TOPIC OUTLINE
Advanced Cardiac System Care
Applying a Cardiac Monitor
Administering a Blood Transfusion
Advanced Respiratory System Care
Measuring Arterial Oxygen Saturation
Care of a Patient with a Chest Drainage System
Measuring Output from a Chest Drainage System
Care of Patient With Sensorineural Disorders
Administering an Eye Irrigation
Administering an Ear Irrigation
Care of a Client With Hearing Aid
Care of a Client With Eye Prosthesis
Care of Patient With Neurological System Disorders
Assessing the Neurological System
Assessing Level of Consciousness Using the Glasgow Coma Scale
Assessing the Patients Mental Status
Assessing Cranial Nerves
Assessing Deep Tendon Reflexes
Care of Patient With Integumentary System Disorders
Assisting with Hydrotherapy for Burn Injury
Care of Patient with Burn Injury (Closed Method)
Care of Patient with Burn Injury (Open Method)
Care of Patient With Renal System Disorders
Administering a Continuous Closed Bladder Irrigation
Caring for a Patients Vascular Access on Hemodialysis
Caring for a Patients Peritoneal Dialysis Catheter
Care of Patient With Musculoskeletal System Disorders
Assessing the Musculoskeletal System
Caring for a Patient in Skin Traction
Caring for a Patient in Skeletal Traction
Care of Patient With Immobilization Device (Cast, Splint, or Collar Brace)
Applying a Sling
Assisting With Cast Application
Caring for a Cast
Care of a Patient During Cast Removal
ADVANCED CARDIAC
SYSTEM CARE
Cardiac monitor
Lead wires
Pregelled (gel foam) electrodes (number varies from 3 to 5)
Soap and water if necessary
Gauze pads
PPE, as indicated
Assessment:
1. Review the patients medical record and plan of care for information about the patients need for cardiac
monitoring.
2. Assess the patients cardiac status, including heart rate, blood pressure, and auscultation of heart sounds.
3. Inspect the patients chest for areas of irritation, breakdown, or excessive hair that might interfere with
electrode placement.
4. Electrode sites must be dry, with minimal hair.
5. The patient may be sitting or supine, in a bed or chair.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
Steps:
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
b.
c.
d.
e.
4
Electrocardiogram (ECG)
Respirations/impedance pneumography via the ECG leads
Intermittent noninvasive blood pressure (NIBP)
Oxyhemoglobin saturation (SpO2)
pEtCO2 (partial pressure of end-tidal CO2, capnography)
Body temperature
Intra-arterial pressure
5
6
Electrode Name
Color
Position
RA
White
Right Arm
LA
Black
Left Arm
LL
Red
Left Leg
RL
C
Green
Brown
Right Leg
Central Chest
Over Sternum
System/
Configuration
3 Electrode
5 Electrode
3 Electrode
5 Electrode
3 Electrode
5 Electrode
5 Electrode
5 Electrode
Electrode system:
a. 3-lead/electrode (red, yellow, green) or (red, yellow, black) - choice of limb leads
c. 5-lead/electrode (red, yellow, green, black, white) - limb leads plus a chest lead (using the white
wire, usually placed in the V1 position)
Electrode Name
RA
LA
LL
RL
C
Color
USA
White
Black
Red
Green
Brown
10
Europe
Red
Yellow
Green
Black
White
9
10
11
12
13
14
11
15
Interpretation
Above 100
60-100
Below 60
Tachycardia (fast)
Normal (adult)
Bradycardia (slow)
12
Blood product
Blood administration set (tubing with in-line filter and Y for saline administration)
0.9% normal saline for IV infusion
Venous access; if peripheral site, preferably initiated with a 20-gauge catheter or larger
3 way stopcock
Clean gloves
IV infusion set
Additional PPE, as indicated
Tape (hypoallergenic)
Pressure infusion bag (optional)
13
Assessment:
1. Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output.
2. Review the most recent laboratory values, in particular, the complete blood count (CBC).
3. Ask the patient about any previous transfusions, including the number he or she has had and any reactions
experienced during a transfusion.
4. Inspect the IV insertion site, noting that the gauge of the IV catheter is a 20 gauge or larger.
Nursing Diagnosis:
1.
2.
3.
4.
5.
Action
Rationale
Steps
14
AB
A
B
O
X
X
X
X
X
X
X
X
Recipient
ABO blood
group
AB
A
B
O
X
X
X
X
AB
X
X
X
X
a.
Blood Type
Whole blood
Composition
Cells and plasma (hematocrit 40%)
b.
c.
Platelets
d.
e.
Cryoprecipitate
f.
g.
h.
Antihemophilic factor
Factor IX concentrate
Albumin
i.
Globulin/ Granulocyte
concentrate
Antithrombin
j.
Indication
Volume replacement and oxygen carrying capacity
(25% blood volume lost)
RBCs mass ,symptomatic anemia
Bleeding due to decreased platelets
Bleeding in patient with coagulation factor
deficiencies
von Willebrand disease, hypofibrinoginemia,
hemophilia A
IgG antibodies
Hemophilia A
Hemophilia B
Hypoproteinemia, burns, volume expansion by 5%
to 25%
Hypogammaglobulinemia, recurrent infection
Antithrombin III
15
5
6
(1) Blood chamber and filter; (2) Tube 3.0 x 4.0; (3) Precision Roller clamp; (4) Flashbulb; (5) Male
luer-lock; (6) Hypodermic needle
(1) Spike protector; (2) Vented spike for tubing; (3) Vented air cap; (4) On/Off roller clamp; (5)
Tube 3.0 x 4.0; (6) Chamber cover; (7) Blood chamber; (8) Blood filter; (9) Precision roller clamp;
(10) Flashbulb; (11) Male luer-lock and cap
16
17
10
11
12
13
14
15
18
19
ADVANCED
RESPIRATORY SYSTEM
CARE
20
21
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
Rationale
.
b. Check the proximal and capillary refill at
the pulse closest to the site.
22
.
Allow the area to dry. If necessary, remove nail
polish and artificial nails after checking pulse
oximeters manufacturer instructions.
6
23
Set the alarm limits for high and low pulse rate
settings.
10
11
12
24
13
Interpretation
Normal
Mild hypoxemia
Moderate hypoxemia
Severe hypoxemia
25
26
IMPLEMENTATION
Steps
3
Action
Follow Standard Protocol.
Rationale
27
Chest tube
28
29
30
10
31
pneumothorax.
11
13
14
15
32
Assessment:
1. Assess the patients vital signs. Significant changes from baseline may indicate complications.
2. Assess the patients respiratory status, including oxygen saturation level. If the chest tube is not
functioning appropriately, the patient may become tachypneic and hypoxic.
3. Assess the patients lung sounds. The lung sounds over the chest tube site may be diminished
due to the presence of fluid, blood, or air.
4. Assess the patient for pain. Sudden pressure or increased pain indicates potential complications.
In addition, many patients report pain at the chest tube insertion site and request medication
for the pain.
5. Assess the patients knowledge of the chest tube to ensure that he or she understands the
rationale for the chest tube.
Nursing Diagnosis
33
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE if indicated.
4
5
6
Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patients privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Maintains privacy.
Prevents any leakage of air into the closed system.
34
35
8
9
10
36
37
Assess the patients eyes for redness, erythema, edema, drainage, or tenderness.
Assess the patient for allergies.
Verify patient name, dose, route, and time of administration.
Assess the patients knowledge of the procedure. If patient has a knowledge deficit about the procedure, this
may be an appropriate time to begin patient education.
5. Assess the patients ability to cooperate with the procedure.
Nursing Diagnosis:
1. Deficient Knowledge
2. Acute Pain
3. Risk for Injury
IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
indicated.
4
39
40
10
11
12
13
14
15
a. To clean the external auditory canal (e.g. certain foreign bodies and accumulation of cerumen) or
apply heat in the ear canal. To instill otic medication.
Equipment:
Assessment:
1.
2.
3.
4.
5.
6.
Assess the affected ear for redness, erythema, edema, drainage, or tenderness.
Assess the patients ability to hear.
Assess the patient for allergies.
Verify patient name, dose, route, and time of administration.
Assess the patients knowledge of medication and procedure.
If the patient has a knowledge deficit about the medication, this may be an appropriate time to begin
education about the medication.
7. Assess the patients ability to cooperate with the procedure.
Nursing Diagnosis:
1. Acute Pain
2. Impaired Skin Integrity
3. Risk for Injury
4. Deficient Knowledge
42
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
43
44
10
11
12
13
45
46
IMPLEMENTATION
Steps
Action
Rationale
47
6
7
Hold the hearing aid so that the canallong portion with holes is in the bottom.
Use other hand to pull-up and back on
outer ear gently push aid into ear until it
is in place.
Adjust volume gradually to comfortable
level for talking.
9
10
49
50
IMPLEMENTATION
Steps
3
Action
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
indicated.
4
5
7
8
Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
10
11
12
13
Prevents dislodgement.
14
15
52
53
54
IMPLEMENTATION
Steps
3
Action
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
This ensures that the correct intervention is
performed on the correct patient.
e. Perform hand hygiene and put on PPE, if Hand hygiene prevents the spread of
indicated.
microorganisms.
Place the patient in a comfortable position This ensures comfort.
(sitting, lying or standing).
Assess the patients behavior, noting:
a. Facial expression observe
variations in facial expression;
55
Suggests obsession.
Suggests amnesia.
10
Interpretation
No muscular contraction or complete paralysis
A barely detectable or palpable muscular
contraction or partial paralysis.
Active movement of body part with gravity
eliminated, or cannot raise body
part/weakness.
Active movement against gravity, or can raise
and lower body part.
Active movement against gravity and some
resistance, or can raise body part with minimal
strength to push and pull.
Active movement against gravity and
full/strong resistance, or normal.
e. Flexion and extension of limbs (Select as Symmetric weakness of the proximal muscles
indicated.)
suggests a myopathy or muscle disorder.
Symmetric weakness of distal muscles suggests a
polyneuropathy, or disorder of peripheral nerves.
Upper Limbs:
comparison.
legs together.
61
11
62
63
64
Point-to-point movements:
12
Dermatome Map
66
13
70
c. Meningeal Signs:
71
14
Loss of the anal reflex suggests a lesion in the S2-S3S4 reflex arc, as in a cauda equina lesion.
72
15
73
74
a. To assess neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or
illness.
Equipment:
Clean gloves
Pen
Paper
Assessment:
1. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
2. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and
ongoing manner.
Nursing Diagnosis:
1. Ineffective airway clearance related to altered level of consciousness (LOC)
2. Risk of injury related to decreased LOC
3. Disturbed sensory perception related to neurologic impairment
Implementation
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right patient
c. Introduce yourself and explain the procedure.
receives the intervention and helps relive anxiety.
d. Provide privacy and position comfortably.
This ensures the patients privacy.
e. Perform hand hygiene and put on PPE if indicated. Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
4
Determine level of arousal using the Glasgow Coma
To assess brain stem function.
Scale. (Skip steps 7 to 13 if cannot be assessed.)
5
Assess eye opening:
To evaluate arousal.
a. Score 4: eyes open spontaneously;
b. Score 3: eyes open to speech;
c. Score 2: eyes open in response to pain only, for
example trapezium squeeze (caution if applying a
painful stimulus);
d. Score 1: eyes do not open to verbal or painful
stimuli.
e. Record C if the patients eyes are closed, or
unable to open his or her eyes because of swelling,
ptosis (drooping of the upper eye lid) or a
75
dressing.
Assess verbal response:
a. Score 5: orientated;
b. Score 4: confused;
c. Score 3: inappropriate words;
d. Score 2: incomprehensible sounds;
e. Score 1: no response. This is despite both verbal
and physical stimuli.
f. Record D if the patient is dysphasic and T if the
patient has a tracheal or tracheostomy tube.
Assess motor response:
a. Score 6: obeys commands. The patient can
perform two different movements;
b. Score 5: localizes to peripheral pain. The patient
does not respond to a verbal stimulus but
purposely moves an arm to remove
the cause of a central painful stimulus.
NOTE: A true localizing response to pain involves
the patient bringing an arm up to chin level.
Painful stimuli that can elicit this response include
trapezium squeeze, suborbital ridge pressure (not
recommended if there is a suspected/confirmed
facial fracture) and sternal rub (not recommended
in some organizations);
c. Score 4: withdraws from pain. The patient flexes
or bends the arm towards the source of the pain
but fails to locate the source of the pain (no wrist
rotation);
d. Score 3: flexion to pain. The patient flexes or
bends the arm; characterized by internal rotation
and adduction of the shoulder and flexion of the
elbow, much slower than normal flexion;
e. Score 2: extension to pain. The patient extends the
arm by straightening the elbow and may be
associated with internal shoulder and wrist
rotation;
f. Score 1: no response to painful stimuli.
76
To evaluate awareness.
8
9
10
11
To promote comfort.
To prevent transmission of infection.
This ensures continuity of care.
This ensures continuity of care.
Interpretation
Normal
Mild brain injury/Lethargy/Confusion/
Obtundation
Moderate brain injury/Stupor
Severe brain injury
Vegetative state (permanent)
Coma
Locked-in Syndrome (high cervical injury)
Brain death
77
a. To assess neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or
illness.
Equipment:
Clean gloves
Pen
Paper
Assessment:
3. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
4. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and
ongoing manner.
Nursing Diagnosis:
4. Ineffective airway clearance related to altered level of consciousness (LOC)
5. Risk of injury related to decreased LOC
6. Disturbed sensory perception related to neurologic impairment
Implementation
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right patient
c. Introduce yourself and explain the procedure.
receives the intervention and helps relive anxiety.
d. Provide privacy and position comfortably.
This ensures the patients privacy.
e. Perform hand hygiene and put on PPE if indicated. Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
4
Assess patients behavior. Note:
To assess general behavior.
a. Facial expression;
b. Posture;
c. Affect; and
d. Grooming.
5
Assess patient's orientation.
Generally for evaluation of mental status (Abnormal
a. Check orientation to time.
findings: Confusion, Delirium).
b. Check orientation to place.
c. Checks orientation to person.
6
Assess frontal lobe function. (Select applicable.)
To evaluate alteration in function of the frontal lobe
a. Attention: working memory (e.g. Ask client to
(Abnormal finding: Dementia).
recite series of digits, spell backwards, or name
months of the year backwards.)
78
10
11
12
13
14
15
80
81
CN I (olfactory nerve):
a. Ask the patient to close the eyes, occlude
one nostril, and then identify the smell of
different substances, such as coffee,
chocolate, or alcohol.
b. Repeat with other nostril.
82
identify them.
c. While patient looks up, lightly touch a wisp
of cotton against the temporal surface of
each cornea.
d. Have the patient clench and move the jaw
from side to side.
e. Palpate the masseter and temporal muscles,
noting strength and equality.
CN VII (facial nerve):
a. Ask the patient to smile, frown, wrinkle
forehead, and puff out cheeks.
83
84
85
86
Equipment:
Taylor/tomahawk
type (triangular
rubber)
PPE, as indicated
Large Hammers
Head oriented
horizontally
Head oriented
vertically
Assessment:
1. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
2. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a
systematic and ongoing manner.
Nursing Diagnosis:
1.
2.
3.
4.
88
Arm supported
Arm unsupported
89
Arm supported
Arm unsupported
Seated patient
Supine patient
91
Seated patient
Supine patient
92
93
10
11
12
Grade
0
1+
2+
3+
4+
Interpretation
No response
Diminished
Brisk, normal
Very brisk
Hyperactive, repeating (clonus)
94
To promote comfort.
Removing PPE reduces the risk for infection
transmission and contamination of other
items. Hand hygiene prevents the spread of
microorganisms. Additional assessments
should be completed, as indicated, to
evaluate the patients health status.
Intervention by other healthcare providers
may be indicated to evaluate and treat the
patients health status.
For continuity of care plan among health care
team members.
95
Right
Left
96
97
Equipment:
Personal protective equipment (PPE): gown, gloves, mask, surgical cap, and shoe covers
Hydrotherapy tank (Hubbard tank)
Bath lifter/wheel chair
Dressing trolley
Gauze pads/Surgical sponge
Antiseptic surgical scrub (e.g. Chlorhexidine gluconate, Betadine)
Normal saline
Bandage scissors
Lund & Browders chart
Patient's gown
Assessment:
Monitor vital signs frequently.
Nursing Diagnosis:
1. Impaired Skin Integrity
2. Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn
wound
3. Acute/Chronic Pain
4. Hypothermia related to loss of skin microcirculation and open wounds
5. Anxiety related to fear and the emotional impact of burn injury
6. Risk for Deficient Fluid Volume
7. Risk for Infection
8. Risk for Imbalanced Nutrition: Less than body requirements
9. Ineffective Protection
98
Implementation
Action
Steps
4
5
6
7
9
10
11
99
Rationale
12
13
14
15
100
101
102
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Implementation
Steps
Action
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
4
5
6
7
10
11
104
12
13
105
microorganisms.
To assess patients transition to floor status.
Replacing fluid that is lost helps prevent / treat
deficient fluid volume.
For continuity of care plan among health care
team members.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
106
Implementation
Steps
3
Action
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
10
11
107
12
13
108
109
110
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient receives
the intervention and helps relive anxiety.
d. Provide privacy.
e. Perform hand hygiene and put on PPE.
4
5
6
111
8
9
10
11
12
13
14
112
15
113
Rationale
e.
5
6
7
8
10
116
117
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patients privacy.
Hand hygiene prevents the spread of microorganisms.
Having the bed at the proper height prevents back and
muscle strain.
b. Assist the patient to a supine The supine position is usually the best way to gain
access to the peritoneal dialysis catheter.
position.
5
6
10
11
12
13
14
15
IMPLEMENTATION
Steps
3
Action
Follow Standard Protocol.
f. Verify or Check Doctors
Order.
g. Identify the patient.
Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
Provide privacy.
j.
RANGE
OF
MANEUVERS
MOTION
AND
The Shoulders:
INSPECTION
a. Observe the shoulder and Scoliosis may cause elevation of one shoulder. With
inspect the scapulae. Note any anterior dislocation of the shoulder, the rounded
swelling, deformity, or muscle lateral aspect of the shoulder appears flattened.
atrophy.
PALPATION
b. If there is a history of shoulder
pain, ask the patient to point
to the painful area and palpate
it to identify the structures
involved.
RANGE
OF
MOTION
AND
MANEUVERS
c. Ask
the
patient
to Inability to perform these movements may reflect
demonstrate the following for weakness or soft-tissue changes from bursitis,
shoulder girdle ROM: flexion, capsulitis, rotator cuff tears or sprains, or tendinitis.
extension,
abduction,
adduction, internal (medial)
and external (lateral) rotation
and circumduction.
The Elbow:
INSPECTION AND PALPATION
a. Inspect the contours of the
elbow, note any nodules or
swelling.
b. Palpate the olecranon process
and press for tenderness and
note
any
displacement,
swelling and thickening.
RANGE
OF
MOTION
AND
MANEUVERS
c. Ask the patient to exhibit
flexion and extension at the
elbow and pronation and
supination of the forearm.
10
The Spine:
INSPECTION
a. Observe the patients posture. In scoliosis, there is lateral and rotator curvature of the
spine to bring the head back to midline. Scoliosis often
Examine spinal curvatures.
becomes evident during adolescence, before
symptoms appear.
PALPATION
b. Palpate the spinous processes Tenderness suggests fracture or dislocation if
of each vertebra with the preceded by trauma, underlying infection, or
arthritis. Tenderness occurs with arthritis, especially at
thumb.
c. Inspect and palpate the para- the facet joints between C5 and C6.
vertebral
muscles
for
RANGE
OF
MOTION
AND
MANEUVERS
e. Assess range of motion in the
spinal column.
f. Flexion. Ask the patient to
bend forward to touch the
toes.
g. Extension. Ask the patient to
bend backward.
h. Rotation. Rotate the trunk by
pulling the shoulder and then
the hip posteriorly.
11
The Hip:
INSPECTION
a. Observe the patients gait Changes in leg length are seen in abduction or
adduction deformities and scoliosis. Leg shortening
while entering the room.
b. Observe the lumbar for and external rotation suggest hip fracture.
lordosis.
c. Inspect the hip for any areas
of muscle atrophy or bruising.
PALPATION
d. On the anterior surface locate
the iliac crest, the iliac
tubercle, and the anterior
superior iliac spine.
e. On the posterior surface
identify the posterior superior
iliac spine, the greater
trochanter,
the
ischial
tuberosity, and the sciatic
nerve.
RANGE
OF
MOTION
AND
MANEUVERS
f. Flexion. Ask the patient to
bend each knee in turn up to
the chest and pull it firmly
against the abdomen.
g. Extension. Extend the thigh
toward you in a posterior
direction.
h. Hyperextension.
i. Abduction. Grasp the ankle
and abduct the extended leg
until you feel the iliac spine
move.
j. Adduction. Move the leg
Abduction
Adduction
Rotation
12
13
RANGE
OF
MOTION
AND
MANEUVERS
e. Range of motion at the ankle
joint includes dorsiflexion and
plantar flexion. While in the
foot, inversion and eversion.
14
4
5
Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patients privacy.
Hand hygiene prevents the spread of microorganisms.
Assessing pain promote patient comfort.
10
11
12
14
15
13
Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)
Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled
Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent
Sensation
Motion
Normal
Tingling
Decreased
Absent
Full
Decreased
Absent
Painful
Immobile
Skin Temperature
Warm
Cool
Cold
Hot
1. Assess the patients medical record, physicians orders, and the nursing plan of care to determine the
type of traction, traction weight, and line of pull.
2. Assess the traction equipment to ensure proper function, including inspecting the ropes for fraying and
proper positioning.
3. Assess the patients body alignment.
4. Perform skin and neurovascular assessments.
5. Assess for complications of immobility, including alterations in respiratory function, skin integrity,
urinary and bowel elimination, and muscle weakness, contractures, thrombophlebitis, pulmonary
embolism, and fatigue.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8. Acute Pain
9. Impaired Physical Mobility
10. Risk for Impaired Skin Integrity
11. Self-Care Deficit (bathing, feeding, dressing, or toileting)
IMPLEMENTATION
Steps:
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient receives
b. Identify the patient.
c. Introduce yourself and explain the the intervention and helps relive anxiety.
procedure.
d. Provide privacy.
This ensures the patients privacy.
Hand hygiene prevents the spread of microorganisms.
e. Perform hand hygiene and put on
PPE, if indicated.
4
Perform a pain assessment and assess Assessing pain and administering analgesics promote
for muscle spasm.
patient comfort.
6
7
10
11
or purulent drainage.
c. Check for elevated body
temperature.
d. Check for elevated pin site
temperature.
e. Check for bowing or bending of the
pins.
Provide pin site care.
a. Using sterile technique, open the
applicator package and pour the
cleansing agent into the sterile
container.
b. Put on sterile gloves.
c. Place the applicators into the
solution.
d. Clean the pin site starting at the
insertion area and working
outward, away from the pin site.
e. Use each applicator once.
f. Use a new applicator for each pin
site.
12
13
14
15
Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)
Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled
Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent
Sensation
Motion
Normal
Tingling
Decreased
Absent
Full
Decreased
Absent
Painful
Immobile
Skin Temperature
Warm
Cool
Cold
Hot
Care of Patient With Immobilization Device (Cast, Splint, or Collar Brace/Cervical Orthosis)
Purpose(s):
a. To prevent complication specific to immobility.
Equipment:
Commercial collar brace
Cotton bandage (e.g. Webril) for padding
Plaster slabs or rolls or prepadded fiberglass splint material (e.g. OCL and Orthoglass) of various widths
(2, 3, 4, and 6 inches)
Room temperature water
Elastic bandage (e.g. Ace bandage)
Medical adhesive tape
Assessment:
1. Assessment of the patients general health, presenting signs and symptoms, emotional status and
understanding of the need for the device and condition of the body parts to be immobilized.
2. Physical assessment of the body parts to be immobilized must include neurovascular assessment, pain and
skin abrasions.
3. The nurse gives the patient information about the underlying pathologic condition and the purpose and
expectation of the prescribed treatment regimen.
Nursing Diagnosis:
1.
2.
3.
4.
5.
IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE.
Rationale
This ensures that the correct intervention is performed on
the correct patient.
Identifying the patient ensures the right patient receives the
intervention and helps relive anxiety.
This ensures the patients privacy.
5
6
9
10
Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)
Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled
Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent
Sensation
Motion
Normal
Tingling
Decreased
Absent
Full
Decreased
Absent
Painful
Immobile
Skin Temperature
Warm
Cool
Cold
Hot
Applying a Sling
Purpose(s):
a. To provide support for an arm or immobilize an injured hand.
Equipment:
Commercial arm sling
ABD (adhesive bandage) gauze pad
Nonsterile gloves and/or other PPE, as indicated
Assessment:
1.
2.
3.
4.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
IMPLEMENTATION
Steps:
Action
Rationale
8
9
10
11
1. Assess the skin condition in the affected area, noting redness, contusions, or open wounds.
2. Assess the neurovascular status of the affected extremity, including distal pulses, color, temperature,
presence of edema, capillary refill to fingers or toes, and sensation and motion.
3. Perform a pain assessment. (If the patient reports pain, administer the prescribed analgesic in sufficient
time to allow for the full effect of the medication.)
4. Assess for muscle spasms. (Administer the prescribed muscle relaxant in sufficient time to allow for the
full effect of the medication.)
5. Assess for the presence of disease processes that may contraindicate the use of a cast or interfere with
wound healing, including skin diseases, peripheral vascular disease, diabetes mellitus, and open or
draining wounds.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.
9. Deficient Knowledge
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on PPE.
5
6
7
Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patients privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Assessment of pain and analgesic administration
ensure patient comfort and enhance cooperation.
10
11
12
13
14
15
Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)
Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled
Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent
Sensation
Motion
Normal
Tingling
Decreased
Absent
Full
Decreased
Absent
Painful
Immobile
Skin Temperature
Warm
Cool
Cold
Hot
5
6
If bleeding or drainage is noted on the cast, mark Marking the area provides a baseline for
the area on the cast. Indicate the date and time monitoring the amount of bleeding or drainage.
next to the area.
10
11
12
13
14
Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)
Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled
Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent
Sensation
Motion
Normal
Tingling
Decreased
Absent
Full
Decreased
Absent
Painful
Immobile
Skin Temperature
Warm
Cool
Cold
Hot
1.
2.
3.
4.
5.
IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctors Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE.
4
6
7
Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patients privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Promotes patients safety. Plaster dust maybe
irritating to the eyes.
The mark will serve as guide in cutting the cast.
The thumb acts as a guard in front of the blade.
10
11
12
13
14
15
References
1. Lynn, P. (2011). Taylors clinical nursing skills: A nursing process approach (3rd ed). China: Lippincott
Williams & Wilkins, pp. 841-845.
2. Drew, B. J., et. al. (2004). Practice standards for electrocardiographic monitoring in hospital
settings. Circulation; 110: 2721-2746. doi: 10.1161/01.CIR.0000145144.56673.59
3. Davis, M. D., et. al. (1992). AARC clinical practice guideline: Sampling for arterial blood gas analysis.
Respiratory Care Journal; 8(37): 891897. doi: 10.4187/respcare.02786
4. Pamela Lynn, Taylor Clinical Nursing Skills, A Nursing Process Approach, 3rd Edition 2011, LWW