Nursing Art Class

UNIT NINE
MEDICATION ADMINISTRATION
Prepared by
Chalie,Ermias&Sheganew
8/8/17 BY CHALIE M. (BSC) 1

Medication administration
Drug:-is any substance that alters the physiologic function
of the body, with the potential of affecting health.
Medication: -is a drug that is used for therapeutic/curative
purpose.
Therapeutic agents are drugs or medications
that, when introduced in to living organism,
modify the physiologic functions of that
organism.
The study that deals with chemicals that affects the bodys
functioning is called pharmacology.

Cont
Drug metabolism in the human body is
accomplished in four basic stages: absorption,
transportation, biotransformation, and
excretion.
For a drug to be completely metabolized, it
must first be given in sufficient concentration to
produce desired effect on body tissues.
When this Critical drug concentration level is
achieved, body tissue change
MECHANISM OF DRUG ACTION
. PHARMACODYNAMICS
Drugs act at the cellular level to achieve their desired effect.
The process by which drugs alter the cell physiology is called
pharmacodynamics.
One of the mechanisms of drug action is a drug receptor
interaction.
The drug fits the receptor sites as the key fits the lock.
Drugs may also combine with enzymes to achieve the expected
effect, which is referred to as drug enzyme interaction.
Some drugs act on cell membrane or alter the cellular
environment.

Cont
. PHARMACOKINETICS
Pharmacokinetics is the study of the movement of drug molecule in the
body in relation to drugs absorption, distribution, metabolism and
excretion.
Absorption:-is a process by which a drug is transferred from its site of
entry into the body to the blood stream.
Distribution:-after it has been absorbed into the blood stream; the
drug is distributed throughout the body.
Metabolism:-metabolism or biotransformation is the breakdown of
the drug to an inactive form in the liver.
Excretion:-after it is broken down into inactive form, elimination of
the drug from the body occurs. Most drugs are excreted by the kidney

FACTORS AFFECTING DRUG ACTION
Age:-infants or children are more responsive to medication
because of the immaturity of their organs, so they
accommodate only small dose. Older people are also very
responsive because of aging.
Sex: - this is due to the difference in body fat and fluid
content between male and female that will affect absorption
and distribution of drugs and also may be due to hormonal
fluctuation/variation.
Weight:-wt and body surface area can affect drug action.
Genetic:-differences in ethnic or racial group may give
different response to the same medication.

ADVERSE DRUG EFFECT
Therapeutic effect is the desired effect in
medication administration.
Drug reaction may be unpredictable and harmful.
Adverse effects are effects that are not intended
or desired.
Side effects are effect of the drug that are
expected but less than the benefit.
Written instructions encourage patients
compliance with medication regimen.
Parts of the medication order
The medication order consists of seven parts. These
are:
Clients name
Date & time of the order
Name of the drug to be administered
Dosage of the drug
Route by which the drug is to be administered
Frequency of administration
Signature of a person writing the order
Nomenclature of drugs
One drug can have several names. These include:
The chemical name:-is a precise description of
a drugs chemical composition; it identifies the
drugs atomic & molecular structure.
The generic name: - is the name designed by
the manufacturer that first develops the drug.
Often the generic name is derived from the
chemical name.

Cont
The official name:-is the name by which the drug
is identified in the official publication.
Eg.TrimethoprimSulfamethoxazole (TMPSMZ)
The trade name(brand name or proprietary
name), is selected by the drug company that sells
the drug & is copyrighted. A drug can have
several trade names when produced by different
manufacturers.
Eg. Bactrim, Co-Trimoxazole, Septra.
Classifications of drugs
Drugs can be classified from d/t perspectives.
For example;
By body system affected by the drug(drugs that
affect the respiratory system, the cardiovascular
system),
By the symptom relieved by the drug (antipain,
analgesics),
By the clinical indications for the drug (antibiotics,
antifungal )

Common abbreviations used in drug
administration
Abbreviations meanings
Po ..by mouth
bid twice a day
acbefore meal
tid .... three times a day
Pc ..after meal
hs at bed time
Qd .every day
prn .as needed
Qod every other day
OD .right eye
Qid .....four times a day

Cont
os ...................left eye
ou both eyes
Q2h every 2 hours
Qhr ...every hour
am . in the morning
Pm ...after noon
IVIntravenous
IM.Intramuscular
ID.Intradermal
SC.Subcutaneous
Statonce onlly
KVOkeep vein open

TYPES OF PREPARATION
Medications are prepared in various forms.
The most desirable form of medication for any client
is determined by the disease process being
treated, age of the person, ability of the client to
swallow etc.
Accordingly, there are
oral preparation
topical preparation
parentral preparation, etc.
Cont
. Oral preparation:-these are medications prepared to be
swallowed by mouth. There are different forms of oral
preparation.
Capsule:-small hollow digestible case usually made of
gelatin, filled with a drug to be swallowed by the patient.
Tablets - a small disc or flat round piece of dry drug
containing one or more drugs made by compressing a
powdered form of drug(s)
Emulsion-oil based preparation
Enteric coated- prepared to be dissolved and absorbed in
the intestine.

Cont
Lozenges-sweet medicinal tablet containing sugar that dissolve
in the mouth so that the medication is applied to the mouth and
throat
Powder-finely ground drugs
Syrup-sugar containing medicine dissolved in water
Suspension-liquid medication with undissolved
solid particles in it and should be shacked before administration.
Elixir-liquid form of drug
Effervescence - drugs given of small bubbles of gas.
Gargle - mildly antiseptic solution used to clean the mouth or
throat.

Cont
2. Topical preparation (externally):- drugs to be applied directly
to the skin or mucus membrane. There are d/t types of topical
preparation:
Cream=non greasy/oily, semi solute preparation
Ointment=semi solute than cream, for external use on skin,
conjunctiva, etc.
Paste=thicker & stiffer than ointment
Lotion=clear, suspension, emollient liquid
Gel or jelly=clear, translucent form.
Suppository=prepared to be inserted through the rectum/
anus, & vagina

3. Parentral preparation: - prepared to be injected
using needle.
Glass capsule:-contain liquid drugs
Vials (glass bottle):-may contain powder dissolved
before administration
Ampoule:-glass flask/container containing a single

dose medication for parentral administration.
DRUG MEASUREMENT SYSTEM
1. The metric system:-the metric system of drug
measurement system is the most widely
accepted and convenient/suitable method.
The basic units of measurement are meter
(linear), liter (volume) & gram (weight). The
metric system is the decimal system in which
each unit can be divided into multiples of 10.

Cont
2. The apothecary system:-less convenient &
precise than the metric system and infrequently
used.
In this system the basic unit of weight is the grain.
The minim, dram, ounce, pint, & quart are used
for volume.
In this system Roman numerals are used to
express numbers (grain x )and quantities less
than one are written in fraction form (grain )
Cont
3. The household system:-used when accurate
systems of measurements are not required,
because it is the least accurate one. Units of
measurement include: drops, teaspoon,
tablespoon, teacup, cups, glasses, etc.

Approximate metric system equivalents
Metric Apothecary Household

5 ml 1 fluid dram 1 teaspoonful
10 ml 2 fluid drams 1 dessertspoonful
15 ml 4 fluid drams 1 tablespoonful
30 ml 1 fluid ounce 1 ounce

Drug Dose Calculations
Several formulas may be used when calculating drug
doses.
One formula uses ratios based on the dose on hand and
the dose desired.
Dose on hand Dose desired
Quantity on hand Quantity desired
Eg. If a health care practitioner wants to administer
Amoxicillin 625 mg po TID and the dose preparation is
250mg/5ml solution how much volume would you
administer
Cont
Answer:
Dose on hand= 250mg
Quantity on hand= 5ml
Dose desired = 625mg
Quantity desired =?
Dose on hand Dose desired
Quantity on hand Quantity desired
Quantity desired= DD QOH = 625mg 5ml
DOH 250 mg
=12.5 ml
Pediatric Dosages
The body surface area method of determining pediatric
doses is based on the body surface area of an adult
weighing 150 lb.
The body surface area of an adult weighing 150 lb. is
1.73 square meters.
The approximate child dose is calculated as
approximate child dose

= Body surface area of child adult dose
Body surface area of adult
Cont
approximate child dose =
Body suface area of child (M) adult dose
1.73 m
A most commonly used formula is Clarks formula for children
2years or younger. This formula assumes that the average
adult weight is 150lb (68kg) and is calculated as follows.
Child dose =
wt of child in pound Usual adult dose
150pound

Intravenous medication calculation
IV flow rates are calculated in drops/min.
To calculate IV drip rate you can use the following
formula.
Drops per min.=
amount of solution(ml) drip rate factor gtt/ml
time in minute
1ml= 15-20 gtt/ml drop, this is the drip rate factor.
So use 15 gtt/ml for adult size cannula(green)
20 gtt/ml for pediatrics size cannula(yellow)
Cont
Q. If you want to administer 1 liter of normal saline for an
admitted adult over 8 hour, what will be the drop per minute to
administer the solution over the given time.
Soln. Amount of solution= 1liter= 1000ml
Time given = 8 hr= 480min.
Drops per min.=
amount of solution(ml) drip rate factor
time in minute
Drops per min.= 1000ml 15 gtt/ml
480min
=31.25~31drop/min

Maintaining safety when administering
medication
Safety is of the most importance in preparing and
implementing drug administration.
The nurse observes the three checks and the five rights when
administering medication.
The three checks:-the label on the medication container should
be checked three times during medication preparation.
When the nurse reaches for container or unit dose package.
Immediately before pouring or opening the medication and
When replacing the container to the drawer or shelf or prior
to giving the unit dose to the client.

The six rights of medication administration
The six rights ensure accuracy when administering medications.

These five rights are:
Right client/pt
Right drug/medication
Right dosage
Right route
Right time
Right documentation
The nurse gives the right medication for a right client in a
right dosage through the right route at the right time and
keep right documentation.

Routes of drug administration
Pharmaceutical preparations are generally designed
for one or two specific route of administration.
The route of administration should be indicated
when the drug is ordered. When administering the
drug, the nurse should ensure that the
pharmaceutical preparation is appropriate for the
route specified. There are different routes of
administration.
These are

1. Oral(po)
Drugs given orally are intended for absorption in the
stomach & small intestine.
Advantage-
Most common & least expensive route
Most convenient &safest route for clients
Doesnt break skin barrier& doesnt cause stress.
Disadvantages
Unpleasant taste
GI- irritation
May discolor or harm the teeth
Cont
Purpose
a. When local effects on GI tract are desired
b. When prolonged systemic action is desired
Contra- indications
1. For a patient with nausea & vomiting, unconscious patients.
2. When digestive juices inactivate the effect of the drug.
3. When there is inadequate absorption of the drug, which
leads to inaccurate determination of the drug absorbed.
4. When the drug is irritating to the mucus membrane of the
alimentary canal

Sublingual and Buccal
Drug Administration
Sublingual and buccal drugs are types of oral
medications.
Certain drugs are given by these routes to prevent
their destruction or transformation in the stomach or
small intestines.
Drugs given by these routes are quickly absorbed by
the mucosas thin epithelium and the abundant blood
supply.
E.g. Nitroglycerine-a drug for treatment of angina
pectoris (severe chest pain)
Sublingual buccal

Enteral Instillation of Drugs
Enteral instillation is the delivery of drugs through a
gastrointestinal tube.
The nurse should crush the tablet into minute
particles and dissolve the crushed tablet in 15 to 30
ml of warm water before instillation unless
contraindicated.
Position the client as appropriate; clients with an NG
tube should be placed on the right side with the
head of the bed slightly elevated for at least 30
minutes after the instillation
2. Suppository
Administration of medication in to the anus
Purpose
To produce a laxative effect. (bowel
movement),suppository is used frequently instead of
enema since it is inexpensive.
To produce local sedative in the treatment of
hemorrhoids or rectal abscess.
To produce general sedative effects when medications
cannot be taken by mouth
To check rectal bleeding
Cont
Rectal suppositories are cone-shaped masses of
substances designed to melt at body temperature
and to produce the intended effect at a slow and
steady rate of absorption.
Suppositories provide a safe and convenient route
for administering drugs that interact poorly with
digestive enzymes or have a bad taste or odour.
They are also used to relieve nausea and vomiting.

Cont
Suppositories are also used to induce relaxation,
relieve pain and local irritation, reduce fever, and
stimulate peristalsis and defecation in clients who are
constipated
Rectal suppositories are contraindicated in
cardiac clients because insertion may stimulate the
vagus nerve, causing cardiac dysrhythmias (abnormal
heart patterns).
rectal or prostate surgery because they may cause
pain on insertion
Cont
With index finger of dominant hand, gently
insert suppository through anus, pass the
internal sphincter, and place against rectal
wall, 10 cm for adults or 5 cm for children and
infants.
Keep client flat on back or on side for 5 minutes.

Kinds of Suppositories Used
1. Bisacodyl is commonly ordered for its laxative
action. It stimulates the rectum and lubricates its contents.
Normally 15 minutes is needed to produce bowel
movement.
2. Glycerin or suppository for bringing about bowel
movement. If soap suppository is used cut a splinter of
soap 2-6 cm. loch and wash it in hot water to smooth the
rough edges before administration.
3. Bismuth - for checking diarrhea.
4. Opium, sodium barbital etc. for sedation

Vaginal Instillations
Medications inserted into the vagina are in the
form of suppositories, creams, gels,
ointments, foams, or douches.
These medications may be used to treat
inflammation, infections, and discomfort, or as
a contraceptive measure.
Sterile technique is usually required

3. Parentral route:
parentral means outside the intestine or alimentary canal.
Medications that are given by injection or infusion are called
parentral route.
These may be injected into ID, SC, IM, IV, intra lesional tissue,
intra spinal, etc.
Medications given by parentral route usually absorbed
completely and begin acting faster than medications given
by other routes.
These medications are given through the skin; bypassing the
skin barrier & makes infection more likely if aseptic
technique is not used

Syringes and Needles
Syringe Hypodermic needle

Draw up the medication.

A) Intradermal Injection
is administration of medication under epidermis, into
the dermis layer of the skin.
The drugs dosage for an ID injection is usually
contained in a small quantity of solution (0.01 to 0.1
ml).
The ID route has the longest absorption period (slow
absorption) of all parentral routes, for this reason, it
is used for diagnostic procedures, such as the
tuberculin skin test, and tests to determine
sensitivity to various substances , because the
bodys reaction to these substances is easily visible.
Sites commonly used are inner surfaces of
forearm(midway between the wrist and
.
elbow)Upper arm, at deltoid area for BCG

vaccination & the upper back.
The needle is inserted at 15 angle to the skin
for intradermal injection.

Equipments-
Tray
file
Receiver
A vial or ampoule of sterile medication
Vial of diluents (when necessary)
Alcohol swab
Dry sterile gauze
Marking pen
Sterile syringe and needle (1 cc syringe with short
bevel, 25 to 27 gauge needle)
Procedure-
Wash your hand
Collect necessary equipments
Refer the chart, be sure that you have the right
patient(follow the 6 rights)
Explain in the procedure to the patient
Remove the vial cap
Clean the rubber top of the vial with alcohol swab
Tighten needle with syringe remove needle guard
Pull back on plunger to fill syringe with an amount of
air equal to amount of solution to be with drawn.
Insert needle into up-right vial. Inject air into bevel
procedure. Cont..
Invert vial and extract/withdraw the desired
amount of medication (touching only syringe
barrel and plunger tip)
Expel any air bubbles
Recheck the amount of medication in the syringe
Turn vial in up-right position and remove needle
select the site of injection
get hold of the arm and locate the site of
injection

procedure. Cont..
Clean the area with an alcohol swab, using the
circular motion; cleanse the area from inside to out
side.
Group the patients arm and gently pull the skin taut
Place the needle close to the skin, side up.
Insert the needle at a 10 to 15 angle until
resistance is felt, and advance the needle
approximately 3 mm below the skin surface;
The needles tip should be visible under the skin.
Inject medication slowly and with draw the needle
Wipe the injection site gently with sterile gauze, do
8/8/17
not massage the area. BY CHALIE M. (BSC) 52
procedure. Cont..
Check for the immediate reaction of the skin
(10-15 minutes later for tetanus, 20-30
minutes later for penicillin).
Chart the date and time of administration of
the drug

B) Subcutaneous (SC) or hypodermic
is administration of medication into the
subcutaneous tissue, just below the skin.
Site of Injection
Outer part of the upper arm
The abdomen below the costal margin to the
iliac crest.
The anterior aspect of the thigh

SC cont..
The needle is inserted at 45 degree angle to
the body.
But the angle of needle insertion is
determined by the size of the needle, the
clients size, the amount of tissue that can be
grasped or bunched, etc.
For sc injection a 25 gauge needle is used, a
3/8 inch needle is inserted at 90 degree angle
for adult; and a 1/2 inch needle is inserted at
45 degree angle for a child.

SC cont
Sc injection sites need to be rotated in an
orderly fashion to minimize tissue damage, aid
absorption, and avoid discomfort for pts
receiving repeated doses.
This route is used to administer insulin, heparin,
adrenalin (0.5ml) and certain immunizations
(measles vaccine).
Ordinarily no more than 1ml of solution is given
subcutaneously.

Equipment -.
1. Disposable syringe and needle
2. Small tray
3. Medication
4. Ampoule of sterile water if medication must
be dissolved
5. Cotton balls soaked with alcohol.
6. File
7. Receiver

Procedure -
Wash hands
Collect necessary equipments
Explain the procedure to the patient
If medication is in ampoule, disinfect the neck of
the ampoule and the file with the cotton ball.
Fill ampoule at the base of neck and snap/break
top off, holding the cotton ball over neck to protect
fingers.
Carefully insert the needle into the ampoule, being
careful that it doesn't touch the glass, draw up
dosage ordered.
procedure. Cont..
If medication is to be mixed with water, open sterile
water for injection ampoule first as described above,
draw up required amount of water and mix well and
then draw up medication.
Expel the air from the syringe
Position the patient
Clean the site (usually it is in upper arms, thighs or
abdomen)
Grasp the area between your thumb & forefinger to
tense it.
Insert the needle elevate about 45 - 60 angle.
Pierce the skin quickly & advance the needle
procedure. Cont..
Aspirate to determine that the needle has not
entered a blood vessel
Inject the drug slowly.
After injecting withdraw the needle
Chart the amount and time of administration
immediately.
Watch for undesired reaction (side effect of
the drug) etc.

C. Intera- Muscular Injection
It is an introduction of a drug into a body's
system via the muscles.
Purpose
To obtain quick action next to the intra-
venous route
To avoid an irritation from the drug if given
through other route.
Absorption is rapid than SC-route, because of
the greater blood supply to the muscle.

The maximum volume to inject on the basis of
.
the site and the clients muscle development:

4 ml for a large muscle (gluteus medius) in a
well developed adult
1 to 2 ml for less developed muscles in
children, elderly, and thin clients
0.5 to 1.0 ml for the deltoid muscle
When more than 4 ml is ordered, the
medication can be divided into two different
sites.

IM injection sites
Common intramuscular injection sites and
muscles
Site Muscle
Dorsogluteal Gluteus maximus
Ventrogluteal Gluteus medius
Anterolateral thigh Vastus lateralis
Upper arm Deltoid

Ventrogluteal (Gluteus medius)
The primary site for administering an IM
injection in clients over 7 months old is the
ventrogluteal (VG) site.
The gluteus medius is a well-developed muscle,
free of major nerves and large blood vessels.
Place palm of left hand on right greater
trochanter so that index finger points toward
anterosuperior iliac spine; spread first and
middle fingers to form a V; injection site is the
middle of the V.
.

Dorsogluteal
Is one of the earliest site of IM injection site at
the dorsal site of the gluteus.
These sites should be avoided in infants and
children. There is a risk of striking the sciatic
nerve.
Place hand on iliac crest and locate the
posterosuperior iliac spine.
Draw an imaginary line between the trochanter
and the iliac spine; the injection site is the
outer quadrant.
Vastus lateralis:
Identify greater trochanter; place hand at
lateral femoral condyle; injection site is middle
third of anterior lateral aspect.
Is most of the time used for infants

Deltoid
Locate the lateral side of the humerus from two
to three fingerwidths below the acromion
process in adults or one fingerwidth below the
acromion process in children.

Equipment:
Disposable syringe and needle
Cotton balls soaked in alcohol(swab)
Small tray
Medication
Ampoule of sterile (if drug is to be dissolved)
Fill
Receiver.

Procedure-
Proceed as with subcutaneous injection
Best site for injection should be area upper,
outer quadrant of the buttocks (gluteal muscle)
Hold the syringe 900 to the area to be injected
After inserting the needle into the buttocks,
pull back on plunger (three times) before
injecting solution, to see that the needle has
not hit a blood vessel. If any blood return
withdraw and inject in a different site.
After injecting the solution, withdraw needle
quickly; and massage the area gently. This aids
8/8/17in the absorption of the medication.
BY CHALIE M. (BSC) 70
Z-Track Injection
place the client in the prone position then pull
the skin to one side, insert the needle at a 90
angle and administer the medication.
waits 10 seconds and withdraws the needle at the
same angle of insertion; the site should not be
massaged because massaging could cause tissue
irritation.
The former method increases the risk of leakage
into the needle track and the subcutaneous
tissue.
.

Note:
1. The needle for i.m. Injection should be long
2. Strict aseptic technique should be observed
throughout the procedure.
3. Injection should not be given in areas such as
inflamed, edematous, those containing moles
and pus.

Complication
Fibrosis
Nerve damage (paralysis)
Abscess
Tissue necrosis
Muscle contraction
Gangrene
Pain
Necrosis and skin slough
Periostitis (infection of the membrane covering
8/8/17
the bone). BY CHALIE M. (BSC) 74
D) Intravenous (IV) injection
It is the introduction of a drug in solution form
into a vein or taking blood from vein often the
amount is not more than 10.ml. at a time.
Purpose
When the given drug is irritating to the body
tissue if given through other routes.
When quick action is desired.
When it is particularly desirable to eliminate
the variability of absorption.
When blood drawing is needed
IV cont
Advantage-
large volume can be given
getting rapid effect.
The route is used to administer fluid if the pt cant
feed by mouth.
Disadvantage
the drugs prepared for IV administration is
expensive
Limited to highly soluble medications.
drug distribution is inhibited by poor circulation.
Site of IV injection
Children Adult
- Jugular Vein - Basalic vein
- Temporal vein - Cephalic vein
- Femoral vein - Radial vein
- Basalic vein -Greatsophanous
vein

Equipment-
Tray
Medication
Sterile needle and syringe
Tourniquet
Antiseptic swabs
Receiver
Treatment chart.
Towel and rubber sheet
Glove
Procedure:-
1. Prepare the tray and the medication
2. Explain the procedure to the patient
3. Position the patient properly
4. Expose the arm and apply the tourniquet
5. Ask patient to open and close his fist

Cont..
6.Hold the needle at about 25 - 300 angle in line
with the vein and puncture a bit below the
point where the needle will pierce the vein.
7. Palpate the vein and clean with antiseptic swab
the site of the injection (which is mainly the
midcubital vein of the arm)
8. Draw back to check whether you are in the
vein or not (blood return should be seen if you
are in the vein)
Procedure. Cont..
9.Once you know that you are in the vein release the
tourniquet gently , and inject (instil) the
medication slowly.
10 Check the patients pulse in between, any
complaint from the patient should not be ignored.
11. As the needle is removed apply pressure over the
site with swab and the forearm is flexed so as to
collapse the vein and prevent bleeding.
12. Watch the patient for minutes before leaving him
13. Chart the medication given, the amount, time &
the reaction of the patient.
Complication
infiltration (swelling and discomfort at the IV
site)
phlebitis (inflammationof a vein).
Air embolism(introduction of air in to the
circulation)

.Intravenous infusion
IV infusion is the administration of a large amount of

fluid (50-500 even more) into the system through a
vein.
Purpose
When the giving drug is irritating to the body tissue
if given through other routes.
When quick action is desired.
When it is particularly desirable to eliminate the
variability of absorption.
When blood drawing is needed ( exsanguinations)
Administering Intravenous solution
Definition: - it is an introduction of a large
amount of fluid (solution) into the blood
stream through a vein.
Purpose: -
To maintain fluid and electrolyte balance and
restore acid-base balance, in case of shock,
To introduce medication through the vein,
particularly antibiotics.

Cont
To supply fluids and electrolytes
To restore fluid volume due to dehydration,
hemorrhage, vomiting,diarrhea etc.
To meet patients basic requirements
To treat emergency condition some
medications are given intravenously
To prevent and treat shock and collapse

Cont..
Indication
To save the patients in life treating condition
To introduce drug in to circulation for
diagnostic and treatment purpose
Malnutrition
Septicemia / sepsis

Equipment:-
Sterile solution (I.V. fluid) with infusion set.
Bandage and scissors
Rubber and towel
Receiver
Tourniquet
I.V. stand
Antiseptic cotton swabs
Padded arm board
Adhesive tape
Medication chart
Preparation of the patient: - since an infusion therapy takes
several hours to complete, the patient should first be made
comfortable/informed.
Procedure:-
1. Wash hands
2. Explain the procedure
3. Prepare the necessary equipment and take to the
patient's bedside.
4. Cut adhesive strips about 8 cm. in length and attach on
outside of infusion set or on the stand.
5. Explain the procedure to the patient.
6. Open the infusion set and connect it with the bag. Run
the fluid through the tube and needle to remove the air.
7. Fix screw (clamp) on the tubing to control the flow of
the fluid.
8. Invert the bottle and hang on the stand.
Procedure. Cont..
8. Clean the skin over the vein to be injected with
antiseptic cotton swabs.
9. Hold needle at 30 degree angle in line with the
vein, pierce the skin and puncture the vein by
supporting the patient's arm with other hand.
10. Release the tourniquet when the needle is in
the vein.
11 Apply adhesive straps over the end of the
needle & tubing, to prevent pull on the needle.

Procedure. Cont..
12. Adjust the rate of flow
Stay with the pt. for some time to see if the solution
is running into the vein at the desired speed and to
see the reaction of the patient.
N.B.
Infusion bottle (bag) should be labelled with the
date, time infusion is started, drops per minute and
any added medication.
Inspect the drip frequently and watch for any signs of
a reaction. Stop the drip if reaction occurs.
Inspect the site of injection to see that the drip is not
leaking.
Reconstituting medications
Medications are reconstituted by adding the
proper diluents (sterile water for injection &
0.9% sodium chloride solution) to a powdered
medication.
Vials of powdered medication can be packaged
along with vials of the proper type and volume
of diluents.

J) BLOOD TRANSFUSION
A blood transfusion is the infusion of whole
blood or a blood component such as blood
plasma, RBCs, or platelets into the venous
circulation.
Whole blood is infrequently used because the
various components can be easily separated
and used for replacement therapy.
The person receiving the blood is called
recipient and that give the blood is called
donor.
FFP blood

Blood typing and cross matching
Before blood can be given to a person, it must
be determined that the blood of the donor and
that of the recipient are compatible.
If incompatible clumping and hemolysis of the
recipients blood cells results and death can
occur.
The laboratory examination to determine a
persons blood type is called typing.
The process of determining compatibility is
called cross-matching.
Blood types
The four main blood groups in the ABO system
of blood typing are: A, B, AB, and O.
Blood type is an inherited trait and it is
determined by the type of antigen and
antibody present in the blood.
Antigen is a substance that causes the
formation of antibody.
Antibody is a protein substance that develops
in response to the presence of antigen in the
body.
Blood types cont
People who have A blood group have A' antigen
and B antibody (agglutinins) on their RBCs;
people who have B blood group have B antigen
and A' antibody.
Those who have AB blood group have both A
and B antigen and no antibody on their RBCs.
Those who have O blood group have no antigen
and have both A and B antibodies (agglutinins)
So people who have O blood group are called
universal donors and those who have AB blood
group are called universal recipient.
Rh-factors
The Rh-factor is an inherited antigen in human blood.
There are 5 antigens in Rh-system but the one
designed D is of first concern.
A person whose blood contains D antigen is called Rh-
positive, and an Rh negative person lacks D antigen.
It is important that an Rh-negative person receives
blood from another Rh-negative person. If Rh-positive
blood is injected into the Rh-negative person, the
recipient develops anti-Rh agglutinins which cause
reaction and hemolysis.
Rh is of special importance during pregnancy because
Rh incompatibility b/n mother and infant/fetus blood
is often the problem when the infant has hemolytic
8/8/17 disease. BY CHALIE M. (BSC) 97
Selection of blood donors
Infection prevention is achieved by careful
screening for TTI of public health importance
Testing for ABO and Rh type identification
Screen the blood/donor for HBV,HCV,HIV and
syphilis
Syphilis- Rapid Plasma Reagent (RPR)
Hepatitis B Virus HbsAg
Hepatitis C Virus-Anti hepatitis C Virus
antibody test
HIV- Rapid tests
Cont
purpose:
To increase the 0xgen carrying capacity in anemia in
suitable cases
During major surgery where much blood loss may be
possible
To maintain blood pressure and blood volume during
hemorrhage
To replace blood platelets and clotting factors in
hemophilia
To provide antibodies and leucocytes
Indications of blood transfusion
Clients with anemia
Clients with cardiovascular failure
Clients with GI-bleeding
Excessive bleeding/blood loss secondary to
injury or trauma, delivery, APH, burn etc
To provide clotting factors normally present in
blood, which may be absent as a result of
disease.

Equipments-
Bottle containing blood, with the patient name, blood
group and Rh. Factor and expiry date.
Blood giving set
Sterile syringes and needle
Cannula No. 20 (1) for child cannula no. 23 (1)
Sterile swabs
I.V. stand
Mackintosh
Towel
Emergency medicine
anti- histamine injection
Sphygmomanometer tray
Antiseptic lotion
Adhesive plaster
PROCEDURE-
Explain procedure to patient
Before blood transfusion is administered, the
nurse has to check the blood group & RH-
factor if cross match of the donor's & the
recipients blood is done and is compatible and
other blood born pathoges.
Needle or cannula is insereted like IV infusion.
It should be kept in position with adhesive tape
and fully comfortable.

Procedure. Cont..
In small child or in case of difficult patient splint
must be needed. It should be securely placed
with a proper bandage.
Regulate the rate of flow from 40-45 drop per
minute or accordinglly.
Note any untoward/problematic reaction, if chill
or shivering or any other complication occurred;
stop the infusion and irrigate the tubing with
sterile fluid.
Record on the chart time, amount of blood given
and vital signs.
Cont..

Note
Blood should be used within 21 days of its withdrawal
date, if sodium citrate is used it can be used until 36 days.
Vital signs should be taken and recorded just before
starting the transfusion.
Store blood at 1-6 c ,continuously monitor and record T0
at least every 4 hourly
Blood exposed to unacceptable temperature for
unknown period should be discarded.
Do not warm the blood before using it as it raises the
temperature of the blood and encourage the growth of
the bacteria.
Blood should not stay out side refrigerator more than 4
hours.
TRANSFUSION REACTIONS
Be familiar with the most usual symptoms of
blood reactions which are:-
Immediate Reaction:
a) Headache d) Backache
b) Chills e) Pyrexia
c) Rash of the skin (urticaria )
Late Reaction
a) Dyspnea d) Renal shut down in
b) Heamaturia severe cases
c) Chest pain e) Rigor (rigidity)
Nursing Interventions in Transfusion Reaction
Discontinue the transfusion but continue IV line
with 0.9% Normal saline
The symptoms are treated as anaphlaxis and
vital signs are monitored.
The reaction is documented according to the
institutions policy.
Collect important samples from the patient
including blood and urine.
Dont discard the transfusion bag before sending
to culture
Risks of blood transfusion
Raised pulse
Pyrexia reaction
Difficulty in breathing
Thrombosis
Oedema
Haematoma
Cough
Sepsis
Cardiac and respiratory distress
Air embolism

8/8/17
Renal failure BY CHALIE M. (BSC) 108
UNIT TEN
Nutrition and Elimination of
Gastro Intestinal And Urinary Tract
.

Nutrition
Nutrients are substances needed for growth,
maintenance and repair of the body.
Metabolism refers to all biochemical and
physiologic processes by which the body
grows and maintains itself.
The basal metabolic rate (BMR) is the rate at
which the body metabolizes food to maintain
the energy requirements of a person who is
awake and at rest.
Therapeutic nutrition .
Therapeutic nutrition is a modification of

nutritional needs based on the disease condition.
It may be the excess or deficit of a nutrition
status. It is combination diet which includes
alteration in minerals, vitamins, proteins,
carbohydrates fats as well as fluid.

Alternative feeding methods
Alternative feeding methods to ensure
adequate nutrition includes both enteral
(through the gastrointestinal system) and
parentral (intravenous method).
Enteral tube feeding (nutrition) is the direct
delivery of nutrients into the GI system.
The more common enteral feedings are
administered through Nasogastric and small
bore feeding tubes through gastrostomy or
Jejunostomy feeding tubes
Gastrostomy is an opening into the stomach.
.
Jejunostomy is an opening into jejunum is

often used when aspiration has been a
problem.
Gastrostomy jejunostomy is necessary along
with feeding the tube can be used (inserted) if
decompression is needed. A double lumen tube
allows feeding to enter the jejunum while the
second lumen drains the stomach.
Tube feedings are nutritionally balanced

Gastrostomy feeding
Definition: Gastrostomy is an operation performed to
create an opening in to the stomach
The purpose is to administering food and medications.
Insertion of the gastrostomy tube requires:-
either upper abdominal midline incision or a left upper
quadrant transverse incision.
Purpose
For long term use and total feeding supplementation.
For patients who cannot tolerate nasogastric or
nasoentric tube.

Gastrostomy feeding cont..
Equipments
Gastrostomy tube
50 ml syringe
Funnel
Clamper
Chart
Measuring jag
Sterile gauze
Adhesive tap
procedure
1. Explain the procedure to the patient
2. Wash hand
3. Assemble the necessary equipment
4. Position the patient in his/ her comfortable
position (mostly sitting position).
5. Pour the fluid (food) into the measuring jag as
prescribed

Cont
6. Connect the syringe with the tube.
7. Hold syringe at angle so that air doesnt enter stomach
and continue pouring the fluid into the syringe or
funnel.
8. Hold syringe perpendicular so feeding can enter by
gravity.
9. After feeding rinse with water and remove the syringe.
10. Cover the tip of the tube with sterile gauze using a
plastic band and attach to the dressing.

Cont..
11. Apply light dressing over the stoma and
tube.
12. Comfort patient; keep the head of the bed
elevated for at least 30minutes after
procedure to aid digestion.
13. Clean return used equipments
14. Wash hands and document procedure in the
clients medical record

NASO GASTRIC TUBE (NG TUBE) INSERTION
.
Definition: Passing a tube through a nasal cavity

down the nasopharynx and oesophagus in to the
stomach
In some instance the tube is passed through the
mouth and pharynx although this route may be
uncomfortable for the adult client and cause
gagging.
This approach often used for infants who are
obligatory nose breathers (who must breath
through the nose) and premature infants who
have no gag reflex.
Indication
1. For clients who cannot swallow or who have
esophageal obstruction
2. decreased level of consciousness.
3. For clients who cannot consume adequate
nutrients to meet the nutritional demands of the
body.
4. For premature infants who have inadequate
sucking reflex.
5. oral Surgery
6. Abdominal distension
7. Poison
Purpose
To decompress the stomach and remove gas
and fluid.
To lavage the stomach and remove ingested
toxins.
To diagnose disorders of GI motility and
other disorders.
To administer medication and feedings.
To treat obstruction.
To compress a bleeding site.
To aspirate gastric content for analysis.
Type of Gastric tubes
1. Levin tubes
Has a single lumen.
Made of plastic or rubber openings near its tip.
Is 125cm long circular marking at specific point serve as
guide for insertion.
The tube is connected to low intermittent suction
(30to40mmHg). The suction is used to avoid erosion or
tearing of the stomach lining.
Used for short term tube feeding because such tubes
are relatively rigid and have large diameter compared
with nasal passage discomfort and mucosal breakdown
are common with prolonged therapy.
2. Gastric sump .
The gastric sump (Salem) tube is a clear plastic

double lumen NG tube used to decompress the
stomach and keep it empty.
It is 120cm long.
3. Enteric tubes
Nasoenteric tubes are used for feeding.
Feeding tubes placed in the duodenum are
160cm long and called nasoduodenal tubes.
Feeding tubes placed in the jejunum are
175cm.
I Gastric Lavage
Definition- This is the irrigation or washing out of the stomach
through nasogastric tube.
Nasogastric intubation refers to insertion of a tube through the
nostril into the stomach;
It is clean procedure
Purpose
1. To remove alcoholic, narcotic or any other poisoning, which has
been swallowed.
2. To clean the stomach before operation
3. To relieve congestion, there by stimulating peristalsis e.g. Pyloric
stenosis
4. For diagnostic purposes
Equipment: .
Basin with warm water or ice

Esophageal tube
Metal or plastic funnel
Large Jug (5 litter)
Solution
Lubricant e.g. liquid paraffin or KY jelly
protective material to put around the patient chest
Pail to receive returned fluid
Glass of water
20 to 50 ml syringe
Equipment
Mackintosh or paper to protect the floor
beneath the pail
A receiver containing mount gag, tongue
depressor, and tongue forceps if patient is
unconscious
Litmus paper
Specimen bottle. If laboratory test is requires
Measuring jug
Stetescope.
Procedure
1. Wash hands
2. Collect necessary equipments
3. Explain procedure to the pt.
4. Protect pt with cape or towel
5. Elevate head of the bed at least a 45 angle or higher, if pt is
conscious
Place comatose clients in semi-Fowlers position.
6. Measure the tube from the tip of the nose up to the ear lobe and
from the bridge of the nose to the end of the sternum. (32 36 c.m.)
If a rubber tube is being used, place it on ice this stiffens the tube,
facilitating insertion. If a plastic tube is being used, place it in warm
water. This makes the tube more flexible, facilitating insertion

.

7. Gently pass the tube over the tongue, slightly to
one side of the midline towards the pharynx. (If
.
patient is unconscious, mouth gug may be used)

8. Ask patient to swallow while inserting the tube
and allow to breath in between swallowing.
9. If air bubbles, cough and cyanosis are noticed the
tube is with drawn and procedure commenced
again.
10. After inserting check the placement,
a. place funnel end in a basin of water to check if
the tube is in the air passage.
if it is in the trachea there will be bubbling so
8/8/17remove quickly BY CHALIE M. (BSC) 130
B. Place stethoscope on the epigastric area and auscultate
.
hushing sound, pushing 5-10 ml of air in to the NG tube at

the same time
If in the gastric area you will auscultate the sound
c. Aspirate some amount of fluid from the tube and check
with blue litmus papers,
If it is in the gastric the blue lithmus paper will change to
red.
9. Fill the small pint measure and power gently until the
funnel is empty, then invert over the pail.
10. Take specimen. If required, and continue the process until
the returned fluid becomes clear and the prescribed
solution has been used.
11. Remove tube gently and
8/8/17
give mouth wash
.

II. GASTRIC ASPIRATION
Aspiration is withdrawal of fluid or gas from gastric
cavity by suction
Purpose
1. To prevent or relieve distention following abdominal
operation
2. In case of gastrointestinal obstruction, to remove
the stomach or gastric contents
3. To keep the stomach empty before an emergency
abdominal operation is done
4. To aspirate the stomach contents for diagnostic
purposes
There are two type of gastric Aspiration
.
1. Intermittent method: - In this case, Aspiration

is done as condition requires and as ordered.
2. Continues method: - Attached to a drainage
bag
There are 2 ways of supplying suction
a. Simple suction by the use of a syringe
b. An electric suction machine
The continues method is indicated when it is
absolutely necessary and desirable to keep the
stomach and duodenum empty and at rest.
III. Providing Enteral Nutrition (Gastric gavages)
Gastric gavage is providing nutritional supplement when the

patient is unable or notwilling to take food per mouth with
normal GI tract functioning
Purpose
1. To provide total supplemental nutrition
2. Restore fluid, electrolyte and acid base balance.
3. Reduce or eliminate catabolism and negative nitrogen balance.
Precaution
Severe pancreatitis
Enterocutaneous fistulae
GI ischemia

Contra indication
Enteral tube feedings are contraindicated in
clients with the following:
Diffused peritonitis
Intestinal obstruction that prohibits normal
bowel functioning
Intractable vomiting; paralytic ileus
Severe diarrhea

Cont..
Equipment
1. NG tube
2. Tap water
3. Formula /Liquid food ( at room
temperature)
4. IV stand
5. Tray
6. Clean Glove
Cont..
7. 50ml syringe
8. Funnel
9. Disposable gavage bag and tubing
10. Towel
11. Tissue paper
12. Dirty receiver
13. Chart

procedure
Procedure
1. Explain the procedure to the patient, provide privacy
2. Wash hands and assemble the necessary equipments.
3. Assist the client to a fowler's position in bed or a sitting
position in a chair, the normal position for eating
If this position is contraindicated, a slightly elevated right
side lying position is acceptable.
These position help/ enhance the gravitational flow of
the solution & prevent aspiration.

Cont
4. Assess the client for feelings of abdominal distension, blenching,

loose stools, flatus or plain;bowel sounds and allergies to foods.
5. If NG tube is not in place follow the NG tube insertion
procedure and insert the tube and secure it.
6. Confirm correct placement of the tube
7. Cover the patients chest with the towel to protect him/her
from spills of food.
8. Aspirate stomach contents to determine amount of residual and
measure it.
If the residual is over 50-100 ml in adults and 10 ml or more
infants, hold the feeding until residual diminishes or subtract the
withdrawn amount from the total feeding and administer the
rest. All these are based on the policy agency.

9. Reinstall the gastric contents to the stomach to prevent
electrolyte imbalance.
10. Before the feeding solution has drained from the neck
of the bottle, instil 50-60 ml of water through the tube,
to prevent tube feeding syndrome and further blockage.
11. Remove air from the feeding tubes and attach it to the
nasogastric tubes and to prevent air from entering to the
stomach, never allow the syringe or the gavage bag to
empty completely.
12. Hang bottle on IV stand beside patient and run the
food through the giving set or if a syringe is to be used
remove plunger from barrel of syringe and attack barrel
to nasogastric tube.

Deliver feeding over the desired length of time (as
ordered). Usually 200-350 ml over 10-15 minutes is
given.
Replace any formula administered by an open system
every 4 hours with fresh formula.
Formula should be at room temperature or cool (not
cold).
13. After the administration of the appropriate amount
of food, flush the tube by adding about
60ml of water to the syringe.
14. If you are administering a continuous feeding, flush
the tube every 4hours to help prevent tube occlusion.

15. To discontinue the NG tube feeding disconnect the
syringe from the feeding tube.
16. Close the tip of the NG tube with its plug cap before
all of the rinse solution has run through to prevent
leakage and contamination.
17. Leave the patient in semi sitting position of slightly
elevated right lateral position for at least
30minutes.
18. Communicate with your patient.
19. Clean and return used equipments.
20. Wash your hand
21. Record the amount given and the patients general
condition.
BASIC TYPES OF FORMULAS
1. Isotonic formula contains proteins, fats, and
carbohydrates with a high molecular weight
and an osmolality equal to that of the body
(300). Isocal and Osmolite are isotonic
formulas that supply 1 kcal/ml and are
lactose-free.
2. Elemental (monomeric) formula contains
monosaccharides and amino acids with
minimal triglyceride content in hypertonic
concentrations.
Vivonex and Vivonex HN are elemental formulas
.
that supply 1 kcal/ml;

they are started at half strength or less and
gradually increased to full strength due to their
hypertonic concentration.
3. Fluid restriction formula contains a highly
concentrated source of kilocalories (2 kcal/ml).
Magnacal is a fluid restriction formula that is
started at half strength or less and gradually
increased to full strength due to the hypertonic
concentration.

Continuous Gavage
Check tube placement at least every 4 hours.
Check residual at least every 8 hours.
If residual is above 100 ml, stop feeding.
Add prescribed amount of formula to bag for
a 4-hour period; dilute with water if indicated.
Hang gavage bag on IV pole.
Flush tube with water every 4 hours following
administration of medications.
Replace disposable feeding bag at least every
24 hours, in accordance with agencys protocol.
Complication of enteral therapy
Diarrhea (most common)
Nausea/ vomiting
Constipation
Aspiration pneumonia
Gas/bloating/ cramping dumping syndrome
Nasopharyngeal irritation
Dehydration

Fecal Elimination
Defecation is the expulsion of feces from the
anus and rectum.
It is also called a bowel movement.
Defecation is normally initiated by two
defecation reflexes.
As the peristaltic waves approach the anus the
internal anal sphincter becomes inhibited from
closing and if the external sphincter is relaxed
defecation occurs this is called the intrinsic
defecation reflex.

parasympathetic defecation reflex is also
.
actively involved in defecation. When the

nerve fibers in the rectum are stimulated
signals are transmitted to the spinal cord and
then back to the descending and sigmoid
colon and the rectum.
Normal defecation is facilitated by
- Thigh flexion which increases the pressure
within the abdomen.
- A sitting position which increases the
downward pressure on the rectum
An adult usually forms 7 to 10 liters of flatus
.
(gas) in the large intestine every 24hours.

The gases include carbon dioxide, methane,
oxygen and nitrogen some are swallowed with
foods and fluids taken by mouth others are
formed through the action of bacteria on the
chime in the large intestine and other gas
diffuses from the blood into the GIT.

Characteristics of normal feces
Color: - in adult brown
Infant yellow
Consistency: - formed soft semisolid moist
Shape: - cylindrical (contour of rectum) about 2.5 cm
in diameter in adults.
Amount: - varies with diet.
Odor: - aromatic affected by ingested food and
persons own bacterial flora.
Constituents: - small amount of undigested
roughage sloughed dead bacteria and epithelial
cell fat protein dried constituent of digestive juices.
Factors that affect defecation
Age and development: - some control of defecation
starts at 1 to 2 years of age by this time children have
learned to walk and nervous and muscular systems are
sufficiently well developed to permit bowel control.
Diet: - certain foods are difficult or impossible for some
people to digested.
Gas producing foods such as cabbage, onion banana
and apple.
Laxative producing foods such as chocolate and
alcohol
constipation producing food such as cheese, pasta
egg and lean meat.
Fluid: - healthy fecal elimination requires a daily fluid
intake of 200 to 300ml. if chime moves abnormally
.
quickly through the large intestine.

Activity; - activity also stimulate peristaltic thus facilitating
the movement of chime along the colon.
Psychological factors: - some people who are anxious or
angry experiences increased peristaltic activity and
subsequent diarrhea.
Life style: - early bowl training may establish the habit of
defecating at regular time.
Medication: - laxative are medication that stimulate bowl
activity and so assist fecal elimination.
Repeated administration of morphine and codeine cause
constipation.
Diagnostic procedure: - barium (used in radiological exam)
presents a further problem. It hardens if you allowed
,
remaining in the colon producing constipation and

sometimes an impaction.
Anesthesia and surgery: - surgery that involves direct
handling of the intestine can cause temporary cessation
of the movement. This condition is called paralytic ileus.
Pathological condition:-spinal cord injuries and head
injuries can decrease the sensory stimulation for
defecation.
Irritants: - spicy food, bacterial toxins and poisons can
irritate the intestinal tract and produce diarrhea and often
large amounts of flatus.
Pain: - who experiences discomfort when defecating e.g.
following hemorrhoid surgery. Often suppress the urge to
8/8/17defecate to avoid pain.BY CHALIE M. (BSC) 154
Common Fecal Elimination problems
There are six common problems related to fecal
elimination.
Constipation: - the passage of small dry hard
stool or the passage of no stool for a period of
time.
Causes or factors contribute to constipation
Irregular defecation habit.
Over use of laxative: - The habitual user of laxatives
eventually requires larger or stronger dose because
they have progressively reduced effect with
continual use.
Inappropriate diet: - low residue foods such as rice,
eggs and lean meats. .
Insufficient fluid: - it reduces the amount of fluid in

the chyme which enters the large intestine. This lack
of fluid in turn results in drier harder feces.
Fecal impaction: - is a mass or collection of
hardened putty like feces in the folds of the
rectum. Impaction results from prolonged
retention and accumulation of fecal material.
Causes of fecal impaction.
Poor defecating habit and constipation
Barium
Lack of activity
8/8/17
Weakened muscle tone
Diarrhea: - the passage of liquid and feces increased
frequency of defecation. .
Fecal incontinence: - refers to loss of voluntary ability

to control fecal and gaseous discharge through the
anal sphincter.
There are two types of fecal incontinence
Partial incontinence: the inability to control flatus
or to prevent minor soiling.
Major incontinence: the inability to control feces
of normal consistency. It is associated with
impaired functioning of anal sphincter or its nerve
supply such as in some neuromuscular disease
spinal cord trauma and tumors of external anal
sphincter.
Flatulence: - air or gas in GIT is called flatus.
.
There are three primary cause of flatus

Action of bacteria on the chyme in the large intestine.
Swallowed air.
Gases that diffuse from the blood stream in to
intestine.
Flatulence is the presence of excessive flatus in the
intestine and leads to stretching and inflation of the
intestines (intestinal distention) this condition is also
referred as timpanites.
Most gases that are swallowed are expelled through
the mouth by belching.

Helminthes: - common parasitic worms or
.
helminthes that infest the intestine are

hookworm round worm pin worm and tape
worm. They cause faulty digestion intestinal
inflammation intestinal obstruction and
anemia

Promoting Regular Defecation .
Privacy: - is extremely important to many people.

Timing: - a client should be encouraged to
defecate when the urge to defecate is recognized.
Nutrition and fluids: - in constipated patient
increase fluid intake
drink hot liquids and fruit juices
include fiber in diet raw fruit whole grain cereals
bread.
For the client who has flatulence the nurse should
limit carbonated beverage, chewing gum, gas
forming foods such as cabbage, beans and
8/8/17 cauliflower. BY CHALIE M. (BSC) 160
.
Regular exercise helps client develop a regular

defecation pattern and normal feces.
Positioning: - clients who are confined in bed
may need assistance to sit on a bed pan.

Enema
Enema is the introduction of fluid into rectum and
sigmoid colon for cleansing, therapeutic or
diagnostic purposes.

Purpose: .
For emptying-Soap solution enema

For diagnostic purpose(Barium enema)
For introducing drug/substance(retention
enema)
Solution used:
Normal saline
Soap solution - sol soap 1gm in 20ml of H2O
Epsom salt 15gm-120gm in 1000ml of H2O

Mechanisms of some solutions used in
enema
Tap water: increase peristalsis by causing
mechanical distension of the colon.
Normal saline solution Dilates, stimulates and
irritates bowel
Soap solution: increases peristalsis due to irritating
effect of soap to the luminal mucosa of colon.
Epsom salt: The concentrated solution causes flow
of ECF(extra cellular fluid) to the lumen causing
mechanical distension resulting peristalsis.

Classification
1. Cleansing(evacuation)
2. Retention
3.return flow enema
4.Passing flatus tube
1. Cleansing enema
A. High enema
is given to clean as much of the colon as possible
The solution container should be 30-45 cm about the
rectum
B. Low enema
is administered to clean the rectum and sigmoid
colon only
Guidelines
Enema for adults are usually given at 40-43OC and
children at 37 OC
Hot-cause injury to the bowel mucous
Cold- uncomfortable and may trigger a spasm of
the sphincter muscles
The amount of solution to be administered
depends on:
Kind of enema
The age of the person and
The personal ability to retain the solution

Amount of solution
Age Amount
<18months 50-200ml
18mont-5yrs 200-300ml
5-12 yrs 300-500ml
12yrs and older 500-1000ml

size
The rectal tube should be appropriate: is
measured in French scale
Age Size
Infants/small child 10 -12fr
Toddler 14 -16fr
Scholl age child 16 -18fr
Adults 22-30fr

Purpose
To stimulate peristalsis and remove feces or
flatus(for constipation)
To soften feces and lubricate the rectum and colon
To clean the rectum and colon in preparation for
an examination. E.g. colonoscopy
To remove feces prior to surgical procedure or
delivery
For incontinent patients to keep the colon empty
For diagnostic test E.g. Before certain x-ray exam-
barium enema
Equipment
1.Container for solution
2.Solution at temperature for adult 40-43
3.Bath thermometer for infant (37.7c)
4.Water proof material /mackintosh/
5.Screen, bath blanket, towel
6.Enema can with tube
7.Gauze to apply lubricant /swab/

Cont
8.Bed pan and toilet tissue
9.IV pole/stand
10. Gloves
11. Receiver /kidney dish/
12. Lubricant
13. Rectal tube /catheter /
14. Clamp, connector, funnel

Procedure
Wash hand
collect equipment
Inform the patient about the procedure.
Put bed side screen for privacy.
Attach rubber tube with enema can with nozzle and
stop cock or clamp.
Place the patient in the left lateral position with the
right leg flexed for adequate exposure of the anus
(facilitate the flow of solution by gravity in to the
sigmoid and descending colon which are on the side).
Fill the enema can with 1000cc of solution for adults.
Procedure cont
Lubricate about 5cm of the rectal to tube
facilitate insertion through the sphincter and to
minimize trauma.
Hung the can at least 45cm from bed or 30cm
from patient on the stand.
Place a piece of mackintosh under the bed.
Make the tube air free by releasing the clamp
and allowing the fluid to run down little to the
bed pan and clamp open to prevents
unnecessary distention.
Lift the upper buttock to visualize the anus.
Procedure cont
Insert the tube
7-10cm in adult smoothly and slowly.
5-7.5 cm in the child.
2.5-3.75cm in an infant.
Raise the solution container and open the
clamp to allow fluid to flow.
Administer the fluid slowlly if client complains
of fullness or pain stop the flow for 30 second
and restart the flow at a slower rate decrease
intestinal spasm and premature of ejection of
the solution.
Procedure cont
Do not allow all the fluid to go as there is a
possibility of air entering the rectum or when the
client can not hold any more and wants to
defecate close the clamp and remove the rectal tube
from the anus and offer the bed pan.
Remove bed pan clean the rectal tube.
Document the procedure.
Note
If resistance is encountered at internal sphincter
ask the clients to take a deep breath then run a
small amount of solution (relaxes the internal
anal sphincter).
2. Retention Enema
Administration of solution to be retained in
rectum for short or long period
Are enemas meant for various purpose in
which the fluid usually medicine is retained in
rectum for short or long period- for local or
general effects
E.g. oil retention enema, or Antispasmodic
enema

Antispasmodic enema .
Principles:
is given slowly by means of a rectal tube
The amount of fluid is usually 150-200cc
Cleansing enema is given after the retention
time is over
Temperature of enema fluid is 37.4 c
Purpose
To supply the body with fluid
To give medication E.g. stimulants paraldehyde or
antispasmodic.
To soften impacted fecal matter.
Other equipment is similar except that the tube for
retention enema is smaller in width.
Procedure
Similar with the cleansing enema but the

enema should be administered very slowly and
always be preceded by passing a flatus tube.
Note
Most medicated retention enema must be
preceded by a cleansing enema. A patient must
rest for hours before giving retention enema.
Elevate foot bed to help patient retain enema.

Procedure cont
Kinds of solution used to supply body with fluid

are plain water, normal saline, glucose 5% soda
bicarbonate 2-5%.
Olive oil 100-200cc to be retained for 6-8hours
is given for sever constipation.

3. Rectal washout (Siphoning Enema)
Colon irrigation or colonic flush
-Also called enterolysis
-is the process of introducing large amount of fluid in
too large bowel for flush in purpose and allow
return or wash out fluid
Purpose
To prepare the patient for x-ray exam and
sigmoidoscopy.
To prepare the patient for rectum and colon
operation
Solution Used
Normal saline
Soda-bi-carbonate solution(to remove excess
mucus)
Tap water
KMNO4 sol. 1:6000 for dysentery or weak
tannic acid
Tr.Asafetida in 1:1000 to relieve distention

Procedure
Insert the tube like the cleansing enema.
The client lies on the bed with hips close to
the side of the bed (client assumes a right side
lying position for siphoning).
Open the clamp and allow running about
1000cc of fluid in the bowel then siphon back
into the bucket.
Carry on the procedure until the fluid return is
clear.
Note
The procedure should not take>2hours.
Should be finished 1hour before exam or x-
ray to give time for the large intestine to
absorb the rest of the fluid.
Give cleansing enema hour before the
rectal wash out.
Allow the fluid to pass slowly.
Amount of solution 5-6 liters until the wash
out rectum fluid becomes clear.
4. Passing a Flatus Tube
Definition: The insertion of a rectal tube
is done to manage flatulence (gas)
following abdominal surgery and/or
reduce abdominal distention due to
flatulence.
Purpose
To decrease flatulence (sever abdominal distention)
Before giving a retention enema

Equipment
1. Rectal tube or catheter, 22 to 30 French
2. Water-soluble lubricant
3. Bedside drainage bag (optional, if rectal tube
used to manage diarrhea)
4. Ostomy odor eliminator or similar product
(optional)
5. Clean gloves
6. Disposable pads or towels
Procedure
Wash hand
Collect equipment
Place the patient in the left lateral position.
Lubricate the tube about 15cm.
Separate the rectum and insert 12-15cm into the
rectum and tape it.
Connect the free end to extra tubing by the glass
connecter.
The end of the tube should reach the tape water
solution in the bowel.
Procedure cont
The amount of air passed can be seen bubbling
through the solution (a funnel may be connected to
free end of tube and placed in an antiseptic solution in
bowel).
Teach client to avoid substance that cause flatulent.
Leave the rectal tube in place for a period or no longer
than 20 minute because it can affect the ability to
voluntarily control the sphincter if placement is
prolonged.
Reinsert the rectal tube every 2-3 hour if the distention
has been unrelieved or re acumulates allow gas to
move in the direction of the rectum.
Urinary Elimination
Micturition, voiding and urination all refers to the
process of emptying the urinary bladder.
Urine collects in the bladder until pressures
stimulate special sensory nerve ending in the
bladder wall called stretch receptor.
This occurs when the adult bladder contains
between 250and 450ml of urine. In children a
considerably small volume 50 to 200ml stimulates
the nerves.
Urinary retention: - when a person unable to void
even though the bladder contains an excessive
amount of urine.
Factors Affecting Voiding
Growth and development: -
Psychosocial factors: - privacy, normal position
and sufficient time.
Fluid and food intake: -
Medication:
Muscle tone and activity:
Pathological conditions: -
Surgical and diagnostic procedure:-

Altered Urine Production
Polyuria (Diuresis):- abnormally large amounts of urine
by the kidney such as 2500 ml/day for an adult.
Polyuria can be the result of
Excessive fluid intake
The ingestion of substances containing caffeine and
alcohol.
Diabetes mellitus
Hormone imbalance (deficiency of anti diuretic
hormone).
Oliguria - voiding scant amount of urine less than 500ml
in 24hour.
Anuria: - adults voiding less than 100ml/day.
Altered Urinary Elimination
Frequency : -voiding at frequent intervals that is
often than usual.
Nocturia :- is increase frequency at night that is
not a result of an increased in fluid intake.
Urgency: -the feeling that the person must void.
Dysuria: -voiding that is either painful or difficult.
Enuresis: - is repeated involuntary urination in
children beyond the age when voluntary
bladder control is normally acquired usually 4
or 5 years of age.
Urinary incontinence: - incontinence is a
.
symptom not a disease.

There are different types of incontinence Total,
Stress, Urge functional and reflex incontinence.
Urinary retention: - is the accumulation of urine
in the bladder with associated inability of the
bladder to empty it self.
Prolonged retention leads to stasis (a slowing of
the flow of urine) and stagnation of urine
which increase the possibility of urinary tract
infection.

Managing Urinary Incontinence (UI)
Continence bladder training:
Promoted voiding:
Pelvic muscle exercise: - referred to as perineal
muscle tightening strengthen pubococcygeal
muscles and can increase the incontinent female
ability to start and stop the stream of urine.
Positive reinforcement
Maintaining skin integrity
Applying external urinary device: - the
application of a condom catheter Commonly
prescribed for incontinent male.
Urinary Catheterization
Urinary catheterization is introduction of a tube
(catheter) through the urethra into the urinary
bladder.
Is performed only when absolutely necessary for fear of
infection and trauma.
Note: - strictly a sterile procedure i.e. the nurse should
always follow aseptic technique
Catheter: is a tube with a hole at the tip
Types of catheter
Straight (plain or Robinson)
Retention (Foley, indwelling)
Catheterization using a straight catheter
Purpose
To relieve discomfort due to bladder distention
To asses the residual urine
To obtain a urine specimen
To empty the bladder prior to surgery

Equipment
Sterile
1. Sterile plain catheter rubber or plastic
2. A bowl for antiseptic
3. Gauze
4. Sterile towel(3#)
5. forceps 3#
6. Sterile receiver
7. Kidney dish
8. Sterile urine specimen container if needed
Clean
1. Rubber and draw sheet
2. Antiseptic solution
3. Receiver
4. Measuring jug
5. Flash light
6. Screen
7. Specimen form

Procedure
Wash hand
collect equipment
Explain the procedure
Prepare the client with perianal care.
Position the patient _dorsal recumbent (pillows
can be used to elevate the buttocks in females)
Drape the client with a sterile drape.
Clean the area with antiseptic solution.
Lubricate the insertion tip of the catheter (5-7cm)
Expose the urinary meatus adequately by
retracting the tissue or the labia minora
Procedure cont
Retract the fore skin of un circumcised male.
Grasp the penis firmly behind the glans and
hold straighten the down ward curvature of
vertical it go to the body _ male holed the
catheter 5cm from the insertion tip.
Insert the catheter into the urethral orifices.
Insert 5cm in females and 20 cm in males or
until urine comes.
Collect the urine for specimen (about 30ml).
Empty or drain the bladder and remove the
catheter.
Note
If resistance is encountered during insertion do note
force it.
Because forceful pressure can cause trauma. Ask the
client to take deep breath relax the external
sphincter (slight resistance is normal).
Dorsal recumbent is used
Female for a better view the urinary meatus
and reduce the risk of catheter contaminates.
Male_ allows greater relaxation of the
abdominal and perennial muscles and
permits easier insertion of the tube.

Inserting a Retention (Indwelling) Catheter
Retention (Foley) catheter
Contains a second smaller tube through out its length
on the inside this tube is connected to a balloon
near the insertion tip.
Purpose
To manage incontinence
To provide for intermittent or continuous bladder
drainage and irrigation.
To prevent infection.
To measure urine out put needs to be monitored
hourly.
Procedure
Equipment
you will need the following in addition to those
equipments used in straight cathter.
Retention catheter
Syringe
Sterile water
Tape
Urine collection bag and tubing

Procedure cont
Explain the procedure to the patient
The outside end of the catheter is bifurcated
i.e. it has two opening one to drain the urine
the other(red) to inflate the balloon.
The balloon are sized by the volume of fluid or
air used to inflate them 5ml-30ml(15
commonly) indicated with the catheter size
18fr -5ml.
Test the catheter balloon.
Follow steps as insertion straight catheter.
Procedure cont
Insert the catheter an additional 2.5-5cm beyond the
point at which urine began to flow (the balloon of the
catheter is located behind the opening at the insertion
tip). This ensures that the balloon is inflated inside the
bladder and not the urethra (cause trauma).
Inflate the balloon with the pre filled syringe
Apply slight tension on the catheter until you feel
resistance: resistance indicates that the catheter
balloon is inflated appropriately and that the catheter
is well anchored in the bladder.
Release the resistance.

Procedure cont
Tape the catheter with tape to the inside of
females thigh or to the thigh or a body of a
male client.
Establish effective drainage.
The bag should be off the floor _ the emptying
spout does not become grossly contaminated.
Document pertinent data.
Removal
Withdraw the solution or air from the balloon
using a syringe and remove gently.
Applying a Condom Catheter
Definition- The condom catheter is an external
drainage system to collect urine from male
clients who have incontinence
Purpose
Provide a means of collecting urine and
controlling incontinence without the risk of
infection that an indwelling urinary catheter
imposes

Equipment
Condom catheter kit with adhesive strip

Urinary drainage bag/bed pan
Clean gloves
Basin with warm water and soap
Towel and washcloth

Procedure
1. Wash hands and apply gloves.
2. Select an appropriate condom catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for excessive hair.
5. Inspect the penis for altered skin integrity.
6. Stretch the shaft of the penis and unroll the
condom to the base of the penis.
7. Follow product directions for the application
of the sealant
Cont..
8. Attach the condom to the drainage apparatus,
9. either a leg bag or bedside drainage bag.
10. Remove gloves and wash hands.
11. Remove and reapply the condom catheter
every 24 to 48 hours, or when leakage occurs.

Bladder Irrigations
A bladder irrigation is carried out usually to washout
the bladder to apply an antiseptic solution to the
bladder lining to treat a bladder infection.
ways of irrigating catheter or bladder.
1.Closed intermittent or continuous irrigation
(irrigating through a three way catheter).
2. Irrigating through catheter after separating the
catheter and tubing (open intermittent system).
Amount of solution to be used is
1000ml -adult bladder
200ml - catheter irrigation.
Suprapubic catheter care
A Suprapubic catheter is inserted through the
abdominal wall above the sympsis pubis into the
urinary bladder.
The catheter may be secured in place with
sutures. The catheter then attached to a closed
drainage system.
Care of clients with Suprapubic catheter include
regular assessment of the clients urine, fluid
drainage system. Skin care around the insertion
site periodic clamping of the catheter preparatory
to removing it and measurement of residual urine.
Supra pubic cont
Leaving the catheter open to drainage for 48to
72 hours then clamping the catheter for 3 to 4
hour periods during the day the client can void
satisfactory amounts.
Care of insertion site involves sterile technique.
Dressing should be changed whenever they are
soiled.
A small amount of povidone iodine is used.

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Metric Apothecary Household

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approximate child dose

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The six rights ensure accuracy when administering medications.

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Syringe Hypodermic needle

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elbow)Upper arm, at deltoid area for BCG

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the site and the clients muscle development:

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IV infusion is the administration of a large amount of

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