NP7-NEW-CHECKLIST.pdf

NP 7 - Care of Mother, SEMESTER, Child, Adolescent (Well Client) Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 25 We claim no credits for them unless otherwise needed. If...

NP 7 - Care of Mother, SEMESTER, Child, Adolescent (Well Client) Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 25 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: ORAL, BUCCAL, AND Correctly Needs Not Done SUBLINGUAL MEDICATION RATIONALE Done Improvement (0) (2) (1) ADMINISTRATION ASSESSMENT 88. Assess for the 10 rights in medication To avoid medication administration administration. errors. 89. Review the action, purpose, normal dosage So that the client’s response to the and route, common side effects, time of medication will be monitored. onset and peak action and nursing implications of each drug. 90. Assess the client's condition to be sure the The condition of the client may order of the health care provider is have changed. appropriate. 91. Assess the client's ability to swallow food To determine the need for an SEMESTER, and fluid. alternate route for medication administration. 92. Assess for any contraindications for Alteration in gastrointestinal administering oral medication such as function may interfere with drug nausea and vomiting, gastric suction or absorption and excretion. gastric surgery. 93. Assess the client's medical record for a To avoid these medications. history of allergies to food or medications. 94. Assess the client's knowledge about the use So client teaching can be tailored of medications. to his/her needs as well assessing compliance for taking the drugs at home or reveal drug dependence or abuse. 95. Assess the client's age. As pediatric/geriatric clients may have special needs according to their ability to swallow a pill. 96. Assess the client's need for fluids. Swallowing a pill is usually easier with fluids. 97. Assess the client's ability to sit or turn to the The client must be able to swallow side. the pill without aspiration. PLANNING / EXPECTED OUTCOMES: 98. The client will swallow the prescribed medication. 99. The client will be able to explain the purpose and schedule for taking the medication. 100. The client will have no gastrointestinal discomfort or alterations in function. 101. The client will show the desired response to the medication such as pain relief, regular heart rate, or stable blood pressure. MATERIALS: 102. Medication: tablet, capsule, or liquid from a bottle or unit dose. 103. medication tray/ cart 104. Measuring spoon, calibrated dropper, medicine cup or straw 105. glass of water 106. Medication Administration Record (MAR) 107. mortar and pestle or pill cutter 108. paper towels 109. clean gloves IMPLEMENTATION: 110. Gather all the materials needed. Arrange the Organizing medications and medication tray and cups at the medication equipment saves time and reduces room. the possibility of error. 111. Wash hands and wear gloves. Reduces the transfer of microorganisms. 112. Prepare the medication for one client at a Comparing the MAR with the label time following the 10 rights. Select the reduces error. correct drug according to the MAR. To prepare the tablet or capsule: Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 26 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  113. Pour the required number of tablets or Avoids wasting expensive capsules into the bottle cap and transfer it to medications and avoids the medication cup without touching them. contamination of medication. 114. Scored tablets may be broken, if necessary, Tablets that are not scored are not using gloved hands or with a pill cutting meant to be broken as this would device. reduce the effectiveness of the tablet. 115. Unit dose tablet should be placed directly The wrapper maintains cleanliness into the medicine cup without opening it until and identification until it is it is administered to the client. administered. 116. For clients with difficulty in swallowing, some A large tablet is usually easier to tablets may be crushed into a powder using swallow if it is ground and mixed a mortar and pestle then mixed in a small with soft food. amount of soft foods. To prepare a liquid medication: 117. Remove the bottle cap from the container Placing the bottle cap upside down and place cap upside down on the cart. prevents contamination of the inside of the container. Hold the bottle with the label up and the Holding the bottle with the label up medication cup at eye level while pouring. keeps spilled liquid from obliterating the label. Fill the cup to the desired level using the Holding the medication cup at eye SEMESTER, surface or base of the meniscus as the level ensures accurate dose. scale, not the edge of the liquid cup. Wipe lip of bottle with paper towel. Wiping the lid of the bottle prevents the bottle cap from sticking. 118. Double-check the MAR with the prepared Reduces error; ensures drugs. Place the MAR with the client’s identification and safety of the medications and do not leave the drugs medications. unattended. Administration of medication: 119. Via oral route 120. Observe the correct time to give the Ensures the therapeutic effect of medication. Identify the client. the drug. To confirm that the medication will be given to the right client. 121. Check the drug packaging if it is present to Prevents giving the wrong ensure the medication type and dosage. medication or wrong dose. 122. Reassess the client's condition and form of Allows the nurse to determine the the medication. route of administration and to know if this route is appropriate. 123. Explain the purpose of the drug and ask if Improves compliance with drug the client has any questions. therapy. 124. Assist the client to a sitting or fowler's Prevents aspiration during position. swallowing. 125. Allow the client to hold the medication cup or So that the client becomes familiar tablet. with medications. 126. Instruct the client to place the medication in Promotes client comfort in the mouth and swallow when able to do so. swallowing the medication. Give a glass of water or other liquid and straw, if needed. For sublingual medication: 127. Instruct client to place medication under the Drug is absorbed through the tongue and allow it to dissolve completely. mucous membranes into the blood vessels so that if it swallowed, the drug may be destroyed by gastric juices. For buccal medication: 128. Instruct client to place the medication in the Promotes local activity on mucous mouth against the cheek until it dissolves membranes. completely. For medication given thru NGT: 129. Crush tablet or open capsules and dissolve Allows medication administration powder with 20 to 30 ml of warm water in a via NGT or feeding tube. Ensures cup. Check placement of the feeding tube that the medication is absorbed before instilling anything into the tube. and utilized correctly. 130. Remain with the client until each medication To ensure the client receives the has been swallowed or dissolved. dose and does not save it or discard it. 131. Assist the client into a comfortable position. Maintains client’s comfort. 132. Remove gloves and dispose of soiled Reduces transfer of supplies. microorganisms. 133. Document the administration on the MAR. Prevents administration error. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 27 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  134. Clean the work area. Wash hands. Reduces transmission of microorganisms. EVALUATION: 135. The client was able to swallow the prescribed medication. 136. The client was able to explain the purpose and schedule for taking the medication. 137. The client has no gastrointestinal discomfort or alteration in function. 138. The client showed the desired response to the medication such as pain relief, regular heart rate, or stable blood pressure. TOTAL / 102 Computation: Raw Score / Total Score X 100 = FINAL GRADE SEMESTER, Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 28 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: ADMINISTRATING EYE (OPTIC) Correctly Needs Not Done RATIONALE Done Improvement (0) AND EAR (OTIC) MEDICATIONS (2) (1) ASSESSMENT 1. Assess the 10 rights of medications. Prevent errors in medication administration. 2. Assess the client's eye and ear condition. Reassessing the client prior to every medication dose prevents possibly injuring the client. 3. Assess the medication order for what part of Prevents error in medication the eye or ear. administration. PLANNING / EXPECTED OUTCOMES: 4. The client will receive the right dose, medication, dosage, route and time. SEMESTER, 5. The client will encounter minimum discomfort during the administration. 6. The client will receive the maximum benefit from the medication. MATERIALS: 7. eye and ear medication 8. clean gloves 9. Tissue 10. medication tray 11. MAR IMPLEMENTATION: 12. Verify physician’s order 13. Assemble all the materials needed. Promotes efficiency. 14. Identify your client. Introduce yourself. Explain the procedure 15. Place client in supine or sitting position. 16. Wash hands. Wear gloves. Decrease contact with bodily fluids. Instilling eye drops and ointment: 17. Remove cap from the eye medication bottle Prevents contamination of the and place on its side at the medication tray. bottle cap / medication. 18. Instruct the client to look up and slightly tilt The cornea is protected as client the head. looks up and reduces stimulation of blink reflex. 19. With the non-dominant hand, hold the upper To expose the conjunctival sac. and lower eyelid with the thumb and index finger 20. With the dominant hand, hold the eye Reduces risk of touching the eye medication ½ to ¾ inch above the eyeball; structure and causing injury. Rest rest hand on client’s forehead. the hands on client’s forehead to stabilize. 21. Holding the eye medication, squeeze the Prevents injury to the cornea. prescribed drop/s of medication on the lower conjunctival sac. If administering eye ointment, apply from inner to outer canthus. 22. Instruct the client to close eyes gently and Distributes solution over blink several times. conjunctival surface and anterior eyeball 23. Apply gentle pressure over the opening to Nasal occlusion prevents systemic the nasolacrimal duct. absorption of medication through the mucous membrane of the nose. 24. Provide the patient with a clean tissue to be A clean tissue may be used to placed below the lower lid absorb the medication that may escape from the eye and roll down the face. 25. Remove gloves. Wash hands. Reduces transmission of microorganisms. 26. Record on the MAR the route, site (which Provide documentation that the eye), time administered. medication was given. Instilling ear drops: 27. Follow steps from 12 to 16. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 29 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  28. Place client’s face on the side with the This prevents loss of any affected ear. medication from the effect of gravity. 29. Straighten ear canal by pulling the pinna Straightening the ear canal helps down and back for children and upward and the medication to reach the lowest outward in adults. area of the ear canal and become distributed over all the surfaces in the outer ear. 30. Instill the drops into the ear canal by holding Touching the tip of the dropper to the dropper at ½ inch above the ear canal. the skin contaminates the dropper. 31. Ask the client to maintain the position for 2-3 Maintaining the position allows minutes then place on comfortable position. time for medication to flow into the lowest area of the ear canal, avoiding the possibility of excessive loss from the ear. 32. Remove gloves. Wash hands. Reduces the transmission of microorganisms. EVALUATION: 33. The client received the right dose, medication, route and time. 34. The client encountered minimum discomfort during the administration. 35. The client received the maximum benefit from the medication. SEMESTER, TOTAL / 70 Computation: Raw Score / Total Score X 100 = FINAL GRADE Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 30 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: ADMINISTERING VAGINAL AND Correctly Needs Not Done RATIONALE Done Improvement (0) RECTAL SUPPOSITORIES (2) (1) ASSESSMENT 1. Assess the ten rights of medication To prevent medication administration. administration error. 2. Assess the client's need and Allows nurse to determine appropriateness for rectal and vaginal effectiveness of the medication. medication. 3. Consider any adjustment that maybe taken. 4. Observe the client for desired therapeutic effect or adverse reactions. PLANNING / EXPECTED OUTCOMES: 5. The client will receive the right medication, SEMESTER, dose, route and time. 6. The client will encounter minimum discomfort during the administration. 7. The client will receive the maximum benefit from the medication. MATERIALS: 8. vaginal / rectal suppositories 9. clean gloves 10. tissue 11. medication tray 12. underpad IMPLEMENTATION: 13. Verify physician’s order. To ensure safe and accurate administration of medication. 14. Assemble the materials needed. Prevents numerous trips to gather supplies and helps the procedure flow smoothly. 15. Identify your client. Introduce yourself. Ensures correct client. Explain the procedure to the client. 16. Provide privacy, adequate lighting and lower The patient should be protected the side rails. from being viewed by others during any procedure. Good light facilitates better visualization. 17. Wash hands and wear gloves. Gloves acts as barrier from contact with stool with vaginal discharges and/or fecal matters. Administering vaginal suppository: 18. Ask the patient whether she needs to void A full bladder may cause prior to inserting medications within the discomfort during insertion, or vagina. patient may wish to get up too soon after the drug has been administered. 19. Remove underwear and place client in This position helps when locating dorsal recumbent with buttocks elevated and the vaginal orifice for proper expose the perineum. insertion of the medication. 20. Assess the client's peri-anal skin condition. To assess the need for perineal care prior to medication administration. 21. Spread the labia with the non-dominant hand The opening to the vagina is best while holding the medication with the other visualized when the labia are hand. retracted. 22. Instruct the client to take slow deep breaths To relax the sphincter muscle and (inhale through the nose and exhale through the mouth) while inserting the suppository prevent expulsion. and tell the patient that she will experience a cool sensation and pressure during administration. 23. Advance the medication further by pushing it To avoid expelling the suppository. with your little finger. 24. Instruct the client to hold medication and Retaining the suppository allows remain in lying position for 15-30 minutes. time to achieve maximal effect 25. Wash hands. To prevent the spread infection. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 31 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  26. Document procedure. Communicates with other healthcare team the effectives of treatment. Administering rectal suppository: 27. Place client in left lateral position for rectal To facilitate adequate viewing and suppository. easy insertion of suppository. 28. Place side rails up. To ensure safety of the client. 29. Drape the client. To maintain privacy. 30. Bring materials to bed side and provide Prevents numerous trips to gather adequate lighting. supplies and helps the procedure flow smoothly. 31. Lower side rails. To facilitate easy access to the client. 32. Place patient comfortably in side lying The descending colon is on the left position. side; this is a more anatomically correct position. 33. Expose patient's buttocks and assess the To assess the need for perineal client’s peri-anal skin condition. care prior to medication administration. 34. Wash hands and apply gloves. Gloves acts as barrier from contact with stool within the rectum. 35. Open the medication package. To expose the medication from the wrapper. 36. Instruct the client to take slow deep breath. SEMESTER, To relax the sphincter muscle and Inhale thru the nose and exhale thru the mouth while inserting the suppository and tell prevent expulsion. patient that he/she will experience cool sensation and pressure during administration. 37. In administering rectal suppository, spread Anus is best visualized when the buttocks with non-dominant hand while buttocks are retracted. holding the medication with the other hand. 38. Slowly and gently advance the medication Slow insertion minimizes pain. further by pushing it with your little finger Correct placement ensures past the anal sphincter. adequate absorption and less chance for expulsion of medication. 39. Remove gloves. Reduces transfer of microorganisms. 40. Instruct patient to hold medication and Retaining the suppository allows remain in lying for 15-30 minutes. time to achieve maximal effect 41. Raise side rails and turn off the drop light. To ensure safety of the client. 42. Wash hands. To prevent the spread infection. 43. Document procedure. Communicates with other healthcare team the effectives of treatment. EVALUATION: 44. The client received the right medication, dose route and time. 45. The client encountered minimum discomfort during the administration. 46. The client received the maximum benefit from the medication. TOTAL / 92 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: % REMARKS: Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 32 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: Correctly Needs Not Done SKILL: OXYGEN ADMINISTRATION RATIONALE Done Improvement (0) (2) (1) ASSESSMENT 1. Assess environment for oxygen safety administration. 2. Assess immediate respiratory status. 3. Identify type of oxygen equipment and source. PLANNING / EXPECTED OUTCOMES: 4. Ensure proper concentration of oxygen. 5. Provide for adequate O2 humidification. 6. Ensure a patent airway. 7. Observe the client's reaction to 0₂ therapy. 8. Ensure the client's comfort. SEMESTER, MATERIALS: 9. oxygen apparatus or source 10. oxygen flow meter with humidifier 11. Nasal cannula 12. Face mask 13. Clean gloves 14. Penlight IMPLEMENTATION: 15. Verify physician’s order for the procedure. 16. Gather all the materials needed. 17. Identify client and introduce self. Explain procedure. 18. Place client on semi-fowler’s position. 19. Wash hands. Wear gloves. Assess the nostrils and mouth 20. Fill the humidifier with H20 21. Attach the oxygen supply tubing to the O₂ equipment. 22. Turn on the oxygen and test for flow. Administer O₂ flow via nasal cannula as ordered or until 5-6 liters per minute (LPM) only. Administer O₂ flow via face mask as ordered or until 10-15 LPM. 23. Position the oxygen equipment properly onto the client. 24. Explain safety precautions to the client and significant others. 25. Stay with the client until you are sure that the flow is maintained and the client is stable. 26. Wash hands. EVALUATION: 27. Client’s breathing pattern is regular and in normal rate. 28. Client is free of cyanosis. 29. Client is resting comfortably. 30. Arterial blood gas values are within normal limits. 31. No disorientation, confusion and difficulty or cognition. TOTAL / 62 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: REMARKS: % Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 33 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: Correctly Needs Not Done SKILL: EINC RATIONALE Done Improvement (0) (2) (1) 1. In advance, prepare decontamination solution by mixing 1 part 5% chlorine bleach to 9 parts water to make 0.5% chlorine solution. Change chlorine solution at the beginning of each day or whatever solution is very contaminated or cloudy. PRIOR TO WOMAN’S TRANSFER TO THE DELIVERY ROOM 2. Ensured that mother is in her position of choice while in labor 3. Asked mother if she wishes to eat/drink or void SEMESTER, 4. Communicated with the mother-informed her of progress of labor, reassurance and encouragement WOMAN ALREADY IN THE DELIVERY ROOM PREPARING FOR DELIVERY 5. Checked temperature in DR area to be 25- 28 Celsius eliminating air draft 6. Asked the woman if she comfortable in the semi-upright position (the default position of delivery table) 7. Ensured the woman’s privacy 8. Removed all jewelry, then washed hands thoroughly observe WHO 1-2-3-4-5- procedure 9. Prepare a clean newborn resuscitation area. Checked the equipment if clean, functional and within easy reach 10. Arranged materials/ supplies in a linear sequence 11. Gloves, dry linen, bonnet, oxytocin injection, plastic clamp, instrument clamp, scissors, 2 kidney basins, 12. In separate sequence, for after the 1 st breastfeed: 13. Eye ointment, stethoscope, to symbolize PE), vit k, hepatitis B, and BCG vaccines (plus cotton balls etc.) 14. Cleaned perineum with antiseptic solution 15. Washed hands and put on 2 pairs of sterile gloves aseptically. (If same worker handles perineum and cord) AT THE TIME OF DELIVERY 16. Encouraged woman to push as desired. 17. Draped the clean dry linen over the mother’s abdomen or arms in preparation for drying the baby. 18. Applied perineal support and did controlled delivery of the head 19. Called out time of birth and sex of baby 20. Informed the mother of outcome 1-3 MINUTES 21. Removed the wet cloth 22. Placed baby in skin to skin contact on the mother’s abdomen or chest 23. Covered baby with dry cloth and the baby’s head with a bonnet 24. Excluded a 2nd baby by palpating the abdomen in preparation for giving oxytocin 25. Used wet cloth to wipe the soiled gloves. Give IM oxytocin within 1 minute of baby’s birth. Disposed of wet cloth properly. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 34 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  26. Removed first set of gloves and decontaminated them properly (in 0.5%chlorine solution in 10 mins.) 27. Palpated umbilical cord to check for pulsations 28. After pulsation stopped, clamped cord using the plastic cord or cord tie 2 cm. from the base. 29. Placed the instrument clamp 5 cm. from the base. 30. Cut near plastic clamp not midway 31. Performed the remaining steps 32. Waited for a strong uterine contraction then applied controlled cord traction and counter traction on the uterus, continuing until placenta was delivered. 33. Massaged uterus until it is firm 34. Inspect lower vagina and perineum for lacerations/tears and repaired lacerations/tears necessary 35. Examined the place for completeness and abnormalities 36. Cleaned the mother, flushed the perineum and applied perineal pad/cloth 37. Checked the baby’s color and breathing; checked that mother was comfortable, uterus contracted. SEMESTER, 38. Disposed of the placenta in a leak-proof container or plastic bag. 39. Decontaminated (soaked in 0.5% chlorine solution) before cleaning, decontaminated 2nd pair of gloves before disposal, stating that decontamination lasts for at least 10 mins. 40. Advised mother to maintain skin to skin contact. Baby should be prone on mother’s chest/ in between the breasts with the head turned to side 15-90 MINUTES 41. Advised mother to observe for feeding cues (cited examples of feeding cues) 42. Supported mother, instructed her on positioning and attachment 43. Waited for FULL BREASTFEED to be completed 44. After complete breastfeed, administered eye ointment (first), did thorough physical examination, then give Vit K, hepatitis B and BCG injections (simultaneously explained purpose of each intervention) 45. Advised OPTIONAL DELAYED bathing of baby (and was able to explain the rationale) 46. Advised breastfeeding per demand 47. In the first hour, checked baby’s breathing and color and checked mother’s vital signs and massaged uterus every 15 minutes. 48. In the second hour, checked mother-baby dyad every 30 minutes to 1 hour 49. Completed all RECORDS. 50. Advised mother to observe for feeding cues (cited examples of feeding cues) TOTAL / 100 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: REMARKS: % Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 35 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: ENEMA Correctly Needs Not Done RATIONALE Done Improvement (0) ADMINISTRATION (2) (1) ASSESSMENT 1. Assess the patient when was the last bowel movement and the amount, color and consistency of the feces. 2. Presence of abdominal distention Distended abdomen appears swollen and feels firm rather than soft when palpated. 3. Assess whether the patient has sphincter control. 4. Assess whether the patient can use a toilet SEMESTER, or commode or must remain in bed and use a bed pan. PLANNING / EXPECTED OUTCOMES: 5. The patient verbalizes decreased discomfort and abdominal distention. 6. The patient remains free of any evidence of trauma to rectal mucosa or other adverse effect. MATERIALS: 7. Clean gloves 8. Linen, pads or paper towels 9. Tubing clamp 10. Enema Solution IMPLEMENTATION: 11. Verify doctor’s order and gather the To identify the right patient and equipment conserves energy and time. 12. For large-volume enema: Solution container with tubing of correct size and tubing clamp, ensure correct solution, amount and temperature. 13. For small-volume enema: Prepackage container of enema solution with lubricated tip. 14. Identify the patient, introduce yourself and explain the procedure. 15. Perform hand hygiene and put on PPE’s To ensure the right patient and provide patient cooperation To prevent transmission of microorganism. 16. Provide patient privacy, lower the side rails of the bed. 17. Lubricate about 5cm (2inch) of the rectal To facilitates insertion through the tube. sphincters and minimizes trauma. 18. Run some solution through the connecting Air instilled into the rectum may tubing of a large-volume enema set and cause unnecessary distention. rectal tube to expel any air in the tubing. 19. Assist adult patient to a left lateral position This position facilitates the flow of with right leg as acutely flexed as possible. solution by gravity into the sigmoid colon and descending colon. Having right leg flexed provides for adequate exposure of the anus. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 36 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  20. Insert the enema tube: A. For patient in the left lateral position, lift the upper buttock to ensure good visualization of the anus. B. Insert the tube smoothly and slow into the The angle follows the normal rectum, directing it toward the umbilicus. contour of the rectum. Slow C. Insert the tube 7 to 10 cm (3 to 4 in) into insertion prevents spasm of the the anal canal. sphincter. D. If resistance is encountered at the internal Anal canal is about 2.5 to 5 cm sphincter, ask the client to take a deep long in the adult. breath then run a small amount of solution through the tube to relax the internal anal sphincter. 21. Never force tube or solution entry. Withdraw the tube. Check for any stool that have blocked the tube during insertion. 22. Slowly administer the enema solution: The higher the solution container is A. Compress a pliable container by hand. held above the rectum, the faster B. During low enemas: Hold or hang the the flow and the greater the force solution container no higher than 30 cm pressure in the rectum. (12inch) above the rectum. C. During high enemas: Hang the solution The fluid must be instilled farther to SEMESTER, container about 45 cm (18inch). clean the entire bowel. 23. Administer fluid slowly, if the patient Administering enema slowly and complains of fullness or pain, lower the stopping the flow momentarily container or use the clamp to stop the flow decreases the like hood of for 30 seconds, then restart the flow at a intestinal spasm and premature slower rate. ejection of solution. 24. If you are using a plastic commercial container, roll it up as the fluid is instilled. This prevents subsequent suctioning of solution. 25. After the solution has been instilled or when the patient cannot hold any more and feels the desire to defecate; close the clamp and remove the enema tube from the anus. Place enema tube in a disposable towel as you withdraw it. 26. Ask the patient to remain lying down. It is Because gravity promotes easier for the patient to retain enema when drainage and peristalsis. lying down than sitting or standing. 27. Request the patient retain the solution for This amount of time usually allows appropriate amount of time, 5 to 10 minutes muscle contractions become for cleansing enema or at least 30 minutes sufficient to produce good result. for retention enema. Promotes comfort. 28. Assist the patient to defecate. 29. Assist the patient returned to bed and raise side rails afterwards 30. Document amount and type of enema solution used; amount, consistency and color of stool. 31. Verify doctor’s order and gather the To identify the right patient and equipment conserves energy and time. EVALUATION: 32. The patient verbalizes decreased discomfort and abdominal distention. 33. Patient remain free from any evidence of trauma to rectal mucosa. 34. Patient verbalizes knowledge after the procedure. TOTAL / 68 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: % REMARKS: Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 37 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: Correctly Needs Not Done SKILL: SURGICAL HANDWASHING RATIONALE Done Improvement (0) (2) (1) ASSESSMENT 1. Prepare yourself. 2. Put on-surgical attire (scrub suit garment). 3. Put on surgical cap or hood, mask and shoe covers. 4. Remove watches, rings and bracelets. 5. Remove nail polish or artificial nails if worn, SEMESTER, and trim nails so they are no longer in length than the fingers. PLANNING / EXPECTED OUTCOMES: 6. To perform the scrubbing technique aseptically. 7. To prevent transfer of pathogens to patient. 8. To perform the scrubbing technique within 8- 10 minutes only. MATERIALS: 9. Liquid cleanser solution 10. Sterile scrub brush 11. Surgical cap or hood 12. Shoe coverings / new slip-on shoes 13. Surgical mask 14. Sterile towel IMPLEMENTATION: 15. Gather all the materials needed. 16. Gather all the materials needed. 17. Turn on water faucet and check for water’s temperature. 18. Moisten hands and arms with liquid cleanser solution. 19. Lather hands and arms for 1 minute with antiseptic solution (betadine soap/phisohex) 20. Rinse hands and arms (finger tips first, then palms, hands, wrist to elbow) until the suds perished. 21. Keep hands higher than the elbows. Water drips should be in the elbow area. 22. Remove sterile brush from dispenser / sterile pack and start scrubbing. Counted Brush-Stroke Method: 23. Add liquid cleanser to sterile brush if necessary. 24. Scrub nails to left hand 30 strokes and all skin surfaces 20 strokes using anatomical position. 25. Scrub over dorsal surface of the hand. 26. Scrub over palmar surface of the hand. 27. Scrub over the wrist. 28. Scrub up in the arm in thirds, ending 2 inches above the elbow. 29. Repeat step 24 to 28 in the right hand and arms. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 38 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  EVALUATION: 30. Confirm that the scrubbing procedure is from 8-10 minutes only. 31. Confirm that the scrubbing procedure is done aseptically. 32. Confirm that right stroke and technique are practiced. TOTAL / 64 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: SEMESTER, Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 39 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: GOWNING AND GLOVING Correctly Needs Not Done RATIONALE Done Improvement (0) (CLOSED METHOD) (2) (1) ASSESSMENT 1. Assess the surrounding environment. 2. Assess the condition of your hands. PLANNING / EXPECTED OUTCOMES: 3. The caregiver will don a sterile gown and gloves without compromising their sterility. MATERIALS: 4. Sterile gown 5. Clean face mask 6. Sterile gloves SEMESTER, IMPLEMENTATION: Gowning: 7. Perform surgical handwashing. 8. The sterile gown comes folded inside out Grasp the gown using the lower portion of the gown. Pat dry hands, wrist to forearms to elbow. Unfold the gown(upright manner ) to expose the neckline. Hold the neckline of the gown and locate for the sleeves. 9. Slip both arms into the sleeves; keep your hands inside the sleeves of the gown and fit in the gown. 10. Keep hands above the waist. 11. The circulating nurse will secure the ties at the neck and waist. Closed Gloving: 12. With hands still inside the gown sleeves, open the inner wrapper of the sterile gloves. 13. With your non-dominant sleeved hand, place the palm of the dominant hand glove over the sleeved palm of the dominant hand. 14. Manipulate the glove cuff with your dominant, sleeved thumb. With your non- dominant hand, turn the cuff over the end of dominant hand and gown’s cuff. 15. With sleeved non-dominant hand, grasp the cuff of the glove and the gown’s sleeve of the dominant hand; slowly extend the fingers in the glove, making sure the cuff of the glove remains above the cuff of the gown’s sleeve. 16. With your dominant sleeved hand, place the palm of the non-dominant hand glove inside the sleeved palm of the non-dominant hand. 17. Manipulate the glove cuff with your non- dominant, sleeved thumb. With your dominant hand, turn the cuff over the end of non-dominant hand and gown’s cuff. 18. With sleeved dominant hand, grasp the cuff of the glove and the gown’s sleeve of the non-dominant hand; slowly extend the fingers in the glove, making sure the cuff of Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 40 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  the glove remains above the cuff of the gown’s sleeve. 19. Interlock gloved fingers and secure fit. TOTAL / 38 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: % REMARKS: SEMESTER, Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 41 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: SKIN PREPARATION Correctly Needs Not Done RATIONALE Done Improvement (0) FOR SURGERY (2) (1) ASSESSMENT 1. Determine the area to be shaved. Allows the nurse to verify the appropriateness of the type of enema ordered 2. Assess the physical condition of the client. Allows the nurse to plan the Determine if the client has bowel sounds. procedure with the client’s Assess for history of constipation, limitations in mind. hemorrhoids or diverticulitis. 3. Assess the client’s mental state, including To ensure if the client can ability to understand and cooperate with the comprehend and cooperate with procedure. the procedures. SEMESTER, PLANNING / EXPECTED OUTCOMES: 4. Area to be shaved depends upon the nature of the operation. 5. Area is shaved thoroughly and sufficiently on wide body areas than small operative sites. 6. No signs of skin eruptions noted which may serve as potential site of infection. 7. Excess and visible hair be removed. 8. To render the operative site as free as possible from bacteria. 9. Surgical incision can be made with a minimum danger of infection. MATERIALS: 10. Razor/Blade 11. Kidney Basin 12. Gauze or Cotton balls 13. Cotton applicator 14. Drape and Patient Gown 15. Soap 16. Pick-up forceps 17. Flashlight / Goose Lamp 18. Tissue 19. Clean and Sterile Gloves 20. Face mask & Surgical Cap 21. Povidone Iodine OPERATIVE FIELD AND AREAS TO BE SHAVED/SKIN PREP: 22. Cranial Operation a. Head or per doctor’s order 23. Chest a. Shaved the affected side from posterior supine to beyond anterior midline. From clavicle to umbilicus 24. Breast Surgery a. From axilla on affected side b. Clavicle line to umbilicus c. Anterior Midline to Posterior midline Arm to elbow 25. Abdomen a. From nipple line (below breast in female) to pubic area b. Laterally to anterior axillary lines Cleanse umbilicus with applicator 26. Lower bowel and rectum a. Umbilical line to medial thigh Lumbar region to medial thigh 27. Neck (Thyroid) a. Anterior neck up to lateral neck line b. Mandible Top of shoulders to chest almost to nipple lines 28. Vaginal Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 42 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  a. Pubic area Perineum and adjacent areas – include the inner aspect of the upper third of thighs IMPLEMENTATION: 29. Verify order for shaving and skin prep. 30. Check the client’s identification, introduce yourself and explain the procedure. 31. Provide privacy. Screen patient. 32. Wash hands and wear clean gloves. 33. Remove or raise patient’s gown up as indicated. Drape adequately. 34. Place towel under area being shaved. 35. Lather area freely with soap or any detergent 36. Using razor, remove the hair with one hand while stretching the skin with other. 37. Hold razor about 30°-40° angles to the skin. Use long gentle strokes, pulling razor in the direction in which the hair grows. Remove repeatedly the excess hair from razor with tissue paper. 38. Inspect skin under direct light to make certain it is free of all hair. On areas where hair is barely visible inspect skin by SEMESTER, continually bending forward so that the eyes are on level with the skin. 39. After hair is removed, clean with soap and / or antiseptic solution. Avoid vigorous rubbing. 40. Rinse skin with warm water and dry. 41. Put patient’s gown and keep comfortable. 42. Document the time, area prepared, observation on the condition of the skin. EVALUATION: 43. Area shaved was appropriate upon the nature of the operation. 44. Area shaved was thoroughly and sufficiently on wide body areas of operative site. 45. No signs of skin eruptions were. 46. Excess and visible hair was removed. 47. Operative site is free as possible from bacteria. 48. Surgical incision was made with a minimum danger of infection. TOTAL / 98 Computation: Raw Score / Total Score X 100 = FINAL GRADE Clinical Instructor: % REMARKS: Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 43 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NAME OF STUDENT: YEAR/SECTION: DATE: GRADE: (%) CLINICAL INSTRUCTOR: SKILL: URINARY CATHETERIZATION Correctly Needs Not Done RATIONALE Done Improvement (0) (MALE & FEMALE) (2) (1) ASSESSMENT 1. Assess the need for catheterization. To make certain the procedure is appropriate for the client’s condition. 2. Determine the type of catheterization To ensure the proper procedure is ordered. carried out. 3. Assess the ability of the client to perform To reduce the transmission of perineal wash before catheterization. microorganisms. To promote independence and cooperation. SEMESTER, 4. Assess if the client can tolerate supine or To facilitate visualization of the dorsal recumbent position perineum and determine if the client can hold still during the procedure. 5. Observe for indication of distress or To determine what teaching and embarrassment. support are needed. 6. Determine adequate lighting. Good lighting is necessary for proper visualization of the meatus. 7. Inspect the urinary meatus’ condition and Determine any history of difficulty determine any allergies to povidone-iodine or and avoid potential complications latex of catheterization. PLANNING / EXPECTED OUTCOMES: 8. The catheter will be inserted with minimal Insertion should not be performed discomfort. immediately before (possible loss of appetite) or after eating (will induce vomiting). 9. The client's bladder will be emptied without To relieve bladder discomfort, complication. distension, gradual decompression and emptying. 10. The nurse will maintain sterility throughout To prevent ascending infection to the procedure. the kidneys. MATERIALS: 11. Screen or curtains 12. Drape sheet 13. Clean gloves 14. Cotton balls soaked with povidone-iodine 15. Underpad 16. Droplight or penlight 17. Sterile gloves 18. Sterile urinary catheter (straight or indwelling of appropriate size) 19. Water-soluble lubricant 20. Urine bag 21. Bandage scissors 22. Adhesive tape (Leucoplast) 23. 10 cc syringe 24. Normal saline solution (NSS) or sterile water 25. Alcohol swab 26. 2% Xylocaine gel (optional) 27. Sterile fenestrated drape (optional) IMPLEMENTATION: 28. Verify physician’s order. To prevent catheterization error. 29. Identify client. Introduce yourself. Explain the Promotes cooperation. procedure. 30. Assemble all the materials needed. Organization facilitates performance of the task 31. Provide privacy. Usage of curtains or screen would prevent unnecessary exposure. 32. Position drop light to ensure adequate Good lighting is necessary for lighting of the perineal area. proper visualization of the urinary meatus. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 44 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  33. Set the bed to a comfortable height to work Promotes proper body mechanics and lower side rail near you. and ensures client’s safety. 34. Wash hands. Hand hygiene deters spread of microorganisms. 35. Stand on the client’s right side if you are right Observe proper body mechanics. – handed or on the other side if left-handed. 36. Place an underpad. I. MALE: 37. Assist the client to a supine position with Relaxes muscles and allows legs spread and feet apart. visualization of the area to facilitate insertion of the catheter. To expose genitalia. 38. Drape the client appropriately exposing only To provide privacy and establish a the penis. sterile field. 39. Open the sterile gloves. Set aside the inner wrapper and use the outer wrapper for the cotton balls soaked with povidone iodine. 40. Apply clean gloves and cleanse perineal Removes dirt and minimizes the area. With your nondominant hand, gently risk of urinary tract infection by grasp the penis perpendicular to the body removing surface pathogens. and retract the foreskin (if uncircumcised). 41. With your other hand, cleanse the glans Moving from the meatus towards penis with antimicrobial cleanser or the base of the glans penis povidone-iodine solution in a circular motion prevents transfer of SEMESTER, from inner to outer aspect then dispose used microorganisms to the meatus. cotton ball. 42. Using a separate cotton ball, cleanse the Prevents transmission of shaft with a downward stroke towards the microorganisms to the meatus base. 43. Remove gloves and wash hands. To prevent transfer of microorganisms. 44. Take the 10 cc syringe from its wrapper and It is necessary to open all supplies prepare appropriate volume for anchorage. and prepare for the procedure. (Apply technique of withdrawing solution from a vial. Open and disinfect rubber port of NSS vial with alcohol swab. Apply negative pressure principle in withdrawing solution by injecting needle into the rubber port of the vial and instill air into the solution as the same amount of solution to be withdrawn and aspirate 8-10 cc. Keep syringe with NSS inside its wrapper.) 45. Cut adhesive tape to be used in securing the catheter. 46. Open the catheter using sterile technique. Avoid exposing the client to ascending infection from an open- ended catheter. 47. Open urine bag using the sterile technique. Prevents contamination of the sterile equipment and the sterile field. 48. Open inner wrapper of sterile gloves. Utilize Maintain sterility. wrapper as sterile field. Cut the lubricant package and pour sufficient amount onto the sterile surface avoiding the tip to touch sterile field. 49. Don sterile gloves. 50. Designate the non-dominant hand as clean hand and the dominant hand as sterile. 51. Open the inner wrapper of the catheter and To prevent the catheter tip from coil it around the sterile hand while pulling dangling or dropping to the out. unsterile field. 52. Take hold of the syringe filled with 8-10 cc Tests the patency of the retention sterile water with the clean hand. Inflate and balloon. Detaching the syringe deflate the retention balloon then detach the prevents accidental inflation during water-filled syringe. (This is not applicable catheter insertion. for straight catheter insertion) 53. Attach the urine bag to the drainage lumen observing aseptic technique. (This is not applicable for straight catheter insertion) 54. Coat the tip of the catheter with water- Facilitates catheter insertion. soluble sterile lubricant avoiding blocking the Blocking the eye port will obstruct eye port. the drainage of urine. 55. Hold the penis with the non-dominant hand Facilitates catheter insertion by perpendicular to the body of the client and straightening urethra. retract gently. Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 45 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  56. Instruct the client to take several deep The catheter can enter the bladder breaths (inhale through the nose and exhale easily when the client’s sphincter thru the mouth) while steadily inserting the relaxes. catheter about 6-8 inches with the other hand until urine flow is noted. (In straight catheter insertion, pull–out the catheter after the bladder has been emptied completely.) 57. Advance the catheter from 1-2 inches more Advancing an indwelling catheter when urine flow is noted. Do not force to an additional 1-2 inches ensures insert the catheter further if you meet placement in the bladder and resistance then notify physician before facilitates inflation of the balloon proceeding with the procedure. without damaging the urethra. 58. Re-attach the water-filled syringe to the Ensures retention of the balloon. inflation port. Inflate the retention balloon Retention catheters are available with 8-10 cc of NSS for anchorage. with a variety of balloon sizes. Use a catheter with the appropriate size balloon. 59. If the client experiences pain during balloon If there is presence of pain, the inflation, deflate the balloon and insert the inflated balloon may still be at the catheter farther into the bladder. If the pain urethra. Continuing the procedure continues with balloon inflation, remove the may cause tissue damage. catheter and notify the client’s health care provider. 60. Once the balloon has been inflated, gently Maximizes continuous bladder SEMESTER, pull the catheter until the retention balloon is drainage and prevents urine resting against the bladder neck. leakage around the catheter. 61. Tape the catheter unto the lower abdomen Prevents excessive traction from or upper part of the thigh with enough slack the balloon rubbing against the that will not pull on the bladder. bladder neck, inadvertent catheter removal, or urethral erosion; this prevents pressure on the penoscrotal angle. 62. Place the drainage bag below the level of the Maximizes continuous drainage of bladder. Do not let it rest on the floor. urine from the bladder (drainage is prevented when the drainage bag is placed above the abdomen). 63. Remove gloves, dispose soiled materials Prevents transfer of and wash hands. microorganisms. 64. Drape and help the client adjust position. Promotes client comfort and Lower bed. safety. 65. Document the procedure. Document urine's character, amount, color/odor and the client's response to the procedure. Monitor urinary status. II. FEMALE: 66. Assist the client to a supine position with Relaxes muscles and allows knees flexed and feet apart. (dorsal visualization of the area to facilitate recumbent) insertion of the catheter. To expose genitalia. 67. Drape the client appropriately exposing only To provide privacy and establish a the vulva. clean field. 68. Open the sterile gloves. Set aside the inner wrapper and use the outer wrapper for the cotton balls soaked with povidone iodine. 69. Don clean gloves. 70. Spread the labia with the non-dominant hand Prevent transfer of while the other hand cleanses the microorganisms. periurethral mucosa with cotton balls soaked with povidone iodine from anterior to posterior portion. Discard used cotton balls after each downward stroke. 71. Use 1-7-7 technique in perineal care. The Prevent transfer of first stroke should start from the clitoris down microorganisms. to the perineum. The second stroke should be done on the distal side of the vulva by moving the cotton balls according to the figure 7 starting from the mons veneris going to the labia in inner-to -outer motion. The third stroke should be done on the proximal side following the same technique. 72. Remove clean gloves and wash hands. To prevent transfer of microorganisms. 73. Take the 10 cc syringe from its wrapper and It is necessary to open all supplies prepare appropriate volume for anchorage. and prepare for the procedure. (Apply technique of withdrawing solution from a vial. Open and disinfect rubber port of Disclaimer: All literary works that appears on the workbook are copyrighted by their own owners. Page 46 We claim no credits for them unless otherwise needed. If you own the rights to any of the works and do not wish them to appear on the workbook, please contact us and they will be promptly removed. Francis Jay N. Enriquez, MAN, RN  NSS vial with alcohol swab. Apply negative pressure principle in withdrawing solution by injecting needle into the rubber port of the vial and instill air into the solution as the same amount of solution to be withdrawn and aspirate 8-10 cc. Keep syringe with NSS inside its wrapper.) 74. Cut adhesive tape to be used in securing the catheter. 75. Open the catheter using sterile technique. 76. Open urine bag using the sterile technique. 77. Open inner wrapper of sterile gloves. Utilize wrapper as sterile field. Cut the lubricant package and pour sufficient amount onto the sterile surface avoiding the tip to touch sterile field. 78. Don sterile gloves. Prevents contamination of the sterile equipment and the sterile field. 79. Designate the non-dominant hand as clean Tests the patency of the retention hand and the dominant hand as sterile. balloon. Detaching the syringe prevents accidental inflation during catheter insertion. 80. Open the inner wrapper of the catheter and To avoid exposing the client to SEMESTER, coil it around the sterile hand while pulling ascending infection from an open- out. ended catheter. 81. Take hold of the syringe filled with 8-10 cc To prevent dangling on unsterile sterile water with the clean hand. Inflate and surface. deflate the retention balloon then detach the water-filled syringe. (This is not applicable for straight catheter insertion) 82. Attach the urine bag to the drainage lumen Facilitates catheter insertion. observing aseptic technique. (This is not Blocking the eye port will obstruct applicable for straight catheter insertion) the drainage of urine. 83. Coat the tip of the catheter with water- For visualization of the urethra. soluble sterile lubricant avoiding blocking the The nondominant hand separates eye port. the labia since the dominant hand is sterile. 84. With the non-dominant hand, expose the urethral orifice. 85. Instruct the client to take several deep The catheter can enter the bladder breaths (inhale through the nose and exhale easily when the client’s sphincter thru the mouth) while steadily inserting the relaxes. catheter about 4-6 inches in the urethral meatus with the dominant hand until urine flow is noted. 86. Advance the catheter from 1-2 inches more Advancing an indwelling catheter when urine flow is noted. Do not force to an additional 1-2 inches ensures insert the catheter further if you meet placement in the bladder and resistance then notify physician before facilitates inflation of the balloon proceeding with the procedure. without damaging the urethra. 87. Re-attach the water-filled syringe to the Ensures retention of the balloon. inflation port. Inflate the retention balloon Retention catheters are available with 8-10 cc of NSS for anchorage. with a variety of balloon sizes. Use a catheter with the appropriate size balloon. 88. Once the balloon has been inflated, gently Maximizes continuous bladder pull the catheter until the retention balloon is drainage and prevents urine resting against the bladder neck. leakage around the catheter. 89. Tape the catheter unto the upper part of the Prevents excessive traction from inner thigh with enough slack that will not the balloon rubbing against the pull on the bladder. bladder neck, inadvertent catheter removal, or urethral erosion; this prevents pressure on the penoscrotal angle. 90. Place the drainage bag below the level of the Maximizes continuous drainage of bladder. Do not let it rest on the floor. urine from the bladder (drainage is prevented when the drainage bag is placed above the abdomen). 91. Remove gloves, dispose soiled materials Prevents transfer of and wash hands. microorganisms. 92. Drape and help the client adjust posi