Therapeutic Procedures 3853

THERAPEUTIC PROCEDURES SELECTED TOPICS ON COMMON NURSING PROCEDURES

UNIVERSAL PRECAUTIONS  HANDWASHING  BARRIER

METHOD  STERILIZATION AND DISINFECTION  IMMUNIZATION  ENVIRONMENTAL CONTROL AND SANITATION  ISOLATION

SURGICAL ASEPSIS  MAINTENANCE  MEDICAL

OF STERILE FIELD

AND SURGICAL ASEPTIC TECHNIQUES

THERAPEUTIC EXERCISES  ISOMETRIC  ISOTONIC  ROM

CHEST PHYSIOTHERAPY  BREATHING  COUGHING\POSTURAL

DRAINANGE  PERCUSSION AND VIBRATION  INCENTIVE SPIROMETER  SUCTIONING  TRACHEOSTOMY CARE  OXYGEN THERAPY

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

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

pulmonary function tests tidal volume- 500  residual volume- 1200  expiratory reserve volume –1200  inspiratory reserve volume – 3100 

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

incentive spirometry – hold 2-6 sec; 4-5 times/H  endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly  visualization – 

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X ray Lung Scxan – 20-40mins isotopes in body for 8 H laryngoscopy Bronchoscopy Thoracentesis- consent, VS and baseline X-ray + post Procedural

Tracheostomy Care  tie

new trache tie before removing the old tie to prevent accidental dislodgement  use precut gauze and perform care OD at least.  soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well  suction prn, oral care prn

Oxygen Delivery Equipment cannula – 2-6 LPM – 24-45%  Mask – 5-8 LPM – 40-60%  parial rebreather – 6-10 LPM – 60-90%  non rebreather – 10-15 LPM – 95-100%  tent – 4-8 LPM – 30-50 %  Venturi mask – 

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2-3 LPM – 24-28% 4 LPM – 30% 6 LPM – 35% 8 LPM – 45% 14LPM – 55%

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

ENEMA They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.  Enemas serve the following purpose: 

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Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications

ENEMA Take note of the general principles of Enema:  Tube: lubricate and insert 3-4 inches  Position: adult- left lateral; infants and children- dorsal recumbent  Administration- administer the enema in a minimum of 15 minutes duration.  Conatainer’s Height- 12 inches above the rectum  Temperature- 42°C or less 

types:     

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

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

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IF FEELING OF FULLNESS – CLAMP – 30 SECS

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

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rectal tubes    

infants-10-12F toddler – 14 –16F school age – 16-18F adult – 22 – 30F

ENEMAS- PRESCRIBED AMOUNT AND TIME  HYPERTONIC

– 5-10MINS – VARIES  HYPOTONIC(TAP)-15-20MIN – 5001000ML  ISOTONIC(SALINE)-15-20MIN- 50ML  SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP  oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.

COLOSTOMY CARE  ostomy

– divert and drain fecal material

 temporary

( trauma / inflammatory

condition)  permanent ( Cancer / congenital or Birth defects  stoma

– red , initial slight bleeding normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation

 parts:  periostomal

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

 ileostomy

– no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full  colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation  avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended

 dry

skin before applying appliance  karaya – barrier to prevent contamination with excreta  appliance can be up to 2 weeks  broadwell 48 – 72 hours to check for periostomal skin  24-48 hours if eroded / ulcerated  refer to enterostomal therapy nurse  with deodorant ( Charcoal filter Disk)

Catheterization, urinary PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.  NURSING ALERT:        Know the necessary facts:

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Principles Position Length of tube in. French number or Circumference Length of tube to be inserted Balloon size

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Male Supine 40 cm./ 15.75 in.

#14- 16

Female Dorsal recumbent 22cm./ 8.66

#18

2-3 in. 6-9 in. 5-10 ml. (30 ml 5-10 ml Can be used to achieve hemostasis of the prostatic area following prostatectomy

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Place to secure

lower abdomen

Inner thigh

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

CATHETER CHANGE  PLASTIC

– 1 WEEK  LATEX – 2-3 WEEKS  SILICONE – 2-3 MOS.  PVC – 4-6 WEEKS

CLOSED INTERMITTENT IRRIGATION  ASPIRATE

FROM PORT  CBI -3 WAY FOLEY CAHETER  CATHETER IRRIGATION ONLY – 200 ML.  BLADDER IRRIGATION – 1000ML  CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED

URINARY DIVERSIONSURINARY STOMA  ILEAL

CONDUIT- EXTERNAL POUCH  KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN  SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS

NORMAL AMOUNT/ DAY  1-3

/ 500-600ML  3-5 / 600-700ML  5-8 / 700-100OML  8-14 / 800 – 1400ML  14 – ADULT / 1500 – 2500  CAN

HOLD 500 – 750 ML

Bladder training Q2 hours and 30 mins void(Trigerring, Credes and valsalva) NEUROGENIC BLADDER Intermitent Catheterization – 2-3 hours if <150ml ----3-4 H weaning-intermittent clamping DTV 1-4 hours after removal for incontinence – kegels exercises

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

PERITONEAL DIALYSIS   

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

CAPD(4-6H INDWELLING), AUTOMATED 30MINS EXCHANGES, INTERMITTENT- 4X A WEEK – 10H/DAY, CONTINOUS – 1 DAY INDWELLING

DRESSINGS PROTECT FROM INJURY , BACTERIAL CONTAMINATION  PROVIDE HUMIDITY  INSULATION  ABSORB DRAINAGE  DEBRIDE THE WOUND  PREVENT HEMORRHAGE  SPLINT / IMMOBILIZE  COMFORT 

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GUAZE, SYNTHETIC , SECURING, TEGADERM

TYPES OF DRESSINGS DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE  WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE  WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)  WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE 

WOUND HEALING HEMOSTASIS---FIBRIN---PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS  FIBROBLAST—COLLAGEN--CAPILLARIES----GRANULATION TISSUE--ESCHAR---(PROLIFERATIVE 3 – 21 DAYS  MATURATION(PHASE 21 DAYS – 2 YEARS) 

pressure ulcer dressings  dry

gauze stage II-IV  tegaderm film/ hydrocolloid – SI - SII  Absorptive Dressing III  Hydrogel – II - III

WOUND CARE PRIMARY  SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)  TERTIARY- ABD. DRAINAGE 

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EXUDATES – SUPPURATION PUS – ABCESS( PYOGENIC BACTERIA)

SURGICAL DRAINS PENROSE – OPEN ENDS  CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBESHEMOVAC / JACK PRATT TO RESERVOIR  D/C 3-7 DAYS POST – OP  PACKAGE – FACILITATE GRANULATION  IRRIGATION LAVAGE - STERILE 

CHEST TUBES AND DRAINAGE SYSTEMS 1-DRAINAGE  2-WATERSEAL  3-COLLECTION/SUCTION 

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

NUTRITIONAL

SUPPORT NGT-GAVAGE AND LAVAGE TPN

Nasogastric Tube Insertion  Purposes: 

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Gastric Gavage- gastric feeding Gastric Lavage- stomach irrigation For decompression Medication and supplemental fluid administration

Principles:  Position: High-Fowler’s position  Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.  Lubricate the tip of the tube by a water soluble lubricant before insertion  Secure the NGT by taping to the bridge of the nose 

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Gastroenteral Feedings This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall. Remember these principles: Position: fowler’s or sitting position Prior to feeding, assess the bowel sounds and residual content Assess for tube placement and patency: 

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Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated. X-ray most accurate Aspirate gastric content Immerse the tip of the tube in water, no bubbles must be produced.

Height of feeding: 12 inches above the patient’s point of insertion Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube

TOTAL PARENTERAL NUTRITION  peripheral<

2 weeks – phlebitis  PIC – Basilic / cephalic  PCC – subclavian  Triple Lumen- infuse and draw blood;TPN;Medications  Atrial- Hickman/Biovac and Groshong; Huber needle port

TOTAL PARENTERAL NUTRITION TPN-IV with bacterial filter(2-3L)  TNA – 1 liter/D-no filter  If no available solution D10W –ok –initial at 50ml/hr 

hyperglycemia- hyperosmolar(HA, N and Vomiting,fever, chills, malaise)  Infection ( IV tubing and filter Q24 changed,solutions refrigerated and warmed just prior to administration  Pneumothorax 

Heat and Cold Therapy  An intervention the reduces inflammation  Principles:  Cold application is generally safer than heat application.  Heat application usually requires a doctor’s order  Cold application is done within 72 hours after an injury, while heat application is done after 72 hours.  The application of heat and cold is done at a maximun of 30 minutes (an average of 15-20 minutes)  Check the area applications are done every 15 minutes.

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

DOSAGES AND CALCULATION CONVERSIONS  MEDICATION DOSAGES 

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D/A X V = Q

INFUSIONS 

TOTAL VOLUME X DROP FACTOR TIME IN HOUR ( 60 MIN.)

THERAPEUTIC DOSE  CLARKS RULE  BSA COMPUTATION  IV INFUSION FOR BURNS 

 MEDICATION

ADMINISTRATION

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

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

IV THERAPY  backflow

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

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

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hemolytic anaphylactic febrile hypervolemic septic

Hygiene and comfort measures

 BEDMAKING-

OD  PERINEAL CARE – FRONT TO BACK  OUTER

TO INNER, ONE COTTONBALL PER STROKE

BEDBATHING AND ND SHAMPOO  FOOT, HAIR , SKIN AND NAIL CARE  ORAL CARE  EYE AND EAR CARE 

THERAPEUTIC BATH SALINE – 4 ML- 500 ML  OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES  CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION  Na CHO3 – 4 ml. – 500 ml H2O 

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cooling / relieves irritation KMnO4 – tablets dissolved in H2O – clears and disinfects

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

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

INFANTS HTCL MANEUVER, JAW THRUST IF SPINAL INJURY IS SUSPECTED  INITIAL BREATHS – 2 – 1 1/2 SECS  SUBSEQUENT BREATHS 1 B/3 SECS; 20 BPM  USE 2 OR 3 FINGERS  DEPTH:1/2 TO 1 INCH  COMPRESSION AT LEAST 100/MIN  RATIO 5:1; CHECK AFTER 20 CYCLES  FOREIGN BODY OBSTRUCTIONS: BACKBLOWS AND CHEST THRUST 

CHILDREN

HTCL / JAW THRUST  2 BREATHS INITIAL DURATION OF 1- 1 ½ SECS  SUBSEQUENT 1 BREATH EVERY 3 SECONDS  20 BREATHS/ MIN  CAROTID ARTERY  HEEL OF HAND  1 TO 1 1\2 INCH  100 BPM; CHECK AFTER 12 CYCLES  ABDOMINAL THRUST- FOR AIRWAY OBSTRUCTION 

ADULTS  HTCL

/ JAW THRUST  INITIAL 2 BREATHS AT LEAST 2 SECS EACH  DEPRESS 1 ½ - 2 INCHES; RATE 60 TO 100  RATIO 5:1  AFTER 4 CYCLES ;RECHECK FOR 10 SECS

ERGONOMICS  TRANSFER

TECHNIQUES  BODY POSITIONING  BODY MECHANICS