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THERAPEUTIC PROCEDURES(protocol)

SELECTED TOPICS ON COMMON NURSING PROCEDURES
UNIVERSAL PRECAUTIONS
HANDWASHING
BARRIER METHOD
STERILIZATION AND DISINFECTION
IMMUNIZATION
ENVIRONMENTAL CONTROL AND SANITATION
ISOLATION
SURGICAL ASEPSIS
MAINTENANCE OF STERILE FIELD
MEDICAL AND SURGICAL ASEPTIC TECHNIQUES
THERAPEUTIC EXERCISES
ISOMETRIC
ISOTONIC
ROM
CHEST PHYSIOTHERAPY
BREATHING
COUGHING\POSTURAL DRAINANGE
PERCUSSION AND VIBRATION
INCENTIVE SPIROMETER
SUCTIONING
TRACHEOSTOMY CARE
OXYGEN THERAPY

Chest Physiotherapy
It is the combination of percussion, vibration, and postural drainage
Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes
Vibration is done during 5 exhalations
Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.
Instruct the client to increase fluid intake to liquefy secretions
This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.
This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy
Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.
Humidify the oxygen first before you administer.
Check for bubbles in the humidifier to promote adequate flow of oxygen
Check for kinks in the tubing
Position: semi-fowlers/ high fowlers position
Place cautionary readings: “NO smoking: Oxygen is in used”
Instruct the client not to use woolen blankets as this may create static electricity
pulmonary function tests
tidal volume- 500
residual volume- 1200
expiratory reserve volume –1200
inspiratory reserve volume – 3100

Vital Capacity- tidal volume + IRV + ERV = 4800
Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
Forced Residual Capacity – ERV + RV

incentive spirometry – hold 2-6 sec; 4-5 times/H
endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly
visualization –
X ray
Lung Scxan – 20-40mins isotopes in body for 8 H
laryngoscopy
Bronchoscopy
Thoracentesis- consent, VS and baseline X-ray + post Procedural




Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental dislodgement
use precut gauze and perform care OD at least.
soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well
suction prn, oral care prn
Oxygen Delivery Equipment
cannula – 2-6 LPM – 24-45%
Mask – 5-8 LPM – 40-60%
parial rebreather – 6-10 LPM – 60-90%
non rebreather – 10-15 LPM – 95-100%
tent – 4-8 LPM – 30-50 %
Venturi mask –
2-3 LPM – 24-28%
4 LPM – 30%
6 LPM – 35%
8 LPM – 45%
14LPM – 55%

Suctioning
PURPOSE: To obtain sputum sample.
NURSING ALERT:
Hyperoxygenate the patient before and after the procedure.
Apply intermittent suction on withdrawal of the catheter.
Do not suction the patient for more than 15 seconds.
Thoracentesis
PURPOSE: Aspiration of fluid and /or air from the pleural space.
NURSING ALERT:
Check the consent.
Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder.
Instruct the patient not to cough, breath deeply or move during the procedure.
After the procedure: Position the patient on the unaffected side/puncture site up.
Check for bleeding at the puncture site and monitor the respiratory function.
Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.

ENEMA
They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.
Enemas serve the following purpose:
Relief of constipation
Relief of flatulence
Lowers down body temperature
Evacuates feces in preparation for diagnostic procedures
Administration of medications
Take note of the general principles of Enema:
Tube: lubricate and insert 3-4 inches
Position:
adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes duration.
Conatainer’s Height- 12 inches above the rectum
Temperature- 42°C or less

types:
carminative – expel flatus – 60 –180 ml.
retention oil – 1 –3 hours(LUBRICANTS)
BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI
wetting/stool softeners- Colace(days)
Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN
Saline- Epson salts, milk of mg(rapid)/mg citrate
return flow – haris flushing , colon irrigation
fleet – commercial
oil 1-3 H retention
others – 5 to 10 mins.
cleansing- irritating( hypertonic osmotic))
high 1000 ml
low 500 ml


T = 40-43 ‘ C ( 105 – 110 ‘ F
CHILDREN 37.7 ( 100 ‘ F)
APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.
INSERT 7 – 10 CM ( 3-4 INCH)-ADULT
5 – 7.5 CM. –CHILD
2.5 – 3.5 – INFANT

IF FEELING OF FULLNESS – CLAMP – 30 SECS


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

rectal tubes
infants-10-12F
toddler – 14 –16F
school age – 16-18F
adult – 22 – 30F
ENEMAS- PRESCRIBED AMOUNT AND TIME
HYPERTONIC – 5-10MINS – VARIES
HYPOTONIC(TAP)-15-20MIN – 500-1000ML
ISOTONIC(SALINE)-15-20MIN- 50ML
SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP
oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.
COLOSTOMY CARE
ostomy – divert and drain fecal material
temporary ( trauma / inflammatory condition)
permanent ( Cancer / congenital or Birth defects
stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation


parts:
periostomal seal
adhesive square –
solid wafer disk skin barrier
liquid skin sealant
drainable end
pouch ( Can be washable)
pouch belt
face plate

ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full
colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation
avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended
dry skin before applying appliance
karaya – barrier to prevent contamination with excreta
appliance can be up to 2 weeks
broadwell 48 – 72 hours to check for periostomal skin
24-48 hours if eroded / ulcerated
refer to enterostomal therapy nurse
with deodorant ( Charcoal filter Disk)
Catheterization, urinary
PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.

NURSING ALERT:
Know the necessary facts:
Principles Male Female
Position Supine Dorsal recumbent
Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.
French number or
Circumference #14- 16 #18
Length of tube to
be inserted 2-3 in. 6-9 in.
Balloon size 5-10 ml. (30 ml 5-10 ml
Can be used to
achieve hemostasis
of the prostatic area
following prostatectomy

Place to secure lower abdomen Inner thigh


The procedure is sterile
 Maintain a close system
 The draining bag must always be below the bladder
 The catheter bag should not be allowed to lie on the floor
 Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it

CATHETER CHANGE
PLASTIC – 1 WEEK
LATEX – 2-3 WEEKS
SILICONE – 2-3 MOS.
PVC – 4-6 WEEKS


CLOSED INTERMITTENT IRRIGATION
ASPIRATE FROM PORT
CBI -3 WAY FOLEY CAHETER
CATHETER IRRIGATION ONLY – 200 ML.
BLADDER IRRIGATION – 1000ML
CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED
URINARY DIVERSIONS-URINARY STOMA
ILEAL CONDUIT- EXTERNAL POUCH
KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN
SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS
NORMAL AMOUNT/ DAY
1-3 / 500-600ML
3-5 / 600-700ML
5-8 / 700-100OML
8-14 / 800 – 1400ML
14 – ADULT / 1500 – 2500

CAN HOLD 500 – 750 ML

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

NEUROGENIC BLADDER
Intermitent Catheterization – 2-3 hours if <150ml>for incontinence – kegels exercises

HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK
AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS
PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H
MONITOR FOR HEMORRHAGE
DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-


COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER
WEIGH BEFORE AND AFTER, WARM DIALYSATE
CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V
PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION

TYPES:
CAPD(4-6H INDWELLING),
AUTOMATED 30MINS EXCHANGES,
INTERMITTENT- 4X A WEEK – 10H/DAY,
CONTINOUS – 1 DAY INDWELLING
DRESSINGS
PROTECT FROM INJURY , BACTERIAL CONTAMINATION
PROVIDE HUMIDITY
INSULATION
ABSORB DRAINAGE
DEBRIDE THE WOUND
PREVENT HEMORRHAGE
SPLINT / IMMOBILIZE
COMFORT

GUAZE, SYNTHETIC , SECURING, TEGADERM
TYPES OF DRESSINGS

DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE
WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE
WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)
WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE
WOUND HEALING
HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS
FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS
MATURATION(PHASE 21 DAYS – 2 YEARS)
pressure ulcer dressings
dry gauze stage II-IV
tegaderm film/ hydrocolloid – SI - SII
Absorptive Dressing III
Hydrogel – II - III
WOUND CARE
PRIMARY
SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)
TERTIARY- ABD. DRAINAGE

EXUDATES – SUPPURATION
PUS – ABCESS( PYOGENIC BACTERIA)
SURGICAL DRAINS
PENROSE – OPEN ENDS
CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR
D/C 3-7 DAYS POST – OP
PACKAGE – FACILITATE GRANULATION
IRRIGATION LAVAGE - STERILE
CHEST TUBES AND DRAINAGE SYSTEMS
1-DRAINAGE
2-WATERSEAL
3-COLLECTION/SUCTION

SEALED PATENCY-AFTER 3 DAYS REEXPANDED
FLUCTUATIONS IN WATER SEAL CHAMBER
RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE

NUTRITIONAL SUPPORT
NGT-GAVAGE AND LAVAGE
TPN
Nasogastric Tube Insertion
Purposes:
Gastric Gavage- gastric feeding
Gastric Lavage- stomach irrigation
For decompression
Medication and supplemental fluid administration
Principles:
Position: High-Fowler’s position
Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.
Lubricate the tip of the tube by a water soluble lubricant before insertion
Secure the NGT by taping to the bridge of the nose

Gastroenteral Feedings
This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall.
Remember these principles:
Position: fowler’s or sitting position
Prior to feeding, assess the bowel sounds and residual content
Assess for tube placement and patency:
Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated.
X-ray most accurate
Aspirate gastric content
Immerse the tip of the tube in water, no bubbles must be produced.
Height of feeding: 12 inches above the patient’s point of insertion
Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube

TOTAL PARENTERAL NUTRITION
peripheral<>Anti-embolism Stocking
Helps prevents thrombophlebitis by promoting venous return from the legs
It usually requires a doctor’s order
The client’s extremeties must be properly measured to assure therapeutic effect
Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes
The stockings must be removed every 8 hours for 20-30 minutes
Assess the skin integrity


DOSAGES AND CALCULATION
CONVERSIONS

MEDICATION DOSAGES
D/A X V = Q
INFUSIONS
TOTAL VOLUME X DROP FACTOR
TIME IN HOUR ( 60 MIN.)
THERAPEUTIC DOSE
CLARKS RULE
BSA COMPUTATION
IV INFUSION FOR BURNS


MEDICATION ADMINISTRATION
RIGHT DRUG
RIGHT DOSAGE
RIGHT ROUTE
RIGHT TIME
RIGHT PATIENT
RIGHT ATTITUDE
RIGHT DOCUMENTATION

PARENTERAL ADMINISTRATION
IM – G 18-21 ; 1 1/2 INCH, Z-TRACK
( RETRACT)
SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN)
INTRADERMAL- 10-15’; G26-27;1\2 INCH BEVEL UP
INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW


IV THERAPY
backflow means patent line
solutions for specific diseases and contraindications of certain solutions
management and troubleshooting
check for phlebitis and infiltration
change line everyday
keep site sterile

BLOOD TRANSFUSION
line – PNSS
vital signs – baseline then Q15 x 4; Q30 x 2; then q h
4 –6 hours
blood typing and crossmatching
watch out for blood transfusion reactions
hemolytic
anaphylactic
febrile
hypervolemic
septic


Hygiene and comfort measures
BEDMAKING- OD
PERINEAL CARE – FRONT TO BACK
OUTER TO INNER, ONE COTTONBALL PER STROKE
BEDBATHING AND ND SHAMPOO
FOOT, HAIR , SKIN AND NAIL CARE
ORAL CARE
EYE AND EAR CARE



THERAPEUTIC BATH
SALINE – 4 ML- 500 ML
OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES
CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION
Na CHO3 – 4 ml. – 500 ml H2O
cooling / relieves irritation
KMnO4 – tablets dissolved in H2O – clears and disinfects

Rotating Tourniquet
APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES
DO NOT RELEASE SIMULTANEOUSLY
PATIENT IN ORTHOPNEIC / FOWLERS POSITION


CPR and ACPLS Protocols
0-1 MINUTE ; CARDIAC IRRITABILITY
0-4 MINUTES; BRAIN DAMAGE NOT LIKELY
4-6 MINUTES; BRAIN DAMAGE POSSIBLE
6-10 MINUTES; BRAIN DAMAGE LIKELY
10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

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