Clinical Nursing Procedures: The Art of Nursing Practice Annamma Jacob, Rekha R, Jadhav Sonali Tarachand
INDEX
A
Abdominal paracentesis 462
ACLS algorithm 393
dosage 394
medications 394
Administering subcutaneous injection 281
articles 281
procedure 281
Administering enema 208
administration of evacuant enema 211
cleansing/evacuant enema 208
fluid amount and tube insertion length agewise 213
paediatric variations 213
procedure 209
special considerations 213
Administering intradermal injection 284
articles 284
procedure 284
purposes 284
Administering intramuscular injection 286
acceptable sites for infants and children 288
articles 286
paediatric variations 288
procedure 286
special consideration 288
special points 289
Administering bolus medications through intravenous route 290
articles 290
disadvantages 290
procedure 290
purposes 290
special considerations 292
Administering metered dose inhalation 301
after care of the patient 303
articles 301
procedure 301
purposes 301
special consideration 303
Administering nasal drops 298
articles 298
general instructions 298
paediatric variation 300
procedure 298
purposes 298
unexpected outcomes 300
Administering nasogastric/orogastric tube feed for children 642
Administering of an intravenous infusion 255
articles required 255
procedure 255
purposes 255
Administering oral medication 270
articles required 270
contraindications 270
paediatric variations 274
procedure 270
purpose 270
special considerations 273
Administering oxygen by mask method 227
articles 227
procedure 227
purposes 227
special considerations 228
Administering oxygen using oxygen tent 229
advantages 229
articles 229
description 229
disadvantages 229
procedure 229
special considerations 230
Administering rectal suppositories 304
articles 304
contraindications 304
paediatric variations 305
procedure 304
purposes 304
special consideration 305
Administering steam inhalation 231
articles 231
procedure 231
purposes 231
special points 233
Administration of medication through nasogastric tube 308
articles required 308
procedure 308
purpose 308
special considerations 309
Administration of nasogastric tube feeding 180
articles 180
indications 180
procedure 180
purposes 180
special considerations 182
Administration of total parenteral nutrition 187
articles 188
methods of parenteral nutrition 187
procedure 188
purposes 187
Admission of a patient in hospital 58
articles 58
procedure 58
purposes 58
Admission procedure 526
Admitting a client to labour room 563
Admitting a patient in psychiatric unit 526
aims of admission procedure 526
procedure 526
types of admissions 526
Albumin 24
Amniocentesis 559
Antenatal abdominal examination 545
Antenatal exercises 550
Anthropometric measurements 659
Anthropometry 645
Application of an ice cap 114
articles 114
contraindications 114
procedure 114
purposes 114
special considerations 115
Application of cold compress 116
articles 116
procedure 116
purposes 116
Application of hot water bag 111
articles 111
contraindications 111
procedure 111
purposes 111
special considerations 113
Applying a condom catheter 192
articles 192
indication 192
procedure 192
purposes 192
special considerations 194
Applying bandages 323
articles 323
principles of bandaging 323
purposes 323
types of bandages 323
Applying binders 332
articles 332, 333, 334
procedure 332, 333, 334
purposes 334
types of binders 332
Applying mask and sterile gown 511
articles required 511
procedures 511
purposes 511
Applying restraints 164
articles 164
procedure 164
special considerations 167
Applying topical medications 310
articles required 310
procedure 310
purposes 310
Arterial puncture 398
Assessing respiration 10
articles 10
normal respiratory rate agewise 10
paediatric variations 10
procedure 10
purposes 10
Assessment of consciousness using Glasgow Coma Scale (GCS) 484
articles 484
procedure 484
purposes 484
Assessment of oxygen saturation using pulse oximeter 234
description 234
indications 234
procedure 234
purposes 234
special considerations 236
Assessment of pulse 6
articles 6
normal pulse rate for infants and children 9
paediatric variations 9
procedure 8
purposes 6
special points 9
Assisting patient to sitting position 134
procedure 134
purposes 134
Assisting in abdominal paracentesis 462
articles 463
paracentesis 462
procedure 463
purposes 463
Assisting in exchange transfusion 628
Assisting in insertion of intrauterine contraceptive device (copper-T) 602
Assisting in oral hygiene for a conscious patient 78
articles 78
indications 78
paediatric variations 80
procedure 78
purposes 78
Assisting the patient with the use of an incentive spirometer 237
articles 237
indications 237
procedure 238
purposes 237
special consideration 239
types 237
Assisting with an amniocentesis 559
Assisting with application of plaster of paris (POP) 336
articles 336
procedure 336
purposes 336
Assisting with application of skin traction 318
additional articles 318
articles 318
guidelines for use of traction 320
procedure 320
purposes 318
special considerations 322
types of traction 318
Assisting with application of slings 315
articles 315
procedure 315
purposes 315
types of slings 315
Assisting with application of splints 313
articles 313
procedure 313
purposes 313
Assisting with arterial puncture 398
articles 398
normal values 400
procedure 398
purposes 398
Assisting with bone marrow aspiration and biopsy 493
articles 493
complications 495
contraindication 493
paediatric variation 496
postprocedural care 495
procedure 494
purposes 493
special consideration 495
Assisting with breastfeeding 621
Assisting with bronchoscopy 415
complications 416
postprocedure care 416
procedure 415
purposes 415
special consideration 416
Assisting with computerized axial tomography scan 489
contraindications 489
follow-up care 490
procedure 489
purposes 489
special considerations 490
Assisting with crutch walking 345
follow-up activities 350
preparatory exercises 345
procedure 346
teaching strategies 351
Assisting with dilatation and curettage procedure 591
Assisting with endoscopic retrograde cholangiopancreatography (ERCP) 469
articles 469
complications 471
postprocedural care 470
procedure 469
purposes 469
special considerations 471
Assisting with endoscopic sclerotherapy 447
articles 447
contraindications 447
postprocedural care 448
procedure 447
purposes 447
Assisting with endotracheal intubation 417
articles 417
complications 417
indications 417
procedure 418
purposes 417
special considerations 420
Assisting with forceps delivery 585
Assisting with hypnosis therapy 540
contraindications 540
drawbacks of hypnotism 541
effects of hypnosis 541
factors involved in hypnosis 541
indications 540
objectives 540
precautions to be followed 541
procedure 540
Assisting with induction of labour 565
Assisting with insertion of central venous catheter 406
contraindications 406
geriatric variation 408
pediatric variation 408
procedure 407
purposes 406
Assisting with insertion of Sengstaken-blakemore tube/balloon tamponade 449
articles 449
procedure 449
purpose 449
special considerations 451
Assisting with insulin subcoma therapy 542
contraindications 542
indications 542
procedure 542
Assisting with intravenous pyelography (IVP) 473
contraindications 473
postprocedure care 474
procedure 473
purposes 473
Assisting with liver biopsy 466
articles 466
postprocedure care 467
procedure 467
purpose 466
types of biopsy 466
Assisting with lumbar puncture 486
articles 486
complications 488
contraindications 486
procedure 486
purposes 486
special considerations 488
Assisting with magnetic resonance imaging (MRI) scan 491
contraindications 491
procedure 491
purposes 491
special considerations 492
Assisting with narcoanalysis/abreactive therapy 543
articles 543
contraindications 543
indications 543
procedure 543
purposes 543
Assisting with obtaining a Papanicolaou smear 46
articles needed 46
methods of obtaining Pap (Papanicolaou) smear 46
procedure 46
purposes 46
special considerations 48
Assisting with postoperative exercises 519
exercises include 519
special considerations 524
Assisting with removal of chest drainage tubes 440
articles 440
follow-up activities 441
procedure 440
special consideration 441
Assisting with renal biopsy 475
articles 476
contraindications 476
other articles 476
postprocedural care 477
procedure 476
purposes 475
Assisting with the use of a urinal 191
articles 191
procedure 191
special consideration 191
Assisting with thoracentesis 434
articles 434
procedure 434
purposes 434
Assisting with tracheostomy 421
articles 421
postprocedural care 422
procedure 422
purposes 421
Assisting with upper gastrointestinal endoscopy 444
articles 445
complications 446
indications 444
postprocedural care 445
procedures 445
purposes 444
Assisting with use of bedpan 206
articles 206
procedure 206
purposes 206
types 206
Assisting with ventouse extraction 589
Assisting with walking using walker and cane 342
cane walking 343
procedure 343
special considerations 344
walker 342
Automated external defibrillator 391
B
Baby bath/tub bath 674
Back massage 106
Bag techniques at home 657
Balloon tamponade 449
Bandages 323
Bandaging 323
Barium enema 456
Barium studies 454
Bathing a newborn 632
Bathing a patient in bed 84
articles 84
procedure 84
purposes 84
special considerations 86
Bed shampoo 94
Bedpan 206
Benedict’s solution 22
Binders 332
Biomedical waste 154
Biopsy 466, 493
Bladder irrigation 204
Blood pressure 11
Blood transfusion reactions and nursing management 265
procedure 265
Body fluids spills 156
Body mechanics 126
Body temperature 2
Bone marrow aspiration 493
Bowel wash 215
Breastfeeding 621
Breast self-examination 52
Bronchoscopy 415
Burn wounds 357
C
Cane walking 343
Cannula method 224
Cardiac bed 76
Cardiac catheterisation 374
Cardiac life support 389
Cardiopulmonary resuscitation 384, 650
articles 650
indications 650
meaning 650
procedure 650
Care of baby undergoing phototherapy 624
Care of body after death 122
articles 122
procedure 122
purposes 122
releasing body 124
Care of newborn in incubator (Isolette) 626
Catheter care 200
Central venous catheter 406, 413
Central venous pressure (CVP) 410
Central venous tubing 414
Cerebral angiography 403
Changing intravenous container, tubing and dressing 259
articles 259
procedure 259
purposes 259
Changing dressing at central venous catheter insertion site 413
articles 413
procedure 413
Changing central venous tubing 414
articles 414
procedure 414
Checking height and weight of a patient 15
articles 15
procedure 15
purposes 15
special considerations 16
Checking specific gravity of urine 20
articles 20
procedure 20
purposes 20
special consideration 21
Checking temperature at home 667
articles 667
principles of the thermometer technique 667
procedure 667
Checking weight and height 661
equipment 661
measuring height 661
principles for checking weight 661
procedure 661, 662
special points 662
Chemical convulsive therapy 537
Chest drainage tubes 440
Chest physiotherapy 241
Chiatric unit 527
Cleansing/evacuant enema 208
Cleft lip 640
Cleft palate 640
Cold compress 116
Cold sponge 120
Collecting blood for peripheral smear 43, 670
articles 43, 670
procedure 43, 670
purposes 43, 670
Collecting blood for routine examination 35
articles 35
procedure 35
purposes 35
Collecting stool specimen for culture 30
articles 30
procedure 30
purpose 30
special considerations 30
Collecting stool specimen for routine examination 28
articles 28
procedure 28
purpose 28
Collecting throat swab for culture 31
articles 31
procedure 31
purpose 31
Collecting urine specimen for routine examination 17
articles 17
procedure 17
purpose 17
special considerations 18
Collecting urine specimen for culture 25
articles 25
procedure 25
purposes 25
special considerations 26
Collecting wound swab for culture 32
articles 32
procedure 32
purpose 32
Collection of 24
hours urine 27
articles 27
procedure 27
purposes 27
Collection of blood for culture 41
articles 41
procedure 41
special considerations 42
Collection of specimens for laboratory investigations 665
articles 665
principles 665
procedure 665
special consideration 666
Collection of sputum for culture 45
equipments 45
procedure 45
special consideration 45
Colonic lavage 215
Colonoscopy 458
Colostomy care 218
Colostomy irrigation 222
Computerized axial tomography scan 489
Condom catheter 192
Conducting a domiciliary delivery 677
articles needed 677
contraindications 677
procedure 678
Conducting a general preoperative assessment and checklist 501
Conducting a normal vaginal delivery 572
Conducting process recording 531
format for process recording 531
general guidelines 531
purposes 531
Connecting and changing intercostal drainage (ICD) bottles 436
articles 436
indications 436
meaning 436
procedure 436
purpose 436
special considerations 438
Crutch walking 345
Cystoscopy 478
D
Defibrillators 389
Digital subtraction angiography 401
Dilatation and curettage procedure 591
Discharge of a patient from hospital 61
article 61
general principles 61
procedure 61
special considerations 62
Discharging a patient from psychiatric unit 527
procedure 527
Discontinuing an intravenous infusion 261
articles 261
procedure 261
Administration of blood (blood transfusion) 262
articles 262
procedure 262
purposes 262
special considerations 264
Disinfection of blood and body fluids spills 156
articles 156
points to be remembered when selecting the disinfectant 158
procedure 156
purposes 156
Domiciliary delivery 677
Draping patient 510
Draping trolley 509
Dressing burns wound 356
articles 356
procedure 357
purposes 356
topical antimicrobial agents used for burn wounds 357
types of wound dressing 356
Dressing wound at home 672
articles 672
principles 672
procedure 672
purposes 672
Drug administration 269
E
Ear irrigation 101
Electrocardiogram 367
Electroconvulsive therapy 533
Electroencephalography 482
Endoscopic retrograde cholangiopancreatography 469
Endoscopic sclerotherapy 447
Endotracheal intubation 417
Endotracheal/tracheal suctioning 427
Enema 208
Estimation of hemoglobin at home using haemoglobinometer 668
articles 668
Estimation of hemoglobin level using hemoglobin testing paper 669
articles 669
procedure 669
purpose 669
special points 669
Exercises 597
Exercise endpoint 372
Exercise stress test 370
Explanation 454
Eye care 97
Eye irrigation 99
F
Feeding helpless patient 173
articles 173
procedure 173
purpose 173
special considerations 174
Feeding infants 640
cleft lip 640
cleft palate 640
Feeding through a gastrostomy/jejunostomy tube 183
articles 183
procedure 183
purpose 183
special considerations 185
Flushing a central venous catheter 409
articles 409
geriatric variation 409
paediatric variation 409
procedure 409
Forceps delivery 585
Fowler’s position 144
G
Gastric lavage 452
Gastric suctioning 442
Gastrostomy 183
Genital care 90
Geriatric variation 408
Giving a baby bath/tub bath 674
articles 674
procedure 674
special note 674
Giving a cold sponge 120
articles 120
contraindication 120
procedure 120
purpose 120
Giving a lap/leg bath 675
articles required 675
procedure 675
purposes 675
Giving a tepid sponge 118
articles 118
procedure 118
purpose 118
Giving sponge bath for a newborn 635
Glasgow Coma Scale (GCS) 484
Glucometer 38
Glucose 23
Growth assessment for children (anthropometry) 645
H
Haemoglobinometer 668
Hair removal 503
Hair wash 94
Handwashing at home 656
Height 661
Heimlich manoeuvre 395, 654
adult 395
children 654
Hemoglobin testing paper 669
Hot water bag 111
Hygienic perineal care 90
Hypnosis therapy 540
Hypnotism 541
I
Ice cap 114
Indoklon 538
Indwelling urinary catheter 202
Inserting medication into vagina 306
articles 306
procedure 306
purposes 306
Insertion of a nasogastric tube 175
articles 175
procedure 175
purposes 175
special consideration 178
Instilling medication into ear 293
articles 293
contraindication 293
paediatric variations 294
procedure 293
purposes 293
special considerations 294
Instilling medication into eyes 295
articles 295
paediatric variations 297
procedure 295
purposes 295
Insulin subcoma therapy 542
Intercostal drainage (ICD) bottles 436
Intradermal injection 284
Intramuscular injection 286
Intrauterine contraceptive device (copper-T) 602
Intravenous infusion 255
Intravenous pyelography (IVP) 473
J
Jejunostomy tube 183
K
KUB X-ray 472
L
Laboratory investigations 665
Labour room 563
Lap/leg bath 675
Lateral/side lying position 147
Lithotomy position 149
Liver biopsy 466
Logrolling patient 131
procedure 131
purpose 131
technique 131
Lumbar puncture 486
M
Magnetic resonance imaging (MRI) scan 491
Mask 227, 511
Measuring blood for glucose level using glucometer 38
articles 38
procedure 38
special considerations 40
Measuring body temperature 2
articles 2
common methods 2
contraindications 2
indications 2
normal temperature in children 5
paediatric variations 5
preparation of child 5
procedure 3
purposes 2
special points 5
Measuring central venous pressure (CVP) 410
articles 410
geriatric variation 411
paediatric variation 411
procedure 410
Measuring intake and output 49
articles 49
procedure 49
purposes 49
special considerations 51
Measuring involution of uterus 595
Medical handwashing 150
Medications 394
Mental status examination (MSE) 528
Metered dose inhalation 301
Monitoring blood pressure 11
articles 11
normal BP range–agewise 14
paediatric variations 14
procedure 11
purposes 11
special precautions 13
Moving a patient up in bed 128
procedure 128
purposes 128
N
Nail and foot care 87
Narcoanalysis/abreactive therapy 543
Nasal drops 298
Nasogastric tube 175, 180
Nebulization therapy 249
Neonatal resuscitation 616
Newborn assessment 608
Newborn care 606
Nonstress test (NST) 552
Normal BP range–agewise 14
Normal diet 171
Normal pulse rate for infants and children 9
Normal respiratory rate agewise 10
Normal temperature in children 5
Normal values 400
Nosocomial infections 159
Nursing considerations 392
O
Open/unoccupied bed 65
Oral care 81
Oral hygiene 78
Oral medication 270
Orogastric tube feed 642
Oropharyngeal sunctioning 431
Orthopneic position 145
Oxygen saturation 234
Oxygen tent 229
Oxygen therapy—cannula method 224
articles 224
procedure 224
purposes 224
special precautions 226
Oxytocin challenge test 555
P
Pacemaker implantation 377
Palpation 545
Pap (Papanicolaou) smear 46
Paracentesis 462
Parenteral nutrition 187
Patient education 382
Patient’s rights 269
Pediatric variation 408
Performing bladder irrigation 204
articles 204
procedure 204
purposes 204
Performing a bowel wash/colonic lavage 215
articles 216
contraindications 215
procedure 216
purposes 215
solutions used 215
special consideration 217
temperature of the solution 215
Performing cardiopulmonary resuscitation 384
articles 384
indications 384
objective of CPR 384
procedure 384
sequence of BLS 384
when to stop CPR 387
Performing a gastric lavage or stomach wash 452
articles 452
procedure 452
purposes 452
solutions used 452
Performing a Heimlich manoeuvre (adult) 395
procedure 395
purposes 395
special considerations 397
Performing newborn assessment 608
Performing nonstress test (NST) 552
Performing surgical scrub 498
articles 498
procedure 498
purposes 498
sepcial consideration 500
Performing a urinary catheterization 195
articles 195
procedure 196
types 195
Performing a venipuncture for intravenous therapy 251
articles used 251
contraindications 251
paediatric variations 254
procedure 251
purposes 251
Performing wound dressing 353
articles 353
procedure 353
purposes 353
special consideration 355
Performing an antenatal abdominal examination and palpation 545
Performing an examination of placenta 578
Performing oxytocin challenge test 555
Performing and suturing episiotomy 581
Performing bag techniques at home 657
principles 657
procedure 658
supplies and equipment 657
Performing catheter care 200
Performing chest physiotherapy 241
articles 241
contraindications 241
indications 241
paediatric variations 243
procedure 241
purpose 241
special considerations 243
Performing colostomy care 218
articles 218
procedure 218
purposes 218
special considerations 220
Performing colostomy irrigation 222
articles 222
procedure 222
purposes 222
Performing defibrillation and advanced cardiac life support (ACLS) 389
articles 390
automated external defibrillator 391
complications 392
indications 389
nursing considerations 392
procedure 390
purpose 389
types of defibrillators 389
Performing ear irrigation 101
articles 101
procedure 101
purposes 101
solutions used 101
Performing endotracheal/tracheal suctioning 427
additional articles 428
articles 427
procedure 428
purposes 427
special considerations 430
Performing eye care 97
articles 97
procedure 97
purposes 97
Performing eye irrigation 99
articles needed 99
procedure 99
purposes 99
Performing gastric suctioning 442
articles 442
procedure 442
purposes 442
special considerations 443
Performing handwashing at home 656
articles 656
purposes 656
procedure 656
Performing Heimlich manoeuvre for children 654
procedure 654
Performing medical handwashing 150
articles 150
indications 150
procedure 150
purposes 150
Performing mental status examination (MSE) 528
format for mental status examination (MSE) 528
general instructions 528
purposes 528
Performing nail and foot care 87
articles 87
procedure 87
purposes 87
Performing nebulization therapy 249
articles 249
procedure 249
purposes 249
Performing neonatal resuscitation 616
Performing oral care for an unconscious patient 81
articles 81
procedure 81
purposes 81
Performing oropharyngeal suctioning 431
articles 431
procedure 431
purposes 431
special consideration 432
Performing postural drainage 245
articles 245
contraindications 245
paediatric variations 248
positions for draining different areas of lungs 245
procedure 246
special considerations 248
Performing skin preparation for surgery 503
articles 503
methods of hair removal 503
procedure 503
purposes 503
special consideration 507
Performing sterile gloving 513
articles required 513
procedure (donning of gloves) 513
purposes 513
Performing urine analysis 663
articles 663
principles 663
procedure 663
purpose 663
Performing vaginal examination for a patient in labour 569
Performing wound irrigation 362
articles 362
procedure 362
purposes 362
special considerations 364
Perineal care 593
Peripheral smear 43, 670
Permanent pacemakers 380
pH 19
Phototherapy 624
Pinsite care in skeletal traction 341
articles 341
procedure 341
Placenta 578
Plaster of Paris 336
Policies for segregation and disposal of biomedical waste 154
Policies on drug administration 269
current practice 269
patient’s rights 269
Positioning and restraining children for procedures 168
preparation of child and parents 168
Positioning of patient in bed 144
articles 144
general principles in positioning 144
purposes 144
Fowler’s position 144
lateral/side lying position 147
lithotomy position 149
orthopneic position 145
prone position 146
Sim’s position/semi-prone position 148
supine position/dorsal recumbent/back lying 146
Trendelenburg position 149
Positioning patients for surgery 515
articles 516
factors that determine position 515
guidelines for positioning a patient on the operation table 515
purposes 515
special considerations 518
Postoperative bed 74
Postoperative exercises 519
Postural drainage 245
Practicing principles of body mechanics 126
advantages/benefits 126
factors affecting body alignment and activity 127
procedure 126
Preparation for and assisting with cerebral angiography 403
complications 404
postprocedural care 404
procedure 403
purposes 403
Preparation for and assisting with digital subtraction angiography 401
indications 401
interfering factors 401
postprocedural care 402
procedures 401
special considerations 402
Preparation for KUB X-ray 472
contraindication 472
purposes 472
Preparation for skull and spine X-ray 480
procedure 481
purposes 480
Preparation for ultrasonography 465
meaning 465
Preparation of patient and assisting with barium enema 456
contraindications 456
indications 456
procedure 456
purpose 456
Preparation of patient and assisting with barium studies (upper GI series) 454
explanation 454
procedure 455
purposes 454
Preparation of patient and assisting with cardiac catheterisation 374
articles 374
contraindications 374
procedure 375
purposes 374
special considerations 376
Preparation of patient and assisting with colonoscopy 458
articles 458
general instruction 458
postprocedure care 459
procedure 458
purposes 458
special consideration 459
Preparation of patient and assisting with cystoscopy 478
articles 478
complications 479
postprocedural care 479
preprocedural preparation 478
procedure 479
purposes 478
Preparation of patient and assisting with electroencephalography (EEG) 482
postprocedure care 482
procedure: the procedure is performed in a special unit 482
purposes 482
Preparation of patient and assisting with exercise stress test 370
contraindications and precautions 370
exercise endpoint 372
indications 370
procedure 371
protocols 372
treatment of adverse reactions 373
Preparation of patient and assisting with pacemaker implantation 377
classification of pacemakers 377
complications 382
patient education 382
postprocedure care 381
preparation of the patient for permanent pacemaker insertion 381
procedure 378, 381
recording 382
special consideration 382
types of permanent pacemakers 380
Preparation of patient and assisting with proctoscopy 460
articles 460
contraindications 460
possible complications 461
procedure 460
purposes 460
special considerations 461
Preparatory exercises 345
Preparing a cardiac bed 76
articles 76
procedure 76
purposes 76
Preparing a postoperative bed 74
articles 74
procedure 74
purposes 74
Preparing prenatal patient for ultrasound examination 557
Preparing occupied bed 70
articles 70
procedure 70
purposes 70
special points 73
Preparing open/unoccupied bed 65
articles 65
procedure 65
purposes 65
special considerations 69
Preparing an operation theater trolley and patient before surgery 508
articles 508
procedure 508
purposes 508
special points 508
Preparing patient and assisting with chemical convulsive therapy 537
advantages of using Indoklon 538
after care of the client 538
contraindications 537
indications 537
preparation of the patient 537
procedure 537
side effects of indoklon and management 539
Preparing patient and assisting with electroconvulsive therapy (ECT) 533
articles 533
complications 535
contraindications 533
indications 533
procedure 533
special consideration 536
Preprocedural preparation 478
Prevention of nosocomial infections 159
measures to prevent nosocomial infections 160
Process recording 531
Proctoscopy 460
Prone position 146
Protocol for sample collection of blood 33
Providing bed shampoo/hair wash 94
articles 94
contraindications 94
procedure 95
purposes 94
special considerations 96
Providing back massage 106
articles 106
contraindications 106
procedure 106
purposes 106
special considerations 108
Providing genital care/hygienic perineal care 90
articles 90
indications 90
procedure 90
purposes 90
Providing immediate newborn care 606
Providing perineal care 593
Providing range of motion exercises 140
general guidelines 140
procedure 140
purposes 140
special points 143
Providing sitz bath 109
articles 109
contraindications 109
indications 109
procedure 109
purposes 109
special consideration 110
Providing tracheostomy care 423
equipment 424
procedure 424
purposes 423
special considerations 426
Psychiatric unit 526
Pulse 6
Pulse oximeter 234
R
Range of motion exercises 140
Reagent strip 23
Recording 382
Recording an electrocardiogram (ECG) 367
articles 367
procedure 367
purposes 367
special considerations 369
Rectal suppositories 304
Removal of sutures and staples 359
articles 359
procedure 359
special considerations 361
specific instructions for staple removal 360
Removing an indwelling urinary catheter 202
articles 202
procedure 202
purposes 202
special considerations 203
Renal biopsy 475
Respiration 10
Routine examination 28
S
Semi-prone position 148
Sengstaken-blakemore tube 449
Serving normal diet 171
articles 171
procedure 171
purposes 171
Sim’s position 148
Sitz bath 109
Skeletal traction 341
Skin traction 318
Skull and spine X-ray 480
Slings 315
special considerations 29, 60, 172, 297, 340
special considerations 60, 340
types 336
Spirometer 237
Splints 313
Sputum for culture 45
Staple removal 360
Steam inhalation 231
Sterile gloving 513
Sterile gown 511
Sterile technique 509
draping patient 510
draping trolley 509
Stomach wash 452
Subcutaneous injection 281
Supine position/dorsal recumbent/back lying 146
Surgery 503, 515
Surgical scrub 498
Sutures and staples 359
Suturing an episiotomy 581
T
Taking anthropometric measurements 659
articles 659
procedure 659
purpose 659
special points 660
Tape 23
Teaching antenatal exercises 550
Teaching breast self-examination (BSE) 52
articles 52
procedure 52
special considerations 54
Teaching postnatal exercises 597
Teaching strategies 351
Teaching testicular self–examination (TSE) 55
procedure 55
special considerations 56
Temperature at home 667
Tepid sponge 118
Testicular self–examination (TSE) 55
Testing urine for albumin 24
articles 24
procedure 24
Testing urine for glucose (reagent strip or tape) 23
articles 23
procedure 23
special consideration 23
Testing urine for glucose (Benedict’s solution) 22
articles 22
procedure 22
purpose 22
Testing urine for pH 19
articles 19
procedure 19
purpose 19
Thermometer technique 667
Thoracentesis 434
Throat swab 31
Topical antimicrobial agents 357
Topical medications 310
Total parenteral nutrition 187
Tracheostomy 421, 423
Traction 318
Transfer of a patient from unit to unit and hospital to hospital 63
articles 63
procedure 63
purposes 63
Transferring a patient between a bed and a stretcher 137
articles 137
procedure 137
purposes 137
variation 138
Transferring a patient from bed to chair 135
procedure 135
purposes 135
Transfusion 628
Trendelenburg position 149
Turning a patient to lateral or prone position 130
purposes 130
procedure 130
special consideration 130
U
Ultrasonography 465
Ultrasound examination 557
Unexpected outcomes 300
Upper gastrointestinal endoscopy 444
Upper GI series 454
Urinary catheterization 195
Urine analysis 663
Use of comfort devices 103
purposes 103
Uterus 595
V
Vaginal delivery 572
Vaginal examination 569
Venipuncture 251
Venous catheter 409
Ventouse extraction 589
W
Walker and cane 342
Weighing a newborn 638
Withdrawing or preparing medications from vial and ampoule 275
articles 275
description 275
procedure 275
special considerations 279
Wound at home 672
Wound dressing 353, 356, 362
Wound swab for culture 32
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Chapter Notes

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Health AssessmentChapter 1

  • 1.1 Measuring Body Temperature
  • 1.2 Assessment of Pulse
  • 1.3 Assessing Respiration
  • 1.4 Monitoring Blood Pressure
  • 1.5 Checking Height and Weight of a Patient
  • 1.6 Collecting Urine Specimen for Routine Examination
  • 1.7 Testing Urine for pH
  • 1.8 Checking Specific Gravity of Urine
  • 1.9 (A) Testing Urine for Glucose (Benedict's Solution)
  • 1.9 (B) Testing Urine for Glucose (Reagent Strip or Tape)
  • 1.10 Testing Urine for Albumin
  • 1.11 Collecting Urine Specimen for Culture
  • 1.12 Collection of 24 Hours Urine
  • 1.13 Collecting Stool Specimen for Routine Examination
  • 1.14 Collecting Stool Specimen for Culture
  • 1.15 Collecting Throat Swab for Culture
  • 1.16 Collecting Wound Swab for Culture
  • 1.17 Protocol for Sample Collection of Blood
  • 1.18 Collecting Blood for Routine Examination
  • 1.19 Measuring Blood for Glucose Level using Glucometer
  • 1.20 Collection of Blood for Culture
  • 1.21 Collecting Blood for Peripheral Smear
  • 1.22 Collection of Sputum for Culture
  • 1.23 Assisting with Obtaining a Papanicolaou Smear
  • 1.24 Measuring Intake and Output
  • 1.25 Teaching Breast Self-examination (BSE)
  • 1.26 Teaching Testicular Self-examination (TSE)2
 
1.1: MEASURING BODY TEMPERATURE
 
DEFINITION
Measuring temperature of the body using a clinical thermometer.
 
COMMON METHODS
  1. Oral
  2. Rectal
  3. Axillary
  4. Tympanic membrane
 
INDICATIONS
  1. Routine part of assessment on admission for establishing a base-line data.
  2. As per agency policy to monitor any change in patient condition.
  3. Before, during and after administration of any drug that affects temperature control function.
  4. When general condition of patient changes.
  5. Before and after any nursing intervention that affects temperature of the patient.
 
PURPOSES
  1. To assess the general health status of patient.
  2. To assess for any alteration in health status.
 
CONTRAINDICATIONS
  1. Oral method
    1. Patients who are not able to hold thermometer in their mouth.
    2. Patients who may bite the thermometer like psychiatric patients.
    3. Infants and small children
    4. Surgery/infection in oral cavity
    5. Trauma to face/mouth
    6. Mouth breathers
    7. Patients with history of convulsion
    8. Unconscious/semi conscious/disoriented patients.
    9. Patients having chills
    10. Unco-operative patients.
    11. Patients who cannot follow instructions.
  2. Rectal method
    1. Patients after rectal surgery
    2. Any rectal pathology (piles/tumor)
    3. Patients having difficulty in assuming required position
    4. Acute cardiac patient
    5. Patients having diarrhea
    6. Reduced platelet count.
  3. Axillary method
    1. Any surgery/lesion in axilla.
 
ARTICLES
A clean tray containing
  1. A bottle with disinfectant solution (dettol 1: 40/savlon 1:20)
  2. A bottle with water3
  3. Thermometer (rectal thermometer in case of rectal method)
  4. A small bowl with cotton swabs
  5. Paper bag/kidney tray
  6. Pens
  7. Flow sheet/graphic chart/paper
  8. Lubricant (in case of rectal method)
    If using more than one thermometer, use 3 bottles (2 with antiseptic solution and one with water).
 
PROCEDURE
Nursing action
Rationale
1. Ascertain method of taking temperature and explain procedure to the patient and instruct him how to co-operate.
  1. In case of oral method, ensure that patient had not taken any hot or cold food and fluids orally or smoked in 15–30 minutes prior to procedure.
  2. For rectal method, provide privacy and position the patient in a Sim's position. In young children position laterally with knees flexed or prone across lap.
  3. For axillary method, expose axilla and pat dry with a towel. Avoid vigorous rubbing.
Causes alteration in temperature reading.
Position ensures easy access to insert thermometer.
Friction produced by rubbing can cause increase in temperature.
2. Wash hands
3. Prepare equipment
  1. If glass thermometer is in disinfectant solution, transfer it to container with plain water using dominant hand.
  2. Wipe thermometer dry, using a clean cotton swab using rotatory motion from bulb to stem.
  3. Shake down the mercury (if needed) by holding thermometer between thumb and forefinger at thetip of stem. Shake till mercury is below 35 degree centigrade (95 degree Fahrenheit).
Ensures complete removal of disinfectant and reduces irritation to tissues.
Using dominant hand reduces chances of accidental breakage.
Wiping from an area of least contamination to an area of greatest contamination prevents spread of organisms.
Reduces chances of error in reading temperature.
4. Check temperature
  1. For oral method
    1. Place bulb of thermometer at base of tongue on the side of frenulum in the posterior sublingual pocket (Figure 1.1(a)).
zoom view
Figure 1.1(a): Positioning thermometer for oral temperature (thermometer under tongue)
Blood supply is more in this area and hence reflects the temperature of blood in the larger blood vessels.
4
    1. Instruct patient to close the lips and not teeth around thermometer.
    2. Leave thermometer in place for 2–3 minutes.
  1. For rectal method
    1. Don clean gloves
    2. Apply lubricant on the bulb of thermometer using cotton ball.
    3. With non-dominant hand, expose the anus raising upper buttocks.(Figure 1.1(b) (i))
    4. Instruct patient to breathe deeply and insert thermometer into anus. (Figure 1.1(b) (ii))
      • 3.5 – 4 cm in adults
      • 1.5 cm in infant
      • 2.5 cm in child
      • Do not force insertion
    5. Hold thermometer in place for 1–2 minutes.
      zoom view
      Figure 1.1(b): (i) Positioning patient for inserting rectal thermometer, (ii) Inserting rectal thermometer
  2. For axillary method
    1. Place bulb in the center of axilla (Figure 1.1(c))
    2. Place arm tightly across chest to hold thermometer in place.
    3. Hold thermometer in place for 3–5 minutes.
zoom view
Figure 1.1(c): Positioning thermometer for obtaining axillary temperature (Thermometer in axilla)
Clenching teeth can cause the thermometer to break and cause injury.
Ensures accurate recording
Lubricant facilitates easy insertion without irritating mucous membrane.
Taking deep breath relaxes external sphincter thereby facilitating easy insertion.
Ensures accurate recording
Prevents thermometer from falling down. Ensures accurate recording
5. Remove thermometer Wipe using a cotton ball from stem to bulb in a rotatory manner.
Wiping from an area of least contamination to an area rotatory manner. of greatest contamination will help in preventing spread of microorganisms.
5
6. Read the temperature, holding thermometer at eye level and rotate it till reading is visible and read it accurately.
Holding at eye level prevents error in reading.
7. Shake down the mercury level
8. Clean thermometer using soap and water.
Removes organic material.
9. Dry it and store it in disinfectant solution.
10. Document temperature
Normal body temperature is 37°C (98.4°F)
11. Wash hands
Reduces risk of transmission of microorganisms.
12. Replace articles.
 
SPECIAL POINTS
  1. It is always best to use individual thermometer for each patient.
  2. When individual thermometer is not used in patient care-units (wards), axillary method is recommended.
  3. For converting temperature from centigrade to Fahrenheit following conversion formula can be used.
    C = 5/9 × F-32
    [C = Centigrade]
    [F = Fahrenheit]
 
PAEDIATRIC VARIATIONS
Methods of assessing body temperature in paediat patients include:
  • Skin temperature sensors
  • Tympanic thermometer.
 
PREPARATION OF CHILD
  • Talk to the child and explain what will be done.
  • Perform an examination in appropriate, non-threatening manner.
  • Place all strange and potentially frightening articles out of sight.
  • Provide privacy especially for school age and adolescent children.
  • Encourage child to handle/use actual equipment/article on a doll, family member or staff.
  • Observe behaviours that signal child's readiness to co-operate.
  • Involve child in the procedure.
  • Explain each step in simple language.
  • Reassure the child throughout the procedure.
  • Discuss findings with family at the end.
  • Praise the child for co-operation and give small rewards such as a sticker.
 
NORMAL TEMPERATURE IN CHILDREN
Age
Centigrade
Fahrenheit
3–11 months
37.4
99
1–3 years
37.6
99
4–7 years
37
98.6
8–13 years
36.8–37
98–98.4
6
 
1.2: ASSESSMENT OF PULSE
 
DEFINITION
Checking pulse rate, rhythm, volume, etc. for assessing circulatory status.
 
PURPOSES
  1. To establish baseline data
  2. To check abnormalities in rate, rhythm and volume
  3. To monitor any change in health status of the patient.
  4. To check the peripheral circulation.
Table 1.2.1   Common sites for checking pulse (Figure 1.2(a))
Site
Location
Reasons for use
1. Radial
Inner aspect of the wrist on thumb side (Figure 1.2(b)).
Easily accessible.
2. Temporal
Site superior (above) and lateral to (away from the midline) the eye (Figure 1.2(c)).
Used when radial pulse is not accessible. Easily accessible pulse in children.
3. Carotid
At the side of the trachea where the carotid artery runs between the trachea and the sternocleidomastoid muscle (Figure 1.2(d)).
To assess cerebral perfusion.
4. Apical
Left side of the chest in the 4th, 5th or 6th intercostal space in the midclavicular line (Figure 1.2(e)).
Used to find out discrepancies with radial pulse.
5. Brachial
Medially in the antembital space (Figure 1.2(f)).
Used to monitor blood pressure and assess for lower arm circulation.
6. Femoral
Below inguinal ligament, midway between symphysis pubis and anterosuperior iliac spine (Figure 1.2(g)).
To assess circulation to lower limb.
7. Popliteal
Medial or lateral to the popliteal fossa with knees slightly flexed (Figure 1.2(h)).
Used to determine circulation to the leg. To take blood pressure in the lower limb.
8. Posterior tibial
On the medial surface of the ankle behind the medial malleolus.
To assess circulation to the foot.
9. Dorsalis p e dis
Along dorsum of foot between extensor tendons of great and first toe (Figure 1.2(i))
To assess circulation to the foot.
10. Ulnar pulse
On the little finger side, outer aspect of the wrist.
To assess circulation to ulnar side of hand. To perform Allen's test.
 
ARTICLES
  1. Wrist watch with second hand
  2. Pen (color as per agency policy)
  3. Vital signs chart and flowsheets7
zoom view
Figure 1.2(a): Common sites for checking pulse
zoom view
Figure 1.2(b): Checking radial pulse
zoom view
Figure 1.2(c): Checking temporal pulse
zoom view
Figure 1.2(d): Checking carotid pulse
zoom view
Figure 1.2(e): Checking apical pulse
8
zoom view
Figure 1.2(f): Checking brachial pulse
zoom view
Figure 1.2(g): Checking femoral pulse
zoom view
Figure 1.2(h): Checking popliteal pulse
zoom view
Figure 1.2(i): Checking dorsalis pedis pulse
 
PROCEDURE
Nursing action
Rationale
1. Explain procedure to patient and check if the patient had just been involved in any activity. If so allow the patient to rest for 10 minutes before taking pulse.
Activity can increase the pulse rate.
2.
  1. Select the pulse site
  2. Assist the patient to a comfortable position. For radial pulse, keep the arm, resting over chest or on the side with palm facing downward. In sitting position, keep the arm resting over thigh with palm facing downward.
Usually radial pulse is selected. If any particular extremity is to be assessed then another pulse site is to be selected.
3. Palpate and check pulse
  1. Place tips of 3 fingers other than thumb lightly over pulse site.
  2. After getting the pulse regularly, count the pulse for one whole minute looking at the second hand on the wrist watch.
  3. Assess for rate, rhythm and volume of pulse and condition of blood vessel.
Thumb is not used for assessing pulse as it has its own pulse which can be mistaken for patient's pulse.
Irregularities can be noticed only if pulse is counted for one whole minute.
Normal pulse is regular and the rate is 70 to 90 bpm
4. Document and report pertinent data in the appropriate record.
5. Wash hands.
9
 
SPECIAL POINTS
  1. Never press both carotids at the same time, as this can cause reflex drop in blood pressure/pulse rate.
  2. Carotid pulse is used for victims of shock and cardiac arrest when pulse is not palpable at other sites.
  3. Brachial and femoral sites are used with cardiac arrest in infants.
 
PAEDIATRIC VARIATIONS
  • In infants and young children the apical pulse is heard through a stethoscope held to the chest at the apex of the heart is more reliable.
  • In older children (> 2 years), radial pulse is taken.
  • Count the pulse for one full minute in infants and young children because of possible irregularities in rhythm.
  • Apical pulse is more accurate, while the child is asleep.
 
NORMAL PULSE RATE FOR INFANTS AND CHILDREN
Age
Pulse rate (Restingbeats per minute)
Newborn
100–170
1 years
30–170
3 vears
30–130
6 years
70–116
10 years
70–110
14 years
60–110
18 years
60–100
10
 
1.3: ASSESSING RESPIRATION
 
DEFINITION
Monitoring inspiration and expiration in a patient.
 
PURPOSES
  1. To assess rate, rhythm and volume of respiration.
  2. To assess for any change in condition and health status.
  3. To monitor the effectiveness of therapy related to respiratory system.
 
ARTICLES
Wrist watch with second hand, graphic record, pen (color according to agency policy).
 
PROCEDURE
Nursing action
Rationale
1. Ensure that patient is relaxed Assess other vital signs such as pulse or temperature prior to counting respirations.
Awareness of the procedure may alter the rate of respiration. Conscious patients when relaxed and unaware of procedure tend to have accurate respiratory rate.
2. Assess for factors that may alter respiration.
Allows nurse to accurately assess for presence and significance of respiratory alteration.
3. Wait for 5–10 minutes before assessing respiration if patient had been active.
Activity may increase rate and depth of respiration.
4. Position patient in sitting or supine position with head elevated at 45–60 degree.
Ensures proper assessment.
5. Keep your fingers over the wrist as if checking pulse, and position patient's hand over his lower chest or abdomen.
Makes the patient less aware of his respiration. Keeping hand over chest or abdomen makes the movement of chest more visible.
6. Observe one complete respiratory cycle-inspiration and expiration.
7. Assess rate, depth, rhythm and character of respiration.
Depth of respiration reveals volume of air moving in and out of lungs. Abnormalities of rhythm and character reveals specific disease condition.
8. Count respiration for one whole minute.
9. Wash hands
10. Record the findings and report any abnormal findings.
 
PAEDIATRIC VARIATIONS
  • In infants observe abdominal movements because respirations are diaphragmatic.
  • Count respirations for one full minute for accuracy because the movements are irregular in infants.
 
NORMAL RESPIRATORY RATE AGEWISE
Age
Rote (Breaths/Minute)
Newborn
36–40
1–12 months
28–32
2-A years
22–26
5–10 years
18–24
11–18 years
16–22
11
 
1.4: MONITORING BLOOD PRESSURE
 
DEFINITION
Measuring blood pressure using a sphygmomanometer.
 
PURPOSES
  1. To determine patient's blood pressure as a baseline for comparing future measurements.
  2. To aid in diagnosis.
  3. To aid in the assessment of cardiovascular system preoperatively and postoperatively, during and after invasive procedures.
  4. To monitor change in condition of the patient.
  5. To assess response to medical therapy.
  6. To determine patient's hemodynamic status.
 
ARTICLES
  1. A sphygmomanometer comprising of:
    1. Compression bag/inflatable rubber bladder enclosed in a cloth cuff (appropriate size)
    2. An inflating bulb (by which pressure is raised)
    3. A manometer (mercury) from which pressure is read.
    4. A screw type release valve for inflation and deflation (pressure control.)
  2. Stethoscope.
  3. Patient chart for recording.
  4. Black/blue pen for charting.
 
PROCEDURE
Nursing action
Rationale
1. Check physician's order, nursing care plan and progress notes
Obtains any specific instruction/information.
2. Explain the procedure and reassure the patient. Ensure that patient has not smoked, ingested caffeine or involved in strenuous physical and mental activity within 30 minutes prior to procedure.
Obtains patient's consent and co-operation and also relieves anxiety. Smoking and ingestion of caffeine can increase blood pressure.
3. Wash and dry hands
Prevents cross-infection
4. Assist the patient to either sitting or King down position and ensure that legs are not crossed
Obtains an accurate reading
5. Collect and check equipment
Ascertains evidence of malfunction
6. Position the sphygmomanometer at approximately heart level of the patient ensuring that mercury level is at zero.(Figure 1.4(a))
zoom view
Figure 1.4(a): Positioning sphygmomanometer at heart level
Helps in obtaining accurate reading.
12
7. Select a cuff of appropriate size (Figure 1.4(b))
zoom view
Figure 1.4(b): Selecting blood pressure cuff of appropriate size
Ensures that compression bladder width is at least 20% wider than the circumference of the mid-point of the exteriinity used. If the bladder is too wide the reading may be erroneously low. If it is too small, the reading may be erroneously high.
8. Expose the arm to make sure that there is no constrictive clothing above the placement of cuff.
Ensures accurate reading.
9. Apply the cuff approximately 2.5 cm above the point where brachial artery can be palpated. The cuff should be applied smoothly and firmly with the middle of the rubber bladder directly over the artery (Figure 1.4(c)).
zoom view
Figure 1.4(c): Application of blood pressure cuff over arm
Ensures accurate reading
Wrapping the cuff too tightly will impede circulation.
Wrapping the cuff very loosely will lead to false elevation of pressure.
10. Secure the cuff by tucking the end under or by fixing the velcro fastener.
Prevents unwrapping of the cuff.
11. Place the entire arm at the patient's heart level.
Obtains accurate reading. For every cm that trie cuff is above/below heart level. Blood pressure varies by 0.8 mm of mercury.
12. Keep trie arm well rested and supported
Ensures comfort of the patient thereby enabling an accurate reading. Movement of arm can cause noise when auscultating.
13. Place yourself in a comfortable position.
14. Connect the cuff tubing to the manometer tubing and close the valve of the inflation bulb.
15. Palpate the radial pulse and inflate the cuff until pulse is obliterated.
Estimates systolic pressure in order to determine how high to pump the mercury in order to avoid error related to auscultatory gap.
13
16. Inflate the compression bag a further 20–30 mm of mercury and then deflate cuff slowlv. Note the point at which pulse reappears. Release the valve.
Ensures accurate reading. If diaphragm is placed too firmly the artery gets compressed. Sounds are heard better with correct placement of stethoscope. Rubbing of stethoscope against an object can obiliterate Korot-Kov's sounds.
17. Palpate brachial artery and place diaphragm of the stethoscope lightly over the brachial artery. Ensure that ear pieces of the stethoscope are placed correctly (slightly tilted forward and ensure that tubing hangs freely) Raise mercury level 20–30 mm of mercury above the point of systolic pressure obtained by means of palpatory method (Figure 1.4(d)).
zoom view
Figure 1.4(d): Auscultatory method of checking blood pressure
Ensures that mercury column is high enough to minimize error related to auscultatory gap. The point at which pulse reappears is the systolic pressure.
18. Release the valve of the inflation bulb, so that mercury column falls at the rate of 2–4 mm of mercury/sec.
Prevents venous congestion and falsely elevated pressure reading due to slower rate of deflation and prevents erroneous reading due to faster rate of deflation.
19. When first sound is heard, the mercury level is noted, this denotes systolic pressure.
First sound is heard when the blood begins to flow through brachial artery.
20. Continue to deflate the cuff, note the point on nanometer at which sound nuffles. This is diastolic pressure.
21. Deflate cuff completely. Disconnect the tubing and remove the cuff from the patient's arm.
Occlusion of artery during the pressure reading causes venous congestion in the forearm.
22. Repeat the procedure after one minute if there is any doubt about the reading.
Waiting time of one minute allows venous blood to drain completely.
23. Ensure that patient is comfortable.
24. Remove equipment and clean ear piece with a spirit swab.
25. Wash and dry hands
Prevents chances of cross-infection.
26. Document the reading in appropriate observation chart or flow chart.
27. Report any abnormal findings.
 
SPECIAL PRECAUTIONS
  1. Do not take blood pressure on a patient's arm if
    1. The arm has an intravenous infusion on it
    2. The arm is injured/diseased.
    3. The arm has a shunt/fistula for renal dialysis.
    4. On the same side if the patient had a radical mastectomy
    5. If the arm is paralysed.14
  2. Always check supine measurement before checking upright measurement.
  3. If comparison is needed for blood pressure in lying/standing position, the patient must be in lying/standing position for a minimum of 3 minutes.
  4. Appropriate sized cuff should be used.
 
PAEDIATRIC VARIATIONS
  • In children, an appropriate cuff size is one having a bladder width that is approximately 40% of the arm circumference midway between the olecranon and acromion processes.
  • Systolic pressure in lower extremities (thigh/calf) is greater than the pressure in the upper extremities.
 
NORMAL BP RANGE–AGEWISE
Age
Blood pressure (mm of Hg)
Newborn
3 years
10 years
16 years
15
 
1.5: CHECKING HEIGHT AND WEIGHT OF A PATIENT
 
DEFINITION
Measuring the height and weight using accurate scales and measuring devices.
 
PURPOSES
  1. To assess fluid balance in patients with fluid retention, renal problems and cardiac problems.
  2. To assess the response to therapy, e.g. diuretics
  3. To ascertain the response to physiological changes or prescribed diet, e. g. pregnancy, high calorie diet.
  4. To obtain baseline data about patient's health status.
 
ARTICLES
  1. Weighing machine (electronic weighing scale) OR Sling scale
  2. Measuring tape
  3. Ruler.
 
PROCEDURE
Nursing action
Rationale
1. Assess the patient's ability to stand independently on the weighing machine.
Ensures safety of patient while checking weight and height.
Checking of weight while standing on electronic scale:
2. Wash hands
Reduces transmission of microorganisms.
3. Explain the procedure to the patient and ask patient to void. Instruct patient to wear a hospital gown.
Helps to gain cooperation of the patient and voiding will reduce the weight of urine in the bladder. Extra clothing will cause errors in reading of weight.
4. Place the weighing machine near the patient.
Reduces risk of fall/injury.
5. Turn on the scale and calibrate it to zero.
Ensures accurate reading.
6. Instruct patient not to step on the scale until the digital display shows zero.
For accurate reading.
7. Ask patient to remove shoes and heavy clothing and step on the scale and stand erect and still.
8. Read weight after digital numbers have stopped fluctuating.
Reading is not accurate when numbers are still fluctuating.
9. Ask the patient to step down and assist the patient back to bed or chair.
Reduces risk of injury.
10. Wash hands
Reduces transmission of microorganisms.
Checking of weight in a sling scale:
11. A sling is placed under the patient carefully without any folds.
More accurate weight will be obtained by leaving no bedding between sling and the patient.
12. Put on the scale and calibrate it to zero.
13. Lower the arms of the sling scale and slip hooks through the holes of the sling.
This is to attach the sling to the sling scale to measure the weight.
16
14. Pump scale until sling rests completely off the bed.
Ensures accurate weight reading.
15. Read weight after digital numbers have stopped fluctuating.
Reading is not accurate when numbers are fluctuating.
16. Lower the sling arms and place the patient comfortably on the bed.
Ensures patient comfort.
Measuring height:
17. Ask the patient to remove the shoes.
Ensures accurate checking of height.
18. A measuring tape can be held or attached to the wall vertically.
19. Instruct the patient to stand erect, with heels together.
Helps in obtaining accurate measurement.
20. With ruler placed horizontally on the head at 90 degree angle to the measuring tape, the height is measured in inches/cms.
21. Provide the patient a comfortable position in bed.
Ensures patient's comfort.
22. Replace the articles
23. Wash hands
Reduces transmission of microorganism.
24. Record the procedure with date, time and height and weight.
Documentation helps in continuity of care.
 
SPECIAL CONSIDERATIONS
  1. Weigh patient at the same time with same amount of clothing each day to enhance accurate reading.
  2. Preferably use the same weighing scale while weighing patients daily.
  3. Weighing machine with attached scale for measuring height can be used to measure height and weight.17
 
1.6: COLLECTING URINE SPECIMEN FOR ROUTINE EXAMINATION
 
DEFINITION
Collection of a small quantity (4 ounce /120 ml) of urine sample in a clean container for testing it in the laboratory.
 
PURPOSE
To detect and measure the presence of abnormalities in urine such as red blood cells, white blood cells, casts, pH, sugar, albumin and specific gravity.
 
ARTICLES
  1. Clean, wide mouthed container.
  2. Bed pan or urinal
  3. Appropriate laboratory forms
  4. Soap and water
  5. Laboratory requisition form
  6. Clean gloves.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and nursing care plan
Obtains specific instructions and information
2. Identify the patient
Ensures that right procedure is performed for right patient.
3. Explain procedure to the patient with specific instructions about washing the genital area (skin around the urethral meatus) with soap and water and give the labelled container. Instruct patient not to wet the label on the out side (Figure 1.6(a))
zoom view
Figure 1.6(a): Cleaning genitalia
Washing the genital area prevents contamination of urine specimen. Label on the container must have the patient's full name, ward, register number of the patient, type of test to be done and date.
4. Ask the patient to direct the first and last part of the urine stream into a urinal or toilet and to collect the middle part of the stream into the specimen container (Figure 1.6(b)).
Collecting the midstream urine avoids contamination of the specimen with organisms normally present on the skin. Four ounces of urine is required for the test.
18
zoom view
Figure 1.6(b): Collecting midstream specimen
5. Have the patient place the specimen container in proper/designated place
6. With gloved hand place the specimen container in polythene bag
Protects health care worker from possible exposure to microorganisms.
7. Send specimen to the laboratory with completed, signed laboratory form
8. Remove gloves and wash hands
9. Record the procedure in the nurse's notes and other appropriate forms.
 
SPECIAL CONSIDERATIONS
  1. It is preferable to collect morning specimens whenever possible.
  2. A clean – catch midstream urine specimen is collected to detect any urinary tract infection.
  3. Specimens collected from menstruating and postpartum patients should have the information included in the requisition form.
  4. Always cover specimen to prevent carbon dioxide from air diffusing into urine which will result in urine becoming alkaline and fostering bacterial growth.19
 
1.7: TESTING URINE FOR pH
 
DEFINITION
Testing urine for pH by dipping litmus paper into it and noting resultant color change.
 
PURPOSE
To determine acid-base balance.
 
ARTICLES
  1. Urine specimen container.
  2. Litmus strip
  3. Clean gloves
  4. Kidney tray.
 
PROCEDURE
Nursing action
Rationale
1. Explain procedure to the patient and provide specimen container
Obtains co-operation of the patient
2. Don gloves obtain specimen from patient
Reduces risk of contamination with urine.
3. Dip litmus strip in urine and keep for one minute and note color change
  • If blue litmus turns red, urine is acidic.
  • If red litmus turns blue, urine is alkaline
Shows the reaction of urine
4. Discard strip into container for infected waste
Proper disposal ensures safety
5. Discard urine specimen in sluice room/toilet
6. Record the procedure in nurse's notes including the result noted
Recording gives information about the result of the procedure.
Note - The normal pH of urine is 4–8.20
 
1.8: CHECKING SPECIFIC GRAVITY OF URINE
 
DEFINITION
Measuring specific gravity of urine using a caliberated hydrometer/urinometer.
 
PURPOSES
  1. To determine the level of concentration of urine.
  2. To diagnose conditions like diabetes insipidus.
 
ARTICLES
  1. Container to collect urine
  2. Calibrated urinometer
  3. Jar for urine
  4. Clean gloves.
 
PROCEDURE
Nursing action
Rationale
1. Explain procedure to the patient and provide container to collect urine
Facilitates co-operation of the patient to collect urine
2. Don gloves.
Reduces risk of contamination.
3. Fill three fourths of jar with urine
Permits urinometer to float free in urine
4. Gently place urinometer into jar
5. Make sure that instrument floats freely and does not touch bottom and sides of jar (Figure 1.8(a))
zoom view
Figure 1.8(a): Measuring specific gravity of urine
If urinometer touches the jar reading will be false
21
6. When urinometer stops bobbing, read specific gravity directly from scale marked on calibrated stem of urinometer. Read scale at lowest point of meniscus to ensure an accurate reading at eye level
(Normal specific gravity of urine is 1.010–1.025)
Reduces errors of reading.
7. Discard urine, and rinse jar and urinometer in running water
Prevents contamination
8. Remove gloves and wash hands.
Reduces transmission of microorganisms.
9. Replace articles and record the procedure in Nurse's Record or flowsheet according to policy
Recording gives information about the procedure results to health workers.
 
SPECIAL CONSIDERATION
Presence of faeces, tissue and menstrual blood falsely elevate specific gravity reading.22
 
1.9 (A): TESTING URINE FOR GLUCOSE (BENEDICT'S SOLUTION)
 
DEFINITION
Testing a specimen of double-voided urine using Benedict's solution for presence of glucose.
 
PURPOSE
To estimate the amount of glucose present in urine.
 
ARTICLES
  1. Spirit lamp
  2. Match box
  3. Test tube with test tube holder
  4. Test tube stand
  5. Benedict's solution
  6. Dropper
  7. Duster
  8. Kidney tray
  9. Clean, disposable gloves.
 
PROCEDURE
Nursing action
Rationale
1. Explain about method of collecting a double voided specimen of urine
Proper explanation helps the patient to collect specimen in a correct manner.
2. Provide labelled container for collecting urine
3. Don gloves and collect urine specimen from patient
Reduces risk of contamination
4. Take test tube and fix in holder. Pour 5 ml of Benedict's solution into test tube.
Benedict's solution is used to find out presence of glucose in urine
5. Light spirit lamp and heat Benedict's solution till it boils, holding test tube with mouth facing away from the nurse.
On heating if color of solution changes, it indicates that the solution is not suitable for testing.
6. Add eight drops of urine using dropper, through the sides and allow to boil for another few seconds
7. Put off flame and allow it to cool
Cooling completes color change when glucose is present in urine
Watch for color change and compare with standard color code
  • Blue –nil
  • Green liquid without deposit
  • Green liquid with yellow deposit
  • Colorless liquid with orange deposit
  • Brick red
Normal urine does not contain sugar
  • No sugar
  • +/1% sugar
  • ++/2% sugar
  • +++/3% sugar
  • ++++/4% or above
9. Discard urine in toilet or sluice room and rinse container
10. Replace the equipment after washing in proper place
11. Discard gloves and wash hands.
Reduces risk of transmission of microorganisms.
12. Record result in “Diabetic urine chart” and inform doctor for appropriate management/insulin order.
Recording the reaction gives information for further management.
23
 
1.9 (B): TESTING URINE FOR GLUCOSE (REAGENT STRIP OR TAPE)
 
DEFINITION
Testing urine for glucose using reagent strips such as Diastix or test tape.
 
ARTICLES
  1. Urine specimen in a container
  2. Reagent strips in container
  3. Clean disposable gloves
  4. Receptacle for used strip.
 
PROCEDURE
Nursing action
Rationale
1. Provide labelled container for collecting urine
2. Explain about method of collection of double voided specimen
Proper explanation helps the patient to collect specimen in a correct manner
3. Don gloves and and collect urine specimen from patient
4. Dip the portion of the strip with reagent in urine
Colour change occurs in the strip according to the amount of glucose present in urine
5. Compare the color of the strip with the color chart on the reagent strip container or separate chart (Figure 1.9(a))
zoom view
Figure 1.9(a): Comparing color of reagent strip with color chart
Colour change indicates the presence and amount of glucose in urine
6. Discard the used strip and used articles.
7. Replace the reusable items and wash hands.
8. Record in the patient's chart result of the test.
Conveys information to physician and other staff.
Note:
Presence of Ketone bodies (acetone) are also tested using reagent tablets (Acetest) or reagent strips (Ketostix). Combined Ketone glucose reagent strips (keto-diastix) are also available for use.
 
SPECIAL CONSIDERATION
The part of the strip with the reagent should not be touched with bare hands. Care should be taken to see that the dipstick should not be exposed to sunlight while storing.24
 
1.10: TESTING URINE FOR ALBUMIN
 
DEFINITION
Testing urine for presence of albumin using hot test method.
 
ARTICLES
  1. Spirit lamp.
  2. Match box.
  3. Test tube and holder.
  4. Test tube stand
  5. 2% solution Acetic acid.
  6. Dropper
  7. Specimen container.
  8. Duster
  9. Kidney tray.
  10. Litmus paper to check the reaction of urine (acidity/alkalimity)
  11. Clean gloves.
 
PROCEDURE
Nursing action
Rationale
1. Explain to the patient about the test to be done and provide container for collecting urine
Obtains co-operation of patient
2. Don gloves
3. Fill ¾ th of a test tube with urine, secure test tube holder at its top end
4. Check the reaction of urine, if found alkaline, add one drop of acetic acid and make it acidic
If the urine is highly alkaline or acidic, it will give false reading.
5. Heat the upper third of urine over the spirit lamp and allow it to boil. Keep the mouth of the test tube away from your face.
Prevents scalding
6. A cloud may appear either due to phosphate or albumin. Add 2–3 drops of acetic acid into the test tube. If the urine still remains cloudy, it indicates the presence of albumin.
  • Clear          = nil
  • Trace          = +
  • Cloudy         = ++
  • Thick cloudiness       = +++
If it becomes clear, it indicates the presence of phosphates
Confirms the presence of albumin Normal urine does not contain albumin
7. Discard the urine and rinse the test tube. Replace articles
Cleaning the test tube and keeping ready helps for the next use.
8. Discard gloves and wash hands.
Prevents transmission of microorganisms.
9. Record the procedure with date and time in nurses' record or flowsheet according to hospital policy
Gives the information about patient's health status.
25
 
1.11: COLLECTING URINE SPECIMEN FOR CULTURE
 
DEFINITION
Collection of a small sample of urine (30 to 60 ml) for detecting the presence and growth of microorgnisms in the sample.
 
PURPOSES
  1. To culture pathogenic microorganisms present in the urine.
  2. To determine antibiotic sensitivity of the pathogens in the urine.
 
ARTICLES
  1. Sterile urine container
  2. Laboratory form
  3. Soap and water
  4. Bed pan (for non-ambulatory patient)
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and identify patient.
Helps to understand purpose of procedure for the patient.
2. Assess the patient's mobility status and activity tolerance to use the toilet facilities
Determines the level of assistance required
3. Explain procedure to patient including reason for collecting specimen, and how patient can collect an uncontaminated specimen (if patient is able to)
Contaminated urine may result in false results.
4. Wash hands and don gloves if nurse is to perform procedure
5. Provide privacy by closing curtains and/or door.
Privacy allows patient to relax and reduces embarrassment.
6. Instruct patient to cleanse the perineum (See Figure 1.6(a))
Female:
Wash the urethral meatus and surrounding area with soap and water.
Male:
Hold the penis with one hand and cleanse the end of penis moving from center to outside using soap and water.
For helpless patients:
The nurse should provide hygienic perineal care.
7. Assist bedridden patient on to bed pan
8. Instruct to open specimen container and place cap with sterile inside surface up and not to touch inside of container and lid.
Contaminated specimen will lead to inaccurate reporting of culture and sensitivity.
9. Instruct ambulatory patients to:
Female:
Sit with legs separated on toilet
Male:
Sit down to control splashing.
Prevents contamination of container from outside.
26
10. Instruct patient to direct the first and last part of the urine stream into the toilet or bedpan, collect the middle part of the stream into the sterile container. (Midstream sample)
Prevents contamination of the specimen with skin flora
11. Replace cap securely on specimen container, cleanse any urine from external surface of container and place container in plastic bag or in the designated place.
Prevents transfer of microorganisms to others
12. Remove bedpan (if applicable) and assist patient to comfortable position
Promotes relaxing enviornment
13. Label specimen and send to laboratory with completed requisition form.
Prevents inaccurate identification that could lead to errors in diagnosis and therapy.
14. Remove gloves and dispose in proper receptacle (if used for bed-ridden patient) and wash hands
Reduces transmission of microorganisms.
15. Transport urine specimen to laboratory within 15 minutes or refrigerate immediately.
Bacteria grow quickly in urine and specimen should be analyzed immediately to obtain correct results.
16. Record in the nurses' notes the time of urine collection and any other observation.
Documents implementation of physician's order.
 
SPECIAL CONSIDERATIONS
  1. Patients who are catheterized should have the specimen withdrawn using a sterile needle and syringe from the catheter's sampling port. Clamp the collection tube for about 30 minutes before taking sample.
  2. Urine specimen must be transported to the laboratory promptly. If not cultured within 30 minutes of collection, urine must be refrigerated and culture done within 24 hours.
  3. About 30 minutes prior to collecting the specimen, patient may be encouraged to drink fluids unless contraindicated.27
 
1.12: COLLECTION OF 24 HOURS URINE
 
DEFINITION
Collection of urine specimen for a period of 24 hours without any spillage or wastage.
 
PURPOSES
  1. To detect kidney, liver and cardiac conditions.
  2. To measure total protein, creatinine, electrolytes,17 ketogenic steroid, oxylate, porphyrins, drugs, vitamins, VMA, minerals, hormones etc.
 
ARTICLES
  1. Clean container with preservative, of not less than 3 liters capacity with label, obtained from the laboratory (biochemistry).
  2. Urinal or kidney tray to collect urine at each voiding.
  3. Appropriate laboratory form, duly filled.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and nursing care plan
Obtains specific instructions/information
2. Identify the patient
Ensures that right procedure is performed on the right patient
3. Explain to the patient, the purpose of procedure and, that all urine for the full 24 hours must be saved
Gains patient's consent and co-operation
4. Instruct the patient to void at the time set to begin the procedure. E.g: at 6.00 a.m. Discard this specimen. Record in Nurses' Notes, the time when collection began
Ensures that urine collected is produced within the 24 hours of testing
5. Measure and pour all the subsequent voidings into the container
A 24 hours collection will accommodate all the variables in body chemistry within a representative period
6. Collect the final specimen at exactly the same time the patient voided 24 hours earlier. E.g: 6.00 a.m. the following day
7. Send the container with urine to laboratory when the collection is over, with requisition forms
8. Record in the Nurse's notes time of completing the collection and despatching the urine to the lab
9. Clean, disinfect and replace the kidney tray or urinal if they are reusable.
28
 
1.13: COLLECTING STOOL SPECIMEN FOR ROUTINE EXAMINATION
 
DEFINITION
Collection of a small quantity of stool sample in a container for testing in the laboratory.
 
PURPOSE
To test the stool for normalcy and presence of abnormalities.
 
ARTICLES
  1. A clean specimen container.
  2. A spatula for putting the specimen into the container.
  3. Dry bed-pan (for helpless patients). Additional bedpan for rinsing and cleaning.
  4. Laboratory requisition form.
  5. Clean gloves.
  6. Waste paper (for wrapping used spatula).
  7. A pitcher of water (for helpless patient).
  8. Tissues/towel.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and ‘Nursing Care Plan’.
Obtains specific instruction and information.
2. Identify the patient.
Helps to perform the right procedure for the right patient.
3. Explain to patient the procedure and make clear what is expected of him/her.
Aids in proper collection of specimen.
4. Give the labelled container and spatula to the patient with instructions.
  1. To defecate into clean dry bedpan
  2. Not to contaminate specimen with urine.
5. Don gloves
6. For helpless patient: assist patient on to the clean bedpan.
7. Leave him with instructions
8. When done, remove and keep aside the bedpan after placing the second one for cleansing
9. Collect about 2 cm of formed stool or 20 to 30 ml of liquid diarrhoeal stool
10. Once the specimen is collected send it to lab with the appropriate requisition forms
11. Wash and replace the reusable articles
12. Dispose off the used spatula wrapped in waste paper.
Prevents contamination
13. Wash and dry hands.
Prevents cross contamination.
14. Record information in the patient's chart.
29
 
SPECIAL CONSIDERATIONS
  1. Send specimen to be examined for parasites immediately, so that parasites may be observed under microscope while viable, fresh and warm.
  2. Inform if bleeding hemorrhoids or hematuria is present.
  3. Postpone test if woman has menstrual periods, until three days after it has ceased.
  4. Consider that intake of folic acid, anticoagulant, barium, bismuth, mineral oil, vitamin C, and antibiotics may alter the results.
  5. Use two bedpans for helpless patient – one for collecting specimen and the another for cleaning.30
 
1.14: COLLECTING STOOL SPECIMEN FOR CULTURE
 
DEFINITION
Collection of a small quantity of stool sample for culture/microbiological examination.
 
PURPOSE
To culture the organisms that are not part of the normal bowel flora, e.g.: Salmonella, Shigella, Rotavirus, etc.
 
ARTICLES
  1. Sterile stool container/specimen container.
  2. Sterile spatula/swab stick.
  3. Bedpans (two bedpans for helpless patients).
  4. Laboratory requisition form.
  5. Clean gloves.
  6. Tissues.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and nursing care plan
Obtains specific instructions and information.
2. Identify the patient
Helps in performing the right procedure for the right patient.
3. Explain to patient the procedure and make clear what is expected of him/her.
  • To defecate into clean dry bedpan.
  • Instruct not to contaminate specimen with urine.
Aids in proper and adequate collection of specimen.
4. Give labelled container and spatula to the patient with instructions:
  • Not to contaminate (touch) inside of the container or lid
  • To collect about 1 cm of formed stool or 10 to 15 ml of a liquid diarrhoeal stool
Stool cultures require only small sample
5. Once the specimen is collected, wear gloves, take the container from patient and send it to the lab with the completed lab requisition
6. Wrap spatula in waste paper and discard appropriately.
7. Wash and replace the reusable articles
8. Wash and dry hands.
Prevents cross contamination
9. Record the procedure in the patients' record.
 
SPECIAL CONSIDERATIONS
  1. Stool specimen for culture can be obtained directly from the rectum using a sterile swab.
  2. If a patient passes blood and mucus, include this information in specimen label.
  3. Provide assistance to helpless patients for sitting on pan, cleaning after defecation and collecting specimen.31
 
1.15: COLLECTING THROAT SWAB FOR CULTURE
 
DEFINITION
Collecting the exudates from throat or tonsil for laboratory test.
 
PURPOSE
To identify the pathogenic organisms.
 
ARTICLES
  1. Tongue depressor to hold the tongue down.
  2. Cotton tipped applicators in sterile packed test tube to collect the specimen for transportation to the lab.
  3. Laboratory requisition form.
  4. Clean, dry, gauze pieces.
  5. Disposable gloves.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order
2. Identify the patient
3. Explain to patient the procedure and instruct him how he/she must co-operate.
Knowledge of the procedure facilitates patient co-operation
4. Wash hands and put on gloves
Protects the health care worker from contamination with saliva.
5. Instruct the patient to open his mouth and hold the tongue down with a tongue depressor. If gag reflex is active in patient, make him to sit upright and if health permits, instruct patient to open mouth, extend tongue and say “Ah”.
Sitting position and extension of tongue helps to expose the pharynx. Saying “Ah” relaxes throat muscles.
6. Carefully yet firmly rub the swab or cotton applicator over areas of exudate or over the tonsil and posterior pharynx, avoiding the cheeks, teeth and gums (Figure 1.15(a))
zoom view
Figure 1.15(a): Obtaining a throat swab for culture examination
Firm rubbing will aid in obtaining an adequate sample.
7. Insert swab or applicator into the sterile packet, or test tube.
Keeping the applicator directly in the packet will avoid contamination
8. Send specimen to the laboratory immediately with the requisition form duly filled
9. Clean and replace the reusable articles
10. Remove gloves and discard wash hands
11. Record in appropriate patient record
32
 
1.16: COLLECTING WOUND SWAB FOR CULTURE
 
DEFINITION
Collection of wound exudates/discharge for laboratory examination.
 
PURPOSE
To identify aerobic and anaerobic organisms present in the wound.
 
ARTICLES
  1. Cotton applicators.
  2. Culture tube or container for transporting the specimen
  3. Laboratory requisition form
  4. Disposable gloves.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order
2. Identify the patient
Ensures that the right procedure is done on right patient.
3. Explain the procedure to patient
Allays anxiety and promotes patient co-operation
4. Screen the bed and provide privacy
Reduces anxiety
5. Wash hands and wear gloves
Reduces risk of transmission of microorganisms.
6. Expose the wound area
7. Using the cotton – tipped applicators, swab and collect as much exudate as possible from the center of the lesion.
Swabbing the surrounding skin will alter the findings
8. Place the swab immediately in appropriate transport culture tube and send to laboratory labelled clearly, specifying the anatomic part from where the specimen was obtained.
Clear labelling aids in accurate reporting of the test
9. Record information in the patient's chart
33
 
1.17: PROTOCOL FOR SAMPLE COLLECTION OF BLOOD
Test
Sample type
Volume required
Container
Related instruction
Normal values
1.
Blood glucose
Serum
3.0 ml clotted
Plain red top
FBS (Fasting) RBS (Random)
70–110 mg% less than 200 mg/dl
2.
BUN (Blood urea nitrogen)
Serum
3.0 ml clotted
Plain red top
10–30 mg/dl
3.
Creatinine
Serum
3.0 ml clotted
Plain red top
0.5–1.5 mg/dl
4.
Total protein
Serum
3.0 ml clotted
Plain red top
6–8 g/dl
5.
AST (Asparatate aminotransferase) ALT (Alanine aminotransferase)
Serum Serum
3.0 ml clotted 3.0 ml clotted
Plain red top Plain red top
7–40 U/L
5–36 U/L
6.
Bilirubin
Serum
3.0 ml clotted
Plain red top
Total 1.0 nig/100 nil Direct 0.4 mg/100 nil Indirect 0.6 mg/100 nil
7.
Cholesterol
Serum
3.0 nil clotted
Plain red top
140–200 mg/dl
8.
Triglycerides
Serum
3.0 ml clotted
Plain red top
40–150 mg/dl
9.
Lipid profile Total lipids HDL, LDL, VLDL
Serum (fasting)
3.0 ml clotted
Red top
Normal HDL cholesterol-more than 45 nig/dl, LDL cholesterol-up to 130 nig/dl, VLDL cholestrol-7–33 mg/dl
10.
Triglycerides
Serum
3.0 ml clotted
Red top
40–150 mg/dl
11.
LDH (Lactic dehydrogenase)
Serum
3.0 ml clotted
Red top
50–150 U/L
12.
Blood gases arterial O2, saturation PO2, PC02/pH
Arterial heparinized blood
1 ml clotted
Syringe
PC02 Above 500 mmHg while on 100% 02
02 saturation 96–100%
P02 = 75–100 mmHg
PC02 = 35–45 mmHg
pH = 7.35–7.45
13.
Electrolytes
Na
K
Mg
CI
Serum
3 ml clotted
Red top
Sodium     135–145 mEq/L
Potasium      3.5–5 niEq/L
Magnesium     1.5–2.5 mEq/L
Chloride    95–105 mEq/L
14.
Uric acid
Serum
3 ml clotted
Red top
Uric acid 2–6 mg/dl
15.
P.T. (prothrombin time)
Citrated
Blue top
Mix well avoid hemolysis send to lab in 30 minutes
10–14 seconds
16.
PTT (partial thromboplastin time)
Citrated
Blue top
25–37 seconds
17.
Bleeding time
Finger prick
Capillary tube and blotting paper
3–9 minutes
18.
WBC
EDTA
3.0 ml clotted
Purple top
Total 4.0–11.0×103/μl
Differential
Neutrophils 60–70%
Lymphocytes-25–35%
34
Monocytes-5–10%
Eosinophils-1–4%
Basophils-up to 1%
19.
RBC
EDTA
3.0 ml clotted
Purple top
Male-4.5–6.5 × 106/μl
Female-3.8–4.8 × 106/μl
20.
Hemoglobin
EDTA
3.0 ml clotted
Purple top
Male-13–18 gm/dl
Female-12–16 gm/dl
21.
Platelets
EDTA
3.0 ml clotted
Purple top
150–400 × 103/μl
22.
Hematocrit
EDTA
2.0 ml
Purple top
Male 45–52%
Female 37–48%
23.
ESR (Erythocyte sedimentation rate)
EDTA with anticoagulant
2.0 ml
Blue top
Male less than 15 mm/hr
Female less than 20 mm/hr
24.
Calcium
Serum clotted 4–6 ml
Red top
No tourniquet
9–11 mg/dl
25.
CPK (Cretinine phosphokinase)
Serum
3.0 ml
Red top
Male 15–105 U/L
Female 10–80 U/L
26.
Thyroid hormone
Serum
5.0 ml
Red top
TSH—0.3–5.4 μU/ml
T—110–230 ng/dl
T—5–12 μg/dl
27.
MCHC
EDTA (with anticoagulant)
2 ml
Blue top
32–36%
35
 
1.18: COLLECTING BLOOD FOR ROUTINE EXAMINATION
 
DEFINITION
Obtaining blood sample by veni puncture for routine lab investigations.
 
PURPOSES
  1. To determine variations if any in blood composition.
  2. To determine any abnormality in order to aid in diagnosis.
 
ARTICLES
  1. Tourniquet.
  2. Small mackintosh.
  3. Syringes 5 ml, 10 ml.
  4. No.20 gauge needles or vacutainer assembly.
  5. Alcohol swabs.
  6. Disposable gloves.
  7. Specimen container – test tube or bottle.
  8. Laboratory requisition form.
  9. Sterile gauze pads (2″× 2″)
  10. Adhesive tapes.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order
2. Identify the patient
Ensures performance of procedure on right patient.
3. Reassure the patient and explain that relatively little blood will be taken
Obtains patient's co-operation and confidence.
4. Wash hands and put on gloves
Protects health care worker from possible exposure to blood.
5. Select and examine the vein, visualize the vein, including the antecubital area, wrist, dorsum (back) of the hand and top of foot (if necessary). Palpate the vein
Select a vein that is visible, palpable and fixed to the surrounding tissues so that it does not roll away
6. Instruct the patient to extend his arm. Hold the arm straight at the elbow with fist clenched
Proper positioning reduces risk of injury
7. Apply the tourniquet 5 to 15 cm above the selected site with just sufficient pressure to obstruct venous flow
A tourniquet when applied increases venous pressure and makes the vein more prominent and easier to enter.
8. Cleanse the skin with alcohol swab in a circular motion; center to periphery. Allow to dry
Cleansing the skin reduces the number of microorganisms
9. Fix chosen vein with thumb and draw the skin taut immediately below the site before inserting needle to stabilize the vein.
The vein may roll beneath the skin when the needle approaches its outer surface, especially in elderly and extremely thin patients.
36
10. Hold the syringe between the thumb and last three fingers with the bevel up and directly in line with the course of the vein. Insert the needle quickly and smoothly under the skin and into the vein (Figure 1.18(a))
zoom view
Figure 1.18(a): Inserting needle into vein
11. Obtain blood sample by gently pulling back on the plunger (Figure 1.18(b))
zoom view
Figure 1.18(b): Obtaining blood sample
Use minimal suction to prevent hemolysis of blood and collapse of vein.
12. Release the tourniquet as soon as the specimen is obtained and ask the patient to open the fist.
13. Apply sterile 2′ × 2′ gauze piece to puncture site without applying pressure and withdraw needle slowly along the line of vein
Slow withdrawl of the needle is less painful and reduces trauma
14. Request patient to apply gentle but firm pressure to site for 2 – 4 minutes
Firm pressure over puncture site prevents leakage of blood into surrounding tissues with subsequent hematoma development
15. Remove the needle from the syringe as soon as possible after withdrawing blood, gently eject the blood sample into the appropriate container without forming bubbles in the test tube or bottle (Some tests require container with anticoagulant)
Gentle ejection of blood prevents hemolysis
16. Invert the tube gently several times to mix blood with anticoagulant where applicable. For some tests blood is allowed to coagulate in the test tube
Gentle handling of specimen prevents risk of hemolysis.
17. Label specimen correctly and send to laboratory immediately with completed requisition forms.
Specimen should reach the laboratory with the minimum of delay for optimum reliability.
18. Dispose the needle and syringe in appropriate containers.
Avoids possible spread of blood–borne diseases.
37
19. Clean all spills with 10% bleach (sodium hypochlorite)
Avoids possible spread of blood-borne diseases. solution. Remove gloves and wash hands.
20. Record in the patient's chart the procedure and the tests for which the sample was sent to the laboratory.
21. Replace the tray with the reusable articles in proper place.
38
 
1.19: MEASURING BLOOD FOR GLUCOSE LEVEL USING GLUCOMETER
 
DEFINITION
Measuring the blood glucose level with the help of a portable glucometer.
 
ARTICLES
  1. Blood glucose meter
  2. Testing strips/reagent strips
  3. Sterile lancet
  4. Cotton balls
  5. Alcohol swab
  6. Disposable gloves.
 
PROCEDURE
Nursing action
Rationale
1. Check physician's order
Confirms time for checking blood glucose.
2. Review manufacturer's instructions for glucometer use.
Helps in doing procedure accurately.
3. Gather articles at the bedside
Provides an organised approach during the procedure.
4. Explain the procedure to the patient.
Helps to gain patient's co-operation
5. Have the patient wash hands with soap and water.
Use warm water if available. Washing hands reduces transmission of microorganisms.
6. Position the patient comfortably in a semi-fowlers position or upright position
Increases blood flow to puncture site.
7. Wash hands. Don disposable gloves
Prevents spread of microorganisms. Gloves protect from exposure to blood and body fluids.
8. Remove test strip from the container and recap container immediately
Immediate recapping protects strips from exposure to light and discoloration.
9. Turn monitor on and check whether the code number on strip matches with the code number on the monitor screen.
Matching the code numbers on the strip and glucometer ensures that machine is calibrated correctly
10. Take the lancet without contaminating it. Select appropriate puncture site.
Aseptic technique maintains sterility.
11. Massage side of finger for adults (heel for children) toward puncture site and wipe with alcohol swab.
Massage increases blood flow to the area.
12. Hold lancet perpendicular to skin and prick site with lancet. (Figure 1.19(a))
zoom view
Figure 1.19(a): Patient pricking side of his finger
Holding lancet in proper position facilitates proper skin penetration.
39
13. Wipe away the 1st drop of blood from the site.
The first drop may impede accurate result because it may contain large amount of serous fluid.
14. Lightly squeeze or milk the puncture site until a hanging drop of blood has formed.
The blood droplet should be large enough to cover the test pad on the strip and it also facilitates accurate test results.
15. Gently touch the drop of blood to pad on the test strip without smearing it (Figure 1.19(b)).
zoom view
Figure 1.19(b): Inserting strip into glucometer
Smearing of the blood will alter results.
16. Insert strip into glucometer according to directions for that specific device. Some devices require that the drop of blood is applied to a test strip that has already been inserted in the monitor. (Figure 1.19(c))
zoom view
Figure 1.19(c): Touching drop of blood to test strip
Correctly inserted strip allows glucometer to read blood glucose level accurately.
17. Apply pressure to puncture site using a dry cotton ball.
This will stop bleeding at the site.
18. Read blood glucose results displayed on the monitor and inform the patient about results. (Figure 1.19(d))
zoom view
Figure 1.19(d): Display of blood glucose level in monitor
19. Turn off the glucometer
20. Dispose supplies appropriately and discard lancet in sharp's container.
Reduces contamination by blood. Sharps must always be handled properly to protect others from accidental injury.
40
21. Remove gloves and discard. Wash hands.
22. Record blood glucose level in the chart
This facilitates documentation of procedure and provides for comprehensive care.
 
SPECIAL CONSIDERATIONS
  1. In patients who require regular blood-glucose monitoring, shallow penetration should be encouraged to avoid tissue damage.
  2. Rotate or change sites to allow time for the penetrated site to heal.
  3. To reduce pain, choose side of fingertips or side of heel for children. where fewer nerve endings are present rather than central part of fingertips.
  4. Patients should compare their personal glucometer reading with the laboratory measured blood glucose level, every 6–12 months.41
 
1.20: COLLECTION OF BLOOD FOR CULTURE
 
DEFINITION
Collection of blood for culture to determine presence of microorganisms in the blood.
 
ARTICLES
  1. Blood culture bottles (3)
  2. Cotton swab
  3. Spirit
  4. Syringe(10- 20 ml)
  5. Needle
  6. Povidone-iodine solution
  7. Sterile gloves
  8. Tourniquet
  9. Laboratory requisition form.
 
PROCEDURE
Nursing action
Rationale
1. Assess the physician's order for blood culture investigation.
Obtains knowledge of samples to be collected and the reason for doing culture.
2. Explain procedure to the patient and provide a comfortable position.
Gains co-operation of the patient during the procedure.
3. Wash hands. Don sterile gloves
Reduces transmission of microorganisms and maintains aseptic technique.
4. Apply tourniquet above the puncture site and palpate the venipuncture site.
Restricts blood flow and promotes easy visibility of veins.
5. Wipe the site with 70% alcohol in a circular manner from center to peripheri for approximately 5 cm in diameter and allow to dry.
6. Cleanse the site again with povidone-iodine starting from center in even widening circles. Allow the iodine to remain on the skin for at least one minute. Clean the site with 70% alcohol
Avoids contamination and maintains a sterile field.
7. Clean the cover of the culture bottles with povidone-iodine followed by spirit.
Maintains sterility of equipment.
8. Puncture the site and draw 10 ml of blood (Adults 10–20 ml of blood preferred)
9. Remove the tourniquet once the blood is collected.
Restores circulation.
10. Remove the needle and apply pressure to the puncture site with dry cotton simultaneously.
Stops bleeding from the puncture site.
11. Change the needle with a fresh needle before injecting the blood into the bottles.
12. Remove the metal cover on the cap of culture bottles and push 10 ml of blood into each of the bottles. While injecting blood into the bottles be careful not to touch the sides of the bottle (Figure 1.20(a))
Maintains strict aseptic technique
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zoom view
Figure 1.20(a): Injecting blood into culture bottle
13. Mix the blood and culture media by shaking the bottle gently.
14. Discard the contaminated articles. Remove gloves
15. Wash hands
Reduces transmission of infection.
16. Fill the lab requisition form appropriately and label the bottles with patient's name, identification number, date and time of collection
17. Transfer the specimen to the lab immediately.
18. Record the procedure in the patient's chart with date and time of collection.
Communicates pertinent information to members of health care team.
19. Repeat the procedure within an interval of 30 minutes to one hour as per the number of samples required from different puncture sites.
 
SPECIAL CONSIDERATIONS
  1. Blood for culture should be taken before antibiotics are administered.
  2. If there is regular periodicity of the fever, the advantageous time to draw blood will be just before the anticipated rise in temperature.
  3. For children, 2–5 ml and neonates 1–2 ml of blood is required for culture investigation.
  4. Blood should never be taken from an IV line or from above an exisiting IV line.
  5. For patients with clinical diagnosis of endocarditis, two or three sets of blood cultures (a set consists of one aerobic and one anaerobic culture from one site) should be performed over a 24-hour period to assess for sustained bacteremia.43
 
1.21: COLLECTING BLOOD FOR PERIPHERAL SMEAR
 
DEFINITION
Obtaining a small sample of blood by skin puncture for peripheral smear.
 
PURPOSES
  1. To detect malarial parasites.
  2. To detect blood cell abnormalities.
 
ARTICLES
  1. Disposable lancet.
  2. Pipette and tubing.
  3. Slides.
  4. Cotton swabs /Alcohol prep pads.
  5. Alcohol.
  6. Disposable gloves.
  7. Laboratory forms.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and nursing care plan.
Obtains specific instructions and information.
2. Identify the patient.
Ensures that right procedure is performed for right patient.
3. Give explanation to patient about the procedure.
Obtains patient's co-operation and consent.
4. Wash hands and put on gloves.
Protects health care workers from possible exposure to blood.
5. Cleanse site (ball of finger) with alcohol and dry with sterile cotton swab.
If any alcohol remains, it will alter red cell morphology. Blood will not collect into a compact drop, but will run down the finger if it is not dry.
6. Prick the skin sharply and quickly with sterile, disposable lancet.
Pricking the skin sharply and quickly minimizes pain during procedure and helps to obtain a flowing sample.
7. Release pressure on the finger, wipe off the first drop of blood.
Epithelial and endothelial cells may be found in the first drop of blood and may render the count inadequate.
8. Allow the blood to flow freely with an adequate puncture.
Pressing out the blood dilutes it with tissue fluid.
9. Obtain the blood sample, fill the pipette and make blood smears on the slides (Figure 1.21(a))
zoom view
Figure 1.21(a): Preparing a peripheral smear
  1. Thin smear
    • Put a drop of fresh blood on the middle of the slide.
    • Use another slide end to allow the drop of blood to spread along the slide.
    • Push the spreader quickly from the center to the left of the slide drawing the blood behind it.
    • Leave the film to dry. Do not blow on it.
  2. Thick smear
    • Put three drops of fresh blood on the left hand quarter of the slide
    • With the corner of another slide mix the blood and smear it in a round form about 1 cm in diameter.
    • Leave the film to dry. Do not blow on it or shake the slide.
44
10. Apply pressure over the puncture site, with a dry cotton ball until bleeding stops.
11. When the film is dry, label the slide wrap it and dispatch to laboratory.
12. Remove gloves, wash hands and dispose off articles in approved containers.
45
 
1.22: COLLECTION OF SPUTUM FOR CULTURE
 
DEFINITION
Collection of coughed out sputum for culture to identify respiratory pathogens.
 
EQUIPMENTS
  1. Sterile specimen container
  2. Sputum cup
  3. Tissue paper
  4. Clean gloves
  5. K-basin
  6. Suction catheter (optional)
  7. Suction apparatus (optional).
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order
2. Explain to client that the specimen must be taken from sputum, coughed up from back of the throat or lungs
Promotes patient's co-operation
3. Ask the patient to sit erect in bed if possible.
Provides easy access for collection of specimen.
4. Wash hands and put on gloves
Reduces transmission of microorganisms.
5. Keep a sterile specimen container ready for the sample and take a tissue paper in hand.
6. Remove lid of container and place with inner side facing upwards
Prevents contamination.
7. Instruct the patient to take deep breaths and then cough out deeply.
It helps to loosen the secretions and obtain adequate specimen.
8. Explain to the patient that he has to expectorate the sputum into sterile labelled container without touching the inside of it.
Prevents contamination of the specimen.
9. Close the container without touching inside of lid.
10. Provide client with tissue paper and a comfortable position. Promotes patient comfort.
11. Replace articles
12. Wash hands
Reduces transmission of microorganisms.
13. Provide mouth care if patient needs it or encourage patient to carry out oral hygiene.
Removes unpleasant taste in mouth.
14. Document obtained specimen, date and time of collection and characteristics of the specimen and send specimen to lab.
Helps in continuity of care.
 
SPECIAL CONSIDERATION
It is preferable to collect an early morning sputum specimen before brushing/rinsing the mouth.46
 
1.23: ASSISTING WITH OBTAINING A PAPANICOLAOU SMEAR
 
DEFINITION
It is a cytologic examination of desquamated epithelial tissue to differentiate normal from anaplastic cells and it is also a widely used cancer screening test.
 
PURPOSES
  1. To detect cervical and vaginal carcinomas.
  2. To perform routine screening and for diagnosing disorders of reproductive system.
 
METHODS OF OBTAINING PAP (PAPANICOLAOU) SMEAR
  1. Slide method
  2. Liquid method (Thin Preparation)
 
ARTICLES NEEDED
  1. A glass slide
  2. A sterile Ayre's spatula
  3. Cusco's speculum
  4. A pipette
  5. Sterile cotton swabs
  6. Sterile gloves
  7. Ether/95% alcohol solution (1: 1)
  8. Spray fixative
  9. A graphite pencil
  10. Light source
  11. K-Y jelly.
 
PROCEDURE
Nursing action
Rationale
1. Check the physician's order and progress notes.
Obtains specific instructions/ information.
2. Identify the patient and check identification against physician's order.
Ensures that the right procedure is performed on the right patient.
3. Explain the pap cytology test to the patient. Allow questions to be asked. Consider the protocols to be followed in specific cases.
Obtains patient's consent and co-operation. Promotes patient education. In rape cases, vaginal swabs may be used for forensic evidence.
4. For patients of child bearing age, test should be done 10–20 days after the first day of LMP, and definitely not when the patient is menstruating or bleeding, unless bleeding is a continuous condition.
A smear taken any time other than in the mid menstrual cycle can result in abnormal findings. Heavy menstrual flow and blood may make the interpretation of the results difficult and may obscure atypical cells.
5. Instruct the patient not to douche for 2 to 3 days before the test.
Douching may remove the exfoliated cells.
6. Instruct the patient not to use vaginal medications or vaginal contraceptives during the 48 hrs before the examination. Intercourse to be avoided the night before the examination.
Use of contraceptives before examination may result in false test results.
47
7. Instruct the patient to empty her bladder and rectum
Ensures comfort during the procedure. before examination.
8. Ask the patient to give the following information:
  1. Age
  2. Use of hormone therapy, birth control pills or contraceptive devices.
  3. Past vaginal surgical repair or hysterectomy.
  4. All medications taken, including prescribed, over-the–counter, and herbal medications.
  5. Any radiation therapy
  6. Any other pertinent clinical history (e.g previous abnormal Pap smear, signs of inflammation or bleeding)
Identifies if patient is an adolescent, pregnant or post–menopausal woman.
Hormones and contraceptive devices can alter the findings.
Some medications alter the test results.
9. Obtain the requirements of the procedure
10. Using the graphite pencil, label the ends of the slide with the patient's name and the collection site.
11. Ask the patient to undress from waist down.
12. Position the patient in a lithotomy position on an examination
Ensures good visibility and promotes comfort and table and drape provides privacy.
13. Don sterile gloves, lubricate and insert a sterile Cusco's speculum.
14.
  1. For endocervical smear:
    Insert a sterile cotton swab into the cervical os (Figure 1.23(a)) and rotate it 360°. Leave the swab in place for 10–20 sec. Remove the swab and smear onto a glass slide. Fix it immediately. Note: fixative must be applied to the slide before drying of the specimen occurs.
    zoom view
    Figure 1.23(a): Obtaining a cervical swab for smear
  2. Ectocervical scraping: Insert Ayre's spatula into the cervical os, rotate or scrape the entire surface at the squamocolumnar junction (Figure 1.23(b)). Remove the spatula and smear onto a glass slide. Fix it immediately (Figure 1.23(c)).
48
zoom view
Figure 1.23(b): Ayre's spatula in cervical os
zoom view
Figure 1.23(c): Preparing slides
  1. Cervical scraping: Insert the pointed edge of a wooden Ayre spatula into the cervical os and rotate the spatula 360 degrees. Spread the cervical scrapings on a glass slide, fix it with an ether/95% ethyl alcohol solution, and dry the slide. A cervix -brush sampling device may be used, and it is recommended to be rotated a full 180 degree to improve the sampling for abnormal cervical cells.
  2. Vaginal pool: Using the blunt side of a wooden Ayre spatula, scrape the vaginal floor behind the cervix. Spread the vaginal pool secretions on a glass slide, spray or soak them in fixative, and dry the slide. Vaginal fluid is obtained for suspected endometrial cancer or for a hormonal evaluation.
  3. Vulval smear: Using the blunt side of a wooden Ayre spatula, directly scrape the vulvar lesion. Spread the scraping on a glass slide and fix immediately with spray fixative.
15. Give the patient a perineal pad after the procedure to absorb any bleeding or drainage.
16. Write the patient's age: the reason for the study, the LMP, etc. on the requisition form and send the slides to the cytology laboratory.
 
SPECIAL CONSIDERATIONS
  1. Smears that dry before fixative is applied cannot be properly interpreted.
  2. Do not lubricate the speculum as it may distort cells.
  3. A smear taken any time other than in the mid menstrual cycle can result in abnormal findings.
  4. Tetracycline or digitalis preparations can affect the appearance of squamous epithelium.
  5. Blood, mucus or pus on the slide makes interpretation difficult.49
 
1.24: MEASURING INTAKE AND OUTPUT
 
DEFINITION
It is defined as the measuring and recording of fluid intake and output (I and O) during a 24-hour period which provides important data about a patient's fluid and electrolyte balance.
 
PURPOSES
  1. To assess patient's general health.
  2. To monitor specific disease conditions
  3. To assess the fluid and electrolyte balance.
 
ARTICLES
  1. Intake and output form at bedside
  2. Intake and output graphic record in chart
  3. Bedpan or urinal or bedside commode
  4. Graduated drinking cup/tumbler
  5. Graduated container for output
  6. Clean gloves
  7. Sign at bedside that patient is on intake and output measurement.
 
PROCEDURE
Nursing action
Rationale
1. Identify the patient
2. Explain the methods of maintaining intake and output. All fluids taken orally must be recorded on the patient's intake and output form (Input and output flow sheet)
Helps to obtain patient's co-operation and encourages patient's participation.
3. Wash hands every time prior to giving oral fluids
Reduces transmission of microorganisms
4. Measure all oral fluids in accordance with institutional policy Example:
  1. Water glassful = 200 ml
  2. Cupful = 120 ml
Paper cup
  1. Large = 200 ml
  2. Small = 120 ml
Soup bowl full = 180 ml
Water pitcher full = 1000 ml
Measure all fluids in the graduated cup/tumbler before giving to patient.
Provides for consistency of measurement
5. Record time and amount of fluid intake in the designated space on bedside chart. Include all semi solid and liquid food (oral, feeds, tube feedings and IV fluids)
Documents the amount of fluids accurately
6. Transfer eight hours total fluid intake from bedside intake and output chart to 24 hour intake and output record in patient's chart.
Provides for data analysis of the patient's fluid status every 8 hour shift.
7. Record all fluid intake in the appropriate column of the 24-hour record
Documents intake by type and amount
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8. Complete 24-hour intake record by adding all eight hour totals.
Provides consistent data for analysis of the patient's fluid status over a 24 hours.
9. For measuring output include urinary output and other drainage from patient. (Figure 1.24(a)).
zoom view
Figure 1.24(a): Measuring urine from urometer
Documents the amount of output accurately.
10. Urinary output
  1. After each voiding measure the urine using a measuring container and record it with the time of voiding on the intake and output form (Figure 1.24(b)).
    zoom view
    Figure 1.24(b): Intake-output chart
  2. For patients with retention catheter, empty the drainage bag into a measuring container at the end of the shift or at prescribed times if output is measured more often. Note and record it.
  3. For infants and incontinent patients the output may be measured by first weighing diapers or incontinent pads that are dry and then subtracting this weight from the weight of soiled items
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11. The amount and type of fluid (urine, drainage from NG tube, drainage tube) are recorded in the intake and output form
Documents output.
12. Transfer 8 hours output total to 24 hours intake and output record on the patient's chart.
Provides for data analysis of the patient's fluid status.
13. Complete 24 hours output record by totalling all 8 hours total.
Provides consistent data for analysis of the patient's fluid status over a 24-hour period
 
SPECIAL CONSIDERATIONS
  1. Follow universal precautions while handling patient's body fluid output viz blood, urine, etc.
  2. Remember that fluids taken to swallow pills must be recorded as intake.
  3. Do not have visitors or family members empty bedpan, urinal or catheter bags.52
 
1.25: TEACHING BREAST SELF-EXAMINATION (BSE)
 
DEFINITION
Breast self-examination is a technique which women use to assess their own breasts to detect breast carcinomas at the earliest.
 
ARTICLES
  1. Mirror
  2. Gloves
  3. Small pillow/rolled towel.
 
PROCEDURE
Nursing action
Rationale
1. Identify the patient and review personal history and family health history.
Identifies risk factors and previous baseline data
2. Explain procedure to the patient. Ask her to disrobe to the waist and to put on a gown with the opening in the front
Provides easy access while maintaining maximum privacy
3. Wash hands. Don gloves if required by agency policy
Prevents transfer of microorganisms and possible contact with discharge when palpating nipples
4. Provide privacy and assist the patient to sitting position facing you and expose chest and breasts.
Allows comparison of breasts bilaterally
5. Explain and teach breast self-examination as you examine. a.
For inspection, ask the patient to stand in front of the mirror and check both breasts for anything unusual with patients:
  1. Arms at sides
  2. Arms raised
  3. Hands pressed on hips
  4. Arms extended straight ahead as patient leans forward (Figure 1.25(a))
  1. Normal skin colour slight inequities in size and symmetry, rounded shape and smooth skin surface are normal.
  2. Redness, blue hue, retraction, dimpling, enlarged pores, edema, lumps, lesions, rashes, ulcers and discharge are abnormal.
  3. Supernumerary nipples along the milk line are a normal variant.
zoom view
Figure 1.25(a): Breast self-examination
6. Explain and teach the palpation method. Teach the patient to use the right hand to palpate the left breast and vice versa. During the examination, place the patient's fingers under your fingers
Teaching during examination reinforces the need for and understanding of breast examinations, and enables the patient to identify normal breast tissue and abnormal tissue if present thus increasing confidence in performing BSE
53
7. Using the pads of the palmar surfaces of the fingertips, palpate the right breast by gently compressing the mammary tissues against the chest wall. Palpation may be performed from the periphery to the nipple, in either concentric circles, wedge sections or vertical strip (Figure 1.25(b)).
Warm temperature, elasticity, tenderness, pain, erythema, masses or nodules are abnormal.
zoom view
Figure 1.25(b): Palpation method. (i) Wedge section, (ii) Concentric circles pattern for breast palpation, (iii) Hands-of-the-clock pattern of breast palpation,
8. Palpate areola and nipple using a similar circular technique as with breast. Pay special attention to subareolar part and gently press the nipple between the fingers
Inflammation, discharge, nodules fissuring and lesions are abnormal.
9. Palpate into axilla starting at anterior axillary line and continuing at an angle to the mid axillary line and up into the axilla (using same circular fingertip motion). Have patient place arm at side and palpate deep into the axilla. Identify posterior axillary, central axillary, anterior axillary and lateral axillary node locations.
Nodes should be less than 1 cm and non tender
10. Repeat steps 7–9 on the left breast, areola, nipple and axilla. Identify normal versus abnormal as with the right breast. Compare breasts bilaterally
11. Assist the patient to supine position. Place arm on examination side under the head, and place a small pillow under the same side scapula
This position spreads breast tissue over the chest wall maximizing palpation accuracy
12. Assist the patient to palpate the breast, areola and nipple as in steps 7–9 with the other hand and vice versa
Helps evaluate examination findings in second position
13. Assist the patient to a sitting position. Review the steps and ask the patient to demonstrate breast self–examination
Provides more comfort for patient. Helps evaluate success of the teaching
14. Allow patient to dress
Provides for patient comfort
15. Remove gloves and wash handsReduce transmission of microorganisms
16. Give the patient written materials to reinforce teaching
Reinforce teaching. Provides a readily available form to patient for reference when at home
17. Record date, time, findings of abnormalities and absence of abnormalities, patient's response to findings and teachings
54
 
SPECIAL CONSIDERATIONS
  1. Instruct patients not to use creams, lotions or powders and not to shave underarms 48 hours before the scheduled assessment, because these things could alter the breast skin or cause folliculitis and lymph node enlargement.
  2. Explain that BSE is best performed after menses (5th –7th day) for pre-menopausal women and first day of the month for postmenopausal women.
  3. Educate even men to perform a monthly BSE and obtain a clinical examination every 1 to 3 years because 1% of all breast cancer is found in men.
  4. Advise the patient to palpate her breasts during shower, as the fingers will glide easily over soapy skin, so that one can concentrate on feeling for changes in the breasts.
  5. During BSE pay special attention to upper outer quadrant area and the tail of Spence, where about 50% of breast cancers develop.
  6. Instruct patient that a baseline mammogram is to be obtained at 35 years and followed by annual mammogram after 40 years.
  7. Determine if patient is taking oral contraceptives, digitalis, diuretics, steroids or estrogen hormones. These medications may cause nipple discharge and hormones may cause fibrocystic changes in breast.
  8. Instruct mother to report if any lumps, tenderness or nipple discharge exists.55
 
1.26: TEACHING TESTICULAR SELF–EXAMINATION (TSE)
 
DEFINITION
Testicular self-examination is a technique used to examine the testes by self for detecting abnormalities like testicular cancer.
 
PROCEDURE
Nursing action
Rationale
1. Identify the patient and review personal history, medication, and family health history
Identifies risk factors and previous baseline data
2. Explain the procedure to patient, provide privacy and ask the patient to disrobe completely and to put on a gown
Obtains patient's co-operation and provides easy access while maintaining maximum privacy
3. Wash hands, and apply clean gloves
Practices clean technique
4. Instruct the patient to stand and fold up his gown to expose the genitalia
Provides best exposure for examination
5. Advise the patient to use both hands to palpate the testes. The normal testicle is smooth and uniform in consistency. Note the size, lie, shape, consistency and tenderness The length of a normal testes should be greater than 4 cm.
The left testicle normally sits slightly lower than right testicle. The testicles are rubbery and approximately equal in size
Pressure on testes normally produces a deep visceral pain. Twisting or torsion of the testes causes venous obstruction, edema and eventually arterial obstruction.
6. Advise the patient to palpate each testis one at a time and feel for any evidence of a small, pea size lump or abnormality (Figure 1.26(a))
zoom view
Figure 1.26(a): Testicular self–examination
7. Teach the patient to locate and palpate the spermatic cord and vas deferens between the thumb and fingers (from epididymis to the inguinal ring) (Figure 1.26(b))
zoom view
Figure 1.26(b): Palpating spermatic cord
Note any nodules or swelling
56
8. Explain that it is normal to find that one testis is larger than the other
9. Assist the patient to a comfortable position. Review the steps and ask the patient to redemonstrate testicular self–examination
Provides more comfort for patient. Evaluate success of the teaching given.
10. Remove gloves and wash hands
Reduces risk of transmission of microorganism
11. Give the patient written materials if available.
Reinforces teaching. Provides a readily available form to patient for reference when at home
12. Record date, time, findings of palpation and patient's response to findings and teaching.
 
SPECIAL CONSIDERATIONS
  1. Advise patient to perform testicular self-examination on one particular day of each month.
  2. It is advisable to perform testicular self-examination after a warm relaxing shower.