CA 102 – OTHER ➢

Medical Order
Ensures that the prescribed treatment is

ASSESSMENT METHOD appropriate for the patient and aligns with

their diagnosis and condition.

• Patient Identification Process:

• Medical Order
✓ Review the order: Clarify the 5 "rights" -
• Proper Handling technique
patient, medication/treatment, dose, route,
• Universal Precaution
and time.
• Handwashing technique
✓ Question unclear orders: Contact the
• Blood Transfusion
prescriber to clarify any ambiguities or illegible
• Chest Physiotherapy
handwriting.
• Suctioning
✓ Check for allergies and contraindications:
• Nasogastric tube insertion & feeding Verify the patient's medical history for allergies
• Enema administration or conditions that would contraindicate the
prescribed treatment.
✓ Document verification: Document in the
Patient Identification patient's chart that you verified the medical
order.
➢ Correctly identifying the patient is crucial for
preventing medical errors. It is the foundation
Types of Orders:
of safe patient care.
Written: Legibly documented in the patient's chart.
Methods:
Verbal: Spoken directly to the nurse by the prescriber
• Ask the patient: "Please state your full name
(requires documentation and often a follow-up written
and date of birth." (If the patient is conscious
order).
and able to communicate.)
• Check the patient's identification band: Electronic: Entered directly into the electronic health
Compare the information on the band to the record (EHR).
patient's medical record. Verify name, date of
birth, medical record number, and any other
unique identifiers.
• Use two identifiers: Combine at least two
Proper Handling Techniques
methods (e.g., name and date of birth, name
and medical record number) to ensure
accuracy. ➢ Protects both the patient and the healthcare
• Involve the patient (when possible): Encourage provider from injury.
patient participation in the identification
Principles:
process to enhance accuracy.
Body Mechanics: Use proper posture, maintain a wide
Special Considerations:
base of support, and lift with your legs, not your back.
• Unconscious patients: Verify identification
Ergonomics: Utilize assistive devices (e.g., lifts,
with a family member or using alternative
transfer belts) when moving or transferring patients.
methods like medical record review.
• Patients with communication barriers: Utilize Patient Safety: Ensure the patient's comfort and safety
interpreters or other communication aids. during movement and handling.
• Never rely on room number or bed location as
primary identification.

MILLAN, TRISHIA L. – BSN 4202 <3

Specific Techniques: on the potential for exposure to blood, body fluids, or
infectious materials.
Logrolling: Used for patients with spinal injuries to
maintain alignment. Safe Injection Practices: Use sterile needles and
syringes for each injection. Avoid recapping used
needles; dispose of them in sharps containers.

Transferring: Utilize appropriate techniques based on

the patient's mobility level and condition (e.g., bed to
chair transfer, gait training).

Respiratory Hygiene/Cough Etiquette: Cover coughs

and sneezes with a tissue or elbow, dispose of used
tissues promptly, and perform hand hygiene.

Environmental Hygiene: Clean and disinfect surfaces

and equipment regularly. Handle soiled linen and waste
Positioning: Properly position patients to prevent
appropriately.
pressure ulcers, promote respiratory function, and
maintain comfort.

Handwashing Technique
➢ The single most effective way to prevent the
spread of infection.

Steps

(Handwashing with Soap and Water):

1. Wet hands with warm running water.

Universal Precautions (Standard Precautions) 2. Apply soap and lather vigorously for at least 20
seconds, covering all surfaces of the hands, including
➢ Prevents the transmission of infectious between fingers, under nails, and the backs of hands.
agents. Treat all patients as potentially
infectious. 3. Rinse hands thoroughly under running water.

Components: 4. Dry hands with a clean towel or air dryer.

Hand Hygiene: Frequent handwashing with soap and (Alcohol-Based Hand Sanitizer):
water or using alcohol-based hand sanitizer.
1. Use if hands are not visibly soiled.
Personal Protective Equipment (PPE): Use gloves, 2. Apply enough sanitizer to cover all surfaces of
gowns, masks, and eye protection as appropriate based the hands.

MILLAN, TRISHIA L. – BSN 4202 <3

 3. Rub hands together until dry (at least 15-20
seconds).
Chest Physiotherapy (CPT)
THE 5 MOMENTS OF HAND HYGIENE
➢ Helps to mobilize and remove secretions from
the lungs.

Components:

Postural Drainage: Positioning the patient to allow

gravity to assist in draining secretions from specific lung
segments.

Percussion (Clapping): Using cupped hands to

rhythmically clap on the patient's chest wall to loosen
secretions.

Vibration: Applying manual vibrations to the chest wall

during exhalation to further loosen secretions.
Blood Transfusion Coughing: Encouraging the patient to cough effectively
to expel mobilized secretions.
➢ Replacing lost blood or blood components to
maintain oxygenation and circulatory volume.

Key Steps: ▪ Indications: Patients with thick secretions,

atelectasis, or other respiratory conditions
1. Verify patient identification: Two qualified
that impair secretion clearance.
healthcare professionals must verify the
▪ Contraindications: Certain medical
patient's identity, the blood product label, and
conditions, such as unstable cardiovascular
the compatibility with the patient's blood type.
status, recent surgery, or fractures.
2. Obtain consent: Ensure informed consent
from the patient.
3. Check blood product: Verify the blood type, Rh
factor, expiration date, and unit number. Suctioning
4. Initiate IV access: Use appropriate gauge
catheter for blood transfusion. ➢ Removes secretions from the airway that the
5. Monitor vital signs: Monitor the patient's vital patient is unable to clear independently.
signs closely throughout the transfusion for
Types:
signs of reaction.
6. Administer blood according to protocol: Use Oropharyngeal/Nasopharyngeal Suctioning: Removes
blood administration set and follow secretions from the mouth and nasal passages.
recommended infusion rates.
7. Document: Document the start and end times Tracheal Suctioning: Removes secretions from the
of the transfusion, the blood product trachea via an endotracheal or tracheostomy tube.
information, and the patient's response.
Procedure:
Transfusion Reactions:
1. Assess the need for suctioning: Observe for
Signs and symptoms: Fever, chills, rash, hives, itching, signs and symptoms of respiratory distress,
shortness of breath, chest pain, back pain, nausea, such as increased respiratory rate, decreased
vomiting, hypotension, tachycardia. oxygen saturation, or audible secretions.
2. Explain the procedure to the patient.
➢ If a reaction occurs: Stop the transfusion 3. Use sterile technique for tracheal suctioning.
immediately and notify the physician.

MILLAN, TRISHIA L. – BSN 4202 <3

 4. Apply suction intermittently while rotating the Procedure:
catheter.
5. Limit suctioning time to prevent hypoxia. 1. Gather your supplies. You will need an enema
6. Monitor the patient's respiratory status before, kit, which typically includes a bag or bottle
during, and after suctioning. with a nozzle, tubing, and a solution. You may
also need a lubricant, such as petroleum jelly
or KY Jelly, and a towel to protect your clothing
or the floor.
Nasogastric Tube (NGT) Insertion and Feeding 2. Prepare the enema solution. Follow the
instructions on the enema kit to prepare the
Purpose: solution. This may involve mixing a pre-
packaged solution with water or preparing a
Feeding: Providing nutrition to patients who are unable solution from scratch.
to eat orally. 3. Find a comfortable position. Lie on your left
side with your knees bent and your arms at
Decompression: Removing gastric contents to relieve your sides. This position will help the solution
pressure or prevent vomiting. flow into your colon.
4. Lubricate the nozzle. Apply a small amount of
Insertion: lubricant to the tip of the nozzle to make
insertion easier.
1. Measure the tube: Determine the insertion 5. Insert the nozzle. Gently insert the nozzle into
depth by measuring from the tip of the nose to your rectum, about 2-4 inches. If you feel any
the earlobe and then to the xiphoid process. resistance or pain, stop and try again at a
2. Lubricate the tip of the tube. different angle.
6. Administer the solution. Slowly squeeze the
3. Insert the tube through the nostril and
bag or bottle to allow the solution to flow into
advance it into the stomach. your colon. If you feel any cramping or
4. Verify placement: Aspirate gastric contents discomfort, stop the flow and wait for it to
and check the pH (should be acidic). Confirm subside before continuing.
placement with an x-ray. 7. Hold the solution. Once the solution has been
administered, remove the nozzle and lie on
your left side for as long as you can
Feeding: comfortably hold the solution, up to 15
minutes.
1. Check for residual: Aspirate gastric contents 8. Empty your bowels. When you feel the urge to
before each feeding to assess for delayed have a bowel movement, go to the toilet and
gastric emptying. empty your bowels. You may experience some
cramping or discomfort as you do so.
2. Administer feeding: Use a feeding pump or
9. Clean up. Dispose of the enema kit and wash
syringe to administer the prescribed amount of your hands thoroughly.
formula.
3. Maintain patient in semi-Fowler's position Important Considerations:
during and after feeding to prevent aspiration.
▪ It is important to talk to your doctor before
using an enema, especially if you have any
underlying medical conditions.
Enema Administration ▪ Do not use an enema too frequently, as this
can lead to dependence and other health
➢ To cleanse the bowel or to treat constipation. problems.
▪ If you experience any pain, bleeding, or other
Types: unusual symptoms after using an enema,
contact your doctor immediately.
▪ Cleansing enemas: Stimulate bowel
evacuation.
▪ Retention enemas: Introduce medications or
fluids into the rectum to be retained.

MILLAN, TRISHIA L. – BSN 4202 <3