Selected Nursing Skills

Chapter 20
Selected Nursing Skills
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Standard Steps in Selected Skills
• All nursing skills must include basic steps for
the safety and well-being of the patient and the
nurse.
• Before the Skill
 Refer to medical record, care plan, or Kardex for
special interventions.
 Introduce yourself; include your name and title or role.
 Identify patient by checking arm band and requesting
patient to state his or her name.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2
• Before the Skill (continued)

 Explain the procedure and the reason it is to be done
in terms the patient can understand, and give the
patient time to ask questions. Advise patient of any
unpleasantness that might be experienced.
 Assess need for and provide patient teaching during
procedure.
 Assess patient.
 Wash hands and don clean gloves according to
agency policy and guidelines from the CDC and
OSHA.
• Before the Skill (continued)

 Assemble equipment and complete necessary
charges.
 Prepare the patient for intervention.
• Close door/pull privacy curtain.
• Raise bed to comfortable working height; lower side rail
on side nearest the nurse.
• Position and drape patient as necessary.
• During the Skill

 Promote patient involvement as possible.
 Assess patient’s tolerance, being alert for signs and
symptoms of discomfort and fatigue.
• Completion of Procedure
 Assist the patient to a position of comfort and place
needed items within easy reach. Be certain patient
has a means to call for assistance and knows how to
use it.
 Raise the side rails and lower the bed to the lowest
position.
• Completion of Procedure (continued)

 Remove gloves and all protective barriers. Store or
remove and dispose of soiled supplies and equipment
according to agency policy and guidelines from CDC
and OSHA.
 Wash hands after patient contact and after removing
gloves.
 Document patient’s response, expected or
unexpected outcomes, and patient teaching.
 Report any unexpected outcomes.
Standard Steps: Step 14
(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis:
Mosby.)
Removing disposable gloves.
Skills for Sensory Disorders
• Irrigations
 Eye irrigations
• Relieve local inflammation of the conjunctiva, apply
antiseptic solution, or flush out exudate or caustic
solutions.
• Warm saline and small syringe or eyedropper are
usually used to instill a few hundred milliliters of
solution.
• Irrigation should always be done from the inner canthus
to the outer canthus.
• Never allow the syringe tip to touch the eye.
• Irrigations (continued)
 Eye irrigations (continued)
• At home, eye irrigation can be performed with an eye
cup.
• A copious irrigation of the eye may be accomplished
with the use of intravenous tubing and bag connected to
a Morgan Therapeutic Lens.
• Irrigations (continued)
 Ear Irrigations
• Using a small syringe and solution at body temperature,
the nurse can cleanse a patient’s external auditory
canal of excess cerumen or exudate from a lesion or an
inflamed area.
• Slow, gentle irrigation works best.
• Irrigation is contraindicated when a vegetable foreign
body obstructs the auditory.
• Irrigation is contraindicated if the patient has a cold, a
high temperature, an ear infection, or an injured or
ruptured tympanic membrane.
Skills for Gastrointestinal
Disorders
• Nasal Irrigation
 It soothes inflamed mucous membranes and washes
away dried mucus, secretions, and possible foreign
matter.
 It may be accomplished with the use of a specially
designed electronic device or a bulb syringe.
 Patients with acute or chronic nasal conditions and
patients who inhale allergens and toxins may derive
benefits from nasal irrigations.
 It is contraindicated with advanced destruction of the
sinuses, foreign bodies, and frequent nosebleeds.
Skills for Heat and Cold Therapy
• The nurse should

 Understand the normal responses to local
temperature variations
 Assess the integrity of the body part
 Determine patient’s ability to sense temperature
variations
 Ensure proper operation of equipment
• The body can tolerate wide variations in
temperature.
• Normal skin temperature is 93.2° F.
• Temperature receptors usually adapt quickly to local
temperatures between 113° and 59° F.
• Pain develops when local temperatures exceed
these limits.
• Excessive heat causes a burning sensation.
• Cold produces a numbing sensation before pain.
• Local Effect of Heat and Cold

 Effects of heat application
• Heat improves blood flow through vasodilation to an
injured part.
• However, blood flow is reduced by vasoconstriction as
the body attempts to control heat loss from the area.
• Periodic removal and reapplication of local heat
restores vasodilation.
• Continuous exposure to heat damages epithelial cells.
• Local Effect of Heat and Cold (continued)

 Effects of cold application
• Exposure of the skin to cold results in vasoconstriction.
• The cell’s ability to receive adequate blood flow and
nutrients results in tissue ischemia.
• The skin initially takes on an erythematous appearance,
followed by a bluish-purple mottling with numbness and
a burning type of pain.
• The skin’s tissue can freeze on exposure to extreme
cold.
• Assessment
 Assess patient’s physical condition for signs of
potential intolerance to heat and cold.
 Observe the area to be treated for impairment of skin
integrity.
 Identify conditions that contraindicate heat or cold
therapy.
• Warm applications are contraindicated when the patient
has an acute localized inflammation; cardiovascular
problems; or active bleeding.
• Cold applications are contraindicated if the site of injury
is edematous or the patient has impaired circulation or
is shivering.
• Patient Safety
 Before heat or cold treatment is applied, the patient
should understand its purpose, the symptoms of
temperature exposure, and precautions taken to
prevent injury.
• Physician's Order
 A prerequisite to heat or cold application is a
physician’s order, which should include body site and
the type, frequency, and duration of application.
• Moist or Dry Applications

 Heat and cold applications can be administered in dry
or moist forms.
 The type of injury, the location of the body part, and
the presence of drainage or inflammation are factors
to be considered.
• Hot, Moist Compresses
 For open wounds, sterile, hot, moist compresses
improve circulation, relieve edema, and promote
consolidation of purulent exudate.
Skill 20-5: Step 4
(From Ignatavicius, D.D., Workman, M.L. [2002]. Medical-surgical nursing across the health care
continuum. [4th ed.]. Philadelphia: Saunders.)
Assess condition of exposed skin and wound on which compress is

to be applied.
• Warm Soaks
 Immersion of a body part in a warmed solution
 Promotes circulation
 Lessens edema
 Increases muscle relaxation
 Can provide a means to debride wounds and apply
medicated solution
 A soak can also be accomplished by wrapping the
body part in dressings and saturating them with
warmed solution or by whirlpool treatments.
Figure 20-1
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.].
St. Louis: Mosby.)
Whirlpool moist heat therapy.
• Paraffin Baths
 Bath consists of a mixture of heated paraffin wax and
mineral oil.
 Patients with painful arthritis or other joint discomforts
of the hands and feet benefit most from these baths.
• Aquathermia (Water-Flow) Pads
 This is used to treat muscle sprains and areas of mild
inflammation or edema.
 This consists of a waterproof plastic or rubber pad
connected by two hoses to an electrical unit that has a
heating element and motor.
Figure 20-2
St. Louis: Mosby.)
Aquathermia pad.
• Commercial Hot Packs

 Commercially prepared, disposable hot packs apply
warm, dry heat to an injured area.
 Sticking, kneading, or squeezing the pack mixes the
chemicals and releases the heat.
• Electric Heating Pads
 Pad consists of an electric coil enclosed within a
waterproof pad covered with cotton or flannel cloth.
 The pad is connected to an electric cord that has a
temperature-regulating unit for a high, medium, or low
setting.
• Cold Moist and Dry Compresses

 Cold compresses should be applied for 20 minutes at
a temperature of 59° F to relieve inflammation and
edema.
 Commercially prepared cold packs are available for
dry application.
 The nurse should observe for burning or numbness,
mottling of the skin, erythema, extreme paleness, or
cyanosis.
Figure 20-3
St. Louis: Mosby.)
Commercial cold pack used for therapy.
• Ice Bags or Collars

 For a patient who has muscle sprain, localized
hemorrhage, or hematoma or who has undergone
dental surgery, an ice bag is ideal to prevent edema
formation, control bleeding, and anesthetize the body
part.
Skills for Administering Parenteral
Fluids
• The overall goal of fluid IV administration is to
correct or prevent fluid and electrolyte imbalances.
• Indications for IV Therapy
 Poor tissue absorption
 Inadequate GI tract function
 Need to maintain medications at optimum levels
Fluids
• The nurse should observe the following guidelines:
 Monitor the solution drop rate at the ordered infusion
rate.
 Infuse the amount of prescribed solution.
 Maintain the patency of the IV catheter.
 Monitor site every 1 to 2 hours; IV line should be
assessed every 4 hours.
 During parenteral therapy, the patient’s I&O should be
recorded.
Fluids
• Intravenous Therapy/Venipuncture
 Before the procedure, assemble and make ready the
equipment.
 Assess the patient’s veins.
 Select and clean a puncture site.
 Perform venipuncture.
 Begin infusion.
 Teach the patient about the signs and symptoms
of problems and ways to perform activities while on
IV therapy.
 Follow strict aseptic principles.
Figure 20-4
(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)
Common intravenous sites. A, Dorsal surface of the hand. B, Inner

arm.
Figure 20-5, A
St. Louis: Mosby.)
A, Apply tourniquet.
Figure 20-5, B
St. Louis: Mosby.)
B, Select intravenous site.

Figure 20-5, C
St. Louis: Mosby.)
C, Cleanse site for venipuncture.
Figure 20-5, D
St. Louis: Mosby.)
D, Pull skin taut as catheter is inserted.
Figure 20-6, A
St. Louis: Mosby.)
A, Close valve.
Figure 20-6, B
St. Louis: Mosby.)
B, Remove insertion port cover.
Figure 20-6, C
St. Louis: Mosby.)
C, Insert spike.
Fluids
• Intravenous Therapy/Venipuncture (continued)
 Tubing is selected based on the patient and type of
infusion to be initiated. The valve is closed.
 The tubing spike is inserted into the insertion port on
the correct fluid bag.
 The fluid bag is held upright, and the tubing drip
chamber is gently squeezed to partially fill it with fluid.
 The valve is slowly opened to permit the flow of fluid
down the tubing.
Fluids
 The venipuncture needle and catheter should be
selected according to the solution to be infused and
the size and condition of the patient’s veins.
 Plastic IV catheters are flexible and have blunt tips
that reduce infiltration and allow the patient to move.
Fluids
 Intravenous monitoring
• Patency
 A condition of being opened and unblocked
• Flow rate is ordered by the physician.
• Assess tubing for kinks or obstructions.
• Inspect and palpate the site for edema, erythema,
induration, heat, and discomfort.
• Assess for signs and symptoms of fluid overload.
Fluids
• Changing the Tubing
 This is most easily accomplished when a new
container of solution is added.
 Connect and prime the new solution container and
tubing.
 Carefully remove the tape, securing the old tubing to
the IV catheter hub while gently stabilizing the
catheter and site.
 Working carefully but quickly, turn off the flow valve of
the old tubing, remove the old tubing from the catheter
hub, insert the new tubing into the catheter hub, and
open the flow valve. Secure with tape.
Fluids
• Discontinuing Intravenous Therapy
 Intravenous infusions are discontinued when
• The prescribed amount of solution has infused
• There are signs of infiltration
• The patient has developed phlebitis or other
complications
Fluids
• Discontinuing Intravenous Therapy (continued)
 Steps for discontinuing an IV infusion:
• Assemble supplies.
• Wash hands.
• Explain procedure to the patient.
• Don gloves.
• Turn IV flow regulator to the “off” position.
• Gently remove tape and dressing from site while
carefully stabilizing the needle or catheter.
Fluids
 Steps for discontinuing an IV infusion (continued):
• Place dry gauze pad over needle insertion site.
• Swiftly withdraw needle or catheter from the site while
applying gentle pressure over the site.
• Hold site above heart level while continuing to apply
direct pressure for about 45 seconds to 1 minute.
• Assess for bleeding from the site.
• Apply a bandage or sterile dressing according to
agency policy.
Fluids
 Steps for discontinuing an IV infusion (continued):
• Gather soiled supplies, remove gloves, and discard in
appropriate containers.
• Wash hands.
• Document promptly and accurately.
• Reevaluate site every 10 to 15 minutes.
• Instruct patient to report any redness, pain, drainage, or
swelling.
Fluids
 Infiltration
• Edema that does not subside generally indicates that
the catheter is out of the vein.
• Discomfort and dysfunction may also indicate that the
solution has infiltrated.
• An infiltrated arm will feel cool, and the skin may have a
blanched appearance.
• The solution is discontinued and another site is used to
continue therapy, preferably in the opposite extremity.
Fluids
 Phlebitis
• This results from mechanical irritation (the needle
moving in the vein), the low pH of some IV solutions,
and highly concentrated additives.
• Classic signs
 Erythema, warmth, edema, and discomfort
• Applying warm compresses to the inflamed area
lessens discomfort.
Fluids
 Septicemia
• A systemic infection occurs from pathogens introduced
into the circulating bloodstream.
• Signs and symptoms
 Fever, chills, prostration, pain, headache, nausea, and
vomiting
• Antibiotic therapy is vigorously initiated if blood cultures
verify a septicemic condition.
Fluids
• Blood Transfusion Therapy
 This is most commonly used to replace blood loss.
 Individuals may store their own blood before
anticipated surgery for infusion during hospitalization.
 The fear of HIV infection has led some patients to
refuse blood products.
 Plasma expanders (Plasmanate, Dextran) can be
used for patients who refuse blood transfusions
because of personal or religious beliefs.
Fluids
• Blood Transfusion Therapy (continued)
 Autologous blood transfusion
• A process of collecting a patient’s lost blood during
surgery or after a traumatic injury and infusing it
intravenously into the patient.
• It is used in cardiac thoracic surgery or after traumatic
chest injury.
• Suction drainage device collects blood in a special bag.
• The blood should be administered immediately or not
more than 6 hours after initial collection.
Fluids
 Initiating a blood transfusion
• Nurse is responsible for assessing and monitoring the
patient before, during, and after transfusion.
• Obtain informed consent.
• An infusion of 0.9% or 0.45% normal saline is initiated.
• Follow established protocol for obtaining the blood,
double-checking the compatibility of the blood with the
patient’s blood, and identifying the patient.
Figure 20-11, A
St. Louis: Mosby.)
A, Opened blood administration set and tubing primed with normal

saline 0.9%.
Figure 20-11, B
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St.
Louis: Mosby.)
B, Attached blood product to the normal saline 0.9%.

Fluids
 Initiating a blood transfusion (continued)
• Baseline vital signs are taken and recorded.
• Prime the special blood filter administration tubing and
piggyback it into the primary infusion line.
• Remain with the patient while slowly infusing the first
50 ml of blood.
• Assess the patient’s response and monitor vital signs.
• The nurse must know the symptoms of blood
transfusion reaction and interventions to initiate for
them.
Fluids
 Blood transfusion reactions
• If the infused blood is not compatible with the patient’s
blood type, a reaction will occur.
• A transfusion reaction is an emergency.
• Signs and symptoms
 Statement of “not feeling right”
 Chills, fever, low back pain, pruritis, hypotension, nausea
and vomiting, decreased urine output, chest pain,
dyspnea
Fluids
 Blood transfusion reactions (continued)
• If a transfusion reaction is suspected
 Stop the infusion.
 Keep the vein open with 0.9% or 0.45% sodium chloride
solution.
 Notify the physician and the blood bank.
 Monitor vital signs and urine output every 15 minutes.
 Reassure and support the patient.
 Send remaining blood to the blood bank for analysis.
Fluids
• Maintaining an Intravenous Site
 Change catheter dressings when loose, wet, or soiled.
 Gauze dressings should be changed every 48 hours.
 Fluid containers may be changed frequently
depending on the rate of infusion and the volume of
the container.
 Change infusion tubing according to facility policy.
 Infusion tubing should not be disconnected to change
a gown or clothing.
Skills for Respiratory Disorders
• Oxygen Therapy
 Goal of oxygen therapy is to prevent or relieve
hypoxia.
 Any patient with impaired tissue oxygenation can
benefit from controlled oxygen administration.
 Oxygen is not a substitute for other treatments and
should be used only when indicated.
 Oxygen should be treated as a drug.
 Oxygen is expensive and can have dangerous side
effects.
 The dosage or concentration of oxygen should be
ordered and continuously monitored.
• Oxygen Therapy (continued)

 Oxygen is a colorless, odorless, and tasteless gas
that will not burn or explode.
 If combined with other factors, such as an electrical
spark or fire, it will support combustion and ignite.
 Oxygen therapy is frequently initiated by a respiratory
therapist, who is a health care professional licensed to
deliver treatment that will improve a patient’s
ventilation and oxygenation needs.
 The signs and symptoms manifested by patients who
might require oxygen will vary according to the degree
of oxygen deficiency.

 Transtracheal oxygen delivery
• A newer method of oxygen delivery is the transtracheal
catheter, which is inserted directly into the trachea
between the second and third tracheal cartilages.
• Delivery does not interfere with drinking, eating, or
talking.
• Oxygen is delivered throughout the respiratory cycle.
• It is recommended for patients with heart failure or
chronic obstructive pulmonary disease.
• The transtracheal opening should be inspected and
cleaned regularly.
Figure 20-13
A transtracheal catheter may be inserted into the trachea between

2nd and 3rd tracheal cartilages.

 Care of the tracheostomy
• A tracheostomy is an artificial opening made by a
surgical incision into the trachea.
• It is performed to provide the patient with a patent
airway.
• After the surgical procedure is performed, the physician
inserts a tracheostomy tube and secures it in place with
cotton tape around the patient’s neck.
• Sterile gauze is placed around the opening under the
flange of the outer tube for skin protection.

 Care of the tracheostomy (continued)
• It is essential that nursing interventions be consistently
implemented that
 Minimize infection risk
 Minimize sensory deprivation

 Care of the patient with a tracheostomy collar and
T-piece/tube
• This requires constant humidification to the airway.
• The T-piece/tube is a T-shaped device with a
15 mm connection with large-lumen tubing.
• A tracheostomy collar is a curved device with an
adjustable strap that fits around the patient’s neck; an
exhalation port remains open at all times and another
connects to large-bore tubing.
Figure 20-15, A
St. Louis: Mosby.)
A, Trach tube (fenestrated) with inner cannula removed and cap in

place to allow speech.
Figure 20-15, B
St. Louis: Mosby.)
B, Trach tube with obturator for insertion and syringe for inflation of
cuff.
Figure 20-16
T-piece/tube.
Figure 20-17
Tracheostomy collar.
Skills for Urinary or Reproductive
Tract Disorders
• Urinary Elimination
 This is a natural process that individuals take for
granted until it is altered by some uncontrollable
physiological factor.
 Patients may require physiologic and psychologic
assistance from the nurse.
 Physiologic support may require the use of an
invasive procedure, such as insertion of a urinary
catheter into the bladder.
 Psychologic assistance may be needed to help the
patient adjust to a visible urine collection drainage
bag.
Tract Disorders
• Urinary Elimination (continued)
 Catheter
• This is a flexible tube that can be inserted into a vessel
or cavity of the body to withdraw or instill fluids.
• Most catheters are made of soft plastic or rubber.
• Catheters may be used for treatment or diagnosis.
• Catheterization of the bladder involves introducing a
urinary catheter through the meatus and urethra and
into the urinary bladder.
Tract Disorders
 Maintaining adequate urinary drainage
• Urinary catheters are used to
 Maintain urine flow
 Divert urine flow to facilitate healing postoperatively
 Introduce medications via irrigation
 Dilate or prevent narrowing of some portions of the
urinary tract
 May be used for intermittent or continuous drainage
Tract Disorders
 Maintaining adequate urinary drainage
• Urinary catheters may be introduced into the bladder,
ureter, or kidney.
• The type and size of urinary catheter used are
determined by the location and cause of the urinary
tract problem.
• Catheters are measured by the French system (Fr).
• Urethral catheters range in size from 14 to 24 Fr for
adult patients.
• Ureteral catheters are usually 4 to 6 Fr and must be
inserted by a physician.
Tract Disorders
• Types of Catheters
 Coudé catheter
• Selected for ease of insertion when enlargement of the
prostate gland is suspected
 Foley catheter
• Designed with a balloon near the tip so that the balloon
may be inflated after insertion, holding the catheter in
the urinary bladder for continuous drainage
Tract Disorders
• Types of Catheters (continued)
 Malecot, Pezzer, and Mushroom catheters
• Used to drain urine from the renal pelvis of the kidney
 Robinson catheter
• Has multiple openings in its tip to facilitate intermittent
drainage
 Ureteral catheter
• Are long and slender to pass into the ureter
Figure 20-18
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Different types of commonly used catheters.

Tract Disorders
 Whistle-tip catheter
• Has a slanted, larger orifice at its tip to be used if there
is blood in the urine
 Cystostomy, vesicostomy, or suprapubic catheters
• Introduced through the abdominal wall above the
symphysis pubis
• Used to divert urine flow from the urethra to treat injury
to the bony pelvis, urinary tract, or surrounding organs;
strictures; or obstructions
• Inserted via a surgical incision or puncture of the
abdomen and bladder walls with a trocar
Tract Disorders
 Condom catheters
• This device is not a catheter but a drainage system
connected to the external male genitalia.
• It is used for the incontinent male to minimize skin
irritation from urine.
Figure 20-19
St. Louis: Mosby.)
A, Condom catheter. B, Condom catheter attached to leg bag.
Figure 20-21
(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis:
Mosby.)
Drainage system must be below the level of the bladder.
Tract Disorders
• Self-Catheterization
 This is used for the patient who experiences spinal
cord injuries or other neurological disorders that
interfere with urinary elimination.
 Intermittent self-catheterization promotes independent
function for the patient.
Tract Disorders
• Routine Catheter Care
 Perineal care and the cleansing of the first 2 inches of
the catheter every 8 hours are expected at minimum.
 The use of powders or lotions on the perineum is
contraindicated.
 Assess the urethral meatus and surrounding tissues
for inflammation, swelling, and discharge. Note
amount, color, odor, and consistency of discharge.
Tract Disorders
• Routine Catheter Care (continued)
 The urinary tubing and collection bag should be
changed only if there are signs of leakage, odor, or
sediment buildup.
 Check the drainage tubing and bag to ensure that no
tubing loops hang below the level of the bladder, that
the tube is coiled and secured onto the bed linen, and
that the tube is not kinked or clamped.
Figure 20-22
St. Louis: Mosby.)
Empty and record urine output from Foley catheter into clean
graduated container.
Tract Disorders
• Bladder Training
 Involves developing the use of the muscles of the
perineum to improve voluntary control over voiding;
may be modified for different problems.
 In preparation for the removal of a urethral catheter,
the physician may order a clamp/unclamp routine to
improve bladder tone.
 For the patient with stress incontinence, instruct to
perform Kegel exercises.
 For habit training, a voiding schedule is established.
Tract Disorders
• Managing Incontinence
 Urinary incontinence occurs because pressure in the
bladder is too great or because the sphincters are too
weak.
 Kegel exercises
 Bladder training
 Credé’s method
 Disposable adult undergarments or underpads
Tract Disorders
• Discontinuing an Indwelling Catheter
 An indwelling catheter must be removed or changed
after a certain period of time.
 It may be removed and replaced by a new catheter or
removed and the patient allowed to excrete urine via
the normal route.
Disorders
• Inserting and Maintaining Nasogastric Tubes
 Nasogastric tube is a pliable tube that is inserted
through the patient’s nasopharynx into the stomach.
 The tube allows for removal of gastric contents and
introduction of liquids into the stomach.
 The primary purpose is decompression or removal of
flatus and fluids from the stomach.
 Nursing challenges: patient comfort and maintaining
patency of the tube
Figure 20-24
St. Louis: Mosby.)
A, Small-bore feeding tube. B, Salem sump tube.
Disorders
• Bowel Elimination
 Elimination of bowel waste (defecation) is a basic
human need and is essential for normal body function.
 Normal bowel elimination depends on several factors:
a balanced diet, including high-fiber foods; a daily fluid
intake of 2000 to 3000 mL; and activity to promote
muscle tone and peristalsis.
 Normal stool (feces) is described for documentation
as moderate in amount, brown, and soft in
consistency and is expelled every 1 to 3 days.
Disorders
• Care of the Patient with Hemorrhoids
 The patient with hemorrhoids has pain when
hemorrhoidal tissues are directly irritated from the
passage of hard stool.
 The primary goal for the patient with hemorrhoids is
soft, formed stools.
 Proper diet, fluids, and regular exercise improve the
likelihood of soft stools.
 Local heat provides temporary relief to swollen
hemorrhoids; sitz bath is the most effective means of
heat application.
Disorders
• Flatulence
 This is the presence of air or gas in the intestinal tract.
 It may occur when a person consumes gas-producing
liquids and foods, such as carbonated beverages,
cabbage, or beans; swallows excessive amounts of
air; or has constipation.
 In hospitalized patients, flatulence is often caused by
decreased peristalsis, abdominal surgery, some
narcotic medications, and decreased physical activity.
Disorders
• Flatulence (continued)
 May cause distention of the stomach and abdomen
and mild to moderate abdominal cramping and pain
 One of the most effective measures to promote
peristalsis and passage of flatus is walking
 Rectal tube may be used
Disorders
• Administering an Enema
 This involves the instillation of a solution into the
rectum and sigmoid colon.
 Primary reason for an enema is promotion of
defecation.
 The volume and type of fluid instilled can lubricate or
break up the fecal mass, stretch the rectal wall, and
initiate the defecation reflex.
 Patients should not rely on enemas to maintain bowel
regularity because enemas do not treat the cause.
 Frequent enemas disrupt normal defecation reflexes,
resulting in dependency on enemas for elimination.
Disorders
• Fecal Incontinence
 The first step in care of the patient with fecal
incontinence is to assess whether fecal impaction is
the cause.
 An impaction involves the presence of a fecal mass
too large or hard to be passed voluntarily.
 Either constipation or diarrhea can suggest the
presence of an impaction.
 An oil retention enema lubricates the rectum and
colon, softens the feces, and facilitates defecation.
 It can be used alone or with manual removal of a fecal
impaction.
Disorders
• Ostomies
 Colostomy
• A surgical creation of an artificial anus on the abdominal
wall formed by incising the colon and bringing it out to
form a stoma on the abdominal surface
• Performed for patients with cancer of the colon,
intestinal obstructions, intestinal trauma, or
inflammatory diseases of the colon
• May be permanent or temporary until intestinal healing
occurs
Disorders
• Ostomies (continued)
 Ileostomy
• A surgical formation of an opening of the ileum onto the
surface of the abdomen through which fecal matter is
emptied
• Performed for patients with inflammatory bowel
conditions and cancer of the large intestine
• Stoma looks like a colostomy, but it is smaller and
located lower on the abdomen
• Patient wears a pouch to collect the semiliquid fecal
matter
Figure 20-25
St. Louis: Mosby.)
Ostomy pouches and skin barriers.

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Chapter 20

Selected Nursing Skills

• Before the Skill (continued)

• Before the Skill (continued)

• During the Skill

• Completion of Procedure (continued)

Removing disposable gloves.

• The nurse should

• Local Effect of Heat and Cold

• Local Effect of Heat and Cold (continued)

• Moist or Dry Applications

Assess condition of exposed skin and wound on which compress is

Whirlpool moist heat therapy.

• Commercial Hot Packs

• Cold Moist and Dry Compresses

Commercial cold pack used for therapy.

• Ice Bags or Collars

Common intravenous sites. A, Dorsal surface of the hand. B, Inner

B, Select intravenous site.

C, Cleanse site for venipuncture.

D, Pull skin taut as catheter is inserted.

B, Remove insertion port cover.

A, Opened blood administration set and tubing primed with normal

B, Attached blood product to the normal saline 0.9%.

• Oxygen Therapy (continued)

• Oxygen Therapy (continued)

A transtracheal catheter may be inserted into the trachea between

• Oxygen Therapy (continued)

• Oxygen Therapy (continued)

• Oxygen Therapy (continued)

A, Trach tube (fenestrated) with inner cannula removed and cap in

Different types of commonly used catheters.

A, Condom catheter. B, Condom catheter attached to leg bag.

Drainage system must be below the level of the bladder.

A, Small-bore feeding tube. B, Salem sump tube.

Ostomy pouches and skin barriers.

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