MIDTERMSKILLS
MIDTERMSKILLS
MIDTERMSKILLS
Assessment:
Height (ht)
Weight (wt) the best indicator for nutritional status of an individual.
Skin folds (fat folds)
BMI (Basal Metabolic Index) = wt in kg/ (ht in meter) ₂
o Below 18.5 underweight
o 18.5 – 24.9 normal
o 25.0 – 29.9 overweight/mild obesity
o 30.0 – 39.9 moderate obesity
Purpose: to identify the client’s health care needs and to prepare diagnostic statements. Uses PRS
format.
P – problem
R – related to factors
S – signs and symptoms
Nursing Diagnosis:
Altered nutrition:
Altered elimination:
Diarrhea
Constipation
Dehydration
Special Diets
Clear liquid
o Water
o Bouillon
o Clear broth
o Gelatin
o Popsicles
o Coffee/tea
o Soda
o Hard candy
Full liquid
o Plain rice cream
o Sherbet
Milk
Pudding/custard
o Strained soups
Strained vegetable juice
Soft – includes soft foods and those with reduced fiber content which require less energy for
digestion
o Chopped or pureed foods
DAT (Diet as Tolerated) – includes those foods which the client can tolerate after surgery or after
GI distress.
Alternative Feeding Methods
Oral Gastric Tube – may be used for feedings, medication administration or removal of contents
from the stomach via aspiration, suction, or gravity drainage. It may also be used to help remove
air from your baby’s stomach.
Nasogastric Feeding – commonly used in Levine Tube French 14-16.
Purposes:
1. To provide feeding – “gastric gavage”
2. To irrigate stomach – “gastric lavage”
3. For decompression – drainage or gastric content
4. To administer medications
5. To administer supplemental fluids.
Size of NG tube
Feeding Decompression
Neonates 6fr 8fr
Infants to 5 8fr 8-10fr
years
Over 5 years 8-10fr 10-14fr
Equipment needed
Tube – (usually #12, #14, #16 or #18 French for a normal adult.
TYPES OF NGT
Techniques:
a. Introduce air 5-20ml and auscultate at the epigastric area and listen to gurgling or
whooshing sound.
b. Aspirate gastric content, which is yellow or greenish color.
c. Immerse tip of the tube in water, no bubbles should be produced.
d. pH test - This method aspires the NG tube and checks the content by using pH paper.
e. Chest Xray - This method offers one of the best ways to check the placement of the NG
tube.
5. Assess residual feeding contents. To check absorption of the last feeding. If ≥ 50ml verify if the
feeding will be given.
6. Introduce feeding slowly. To prevent crampy pain or vomiting.
7. Maintain 12 inches above tube’s point of insertion.
8. Instill 60ml of water into the NGT after feeding. To clean the lumen of the tube.
9. Clamp the NGT before all the water is instilled. To prevent entry of air into the stomach.
10. Maintain client on fowler’s position for at least 30 mins. To prevent potential aspiration.
11. After care equipment then, document observation.
Pneumothorax
Pulmonary hemorrhage
Pleural effusion
Trauma injuries
Abscess formation
Nosebleeds
Asphyxia
Secondary infection
Pneumonitis
Vomiting
Aspiration
Diarrhea – due to lactose intolerance
Constipation
Hyperglycemia
Abdominal distention
Bowel Elimination
Defecation is an expulsion of feces from the rectum. It has an involuntary phase when feces
is in the rectum. It becomes involuntary when it reaches to anal sphincter and must relax for
evacuate of the rectum, facilitates by increase abdominal pressure “Valsalva maneuver”.
Characteristics of Stool
Abnormal Characteristics
Constipation
Fecal impaction – hardened stool
Diarrhea
Flatulence – presence of excessive gas
Fecal incontinence – involuntary elimination of bowel contents assoc. with emotional
impairments, mental neurologic.
Diarrhea
Refers to frequent evacuation of watery stools for 3-5 time or more. It is associated with
increased gastric motility.
Urinary Bladder
Micturition
it is the act of expelling urine from the bladder also called voiding or urination.
Characteristics:
color: amber/straw
odor: aromatic
transparency: clear
pH: slightly acidic
Problems in Urinary Elimination
1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on
training).
2. Perform hand hygiene using hand sanitizer/hand washing.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by other
healthcare personnel.
4. Put on N95 filtering facepiece respirator or higher (use a facemask is a respirator is not
available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not
bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be
extended under chin. Both your mouth and nose should be protected. Do not ware
respirator/facemask under your chin or store in scrubs pocket between patients*
Respirator: respirator straps should be placed on crown of head (top strap) and base of
neck (bottom strap). Perform a user seal check each time you put in the respirator.
Facemask: mask ties should be secured on crown of the head (top tie) and base of neck
(bottom tie). If mask has loops, hook them appropriately around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half facepiece elastomeric
respirator, select the proper eye protection to ensure that the respirator does not interfere with
the correct positioning of the eye protection, and the eye protection does not affect the fit or
seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent
protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown. Healthcare personnel may now
enter patient room.
1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves
can be removed using more than one technique (e.g., glove-in-glove or bird beak).
2. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and
pulling upwards and away from head. Do not touch the front of face shield or goggles.
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than
untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and
carefully pull gown down and away from the body. Rolling the gown down is an acceptable
approach. Dispose in trash receptacle. *
6. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the
front of the respirator or facemask.*
Respirator: Remove the bottom strap by touching only the strap and bring it carefully
over the head. Grasp the top strap and bring it carefully over the head, and then pull the
respirator away from the face without touching the front of the respirator.
Facemask: Carefully untie (or unhook from the ears) and pull away from face without
touching the front.
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if
your workplace is practicing reuse.*
Standard Precautions
- used in the care of all hospitalized individuals regardless of their diagnosis or possible infection
status. They are used in any situations involving blood, all body fluids, excretions, and secretions
except sweat (whether or not blood is present or visible), nonintact skin, and mucous
membranes.
- SP include (a) hand hygiene; (b) use of personal protective equipment (PPE), which includes
gloves, gowns, eyewear, and masks; (c) safe injection practices; (d) safe handling of potentially
contaminated equipment or surfaces in the client environment; and (e) respiratory
hygiene/cough etiquette (sleeve sneeze).
Isolated Precautions
- create barriers between people and germs. These types of precautions help prevent the spread
of infection in the hospital. Anybody who visits a hospital patient who has an isolation sign
outside their door should stop at the nurses' station before entering the patient's room.
Transmission-Based Precautions
- precautions are used in addition to standard precautions for clients with known or suspected
infections that are spread in one of three ways: by airborne or droplet transmission, or by
contact
- designed for all clients in hospital reduce risk of transmission of microorganisms from
recognized and unrecognized sources.
- These precautions apply to (a) blood; (b) all body fluids, excretions, and secretions except sweat;
(c) nonintact (broken) skin; and (d) mucous membranes
Contact Precautions
Transmission-Based Precautions
1. Contact Precautions
Everyone must: clean hand when entering and leaving room. Gown and glove at door.
Doctor and Staff Must: use patient-dedicated or disposable equipment. Clean and disinfect
shared equipment.
Sample disease on Contact Precaution:
MRSA (mask if respiratory infection)
VRE
Adenovirus
Diarrhea
C. difficile
Rotavirus
E coli 0157
Enterovirus
Salmonella
Shigella
Hepatitis A
Herpes Zoster (shingles localized)
Herpes simplex
Parainfluenza (mask if coughing)
RSV (mask if productive cough)
Lice
Scabies
Chicken pox (symptomatic, until all lesions crusted and dried)
2. Droplet Precaution
Everyone must: clean hands when entering and leaving room. Wear mask.
Doctors and staff must: wear eye protection with respiratory symptoms and standard
precautions if contact with secretions likely.
Sample diseases on Droplet Precautions:
Pertussis
Influenza A or B
MRSA (respiratory infection)
Neissera meningitides (suspected or confirmed)
Coxsackie
Bacterial meningitis (for 24 hours after effective antibiotic therapy)
RSV (droplet and contact)
Mumps
Rubella
Droplet Precautions
1. Place client in private room.
2. If a private room is not available, place client with another client who is infected with the same
microorganism.
3. Wear a mask if working within 1 m (3 ft) of the client.
4. Limit movement of client outside the room to essential purposes. Place a surgical mask on the
client while outside the room.
3. Airborne Precaution
Everyone must: clean their hands, including before entering and when leaving the room. Put on
a fit-tested N95 or higher-level respirator before room entry. Remove respirator after exiting the
room and closing the door. Door to room must remain closed.
Sample disease on airborne precautions:
Chicken pox
Disseminated herpes zoster (shingles)
Measles
N95 mask:
Tuberculosis
SARS
Avian influenza
Assessment:
1. Check for history of nasal surgery or deviated septum.
2. Assess patency of nares.
3. Determine presence of gag reflex.
4. Assess mental status or ability to participate in the procedure
Equipment:
1. Large- or small-bore tube (nonlatex preferred) / NG Tube
2. Non-allergenic adhesive tape, 2.5 cm (1 in.) wide
3. Clean gloves
4. Water-soluble lubricant
5. Facial tissues
6. 20- to 50-mL catheter-tip syringe / Asepto Syringe
7. Basin
8. Stethoscope
STEPS RATIONALE
Assist the client to a High-Fowler’s position if his It is often easier to swallow in this position and
or her health condition permits, and support the gravity helps the passage of the tube.
head on a pillow.
Introduce yourself, verify client’s identity and To gain client’s cooperation.
explain to the client what you are going to do.
Wash hands and provide privacy.
Determine how far to insert the tube. This length approximates the distance from the
Use the tube to mark off the distance from nares to the stomach.
the tip of the client’s nose to the tip of the
earlobe and then from the xiphoid. This
distance varies among individuals.
Mark this length with adhesive tape if the
tube does not have markings.
Insert the tube.
• Lubricate the tip of the tube well with water- A water-soluble lubricant dissolve if the tube
soluble lubricant or water to ease insertion. accidentally enters the lungs. An oil-based
lubricant, such as petroleum jelly, will not
dissolve and could cause respiratory
complications if it enters the lungs.
• If the client continues to gag and the tube does To determine if the tube is really in client’s
not advance with each swallow, withdraw it stomach and not.
slightly, and inspect the throat by looking through
the mouth.
PURPOSES:
ASSESSMENT:
EQUIPMENT:
STEPS RATIONALE
Assist the client to a Fowler’s position (at least These positions enhance the gravitational flow of
30° elevation) in bed or a sitting position in a the solution and prevent aspiration of fluid into
chair, the normal position for eating. If a sitting the lungs.
position is contraindicated, a slightly elevated
right sidelying position is acceptable.
Introduce yourself, verify client’s identity and To gain client’s cooperation.
explain to the client what you are going to do.
Wash hands For infection control.
Provide privacy. This procedure may be embarrassing to some
clients.
Remove the plunger from the syringe and Pinching or clamping the tube prevents excess air
connect the syringe to a pinched or clamped from entering the stomach and causing
gastric tube distention.
Assess tube placement. Determines location of the tube.
Testing the pH
Checking for residual contents
Auscultating for gurgling sounds by injecting air.
Administer the feeding. Quickly administered feedings can cause flatus,
While clamping the NG tube, pour the feeding cramps, and/or vomiting.
unto the Asepto syringe, release clamping, and
permit the feeding to flow slowly. If the client
experiences discomfort, pinch or clamp the
tubing to stop the flow.
Finish the feeding by adding water to the NG Flushes any residual feeding that may obstruct
tube. tube.
Ask the client to remain sitting upright in Fowler’s These positions facilitate digestion and
position or in a slightly elevated right lateral movement of the feeding from the stomach
position for at least 30 minutes. along the alimentary tract, and prevent the
potential aspiration of the feeding into the lungs.
Perform after care and monitor the client for
possible problems.
Document all relevant information
NASOGASTRIC TUBE(NGT) REMOVAL
ASSESSMENT:
EQUIPMENT:
Tissues
Clean gloves
Moisture-proof trash bag
STEPS RATIONALE
Check doctor’s order for confirmation of removal
of NGT.
Assist the client to a sitting position, if possible.
Introduce yourself, verify client’s identity and To gain client’s cooperation/
explain to the client what you are going to do.
Wash hands. For infection control.
Provide privacy. This procedure may be embarrassing to some
clients.
Don clean gloves For infection control.
Remove the adhesive tape securing the tube to
the nose.
Pinch the tube with the gloved hand. Smoothly, Pinching the tube prevents any contents inside
withdraw the tube. the tube from draining into the client’s throat.
Place the tube in the trash bag. Placing the tube immediately into the bag
prevents the transference of microorganisms
from the tube to other articles or people.
Ensure client comfort. Excessive secretions may have accumulated in
Provide mouth care if desired. the nasal passages.
Perform after care and monitor the client for
possible problems.
Document all relevant information. Record the removal of the tube, the amount and
appearance of any drainage.
OROGASTRIC TUBE (OGT) FEEDING
DEFINITION:
A thin soft tube is passed through a child’s mouth, through the oropharynx, through the
esophagus and into the stomach
PURPOSES:
ASSESSMENT:
EQUIPMENT:
STEPS RATIONALE
Place the infant/child in a upright position. This position decreases the risk of aspiration.
Remove the plunger from the syringe and place
the tip of the syringe into the enteral tube
connector at the end of the enteral tube.
Holding the syringe and enteral tube straight,
pour the prescribed amount of feeding into the
syringe.
Let it flow slowly through tube.
Pour the prescribed amount of water into the Flushing prevents blockage of tube.
syringe and allow to flow through to flush the
feeding tube.
Replace the cover of the tube. Flushing prevents blockage of the tube.
Replace cover of the tube. To ensure that no air can pass through the tube.
Maintain infant/child’s upright position for 30 To avoid regurgitation.
minutes.
Perform after care.
Document all pertinent observations.
ADMINISTERING A GASTROSTOMY OR JEJUNOSTOMY TUBE FEEDING
DEFINITION:
A percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is created
by using an endoscope to visualize the inside of the stomach, making a puncture through the skin and
subcutaneous tissues of the abdomen into the stomach, and inserting the PEG or PEJ catheter through
the puncture. The surgical opening is sutured tightly around the tube or catheter to prevent leakage.
PURPOSES:
To restore or maintain nutritional status.
ASSESSMENT:
1. For any clinical signs of malnutrition or dehydration.
2. For allergies to any food in the feeding. If the client is lactose intolerant, check the tube feeding
formula. Notify the primary care provider if any incompatibilities exist.
3. For the presence of bowel sounds.
4. For any problems that suggest lack of tolerance of previous feedings (e.g., delayed gastric
emptying, abdominal distention, diarrhea, cramping, or constipation).
EQUIPMENT:
1. Correct type and amount of feeding
2. Asepto syringe
3. Emesis basin
4. Clean gloves
5. Water
STEPS RATIONALE
Introduce yourself, verify client’s identity and
explain to the client what you are going to do.
Wash hands and provide privacy. To gain client’s cooperation.
Don gloves For infection control.
Administer the feeding.
• Hold the barrel of the syringe 7 to 15 cm (3 to 6
in.) above
• Slowly pour the solution into the syringe and Quickly administered feedings can cause flatus,
allow it to flow through the tube by gravity. cramps, and/or vomiting.
Just before the syringe is empty, add 30 mL of Water flushes the tube and preserves its patency.
water.
Remove the syringe, and then clamp or plug the To prevent blockage.
tube.
Remove and discard gloves.
Perform hand hygiene For infection control.
Ensure client comfort and safety. This prevents the risks of aspiration.
Position the client in semi-sitting or sitting
position.
Perform aftercare and wash hands.
Document all pertinent observations.
NASOGASTRIC TUBE INSERTION AND FEEDING
Introduction:
Nasogastric tube feeding is common practice and many tubes are inserted daily without incident.
However, there is a small risk that the tube can become misplaced into the lungs during insertion,
or move out of the stomach at a later stage.
Auscultation must not be used to check correct nasogastric tube (NGT) placement as studies have
shown this method to be inaccurate. NG tubes should be aspirated and the tube position confirmed
using pH indicator strips that are CE marked and intended for use on human gastric aspirate.
DEFINITION OF NGT INSERTION
Naso-gastric a method of introducing a tube through nose into stomach for therapeutic or
diagnostic purpose.
Naso-gastric feeding tube:
Defined as between a between a 6 – 8 French gauge. The length of the tube is measured in cm
starting at the distal tip (stomach end = “0” cm). The tube is made of silicone or polyurethane
which is passed through the nostril via the naso-pharynx into the esophagus, then stomach.
Nasogastric tubes used for the purpose of feeding must be radio-opaque throughout their
length and have
PURPOSE OF NGT
INSERTION:
Medical Staff:
The decision to commence artificial nutrition via a naso-gastric tube is a medical decision to be
made in conjunction with the patient, the patients’ family and members of the MDT.
Before a decision is made to insert a naso-gastric tube, an assessment is undertaken to identify
if nasogastric feeding is appropriate for the patient, and the rationale for any decisions is
recorded in the patients’ medical notes.
Radiology Department:
Radiographers: are responsible for ensuring that the nasogastric tube can be clearly seen on the
x-ray to be used to confirm tube position.
Introduction:
Patients in the hospital, as well as home care settings, often require nutritional supplementation
with enteral feeding.
Enteral feeding can be administered via nasogastric, nasoduodenal and nasojejunal means. The
focus of this clinical practice guideline is on the nursing management of nasogastric tube
feeding.
Nasogastric tube feeding may be accompanied by complications.
Thus, it is important for the practitioner to be aware of how to
DEFINITION:
Nasogastric tube feeding is defined as the delivery of nutrients from the nasal route into the
stomach via a feeding tube
MANAGEMENT OF NGT FEEDING:
pH TESTING:
A Combination of aspirate appearance and pH testing can be used to help make correct
predictions about tube placement in the stomach.
pH value of aspirates from feeding tubes should be used to differentiate between gastric and
respiratory placement.
The pH values and their corresponding indications and action:
Flush feeding tubes with 30 ml of water before and after intermittent feeding, every 4-hourly
during continuous feeding and after checking for gastric residuals. More frequent flushing might
be ordered according to patient’s condition.
Flush feeding tube before and after administration of each Medicine and after checking for
residual.
FEEDING POSITION:
TYPES OF FEEDING:
1. Bolus Feeding:
The total volume of feeds administered should not exceed 400ml during each bolus feed.
Both the speed and volume with which formula is delivered has an impact on intragastric
pressure and the probability of gastroesophageal reflux.
Bolus feeding of more than 400 ml and rapid infusion may result in abdominal distension and
discomfort.
2. Continuous Feeding
Use feeding pump for administration of continuous feeds.
Start with an initial slow rate of 10 to 40 ml/hour. Advance to the goal rate by increasing the
rate by 10 to 20 ml/hour every 8-12 hours as tolerated.
Continuous feeding is recommended for patients who are critically ill, receiving jejunal feedings;
or patients who are unable to tolerate intermittent feedings. Pump-assisted delivery of enteral
feeds is highly recommended for small
Management of Feeding Intolerance
Gastric residual volume (GRV) should be checked 4-8 hourly in Continuously fed patients and
before each intermittent feeding.
GRV greater than 200 ml should prompt careful bedside evaluation and initiation of appropriate
feeding method and feeding volume. GRV reading should be evaluated in conjunction with
physical examination for abdominal distension, absence of bowel sounds, and presence of
nausea and vomiting.
A trend in GRV may be more important than an isolated high level of GRV.
There is no significant difference between returning and not returning gastric residuals.
DECLOGGING:
Use warm water to declogg obstructed feeding tubes. If unsuccessful, pancreatic enzyme with
sodium bicarbonate may be used.
Warm water is the most effective irrigant in declogging blocked feeding tubes. However, a
solution of digestive enzymes (pancrealipase) mixed with sodium bicarbonate (to activate the
enzyme) has been shown to be fairly effective in dissolving formula occlusions.
RECAPTUALIZATION:
Nasogastric tube feeding may be accompanied by complications. Thus, it is important for the
practitioner to be aware of how to prevent these complications so that nasogastric tube feeding can be
administered successfully and safely.
CAPILLARY BLOOD GLUCOSE TESTING
- Capillary blood glucose (CBG) testing was developed to replace home urine glucose testing by
patients or by the staff in physician offices. CBG testing can also be applied in the hospital
laboratory as a cost-effective method to rapidly test blood glucose levels.
Purpose:
convenient way of monitoring blood glucose patterns and can be a useful aid in guiding
treatment changes in patients with type 1 and type 2 diabetes especially during periods of
instability, for example, illness or frequent hypo glycaemia.
A test to determine blood glucose level
Objectives:
Materials:
1. Glucometer
2. Lancet holder
3. Test strips
4. Gloves
5. Alcohol
6. Cotton balls
7. Lancets
STEPS RATIONALE
1. Test the machine’s calibration with a Varies the machine accuracy.
control strip or solution supplied by the
manufacturers. If not have been done since
midnight
2. Arrange care so that the test is Ensure consistency in obtaining data and
performed approximately 30 minutes before a facilitates detection of trends.
meal and at bed time.
3. Collect the necessary equipment and Promote efficient time management.
Supplies.
4. Turn on the machine, observe the last Prepare the machine for testing the blood
blood glucose reading current test strip sample. The machine retains the last glucose
code and the message “insert strip”
measurement in its memory
5. Place the matched end of one strip into Locates the strip in position for the action
the holder with one test strip. of the blood.
6. Assemble the lancet within the spring Loads hold the lancet in place and prepare
loaded lancet holder. the lancet for rapid trust to the skin.
7. Don clean gloves after washing hands or Provides a barrier to blood exposure.
performing hand antisepsis with alcohol rub.
8. Select a non-traumatized side of a Avoid puncturing an area with sensitive nerve
clients’ finger or thumb; avoid the central Endings.
pads
9. Place the injector, if used, against the The lancet is designed to pierce the skin at
site, and release the needle, thus permitting a specific depth when it is in a
it to pierce the skin. Make sure the lancet is perpendicular position relative to the skin.
perpendicular to the site.
9.Prick the site with a lancet or needle,
using a darting motion.
Gently squeeze (but do not touch) the puncture
site until a drop of blood forms. The size of the
drop of blood can vary depending on the meter.
Some meters require as little as 0.3 mL of blood
to accurately test blood sugar.
Hold the reagent strip under the puncture site Smearing will cause an inaccurate reading.
until adequate blood covers the indicator square.
The pad will absorb the blood and a chemical
reaction will occur.
Do not smear
Ask the client to apply pressure to the skin Pressure will assist hemostasis.
puncture site with a 2×2 gauze.
10. Expose the blood to the test strip for the
period and the manner specified by the
manufacturer. As soon as the blood is placed on
the test strip:
Follow the manufacturer’s recommendations on The blood must remain in contact with the test
the glucose meter and monitor for the amount of strip for a prescribed time to obtain accurate
time indicated by the manufacturer results.
1. Measure the blood glucose.
Documentation:
Generally, refers to the type of care that first-responders, healthcare providers and public safety
professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an
obstructed airway, requires knowledge and skills in cardiopulmonary resuscitation (CPR), using
automated axternal defibrillators (AED) and relieving airway obstructions in patients of every age.
(REDCROSS)
Is a level of medical care which is used for victims of life-threatening illnesses or injuries until they
can be given full medical care by advanced life support providers. It can be provided by trained
medical personnel, such as emergency medical technicians, and by qualified bystanders. (Wikipedia)
Includes recognition of signs of sudden cardiac arrest SCA) heart attack, stroke, and foreign-body
airway obstruction (FBAO): cardiopulmonary resuscitation (CPR): and defibrillation with an
automated external defibrillator (AED)
CPR means giving rescue breaths followed by a number of chest compressions, and repeating
this cycle continuously until the ambulance arrives.
Compressions – push hard and fast on the center of the victim’s chest.
Airway – tilt the victim’s head back, and lift the chin to open the airway.
Breathing – give mouth-to-mouth rescue breaths.
Ensure your own safety first. then that of the victim (for example, if the victim s lying on a road, take
steps to alert oncoming traffic).
Gently tap the victim and shout "are you alright?" If the victim can respond and there is no further
danger from their location, leave the victim in the position they are in. If there is no response, shout
for help. Send for help if there is more than one rescuer present.
Ask that person to dial 911/ depend on your local number for an ambulance cand return to confirm
that the ambulance is on the way. Tell the ambulance dispatcher the location and telephone number
closest to the scene and be prepared to provide other information before hanging up.
Do not hang up until instructed to do so.
If alone, the rescuer should assess the victim for unresponsiveness and absence of signs of life before
going for help,
The victim must be on his/her back on a firm surface
If the victim is unconscious, breathing and has other signs of life, turn the victim onto his/her side in
the recovery position and ensure the airway is kept open.
PROCEDURE
1. Position the casualty lying on their back. Ensure they are on a firm surface
2. Kneel to one side of the casualty.
3. Locate the notch where the ribs meet the breastbone.
4. Place the middle finger of one hand in the notch and the index finger next to the middle finger
5. Place the heel of the other hand next to the two fingers.
6. Place the other hand on top so the heels of both hands are over the same point on the
breastbone.
7. Interlock the fingers to keep them off the chest.
8. With your elbows straight and locked, and your shoulders over the casualty’s chest, press straight
down using the weight of your body to compress the breastbone 4 - 5cm (the depth of an adult's
thumb). Use a smooth uninterrupted rhythm allowing equal time for compression and relaxation.
9. Give 30 compressions at a rate of 80-100 compressions a minute.
10. Give two slow, full breaths.
11. Reposition hands and administer a further 30 compressions/two breaths
12. Continue the ratio of 30 compressions/two breaths. After completing four cycles of chest
compressions and breaths, administer two further breaths and then check the pulse in the neck.
Recovery position
The recovery position Is designed for unconscious casualties (but do not use if you suspect the casualty
has neck or spinal injuries). It helps to maintain an open airway and allows vomit and other fluid to drain
freely from the mouth. To move a causality lying on their back into the recovery position, follow these
step
AED) are portable, life-saving devices designed to treat people experiencing sudden cardiac arrest, a
medical condition in which the heart stops beating suddenly and unexpectedly
COMPONENTS OF AN AED:
a. On button (power)
b. Shock button (to deliver a shock)
c. Display screen (voice/text commands)
4. Defibrillation is the stopping of the fibrillation of the heart to restore normal contractions, especially
by the use of an electric shock.
Altered Level of Consciousness (LOC)
Consciousness may be impaired by any disorder that affects the cerebral Hemisphere of the
brain stem. When assessing LoC, make sure that you provide a stimulus that' s strong enough to
get a true picture of the patient s baseline.
The Glasgow Coma Scale offers an Objective way to assess the patient's LOC. Decerebrate and
decorticate postures are indicators of severe neurologic damage. LOC 1s the most sensitive
indicator of neurologic dysfunction and may be a valuable adjunct to other findings.
- The reliability of the GCS is based on recording the patient 'best" response.
- If the patient does not follow commands or 1s unresponsive to voice, then the nurse proceeds to
increasingly noxious (painful) stimuli to elicit an eye and motor response.
- Typically, the patient’s response to central pain (brain response) 1s assessed first.
- On the basis on this respon.se, peripheral pain may then be assessed.
- Failure to apply painful stimuli appropriately may lead to an incorrect conclusion about the patient
's neurologic status.
- If the patient responds fully to voice or light touch, there is no need to progress to more vigorous or
painful stimuli.
PROCEDURE
1. Start with the least noxious irritation or pressure and proceed to more painful stimulation it the
patient does not respond.
2. Begin each phase of the assessment by speaking in a normal voice.
3. If no response is obtained, use a loud voice. If the patient does not respond, gently shake him or
her.
4. The shaking should be similar to that sed in attempting to wake up a child.
5. 1f that is unsuccessful, apply painful stimuli using one of these methods:
METHODS
Supraorbital (above eyes) pressure by placing a thumb under the orbital rim in the middle of the
eyebrow and pushing upward. Do not use this technique if the patient has orbital or facial fractures.
Trapezius muscle squeeze by pinching or squeezing the trapezius muscle located at the angle of the
shoulder and neck muscle.
Mandibular (jaw) pressure to the jaw by using your index and middle fingers to pinch the 1lower
jaw.
Sternal (breastbone) rub by making a fist and rubbing/twisting your knuckles against the Sternum
NOTE:
Although the initial response to pain may be abnormal flexion or extension, continued
application of pain for no more than 20 to 30 seconds may demonstrate that he or she can
Localize or Withdraw.
If the patient does not respond after 20 to 30 seconds, stop applying the painful stimulus.
A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and
should be communicated to the health care provide immediately.
Other findings requiring urgent communication with the health care provider include a new
finding of abnormal flexion Or extension, particularly of the upper extremities (decerebrate or
decorticate posturing) pinpoint, dilated, and nonreactive pupils and sudden or subtle changes in
mental status. Remember, changes in cognition are the earliest signs or changes in neurologic
status.
Early recognition of neurologic changes and communicating changes to the health care provider
provide the best opportunity to prevent complications and preserve function
Level of Consciousness
- Level of consciousness (LOC) can lie anywhere along a continuum from a state of alertness to
Coma. A fully alert client responds to questions Spontaneously? a comatose client may not
respond to verbal stimuli
- The Glasgow Coma scale was originally developed to predict recovery from a head injury
however, it is used by many professionals to assess LOC. It tests in three major areas: eye
response, motor response, and verbal response. An assessment totaling 15 points indicates the
client is alert and completely oriented. A comatose Client scores 7 or less
NON-SURGICAL MASK AND GOWN TECHNIQUE
PROCEDURE:
1. Assemble equipment.
2. Write name on envelope for which to keep mask.
3. Using both hands, open the mask at the corners taking care not to touch the inside part.
4. Place the mask over the mouth & nose, then the string at the back.
5. Hold gown at shoulder seams, take gown from hook & hold at arm length.
6. Open gown & slipped arms through sleeves. 2
7. Draw the neck of the gown into place, touching only the inner part of the gown.
8. Tie the upper strings at the neck.
9. Draw the left side of the gown across the back & cross right side over it.
10. Draw the belt end & fasten them at the back.
1. Wash hands with betadine wash & dry them with the towel.
2. Unfasten the string of the gown at the back of the neck and belt.
3. Put one finger inside the sleeve without touching the outer part & place it over the head.
4. With the protected end, pull the other sleeves with the opposite hand.
5. Slip the gown off, turning inside out.
6. Make a pocket at the shoulder seams & hang the gown on the rack.
7. Remove the mask by touching only the ties.
8. Scrub hands, forearms & elbow thoroughly with soap & water for at least 1 minute in
the utility room.
Note:
1. Mask should never be place inside the worker’s pocket or be left hanging around the neck.
2. It should not be used the next day (change daily).
3. Wash hands well before & after entering the patient’s room.
ADMINISTERING A TUBE FEEDING
Procedure:
1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to do,
why it is necessary, and how the client can cooperate.
2. Assist the client to a Fowler’s position in bed, or a sitting position in a chair. If a sitting position is
contraindicated, a slightly elevated right- side lying position is acceptable.
3. Perform hand hygiene, and observe other appropriate infection control procedures.
4. Provide for client privacy.
5. Assess the tube placement.
Attach the syringe to the open end of the tube, and aspirate. Check Ph.
o Allow 1 hour to elapse before testing the Ph, if the client has received medication.
o Use Ph meter rather than Ph paper, if the client is receiving a continuous feeding.
If the tube was placed in the stomach, aspirate all contents, and measure the amount
before administering the feeding.
If 100 ml (or more than half of the last feeding) is withdrawn, check with the nurse in charge
or refer to agency policy before proceeding.
Re-instill the gastric contents into the stomach, if this is the agency policy or the primary
care provider’s order.
If the client is on a continuous feeding, check the gastric residual every 4-6 hours or
according to agency protocol.
6. Administer the feeding.
Before administering feeding:
o Check the expiration date of the feeding.
o Warm the feeding to room temperature.
Remove the bulb from the syringe, and connect the syringe to a pinched or clamped
Nasogastric tube.
Add the feeding to the syringe barrel.
Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to
adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute, if the
client experiences discomfort.
After feeding, instill 50-100 ml of water through the feeding tube.
Be sure to add the water before the feeding solution has drained from the neck of a syringe
or from the tubing.
7. Clamp the feeding tube.
Clamp the feeding tube before all of the water instilled.
8. Ensure client comfort and safety.
Secure the tubing to the client’s gown.
Ask the client to remain sitting upright in fowler’s position or in a slightly elevated right
lateral position for at least 30 minutes.
Check the agency’s policies on the frequency of changing the Nasogastric tube and the use
of smaller-lumen tubes if a large- bore tube is in place.
9. Dispose of equipment appropriately.
If the equipment is to be reused, wash it thoroughly with soap and water, so that it is ready
for reuse.
Change the equipment every 24 hours, or according to agency policy.
10. Document all relevant information.
Document the feeding, including amount and kind of solution taken, duration of the feeding,
and assessment of the client.
Record the volume of the feeding and water administered on the client’s intake and output
record.
11. Monitor the client for possible complications.
Carefully assess client’s receiving tube feedings for problems.
To prevent dehydration, give the client supplemental water in addition to the prescribed
tube feeding, as ordered.
DONNING STERILE GOWNS AND CLOSED GLOVING
PROCEDURE:
1. Don surgical attire and scrub your arms and hands as described.
2. Have the circulating nurse or other designated person open the sterile gown and gloves.
3. Don Gown
4. Pick up and unfold the gown.
5. Identify the inner surface of the gown and pick up the gown beneath the neckband without
touching the sterile field or other surface of the gown.
6. Make sure you have control of all the folded layers to avoid dangling the gown against the
unsterile surfaces.
7. Move away from the tablet, holding the gown away from your body at arm’s length, holding the
gown away from your body at arm’s length and allow it to unfold from the top down. Do not let
the gown touch the floor.
8. Hold the gown just below the neckband near the shoulders and slide both hands into the
sleeves until the fingers are at the end of the cuffs but not through the cuffs. The fingers
remained covered to prepare for the closed gloving.
9. Have someone tie the gown
10. Put on the gloves.
11. Apply the first glove.
12. With your hands covered by the sterile gown cuffs. The first glove goes on the dominant hand
13. Position the glove on the forearm so the cuff faces the hand and the fingers face the elbow.
14. Begin to put the opposite hand into the glover with the sleeve cover of the hand to be gloved.
15. Grasp the back of the glove cuff with the sleeve-covered second hand and turn the cuff over the
sleeve.
16. Push your fingers into the glove.
17. Apply the second glove.
18. Use your sterile hand to pick up the second glove. Put the second glove in the same position as
the first on the opposite forearm.
19. Put on the second glove in the same manner as the first.
20. Adjust the gloves for fit and comfort.
ENTERING AND LEAVING AN ISOLATION ROOM
Procedure:
1. CAREGIVER
2. ADVOCATE
3. HEALTH EDUCATOR
4. RESEARCHER
5. TEAM LEADER/MANAGER
6. COORDINATOR/COLLABORATOR
7. TRAINER/FACILITATOR
8. COMMUNITY ORGANIZER
1. CAREGIVER
The caregiver role has traditionally included those activities that assist the client physically and
psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial,
developmental, cultural and spiritual levels.
2. CLIENT ADVOCATE
Client advocate acts to protect the client. Represent the client’s needs and wishes to other health
professionals, such as relaying the client’s wishes for information to the physician. Assist clients in
exercising their rights and help them speak up for themselves.
4. RESEARCHER
Research is essential.
It is the only evidence-based method of deciding whether a new approach to treatment or care is better
than the current standard, and is essential to diagnose, treat, prevent, and cure disease. Research
nurses play a vital role in delivering research, and ultimately improving patient care.
5. TEAM LEADER/MANAGER
A leader influences others to work together to accomplish a specific goal. The leader role can be
employed at different levels; individual client, family, groups of clients, colleagues, or the community.
Effective leadership is a learned process requiring an understanding of the needs and goals that
motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence
others.
6. NURSE MANAGER
The nurse manages the nursing care of individuals, families, and communities. Delegates nursing
activities to ancillary workers and other nurses, and supervises and evaluates their performance.
6. COORDINATOR
a. A nurse coordinator supervises and coordinates care for his assigned unit or patients.
b. This is referred to as a charge nurse
c. Ensures that patient care is up to applicable standards and works to make sure the patients in
his care, other staff members, and visitors are safe in the health care environment.
d. Assist with developing care plans for patients and make sure they are carried out according to
the facility's standards.
e. Helps to hire and train new staff members for his unit and provides evaluations of their work as
well.
f. Helps to hire and train new staff members for his unit and provides evaluations of their work as
well.
g. Communicates with doctors, patients, and loved ones of patients regarding plans for patient
care.
h. Help establish care plans for the patients in his unit or department and revise them as
necessary.
i. Monitor the health care environment to ensure patient care plans are carried out as expected.
j. Inform other nursing staff members or the doctor in charge of the patient’s treatment, if there
are problems noted with care.
k. Ensure patient responses to treatment are documented as well.
l. Instructs staff members in order to help them provide adequate patient care.
m. Prepares staff evaluations as well.
n. Work to ensure that an adequate number of staff members are available for a particular shift.
6. COLLABORATOR
Collaborative care – is a healthcare model which aims to improve patient outcomes through inter-
professional cooperation.
This will commonly include a primary or tertiary care team working with allied health professionals –
such as dieticians, physiotherapists or mental health professionals – or medical specialists.