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    Nursing Procedures

    Uploaded by

    Michael Angelo Seña
    The document outlines various nursing procedures including steam inhalation, suctioning, nasogastric feeding tube insertion, tube feeding, enemas, urinary catheterization, bed baths, foot care, oral care for unconscious patients, hair shampooing, and use of restraints. Key steps are provided for each procedure such as patient positioning, sterile technique, checking placement of tubes, monitoring for complications, and ensuring safety and privacy.

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    Nursing Procedures

    Uploaded by

    Michael Angelo Seña
    163 views2 pages
    The document outlines various nursing procedures including steam inhalation, suctioning, nasogastric feeding tube insertion, tube feeding, enemas, urinary catheterization, bed baths, foot care, oral care for unconscious patients, hair shampooing, and use of restraints. Key steps are provided for each procedure such as patient positioning, sterile technique, checking placement of tubes, monitoring for complications, and ensuring safety and privacy.

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    The document outlines various nursing procedures including steam inhalation, suctioning, nasogastric feeding tube insertion, tube feeding, enemas, urinary catheterization, bed baths, foot care, oral care for unconscious patients, hair shampooing, and use of restraints. Key steps are provided for each procedure such as patient positioning, sterile technique, checking placement of tubes, monitoring for complications, and ensuring safety and privacy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    163 views2 pages

    Nursing Procedures

    Uploaded by

    Michael Angelo Seña
    The document outlines various nursing procedures including steam inhalation, suctioning, nasogastric feeding tube insertion, tube feeding, enemas, urinary catheterization, bed baths, foot care, oral care for unconscious patients, hair shampooing, and use of restraints. Key steps are provided for each procedure such as patient positioning, sterile technique, checking placement of tubes, monitoring for complications, and ensuring safety and privacy.

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    NURSING PROCEDURES

    1. Steam Inhalation

    it is a dependent nursing action

    Place the spout 12 - 18 in away from the client's nose or adjust the distance as necessary.
    2. Suctioning

    Assess the lungs before the procedure for baseline information.

    Position: conscious - semi-fowlers... unconscious - lateral position

    Hyper oxygenate before and after procedure

    observe sterile technique

    Apply suction during withdrawal of the catheter

    Time: adult - 10 sec to maximum of 15 sec... pedia - maximum of 10sec


    3. Nasogastric Feeding (gastric gavage) insertion

    clean procedure not sterile - rationale: not all things that we ingest through mouth are sterile.

    From tip of the nose to tip of the earlobe to the xyphoid - adult

    from tip of the earlobe to the tip of the nose to xyphoid - pedia
    4. Tube Feeding

    Semi - fowler's position


    Assess tube placement by: x-ray(most reliable), by pH or by placing the tip to the basin of water,
    if bubbles occur, it is not in the right place.

    Assess residual feeding: it should be empty after 2 - 3 hrs... report to physician if it is more than
    100 ml.

    Height of feeding is 12 in. above

    Ask client to remain upright position for at least 30 min

    Most common problem: Diarrhea due to lactose intolerance


    5. Enema

    Check foe MD's order

    provide privacy

    position is left lateral

    Insert 3 - 4 in of rectal tube

    If abdominal cramps occur, temporarily stop the flow until the cramp is gone.

    height of enema - 18 in

    discontinue if there is bleeding and report to MD.


    6. Urinary Catheterization

    Verify MD's order

    Practice strict asepsis

    Provide privacy

    Perineal care before the procedure

    Catheter size: male 14 -16 , female 12 -14

    Lenght of catheter insertion: male - 6-9 in., female - 3-4 in


    For Retention Catheter
    Male - anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure.
    Female - inner aspect of the thigh.
    7. Bed Bath

    Provide privacy

    Expose, wash and dry one body part at a time

    Use warm water (110 -115F) 43 - 45C

    Wash from cleanest to dirtiest or distal to proximal to increase venous return.


    8. Foot Care

    Soaking the feet of diabetic patient is no longer recommended

    Cut nail straight across


    9. Oral Care for Unconscious client

    Place in side lying position


    Have the suction apparatus readily available - to drain extra secretion if necessary
    10. Hair Shampoo

    Place client diagonally in bed

    Cover the eyes with wash cloth

    Plug the ears with cotton balls

    Massage the scalp with the fatpads of the fingers to promote circulation in the scalp
    11. Restraints

    Secure MD's order for each episode of restraints application

    Check circulation every 15 min

    Remove restraints at least every 2 hrs. for 30 mins

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