- indwelling catheter has a small balloon inflated on

the end of it. This prevents the catheter from sliding

out of your body. When the catheter needs to be
Urinary Catheterization: removed, the balloon is deflated.
- the introduction of a catheter through the urethra 2. CONDOM CATHETER:
into the bladder for the purpose of withdrawing
urine. - can be used by men with incontinence.

PURPOSES: - there is no tube placed inside the penis.

● To relieve urinary retention - instead, a condom-like device is placed over the

● To obtain a sterile urine specimen from a penis.
woman
- a tube leads from this device to a drainage bag.
● To measure the amount of residual urine in
the bladder - condom catheter must be changed everyday.
● To empty bladder before and during surgery
and before certain diagnostic examinations. 3. INTERMITTENT CATHETERS:
- you would only use an intermittent catheter when
you only need to use a catheter to drain the bladder
SIZES URETHRAL CATHETER: and then remove it.
CHILDREN: 8 – 10 Fr - this can be done only once or several times a day.
FEMALE ADULT: 12 – 16 Fr - the frequency will depend on the reason you need to
use this method or how much urine needs to be
MALE ADULT: 16 – 20 Fr
drained from the bladder.

URINARY CATHETERS:
DRAINAGE BAGS:
- a tube placed in the body to drain collect urine from
- catheter most often attached to a drainage bag.
the bladder.
- keep the drainage bag lower than your bladder so
● Urinary Incontinence: leaking urine or being
that urine does not flow back up into your bladder.
unable to control when you urinate.
● Urinary Retention: being unable to empty - empty the drainage device when it is about one half
your bladder when you need to. full and a t bedtime.
● Surgery on the prostate or genitals
● Other medical conditions such as multiple - Always wash your hands with soap and water before
sclerosis, spinal cord injury, dementia, or emptying the bag.
other operations.
TYPES OF CATHETERS: PREPARATION OF THE PATIENT:
- FOLEY CATHETER: common type of indwelling 1. ADEQUATE EXPLORATION: on some
catheter. It has soft, plastic or rubber tube that is instances, catheterization is the last resort,
inserted into the bladder to drain the urine. use other techniques first for drawing out the
1. INDWELLING CATHETERS: urine before proceeding to catheterization.
2. POSITION: dorsal recumbent for the female
- one that is left in the bladder. and supine for the male using a form mattress
or treatment table, Sim’s or Lateral position
- can be used for short or a long time.
can be an alternate for the female patient.
- collects urine by attaching to a drainage bag. 3. PROVISION OF PRIVACY
(the bag has valve that can be opened to allow to
urine to flow out.:
RETENTION OR INDWELLING CATHETER (FOLEY)
- may be inserted into the bladder in 2 ways:
- A catheter to remain in place for the following
● Catheter is inserted through the urethra. This purposes:
is the tube that carries urine from the bladder
a. The gradual decompression of an over distended
to the outside of the body.
bladder
● Insert a catheter into your bladder through a
small hole in your lower belly. b. for intermittent bladder drainage
c. for continuous bladder drainage 8. Teach the patient the importance of personal
hygiene, especially the importance of careful
- an indwelling catheter has a balloon which is
cleaning after bowel movement and thorough
inflated after the catheter is inserted into the bladder.
washing of hands frequently.
Because the inflated balloon is larger than the
opening to the urethra, the catheter is retained in the
bladder.
REMOVING THE INDWELLING CATHETER AND
PROCEDURE OF INSERTION: AFTERCARE OF THE PATIENT:
1. Inflate the balloon with the prefilled syringe 1. Be sure the balloon is deflated before
before inserting the catheter to check for attempting to remove the catheter. This may
balloon patency. Aspirate the fluid back into be done by inserting a syringe into the
the syringe when it is determined that the balloon valve or by cutting the balloon valve.
balloon is patent. 2. Have the patient take several deep breaths to
2. Hold the catheter with one hand and inflate help him relax while gently removing the
the balloon according to the manufacturer’s catheter. Wrap the catheter in a towel or
instructions, as soon as the catheter is in the disposable, waterproof drape.
bladder and urine has begun to drain from 3. Clean the area at the meatus thoroughly with
bladder. Usually 5 ml to 10 ml of sterile antiseptic swabs after the catheter is
water is used. removed.
3. If the patient complains of pain after the 4. See to it that the patient’s fluid intake is
balloon is inflated, allow it to empty and generous and record the patient’s intake and
replace the catheter with another one. The output. Instruct the patient to void into the
balloon is probably located in the urethra and bedpan or urinal
is causing discomfort owing to distention 5. Observe the urine carefully for any signs of
4. Exert slight tension on the catheter after the abnormality
balloon is inflated to assure its proper 6. Record and report any usual signs such as
placement in the bladder. discomfort, a burning sensation when
5. Connect the catheter to the drainage tubing voiding, bleeding, and changes in vital signs,
and drainage bag if not already connected. especially the patient’s temperature. Be alert
6. Tape the catheter along the anterior aspect of to any signs of infection and report them
the thigh for a female patient. Be sure there is promptly.
no tension on the catheter when it is taped to
the patient.
7. Hang the drainage bag on the frame of the bed LUBRICATE:
below the level of the bladder.
Male: 5 -7 inches
Female: 1 – 2 inches

CARING FOR THE PATIENT WITH AN INDWELLING

CATHETER: DEFINITION:
1. Be sure to wash hands before and after caring - Administration of feed directly into the stomach
for a patient with an indwelling catheter. through the nose (nasogastric) or mouth (orogastric).
2. Clean the perineal area thoroughly, especially
around the meatus, twice a day and after each PURPOSES:
bowel movement. This helps prevent
- to provide adequate nourishment to the patients
organisms for entering the bladder.
who cannot feed themselves (ex. Surgery in oral
3. Use soap or detergent and water to clean the
cavity, unconscious or comatose state.)
perineal area and rinse the area well.
4. Make sure that the patient maintains a - to administer medications.
generous fluid intake. This helps prevent
INDICATIONS:
infection and irrigates the catheter by
increasing urinary output. 1. Head and Neck injury
5. Encourage the patient to be up and about as 2. Coma
ordered. 3. Obstruction of esophagus or oropharynx
6. Record the patient’s intake and output 4. Severe anorexia nervosa
7. Note the volume and character of urine and 5. Recurrent episodes of aspiration
record observations carefully 6. Increased metabolic needs – burns, cancer,
etc.,
 7. Poor oral intake - DIARRHEA:
EQUIPMENT: ● Type of feed
● Gut injection
1. Formula feed
2. Graduated container - CONSTIPATION:
3. Large syringe (30 – 60 ml)
● Inadequate fluid intake
4. Water in a container
● Immobility
5. Stethoscope
● Use of opiates
6. Kidney tray
7. Towel and mackintosh - BLOCKED TUBE:
8. Clean gloves
● Inadequate or no flushing of tube
● Administering meds via tube
TYPES OF NGT:
- DERANGED ELECTROLYTES

1. FINE-BORE FEEDING TUBE: - FLUID OVERLOAD

- Short term enteral feeding (4 – 6 weeks) - INTESTINAL OBSTRUCTION

● Malnutrition - DISLODGED TUBE

● Head and neck surgery - WEIGHT / LOSS GAIN
● Inadequate intake
● Oral cavity fistulae - EXCORIATION OF SKIN AROUND TUBE

- to prolong and sustain life Risks associated with NGT

2. RYLE’S TUBE: - pneumothorax
- to drain gastric contents - coiling of the tube in the throat
● Abdominal distention - sinusitis
● Unconscious patient
● Major surgery - acid reflux
● Intestinal obstruction
- aspiration pneumonitis
- to stop vomiting and prevent aspiration
- severe sepsis

CONTRAINDICATIONS:
MEASURE LENGTH OF FEEDING TUBE:
- head injury
- from bridge of nose to ear to the bottom of xiphoid
- rhinorrhea process.

- obstructing esophageal POSITIONING OF PATIENT DURING INSERTION:

- epistaxis - Semi fowlers position (45 degree)

- feeding above an obstruction

- recent gastro esophageal anastomosis
Procedures:
- history of nasal or sinus surgery
- occlusions
Before:
Complications of NGT feeding: 1. Identify patient and explain procedure to
- ASPIRATION: patient and that feeding will take around 10
to 20 minutes to complete. Also explain that
● Due to feed regurgitation patient will experience a feeding of fullness
● Or incorrect tube placement after feeding. Proper explanation allays
- NAUSEA AND VOMITING: anxiety and ensures cooperation.
Explanations to be given to patients who are
● Due to rapid feeding comatose or unconscious as they may hear
● Poor gastric emptying and perceive the instructions.
 2. Assess for food allergies, time of last feed, 12. Fill syringe barrel with water and allow fluid
bowel sounds, and laboratory values. Proper to flow by gravity, raising the barrel above the
Assessment will prevent risk of level of the patient’s head. Water clears the
complications. tube and the rate of flow is regulated by
3. Place container with feed in warm water. raising or lowering the syringe.
Warms the fluid to be fed. 13. Pour feed into syringe barrel and allow it to
4. Assist patient to fowler’s position (35 to 45 flow by gravity. Keep on pouring feed /
degree). Fowler’s position enhances formula to barrel when it is three quarters
gravitational flow of feed through tube and empty. Pinch tube whenever necessary to
prevents risk of aspiration. stop when pouring. Prevents air from
entering tube.
14. After feeding the patient flush the tube with
During: at least 30cc of water. Prevents clogging of
tube.
5. Wash hands. Reduces risk of transmission of 15. After tube is clear close end of the feeding
microorganisms. tube while pinching the tube. Prevents
6. Spread towel and mackintosh over the leakage. Pinching prevents air entry.
patient’s chest. Reduces risk of transmission 16. Rinse equipment with warm water and dry.
of microorganisms. Prevents bacterial growth.
7. Don gloves and attach syringe to nasogastric 17. Keep head of bed elevated for 30 to 60
tube. Pinch tube while attaching the syringe minutes after feeding. Prevents aspiration.
to the tube. Pinching of the tube prevents air
from entering the tube.
8. Aspirate stomach contents. If there is doubt
After:
about tube placement inform physician and
obtain an order for X-ray. If residual gastric 18. Wash hands. Reduces the risk of transmission
contents exceed 100ml for intermittent tube of microorganisms
feedings or greater than 1.5 times the hourly 19. Document type and amount of feeding,
rate for continuous feeding, withhold feed amount of water given, and tolerance of feed.
and notify physician. 20. Monitor breath sounds, bowel sounds, gastric
9. Also assess the aspirant for visual aspirates: distention, diarrhea, constipation, and intake
- Visual characteristics of feeding tube and output. Evaluates for aspiration effects on
aspirates: gastrointestinal system and therapeutic
● GASTRIC: may be grassy green with effects of feeding.
sediment, brown (if blood is present 21. Instruct the patient to notify nurse if he
and has been acted upon by gastric experiences a sensation of fullness, nausea,
acid). May also appear clear and and vomiting. Indicates intolerance of feed.
colorless (often with shreds of
SPECIAL CONSIDERATIONS:
off-white to tan mucus or sediment).
● INTESTINAL: generally, more 1. Intermittent/continuous feeding of solution
transparent than gastric aspirants and from an intravenous (IV) pole and adjusting
may appear bile-stained tanging in the rate of administration by flow regulators
color from light to dark golden yellow are done in some situations.
or brownish green. 2. Siphon method can be used to administer
● RESPIRATORY: tracheobronchial clear fluid. This is done immersing the tip of
secretions may consist of off-white to the tube in the feed, taking care to avoid air
tan sediment. entering into it and then raising the container
12 inches above tube according to institution
- Assessing aspirants for visual characters
policy.
provides information about placement of
3. Change the nasogastric tube according to
tube.
institution policy.
10. If residual contents are within limits and 4. Change the articles, every 24 hours or
placement of tube is confirmed, return gastric according to institution policy.
contents to stomach through syringe using
gravity to regulate flow. Returning gastric
contents to stomach prevents fluid and - commonly called STOMACH WASH or GASTRIC
electrolyte imbalance. SUCTION, the process of cleaning out the contents of
11. If tube placement is confirmed in stomach, the stomach.
pinch the feeding tube prevents air from
entering the stomach and causing distention.
- it has been used for eliminating poisons from the 2. LARYNGOSPASM: uncontrolled and
stomach. involuntary muscle contraction (spasm) of
the larynx cord.
PURPOSE:
- For urgent removal of ingested substance to 3. HYPOXIA and HYPERCAPNIA: lack of oxygen
decrease systemic absorption. in the body tissues.

- to empty the stomach before endoscopic procedure. 4. BRADYCARDIA: pulse slow and lower than
- to diagnose gastric hemorrhage and to arrest normal.
hemorrhage.
5. SHORTNESS OF BREATH: patient might
INDICATION: experience dyspnea due to a tube inserted
through the oropharynx that can obstruct the
- With patient has ingested poison
patient airway, which cause low oxygen
- collecting stomach acid for tests supply.

- cleaning the stomach before and upper endoscopy

6. MECHANICAL INJURY: to the throat,
in someone who has been vomiting blood.
esophagus, and stomach.
- relieving pressure in someone with blockage in the
intestines
CONTRAINDICATIONS:
- Loss of airway protective reflexes, such as in a A. HYPERTONIC SOLUTIONS:
patient with a depressed state of consciousness.
- Hypertonic Sodium Chloride
- Ingestion of a corrosive substance such as a strong
- 3 % NaCl
acid or alkali.
- 5 % NaCl
- Ingestion of a hydrocarbon with high aspiration
potential. USES:
- Patients who are at risk of hemorrhage or - used in the acute treatment of severe hyponatremia
gastrointestinal perforation. and should only be used in critical situations to treat
hyponatremia.
TECHNIQUE:
- used in patients with cerebral edema
1. Gastric lavage involves the passage of a tube
via the mouth or nose down into the stomach, - some patients may need diuretic therapy to assist in
followed by sequential administration and fluid excretion.
removal of small volumes of liquid.
2. The placement of the tube in the stomach CAUTION:
must be confirmed either by air insufflation - should be infused at a very low rate to avoid risk of
while listening to the stomach, by pH testing a pulmonary edema
small amount of aspirated stomach contents,
or x-ray. This is to ensure the tube is not in the - if administered in large quantities and rapidly, they
lungs. may cause ECF excess and circulatory overload.
3. Lavage is repeated until the returning fluid
- Dextrose 10 % (D10W)
shows no further gastric contents.
4. If the patient is unconscious or cannot protect - Dextrose 10 % in water
their airway then the patient should be
USES:
intubated before performing lavage.
- used in treatment of ketosis of starvation and
COMPLICATION:
provides calories and free water.
1. ASPIRATION PNEUMONIA: while taking the
CAUTION:
unwanted poison or drugs out of the stomach
(lavage), the substances might accidentally - Should be administered using a central line if
enter the respiratory canal, into the lungs and possible.
cause aspiration pneumonia.
- Dextrose 20 % (D20W)
- Dextrose 20 % in water
 8. MONITOR BLOOD GLUCOSE CLOSELY: rapid
infusion of hypertonic dextrose solutions can
USES:
cause hyperglycemia. Use with caution for
- Used as an osmotic diuretic that causes fluid shifts patients with diabetes mellitus.
between various fluid compartments to promote 9. CHECK INTEGRITY OF IV SOLUTION:
diuresis. solution should be clear with the container
and seals intact. IV solutions are covered in
- Dextrose 50 % (D50W) overwrap, do not remove until ready for use.
- Dextrose 50 % in Water Check for minute leaks by squeezing the
container firmly, if leaks are found, discard
solution may be compressed.
USES: - 5 % Dextrose in 0.9 % Saline:
- used to treat severe hypoglycemia ● Fluid and electrolyte replenishment
- administered rapidly via IV bolus - 5 %Dextrose in 0.45 % Saline:
● Maintenance fluid
NURSING CONSIDERATIONS FOR HYPERTONIC - 5 % Dextrose in Lactated Ringer’s
SOLUTIONS:
● Fluid and electrolyte replenishment and
1. DOCUMENT FOR BASELINE DATA: before caloric supply
infusion, assess the patient’s vital signs,
edema status, lung sounds, and heart sounds, B. HYPOTONIC SOLUTIONS:
glucose levels. Continue monitoring during
and after the infusion.
2. WACTH FOR SIGNS OF HYPERVOLEMIA: - 0.45 % Sodium Chloride Solution (0.45 % NaCl)
since hypertonic solutions move fluid from
the ICF to the ECF, they increase the ● Half-strength normal saline
extracellular fluid volume and increase the ● ½ NS
risk for hypervolemia. Look for signs of
USES:
swelling in arms, legs, face, shortness of
breath, high blood pressure, and discomfort - Used for replacing water in patients who have
in the body. hypovolemia with hypernatremia
3. MONITOR AND OBSERVE THE PATIENT
CAUTION:
DURING ADMINISTRATION: hypertonic
solutions should be administered only in high - Excessive use may lead to hyponatremia due to the
acuity areas with constant nursing dilution of sodium.
surveillance for potential complications.
4. VERIFY ORDER: prescriptions for hypertonic
solutions should state the specific hypertonic - 0.33 % Sodium Chloride Solution (0.33 % NaCl)
fluid to be infused, the total volume to be
infused, the infusion rate and the length of ● 5 % Dextrose in 0.33 Sodium Chloride
time to continue the infusion. ● 1/3 strength normal saline
5. ASSESS HEALTH HISTORY: patients with
kidney or heart disease and those who are
USES:
dehydrated should not receive hypertonic IV
fluids. These solutions can affect renal - Used to allow kidneys to retain needed amounts of
filtration mechanisms and can easily cause water. Free water helps kidneys eliminate solutes.
hypervolemia to patients with renal or heart
- typically administered for patients with dextrose to
problems.
increase tonicity.
6. PREVENT FLUID OVERLOAD: ensure that
administration of hypertonic fluids does not CAUTION:
precipitate fluid volume excess or overload.
7. DO NOT ADMINISTER PERIPHERALLY: - Used in caution for patients with heart failure and
hypertonic solutions can cause irritation and renal insufficiency.
damage to the blood vessel and should be
administered through a central vascular
access device inserted into a central vein. - 0.225 % Sodium Chloride (0.255% NaCl)
● 5 % Dextrose in 0.225 Sodium Chloride
 This is because the glucose is metabolized quickly,
leaving free water which is hypotonic.
USES:
● Useful for mixed with meds hypernatremia
- Used as maintenance fluid for pediatric as it is most
hypotonic fluid available.
- typically administered with dextrose to increase C. ISOTONIC SOLUTIONS:
tonicity
- Normal Saline Solution (NSS) (0.9 % NaCl)
● Isotonic solution of choice for expanding ECF
- 2.5 % Dextrose in Water (D2.5W)
Volume
USES: ● Infused to correct extracellular fluid volume
deficit
- used to treat dehydration and decrease the levels of ● Used alongside administration of blood
sodium and potassium products
CAUTION: ● Used to replace large sodium losses with
heart failure, pulmonary edema, and renal
- Should not be administered with blood products as impairment
it can cause hemolysis of red blood cells.
CAUTION:
- Should not be used for patients with heart failure,
NURSING CONSIDERATIONS FOR HYPOTONIC pulmonary edema, and renal impairment.
SOLUTIONS:
- Dextrose 5% in Water D5W)
1. DOCUMENT BASELINE DATA
2. DO NOT ADMINISTER IN ● Initially isotonic and provides free water
CONTRAINDICATED CONDITIONS: when dextrose is metabolized (making it
Hypotonic solutions may exacerbate existing hypotonic)
hypovolemia and hypotension causing ● Expands the ECF and ICF, helpful in
cardiovascular collapse. Avoid use in patients rehydrating and excretory purposes.
with liver disease, trauma, or burns. CAUTIONS:
3. RISK FOR INCREASED INTRACRANIAL
PRESSURE (IICP) - should not be used for fluid resuscitation because
4. MONITOR FOR MANIFESTATIONS OR FLUID hyperglycemia can result. Should be avoided in
VOLUME DEFICIT. clients at risk increased intracranial pressure.
5. DO NOT ADMINISTER ALONG WITH BLOOD
- Lactated Ringer’s Solution in 5% Dextrose:
PRODUCTS.
6. CHECK INTEGRITY OF IV SOLUTION ● D5LR
● LR
● Ringer’s Lactate
- 0.45 % Saline:
● Hartmann Solution
● Fluid replacement among patients with
USES:
hypovolemia
● Avoid in patients with trauma, risk for - uses to correct dehydration, sodium depletion, and
increased ICP or burns. replace GI tract fluid losses
- also used in fluid losses caused by burns, fistula
drainage, and trauma.
HYPOTONIC FLUIIDS:
- often administered for patients with metabolic
- have lower concentration of solutes than blood
acidosis because it is an alkalizing solution.
plasma. This causes an intracellular shift of fluid,
leading to cellular swelling. CAUTION:

- HALF NORMAL SALINE: (0.45% NS) the classic - should not be given to patients who cannot
hypotonic fluid metabolize lactate. Used in caution for patients with
heart failure and renal failure.
● Useful for maintenance fluids
- Ringer’s Solution
- D5W: 5% Dextrose in Water (D5W) is technically
considered isotonic, but it acts as a hypotonic fluid.
 ● Similar indications for Lactated Ringer’s
solution but without the contraindications
related to lactate.
NURSING CONSIDERATIONS FOR ISOTONIC
SOLUTIONS:
1. DOCUMENT BASELINE DATA
2. OBSERVE FOR SIGNS OF FLUID OVERLOAD
3. MONITOR MANIFESTATIONS OF - CURETTE: a surgical instrument designed for
CONTINUED HYPOVOLEMIA scraping or debriding biological tissue or debris in a
4. PREVENT HYPERVOLEMIA biopsy, excision or cleaning procedure.
5. ELEVATE THE HEAD OF THE BED AT 35 TO
45 DEGREES - DeBakey TISSUE FORCEP: type of atraumatic
6. EDUCATE PATIENTS AND FAMILIES tissue used in vascular procedure to avoid tissue
7. CLOSE MONITORING FOR PATIENTS WITH damage during manipulation.
HEART FAILURE
8. CHECK INTEGRITY OF IV SOLUTION
- Hegar’s Uterine Dilators: used to measure the
level of dilation of a woman’s uterus or to induce
IV FLUIDS: further dilation.
1. HYPERTONIC: enter the vessel from the cells.
Therefore, the cell will SHRINK.
2. ISOTONIC: stays where it put, stay the same - POZZI FORCEPS
(ISO MEANS EQUAL) TENACULUM: specialized
3. HYPOTONIC: go out of the vessel + into the OB/Gyne device used for
cell. Therefore, the cell will SWELL. holding multiple structures,
such as the cervix, uterus,
blood vessels and the
IV FLUIDD CALCULATION: fallopian tubes in order to
perform multiple
1. FLOW RATE: (ml/hr)
gynecological procedures.
e.g. D5 ¼ NS 500 cc to run for 24 hours
500 ml / 24 hours
- COLLIN VAGINAL SPECULUM: a gynecological
Ans: 21 ml/hr instrument used for performing pelvic examinations;
pap smears or examining the cervix.
2. DRIP RATE:

- UTERINE SOUND: used for

e.g. Normal Saline 500 cc to run for 6 hours (drop probing and dilating the uterus
factor: 20 drops / ml) through the cervix to measure
the length of the cervical canal
and the uterus.

- CHERON DRESSING FORCEPS:

ANSWER: 28 gtts/min. device used for grasping, holding,
and mobilizing dressing
3. BASIC DRUG CALCULATION:
materials of different sizes with
purpose of absorbing blood and
fluids.

e.g.: Order: Ampicillin 350 mg

- 100 ml GALLIPOT: a small jar of glazed
Stock: Ampicillin 500 mg in a 5 ml vial
earthenware, used for holding medicine.

- STAINLESS STEEL INSTRUMENT

Answer: 3 ml BASKET: sturdy and corrosion
resistant metal used for medical instruments.

- DOYEN RETRACTORS: used

CAESARIAN SECTION INSTRUMENTS: for retracting the bladder away

- BACKHAUS TOWEL CLAMPS: used to fasten drapes from the incision site on the
of towels to patient during medical procedures in uterus and guarding potential
order to stay on.
injury when suturing.

- OUTLET FORCEPS: used

when - LANGENBECK RETRACTORS:
used to retract skin during
● Fetal scalp is visible closure of the rectus sheath. Can
without separating be used in pairs.
the labia
● The fetal skull has
reached the pelvic
floor
● The sagittal suture is in the anteroposterior - MORRIS RETRACTORS AND BALFOUR
diameter or right or left occiput anterior or RETRACTORS: commonly used retractors.
posterior position (rotation does not exceed
45)
- ARTERY FORCEPS: for
controlling bleeding and for the
retraction of tissues, skin, etc.
Other name is hemostatic - BALFOUR RETRACTORS: self-retaining and not be
forceps. held once it is inserted.

- GREEN ARMYTAGE
FORCEPS: used to hold the
incised uterine edges prior - MAYO SCISSORS: classified ads dissecting or suture
to closing the hysterectomy scissors used to cut tough scar tissue.

incision. Fur forceps are

commonly used.

- SPONGE HOLDING FORCEPS: used to hold sponges

and swabs. - SPENCER LIGATURE
SCISSORS: used for cutting
stitches or suture.

- ALLIS TISSUE FORCEPS: used

to hold or grasp heavy tissue

- Period of time constitutes the surgical experience, it

includes the pre-operative, intraoperative, and post
- LITTLEWOOD TISSUE -operative phase of nursing care.
FORCEPS: used for grasping
slippery tissue.
- PREOPERATIVE PHASE: period of time when the MAINTENANCE OF SAFETY:
decision for surgical intervention is made to when the
1. Maintains specific, controlled environment
patient is transferred to the operating room table.
2. Effectively manages human resources,
- INTRAOPERATIVE PHASE: period of time that equipment, and supplies for individual
begins with transfer of the patient to the operating patient care
room area and continues until the patient is admitted 3. Transfers patient care to operating room bed
or table
to the Post Anesthesia Care Unit.
4. Positions patient based on functional
- POSTOPERATIVE PHASE: period of time that begins alignment and exposure of surgical site
with the admission of the patient to the postoperative 5. Applies grounding device to patient
anesthesia care unit and ends after follow up 6. Ensures that the sponge, needles, and
evaluation in the clinical setting or home. instrument counts and correct
7. Completes intraoperative documentation
PREOPERATIVE PHASE PHYSIOLOGIC MONITORTING:
PRE-ADMISSION TESTING: 1. Calculates effects on patient of excessive fluid
1. Initiates initial pre-operative assessment loss or gain
2. Initiates education appropriate to patients 2. Distinguishes normal from abnormal cardio
needs pulmonary data
3. Involves family in interview 3. Reports changes in patients’ vital signs
4. Verifies completion of pre-operative 4. Institutes measures to promotes
diagnostic testing. normothermia, intravenous
5. Verifies understanding of surgeon specific PSYCHOLOGICAL SUPPORT: (before induction and
pre-operative orders (bowel preparation, when patient is conscious)
pre-operative shower)
6. Discusses and reviews advance directive 1. Provides emotional support to patient
document 2. Stands near touches patient during
7. Begins discharge planning including need for procedures and induction
transportation and care. 3. Continues to assess patient’s emotional status

ADMISSION TO SURGICAL CENTER: POST OPERATIVE PHASE

1. Completes pre-operative assessment TRANSFER OF PATIENT TO POST ANESTHESIA

2. Assesses for risks of postoperative CARE UNIT:
complications
1. COMMUNICATES INTRAOPERATIVE
3. Reports unexpected findings or any
INFORMATION:
deviations from normal.
● Identifies patient by name
4. Verifies that operative consent has been
● States type of surgery performed
signed.
● Identifies type and number of
5. Coordinates patient education and plan of
anesthetics and analgesic agents used.
care with nursing staff and other health team
● Reports patient’s vital signs and
members.
response to surgical procedure and
6. Reinforces previous education.
anesthesia
7. Explain phases in perioperative period and
● Describes intraoperative factors
expectations
insertion of drains or catheters,
8. Answers patients and family’s questions.
administration of blood, medications
IN THE HOLDING AREA: during surgery and or occurrence of
unexpected events
1. Identifies patient ● Describes physical limitation
2. Assesses patient’s status, baseline pain and ● Reports patient’s pre-operative level
nutritional status. of consciousness
3. Reviews medical record ● Communicates necessary equipment
4. Verifies surgical site and that it has been needs
marked per institutional policy ● Communicates presence of family or
5. Establishes IV line significant others
6. Administers medications if prescribed
7. Takes measures to ensure patients comfort POST OPERATIVE ASSESSMENT RECOVERY AREA:
8. Provides psychological support
1. Determines patient’s immediate response to
9. Communicates patient’s emotional status to
surgical intervention
other appropriate members of the health care
2. Monitor patient’s vital signs and physiologic
team
status
INTRAOPERATIVE PHASE 3. Administers medication, fluid and blood
components therapy if prescribed
 4. Provides oral fluids if prescribed for - Ensure that mother is in her position of choice while
ambulatory surgery patients in labor
5. Assesses patient’s readiness for transfer in
hospital unit or for discharge home based on - Asked mother if she wishes to eat/drink or void
institutional policy - Communicated with the mother: informed her of
SURGICAL NURSING UNIT: progress of labor, gave reassurance and
encouragement.
1. Continues close monitoring of patients
physical and psychological response to
surgical intervention
2. Assesses patient’s pain level and administers
appropriate pain relief measures WOMAN ALREADY IN THE DR
3. Provides education to patient during
- Checked temperature in DR area to be 25 – 28 C;
immediate recovery period
eliminated air draft
4. Assists patients in recovery and preparation
for discharge home -Asked woman if she is comfortable in the
5. Determines patient’s psychological status semi0-upright position (the default position of
6. Assists with discharge planning delivery table)
- Ensured the woman’s privacy
CATEGORIES OF SURGERY BASED ON URGENCY - Removed all jewelry then washed hands thoroughly
observing the WHO 1-2-3-4-5 procedure
- EMERGENT: patient requires immediate attention;
disorder maybe life threatening - Prepared a clear, clean newborn resuscitation area
on a firm and flat surface. Checked the equipment if
INDICATION FOR SURGERY: without delay clean, functional and within easy reach.
Ex. Severe bleeding, bladder or intestinal - Arranged materials/supplies in a linear sequence;
obstruction, fractured skull, gunshot or stab
wounds, excessive burns. a. Gloves, dry linen, bonnet, oxytocin injection, plastic
clamp, instrument clamp, scissors, 2 kidney basins
- URGENT: patient required prompt attention
b. In a separate sequence, for after the 1st breastfeed;
INDICATION OF SURGERY: within 24 to 30 Eye ointment, (stethoscope to symbolize PE), vitamin
hours. K, hepatitis B and BCG vaccines (plus cotton balls,
Ex. Acute gallbladder infection, kidney or etc.)
urinary stones. - Cleaned the perineum with antiseptic solution.
- REQUIRED: patient needs to have surgery - Washed hands and put on 2 pairs of sterile gloves
INDICATOIN FOR SURGERY: plan within a few aseptically. (If same worker handles perineum and
weeks or months cord).

Ex. Prostatic hyperplasia without AT THE TIME OF DELIVERY:

bladder obstruction, thyroid disorder, - Encouraged woman to push as desired
cataracts.
- Draped the clean, dry linen over the mother’s
- ELECTIVE: Patient should have surgery abdomen or arms in preparation for drying the baby.
INDICATION FOR SURGERY: failure to have - Applied perineal support and did controlled
surgery not catastrophic delivery of the head
Ex. Repair of scars, simple hernia, vaginal - Called out time of birth and sex of baby
repair
- Informed the mother of outcome
- OPTIONAL: decision rests with patient
FIRST 30 SECONDS:
INDICATION FOR SURGERY: personal
preference - thoroughly dried baby for at least 30 seconds,
starting from the face and head, going down to the
Ex. Cosmetic surgery trunk and extremities while performing a quick check
for breathing.
1-3 MINUTES:

“ESSENTIAL INTRAPARTUM NEWBORN CARE” - Removed the wet cloth

PRIOR TO WOMAN’S TRANSFER TO THE DR - Placed baby in skin-to-skin contact on the mother’s
abdomen or chest
- Excluded a 2nd baby by palpating the abdomen in - In the first hour; check baby’s breathing and color;
preparation for giving oxytocin and check mother’s vital signs and massaged uterus
every 15 minutes.
- Gave IM oxytocin within one minute of baby’s birth
after wiping the soiled gloves with the wet cloth. - In the second hour; check mother-baby dyad every
30 minutes to 1 hour.
- Removed 1st set of gloves after positioning the baby
for cord clamping. Decontaminated the gloves - Completed all RECORDS.
properly (0.5 % chlorine solution at least 10 minutes)
- Palpated umbilical cord to check for pulsations
- Placed the instrument clamp for 5 cm from the base
DRESSING:
- Cut near plastic clamp (not midway)
- A dressing is a sterile pad or compress applied to
- Performed the remaining steps of the AMTSL: wound to promote healing and protect the wound
from further harm.
- waited for strong uterine contractions then
applied controlled contraction and counter - It is used to have direct contact with a wound but
traction on the uterus, continuing until bandage is used to hold a dressing in place.
placenta was delivered.
GENERAL INSTRUCTION:
- massaged the uterus until it is firm.
1. Practice strict aseptic technique to prevent
- Inspected the lower vagina and perineum for cross infection to the wound and from the
lacerations/tears and repaired lacerations/tears, as wound.
necessary. 2. All articles should be disinfected thoroughly
to make sure that they are free from
- Examined the placenta for completeness and pathogens
abnormalities. 3. Wash hands thoroughly before and after the
- Cleaned the mother; flushed perineum and applied procedure.
perineal pad/napkin/cloth. 4. Instruments used for one dressing cannot be
used for another until they have been
- Checked baby’s color and breathing; checked that sterilized.
mother was comfortable, uterus contracted. 5. Use masks, sterile gloves and gowns for large
dressings to minimize the wound
- Disposed of the placenta in a leak-proof container or
contamination.
plastic bag.
6. Dressings are not changed for at least 15
- Decontaminated (soaked in 0.5 % chlorine solution) minutes after the room has been swept or
instruments before cleaning; decontaminated 2nd pair cleaned.
of gloves before disposal, stating that decomposition 7. Use individually wrapped sterile dressings
lasts for at least 10 minutes. and equipment for the greatest safety of the
wound.
- Advised mother to maintain skin-to-skin contact. 8. Create a sterile field around the wound by
Baby should be prone on mother’s chest in between spreading sterile towels.
the breasts with head turned to one side. 9. Avoid talking, coughing, and sneezing when
15 – 90 MINUTES: the wound is opened.
10. During the procedure, the nurse works
- Advised mother to observe for feeding cues and carefully to avoid contaminating the patient’s
cited examples of feeding cues. skin, clothing and bed linen with soiled
instruments and dressings
- Supported mother, instructed her on positioning 11. Cleaning the wound should be done from the
and attachment cleanest area to the less clean area. Consider
- Walled for FULL BREASTFEED to be completed the wound area cleaner than the skin area
even if the wound is infected. Therefore, clean
- After a complete breastfeed, administered eye the wound from its center to the periphery.
ointment (first), did through physical examination, 12. If the dressings are adherent to the wound
then did Vitamin K, hepatitis B and BCG injections due to drying of the secretions or blood, wet it
(simultaneously explained purpose of each with physiologic saline before it is removed
intervention). from the wound.
13. When dressing the wound, keep the wound
- Advised OPTIONAL/DELAYED bathing of baby (and
edges are near as possible to promote healing.
was able to explain the rationale).
14. When drains are in place, anticipate drainage
- Advised breastfeeding per demand and re-enforce the dressings accordingly. The
dressings over the drains should not be
combined with the dressings on the wound
line.
 15. The amount of discharge from the wound - Gloves, masks and gowns: to use when large wounds
should be accurately measured by recording are dressed
the number and size of the dressings changed.
Note the color, odor, amount and consistency - Cotton balls, gauze pieces pads, etc., as necessary: to
of the drainage. clean and dress the wound
16. When the wound drainage is diminished, the - Slit or dressing towels: to create a sterile field
drains are to be shortened. This should be around the wound
done in consultation with the doctor. Usually
the doctor gives a written order. An unsterile tray containing:
17. Before doing the dressing, inspect the wound
- Cleaning solutions as necessary: to clean the wound
for any complications such as dehiscence and
and the surrounding area
evisceration. If present, report it immediately
to the surgeon and immediate steps are to be - Ointment and powders as ordered: to apply on the
taken wound
18. Avoid meal timings
19. Give an analgesic prior to be painful dressings - Vaseline gauze in sterile containers: to prevent the
dressing adhering to the wound
PRELIMINARY ASSESSMENT
- Ribbon gauze in sterile containers: to pack a sinus
- Check the diagnosis and the general condition of the tract or penetrating wound
patient
- Swab sticks in sterile container: to apply
- Check the purpose for which the dressing is to be medications if necessary.
done
- Transfer forceps in a sterile container: to handle the
- Check the condition of the wound – the type of the sterile supplies
wound, the types of suturing applied, the type of
dressings to be applied, etc. - Bandages, binders, pins, adhesive plaster, and
scissors: to fix the dressing in place
- Check the physician’s orders for the type of dressing
to be applied and the specific instructions, if any, - A large bowel with disinfectant solution: to discard
regarding the cleaning solutions, removal of sutures, the used instruments
drains and the application of medications, etc. - Kidney tray and paper bag: to collect the wastes
- Check the patient’s name, bed number and other - Mackintosh and towel: to protect the bed with linen
identifications and patient clothes
- Check the nurse’s records to find out the general PREPARATION OF THE PATIENT AND THE
condition of wound ENVIRONMENT
- Check the abilities and limitations of the patient 1. Identify the patient and explain the procedure
- Check the consciousness of the patient and the to win the confidence and cooperation.
ability to follow instructions Explain the sequence of the procedure and
tell the patient how he can cooperate in the
- Check the articles available in the unit. procedure
2. Provide privacy with curtains and drapes
PREPARATION OF THE ARTICLES
3. Apply restraints, in case of children
ARTICLES: 4. AS far as possible, avoid meal timings; the
dressings may be done either one hour before
A sterile tray containing: the meals or after meals
- 1 Artery Forceps: To clean the wound 5. Offer bedpan or urinal prior to the dressings
6. See that the cleaning of the room is done at
- 2 Dissecting Forceps: To clean/to hold the gauze least one hour before the expected time of the
piece / to scratch dead tissue dressings.
7. Shave the area if necessary to remove the
- 1 Scissors: for the debridement of the wound, if hairs. Removal of the adhesive is more painful
necessary or to cut the gauze pieces fit around the if the hair is present. So, the shaving should
drainage tubes, etc. be done before the first dressing is applied
- 1 Sinus Forceps: to open the sinus tract or to pack 8. Place patient in a comfortable and relaxed
the sinus tract, if necessary position depending on the area to be dressed
9. Give proper support to the body parts if the
- 1 Probe: to open the sinus tract or to pack the sinus patient has to raise and hold it position for a
tract, if necessary considerable time
10. See that the patient’s room is in order with no
- 1 Small Bowl: to take the cleaning solutions
unnecessary articles. Clear the bedside table
- 1 Safety Pin: to fix the drain, in case the drains are or the overbed table, so that there is sufficient
cut short
 space to set up a sterile field and to arrange 3. Remove the mackintosh and towel
needed supplies and equipment. 4. Take all articles to the utility room. Discard
11. Close the doors and windows to prevent soiled dressings into a covered container and
drafts. Put off fan send for incineration. Remove the
12. Adjust the height of the bed for the instruments and other articles from the
comfortable working of the doctor or nurse so disinfectant solution and clean them
that they have neither to stop nor overreach thoroughly. Dry them. Re-set the tray and
to do the dressing. Bring the patient to the send for autoclaving.
edge of the bed. 5. Wash hands
13. Call for assistance if necessary e.g., to do the 6. Return to the bedside to assess the comfort of
unsterile procedure, to transfer sterile the patient
supplies, etc.
14. Protect the bed with a mackintosh and towel DOCUMENTATION
15. Fold back the upper bedding towards the foot 1. Record the procedure on the nurse’s record
end of the bed leaving a bath blanket or sheet with date and time
over the patient. Expose the part as necessary 2. Record the condition of the wound, the type
16. Untie the bandage or adhesive and remove and amount of drainage, condition of the
the. Make use that the dressing is not sutures, etc.
removed from its place until the nurse is 3. On the nurse record date, time, type of wound
ready to do dressing (after washing her and sign
hands) 4. Report to the surgeon any abnormalities
17. Turn the head of the patient to one side, so found
that the patient may not see the wound and
get worried about it
PROCEDURE
Purpose
STEPS OF PROCEDURES: 1. Deliver low to moderate levels of oxygen to relieve
hypoxia.
1. Tie the mask: to prevent wound Assessment/Preparation
contamination with droplets ● Assess respiratory status (i.e., breath sounds,
2. Wash hands thoroughly: to prevent cross respiratory rate and depth, presence of sputum, arterial
contamination blood gases if available).
● Assess past medical history, noting chronic obstructive
3. Put on gown, gloves etc., as necessary: to
pulmonary disease (COPD). For clients with COPD,
ensure asepsis hypoxemia is often the stimulus to breathe because they
4. Open the sterile tray. Spread the sterile towel chronically have high blood levels of carbon dioxide. If
around the wound: pour physiologic saline additional oxygen is needed, a low-flow system is
and wet it before removal essential to maintain slight hypoxemia so breathing is
5. Pick up dissecting forceps and remove the stimulated.
dressings and put it in the paper bag. Discard ● Assess for clinical signs and symptoms of hypoxia:
anxiety, decreased level of consciousness, inability to
the dissecting forceps in the bowl of lotion
concentrate, fatigue, dizziness, cardiac dysrhythmias,
6. Note the type and the amount of drainage pallor or cyanosis, dyspnea.
present Equipment
7. Ask the assistant to pour small amount of ● Oxygen source
cleansing solution into the bowl ● Flowmeter
8. Clean wound from the center to periphery, ● "No smoking" sign
discarding the used swabs after each stroke ● Humidifier and distilled water (for high-flow
9. After thoroughly cleaning of the wound, dry O2 therapy)
Procedure
the wound with dry swabs using the same
1. Review chart for physician's order for oxygen to ensure
precautions. Discard the forceps in the bowl that it includes method of delivery, flow rate, titration
of lotion orders; identify client.
10. Apply medications if ordered Rationale: Prevents potential errors.
11. Apply the sterile dressings. Apply the gauze 2. Wash your hands.
pieces first and then the cotton pads. Rationale: Handwashing reduces transmission of
Reinforce the dressings on the dependent microorganisms.
3. Identify client and proceed with 5 rights of medication
parts where the drainage may collect
administration. Explain procedure to client. Explain that
12. Remove the gloves and discard it into bowl oxygen will ease dyspnea or discomfort, and inform
with lotion client concerning safety precautions associated with
13. Secure the dressings with bandage or oxygen use. Encourage him or her to breathe through
adhesive tapes the nose.
Rationale: Oxygen is a drug and administering using the 5
AFTER CARE OF THE PATIENT AND THE ARTICLES rights avoids potential errors. Teaching helps ensure
compliance with therapy.
1. Help in the patient to dress up and to take a 4. Assist client to semi- or high Fowler's position, if
comfortable position in the bed tolerated.
2. Replace the bed linen Rationale: These positions facilitate optimal lung expansion.
 5. Insert flowmeter into wall outlet. Attach oxygen tubing FACTORS:
to nozzle on flowmeter. If using a high O2 flow, attach
humidifier. Attach oxygen tubing to humidifier 1. Time of the day
Rationale: Oxygen in high concentrations can be drying to
2. Age
the mucosa.
6. Turn on the oxygen at the prescribed rate (Fig. 5). Check 3. Gender
that oxygen is flowing through tubing (Fig. 6). 4. physical exercise
Rationale: Oxygen must be administered as prescribed. 5. emotions
7. Hold nasal cannula in proper position with prongs
curving downward 6. pregnancy
8. Place cannula prongs into nares 7. environment changes
9. Wrap tubing over and behind ears 8. infection
10. Adjust plastic slide under chin until cannula fits snugly
11. Place gauze at ear beneath tubing as necessary
9. drugs
Rationale: Proper placement in nares ensures accurate 10. food
administration. Note: The cannula permits some freedom of
movement and does not interfere with the client's ability to DIFFERENT ROUTE/SITES IN TAKING PR;
eat or talk.
12. If prongs dislodge from nares, replace promptly. 1. apical
Rationale: To ensure correct oxygen delivery and prevent 2. carotid
hypoxemia.
3. radial
13. Assess for proper functioning of equipment and observe
client's initial response to therapy. 4. brachial
Rationale: Assessment of vital signs, oxygen saturation, color, 5. temporal
breathing pattern, and orientation helps the nurse evaluate
6. femoral
effectiveness of therapy and detect clinical evidence of
hypoxia. 7. popliteal
14. Monitor continuous therapy by assessing for pressure 8. dorsalis pedis
areas on the skin and nares every 2 hours and
rechecking flow rate every 4 to 8 hours. NORMAL RANGE;
Rationale: Permit early detection of skin breakdown or
inadequate flow rate. Pulse Rate:

- Newborn: 120-160 bpm

- Adult: 60-100 bpm

Respiratory Rate:

- Newborn: 30-50 per minute

- Adult: 12-20 per minute

PULSE RATE:

- SKILLS/ABILITY

1. Washes hands.

2. Explain procedure to the patient.

3. Have the patient rest his arm along the side of his
body with the wrist extended and the palm of the
hand downward.

4. Place the 2nd and 3rd fingers along the radial

artery and press it gently against the radius.

5. Apply only enough pressure so that you can feel the

PULSE RATE. patient’s pulsating artery distinctly.

- the beating of the heart 6. Using a watch with a second hand, count the
number of pulsations felt on the patient’s artery for
RESPIRATORY RATE. one full minute.
- the act of breathing 7. Document the result
TEMPERATURE RESPIRATORY RATE:
- to determine the degree of internal heat of a 1. Washes hands
patient’s body.
2. Explain the procedure to the patient 5. emotions
6. pregnancy
3. While the fingertips are still in place after counting
7. environment changes
the PR, observe the patient’s respiration
8. infection
4. Note the rise and fall of the patient’s chest with 9. drugs
each inspiration. 10. food

5. Using a watch with a second hand, count the 1. Identify the patient.
number of respirations for one full minute.
2. Explain the procedure to the patient
6. Document the result
3. Washes hands
TEMPERATURE:
4. Place the patient in a comfortable position with the
1. Identify patient arm supported and palms upward

2. Explain the procedure to the patient 5. Roll the patient’s sleeves above the elbow

3. Make sure the thermometer is in operating 6. Place the cuff so that the inflatable bag is centered
condition over the brachial artery. The lower edge of the cuff is
1 inch above the antecubital fossa.
4. Perform hand hygiene and don gloves if
appropriate or indicated. 7. Wrap the cuff smoothly around the arm and tuck
the end of the cuff securely under the preceding
5. Select the appropriate site
wrapper. If using an aneroid gauge, check if the
6. If stored in a chemical solution, wipe the needle gauge is within the zero mark. If using the
thermometer dry with soft tissue, using a firm mercurial sphygmomanometer, place yourself in a
twisting motion. Wipe from bulb toward fingers. way that the meniscus of the mercury can be read at
eye level.
7. Grasp the thermometer firmly with the thumb and
forefinger. Pressed and on the digital thermometer. 8. Use fingertips to feel for the strong pulsation of the
brachial artery
8. Leave the thermometer in place until
signals/sounds are heard. (1 full minute) 9. Tighten the screw valve on the air pump.

9. Place thermometer’s bulb within the back of the 10. Inflate the cuff while continuing to palpate the
right or left pocket under patient’s tongue and tell the artery. Note the point on the gauge where the pulse
patient to close lips around thermometer (oral), in disappears.
the rectum as described when using a digital
11. Deflate the cuff and wait 15 seconds.
thermometer (rectal), or in the center of the axilla
with arm against chest wall (axillary). 12. Place the stethoscope earpieces in the ears. Direct
the era tips forward into the canal and not against the
11. Remove thermometer. Using a firm twisting
ear itself.
motion, wipe it once from fingers down to the bulb.
13. Place the stethoscope bell or diaphragm firmly
11. Read the thermometer by holding it horizontally
but with as little as possible over the brachial artery.
at eye level.
Do not allow stethoscope to touch clothing or cuff.
12. Dispose of tissue in a receptacle for contaminated
14. Pump the pressure 30 mm Hg above the point at
items.
which the systolic pressure was palpated and
14. Wash thermometer in soapy water. Rinse and dry estimated. Open manometer valve and allow air to
and replace the thermometer in its container. escape slowly (allowing the gauge to drop 2 to 3 mm
per heartbeat).
BLOOD PRESSURE MONITORING
15. Note the point on the gauge at which the first
- NORMAL RANGE: 120/60 faint, but clear, the sound appears and slowly
FACTORS: increases in intensity. Note this number as the
systolic pressure.
1. time of the day
2. age 16. Note the pressure at which the sound first
3. gender becomes muffled. Also, observe the point at which
4. physical exercise
sound completely disappears. These may occur
separately or at the same point.

17. Allow remaining air to escape quickly. Repeat any

suspicious reading but wait for 30 to 60 seconds
between readings to allow normal circulation to
return to the limb. Be sure to deflate the cuff
completely between attempts to check blood
pressure.

18. Remove the cuff and clean the equipment

19. Perform hand hygiene. If gloves are worn, discard

them in the proper receptacle.

20. Document the result