PERIOPERATIVE NURSING GOALS: • Constructive – repairing the damaged tissue or congenitally defected organ.

Multiple
wound repair
DEFINITION OF TERMS: 1. To provide safe, supportive, and comprehensive care.
- Example: cleft lip/palate
2. To assist the surgeon by functioning effectively as a member of the surgical team.
• Surgery –Branch of medicine concerned with diseases and conditions which require or • Restorative – performed to improved client’s functional ability
3. To create and maintain an aseptic/sterile environment.
are amenable to operative procedures. - Example: finger reimplantation
- Surgery can involve cutting, abrading, suturing, laser or otherwise physically FUNDAMENTAL PURPOSES OF THE OPERATING ROOM: It is a place: • Cosmetics – performed primarily to alter/enhance personal appearance
changing body tissues and organs.” - Example: liposuction, revision of scars, rhinoplasty
1. To correlate theory and practice.
• Surgeon – a doctor who specializes in evaluating and treating conditions that may
2. To develop skills in assisting the surgeon in the operation. FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE SURGERY:
require surgery or physically changing human body, the removal of organs, masses, and
3. To create a suitable sterile field for surgical procedure to prevent complications.
tumors and in doing other procedures. 1. Obstruction – a blockage; are dangerous because they block the flow of blood, air,
• Sterile – free from living germs or microorganisms; aseptic: sterile surgical instruments. AIMS OF THE HEALTHCARE IN THE OPERATING ROOM: CSF, urine and bile through the body.
• Asepsis – state of being free from pathogenic microorganisms 2. Perforation – a rapture of an organ, artery, or a bleb
• Safe - “Don’t hurt me”
- Process of removing pathogenic microorganisms or protecting against infection by 3. Erosion – break in the continuity of tissue surface. Can be caused by irritation, infection,
• Effective - “Don’t kill me”
such organisms. ulceration or inflammation. Can be damage the walls of the blood vessels resulting in
• Patient-centered - “Don’t leave me helpless”
• Sepsis – severe illness caused by overwhelming infection of the bloodstream by serious bleeding.
bacterial infection that can originate anywhere in the body. • Timely - “Don’t make me wait” 4. Construction – reconstruct what is being damaged
• Disinfectant – any chemical agent used chiefly on inanimate objects to destroy or inhibit SURGICAL CONSCIENCE: EFFECTS OF SURGERY TO THE CLIENT:
the growth of harmful organisms.
• Antiseptics – is a substance that prevents or arrests the growth or action of • Implies an awareness of the importance of strictly applying knowledge to ensure quality • Stress response is elicited
microorganisms either by inhibiting their activity or by destroying him. of practice; inner voice conscientious practice of asepsis and sterile techniques at all • Defense against infection is lowered
times.
- Term is used especially for preparations applied topically to living tissue. • Vascular system is disrupted
• Sterilization – destruction of all living microorganisms, as pathogenic bacteria, PHASES OF PERIOPERATIVE NURSING: • Organ functions are disrupted
vegetative forms, and spores. • Body image may be disturbed
• Disinfection – the process of destroying or inhibiting growth of microorganism on A. Preoperative Phase – the period of time from the decision for surgery until the patient
• Lifestyle may change
inanimate objects. is transferred into the operating room.
B. Intraoperative Phase – the period of time from when patient is transferred into the THE SURGICAL RISK PATIENTS:
PREFIXES: operating room to the admission to Post Anesthesia Care Unit (PACU)
• Extremes if age (very young and very old)
C. Post-Operative Phase – the period of time that begins with admission to the PACU and
• Supra – above; beyond • Extremes of weight (emaciation, obesity)
ends with follow-up evaluation in the clinical setting or at home.
• Ortho – joint • Dehydrated patients
• Chole – bile/gall CLASSIFICATION OF SURGERY: ACCORDING TO URGENCY • Nutritional deficits
• Cyato – bladder • Patients with severe trauma or injury, infection/sepsis
1. Emergent – patient requires immediate attention, disorder may be life-threating
• Encephalo – brain • Patient with cardiovascular disease
therefore, NO DELAY!!!
• Entero – intestine - Example: severe bleeding, bladder/intestinal obstruction, fractured skull, • Endocrine dysfunction (diabetes mellitus)
• Hystero – uterus gunshot/stab wounds, extensive burns • Hypertensive and hypotensive patient
• Mast – breast 2. Urgent – patient requires prompt attention within 24hrs to 30 hrs. • Hypovolemia
• Meningo – membrane; meninges - Example: acute gallbladder infection, kidney or ureteral stones • Hepatic disease
• Myo – muscles 3. Required – plan within weeks or months • Preexisting mental or physical disability
• Nephron – kidney - Example: cataract extraction/prostatic hyperplasia
• Nuero – nerve PROBLEMS THAT MAY ARISE IN SURGERY:
4. Elective – patient should have surgery
• Oophor – ovary - Example: repeated CS 1. Surgical risk patient – probability of morbidity or mortality following surgery.
• Pneumo – lungs 5. Optional – decision rests within patient 2. Pain
• Pyelo – kidney pelvis - Example: cosmetic surgery 3. Hemorrhage
• Salphingo – fallopian tube 4. Infection
TYPES OF SURGERY:
• Thoraco – chest 5. UTI
• Viscero – organ esp. abdomen 1. Major – normally involves opening of the body, allowing the surgeon access the area
PERIOPERATIVE PHASE:
where the procedure needs to be completed. It involves major trauma to the tissue, high
SUFFIXES: risk of infection, removal of an organ and an extended recovery period. NURSING ACTIVITIES:
• Oma – tumor; swelling - Example: CS, organ-replacement kidney transplant, heart surgeries, Total
Abdominal Hysterectomy Bilateral Salphingo Oophorectomy (TAHBSO), gallbladder • Assessment of the client (baseline evaluation of the pt. before the day of surgery-
• Ectomy – removal of an organ or gland interview).
• Rhaphy – suturing or stitching of a part or an organ surgeries
2. Minor – those that are minimally invasive cases. Allows the surgeon to perform the • Identification of potential/actual health problems.
• Scopy – looking into • PREADMISSION TESTING – ensure necessary tests have been performed.
procedure without damaging extensive amounts of tissue. The risk of infection is not like
• Ostomy – making an opening or stoma - X-ray laboratories, MRI (Any diagnostics)
major surgeries and patient’s recovery time is much shorter.
• Otomy – cutting into - Nothing per orem
- Example: circumcision, debridement, breast biopsy
• Plasty – to repair or restore - Allergies
• Cele – tumor; hernia; swelling PURPOSE: - Establish rapport
• Itis – inflammation of • Pre-op teaching involving the client & support persons.
• Diagnostic – verifies suspected diagnosis performed to determine the origin and cause
PERIOPERATIVE NURSING: of a disorder or the cell type. PERIOPERATIVE ASSESMENT:
- Example: biopsy, explore lap
• Operative Room Nursing – the identification of physiological and sociological needs of • Nutritional and Fluid Status – obesity, weight loss, malnutrition, deficiencies in specific
• Exploratory – estimates the extent of the disease or injury
the client and the implementation of an individualized program of nursing care in order nutrients, metabolic abnormalities, and the effect of medications on nutrients, fluid and
- Example: exploratory laparotomy
to restore or maintain health and welfare of the patient before, during, and after surgical electrolyte imbalances.
• Curative – removes or repairs damaged tissues. Performed to resolve a health problem
intervention. • Dentition
by repairing and removing cause.
• Philosophy – to give service that aims to provide comprehensive support physically, • Drug and Alcohol Use
- Example: laparoscopic cholecystectomy, mastectomy, hysterectomy
morally. • Respiratory Status
• Ablative – removing diseased organ that can’t wait anymore
• A perioperative nurse is a registered nurse (RN) who works in the operating room. • Cardiovascular Status
- Example: emergency surgery
- Sometimes called “surgical” or an “operating nurse” • Hepatic and Renal Function
• Palliative – relieves symptom but does not cure the underlying disease process.
- This specialized nurse care for patients before, during, and after surgery. • Endocrine Function
- Example: colostomy
• A perioperative nurse may serve as a scrub nurse – selecting and passing instruments
• Reconstructive – partial or complete restoration of a damaged organ/tissue to bring • Immune Function
and supplies used for the operation, or as a circulating nurse – managing the overall
back the original appearance and function • Previous Medication Use
nursing care in the operating room and helping maintain a safe, comfortable
- Example: mammoplasty, face-lift
environment
DAY OF THE SURGERY: - CBC 2. Operating Surgeon – pre-op dx & care. Performance of operation. Post-opt mgt &
- Electrolytes care
• Pt. teaching reviewed
- PT/PTT (Prothrombin Time; Partial thromboplastin time) - Assumes all responsibilities for all medical acts of judgment & mgt.
• Informed consent confirmed
- Urinalysis 3. Surgeon & assistants – scrub & perform the surgery.
• Pts. identify & surgical site verified - ECG 4. Registered Nurse 1st asst. – practices under the direct supervision of the surgeon.
• IVF started - Blood typing & crossmatch (Handling tissue, suturing, maintain hemostasis).
PSYCHOLOGICAL SUPPORT: • NPO – to prevent aspiration 5. Anesthesiologist
• Bowel prep & skin prep 6. Nurse Anesthetist – administers the anesthetic agent & monitors the patient’s
• Assess client's fear, anxieties, support systems & pattern of coping. • Cardio-pulmonary (CP) clearance – for pts. above 40 years old or with comorbidities. physical status throughout the surgery.
• Establish trusting relationship with client & significant others. • Mediate preoperative preparation – compete checklist and chart
• Explain routine procedures, encourage verbalization of fears & allow client to ask SCRUB NURSE:
- Hospital gown, voiding, removal of dentures, jewelry, contacts, etc.
questions. - Preoperative medications • Performing surgical hand scrubbing
• Demonstrate confidence in surgeon & staff. • Transporting the pt. to the Presurgical area about 30- 60 mins. before anesthetics is to • Setting up the sterile tables
• Provide for spiritual care if appropriate. be given. • Preparing sutures, ligatures, & special equipment
PERIOPERATIVE TEACHING: • Attend to family needs. • Assisting the surgeon & the surgical assistants
• Counts all the needles, sponges, & instruments
• Frequently done on an outpatient basis. LEGAL PREPARATION: Surgeon (informed consent)
• Labels obtained specimens
• Assess client's level of understanding of surgical procedure & it's implications. 1. Surgical procedures, alternatives, possible complications & disfigurement or removal of
• Answer questions, clarify & reinforce explanations given by the surgeon. CIRCULATING NURSE:
body parts are explained.
• Explain routine pre- & post-op procedures & any special equipment to be used. 2. It is part of the nurse's role as client advocate to confirm that the client understands • Manages the OR
• Preoperative experience information given • Monitors the activities of the surgical team
• Preoperative medicine • Checks the OR conditions
INFORMED CONSENT:
• Breathing exercises, coughing, incentive spirometer • Continually assess the patient for signs of injury & implements appropriate interventions
• Leg exercises • Invasive procedures, such as surgical incisions, biopsy, cystoscopy or paracentesis. • Verifies consent
• Position changes & movement • Procedures requiring sedation or anesthesia. • Coordinates the team
• Pain management • A non-surgical procedure, such as arteriography. • Ensures cleanliness, proper temperature, humidity, lighting, safe function of equipment,
• Pain scale assessment • Procedures involving radiation. and the availability of supplies & materials
• Reducing anxiety and fear, support of coping • Adult client signs own permit unless unconscious or mentally incompetent. • Assists with patient positioning, skin prep, managing surgical specimens & documenting
• Special considerations r/t to outpatient surgery - If unable to sign, relative (spouse/next of kin) or guardian will sign. intraoperative events.
- If an emergency, permission via telephone/telegram is acceptable: have 2nd listener • Monitors aseptic practices.
DIAPHRAGMATIC BREATHING AND SPLINTING WHEN COUGHING:
on the phone when telephone permission is given. • Facilitates "time-out"
- Consents are not needed for emergency cases if all 4 of the ff. criteria are met:
1. There is an immediate threat to life. NURSING ACTIVITIES:
2. Experts agree that it is an emergency. • Activities providing for patient’s safety.
3. Client is unable to consent • Maintenance of aseptic environment.
4. A legally authorized person cannot be reached.
• Ensuring proper function of equipment.
• Minors under 18 y/o must have consent signed by an adult (i.e. parent or legal guardian).
• Providing surgeons with specific instruments & supplies for surgical field.
• Emancipated minor may sign his/her own consent.
• Completing documentation.
• Witness to informed consent may be a nurse, another M.D., clerk or any other authorized
• Positioning patients.
person but NOT student nurses. (To ensue legal purposes)
• Acting as a scrub/circulating nurse.
• The nurse witnessing informed consent, specifies whether witnessing explanation of
surgery or just signature of the client. PREVENTION OF INFECTION:

PERIOPERATIVE MEDICATION: Purposes • The surgical environment – cool temperature, located at the central portion of other
supportive services.
1. To relieve fear & anxiety
- Unrestricted zone: where street clothes are allowed.
- Ex: diphenhydramine
- Semi restricted zone: where attire consists of scrub clothes & caps.
2. To reduce dose needed for induction & maintenance of anesthesia.
- Restricted zone: where scrub clothes, shoe covers, caps & masks are worn.
3. To prevent reflex bradycardia that happens during induction of anesthesia.
4. To minimize oral secretions. BASIC GUIDELINES OF SURGICAL ASEPSIS:
LEG EXERCISES AND FOOT EXERCISES: - Antiemetics: decrease gastric emptying, nausea & vomiting.
Ex: Metoclopramide • All materials in contact with the wound and within the sterile field must be sterile.
- Sedatives/Hypnotics/Tranquilizer: decrease anxiety and provide sedation • Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from
Ex: Hydroxyzine, Valium (Diazepam), Midazolem 2 inches above the elbow to the cuff.
- Narcotics: relieve pain/discomfort • Only the top of a draped table is considered sterile. During draping, the drape is held
Ex: Demerol/Fentanyl/Licotine well above the area and is placed from front to back.
- Anticholinergics: decrease secretion of saliva and gastric juices; prevents • Items are dispensed by methods to preserve sterility.
bradycardia • Movements of the surgical tear are from sterile to sterile and form unsterile to sterile
Ex: Atropine sulfate only.
- Histamine H2 antagonist: prevent aspiration pneumonitis/prevents allergies • Movement around the sterile field must not cause contamination of the field. At least a
Ex: Ranitidine (Zantac), Famotidine 1-foot distance from the sterile field must be maintained.
• Operating room attire (which includes scrub suits, gowns, head coverings, and face
INTRAOPERATIVE PHASE: masks) should not be worn outside the operating room suite. If such occurs, change all
MEMBERS OF THE SURGICAL TEAM: attire before re-entering the clean area. (The operating room & adjacent supporting
areas are classified as "clean areas.")
• Patient • All members of the surgical team having direct contact with the surgical site must
PERIOPERATIVE NURSING INTERVENTIONS: • Anesthesiologist/Anesthetist perform the surgical hand scrub before the operation.
• Surgeon • If sterile gloves are torn, punctured, or have touched an unsterile surface or item, they
• Physical Preparation – patient safety is a primary concern.
• Nurses (Scrub & Circulating) are considered contaminated.
- Obtain history of past medical conditions, surgical procedures, dietary restrictions &
• Surgical technologies • The safest, most practical method of sterilization for most articles is steam under
medications.
1. Patient – the most important member of the surgical team. May feel relaxed & pressure. (Autoclave)
- Perform baseline head-to-toe assessment, including VS, height & weight.
prepared, or fearful & highly stressed. Is also subject to several risk. • Label all prepared, packaged, and sterilized items with an expiration date.
• Ensure that diagnostic procedures pertinent to surgery are performed as ordered. (Do
not remove any patient' results in the patient chart.) • Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days.
 • Use articles sterilized in cotton muslin (Eco bag – blue paper bag) wrappers and sealed STAGES OF GENERAL ANESTHESIA: • Malignant hyperthermia
in plastic within 180 calendar days. • Disseminated intravascular coagulation (DIC
1. STAGE I: Beginning Anesthesia
• Unsterile articles must not come in Contact with sterile articles.
→ Warm, dizziness, & feeling of detachment. POST-ADVSERSE EFFECTS OF SURGERY & ANESTHESIA:
• Make sure the patient's skin is as clean as possible before a surgical procedure. (Skin
→ Ringing, roaring or buzzing in the ears.
preparation) • Allergic reactions & drug toxicity or reactions
→ Still conscious but may sense inability to move the extremities easily.
• Take every precaution to prevent contamination of sterile areas or supplies by airborne • Cardiac arrhythmias
→ Noises are exaggerated: even low voices or minor sound seem loud &
organisms. • CNS changes and oversedation or undersedation
unreal.
• Trauma: laryngeal, oral, nerve, and skin, including burns
HANDLING STERILE ARTICLES: → Unnecessary Noises & motions should be avoided
• Hypotension
2. STAGE II: Excitement
• When you are changing a dressing, removing sutures, or preparing the patient for a • Thrombosis
→ Struggling, shouting, talking, singing, laughing or crying: (avoided if given
surgical procedure, it will be necessary to establish a sterile field from which to work.
smoothly & quickly). GERONTOLOGIC CONSIDERATIONS:
The field should be established on a stable, clean, flat, dry surface.
→ Pupils dilated (but contract if exposed to light)
• An article is either sterile or unsterile, there is no in-between. If there is doubt about the • Elderly patients are at increased risk for complications due to surgery and anesthesia
→ PR rapid & RR irregular.
sterility of an item, consider it unsterile. because of:
→ Restraining the patient may be possible.
• Any time the sterility of the field has been compromised, replace the contaminated field - Increased likelihood of coexisting conditions
3. STAGE III: Surgical Anesthesia
and setup. - Aging heart and pulmonary systems
→ Reached by continuous administration of anesthetic vapor or gas.
• Do not open sterile articles until they are ready for use. - Decreased homeostatic mechanisms
→ Pt. is unconscious & lies quietly.
• Do not leave sterile articles unattended once they are opened and placed on a sterile - Changes in responses to drugs and anesthetic agents due to aging changes such
field. → Pupils are small but contract when exposed with light
as decreased renal function and changes in body composition of fat and water.
• Do not return sterile articles to a container once they have been removed from the → RR regular, PR is normal, skin pink/flushed
container. 4. STAGE IV: Medullary Depression NURSING GOALS OF PATIENT IN THE INTRAOPERATIVE PERIOD:
• Never reach over a sterile field → Reached when too much anesthesia has been administered.
• Reducing Anxiety
• When pouring sterile solutions into sterile containers or basins, do not touch the sterile → Respirations shallow, pulse weak & thready.
• Preventing positioning injuries
container with the solution bottle. Once opened and first poured, use bottles of liquid → Pupils widely dilated & no longer contract when exposed to light.
• Maintaining patient safety
entirely. If any liquid is left in the bottle, discard it → CYANOSIS develops & w/o prompt intervention -> DEATH
• Maintaining the patient's dignity
• Never use an outdated article. Unwrap it, inspect it, and, if reusable, rewrap it in a new GA DELIVERY METHODS: • Avoiding complications
wrapper for sterilization
❖ Intravenous Administration PROTECTING THE PATIENT FROM INJURY:
REMINDERS: → Onset of anesthesia is pleasant
• Patient Identification
• Surgical hand scrubbing → Duration of action is brief
• Correct informed consent
• Gowning and gloving → Causes little N&V
• Verification of records of health history and exam
• Serving gown to surgeon & other members of the surgical team → IV agents are nonexplosive, require little equipment, and are easy to
• Results of diagnostic tests
• Serving gloves administer.
• Allergies (include latex allergy)
→ Useful for short procedures
CLASSIFICATION OF INSTRUMENTS: • Monitoring and modifying the physical environment
→ C/t: children, patients susceptible to respiratory obstruction
2. Regional Anesthesia – involves injection of a local anesthetic (numbing agent) around • Safety measures such as grounding of equipment, restraints, and not leaving a sedated
• Cutting & dissecting patient
major nerves or the spinal cord to block pain from a larger but still limited part of the
• Grasping & holding • Verification and accessibility of blood
body.
• Clamping & occluding
Types: POST-OP:
• Exposing & retracting
a. Epidural Anesthesia
• Suturing & stapling 1. STAGE I: INDUCTION – the earliest stage lasts from when you take the medication until
→ Commonly used conduction block
• Viewing you go to sleep ... lose ability to feel pain.
→ Injecting a local anesthetic into the epidural space that surrounds the dura
• Suctioning & aspirating 2. STAGE II: EXCITEMENT OR DELIRIUM – the second stage can be dangerous, so the
matter of the spinal cord.
• Dilating & probing anesthesiologist will want to get yoy through it as quickly as possible. You can have
→ block sensory, motor & autonomic functions.
• Measuring controlled movements, fast heartbeat, and irregular breathing. You might vomit, which
→ Doses are much higher than spinal because epidural anesthetic does not
could make you choke or stop breathing.
ANESTHESIA: make direct contact w/the spinal cord or nerve roots.
3. STAGE III: SURGICAL ANESTHESIA – at this stage, surgery can take place. Your eyes
→ ADVANTAGE: absence of headache
• A state of narcosis, analgesia, relaxation & reflex loss. stop moving, your muscles completely relax and you may stop breathing w/out the help
→ DISADVANTAGE: greater technical challenge of introducing the anesthesia
• Involve the use of medication that block pain sensations (analgesia) during surgery and of machines. The anesthesiologist will keep you at this stage until the procedure is over.
in the epidural space.
other medical procedures. 4. STAGE IV: OVERDOSE – if you get too much anesthesia your brain will stop telling your
→ If (+) accidental puncture of the dura happens & the anesthetic travels toward
• Anesthesia also reduces many of your body's normal stress reactions to surgery heart and lungs to work. It's / rare with modern technology, but it can be fatal
the head -> High Spinal Anesthesia -› Severe Hypotension, Respiratory
TYPES OF ANESTHESIA: Depression -> Arrest RESPONSIBILITIES OF PACU NURSE:
b. Spinal Anesthesia
• General Anesthesia • Review pertinent information and baseline assessment upon admission to the unit.
→ Local anesthetic is introduced at lumbar level between L4 & L5.
• Local Anesthesia • Assessments include airway and respirations, cardiovascular function, surgical site,
→ Produces anesthesia of lower extremities, perineum & lower abdomen.
• Regional Anesthesia function of the central nervous system, also assess Is and all tubes and equipment.
→ Lumbar puncture done -> knee - chest position
• Moderate Sedation • Reassess VS and patient status every 15 mins. or more frequently as needed.
→ As soon as the injection has been made -› position pt. on his back
• Monitored Anesthesia Care • Provide report and transfer the patient to another unit or discharge the patient to home
3. Local Anesthesia – involves injection of a local anesthetic (numbing agent) directly into
1. General Anesthesia – affects your entire body and renders you unconscious. the surgical area to block sensations. NURSING MANAGEMENT IN THE PACU:
- The patient would be completely unaware and not feel pain during the surgery or the - Often administered in combination with Epinephrine.
procedure. - ADVANTAGES: • Provide care for the patient until he/she has recovered from the effects of anesthesia
- Also causes forgetfulness (amnesia) & relaxation of the muscles throughout your Simple, economical, non-explosive. • Patient has resumption of motor and sensory function, is oriented, has stable V5, and
body. Equipment needed is minimal. shows no evidence of hemorrhage or other complications of surgery.
- Suppresses many of your body's normal automatic functions, such as those that Post-op recovery is brief. • Frequent skilled assessment of the patient is vital.
control breathing, heartbeat, circulation of the blood (such as blood pressure), Undesirable effects of Gen. anesthesia are avoided. • Deep breathing and coughing reflex.
movements of the digestive system, and throat reflexes such as swallowing, Ideal for short & superficial surgical procedures • ALERTI COUGHING IS C/ in who have undergone intracranial, eye and plastic surgeries
coughing, or gagging. = increased intracranial pressure
- Monitoring of the heart, breathing, blood pressure, & other vital function is important. INTRAOPERATIVE COMPLICATIONS:
- Endotracheal (ET) tube • Nausea & vomiting
- Laryngeal mask airway • Anaphylaxis
• Hypoxia & respiratory complications
• Hypothermia
 SUCTIONING MATERIALS: - Turn on the suction, and set the pressure in accordance with agency policy. For a
wall unit, a pressure setting of about 100 to 120 mm Hg is normally used for adults,
INTRODUCTION:
50 to 95 mm Hg for infants and children.
• Suctioning of tracheostomy tube is only done as necessary. Sterile technique must - Put on goggles, mask, and gown if necessary.
be observed. Nurses should be aware that there is a frequency for the need of suctioning - Put on sterile gloves. Some agencies recommend putting a sterile glove on the
during immediate postoperative period. dominant hand and an unsterile glove on the nondominant hand to protect the nurse.
• Tracheal Suctioning: A means of clearing thick mucus and secretions from the trachea - Holding the catheter in the dominant hand and the connector in the nondominant
and lower airway through the application of negative pressure via a suction catheter. hand, attach the suction catheter to the suction tubing
5. Flush and lubricate the catheter.
PURPOSES: - Using the dominant hand, place the catheter tip in the sterile saline solution. - Using
• Removes thick mucus and secretions from the trachea and lower airway to maintain the thumb of the nondominant hand, occlude the thumb control and suction a small
patent airway and prevent airway obstructions amount of the sterile solution through the catheter.
• To promote respiratory function (optimal exchange of oxygen and carbon dioxide into Rationale: This determines that the suction equipment is working properly and
and out of the lungs) lubricates the outside and the lumen of the catheter. Lubrication eases insertion
and reduces tissue trauma during insertion. Lubricating the lumen also helps
• To prevent pneumonia that may result from accumulated secretions
prevent secretions from sticking to the inside of the catheter.
PRELIMINARY ASSESSMENT: 6. If the client does not have copious secretions, hyperventilate the lungs with a
resuscitation bag before suctioning.
• Assess the client for the presence of congestion on auscultation of the thorax.
- Summon an assistant, if one is available, for this step.
• Note the client’s ability or inability to remove the secretions through coughing.
- Using your nondominant hand, turn on the oxygen to 12 to 15 L/min.
PLANNING: - If the client is receiving oxygen, disconnect the oxygen source from the
tracheostomy tube using your nondominant hand.
• Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring - Attach the resuscitator to the tracheostomy or endotracheal tube.
application of scientific knowledge and problem solving. This skill is performed by a - Compress the Ambu bag three to five times, as the client inhales. This is best done
nurse or respiratory therapist and is not delegated to UAP. by a second person who can use both hands to compress the bag, thus, providing
a greater inflation volume.
- Observe the rise and fall of the client’s chest to assess the adequacy of each
ventilation.
- Remove the resuscitation device and place it on the bed or the client’s chest with
the connector facing up.

Variation: Using a Ventilator to Provide Hyperventilation

- If the client is on a ventilator, use the ventilator for hyperventilation and

hyperoxygenation. Newer models have a mode that provides 1 0 0 % oxygen for 2
minutes and then switches back to the previous oxygen setting as well as a manual
breath or sigh button.
Rationale: The use of ventilator settings provides more consistent delivery of
• Resuscitation bag (Ambu bag) connected to 100% oxygen oxygenation and hyperinflation than a resuscitation device.
• Sterile towel (optional) 7. If the client has copious secretions, do not hyperventilate with a resuscitator.
• Equipment for suctioning - Instead: Keep the regular oxygen delivery device on and increase the liter flow or
• Goggles and mask if necessary adjust the Fi02 to 100% for several breaths before suctioning.
• Gown (if necessary) as Sterile gloves Rationale: Hyperventilating a client who has copious secretions can force the
• Moisture-resistant bag secretions deeper into the respiratory tract.
8. Quickly but gently insert the catheter without applying any suction.
PREPARATION OF PATIENT AND ENVIRONMENT: - With your nondominant thumb off the suction port, quickly but gently insert the
catheter into the trachea through the tracheostomy tube.
• Determine if the client has been suctioned previously and, if so, review the
Rationale: To prevent tissue trauma and oxygen loss, suction is not applied
documentation of the procedure. This information can be very helpful in preparing the
during insertion of the catheter
nurse for both the physiologic and psychologic impact of suctioning on the client.
Prepare the client. - Insert the catheter about 12.5 cm (5 in.) for adults, less for children, or until the client
coughs or you feel resistance.
• If not contraindicated because of health, place the client in the semi-Fowler’s position to
Rationale: Resistance usually means that the catheter tip has reached the
promote deep breathing, maximum lung expansion, and productive coughing.
bifurcation of the trachea. To prevent damaging the mucous membranes at the
POINTS TO REMEMBER (SAFETY MEASURES): - Rationale: Deep breathing oxygenates the lungs, counteracts the hypoxic effects of
bifurcation, withdraw the catheter about 1 to 2 cm (0.4 to 0.8 in.) before applying
suctioning, and may induce coughing. Coughing helps to loosen and move
• Lifespan Considerations suction.
secretions.
- Infant and Child 9. Perform suctioning.
• If necessary, provide analgesia before suctioning. Endotracheal suctioning stimulates
- Restrain the child gently with the help of an assistant and maintain the child’s head - Apply suction for 5 to 10 seconds by placing the nondominant thumb over the thumb
the cough reflex, which can cause pain for clients who have had thoracic or abdominal
in the midline position. port.
surgery or who have experienced traumatic injury.
- To be aware of any special problems, do a thorough lung assessment before and Rationale: Suction time is restricted to 10 seconds or less to minimize oxygen
- Rationale: Premedication can increase the client’s comfort during the suctioning
after the whole procedure. loss.
procedure.
• Home Care Considerations - Rotate the catheter by rolling it between your thumb and forefinger while slowly
- Encourage the client to clear airway by coughing, if possible. PROCEDURE: withdrawing it.
- If cannot cough properly, encourage the client to suction their secretions. Rationale: This prevents tissue trauma by minimizing the suction time against
1. Prior to performing the procedure, introduce self and verify the client’s identity using
- Advise the client or caregiver to use clean gloves in performing the procedure. any part of the trachea.
agency protocol. Explain to the client what you are going to do, why it is necessary, and
- The nurse should teach the caregiver on how to determine the need for suctioning. - Withdraw the catheter completely, and release the suction.
how he or she can cooperate. Inform the client that suctioning usually causes some
- Discuss to the caregiver the correct process and rationale underlying the practice of - Hyperventilate the client.
intermittent coughing and-that this assists in removing the secretions.
suctioning. - Suction again, if needed.
2. Perform hand hygiene and observe other appropriate infection control procedures (e.g.,
- Emphasize the importance of adequate hydration as it thins secretions, which can 10. Reassess the client’s oxygenation status and repeat suctioning.
gloves, goggles).
aid in the removal of secretions by coughing or suctioning - Observe the client’s respirations and skin color. Check the client’s pulse if necessary,
3. Provide for client privacy.
using your nondominant hand.
4. Prepare the equipment.
- Encourage the client to breathe deeply and to cough between suctions.
- Attach the resuscitation apparatus to the oxygen source.
- Allow 2 to 3 minutes with oxygen, as appropriate between suctions when possible.
- Adjust the oxygen flow to 100%.
Rationale: This provides an opportunity for reoxygenation of the lungs.
- Open the sterile supplies in readiness for use.
- Place the sterile towel, if used, across the client’s chest below the tracheostomy.
 - Flush the catheter and repeat suctioning until the air passage is clear and the • Friedrich III, German Emperor (1831 – 1888) - He had incurable cancer of the larynx, TYPES OF TRACHEOSTOMIES:
breathing is relatively effortless and quiet. which had been misdiagnosed by the English doctor Morell Mackenzie (later knighted
• Surgical tracheostomy: performed in the OR or at bedside under moderate sedation
- After each suction, pick up the resuscitation bag with your nondominant hand and by Queen Victoria). When the error was caught, it was too late to operate. Later swelling
ventilate the client with no more than three breaths. • Percutaneous dilatational tracheostomy is done at the patient’s bedside, usually in the
by the tumor caused the prince to begin to suffocate, and so on February 9, 1888, a
11. Dispose of equipment and ensure availability for the next suction. ICU setting. contraindicated in anatomical irregularities or coagulation problems.
tracheotomy was performed and a silver tube was put. As a result of this operation,
- Flush the catheter and suction tubing. Friedrich was unable to speak for the remainder of his life, and communicated through TEMPORARY VS PERMANENT TRACHEOSTOMY:
- Turn off the suction and disconnect the catheter from the suction tubing. writing. Friedrich ruled for only 99 days before his death, being succeeded by his son
- Wrap the catheter around your sterile hand and peel the glove off so that it turns Wilhelm II. • Appearance is the same Temporary: The upper airway will remain connected to the
inside out over the catheter. • Elizabeth Taylor's Tracheostomy - Taylor went to Europe, awaiting production of lower airway if the tracheostomy tube
- Discard the glove and the catheter in the moisture-resistant bag. Cleopatra. In spring of 1961, she developed a case of pneumonia, which led to an • were to be dislodged
- Replenish the sterile fluid and supplies so that the suction is ready for use again. emergency tracheotomy and worldwide talk of her impending death. The swelling of • Permanent: The larynx is removed and no connection exists between the upper airway
Rationale: Clients who require suctioning often require it quickly, so it is sympathy was widely thought to have influenced Academy voters, who awarded Taylor and the trachea itself.
essential to leave the equipment at the bedside ready for use. her first Best Actress Oscar — Elizabeth later commented, I knew it was a sympathy POTENTIAL SHORT-TERM COMPLICATIONS:
- Be sure that the ventilator and oxygen settings are returned to pre suctioning award, but I was still proud to get it." Meanwhile, Taylor's competitor Shirley MacLaine
settings. memorably quipped, "I lost to a tracheotomy!" • Subcutaneous emphysema – air escapes around stoma; generally, of no clinical
Rationale: On some ventilators this is automatic, but always check. It is very • Stephen Hawking - Stephen Hawking (physicist) Stephen Hawking developed motor consequence –can be palpated around the stoma site
dangerous for clients to be left on 100% oxygen. neurone disease when he was in his early 20s. Most patients with the condition die • Thinning of the trachea (Tracheomalacia)
12. Provide for client comfort and safety. within five years, and according to the Motor Neurone Disease Association, average life • Dislodgement of the tube
- Assist the client to a comfortable, safe position that aids breathing. If the person is expectancy after diagnosis is 14 months. But Professor Hawking, the Cambridge • Due to excessive manipulation of the tracheostomy tube during coughing or suctioning–
conscious, a semi-Fowler’s position is frequently indicated. If the person is University physicist and cosmologist and author of A Brief History of Time, has (more in the first 48 hours).
unconscious, Sims’ position aids in the drainage of secretions from the mouth. confounded the statistics and recently celebrated his 73rd birthday.
13. Document relevant data. POTENTIAL LONG-TERMS COMPLICATIONS TRACHEOSTOMY:
TRACHEOSTOMY
- Record the suctioning, including the amount and description of suction returns and • Narrowing of the airway above the site of tracheostomy
any other relevant assessments. • A tracheostomy is the formation of an opening into the trachea usually between the • Once tracheostomy tube is removed, the opening may not close on its own
Sample Documentation second and third rings of cartilage. • Dysphagia
12/23/2012 1000 Coarse rales in RLL and LLL. Requires suctioning every 1-2 hrs. Obtain • Tracheal ischemia and necrosis
large amount of pinkish tinged white thin mucous via ETT. Breath sounds clearer after IDENTIFYING TRACHEOSTOMY PARTS:
suctioning. Pt. signals when he wants to be suctioned.
— J. Roberts, RN • Cuffed Tracheostomy Tube Consists of three parts:
▪ Outer cannula with an inflatable cuff and pilot tube
▪ An inner cannula
VARIATION: CLOSED AIRWAY/TRACHEAL SUCTION SYSTEM (IN-LINE CATHETER) ▪ An obturator
- If a catheter is not attached, put on clean gloves, aseptically open a new closed • Cuffless tubes
catheter set, and attach the ventilator connection on the T piece to the ventilator ▪ More suitable for long term ventilation
tubing. Attach the client connection to the endotracheal tube or tracheostomy. ▪ patient must have effective cough and gag reflex to prevent aspiration risk
- Attach one end of the suction connecting tubing to the suction connection port of the • Fenestrated Tube
closed system and the other end of the connecting tubing to the suction device. ▪ Have an opening on the posterior wall of outer cannula allowing air to flow through
- Turn suction on, occlude or kink tubing, and depress the suction control valve (on the upper airway and hence allows patient to speak
the closed catheter system) to set suction to the appropriate level. Release the ▪ Often used during weaning process
suction control valve. • Communication and Tracheostomies
- Use the ventilator to hyperoxygenate and hyperinflate the client’s lungs. ▪ Patients being weaned off trach tubes may have either a cuffless or fenestrated tube
- Unlock the suction control mechanism if required by the manufacturer. to allow airflow past the larynx
- Advance the suction catheter enclosed in its plastic sheath with the dominant hand.
NURSING CARE EXAMINATION:
Steady the T piece with the non- dominant hand.
- Depress the suction control valve and apply suction for no more than 10 seconds • Be aware of when and why the trach was inserted, how it was performed, the type and
and gently withdraw the catheter. size of tube inserted
- Repeat as needed remembering to provide hyperoxygenation and hyperinflation as • Examine the patient at the start of visit.
needed. • Observe for signs of hypoxia, infection or pain
- When completed suctioning, withdraw the catheter into its sleeve and close the • Chest: Auscultate breath sounds
access valve, if appropriate. • Examine trach tube, as well as stoma site for redness, purulent drainage, and bleeding
Rationale: If the system does not have an access valve on the client connector, around the stoma
the nurse needs to obsen/e for the potential of the catheter migrating into the
airway and partially obstructing the artificial airway. TRACHEOSTOMY HUMIDIFICATION:
- Flush the catheter by instilling normal saline into the irrigation port and applying
• The nose provides warmth, moisture and filtration for the air we breathe.
suction. Repeat until the catheter is clear.
• Having a tracheostomy tube by-passes these mechanisms so humidification must be
- Close the irrigation port and close the suction valve.
provided to keep secretions thin and to avoid mucus plugs
TRACHEOSTOMY: • Ideal room air temperature is 22C,10mmH2O/L
• Larynx: 31-33C, 26-32 mmH2O/L
PART 1: TRACHEOSTOMY CARE “Tracheostomy The Enabling Disability”
• Mid-trachea: 34C, 34-38 mmH2O/L
HISTORY: • Main bronchi: 37C, 44mmH2O/L Ambient water humidification Heat moisture exchanger
(attached to the outside of a trach tube for long- term trach patients) – looks like a t-tube
• The first instance of tracheotomy was portrayed way back in 3600 BC on Egyptian
attachment.
artifacts by engravings in Abydos and Sakkara regions of Egypt depicting tracheostomy.
• Antonio Musa Brasavola, an Italian physician, performed the first documented case of TYPES OF TRACHEOSTOMY HUMIDIFICATION SYSTEMS:
a successful tracheotomy in a patient, who suffered from a tonsillar obstruction and • Tracheostomy is done to
▪ Provide mechanical ventilation on a long-term basis as in cases of neuromuscular • Ambient water humidification Heat moisture exchanger (attached to the outside of a
recovered from the procedure. He published his account in 1546.
disease trach tube for long- term trach patients) – looks like a t-tube attachment.
• In 1620, Habicot performed the first pediatric tracheotomy. The procedure was
▪ Facilitate weaning from mechanical ventilation by decreasing anatomical dead
performed on a sixteen- year-old boy who had swallowed a bag of gold in an attempt to NURSING CARE: HELP TO THIN AND MOBILIZE SECRETIONS
space: A COPD patient on mechanical ventilation
keep the gold from being stolen. The bag became lodged in the boy's esophagus and
▪ To bypass obstruction: Cancer larynx • Frequent repositioning,
obstructed his trachea. After Habicot performed the tracheotomy, he manipulated the
bag of gold so that it would pass. It was eventually recovered per rectum.
▪ To maintain an open airway: A comatose patient • Deep breathing and coughing,
▪ To remove secretions more easily: Inability to swallow or cough: stroke patient • Chest physiotherapy,
• Oral and parenteral hydration
 • Supplemental humidification • Can a patient eat with a Tracheostomy:
- Yes, generally speaking (patient may need an evaluation by a speech pathologist to
NURSING CARE – SUCTIONING:
determine swallowing ability)
• Necessary for all trach patients to remove secretions • Why can’t we use the Passey Muir valve with the cuff inflated?
• Routinely done 2x / day, but more often if a newly placed tracheostomy or when there is - The speaking valve is a one-way airflow mechanism. The patient inhales air through
infection present the speaking valve but exhales it around the tracheostomy tube and then through
• Suctioning activates psychological and physiological reflexes that make the experience the nose or mouth.
both uncomfortable and frightening. - If the cuff is inflated with a speaking valve, the patient will only be able to inhale air
and will not be able to exhale since there will not be any room around the
SELECTING A SUCTION CATHETER: tracheostomy
• Selection of the appropriate size suction catheter is vital in reducing the risk of trauma • What is the tracheostomy plug Used for?
during suctioning RLE PRELIM-MIDTERM | 6 Compiled by: Monceda, Chielo B. - Two purposes:
• Divide the internal diameter of the tracheostomy by two, and multiply the answer by ▪ Decannulation of the tracheostomy tube
three to obtain the French gauge suction catheter: – Size 8 tracheostomy tube (patient); Used to plug trach tube for 12 hours the first day and 24 hours the second
(8mm/2) x 3 = 12; therefore, a size 12F gauge catheter is suitable for suctioning. day
If the patient tolerates plugging, then decannulation can take place
GATHERING EQUIPMENTS FOR SUCTIIONING: ▪ It can be used for speech, but not as a speaking valve
• PPE – (mask, goggles, gloves) PART 2: TRACHEOSTOMY CARE
• Bottle of normal saline PURPOSES:
DEFINITION OF TERMS:
• Appropriately sized suction catheter
• To maintain airway patency by removing mucus and encrusted secretions.
• Trach care kit • A tracheostomy It is a surgical procedure to create an opening between 2-3 (3-4) • To maintain cleanliness and prevent infection at the tracheostomy site
• Disposable inner cannula if appropriate tracheal rings into the trachea through the neck just below the larynx through which an
• To facilitate healing and prevent skin excoriation around the tracheostomy incision
• Oxygen source – connected to patient indwelling tube is placed and thus an artificial airway is created. It is used for clients
• To promote comfort
• Suction equipment regulator set at 80-120 mmHg needing long-term airway support.
• To prevent displacement
• Ambu bag to ventilate patient prior to suctioning if appropriate • Decannulation - The process whereby a tracheostomy tube is removed once patient
no longer needs it. PRELIMINARY ASSESSMENT:
PROCEDURE FOR SUCTIONING:
• Humidification - The mechanical process of increasing the water vapor content of an
Check:
• Place patient in semi-fowler’s position inspired gas.
• Select appropriately sized suction catheter • Stoma - An opening, either natural or surgically created, which connects a portion of the ✓ Respiratory status (ease of breathing, rate, rhythm, depth, lung sounds, and oxygen
• Hyper oxygenate BEFORE each suction pass (except patients with long-term body cavity to the outside environment (in this case, between the trachea and the saturation level)
tracheostomy) anterior surface of the neck). ✓ Pulse rate
• Insert catheter to a pre-measured depth • Tracheostomy: Tracheal Suctioning: - A means of clearing thick mucus and secretions ✓ Secretions from the tracheostomy site (character and amount)
• Apply suction on withdrawal of catheter from the trachea and lower airway through the application of negative pressure via a ✓ Presence of drainage on tracheostomy dressing or ties
• Limit suctioning to 5 seconds suction catheter. ✓ Appearance of incision (redness, swelling, purulent discharge, or odor)
• Tracheostomy tube: - A curved hollow tube of rubber or plastic inserted into the ✓ Materials available in unit
• Use suction pressure between 80 – 120 mmHg
• Limit suctioning to 3 passes tracheostomy stoma (the hole made in the neck and windpipe (Trachea) to relieve
POINTS TO REMEMBER (SAFETY MEASURES):
airway obstruction, facilitate mechanical ventilation or the removal of tracheal
• Discontinue if HR drops by 20; increases by 40, produces arrhythmias, or decreases 02
secretions. • Lifespan Considerations
< 90%
• Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange - Infant and Child
TRACHEOSTOMY TIES: that rests against the neck and allows the tube to be secured in place with tape or ties. ▪ An assistant may be necessary during tracheostomy care to prevent active
• Tracheostomy tubes also have an obturator which is used to insert the outer cannula children from dislodging or expelling their tracheostomy tubes.
• Ties are generally changed daily
which is then removed afterwards. The obturator is kept at the client’s bedside in case ▪ Always make a sterile, packaged tracheostomy available at bedside for
• To lower the risk of accidental trach tube coming out, tie changes should be: performed
the tube becomes dislodged and needs to be reinserted. emergency purposes.
by TWO PEOPLE or with new ties secured BEFORE OLD TIES are removed.
• Nurses provide tracheostomy care for clients with new or recent tracheostomy to ▪ Encourage parents to participate with the procedure in an effort to comfort the
MAINTENANCE OF THE INNER CANNULA: maintain patency of the tube and minimize the risk for infection (since the inhaled air by child and promote client teaching.
the client is no longer filtered by the upper airways). ▪ Care for the skin at the tracheostomy site is important especially for the elders
• The majority of trach tubes have inner cannulas that require cleaning one to three times whose skin is more fragile and prone to breakdown.
• Initially a tracheostomy may need to be suctioned and cleaned as often as every 1 to 2
daily unless they are disposable • Home Care Modification
hours. After the initial inflammatory response subsides, tracheostomy care may only
• Use sterile technique to clean the reusable cannula with ½ strength hydrogen peroxide ▪ Emphasize the importance of handwashing before performing tracheostomy care.
need to be done once or twice a day, depending on the client.
and normal saline ▪ Describe the function of each part of the tracheostomy tube.
COMPONENTS OF TRACHEOSTOMY TUBE: ▪ Explain the proper way on how to remove, change, and replace the inner cannula.
NURSING CARE-TRACH CUFF PRESSURE:
• Outer tube ▪ Clean the inner cannula two or three times a day.
• Cuff pressure (balloon) should be maintained at 20 mmHg of pressure via a manometer ▪ Check and clean the tracheostomy stoma.
• Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
– should be assessed daily; ▪ Suction tracheal secretions if necessary.
• Flange: Flat plastic plate attached to outer tube – lies flush against the patient’s neck.
• If you don’t have a manometer measuring device – check. With a stethoscope placed ▪ Assess for symptoms of infection (i.e., increased temperature, increased number of
• 15mm outer diameter termination: Fits all ventilator and respiratory equipment. All
on the neck, inflate the cuff until you no longer hear hissing; deflate the cuff in tiny secretions, change in color or odor of secretions).
remaining features are optional
increments until a slight his returns ▪ Advise and encourage parents to participate with the procedure in an effort to
• Cuff: Inflatable air reservoir (high volume, low pressure) – helps anchor the
• Why? comfort the child and promote client teaching.
tracheostomy tube in place and provides maximum airway sealing with the least amount
▪ Assess and evaluate how the cuff is working ▪ Provide contact information for emergencies.
of local compression. To inflate, air is injected via the…
▪ Periodically relieve pressure on the trachea
• Air inlet valve: One way valve that prevents spontaneous escape of the injected air. DEALING WITH EMERGENCIES:
▪ Let secretions above the cuff drain down so you can suction them
• Air inlet line: Route for air from air inlet valve to cuff.
• If the tracheostomy tube falls out
NURISNG CARE: CHANGING THE TRACH TUBE • Pilot cuff: Serves as an indicator of the amount of air in the cuff
▪ DON’T PANIC!
• Fenestration: Hole situated on the curve of the outer tube – used to enhance airflow in
• Tube changes can be done safely on a 1–3-month basis using a clean technique ▪ Once the tracheostomy tube has been in place for about 5 days the tract is well
and out of the trachea. Single or multiple fenestrations are available.
• Silicon tubes can crack and tear; soft PVC tubes can stiffen with time formed and will not suddenly close.
• Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube
▪ Reassure the patient
NURSING CARE: TRACHEOSTOMY SITE CARE AND DRESSING opening (a) former – during expiration to facilitate speech and swallow, (b) latter – during
▪ Call for medical help.
both inspiration and expiration prior to decannulation.
• Clean stoma with Q-tip moistened with NS; ▪ Ask the patient to breathe normally via their stoma while waiting for the doctor.
• Avoid using hydrogen peroxide unless infection present (as it can impair healing) ▪ The stay suture (if present) or tracheal dilator may be used to help keep the stoma
• Dressings around the stoma are changed open if necessary.
▪ Stay with patient.
FAQ’S: ▪ Prepare for insertion of the new tracheostomy tube
 ▪ Once replaced, tie the tube securely, leaving one finger-space between ties and the PREPARATION OF PATIENT AND ENVIRONMENT: - Twill tape and specially manufactured Velcro ties are available. Twill tape is
patient’s neck. inexpensive and readily available; however, it is easily soiled and can trap moisture
• Planning
▪ Check tube position by that leads to irritation of the skin of the neck. Velcro ties are becoming more
asking the patient to inhale deeply they should be able to do so easily and - Tracheostomy care involves application of scientific knowledge, sterile technique,
commonly used. They are wider, more comfortable, and cause less skin abrasion
and problem solving, and therefore needs to be performed by a nurse or respiratory
comfortably, and
therapist. PROVIDING TRACHEOSTOMY CARE:
hold a piece of tissue in front of the opening – it should be “blown” during patient’s
exhalation. • Prepare the client and the equipment.
• Soft foam collar Velcro tracheostomy tube holder tie.
• Patient is having Acute Dyspnea - Acute dyspnea for patient with tracheostomy is most - To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.
commonly caused by partial or complete blockage of the tracheostomy tube retained - Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile
secretions. To unblock the tracheostomy tube: normal saline into separate containers.
▪ ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to - Establish the sterile field.
expectorate secretions. - Open other sterile supplies as needed including sterile applicators, suction kit, and
▪ REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will tracheostomy dressing.
automatically be removed when you take out the inner cannula. The outer tube – PROCEDURE:
which does not have secretions in it – will allow the patient to breath freely. Clean
and replace the inner cannula. 1. Introduce self and verify the client’s identity using agency protocol. Explain to the
▪ SUCTION: If coughing or removing the inner cannula do not work, it may be that client everything that you need to do, why it is necessary, and how can he cooperate.
secretions are lower down the patient’s airway. Use the suction machine to remove Eye blinking, raising a finger can be a means of communication to indicate pain or
secretions. distress.
▪ If these measures fail – commence low concentration oxygen therapy via a 2. Observe appropriate infection control procedures such as hand hygiene.
tracheostomy mask, and call for medical assistance. 3. Provide for client privacy
▪ It is possible that the tracheostomy may have become displaced. Stay with the 4. Suction the tracheostomy tube, if necessary.
patient until assistance arrives. Prepare for change of tracheostomy tube. - Put a clean glove on your nondominant hand and a sterile glove on your dominant
• Patient needing Cardiopulmonary Resuscitation – in the event of cardiopulmonary hand (or put on a pair of sterile gloves).
• Tracheostomy tube tie.
arrest, treat tracheostomy patients as other patients: - Suction the full length of the tracheostomy tube to remove secretions and ensure a
▪ Step 1: Expose the patient’s neck. Remove any clothing covering the tracheostomy patent airway.
tube and the neck area. Do not remove tracheostomy. - Rinse the suction catheter and wrap the catheter around your hand, and peel the
▪ Step 2: Check the patency of the inner cannula. To check inner cannula: Wearing a glove off so that it turns inside out over the catheter.
non-sterile glove, remove inner cannula. If clean, reinsert and lock into place. If - Unlock the inner cannula with the gloved hand. Remove it by gently pulling it out
soiled – replace. Continue resuscitation. toward you in line with its curvature. Place it in the soaking solution. Rationale: This
▪ Step 3: Ventilate. Use the ambu-bag directly to the t-tube. If unable to ventilate: moistens and loosens secretions.
Try to suction. To remove or clear the secretions blocking the tube. - Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved
If still unable to ventilate. The tube may be displaced and the doctor may: hand and peel the glove off so that it turns inside out over the dressing. Discard the
1. Change the tube glove and the dressing.
2. Intubate orally - Put on sterile gloves. Keep your dominant hand sterile during the procedure.
5. Clean the inner cannula.
TRACHEOSTOMY CARE MATERIALS: - Remove the inner cannula from the soaking solution.
• Sterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile nylon - Clean the lumen and entire inner cannula thoroughly using the brush or pipe
cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by
brush or pipe cleaners, sterile applicators, gauze squares)
holding it at eye level and looking through it into the light.
• Sterile suction catheter kit (suction catheter and sterile container for solution)
- Rinse the inner cannula thoroughly in the sterile normal saline. TWO-STRIP METHOD (TWILL TAPE):
• Sterile normal saline (Check agency protocol for soaking solution)
- After rinsing, gently tap the cannula against the inside edge of the sterile saline
• Sterile gloves (2 pairs) • Cut two unequal strips of twill tape, one approximately 25 cm (10 in.) long and the other
container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do
• Clean gloves about 50 cm (20 in.) long. Rationale: Cutting one tape longer than the other allows them
not dry the outside. Rationale: This removes excess liquid from the cannula and
• Towel or drape to protect bed linens prevents possible aspiration by the client, while leaving a film of moisture on the
to be fastened at the side of the neck for easy access and to avoid the pressure of a
• Moisture-proof bag outer surface to lubricate the cannula for reinsertion.
knot on the skin at the back of the neck.
• Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze dressing 6. Replace the inner cannula, securing it in place. • Cut a l-cm (0.5-in.) lengthwise slit approximately 2.5 cm (1 in.) from one end of each
• Cotton twill ties - Insert the inner cannula by grasping the outer flange and inserting the cannula in the strip. To do this, fold the end of the tape back onto itself about 2.5 cm (1 in.), then cut a
• Clean scissors direction of its curvature. slit in the middle of the tape from its folded edge.
- Lock the cannula in place by turning the lock (if present) into position to secure the • Leaving the old ties in place, thread the slit end of one clean tape through the eye of the
flange of the inner cannula to the outer cannula. tracheostomy flange from the bottom side; then thread the long end of the tape through
7. Clean the incision site and tube flange. the slit, pulling it tight until it is securely fastened to the flange.
- Using sterile applicators or gauze dressings moistened with normal saline, clean the - Rationale: Leaving the old ties in place while securing the clean ties prevents
incision site. Handle the sterile supplies with your dominant hand. Use each inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner
applicator or gauze dressing only once and then discard. Rationale: This avoids avoids the use of knots, which can come untied or cause pressure and irritation.
contaminating a clean area with a soiled gauze dressing or applicator. • If old ties are very soiled or it is difficult to thread new ties onto the tracheostomy flange
- Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile with old ties in place, have an assistant put on a sterile glove and hold the tracheostomy
normal saline; use a separate sterile container if this is necessary) to remove crusty in place while you replace the ties. This is very important be- cause movement of the
secretions. Check agency policy. Thoroughly rinse the cleaned area using gauze tube during this procedure may cause irritation and stimulate coughing. Coughing can
squares moistened with sterile normal saline. Rationale: Hydrogen peroxide can be dislodge the tube if the ties are undone.
irritating to the skin and inhibit healing if not thoroughly removed. • Repeat the process for the second tie.
- Clean the flange of the tube in the same manner. • Ask the client to flex the neck. Slip the longer tape under the client’s neck, place a finger
- Thoroughly dry the client’s skin and tube flanges with dry gauze squares. between the tape and the client’s neck and tie the tapes together at the side of the neck.
8. Apply a sterile dressing. - Rationale: Flexing the neck increases its circumference the way coughing does.
- Use a commercially prepared tracheostomy dressing of non- raveling material or Placing a finger under the tie prevents making the tie too tight, which could interfere
open and refold a 4-in. x 4-in. gauze dressing into a V shape. Avoid using cotton- with coughing or place pressure on the jugular veins.
filled gauze squares or cutting the 4- in. x 4-in. gauze. Rationale: Cotton lint or. • Tie the ends of the tapes using square knots. Cut off any long ends, leaving
gauze fibers can be aspirated by the client, potentially creating a tracheal abscess. approximately 1 to 2 cm (0.5 in.).
- Place the dressing under the flange of the tracheostomy tube. - Rationale: Square knots prevent slippage and loosening. Adequate ends beyond
- While applying the dressing, ensure that the tracheostomy tube is securely the knot prevent the knot from inadvertently untying.
supported. Rationale: Excessive movement of the tracheostomy tube irritates the • Once the clean ties are secured, remove the soiled ties and discard.
trachea.
9. Change the tracheostomy ties.
- Change as needed to keep the skin clean and dry.
ONE-STRIP (TWILL TAPE): • Improve balance 4. The patient taught to support his/her weight on the hand pieces. (For patient who are
unable to support their weight through the wrist and hand because of arthritis or fracture,
• Cut a length of twill tape 2.5 times the length needed to go around the client’s neck from GOALS OF REHABILITATION:
platform crutches that support the forearm and allow the weight to the borne through the
one tube flange to the other.
• REHABILITATION is a creative, dynamic process that requires a team of professions elbow are available). If weight is borne on the axilla, the pressure of the crutch can
• Thread one end of the tape into the slot on one side of the flange. damage the branchial plexus nerve producing “crutch paralysis”.
working together with patients and families. Its goal is to evaluate progress and modify
• Bring both ends of the tape together. Take them around the client’s neck, keeping them 5. For minimum stability, the patient first assumes the tripod position by placing the
goals as necessary to facilitate rehabilitation and to promote independence, self-respect
flat and untwisted. crutches about 20-25 cm (8-10 inches) in front and to the side of his/her toes (This base
and an acceptable quality of life for the patient.
• Thread the end of the tape next to the client’s neck through the slot from the back to the of support is adjusted according to the height of the patient; a tall person requires a
1. Motivate patient.
front. broader base of support than does a short person). In this position, the patient learns
2. Help patient identify the safe limits of independence activity.
• Have the client flex the neck. Tie the loose ends with a square knot at the side of the how to shift weight and maintain balance.
3. Let the patient know when to ask for assistance.
client’s neck, allowing for slack by placing two fingers under the ties as with the two-strip 6. Before teaching crutch walking, the nurse or therapist determines which gait will be best
4. The nurse should guide, teach and support the patient.
method. Cut off long ends. for the patient, the selection of the crutch gait depends on the type and severity of
5. Be consistent in giving instructions and in giving assistance to facilitate the learning
10. Tape and pad the tie knot. disability and om the patient’s physical condition, arm and trunk strength, and body
process.
- Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape over the balance. The patient should be taught two gaits so that he/she can change from one to
6. Offers a little ingenuity
knot. another. Shifting crutch gaits relieves fatigue because each gait requires the use of a
- Rationale: This reduces skin irritation from the knot and prevents confusing the knot NURSING STRATEGIES APPROPRIATE FOR PROMOTING SELF-CARE: different combination of muscles (if a muscle is forced to contract steadily without
with the client’s gown ties relaxing the circulation of the blood to that part is decrease).
• PREPARING THE PATIENT TO WALK WITH CRUTCHES
11. Check the tightness of the ties. 7. The nurse walks with the patient who is just learning how to ambulate with crutches,
▪ Preparatory exercises are prescribed to strengthen the shoulder girdle and upper
- Frequently check the tightness of the tracheostomy ties and position of the holding him/her at the waist as needed for balance.
extremity muscles.
tracheostomy tube. 8. During this time, the nurse protects the patient from falls and continually assesses the
▪ Crutches need to be adjusted to the patient before the patient begins ambulating.
- Rationale: Swelling of the neck may cause the ties to become too tight, interfering patient’s stability and stamina, since prolonged periods of bed rest and inactivity affects
▪ To determine the approximate crutch length, the patient may be measured standing
with coughing and circulation. Ties can loosen in restless clients, allowing the a patient’s strength and endurance. Sweating and shortness of breath are indications
or lying down.
tracheostomy tube to extrude from the stoma. that crutch walking practice should be stopped and the patient permitted to rest.
▪ A standing patient is positioned against the wall with the feet slightly apart and away
12. Document all relevant information.
from the wall. MUSCLE GROUPS IMPORTANT FOR CRUTCH WALKING:
- Record suctioning, tracheostomy care, and the dressing change, noting your
▪ A distance of 5 cm (2 inches) is marked on the floor, out to the side from the tip of
assessments. • SHOULDER DEPRESSORS – to stabilize the upper extremity and prevent shoulder
the toe; 15 cm (6 in.) is measured straight ahead from the first mark, and this point
- Sample Documentation hiking.
is marked on the floor.
▪ 12/23/2012 0900 Respirations 18- 20/min. Lung sounds clear. Able to
▪ 5 cm (2 in.) is measured below the axilla to the second mark for the approximate • SHOULDER ADDUCTORS – to hold the crutch top against the chest wall.
expectorate secretions requiring little suctioning. Large number of thick
crutch length. If the patient has to be measured while lying down, he/she is • ARM FLEXORS, EXTENSORS, ABDUCTORS (shoulder) – to move crutches forward,
secretions cleansed from inner cannula. Inner cannula changed. Trach dressing
measured from the anterior fold of the axilla to the sole of the foot, and then 5 cm (2 backward, and sideways.
changed. Skin around trach is intact but slightly red in color 0.2 cm around entire
in.) is added. • FOREARM EXTENSORS – to prevent flexion or buckling; important in raising the body
opening. No broken skin noted in the reddened area. — G. Wayne, RN
▪ If the patient height is used, 40 cm (16 in.) is subtracted to obtain the approximate for swinging gait.
VARIATION: USING A DISPOSABLE INNER CANNULA crutch length. The hand piece should be adjusted to allow 20 to 30 degrees of the • WRIST EXTENSORS – to enable weight bearing on hand pieces.
flexion at the elbow. The wrist should be extended and the hand dorsiflexed. A foam • FINGERS & THUMB FLEXORS – to grasp the hand piece
• Check policy for frequency of changing inner cannula because standards vary among
rubber pad on the underarm piece is used to relieve pressure of the crutch on the
institutions. TEACHING MANEUVERING TECHNIQUES:
upper arm and thoracic cage. For safety, crutches should have large rubber tips, and
• Open a new cannula package. the patient should wear firm-soled shoes that fit well. • Before a patient is considered to be independent in crutch walking, he/she needs to
• Using a gloved hand, unlock the current inner cannula (if present) and remove it by
DIFFERENT GAIT POSITION: learn to sit in a chair, stand from sitting, and go up and go down stairs.
gently pulling it out toward you in line with its curvature.
▪ To sit down
• Check the cannula for amount and type of secretions and discard properly.
• 4 POINT GAIT 1. Grasp the crutches at the hand pieces for control.
• Pick up the new inner cannula touching only the outer locking portion. 13. Partial weight bearing both feet 2. Bend forward slightly while assuming a sitting position.
• Insert the new inner cannula into the tracheostomy. 14. Maximal support provided 3. Place the affected leg forward to prevent weight bearing and flexion
• Lock the cannula in place by turning the lock (if present). 15. Requires constant shift of weight
CRUTCH WALKING • 3 POINT GAIT + KNEE GAIT (partial) ▪ To stand up:
16. Partial weight bearing both feet 1. move forward to the edge of the chair with the strong leg slightly under the seat.
DEFINITION: 17. Provides less support 2. Place both crutches in the hand on the side of the affected extremity.
18. Faster than a 4-point gait 3. Push down on the hand piece while raising the body to a standing position.
• Assisting patient to walk using crutches while providing support and as a convenient
method of getting from one place to another. Different types of walking aid walker, cane • 3 POINT GAIT (complete) ▪ To go down stairs:
/ stick, crutches. 19. Non-weight bearing 1. Walk forward as far as possible on the stop.
20. Requires good balance 2. Advance crutches to the lower step. The weaker leg is advance first and then
• GAIT – is a term to describe human locomotion, it is pattern of walking or a sequence
21. Requires arm strength the stronger one. In this way, the stronger extremity shares with the arms the
of foot movements.
22. Faster gait work of raising and lowering the body weight.
• REHABILITATION – making able again; relearning skills or abilities or adjusting existing
23. Can use with walker ▪ To go upstairs:
function.
• SWING TO 1. Advance the stronger leg first up to the next step.
• DISABILITY – restriction or lack of ability to perform an activity in a normal manner; the
24. Weight bearing both feet 2. Advance the crutches and the weaker extremity. Note: That the strong leg goes
consequences of impairment in terms of an individual’s functional performance and
25. Provides stability up first and comes down last. A memory device for the patients is, “UP WITH
activity. Disabilities represents disturbances at the level of the person (e.g., bathing,
26. Requires arm strength THE GOOD, DOWN WITH THE BAD”.
dressing, communication, walking, grooming).
27. Can use with walker
• ASSISTIVE TECHNOLOGY – any item, piece of equipment, or product system – AMBULATING WITH A WALKER:
• SWING THROUGH
whether acquired commercially, off the shelf, modified or customized – that is used to
28. Weight bearing • A walker provides more support and stability than a cane or crutches. There are two
improve the functional capabilities of individuals with disabilities.
29. Require arm strength types of walkers:
• HABILITATION – making able; learning new skills and abilities to meet maximum
30. Requires coordination/ balance ▪ PICK-UP WALKERS – (one that has to picked up and moved with each step
potential.
31. Most advance gait forward) does not permit a natural walking pattern and is useful for patients who
• IMPAIREMENT – loss or abnormality of physiological, psychological or anatomic
have poor balance or limited cardiovascular reserve or who cannot use crutches
structure or function at the organ level; an abnormality of body structure, appearance, NURSING STRATEGIES APPROPRIATE FOR PROMOTING MOBILITY AND AMBULATION
▪ ROLLING WALKER – Allows automatic and is used by patient who cannot lift or
and organ system function resulting from any cause. AND THE USE OF ASSISTIVE DEVIC:
who inappropriately carry a pick-up walker. The height of the walker is adjusted to
PURPOSE OF WALKING AIDS: TEACHING CRUTCH WALKING: the patient. The patient’s arm resting on the walker hand grips should exhibit 20-30
degrees of flexion and the elbows. The patient should wear sturdy, well-fitting shoes.
• Increase area of support or base of support 1. The nurse or physical therapist explains and demonstrates to the patient how to use the
• Maintain centre of gravity over supported area crutches. USING A CANE:
• Redistribute weight bearing area by decreasing force on injured or inflamed part or limb. 2. The patient learns standing balance by standing on the unaffected leg by a chair.
• A cane helps the patient walk with greater balance and support and relieves the pressure
• Can be compensate for weak muscles 3. To help the patient maintain balance, the nurse holds the patient near the waist or uses
on weight-bearing joints by redistributing weight. Quad canes (four footed canes)
• Decrease pain a transfer belt.
provide more stability than straight canes.
 • To fit the patients for a cane, the patient’s is instructed to flex the elbow at a 30-degree A number of drugs can potentiate the effects of insulin resulting in hypoglycemia: • weight gain and constipation
angle, hold the handle of the cane about level with the greater trochanter, and place the • rash and/or itching over the whole body
• Lipoatrophy at injection sites has been associated with all types of insulin, it has an
tip of the cane 15 cm (6 inches) lateral to the base of the fifth toe. Adjustable canes • shortness of breath, difficulty breathing, or swallowing, fast heartbeat and abnormal
estimated prevalence of 3.6%. The precise pathogenesis remains unclear, but possible
make individualization easy heartbeat
mechanisms include immune reaction to insulin or excipients of the injection solution,
• Wheezing, weakness
INSULIN ADMINISTRATION injury from cold insulin, or trauma from repeated local injections. A study by Lopez,
Velazquez, Castells et al. examined subcutaneous biopsies in acute and chronic insulin • Dizziness and sweating
• Insulin is necessary for normal carbohydrate, protein, and fat metabolism. • blurred vision, muscle cramps
injection sites. They found atrophy of lobular adipose tissue and variable extent of
• People with type 1 diabetes mellitus do not produce enough of this hormone to sustain angiocentric and lobular lymphocytic infiltrate. Focal fibrosis was present in all chronic • swelling of the arms, hands, feet, ankles, or lower legs
life. However, over time, many of these individuals will show decreased insulin injection sites.
production, therefore requiring supplemental insulin for adequate blood glucose control, NURSING RESPONSIBILITIES:
• Chronic use of the same injection site increases the risk of lipoatrophy. Patients learn
especially during times of stress or illness. Insulin dosage must be individualized and • Responsibility for the procedure is with the Registered Nurse. They must ensure that
that these areas become relatively pain free and continue to use them. The fibrotic
balanced with medical nutrition therapy and exercise. they are competent in the following before undertaking the procedure:
changes that occur at lipotrophic sites is believed to affect insulin absorption from
• Insulin is obtained from pork pancreas or is made chemically identical to human insulin lipoatrophic areas can result in difficulties in achieving ideal blood glucose control. • Understanding and interpreting an insulin prescription sheet
by recombinant DNA technology or chemical modification of pork insulin. 5 TYPES OF INSULIN: • Drawing up the correct dose of insulin into an insulin syringe or correctly using a pen
• Insulin analogs have been developed by modifying the amino acid sequence of the 1. Short-acting insulin device
insulin molecule. 32. What it’s called: Humulin R, Novolin R • Knowledge of injection sites
• Insulin injection is used to control blood sugar in people who have type 1 diabetes 33. Short-acting insulin covers your insulin needs during meals. It is taken about 30 • Examination of injection sites for lipodystrophy (lumpy areas)
(condition in which the body does not make insulin and therefore cannot control the minutes to an hour before a meal to help control blood sugar levels. • Administering a subcutaneous injection
amount of sugar in the blood) or in people who have type 2 diabetes (condition in which 34. This type of insulin takes effect in about 30 minutes to one hour, and peaks after • Safe disposal of sharps, immediately after use
the blood sugar is too high because the body does not produce or use insulin normally) two to four hours. Its effects tend to last about five to eight hours. • The use of a blood glucose meter to monitor blood glucose and interpretation of the
that cannot be controlled with oral medications alone. 35. The biggest advantage of short-acting insulin is that you don't have to take it at result.
• Over time, people who have diabetes and high blood sugar can develop serious or life- each meal. You can take it at breakfast and supper and still have good control
threatening complications, including heart disease, stroke, kidney problems, nerve because it lasts a little longer,” Dr. Chandalia says. DIABETIC FOOT CARE TIPS:
damage, and eye problems. 2. Rapid-acting insulin 1. You may think of diabetes as a blood sugar problem, and it is.
• Using medication(s), making lifestyle changes (e.g., diet, exercise, quitting smoking), 36. What it’s called: Humalog (lispro), NovoLog (aspart), Apidra (glulisine) → But the nerve and blood vessel damage caused by diabetes can also become a
and regularly checking your blood sugar may help to manage your diabetes and improve 37. Rapid-acting insulin is taken just before or after meals, to control spikes in blood problem for your feet if you develop neuropathy (which occurs in about 70
your health. sugar. This type is typically used in addition to a longer-acting insulin. percent of people with diabetes) and lose feeling in your feet or hands or get an
• This therapy may also decrease your chances of having a heart attack, stroke, or other 38. It often works in 15 minutes, peaks between 30 and 90 minutes, and lasts 3 to 5 infection. To ensure the best possible foot health, follow these 11 easy tips to
diabetes-related complications such as kidney failure, nerve damage (numb, cold legs hours. avoid injury, and your feet will be healthy longer
or feet; decreased sexual ability in men and women), eye problems, including changes 39. “You can take it a few minutes before eating or as you sit down to eat, and it 2. Inspect Your Feet Every Day
or loss of vision, or gum disease. starts to work very quickly,” says Manisha Chandalia, MD, director of the Stark
→ Nerve damage is a complication of diabetes that makes it hard to feel when you
• Insulin controls high blood sugar but does not cure diabetes. Diabetes Center at the University of Texas Medical Branch, in Galveston.
have sores or cracks in your feet. “Patients with diabetes are looking for any
3. Intermediate-acting insulin
STORAGE: Insulin injection is in a class of medications called hormones. changes in color, sores, or dry, cracked skin,” says podiatrist Steven Tillet, DPM,
40. What it’s called: Humulin N (NPH), Novolin N (NPH)
Insulin injection is used to take the place of insulin that is normally of Portland, Ore. Place a mirror on the floor to see under your feet or ask a friend
• Vials produced by the body. 41. Intermediate-acting insulin can control blood sugar levels for about 12 hours or
or relative for help if you can’t see all parts of your feet clearly
• Pens longer, so it can be used overnight.
3. Skip 'Hot' Tubs
• Pump 42. It begins to work within one to four hours, and peaks between four and 12 hours,
→ When people with diabetes develop nerve damage or neuropathy, it’s hard to tell
depending on the brand.
SINGS & SYMPTOMS OF HYPOGLYCEMIA: if the bath water is too hot. “They won’t realize they are actually scalding their
43. “Intermediate-acting insulin offer baseline insulin coverage and can be used with
skin,” explains Dr. Tillet. Stepping into a bath before checking the temperature
• Similar to the way a car needs gas to run, your body and brain need a constant supply short-acting insulin or rapid-acting insulin,” says Dr. Chandalia.
can cause serious damage to your feet, and burns and blisters are open doors
of sugar (glucose) to function properly. If glucose levels become too low, as occurs with 4. Long-acting insulin
to infection. Use your elbow to check the water temperature before getting into
hypoglycemia, it can cause these signs and symptoms: 44. What it’s called: Lantus (glargine), Levemir (detemir)
the tub or shower.
▪ Heart palpitations 45. Long-acting insulin has an onset of one hour, and lasts for 20 to 26 hours with
4. Invest in Proper Footwear and Socks
▪ Fatigue no peak.
→ Shoe shopping for people with diabetes requires a little more attention to detail
▪ Pale skin 46. This insulin type tends to cover your insulin needs for a full day. It is often taken
than you may be used to. Tillet advises looking for shoes with more depth in the
▪ Shakiness at bedtime.
toe box, good coverage of both top and bottom, and without seams inside the
▪ Anxiety 47. “These long-acting insulin provide 24-hour coverage, and have been helpful at
shoe that can rub on your foot. Likewise, seek socks without seams, preferably
▪ Sweating achieving good blood sugar control in type 2 diabetes with just one shot,” Dr.
socks that are padded and made from cotton or another material that controls
▪ Hunger Chandalia says.
moisture.
▪ Irritability 5. Pre-mixed insulin
5. Don't Go Barefoot
48. What it’s called: Humulin 70/30, Novolin 70/30, NovoLog 70/30, Humulin 50/50,
SIGNS & SYMPTOMS OF HYPERGLYCEMIA: Early signs and symptoms → Wearing shoes with good coverage outside to protect your feet makes sense to
Humalog mix 75/25, Humalog mix 50/50
most people, but even inside your house, puttering around without shoes puts
49. This type of insulin combines intermediate- and short-acting insulin. It is often
• Recognizing early symptoms of hyperglycemia can help you treat the condition promptly. your feet at risk for small cuts, scrapes, and penetration by splinters, glass
taken twice a day before meals. It should be taken 10 minutes to 30 minutes
Watch for: shards, and the misplaced sewing needle or thumbtack. If you have neuropathy,
before eating.
▪ Frequent urination you might not notice these dangerous damages until they become infected. It’s
50. Pre-mixed insulin takes effect in 5 to 60 minutes, and its peak times vary. Its
▪ Increased thirst best to wear shoes at all times, even in the house.
effects last from 10 to 16 hours.
▪ Blurred vision 6. Keep Your Skin Dry
51. “Pre-mixed insulin was designed to be more convenient. But not everybody has
▪ Fatigue → Make sure that drying your feet is part of your hygiene routine. “The space
the same insulin requirements, so they don’t fit neatly into the pre-mixed
▪ Headache between the toes is very airtight,” says Tillet. “Skin gets moist and breaks down,
categories,” Dr. Chandalia says.
▪ Coma leading to infection.” Prevent this by toweling off thoroughly after washing your
▪ Abdominal pain INSULIN INJECTION SITES: feet and by removing wet or sweaty socks or shoes immediately. You can still
use moisturizer to prevent dry, cracked skin — just avoid putting it between your
NORMAL BLOOD SUGAR LEVEL: Normal Blood Sugars ✓ Upper outer arms
toes.
✓ Abdomen
• A normal fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dL 7. Treat Foot Woes Promptly
✓ Buttocks
• A normal blood sugar level two hours after eating is less than 140 mg/dL → Attend to bunions, calluses, corns, hammertoes, and other aggravations
✓ Upper outer thighs
promptly, so they don’t lead to infection due to pressure sores and uneven
COMPLICATIONS OF INSULIN THERAPY:
WHAT SIDE EFFECTS CAN THIS MEDICATION CAUSE? rubbing. Even seemingly harmless calluses may become problems if you ignore
• Hypoglycemia is the most common and most serious complication of insulin therapy. them, notes Tillet. See a podiatrist, a doctor who specializes in foot care, instead
• This medication causes changes in your blood sugar. You should know the symptoms
• Hypoglycemia can be potentially life-threatening. Most patients who use insulin of heading to the pharmacy for an over-the-counter product for feet — some
of low and high blood sugar and what to do if you have these symptoms.
experience hypoglycemia at one time or another. products are irritating to your skin and can actually increase the risk of infection
• redness, swelling, and itching at the injection site
• If a patient injects too much insulin blood glucose level can fall low enough to cause even while they treat the bunion, callus, or corn on your foot.
• changes in the feel of your skin, skin thickening (fat build-up), or a little depression in
hypoglycemia.
the skin (fat breakdown)
 8. Consider Orthotics • Condition of the hair and scalp. • To support family members during the initial hours of their bereavement
→ Because wearing the correct shoes is so important, orthotic footwear is a great • Evenness of the hair growth over the scalp, hair texture, oiliness, thickness or • To show respect to the deceased
investment in protection and comfort. Shoes made especially for people with thinness, presence of lesions, infections and infestations.
• Self-care activities (any problems managing hair care) REVIEW STRATEGIES OF GRIEVING: 10 STRATEGIES FOR COPING WITH GRIEF
diabetes are available at specialty stores and through catalogs, or you can visit
your podiatrist for advice. Medicare Part B will cover one pair of depth-inlay or • Grief is a personal experience, unique to each mourner and unique to each loss
LIFE SPAN CONSIDERATIONS:
custommolded diabetic shoes a year, plus additional inserts to reduce pressure • Grief comes in ways as lives of peace and calm are suddenly shattered by overpowering
on your feet. Your doctor may recommend this type of diabetic shoe if you have • INFANTS: Shampoo an infant’s hair daily to prevent seborrhea. emotion
an ulcer or sore that is not healing • CHILDREN: Monitor school-age children for nits (pediculosis) 1. TAKE TIME OUT. In many ways, the experience of grief is similar to recovery from
9. Opt for Non-Impact Aerobics • OLDER ADULTS: Ensure adequate warmth for older adults when shampooing their a serious illness; some days will be darker, and some will be brighter. Recognize
→ People with diabetes benefit from exercise, but you still must go easy on your hair, they are susceptible to chilling. your limits, and separate the things that must be done from those that can wait.
feet. Many fitness classes and aerobics programs include bouncing, jumping, 2. AVOID MAKING MAJOR DECISIONS. Grief can cloud your judgment and make it
IMPORTANT REMINDER:
and leaping, which may not be the best activities for your feet, especially if you difficult to see beyond the pain you're feeling at the moment. Impulsive decisions
have neuropathy. Instead, look into programs, such as walking, that don’t put too • Prior to performing the procedure, introduce self and verify the client’s identity using can have far-reaching implications for which you may be unprepared. If you must
much pressure on your feet. Just make sure you have the right shoe for whatever agency protocol. make an important decision, discuss your options with someone you trust, such as
activity you choose. • Explain the procedure, why it is necessary, and how he or he can participate. a friend or parent.
10. Quit Smoking Now • Perform hand hygiene and observe other infection prevention procedures. 3. TALK. Painful feelings held inside are like an infection festering in a wound – they
→ The dangers of smoking run from your head to your feet. “The nicotine in a need to come out in order for you to heal. When friends ask how they can help, ask
POST-MORTEM
cigarette can decrease the circulation in the skin by 70 percent,” says Tillet. So them to just be with you and listen. If you think you need more than the support of
if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood DEFINITIONS OF TERMS: your friends, consider talking with a professional counselor.
that helps keep them healthy and fights infection. “Diabetic patients already have 4. EXPRESS YOURSELF CREATIVELY. Writing is another excellent way to express
risk factors that compromise their blood vessels. It’s never too late to stop • Deceased – no longer living or a dead
yourself. Try keeping a journal or writing letters, whether you send them or not. When
smoking,” says Tillet. • Autopsy – a medical procedure that consist of a thorough examination performed on a
words won't come, artistic outlets like painting or sculpting can help you to
11. Control Blood Sugar body after death to evaluate disease or injury that may be present
communicate what's in your heart and soul. Creative expression can bring clarity to
→ “There’s a direct relationship between blood sugar level and damage to the nerve • Death – the cessation of all biological functions that sustain an organism the turmoil you feel and insight into feelings you weren't aware of.
cells,” says Tillet. Out-of-control blood sugar leads to neuropathy, which will • Embalming – to treat a dead body so as to preserve it, as with chemicals drugs or 5. HONOR YOUR LOVED ONE'S MEMORY. Preserve your memories in ways that are
make it hard to know when your feet are at risk or being damaged. The better balsams to keep it from decaying. The art and science of preserving human remains by comforting and meaningful. Enlarge and frame a favorite photo of your loved one, or
you are at controlling your blood sugar, the healthier your feet will be over the treating them to forestall decomposition and the intention is to keep them suitable for compile a scrapbook of letters and mementoes from the good times you shared.
long term. Finally, if you already have an infection, high blood sugar levels can public viewing. Make a quilt from his clothing, or plant a tree or a bed of his favorite flowers to create
make it hard for your body to fight it • Expired – to come to an end a lasting tribute. Contributing time or money to your loved one's favorite cause or
• Forensic medicine – the branch of medicine dealing with the application of medical charity is also a noble way to honor her memory.
BED SHAMPOO knowledge to establish facts in civil or criminal legal cases, such as an investigation into 6. TAKE CARE OF YOUR PHYSICAL HEALTH. Grief takes a physical toll as well as
HAIR the cause and time of a suspicious death. Also known as forensic pathology. an emotional toll. Rest, exercise, and proper nutrition are essential to healing.
• Forensic pathology – it is pathology that focuses on determining the cause of death by Counteract a poor appetite by eating small amounts of healthy foods rather than
• Often reflects a person’s feelings of self-concept and sociocultural well-being. examining the corpse. The post mortem is performed by a medical examiner, usually large meals. If you have difficulty sleeping, try taking brief naps or just putting your
• It also reflects state of health. during the investigation of criminal law cases and civil law cases in some jurisdictions feet up and relaxing whenever you can. And while you may not be motivated to
• Becoming familiar with health care needs and practices is an important aspect of • Mourning – the behavioral process through which grief is eventually resolved or altered exercise, just taking a brief walk now and then can lift your spirits and help you to
providing competent nursing care to all clients.
• Morgue – a room or building usually run by a state or municipal government. In which sleep at night.
• Conducting an assessment for problems such as dandruff, alopecia, pediculosis, scalp
bodies are kept until they are autopsied or identified 7. AVOID USING CHEMICALS TO NUMB YOUR FEELINGS. Attempting to numb
lesions, or excessive dryness or matting is helpful in caring your client’s hair.
• Mortician – a person trained in the care and disposal of the dead; also referred to as your feelings with alcohol, illicit drugs, or prescription medications will only prolong
SHAMPOOING THE HAIR undertaker the pain. Eventually, one way or the other, you must come to terms with your grief.
• Shroud – a large piece of plastic or cotton material used to enclose a body after death 8. HAVE FUN. Grieving is difficult, but it doesn't mean you have to feel bad all the time;
• Hair is washed as often as needed to keep it clean.
in fact, it's important to take a break from focusing on your grief. Have fun when you
• DIFFERENT WAYS TO SHAMPOO CLIENT’S HAIR (depending on their health): DYING PATIENT’S BILL OF RIGHTS:
can, whether it's reading a good book, watching a movie, playing cards, or resuming
1. Client who is well can shower alone.
• I have the right to be treated as a living human being until I die other activities you enjoyed before your loss. Don't feel guilty about it.
2. Unable patient may be given a shampoo while sitting on a chair in front of a sink 9. PLAN AHEAD FOR SPECIAL OCCASIONS. Anniversaries and holidays can be
• I have the right to maintain a sense of hopefulness however changing its focus may be
3. Back-lying patient may be given a shampoo on a stretcher wheeled to a sink. stressful times when you've lost someone you love, and especially so in the first year
• I have the right to be cared for by those who can maintain a sense of hopefulness,
4. Bed ridden patient must remain in bed and can be given a shampoo in the or two. Talk with family members about your concerns; this may be a good time to
bedside. however changing this might be
• I have the right to express my feelings and emotions about my approaching death in my introduce new traditions to mark special occasions.
• Water used for the shampoo should be 40.5 degrees Celsius (105 degrees 10. REACH OUT. In the beginning, grief may be so intense that you just want to
Fahrenheit) for an adult and child to be comfortable and not injure the scalp. Usually, own way
• I have the right to participate in decisions concerning my care withdraw or isolate. Soon, though, you'll be ready to ease back into social contact.
the client will supply a liquid or cream Make a date with an old friend, or invite a neighbor to lunch. Or try volunteering with
• If the shampoo is being given to destroy lice, a medicated shampoo should be used. • I have the right to expect continuing medical and nursing attention even though “cure”
your church or favorite charity – you'll make new social contacts while you help
• An individual needs a shampoo depending largely on the person’s activities and the goals must be changed to “comfort” goals
others, and you'll feel good about yourself.
amount of sebum secreted by the scalp • I have the right to die alone. I have the right to be free from pain
• African-American wash their hair less often than any other ethnic groups because the • I have the right to have y questions answered honestly DISCUSS PHYSIOLOGIC CHANGES AFTER DEATH:
hair is drier. Frequently shampooing could damage their hair. Other African-Americans • I have the right not be deceived
• Failure of the body functions of the respiratory, circulatory and nervous system.
style their hair in small braids, these braids do not have to be unbraided for • I have the right to have help from and from my family in accepting my death
• The person is declared clinically dead if there no breathing, NO
shampooing and washing. However, if necessary, the nurse should obtain the client’s • I have the right to die in peace and dignity
1. Early/Immediate changes of death
permission to do so. • I have the right to return my individuality and not to be judged for decisions which may
▪ Cessation of respiration
be contrary t the beliefs of others
PROVIDING HAIR CARE ▪ Cessation of circulation
• I have the right to discuss and enlarge my religious and/or spiritual experiences,
▪ Muscular relaxation
PURPOSE: whatever this may mean to others.
▪ Loss of reflexes
• I have the right to expect that the sanctity of the human body will be respected after
• To stimulate the blood circulation to the scalp. ▪ Skin pallor and dilated of pupils
death
• To distribute hair oils and provide a healthy sheen. ▪ Not immediate – after one or two after death
• I have the right to be cared for by caring, sensitive, knowledgeable people who will ▪ ALGOR MORTIS – colling and there is heat loss
• To increase client’s comfort.
attempt to understand my needs and will be able to gain satisfaction in helping me face
• To assess or monitor hair or scalp problems (e.g., matted hair or dandruff) → Body cooling does note occur at a uniform rate
death
→ Skin cools more rapidly that the inside of the body
ASSESSMENT:
PURPOSE OF POST MORTEM CARE: ▪ LIVOR MOTIS – (hypostasis) discoloration of independent region
• History of the following conditions or therapies: recent chemotherapy, hypothyroidism, → Color of rividity is red-purple
• To cleanse the patient’s body and prepare it for removal from the hospital after death
radiation of the head, unexplained hair loss, and growth of excessive body hair. → Fixed after 6-12 hours
• Usual hair care practices and routinely used hair care product (shampoo, conditioner, • To aid in preserving the physical appearance of the deceased
→ Blood will not flew, small blood vessels very congested w/ blood
hair oil preparation, hair spray). • To prevent discoloration and damage of the corpse skin
→ Fat starts to become semi-solid
• Whether wetting the hair will make it difficult to comb the hair. • To safeguard all belongings of the deceased
→ Settling of the blood
 → Rupture of small blood vessels from pressure ✓ Once completed, change the patient to a fresh gown, comb his hair and cover with a POINTS TO REMEMBER (SAFETY MEASURES):
→ Discoloration more rapid from red-purple to cherry red – petechial spot during fresh linen up to his chin, leaving his arms exposed his sides.
• When lifting an object, avoid bending and twisting at the same time. Instead, face the
asphyxia death (hanging) ✓ Raised the part of the head. A condition called livor mortis will begin to set in at about
object and bend at the knees (not the back).
▪ RIGOR MOTIS – stiffening of the body seen within 2-4 hours after death 20 minutes after the patient has passed. Once the circulation in the body has stopped,
gravity takes over, pulling the blood downward. • Before lifting, move close to and directly in front of the object. Make sure your feet are
→ On set maybe delayed due to environmental condition. Persists within 24
✓ If the head is not elevated, the blood will begin to pool around the sides of the face, flat on the floor and shoulders are apart. Bend the knees and lift smoothly. Use the same
hours after onset
earlobes and the neck, leaving a deep reddish-purple discoloration in these areas. To movement when putting the object down again.
→ After death, lactic acid produces which interacts with a actin and myosin
prevent this, raise the head of the bed and place on or two pillows under the patient • Avoid overreaching. If you have to reach up to a high level, make sure you are standing
causing cross linking due to disappearance of ATP (Acute
✓ Place a washcloth under the patient’s chin. Rigor mortis, a stiffening of the muscles, can on a firm level surface. Avoid standing on tiptoes. Not only is this an unstable position
Thrombocytopenic Purpura) – low blood platelet level causing bleeding into
begin as soon as ten minutes after death and can take up to 6 hours to occur. Placing a to stand in, for prolonged periods of time it can place unnecessary strain on the back
the skin and elsewhere. Which break linkages of actin and myosin that is more
rolled-up washcloth under the chin will help the jaw stay closed until rigor mortis takes and neck.
complexed until it remains to decomposition.
place. • If the patient requires cervical spine precautions, the head holder is in charge of the
2. Late
procedure ensuring that all of the team members are ready to turn in a coordinated
▪ Decomposition LOG ROLLING manner. If cervical spine has been cleared and the thoracolumbar requires
▪ Mummification
DEFINITION OF TERMS immobilization, a nominated person should control the roll to ensure it is coordinated
▪ Skeletonization
and the patient maintains neutral alignment
▪ 4 tissue changes:
• Log Rolling- is a maneuver used to move a patient without flexing the spinal column. • The patient is required to make only a quarter turn rather than a half turn each time the
→ Greenish discoloration of skin marbling – hydrogen sulfide producing bacteria
Patient's legs are stretched, the head is held, to immobilize the neck. position is changed. If the patient experiences pain while turning, a quarter turn will be
→ Bloating of abdomen and gas formation
• Lumbar Hernia – lumbar disk hernia occurs at the L4-L5 or the L5-S1 interspace. A less painful than a half turn.
→ Blisters and skin slippage, loss of hair and nails
herniated lumbar disk produces low back pain accompanied by varying degrees of • Turning may be impossible if the patient has fractures that require traction appliances.
3. Tissue Changes
sensory and motor impairment. • Turning may be harmful to patients with spinal injuries. In these cases, you need to rub
(IDK UNSAY NOTES DIRI NA PART) • Myelography – a diagnostic exam that determines diagnosis of lumbar disk diseases. the back by lifting the patient slightly off the bed and massaging with your hand held flat.
• Arachnoiditis - Inflammation of the arachnoid membrane It is especially important to prevent skin breakdowns in the person who lies on his back
• Logrolling is a technique used to turn a patient whose body must at all times be kept in for long periods of time.
a straight alignment (like a log). This technique is used for the patient who has a spinal • For the initial development of skin breakdown, a patient does not have to lie on his back
injury. Logrolling is used for the patient who must be turned in one movement, without for long periods of time, especially if moisture and sheet wrinkles are present
IDENTIFY THE CLINICAL CHANGES AFTER DEATH: twisting. Logrolling requires two people, or if the patient is large, three people.
MATERIALS:
• Clinical death is the medical term for cessation of blood circulation and breathing, the
two necessary criteria to sustain human and many other organisms’ lives. It occurs when
the heart stops beating in a regular rhythm, a condition cardiac arrest.
• Stopped blood circulation has historically proven irreversible in most cases. Prior to
the invention of cardiopulmonary resuscitation (CPR), defibrillation, epinephrine
injection and other treatments in the 20th century, the absence of blood circulation
(and vital functions related to blood circulation) was historically considered the official
definition of death. With the advent of these strategies, cardiac arrest came to be called
death rather than simply death, to reflect the possibility of post-arrest resuscitation.
• at the onset of clinical death, consciousness is lost within several seconds. Measurable
brain activity stops within 20 to 40 seconds. Irregular gasping may occur during this early
time period, and is sometimes mistaken by rescuers as a sign that CPR is not necessary.
During clinical death, all tissues and organs in the body steadily accumulate a type of
injury called ischemic injury.

NURSING RESPONSIBILITIES:

• Care of valuables
- Valuables with the patient at the time of death should be identified, accounted for
and sent to the department of the institution for safe keeping until family claims for it PREPARATION OF PATIENT & ENVIRONMENT:
- Valuables taken or given to the patient’s family should be voted on the form sheet ✓ Explain the procedure to the patient
specified by institution ✓ Request that they lay still and resist assisting
• Care for the body ✓ Secure all lines, drains and tubes
- Post mortem care of the body is not required unless the physical has pronounced ✓ Ensure that the log rolling team is correctly positioned.
the patient to be dead. DEMONSTRATE THE PROPER BODY MECHANICS IN MOVING PATIENT ✓ Know the different patient positions required.
- Indicate in the cart the time the patient was pronounced dead and the physical ▪ Supine/Dorsal position
pronouncing. • Body mechanics is a term used to describe the ways we move as we go about our daily ▪ Side-lying/Lateral position
- Have the body cleaned and properly identified. lives. It includes how we hold our bodies when we sit, stand, lift, carry, bend, and sleep. ▪ Prone (on abdomen) position
- If the patient is communicable, the water used in cleaning must be medicated Poor body mechanics are often the cause of back problems. When we don't move ▪ One example of a schedule for turning would be: 1000– Prone position 1200–Left
- Inform the medico legal officer, suicide, homicide, or illegal therapeutic practices correctly and safely, the spine is subjected to abnormal stresses that over time can lead Sim’s position 1400–Supine position 1600–Right Sim’s position 1800–Prone
causes death to degeneration of spinal structures like discs and joints, injury, and unnecessary wear position
- Prevent all means of discoloration or scarring of the body as it is distressed to the and tear.
family • Most patient fear surgery on any part of the spine and therefore need explanation about PROCEDURES:
- Accomplish necessary papers related to death the surgery and reassurance that it will not weaken the back. To facilitate the post-
✓ Person 1 supports upper body hands on shoulder and hip
- Provide all means to comfort the family and relatives who may be around. operative turning procedure, the patient is taught to turn as a unit (called log rolling) as
✓ Person 2 supporting abdomen and lower legs hands on hip and lower legs
part of the preoperative preparation. Before surgery, the patient is also encouraged to
HOW TO PERFORM THE POST MORTEM CARE: IMPORTANT TIPS ✓ Person 3 may be required to provide more support to lower body
take deep breaths, cough and perform muscle-setting exercises to maintain muscle
✓ The head holder ensures the team is ready and the roll is coordinated
✓ Place the patient in a supine position tone.
✓ Ensure that the patient is in neutral alignment (straight) and avoid any rotational
- Once the patient’s death has been confirmed PRELIMINARY ASSESSMENT CHECK: movements of the individual spinal segments
✓ Place the patient in an upright position ✓ On completion of the roll, position the patient in alignment, The turn must occur in one
✓ Straightening the limbs by the sides and lowering the eyelids ✓ Assess the need for pain relief smooth action with the patient’s head and body remaining in anatomical alignment at all
✓ If the eyelids will not remain close on their own initially, place wet gauze pads over the ✓ Ensure that the current collar is well fitting prior to the log roll times.
closed eyes until they remain close on their own ✓ Assemble all necessary equipment
✓ Bathe the patient. It is normal for any excess secretions in the body, such as in the bowel ✓ Assess the need for a pillow in between lower limbs for support
and bladder, to exit the body once death has occurred.
✓ Out of respect to the patient and the family, the deceased should be bathe completely
with just as much as care as you’d give as if he is alive
 TRANSPORING PATIENTS PROCEDURES: ASSISTING THE CLIENT W/ TRANSFER

DEFINITION OF TERMS: • A transfer is a movement of the client from one place to another (e.g. Bed to chair, chair
to commode, wheelchair to tub). As soon as the client is permitted out of bed, transfer
• Therapeutic exercises – are prescribed by the physician & performed w/ assistance &
activities are started. The nurse assesses the client’s ability to participate actively in the
guidance of the physical therapist. It promotes optimal use of capabilities for daily body
transfer & determine in conjunction w/ an occupational therapist/physical therapist are
functions.
required adaptive equipment to promote independence & safety. It is important that the
• Abduction – Movement away from the midline of the body.
client maintain muscle strength & if possible, perform push-up exercises to strengthen
• Adduction – Movement towards the midline of the body. the arm & shoulder extensor muscles. The push-up exercise requires the client to sit
• Flexion – Bending of a joint so that the angle of the joint diminishes. upright in bed; a book is placed under each of the client’s hands to provide a hard
• Extension – The return movement from flexion; to joint angle is increased. surface, & the client is instructed to push down on the book raising the body.
• Dorsiflexion – Movement that flexes/ bends the hand back towards the body or the foot • The nurse should encourage the pt. to raise & move the body in different directions by
towards the legs. means of these push-up exercises. The nurse teaches the client how to transfer.
• Palmar flexion – Movement that flexes/bends the hand in the direction of the palm.
• Plantar flexion – Movement that flexes/bends the hand in the direction of the foot in the TECHNIQUE FOR MOVING THE CLIENT TO THE EDGE OF THE BED:
direction of the sole. • Move head & shoulders of patient toward the edge of the bed.
• Rotation – Turning or movement of a part around its axis. • Move feet & legs to the edge of the bed. The patient is now in crescent position, w/c
RANGE OF MOTION EXERCISES: gives good range of motion to the lateral trunk muscles.
• Place both arms well under the patients hips & tighten.
• This involves moving a joint through its full range in all appropriate planes. To maintain • Straighten your back while moving the patient towards you.
or increase the motion of a joint, range-of-motion exercises are initiated as soon as the
patient's condition permits. To accommodate the wide variation in the degrees of motion TECHNIQUE FOR SITTING PATIENT ON THE EDGE OF THE BED:
that people of varying body builds and age groups can attain. 1. Place arm & hand under the patient’s shoulder.
• Pronation – rotation of the forearm so that the palm of the hand is down. 2. Instruct the pt to push into the bed w/ the elbow while you lift the patient’s shoulders w/
• Supination - rotation of the forearm so that the palm of the hand is up. one arm & swing the legs over the edge of the bed w/ the other
• Opposition - touching the thumb to each fingertip on the same hand.
• Inversion - movement that turns the sole of the foot inward. TECHNIQUE IN ASSISTING PATIENT TO STAND:
• Eversion - movement that turns the sole of the foot outward. 1. Position the patients feet so that they will be well grounded.
WAYS OF PROMOTING THERAPEUTIC EXERCISES: 2. Face the patient while firmly grasping each side of the patient’s rib cage w/ your hands.
3. Push your knee against one knee of the pt.
• Passive - An exercise carried out by the therapist or the nurse w/o assistance from the 4. Rock the patient forward to a standing position
pt. To maintain as much joint range of motion as possible to maintain circulation. 5. Ensure that the patient’s knees are locked (in full extension) while standing. Locking the
• Active-Assistive - An exercise carried out by the pt. w/ the assistance of the patient’s knees is a safety measure for those who are weak or have been in bed for
therapist/nurse. To encourage normal muscle fxn. some time.
• Active - An exercise accompanied by the pt. w/o assistance, activities including turning 6. Give the patient enough time to establish balance.
from side-to-side & from back to abdomen & moving up & down on bed. To increase 7. Pivot the patient into a sitting position in the chair.
muscle strength.
METHODS OF PATIENT TRANSFER FROM THE BED TO A WHEELCHAIR. WHEELCHAIR
• Resistive - An active exercise carried out by the pt. working against resistance produced
IS IN A LOCKED POSITION. COLORED AREAS INDICATES NON-WEIGHT-BEARING
by either manual/mechanical. To provide resistance to increase muscle power.
BODY PARTS:
• Isometric or muscle setting - alternately contracting & relaxing a muscle while keeping
the part to a fixed position, this exercise is performed by the pt. To maintain strength 1. Weight bearing transfer from bed to chair. The patient stands up, pivot until his back is
when a joint is immobilized. in the opposite of the new seat & sits down.
2. Left – non weight bearing transfer from chair to bed (right) with legs braced.
PRELIMINARY ASSESSMENT CHECK:
3. Left – non weight bearing transfer, combined method. Right – non weight bearing
✓ Assess the need for pain relief transfer, pull up method.
✓ Assemble all necessary equipment

POINTS TO REMEMBER (SAFETY MEASURES): SAFETY IS THE PRIMARY CONCERN

DURING A TRANSFER:

• Wheelchairs & beds must be locked before the patient transfers.

• Detachable arm & foot rests are removed to make getting in & out of the chair easier.
• One end of the transfer board is placed under the patient’s buttocks & the other end on
the surface to w/c the transfer is being made. (e.g. chair)
• The patient is instructed to lean forward, push-up w/ his or her hands, & then slide across
the board to the other surface. The nurse frequently assists weak & incapacitated
patients. The nurse supports & gently assists the patient during position changes,
protecting the patient from injury. The nurse avoids pulling on the weak/paralyzed upper
extremities to prevent dislocation of the shoulder. The patient is assisted to move
towards the stronger side.