Name: Anna Carmina M.

Allado
Year & Section: 4NUR-1
Fundamentals of Nursing Practice

Selfactualization

Four Central Concepts

o
o
o
o

Self-esteem

Person/ Client
Recipient of nursing care
Health
-Well-being/ w ellness of the person
Environment
-Internal and external surroundings
Nursing
-Attribute, characteris tic of the nurse

Love and belongingness

Safety and security
Physiologic

Concepts of Man and his Basic Human Needs

o
o
o

Man is biopsychosocial and spiritual being who is in

constant contact w ith the environment.
Man is an open system in constant interaction w ith a
changing environment.
Man is a unif ied whole composed of parts which are
interdependent and interrelated with each other.

Safety and Security Needs

-Shelter, free from danger and injury
Two Types Safety
o

Dimension: Sister Calista Roy

o
o
o
o
o
o

Biological
-Man is like all other man in terms of physical anatomy
Spiritual
-Man is like all other man believing in one higher being
Social
-Man is like some other man but w ith different cultures
Psychological
-Man is like no other man in terms of behavior and
attitudes
Man is composed of parts which are greater than and
different from the sum of all his parts.
Man is composed of subsystems and suprasystems.

Physical Safety
-ex. Suicidal patient- there should be at least 2
responsible companions at the bedside
Psychological Safety
-ex. Being competent- giving the right medications to
the client

Concepts of Nursing
Nursing
-Act of utilizing the environment of the patient to assist him in his
recovery (Nightingale)
-Theoretical system of knowledge that prescribes a process of
analysis and action related to the care of the ill person (Roy)

Subsystems
-Within man
-ex. cardio, respi, psychological
Suprasystems
-Outside man
-ex. family, community
Characteristics of Basic Human Needs
o
o
o
o
o
o

Universal
Met in different ways
Stimulated by external and internal factors
Priorities may be altered
May be deferred
Unmet human need results in disruption of normal body
activities and frequently leads to eventual illness

Abraham Maslow s Hiearchy of Needs

-Humanistic science dedicated to compassionate concern with

maintaining and promoting health and preventing illness and
caring for and rehabilitating the sick and dis abled (Rogers)
-Helping or assisting service to persons who are wholly or partly
dependent, when they, their parents and guardians, or other
adults responsible for their care are no longer able to give or
supervise their care (Orem)
-Protection, promotion and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through the
diagnosis and treatment of human response, and advocacy in the
care of individuals, families, communities and population (ANA,
2003)
Levels of Prevention
o
o
o

Prim ary
-Health promotion and disease prevention
Secondary
-Early detection and prompt treatment
Tertiary
-Rehabilitation

Historical Developments of Nursing

o
o

Period of Intuitive Nursing

-Pre-historic times
Apprentice Period or Nursing
-On-the-job training
-No formal education

o
o

-Taught by more experience one

Educated Period of Nursing
-Establishment of Nightingale School of Nursing in Italy
Contemporary Period of Nursing
-End of the World War 2 until present times
-Scientific and technological advancement
-Establishment of World Health Organization (WHO)

Current Trends in Nursing

o
o
o
o
o
o
o

Nursing Theories: JOHHNNPARROLL

Hall
Henderson
Nightingale
Newman
Peplau (Psych Nurse)
Abdellah

Roy
Rogers
Orlando

Leininger
Levine

-Established Red Cross

Fabiola
-Wife of Emilio Aguinaldo
-Founder of Philippine Red Cross

Evidence-based practice
Community-based nursing
Decreased length of hospital stay
Aging population
Increase in chronic care conditions
Independent nursing practice
Culturally competent care

Johnson
Orem

Clara Barton

Behavioral System Model

Self-care Theory/ Self -care
Deficit Theory
3 Cs; Core, Care, Cure
14 Fundamental needs/
Nature of Nursing Model
Environmental Theory
Health Systems Model/ Total
Person Model
Interpersonal Relation
Model, Psychodynamic
21 Nursing Problems/
Patient-centered
Approaches to Nursing
Model
Adaptation Theory
Science of Unitary Theory
Nursing Process Theory/
Dynamic Nurse-Patient
Relationship Model
Transcultural Theory of
Nursing
4 Principles of Conservation

Health, Disease, Illness

Health
-Defined in terms of the presence or absence of disease
A state of complete physical, mental and social well-being and
not merely the absence of dis ease or infirmity. (WHO, 1948)
Illness
-Personal state
-Highly subjective
-Not synonymous to a dis ease and may or may not be related to a
disease
Classification of Illness
o
o

Acute
-Sudden
-Short-term
Chronic
-Gradual
-Extended periods of exacerbation
-Long-term

Disease
-Alteration in body functions resulting in a reduction of capacities
or a shortening of the normal life span
Models of Health and Illness

Additional Nursing Theories

Jean Watson
Im ogene King
Betty Newman
Patricia Benner

Clinical Context
o
o
o
o
o

Expert
Proficient
Competent
Advanced Beginner
Novice

St- Elizabeth of Hungary

-Patroness of Nurses
St. Catherine of Siena
-1st lady with a lamp

Sm iths Model of Health

Human Caring Theory
Goal Attainment Theory
Total Person Model
Novice-Expert Theory

o
o
o
o

Clinical Model
-Person considered being normal if without signs and
symptoms of a disease
Role Performance
-Considered normal if you are able to perform your role/
task
Adaptation
-Normal people able to cope/ adjust
Eudaemonistic
-Normal/ healthy people if self -actualization was met

Leavell and Clark Model

o
o

Agent-Host-Environment Model
Ecologic Model

Environment

Stages of Health Behavior Change

o
o

Agent
(-) bacteria

Host

(+) fresh air

o
o

Dunns High Level Wellness Grid

Health-Illness Continua

Favorable

Precontemplation
-Without intention to change
Contemplation
-With intentions to change
-May take months-years
Preparation
-Planning to have the change
Action
-Observable
Maintenance
-Integrate the healthy behavior to lifestyle; prevent
relapses
Termination

Nursing Process

Protected Poor Health

High Level Wellness

Death

Peak Wellness

Poor Health

People may be excused from normal duties and role

expectations

Emergent High Level Wellness

Unfavorable

Travis Illness/ Wellness Continuum

Characteristics:
o
o
o
o
o
o

Cyclic and dynamic nature

Critical-thinking skills
Decision-making
Client-centered
Interpersonal and collaborative
Universally applicable

Assessment

Travis Model

Types of Assessment
o
o
Prematu
re Death

High
Level
Wellness

o
o

Initial Assessment
-Upon admission
-Provide baseline data
Problem-focused Assessment
-On-going
-Identifies new problems that were overlooked
Em ergency Assessment
-To be able to identify lif e-threatening crisis
Time-Lapsed Assessment
-After a period of time for the purposes of evaluation

Types of Data
Health Status, Beliefs and Practices
Factors Affecting Health Status, Beliefs and Practices
o
o
o
o
o

Factors in the human dimensions that influence healthillness status

Risk-factors for illness
Beliefs and practice
Basic human needs
Self-concept

Suchm an Five Stages of Illness

o
o
o

Symptoms of experience
Assumption of the sic k role
Recovery or rehabilitation

Stage 2: Assumption of the Sick Role

o

Accepts the sick role and seeks confirmation from

family and friends

o
o

Subjective data/ symptoms/ covert

Objective data/ signs/ overt

Steps in Assessment
1.

Collection of data

Principal Methods
o
o
o
2.
3.
4.
5.
6.

Observing
Interview ing
Examining
-IPPA approach; abdomen IAPPalpation
Validation of data
Organizing data
Categorizing or identifying patterns of data
Making influences or impressions
Recording/ reporting data

Two Phases
o

Social Phase

-Establish rapport
Professional Phase
-History taking, collecting data

M-easurable
A-ttainable

Types of Space
o
o
o
o

R-ealistic

Intimate Space
-Touching to 1 feet
-Doing procedures ex. enema
Personal Space
-1 to 4 feet
-Interview
Social Space
-4 to 12 feet
Public Space
-12 to 18 feet

T-ime-bound
Documenting and Reporting
Purposes of Client Records
o
o
o
o
o
o
o

Nursing Diagnosis
Medical Diagnosis vs. Nursing Diagnosis

Communication
Planning client care
Audit
Research
Education
Reimbursement
Legal documentation

Documentation System
Focuses on illness, injury
and disease process
Remains constant until cure
is affected

Focuses on response to
actual or potential health
problems
Changes as the clients
response or health problems
change
Identifies situation in w hich
the nurse is licensed and
qualified to interview

1.

Source-Oriented Record

Components:

Components of a Nursing Diagnosis

o
o
o
o
o
o
o
o
o
o
o
o
2.

Basic Two Part Statement

Basic Components:

Identifies
condition
that
practitioners is licensed and
licensed and qualified to
treat

Wellness Diagnosis
-Describes human responses to levels of wellness an individual,
family or community that have a readiness for enhancement

o
o
o
o

Problem- Etiology
o
o

Constipation related to prolonged laxativ e use

Ineffective
breast-feeding
related
to
engorgement

Standing order sheet

Vital signs sheet
Intake and output sheet
IVF sheet
Physicians order sheet
Medication sheet
Nurses notes sheet
Laboratory sheet
Radiology sheet
Admitting history
Personal record sheet
Consent
Problem-Oriented Medical Record

breast

Database
Problem list
Plan of care
Progress notes

Methods
Planning
-Select the appropriate nursing intervention
Three Phases of Planning
o
o
o

Initial Planning
On-going Planning
Discharge Planning

o
o
o
o

Steps
o
o
o
o

Setting priorities
Establishing client goals
Selecting nursing interventions
Writing nursing orders

Goal: SMART
S-pecif ic

Narrative Charting
Focus Charting
-Records changes or response of client to the treatment
-DAR
SOAP, SOAPIE, SOAPIER, APIE
CBE
-Charting by Exception
-Significant changes or abnormal manifestations or
exception to what is normal
-Makes use of checklist

Standard checklist

Unique checklist

Legal Guidelines for Recording

1.
2.
3.

Do not erase, apply correction fluid or scratch out an

error made w hile recording
Correct all errors promptly
Record only facts

4.
5.
6.

Do not leave blank spaces on the nurses notes

All record entries should be legible and written in ink
(black)
Chart for yourself

o
o
o

Remittent
Constant
Relapsing

Nursing Interventions
Reporting
o
o
o
o
o

Change-of-Shift-Report
Telephone report
Telephone order
Transfer report
Incident report

Vital Signs
o
o
o
o
o

Temperature
Pulse
Respiration
Blood Pressure
Pain

Body Temperature

o
o
o
o
o
o

Provide extra blankets- feels chilled

Remove excess blankets- feels warm
Adequate nutrition and fluids
Reduce physical activ ity
Oral hygiene
TSB- heat loss

B.

Hypothermia
o
Accidental
o
Induced

Unexpected Situations and Associated Interventions

o
o

Heat produced= heat lost

1.
2.

Core Temperature
Surface Temperature

Factors Affecting Body Temperature

o
o
o
o
o
o
o

Age
Exercise
Hormones
Stress
Environmental temperature
Medications
Diurnal variation
-Fluctuation of body temperature depending on the time
of the day

Low est- 4 am to 6 am

Highest- 6 pm to 8 pm; 8 pm to 12 am

34-36C Hypothermia

36-37C Average

38-40C Pyrexia

41-42C Hyperpyrexia (death)

Norm al

Assessing the Pulse

A.
o
o
o
o
B.

Unexpected Situations and Associated Interventions

Oral- 36.5-37.5C
Axilla- 36-37C
o
o
Alterations in Body Temperature
A.
o
o
o

Pyrexia/ Fever- up to 40C

Onset/ Chill Phase
-HR, RR, shivering, cold skin, cessation of
sweating
Course/ Plateau Phase
-Absence of chills, feels warm, HR, RR, thirst
Abatement Phase
-Flushed skin, sweating, shiv ering

Common Types of Fever

o

Intermittent

Palpation
Rate
Rhythm- pattern/ interval
Pulse volume- strength/ amplitude
Elasticity of arterial wall
Auscultation
o
Stethoscope
Apical- PMI
-3-4th ICS MCL
-4-5th ICS MCL

Pulse Deficit

Rectal/ Tympany- 37-38C

Temperature reading is higher or lower than

expected
-Reassess temperature with different thermometer
During rectal temperature assessment, patient
reports feeling lightheaded or passes out
-Remove thermometer immediately
-Quickly assess BP and HR
-Notify physician
-Do not attempt to take another rectal temperature on
this patient

The pulse is irregular

-Monitor pulse for 1 minute
-If difficult to assess, validate pulse measurement by
taking apical pulse for 1 minute
-If this is a change for the patient, notify the physic ian
The pulse is palpated but then disappears
-Apply moderate pressure on the pulse
You cannot palpate a pulse
-Use a portable Ultrasound Doppler to assess the puls e
-If this is a change in assessment or if you cannot find
the pulse using a Doppler, notify the physic ian

Respirations
Three Processes
o
o
o

Ventilation
Diffusion
Perfusion

Inhalation/ Inspiration- 1 to 1.5 seconds

Exhalation/ Expiration- 2 to 3 seconds

-Any event or stimulus that causes an individual to experience

stress

Assessing Ventilation
Models of Stress
o
o
o
o
o

Respiratory rate
Depth
Rhythm
Volume
Ease and effort

Alteration in Breathing Pattern

o

Rate
-Tachypnea
-Bradypnea
-Apnea
-Eupnea
Rhythm

Biots
-Shallow with epis odes of apnea

Cheyne-Stokes
-Shallow , irregular, deep, apnea

Kussm auls
-Deep and rapid
-Metabolic acidosis
-Diabetes Mellitus

o
o
o
o

Stim ulus-based (Holmes and Rahe)

-Disturbing or disruptive characteris tic w ithin the
environment
Response-based (Selye)
-Non-specific response of the body to any demand
made upon it
Transaction-based (Lasarus)
-Individual perceptual response rooted in psychological
and cognitive process
Adaptation Model
-An anxiety provoking stimuli
-People experience anxiety and increased stress when
they are unprepared with stressful situation

Source of Stress
o
o
o
o

Intrinsic/ Internal stressor

Extrinsic. External stressor
Developmental stressor
Situational stressor

Characteristics of Stress
Arterial Blood Pressure
o
o
o
o

Systolic pressure= < 120mmHg

Diastolic pressure= <80mmHg
Pulse pressure= 40mmHg
Korotkoff sounds

Physiology of Arterial Blood Pressure

o
o
o
o
o

BP= CO x R
Pumping action of the heart
Peripheral vascular resistance
Blood volume
Blood viscosity

Methods of Blood Pressure Taking

o
o

Auscultatory Method
Palpatory Method

Sources of Error in BP Assessment

o
o
o
o
o
o
o

Bladder cuff too narrow

Bladder cuff too w ide
Arm unsupported
Deflating cuff too quickly; too slowly
Arm above the level of the heart
Assessing immediately after a meal or while client
smokes or has pain
Failure to identify auscultatory gap

*Pump cuff up to 20-30mmHg

Homeostasis, Stress and Adaptation
Stress
-A condition in w hic h the person experiences changes in the
normal balanced state
Stressor

o
o
o
o
o
o
o

Fabric of life
Organism reacts as a unified whole
Not a nervous energy
Not alw ays results to feeling of dis tress
Not alw ays due to tis sue injury
Not alw ays something to be avoided
Whenever prolonged or intense may lead to exhaustion

Factors Influencing Manifestations of Stress

o
o
o
o
o
o

Nature and intensity of stressor

Perception of the stressor
Duration of exposure to stressor
Number of stressors experienced with a stressor
Age
Support people

Classifications of Homeostasis
o
o

Physiologic
-Internal environment of body is stable and constant
Psychologic
-Refers to emotional
-Psychologic al, mental balance or state of well-being

Characteristics of Homeostasis Mechanisms

o
o
o
o

Self-regulatory (come automatically)

Compensatory (counter-balancing)
Regulated by feedback mechanism
Require several feedback mechanism to correct one
physiologic imbalance

Two Major Homeostatic Regulators

o
o
o

Autonom ic Nervous System

-Sympathetic and parasympathetic
Endocrine System
-Pituitary, thyroid, parathyroid, pancreas and adrenal
glands
Plus Organ Systems

-Respiratory, cardiovascular, GI, renal

General Physiological Adaptive Mechanisms

Modes of Adaptation
o
o
o
o

Neurohypophyseal Responses

Physiologic
-GAS and LAS
-Compensatory physical changes
Psychologic
-Involves a change in attitudes or behavior
Sociocultural
-Changes in persons behavior in accordance with
names, conventions and beliefs of various groups
Technological
-Involves the use of modern technology

Posterior Pituitary Gland

Anti-diuretic Hormone

Oxytocin

Kidneys Uterine Contractions

General Adaptation Syndrome

H2O Reabsorption

General Adaptation Syndrome Stages

o

Alarm
-Awareness of stressor
-Increase vital signs
-Mobilization of defenses
-Increase hormone level
Resistance
-Repel stressor
-Adaptations
-Normalization of hormone levels
-Normalization of vital signs
-Increase in body resis tance
Exhaustion
-Decrease energy level
-Breakdow n in feedback mechanism
-Organ or tis sue damaged
-At decrease physiological function

Urine Output

Blood volume

BP

General Adaptation Syndrome

o

Alarm Reaction

Hypothalamus

Posterior Pituitary

Increase ADH
Increase:
o

Water reabsorption

Decrease:
General Physiological Adaptive Mechanisms
o
SAMR

Urine output

Anterior Pituitary

(Sym pathoadreno-medullary response)

(Fight or Flight)
Sympathetic Nervous System

-Increase ACTH- Adrenal Cortex

Increase Cortisol
Increase:
o
o
o

Increase in physiological activities

Gluconeogenesis
CHON catabolism
Fat catabolism

Adrenal Medulla
Increase Aldosterone
Epinephrine
Norepinephrine
Increase in physiological activities
Physiological Indicators of Stress
o
o
o
o
o
o
o

Increased mental alertness, restlessness

Dilated pupils, increased vis ual perception
Dryness of the mouth, decreased salivary secretion,
thirst
Tachycardia, increased CO
Bronchodilation, hyperventilation
Peripheral vasoconstriction, increased BP
Pallor, cold, clammy skin, diaphoresis

Increase:
o
o
o

Na absorption
Water reabsorption
K secretion

Decrease:
o

Urine output

SNS and Adrenal Medulla

Increase Epinephrine
Increase:
o

HR

o
o
o

Oxygen intake
Blood sugar
Mental acuity

Sanguinous- reddish
o

Increase Norepinephrine
Increase:
o
o

Reparative Phase

Regeneration

Fibrous tissue (scar formation)

Types of Wound Healing

Blood flow to skeletal muscles
Arterial BP

Fight or Flight

o
o
o

Recovery
o

Systemic Manifestations
Resistance

Stabilization

Hormonal levels return to normal

PNS activity

Adaptation to stressor
Exhaustion

Decrease energy levels

Decrease physiological adaptation

Death

Local Adaptation Syndrome

o

Primary Intention
Secondary Intention
Tertiary Intention

Tissue Injury

Vascular and Cellular Response

Fever
Leukocytosis
Increase in number of plasma proteins
Increase ESR
Malaise
Nausea and anorexia
Weight loss
Tachypnea and tachycardia

Management
o
o

Local manifestations

1.

o
o
o
o
o
o
o
o

o
o
o
o
o

Increase capillary permeability

Elevate the area

Heat and cold application
Cold= first 24-72 hours
Heat= after 72 hours
Diet= increase calorie, protein, Vitamin C
Adequate hydration
Pharmacotherapy
Surgery
Monitor degree of inflammation, resolution of bleeding,
adequate blood flow and nerve conduction distal to the
area

Physiologic Effects of Heat and Cold

Hyperemia

Edema

Fluid

Exudate production

Heat
Vasodilation
Increase capillary
permeability
Increase cellular metabolism
Increase inflammation
Sedative effect

Cold
vasoconstric tion
Decrease capillary
permeability
Decrease cellular
metabolis m
Decrease inflammation
Local anesthetic effect

Pain
Heat and Cold Application
Impaired functioning
o

Leukocytes enter the injured part

Pavementing

Emigration

Leukocytosis
Diapedesis

-Act of squeezing out

o

Exudate Production

Serous- whitish
Serous-sanguinous- pinkish

o
o

Done for 30 minutes

Average 15-20 minutes

Dry Heat
o
o
o

Hot Water Bags- temperature 110 to 125F

Disposable hot packs
Floor lamp, gooseneck lamp heat cradle

Bulb-25 watts
Distance-18-24 inches
Dry Cold Application
o
o

Ice collar
Ice cap

Moist Heat Application

o
o
o

Warm moist compress

Warm socks
Sitz Bath

Sitz Bath or Hip Bath

o
o
o
o

Used to soak the clients pelvic area

Immersed from the mid-thighs to the iliac crests or
umbilicus
Water temperature- 40-43C
Duration: 15-20 minutes

o
o
o
o

Gurgles (rhonchi)
-Continuous, low -pitched, coarse, gurgling harsh sound
with moaning/ snoring quality
Friction rub
-Superficial grating or cracking sounds
Wheeze
-Continuous, high-pitched, squeaky musical sounds
Vocal (tactile) Fremitus
-Faintly perceptible vibrations felt through the chest wall
when the client speaks

Sputum
Diagnostic Studies

Oxygenation
Anatom y and Physiology
o
o

Upper respiratory tract

-Nose, pharynx, larynx
Lower respiratory tract
-Trachea, bronchi, bronchioles, lungs

Three Processes
o

o
o

Pulm onary Ventilation

-Clean airw ays
-Intact CNS and respiratory center
-Medulla oblongata and pons
-Carotid and aortic bodies
-Intact Thoracic Cavity
-Adequate pulmonary compliance and recoil
Diffussion
-Concentration of the gases
-Thickness of the membrane
Perfusion
-CO
-No. of erythrocytes and blood hct

Signs of Hypoxia
o
o
o
o
o
o
o
o

Increase restlessness or light headedness

Rapid pulse
Rapid, shallow respirations and dyspnea
Elevated BP
Flaring of nares
Substernal or intercostals retractions
Cyanosis
Clubbing of fingers

o
o
o

Specimen Collection
o
o
o

o
o
o

Specimen collection
Removal of pleural fluid
Instill medication

Pre-test:
o

Consent not to cough or talk during procedure at the

side of the bed with upper torso supported on over bed
table

Post-test:
o
o

Auscultate breath sounds

Observe for signs and symptoms of pneumothorax,
leakage at puncture site

Bronchoscopy
o
o
o
o
o

Diagnosis
Biopsy
Specimen collection
Examination of structure/ tissues
Removal of foreign bodies

Pre-test:
Vesicular
-Soft intensity, low pitched
-T5 onward
-Peripheral lung, base of the lung
Bronchovesicular
-Moderate intensity, moderate pitch
-T3-T5
-Between scapulae lateral to the sternum
Bronchial
-High pitch, loud harsh sounds
-T1-T3
-Anteriorly over the trachea

Adventitious: Breath Sounds

o

Morning, upon aw akening

Mouth care prior to collection
1-2 tbsp (15-30 ml)

Thoracentesis

Norm al Breath Sounds

o

Culture and Sensitivity

AFB
Cytology

Crackles (rales)
-Fine, short, interrupted crackling sounds

o
o
o
o

Consent
Remove denture
Oral hygiene
NPO 6-12 hours

Post-test:
o
o
o
o

NPO until return of gag reflex

On side or in semi-fow lers position
Ice bags to throat
Discourage talking or coughing

Respiratory Modalities
Abdom inal (Diaphragmatic) Pursed-lip breathing

o
o
o

Semi/ high fowlers position

Slow deep breath, hold for a counrto of 3 then slow ly
exhale through mouth and pursed lip
5-10 slow deep breaths every 2 hours on waking hours

Coughing Exercise
o
o
o
o
o

Upright position
Contraindicated: post-brain, spinal or eye surgery
Take 2 slow deep breaths; on thr 3rd breath, hold for
few seconds, cough twice w ithout inhaling in betw een
May splint surgic al incisions
Every 2 hours while awake

Incentive Spirometry
o
o

A breathing device that provides visual feedback that

encourage patient to sustain deep voluntary breathing
and maximum inspiration
10 times every 1-2 hours

Vibration
o
o

Perform by contracting all the muscle in the nurses

upper extremities to cause vibration while applying
pressure to the clients chest wall
One hand over the other

Suctioning
Purposes:
o
o
o
o

Maintain patent airway

Promote adequate exchange of O2 and CO2
Substitute for effective coughing
Specimen collection

Size:
o
o
o

Adult: Fr 12-18
Pediatrics: Fr 8-10
Infant: Fr 5-8

Chest Physiotherapy
Length:
o
o
o
o

Postural drainage
Percussion
Vibration
Positioning-> percussion-> vibration-> removal of
secretions by cough or suction

Postural Drainage

From the tip of the nose to earlobe (5 inches)

o
o
o
o
o

Purposes:
o
o

Aids in airway clearance of mucus in patients with

retained tracheobronchial secretions
Movement from smaller peripheral airw ays into larger
central airways

Contraindications
o
o
o
o
o
o
o
o

ICP more than 20mmHg

Head and neck injury
Active hemorrhage
Recent spinal surgery
Active hemoptysis
Pulmonary edema
Confused or anxious patients
Rib fracture

When
o
o
o

Morning
At bed time
30 minutes-1 hour before or 1-2 hours after meal

Nasopharyngeal: 5-6 inches

Oropharyngeal: 3-4 inches
Nasotracheal: 8-9 inches
Endothracheal: length of ET + 1 cm
Tracheostomy tube: length of tracheostomy tube + 1
cm

Hypoderm ic (intradermal)/ (IM injection)

o
o
o
o

Green- Gauge 21
Blue- Gauge 23
Orange- Gauge 25, 26
Brown- Gauge 18

Increase number= increase dm

IV Catheter
o
o
o
o
o
o
o
o

Green- Gauge 18
Pink- Gauge 20
Blue- Gauge 22
Yellow - Gauge 24
Duration of suction: 10-15 seconds
Intermittent suctioning upon w ithdrawal using rotating
motion
If to repeat, allow 30 seconds to 1 minute interval
No > 3 suction passes per suctioning episode

Unexpected Situations and Associated Interventions

Each position
o
-Assumed for 10-15 minutes
Entire treatment
-Should only last for 30 minutes
Percussion
o
o

Rhythmical force provided by clapping the nurses

cupped hands against the clients thorax
Over affected segment for 1-2 minutes

o
o

Patient vomits during suctioning

-If patient gags or becomes nauseated, remove the
catheter; it has probably entered the esophagus
inadvertently.
-If the patient needs to be suctioned again, change
catheters because it is probably contaminated
-Turn patient to the side and elevate the head of the
bed to prevent aspiration
Secretions appear to be stomach contents
-Ask the patient to extend the neck slightly. This helps
to prevent the tube from passing into the esophagus
Epistaxis is noted with continued suctioning

-Notify the physician and anticipate the need for a nasal

trumpet

-Ensure that the flap is closed and edges of tent are

tucked under blanket
-Check oxygen delivery unit to ensure that rate has not
been changed

Oxygen Therapy
Special Considerations:
o
o

Given w ith a doctors order

Careful and continuous assessment to evaluate the
need for and its effect on the patient

Safety Precautions:
o
o

Simple Face Mask

Partial Rebreather Mask
Non-Breather Mask
Venturi Mask

Nasal Cannula
o
o

No smoking and Oxygen in Use signs at the door

Disconnect grounded electrical equipment

Types of Face m ask

o
o
o
o

Inhalation Therapy

20-40%
% Oxygen delivered

Moist Inhalation
-Steam inhalation
-12-18 inches
-15-20 minutes
Dry Inhalation
-Metered dose inhaler
-Use of spaces
-Hold breath for 10 seconds
-5 minutes interval

One Bottle System

-Drainage + w ater seal
-Tip of the tube should be immersed 2 cm on the sterile w ater
-2-3 feet below chest level
-Never ris e above the level of the heart
-Alw ays check patency

Priority Nursing Interventions:

Two Bottle System
o
o

Check frequently both prongs in the patients nares

Encourage patient to breath

Unexpected Situations and Associated Interventions

o

Patient was fine on oxygen delivered via nasal

cannula but now is cyanotic and the pulse oximeter
reading is less than 93%
-Check to see that oxygen tubing is still connected to
the flow meter and the flow meter is still on the previous
setting
-Assess lung sounds to note any changes
When dozing, the patient begins to breathe through
the mouth
-Temporarily place the nasal cannula near the mouth

-Drainage + w ater seal (2 cm) + suction (20 cm)

Types of Two Bottle System
o

Without suction
-1st bottle: drainage
-2nd bottle: water seal
-Intermittent bubbling in 2nd bottle
With suction
-1st bottle: drainage and water seal
-2nd bottle: suction control
-Intermittent bubbling in w ater seal and gentle bubbling
in suction control bottle is normal

Fluctuations should synchronize with Respiration

Simple Mask
-40-61%
Nursing Interventions
o
o

Monitor patient frequently to check placement of the

mask
Support patient if claustrophobic

Oxygen Hood
Oxygen Tent
Unexpected Situations and Associated Interventions
o

Child refuses to stay in tent

-Parent may play games in tent w ith child
-Alternative methods of oxygen delivery may need to be
considered if child still refuses to stay in tent
It is difficult to m aintain an oxygen level above 40%
in the tent

o
o
o
o
o

Intermittent bubbling is normal

Continuous bubbling indicates presence of leak
No fluctuations should be noted
Check patient first before tubing
Validate if lung has re-expanded by x-ray

Three Bottle System

o
o
o

1st bottle: drainage

2nd bottle: water seal
3rd bottle: suction

-Intermittent bubbling in 2nd bottle is normal

-Gentle bubbling in 3rd bottle is normal
Care of Client w ith Chest Tube
o
o

Occlusiv e dressing around the chest tube insertion

No dependent loops or kinks in the drainage
tubing

o
o

Drainage bottle below clients chest

Available at bedside:
-Gentle bubbling is normal
-Intake and output per shif t
-Immersed w ith sterile water (priority)
-Clamp w ith Kelly Padded (2nd option)
-Put a mark on the bottle

Unexpected Situations and Associated Interventions

o

Chest tube becomes separated from the drainage

device
-Put on gloves
-Open sterile normal saline or w ater and insert the
chest tube into the bottle while preventing
contamination of the chest tube
-Assess patient for any signs of respiratory dis tress
-Notify physician
-Do not leave the patient
-Antic ipate the need for a new drainage system
Chest tube becomes dislodged
-Put on gloves
-Immediately apply an occlusiv e dressing to the site
-Assess the patient for any signs of respiratory distress
-Notify physician
-Antic ipate the need for chest x-ray
While assessing the chest tube, you notice a lack of
drainage when there had been drainage previously
-Check for kink in the tubing or a clot in the tubing
-Notice the amount of suction that the chest tube is set
on
-Milking of the tubing (squeezing or releasing small
segments of tubing between the fingers) and stripping
of the tubing (squeezing the length of the tube without
releasing it) are strictly not recommended
-If the suction is not set appropriately, adjust until the
ordered amount is achieved
-Keeping the tubing horizontal across the bed or chair
before dropping vertically into the drain device and
avoiding dependent loops optimize drainage
-Notify the physician if the lack of drainage persists
Drainage exceeds 100 m l/ hour or becomes bright
red
-Notify the physician

Indications:
o
o
o

Care of the Patients with Endotracheal Tube

o
o
o
o
o

o
Oropharyngeal
Nasotracheal
Endotracheal
Tracheostomy tube

o
Oropharyngeal/ Oral Airway
o
o
o

Prevents tongue from falling back against the posterior

pharynx
Measurement from opening of the mouth to the ear
(back angle of the jaw)
Check for loose teeth, enlarged tongue

Nasopharyngeal Airway/ Nasal Trumpets

Indications:
o
o

Clenched teeth
Enlarged tongue

Endotracheal Tube

Reposition at least every 24-48 hours

Depth and length during insertion should be maintained
Level of tube: gumline/ biteline
Maintain cuff pressure 20-25 mmHg
Check lips for cracks and irritation

Unexpected Situation and Associated Interventions

Artificial Airw ays

o
o
o
o

Route for mechanical ventilator

Easy access for secretions removal
Artif icial airway to relieve mechanical airway obstruction

Patient was
accidentally extubated during
suctioning
-Remain w ith patient
-Instruct assistant to notify physician
-Assess patients vital signs, ability to breathe without
assis tance and oxygen saturation
-Be ready to administer assis ted breaths with a bag
valve mask or administer oxygen
-Antic ipate need for reintubation
Oxygen saturation level decreases after suctioning
-Hyperoxygenate patient
-Auscultate lung sound
-If lung sounds are absent over one lobe, alert staff to
notify the physician
-Remain w ith the patient because patient may have
pneumothorax
-Antic ipate order for STAT chest x-ray and chest tube
placement
Patient develops signs of intolerance to suctioning.
Oxygen saturation level decreases and rem ains low
after hyperoxygenation; patient becomes cyanotic
or patient becomes bradycardic
-Stop suctioning
-Auscultate lung sounds
-Consider hyperventilating the patient w ith manual
resuscitation device
-Remain w ith the patient
-Alert staff to notify physician
Patient is accidentally extubated during tape
change
-Same w ith during suctioning
Patient is biting on endotracheal tube
-Obtain a bite block
-With the help of an assistant, place the bite block
around the endotracheal tube or in the patients mouth
Depth of endotracheal tube changes with
respiratory cycle
-Remove old tape
-Repeat taping of the endotracheal tube, ensuring tape
is snug against the patients face
Lung sounds are greater on one side
-Check the depth of the endotracheal tube
-If the tube has been advanced, the lung sounds will
appear greater on the side on which the tube is further
dow n
-Remove tape and move tube so that it is places
properly
-If the depth has not changed, assess patients oxygen
saturation level, skin color and respiratory rate
-Notify physician
-Antic ipate the need for chest x-ray

Tracheostomy Tube

-To maintain patient airw ay and prevent infection of respir atory

tract

o
o

Care of the Patient w ith Tracheostom y Tube

o
o
o
o

Sterile technique: acute phase

Clean technique: home care
1st 24 hours: tracheostomy care every 4 hours
Prevent aspiration

Unexpected Situations and Associated Interventions

o

Triceps/ Skin fold

Body Mass Index= weight in kilograms/ height in
meter square
20-25%- Normal
26-30%- Mild obesity
30-40%- Moderate obesity
Above 40%- Severe obesity

1 meter= 3.3 feet or 39.6 inches

o

Patient coughs hard enough to dislodge

tracheostomy tube
-Keep a spare tracheostomy and obturator at the
bedside
-Insert obturator into the tracheostomy tube and insert
tracheostomy into stoma
-Remove obturator
-Secure ties and auscultate lung sounds
Lung sounds do not improve greatly and oxygen
saturation remains low after 3 suctionings
-Allow time for patient

Biochemical Tests

Hem oglobin
<12-18 g/dl= anemia

<40-50%= anemia
>40-50%= dehydration)

-Sum of all the interactions betw een an organism and the food it
consumes

According to Function

Body Building
-Form tissues or are structural component of the
body
Water- 2/3 of the body weight
CHON- 20%
CHO- 1%
Fats- 20%
Minerals- 4%

Energy giving
-CHO, fats and CHON

Regulate body processes

Inorganic

-Minerals and water

o

According to Essentiality

Dietary essential

Non-essential

Physical/ instrumental Method (Anthropometry)

Weight
Height
Mid-upper arm circumference

and

severe

Blood, Urea, Nitrogen

<17-18 mg.dl= malnutrition, overhydration

Creatinine

>0.4-1.5 mg/dl= dehydration

<0.4-1.5 mg/dl= reduction in total muscle mass, severe
maltnutrition
o
o

Clinical Exam ination

Dietary Survey

Types of Diets
o
o

Assessing Nutritional Status

o

intake

>17-18 mg/dl= starvation, high CHON intake, severe

dehydration

-All nutrients

-CHON, CHO, fat and vitamins

Total Lymphocyte Count

<1800= impaired nutritional

debilitating disease

Nutrient Classification

According to Chemical Nature

Organic

Transferin

<240-480 mg/dl= CHON deficiency

-Combination of processes by which a living organism receives

and utilizes material or substances

Serum Albumin

<3.3-5 g/dl= malnutrition and malabsorption

Nutrition

Hem atocrit

o
o

Regular
Has all essentials, no restrictions
No special diet needed
Clear liquid
-See-through foods like broth, tea, strained juices,
and gelatin
-Recovery from surgery or very ill
Full liquid
-Clear liquids plus milk products, eggs
-Transition from clear to regular diet
Soft
-Soft consistency and mild spice
-Diffic ulty swallow ing
Mechanically soft
-Regular diet but chopped ground

o
o

o
o
o
o
o
o

-Diffic ulty chewing

Bland
-Chemically and mechanically non-stimulating, no
spicy food
-Ulcers or colitis
Low-residue
-No bulky food, apples or nuts, fiber foods having
skins and seeds
-Rectal disease
High calorie
-High CHON, vitamin and fat
-Malnourished
Low calorie
-Decrease fat, no whole milk, cream, eggs,
complex CHO
-Obese
Diabetic
-Balance of CHON, CHO and fat
-Insulin-food imbalance
High protein
-Meat, fish, milk, cheese, poultry, eggs
-Tissue repair and underweight
Low fat
-Little butter, cream, w hole milk or eggs
-Gallbladder, liver or heart disease
Low cholesterol
-Little meat or cheese
-Need to decrease fat intake
Low sodium
-No salt added during cooking
-Heart or renal disease
Tube feeding

Protein-Modified Diet

Salem-Sump Tube
-Double lumen stomach tube (the other lumen serves as airway to
prevent adherence of the tube to the gastric mucosa)
Sengstaken-Blakemore Tube
-Triple lumen stomach tube used to treat bleeding esophageal
varices
Minnesota Sump
-Four lumen stomach tube
Cantor Tube
-Single lumen intestinal tube
Harris Tube
-Single lumen intestinal tube
Miller-Abbott Tube
-Double lumen intestinal tube
Enteral Nutrition
o
o
o

Unexpected Situations and Associated Interventions

Gluten-free diet
o
o
o

Nasogastric tube feeding

Gastrostomy tube feeding
Jejunostomy tube feeding

Purpose to eliminate gluten (protein) form the diet

Malabsorption syndromes and celiac disease
Avoid barley, rye, oats, wheat, cream sauces,
breaded foods, cakes, breads, muffin

PKU (Phenylketonuria) diet

o
o

Purpose to control intake of phenyalanine, an amino

acid that cannot be metabolized
Avoid breads, meat, fish, poultry, cheese, legumes,
nuts, eggs

Low-purine diet
o
o

Indicated for gout, uric acid retention, kidney stones

Avoid organ meats, fis h and lobster, dries peas and
beans, nuts, oatmeal
Enteral Nutrition
Parenteral Nutrition
Cancer
Non-functional GIT
Neurological and
Extended bow el rest
muscular disorders
GI disorder
Pre-operative TPN
Respiratory failure w ith
prolonged intubation

Gastrointestinal Tubes
Levin Tube
-Single lumen stomach tube

Tube found not to be in the stom ach or

intestine
-Replace the tube
Patient complains of nausea after tube feeding
-Ensure that head of bed remains elevated and
that suction equipment is at bedside
-Check medication record to see if any antiemetics have been ordered for patient
-Consider notifying the physic ian for an order for
an anti-emetic
When attempting to aspirate contents, the
nurse notes that tube is clogged
-Try using warm water and gentle pressure to
remove the clog
-Never use a stylet to unclog tubes
-Tube may have to be replaced

Gastric Lavage
o
o
o

Irrigant (normal saline) usually 1000-1500 cc for

adult , 500 cc for pediatrics
Rather than reinstill the stomach aspirate, place it
into a measuring container for later disposal
Continue to instill and aspirate until returns are
clear or pink-tinged

Gastric Decompression
o

If using suction: can be intermittent or continuous and

pressure can be low (20-40 mmHg) or high (80-120
mmHg)

Gastrostom y/ Jejunostom y Feeding (long-term nutritional

support, more than 6-8 weeks)

o
o
o
o
o

Place in high fow lers position

Check the patency of the tube: pour 15-30 cc water
Check for residual feeding
Hold asepto syringe 3-6 inches above ostomy feeding
Frequently assess for skin breakdown

Unexpected Situations and Associated Interventions

o

Gastrostom y tube is leaking large amount of

drainage

o
o
o
o
o
o
o

Observe for air embolism, subcutaneous bleeding,

allergic reactions
Vital signs every 4 hours
CBG (hyperglycemia) and urine specific gravity
(hyperosmolar dieresis)
Change tubing every 24 hours
Monitor input and output
Weigh once a day
Do not catch up if delayed

Complications
-Check tension of tube
-Apply gentle pressure tube while pressing the external
bumper closer to the skin
-If the tube has an internal balloon holding it in place,
check to make sure the balloon is inflated properly
o

o
o
o
o
o

Assessment

Skin irritation is noted around insertion site

o
o

-Stop the leakage as described above and apply a skin

barrier
o

Site appears erythem atous and patient complains

of pain at site
-Notify physician; patient could be developing cellulitis
at the site

Complications:
o
o
o
o
o
o
o
o

Pulmonary aspiration
Diarrhea/ constipation
Tube occlusion/ dis placement
Abdominal cramping, nausea and vomiting
Delayed gastric emptying
Serum electrolyte imbalance
Fluid overload
Hyperosmolar dehydration

Air embolism
Catheter occlusion and sepsis
Electrolyte imbalance
Hypo/ hyperglycemia
Thrombosis

o
o
o

IAAP approach
Bowel sounds (4 quadrants)

Active- every 5-20 seconds

Hypoactive- one per minute

Hyperactiv e- every 3 seconds

Absent- none heard in 3-5 minutes

Fecalysis
-An inch of formed stool, 15-30 ml of liquid stool
Fecal occult blood testing/ Guiac Test

False-positive

False-negative
Diagnostic Exam ination

Upper GI series (Barium Swallow)

o

Fluoroscopic exam of the upper GI

Pre-test:
o
o

NPO from midnight or 6-8 hours ore-test

Barium w ill taste chalky

Parenteral Nutirition
Post-test:
-Hyperalimentation
o
Site of insertion
o
o

Intraclavicular: Right or Left jugular vein, hinders head

and neck movements
Supraclavicular: Right or Left jugular vein, hinders head
and neck movements

Indications
o
o
o
o
o

Severe burns bowel disease disorder

Acute renal failure
Hepatic failure
Metastatic cancer
Major surgery wherein client will be NPO for more than
5 days

Preparations/ Procedures
o
o
o
o

Explain procedure
Valsalv a maneuver as catheter being inserted with
head down in the opposite direction or insertion
Cover area w ith sterile dressing
Regulate at ordered rate

Laxatives to enhance elimination of barium and prevent

obstruction or impaction

Lower GI Series (Barium Enem a)

Pre-test:
o
o
o
o

NPO 8 hour pre-test

Enema the morning of test
Laxative or suppository
Cramping may be experience during

Post-test:
o

Laxative and fluids to assist in expelling barium

Endoscopy
Pre-test:
o
o
o
o

NPO 6-8 hours

Consent
Local anesthetic will be used
Hoarseness and sore throat for several days

o
o
o

Post-test:
NPO until w ith gag reflex
Warm normal saline gargles

o
o

Colonoscopy
Pre-test:
o
o
o
o

NPO 8 hours
Laxative and enemas
Consent
Instrument w ill be inserted into the rectum

Enem a Adm inistration

Post-test:
o

Observe for rectal bleeding and signs of perforation

Pre-test:

o
o
o
o
o

Vital signs every 8-12 hours

Right side lying w ith pillow against the abdomen
Observe site for bleeding

Alteration in Stool Characteristics

o
o
o
o

Acholic Stool
Hematochezia
Melena
Steatorrhea

Adult 750-1000 ml
Adolescent 500-750 ml
School-aged 300-500 ml
Toddler 230-350 ml
Infant 150-250 ml

Length of Insertion:
o
o
o

Adult 2-4 inches

Child 2-3 inches
Infant 1-1 inches

Enem as until clear

-When no solid fecal material exists but no solution maybe
colored

Fecal Elim ination Problems

o
o

Adult- Fr 22-30
Child- Fr 12-18

Correct Volume:
NPO 6-8 hours
Consent
Hold breath during biopsy

Post-test:
o
o
o

Appropriate Size:
o
o

Liver Biopsy

o
o
o

High enema- 12-18 inches

Low enema- 12 inches
Carminative Enema
-60-80 ml of fluid
Retention Enema
-Solution retained for 1-3 hours
-Oil enema, antibiotic enema, antihelminthic enema,
nutritive enema
Return-flow enema
-To expel flatus
-Alternating flow of 100-200 ml of fluid in and out of the
rectum

Commonly Used Enema Solution

Diarrhea
Constipation

Solution
Hypertonic

Hypotonic

Constituents
Sodium,
Phosphate
Solution
Tap w ater

Isotonic

Normal saline

Soapsuds

2-5 ml soap to 1 L
water
Mineral, olive,
cottonseed

Types of Laxatives
Type
Bulk-forming
Em olient/ stool
softener
Stim ulant/
irritant
Lubricant
Saline/ osmotic

Action
Increase fluid,
gaseous or solid
bulk
Softens, delays
drying of feces
Irritates,
stimulates
Lubricates
Draws water into
intestine

Exam ples
Metamucil,
Citrucel
Colace
Dulcolax,
Senokot, Castor
oil
Mineral oil
Epsom salts, Milk
of Magnesia, Mg
citrate

Oil

Enem a

Cleansing Enema
-Prior to diagnostic test, surgery
-In cases of constipation and impaction
-Either be:

Distends colon,
stimulated,
softens
Distends colon,
stimulated,
softens
Irritates mucosa,
distends colon
Lubricates feces

Unexpected Situations and Associated Interventions

o

Types of Enem a

Action
Draws water into
colon

Solution does not flow into rectum

-Reposition rectal tube
-If solution w ill still not flow, remove tube and check for
any fecal contents
Patient cannot retain enema solution for adequate
am ount of time
-Patient may need to be placed on bedpan in thee
supine position while receiving enema

o
o

-The head of the bed may be elevated 30 degrees for

the patients comfort
Patient cannot tolerate large amount of solution
-Amount and length of administration may have to be
modified if patient begins to complain of pain
Patient complains of severe cramping w ith
introduction of enema solution
-Lower solution container and check temperature and
flow rate
-If the solution is too cold or flow rate too fast, severe
cramping may occur

Bladder Elim ination

o
o
o

Im plementation
o

Assessment
Urine Characteristics
o
o
o
o
o

pH- 4.6-8.0 (average 6)

Specific gravity- 1.010-1.025
Color- amber/ straw
Odor- aromatic upon voiding
Transparency- clear

Types of Urinary Alterations

o
o
o
o
o
o
o
o
o
o
o

Urgency
Dysuria
Frequency
Hesitancy
Nocturia
Retention
Residual urine
Polyuria
Oliguria
Anuria
Incontinence
Functional
Overflow
Reflex
Stress
Urge

Force fluids
Pink-tinged urine 24-48 hours
Warm sitz bath and analgesics

o
o
o
o
o
o

Prevent urinary tract infection

-Frequent voiding 9every 2-4 hours)
-Avoid use of hrash soaps, bubble bath, powder or
sprays on perineal area
-Proper perineal hygiene
-Increase acidity of urine
Managing Urinary Incontinence
Bladder training
-Inhibiting the urge-to-void sensation
Pelvic muscle exercise- Kegels Exercis e
-Contracting for 3-5 seconds; 10 contractions/ sessions;
5 times daily
-Positive reinforcements
-Meticulous skin care
-Avoid stimulants at night
-External drainage device (males)
Condom catheter- leaving 2.5 cm/ 1 inch betw een the
end of penis and rubber
Managing Urinary Retention
-Promote relaxation
-Provide adequate time for voiding
-Cholinergic drugs as ordered (Urecholine)
-Manual pressure on the bladder- Credes Maneuver
-Urinary catheterization as ordered
Intermittent/ Single Catheterization
Indwelling/ Retention Catheterization
Continuous Bladder Irrigation
Indications for Catheterization
Decompression
Instillation
Irrigation
Specimen collection
Urine Measurement
-Residual urine
-Hourly urine output
Promotion of healing of GUT

Intravenous Pyelogram (IVP)

Catheterization

-Fluoroscopic visualization of the tract

Catheter size (Potter and Perry)

Pre-test:
o
o
o
o

Assess for iodine sensitivity

Enema the night before
Consent
NPO for 8 hours

Post-test:
o

Force fluids

Cytoscopy
Pre-test:
o
o
o
o

o
o
o

Children- Fr 8-10
Female Adult Fr 14-16 (Fr 12 young gir ls)
Male Adult Fr 16-18

Position
o
o

Female- dorsal recumbent

Male- supine w ith thighs slightly abducted

Length of Insertion
o
o

Female- 2-3 inches (5-7.5 cm)

Male- 7-9 inches (17-22.5 cm)

Anchor
General or local anesthesia
Consent
NPO
Enema as ordered

Post-test:

o
o

Female- inner thigh

Male- top of thigh or lower abdomen

Unexpected Situations and Associated Interventions

o
o

No urine flow is obtained and you note that catheter

is in vaginal orifice
-Leave catheter in place as a marker
-Obtain new sterile gloves and catheter set
-Once new catheter set is correctly in place, remove the
catheter in the vaginal orif ice
Urine flow is initially well established and urine is
clear but after several hours, flow dwindles
-Check tubing for kinking
Patient complains of extreme pain when you are
inflating the balloon
-Stop inflation of balloon
-Withdraw solution form the balloon
-Insert catheter an additional 0.5-1 inch and low ly
attempt to inflate the balloon again

Bladder Irrigation
o
o

Open System (Intermittent)

-For instillation if medications or irrigation of catheter
Closed Systems (Interm ittent or Continuous)
-For those who had genitourinary surgery
-For instillation of medications, promoting homeostasis,
flushing of clots or debris

Unexpected Situations and Associated Interventions

o

Continuous bladder irrigation begins and hourly

drainage is less than amount of irrigation being
given
-Palpate for bladder dis tention
-If patient is lying supine, rolling the patient onto his or
her side may increase amount of drainage
-Check if tubing is not kinked
-If return flow remains decreased, notify physician
Bladder irrigation is not flowing at ordered rate
even w ith clamp w ide open
-Check tubing for kinks or pressure points
-Raise the bag 3-6 inches and then check flow of
irrigation solution