Chapter 20 Selected Nursing Skills

Chapter 20 Selected Nursing Skills
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Standard Steps in Selected Skills
All nursing skills must include basic steps for the safety and well-being of the patient and the nurse. Before the Skill Refer to medical record, care plan, or Kardex for special interventions. Introduce yourself; include your name and title or role. Identify patient by checking arm band and requesting patient to state his or her name. Why should the nurse check the medical record and/or the Kardex prior to performing a skill? Why should the patient state his/her name to the nurse?

Before the Skill (continued) Explain the procedure and the reason it is to be done in terms the patient can understand, and give the patient time to ask questions. Advise patient of any unpleasantness that might be experienced. Assess need for and provide patient teaching during procedure. Assess patient. Wash hands and don clean gloves according to agency policy and guidelines from the CDC and OSHA. Why should the nurse assess the patient during the procedure? Why is it important to don gloves?

Before the Skill (continued) Assemble equipment and complete necessary charges. Prepare the patient for intervention. Close door/pull privacy curtain. Raise bed to comfortable working height; lower side rail on side nearest the nurse. Position and drape patient as necessary. Why should the bed be raised to a comfortable working height? How might the nurse provide privacy for the patient during a procedure?

During the Skill Promote patient involvement as possible. Assess patient’s tolerance, being alert for signs and symptoms of discomfort and fatigue. Completion of Procedure Assist the patient to a position of comfort and place needed items within easy reach. Be certain patient has a means to call for assistance and knows how to use it. Raise the side rails and lower the bed to the lowest position. What signs and symptoms indicate discomfort? Why should the nurse raise the side rails and place the call light within reach of the patient?

Completion of Procedure (continued) Remove gloves and all protective barriers. Store or remove and dispose of soiled supplies and equipment according to agency policy and guidelines from CDC and OSHA. Wash hands after patient contact and after removing gloves. Document patient’s response, expected or unexpected outcomes, and patient teaching. Report any unexpected outcomes. What type of unexpected outcomes might the patient experience during a procedure?

Removing disposable gloves.
Standard Steps: Step 14 (From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.) Removing disposable gloves.

Skills for Sensory Disorders
Irrigations Eye irrigations Relieve local inflammation of the conjunctiva, apply antiseptic solution, or flush out exudate or caustic solutions. Warm saline and small syringe or eyedropper are usually used to instill a few hundred milliliters of solution. Irrigation should always be done from the inner canthus to the outer canthus. Never allow the syringe tip to touch the eye. In what situations would eye irrigation be appropriate? What is the canthus? Why should the syringe never be allowed to touch the eye?

Irrigations (continued) Eye irrigations (continued) At home, eye irrigation can be performed with an eye cup. A copious irrigation of the eye may be accomplished with the use of intravenous tubing and bag connected to a Morgan Therapeutic Lens. What is a Morgan Therapeutic Lens?

Irrigations (continued) Ear Irrigations Using a small syringe and solution at body temperature, the nurse can cleanse a patient’s external auditory canal of excess cerumen or exudate from a lesion or an inflamed area. Slow, gentle irrigation works best. Irrigation is contraindicated when a vegetable foreign body obstructs the auditory. Irrigation is contraindicated if the patient has a cold, a high temperature, an ear infection, or an injured or ruptured tympanic membrane. Why is irrigation contraindicated for patients with fever, ear infection, and ruptured tympanic membrane? Why should the water temperature not be any hotter than body temperature? What is a vegetable foreign body?

Skills for Gastrointestinal Disorders
Nasal Irrigation It soothes inflamed mucous membranes and washes away dried mucus, secretions, and possible foreign matter. It may be accomplished with the use of a specially designed electronic device or a bulb syringe. Patients with acute or chronic nasal conditions and patients who inhale allergens and toxins may derive benefits from nasal irrigations. It is contraindicated with advanced destruction of the sinuses, foreign bodies, and frequent nosebleeds. What is the pathophysiology to support nasal irrigations for patients with acute or chronic conditions? Why are nasal irrigations contraindicated for patients with foreign bodies and/or nosebleeds?

Skills for Heat and Cold Therapy
The nurse should Understand the normal responses to local temperature variations Assess the integrity of the body part Determine patient’s ability to sense temperature variations Ensure proper operation of equipment What are the normal responses to local temperature variations? Why is it important to assess the patient’s skin integrity?

The body can tolerate wide variations in temperature. Normal skin temperature is 93.2° F. Temperature receptors usually adapt quickly to local temperatures between 113° and 59° F. Pain develops when local temperatures exceed these limits. Excessive heat causes a burning sensation. Cold produces a numbing sensation before pain. How might an older adult react to variations in local temperatures? They might not be able to assess the extent of the heat or cold, which can result in injury.

Local Effect of Heat and Cold Effects of heat application Heat improves blood flow through vasodilation to an injured part. However, blood flow is reduced by vasoconstriction as the body attempts to control heat loss from the area. Periodic removal and reapplication of local heat restores vasodilation. Continuous exposure to heat damages epithelial cells. What is the result to the skin if heat causes damage to the epithelial cells?

Local Effect of Heat and Cold (continued) Effects of cold application Exposure of the skin to cold results in vasoconstriction. The cell’s ability to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on an erythematous appearance, followed by a bluish-purple mottling with numbness and a burning type of pain. The skin’s tissue can freeze on exposure to extreme cold. How might the application of cold cause ischemia?

Assessment Assess patient’s physical condition for signs of potential intolerance to heat and cold. Observe the area to be treated for impairment of skin integrity. Identify conditions that contraindicate heat or cold therapy. Warm applications are contraindicated when the patient has an acute localized inflammation; cardiovascular problems; or active bleeding. Cold applications are contraindicated if the site of injury is edematous or the patient has impaired circulation or is shivering. What signs and symptoms might indicate intolerance to heat and cold? Why is heat contraindicated for patients with cardiovascular disease and those with active bleeding? Why is cold application contraindicated for a site that is edematous?

Patient Safety Before heat or cold treatment is applied, the patient should understand its purpose, the symptoms of temperature exposure, and precautions taken to prevent injury. Physician's Order A prerequisite to heat or cold application is a physician’s order, which should include body site and the type, frequency, and duration of application. What precautions can be taken to prevent injury? Why is a physician’s order necessary for heat or cold application?

Moist or Dry Applications Heat and cold applications can be administered in dry or moist forms. The type of injury, the location of the body part, and the presence of drainage or inflammation are factors to be considered. Hot, Moist Compresses For open wounds, sterile, hot, moist compresses improve circulation, relieve edema, and promote consolidation of purulent exudate. What is a compress? How would a sterile, hot, moist compress promote wound healing?

Skill 20-5: Step 4 (From Ignatavicius, D.D., Workman, M.L. [2002]. Medical-surgical nursing across the health care continuum. [4th ed.]. Philadelphia: Saunders.) Assess condition of exposed skin and wound on which compress is to be applied.

Warm Soaks Immersion of a body part in a warmed solution Promotes circulation Lessens edema Increases muscle relaxation Can provide a means to debride wounds and apply medicated solution A soak can also be accomplished by wrapping the body part in dressings and saturating them with warmed solution or by whirlpool treatments. How often should cooled water be removed and replaced with heated water? How does a whirlpool assist in debridement of a wound?

Whirlpool moist heat therapy.
Figure 20-1 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Whirlpool moist heat therapy.

Paraffin Baths Bath consists of a mixture of heated paraffin wax and mineral oil. Patients with painful arthritis or other joint discomforts of the hands and feet benefit most from these baths. Aquathermia (Water-Flow) Pads This is used to treat muscle sprains and areas of mild inflammation or edema. This consists of a waterproof plastic or rubber pad connected by two hoses to an electrical unit that has a heating element and motor. Who typically administers a paraffin bath within a hospital? Are paraffin baths available in the home? Why are aquathermic pads safer than heating pads? Why is distilled water used instead of tap water for aquathermic devices?

Figure 20-2 Aquathermia pad.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Aquathermia pad.

Commercial Hot Packs Commercially prepared, disposable hot packs apply warm, dry heat to an injured area. Sticking, kneading, or squeezing the pack mixes the chemicals and releases the heat. Electric Heating Pads Pad consists of an electric coil enclosed within a waterproof pad covered with cotton or flannel cloth. The pad is connected to an electric cord that has a temperature-regulating unit for a high, medium, or low setting. Why should nurses advise patients not to lie on electrical heating pads? Why are heating pads not utilized in acute care settings?

Cold Moist and Dry Compresses Cold compresses should be applied for 20 minutes at a temperature of 59° F to relieve inflammation and edema. Commercially prepared cold packs are available for dry application. The nurse should observe for burning or numbness, mottling of the skin, erythema, extreme paleness, or cyanosis. What adverse reactions should the nurse ask the patient to report? At what point should the nurse remove the cold compress to avoid frostnip?

Commercial cold pack used for therapy.
Figure 20-3 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Commercial cold pack used for therapy.

Ice Bags or Collars For a patient who has muscle sprain, localized hemorrhage, or hematoma or who has undergone dental surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body part. Describe the application of an ice bag or collar. In what situations would an ice bag application be appropriate?

Skills for Administering Parenteral Fluids
The overall goal of fluid IV administration is to correct or prevent fluid and electrolyte imbalances. Indications for IV Therapy Poor tissue absorption Inadequate GI tract function Need to maintain medications at optimum levels Why must a surgery patient have an IV? How long does the postoperative patient have an IV?

The nurse should observe the following guidelines: Monitor the solution drop rate at the ordered infusion rate. Infuse the amount of prescribed solution. Maintain the patency of the IV catheter. Monitor site every 1 to 2 hours; IV line should be assessed every 4 hours. During parenteral therapy, the patient’s I&O should be recorded. Why is it important to monitor the drip rate? How does the nurse assess patency of the IV line? Why should the IV site be assessed every 1 to 2 hours? Why should the patient who is receiving parental therapy be monitored for I&O?

Intravenous Therapy/Venipuncture Before the procedure, assemble and make ready the equipment. Assess the patient’s veins. Select and clean a puncture site. Perform venipuncture. Begin infusion. Teach the patient about the signs and symptoms of problems and ways to perform activities while on IV therapy. Follow strict aseptic principles. Describe the steps of venipuncture. What equipment is necessary for venipuncture and IV infusion? What signs and symptoms should the nurse instruct the patient to report?

Common intravenous sites. A, Dorsal surface of the hand. B, Inner arm.
Figure 20-4 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Common intravenous sites. A, Dorsal surface of the hand. B, Inner arm.

Figure 20-5, A A, Apply tourniquet.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Apply tourniquet.

B, Select intravenous site.
Figure 20-5, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Select intravenous site.

C, Cleanse site for venipuncture.
Figure 20-5, C (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) C, Cleanse site for venipuncture.

D, Pull skin taut as catheter is inserted.
Figure 20-5, D (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) D, Pull skin taut as catheter is inserted.

Figure 20-6, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Close valve.

B, Remove insertion port cover.
Figure 20-6, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Remove insertion port cover.

Figure 20-6, C C, Insert spike.
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) C, Insert spike.

Intravenous Therapy/Venipuncture (continued) Tubing is selected based on the patient and type of infusion to be initiated. The valve is closed. The tubing spike is inserted into the insertion port on the correct fluid bag. The fluid bag is held upright, and the tubing drip chamber is gently squeezed to partially fill it with fluid. The valve is slowly opened to permit the flow of fluid down the tubing. Why is the IV tubing valve closed when spiking the IV bag? Why is the drip chamber partially filled prior to opening the IV valve? Why is the valve opened and the IV fluid allowed to flow, when the fluid is not connected to the patient?

Intravenous Therapy/Venipuncture (continued) The venipuncture needle and catheter should be selected according to the solution to be infused and the size and condition of the patient’s veins. Plastic IV catheters are flexible and have blunt tips that reduce infiltration and allow the patient to move. Why is the venipuncture needle size compared to the patient’s veins? Why is IV fluid a consideration regarding the needle size of the IV catheter?

Intravenous Therapy/Venipuncture (continued) Intravenous monitoring Patency A condition of being opened and unblocked Flow rate is ordered by the physician. Assess tubing for kinks or obstructions. Inspect and palpate the site for edema, erythema, induration, heat, and discomfort. Assess for signs and symptoms of fluid overload. Why should the nurse assess for patency? Why is the IV site assessed for edema, erythema, induration, heat, and pain? What signs and symptoms would indicate fluid overload?

Changing the Tubing This is most easily accomplished when a new container of solution is added. Connect and prime the new solution container and tubing. Carefully remove the tape, securing the old tubing to the IV catheter hub while gently stabilizing the catheter and site. Working carefully but quickly, turn off the flow valve of the old tubing, remove the old tubing from the catheter hub, insert the new tubing into the catheter hub, and open the flow valve. Secure with tape. When and why is it necessary to change IV tubings during a blood transfusion?

Discontinuing Intravenous Therapy Intravenous infusions are discontinued when The prescribed amount of solution has infused There are signs of infiltration The patient has developed phlebitis or other complications

Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion: Assemble supplies. Wash hands. Explain procedure to the patient. Don gloves. Turn IV flow regulator to the “off” position. Gently remove tape and dressing from site while carefully stabilizing the needle or catheter. Why is it important to don gloves when removing an IV? Why is it important to stabilize the catheter when removing an IV?

Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion (continued): Place dry gauze pad over needle insertion site. Swiftly withdraw needle or catheter from the site while applying gentle pressure over the site. Hold site above heart level while continuing to apply direct pressure for about 45 seconds to 1 minute. Assess for bleeding from the site. Apply a bandage or sterile dressing according to agency policy. Why is a gauze pad needed when removing an IV? Why is pressure applied to the site when removing the IV? Why should the nurse apply a Band-Aid or sterile dressing to the IV site once the catheter has been removed?

Discontinuing Intravenous Therapy (continued) Steps for discontinuing an IV infusion (continued): Gather soiled supplies, remove gloves, and discard in appropriate containers. Wash hands. Document promptly and accurately. Reevaluate site every 10 to 15 minutes. Instruct patient to report any redness, pain, drainage, or swelling. What would the nurse document after removing an IV? Why is the IV site reevaluated every 10 to 15 minutes?

Intravenous Therapy/Venipuncture (continued) Infiltration Edema that does not subside generally indicates that the catheter is out of the vein. Discomfort and dysfunction may also indicate that the solution has infiltrated. An infiltrated arm will feel cool, and the skin may have a blanched appearance. The solution is discontinued and another site is used to continue therapy, preferably in the opposite extremity. What does the term “infiltration” mean? Why would the IV site feel cool if the IV has infiltrated? Why is the IV discontinued and the IV restarted in the opposite extremity?

Intravenous Therapy/Venipuncture (continued) Phlebitis This results from mechanical irritation (the needle moving in the vein), the low pH of some IV solutions, and highly concentrated additives. Classic signs Erythema, warmth, edema, and discomfort Applying warm compresses to the inflamed area lessens discomfort. What is phlebitis? What is the pathophysiology regarding the signs of phlebitis?

Intravenous Therapy/Venipuncture (continued) Septicemia A systemic infection occurs from pathogens introduced into the circulating bloodstream. Signs and symptoms Fever, chills, prostration, pain, headache, nausea, and vomiting Antibiotic therapy is vigorously initiated if blood cultures verify a septicemic condition. What is a layperson’s term that means septicemia? Blood poisoning. Why is sterile technique important when performing venipuncture for IV therapy? If septicemia is suspected, what should the nurse do with IV catheters that have had contact with the patient?

Blood Transfusion Therapy This is most commonly used to replace blood loss. Individuals may store their own blood before anticipated surgery for infusion during hospitalization. The fear of HIV infection has led some patients to refuse blood products. Plasma expanders (Plasmanate, Dextran) can be used for patients who refuse blood transfusions because of personal or religious beliefs. How has HIV detection decreased the risk of HIV transmission? In what situations would plasma expanders be utilized?

Blood Transfusion Therapy (continued) Autologous blood transfusion A process of collecting a patient’s lost blood during surgery or after a traumatic injury and infusing it intravenously into the patient. It is used in cardiac thoracic surgery or after traumatic chest injury. Suction drainage device collects blood in a special bag. The blood should be administered immediately or not more than 6 hours after initial collection. Why would a patient consider autologous blood transfusions? Why is it important to infuse the blood within 6 hours after collection?

Blood Transfusion Therapy (continued) Initiating a blood transfusion Nurse is responsible for assessing and monitoring the patient before, during, and after transfusion. Obtain informed consent. An infusion of 0.9% or 0.45% normal saline is initiated. Follow established protocol for obtaining the blood, double-checking the compatibility of the blood with the patient’s blood, and identifying the patient. Why is an IV of 0.9% or 0.45% normal saline initiated when administering blood? Why is an informed consent necessary when administering blood? Describe the proper procedure to check blood compatibility when administering blood.

Figure 20-11, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Opened blood administration set and tubing primed with normal saline 0.9%.

B, Attached blood product to the normal saline 0.9%.
Figure 20-11, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Attached blood product to the normal saline 0.9%.

Blood Transfusion Therapy (continued) Initiating a blood transfusion (continued) Baseline vital signs are taken and recorded. Prime the special blood filter administration tubing and piggyback it into the primary infusion line. Remain with the patient while slowly infusing the first 50 ml of blood. Assess the patient’s response and monitor vital signs. The nurse must know the symptoms of blood transfusion reaction and interventions to initiate for them. Why is it necessary to obtain baseline vital signs prior to administration of blood? Why is the blood piggy-backed into a primary solution? Why should the nurse remain with the patient during the first 50 mL of infused blood? Why should the nurse monitor the patient’s vital signs during the infusion of blood? What are the signs and symptoms of a possible reaction to a blood transfusion?

Blood Transfusion Therapy (continued) Blood transfusion reactions If the infused blood is not compatible with the patient’s blood type, a reaction will occur. A transfusion reaction is an emergency. Signs and symptoms Statement of “not feeling right” Chills, fever, low back pain, pruritis, hypotension, nausea and vomiting, decreased urine output, chest pain, dyspnea Why is close monitoring of the patient important during a blood transfusion? What might be a complication if the patient has a reaction to blood?

Blood Transfusion Therapy (continued) Blood transfusion reactions (continued) If a transfusion reaction is suspected Stop the infusion. Keep the vein open with 0.9% or 0.45% sodium chloride solution. Notify the physician and the blood bank. Monitor vital signs and urine output every 15 minutes. Reassure and support the patient. Send remaining blood to the blood bank for analysis. Why is it important to maintain the IV infusion when the blood transfusion has been stopped due to a suspected reaction? Why are vital signs monitored every 15 minutes? Why is the remaining blood sent back to the blood bank?

Maintaining an Intravenous Site Change catheter dressings when loose, wet, or soiled. Gauze dressings should be changed every 48 hours. Fluid containers may be changed frequently depending on the rate of infusion and the volume of the container. Change infusion tubing according to facility policy. Infusion tubing should not be disconnected to change a gown or clothing. Why should catheter dressing sites be changed when wet or loose? Why should gauze dressings be changed every 48 hours? Why should the nurse not disconnect IV tubing when changing a gown or clothing?

Skills for Respiratory Disorders
Oxygen Therapy Goal of oxygen therapy is to prevent or relieve hypoxia. Any patient with impaired tissue oxygenation can benefit from controlled oxygen administration. Oxygen is not a substitute for other treatments and should be used only when indicated. Oxygen should be treated as a drug. Oxygen is expensive and can have dangerous side effects. The dosage or concentration of oxygen should be ordered and continuously monitored. What is hypoxia? Why should oxygen be treated as a drug?

Oxygen Therapy (continued) Oxygen is a colorless, odorless, and tasteless gas that will not burn or explode. If combined with other factors, such as an electrical spark or fire, it will support combustion and ignite. Oxygen therapy is frequently initiated by a respiratory therapist, who is a health care professional licensed to deliver treatment that will improve a patient’s ventilation and oxygenation needs. The signs and symptoms manifested by patients who might require oxygen will vary according to the degree of oxygen deficiency. What is necessary for oxygen to ignite? What signs and symptoms might a person display who is in need of oxygen therapy?

Oxygen Therapy (continued) Transtracheal oxygen delivery A newer method of oxygen delivery is the transtracheal catheter, which is inserted directly into the trachea between the second and third tracheal cartilages. Delivery does not interfere with drinking, eating, or talking. Oxygen is delivered throughout the respiratory cycle. It is recommended for patients with heart failure or chronic obstructive pulmonary disease. The transtracheal opening should be inspected and cleaned regularly. How does transtracheal oxygenation not interfere with eating or drinking? Why would heart failure and/or COPD patients require transtracheal oxygen therapy? Why should the transtracheal opening be inspected and cleansed regularly?

Figure 20-13 A transtracheal catheter may be inserted into the trachea between 2nd and 3rd tracheal cartilages.

Oxygen Therapy (continued) Care of the tracheostomy A tracheostomy is an artificial opening made by a surgical incision into the trachea. It is performed to provide the patient with a patent airway. After the surgical procedure is performed, the physician inserts a tracheostomy tube and secures it in place with cotton tape around the patient’s neck. Sterile gauze is placed around the opening under the flange of the outer tube for skin protection. What types of patients might require a tracheostomy? What might irritate the tracheostomy airway? Lint may irritate, so it is important to use lint-free wipes. What is the nurse’s primary concern when caring for a tracheostomy patient? Keeping the airway open.

Oxygen Therapy (continued) Care of the tracheostomy (continued) It is essential that nursing interventions be consistently implemented that Minimize infection risk Minimize sensory deprivation How can the nurse minimize the risk of infection? How can the nurse minimize sensory deprivation?

Oxygen Therapy (continued) Care of the patient with a tracheostomy collar and T-piece/tube This requires constant humidification to the airway. The T-piece/tube is a T-shaped device with a 15 mm connection with large-lumen tubing. A tracheostomy collar is a curved device with an adjustable strap that fits around the patient’s neck; an exhalation port remains open at all times and another connects to large-bore tubing. Why is constant humidification required for the patient with a tracheostomy? Why is a tracheostomy collar utilized when caring for the patient?

Figure 20-15, A (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Trach tube (fenestrated) with inner cannula removed and cap in place to allow speech.

Figure 20-15, B (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Trach tube with obturator for insertion and syringe for inflation of cuff.

Figure 20-16 T-piece/tube.

Figure 20-17 Tracheostomy collar.

Skills for Urinary or Reproductive Tract Disorders
Types of Catheters Coudé catheter Selected for ease of insertion when enlargement of the prostate gland is suspected Foley catheter Designed with a balloon near the tip so that the balloon may be inflated after insertion, holding the catheter in the urinary bladder for continuous drainage Why is the coudé catheter beneficial for patients with prostate problems?

Types of Catheters (continued) Malecot, Pezzer, and Mushroom catheters Used to drain urine from the renal pelvis of the kidney Robinson catheter Has multiple openings in its tip to facilitate intermittent drainage Ureteral catheter Are long and slender to pass into the ureter

Different types of commonly used catheters.
Figure 20-18 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Different types of commonly used catheters.

Types of Catheters (continued) Whistle-tip catheter Has a slanted, larger orifice at its tip to be used if there is blood in the urine Cystostomy, vesicostomy, or suprapubic catheters Introduced through the abdominal wall above the symphysis pubis Used to divert urine flow from the urethra to treat injury to the bony pelvis, urinary tract, or surrounding organs; strictures; or obstructions Inserted via a surgical incision or puncture of the abdomen and bladder walls with a trocar What types of patients would require a whistle-tip catheter? What type of patient would require a suprapubic catheter?

Types of Catheters (continued) Condom catheters This device is not a catheter but a drainage system connected to the external male genitalia. It is used for the incontinent male to minimize skin irritation from urine. How is a condom catheter applied? How does it limit skin irritation?

A, Condom catheter. B, Condom catheter attached to leg bag.
Figure 20-19 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Condom catheter. B, Condom catheter attached to leg bag.

Drainage system must be below the level of the bladder.
Figure 20-21 (From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.) Drainage system must be below the level of the bladder.

Self-Catheterization This is used for the patient who experiences spinal cord injuries or other neurological disorders that interfere with urinary elimination. Intermittent self-catheterization promotes independent function for the patient. Does the patient who performs self-catheterization use the sterile or the clean technique?

Routine Catheter Care Perineal care and the cleansing of the first 2 inches of the catheter every 8 hours are expected at minimum. The use of powders or lotions on the perineum is contraindicated. Assess the urethral meatus and surrounding tissues for inflammation, swelling, and discharge. Note amount, color, odor, and consistency of discharge. Why is routine catheter care important? Why are lotions and powders contraindicated? What does inflammation, odor, and color of discharge indicate?

Routine Catheter Care (continued) The urinary tubing and collection bag should be changed only if there are signs of leakage, odor, or sediment buildup. Check the drainage tubing and bag to ensure that no tubing loops hang below the level of the bladder, that the tube is coiled and secured onto the bed linen, and that the tube is not kinked or clamped. Why is it important to keep the collection bag lower than the level of the bladder? What should the nurse assess in the urinary drainage system?

Figure 20-22 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Empty and record urine output from Foley catheter into clean graduated container.

Bladder Training Involves developing the use of the muscles of the perineum to improve voluntary control over voiding; may be modified for different problems. In preparation for the removal of a urethral catheter, the physician may order a clamp/unclamp routine to improve bladder tone. For the patient with stress incontinence, instruct to perform Kegel exercises. For habit training, a voiding schedule is established. What types of patients benefit from bladder training? How does the clamp/unclamp procedure of catheter tubing assist the patient? What are Kegel exercises? What is the benefit of a voiding schedule?

Managing Incontinence Urinary incontinence occurs because pressure in the bladder is too great or because the sphincters are too weak. Kegel exercises Bladder training Credé’s method Disposable adult undergarments or underpads How do Kegel exercises and bladder training benefit the incontinent patient?

Discontinuing an Indwelling Catheter An indwelling catheter must be removed or changed after a certain period of time. It may be removed and replaced by a new catheter or removed and the patient allowed to excrete urine via the normal route. What conditions require a urinary catheter to be removed?

Inserting and Maintaining Nasogastric Tubes Nasogastric tube is a pliable tube that is inserted through the patient’s nasopharynx into the stomach. The tube allows for removal of gastric contents and introduction of liquids into the stomach. The primary purpose is decompression or removal of flatus and fluids from the stomach. Nursing challenges: patient comfort and maintaining patency of the tube What type of patient would require a nasogastric tube? How can the nurse provide comfort for the patient with an NG tube? How can the nurse maintain patency of the NG tube?

A, Small-bore feeding tube. B, Salem sump tube.
Figure 20-24 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Small-bore feeding tube. B, Salem sump tube.

Bowel Elimination Elimination of bowel waste (defecation) is a basic human need and is essential for normal body function. Normal bowel elimination depends on several factors: a balanced diet, including high-fiber foods; a daily fluid intake of 2000 to 3000 mL; and activity to promote muscle tone and peristalsis. Normal stool (feces) is described for documentation as moderate in amount, brown, and soft in consistency and is expelled every 1 to 3 days. Why is the nurse documenting the patient’s stool color, consistency, and amount? Why does the nurse note how often the patient has a bowel movement?

Care of the Patient with Hemorrhoids The patient with hemorrhoids has pain when hemorrhoidal tissues are directly irritated from the passage of hard stool. The primary goal for the patient with hemorrhoids is soft, formed stools. Proper diet, fluids, and regular exercise improve the likelihood of soft stools. Local heat provides temporary relief to swollen hemorrhoids; sitz bath is the most effective means of heat application. How can the nurse assist the patient to prevent hard stools? How does a sitz bath help the patient with hemorrhoids?

Flatulence This is the presence of air or gas in the intestinal tract. It may occur when a person consumes gas-producing liquids and foods, such as carbonated beverages, cabbage, or beans; swallows excessive amounts of air; or has constipation. In hospitalized patients, flatulence is often caused by decreased peristalsis, abdominal surgery, some narcotic medications, and decreased physical activity.

Flatulence (continued) May cause distention of the stomach and abdomen and mild to moderate abdominal cramping and pain One of the most effective measures to promote peristalsis and passage of flatus is walking Rectal tube may be used How does walking assist in the passage of flatulence? What is a rectal tube? What type of patient might require a rectal tube?

Administering an Enema This involves the instillation of a solution into the rectum and sigmoid colon. Primary reason for an enema is promotion of defecation. The volume and type of fluid instilled can lubricate or break up the fecal mass, stretch the rectal wall, and initiate the defecation reflex. Patients should not rely on enemas to maintain bowel regularity because enemas do not treat the cause. Frequent enemas disrupt normal defecation reflexes, resulting in dependency on enemas for elimination. Why is it important for patients not to rely on enemas for defecation? How do frequent enemas disrupt the defecation cycle?

Fecal Incontinence The first step in care of the patient with fecal incontinence is to assess whether fecal impaction is the cause. An impaction involves the presence of a fecal mass too large or hard to be passed voluntarily. Either constipation or diarrhea can suggest the presence of an impaction. An oil retention enema lubricates the rectum and colon, softens the feces, and facilitates defecation. It can be used alone or with manual removal of a fecal impaction. What type of patient might encounter a fecal impaction? How is an impaction removed manually?

Ostomies Colostomy A surgical creation of an artificial anus on the abdominal wall formed by incising the colon and bringing it out to form a stoma on the abdominal surface Performed for patients with cancer of the colon, intestinal obstructions, intestinal trauma, or inflammatory diseases of the colon May be permanent or temporary until intestinal healing occurs

Ostomies (continued) Ileostomy A surgical formation of an opening of the ileum onto the surface of the abdomen through which fecal matter is emptied Performed for patients with inflammatory bowel conditions and cancer of the large intestine Stoma looks like a colostomy, but it is smaller and located lower on the abdomen Patient wears a pouch to collect the semiliquid fecal matter What is the difference between a colostomy and an ileostomy?

Ostomy pouches and skin barriers.
Figure 20-25 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Ostomy pouches and skin barriers.

Laboratory Values Identify laboratory values for ABGs (pH, PO2, PCO2, SaO2, HCO3), BUN, cholesterol (total), glucose, hematocrit, hemoglobin, glycosylated hemoglobin (HgbA1C), platelets, potassium, sodium, WBC, creatinine, PT, PTT & APTT, INR Need to know Lab Values: pH PO pC mm Hg HCo meq/L BUN- Total cholesterol-8-25 mg dl HgbAIc—Good control 7% or less Fair- 7%-8% Poor-8% or more PT seconds (male) /3 seconds (Female) INR-2-3 Platelets-150, ,000 Sodium K WBC creatinine mg/dl

Chapter 20 Selected Nursing Skills

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Chapter 20 Selected Nursing Skills

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