Nursing Skills and Interventions

NURSING PROCEDURES
&
INTERVENTIONS
CCNURCA: 544169–TEMPUS–1–2013-1-BE-TEMPUS-JPCR
IMPRESSUM
Authors:
Prof dr sc Dejan Bokonjić

Prof dr sc Maja Račić
Doc dr sc Harun Hodžić
v.asist Mirza Oruč
Belinda Drieghe
Lubica Rybarova
Maarten Kaajik
DTP: Mirza ORUČ
Proof Reading: prof dr sc Nebojša Vasić
Editor: Medicinski fakultet Univerziteta u Zenici
Printing: Feta – grand d.o.o.
This book is outcome of CCNURCA: 544169–TEMPUS–1–2013-1-BE-

TEMPUS-JPCR and it is free of charge.
---------------------------------------
CIP - Katalogizacija u publikaciji
Nacionalna i univerzitetska biblioteka Bosne i Hercegovine, Sarajevo
616-082:614.253.5
NURSING procedures & interventions / [authors Dejan Bokonjić ... [et al.] ;
[editors Dejan Bokonjić & Mirza Oruč]. - Zenica : Univerzitet, 2017. - 96 str. : ilustr. ;
26 cm
ISBN 978-9958-639-89-0
1. Bokonjić, Dejan
COBISS.BH-ID 23801350
-----------------------------------
1
NURSING PROCEDURES &
INTERVENTIONS
Editors: Prof dr sc Dejan Bokonjić & Mirza Oruč MA
Zenica, 2017
2
CONTENT
Vital signs 3
Urinary incontinence 17
Urinary catheterisation 20
Constipation 29
Enema 34
Decubitus 38
Oxygen therapy 46
Drug application 52
Central Vein line 73
Injections 77
Wound care 87
3
4
Vital signs
Definition
This procedure provides guidelines for monitoring, reporting and

documenting patient vital signs. Monitoring of vital signs includes checking
the patient’s temperature, pulse, respiration and blood pressure. Additionally,
neuroscience nurse can include assessment of pupils, level of consciousness,
movement and speech as additional vital signs.
Purpose:
- identifying the existence of an acute medical problem.

- measuring of vital signs can rapidly quantify the magnitude of an
illness and capacity of the body to deal with the pathologic or
physiologic stress.
- can be a marker of chronic disease states
Contributing factors
- age
- gender
- heredity
- race
- lifestyle
- environment
- medications
- pain
- exercise and metabolism
- anxiety and stress
- different acute diseases
- different chronic diseases
- sweat gland activity, reduced metabolism and poor vasomotor
control
5
Clinical signs
The normal body temperature of a person varies depending on gender, recent

activity, food and fluid consumption, time of day and related to women the
stage of the menstrual cycle. Body temperature can be raised due to the
inflammatory or infectious diseases. Clinical signs of high temperature are;
sweating, usually cold hands and foots, raised body temperature, feeling cold
or warm.
The pulse rate is a measurement of the heart rate or the number of times the
heart beats per minute. The pulse rate may fluctuate and increase with
exercise, illness, injury, and emotions. Clinical sign of rapid pulse is fast
heartbeat, restlessness, palpitations and clinical sign of slow pulse is fatigue,
shortness of breath, intolerance of exercise and etc.
The respiration rate is the number of breaths a person takes per minute.
Respiration rates may increase with fever, illness and other medical
conditions. Clinical sign of rapid breathing includes using of auxiliary
musculature, intolerance of exercises and etc.
Blood pressure, measured with a blood pressure cuff and stethoscope by a

nurse or other health care provider, is the force of the blood pushing against
the artery walls. The higher number, or systolic pressure, refers to the
pressure inside the artery when the heart contracts and pumps blood through
the body. The lower number, or diastolic pressure, refers to the pressure
inside the artery when the heart is at rest and is filling with blood.
Clinical sign of high blood pressure are headaches, shortness of breath or

nosebleeds, facial flushing, dizziness
Clinical signs of low blood pressure are: dizziness, fainting, lack of

concentration, blurred vision, nausea, cold skin, rapid, shallow breathing,
fatigue, depression, thirst,
Nursing diagnosis
Goals
 To follow vital signs, to identify and assess causative/contributing
factors
6
Assessment
When assessing vital signs check and record the following signs:
- evaluate blood pressure, pulse and frequency of breathing

- evaluate respiratory status and respiratory rate
- evaluate heart rate
- evaluate body temperature
Nursing intervention
Goals
 to measure and follow vital signs in patient
Procedure
Measuring blood pressure:
A patient blood pressure can be taken in the following way:
This method represents non – invasive method for blood pressure

measurement.
Procedure:
- Like in every procedure first we need to check patient’s identity and
to ask patient is he/her familiar with procedure (sometimes patients
can feel uncomfortable during the air inflation feeling a lot of
pressure).
- This procedure comprises few preconditions that can affect
measurement and values of blood pressure. After placing patient in
comfortable position ask whether she/he has done some physical
activity, drunk coffee, smoked cigarettes, experienced something
stressful etc.
- While preparing the equipment (apparatus – sphygmomanometer)
nurse always need to take care about the size of cuff and perform
disinfection of membranes and olives
- First place the patient in comfortable position. If the patient is
moveable you can ask him / her to take comfortable sitting position if
not than whole procedure can be conducted while patient is lying on
his back.
- For routine and daily check of blood pressure is measured on the left
7
hand and during examination blood pressure is measured on both
hands (left and right). Whole hand or part of the hand near the cubital
region need to be released from clothes otherwise take into account
the impact of clothes on blood pressure. Hand positioned at the heart
level fist need to be released while palm should be open upwards.
- Cuff placed 2,00 – 2,5 cm above the elbow need to be tighten so
much that you can easily drag one finger below.
- Palpate the brachial artery.
- Place the stethoscope membrane on brachial artery, palpate pulse
again, and use stethoscope to listen heartbeats.
- Close the air release valve that is connected to air inflation bulb.
When the valve is closed start to inflate the air into the cuff. Inflate
the air until you hear the last sound of heartbeat, look at the
manometer and remember the value. After that you can add more
pressure on air inflation bulb (around 25 – 30 mm Hg).
- The next step is to slowly open valve to release the air from cuff. Air
releasing need to be slow - around 2-3 mmHg/second.
- When you hear the last heartbeat again look at the manometer and
remember the value, then slowly release the 20-30 mmHg of air after
which you can open air releasing valve to free the air very fast till you
reach the value of 0 mm Hg.
- First sound that you have heard and that you remembered is
considered to be value of systolic blood pressure, while the time of
the last heard sound is considered as a diastolic blood pressure value.
- After the procedure is completed note all values in a patient chart,
(value, time and date).
- Clean and store all the equipment, disinfect the surfaces (membrane
and olives on stethoscope)
- Wash your hand.
8
9
Heart rate
A patient’s heart rate can be taken in the following way:
- explain the patient procedure

- patient should be relaxed
- the pulse can be found on the side of the neck, on the inside of the
elbow, or at the wrist
- in principle it is easier to take the pulse at the wrist.
- using the first and second fingertips press firmly but gently on the
arteries until you feel a pulse
- begin counting the pulse when the clock's second hand is on the 12
- count your pulse for 60 seconds (or for 15 seconds and then multiply
by four to calculate beats per minute).
- while counting do not watch the clock continuously but concentrate
on the beats of the pulse
- if unsure about your results ask another person to count for you.
10
11
Respiratory rate
A patient’s respiratory rate can be taken in the following way:

- the respiration rate is the number of breaths a person takes per minute
- it can be measured using stethoscope or watching excursions of
thorax
- the rate should be usually measured when a person is at rest and
simply involves counting the number of breaths for one minute by
checking how many times the chest rises
- when checking respiration it is important to note whether a person has
any difficulty while breathing
Temperature
A patient's body temperature can be taken in any of the following ways:
- Orally. Temperature can be taken by mouth using either the classic

glass thermometer, or the more modern digital thermometers.
- Rectally. Temperatures taken rectally (using a glass or digital
thermometer) tend to be 0.5 to 0.7 degrees C higher than when taken
by mouth.
- Axillary. Temperatures can be taken under the arm using a glass or
digital thermometer. Temperatures taken in this way tend to be 0.5
degrees C lower than those temperatures taken by mouth.
- By ear. A special thermometer can quickly measure the temperature
of the ear drum which reflects the body temperature.
- By skin. A special thermometer can quickly measure the temperature
of the skin on the forehead.
Equipment:
- Thermometer (type is depending from the type of measurement)

Thermometers have characteristic look and design for different kinds of
measurement. Thermometer used for axillar, oral and rectal measurement
looks like an elongated glass pipe. On one side there is reservoir with mercury
(in thin part) and on another part is scale graduated in Celsius of Fahrenheit.
Typical scale is graduated from 32 to 42 degrees of Celsius, while special
thermometers that measure hypothermia are graduated from 21 degrees of
Celsius. Diameters of glass thermometers are different which depends on the
place of measurement. Thermometers for oral and rectal measurement are
12
usually thinner than thermometers for axillary measurement. Handling with
these thermometers asks for precaution because they can break easily and hurt
a patient or a nurse.
Another type of thermometers are electrical thermometers that can be used in
all kinds of temperature measurement. Depending on the place of
measurement they can have different design for measuring body temperature
on membrane tympani. Positive side of this thermometers is that time of
measurement is shortened and they are safer, but nurse always need to follow
the life of batteries and sensors that can give false results if they are broken.
The third type of thermometers are thermometers based on chemical changes
and they are predominantly in the form of stripes. They can be used just for
orientation not for precise measurement.
- Alcohol soaked cotton balls
- Few napkins
- Lubricant (in care of rectal or vaginal measurement)
Procedures
Axillar body temperature measurement:
- Check the patient’s identity, explain the procedure if he / she is not familiar
with it and secure them the privacy and comfortable position. This procedure
can be done in sitting position or patient can be laying on his back or side.
This procedure is appropriate because it is applicable for all age groups and
two big folds of skin are needed.
- Prepare the thermometer. If the thermometer is standing in the container with
other thermometers soaked in disinfection than it is needed just to clean
thermometer with cold water. If the thermometer is not placed in disinfection
than it is needed to disinfect it with cotton balls soaked in alcohol with one
move from reservoir till the end. Check the level of mercury if the level of
mercury is above 36 degrees of C. Apply one or two energetic moves with
thermometer in your hand to shake down the mercury (be careful while doing
this not to hit any hard object that can cause damage or breakage of it). Check
the level of mercury again and which should be below 36 C (it is
recommended that mercury is in reservoir).
- Ask patient to raise his / her hand and clean the axilla (do not rub or make fast
moves; tap the axilla with napkins to clean it from sweat).
- Place the thermometer into axilla in that position that reservoir of mercury
covers all sides, then ask the patient to lower his hand and to hold the
thermometer with his hand in that way that he will hold his hand on the
13
opposite shoulder or at the level of opposite hip if he cannot touch the
shoulder.
- Thermometer should stay in axilla 8-10 minutes (for adult patient) or 4-8
minutes (children).
- After this time take the thermometer out, check the level of mercury and write
it down in the patient chart and nursing chart (type, value and date).
- Disinfect the thermometer
- Wash your hands
14
Oral body temperature measurement:
- Check the patient identity, explain him procedure if he is not familiar

with it and secure him privacy and comfortable position. This
procedure is very effective and shorter than axillar method of
measurement but it has a lot of limitations like right positioning of
thermometers (below tongue phrenulum), time of food consummation,
temperature of food, awareness of patient about the procedure and
possible injuries if they do not follow the procedure, age of patient.
- Place the patient in a comfortable position.
- Check with the patient to eliminate all factors that can influence on
value like; did he have any meals, drinks or cigarettes in last 15
minutes, physical activity or a hot shower in last 45 minutes.
- Check the oral cavity for any signs of injuries or malformation.
- Place the thermometer into mouth (prepare the thermometer like it was
described in previous text; thermometer used for this procedure is
thinner than thermometer for axillar measurement), right position is
below the tongue phrenulum.
- Instruct the patient to hold thermometer with lips, not to hold it with
teeth, because it can break and cause injuries. Thermometer should stay
in the patient mouth for 3-5 minutes or (according to some authors) 8-
9 minutes.
- After that take the thermometer out and check the mercury level. Write
the value into patient chart and nursing chart.
- Disinfect the thermometer and store it
- Wash your hand.
Rectal body temperature measurement
When all other methods cannot be used for body temperature measurement
than this type of measurement can be used. This method is very often in
podiatry but sometimes when there is no other way it can be used with adult
persons. This method is very uncomfortable for patients and takes a lot of risk
to perform it.
- Check the patient’s identity and if the patient is aware explain the whole
procedure and what is expected.
- Ensure the patient privacy.
15
- For this procedure you need non-sterile gloves, wear them.
- Place the patient in a suitable, comfortable position (laying on the back,
or on side; if this method is applied on a child than place the child on
your knees lying on the stomach so an anal region is in front of you).
- Prepare the thermometer (as it is described previously, but be aware
what kind of disinfect was used, to wash it because of the rectal
mucosa), prepare the lubricant on a napkin or cotton gauze and rub the
thermometer with lubricant, from reservoir till the end.
- Ask a patient to take few deep breaths, with your non - dominant hand
move out the gluteus using your finger exposing rectum (check the
rectum for any sign of infection, bleeding etc.), apply the thermometer
into rectum 4-5 cm in adults or 2-3 cm in children. (Be aware that part
with mercury reservoir is taken into rectum). During applying the
thermometer take care not to damage rectum or its mucosa.
Thermometer should be in rectum for 5 minutes.
- Take of the thermometer after proper time and clean it with napkin (it
can be dirty from fecal masses) and read the value.
- Place the patient into a comfortable position.
- Wash, disinfect and store the thermometer, dispose the gloves and all
used materials.
- Wash your hands
- Document all values into nursing chart and patient chart.
Documentation
- document the blood pressure
- document the heart rate
- document the respiratory rate
- document the body temperature
Evaluation
 The patient will have all vital signs measured and
followed
 All values will be precisely documented
 The patient will experience a minimum of discomfort
during the procedure
16
Urinary incontinence
Definition
Urinary incontinence (UI) is defined as the “involuntary loss of urine so

severe as to have social and/or hygiene consequences” (NIH,1988). UI or
unintentional loss of urine is a health problem causing inconvenience and
distress to many individuals. There are several types of incontinence like
stress incontinence, urge incontinence, mixed incontinence, over-flow
incontinence, transient incontinence and functional incontinence.
Purpose
- to determine the cause of the incontinence,

- to detect related urinary tract and nervous system pathology,
- and to evaluate patient mental and physical status, comorbidity,
medications, environment, quality of life and availability of resources.
- pregnancy,
- childbirth,
- excessive weight,
- dietary choices,
- smoking,
- bladder infection,
- hormone disturbances
- pelvic organ prolapse,
- diabetes,
- brain or neurological disorders,
- mobility issues,
- severe constipation
- and other medical problems.
Clinical signs
Stress incontinence: Urine leaks when you exert pressure on your bladder by
coughing, sneezing, laughing, exercising or lifting something heavy.
Urge incontinence: A sudden, intense urge to urinate followed by an
involuntary loss of urine. Urge incontinence may be caused by infection, or a
more severe condition such as neurologic disorder or diabetes.
17
Overflow incontinence. Frequent or constant loss of urine due to a bladder
that doesn't empty completely.
Functional incontinence. A physical or mental impairment stops patient to go
to the toilet in time.
Mixed incontinence. Several types of urinary incontinence.
Nursing diagnosis
Goals
 To follow urinary incontinence, to identify and assess
causative/contributing factors
Assessment
When assessing urinary incontinence, check and record the following signs:
- history-taking: ask about: past medical/ surgical/ obstetric history,

medications, duration of UI, circumstances of leak e.g. coughing,
straining, sense of urgency, bladder storage symptoms e.g. frequency,
urgency, nocturia, psychological and social history and etc.
- physical examination: conduct systematic physical examination to
identify abnormalities that have a direct bearing on the incontinence
- direct observation of leakage: observe for urine leakage after
coughing
- send a sample of urine for urinalysis and culture
- measure residual bladder volume by in-out catheterization or bladder
scanning within a few minutes after voiding.
- following amount of voiding preferably for three days using a bladder
chart
Goals
 to measure and follow urinary incontinence signs in patient
Procedure

- make sure that patient feels comfortably
- identify and treat causes of transient UI
- develop an individualized plan of care using data obtained from the
18
history and physical examination. Implement toileting programs.
- avoid medications that may contribute to UI
- avoid indwelling urinary catheters whenever possible to avoid risk for
UTI
- monitor fluid intake and maintain an appropriate hydration schedule.
- limit dietary bladder irritants.
- consider weight loss for those with a high body mass index (BMI)
- modify the environment to facilitate continence.
- prevent skin breakdown by providing immediate cleansing after an
incontinent episode
- for stress UI: explain pelvic floor muscle exercises, provide toileting
assistance and bladder training and include other team members if
pharmacological or surgical therapies are warranted.
- For urge UI: implement bladder training and collaborate with team
members if pharmacologic therapy is warranted.
- for overflow UI: allow sufficient time for voiding, discuss with
interdisciplinary team the need for determining a post-void residual (if
catheterisation is necessary sterile intermittent is preferred over
indwelling catheterization)
- for functional UI: provide individualized, scheduled toileting, timed
voiding, provide adequate fluid intake, include physical and
occupational therapy and modify environment to maximize
independence with continence
Documentation
- document the presence/absence of UI for all patients on
admission
- document assessment of continence status throughout hospital
stay.
- document the presence/absence of an indwelling urinary
catheter
- identify and document possible etiologies of the UI
Evaluation
 The patient will have fewer or no episodes of UI or
complications associated with UI.
 The patient will feel much more comfortable
19
URINARY CATHETERISATION
Problems that are caused by pathological work of urinary system like urinary
incontinency, anuria, urine retention, preoperative and postoperative health
care, obstruction of urinary tracts, retention caused by neurological paralysis
of a patient are followed by procedure of urinary catheterisation. This
procedure enables patient’s normal urine flow by positioning special urinary
catheter (Foley) catheter in urinary bladder.
Nurse role in this procedure is vital; this procedure is followed by all sterile
rules and sometimes is uncomfortable for patients. Depending on the rules of
Institution a nurse can perform full procedure or work as a member of team.
This procedure if performed by using all rules of sterile techniques with
extreme precaution to prevent injuries or infections.
Equipment
- Sterile set for catheterisation or if you are not using factory made set
than equipment need to be adequately prepared and sterile.
- Sterile Foley catheter (proper size)
- Syringe with 5-8 ml of sterile aqua
- Towel and napkins
- Soap and water
- Oilcloth or linen baking
- Sterile gloves
- Non – sterile gloves
- Sterile compress with an appropriate open
- Sterile cotton balls and sterile pincette antiseptic suitable for perianal
region
- Dish for urine disposal
- Sterile lubricant
- Sterile urine collective bag
- Plaster
20
21
22
23
Procedure:
- Verify order for catheter insertion by checking a nursing chart or a
patient chart if is prescribed that patient need catheter.
- Check with patient allergy history, especially check the allergy on
lates or different types of lidocain, iodine povid or similar.
- Explain the whole procedure to the patient considering all aspects of
patient nature (age, education level, cultural and religious influence
etc.), be honest with patient and tell him what to expect. Ensure the
patient privacy.
- Wash your hands
- Place the patient in a right position. Male: supine position with legs
extended, female supine position with knee flexed and separated, feet
flat on the bad.
- Clean the perianal area with soap and water and let it dry.
- Create an area for the sterile field and open packaging using sterile
hygiene trolley or a table near the bad or similar.
- Drape the patient with sterile drapes supplied in the kit or outside kit.
- Wear the sterile gloves (from this moment the whole procedure must
be sterile).
- Soaked the cotton balls/swabs with iodine solution for disinfection (if
the patient is allergic to iodine use other disinfection means with
similar impact).
- Open the lubricant and lubricate the catheter up (minimum for 5 cm.)
- Check the clamp of urine bag that is closed (sometimes if you are not
using catheterisation kit, this procedure is slightly different, you need
to prepare all this steps before putting on sterile gloves).
- Prepare the place for insertion of catheter. It is different for male and
female:
Female: Use your non-dominant hand to separate labia for cleaning
process. Use your dominant hand to clean the area (non-dominant
hand is continuously holding labia separated), with one single
downward move first clean the edges, then centre and meatus itself
(you need minimally 4 cotton balls/swab, be careful to keep cotton
balls/swabs clean)
Male: use your non-dominant hand to retract the foreskin before
cleaning if the patient is uncircumcised and if it is circumcised you
can skip this step. Use your non-dominant hand to hold the penis in
60 – 90 degree angle. Make circular moves with cotton balls/swabs
soaked in disinfection means with dominant hand, start from meatus
and continue outward. Repeat this 3-4 times and each time use new
cotton ball/swab.
24
- use your dominant hand to prepare catheter take the catheter from a
sterile bag or a kit and be very attentive to maintain sterility.
- Insert the catheter through urethra meatus until you see the urine:
Female 6 – 8 cm Male: to the catheter bifurcation.
- If you felt any resistance stop immediately and note the physician.
- Attach the saline – filled syringe and inflate the balloon if indwelling
catheter.
- Hang the urine collection bag below bladder level.
- Dispose al used equipment
- Clean the perianal area
- Cover a patient to restore privacy
- Wash your hands
- Document the procedure and patient tolerance to the catheter size,
colour, clarity of urine and any other relevant information.
25
How to remove urinary catheter
This procedure is quite simple.
- Check the patient identity, date of catheter application and order to
remove catheter.
- Explain the patient the whole procedure, tell him that he can feel little
uncomfortable.
26
- Wear non – sterile gloves
- Connect the syringe to the valve mechanism on catheter.
- Pull the syringe clip backward (thus you will empty cuff that is
holding catheter fixate). Amount of aqua that is inserted into cuff
should be noticed into a patient chart or on the cuff. Wait until the full
amount is in syringe.
- Take the catheter with an absorbent cotton and pull it very easy and
gently out.
- Prepare the urination container for patient.
- Note the amount of urine in urine bag before you dispose it
- Check the patient for next 12 to 24 hours to be sure that patient is
urinating.
- Document whole procedure, date and time.
OSCE EXAMPLE
Preparation of material: Points (max 4,5 points-each 0,5 points)
a) mask
b) sterile gloves
c) sterile catheter
d) local anesthetic -lidocain gel
e) gauze for disinfection
f) Disinfectant
g) loin
h) urine bag
i) syringe, needle, 0,9%NaCl
Task 1: Explanation to the patient Points (max 3 points)
a) explanation about procedure and possible

complication given to the patient
b) ask the patient to take off clothes
c) positioning of patient-lie on the back
Task 3: List of necessary steps for catheterisation Points(max 8 points)
27
a) get the sterile gloves
b) disinfection of perineal area
c) positioning of the loin
d) get the sterile catheter out of the pack
e) application of local anaesthetic on the top of the

catheter
f) insertion of the catheter through ureter into

urinary bladder-getting urine or aspiration of the
urine
g) installation of 5 ml of 0,9%NaCl in an
appropriate hole on the catheter-for the fixation of
the catheter
h) connection of the urinary catheter with an

urinary bag
28
CONSTIPATION - OBSTIPATION - FECAL IMPACTION
Definition
Constipation is generally described as having fewer than three bowel

movements a week. Chronic constipation is infrequent bowel movements or
difficult passage of stools that persists for several weeks or longer.
Obstipation is severe constipation resulting from an obstruction in the
intestines. A fecal impaction is a large lump of dry, hard stool that stays stuck
in the rectum. It is most often seen in people who are constipated for a long
time. It often occurs in people who have had constipation for a long time and
have been using laxatives.
 older age
 inadequate fluid intake
 low-fibre diet
 inactivity
 immobility
 medication use
 lack of privacy
 pain, fear of pain
 laxative abuse
 pregnancy
 tumor or other obstructing mass
 neurogenic disorders
 use of medications, particularly narcotic analgesics
 stress and depression
 privacy issues (being away from home, hospitalized or otherwise
being deprived of adequate privacy can result in constipation).
Clinical signs
 Infrequent passage of stool

 Passage of hard, dry stool
 Small, semi-formed stools
 Straining at stools
 Passage of liquid fecal seepage
29
 Frequent but non-productive desire to defecate
 Anorexia
 Abdominal distention, cramping and bloating
 Nausea and vomiting
 Dull headache, restlessness, and depression
 Verbalized pain or fear of pain
 Rectal bleeding
 Bladder pressure or loss of bladder control
 Lower back pain
 Rapid heartbeat or light-headedness from straining to pass stool
Nursing diagnosis
Goals
 To identify and assess causative/contributing factors
Assessment
 Evaluate usual dietary habits, oral/dental health, eating habits, eating
schedule and liquid intake.
 Evaluate change in mealtime, type of food, disruption of usual
schedule
 Assess activity level and exercise pattern
 Evaluate current medication usage (drugs that can cause constipation
include the following: narcotics, antacids with calcium or aluminium
base, chemotherapy, steroids, antidepressants, anticholinergics,
antihypertensives and iron and calcium supplements).
 Determine access to bathroom (ability to perform self-care activities)
and assess privacy for elimination (use of bedpan, access to bathroom
facilities with privacy during work hours).
 Evaluate pain with defecation (hemorrhoids, anal fissures, or other
anorectal disorders that are painful can cause ignoring the urge to
defecate, which results over time in a dilated rectum that no longer
responds to the presence of stool).
 Identify areas of stress (personal relationships, occupational factors,
financial problems)
 Ask about anxiety
 Assess usual pattern of elimination; compare with present pattern.
Include size, frequency, odour, colour, and quality of feces ("Normal"
frequency of passing stool varies from twice daily to once every third
or fourth day. It is important to ascertain what is "normal" for each
individual).
30
 Assess degree to which patient's procrastination contributes to
constipation (ignoring the defecation urge eventually leads to chronic
constipation, because the rectum no longer senses, or responds to, the
presence of stool. The longer the stool remains in the rectum, the drier
and harder (and more difficult to pass) it becomes.
 Ascertain duration of current problem and degree concern (short-
standing or long-standing)
 Evaluate laxative use, type and frequency.
Evaluate reliance on enemas for elimination.
 Assess for history of neurogenic diseases, such as multiple sclerosis,
Parkinson's disease.
 Palpate abdomen and provide rectal exam
Goals
 to help the patient to establish and maintain normal bowel habits
Procedure
 Encourage daily fluid intake of 2000 to 3000 ml per day, if not
contraindicated medically (Suggest drinking warm, stimulating fluids
(tea, hot water) to promote soft stool).
 Encourage increased fibre in diet (raw fruits, fresh vegetables) to
improve consistency of stool and facilitate passage; a minimum of 20
gm of natural dietary fibre per day is recommended.
 Encourage patient to consume prunes, prune juice, cold cereal, and
bean products.
 Encourage physical activity and regular exercise.
 Encourage a regular time for elimination.
 Encourage/support treatment of underlying medical causes where
appropriate to improve body function, including the bowel.
 Encourage isometric abdominal and gluteal exercises
 Teach use of pharmacological agents as ordered, as in the following:
 Bulk fibre (Metamucil and similar fibre products)-these
increase fluid, gaseous,
and solid bulk of intestinal contents
 Stool softeners (these soften stool and lubricate intestinal
mucosa).
31
 Chemical irritants (these irritate the bowel mucosa and
cause rapid propulsion of contents of small intestines.
 Suppositories (these aid in softening stools and stimulate
rectal mucosa; best results occur when given 30 min before usual
defecation time or after breakfast.
 Apply oil retention enema (to soften stool) if needed
 Apply lubricant ointment if needed
 Digitally remove fecal impaction if necessary.
 Suggest the following measures to minimize rectal discomfort
(shrink swollen hemorrhoidal tissue):
 Warm sitz bath
 Hemorrhoidal preparations
For hospitalized patients, the following should be employed:
 Orient patient to location of bathroom and encourage use, unless

contraindicated (A sitting position with knees flexed straightens the
rectum, enhances use of abdominal muscles and facilitates
defecation).
 Offer a warmed bedpan to bedridden patients; assist patient to
assume a high Fowler's position with knees flexed (This position best
uses gravity and allows for effective Valsalva's manoeuver).
 Curtain off the area
 Allow patient time to relax.
 Educate patients
 Explain or reinforce to patient and caregiver the importance of the
following:
 A balanced diet that contains adequate fibre, fresh fruits,

vegetables, and grains (twenty gm/day is recommended)
 Adequate fluid intake (eight glasses per day or 2000-3000 ml
per day, unless it is differently advised by the doctor)
 Regular meals (successful bowel training relies on routine)
 Regular time for evacuation and adequate time for defecation
 Regular exercise/activity
 Privacy for defecation
Documentation
 Document date and time of assessment
32
 Document pattern of elimination, colour, consistency,
frequency and amount of stool passed
 Document found contributing and causative factors
 Document type of intervention
 Document further preventive strategy
Evaluation
 The patient's rectum will be free of feces
 The patient will establish and maintain normal bowel
habits
33
ENEMA ADMINISTRATION PROCEDURE
An enema is the installation of a solution into the rectum and sigmoid colon.
An enema is given to treat severe constipation, unresponsive for other
measures, or to cleanse the bowel for diagnostic procedures.
Goal
 To safely and effectively administer enema with the minimum of
discomfort for the patient
Indications
 Patients who has constipation and faecal loading
 Patients being prepared for surgery or a procedure
 Patients needing the removal of residual barium enema/meal
Equipment
• Micralax enema or fleet (phosphate) enema
• Lubricant (Vaselinum)
• Non-sterile gloves
• Blue under sheet
• White coat or uniform
• Protective eyewear (if at risk of splash)
• +/- Bedpan as required
Procedure
 Explain procedure to patient
 Obtain required equipment
 Ensure patient’s privacy
 Put on white coat or uniform and protective eyewear
 Perform hand hygiene and put on non-sterile gloves
 Position patient in the left lateral position in a knee-chest position
if tolerated and place a blue under sheet under their buttocks
 Remove cap and lubricate tip of an enema tube
 Instruct patient to relax and to breath normally
 Slowly and gently insert a tube approx. 3 cm into the rectum
 Ask the patient to take a deep breath in (relaxes the sphincter), if
resistance is encountered at the internal sphincter
 Squeeze the tube to instil all of the contents into the rectum, and
keep the chamber compressed as you withdraw the tube (prevents
suction of fluid back into the chamber)
 Dispose of rubbish adhering to infection control policy
34
 Instruct patient to remain lying in bed for as long as comfortable
before opening bowels
 Assist patient to mobilize to bathroom or onto bedpan as required
 Perform hand hygiene
 Offer patient the opportunity to perform hand hygiene
Documentation
 Document date and time of procedure

 Document colour, consistency, odour and amount of stool
passed
 Document any alterations in perianal skin integrity
 Document the patient’s tolerance and reaction of the procedure
(note any complication from the procedure and pain)
Evaluation
 The patient's rectum will be free of faeces

 The patient will experience a minimum of discomfort during the
procedure
 The patient will not experience any adverse side effects during or
as a result of this procedure
35
DIGITAL REMOVAL OF FECAL IMPACTION
Sometimes, because of severe constipation, the faeces become so hard and
large that it will not pass through the anus without tissue damage. When this
happens, nurse needs to remove the faeces manually.
Goal
• To safely and effectively remove impacted faeces with the
minimum of discomfort
for the patient
Equipment
 Disposable absorbent pads
 Bedpan
 Non-sterile gloves
 Plastic shovel
 Blue under sheet
 Bag for faeces removal
 Soap
 Wash bowel
 Towel
 Water/soluble lubricant
Procedure
 Explain procedure and rationale to patient
 Pull curtains around bed or close door to room to maintain
patient’s privacy.
 Ask the patients to lay down on the side with knees flexed and
back toward the nurse.
 Place a blue under sheet under the patient's buttocks, and a
bedpan to hold removed stool nearby.
 Perform hand hygiene
 Put on non-sterile gloves and apply lubricant to the index finger
that will be inserted to break up the impaction.
 Insert a gloved, lubricated index finger and massage around the
anal sphincter and edges of the impaction, gradually working the
gloved finger into the mass to break it up.
 Dislodge the broken-up pieces of stool carefully working them
downward toward the end of the rectum.
36
 Check regularly to assure that there are no untoward effects such
as weakness, diaphoresis or clamminess, or changes in pulse rate.
 Stop procedure if heart rate drops or rhythm changes from the
patient’s baseline.
 Dispose used under sheet and gloves into the plastic bag and
safely dispose it in the space provided.
 Wash your hand thoroughly
Documentation
 Document date and time of procedure

 Document colour, consistency, odour and amount of stool
passed
 Document any alterations in perianal skin integrity
 Document the patient’s tolerance and reaction of the procedure
(note any complication from the procedure and pain)
Evaluation
 The patient's rectum will be free of faeces

procedure
 The patient will not experience any adverse side effects during
procedure or as a result of the procedure
37
DECUBITUS
Definition
Decubitus (bed sore, pressure) ulcer is an ulcer occurring on the skin of any
bed-ridden patient, particularly over bony prominence or where two skin
surfaces press against each other. Four grades of decubitus ulcers can be
recognized on the basis of pathophysiology of soft tissue breakdown
overlying bony prominences (Table 1). Pressure relief and pressure reduction
devices for the prevention of skin breakdown include a wide range of
surfaces, specialty beds, mattresses and other devices. Preventive measures
are usually not reimbursable, even though costs related to treatment once
breakdown occurs are greater.
Table1. Classification of decubitus
Stage Description
intact skin with redness
Stage I
(erythema) and sometimes with
warmth
Stage I partial-thickness loss of skin, an
abrasion, swelling, and possible
blistering or peeling of skin.
Stage III full-thickness loss of skin, open
wound (crater), and possible
exposed under layer.
Stage IV full-thickness loss of skin and
underlying tissue, extends into
muscle, bone, tendon, or joint.
Possible bone destruction,
dislocations, or pathologic
fractures (not caused by injury).
 Old age
 Immobility
 Mechanical forces (pressure, shear, friction)
 Pronounced bony prominences
 Poor circulation
38
 Poor nutrition
 Poor hygiene
 Altered sensation
 Incontinence
 Edema
 Spinal injury
 Presence of circulatory problems
 Obesity
 Diabetic foot
 Environmental moisture
 History of radiation
 Hyperthermia or hypothermia
Clinical signs
 Redness, heat, tenderness and discomfort in the area

 The area becomes cold to touch and insensitive
 Local edema
 Later, the area becomes blue or purple
 Due to continued pressure that circulation is cut off, the gangrene
develops and affected area is sloughed
Nursing diagnosis
Goals
1. to provide the assessment of the decubitus ulcers
2. to provide the assessment of the risk/contributing factors
Assessment
 Determine age.
 Assess general condition of skin (healthy skin varies from individual
to individual, but should have good turgor, feel warm and dry to the
touch, be free of rashes scratches, bruises, excoriation) and have quick
capillary refill (less than 6 seconds).
 Specifically assess skin over bony prominences (sacrum, trochanters,
scapulae, elbows, heels, inner and outer malleolus, inner and outer
knees, back of head).
 Assess patient's awareness of the sensation of pressure.
 Assess patient's ability to move (shift weight while sitting, turn over
in bed, move from bed to chair).
 Assess patient's nutritional status, including weight and weight loss
39
 Assess for edema (skin stretched tautly over edematous tissue is at
risk for impairment).
 Assess for history of radiation therapy (radiated skin becomes thin
and friable, may have less blood supply)
 Assess for faecal and/or urinary incontinence.
 Assess for environmental moisture (wound drainage, high humidity).
 Check for repositioning
 Assess surface that patient spends majority of time on (mattress for
bedridden patient, cushion for persons in wheelchairs).
 Assess amount of shear (pressure exerted laterally) and friction
(rubbing) on patient's skin.
 Reassess skin often and whenever the patient's condition or treatment
plan results in an increased number of risk factors.
 For grade 1 decubitus ulcers skin integrity complete checklist at least
monthly
 For decubitus ulcers grade 2 – 4 skin complete checklist at least
weekly
 For patients at risk of decubitus ulcers or have healed decubitus ulcers
reassess for pressure release need at least every three months for as
long as it is required.
 Check for pain
 Check for infection
Goals
 to improve circulation
 to facilitate healing
 to prevent infection
 to prevent further damage
 to treat decubitus ulcers
Equipment
 hypoallergenic tape
 syringe 10 ml
 needle 21 G
 two pairs of gloves
 isotonic saline solution
 sterile gauze swabs 10x10 cm
40
 sterile cotton tampons
 sterile dressings
 blue under sheet
 sterile scissors
 alcohol swabs
 waste receptacles
Preparation
 The setting should be prepared including the decontamination of the

working surface or tray to be used with detergent and water or
detergent wipes and then dried
 Hand hygiene should be performed
 The extent of the use of drapes and protective clothing will also
depend on the type of procedure and its’ complexity.
 All packaged sterile items for the procedure should be assembled
prior to starting the procedure.
 Staff should check the packaging is intact and expiry date has not
been exceeded.
 All packaged sterile items, such as needles and syringes, should be
opened carefully by peeling back the packaging and not pushing it
through the backing paper.
 If possible 30 minutes should be left after bed making or domestic
cleaning before exposing or dressing wounds.
Procedure
 Explain procedure and rationale to patient

 Pull curtains around bed or close the door to room to maintain
patient’s privacy.
 Place the patient in the most comfortable position and provide
easy access to the ulcer site
 Protect the sheet with a blue under sheet
 Put on gloves, remove the dressing and dispose it into the waste
receptacle to prevent the contamination of sterile area
 Clean and irrigate the wound using isotonic saline solution. This
may be carried out utilising a syringe in order to produce gentle
pressure in order to loosen debris. Dry surrounding skin with
sterile gauze swab.
41
 Do not use gauze swabs and cotton wool for ulcer cleaning
because this can cause mechanical damage to new tissue and the
shedding of fibres from gauze swabs/cotton wool delays
healing.
 Remove visible debris and devitalised tissue if present
 Remove dressing residue
 Remove excessive or dry crusting exudates (wound cleansing
should not be undertaken to remove 'normal' exudate)
 Refer the patients with glued, necrotizing material for debrid
 ement.
 Choose and prepare appropriate dressing according to the need of
wounds (to be drained, protected or keep moist), dressing effects,
the availability and practicality of the dressing. Used the dressing
in accordance with the manufacturers’ instructions or research
protocols.
 When uncertain about which dressing to use, a gauze dressing
moistened in saline solution may be applied. Gently put a
dressing over the ulcer's surface. Do not impale the gauze into
the ulcer. Change the dressing frequently to keep the wound
moistened.
 When using hydrocolloid dressing, carefully take the dressing out
of the package, remove the protective liner from the adhesive
side of the dressing and place it over the ulcer. Creases need to
be flattened. If needed, attach edges of the dressing to the intact
skin using tape.
 For the ulcers with excessive exudate and infected ulcers alginate
dressing may be applied. Switch to another type of the dressing
when the drainage stops and the wound bed looks dry. For non-
adherent surfaces, foam dressing may be applied. Change the
dressing when the foam stops absorbing the exudate.
 For painful ulcers hydrogel dressings may be applied.
 When dressing change is completed, remove the gloves and
dispose them into the waste receptacles. Dispose all other waste
into the waste receptacles.
 Wash the hands
 Plan preventive strategy
42
Decubitus prevention
 Encourage implementation of pressure-relieving devices

commensurate with degree of risk for skin impairment:
 For low-risk patients: good-quality (dense, at least 5
inches thick) foam mattress overlay.
 Mattresses less than 4 to 5 inches thick do not relieve
pressure; because they are made of foam, moisture can
be trapped. A false sense of security with the use of
these mattresses can delay initiation of devices useful
in relieving pressure.
 For moderate risk patients: water mattress, static or
dynamic air mattress.
 For high-risk patients or those with existing stage III or
IV pressure sores (or with stage II pressure sores and
multiple risk factors): low-air-loss beds or air-fluidized
therapy
 Encourage patient and/or caregiver to maintain functional body
alignment.
 Limit chair sitting to 2 hours at any one time (pressure over sacrum
may exceed 100 mm Hg pressure during sitting. The pressure
necessary to close skin capillaries is around 32 mm Hg; any pressure
greater than 32 mm Hg results in skin ischemia).
 Encourage ambulation if patient is able.
 For patients in bed, encourage repositioning every 1-2 hours unless
contraindicated
 Avoid raising the head of the bed for over than 30 degrees
 Avoid placing the patients directly on his trochanter, instead place
him on the flank under the angle of 30 degrees.
 Increase tissue perfusion by gently massaging around affected area.
 Avoid massaging reddened area because this may damage skin
further.
 Clean, dry, and moisturize skin, especially over bony prominences,
twice daily or as indicated by incontinence or sweating. If powder is
desirable, use medical-grade cornstarch; avoid talc.
 Encourage adequate nutrition and hydration:
 2000 to 3000 calories per day (more if increased
metabolic demands).
 Fluid intake of 2000 ml per day unless medically
restricted (hydrated skin is less prone to breakdown).
 Consult the doctor if the patient has cardiovascular
problem
43
 Encourage use of lift sheets to move patient in bed and discourage
patient or caregiver from elevating HOB repeatedly. Remove all
creases of the linen. Place a pillow in a comfortable position.
 Leave blisters intact by wrapping in gauze, or applying a hydrocolloid
(Duoderm ) or a vapour-permeable membrane dressing (maintains the
skin's natural function as barrier to pathogens while the impaired area
below the blister heals).
 Teach patient and caregiver the cause(s) of decubitus ulcer
development:
 Pressure on skin, especially over bony prominences

 Incontinence
 Poor nutrition
 Shearing or friction against skin
 Teach patient or caregiver the proper use and maintenance of
pressure-relieving devices to be used at home.
Documentation
 Record the date and time of initial and subsequent treatment

 Note the specific treatment given
 Note preventive strategies provided and planned
 Describe the decubitus ulcer's location, size (length, width, depth),
colour and appearance of the wound bed, consistency, colour, amount
and odour of drainage and the condition of surrounding skin
 Provide and document reassessment of decubitus ulcer's at least once
a week
 Note changes in ulcer's appearance
 Note the advice to carers
Evaluation
 Ulcer management is practiced in accordance with the best available
evidence for optimizing healing
 Ulcer management dressings, pharmaceuticals and devices are used in
accordance with the manufacturer’s instructions or research protocols
procedure
 The ulcer is healed within the expected period of time (in accordance
with the phase)
 Patient's skin remains intact
44
 No redness over bony prominences
 Capillary refill <6 seconds over areas of redness.
45
OXYGEN THERAPY
Definition
Oxygen therapy is the administration of supplemental oxygen (02) using

mask, nasal canulla or laryngo-tracheal tubus at the concentration greater
than in the room air to the patient in order to relieve hypoxemia and to treat
and to prevent hypoxia.
Purpose:
- to increase oxygen saturation in tissue,

- to treat hypoxia in hypoxemic patients,
- to prevent hypoxia,
- to reduce anxiety associated with lack of oxygen,
- to reduce fear from suffocation and death,
- to achieve effective respiration,
- to improve patient´s comfort and health status,
- to improve the patient´s quality of life
Chronic obstructive pulmonary diseases

Anemia
Acute respiratory distress syndrome
Medications, which depress breathing
Congenital heart disease — heart defects that are present at birth
Asthma and Bronchitis
Emphysema
High altitudes
Interstitial lung disease
Pneumonia
Pneumothorax
Pulmonary edema
Pulmonary embolism
Restrictive pulmonary diseases
Sleep apnea
46
Clinical signs
Colour of skin, ranging from blue to pale
Confusion
Cough
Fast heart rate
Rapid breathing
Shortness of breath
Sweating
Wheezing or stridor
Using auxiliary respiratory muscles
Nursing diagnosis
Goals
 To identify and assess causative/contributing factors
Assessment
When assessing for hypoxemia, check and record the following signs:
- evaluate complete vital signs (blood pressure, pulse and frequency of
breathing)
- evaluate respiratory status.
- auscultate lungs and heart.
- investigate is there any chronic pulmonary or cardiac conditions.
- check capillary refill on all extremities. Capillary refill time varies
with age should return to normal within two to three seconds in all
patients.
- evaluate is there peripheral or central cyanosis
- looking for evidence of restlessness
- check how patient is answering questions and is there any confusion
- check the level of consciousness
Goals
 to help the patient to establish normal level of oxygen in blood
Procedure
- ensure that a proper oxygen device and flow rate or FiO2, is
47
introduced
- provide appropriate supplies.

- introduce yourself and explain the procedure to the patient.
- prepare the device and connect it to the flowmeter.
- adjust the oxygen flow rate appropriately
- depends of the device it has been selected adjust the flow to that rate
which corresponds to the device being used. Consult the package
insert for further instructions.
- be cautious the flow rates in excess of this may increase the
expiratory work of breathing.
- place the device on the patient’s face. Masks should fit on the face to
ensure an adequate FiO2 delivery.
- assure patient comfort and tolerance of the device.
- for infants and children who may not tolerate masks modify the fit as
necessary to ensure compliance and adequate oxygenation (prongs,
oxyhood, etc.)
- if there is need for transport of patients to oxygen therapy, obtain a
transport cylinder; verify its contents.
- tighten the regulator onto the cylinder; open the valve one turn and
verify the pressure.
- attach the delivery device for transport
- Continue procedure like it was described above
- monitor the effect of therapy with pulse oximetry and/or blood gas
analysis.
- assess the patient for tolerance of therapy
Documentation
- document the initiation of oxygen therapy, changes in therapy,
and the effect and tolerance of therapy.
- document the way of usage of therapy
- document mode of delivery (device and FiO2)
- document level of SpO2
- document indications for usage of oxygen.
Evaluation
 The patient will have normalized vital signs and feel
better
 The patient will establish and maintain normal blood
levels of oxygen
48
49
50
51
DRUG APPLICATION – Enteral procedure
Definition
As the part of daily work nurse administers various drug and

medications based on physician prescription. Drug administration
means taking in different mediation via different absorption ways
(mucosa, skin, parenteral etc.).
Usually there are two ways of drug administration; enteral and

parenteral. Enteral means that drug is taken in via digestive system.
Parenteral mean all other ways that do not use digestive system, like
drug application via mucosa, skin, intramuscular way, intravenous
way, subcutaneous way and intradermal way.
Nursing procedure for drug administration is very similar in few steps

but differs in steps of realization. Most common ways of drug
administration is:
Enteral Parenteral
Digestive system (mucosa Intramuscular,

of mouth, sublingual,
mucosa of buccae, mucosa Intravenous,
of whole digestive system) Via skin
Subcutaneous
Intradermal
Nursing diagnosis
- To provide that patients have therapy on time

- To improve rehabilitation process.
Assessment
52
Before administration of any kind of drugs it is important to make
assessment based on patient condition, age etc.
Nursing interventions – oral administration of drugs.
Nursing interventions are various for different kinds of type of drugs

and medication. Usually drugs taken via mouth or enteral are different types
of tablets, pills, etc.
Before starting of application of any kind of medication it is important

to make three checks:
- Check the medication prescription and compare it with medication

from pharmacy
- Check the way of medication application, dosage, time of
application and route of application
- Check the identity of patient
Equipment:
- Cups for pills,

- Pills
- Glass of water
Procedure
Before giving pills by mouth it is important that nurse checks all

contraindication for this procedure like the state of conscience, the
state of oral cavity etc.
Before giving medication to patients it is necessary to explain all steps

of procedure and possible side effects.
Following steps of procedure are:
- Conduct all necessary check – out

- Explain patient the procedure
53
- Patient should be positioned in a comfortable position. If it is
possible it is semi – seat position (Fowler position); if patient is
not able to be placed in this position it is recommended to use
patient’s bed options for placing him/her in a comfortable
position.
- Prepare appropriate liquid (tea or water) that will patient use while
taking drugs.
- Explain and show what kind of pills/tablet patient is going to take
- If the patient is in position to take pills/tablet on his own nurse
should give him a cup with pill tablet and ask him to swallow. If
the patient is not in possibility to do this by his own Nurse should
ask a patient to open mouth and nurse puts pills/tablet in his
mouth.
- Along with pills Nurse should give a patient a glass of water/tea
and asks to drink it with pills and swallow easy.
- It is important to determine if patient is capable to take more than
one pill at the time and to make sure that Nurse helps patient to
take all necessary pills/tablet.
Documentation
Time, date and type of pills administration trough mouth should be

notices on patient chart and Nursing chart. All data should be written clearly
with date, time, amount and type of medication given to the patients along
with sign of person/nurse who give medication.
Evaluation
Evaluation of procedure comprises three levels:
1. After the medication is administered it is important to check did

the patient swallow the medication
2. After the end of shift/day it should be evaluated whether the
prescribed medications were administered
3. At the date of patient discharge it should be evaluated did the
patient received all necessary medication in a proper way.
54
EXCEPTION
If there is an obstacle for administration of drugs through mouth different

types of medications can be administered by nasogastric tube (procedure of
nasogastric tube is explained in a separate procedure). General description,
Nursing diagnosis and Assessment resembles the procedure of medical
application through mouth.
Procedure:
Equipment:
- Drug soluble in water (tablets, cup for tablets,)

- 2x Syringe
- Gloves
- Waste disposal dish
- 15-30 ml of water
Procedure:
- Check the identification of patient, if patient is communicating

ask him for his name, if not check the bracelet or patient chart for
his name.
- Check the medication in accordance with all rules for drug
administration.
- Prepare all necessary equipment (if the drug is in the form of
tablet it should be chopped up in small pieces). Drug can be
chopped in small pieces with a spatula and a cup for pills after
which 5 ml of aqua should be added.
- Nurse should wash hand and put on the gloves.
- Put the patient in an appropriate position, semi – sitting position
(Fowler position) if patient is in ability to take that position alone,
if not Nurse should help him and use the bed options to make
easier for patient to obtain Fowler position.
- Remove the plug from nasogastric tube
- Check the position of nasogastric sonda. If necessary aspirate
some of the gastric content. (Aspiration of gastric content is done
by connecting Syringe with minimum of 50 ml to nasogastric
tube). If the aspiration is conducted and it is positive, syringe used
55
for aspiration should be detached and syringe with prepared drug
should be connected.
- Check again is the drug/tablet ready for application.
- Applicate the drug using the methods of free fall with syringe.
- After the drug is administered, nasogastric tube should be washed
out with 15-30 ml of water (maximum 50 ml of liquid). Amount
of this liquid should be noted on the patient chart and Nursing
chart.
- Syringe used for drug administration should be removed and
Nasogastric tube should be plugged,
- Patient should stay in Fowler position at least 30 minutes and
comfortable conditions should be ensured for him.
- All equipment that is used for this drug administration equipment
should be discarded (what is for a single use).
- Nurse must wash her hands thoroughly.
- Notice the amount of drugs, liquid, time, date and person who
administered this drug in patient chart and Nursing chart.
Documentation
Time, date and type of pills administration trough mouth should be

notified on the patient chart and Nursing chart. All data should be written
clearly with date, time, amount and type of medication given to the patients
along with sign of person/nurse who gave medication.
Evaluation
Evaluation of procedure comprises three levels:
1. It is important to check did the patient swallow the medication

2. After the end of shift/day nurses check are the prescribed
medications administered
3. On date of patient’s discharge it should be evaluated did the
patient received all necessary medication in a proper way.
56
RECTAL/ANAL DRUG ADMINISTRATION
Definition
When there is obstacle to administer drug orally some of the medications can
be administered per rectum (PR). Medication that are usually administered
PR are good for local and for systematic treatment, because the physiology
and anatomy characteristics of rectal mucosa ensure fast medication
absorption. Enema procedure is used for therapeutic and diagnostic purpose
and sometimes it can be used for medication administration (Enema
medication administration is described in procedure about enema). Usually
types of medication administered per rectum are different types of
suppositories and different types of unguents.
This method with all benefits also has some deficiencies that are usually
caused by contraindication. Contraindication for this procedure are the lack
of consent, anal surgery, abnormalities or trauma, pruritus or any other
malformation of anal region.
Nursing diagnosis:
- To help in recovery process

- To give therapy at proper time and prescribed way
Assessment
This procedure requires very serious approach. Nurse needs to examine

perianal region for following signs: soreness or redness, infestations,
hemorrhoids, pruritus, skin tags, bleeding, foreign bodies wounds etc. Nurse
needs to assess is the perianal region suitable for drug administration.
Furthermore, it is very important to confirm that all above mentioned
contraindications are not existing otherwise they can cause serious problems
for patients.
57
Procedure
Equipment:
This procedure has several similarities with procedure for enema insertion
but it is simpler and demand lower number of material units for this
procedure:
Materials that are necessary for this procedure are:
- Suppositories
- Gloves (clean not sterile)
- Lubricant
- Waste bag
- Absorbent pad
- Gauze swabs or tissues
- Bedpan and toilet paper.
Procedure:
Once the equipment is prepared nurse can start with procedure according to
the following steps:
- Conduct the check of medication and compare is it the medication

prescribed by physician the same with the prescription on
patient’s chart.
- Check the patient’s identity by comparing his name on the
patient’s chart with the name on the patient’s bracelet or (if patient
is communicative) ask him for his name and surname.
- After the first two steps it is very important to explain to the
patient procedure in terms that patient is able to understand (what
to expect from procedure etc.) and ask the patient does he/she
understand the procedure.
- Ensure privacy for patients by using curtains around the bed
space.
- Nurse now need to wash hands and to prepare medication
(suppository or unguentum)
- Patient should be positioned in an appropriate position: it is
position on the left side with the right knee raised towards the
chest. The next step is to uncover gluteal area. This position helps
58
nurse to enable gravity – assisted flow through rectum toward the
sigmoid colon. Under the patient's hips and buttocks place an
absorbent pad. When patient feels comfortable and ready for
procedure start with the application of suppository.
- Wash your hands once again and wear non-sterile gloves.
- Remove all packaging of suppositories and place it onto a clean
dressing trolley or similar.
- Take the lubricant and squeeze sufficient amount on gauze and
lubricate the apex of suppository.
- Ask patient to take deep breath, to relax and concentrate on
breathing. With non-dominant hand part the buttocks, while with
dominant hand place the suppository in an anal canal for 2- 4 cm
using a gloved index finger. If there is several suppository
prescribed repeat this step. Note to patient that is very
important to keep suppository in an anal canal as long as
possible or at least for 20 minutes while defecation reflex
passes.
Exception: procedure is the same for administration of
unguentum, just for unguentum special factory made
applicator is used.
- Wipe away excess traces of lubricant from the anal area
- Place all used equipment in clinical waste and wash your hands
with disinfection agent
- Patient should be left in a comfortable position to ensure
medication absorption
- Document type, amount, time and person who delivered
medication on the patient chart and Nursing chart.
- Observe patient for any adverse reactions.
Documentation
A nurse must document all steps that are conducted within this procedure
like: type of medication that is used, dosage, time and person who
administrated this medication
All steps should be documented in the patient’s chart and Nursing chart.
59
Evaluation
Procedure can be evaluated in the following manner:
1. Immediately after procedure evaluate is the patient suitable to hold

medication in an anal canal to ensure absorption of medication
2. After the medication has been absorbed check the benefits of the
treatment.
PROCEDURE OF VAGINAL DRUG ADMINISTRATION
Definition
Vaginal drug administration represents a local drug administration where

vaginal mucosa is a media for drug conducting. Anatomical and
physiological characteristics demand specific medication that can be used in
a vaginal area. Usually it is different types of suppository, unguentum, gels
etc.
These medications are usually used for treatment of various infections

inflammations and as contraceptive. Vaginal drugs usually are prepared with
special applicator what ensures that drug can be applied in all parts of vaginal
area.
Nursing diagnosis
- To help improvement of treatment

- To provide on–time application of therapy
Assessment
It is necessary to asses all factors that can lead to contraindications of vaginal

drug administration. It is necessary to check identity of the patient, the
appropriateness of drugs, dosage and time. Patient should be able to take
position laying on back and it is recommended to apply this drug before
sleeping if it is not indicated differently.
60
Procedure
Equipment
- Vaginal mediation with applicator or without

- Glows non – sterile
- Swabs
- Sanitary pad
- lubricant
Procedure
- Prepare all equipment on the hygiene trolley or similar

- Check the patient identity by asking her name, check the bracelet,
patient’s chart and the number of room and bed.
- Check the dosage, date and the type of vaginal drug.
- Ensure the patient comfort and intimacy using bed curtains.
Explain the procedure to the patient. It is good for patient to
empty an urinary bladder before implementation of vaginal drugs.
- Put patient in a gynecological position, laying down on the back
with separated band knees.
- Wash your hands and put on non-sterile gloves.
- Uncover the vagina area, only perineum.
- If unguentum, cream or gel is used you need an applicator. Put the
clip in the applicator on a drug tube. Easily put pressure on a drug
tube so that applicator fills with drug. Take off the applicator from
a tube and lubricated it. The applicator should be held for a
cylinder and inserted into vagina. To ensure patient’s comfort
point applicator first downstream toward the spine and then up
and back toward the cervix and then press the applicator clip. If
you use suppository, place the suppository into the applicator, put
the applicator in a position as described earlier. If suppository
comes to the distal end of vagina press the clip and take the
applicator out while holding pressure on the applicator clip.
Before placing suppository into the applicator suppository it must
be lubricated.
- After placing vaginal medication place the sanitary pad to prevent
bed and clothes of patient from getting dirty.
61
- Help the patient to take comfort position and tell her to stay as
long as possible in the bed for next few hours.
- After finishing application all equipment that is for single use
should be disposed. If an applicator is for multiple use it must be
washed with soap, disinfection media and warm water (one
applicator can be used just for one same patient).
- Wash your hands
-
Documentation
Document all that you have done, note the date and time of application, drug
dosage, usage of applicator, effects of treatment and all other relevant
information.
Evaluation
It is very important to notice that this drug can make local complication like
local irritation. This procedure can be evaluated after few hours to see has the
vaginal drug been absorbed properly.
NOTE: it is recommended to teach the patient to be able to administer

vaginal medication by herself.
IV THERAPY
Definition
More than 800% of hospitalized patients receive some kind of i.v therapy (i.v.
– intravenous therapy). I.V. therapy means that medication is put directly into
blood flow into veins by using some of the methods for application of blood
therapy. I.V. therapy can be performed in two ways:
1. One that is using peripherals veins and

2. Central venous therapy using major large veins
Peripheral veins are used for application of infusion solution using hand, pals,
and leg and foot veins for short time for the occasional application of therapy.
Central venous therapy is usually used vena cava superiors and vena jugulars
62
interna and externa and it is used for patients that need to take large amount of
solution, hypertonia solutions, medication with caustic impact and high
calories parenteral nutrition.
I.V. therapy is mostly used for fluid and electrolyte compensation,

maintenance of water-salt balance, medication application, blood transfusion
and parenteral nutrition (feeding)
I.V: therapy can be applied in hospital and house environment.
Nursing diagnosis
- To apply therapy
- To improve nutrition status of patients via parenteral feeding
- To improve status of electrolytes
- To maintain water – salt balance
Assessment
Indications for I.V. therapy are various depending on therapy goals, the length
of therapy, diagnosis, age, veins status etc. I.V. therapy can be used for a single
application of medication if the medication need to be put in blood flow
immediately. There are three types of medication I.V. application:
1. Infusion solution through peripheral veins

2. I.V. bolus putting medication directly into blood flow
3. Using central vein
Procedure
This procedure, as mentioned above, will be shown in three different areas:

using infusion system, using I.V. bolus and the role of the nurse during the
placement of central vein catheter.
Infusion system
Equipment
- Infusion system
- Tupfers
- Alcohol or other relevant disinfection mean
63
- I.V. solution
- I.V. medication
- I.V. stand
- Adhesive tape
- Non – sterile gloves
- Tourniquet
- Cannula I.V.
- Needle dispenser
- Sterile gauze
64
65
Procedure
- Sort the equipment on the sanitary trolley or similar

- Check the equipment sterilization, dates etc.
- Check the patient’s identity from a bracelet, the patient chart or ask a
patient for his/her name. Check the infusion solution and medication
following all steps for medication/drugs security protocol. Infusion
solutions are specific; if the solution is packed in a glass bottle check
the bottle for wracks or - if the solution is in a plastic bag check the
plastic bag for leaking and check the solution colour which has to be
clear not blurred.
- Wash your hands
- Open the I.V. infusion system following all steps to maintain aseptic
condition. Take the clamp and move it to the chamber for dropping and
then close the regulator wheel.
- If the solution is in a plastic bag place it on the flat, solid surface or
hang it on the stand. Take off the protection cap or protective folia of
I.V., then take of the protective cap from the pin that goes into a plastic
bag on an infusion system. With one hand hold thigh the infusion bag
near the place of the connection with an infusion set and with other
hand put the pin inside the plastic bad. Hang the infusion bag and press
the chamber for dropping to be half full.
- Infusion solution can be packed into glass bottles without valve so you
need to remove metal cover from the bottle and remove disk beneath if
it exists. Place the bottle on a stabile surface and use an alcohol swab
to clean the rubber cap. Take the cap from the pin of infusion system
and put it through the rubber cap into bottle. Angle of pin should be 90
degrees. Turn the bottle and you will see forming of bubbles and you
will hear the air noise. If there are no such signs throw the bottle away.
If everything is correct hang the bottle on the stand and press the
chamber for dropping to be half full.
- Bottle with valve procedure is the same like for bottle without valve –
only a pin should be placed through the specific place near the air valve
(this place is usually marked on these bottles).
- After the connection of bottle with infusion solution infusion system
should be prepared (bottle is hanging on I.V. stand), take the infusion
system in your hand and if you have in your presence a bedpan or a
66
bucket or the sink point the distal part of system towards it and slowly
open the clamp wheel. Hold the clamp fully open until the all air
bubbles that are created in the system go out. When all air bubbles go
out hang the system on the stand. (if you are doing this outside the
patient’s room place the etiquette on the bottle with patient’s name,
room number, bed number and medication that are in infusion).
- Explain to the patient all procedure and ensure him comfort. Ask a
patient to take a comfortable position if he/she can move.
- Before starting procedure choose the place for I.V. (usually veins of
hand and palm). It is recommended to use distal veins, so if therapy last
longer you can move I.V. places of administration)
- When you choose I.V. place ask a patient to take a comfortable
position.
- Put on the gloves and place the tourniquet 15 cm above the place of
I.V. set insertion. Easily palpate the vein with the fingers of a non-
dominant hand, stretch the skin with non-dominant hand to fixate the
vein.
- Make the disinfection of the area by using disinfection media (alcohol
or povidon iodum- never combine these two) by making round moves
from a centre to a periphery in range 5-0 cm.
- Take the cannula with your dominant hand for a plastic delta part and
take of the protective cap, then rotate the needle until the slope is
looking up.
- With fingers of a non-dominant hand stretch the skin minimum 4 cm
from the place of insertion to fixate the vein.
- Tell the patient the moment when you will place the cannula. Place the
cannula in the above explained position using angle of 15 – 25 degrees.
- With an energetic move place the cannula into vein, press the rubber
mouth of cannula to see is there any blood that will prove you that you
located the vein. If the blood is shown place the cannula minimally half
of its length and take the needle.
- Remove the tourniquet
- Place the cannula (full length) into a vein. Place the gauze below the
cannula to prevent blood to contact skin, and connect the infusion
system if you have not done that before. (An infusion system can be
connected before the placing cannula).
67
- Open the clamp on infusion system and regulate the speed of solution
flow.
- Fixate the cannula using U or H or some other methods.
- Stay with patient for next 10 minutes to check possible complication
and reaction that can be caused by cannula, solution or some other
reason.
- Dispose all used material.
- Document all steps that are done
Exception:
Sometimes medication need to be administer directly into a vein without using

an infusion system with an infusion solution. Procedure is very similar to steps
for preparation of infusion system with an infusion solution.
Equipment:
- Swabs soaked in alcohol or similar 5 pcs

- I.V. medication
- Adhesive tape
- Gloves (non – sterile)
- Tourniquet
- Cannula I.V. or a needle 2 pcs
- Needle dispenser
- Sterile gauze
Procedure:
- Sort the equipment on the sanitary trolley or similar

- Check the equipment sterilization, dates etc. If the I.V. medication is
packed as powder it is necessary to solute medication using sterile aqua
in an appropriate ratio that is prescribed.
- Check the patient identity comparing name from a chart, from a
bracelet, and patient’s chart and ask a patient for his/her name. Check
the all medication following rules for medication check.
- Wash your hands
- Prepare all material in a proper way to maintain the aseptic condition
of equipment. Open the syringe and fill it with drug. Drug packed in
ampulla are easier to be used than those packed as powder. If you use
68
drugs from ampulla, check the date on ampulla and the type of drug
administration. Clean the neck of ampulla with swab soaked in alcohol,
and if there is a sign that ampulla can be opened use your non- dominant
hand to hold an ampulla still and use your dominant hand to take the
ampulla neck with a thumb and a forefinger. With a strong move open
the ampulla. If the ampulla need to be opened with a saw first make
three sharp move with a saw. Drugs packed as powder need to be
soluted in the following way: use a sterile syringe, a needle and an
ampulla of 5 ml with sterile aqua. Open the syringe and a needle then
connect the needle to the syringe. Remove the protective cap from a
needle and pull aqua into the syringe. With a non-dominant hand use
your thumb and a fore finger to hold aqua ampulla upside down
(vacuum in ampulla will prevent aqua from leaking). With a dominant
hand place the needle in ampulla and use three fingers to pull aqua into
the syringe. When aqua is in the syringe open the bottle where powder
rug is, remove the steel cap and clean the rubber cap with alcohol. Place
the needle through the rubber cap by holding bottle with your non
dominant hand and by a dominant hand hold the syringe with needle.
Insert the aqua into bottle and shake a bottle until you get a clear
solution. And with same needle (that is still into the bottle) and syringe
pull the appropriate dosage of drug. Before the administration drug into
vein it is recommended to change a needle.
- Explain to the patient all the procedure and ensure him/her comfort.
Ask a patient to take comfortable position if he/she can move.
- Before starting procedure choose the place for I.V. (usually it is veins
of hand and a palm) it is recommended that you use distal veins. Thus
if therapy lasts longer you can change I.V. places of administration
having in mind that all peripheral veins are appropriate locations I.V.
therapy.
- When you choose I.V. location ask a patient to take comfortable
position.
- Put on the gloves and place the tourniquet 15 cm above the place of
I.V. set insertion. Easily palpate the vein with the fingers of a non-
dominant hand, then stretch the skin with a non-dominant hand to fixate
the vein.
69
- Make the disinfection of a selected area by using disinfection media
(alcohol or povidon iodum- never combine these two) by making round
moves from a centre to a periphery in the range of 5-0 cm.
- For this purpose you can use cannula, (usage of cannula is described in
the procedure about infusion) or a needle. The syringe with a needle
need to be rotated until the slop looks up (before inserting needle into
a vein air need to be pulled out the syringe – with a non-dominant
hand hold the syringe with a needle in the straight position and with a
dominant hand make an easy pressure on the syringe clip until the air
is pulled out.
- With fingers of non-dominant hand stretch the skin minimum 4 cm
from place of insertion to fixate the vein.
- Tell the patient the moment when you will place the needle. Place the
needle in the above explained position using angle of 15 – 25 degrees.
- With a single move place the needle into a vein, then slightly pull the
syringe toward yourself to see have you hit the vein. If the blood is
shown place the needle into a vein.
- Remove the tourniquet.
- Administer drug very slowly.
- When the drug is fully administered take out the needle with a slow
uninterrupted move then put swab with alcohol on the place of insertion
and fixate it with an adhesive tape.
- Explain to the patient that he/she needs to make small pressure on that
place to stop bleeding.
- Stay with a patient for next 10 minutes to check possible complication
and reaction.
- Document all steps that are done.
Documentation
It is crucial that all steps are documented: date, time, the type of I.V. system,
name, as well as the dosage of infusion system. If some of medication is added
to infusion solution it should also be documented. All this data need to be
signed in the patient and nursing chart and signed by person who performs this
procedure.
70
Evaluation
All steps of this procedure should be evaluated because of potential

complications such as local phlebitis, extravasation, cannula movement,
occlusion, vein irritation, pain on the place of application, hematoma, vein
spasm, thrombosis, thrombophlebitis, nerve damage etc. Further complications
can be systematic infection, allergic reaction, circulation overload and air
embolism. All these steps need to be evaluated so that above mention
complications could be avoided. Nurses evaluate all steps comprising the laws
of antiseptic and aseptic methods, and it must be checked if the patient show
any kind of reaction.
Notes
Always use the sterile infusion system, it is recommended that I.V. system
stays in vain for 48 or maximum 72 hours.
OSCE EXAMPLE
Preparation of the material necessary for the application of the drug: Points
(max 3 points, each 0,5 points)
-syringe with medicine and needle
-supporter arm
-alcohol
-gauze for disinfection
-tupfer
-loin
Demonstration done not done

1. Explanation to the patient done not done
2. Choose the vein for application done not done
3. Ligature of the arm above place done not done
of insertion
71
4. Disinfection of the place of done not done
insertion
5. Removing air from syringe done not done
6. Insertion of the needle into vein done not done

at an angle of 45 degrees
7. Checking the position of the done not done
syringe (aspiration of the blood)
8. Insertion of needle few mm done not done

proximal
9. Application of the drug done not done
10. Withdrawing the needle done not done
11. Application of the tupfer for done not done

stopping of the bleeding
12. Placing the patch done not done
13. Say patient not to bend arm done not done
72
CENTRAL VEIN LINE (CENTRAL VENOUS CATHETER)
Definition
This procedure is very specific because it is combination of a team work

(physician and nurse) to open and maintain access to the central vein. Places
for vena iugularis externa and interna, vena subclavia and vena basilica.
Central vein is used for fast and large therapy including parenteral nutrition of
patient. Measurement of central venous pressure can be done when the
medication need a large amount of solution. It is highly recommended in
emergency cases when peripheral veins are not available. Using CV is suitable
for diagnostic purposes because you can take as many samples as you want
without using peripheral veins and giving them enough time to recover.
Central venous catheter can be placed in vena subclavia but because of it length
it ends in vena cava superior or right atrium, using vena iugularis interna and
vena basilica catheter ends in vena cava superior
Potential complications are increased with CV like pneumothorax, sepsis,

thrombus forming and perforation of blood vessel and organs. CV can decrease
patient movement, and it is very complicated to perform. This procedure is
fully sterile and it is conducted in a team work o (physician and nurse).
Removing is done by specially educated nurse or a physician if bacteriology
analysis of the top of the catheter is obligatory.
Procedure
Equipment
For placing central venous catheter it is necessary to prepare:
- Gloves – sterile (sterile coat)

- Covering, protective surface, sterile pads
- Sterile compress, masks
- Swab with alcohol and swab with some other antimicrobial solution
- Physiology solution 0,9% Na CL
- Syringe 3 ml
- Lidocain
- 5% dextrose solution in water
- Syringes for blood samples
73
- Material for sutures
- Two central venous catheters size 14 and 16G (this is a typical size for
adults – the size of central venous catheter need to be determined based
on the patient constitution and age).
- Sterile tupfer 10x10
- Adhesive bandage
For removing central venous catheter you need to prepare following:
- Gloves – one pair of clean and one pair of sterile gloves

- Swabs soaked in alcohol
- Povidone – iodine,
- Sterile gaze 10x10
- Paean
- Adhesive bandage
Procedure is conducted in teams - usually physicians conduct the placement of

catheter but nurses are also involved in process.
- Patient needs to be introduced with all the steps of procedure and if

he/she is able a patient signs the consent for procedure.
- Patient needs to be positioned in Trendelenburg position (this help vein
dilatation and lower the risk of air embolism). If the catheter is placed
in vena subclavia it is good to place rolled sheet lengthwise between
shoulders. If the catheter is placed into iugular vein rolled sheet should
be placed opposite shoulder to make an anatomical position more
visible. Under the patient it is recommendable to place protective sheet.
It is advisable that patient turns head to opposite direction.
- Prepare the place for catheter insertion (place should be shaved or
trimmed)
- Wash your hands
- Sterile field should be prepared on the table using sterile sheet of sterile
compress. Person who conducts placing central venous catheter wears
a mask, sterile gloves and a sterile coat. The next step is cleaning the
area with swab with 70% alcohol solution, using tupfers with iodine
making concerting round from centre to outside (this is usually done
by nurses).
74
- Second person (in most cases physician) wears a sterile mask and a
coat.
- Nurse opens the 3ml syringe with a needle 25G size and using sterile
technique give them to physician. Nurse cleans the top of lidocain
bottle and turns it toward physician who will fill up the syringe with
lidocain and apply it to the selected area.
- Nurse will open catheter and using aseptic technique give it to
physician to conduct application.
- While physician is placing the catheter nurse should prepare infusion
set to be connected the very moment the catheter is placed into a central
vein.
- When physician confirms that catheter is in the central vein the infusion
solution is used.
- Place the label with date and time of placing catheters and its length
- Dispose all used material that are for disposal, and materials that can
be reused send to washing and sterilization.
- Document all steps in the patient and nursing chart.
Removing Central venous catheter:
Procedure:
- Place the patient in an appropriate position – on the back to prevent

development of embolism.
- Wash your hands, wear the clean gloves and mask.
- Turn of all infusions and put the sterile compress to create sterile field.
- Remove the dressing material from catheter area wearing the sterile
gloves. Clean the catheter area with alcohol or iodine solution.
- Remove the sutures and pull out the catheter using slow and continuous
move. Patient should make Valsalva maneuver to prevent air embolism
- The location of catheter entering should be cleaned with iodine
solution, covered with sterile gauze and fixed with an adhesive track.
Place should be covered at least for 48 hours.
- Take the swab from catheter or take part of catheter (it is recommended
that is the top of catheter) and send it to microbiology analysis.
75
Documentation
Central venous catheter is very complex procedure and all steps from placing,
drugs administration, dressing, removing and swab control should be noted.
Note when, where and who have conducted procedure in the patient and
nursing chart.
Every drug administration need to be noted in the patient chart and signed by
person whom performed it. Dressing of catheter is very important. Note time
and date of central venous catheter dressing which is very important in
prevention of infection (it should be noted in the patient chart including date
and time of removing of catheter).
Evaluation
Success of the procedure can be evaluated in the following way:
- First evaluation is done after the procedure of placing catheter

(checking success and potential complications).
- Second evaluation is done during the use of catheter – follow up the
catheter area in order to mark signs of infections or any other
complications.
- Third evaluation is done after removing central venous catheter.
76
INJECTIONS
Definition
Most common type of parenteral therapy is therapy application by injections

of different types. Types of injections can be:
- Intramuscular (injection is applied directly into muscle)

- Intravenous (injection is applied directly into vein – described in
previous chapter)
- Subcutaneous (sub dermal injection) and intracutanoues injection
- Intradermal injection
Usage of injections enables faster and better impact of drugs increasing the
speed of drug impact. Dosage is more precise and it is used when drugs cannot
be applied via digestive system. This procedure is quite complex because the
nurse and patient need preparation. Procedure is followed by pain occurrence
so patient usually feels uncomfortable during this procedure. Preparation of
equipment is similar to all types of injection. Choosing location and drug
application depends on the type of injection.
Procedure
General equipment:
- Drug that can be packed in ampulla or lagena (powder)

- Syringe 2 pcs
Syringes are made from plastic and they are for single use. They come
in sterile pack with graduation in millimeters or ccm (depending on
purpose they can be from 1ml, 2ml, 5ml, 10ml, 20ml and 50 ml). They
have two-parts tube (barrel) and clip (plunger). Plunger can be pulled
and pushed along the barrel. There is also some special type of syringe
like syringes for insulin which are graduated in insulin units.
- Needles 2psc are produced for single use and they can be of different
size. The size of needle is measured in gauge from 7 to 34 G, most
common use in nursing interventions are 14-28G, as the G higher the
needle diameter and length is smaller. Needles are also produced in
different colours to make easier work for nurse. Colours are specific
for intramuscular use, intravenous use, subcutaneous ET.
77
- Swabs with alcohol or other relevant disinfection remedy 3- 5 psc
- Bed pen
- Gloves non-sterile
78
Procedure:
- Each type of injection application is initiated in the same way. First it

is necessary to follow all the rules about the drug application (check
the date, dosage, time, patient, room, bed number).
- Space/surface where equipment is sorted need to be clean (a
hygiene/therapy trolley or similar). Before sorting equipment and
before preparation of drugs nurse washes her hands.
- Drug/medication preparation is different if the drug is in ampulla or
lagena. Drugs packed in ampulla are easier to be used than those packed
as powder. If drugs in the form of ampulla are used it is necessary to
check the date on ampulla and type of drug administration. Clean the
neck of ampulla with swab soaked in alcohol, and if there is sign that
ampulla can be opened without sawing use your non-dominant hand to
hold ampulla still and use your dominant hand to take the ampulla neck
with a thumb and a forefinger. With a single strong move open the
ampulla. If the ampulla needs a saw for opening first make three sharp
moves. Drugs packed as powder in lagena need to be soluted in the
following way: use a sterile syringe, a needle and an ampulla of 5 ml
of sterile aqua. Open the syringe and a needle; then connect the needle
to the syringe. Remove the protective cap from a needle and pull aqua
into the syringe. With non-dominant hand use your thumb and fore
finger to hold aqua ampulla upside down (vacuum in ampulla will
prevent aqua from leaking) and with dominant hand place the needle in
ampulla and use first three fingers to pull aqua into the syringe. When
aqua is in the syringe open the bottle where powder rug is, remove the
steel cap and clean the rubber cap with alcohol. Place the needle
through the rubber cap by holding bottle with your non dominant hand
and with dominant hand hold syringe with needle. Insert the aqua into
a bottle and shake the bottle until you get a clear solution. And with
the same needle (that is still into bottle) and syringe pull the appropriate
dosage of drug. Before administering drug into vein it is recommended
to change a needle.
- Before application of drug change the needle.
- Check again the patient’s identity by asking him for his name.
- In order to make the procedure as much as comfortable for patient
explain to him the full procedure and tell him what to expect.
79
- Clean the place of administration of drug using swabs with alcohol
using round circles moving from centre towards outside in radius at
least of 5 cm.
- Tell the patient when you will insert the needle
- Apply the injection and insert drug
- After the insertion of drug remove the injection with one continuous
move and on the place of puncture put the alcohol swab
Above described procedure is for all kinds of injections. In the text below
specific places of injections and procedure will be explained.
80
INTRACUTANEOUS INJECTIONS
These injections are given into dermis, mostly used for different allergy tests.
Dosage of applied drug by this method is usually 0, 5 ml. Most common places
for intacutaneosu injection are inner side of forearm and outer side of upper
arm. Suitable place for this injections is also upper back area – shoulder blades
area and upper thorax area.
Procedure for intracoutaneus injections is consisted of all general procedure

steps for injections with some specifics like:
- Prepare the equipment and drugs as it was explained

- Prepare the patient and explain to him the whole procedure.
- Choose the proper place for injection application – most common is an
inner side of forearm.
- Clean the place with cotton swabs soaked in alcohol as it was explained
- Use your non-dominant hand to stretch skin.
- Rotate the needle with syringe so that needle slope is facing up.
- Install the needle using angle of 10-15 degrees. Needle is applied
around 3 mm.
81
- When the needle is in an adequate position insert the drug using easy
pressure on the syringe plunger (clip). When the drug is inserted with
one single continuous move remove the injection.
- Do not massage place of application.
- If the place of application is used for testing mark the place.
- Dispose all used material in accordance with institution rules.
Subcutaneous injection:
This type of injections represents injections that are given directly into
subcutaneous tissue. Most common drugs applied in this way are insulin,
heparin and some types of painkillers, vaccine etc. Dosage for application of
subcutaneous injection is 1-2ml.
Place for application of subcutaneous injections are: outer part of upper arm,
upper part of abdominal wall and back and outer part of thigh.
Procedure is similar to general procedure for injection application:
- Check the medicine following all the steps for drug check.
- Check the identity of patient and prepare equipment and drug (as it is
previously described).
- Wash your hands, explain the procedure to the patient.
- Choose the location of drug application. (Location need to be clean
without any bruise, oedema, scratch or any other changes in skin
integrity. That is recommended whenever you administer subcutaneous
injection because this type of injections is used for long lasting
therapy).
- Patient should take comfortable position.
- Place of drug insertion need to be cleaned with cotton swab soaked in
alcohol using circular motions from centre to outside.
- Remove the needle cap.
- Use your non-dominate hand to wrinkle skin on the place of application
and insert the injection using angle from 30 to 90 degrees. Drug should
be applied very slowly. After the application take out the needle with
slow continuous move.
82
- Place of injection application need to be rubbed with alcohol soaked
cotton swab to improve drug absorption. (Rubbing is not allowed after
the application of heparin).
- Patient should be in a comfortable position
- Document all steps about drugs, date and time.
- Dispose all used material and it is recommended to visit the patient
after 30 minutes.
83
INTRAMUSCULAR INJECTION
One of the most common places for injection application is muscle tissue. This
method is used for application of drugs of common dosage of 5 ml with fast
absorption. Places for application of intramuscular injections are large muscles
like gluteus maximum, musculus quadriceps femoris and musculus deltoideus.
Musculus gluteus is most commonly used muscle for application of injections
for adults.
Procedure for this injection application is similar to general rules of injections

applications:
- Check the equipment, prepare the drugs following rules for drug
administration
- Check the identity of patients and drug prescription.
- Wash your hands, prepare equipment and drug.
- Explain the procedure to the patient.
- Choose the location for injection insertion.
If the maximum gluteus is used as the location for intramuscular
injection, locating of puncture point of this muscle is very important
because if the place is chosen wrongly nervus ischiadicus can be
84
damaged. Location of intramuscular injection application on musclus
glutes is upper lateral quadrant. To determine this quadrant you need to
ask patient to lay on his stomach, gluteus need to be open and separated
by imaginary lines. Upper horizontal line is spread among two crista
illiaca, lower horizontal line is spread among thigh and seat muscles,
outer vertical line follows the lateral body line and inner vertical line
follows gluteal fissure. The quadrat is divided into 4 quadrants and
injection is applied into upper lateral quadrant, 5-7 cm below the spina
of illiac bone.
If the patient is lying on the side one imaginary line is drawn between
spina illiaca superior posterior and trochanter femors major. Then
injection can be applied on the side up from the imaginary line because
nervus ischiadicus goes below this line.
If you choose place on thigh you can use muscles rectus femoris and
musculus vastus lateralis. Patient needs to lay on his/her back or to be
in seated position. Usually this location is used for smaller doses of
drug. Places of application are front, lateral and middle third part of
thigh. Muscles need to be relaxed not stretched. This place is not
recommended for undernourished patient because it can be very
painful.
If you choose muscles deltoids as the location of injection you need to
know that you can give drug in dosage 1-2 ml. Patient needs to be in
sitting or standing position. Choose the middle of muscles deltoids. It
is recommended not to use drugs that irritate and nurses need to be
careful because radial nerve can be damaged.
- Clean the place for injection application. Use a thumb and a forefinger
of non-dominant hand to stretch the skin and with sharp movement at
90 degree angle apply needle.
- When needle is inserted pull the plugger (clip) to check is there any
blood. If the blood shows up that is sign that needle hit the blood vessel
and procedure need to be repeated. If there is no blood apply the drug
easily. Use non-dominate hand and apply alcohol soaked cotton swab
and easily rub the place of insertion to lower the pain.
- Place the patient in comfortable position.
- Wash your hands.
- Document all steps about procedure and drug.
85
- After 30 minutes visit thee patient.
86
WOUND CARE
Definition
Acute Wound is the result of tissue damaged by trauma. This may be
deliberate, as in surgical wounds of procedures, or be due to accidents caused
by blunt force, projectiles, heat, electricity, chemicals or friction. An acute
wound is by definition expected to progress through the phases of normal
healing, resulting in the closure of the wound.
Chronic Wound fails to progress or respond to treatment over the normal
expected healing time frame (4 weeks) and becomes "stuck" in the
inflammatory phase.
Aseptic Technique
Aseptic technique means “without micro-organisms”. It refers to the
procedure used to avoid the introduction of pathogenic organisms into the
vulnerable body site. The principle aim of an aseptic technique is to protect
the patient from contamination by pathogenic organisms during medical and
nursing procedures.
Wound chronicity is attributed to the presence of intrinsic and extrinsic

factors including medications, poor nutrition, co-morbidities or inappropriate
dressing selection. A number of local and systemic factors can delay or
impair wound healing. These may include:
 Malnutrition
 Reduced Blood supply
 Medication (non-steroidal anti-inflammatory drugs and
corticosteroids)
 Chemotherapy
 Radiotherapy
 Psychological stress and lack of sleep
 Obesity
 Infection
 Reduced wound temperature
 Underlying Disease
 Maceration
 Inappropriate wound management
 Patient compliance
 Unrelieved pressure
87
 Immobility
 Substance abuse including alcohol and cigarette smoke
Clinical signs
1. Acute Surgical Wound is a clean cut with a sharp instrument which
cuts or punctures the skin deliberately during a surgical procedure.
Acute surgical wounds normally proceed through an orderly and
timely reparative process resulting in sustained restoration of
anatomic and functional integrity. If an acute wound fails to heal
within six weeks, it can become a chronic wound.
2. Trauma Wound is a stressful event caused by either a mechanical or
a chemical injury resulting in tissue damage. Depending on its level,
trauma can have serious short-term and long-term consequences.
3. Burns are the injuries to tissues caused by heat, friction, electricity,
radiation, or chemicals. Burns may be caused by even a brief
encounter with heat greater than 120°F (49°C). The source of this heat
may be the sun, hot liquids, steam, fire, electricity, friction (causing
rug burns and rope burns), and chemicals (causing a caustic burn
upon contact).
4. Chronic Wound fails to heal in an orderly and timely manner. The
clinical signs of chronic wounds may include: non-viable wound
tissue (slough and/or necrosis), lack of healthy granulation tissue
(wound tissue may be pale, greyish and avascular), no reduction in
wound size over time and recurrent wound breakdown.
5. Pressure injury is a localised injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, shear
and/or friction, or a combination of these factors.
6. Infected Wound represents the invasion of wound tissue by and
multiplication of pathogenic microorganisms, which may produce
subsequent tissue injury and progress to overt disease through a
variety of cellular or toxic mechanisms
Nursing diagnosis
Goals
 To provide the assessment of the wound
 To provide the assessment of risk&contributing factors
88
Assessment
1. Provide the assessment of wound bed. Check if the tissue is:
 Granulating: healthy red tissue which is deposited during the repair

process, presents as pinkish/red coloured moist tissue and comprises
of newly formed collagen, elastin and capillary networks. The tissue
is well vascularized and bleeds easily
 Epithelializing: process by which the wound surface is covered by
new epithelium; this begins when the wound has filled with
granulation tissue. The tissue is pink, almost white, and only occurs
on top of healthy granulation tissue.
 Sloughy: the presence of devitalized yellowish tissue. Is formed by an
accumulation of dead cells. Must not be confused with pus
 Necrotic: wound containing dead tissue. It may appear hard dry and
black. Dead connective tissue may appear grey. The presence of dead
tissue in a wound prevents healing
 Hyper granulating; granulation tissue grows above the wound margin.
This occurs when the proliferative phase of healing is prolonged
usually as a result of bacterial imbalance or irritant forces
2. Provide wound measurement
 All wounds require a two-dimensional assessment of the wound

opening and a three- dimensional assessment of any cavity
 Use a paper tape to measure the length and width in millimetres. The
circumference of the wound is traced if the wound edges are not even
 Measure the wound depth using a dampened cotton tip applicator
3. Provide the assessment of wound edges
 Healthy wound edges present as advancing pink epithelium growing

over mature granulated tissue.
 Colour - pink edges indicate growth of new tissue; dusky
edges indicate hypoxia; and erythema indicates physiological
inflammatory response or cellulitis
 Raised - wound edges (where the wound margin is elevated
above the surrounding tissue) may indicate pressure, trauma or
malignant changes
 Rolled -wound edges (rolled down towards the wound bed)
may indicate wound stagnation or wound chronicity
89
 Contraction - wound edges are coming together, signs of
healing
 Sensation - increased pain or the absence of sensation should
be noted
4. Provide the assessment of the exudate
 Exudate is produced by all acute and chronic wounds (to a greater or

lesser extent) as part of the natural healing process. It plays an
essential part in the healing process in that it:
 Contains nutrients, energy and growth factors for metabolising
cells
 Contains high quantities of white blood cells
 Cleanses the wound
 Maintains a moist environment
 Promotes epithelialisation
 Assess the type, amount and odour of exudate to identify any changes
(too much exudate leads to maceration and degradation of skin while
too little can result in the wound bed drying out. It may become more
viscous and odorous in infected wounds).
 The exudate may be: serous (normal, an increase may be indicative of
infection), haemoserous (normal), sanguinous (trauma to blood
vessel) and purulent (infection)
5. Check for infection
 Check for local indicators

 Redness (erythema or cellulitis) around the wound
 Increased amounts of exudate
 Change in exudates colour
 Malodor
 Localized pain
 Localized heat
 Delayed or abnormal healing
 Wound breakdown
 Check for systemic indicators
 Increased systemic temperature
 General malaise
 Increased leucocyte count
 Lymphangitis
90
 If any of the above clinical indicators are present medical review
should be instigated and referral to microbiology laboratory should be
considered
6. Provide the assessment of the surrounding skin
 Surrounding tissue may present as

 Healthy
 Macerated
 Dry/flaky
 Eczematous
 Black/blue discoloration
 Fragile
 Oedema
 Erythema
 Induration (hardening)
 Cellulitis
 Examine surrounding skills carefully as part of the process of
assessment and appropriate action taken
7. Check for pain
 Provide pain assessment using one of the numerous pain assessment

tools
 Document pain scores clearly in patient’s record.
 Assess the pain with regard to choice of the most appropriate
dressing. Assessment of pain before, during and after the dressing
change may provide vital information for further wound management.
8. Check for diabetes
Goals:
 To promote and provide wound healing

 To prevent wound infection
91
Equipment:
 Sterile gauze and dressings as appropriate

 Vaseline gauze
 Sterile gloves
 Exam gloves
 Antiseptic swabs
 Tapes
 Waste receptacles
 Bath blanket
 Sterile isotonic saline
 Syringe 10 ml
 Sterile needle 21 G
Preparation
 The setting should be prepared including the decontamination of the

working surface or tray to be used with detergent and water or
detergent wipes and then dried
 Hand hygiene should be performed
 The extent of the use of drapes and protective clothing will also
depend on the type of procedure and its complexity.
 All packaged sterile items for the procedure should be assembled
prior to starting the procedure.
 Staff should check the packaging is intact and expiry date has not
been exceeded.
 All packaged sterile items, such as needles and syringes should be
opened carefully by peeling back the packaging and not pushing it
through the backing paper.
 If possible 30 minutes should be left after bed making or domestic
cleaning before exposing or dressing wounds.
Procedure
 Gently remove the dressing in a way that minimises pain and exposed
wound for the minimum time to avoid contamination and maintain
temperature
 Perform the wound cleansing using aseptic technique procedure in a
way that minimises the trauma of the wound
 Clean and irrigate the wound using isotonic saline solution. This may
be carried out utilising a syringe in order to produce gentle pressure in
order to loosen debris.
92
 Do not use gauze swabs and cotton wool because this could cause
mechanical damage to new tissue and the shedding of fibres from
gauze swabs/cotton wool delays healing.
 Warm fluids to 37°C to support cellular activity
 Use Antiseptics only sparingly for infected wounds
 Avoid alcohol as tissue is degraded
 Remove visible debris and devitalised tissue if present
 Remove dressing residue
 Remove excessive or dry crusting exudates (wound cleansing should
not be undertaken to remove 'normal' exudate)
 Choose the dressing according to the stages of healing (Table 1 and 2)
 Maintain a moist environment at the wound/dressing interface
 Be able to control (remove) excess exudates. A moist wound
environment is good, a wet environment is not beneficial.
 Do not stick to the wound, shed fibres or cause trauma to the wound
or surrounding tissue on removal
 Protect the wound from the outside environment
 Keep the wound close to normal body temperature
 Perform procedure avoiding accidental contamination of sterile
equipment and site
 Change the gloves and decontaminate hands at any stage when
contamination has occurred
 Reassess the wound with every dressing change to ensure the most
appropriate products are used
 Document the outcomes of the assessment
 Educate patients about ongoing wound treatment process
Table 1. Type of dressings
Type of dressing Description

Primary dressing comes directly in contact with the wound bed
Secondary dressing cover a primary dressing when the primary
dressing does not protect the wound from
contamination
Occlusive dressing covers a wound from the outside environment
and keep nearly all wound vapours at the
wound site
Semi-occlusive dressing allows some oxygen and moisture vapour to
evaporate
Table 2. Choice of dressing according to the amount of the exudate
93
Dry wound Minimal Moderate Heavy exudate
exudate exudate
Non adherent
Hydrogel Calcium alginate Hydrofibre
island dressing
Hydrocolloid Hydrocolloid Hydrofibre Foam
Films semi Silicone Absorbent

Foams
permeable absorbent dressing
Negative
Negative
pressure wound
Pressure
therapy
Hydrocolloid:
Ostomy bags
paste/powder
Documentation
 Document type and appearance of wound
 Document amount and type of drainage, colour,
consistency and odour of exudate
 Document status of surrounding skin
 Document type and amount of solution used
 Document the patient’s reaction to procedure
 Capture wound documentation in progress notes and
treatment plans
Evaluation
 Wound management is practiced in accordance with
the best available evidence for optimizing healing in
acute and chronic wounds
 Wound management dressings, pharmaceuticals and
devices are used in accordance with the
manufacturer’s instructions or research protocols
94
 The wound is healed within the expected period of
time (in accordance with the phase)
 Infectious and noninfectious complications of the
wound are prevented
95

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NURSING PROCEDURES

Prof dr sc Dejan Bokonjić

DTP: Mirza ORUČ

Proof Reading: prof dr sc Nebojša Vasić

Editor: Medicinski fakultet Univerziteta u Zenici

Printing: Feta – grand d.o.o.

This book is outcome of CCNURCA: 544169–TEMPUS–1–2013-1-BE-

Editors: Prof dr sc Dejan Bokonjić & Mirza Oruč MA

Central Vein line 73

This procedure provides guidelines for monitoring, reporting and

- identifying the existence of an acute medical problem.

The normal body temperature of a person varies depending on gender, recent

Blood pressure, measured with a blood pressure cuff and stethoscope by a

Clinical sign of high blood pressure are headaches, shortness of breath or

Clinical signs of low blood pressure are: dizziness, fainting, lack of

- evaluate blood pressure, pulse and frequency of breathing

Measuring blood pressure:

A patient blood pressure can be taken in the following way:

This method represents non – invasive method for blood pressure

A patient’s heart rate can be taken in the following way:

- explain the patient procedure

A patient’s respiratory rate can be taken in the following way:

- explain the patient procedure

A patient's body temperature can be taken in any of the following ways:

- Orally. Temperature can be taken by mouth using either the classic

- Thermometer (type is depending from the type of measurement)

Axillar body temperature measurement:

- Check the patient identity, explain him procedure if he is not familiar

Rectal body temperature measurement

Urinary incontinence (UI) is defined as the “involuntary loss of urine so

- to determine the cause of the incontinence,

- history-taking: ask about: past medical/ surgical/ obstetric history,

- explain the patient procedure

Preparation of material: Points (max 4,5 points-each 0,5 points)

Task 1: Explanation to the patient Points (max 3 points)

a) explanation about procedure and possible

Task 3: List of necessary steps for catheterisation Points(max 8 points)

b) disinfection of perineal area

c) positioning of the loin

d) get the sterile catheter out of the pack

e) application of local anaesthetic on the top of the

f) insertion of the catheter through ureter into

h) connection of the urinary catheter with an

Constipation is generally described as having fewer than three bowel

 Infrequent passage of stool

For hospitalized patients, the following should be employed:

 Orient patient to location of bathroom and encourage use, unless

 A balanced diet that contains adequate fibre, fresh fruits,

 Document date and time of assessment

 Document date and time of procedure

 The patient's rectum will be free of faeces

 Document date and time of procedure

 The patient's rectum will be free of faeces

Table1. Classification of decubitus

 Redness, heat, tenderness and discomfort in the area

 The setting should be prepared including the decontamination of the

 Explain procedure and rationale to patient

 Encourage implementation of pressure-relieving devices

 Pressure on skin, especially over bony prominences