FUNDAMENTALS OF NURSING NURSING PROCEDURES

1. Steam Inhalation 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. 2. Suctioning 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. Nasogastric Feeding (gastric gavage) Insertion: a. Fowler’s position b. Tip of the nose to tip of the earlobe to the xyphoid Tube Feeding a. Semi-Fowler’s position b. Assess tube placement c. Assess residual feeding 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 4. Enema 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. g. Height of enema can – 18 inches 5. Urinary Catheterization a. Verify MD’s order b. Practice strict asepsis c. Perineal care before the procedure d. Catheter size: male-14-16 , female – 12 – 14 e. Length of catheter insertion male – 6-9 inches ,female – 3-4 inches For retention catheter: 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