Taif University Nursing Department Procedures Logbook - Fundamentals of Nursing I PDF

College of Applied Medical Sciences College of Applied Nursing Medical Sciences Department Nursing Department PROCEDURES’ LOGBOOK...

College of Applied Medical Sciences College of Applied Nursing Medical Sciences Department Nursing Department PROCEDURES’ LOGBOOK Fundamentals of Nursing I First semester Student name: ………………………………………………………….………………………….. Academic No.: ………………………………………………………….……………………….… Instructor name: ………………………………………………………….…….…………………… Division: ……………..……………. Day: ………………………… O am O pm  Taif University College of Applied Medical Sciences Nursing Department TABLE OF CONTENT Page List of Topics Category No# Asepsis Nursing Skills SKILL Performing Hand Hygiene. B 4 SKILL Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, B 7 Eyewear). SKILL Establishing and Maintaining a Sterile Field. B 11 SKILL Applying and Removing Sterile Gloves (Open Method). B 16 Vital Signs and Pain Assessment Nursing Skills SKILL Assessing Body Temperature. B 19 SKILL Assessing Respiration. B 22 SKILL Assessing a peripheral Pluses. B 25 SKILL Assessing an Apical Pluse. B 29 SKILL Assessing an Apical-Radial Pulse. B 32 SKILL Assessing Oxygen Saturation with Pulse Oximetry. B 34 SKILL Assessing Blood Pressure by Sphygmomanometer (Arterial Blood Pressure). B 37 SKILL Assessing Blood Pressure Electronically. B 41 Oxygenation Nursing Skills SKILL Administering Oxygen by Cannula, Face Mask or Face Tent. A 44 SKILL Oropharyngeal, Nasopharyngeal and Nasotracheal Suctioning. A 48 SKILL Collecting Sputum Specimen by Suctioning. A 51 SKILL Collecting Sputum Culture by Expectorations. C 53 SKILL Obtaining Throat Culture, Obtaining a Nose Culture. B 55 Nutrition Nursing Skills SKILL Inserting a Nasogastric Tube. A 59 SKILL Administering a Tube Feeding. A 64 SKILL Administering a Gastrostomy or Jejunostomy Feeding. A 68 SKILL Removing a Nasogastric Tube. B 71 SKILL Irrigating Feeding Tube. A 74 Hygiene Nursing Skills SKILL Bathing an Adult Client. C 77 SKILL Providing Hair, Ear, Nose, and Eyes Care. C 83 SKILL Providing Perineal-Genital Care. C 85 SKILL Providing Special Oral Care for the Unconscious Client. C 89 SKILL Providing Foot Care and Nails. C 92 Bed Making Nursing Skills SKILL Changing an Unoccupied Bed. C 95 SKILL Changing an Occupied Bed. C 100 2  Taif University College of Applied Medical Sciences Nursing Department Circulation Nursing Skills SKILL Obtaining a Capillary Blood Specimen to Measure Blood Glucose. A 103 SKILL Collecting Blood Specimen and Culture by Venipuncture. A 107 Fluid, Electrolyte, and Acid–Base Balance Nursing Skills SKILL Starting an Intravenous Infusion. A 114 SKILL Monitoring an Intravenous Infusion. B 121 SKILL Changing an Intravenous Container and Tubing. B 126 SKILL Discontinuing an Intravenous Infusion. B 129 SKILL Changing an Intravenous Catheter to an Intermittent Infusion Lock. B 132 SKILL Initiating, Maintaining, and Terminating a Blood Transfusion Using Y-Set. A 135 3  Taif University College of Applied Medical Sciences Nursing Department Performing Hand Hygiene Introduction: Hand hygiene is important in every setting, including hospitals. It is considered one of the most effective infection prevention measures. Any client may harbor microorganisms that are currently harmless to the client yet potentially harmful to another person or to the same client if they find a portal of entry. Purpose : To reduce the number of microorganisms on the hands To reduce the risk of transmission of microorganisms to clients To reduce the risk of cross contamination among clients To reduce the risk of transmission of infectious organisms to oneself. Assessment & Preparation: Assessment: Determine the client’s: Presence of factors increasing susceptibility to infection and possibility of undiagnosed infection (e.g., HIV) Use of immunosuppressive medications Recent diagnostic procedures or treatments that penetrated the skin or a body cavity Current nutritional status Signs and symptoms indicating the presence of an infection: Localized signs: swelling, redness, pain or tenderness with palpation or movement, palpable heat at site, loss of function of affected body part, presence of exudate Systemic indications: fever, increased pulse and respiratory rates, lack of energy, anorexia, enlarged lymph nodes. Preparation: Prepare the following equipment: Soap Warm running water Paper towels 4  Taif University College of Applied Medical Sciences Nursing Department Performing Hand Hygiene Procedure Rationale 1. Preparation : Assess the hands: Nails should be kept short. Most agencies do not permit health Short, natural nails are less likely to care workers in direct contact with clients to have any form of harbor microorganisms, scratch a client, or puncture gloves. artificial nails. Although the research is Removal of all jewellery is recommended. controversial, microorganisms can lodge in the settings of jewelry and under rings. Removal facilitates proper cleaning of the hands and arms. A nurse who has open sores may Check hands for breaks in the skin, such as hangnails or cuts. require a work assignment with decreased risk for transmission of infectious organisms due to the chance of acquiring or passing on an infection. 2. If you are your hands where the client can observe you, introduce yourself and explain to the client what you are going to do and why it is necessary 3. Turn on the water and adjust the flow is warm. Warm water removes less of the There are five common types of faucet controls: protective oil of the skin than hot a. Hand-operated handles. water. b. Knee levers. c. Foot pedals. d. Elbow controls. Move these with the elbows instead of the hands. e. Infrared control. Motion in front of the sensor causes water to start and stop flowing automatically. Adjust the flow so that the water is warm. 4. Wet the hands thoroughly by holding them under the running The water should flow from the least water and apply the soap to the hands. contaminated to the most Hold the hands lower than the elbows so that the water flows contaminated area; the hands are generally considered more from the arms to the fingertips. contaminated than the lower arms If the soap is liquid, apply 2 to 4 ml (1 tsp). If it is a bar soap, granules, or sheets, rub them firmly between the hands. 5. Thoroughly wash and rinse the hands. The circular action creates friction Use firm, rubbing, and circular movements to wash the palm, that helps remove microorganisms back, and wrist of each hand. Be sure to include the heel of the mechanically. Interlacing the fingers and thumbs cleans the interdigital hand. Interlace the fingers and thumbs, and move the hands spaces. back and forth. The WHO (2009) recommends these steps: 5  Taif University College of Applied Medical Sciences Nursing Department a. Right palm over left dorsum with interlaced fingers and vice versa b. Palm to palm with fingers interlaced c. Backs of fingers to opposing palms with fingers interlocked d. Rotational rubbing of left thumb clasped in right palm and vice versa. e. Continue these motions for about 30 seconds. The nails and fingertips are Rub the fingertips against the palm of the opposite hand. commonly missed during hand Rinse the hands. hygiene. 6. Thoroughly pat dry the hands and arms. Dry hands and arms thoroughly with a paper towel without Moist skin becomes chapped readily scrubbing. as does dry skin that is rubbed vigorously; chapping produces Discard the paper towel in the appropriate container. lesions. 7. Turn off the water. Use a new paper towel to grasp a hand-operated control. This prevents the nurse from picking up microorganisms from the faucet Apply hand lotion if desired. Use only agency-approved hand handles. Hand lotions are important to lotions and dispensers. Other lotions may make hand hygiene prevent skin dryness and irritation. less effective, cause the breakdown of latex gloves, and become contaminated with bacteria if dispensers are refilled. Variation: Hand Washing Before Performing Sterile Skills Apply the soap and wash as described in step 4, but hold the In this way, the water runs from the hands higher than the elbows during this hand wash. Wet the area that hands and forearms under the running water, letting it run from now has the fewest microorganisms to areas with a relatively the fingertips to the elbows so that the hands become cleaner greater number of pathogens. than the elbows. After washing and rinsing, use a towel to dry one hand A clean towel prevents the transfer thoroughly in a rotating motion from the fingers to the elbow. of microorganisms from one elbow Use a new towel to dry the other hand and arm. (least clean area) to the other hand Apply sterile gloves before touching any unsterile items. (cleanest area). KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 6  Taif University College of Applied Medical Sciences Nursing Department Applying and Removing Personal Protective Equipment Introduction: All health care providers must apply PPE (clean or sterile gloves, gowns, masks, and protective eyewear) according to the risk of exposure to potentially infective materials. Purpose : To protect health care workers and clients from transmission of potentially infective materials. Assessment & Preparation: Assessment Consider which activities will be required while the nurse is in the client’s room at this time. Because this will determine which equipment is required. Preparation: Prepare the following equipment: As indicated according to which activities will be performed, ensure that extra supplies are easily available. Gown Mask Eyewear Clean gloves 7  Taif University College of Applied Medical Sciences Nursing Department Applying and Removing Personal Protective Equipment Procedure Rationale 1. Preparation: Remove or secure all loose items such as name tags or jewelry 2. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 3. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. 4. Perform hand hygiene. 5. Apply a clean gown. Pick up a clean gown, and allow it to unfold in front of you without allowing it to touch any area soiled with body substances. Slide the arms and the hands through the sleeves. Fasten the ties at the neck to keep the gown in place. Overlap the gown at the back as much as possible, and Overlapping securely covers the fasten the waist ties or belt. uniform at the back. Waist ties keep the gown from falling away from the body, which can cause inadvertent soiling of the uniform. 6. Apply the face mask. Locate the top edge of the mask. The mask usually has a narrow metal strip along the edge. Hold the mask by the top two strings or loops. Place the upper edge of the mask over the bridge of the With the edge of the mask under the nose, and tie the upper ties at the back of the head or glasses, clouding of the glasses is less secure the loops around the ears. If glasses are worn, fit likely to occur. the upper edge of the mask under the glasses. Secure the lower edge of the mask under the chin, and To be effective, a mask must cover tie the lower ties at the nape of the neck. both the nose and the mouth, because air moves in and out of both. If the mask has a metal strip, adjust this firmly over the A secure fit prevents both bridge of the nose. the escape and the inhalation of microorganisms around the edges of the mask and the fogging of eyeglasses. Wear the mask only once, and do not wear any mask A mask should be used only once longer than the manufacturer recommends or once it because it becomes ineffective when becomes wet. moist. Do not leave a used face mask hanging around the neck. 8  Taif University College of Applied Medical Sciences Nursing Department 7. Apply protective eyewear if it is not combined with the face mask. 8. Apply clean gloves. No special technique is required. If wearing a gown, pull the gloves up to cover the cuffs of the gown. If not wearing a gown, pull the gloves up to cover the wrists. 9. To remove soiled PPE, remove the gloves first since they are the most soiled. If wearing a gown that is tied at the waist in front, undo the ties before removing gloves. Remove the first glove by grasping it on its palmar This keeps the soiled parts of the surface, taking care to touch only glove to glove. used gloves from touching the skin of the wrist or hand. Pull the first glove completely off by inverting or rolling the glove inside out. Continue to hold the inverted removed glove by the Touching the outside of the second fingers of the remaining gloved hand. Place the first soiled glove with the bare hand is two fingers of the bare hand inside the cuff of the avoided second glove. Pull the second glove off to the fingers by turning it The soiled part of the glove is folded inside out. This pulls the first glove inside the second to the inside to reduce the chance of glove. transferring any microorganisms by Using the bare hand, continue to remove the gloves, direct contact. which are now inside out, and dispose of them in the refuse container. 10. Perform hand hygiene. Contact with microorganisms may occur while removing PPE. 11. Remove protective eyewear and dispose of properly or place in the appropriate receptacle for cleaning. 12. Remove the gown when preparing to leave the room. Avoid touching soiled parts on the outside of the gown, The top part of the gown may be if possible. soiled, for example, if you have been holding an infant with a respiratory infection. Grasp the gown along the inside of the neck and pull down over the shoulders. Do not shake the gown. Roll up the gown with the soiled part inside, and discard it in the appropriate container. 13. Remove the mask. Remove the mask at the doorway to the client’s room. If using a respirator mask, remove it after leaving the room and closing the door. This prevents the top part of the mask from falling onto the chest. 9  Taif University College of Applied Medical Sciences Nursing Department If using a mask with strings, first untie the lower strings The front of the mask through which of the mask. the nurse has been breathing is Untie the top strings and, while holding the ties contaminated. securely, remove the mask from the face. If side loops are present, lift the side loops up and away from the ears and face. Do not touch the front of the mask. Discard a disposable mask in the waste container. Perform proper hand hygiene again. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 10  Taif University College of Applied Medical Sciences Nursing Department Establishing and Maintaining a Sterile Field Introduction: A sterile field is a microorganism-free area. Nurses often establish a sterile field by using the innermost side of a sterile wrapper or by using a sterile drape. When the field is established, sterile supplies and sterile solutions can be placed on it. Sterile forceps are used in many instances to handle and transfer sterile supplies. Purpose : To ensure that sterile items remain sterile. Assessment & Preparation: Assessment Review the client’s record or discuss with the client exactly what procedure will be performed that requires a sterile field. Assess the client for the presence of or risk for infection and ability to participate with the procedure. Preparation: Prepare the following equipment: Package containing a sterile drape Sterile equipment as needed (e.g., wrapped sterile gauze, wrapped sterile bowl, antiseptic solution, sterile forceps). 11  Taif University College of Applied Medical Sciences Nursing Department Establishing and Maintaining a Sterile Field Procedure Rationale 1. Preparation: Ensure that the package is clean and dry; if moisture is noted on the inside of a plastic-wrapped package or the outside of a cloth-wrapped package, it is considered contaminated and must be discarded Check the sterilization expiration dates on the package, and look for any indications that it has been previously opened. Spots or stains on cloth or paper-wrapped objects may indicate contamination, and the objects should not be used. Follow agency practice for disposal of possibly contaminated packages. 2. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 3. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments. 4. Perform hand hygiene and observe other appropriate infection prevention procedures. 5. Provide for client privacy. 6. Open the package. If the package is inside a plastic cover, remove the cover. To Open a Wrapped Package on a Surface Place the package in the work area so that the top flap of the wrapper opens away from you. Reaching around the package (not over it), pinch the Touching only the outside of the first flap on the outside of the wrapper between the wrapper maintains the sterility of the thumb and index finger. inside of the wrapper. Pull the flap open ,laying it flat on the far surface. By using both hands, you avoid reaching Repeat for the side flaps, opening the topmost one first. over the sterile contents. Use the right hand for the right flap, and the left hand for the left flap. Pull the fourth flap toward you by grasping the corner that is turned down. Variation: Opening a Wrapped Package While Holding it : Hold the package in one hand with the top flap opening away from you. Using the other hand, open the package as described above, pulling the corners of the flaps well back. Tuck each of the corners into the hand holding the package so that they do not flutter and contaminate 12  Taif University College of Applied Medical Sciences Nursing Department sterile objects. The hands are considered contaminated, and at no time should they touch the contents of the package. Variation: Opening Commercially Prepared Packages If the flap of the package has an unsealed corner, hold the package in one hand, and pull back on the flap with the other hand. If the package has a partially sealed edge, grasp both sides of the edge, one with each hand, and pull apart gently. 7. Establish a sterile field by using a drape. Open the package containing the drape as described above. With one hand, pluck the corner of the drape that is folded back on the top touching only one side of the drape. Lift the drape out of the cover, and allow it to open If the drape touches the outside of the freely without touching any objects. package or any unsterile surface, it is considered contaminated. With the other hand, carefully pick up another corner of the drape, holding it well away from you and, again, touching only the same side of the drape as the first hand. Lay the drape on a clean and dry surface, placing the By placing the lowermost side farthest bottom (i.e., the freely hanging side) farthest from you. away, you avoid leaning over the sterile field and contaminating it. 8. Add necessary sterile supplies, being careful not to touch the drape with the hands. To Add Wrapped Supplies to a Sterile Field Open each wrapped package as described in the preceding steps. With the free hand, grasp the corners of the wrapper, The sterile wrapper now covers the and hold them against the wrist of the other hand. unsterile hand. Place the sterile bowl, drape, or other supply on the sterile field by approaching from an angle rather than holding the arm over the field. Discard the wrapper. Variation: Adding Commercially Packaged Supplies to a Sterile Field Open each package as previously described. Hold the package 15 cm (6 in.) above the field, and allow the contents to drop on the field. Keep in mind At a height of 15 cm (6 in.), the outside that 2.5 cm (1 in.) around the edge of the field is of the package is not likely to touch and considered contaminated. contaminate the sterile field. Adding Solution to a Sterile Bowl 13  Taif University College of Applied Medical Sciences Nursing Department Liquids (e.g., normal saline) may need to be poured into containers within a sterile field. Unwrapped bottles that contain sterile solution are considered sterile on the inside and contaminated on the outside because the bottle may have been handled. Bottles used in an operating room may be sterilized on the outside as well as the inside, however, and these are handled with sterile gloves. Once a sterile bottle has been opened, its Obtain the exact amount of solution, if possible. sterility cannot be ensured for future use. Follow agency policy for reuse of opened sterile solution bottles. Before pouring any liquid, read the label three times to make sure you have the correct solution and concentration (strength). Wipe the outside of the bottle with a damp towel to remove any large particles that Inverting the lid maintains the sterility of could fall into the bowl or field. the inside surface because it is not Remove the lid or cap from the bottle and invert the lid allowed to touch an unsterile surface. before placing it on a surface that is not sterile. Any solution that flows down the outside of the bottle during pouring will not damage or obliterate the label. Hold the bottle so that the label is against the palm of At this height, there is less likelihood of the hand. contaminating the sterile field by touching the field or by reaching an arm over it. Hold the bottle of fluid at a height of 10 to 15 cm (4 to If a barrier drape (one that has a water- 6 in.) over the bowl and to the side of the sterile field so resistant layer) is not used and the drape that as little of the bottle as possible is over the field. is on an unsterile surface, moisture will Pour the solution gently to avoid splashing the liquid. contaminate the field by wicking microorganisms through the drape. Such drips would contaminate the sterile field if the outside of the bottle is not sterile. Tilt the neck of the bottle back to vertical quickly when Replacing the lid immediately maintains done pouring so that none of the liquid flows down the the sterility of the inner aspect of the lid outside of the bottle. and the solution. If the bottle will be used again, replace the lid securely and write on the label the date and time of opening. Depending on agency policy, a sterile container of solution that is opened may be used only once and is then discarded (such as in the operating room). In other settings, policy may permit recapped bottles to be reused within 24 hours. 9. Use sterile forceps to handle sterile supplies. Forceps are usually used to move a sterile article from one place to another, for example, transferring sterile gauze from 14  Taif University College of Applied Medical Sciences Nursing Department its package to a sterile dressing tray. Forceps may be disposable or resterilized after use. Commonly used Gravity prevents liquids on the tips of forceps include hemostats and tissue forceps. the forceps from flowing to the unsterile If forceps tips are wet, keep the tips lower than the wrist handles and later back to the tips. at all times, unless you are wearing sterile gloves. Items held below waist or table level are considered contaminated. Hold sterile forceps above waist or table level, While out of sight, forceps may, whichever is higher. unknown to the user, become unsterile. Hold sterile forceps within sight. Any forceps that go out of sight should be considered unsterile. The edges and outside of the sterile field are considered unsterile. When using forceps to lift sterile supplies, be sure that the forceps do not touch the edges or outside of the The handles of these forceps harbor wrapper. microorganisms from the bare hand. When placing forceps whose handles were in contact with the bare hand, position the handles outside the sterile area. Deposit a sterile item on a sterile field without permitting moist forceps to touch the sterile field when the surface under the absorbent sterile field is unsterile and a barrier drape is not used. 10. Document that sterile technique was used in the performance of the procedure. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 15  Taif University College of Applied Medical Sciences Nursing Department Applying and Removing Sterile Gloves (Open Method) Introduction: Sterile gloves may be applied by the open method or the closed method. The open method is most frequently used outside the operating room because the closed method requires that the nurse wear a sterile gown. Gloves are worn during many procedures to enable the nurse to handle sterile items freely and to prevent clients at risk (e.g., those with open wounds) from becoming infected by microorganisms on unsterile gloves or the nurse’s hands. Purpose : To enable the nurse to handle or touch sterile objects freely without contaminating them. To prevent transmission of potentially infective organisms from the nurse’s hands to clients at high risk for infection Assessment & Preparation: Assessment: Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves. Check the client record and ask about latex allergies. Use non latex gloves whenever possible. Equipment: Packages of sterile gloves. Preparation: Ensure the sterility of the package of gloves. 16  Taif University College of Applied Medical Sciences Nursing Department Applying and Removing Sterile Gloves (Open Method) Procedure Rationale 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 2. Explain to the client what you are going to do, why it is necessary. 3. Perform hand hygiene and observe other appropriate infection prevention procedures 4. Provide for client privacy. 5. Open the package of sterile gloves. Place the package of gloves on a clean, dry Any moisture on the surface could contaminate surface the gloves. Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package. Remove the inner package from the outer package. Open the inner package according to the The inner surfaces, which are next to the sterile manufacturer’s directions. Some manufacturers gloves, will remain sterile. provide a numbered sequence for opening the flaps and folded tabs to grasp for opening the flaps. If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces. 6. Put the first glove on the dominant hand. If the gloves are packaged so that they lie side The hands are not sterile. By touching only by side, grasp the glove for the dominant hand the inside of the glove, the nurse avoids by its folded cuff edge (on the palmar side) contaminating the outside. with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff. Or If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above, using the opposite hand. Insert the dominant hand into the glove and If the thumb is kept against the palm, it is less likely pull the glove on. Keep the thumb of the to contaminate the outside of the glove. inserted hand against the palm of the hand during insertion. Attempting to further unfold the cuff is likely to Leave the cuff in place once the unsterile hand contaminate the glove. releases the glove. 17  Taif University College of Applied Medical Sciences Nursing Department 7. Put the second glove on the nondominant hand. Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm. Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as In this position, the thumb is less likely to touch the possible from the palm. arm and become contaminated. Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by sliding the fingers under the cuffs. 8. Remove and dispose of used gloves. There is no technique for removing sterile gloves that is different from removing unsterile gloves. If they are soiled with secretions, remove them by turning them inside out. Perform hand hygiene. 9. Document that sterile technique was used in the performance of the procedure. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 18  Taif University College of Applied Medical Sciences Nursing Department Assessing Body Temperature Introduction: Body temperature reflects the balance between the heat produce and the heat lost from the body and is measured in heat units called degrees. The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Purpose: To establish baseline data for subsequent evaluation. To identify whether the core temperature is within normal range. To determine changes in the core temperature in response to specific therapies (e.g. antipyretic medication , invasive procedure). To monitor clients at risk for imbalanced body temperature. (e.g., clients at risk for infection or diagnosis of infection; those who have been exposed to temperature extremes) Assessment & Preparation: Assessment: Clinical signs of fever. Clinical signs of hypothermia. Site and method most appropriate for measurement. Factors that may alter core body temperature. Preparation: Prepare the following equipment: Thermometer. Thermometer sheath or cover. Clean gloves. Water-soluble lubricant for a rectal temperature. Towel for axillary temperature. Tissues. 19  Taif University College of Applied Medical Sciences Nursing Department Assessing Body Temperature Procedure Rationale 1. Check that all equipment is functioning normally. 2. Introduce self and verify the client's identity using agency protocol. 3. Explain to the client what you are going to do. 4. Perform hand hygiene and observe appropriate infection control procedures. Apply gloves if performing a rectal temperature. 5. Provide for client privacy. 6. Place the client in the appropriate position(e.g. lateral or Sims' position for inserting a rectal thermometer ). 7. Place the thermometer. Apply a protective sheath or probe cover if appropriate. Lubricate a rectal thermometer. 8. Wait the appropriate amount of time. Electronic and tympanic thermometers will indicate that the reading is complete through a light or tone. Check package instructions for length of time to wait prior to reading chemical dot or tape thermometers. 9. Remove the thermometer and discard the cover or wipe with a tissue if necessary. If gloves were applied , remove and discard them. Perform hand hygiene. 10. Read the temperature and record it on your worksheet. If the temperature is obviously too high, too low, or inconsistent with the client’s condition, recheck it with a thermometer known to be functioning properly. 11. Wash the thermometer if necessary and return it to the storage location. 12. Document the temperature in the client record. A rectal temperature may be recorded with an ''R'' next to the value or with the mark on a graphic sheet circled. An axillary temperature may be recorded with "AX" or marked on a graphic sheet with an X. 13. INFANTS The body temperature of newborns is extremely labile, and newborns must be kept warm and dry to prevent hypothermia. Using the axillary site, you need to hold the infant’s arm against the chest. The axillary route may not be as accurate as other routes for detecting fevers in children. The tympanic route is fast and convenient. Place the infant supine and stabilize the head. Pull the pinna straight back and slightly downward. 20  Taif University College of Applied Medical Sciences Nursing Department Remember that the pinna is pulled upward for children over 3 years of age and adults, but downward for children younger than age 3. Direct the probe tip anteriorly and insert far enough to seal the canal. The tip will not touch the tympanic membrane. Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes. The tympanic membrane route may be more accurate in determining temperature in febrile infants. When using a temporal artery thermometer, touching only the forehead or behind the ear is needed. The rectal route is least desirable in infants. 14. CHILDREN Tympanic or temporal artery sites are preferred. For the tympanic route, have the child held on an adult’s lap with the child’s head held gently against the adult for support. Pull the pinna straight back and upward for children over age 3. Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes. The oral route may be used for children over age 3, but nonbreakable, electronic thermometers are recommended. For a rectal temperature, place the child prone across your lap or in a side- lying position with the knees flexed. Insert the thermometer 2.5 cm (1 in.) into the rectum. 15. OLDER ADULTS Older adults’ temperatures tend to be lower than those of middle-aged adults. Older adults’ temperatures are strongly influenced by both environmental and internal temperature changes. Their thermoregulation control processes are not as efficient as when they were younger, and they are at higher risk for both hypothermia and hyperthermia. Older adults can develop significant buildup of ear cerumen (earwax) that may interfere with tympanic thermometer readings. Older adults are more likely to have hemorrhoids. Inspect the anus before taking a rectal temperature. Older adults’ temperatures may not be a valid indication of the seriousness of the pathology of a disease. They may have pneumonia or a urinary tract infection and have only a slight temperature elevation. Other symptoms, such as confusion and restlessness, may be displayed and need follow-up to determine if there is an underlying process. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 21  Taif University College of Applied Medical Sciences Nursing Department Assessing Respirations Introduction Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs. Purpose To acquire baseline data against which future measurements can be compared To monitor abnormal respirations and respiratory patterns and identify changes To monitor respirations before or after the administration of a general anesthetic or any medication that influences respirations To monitor clients at risk for respiratory alterations (e.g., those with fever, pain, acute anxiety, chronic obstructive pulmonary disease, asthma, respiratory infection, pulmonary edema or emboli, chest trauma or constriction, brainstem injury) Assessment Assess Skin and mucous membrane color (e.g., cyanosis or pallor) Position assumed for breathing (e.g., use of orthopneic position) Signs of lack of oxygen to the brain (e.g., irritability, restlessness, drowsiness, or loss of consciousness) Chest movements (e.g., retractions between the ribs or above or below the sternum) Activity tolerance Chest pain Dyspnea Medications affecting respiratory rate Equipment Clock or watch with a sweep second hand or digital seconds indicator 22  Taif University College of Applied Medical Sciences Nursing Department Assessing Respiration Procedure Rationale 1. For a routine assessment of respirations, determine the client’s activity schedule and choose a suitable time to monitor the respirations. A client who has been exercising will need to rest for a few minutes to permit the accelerated respiratory rate to return to normal. 2. Introduce self and verify the client’s identity using agency protocol 3. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments 4. Perform hand hygiene and observe appropriate infection prevention procedures. 5. Provide for client privacy 6. Observe or palpate and count the respiratory rate. The client’s awareness that the nurse is counting the respiratory rate could cause the client to purposefully alter the respiratory pattern. If you anticipate this, place a hand against the client’s chest to feel the chest movements with breathing, or place the client’s arm across the chest and observe the chest movements while supposedly taking the radial pulse. Count the respiratory rate for 30 seconds if the respirations are regular. Count for 60 seconds if they are irregular. An inhalation and an exhalation count as one respiration 7. Observe the depth, rhythm, and character of respirations. Observe the respirations for depth by watching the movement of the chest During deep respirations, a large volume of air is exchanged; during shallow Observe the respirations for regular or irregular rhythm respirations, a small volume is Observe the character of respirations—the sound they produce exchanged and the effort they require Normally, respirations are evenly spaced Normally, respirations are silent and effortless. 8. Document the respiratory rate, depth, rhythm, and character on the appropriate record 9. INFANTS AND CHILDREN An infant or child who is crying will have an abnormal respiratory rate and rhythm and needs to be quieted before respirations can be accurately assessed. 23  Taif University College of Applied Medical Sciences Nursing Department Infants and young children use their diaphragms for inhalation and exhalation. If necessary, place your hand gently on the infant’s abdomen to feel the rapid rise and fall during respirations. Most newborns are complete nose breathers, so nasal obstruction can be life threatening. Some newborns display “periodic breathing” in which they pause for a few seconds between respirations. This condition can be normal, but parents should be alert to prolonged or frequent pauses (apnea) that require medical attention. Compared to adults, infants have fewer alveoli and their airways have a smaller diameter. As a result, infants’ respiratory rate and effort of breathing will increase with respiratory infections. Count respirations prior to other uncomfortable procedures so that the respiratory rate is not artificially elevated by the discomfort. 10. OLDER ADULTS Ask the client to remain quiet, or count respirations after taking the pulse. Older adults experience anatomic and physiological changes that cause the respiratory system to be less efficient. Any changes in rate or type of breathing should be reported immediately. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 24  Taif University College of Applied Medical Sciences Nursing Department Assessing a Peripheral Pulse Introduction: The pulse is a wave of blood created by contraction of the left ventricle of the heart. Purpose : To establish baseline data for subsequent evaluation. To identify whether the pulse rate is within normal range. To determine the pulse volume and whether the pulse rhythm is regular. To determine the equality of corresponding peripheral pulses on each side of the body. To monitor and assess changes in the client's health status. To monitor client's at risk for pulse alterations. To evaluate blood perfusion to the extremities. Assessment & Preparation: Assessment: Clinical signs of cardiovascular alterations such as dyspnea , fatigue , pallor , cyanosis , palpitations or impaired peripheral tissue perfusion. Factors that may alter pulse rate (e.g. emotional status and activity level). Which site is most appropriate for assessment based on the purpose. Preparation: Equipment: Clock or watch with a sweep second hand or digital seconds indicator. If using a DUS: transducer probe, stethoscope headset (some models), transmission gel, and tissues/wipes. 25  Taif University College of Applied Medical Sciences Nursing Department Assessing a Peripheral Pulse Procedure Rationale 1. If using a DUS ,check that the equipment is functioning normally. 2. Introduce self and verify the client's identity using agency protocol. 3. Explain to the client what you are going to do. 4. Perform hand hygiene and observe appropriate infection control procedures. 5. Provide for client privacy. 6. Select the pulse point. Normally the radial pulse is taken. unless it cannot be exposed or circulation to another body area is to be assessed. 7. Assist the client to a comfortable resting position. When the radial pulse is assessed , with the palm facing downward , the client's arm can rest alongside the body or the forearm can rest at a 90 degree angle across the chest. For the client who can sit , the forearm can rest across the thigh , with the palm of the hand facing downward or inward. 8. Palpate and count the pulse. Place two or three middle fingertips lightly and squarely over the Using the thumb is pulse point. contraindicated because the nurse's thumb has a pulse that Count for 15 seconds and multiply by 4. Record the pulse in could be mistaken for the client's beats per minutes on your worksheet. pulse. If taking a client's pulse for the first time , when obtaining baseline data or if the pulse is irregular , count for a full minute , If an irregular pulse is found also take the apical pulse. 9. Assess the pulse rhythm and volume : Assess the pulse rhythm by noting the pattern of the intervals between the beats. A normal pulse has equal time periods between beats. If this is an initial assessment , assess for 1 minute. Assess the pulse volume. A normal pulse can be felt with moderate pressure and the pressure is equal with each beat.Record the rhythm and volume on your worksheet. 10. Document the pulse rate , rhythm and volume and your actions in the client record. Also record in the nurse's notes pertinent related data such as variation in pulse rate compared to normal for the client and abnormal skin color and skin temperature. 26  Taif University College of Applied Medical Sciences Nursing Department 11. Using a DUS If used, plug the stethoscope headset into one of the two output jacks located next to the volume control. DUS units may have two jacks so that a second person can listen to the signals. Apply transmission gel either to the probe at the narrow end of the plastic case housing the transducer, or to the client’s skin. Press the “on” button. Ultrasound beams do not travel Hold the probe against the skin over the pulse site. Use a light well through air. The gel makes pressure, and keep the probe in contact with the skin. an airtight seal, which then Adjust the volume if necessary. Distinguish artery sounds from promotes optimal ultrasound wave vein sounds. The artery sound (signal) is distinctively pulsating transmission. and has a pumping quality. The venous sound is intermittent and varies with respirations. Both artery and vein sounds are heard simultaneously through the DUS because major arteries and Too much pressure can stop the veins are situated close together throughout the body. If arterial blood flow and obliterate the sounds cannot be easily heard, reposition the probe. If you cannot signal. hear any pulse, move the probe to several different locations in the same area before determining that no pulse is present. After assessing the pulse, remove all gel from the probe to Alcohol or other disinfectants may prevent damage to the surface. Clean the transducer with water- damage the face of the transducer. based solution. Remove all gel from the client. 12. INFANTS Use the apical pulse for the heart rate of newborns, infants, and children 2 to 3 years old to establish baseline data for subsequent evaluation, to determine whether the cardiac rate is within normal range, and to determine if the rhythm is regular. Place a baby in a supine position, and offer a pacifier if the baby is crying or restless. Crying and physical activity will increase the pulse rate. For this reason, take the resting apical pulse rate of infants and small children before assessing body temperatures. Locate the apical pulse in the left fourth intercostal space, lateral to the midclavicular line during infancy. Brachial, popliteal, and femoral pulses may be palpated. Due to a normally low blood pressure and rapid heart rate, infants’ other distal pulses may be hard to feel. Newborn infants may have heart murmurs that are not pathologic, but reflect functional incomplete closure of fetal heart structures (ductus arteriosus or foramen ovale). 13. CHILDREN To take a peripheral pulse, position the child comfortably in the adult’s arms or have the adult remain close by. This may decrease anxiety and yield more accurate results. To assess the apical pulse, assist a young child to a comfortable supine or sitting position. Demonstrate the procedure to the child using a stuffed animal or doll, and allow the child to handle the stethoscope before 27  Taif University College of Applied Medical Sciences Nursing Department beginning the procedure. This will decrease anxiety and promote cooperation. The apex of the heart is normally located in the left fourth intercostal space in young children; fifth intercostal space in children 7 years of age and over, between the MCL and the anterior axillary line. Count the pulse prior to other uncomfortable procedures so that the rate is not artificially elevated by the discomfort. 14. OLDER ADULTS If the client has severe hand or arm tremors, the radial pulse may be difficult to count. Cardiac changes in older adults, such as decrease in cardiac output, sclerotic changes to heart valves, and dysrhythmias, may suggest that obtaining an apical pulse will be more accurate than a peripheral pulse. Older adults often have decreased peripheral circulation. To detect these, pedal pulses should also be checked for regularity, volume, and symmetry. The pulse returns to baseline after exercise more slowly than with other age groups. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 28  Taif University College of Applied Medical Sciences Nursing Department Assessing an Apical Pulse Introduction: Assessment of the apical pulse is indicated for clients whose peripheral pulse is irregular or unavailable and for clients with known cardiovascular, pulmonary, and renal diseases. It is commonly assessed prior to administering medications that affect heart rate. Purpose : To obtain the heart rate of an adult with an irregular peripheral pulse To establish baseline data for subsequent evaluation To determine whether the cardiac rate is within normal range and the rhythm is regular To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to improve heart action. Assessment & Preparation: Assess: Clinical signs of cardiovascular alterations such as dyspnea (difficult respirations), fatigue/weakness, pallor, cyanosis (bluish discoloration of skin and mucous membranes), palpitations, syncope (fainting), or impaired peripheral tissue perfusion as evidenced by skin discoloration and cool temperature. Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect heart rate such as digoxin, beta-blockers, or calcium channel blockers). Preparation: Equipment : Clock or watch with a sweep second hand or digital seconds indicator Stethoscope Antiseptic wipes If using a DUS: the transducer probe, the stethoscope headset, transmission gel, and tissues/wipes 29  Taif University College of Applied Medical Sciences Nursing Department Assessing an Apical Pulse Procedure Rationale 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 2. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments. 3. Perform hand hygiene and observe appropriate infection prevention procedures. 4. Provide for client privacy. 5. Position the client appropriately in a comfortable supine position or in a sitting position. Expose the area of the chest over the apex of the heart. 6. Locate the apical impulse. This is the point over the apex of the heart where the apical pulse can be most clearly heard. Palpate the angle of Louis (the angle between the manubrium, the top of the sternum, and the body of the sternum). It is palpated just below the suprasternal notch and is felt as a prominence. Slide your index finger just to the left of the sternum, and palpate the second intercostal space. Place your middle or next finger in the third intercostal space, and continue palpating downward until you locate the fifth intercostal space. Move your index finger laterally along the fifth intercostal space toward the MCL. Normally, the apical impulse is palpable at or just medial to the MCL. 7. Auscultate and count heartbeats. Use antiseptic wipes to clean the earpieces and diaphragm of The diaphragm needs to be cleaned the stethoscope. and disinfected if soiled with body substances. Warm the diaphragm of the stethoscope by holding it in the The metal of the diaphragm is palm of the hand for a moment. usually cold and can startle the client when placed immediately on the chest. Insert the earpieces of the stethoscope into your ears in the This position facilitates hearing. direction of the ear canals, or slightly forward. Tap your finger lightly on the diaphragm. This is to be sure it is the active side of the head. If necessary, rotate the head to select the diaphragm side. Place the diaphragm of the stethoscope over the apical The heartbeat is normally loudest impulse and listen for the normal S1 and S2 heart sounds, over the apex of the heart. which are heard as “lub-dub. 30  Taif University College of Applied Medical Sciences Nursing Department Each lub-dub is counted as one heartbeat. The two heart sounds are produced by closure of the heart valves. The S1 heart sound (lub) occurs when the atrioventricular valves close after the ventricles have been sufficiently filled. The S2 heart sound (dub) occurs when the semilunar valves close after the ventricles empty. If you have difficulty hearing the apical pulse, ask the supine This positioning moves the apex of client to roll onto his or her left side or the sitting client to lean the heart closer to the chest wall. slightly forward. If the rhythm is regular, count the heartbeats for 30 seconds A 60-second count provides a more and multiply by 2. If the rhythm is irregular or for giving accurate assessment of an irregular certain medications such as digoxin, count the beats for 60 pulse than a 30-second count. seconds. 8. Assess the rhythm and the strength of the heartbeat. Assess the rhythm of the heartbeat by noting the pattern of intervals between the beats. A normal pulse has equal time periods between beats. Assess the strength (volume) of the heartbeat. Normally, the heartbeats are equal in strength and can be described as strong or weak. 9. Document the pulse rate and rhythm, and nursing actions in the client record. Also record pertinent related data such as variation in pulse rate compared to normal for the client and abnormal skin color and skin temperature. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 31  Taif University College of Applied Medical Sciences Nursing Department Assessing an Apical-Radial Pulse Introduction An apical-radial pulse may need to be assessed for clients with certain cardiovascular disorders. Normally, the apical and radial rates are identical. An apical pulse rate greater than a radial pulse rate can indicate that the thrust of the blood from the heart is too weak for the wave to be felt at the peripheral pulse site, or it can indicate that vascular disease is preventing impulses from being transmitted. Any discrepancy between the two pulse rates is called a pulse deficit and needs to be reported promptly. Purpose To determine adequacy of peripheral circulation or presence of pulse deficit. Assessment Clinical signs of hypovolemic shock (hypotension, pallor, cyanosis, and cold, clammy skin. Equipment Clock or watch with a sweep second hand or digital seconds indicator Stethoscope Antiseptic wipes Preparation If using the two-nurse technique, ensure that the other nurse is available at this time. 32  Taif University College of Applied Medical Sciences Nursing Department Assessing an Apical-Radial Pulse Procedure Rationale 1. Introduce self and verify the client’s identity using agency protocol 2. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments 3. Perform hand hygiene and observe appropriate infection prevention procedures. 4. Provide for client privacy. 5. Position the client appropriately. Assist the client to a comfortable supine or sitting position. Expose the area of the chest over the apex of the heart. If previous measurements were taken, determine what position the This ensures an accurate client assumed, and use the same position comparative measurement. 6. Locate the apical and radial pulse sites. In the two-nurse technique, one nurse locates the apical impulse by palpation or with the stethoscope while the other nurse palpates the radial pulse site 7. Count the apical and radial pulse rates Two-Nurse Technique Place the clock or watch where both nurses can see it. The nurse who is taking the radial pulse may hold the watch. Decide on a time to begin counting. A time when the second hand is on 12, 3, 6, or 9 or an even number on digital clocks is usually This ensures that selected. The nurse taking the radial pulse says “Start. simultaneous counts are Each nurse counts the pulse rate for 60 seconds. Both nurses end taken the count when the nurse taking the radial pulse says, “Stop.” The nurse who assesses the apical rate also assesses the apical pulse A full 60-second count is rhythm and volume (i.e., whether the heartbeat is strong or weak). necessary for accurate If the pulse is irregular, note whether the irregular beats come at assessment of any random or at predictable times discrepancies between The nurse assessing the radial pulse rate also assesses the radial the two pulse sites. pulse rhythm and volume One-Nurse Technique Within a few minutes: Assess the apical pulse for 60 seconds, and Assess the radial pulse for 60 seconds. 8. Document the apical and radial (AR) pulse rates, rhythm, volume, and any pulse deficit in the client record. Also record related data such as variation in pulse rate compared to normal for the client and other pertinent observations, such as pallor, cyanosis, or dyspnea. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 33  Taif University College of Applied Medical Sciences Nursing Department Measuring Oxygen Saturation (Pulse Oximetry) Introduction A pulse oximeter is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger , toe, nose, earlobe, or forehead (or around the hand or foot of a neonate). The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied by oxygen. The pulse oximeter can detect hypoxemia (low oxygen saturation) before clinical signs and symptoms, such as a dusky color to skin and nail beds, develop. Factors Affecting Oxygen Saturation Reading : Hemoglobin Circulation Activity Carbon monoxide poisoning. Purposes To estimate the arterial blood oxygen saturation. To detect the presence of hypoxemia before visible signs develop Assessment Assess the best location for a pulse oximeter sensor based on the client's age and physical condition. ( Unless contraindicated , the finger is usually selected for adults ). Assess the client's overall condition including risk factors for development of hypoxemia ( e.g. respiratory or cardiac disease ) and hemoglobin level. Assess vital signs , skin color and temperature , nail bed color and tissue perfusion of extremities as baseline data. Assess adhesive allergy. REMEMBER : Pulse oximetry values are not reliable detectors of hypoventilation if the patient is receiving supplemental oxygen. Normal oxygen saturation is 95% to 100%, and below 70% is life threatening. Preparation Prepare the following equipment: Alcohol wipe Sheet or towel. Pulse oximeter ( check the oximeter equipment is functioning normally ). Nail polish remover as needed 34  Taif University College of Applied Medical Sciences Nursing Department Measuring Oxygen Saturation (Pulse Oximetry) Procedure Rationale 1. Introduce self and verify the client's identity using agency protocol. 2. Explain to the client what you are going to do 3. Perform hand hygiene and observe appropriate infection control procedures. 4. Provide for client privacy. 5. Choose a sensor appropriate for the client's weight , size , and desired location.Because weight limits of sensors overlap. If the client is allergic to adhesive , use a clip or sensor without adhesive. If using an extremity , assess the proximal pulse and capillary refill at the point closest to the site. If the client has low tissue perfusion due to peripheral vascular disease or using vasoconstrictive medication , use a nasal sensor or a reflectance sensor on the forehead Avoid using lower extremities that have a compromised circulation and extremities that are used for infusions or other invasive monitoring. 6. Prepare the site. Clean the site with an alcohol wipe before applying the sensor. It may be necessary to remove a female client's dark nail Nail polish may interfere with polish. accurate measurements. Alternatively , position the sensor on the side of the finger rather than perpendicular to the nail bed. 7. Apply the sensor , and connect it to the pulse oximeter. Make sure the LED and photodetector are accurately aligned , that is opposite each other on either side of the finger , toe, nose or earlobe. Many sensors have markings to facilitate correct alignment of the LEDs and photo detector. Attach the sensor cable to the connection outlet on the oximeter. Turn on the machine according to the manufacturer's directions. Appropriate connection will be confirmed by an audible beep indicating each arterial pulsation. Some devices have a wheel that can be turned clockwise to increase the pulse volume and counterclockwise to decrease it. Ensure that the bar of light or waveform on the face of the oximeter fluctuates with each pulsation. 35  Taif University College of Applied Medical Sciences Nursing Department 8. Set and turn on the alarm when using continuous monitoring. Check the preset alarm limits for high and low oxygen saturation and high and low pulse rates Change these alarm limits according to the manufacturer's directions as indicated. Ensure that the audio and visual alarms are on before you leave the client. 9. Ensure client safety. Inspect and move or change the location of an adhesive toe of finger sensor every 4 hours and a spring – tension sensor every 2 hours. Inspect the sensor site tissues for irritation from adhesive sensors. 10. Ensure the accuracy of measurement Minimize motion artifacts by using an adhesive sensor , Movement of the client's finger or toe may or immobilize the client's monitoring site. be misinterpreted by the oximeter as arterial pulsations. If indicated , cover the sensor with a sheet or towel to Bright room light may be sensed by the block large amounts of light from external sources (e.g, photo detector and alter the Spo2 value sunlight , procedure lamps or bilirubin lights in the nursery ). A large discrepancy between the two Compare the pulse rate indicated by the oximeter to the values may indicate oximeter radial pulse periodically. malfunction. 11. Document the oxygen saturation on the appropriate record at designated intervals. KOZIER&ERB'S FUNDAMENTALS OF NURSING , TENTH EDITION NURSING DEPARTMENT TAIF UNIVERSITY Approved : 13/5/2019 Reference { 12 } 36  Taif University College of Applied Medical Sciences Nursing Department Assessing Arterial Blood Pressure Introduction: The Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries, there are two blood pressure measures. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles. The diastolic pressure is the pressure when the ventricles are at rest. The difference between the diastolic and the systolic pressures is called the pulse pressure. A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg during exercise. Purpose: To obtain a baseline measurement of arterial blood pressure for subsequent evaluation. To determine the client’s hemodynamic status (e.g., cardiac output, stroke volume of the heart and blood vessel resistance) To identify and monitor changes in blood pressure resulting from a disease process or medical therapy ( e.g. presence or history of cardiovascular disease , renal disease, circulatory shock, or acute pain; rapid infusion of fluids or blood products) Assessment & Preparation: Assessment: Signs and symptoms of hypertension ( e.g. headache , ringing in the ears , flushing of face nosebleeds, fatigue). Signs and symptoms of hypotension ( e.g. tachycardia , dizziness, mental confusion , restlessness , cool and clammy skin , pale or cyanotic skin). Factors affecting blood pressure( e.g. activity, emotional stress, pain, and time the client last smoked or ingested caffeine). Some blood pressure cuffs contain latex. Assess the client for latex allergy and obtain a latex – free cuff if indicated. Preparation: Equipment : Stethoscope or DUS Blood pressure cuff of the appropriate size Sphygmomanometer 37  Taif University College of Applied Medical Sciences Nursing Department Assessing Arterial Blood Pressure Procedure Rationale 1. Ensure that the equipment is intact and functioning properly.Check for leaks in the tubing between the cuff and the sphygmomanometer. 2. Make sure that the client has not smoked or ingested Smoking constricts blood vessels , and caffeine within 30 minutes prior to measurement. caffeine increase the pulse rate. Both of these cause a temporary increase in blood pressure. 3. Introduce self and verify the client's identity using agency protocol. 4. Explain to the client what you are going to do. 5. Perform hand hygiene and observe appropriate infection control procedures. 6. Provide for client privacy. 7. Position the client appropriately : The adult client should be sitting unless otherwise Legs crossed at the knee result in specified.Both feet should be flat on the floor. elevated systolic and diastolic blood The elbow should be slightly flexed with the palm of the pressures. hand facing up and the arm supported at heart level. Readings in any other position should be specified. The The blood pressure increases when the blood pressure is normally similar in sitting, standing, and arm is below heart level and decrease lying positions, but it can vary significantly by position in when the arm is above heart level. certain persons. Expose the upper arm. 8. Wrap the deflated cuff evenly around the upper arm. The bladder inside the cuff must be Locate the brachial artery. Apply the center of the bladder directly over the artery to be directly over the artery. compressed if the reading is to be For an adult , place the lower border of the cuff accurate. approximately 2.5 cm above the antecubital space. 9. If this is the client's initial examination , perform a The initial estimate tells the nurse the preliminary palpatory determination of systolic pressure. maximal pressure to which the sphygmomanometer needs to be elevated in subsequent determinations.It also prevents underestimation of the systolic pressure or overestimation of Palpate the brachial artery with the fingertips. the diastolic pressure should an Close the valve on the bulb. auscultatory gap occur. Pump up the cuff until you no longer feel the brachial pulse.At that pressure the blood cannot flow through the artery. Note the pressure on the sphygmomanometer at which pulse is no longer felt 38  Taif University College of Applied Medical Sciences Nursing Department Release the pressure completely in the cuff and wait 1 to 2 This gives an estimate of the systolic minutes before making further measurements. pressure. A waiting period gives the blood trapped in the veins time to be released.Otherwise , false high systolic readings will occur. 10. Position the stethoscope appropriately : Cleanse the earpieces with antiseptic wipe. Insert the ear attachments of the stethoscope in your ears Sounds are heard more clearly when the so that they tilt slightly forward. ear attachments follow the direction of Ensure that the stethoscope hangs freely from the ears to the ear canal. the diaphragm. If the stethoscope tubing rubs against an object , the noise can block the sounds Place the bell side of the amplifier of the stethoscope over of the blood within the artery. the brachial pulse site. Because the blood pressure is a low- Place the stethoscope directly on the skin not on clothing frequency sound , it is best heard with over the site. the bell-shaped diaphragm. Hold the diaphragm with the thumb and index finger. This is to avoid noise made from rubbing the amplifier against cloth. 11. Auscultate the client's blood pressure : Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared. Release the valve on the cuff carefully so that the pressure If the rate is faster or slower , an error in decreases at the rate of 2 to 3 mmHg per second. measurement may occur. As the pressure falls , identify the manometer reading at Korotkoff phases 1,4,and 5. There is no clinical significance to Deflate the cuff rapidly and completely. phases 2 and 3. Wait 1 to 2 minutes before making further determinations. This permits blood trapped in the veins Repeat the above steps to confirm the accuracy of the to be released. reading—especially if it falls outside the normal range (although this may not be routine procedure for hospitalized or well clients). If there is greater than 5 mmHg difference between the two readings, additional measurements may be taken and the results averaged. 12. If this is the client's initial examination repeat the procedure on the client's other arm.There should be a difference of no more than 10 mmHg between the arms. The arm found to have the higher pressure should be used for subsequent examinations. 13. Remove the cuff from the client's arm. 14. Wipe the cuff with an approved disinfectant. Cuffs can become significantly contaminated. 39  Taif University College of Applied Medical Sciences Nursing Department 15. Document and report pertinent assessment data according to agency policy. Record two pressures in the form “130/80” where “130” is the systolic (phase 1) and “80” is the diastolic (phase 5) pressure. Record three pressures in the form “130/90/0,” where “130” is the systolic, “90” is the first diastolic (phase 4), and sounds are audible even after the cuff is completely deflated. Use the abbreviations RA or RL for right armor right leg and LA or LL for left arm or left leg. 40  Taif University College of Applied Medical Sciences Nursing Department Assessing Blood Pressure Electronically Introduction: Many different styles of electronic blood pressure machines are available to determine blood pressure automatically. Electronic machines rely on an electronic sensor to detect the vibrations caused by the rush of blood through an artery. Although electronic blood pressure machines are fast, you must consider their advantages and limitations. Purpose: The devices are used when frequent assessment is required such as in critically ill or potentially unstable patients. During or after invasive procedures. When therapies require frequent monitoring. Assessment & Preparation: Assessment: Determine appropriateness of using electronic blood pressure measurement. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device. Preparation: Equipment: Electronic blood pressure machine Source of electricity Blood pressure cuff of appropriate size as recommended by manufacturer Pen and vital sign flow sheet or electronic health record (EHR). 41  Taif University College of Applied Medical Sciences Nursing Department Assessing Blood Pressure Electronically Procedure Rationale 1. Determine appropriateness of using electronic blood pressure measurement. Patients with irregular heart rate, peripheral vascular disease, seizures, tremors, and shivering are not candidates for this device. 2. Determine best site for cuff placement. 3. Collect and bring appropriate equipment to patient’s bedside. 4. Perform hand hygiene. 5. Assist patient to comfortable position, either lying or sitting. 6. Plug in and place device near patient ,ensuring that connector hose between cuff and machine reaches. 7. Locate on/off switch and turn on machine to enable device to self- test computer systems. 8. Select appropriate cuff size for patient extremity and appropriate cuff for machine. Electronic blood pressure cuff and machine must be matched by manufacturer and are not interchangeable. 9. Expose extremity by removing constricting clothing to ensure proper cuff application. Do not place blood pressure cuff over clothing. 10. Prepare blood pressure cuff by manually squeezing all the air out of the cuff and connecting it to connector hose. 11. Wrap flattened cuff snugly around extremity, verifying that only one finger can fit between cuff and patient’s skin. Make sure that “artery” arrow marked on outside of cuff is placed correctly. 12. Verify that connector hose between cuff and machine is not kinked. Kinking prevents proper inflation and deflation of cuff. 13. Following manufacturer directions, set frequency control for automatic or manual and press the start button. The first blood pressure measurement pumps cuff to a peak pressure of about 180 mm Hg. After this pressure is reached, the machine begins a deflation sequence that determines the blood pressure. The first reading determines peak pressure inflation for additional measurements. 14. When deflation is complete, digital display provides most recent values and flash time in minutes that has elapsed since the measurement occurred. 42  Taif University College of Applied Medical Sciences Nursing Department 15. Set frequency of measurements and upper and lower alarm limits for systolic, diastolic, and mean blood pressure readings.Intervals between measurements can be set from 1 to 90 minutes. The nurse determines frequency and alarm limits based on patient’s acceptable range of blood pressure, nursing judgment, and health care provider order. 16. Obtain additional readings at any time by pressing the start button. Pressing the cancel button immediately deflates the cuff. 17. If frequent measurements are required, the cuff may be left in place. Remove it at least every 2 hours. Patients with abnormal To assess underlying skin bleeding tendencies are at risk for microvascular rupture from integrity and if possible repeated inflations. When patient no longer requires frequent blood alternate measurement sites. pressure monitoring, remove and clean cuff according to agency policy. To reduce transmission of microorganisms. 18. Discuss findings with patient. Perform hand hygiene. 19. Compare electronic blood pressure readings with auscultatory measurements to verify accuracy of electronic device. 20. Record blood pressure and site assessed on vital sign flow sheet, EHR, or nurses’ notes; record any signs or symptoms of blood pressure alterations in narrative form in EHR and nurses’ notes; report abnormal findings to nurse in charge or health care provider. 43  Taif University College of Applied Medical Sciences Nursing Department Oxygen therapy Introduction: Low – flow and high –flow systems are available to deliver oxygen to the client. The choice of system depends on the client's oxygen needs , comfort and developmental considerations. Purpose : Cannula: To deliver a relatively low concentration of oxygen when only minimal O2 support is required. To allow uninterrupted delivery of oxygen while the client ingests food or fluids. Face Mask : To provide moderate O2 support and a higher concentration of oxygen and humidity than is provided by cannula. To provide a high flow of O2 when attached to a Venturi system Face Tent To provide high humidity. To provide oxygen when a mask is poorly tolerated. REMEMBER : Before administering oxygen : o Check the order for oxygen including the administering device and the liter flow rate (L/min ) or the percentage of oxygen. o Check the levels of oxygen (PaO2) and carbon dioxide (PaCO2) in the client’s arterial blood (PaO2 is normally 80 to 100 mmHg; PaCO2 is normally 35 to 45 mmHg). o If the client has not had ABGs ordered , oxygen saturation should be checked using a noninvasive oximeter. Assessment & Preparation: Assessment: Assess the skin and mucous membrane color : Note whether cyanosis is present. Assess the breathing patterns. Assess the chest movements. Assess the chest wall configuration ( e.g kyphosis ) Assess lung sounds audible by auscultating the chest and by ear. Presence of clinical signs of hypoxemia , tachycardia, tachypnea, restlessness and confusion. Presence of clinical signs of hypercarbia , restlessness , hypertension, headache , lethargy , tremor. Presence of clinical signs of oxygen toxicity : tracheal irritation and cough , dyspnea and decreased pulmonary ventilation. Determine : Vital signs, especially pulse rate and quality, and respiratory rate, rhythm, and depth. Whether the client has COPD. 44  Taif University College of Applied Medical Sciences Nursing Department Results of diagnostic studies such as chest x-ray. Hemoglobin, hematocrit, and complete blood count. Oxygen saturation levels. Arterial blood gases levels, if available. Pulmonary function tests, if available. Preparation: Prepare the following equipment: Oxygen supply with a flow meter and adapter. Humidifier with distilled water or tap water according to protocol. Nasal cannula and tubing or face mask or face tent. Tape , Padding for the elastic band. 45  Taif University College of Applied Medical Sciences Nursing Department Administering Oxygen by Cannula, Face Mask, or Face Tent Procedure Rationale 1. Determine the need for oxygen therapy , and verify the order for the therapy. 2. Perform a