Professional Documents
Culture Documents
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:
173
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.
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).
174
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.
175
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
Documentation
The following should be noted on the client's chart:
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:
176
FACULTY SIGNATURE: __________________________
Reference(s):
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.
177
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.
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.
178
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
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.
179
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.
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.
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.
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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:
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: ____________________________
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.
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.
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:
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: ____________________________
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.
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.
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.
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.
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.
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.
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.
FEEDBACK/COMMENTS:
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: ____________________________
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.
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.
8. Wash hands.
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.
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
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.
199
PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
4. Vibrate during five exhalations over one affected
lung segment.
FEEDBACK/COMMENTS:
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.
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.
3. Wash hands.
202
12. Record clients response to therapy.
FEEDBACK/COMMENTS:
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
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:
Endotracheal Tube:
Contraindications:
1. Awake patient.
2. Airway can be managed less invasively.
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):
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
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
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.
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.
Documentation:
Procedure note describes indications, equipment and technique, number of attempts and how placement was confirmed, as well as complications and their
management.
FEEDBACK/COMMENTS:
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
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.
PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
8. Remove gloves and wash hands.
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.
PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
15. Check tube placement.
212
Documentation
20. Document procedure and any observations
such as status of surrounding skin and
amount of type of drainage.
FEEDBACK/COMMENTS:
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: ____________________________
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.
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.
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.
217
c. If no leak is present, slowly remove 0.2-
0.3 ml more air.
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.
FEEDBACK/COMMENTS:
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
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.
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
Mindanao State University Iligan Institute of Technology College of Nursing
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.
PROCEDURE
PROCEDURE
10. Set up the cup or container, touching only
its outside.
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.
K. Wash hands.
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. Put on gloves.
c. Open and pour saline.
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.
Documentation
21. Document the procedure and observations.
Include the amount and description of
suction returns and any other relevant
assessments.
FEEDBACK/COMMENTS:
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
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.
. 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:
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.
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.
FEEDBACK/COMMENTS:
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
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
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:
IMPLEMENTATION
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.
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.
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:
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
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
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:
IMPLEMENTATION
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.
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
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.
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:
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
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:
IMPLEMENTATION
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.
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 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.
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
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.
PROCEDURE RATIONALE 0 1 2 3 4 5 6 7 8 9
6. Prime blood administration set with the normal saline
IV fluid.
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 .
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
FEEDBACK/COMMENTS:
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
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
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.
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
FEEDBACK/COMMENTS:
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
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.
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.
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
FEEDBACK/COMMENTS:
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
ANNEX