreatitis (swollen and
inflamed pancreas), anemias. AST levels may also increase after burns (deep), heart procedures, seizure, surgery.

Low Level: Chronic Renal dialysis and vitamin B6 deficiency.

 ALP
Alkaline phosphatase (ALP) is a protein found in all body tissues. Tissues with higher amounts of ALP include the liver,
bile ducts, and bone. It is used as an index of liver and bone disease when correlated with other clinical findings.

Normal Range: 25-100 U/L

High Level: Biliary obstruction, bone conditions, osteoblastic bone tumors, osteomalacia, a fracture that is healing, liver
disease or hepatitis, eating a fatty meal if you have blood type O or B, hyperparathyroidism, leukemia, lymphoma,
Paget's disease, Rickets, Sarcoidosis, myocardial infarction, chronic renal failure, heart failure.

Low Level:Hypophosphatasia, malnutrition, protein deficiency, Wilson's disease, pernicious anemia and severe anemias,
hypothyroidism, magnesium and zinc deficiency (nutritional).

 Albumin
Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid
portion of the blood.

Normal Range: 3.5- 4.8 g/dL or 35-48 g/L; Panic value is <1.5g/dL

High Level: No pathology causes the liver to produce more albumin. An increased level may reflect dehydration.

Low Level: Lower-than-normal levels of serum albumin may be a sign of, Kidney diseases, Liver disease (for example,
hepatitis, or cirrhosis that may cause ascites), AIDS, severe burns, malnutrition and acute and chronic infections.
Decreased blood albumin levels may occur when your body does not get or absorb enough nutrients, such as after
weight-loss surgery, Crohn's disease, low-protein diets, Sprue and Whipple's disease.

 Bilirubin
Bilirubin is a yellowish pigment found in bile, a fluid made by the liver. A small amount of older red blood cells are
replaced by new blood cells every day. Bilirubin is left after these older blood cells are removed. The liver helps break
down bilirubin so that it can be removed from the body in the stool. This can be measured in the urine and blood. Large
amounts of bilirubin in the blood can lead to jaundice. Jaundice is a yellow color in the skin, mucus membranes, or eyes.
Jaundice is the most common reason to check bilirubin levels. In newborns, bilirubin levels are higher for the first few
days of life. Jaundice can also occur when more red blood cells than normal are broken down. This can be caused by
Erythroblastosisfetalis, Hemolytic anemia and transfusion reactions.

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Normal Range: Total (0.3- 1.0 mg/dL); Direct (0.0- 0.2 mg/dL); Indirect (0.1- 1.0 mg/dL); Panic value is >12 mg/dL

High Level: Total (Hepatitis, obstruction of the common bile or hepatic ducts, pernicious anemia, sickle cell anemia);
Direct (cancer of the head of the pancreas, choledocholithiasis); Indirect (hemolytic anemias, drug toxicity, transfusion
reaction).

Low Level: Not clinically significant.

 Ammonia
The liver converts Ammonia, a by-product of protein metabolism, into urea which is excreted by the kidneys.

Normal Range: 35-65 microgram/dL

High Level: Liver disease, such as cirrhosis or hepatitis, Reye syndrome, heart failure, renal failure, severe bleeding from
the stomach or intestines.

Low Level: Renal failure.

 GGT
Gamma-glutamyltransferase (GGT) is a test to measure the amount of the enzyme GGT in the blood. This test is used to
detect diseases of the liver or bile ducts. It is also done with other tests (such as the ALT, ALP, and bilirubin tests) to tell
the difference between liver or bile duct disorders and bone disease. It may also be done to screen for or monitor alcohol
abuse.

Normal Range: Men (1-94 U/L); Women (1-70 U/L)

High Level: Greater-than-normal levels of GGT may be due to, Alcohol abuse, Diabetes, Flow of bile from the liver is
blocked (cholestasis), Heart failure, Hepatitis, Liver ischemia (lack of blood flow), Liver necrosis, Liver tumor, Lung
disease, Pancreas disease, Scarring of the liver (cirrhosis), Use of drugs that are toxic to the liver. Drugs that may
increase GGT include alcohol, Phenytoin and Phenobarbital.

Low Level: Not clinically significant. May be reduced by drugs such as birth control pills and Clofibrate.

 Prothrombin Time
Previously discussed.

RENAL FUNCTION TESTS

 Blood Urea Nitrogen (BUN)
BUN is a by-product of protein metabolism. This test is used to determine the adequacy of renal function but it may also
produce false-positive result as it is dependent on renal blood flow, protein metabolism, catabolism, drugs and diet. BUN
can also reflect protein tolerance, hydration status, degree of catabolism and risk of uremic syndrome.

Normal range: 6 – 20 mg/dL

High Level: Hypovolemia, excessive protein levels in the gastrointestinal tract, congestive heart failure, gastrointestinal
bleeding, heart attack, urinary tract obstruction, glomerulonephritis, pyelonephritis, acute tubular necrosis, kidney failure,
shock.

Low Level: Low protein diet, malnutrition, liver failure, fluid overload.

Drugs that may increase BUN: Allopurinol, furosemide, indomethacin, cisplatin, methyldopa, propanolol, tetracyclines,

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rifampin, vancomycin, thiazide diuretics, gentamycin, carbamazepine, aminoglycosides, amphotericin B.

Drugs that may decrease BUN: Streptomycin, chloramphenicol.

 Creatinine
Creatinine is the product of muscle metabolism. Whenever there is an elevation in serum creatinine levels, renal
dysfunction is usually suspected since the kidneys are responsible for the excretion of creatinine in the body. In general,
creatinine levels vary depending on a person’s body size and muscle mass.

Normal range: Men (0.7 to 1.3 mg/dL); Women (0.6 to 1.1 mg/dL)

High Level: Preeclampsia, dehydration, renal problems, rhabdomyolysis, blocked urinary tract, myasthenia gravis,
hyperthyroidism, muscular dystrophy.

Low Level: Spinal cord injuries, cachexia, sudden decrease in activity.

Drugs that may increase creatinine: Aminoglycosides, methicillin, amphotericin B, cistplatin, dextran,cyclosporine,
gallium, lithium, hydroxyurea, methoxyflurane, nitrofurantoin, plicamycin, pentamidine, streptozocin.

Drugs that may decrease creatinine: Neuromuscular blocking agents.

QUICK NOTES
 No Pee, no K (do not give potassium without adequate urine output).
 Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of thestomach) with the
HOB elevated (to prevent aspiration).
 After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-60 degrees, don't
elevate HOB more than 45 degrees. Maintain hip abduction by separatingthighs with pillows.
 Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily toprovide for hip
extension.
 Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily toprovide for hip
extension.
 Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed.
 Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure.
 Demorol for pancreatitis, NOT morphine sulfate
 Myasthenia Gravis: worsens with exercise and improves with rest.
 Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS usefilter needle.
 Prior to a liver biospyits important to be aware of the lab result for prothrombin time.
 Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety,urine specific
gravity >1.030.
 Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urinespecific gravity
<1.010; Semi-Fowler’s.
 Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges,beans, potatoes,
carrots, celery).
 Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression,decreased cardiac
contractility, ECG changes, reflexes.
 Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmoticdiuretics, fluids
 Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;hypotonic
solution

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 Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor
 Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent
tendon reflexes, sedative effect on CNS
 HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
 HyperMg: depresses the CNS, hypotension, facial flushing, muscle weakness, absent deeptendon reflexes,
shallow respirations, emergency.
 Digoxin-check pulse, less than 60 hold, check dig levels and potassium levels.
 Apresoline(hydralazine)-tx of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lyingposition;
take with meals.
 Dilantin: tx of seizures. thera drug level: 10-20.
 ICP AND SHOCK HAVE OPPOSITE V/S
 ICP-increased BP, decreased pulse, decreased resp.
 Shock- decreased BP, increased pulse, increased resp.
 COPD is chronic, pneumonia is acute. Emphysema and bronchitis areboth COPD.
 Angina (low oxygen to heart tissues) = no dead heart tissues. MI=dead heart tissue present.

REVERSE AGENTS FOR TOXICITY

 Heparin= protamine sulfate

 Coumadin= vitamin k
 Ammonia= lactulose
 Acetaminophen= n-Acetylcysteine.
 Iron= deferoxamine
 Digitoxin, digoxin= digibind.
 Alcohol withdraw= Librium.
 Methadone is an opioid analgesic used to detoxify/treat pain innarcotic addicts.
 Med of choice for CHF is Ace inhibitor.
 Med of choice for anaphylactic shock is Epinephrine
 Med of choice for Status Epilepticus is Valium.
 S3 sound is normal in CHF, not normal in MI.
 Diverticulitis (inflammation of the diverticulum in the colon) pain isaround LL quadrant.
 Appendicitis (inflammation of the appendix) pain is in RL quadrant withrebound tenderness.
 Portal hypotension + albuminemia= Ascites.
 Beta cells of pancreas produce insulin
 Morphine is contraindicated in Pancreatitis. It causes spasm of theSphincter of Oddi. Therefore Demerol should
be given.
 Never give K+ in IV push.
 Diabetic ketoacidosis (DKA)= when body is breaking down fat instead ofsugar for energy. Fats leave ketones
(acids) that cause pH to decrease.
 DKA is rare in diabetes mellitus type II because there is enoughinsulin to prevent breakdown of fats.
 Sign of fat embolism is petechiae. Treated with heparin.
 For knee replacement use continuous passive motion machine.
 Give prophylactic antibiotic therapy before any invasive procedure.
 Glaucoma patients lose peripheral vision. Treated with meds
 Cataract= cloudy, blurry vision. Treated by lens removal-surgery
 Co2 causes vasoconstriction.
 Most spinal cord injuries are at the cervical or lumbar regions
 TIA (transient ischemic attack) mini stroke with no dead brain tissue

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 CVA (cerebrovascular accident) is with dead brain tissue.
 Atropine used to decrease secretions
 Phenergan an antiemetic used to reduce nausea
 Diazepam is a commonly used tranquilizer given to reduce anxiety before OR
 Demerol is for pain control
 Do not give demerol to pts. with sickle cell crisis.
 Iron injections should be given Z-track so they don't leak into SQ tissues.
 Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides WITH food.
 NO VITAMIN C with Allopurinol.
 Anticholinergic effects—assessment----->Dry mouth==can't spit; urinary retention=can't urinate; constipated
=can't pass stool; blurred vision=can't see
 When you see Coffee-brown emesis, think peptic ulcer
 Anytime you see fluid retention. Think heart problemsfirst
 Renal impairment: serum creatinine elevated and urine clearance decreased
 Blood tests for MI: Myoglobin, CK and Troponin
 During sickle cell crisis there are two interventions to prioritize: fluids and pain relief.
 No nasotracheal suctioning with head injury or skull fracture.
 Iatragenic means it was caused by treatment, procedure, or medication.
 The vital sign you should check first with high potassium is pulse (due to dysrhythmias).
 An occlusive dressing is used if a chest tube is accidentally pulled out of the patient.
 Atropine blocks acetylcholine (remember it reduces secretions).
 Hypotension and vasoconstricting meds may alter the accuracy of o2 sats.
 An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph of theaspirate is <5.0.
Aspirate should be checked at least every 12 hrs.
 Ambient air (room air) contains 21% oxygen.
 If your normally lucid patient starts seeing bugs you better check his respiratory status first.The first sign of
hypoxia is restlessness, followed by agitation, and things go downhill from thereall the way to delirium,
hallucinations, and coma. So check the o2 stat, and get abg’s if possible.
 Lasix can cause a patient to lose his appetite (anorexia) due to reduced potassium.
 After g-tube placement the stomach contents are drained by gravity for 24 hours before it canbe used for
feedings.
 Level of consciousness is the most important assessment parameter with status epilepticus.
 Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which wouldmanifest itself as
mental confusion, etc.
 Can’t cough=ineffective airway clearance.
 A patient with a low hemoglobin and/or hematocrit should be evaluated for signs ofbleeding, such as dark stools
 Safety over Nutrition with a severely depressed client.
 Patients with GERD should lay on their left side with the HOB elevated 30 degrees.

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 DIABETES AND INSULIN NOTES
 Most Common Symptoms

Increased thirst (Polydipsia)

Frequent urination (Polyuria)

Increased hunger (Polyphagia)

 Insulin
 A hormone produced by the pancreas to control blood sugar.
 Diabetes can be caused by too little insulin, resistance to insulin, or both.
 Glucose enters the bloodstream, the pancreas makes insulin which allows glucose to move from the bloodstream
into muscle, fat, and liver cells, where it can be stored or used as fuel.
 People who have type 1 diabetes and some people who have type 2 diabetes need to take insulin to help control
their blood sugar levels.
 The goal of taking insulin is to keep the blood sugar level in a normal range as much as possible.

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 Sliding Scale Insulin
 The term “sliding scale” refers to the progressive increase in the pre-meal or night time insulin dose,
based on pre-defined blood glucose ranges.
 The amount of carbohydrate to be eaten at each meal is pre-set.
 The basal (background) insulin dose does not change. The same long-acting insulin dose is taken no
matter what the blood glucose level.
 The bolus insulin is based on the blood sugar level before the meal or at bedtime.
 Pre-mixed insulin doses are based on the blood sugar level before the meal.

 Mixing Insulin

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 Insulin Nursing Considerations
 Assessing site before administration.
 Rotating site when administering multiple doses.
 Monitoring blood glucose level- depends on insulin regime and patient’s general health status.
 Monitor for hypoglycemia at time of peak action of insulin.
 Notify physician promptly for extremely elevated blood sugar levels.

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