Therapeutic Procedure1

8/12/2019 Therapeutic Procedure1

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THERAPEUTIC PROCEDURESSELECTED TOPICS ON COMMON NURSINGPROCEDURES

UNIVERSAL PRECAUTIONS HANDWASHING BARRIER METHOD STERILIZATION AND DISINFECTION IMMUNIZATION ENVIRONMENTAL CONTROL AND SANITATION ISOLATION

SURGICAL ASEPSIS MAINTENANCE OF STERILE FIELD

MEDICAL AND SURGICAL ASEPTIC TECHNIQUES

THERAPEUTIC EXERCISES ISOMETRIC ISOTONIC

ROM

OXYGENATIONCHEST PHYSIOTHERAPY TURNING COUGHING DEEP BREATHING POSTURAL DRAINANGE PERCUSSION AND VIBRATION INCENTIVE SPIROMETRY SUCTIONING TRACHEOSTOMY CARE OXYGEN THERAPY

VENTILATOR CARE AND MANAGEMENT

Chest Physiotherapy It is the combination of percussion, vibration, and postural drainage Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this

can be performed for 3-5 minutes Vibration is done during 5 exhalations



Postural drainage is done for 15-20 minutes usually performed 3-4 times aday.

Instruct the client to increase fluid intake to liquefy secretions This procedure should not be performed in clients who are pregnant, with

chest injuries, dizzy, with pulmonary embolism and abdominal surgery.

This procedure is done before meal or 90 minutes after a meal

Oxygen Therapy Indicated to clients who needs additional oxygen, those clients who

have reduced lung diffusion of oxygen through the respiratorymembrane, heart failure leading to inadequate transport of oxygen.

Humidify the oxygen first before you administer. Check for bubbles in the humidifier to promote adequate flow of

oxygen

Check for kinks in the tubing Position: semi-fowlers/ high fowlers position Place cautionary readings: “NO smoking: Oxygen is in used” Instruct the client not to use woolen blankets as this may create

static electricity

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

inspiratory reserve volume – 3100

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

incentive spirometry – hold 2-6 sec; 4-5 times/H (TO MAXIMIZERESP.&MOBILIZE SECRETIONS

endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification

and aerosol, deflate cuff occasionaly visualization –

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



Tracheostomy Care tie new trache tie before removing the old tie to prevent accidental

dislodgement.ALLOW 2 FINGERS TO BE INSERTED UNDER TIE use precut gauze and perform care OD at least. soak inner cannula in antiseptic soak with hydrogen peroxide, rinse

well suction prn, oral care prn(PROCEDURE DONE q8h AND PRN)

Oxygen Delivery Equipment cannula – 2-6 LPM – 24-45%

Mask – 5-8 LPM – 40-60% parial rebreather – 6-10 LPM – 60-90% non rebreather – 10-15 LPM – 95-100% tent – 4-8 LPM – 30-50 % Venturi mask –

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

Suctioning PURPOSE: To obtain sputum sample. NURSING ALERT: ASSESS BREATH SOUNDS

Hyperoxygenate the patient before and after theprocedure.

Apply intermittent suction on withdrawal of the catheter.

Do not suction the patient for more than 15 seconds.IDEAL 10 SECS

Thoracentesis PURPOSE: Aspiration of fluid and /or air from the pleural space. NURSING ALERT: Check the consent.



Position: Sitting on the side of the bed with feet on a chair, leaning over abedside table. If the patient unable to sit, the patient may lie in his/her side withhands on the side resting on opposite shoulder.

Instruct the patient not to cough, breath deeply or move during theprocedure.

After the procedure: Position the patient on the unaffected side/puncture siteup.

Check for bleeding at the puncture site and moni tor the respiratoryfunction.

Notify the physician if signs of pneumothorax, air embolism and pulmonaryedema occur.

ELIMINATIONENEMA

They act by distending the intestines that increases peristalsis andexpulsion of feces and flatus.

Enemas serve the following purpose: Relief of constipation Relief of flatulence Lowers down body temperature Evacuates feces in preparation for diagnostic procedures Administration of medications

ENEMA Take note of the general principles of Enema: Tube: lubricate and insert 3-4 inches

Position: adult- left lateral; infants and children- dorsal recumbent Administration- administer the enema in a minimum of 15 minutes

duration. Conatainer’s Height- 12 inches above the rectum Temperature- 42°C or less



types: carminative – expel flatus – 60 –180 ml. retention oil – 1 –3 hours(LUBRICANTS) BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI wetting/stool softeners- Colace(days)

Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl,Cascara)-SUPPOSITORIES-30 MIN

Saline- Epson salts, milk of mg(rapid)/mg citrate return flow – haris flushing , colon irrigation fleet – commercial

oil 1-3 H retention others – 5 to 10 mins.

cleansing- irritating( hypertonic osmotic)) high 1000 ml low 500 ml

T = 40-43 ‘ C ( 105 – 110 ‘ F) CHILDREN 37.7 ( 100 ‘ F) APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN

CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.INSERT 7 – 10 CM ( 3-4 INCH)-ADULT 5 – 7.5 CM. –CHILD 2.5 – 3.5 – INFANT

IF FEELING OF FULLNESS – CLAMP – 30 SECS

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

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



ENEMAS- PRESCRIBED AMOUNT ANDTIME HYPERTONIC – 5-10MINS – VARIES

HYPOTONIC(TAP)-15-20MIN – 500-1000ML ISOTONIC(SALINE)-15-20MIN- 50ML SOAP SUDS- 10-15MIN- 1 LITER + 3-5 ML. SOAP OIL ( MINERAL/COTTONSEED) – 30-60 MIN- 90-

120ML.IN ADMINISTRATION OF ENEMAS. THE FOLLOWING

ARE TRUE:CHECK ALL THAT APPLY DO NOT ADMINISTER IN PRESENCE OF ABDL.PAIN,

SUSPECTED APPENDICITIS . SLOW INSTILLATION IN NAUSEA

AND VOMITING OIL RETENTION ENEMAS IRRITATES COLON,CAUSING

REFLUX EVACUATION WHILE TAP WATER SOFTENS FECES,STIMULATES EVACUATION AND ACTS AS A VOLUMEEXPANDER

HOLD IRRIGATION SET NO MORE THAN 12 INCHES

OSTOMY CARE ostomy – divert and drain fecal material

temporary ( trauma / inflammatory condition) permanent ( Cancer / congenital or Birth defects

stoma – red , initial slight bleeding - normal, no redness orirritation 2 to 5 inches sorrounding the area no burningsensation

parts: periostomal seal adhesive square –

solid wafer disk skin barrierliquid skin sealant

drainable end pouch ( Can be washable)



pouch belt face plate

ileostomy – no irrigation , wet fecal material , appliance all

the time , meticulous skin care,prevent skin breakdown,constant flow not regulated, bag emptied half full

colostomy – solid , can irrigate , can be bowel trained ,pouch may not be worn and emptied after every defecation

avoid gas forming foods and nuts , but can have any foodat tolerated after 6 weeks… yogurt recommended

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

Catheterization, urinaryPURPOSE: To determine residual urine and obtain sterile

specimen. It can be a straight catheter, suprapubic,indwelling catheter, and external device catheter.

NURSING ALERT: Know the necessary facts:

Principles Male Female Position Supine Dorsal recumbent Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in. French number or

Circumference #14- 16 #18 Length of tube to be inserted 2-3 in. 6-9 in. Balloon size 5-10 ml. (30 ml 5-10 ml Can be used to achieve hemostasis of the prostatic area following prostatectomy

Place to secure lower abdomen Inner thigh



The procedure is sterile INSERT AN ADDITIONAL INCH BEFORE INFLATING THE BALLOON Maintain a close system.SHOLUD NOT BE DISCONNECTED FROM

THE DRAINAGE SYSTEM EXCEPT TP PERFORM ORDEREDIRRIGATIONS

The draining bag must always be below the bladder The catheter bag should not be allowed to lie on the floor Do not allow the drainage spout to touch the collection receptacle or on

the toilet bowl when draining it REMOVE NO MORE THAN 700 CC IN ONE TIME, WAIT 15-30 MIN.,THEN

CONTINUE COIL EXCESS TUBING ON BED Monitor for foul-smelling urine with blood,mucus or pus

CATHETER CHANGE PLASTIC – 1 WEEK LATEX – 2-3 WEEKS SILICONE – 2-3 MOS. PVC – 4-6 WEEKSSpecial prec. For type used Ureterostomy tube-never irrigate Straight cathetedo not remove more than 1000cc at one

time Clamp intermittently (2-4 hours) prior to removal

CATHETER IRRIGATIONS TO PREVENT OBSTRUCTION OF FLOW AND CATHETER Sterile technique ; cleanse around catheter, disconnect tubing Gently instill 30-60cc of solution Fluid drained by gravity into sterile basin ;if it does not return,the

syringe bulb should be depressed to provide gentle suction Repeat according to orders Disinfect ends of cath. Tubing and reconnect

INTERMITTENT SELF-CATHETERIZATION USED TO TREAT PERSISTENT URINARY RETENTION(SCI,

MULT.SCLEROSIS, TBI) WASH CATH. WITH WARM SOAP AND WATER



AFTER URINE FLOWS ADVANCE 1-1 ½ INCH, PRESS DOWN ABDOMINALMUSCLES, RINSE WITH COOL TAP WATER

DONE Q3-4H,CONSISTENTLY CLEAN TECHNIQUE-350-400CC EACH TIME USE CATHETER FOR 2-4 WEEKS STORE CATH IN A PLASTIC

CONTAINER DRY ,NEVER STORE WET OR IN ANTISEPTIC SOLUTION INSTRUCT PAYIENT TO DRINK 250CC/H OR 2L/DAY

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

RELEASED( IF NOT CBI)

URINARY DIVERSIONS-URINARY STOMA URETEROSTOMY ILEAL CONDUIT- ILEUM CREATED INTO A POUCH ONE END CREATES

THE STOMA(LESS STENOSIS AND INFECTION) ;EXTERNAL POUCH KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL

SUTURED TO THE ABDOMEN SUPRAPUBIC CATHETER – AP INSERTS CATHETER ,SECURED WITH

SUTURES AND RETENTION BODY SEAL ; INTERMITTENT ATHETERIZATION q 3-4 HOURS

NORMAL AMOUNT/ DAY 1-3 / 500-600ML 3-5 / 600-700ML 5-8 / 700-100OML 8-14 / 800 – 1400ML 14 – ADULT / 1500 – 2500

CAN HOLD 500 – 750 ML

Bladder trainingQ2 hours and 30 mins void(Trigerring, Credes and valsalva)

NEUROGENIC BLADDERIntermitent Catheterization – 2-3 hours if <150ml ----3-4 Hweaning-intermittent clamping



DTV 1-4 hours after removal

for incontinence – kegels exercises

HEMODIALYSIS DONE 3-5 HOURS – 2-3 TIMES A WEEK AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H MONITOR FOR HEMORRHAGE DISEQUILIBRIUM

SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIREMBOLISM AND SEPSIS-COMPLICATIONS

PERITONEAL DIALYSIS TENCKOFF,GORE-TEX CATHETER

WEIGH BEFORE AND AFTER, WARM DIALYSATE CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING)

, FEVER , ABDL TENDERNESS AND N & V PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN

STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION TYPES:

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

WOUND CARE

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

GUAZE, SYNTHETIC , SECURING, TEGADERM

TYPES OF DRESSINGS DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION –

SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE



WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED(VARIATION @ DRYING)

WET TO WET – KEEP MOIST – WOUND BATHED – MOISTUREDILUTES VISCIOUS EXUDATE

WOUND HEALING HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION

PHASE 3-4DAYS FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION

TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS MATURATION(PHASE 21 DAYS – 2 YEARS)

pressure ulcer dressings dry gauze stage II-IV tegaderm film/ hydrocolloid – SI - SII Absorptive Dressing III Hydrogel – II - III

WOUND CARE PRIMARY SECONDARY- INCREASED INFECTION INCREASED TIME

INCREASED ESCHAR( PRESSURE SORES) TERTIARY- ABD. DRAINAGE

EXUDATES – SUPPURATION

PUS – ABCESS( PYOGENIC BACTERIA)

SURGICAL DRAINS

PENROSE – SIMPLE LATEX DRAIN ; OPEN ENDS;NOTSUTURED BUT LAYERED IN GAUZE DRESSING-EXPECTDRAINAGE

T-TUBE – GALLBLADDER SURGERY ; PLACED IN THECOMMON BILE DUCT;DRAINAGE 500-1000CC/DAY; BLOODY

FOR FIRST 2 HOURS DRAINAGE BAG ON BED BELOWINSERTION

CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRYOF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR ;report if drainage suddenly increases or becomes bright red D/C 3-7 DAYS POST – OP PACKAGE – FACILITATE GRANULATION



IRRIGATION LAVAGE - STERILE

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

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

GAUZE;EXTRA BOTTLE

TUBES CLAMPED ONLY TO CHECK AIR LEAKS OR TO CHANGEDRAINAGE APPARATUS

MILK TUBING IN THE DIRECTION OF THE DRAINAGE SUCTION CONTROL CHAMBER – 20 CM STERILE H2O WATER SEAL 2 CM PATIENT CHANGE POSITION FREQUENTLY AND DRAINAGE BELOW

INSERTION SITE FOR REMOVAL INSTRUCT PATIENT TO DO VALSALVA CONSTANT BUBBLING-LEAK IF CHEST TUBE DISLODGED – APPLY OCCLUSIVE DRESSING TENTED

ON ONE SIDE TO ALLOW FOR ESCAPE OF AIR IF DISCONNECTED-CLAMP, CUT TIP, INSERT STRERILE CONNECTOR

AND REAATACH/ IMMERSE IN 2 CM H2O UNTIL SYSTEM RE-ESTABLISHED

NUTRITIONAL SUPPORTNGT-GAVAGE AND LAVAGETPN

Nasogastr ic Tube Insertion Purposes:

Gastric Gavage- gastric feeding Gastric Lavage- stomach irrigation For decompression



Medication and supplemental fluid administration

Principles: Position: High-Fowler’s position Length of tube to be inserted: measured from the tip of the nose to

the tip of the earlobe to the xiphoid process (approximately 50cm. Lubricate the tip of the tube by a water soluble lubricant before

insertion Secure the NGT by taping to the bridge of the nose

Gastroenteral Feedings This is the administration of formula through a tube placed into the GIT, either

by Nasogastric route or surgically created slit on the abdominal wall. Remember these principles:

Position: fowler’s or sitting position Prior to feeding, assess the bowel sounds and residual content Assess for tube placement and patency:

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

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

tube

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

TOTAL PARENTERAL NUTRITION TPN-IV with bacterial filter(2-3L)

TNA – 1 liter/D-no filter If no available solution D10W –ok –initial at 50ml/hr

hyperglycemia- hyperosmolar(HA, N and Vomiting,fever, chills,malaise)

Infection ( IV tubing and filter Q24 changed,solutions refrigeratedand warmed just prior to administration



Pneumothorax

Heat and Cold Therapy An intervention the reduces inflammation

Principles: Cold application is generally safer than heat application. Heat application usually requires a doctor’s order Cold application is done within 72 hours after an injury, while heat

application is done after 72 hours. The application of heat and cold is done at a maximun of 30

minutes (an average of 15-20 minutes) Check the area applications are done every 15 minutes.

Anti -embolism Stock ing Helps prevents thrombophlebitis by promoting venous return from

the legs It usually requires a doctor’s order The client’s extremeties must be properly measured to assure

therapeutic effect Apply stockings before getting out of bed. If the client forgot to wear

the stockings, instruct himn or her to assume modified

trendelenburg’s position for 15-20 minutes The stockings must be removed every 8 hours for 20-30 minutes Assess the skin integrity

DOSAGES AND CALCULATION CONVERSIONS MEDICATION DOSAGES

D/A X V = Q

INFUSIONS TOTAL VOLUME X DROP FACTOR

TIME IN HOUR ( 60 MIN.)

THERAPEUTIC DOSE CLARKS RULE BSA COMPUTATION IV INFUSION FOR BURNS

MEDICATION ADMINISTRATION



RIGHT DRUGRIGHT DOSAGERIGHT ROUTE

RIGHT TIMERIGHT PATIENTRIGHT ATTITUDERIGHT DOCUMENTATION

PARENTERAL ADMINISTRATION• IM – G 18-21 ; 1 1/2 INCH, Z-TRACK

( RETRACT) SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR

MASSAGE ( INSULIN AND HEPARIN)• INTRADERMAL- 10-15’; G26-27;1\2 INCH BEVEL UP• INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25

; RELEASE TOURNIQUET IF WITH BACKFLOW

IV THERAPY backflow means patent line solutions for specific diseases and contraindications of

certain solutions management and troubleshooting check for phlebitis and infiltration change line everyday keep site sterile

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

hemolytic



anaphylactic febrile hypervolemic septic

Hygiene and comfort measures

BEDMAKING- OD PERINEAL CARE – FRONT TO BACK

OUTER TO INNER, ONE COTTONBALL PER STROKE

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

THERAPEUTIC BATH SALINE – 4 ML- 500 ML OATMEAL/AVENO – SOOTHES SKIN IRRITATION,

LUBRICATES CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION Na CHO3 – 4 ml. – 500 ml H2O

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

Rotating Tourniquet GET MEAN APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE /

ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITYFOR ONLY 15 MINUTES

DO NOT RELEASE SIMULTANEOUSLY PATIENT IN ORTHOPNEIC / FOWLERS POSITION

CPR and ACPLS Protocols



0-1 MINUTE ; CARDIAC IRRITABILITY 0-4 MINUTES; BRAIN DAMAGE NOT LIKELY 4-6 MINUTES; BRAIN DAMAGE POSSIBLE 6-10 MINUTES; BRAIN DAMAGE LIKELY 10 MINUTES-IRREVERSIBLE BRAIN DAMAGE

INFANTS HTCL MANEUVER, JAW THRUST IF SPINAL INJURY IS

SUSPECTED INITIAL BREATHS – 2 – 1 1/2 SECS SUBSEQUENT BREATHS 1 B/3 SECS; 20 BPM USE 2 OR 3 FINGERS DEPTH:1/2 TO 1 INCH COMPRESSION AT LEAST 100/MIN

RATIO 5:1; CHECK AFTER 20 CYCLES FOREIGN BODY OBSTRUCTIONS: BACKBLOWS AND CHESTTHRUST

CHILDREN HTCL / JAW THRUST 2 BREATHS INITIAL DURATION OF 1- 1 ½ SECS SUBSEQUENT 1 BREATH EVERY 3 SECONDS 20 BREATHS/ MIN CAROTID ARTERY

HEEL OF HAND 1 TO 1 1\2 INCH 100 BPM; CHECK AFTER 12 CYCLES ABDOMINAL THRUST- FOR AIRWAY OBSTRUCTION

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

ERGONOMICS TRANSFER TECHNIQUES BODY POSITIONING BODY MECHANICS

Therapeutic Procedure1

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