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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

OBTAINING OXYGEN SATURATION AND MONITORING


Purpose
Provides a noninvasive method for monitoring the oxygen saturation of arterial blood

Equipment

Pulse oximeter
Sensor (permanent or disposable)
Alcohol wipe(s)
Nail polish remover, if indicated

Assessment
Assessment should focus on the following:

Signs and symptoms of hypoxemia (restlessness; confusion; dusky skin, nailbeds, or mucous membranes)
Quality of pulse and capillary refill proximal to potential sensor application site
Respiratory rate and character
Previous pulse oximetry readings
Amount and type of oxygen administration, if applicable
Arterial blood gases, if available

Nursing Diagnoses
Nursing diagnosis may include the following:

Impaired gas exchange related to excessive secretions


Ineffective tissue perfusion

Outcome Identification and Planning


Desired Outcomes
Sample desired outcomes include the following:

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Client's arterial oxygen saturation (SaO2) remains between 95% and 100%.
Client exhibits signs of adequate gas exchange evidenced by respirations 18 to 20, nailbeds pink, capillary refill less than 3 seconds.
Client demonstrates knowledge of factors affecting pulse oximeter readings.

Special Considerations in Planning and Implementation


Pediatric
For children, choose an appropriate-sized sensor.

Geriatric
Be sensitive to probe placement in elderly clients: avoid tension on the probe site and be careful when applying tape to dry, thin skin.
Home Health
Pulse oximetry monitoring has mostly replaced home arterial blood gas measurement.

Transcultural
Keloids may be present on the earlobes of clients of African descent and may not allow accurate SaO2 readings. These ropelike scars result from an exaggerated
wound-healing process after ear piercing.

Delegation
Pulse oximetry measurement can be performed by unlicensed assistive personnel.

Implementation

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Perform hand washing and organize
equipment.
2. Explain the procedure to client (if conscious).

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3. Plug in oximeter and choose sensor. Sensor
types may vary according to the client's weight
and site considerations. If using a disposable
sensor, connect sensor to cable.
4. Prepare site. Use alcohol swab to cleanse site
gently. Get rid of nail polish or acrylic nails, if
needed, if a finger is being used as the
checking site.
5. Check capillary refill and pulse proximal to the
chosen site.
6. Assess the alignment of the light-emitting
diodes (LEDs) and the photo detector (light-
receiving sensor). These sensors should be
directly opposite each other (Fig. 6.25).
7. Turn on the pulse oximeter. DISPOSABLE
SENSORS NEED TO BE ATTACHED TO
THE CLIENT CABLE BEFORE TURNING
THE PULSE OXIMETER ON.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
8. Listen for a beep and note waveform or bar of
light on front of pulse oximeter.

9. Check and monitor alarm limits. Reset if


necessary. Make sure that both high and low
alarms are on before leaving the client's room.
Alarm limits for both high and low SaO2 and
high and low pulse rate are preset by the
manufacturer but can be easily reset in
response to doctor's orders.
10. Tell the client that common position changes
may trigger the alarm, such as bending the

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elbow or gripping the side rails or other
objects.
11. Relocate finger sensor at least every 4 hours.
Shift spring tension sensor at least every 2
hours.
12. Evaluate adhesive sensors at least every shift.

Evaluation

Desired outcome met: Pulse oximeter reading 97%.


Desired outcome met: Client alert and oriented X 3.
Desired outcome met: Respirations even and nonlabored with rate of 12 breaths per minute.

Documentation
The following should be noted on the client's chart:

Type and location of sensor


Presence of pulse proximal to sensor and status of capillary refill
Percentage of oxygen saturation in arterial blood (SaO2)
Rotation of sensor according to guidelines and status of site
Percentage of oxygen (or room air) client is receiving
Interventions as a result of deviations from the norm

Sample Documentation
Date: 1/7/05
Time: 1800
Finger sensor (probe) applied to left index finger; capillary refill brisk, radial pulse present. Pulse oximeter yielding SaO2 of 96% on room air.
Time: 2200
Finger probe applied to right index finger; capillary refill brisk, radial pulse present. Pulse oximeter yielding SaO2 of 97% on room air.

FEEDBACK/COMMENTS:

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FACULTY SIGNATURE: __________________________

Reference(s):

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ADMINISTRATION OF OXYGEN BY CANNULA, FACE MASK/VENTURI AND FACE TENT


A variety of devices are available for delivering oxygen to the patient. Each has a specific function and oxygen concentration. Device selection is based on the
patients condition and oxygen needs. A nasal cannula, also called nasal prongs, is the most commonly used oxygen delivery device. The cannula is a disposable
plastic device with two protruding prongs for insertion into the nostrils. The cannula connects to an oxygen source with a flow meter and, many times, a
humidifier. It is commonly used because the cannula does not impede eating or speaking and is used easily in the home. Disadvantages of this system are
that it can be dislodged easily and can cause dryness of the nasal mucosa. A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen.

When a patient requires a higher concentration of oxygen than a nasal cannula can deliver (6 L or 44% oxygen concentration), use an oxygen mask. Fit the
mask carefully to the patients face to avoid leakage of oxygen. The mask should be comfortably snug, but not tight against the face. Disposable and reusable
face masks are available. The most commonly used types of masks are the simple facemask, the partial rebreather mask, the nonrebreather mask, and the
Venturi mask.

Oxygen tents are often used in children who will not leave a face mask or nasal cannula in place. The oxygen tent gives the patient freedom to move in the
bed or crib while humidified oxygen is being delivered; however, it is difficult to keep the tent closed, because the child may want contact with his or her
parents. It is also difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50%. Frequent assessment of the childs
pajamas and bedding is necessary because the humidification quickly creates moisture, leading to damp clothing and linens, and, possibly, hypothermia.

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SPECIAL CONSIDERATIONS:
Oxygen administration may need to be continued in the home setting. Portable oxygen concentrators are used most frequently. Caregivers require
instruction concerning safety precautions with oxygen use and need to understand the rationale for the specific liter flow of oxygen.
To prevent fires and injuries, take the following precautions:
o Avoid open flames.
o Place No Smoking signs in conspicuous places in the patients home.
o Instruct the patient and visitors about the hazard of smoking when oxygen is in use.
o Check to see that electrical equipment used in the room is in good working order and emits no sparks.
o Avoid using oils in the area. Oil can ignite spontaneously in the presence of oxygen.
Different types of face masks are available for use.
Its important to ensure the mask fits snugly around the patients face. If it is loose, it will not effectively deliver the right amount of oxygen.
The mask must be removed for the patient to eat, drink, and take medications. Obtain an order for oxygen via nasal cannula for use during meal
times and limit the amount of times the mask is removed to maintain adequate oxygenation.

Equipment: Flow meter connected to oxygen supply


Humidifier with sterile
Distilled water (optional for low-flow system)
Nasal cannula and tubing
Facemask, specified by physician
Gauze to pad elastic band and tubing over the ears
Oxygen tent
Oxygen analyser
Small blankets for blanket rolls
PPE, as indicated

Assessment: Assess the patients oxygen saturation level before starting oxygen therapy to provide a baseline for evaluating the effectiveness of
oxygen therapy. Assess the patients respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory
distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea.

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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Bring the necessary equipment to the bedside or
overbed table

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
4. Close curtains around bed and close the door to the
room, if possible.

5. Explain what are you going to do and the reason


for doing it to the patient. Review safety
precautions necessary when oxygen is in use. Place
NO SMOKING signs in appropriate areas.
NASAL CANNULA
6. Connect nasal cannula to oxygen set up with
humidification, if one is use. Adjust flow rate as
ordered. Check that oxygen is flowing out of
prongs.
7. Place prongs in patients nostrils. Place the tubing
over and behind each ear with adjuster comfortable
under the chin. Alternately, the tubing may be
placed around the patients head, with the adjuster

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a the back or the base of the head. Place the gauze
pads at ear beneath the tubing, as necessary.
8. Adjust the fit of the cannula, as necessary. Tubing
should be snug but not tight against the skin.

9. Encourage patients to breathe through the nose


with the mouth closed.

10. Reassess patients respiratory status, including


respiratory rate, effort, and lung sounds. Note any
signs of respiratory distress, such as tachypnea,
nasal flaring, use of accessory muscles, or
dyspnea.
11. Remove PPE, if used. Perform hand hygiene.

12. Put on clean gloves. Remove and clean the cannula


and assess nares at least every 8 hours, or
according to agency recommendation. Check nares
for evidence of irritation or bleeding.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
MASK/VENTURI
13. Attach facemask to oxygen source (with
humidification, if appropriate, for the specific
mask). Start the flow of oxygen at the specified
rate. For a mask with a reservoir, be sure to allow
oxygen to fill the bag before proceeding to the next
step.
14. Position facemask over the patients nose and
mouth. Adjust elastic strap so that the mask fits
snugly but comfortably on the face. Adjust the flow
rate tot eh prescribed rate.
15. If the patient reports irritation or redness is noted,
use gauze pads under the elastic strap at pressure
point to reduce irritation to ears and scalp.
16. Reassess patients respiratory status, including
respiratory rate, effort, and lung sounds. Note any
signs of respiratory distress, such as tachypnea,
nasal flaring, use of accessory muscles, or
dyspnea.

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OXYGEN TENT
17. Calibrate the oxygen analyzer according to
manufacturers directions.

18. Place the tent over the crib or bed. Connect the
humidifier to the oxygen source in the wall or the
tank and connect the tent tubing to the humidifier.
Adjust flow rate as ordered by physician. Check
that oxygen is flowing into tent.
19. Turn analyzer on. Place the oxygen analyzer probe
in tent, out of the patients reach.

20. Adjust oxygen as necessary, based on sensor


readings. Once oxygen levels reach the prescribed
amount, place the patient in the tent.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
21. Roll small blankets like a jelly roll and tuck tent
edges under blanket rolls, as necessary.
22. Encourage patient and family members to keep
tent flap closed.
23. Reassess patients respiratory status, including
respiratory rate, effort, and lung sounds. Note any
signs of respiratory distress, such as tachypnea,
nasal flaring, use of accessory muscles, grunting,
retraction, or dyspnea.
24. Remove PPE, if used. Perform hand hygiene.

25. Frequently check bedding and patients pajamas for


moisture. Change as needed to keep the patient
dry.

UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS:


Patient was fine on oxygen delivered by nasal cannula but now is cyanotic, and the pulse oximeter reading is less than 93%: Check to see that the
oxygen tubing is still connected to the flow meter and the flow meter is still on the previous setting. Someone may have stepped on the tubing,
pulling it from the flow meter, or the oxygen may have accidentally been turned off. Assess lung sounds to note any changes.

181
Areas over ear or back of head are reddened: Ensure that areas are adequately padded and that tubing is not pulled too tight. If available, a skin care
team may be able to offer some suggestions.
When dozing, patient begins to breathe through the mouth: Temporarily place the nasal cannula near the mouth. If this does not raise the pulse
oximeter reading, you may need to obtain an order to switch the patient to a mask while sleeping.
Areas over ear or back of head are reddened: Ensure that areas are adequately padded and that tubing is not pulled too tight. If available, a skin-
care team may be able to offer some suggestions.

Child refuses to stay in tent: Parent may play games in tent with child if this will help child to stay in tent. Alternative methods of oxygen delivery may
need to be considered if child still refuses to stay in tent.
It is difficult to maintain an oxygen level above 40% in the tent: Ensure that the flap is closed and edges of the tent are tucked under blanket. Check
oxygen delivery unit to ensure that the rate has not been changed. Encourage patient to leave flaps closed. If still a problem, analyzer may need to
be replaced or recalibrated.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

182
Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

USING HANDHELD RESUSCITATION BAG AND MASK (AMBU BAGGING)

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a bag and mask may be used to deliver oxygen
until the patient is resuscitated or can be intubated with an endotracheal tube. Bag and mask devices are frequently referred to as Ambu bags (air mask bag
unit) or BVM (bag-valve-mask device). The bags come in infant, pediatric, and adult size. The bag consists of an oxygen reservoir (commonly referred to
as the tail), oxygen tubing, the bag itself, a one-way valve to prevent secretions from entering the bag, an exhalation port, an elbow so that the bag can lie
across the patients chest, and a mask.

EQUIPMENT: Handheld resuscitation device with a mask


Oxygen source
Disposable gloves
Face shield or goggles and mask
Additional PPE, as indicated
ASSESSMENT:
Assess the patients respiratory effort and drive. If the patient is breathing less than 10 breaths per minute, is breathing too
shallowly, or is not breathing at all, assistance with a BVM may be needed. Assess the oxygen saturation level. Patients who have decreased respiratory
effort and drive may also have a decreased oxygen saturation level. Assess heart rate and rhythm. Bradycardia may occur with a decreased oxygen
saturation level, leading to a cardiac dysrhythmia. Many times, a BVM is used in a crisis situation. Manual ventilation is also used during airway suctioning.

SPECIAL CONSIDERATIONS:

183
Air can be forced into the stomach during manual ventilation with a mask, causing abdominal distention. This distention can cause vomiting and
possible aspiration. Be alert for vomiting; watch through the mask. If the patient starts to vomit, stop ventilating immediately, remove the mask, wipe
and suction vomitus, as needed, then resume ventilation.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. If not in crisis situation, perform hand
hygiene.

2. Put on PPE, as indicated.

3. If not an emergency, identify the patient.

4. Explain what you are going to do and the


reason for doing it to the patient, even if the
patient does not appear to be alert.

5. Put on disposable gloves. Put on face shield


or goggles and mask.

6. Ensure that the mask is connected to the


bag device, the oxygen source, and the
oxygen turned on, at a flow rate of 10-15L
per minute. This may be done through
visualization or listening to the open end of

184
the reservoir or tail: if air is heard flowing,
the oxygen is attached and on.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
7. If possible, get behind head of bed and
remove headboard. Slightly hyperextend
patients neck (unless contraindicated). If
unable to hyperextend, use jaw thrust
maneuver to open the airway.
8. Place mask over the patients face with
opening over oral cavity. If mask is
teardrop-shaped, the narrow portion should
be placed over the bridge of the nose.
9. With the dominant hand, place three fingers
on the mandible, keeping head slightly
hyperextended. Place thumb and one finger
in C position around the mask, pressing hard
enough to form a seal around the patients
face.
10. Using nondominant hand, gently and slowly
(over 2 to 3 seconds) squeeze the bag,
watching chest for symmetrical rise. If two
people are available, one person should
maintain a seal on the mask with two hands
while the other squeezes the bag to deliver
the ventilation and oxygenation.
11. Deliver the breaths with the patients own
inspiratory effort, if present. Avoid delivering
breaths when the patient exhales. Deliver
one breath every 5 seconds, if patients
drive is absent. Continue delivering breaths
until patients drive returns or until patient is
intubated and attached to mechanical
ventilation.
12. Dispose of equipment appropriately.

185
13. Remove face shield or goggles and mask.
Remove gloves and additional PPE, if used.
Perform hand hygiene.

FEEDBACK/COMMENTS:

UNEXPECTED SITUATION AND ASSOCIATED INTERVENTIONS:


Breaths become increasingly difficult to deliver due to resistance: Obtain order for placement of naso- or orogastric tube to remove air from the stomach
(many institutions have policies that allow placement of a gastric tube during resuscitation). If air is delivered too fast, it may be introduced into the
stomach. When the stomach fills with air, it decreases the space available for the lungs to inflate.
Chest is not rising when breaths are delivered, and resistance is felt: Reposition the head or per- form the jaw thrust maneuver. If the chest is not rising
at all and resistance is being met, the tongue or another object is most likely obstructing the airway. If repositioning does not resolve the effort,
consider performing the Heimlich maneuver.
Chest is rising asymmetrically: Instruct assistant to listen to lung sounds bilaterally. Patient may need a chest tube placed due to pneumothorax.
Anticipate the need for chest tube placement.
Oxygen saturation decreases from 100% to 80%: Assess whether chest is rising. If chest is rising asymmetrically, the patient may have a pneumothorax.
Anticipate the need for a chest tube. Check oxygen tubing. Someone may have stepped on the tubing, either kinking the tubing or pulling the tubing
from the oxygen device.
A seal cannot be formed around the patients face, and a large amount of air is escaping around mask: Assess face and mask. Is the mask the correct
size for the patient? If the mask size is correct, reposition fingers, or have a second person hold the mask while you compress the bag.

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

186
Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

CHANGING OXYGEN CYLINDERS


Description:

Oxygen cylinders are used every day in hospitals, homes and ambulances. They come in various sizes, depending upon the needs of the patient. Smaller e-
cylinders are often used with home-health patients. These are especially useful for transporting oxygen-dependent patients. Replacing a near-empty oxygen
cylinder with a full one is easily accomplished with the correct tools and a safety-first attitude.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Place the patient on an alternate oxygen source
during the cylinder change-out procedure.
Ensure that this source is functioning properly.
2. Turn off the oxygen flow meter from the old
cylinder. Turn the top fitting on the cylinder
yoke clockwise using a cylinder wrench to close
the cylinder. Loosen and disconnect the
regulator from the empty cylinder. Discard the
used plastic gasket.
3. Remove the plastic band from the full e-
cylinder. Flush the cylinder by quickly opening
and closing the top fitting on the yoke. Take the
plastic gasket included with the new cylinder
and install it in the regulator. Attach and
tighten the regulator to the yoke of the new
cylinder using the cylinder wrench. Turn on the

187
flow meter to the prescribed flow. Listen and
feel to ensure that oxygen is flowing through
the system. Reconnect the patient to the
cylinder
4. Check the pressure remaining in the oxygen
cylinder. Cylinders should be changed if <3/4
full (<10,000kPa)
5. Ensure that the oxygen cylinder is turned off.
Release any pressure in medical oxygen
regulator by opening the oxygen flow meter.
6. Remove the medical oxygen regulator from the
oxygen cylinder. To remove, unscrew in a
counter clockwise direction. Then lift off the
oxygen cylinder.
7. Obtain a new/full oxygen cylinder and remove
the plastic cover from the oxygen cylinder
valve. Dispose plastic cover in the garbage bin.
8. Attach medical oxygen regulator to new/full
oxygen cylinder. Endure regulator pins align
with oxygen cylinder holes.
9. Once medical oxygen regulator has been
attached securely, open the oxygen cylinder
valve and check the medical oxygen regulator
pressure gauge. The pressure should read >15
000 kPa.

FEEDBACK/COMMENTS:

188
FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

TEACHING DEEP BREATHING EXERCISES

189
Definition:
Lung inflation techniques include diaphragmatic breathing exercises, apical and basal lung expansion exercises, and use of blow bottles, sustained maximal
inspiration (SMI) devices , or intermittent positive pressure breathing (IPPB) apparatuses.
Apical Expansion exercises are often required for clients who restrict their upper chest movement because of pain from severe respiratory disease or surgery
eg, lobectomy.

Purpose:
To promote the exchange of gases in the lungs and strengthen the muscles used for breathing.

Indication:
For clients with restricted chest expansion such as people with chronic obstructive pulmonary disease (COPD) or people recovering from thoracic surgery.
.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Assess the clients condition and identify
anything that may affect the success of the
procedure.

Abdominal (diaphragmatic ) and Pursed-Lip


Breathing

190
2. Explain to the client that diaphragmatic breathing
can help the person breath more deeply and with
less effort.
3. Have the client assume either a comfortable
semi-Fowlers position with knees flexed, back
supported, and with one head pillow or a supine
position with one head pillow and knees flexed.
After learning, the client can practice.

4. Have the client place one or both hands on the


abdomen just below the ribs.

5. Instruct the client to breath in deeply through the


nose with the mouth closed, to stay relaxed, not
to arch the back, and to concentrate on feeling
the abdomen rise as far as possible.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
6. If the client has difficulty raising the abdomen,
instruct the person to take a quick, forceful
inhalation through the nose.

7. Instruct the client to purse the lips as if about to


whistle; to breath out slowly and gently, making
a slow whooshing sound; to avoid puffing out
the cheeks; to concentrate on feeling the
abdomen fall or sink; and to tighten the
abdominal muscles while breathing out.
8. If the client has COPD, teach the double cough
technique. Have the client a. Breath in through
the nose and inflate the lungs to the mid
inspiration point, rather than to the full deep
inspiration point.

Simultaneously exhale and cough two or more


abrupt, sharp coughs in rapid succession.

191
9. Instruct the client to use this exercise whenever
feeling short of breath to increase it gradually 5-
10 minutes four times a day.

APICAL EXPANSION EXERCISES


10. Place your fingers below the clients clavicles and
exert moderate pressure, or have the client place his
or her fingers over the same area.

10. Instruct the client to inhale through the nose and


to concentrate on pushing the upper chest
upward and forward against the fingers.

11. Have the client hold the inhalation for a few


seconds.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
12. Have the client exhale through the mouth or nose
slowly, quietly and passively while concentrating
on moving the upper chest inward and
downward.

13. Instruct the client to perform the exercise for at


least five respirations four times a day.

BASAL EXPANSION EXERCISES


14. Place the palms of your hands in the area of the
lower ribs along the midaxillary lines, and exert
moderate pressure, or have the client place his
or her hands over the same areas.

15. Instruct the client to inhale through the nose and


to concentrate on moving the lower chest
outward against the hands.

16. Have the client hold the inhalation for a few


seconds.

192
17. Have the client exhale through the nose or mouth
slowly, quietly and passively. If the person has
COPD, observe the rate and character of the
exhalation. Normal exhalation is slow, and the
upper chest appears relaxed. If the exhalation
appears difficult or there is in drawing of the
upper chest, encourage pursed-lip exhalation.

18. Instruct the client to perform this exercise at


least five respirations four times a day.

19. Correct the patients breathing technique as


necessary.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

193
Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ASSISTING CLIENT TO USE INCENTIVE SPIROMETER


Definition:
Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to clients about inspiratory volume.

Purpose:
It is used to promote deep breathing to prevent or treat atelectasis in the postoperative client.

Equipment:
Incentive spirometer

194
UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Wash hands.

2. Instruct client to assume semi-Fowlers or high Fowlers


position.

3. Either set or indicate to client on the device scale, the


volume level to be attained with each breath.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
4. Demonstarte to client how to place mouthpiece of
spirometer so that lips completely cover mouthpiece.

5. Instruct client to inhale slowly and maintain constant


flow through unit. When maximal inspiration is reached,
client should hold breath for 2 to 3 seconds and then
exhale slowly.
6. Instruct client to breath normally for short period.

7. Have client repeat maneuver until volume goals are


achieved.

8. Wash hands.

9. Record the procedure done and clients ability to perform


it.

FEEDBACK/COMMENTS:

195
FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ADMINISTERING PERCUSSION, VIBRATION, and POSTURAL DRAINAGE TO ADULTS

Definition:
Percussion sometimes called clapping or cupping, is forcefully striking the skin with cupped hands.
Vibration is a series of vigorous quivering produced through hands that are placed flat against chest wall.
Postural drainage is the drainage, by gravity, of secretions from various lung segments.

Indication:
For clients who produce greater than 30cc of sputum per day or have evidence of atelectasis by chest x-ray examination.

Contraindication:
1. Percussion is contraindicated in clients with bleeding disorders, osteoporosis, or fractured ribs.

Considerations:
Postural drainage, percussion and vibration is best tolerated if done between meals , at least two hours after the patient has eaten, to decrease the
possibility of vomiting.

Purpose:
1. To mechanically dislodge and loosen mucous secretions.

196
2. Facilitate drainage of mucous secretions by gravity.

Equipment:
1. A bed that can be placed in Trendelenburg position.
2. Towel

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Wash Hands

2. Explain the procedure to the client

3. Provide visual and auditory privacy

4. Assist the client to the appropriate position


for postural drainage.

5. Have the client lie back at a 30o angle.


Percuss and vibrate between the clavicles and
above the scapulae.
6. Have the client sit upright in a chair or in bed
with the head bent slightly forward. Percuss
and vibrate the area between the clavicles
and scapulae.
7. Have the client lie on a flat bed with pillows
under the knees to flex them.Percuss and
vibrate the upper chest below the clavicles

197
down to the nipple line, except for women.
The breasts of women are not percussed,
because percussion may cause pain.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
8. Elevate the foot of the bed about 15o or
40cm and have the client lie on the left
side. Help the client to lean back slightly
against pillows extending at the back from
the shoulder to the hip. A pillow may be
placed between the knees for comfort. For a
male, percuss and vibrate over the right side
of the chest at the level of the nipple
between the 4rth and 6th ribs For a female,
position the heel of your hand toward the
axilla and your cupped fingers extending
forward beneath the breast to percuss and
vibrate beneath the breast.
9. Elevate the foot of the bed as in step 6, and
have the client lie as in step 6 except on the
right side. Percuss and vibrate the right side
of the chest as in step7
10. Have the client lie on the abdomen on a flat
bed, and place two pillows under the hips.
Percuss and vibrate the middle area of the
back on both sides of the spine.
11. Have the client lie on the unaffected side, with
the upper arm over the head. Elevate the foot
of the bed about 30o or 45 cm , or to the
height tolerated by the client. Place one pillow
between the knees. Another under the head
is optional.Percuss and vibrate the affected
side of the chest over the lower ribs, inferior
to the axilla.
12. Have the client lie partly on the unaffected
side and partly on the abdomen. Elevate the
foot of the bed about 30o or 45cm (18in.), or
to the height tolerated by the client. As an
alternative, elevate the hips with pillows.

198
Percuss and vibrate the uppermost side of the
lower ribs.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
13. Have the client lie prone. Elevate the foot of
the bed about 30o or 45cm (18in.), or to the
height tolerated by the client. Elevate the hips
on two or three pillows to produce a jackknife
position from the knees to the
shoulders.Percuss and vibrate over the lower
ribs on both sides close to the spine, but not
directly over the spine or the kidneys.

PERCUSSION
1. Ensure that the area to be percussed is covered.
2. Ask the client to breath slowly and deeply.

3. Cup your hands, ie, old your fingers and thumb


together , and flex them slightly to form a cup,
as you would to scoop up water.
4. Relax your wrists, and flex your elbows.
5. With both hands cupped, alternately flex and
extend the wrists rapidly to slap the chest. The
hands must remain cupped so that air cushions
the impact, to avoid injuring the client.

6. Percuss each affected lung segments for 1-2


minutes.
VIBRATION
1. Place your flattened hands, one over the other
(or side by side) against the affected chest area.
2. Ask the client to inhale deeply through the mouth
and exhale slowly through pursed lips or the
nose.

3. During the exhalation, straighten your elbows,


and lean slightly against the clients chest while
tensing your arm and shoulder muscles in
isometric contractions.

199
PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
4. Vibrate during five exhalations over one affected
lung segment.

5. Encourage the client to cough and expectorate


secretions into the sputum container. Offer the
client mouthwash
6. Auscultate the clients lungs, and compare the
findings to the baseline data.

7. Document the percussion, vibration, and postural


drainage and assessments. Note the amount,
color, and character of expectorated secretions.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW.

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

200
STEAM INHALATION

DEFINITION:
A treatment to provide warm, moist air for the patient to breath.

INDICATION:
1. Irritation (tickling or pain in throat) by moistening mucous membranes.
2. Acute or chronic inflammation and congestion of mucous membranes of nose and throat due to colds and bronchitis.
3. Coughing (relaxes muscles).
4. Dry or thick secretions.

PURPOSES:
1. To relieve swelling, inflammation, congestion and pain in the nose and throat in upper respiratory infections.
2. To stimulate expectoration.
3. To reduce dryness of mucous membrane.
4. To relieve spasmodic breathing.

EQUIPMENT:
1. Pitcher
2. Basin
3. Boiling water
4. Paper cone
5. Bath towel and face towel (patients gown)
6. Drug ordered (optional)

NOTE: If an electric inhaler/ vaporizer is used, please study operation manual/ package.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

201
0 1 2 3 4 5 6 7 8 9
1. Check doctors order.

2. Explain procedure to client.

3. Wash hands.

4. Place boiling water about 1/3 to full in a


pitcher.

5. Add ordered medication, if any.

6. Bring pitcher on a basin to the bedside. Place


on a firm surface.

7. Assist client to assume convenient position.


May sit at edge of bed. Provide privacy PRN.

8. Place paper cone on mouth of pitcher.

9. Place bath towel over clients chest. Provide


face towel over clients forehead and eyes as
necessary. At about one foot away from the
paper cone, have the client inhale steam.

10. Remove pitcher at the end of prescribed


period. Wipe clients face and make him
comfortable. Protect from cold air.

11. Wash used article with soap and water


(except cone). Rinse and dry and return to
proper place. Wash hands.

202
12. Record clients response to therapy.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

INSERTING AN ORAL AIRWAY


Descriptions:

An oropharyngeal airway (also known as an oral airway, OPA or Guedel pattern airway) is a medical device called an airway adjunct used to maintain
a patent (open) airway. It does this by preventing the tongue from covering the epiglottis, which could block the person from breathing. To an
unconscious person, the muscles in their jaw relax and allow the tongue to obstruct the airway. [1
Endotracheal intubation is the placement of a tube into the trachea to maintain a patent airway in those who are unconscious or unable to maintain
their airway.

203
Purpose:
Oral airway:

1. Holds tongue forward to maintain open airway


2. Facilitates removal of secretion

Endotracheal Tube:

1. Treatment of symptomatic hypercapnia


2. Treatment of symptomatic hypoxemia.
3. Airway protection against aspiration.
4. Pulmonary toilet. Facilitation of suctioning
5. Delivery of anaesthetic and other drugs via the endotracheal tube (ETT)
6. More effective ventilation and oxygenation

Contraindications:

1. Awake patient.
2. Airway can be managed less invasively.

Equipment (Oral airway):

Oral airway
Equipment for suctioning
Tape strips (one approximately 20 inches, one 16 inches (may use commercially manufactured airway holder)
Tongue depressor
Petroleum jelly
Mouth moistener or swabs with mouthwash
Non sterile gloves
Equipment (Endotracheal Tube):

1. IV access, EKG, pulse oxy monitors


2. Suction apparatus
3. Non- rebreather mask
4. Oxygen
5. Bag valve mask
6. Appropriate size endotracheal tube (7.5 mm adult, child = diameter of little finger); with stylet and 10cc syringe
7. Laryngoscope blade and handle

204
8. Tape

Assessment
Assessment should focus on the following:
Level of consciousness, agitation, and ability to push airway from mouth
Respiratory status (respiratory rate, congestion in upper airways), blood pressure, pulse
Presence of cyanosis
Color, amount, and consistency of secretions
Condition of oral mucous membranes
Alternative methods of maintaining airway
Use of dentures/dentition aids

Nursing Diagnoses
Nursing diagnoses may include the following:
Ineffective breathing pattern related to airway blockage by tongue

Outcome Identification and Planning


Desired Outcomes
Sample desired outcomes include the following:
Client will attain and maintain clear airway passage, evidenced by non-labored respirations and clear breath sounds.
Airway is patent and free of secretions.

Special Considerations in Planning and Implementation


General
If client is alert and agitated enough to push airway out or resist it, DO NOT INSERT. Airway could stimulate gag reflex and cause client to aspirate. Use
another method of maintaining airway, if needed. If goal is to prevent client from biting on endotracheal tube, use a bite block, preferably a dental bite
block, and secure it well to prevent block from sliding to back of throat.

Pediatric
Check for appropriate airway size before insertion because pediatric-sized oral airways are available. Use the Broselow pediatric kit or place the airway on
the outside of the child's face in the appropriate position to approximate size.

Geriatric
Remove dentures, if present, before insertion.
End-of-Life Care
If desired, use oral airways to maintain an open airway and provide access for suctioning in clients who are not alert. Do not use them in clients who are
alert, as they are uncomfortable and unnatural.

Home Health
Teach family how to insert airway and perform maintenance between nurse's visits.

205
Transcultural
Clients from some ethnic/cultural backgrounds consider touching the head a taboo. Discuss alternatives, such as having a family member assist with
insertion. With clients of African or Mediterranean descent, use caution when assessing for cyanosis, particularly around the mouth, because this area may
be dark blue normally. Coloration varies from person to person and should be carefully evaluated on an individual basis.

Delegation
Insertion of oral airways should not be delegated to unlicensed assistive personnel. Respiratory therapy personnel often perform the procedure.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9

FOR ORAL AIRWAY

1. Explain the procedure to client and family.

2. Perform hand hygiene and organize


equipment.

3. Lay long strip of tape down with sticky side


up and place short strip of tape over it with
sticky side down, leaving equal length of
sticky tape exposed on either end of long
strip. Split either end of tape 2 inches. A
commercial holder may also be used.
4. Don gloves.

5. Rinse airway in cool water.

206
6. Open mouth and place tongue blade on front
half of tongue.
7. Turn airway on side and insert tip on top of
tongue .
8. Slide airway in until tip is at lower half of
tongue.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
9. Remove tongue blade.

10. Turn airway so tip points toward tongue;


outer ends of airway should be vertical.

11. Place tape under client's neck with ends


lying on either side.

12. Pull one end of tape across client's mouth


with splits taped across upper and lower
ends of airway.

13. Repeat with other end of tape.

14. Suction mouth and throat if needed.

15. Swab mouth with moisturizer and


mouthwash.

16. Apply petroleum jelly to lips.

207
17. Position client in good alignment and for
comfort.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
18. Evaluate respirations.

19. Raise side rails and place call light within


reach.

20. Remove gloves and perform hand hygiene.

Documentation:
Procedure note describes indications, equipment and technique, number of attempts and how placement was confirmed, as well as complications and their
management.

Items for Evaluation:


Understands indication.
Appropriate preparation and pretreatment.
Successful airway management.
Understands and manages complications.
Proper documentation in the medical record.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

208
Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

PROVIDING TRACHEOSTOMY CARE


Definition:
The nurse provides tracheostomy care for the client with a new or recent tracheostomy to maintain patency of the tube and reduce the risk of infection.
Initially, a tracheostomy may need to be suctioned and clean as often as every 1 to 2 hours. After the initial inflammation response subsides, tracheostomy
care may only need to be done once or twice a day, depending on the client.

Purposes:
1. To maintain airway patency.
2. To maintain cleanliness and prevent infection at the tracheostomy site
3. To facilitate healing and prevent skin excoriation around the tracheostomy incision
4. To promote comfort.

Special Considerations:
1. Suction the inner cannula before its removal.
2. Remove the tracheostomy dressing and inner cannula with your non-dominant clean hand.
3. Wear sterile gloves on both hands to clean the tube.
4. Inspect the cannula for cleanliness and remove excess liquid from it before insertion.
5. Lock the inner cannula after insertion.
6. Assess the status of the incision and surrounding skin.
7. Use noncotton-filled gauze square for cleaning and for the dressing.

209
8. Securely support the tracheostomy tube when cleaning it, and when applying the dressing and tie tapes.
9. Always fasten clean ties before removing soiled ties unless an assistant to hold the tracheostomy tube in place is available.

Equipments:
Scissors
1 pair of clean gloves
1 pair of sterile gloves
Hydrogen peroxide
Normal saline
Tracheostomy kit (4x4-inch gauze, cotton-tipped applicators, tracheostomy dressing, basin, small bottle brush or pipe cleaner, twill tape or
tracheostomy ties/collar)
Oral care equipment
Bag for soiled dressings

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
Assessment
1. Although done routinely after tracheostomy
care, assess the patients dressing for
drainage or soiling.
Planning
2. Wash your hands.
3. Obtain tracheostomy care kit.

Implementation
4. Identify the patient.
5. Provide privacy.

210
6. Explain what you are going to do.

7. Put on clean gloves, and remove old


dressing and discard.
a. Hold tube while you remove dressing.
b. Place your fingers around tube while you
remove dressing.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
8. Remove gloves and wash hands.

9. Put on sterile gloves.

10. With sterile, moistened swabs, clean around


edges of tracheostomy opening.

11. Note any redness or swelling.

12. Prepare the dressing using precut or 4x4


gauze squares:
a. If 4x4 gauze, open first fold.
b. Fold in half lengthwise.
c. Fold each end toward center.

13. Secure the tube by gently holding in place.


Cut and remove soiled tape.
14. Position new dressing.

211
a. Thread tape through flange on one side.
b. Bring tape around back of patients neck.
c. Pass tape through opposite flange.
d. Tie tape securely at side of neck.

It is helpful for you or the patient to hold


a finger under the tape as it is tightened.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
15. Check tube placement.

16. Perform oral care.

17. Dispose of equipment.


18. Remove gloves, and wash your hands.
Evaluation
19. Evaluate, using the following criteria:
a. Tracheostomy tube securely in place.
b. No redness or swelling present
c. No secretions present.
d. Dressing and tapes clean and dry.
e. Absence of stale or foul-smelling breath

212
Documentation
20. Document procedure and any observations
such as status of surrounding skin and
amount of type of drainage.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

213
Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

DEFLATING AND INFLATING A CUFFED TRACHEOSTOMY TUBE

Definition:
A cuffed trachestomy tube compounds the nursing care requirements of the patient in acute respiratory failure. To give intelligent, knowledgeable
care, it is essential to have a thorough understanding of the cuffed tube its design, purpose, principles of use, and the potential dangers associated with it.
The cuff is so design that when it is properly inflated, it forms a seal between the tracheostomy tube and the trachea, preventing air from entering or
escaping around the tube. The cuff, usually made of soft rubber, encircles the lower portion of the outer cannula of the tracheostomy tube. Once the
tracheostomy tube is in place in the patients trachea, the cuff is inflated to form the seal. The only route of effective air exchange; with the cuff inflated, is
the lumen of the tracheostomy tube. The inflated cuff also reduces the possibility of aspiration of secretions into the lower trachea and bronchi. Nothing gets
by the seal created in the trachea by the inflated cuff.

Purposes:
Cuffed tracheastomy tubes are generally inflated:
1. During the first 12 hours after a tracheostomy;
2. When the client is being ventilated or receiving IPPB therapy, to prevent leakage;
3. When the client is eating or receiving oral medications, and for a prescribed period of time following meals or medications (e.g., 30 minutes), to
prevent aspiration; and
4. When the client is comatose, to prevent aspiration of oropharyngeal secretions.

At other times the cuff is deflated. If double-cuffed tubes are used, deflation and inflation must be done at regular intervals according to the
manufacturers directions.

Critical Elements:
For cuff deflation:
1. Maintain asepsis when suctioning.
2. Suction the oropharngeal cavity adequately before cuff deflation.
3. Withdraw the correct amount of air while the client inhales and while providing a positive pressure breath if ordered.
4. If the cough reflex is stimulated after deflation, suction the lower airway.

For cuff inflation:


1. Inflate the cuff on inhalation.
2. Follow the minimal leak technique.
3. Make sure the cuff pressure does not excess 15-20 mm Hg or 25 cm H2O.

214
4. Clamp the inflation tube if required.
5. Document the exact amount of air used to inflate the cuff.

Equipments:
1. Equipment needed for suctioning the oropharyngeal cavity
2. 5- to 10- ml syringe
3. Stethoscope
4. Rubber-tipped hemostat
5. Manual resuscitator (Ambu bag)
6. Manometer specifically designed to measure cuff pressure (if available)
7. Sterile three-way stopcock (optional)

215
UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Check the physicians orders to determine when
the cuffed tube should be inflated.

2. Assist the client to a semi-fowlers position unless


contraindicated. Clients receiving positive
pressure ventilation should be placed in a supine
position so that secretions above the cuff site are
moved up into the mouth.

3. Assess the clients respiration, pulse, color,


breath sounds, and behavior.

Deflating the Cuff


4. Suction the oropharyngeal cavity before
inflating the cuff. Discard the catheter after use.
5. If a hemostat is clamping the cuff inflation tube,
unclamp it. Some tubes have one-way valves
that replace the hemostat.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9

216
6. Attach the 5- or 10-ml syringe to the distal end
of the inflation tube, making sure the seal is
tight.

7. Suction the lower airway with a sterile catheter,


if the cough reflex is stimulated during cuff
deflation.

8. Assess the clients respirations, and suction the


client as needed. If the client experiences
breathing difficulties, reinflate the cuff
immediately.

Inflating the Tracheal Cuff


9. Add the least amount of air following the
manufacturers recommendations, to create a
minimal air leak. The minimal leak technique is
designed to prevent tracheal damage and is
performed as follows:
a. Inflate the cuff on inhalation, and place
your stethoscope on the clients neck
adjacent to the trachea.

b. Listen for squeaking or gurgling sounds,


which indicate a leak.

217
c. If no leak is present, slowly remove 0.2-
0.3 ml more air.

d. Listen again for sounds.

e. The cuff is inflated sufficiently when:


You cannot hear the clients voice.
You cannot feel any air movements
from the clients mouth, nose, or
tracheostomy site.
You hear a slight or no leak from the
positive pressure ventilation when
auscultating the neck adjacent to the
trachea during inspiration.

10. Measure the cuff pressure:


a. Attach the cuffs pillow port to the cuff
pressure manometer.

b. Read the dial on the manometer. The


pressure should not exceed 15-20 mm
Hg or 25 cm H2O.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
11. Clamp the inflation tube with the hemostat if
the tube does not have a one-way valve.

218
12. Remove the syringe.

13. Determine the exact amount of air used to


inflate the cuff.

14. Document the time of the deflation and/or


inflation, the amount of air withdrawn and/or
injected, and your assessments.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

SUCTIONING (OROPHARYNGEAL, NASOPHARYNGEAL, ENDOTRACHEAL AND TRACHEOSTOMY TUBE)


Definition:
Suctioning clears secretions from the airway of patients who cannot mobilize and expectorate them without assistance. It involves aspirating secretions
through a catheter connected to a suction source. The purpose is to remove secretions from the pharynx and nose by a suction catheter inserted through the
mouth and nose.

219
An endotracheal tube is inserted by the physician or nurse with specialized education through either the mouth or the nose and into the trachea with
the guide of a laryngoscope. The tube terminates just superior to the bifurcation of the trachea into the bronchi. Because the tube passes through the epiglottis
and glottis, the client is unable to speak while it is in place.
A tracheostomy is a surgical incision into the trachea to insert a tube through which the patient can breathe more easily and secretions can be removed.
It is performed more commonly as a prophylactic procedure so that secretions in there respiratory tract can be removed more effectively before a patients
breathing is severely. Because the tracheostomy opens directly into the trachea, which is highly susceptible to infection, the nurse must have a thorough
knowledge of sterile technique to care for and suction a tracheostomy.

Parts Of A Tracheostomy Tube:


1. Inner cannula - the "sleeve" inside of the tracheostomy tube that can be removed for cleaning.
2. Neck plate (flange) - site for ties; prevents movement and skin-breakdown secondary to pressure points.
3. Obturator - a guide for positioning the actual trach tube.
4. Cuff - inflates with air inside the trachea to seal the trach wall, preventing aspiration and potential air leak around the cannula. Cuffed trach tubes
are used predominately for patients who require mechanical ventilation with high pressures. For patients requiring only nocturnal ventilation, the
cuff can be deflated during the day.

Types Of Tracheostomy Tubes:


Composition - The tube material is chosen on desired flexibility. Metal tubes (Jackson tubes) are rigid. Silicone tubes are very flexible. Polyvinyl
chloride (PCV) tubes may be flexible or rigid. Shiley and Portex are plastic tubes.
Double-cannula tube - Contains a removable, inner cannula. Double-cannula tubes are used mostly for children with thick, copious secretions.
Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes. Can be cuffed or un-cuffed depending on the indication.
Single-cannula tube - Used mostly for infants and small children. Single-tubes are typically plastic and uncuffed.
Fenestrated tube - Contains an opening on the superior portion of the cannula, where air can travel from the vocal cords, into the cannula, and
up through the fenestration to the oropharynx. This allows the patient to vocalize.

220
Indications:
This procedure is indicated when the client:
1. Has endotracheal or tracheostomy tube in place;
2. Is unable to cough and expectorate secretions effectively (e.g., infants and comatose patients);
3. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract; and
4. Is dyspneic or appears cyanotic.

Purposes:
1. To remove secretions that obstruct the airway;
2. To facilitate respiratory ventilation;
3. To obtain secretions for diagnostic purposes; and
4. To prevent infection that may result from accumulated secretions in the respiratory tract.

Special Considerations:
1. Maintain the sterility of the dominant glove, suction catheter, normal saline, and syringe, if used.
2. Assess the clients respirations, pulse, color, breath sounds, and behavior before and after the procedure.
3. For clients who do not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning.
4. For clients who have copious secretions, increase the oxygen liter flow before suctioning.
5. Use appropriate suction pressure.
6. Restrict each suction time to 10 seconds and total suctioning time to no more than 5 minutes.
7. Reapply supplementary oxygen as required during and after the procedure.
8. Replenish supplies in readiness for the next suction.

221
Equipments:
Towels or pads Sterile normal saline or water
Emesis basin lined with paper Sterile gloves
Portable or wall suction machine: includes a collection bottle, a Sterile suction catheter
tubing system connected to the suction catheter, and a For adults - #12 to # 18
gauge that registers the degree of suction For children - # 8 to # 10
Sterile disposable container for sterile fluids For infants - # 5 to # 8
Note: If both oropharynx and nasopharynx are to be suctioned, one sterile catheter is required for each.
Types of Suction Catheter
1. Open-tipped catheter has an opening at the end and several openings along the sides. It is effective for thick mucus plugs, but it can
irritate the tissue.
2. Whistle-tipped catheter has a slanted opening at the tip.
Most catheters have a thumb port on the side, which is used to control the suction. Several openings along the sides of the tip of the suction catheter
ensures distribution of negative pressure of the suction over a wide area, thus preventing excessive irritation of any area of the respiratory mucous
membrane.

Water-soluble lubricant or glass of sterile water Sputum trap or cup, if specimen is to be collected
Y-connector Sterile forceps (in cases where institution practices such or in
Sterile gauzes absence of gloves)
Moisture-resistant disposable bag Resuscitation bag (Ambu bag) connected to 100% oxyge

222
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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
OROPHARYNGEAL AND NASOPHARYNGEAL
SUCTIONING
A. Prepare the client.
1. Wash hands and observe other appropriate
infection control procedures (e.g., gloves,
goggles.

2. Gather necessary equipment and supplies.

3. Explain to the client, regardless of level of


consciousness, the purpose and rationale
of the procedure. Provide information that
suctioning will relieve breathing difficulty
and the procedure is painless but may
stimulate the cough, gag, or sneeze reflex.

4. Assess for signs and symptoms indicating


upper airway secretions: gurgling
respirations, restlessness, vomitus in the
mouth, and drooling. Monitor HR, RR,
color, and ease of respirations.

5. Position the client correctly.

PROCEDURE

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For oropharyngeal and nasopharyngeal


suctioning:
a. Position a conscious person who has a
functional gag reflex in the semi-
Fowlers position with the head turned
to one side for oral suctioning or with
the neck hyperextended for nasal
suctioning.

b. Position an unconscious client in the


lateral position facing you.

6. Place the towel or pad over the pillow or


under the chin. Provide emesis basin under
the chin or side of the face.

B. Prepare the equipment.


7. Set the pressure on the suction gauge and
turn on the suction. Many suction devices
are calibrated to three pressure ranges:
Wall unit
Adult: 100-120 mmHg
Child: 95-110 mmHg
Infant: 50-95 mmHg
Portable unit
Adult: 10-15 mmHg
Child: 5-10 mmHg
Infant: 2-5 mmHg

8. Hyperoxygenate client before inserting


catheter and suctioning.
9. Open the sterile suction package.

PROCEDURE
10. Set up the cup or container, touching only
its outside.

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11. Pour sterile water or saline into the sterile


container.
12. Don the sterile gloves, or don a nonsterile
glove on the non-dominant hand and
sterile glove on the dominant hand.
13. With you sterile gloved hand, pick up the
catheter, and attach it to the suction unit.
14. Open the lubricant if performing
nasopharyngeal suctioning.

C. Make an approximate measure of the depth for


the insertion of the catheter and test the
equipment.
For oropharyngeal and nasopharyngeal
suctioning:
15. Measure the distance between the tip of
the clients nose and the earlobe or about
13cm (5in) for an adult. The appropriate
distance for an infant or small child is 4 to
8 cm (1.6 to 3.2 in) or 8 to 12 cm (3.2 to
4.8 in) for an older child.
For nasal tracheal suctioning, measure the
distance between the tip of the clients
nose to the earlobe and then along the side
of the neck to the thyroid cartilage (Adams
apple). For oral tracheal suctioning,
measure from the mouth to the
midsternum
16. Mark the position on the tube with the
fingers of the sterile gloved hand.
PROCEDURE
17. Test the pressure of the suction and the
patency of the catheter by applying your
sterile gloved finger or thumb to the port
or open branch of the Y connector (the
suction control) to create suction.
D. Lubricate and introduce the catheter.

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For nasopharyngeal suction:


a. Lubricate the catheter tip with water-
soluble lubricant.

b. Without applying suction, insert the


catheter the premeasured or recommended
distance into either nares, and advance it
along the floor of the nasal cavity.

c. Never force the catheter against an


obstruction. If one nostril is obstructed, try
the other.

For an orpharyngeal suction:


a. Moisten tip with sterile water or saline.

b. Pull the tongue forward, if necessary, using


gauze.

c. Do not apply suction during insertion.

d. Gently advance the catheter about 4 to 6


inches along one side of the mouth into the
oropharynx.

E. Perform suctioning.
18. Apply your finger to the suction control
port to start suction, and gently rotate the
catheter. Suction intermittently as catheter
is withdrawn.

19. Apply suction for 5 to 10 seconds; then


remove your finger form the control, and
remove the catheter. A suction attempt
should last only 10 to 15 seconds. During
this time, the catheter is inserted, the

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suction applied and discontinued, and the


catheter removed.
It may be necessary during
oropharyngeal suctioning to apply suction
to secretions that collect in the vestibule of
the mouth and beneath the tongue.

F. Clean the catheter, and repeat suctioning as


above.
20. Wipe off the catheter with sterile gauze if it
is thickly coated with secretions. Dispose of
the gauze in a moisture-resistant bag.

21. Flush the catheter with sterile water or


saline.

22. Relubricate the catheter, and repeat


suctioning until the air passage is clear.
Note: Allow 20- to 30-second intervals
between each suction, and limit suction to
5 minutes in total.

23. Alternate nares for repeat suctioning.

24. Encourage client to breathe deeply and to


cough between suctions.

G. Obtain a specimen if required.


a. Attach the suction catheter to the rubber
tubing of the sputum trap.

b. Attach the suction tubing to the sputum


trap air vent.
c. Suction the clients nasopharynx or
oropharynx. The sputum trap will collect
the mucus during suctioning.

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d. Remove the catheter from the client.


Disconnect the sputum trap rubber tubing
from the trap air vent.
e. Connect the rubber tubing of the sputum
trap to the air vent.
f. Flush the catheter to remove secretions
from the tubing.

H. Promote client comfort.


25. Offer to assist the client with oral or nasal
hygiene.

I. Dispose of equipment and ensure availability for


the next suction.
26. Dispose of the catheter, gloves, water and
waste container. Wrap the catheter around
your sterile glove and roll it inside the
glove for disposal.

27. To ensure that equipment is available for


the next suctioning, change suction
collection bottles and tubing daily or more
frequently as necessary.

J. Assess the effectiveness of suctioning.


28. Auscultate the clients breathing sounds to
ensure they are clear secretions. Observe
for restlessness or presence of oral
secretions.

K. Wash hands.

L. Document relevant data.

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a. Record the procedure: the amount,


consistency, color, and odor of sputum
(e.g., foamy, white mucus: thick, green-
tinged mucus; or blood-flecked mucus),
clients breathing status before and after
the procedure and the clients reaction to
the procedure.

b. If the technique is carried out frequently,


e.g., q1h, it may be appropriate to record
only once, at the end of the shift; however,
the frequency of the suctioning must be
recorded.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
TRACHEOSTOMY AND ENDOTRACHEAL
TUBE SUCTIONING
1. Test suction apparatus.
a. Turn on either the wall suction or the
portable suction machine.

b. Place your thumb over the end of the


unsterile tubing that is attached to the
suction equipment and test for pull.

c. Keep the suction regulated to a range of


efficiency, usually low to medium.

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2. Position the patient: Supine or mid-fowlers


with head slightly toward you if conscious;
lateral position facing you if unconscious.

3. Put on eye protection and mask.

4. Prepare 5 mL sterile saline in a syringe;


remove needle.

5. Open kit and prepare equipment.


a. Place drape or towel over patients chest.

b. Put on gloves.
c. Open and pour saline.

d. Attach catheter to suction tubing, and


moisten catheter in normal saline
solution.

6. Attach breathing bag to oxygen source.

7. Attach breathing bag to


tracheostomy/endotracheal tube and provide
three breaths as the client inhales. If the
client has copious secretion, do not

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hyperventilate with a resuscitator. Instead,


keep the regular O2 device on and increase
the liter flow or adjust the FiO2 to 100% for
several breaths before suctioning.

8. Instill saline into tracheostomy/endotracheal


tube (if this is the policy).
9. Perform suctioning.
A. Apply intermittent suction for 5-10 seconds
by placing the non-dominant thumb over
the thumb port.
B. Rotate the catheter by rolling it between
you thumb and forefinger while slowly
withdrawing it.
C. Rinse the catheter with sterile water of
normal saline solution.
D. Provide ventilation immediately after the
suction catheter is removed (usually done
by an assistant) to supply needed oxygen.

E. Stop the procedure when there is persistent


coughing.

10. Observe the patient for dyspnea and skin


color changes.

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11. If these symptoms of hypoxia occur, provide


additional deep breaths of oxygen.
12. Turn off the suction and listen for clear
breath sounds.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
13. If the breathing sounds are not clear, repeat
steps 17a through d.

14. If the breathing sounds clear, use the


breathing bag to provide three or four deep
breaths of oxygen.

15. Disconnect the catheter from the suction


tubing.

16. Pull sterile glove over catheter to cover it,


and remove eye protection and mask.

17. Discard disposable equipment, and take


nondisposable equipment to appropriate
place for cleaning.

18. Wash your hands.

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19. Perform oral hygiene.


Evaluation
20. Evaluate using the following criteria:
a. Tracheostomy/endotracheal tube
securely in place.

b. Respiratory rate and depth normal.

c. Breath sounds clear.

d. Patient resting comfortably.

Documentation
21. Document the procedure and observations.
Include the amount and description of
suction returns and any other relevant
assessments.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

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Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

MONITORING A CLIENT WITH CHEST DRAINAGE

Definition:
Policies and procedures vary considerably from agency to agency in regard to chest drainage interventions. Certain interventions, such as milking a chest
tube to maintain patency, may be prohibited. The nurse must therefore review agency policies before intervening.
Equipment:
- Two rubber-tipped Kelly clamps
- A sterile petrolatum gauze
- A sterile drainage system
- Antiseptic swabs
- Sterile 4 x 4 gauzes
- Air-occlusive tape
- A mechanical chest tubing stripper, if ordered
- Specimen supplies, if needed:
. A povidone-iodine swab
. A sterile #18 or #20 gauge needle
. A 3-or 5-ml syringe
. A needle protector
. A label for the syringe
. A laboratory requisition
Intervention:
Essential data include
. Vital signs for baseline data and then every 4 hours.
. Breath sounds. Auscultate bilaterally for baseline data. Diminished or absent breath sounds indicate inadequate lung expansion and recurrent pneumothorax
after chest drainage is established.

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. Clinical signs of pneumothorax before and after chest tube insertion. Leakage or blockage of a chest tube can seriously impair ventilation. Signs include
sharp pain on the affected side; weak, rapid pulse; pallor; vertigo; faintness; dyspnea; diaphoresis; excessive coughing; and blood-tinged sputum.
. Chest movements. A decrease in chest expansion on the affected side indicates pneumothorax.
. Dressing site. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foul-smelling discharge. Palpate around the dressing site and
listen for a crackling sound indicative of subcutaneous emphysema can result from a poor seal at the chest tube insertion site. It is manifested by a crackling sound
that is heard when the area around the insertion site is palpated.
. Level of discomfort. Analgesics often need to be administered before the client moves or does deepbreathing and coughing exercises.

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
Safety Precautions:
1. Keep two 15- to 18-cm (6-7-in.) rubber-tipped Kelly
clamps within reach at the bedside, to clamp the
chest tube in an emergency, eg, if leakage occurs in
the tubing.
2. Keep one sterile petrolatum gauze within reach at
the bedside to use with an air-occlusive material if
the chest tube becomes dislodged.
3. Keep an extra drainage system unit available in the
clients room. In most agencies the physician is
responsible for changing the drainage system
except in emergency situations, such as malfunction
or breakage. In these situations:

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a. Clamp the chest tubes


b. Reestablish a water-sealed drainage system.
c. Remove the clamps, and notify the
physician.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
4. Keep the drainage system below chest level and
upright at all times, unless the chest tubes are
clamped.
5. If the chest tube becomes disconnected from the
drainage system:
a. Have the client exhale fully.

b. Clamp the chest tube close to the insertion


site with two rubber-tipped clamps placed in
opposite directions.

c. Quickly clean the ends of the tubing with an


antiseptic, reconnect them, and tape them
securely.

d. Unclamp the tube as soon as possible.

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e. Assess the client closely for respiratory


distress.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
6. If the chest tube becomes dislodged from the
insertion site:
a. Remove the dressing, and immediately apply
pressure with the petrolatum gauze, your
hand, or a towel.

b. Cover the site with sterile 4 x 4 gauze


squares.
c. Tape the dressing with air-occlusive tape.
d. Notify the physician immediately
e. Assess the client for respiratory distress
every 15 minutes or as health indicates.

7. Do not empty a drainage bottle unless there is an


order to do so. Commercial systems cannot be
emptied.

8. If the drainage system is accidentally tipped over:


a. Immediately return it to the upright position.

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b. Ask the client to take several deep breaths.


c. Notify the nurse in charge and the physician.
d. Assess the client for respiratory distress.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ASSISTING A PERIPHERAL VENOUS ACCESS IV INFUSION

DESCRIPTION: Aiding the primary health care provider/Intravenous therapist during the Intravenous fluid administration is an essential part of routine patient
care. The primary careprovider often orders IV therapy to prevent or correct problems in fluid and electrolyte balance. The nurse must also verify the amount and
type of solution to be administered, as well as the prescribed infusion rate.
EQUIPMENT
IV solution, as prescribed
Patients chart
Towel or disposable pad
Nonallergenic tape
IV administration set
Label for infusion set (for next change date)
Transparent site dressing
Tourniquet
Time tape and/or label (for IV container)
Cleansing swabs (chlorhexidine preferred)
Clean gloves
IV pole
IV catheter (over the needle, Angiocath) or butterfly needle
Intravenous tubing
Alcohol wipes
Skin protectant wipe (e.g., SkinPrep)
Prefilled 2-mL syringe with sterile normal saline for injection

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ASSESSMENT
Go over the patients chart for baseline data, such as vital signs, intake and output balance, and
pertinent laboratory values, such as serum electrolytes. Evaluate the appropriateness of the Intravenous fluid prescribed by the physician basing on the laboratory
data results of the patient.

Assess arms and hands for potential sites for initiating the IV. Determine the most desirable accessible vein. The cephalic vein, accessory cephalic
vein,metacarpal, and basilic vein are appropriate sites for infusion (INS, 2006).

Determine accessibility based on the patients condition. For example, a person with severe burns on both forearms does not have vessels available in these
areas, or a patient with a history of axillary node dissection should not have venipuncture in the affected arm.

Do not use the antecubital veins if another vein is available. They are not a good choice for infusion because flexion of the patients arm can displace the IV
catheter over time.

Do not use veins in the leg, unless other sites are inaccessible, because of the danger of stagnation
of peripheral circulation and possible serious complications.

Do not use veins in surgical areas. For example, infusions in the arm should not be given on the same side as recent extensive breast surgery, because of
vascular disturbances in the area, or in an arm that has a device inserted for dialysis (e.g., fistula or shunt).

NURSING DIAGNOSIS
Determine the related factors for the nursing diagnosis based on the patients current status. Appropriate nursing diagnoses may include:

Deficient Fluid Volume Impaired Skin Integrity


Risk for Injury Risk for Deficient Fluid Volume
Risk for Infection

OUTCOME IDENTIFICATION AND PLANNING


The expected outcome to achieve when assissitng a peripheral venous access IV infusion is that the access device is inserted using sterile technique on the first
attempt. Also, the patient experiences minimal trauma, and the IV solution infuses without difficulty.

IMPLEMENTATION

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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Verify the IV solution order on the patients
chart with the medical order. Clarify any
inconsistencies. Check the patients chart for
allergies. Check for color, leaking, and expiration
date. Know techniques for IV insertion,
precautions, purpose of the IV administration,
and medications if ordered.

2. Gather all equipment and bring to the bedside.

3 . Perform hand hygiene and put on PPE,


ifindicated.

4. Identify the patient.

5 Close curtains around bed and close the door to


the room, if possible. Explain what you are going
to do and why you are going to do it to the
patient. Ask the patient about allergies to

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medications, tape, or skin antiseptics, as


appropriate. If considering using a local
anesthetic, inquire about allergies forthese
substances as well.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
Prepare the IV Solution and Administration Set
6. Compare the IV container label with the
doctors order. Remove IV bag from outer wrapper,
if indicated. Check expiration dates. Alternately,
label the solution container with the patients name,
solution type, additives, date, and time.
7. Maintain aseptic technique when opening sterile
packages and IV solution. Remove administration set
from package . Apply label to tubing reflecting the
day/date for next set change, per facility guidelines.
8. Close the roller clamp or slide clamp on the IV
administration set . Invert the IV solution container and
remove the cap on the entry site, taking care not to
touch the exposed
entry site. Remove the cap from the spike on the
administration set. Using a twisting and pushing
motion, insert the administration set spike into the
entry site of the IV container.
9. Hang the IV container on the IV pole. Squeeze
the drip chamber and fill at least halfway.
10. Open the IV tubing clamp, and allow fluid to
move through tubing. Allow fluid to
flow until all air bubbles have disappeared and the
entire length of the tubing is primed (filled) with IV
solution . Close the clamp. After fluid has filled the
tubing, recap the end of the tubing.
11. Prepare and place the following on the IV tray:
clean gloves, tourniquet, IV tag/label, cleansing
swabs (chlorhexidine preferred), IV catheter (over the
needle, Angiocath) or butterfly needle, and alcohol
wipes.

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12. After the IV therapist successfully inserted the


IV catheter, remove equipment and return the patient
to a position of comfort. Lower bed, if not in lowest
position.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
13. Return to check flow rate and observe IV site
for infiltration 30 minutes after starting infusion, and at
least hourly thereafter. Ask the patient if he or she is
experiencing any pain or
discomfort related to the IV infusion.
14. Document the location where the IV access was
placed, as well as the size of the IV catheter or
needle,the type of IV solution, and the rate of the IV
infusion.

EVALUATION

The expected outcome is met when the IV access is initiated on the first attempt; fluid flows easilyinto the vein without any sign of infiltration; and the patient
verbalizes minimal discomfort relatedto insertion and demonstrates an understanding of the reasons for the IV.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW

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Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

CHANGING AN IV SOLUTION CONTAINER AND ADMINISTRATION SET


Intravenous fluid administration frequently involves multiple bags or bottles of fluid infusion. Verify the amount and type of solution to be administered, as well as
the prescribed infusion rate.
In addition, monitor these fluid infusions and replace the fluid containers, as needed.

Focus on the following points:


If more than one IV solution or medication is ordered, check facility policy and appropriate literature to make sure that the additional IV solution can be attached to
the existing tubing.
As one bag is infusing, prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container.
Ongoing assessments related to the desired outcomes of the IV therapy, as well as assessing for both local and systemic IV infusion complications, are required.
Before switching the IV solution containers, check the date and time of the infusion administrationset to ensure it does not also need to be replaced. For simple IV
solutions, every 72 to 96 hours isrecommended.

EQUIPMENT
For solution container change:
IV solution, as prescribed
Patients chart/record
IV tag/label
PPE, as indicated
For tubing change:
Administration set
Label for administration set (for next change date)
Sterile gauze
Nonallergenic tape
Clean gloves

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Additional PPE, as indicated


Alcohol wipes

ASSESSMENT

Review the patients record for baseline data, such as vital signs, intake and output balance,and pertinent laboratory values, such as serum electrolytes.

Assess the appropriateness of the solution for the patient. Review assessment and laboratory data that may influence solution administration.

Inspect the IV site. The dressing should be intact, adhering to the skin on all edges. Check for any leaks or fluid under or around the dressing. Inspect the
tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. Also inspect the site
for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site.

Ask the patient if he/she is experiencing any pain or discomfort related to the IV line. Pain or discomfort is sometimes associated with both infiltration and
phlebitis.

NURSING DIAGNOSIS
Determine the related factors for the nursing diagnosis based on the patients current status. An appropriate nursing diagnosis is Risk for Injury. Other nursing
diagnoses that may be appropriateinclude:

Deficient Fluid Volume Risk for Infection


Risk for Deficient Fluid Volume Impaired Skin Integrity

OUTCOME IDENTIFICATION AND PLANNING


The expected outcome to achieve when changing an IV solution container and tubing is that the prescribed IV infusion continues without interruption and no infusion
complications are
identified.

IMPLEMENTATION

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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Verify IV solution order on the patients chart
with the medical order. Clarify any
inconsistencies. Check the patients chart for
allergies. Check for color, leaking, and expiration
date. Know the purpose of the IV administration
and medications if ordered.
2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if


indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to


the room, if possible. Explain what you are going to do
and why you are going to do it to the patient. Ask the
patient about allergies to
medications or tape, as appropriate.
6. Compare IV container label with the doctors
order . Remove IV bag from outer wrapper, if
indicated. Check expiration dates. Alternately,
label solution container with the patients name,
solution type, additives, date, and time.

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PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
7. Maintain aseptic technique when opening sterile
packages and IV solution. Remove
administration set from package. Apply label to
tubing reflecting the day/date for next set
change, per facility guidelines.
8. Carefully remove the cap on the entry site of the
new IV solution container and expose the entry
site, taking care not to touch the exposed entry
site.
9. Lift empty container off IV pole and invert it.
Quickly remove the spike from the old IV
container, being careful not to contaminate it.
Discard old IV container.
10. Using a twisting and pushing motion, insert the
administration set spike into the entry site of the
IV container. Hang the container on the IV pole.
11. Alternately, hang the new IV fluid container on
an open hook on the IV pole. Carefully remove
the cap on the entry site of the new IV solution
container and expose the entry site, taking care
not to touch the exposed entry site. Lift empty
container off the IV pole and invert it. Quickly
remove the spike from the old IV container,
being careful not to contaminate it . Discard old
IV container. Using a twisting and pushing
motion, insert the administration set spike into
the entry port of the new IV container as it
hangs on the IV pole .
12. If using gravity infusion, slowly open the roller
clamp on the administration set and count the
drops. Adjust until the correct drop rate is
achieved .
13. Hang the IV container on an open hook on the
IV pole. Close the clamp on the existing IV
administration set. Also, close the clamp on the

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short extension tubing connected to the IV


catheter in the patients arm.

PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
14. Put on gloves. Remove the current infusion
tubing from the access cap on the short
extension IV tubing. Using an antimicrobial
swab, cleanse access cap on extension tubing.
Remove the end cap from the new
administration set. Insert the end of the
administration set into the access cap. Loop the
administration set tubing near the entry site,
and anchor with tape (nonallergenic) close to
site .
15. Open the clamp on the extension tubing. Open
the clamp on the administration set.
16. If using gravity infusion, slowly open the roller
clamp on the administration set and count the
drops. Adjust until the correct drop rate is
achieved.
17. Remove equipment. Ensure patients comfort.
Remove gloves. Lower bed, if not in lowest
position.
18. Remove additional PPE, if used. Perform hand
hygiene.
19. Return to check flow rate and observe IV site for
infiltration 30 minutes after starting infusion,
and at least hourly thereafter. Ask the patient if
he or she is experiencing any pain or discomfort
related to the IV infusion.
20. Document the type of IV solution and the rate of
infusion; and the presence of redness, swelling,
or drainage. Record the patients reaction to the
procedure and pertinent patient teaching, such
as alerting the nurse if the patient experiences
any pain from the IV or notices any swelling at
the site. If necessary, document the IV fluid
solution on the intake and output record.

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EVALUATION

The expected outcome is achieved when the IV solution container and administration set are changed;the IV infusion continues without interruption; and no infusion
complications are identified.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

MONITORING AN IV SITE AND INFUSION


The nurse is responsible for monitoring the infusion rate and the IV site. This is routinely done as part of the initial patient assessment and at the beginning of a
work shift. In addition, IV sites are checked at specific intervals and each time an IV medication is given, as dictated by the institutions policies. Monitoring the
infusion rate is a very important part of the patients overall management. If the patient does not receive the prescribed rate, he or she may experience a fluid
volume deficit. In contrast, if the patient is administered too much fluid over a period of time, he or she may exhibit signs of fluid volume overload. Other
responsibilities involve checking the IV site for possible complications and assessing for both the desired effects of an IV infusion as well as potential adverse
reactions to IV therapy.

EQUIPMENT
PPE, as indicated

ASSESSMENT

Inspect the IV infusion solution for any particulates and check the IV label. Confirm it is the solution ordered.
Check the tubing for kinks or anything that might clamp or interfere with the flow of the solution.
Inspect the IV site. The dressing should be intact, adhering to the skin on all edges.
Assess fluid intake and output.
Assess for complications associated with IV infusions.
Assess the patients knowledge of IV therapy.

NURSING DIAGNOSIS
Determine the related factors for the nursing diagnosis based on the patients current status. Appropriate
nursing diagnoses may include:

Excess Fluid Volume Risk for Infection Risk for Injury


Deficient Fluid Volume Risk for Deficient Fluid Volume

OUTCOME IDENTIFICATION AND PLANNING


The expected outcome to be met when monitoring the IV infusion and site is that the patient remains free from complications and demonstrates signs and symptoms
of fluid balance.

IMPLEMENTATION

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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Verify IV solution order on the patients chart with
the medical order. Clarify any inconsistencies. Check
the patients chart for allergies. Check for color,
leaking, and expiration date. Know purpose of the IV
administration and medications, if ordered.
2. Monitor IV infusion every hour or per agency policy.
More frequent checks may be necessary if medication is
being infused
3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the


room, if possible. Explain what you are going to do
to the patient.
6. Check tubing for anything that might interfere with
flow. Be sure clamps are in the open position.
7. Observe dressing for leakage of IV solution.

8. Inspect the site for swelling, leakage at the site,


coolness, or pallor, which may indicate infiltration
(Figure 4). Ask if patient is experiencing any pain or
discomfort. If any of these symptoms are present,
the IV will need to be removed and restarted at
another site. Check facility policy for treating
infiltration.

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PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
9. Inspect site for redness, swelling, and heat. Palpate
for induration. Ask if patient is experiencing pain.
These findings may indicate phlebitis. Notify primary
care provider if phlebitis is suspected. IV will need
to be discontinued and restarted at another site.
Check facility policy for treatment of phlebitis.
10. Check for local manifestations (redness, pus,
warmth, induration, and pain) that may indicate an
infection is present at the site, or systemic
manifestations (chills, fever, tachycardia,
hypotension) that may accompany local infection at
the site. If signs of infection are present,
discontinue the IV and notify the primary care
provider. Be careful not to disconnect IV tubing
when putting on patients hospital gown or assisting
the patient with movement.
11. Be alert for additional complications of IV therapy.

a. Fluid overload can result in signs of cardiac


and/or respiratory failure. Monitor intake and
output and vital signs. Assess for edema and
auscultate lung sounds. Ask if patient is
experiencing any shortness of breath.

b. Check for bleeding at the site.


12. If possible, instruct patient to call for assistance if
any discomfort is noted at site, solution container is
nearly empty, flow has changed in any way, or if
the electronic pump alarm sounds.

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ADMINISTERING BLOOD TRANSFUSION

A blood transfusion is the infusion of whole blood or a blood component, such as plasma, red blood cells, or platelets, into a patients venous circulation. Before a
patient can receive a blood product, his or her blood must be typed to ensure that he or she receives compatible blood. Otherwise, a serious and life-threatening
transfusion reaction may occur involving clumping and hemolysis of the red blood cells and, possibly, death (Table 1). The nurse must also verify the infusion rate,
based on facility policy or medical order. Follow the facilitys policies and guidelinesto determine if the transfusion should be administered by electronic pump or by
gravity.

Table 1 TRANSFUSIONS REACTIONS

Reaction Signs and Symptoms Nursing Activity


Allergic reaction: allergy to transfused blood Hives, itching , Anaphylaxis Stop transfusion immediately and keep vein
openwith normal saline.
Notify physician stat.
Administer antihistamine parenterally, as
necessary.
Febrile reaction: fever develops during infusion Fever and chills, Stop transfusion immediately and keep vein
Headache open with normal saline.
Malaise Notify physician.
Treat symptoms.
Hemolytic transfusion reaction: incompatibility of Immediate onset Stop infusion immediately and keep vein open
blood product Facial flushing with
Fever, chills normal saline.
Headache Notify physician stat.
Low back pain Obtain blood samples from site.
Shock Obtain first voided urine.
Treat shock if present.
Send unit, tubing, and filter to lab.
Draw blood sample for serologic testing and
send
urine specimen to the lab.

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Circulatory overload: too much blood administered Dyspnea Slow or stop infusion.
Dry cough Monitor vital signs.
Pulmonary edema Notify physician.
Place in upright position with feet dependent.
Bacterial reaction: bacteria present in blood Fever Stop infusion immediately.
Hypertension Obtain culture of patients blood and return
Dry, flushed skin blood
Abdominal pain bag to lab.
Monitor vital signs.
Notify physician.
Administer antibiotics stat.

EQUIPMENT

Blood product
Blood administration set (tubing with in-line filter and Y for saline administration)
0.9% normal saline for IV infusion
IV pole
Venous access; if peripheral site, preferably initiated with a 20-gauge catheter or larger
Clean gloves
Additional PPE, as indicated
Tape (hypoallergenic)
Second nurse to verify blood product and patient information

ASSESSMENT

Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output.
Review the most recent laboratory values, in particular, the complete blood count (CBC).
Ask the patient about any previous transfusions, including the number he or she has had and any reactions experienced during a transfusion.
Inspect the IV insertion site, noting that the gauge of the IV catheter is a 20 gauge or larger.

NURSING DIAGNOSIS

Determine the related factors for the nursing diagnosis based on the patients current status. Appropriate
nursing diagnoses may include:
Risk for Injury Excess Fluid Volume Decreased Cardiac Output

Deficient Fluid Volume Ineffective Peripheral Tissue Perfusion

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OUTCOME IDENTIFICATION AND PLANNING

The expected outcome to achieve when administering a blood transfusion is that the patient will remain free of injury and any signs and symptoms of IV
complications. In a ddition, the capped venous access device will remain patent

IMPLEMENTATION

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
1. Verify the medical order for transfusion of a
blood product. Verify the completion of informed
consent documentation in the medical record.
Verify any medical order for pretransfusion
medication. If ordered, administer medication at
least 30 minutes before initiating transfusion.
2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if


indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the
room, if possible. Explain what you are going to do and
why you are going to do it to the patient. Ask the
patient about previous
experience with transfusion and any reactions. Advise
patientto report any chills, itching, rash, or unusual
symptoms.

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PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
6. Prime blood administration set with the normal saline
IV fluid.

7. Put on gloves. If patient does not have a venous


access in place, initiate peripheral venous access.
Connect the administration set to the venous access
device via the extension tubing. Infuse the normal
saline per facility policy.
8. Obtain blood product from blood bank according to
agency policy.

9. Two nurses compare and validate the following


information with the medical record, patient
identification band, and the label of the blood product:
Medical order for transfusion of blood product
Informed consent
Patient identification number
Patient name
Blood group and type
Expiration date
Inspection of blood product for clots
9. Obtain baseline set of vital signs before beginning
transfusion.

10. Put on gloves.

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PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
11. Close the roller clamp closest to the drip chamber
on the blood product side of the administration set.
Remove the protectivecap from the access port on the
blood container. Remove the cap from the access spike
on the administration set. Using a pushing and twisting
motion, insert the spike into the access port on the
blood container, taking care not to contaminate the
spike. Hang blood container on the IV pole. Open the
roller clamp on the blood side of the administration set.
Squeeze drip chamber until the in-line filter is saturated
.
Remove gloves.
12.Start administration slowly (no more than 25 to 50
mL for the first 15 minutes). Stay with the patient for
the first 5 to 15 minutes of transfusion. Open the roller
clamp on the administration set below the infusion
device. Set the rate of flow and begin the transfusion.
Alternately, start the flow of solution by releasing the
clamp on the tubing and counting the
drops. Adjust until the correct drop rate is achieved.
Assess the flow of the blood and function of the infusion
device.Inspect the insertion site for signs of infiltration.
13. Observe patient for flushing, dyspnea, itching,
hives or rash, or any unusual comments.
14. After the observation period (5 to 15 minutes)
increase thevinfusion rate to the calculated rate
to complete the infusionwithin the prescribed
time frame, no more than 4 hours.
15. Reassess vital signs after 15 minutes .

16. Maintain the prescribed flow rate as ordered or


as deemed appropriate based on the patients
overall condition, keeping in mind the outer
limits for safe administration. Ongoing
monitoring is crucial throughout the entire
duration of the blood transfusion for early
identification of any adverse reactions.

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PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
17. During transfusion, assess frequently for
transfusion reaction. Stop blood transfusion if you
suspect a reaction. Quickly replace the blood tubing
with a new administration set primed with normal
saline for IV infusion. Initiate an infusion of normal
saline for IV at an open rate, usually 40 mL/hour.
Obtain vital signs. Notify physician and blood
bank.
18. When transfusion is complete, close roller clamp on
blood side of the administration set and open the
roller clamp on the normal saline side of the
administration set. Initiate infusion of normal
saline. When all of blood has infused into the
patient, clamp the administration set. Obtain vital
signs. Put on gloves.Cap access site or resume
previous IV infusion. Dispose of blood-transfusion
equipment or return to blood bank, according to
facility policy.
19. Remove equipment. Ensure patients comfort.
Remove gloves. Lower bed, if not in lowest
position.
20. Remove additional PPE, if used. Perform hand
hygiene.
21. Document that the patient received the blood
transfusion; include the type of blood product.
Record the patients condition throughout the
transfusion, including pertinent data, such as vital
signs, lung sounds, and the subjective response of
the patient to transfusion. Document any
complications or reactions and whether the patient
had received the transfusion without any

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complications or reactions. Document the


assessment of the IV site, and any other fluids
infused during the procedure. Document transfusion
volume and other IV fluid intake on the patients
intake and output record.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

ASSISTING, MONITORING & MAINTAINING PATIENTS WITH OF CENTRAL VENOUS


CATHETER (TPN)
Definition

TOTAL PARENTERAL NUTRITION is a method of delivering total nutrition through a catheter placed in a large central vein. A large vein of blood flow is needed to dilute
the solution rapidly.

Assessment
1. Verify policy regarding CVP insertion.
2. Review clients past medical history including allergies.
3. Assess the clients ability to cooperate with the procedure.
Key Critical Points:
Only competent staff (or training staff supervised by competent staff) are to insert Peripherally Inserted Central Venous Catheters (PICC)
Accurate documentation and record keeping should be maintained to ensure patient safety
Equipment
Central venous catheter
Central venous catheter insertion kit, if available
Order stating type of catheter to be placed and number of lumens
Scalpel
Suture kit
Air occlusive dressing
Gauze
Sterile, latex-free gloves
A 5-ml syringe with heparinized saline for each lumen
Lidocaine
Betadine

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UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
Client Education
Explain sensation felt during insertion.
Explain with pictures what CVC look like.
Explain care of CVC and troubleshooting (e.g.
difficulty flushing, catheter leaking)
Describe signs of infection or thrombus
formation involving CVC and how to handle
these situations.
Wash hands.

Wear barrier precautions including a cap, mask, sterile


gown, sterile gloves, and a sterile full body drape.
Check doctors written orders stating type of catheter to
be placed and number of lumens.
Identify client and check for drug or iodine allergies.

Drape the entire upper body and arm of the patient (while
maintaining a sterile field) with a large fenestrated drape
leaving only a small opening at the insertion site.
Clean chest area with betadine and drape appropriately.
Use aqueous povidone-iodine 10% or sterile normal saline
0.9% (NB: the drying time for aqueous based antiseptics is
longer than alcohol based products)
The solution should be applied vigorously to an area of
skin approximately 30cm in diameter, in a circular
motion beginning in the centre of the proposed site and

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moving outward, for at least 30 seconds: (repeat 3


times)
Allow the antiseptic to air dry completely prior to
inserting the catheter; do not wipe or blot.

Assist with administration of subcutaneous lidocaine.

The catheter should be inserted by a competent


healthcare team member. It should be inserted in an
area where asepsis can be maintained.
The catheter tip position should be confirmed by a
modified X-ray result to allow visualization or the
clinical may consider UTZ guided access.
Clinicians should use the smallest gauge of catheter
that will accommodate the prescribed therapy to reduce
the risk of phlebitis.
Prior to insertion, the central venous catheter lumens
must be primed with normal saline or heparinized
saline. (Must be flushed.) Remember flush catheters
immediately: after placement ; prior to and after fluid
infusion or injection (as an empty fluid container lacks
infusion pressure and will allow blood reflux into the
catheter lumen from normal venous pressure) and prior to
and after blood drawing.
A small incision is made and the central venous
catheter is inserted directly into the subclavian vein and
threaded through the innominate vein into the superior
vena cava. Be familiar with the types of catheters
generally used in your facility.
The physician, or qualified practitioner secures the
central venous catheter with one suture and covers the
wound with an air occlusive dressing. Assist the
clinician by providing the necessary dressings
materials.
Checks each lumen of the catheter for patency by
flushing with normal saline or heparinized saline
(depending on the type of catheter inserted).

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Chest X-ray is performed.


Wash hands.
Documentation:
Document date and time of insertion.
Note the type of catheter inserted, site, x-ray
results, and how client tolerated the procedure.
Note unusual observations.
MAINTAINING & MONITORING
If gauze is used, it should be changed by a clinician at
least every 48 hours OR if damp, no longer adherent or
soiled:
The dressing (including semi-permeable polyurethane
types) should not be immersed or submerged in water: -
showering is preferable to bathing, and swimming should
be avoided with any external catheter, in order to prevent
colonisation by Gram-negative organisms, especially
Pseudomonas spp.
Cleanse the area, Cleansing should use a circular motion
moving in concentric circles from the site outward:
Remove blood or ooze from catheter insertion site with
sterile 0.9% sodium chloride.
The insertion site should be examined each shift for
erythema, exudate, tenderness, pain, redness, swelling,
suture integrity, catheter position and also fever & signs of
sepsis. Monitor hypo and hyperglycemia signs and
symptoms.
Monitor vital signs every 4-8 hours. Monitor flow rate
every 4 hours, prescribed flow rate should be strictly
followed to prevent hyperglycemic intolerance.
Instruct client to:
Weigh self daily.
Monitor intake and output.
Report sudden increases in weight or decreased
urine output.

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Keep all appointments for follow-up care and


laboratory testing.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

CAPPING A PRIMARY LINE FOR INTERMITTENT USE


EQUIPMENT
Lock device
Clean gloves
4x4 gauze pad
Normal saline or heparin flush prepared in a syringe
Alcohol wipe
Tape
Extension tubing (optional)

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
Gather equipment and verify physicians order.

Fill lock or adapter device with normal saline or


heparin flush.

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Explain the procedure to the patient.

Perform hand hygiene.


Assess the IV site.

Clamp off primary IV tubing.


When Extension Tubing is Present

Don gloves. Clamp the extension tubing if a clamp is


present. Remove the IV tubing from the extension set
and attach the lock or adapter device. Cleanse the
cap of the lock of adapter device with an alcohol
swab.
Unclamp the extension set and insert a saline or
heparin flush syringe into the cap and flush the line.
Reclamp the extension tubing and remove the
syringe.
When Connecting Directly to the Hub of the IV
Access Catheter
Follow actions 1 through 5.
Prime the lock of adapter device and extension set (if
one is to be attached to the device) with normal
saline. Clamp the extension set if one is being used.

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Don clean gloves.

Place gauze 4x4 sponge underneath IV connection


hub between IV catheter and tubing.
Stabilize hub of IV catheter with nondominant hand.
Use dominant hand to quickly twist and disconnect IV
tubing from the catheter. Discard it. Attach the
primed lock or adapter device (or adapter device and
extension set) to the IV catheter hub.
Cleanse cup with an alcohol wipe and unclamp the
extension set (if used).
Insert the syringe with blunt cannula or standard
syringe and gently flush with saline or heparin flush.
Remove syringe carefully and reclamp the extension
tubing (if used).

Remove gloves and dispose of them appropriately.

Tape lock or adapter device (and extension tubing if


used).
Perform hand hygiene and ensure the patient is
comfortable.
Chart on IV administration record.

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Name: ______________________________________________ Date: ____________________________

Evaluator: ___________________________________________ Score: ___________________________

MONITORING INTAKE AND OUTPUT (I & O)


One of the most basic methods of monitoring a client's health is measuring intake and output , commonly called I and O. By monitoring the amount of fluids a
client takes in and comparing this to the amount of fluid a client puts out. The health care team can gain valuable insights into the client's general health as
well as monitor specific disease conditions.

INTAKE
- all those fluids entering the client's body such as water, ice chips, juice, milk, coffee and ice cream. Artificial fluids include: parenteral, central lines, feeding
tubes, irrigation and blood transfusion.

OUTPUT
- all fluid that leaves the client's body such as: urine, perspiration, exhalation, diarrhea, vomiting, drainage from all tubes and bleeding.

Equipment: - Non-sterile gloves


- Sign at bedside stating patient is for I & O monitoring
- I & O form at bedside
- I & O graphic record in chart Purpose:
- Pencil and paper - helps evaluate client's fluid and electrolyte balance
- Calibrated drinking glass - suggests various diagnosis
- Bedside pan, commode or urinal - influence the choice of fluid therapy
- Calibrated container to measure outputs - document the client's ability to tolerate oral fluids
- Weighing scale - recognize significant fluid losses

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IDEAL DAILY FLUID INTAKE AND OUTPUT


SOURCE AMOUNT ROUTE AMOUNT
Water consumed as fluid 1500 mL Urine 1400 1500 mL
Water present in food 750 mL Insensible fluid loss 350 400 mL
Water produced by 350 mL Lungs 350 400 mL
oxidation
Skin 100 mL
Sweat 100 mL
Feces 200 mL
TOTAL INTAKE 2,600 mL TOTAL OUTPUT 2300-2600 mL

UNSATISFACTORY
NOT PERFORMED

SATISFACTORY

VERY GOOD

EXCELLENT
GOOD
PROCEDURE RATIONALE

0 1 2 3 4 5 6 7 8 9
Ideally intake and output should be monitored
In critical situations, intake and output should be
monitored on an hourly basis.Urine output less than
500ml in 24 hours or less than 30cc/hour indicates
renal failure
Daily weights are often done. Indicate fluid retention
or loss
Identify if patient undergone surgery or with medical
problem

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Record the type and amount of all fluids and describe


the route at least every 8 hours
If irrigating a nasogastric or another tube or bladder,
measure the amount instilled and subtract it from the
total output
Keep toilet paper out of client urine output

Measure drainage in a calibrated container and


observe it at eye level.

FEEDBACK/COMMENTS:

FACULTY SIGNATURE: __________________________

Reference(s):

Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3 rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses Guide to Clinical Procedures. 5 th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursin Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadephia: LWW

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ANNEX

INTAKE AND OUTPUT FORM


NAME OF Date: Shift:
PATIENTS INTAKE OUTPUT
ORAL IV TOTAL FREQUENCY AMOUNT STOOL

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