FUNDAMENTALS OF
NURSING
a. It is dependent nursing function.
b. Heat application requires physician's order.
c. Place the spout 12-18 inches away from the client's nose or adjust the distance as
necessary.
a. Assess the lungs before the procedure for baseline information.
b. Position: conscious - semi-fowler's
c. Unconscious - lateral position
d. Size of suction catheter- adult- fr 12-18
e. Hyper oxygenate before and after procedure
f. Observe sterile technique
g. Apply suction during withdrawal of the catheter
h. Maximum time per suctioning -15 sec
3- Nasngastric Feeding (gastric gavage)
a. Fowler's position
b. Tip of the nose to tip of the earlobe to the xyphoid
a. Semi-Fowler's position
b. Assess tube placement
c. Assess residual feed ing
d. Height of feeding is 12 inches above the tube's point of insertion
e. Ask client to remain upright position for at least 30 min.
f. Most common problem of tube feeding is Diarrhea due to lactose intolerance
a. Check MD's order
b. Provide privacy
c. Position left lateral
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube
f. If abdominal cramps occur, temporarily stop the flow until cramps are gone.
Height of enema can - 18 inches
5. Urinary Catheterization Verify MD's order
a. Practice strict asepsis erineal care before the procedure
, b. Catheter size: male-14-16 , female- 12 - 14
c. Length of catheter insertion male - 6-9 inches ,female - 3-4 inches
Male -anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure
Female- inner aspect of the thigh
TYPES OF OSTOMIES
a. Ileostomy
Liquid to semi-formed stool, dependent upon amount of bowel removed
May skew fluid & electrolyte balance, especially potassium & sodium
Digestive enzymes in stool irritate skinDo NOT give laxatives
Ileostomy lavage may be done if needed to clear food blockage
May not require appliance set; if continent ileal reservoir or Koch pouch
b. Colostomy
Ascending-must wear appliance—semi-liquid stool
Transverse-wear appliance--semi-formed stool
Loop stoma
Proximal end-functioning stoma
Distal end-drains mucous
Plastic rod used to keep loop out
Usually temporary
Double barrel
Two stomas
Similar to loop but bowel is surgically severed
Sigmoid
Formed stool
Bowel can be regulated so appliance not needed
May be irrigated
Stoma assessment
a. Color-should be same color as mucous membranes (normal stoma color-
Red not dusky or pale: sign of infection)
b. Edema-common after surgery. Bleeding-slight bleeding common after
surgery
Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are
done to promote evacuation of feces at a regular and convenient time Recommended
with sigmoid colostomy
Initiated 5 to 7 days postop
Done in semi - Fowler's position; then sitting on a toilet bowl once ambulatory.
Use warm normal saline solution
Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently
Dilate stoma with lubricated gloved finger before insertion of catheter
Lubricate catheter before insertion.
Insert 3 to 4 inches of the catheter into the stoma
NURSING
a. It is dependent nursing function.
b. Heat application requires physician's order.
c. Place the spout 12-18 inches away from the client's nose or adjust the distance as
necessary.
a. Assess the lungs before the procedure for baseline information.
b. Position: conscious - semi-fowler's
c. Unconscious - lateral position
d. Size of suction catheter- adult- fr 12-18
e. Hyper oxygenate before and after procedure
f. Observe sterile technique
g. Apply suction during withdrawal of the catheter
h. Maximum time per suctioning -15 sec
3- Nasngastric Feeding (gastric gavage)
a. Fowler's position
b. Tip of the nose to tip of the earlobe to the xyphoid
a. Semi-Fowler's position
b. Assess tube placement
c. Assess residual feed ing
d. Height of feeding is 12 inches above the tube's point of insertion
e. Ask client to remain upright position for at least 30 min.
f. Most common problem of tube feeding is Diarrhea due to lactose intolerance
a. Check MD's order
b. Provide privacy
c. Position left lateral
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube
f. If abdominal cramps occur, temporarily stop the flow until cramps are gone.
Height of enema can - 18 inches
5. Urinary Catheterization Verify MD's order
a. Practice strict asepsis erineal care before the procedure
, b. Catheter size: male-14-16 , female- 12 - 14
c. Length of catheter insertion male - 6-9 inches ,female - 3-4 inches
Male -anchor laterally or upward over the lower abdomen to prevent penoscrotal pressure
Female- inner aspect of the thigh
TYPES OF OSTOMIES
a. Ileostomy
Liquid to semi-formed stool, dependent upon amount of bowel removed
May skew fluid & electrolyte balance, especially potassium & sodium
Digestive enzymes in stool irritate skinDo NOT give laxatives
Ileostomy lavage may be done if needed to clear food blockage
May not require appliance set; if continent ileal reservoir or Koch pouch
b. Colostomy
Ascending-must wear appliance—semi-liquid stool
Transverse-wear appliance--semi-formed stool
Loop stoma
Proximal end-functioning stoma
Distal end-drains mucous
Plastic rod used to keep loop out
Usually temporary
Double barrel
Two stomas
Similar to loop but bowel is surgically severed
Sigmoid
Formed stool
Bowel can be regulated so appliance not needed
May be irrigated
Stoma assessment
a. Color-should be same color as mucous membranes (normal stoma color-
Red not dusky or pale: sign of infection)
b. Edema-common after surgery. Bleeding-slight bleeding common after
surgery
Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are
done to promote evacuation of feces at a regular and convenient time Recommended
with sigmoid colostomy
Initiated 5 to 7 days postop
Done in semi - Fowler's position; then sitting on a toilet bowl once ambulatory.
Use warm normal saline solution
Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently
Dilate stoma with lubricated gloved finger before insertion of catheter
Lubricate catheter before insertion.
Insert 3 to 4 inches of the catheter into the stoma
