Nursing Manual

Purpose of Charting: To make record of—

1. The significant observation of the patient’s condition both mental and physical.
2. The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
3. The incident which might have some bearing on the patient’s condition.

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I. Equipment:

• Tray with big basin of disinfectant solution. Creosol solution 5%.
• Medicine glass
• A pitcher of 1% creosol solution
• Sputum cup brush
• Several pieces of dusting cloth
• Sapolio or Cleanser
• Short-sleeved gown

II. Procedure:

1. Put on the gown.
2. Collect all the sputum cups in a tray.
3. Empty their contents into the hopper. Wash with cold water. Rinse with hot water. Use brush p.r.n.
4. Place cup in basin of disinfectant solution of 5% Creosol solution for 2 hours.
5. Remove after, clean inside and out with soapy warm water. Remove stains.
6. Rinse with hot water and dry the outside.
7. Fill each sputum cup with 50 cc of 1% of Creosol solution and place in the trays, distribute back to each patient.
8. For children and delirious patients, do not put Creosol solution inside their sputum cups.

I. Equipment:

1. Tray with bedpan brush, bedpan swab
2. Short-sleeved gown
3. Can of disinfectant solution
4. Soap or any cleanser
5. Several pieces of dusting cloth

II. Procedure for Cleaning Bedpans and Urinals

1. Put on the short-sleeved gown
2. Collect the bedpans
3. Empty the contents one by one into the hoper. Wash with clean cold water. Use brush p.r.n. Follow with hot water.
4. Put the bedpan in the scan of disinfectant
5. Remove after, wash inside and outside with warm soapy water. Remove any stains using the cleanser
6. Rinse with hot water
7. Wipe to dry with the bedpan wiper and hang it at the bedpan rack.

Purpose:

To introduce drugs, bacteria or their toxins and other organic preparations to test whether the body is sensitive to the preparation to be injected.

Site of Injection:

Inner aspect of forearm or upper arm

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Tube feeding is the introduction of nourishment into the stomach by mechanical means through the hose and/or mouth.

Points to Remember:

1. Give mouth care frequently at least 4 times daily.
2. Wet lips and mouth frequently.
3. If not contraindicated, let patient chew some solid food but do not allow him to swallow.

Equipments:

Tray with:

• Feeding tube of appropriate size
• Lubricant, water may do
• OS and kidney basin
• Syringe and small funnel
• Bed protector and rubber apron
• Bath towel
• Bowl containing the nourishment

Preparation of Patient:

Same as in lavage

Procedure:

1.The same as in lavage until the tube is inserted.
2.After the tube has been inserted and is sure to be in the stomach, the nourishment is introduced using any of this methods:
a.Connect funnel to the tubes and pour the nourishment into the funnel slowly. Hold funnel at a height which will alloy, the solution to enter the stomach.
b.If given by gravity drip method) connect feeding tube with the drip set connected with the bottle of nourishment.
c.If given by syringe, inject the nourishment thru the tube, climinating as much air as possible
3.Flush tube with drinking water.
4.Wait a few minutes, then clamp tube close to the mouth or nose and withdraw gently. If tube is left for subsequent feeding, secure tube in ph-ice adhesive tape along the side of the face- in front of the ear or along the nose and the forehead. Clamp the free and of the tube.
5.Make patient comfortable.
6.Clean equipment and keep.

Chart:

Record time, kind of feeding, person who inserted the tube, amount of food taken and patient’s reactions

Purpose of Sitz Bath:

1.To aid healing a wound in the area by cleaning on discharges and slough
2.To induce voiding in urinary retention
3.To relieve pain, congestion and inflammation in cases of:
    a.Hemorrhoids
    b.Tenesmus
    c.After proctoscopic or cycloscopic examination
    d.Sciateca
    e.Uterine and renal colic
4.To induce menstruation.

Contraindication: Menstruating or pregnant women

Equipment:

• Sitz tub half filled with water 105F
• Pitcher of water 130F
• Bath thermometer
• Ice cap-with cover
• Fresh camisa
• Bath towel
• Bath blanket
• Rubber ring p.r.n.

Preparation of Equipment:

1. Take all necessary equipment to bathroom or treatment room.
2. Run water into tub and check temperature—105F
3. Place rubber ring at bottom of tub p.r.n. or line bottom with towel.

Sitz Bath Procedure:

1. Help patient undress and drape with bath blanket. Pin at the back.
2. Help patient set in the tub bringing the blanket covering him around the shoulder and over the edge of the tub.
3. Place ice cap on the head.
4. Place folded towel at the edge of the tub where the patient’s back rests and place another towel under the knees where they rest on the interior edge of the tub.
5. Gradually raise the temperature of the water to 115-F by pouring hot water at the sides of the tub. Let patient soak for 20-30 minutes.
6. After the Treatment, dry patient thoroughly, and put on fresh gown. Let patient sit on a chair for a while before taking him back to bed.

NOTE: Use aseptic technique if there is lesion or in the area, disinfect tub.

Chart: Time, duration, drug added to water p.r.n. and effect on patient.

Purpose:

1.To remove cerebrospinal fluid by gravity flow in order to:
    a.Secure specimen for diagnosis
    b.Relieve intracranial pressure
    c.Introduce drugs in therapy.
    d.Introduce air or opaque liquid before taking X-ray for diagnosis
2.To determine the pressure within the cerebrospinal canal.

Point to Remember:

1. Observe strict asepsis.
2. See to it that the patient does not move during procedure.
3. To prevent the needle from breaking inside the spinal column.
4. Keep patient flat in bed without pillow for about 8 hours. May turn to sides

Equipment:

1.    Skin disinfection tray with a bottle of colledion
2.    Sterile tray with:
    a.Two spinal needles with stylets g-19 or 20
    b.Hypodermic needle no.24
    c.Intramuscular needle no. 22
    d.One 5-cc syringe
    e.One 1.0 cc syringe
    f.Medicine glass
    g.Four 0.5
    h.Specimen bottles or test tubes
    i.Treatment sheet or operating towels
    j.Rubber gloves 3 drugs ordered
3.local anesthetic
4.Sterile manometer, three-way stop cock
5.bed screen
6.bed protector
7.fracture board

Procedure:

1.Assemble equipment and bring to bedside.
2.Explain the procedure to the patient. Gain his cooperation. Get consent for puncture.
3.Screen the bed, replace top sheet with blanket.
4.Assist to assume the desired position for lumber puncture either.
    a.Recumbent position—if mattress is soft bed hoards should be placed under the mattress to make the surface less flexible. Place the patient on his side on he edge of the bed. Ask patient to assume the “Fatal position”.
    b.Sitting position—place the patient on sitting position in hood or on the chair with the back arched.
5.Uncover the lower hack.
6.Disinfect the area about the site of puncture.
7.Physician put the gloves. He drapes the area
8.Assist in the procedure as needed—The doctor gives the anesthetic, inserts the needle.
9.Receive the specimen as it drops from the hub of the needle, not the rate of drops per minute
10.Physician inserts the stylets then removes the needles
11.Press the site of puncture with alcohol sponge, apply collodion
12.Place patient in dorsal recumbent without pillow
13.Make patient comfortable
14.Clean and keep equipment.

Charting:

Record treatment performed, amount of fluid color character, rate of flow, drugs instilled if any, amount of drugs, person who did the procedure reaction of the patient.

I. Purpose:

• To make the skin as clean as possible with a minimum of irritation to prevent infection

II. Preparation of the Patient and the Environment:

1. Explain the procedure to the patient.
2. Close the window if necessary
3. Draw the curtains

III. Equipment:

• Tray containing:
• Safety razor with new blade
• A bowl for soap solution
• A bowl for warm water
• Bottle of green soap
• Several O.S
• Cotton applicators
• Kidney basin
• Flashlight p.r.n
• Bath towel
• Washcloth
• Bed protector
• Bed screen p.r.n

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I. Purpose

1. To provide warmth and comfort for the patient.
2. To provide protection for the bed.
3. To arrange the bed and other furniture in order to facilitate the transfer of the patient from stretcher to bed.

II. Equipment

• The same linen as those used for making on occupied bed plus the following”
• Bath towel
• Small robber sheet
• Woolen blanket
• 3 hot water bags w/cover p.r.n.

On the Bedside Table:

• Stethoscope
• Sphygmomanometer
• Kidney basin
• Swipes
• Padded tongue depressor
• p.r.n.
• Observation Sheet

In the Room

• Oxygen tank with complete
• Tubbings, humidifier and nassal catheter
• Suction apparatus
• Stand
• Drainage bottles

III. Procedure:

1. Strip on the bed and turn the mattress.
2. Make an ordinary bed with the top sheet untucked at the foot part. (If weather is cold, place bath blanket over the top sheet.) Fold back lop side of the sheet about 14 inches and the bottom side folded back even with the foot of the mattress.
3. Fanfold together the top sheet and blanket towards the side away from the door.
4. Place the small rubber sheet across the hood part of the bed.
5. Place the bath towel over the small rubber sheet.
6. Slip the pillowcase and put the pillow upright against the bars of the head of the bed.
7. Put the hot water bags at the foot and center of the bed if the weather is cold.
8. Place the necessary articles on the bedside table and the irrigating stand, suction machine and oxygen set-up adjacent to the bed.
9. Arrange unit.

I. In Dorsal Recumbent Position:

1. Arrange the pillows in the order to support the weight of the shoulders and head.
2. Relieve strain on the muscles of the back by supporting it, fill in the hollows with small pillows, small pads, or a hot water bottle partially filled with warm water.
3. Relieve strain on the abdominal muscles and on tendons under the knees. Support with the knee rest provided on the Gatch bed or with a pillow.

II. Turning to One Side:

A. To turn the patient toward you:

1. Move the patient to the side of the bed away from you by putting your forearms under the body then sliding first the head and shoulders, next the hips then legs across the bed.
2. Place one of your arms across the patient’s back reaching from the far side to the side nearer you and the other arm across his hips on the same way.
3. Lift and turn him gently toward you to the middle of the bed.
4. See that the head, shoulders and hips are properly adjusted, that the neck and shoulders are not cramped and the arms are not pinned under the body.
5. Flex the knees with the upper leg flexed a little more than the lower leg.
6. Support the legs by placing a pad or small pillow between them.
7. Support the whole length of the back with pillows so that the patient can relax comfortably.
8. A small pillow placed against the abdomen gives relief and comfort especially when the patient is suffering from gas pains.

B. To turn patient away from you:

1. From the side nearest you, slip one arm under the patient’s shoulder reaching the far shoulder and place the other around the hips in the same way.
2. Lift and draw his far side slightly toward you so that he is gradually turned away from you.