PROCEDURE RATIONALE
PURSED LIP BREATHING  Inhale through the nose
 Exhale through the nose
and evenly against
pursed lips while
contracting the
abdominal muscles.
 Sit in a chair. Fold the
arms across the
abdomen.
a. Inhale through
the nose
b. Bend over and b. leaning forward pushes the
exhale slowly through abdominal organs upward.
pursed lip while
counting to 7.
 While walking:
a. Inhale while
walking 2 steps
b. Exhale through
pursed lips while
walking 4 steps.
COUGHING EXERCISES  Inhale deeply and hold
your breath for a few
seconds.
 Cough twice while
exhaling.
 For huff coughing, lean
forward and exhale
sharply with a huff
sound mid exhalation.
 Inhale but taking rapid
short breaths in
succession(sniffing)
 Rest and breathe slowly
between coughs
 Try to avoid prolonged
episodes of coughing
NURSING INTERVENTION
Clear the nasal passages
 Pursing lips increases before beginning breathing
intrabronchial exercises.
pressure (helps
bronchi maintain in Always inhale through the
an open position) as nose-permits FILTRATION,
well as intra alveolar HUMIDIFICATION, and
pressure. WARMING of air. Breath
slowly in a rhythmic and
relaxed manner-permits
mire complete exhalation
and emptying of lungs;
helps overcome anxiety
associated with dyspnea
and 02 requirement.
 Try any similar Avoid sudden exertion.
combinations
according to Practice breathing exercises
breathing tolerance in several positions, as air
of a patient. distribution and pulmonary
circulation vary according to
position of the chest.
(LIPPINCOTT MANUAL, 5TH
EDITION)
 The first cough
loosens the mucus; Give cough suppressants,
second expels expectorants and mucolytic
secretions agents as prescribed.
 Helps keep your
airways open while Make sure the patient is
moving secretions up adequately hydrated to
and out of the lungs. liquefy sputum.
 Prevent mucus from Assist the patient to cough
moving back into productively by controlled
smaller airways. coughing
Discourage smoking
Encourage oral hygiene.
 May cause fatigue (FUNDAMENTALS OF
and hypoxia. NURSING KOZIER AND
ERBS) 10TH EDITION
(LIPPINCOTT MANUAL, 5TH
EDITION)
DIAPHRAGMATIC
EXCURSION
 Place one hand  Help patient to Clear nasal passages
on stomach just below become aware of the
the ribs and the other diaphragm and its Inhale through the nose
hand on the middle of function in breathing.
the chest  Slow inhalation Breathe slowly in a rhythmic
 Breathe in provides ventilation and relaxed manner
slowly and deeply and hyperinflation of
through the nose, letting the lungs. Avoid sudden exertion
the abdomen protrude
as far as it will. The Practice breathing exercises
abdomen enlarges in several position.
during inspiration and
decreases inside during (LIPPINCOTT MANUAL, 5TH
expiration.  Contracting the EDITION)
 Breathe out abdominal muscles
through pursed lips assist the diaphragm
while contracting the in rising to empty the
abdominal muscles. lungs. The hand
Press firmly inward and generates pressure
upward on the abdomen on the abdomen to
while breathing out. facilitate more
complete expiration.
 Contraction of the
 Chest should abdominal muscles
not move; attention is should take place
directed at the during expiration.
abdomen, not the chest
 Repeat for
approximately 1min.
work up to 10min. 4
times daily.
 Learn to do
diaphragmatic breathing  Helps the patient
while lying, then sitting, breathe in a
and ultimately standing controlled manner
and walking. during activities that
produce dyspnea.

CHEST PHYSIO THERAPY

(CPT)  Instruct patient to use  Helps patient to relax Make the patient
diaphragmatic breathing and helps widen the comfortable before the
 Position the patient in airways. procedure starts and as
prescribed postural  Patient is positioned comfortable as possible
drainage position. Spine according to the area while he assumes each
straight to promote rib of the lung that is to position.
cage expansion be drained
 Percuss with cupped  This action helps to Auscultate the chest to
hands over the chest dislodge mucus plugs determine the areas of
wall for 1-2 min from; and mobilize needed drainage
 a. Lower ribs to
shoulder in the back
b. Lower ribs to
top chest in front
 Avoid clapping over the
spine, liver, kidneys,
spleen, breast, scapula,
clavicle or sternum.
 Vibrate the chest wall as
the patient exhales
slowly through pursed
lips.
a. Place one hand
on top of the other over
affected area
b. Tense the
muscle of the hands and
arms while applying
moderate pressure
downward and vibrate
hands and arms.
c. Relieve
pressure on the thorax
as it inhales
d. Encourage to
cough, using abdominal
muscles after 3-4
vibrations
 Listen with stethoscope
for change in breath
sounds
 Repeat percussion and
vibration cycle 15-20min
secretions toward
the main bronchi and Upper lobes drained in
trachea. Air trapped upright position while lower
between the and middle drained in a
operator’s hand and head down position.
chest wall will
produce and Have patient assume left
characteristics hollow prone and left oblique
sound. positions
Encourage the patient to
 Sets up vibration that cough after he has spent the
carries through the allotted time in each
chest wall and helps position
free the mucus.
Encourage diaphragmatic
breathing throughout
postural drainage
c. maneuver is
performed in the Chest wall percussion may
direction in be prescribed to loosen and
which the ribs propel sputum in the
move on direction of gravity
expiration drainage.
d. contracting
abdominal
muscles while (LIPPINCOTT MANUAL,5TH
coughing EDITION)
increases cough
effectiveness. (FUNDAMENTAL OF
 Appearance of moist NURSING KOZIER AND ERBS,
sounds(crackles) 10TH EDITION)
indicates movement
of air around mucus
in the bronchi

NASOTRACHEAL  Ascertain that the Procedure must be done Monitor HR, color, ease of
SUCTIONING suction apparatus is aseptically, as the catheter respirations. If the patient is
functional. place suction will be entering the trachea on monitor, continue
tubing within easy below the level of the vocal monitoring heart rate or
reach. cords, and introduction of arterial blood pressure.
bacteria is contraindicated discontinue the suctioning
and apply y if HR decreases
A thorough explanation will by 20 bpm or increases by
 Inform and instruct the decrease patient anxiety and 40 bpm, if BP decreases, or
patient regarding promote patient cooperation. if cardiac dysrhythmia is
procedure noted.
 NT suctioning must follow (LIPPINCOTT MANUAL,5TH
 Place the patient in a CPT, postural drainage, or EDITION)
semi –fowlers or sitting nebulization therapy. The
position if possible. patient should not be
suctioned after eating or after
a tube feeding is given, unless
absolutely necessary to
decrease the possibility of
emesis and aspiration.

 Place sterile towel

across the patient’s
chest. Squeeze small
amount of sterile
anesthetic water-soluble
lubricant jelly onto the
towel.

 Open sterile pack

containing curved-
tipped suction catheter

 Aseptically glove both

hands. Designate one
hand as a sterile and the Contaminated hand must also
other as contaminated. be gloved to ensure that
organisms in the sputum so
not come in contact with the
nurse’s hand, possibly
 Grasp sterile catheter resulting in infection of the
with sterile hand. nurse.

 Lubricate catheter
anesthetic jelly and pass
the catheter into the
nostril and back into the If obstruction is met, do not
pharynx. force the catheter-remove it
and try the other nostril.
 Pass the catheter into
the trachea. To do this,
ask the patient to cough
or say “ahh”. If he is Presence of catheter in the
incapable of either, try trachea is indicated by;
to advance the catheter a. Sudden paroxysms of
on inspiration. Asking coughing
the patient to stick out b. Movement of air
his tongue, or hold his through the catheter
tongue extended with a c. Vigorous bubbling of
air when the distal
 gauze sponge, may also
help to open the airway.
d.
end of the suction
catheter is placed in
a cup of sterile water.
Inability if the patient
to speak.

 Never apply until

catheter is in the
trachea
a. Once correct position is Because entry into the
ascertained, apply trachea is often difficult, less
suction and gently change in arterial oxygen may
rotate catheter while be caused by leaving the
pulling it slightly catheter in the trachea than
upward. Do not remove by repeated insertion
catheter from the attempts.
trachea.

 Disconnect the catheter

from the suctioning
source after 5-15 sec.
apply o2 by placing a Be sure that adequate time is
face mask over the allowed to reoxygenate the
patients nose, mouth , patient, as o2 is removed, as
and catheter, and well as secretions, during
instruct the patient to suctioning.
breathe deeply/

 Reconnect the suction

source. Repeat suction if
necessary.
No more than 3-4 suction
passes should be made per
 During the last suction suction episode.
pass, remove the
catheter completely
while applying suction Never leave the catheter in
and rotating the the trachea after the suction
catheter gently. apply procedure is concluded, as the
o2 when catheter is epiglottis is splinter open and
removed. aspiration may occur.
TRACHEOSTOMY AND  Inform and instruct the Ensure adequate ventilation
ENDOTRACHEAL TUBE patient regarding and oxygenation through
procedure the use of mechanical
ventilation, CPAP device or
tracheostomy mask.

 Place the patient in a Deep breathing oxygenates

semi –fowlers or sitting the lungs, counteracts the Assess breath sounds every
position if possible. hypoxic effects of suctioning, 2hrs. note evidence of

 Grasp sterile catheter
with sterile hand.
 Flush and lubricate the
catheter
a. Use thumb of the
nondominant hand,
occlude the thumb
control and suction a
small amount of the
sterile solution through
the catheter.
If the client does not have
copious secretions,
hyperventilate the lungs with a
resuscitation bag before
suctioning.
a. use your nondominant
hand, turn on o2 to 12-
15L/min
b. if the client is receiving
o2, disconnect the o2
source from the
tracheostomy tube using
your nondominant
hand.
c. Attach resuscitator to
the tracheostomy or
ETT.
d. Compress the ambu bag
5times, as the client
inhales. This is best done
by a second person who
can use both hands to
compress the bag.
e. Observe the rise and fall
of the client’s chest to
assess the adequacy of
each ventilation
f. Remove resuscitation
device and place it on
the bed.
If the client has copious
secretions, o not hyperventilate
and hyper oxygenate.
Quickly but gently insert the
and may induce coughing.
Determines the suction
equipment is working
properly. Lubricating the
lumen also helps prevent
secretions from sticking to the
inside of the catheter.
Hyperventilating a client who
has copious secretions can
force the secretions deeper
ineffective secretion
clearance which suggests
need for suctioning
Provide adequate humidity,
as the natural humidifying
pathway of the oropharynx
is bypassed. Clear airway of
secretions as needed with
suctioning.
Use aseptic technique when
entering the artificial
airway.
Elevate the patient to a
semi fowlers or sitting
position, when possible,
because these positions
result in improved lung
compliance. Patients
position however should be
changed for at least every
2hrs to ensure ventilation of
all lung segments and
prevent secretion
stagnation and skin
breakdown.
Confirm proper tube
position by auscultating
breath sounds and
documenting that the
distance from the proximal
end of the tube to the teeth
is unchanged.
Monitor cuff pressure. ET
tube cuffs should be inflated
continuously and deflated
only during intubation,
extubation and tube
repositioning. The internal
cuff pressure should be
checked for every 4hrs.
Tracheostomy tube cuffs
also should be inflated
continuously in patients on
mechanical ventilation or
CPAP.
catheter without applying any
suction.
Insert catheter about 0.5-1cm
past the distal end of the tube for
an open system, and 1-2cm past
the distal end for a closed system
or until the client coughs. If you
feel resistance, withdraw the
catheter about 1-2cm before
applying suction.
Perform suction
a. Apply 5-10seconds
b. rotate the catheter by
rolling it between your
thumb and forefinger
while slowly
withdrawing it.
c. Withdraw the catheter
completely, and release
the suction.
d. Hyperventilate the
client.
e. Suction again, if needed
Reassess the client’s oxygenation
status and repeat suctioning.
a. Encourage client to
breathe deeply and to
cough between suctions,
b. Allow 2-3 minutes of o2,
as appropriate between
suctions when possible.
c. Flush the catheter and
repeat suctioning until
the air passage is clear
and the breathing is
relatively effortless and
quiet.
d. After each suction, pick
up the resuscitation bag
with your nondominant
hand and ventilate the
client with no more than
three breaths.
Provide client comfort and safety
Document relevant data
into the respiratory tract.
To prevent tissue trauma and
o2 loss, suction is not applied
during insertion of the
catheter.
Resistance usually means that
the catheter tip has reached
the bifurcation of the trachea.
Withdrawing the catheter will
prevent damaging the mucous
membranes at the bifurcation
Suction time is restricted to
10seconds or less to minimize
o2 loss.
Prevents tissue trauma by
minimizing the suction time
against any part of the
trachea.
This provides an opportunity
for reoxygenation of the
lungs.
Et tubes have mouth care
every shift, or as frequently
as needed. Oral secretions
tend to stagnate, and risk of
oral infection is increased.
An oral ET tube may also
stimulate an increase in the
production of oral
secretions. The tube must
be secured at all times.
Tracheostomy tubes has
stoma and should be
cleaned once a shift or more
frequently if needed, and
the tracheostomy tis
changed once a day.
Have available at all times at
the patient’s bedside a
resuscitation bag, o2
source, and mask to
ventilate the patient in the
event of accidental tube
removal.
(LIPPINCOTT MANUAL,5TH
EDITION)
OXYGEN ADMINISTRATION
Post NO SMOKING signs on the
patient’s door and in view of
NASAL CANNULA patient and visitors.
Show the nasal cannula to the
patient and explain the
procedure.
Make sure that the humidifier is
filled to the appropriate mark.
Attach the connecting tube from
the nasal cannula to the
humidifier outlet.
Set the flow rate prescribed
liters/minute. Feel to determine
if oxygen is flowing through the
tips of the cannula
Place the tip of the cannula in the
patient’s nose
Record flow rate used and
immediate patient response.
Assess patient’s condition, ABG
or SAO2, and the functioning of
equipment at regular intervals.
Determine patient comfort with
oxygen use.
Post NO SMOKING signs on the
patient’s door and in view of
FACE MASK patient and visitors.
Determine current vital
signs, level of
consciousness, and most
recent ABG.
Assess risk for CO2
retention with oxygen
administration.
Humidification may not be
ordered if the flow rate is less LIPPINCOTT MANUAL,5TH
than 4 L/min. EDITION)
(FUNDAMENTAL OF
NURSING KOZIER AND ERBS,
10TH EDITION)
Because a nasal cannula is a
low flow system, oxygen
concentration will vary,
depending on the patient’s
respiratory rate and tidal
volume. Approximate oxygen
concentrations delivered are:
1liter= 24-25%
2liters=27-29%
3liters=30-33%
4liters=33-37%
5liters=36-41%
6liters=39-45%
Show the aerosol mask to the
patient and explain the
procedure
Make sure the nebulizer is filled
to the appropriate mark.
Attach the large bore tubing from
the mask to the nebulizer outlet.
Set desired oxygen concentration
on nebulizer bottle and plug in
the heating element, if used.
If the patient is tachypneic and a
concentration of 50% oxygen or
greater is desired, 2 nebulizers
and flow meters should be yoked
together.
Adjust the flow rate until the
desired mist is produced
Apply the mask to the patients
face and adjust the straps so that
the mask fits securely.
Drain the tubing frequently by
emptying condensate into a
separate receptacle, not into the
nebulizer. If a heating element is
used, the tubing will have to be
drained more often.
If a heating element is used,
check the temperature. The
nebulizer bottle should be warm,
not hot to touch.
Determine current vital
signs, level of
If the nebulizer bottle is not consciousness, and most
sufficiently full, less moisture recent ABG.
will be delivered.
Assess viscosity and volume
of sputum produced.
The inspired oxygen (LIPPINCOTT MANUAL,5TH
concentration is determined EDITION)
by the nebulizer setting. Usual
percentage are 35%-50%.
The aerosol mask is low flow
system. Yoking two nebulizers
together doubles nebulizer
flow but does not change the
inspired oxygen
concentration.
This ensures that the patient
is receiving flow sufficient to
meet inspiratory demand and
maintains a constant accurate
concentration of oxygen.
Tubing must be kept free of
condensate. Condensate
allowed to accumulate in the
delivery tube will block flow
and alter oxygen
concentration. If condensate
is emptied into the nebulizer,
bacteria may be aerosolized
into the lungs.
Excessive temperatures can
cause airways burn; patients
with elevated temperatures
should be humidified with an

Post NO SMOKING signs on the
patient’s door and in view of
patient and visitors.
Fill humidifier with sterile
distilled water.
REBREATHER AND
NONREBREATHER MASK
Attach tubing to outlet on
humidifier
Attach flowmeter
Show the mask to the patient
and explain the procedure
Flush the reservoir bag with
oxygen to inflate the bag and
adjust flowmeter to 6-10L/min
Place the mask on the patients
face.
Adjust the liter flow so that the
rebreathing bag will not collapse
during the inspiratory cycle, even
deep inspiration.
Stay with the patient for a time
Remove mask periodically to dry
the face around the mask.
Assess risk for CO2retention with
o2 administration
Post NO SMOKING signs on the
patient’s door and in view of
patient and visitors.
unheated device.
Less moisture will be
delivered if bottle is not full.
Bag serves as reservoir,
holding o2 for patient
inspiration
It must be fit snugly,
As there must be an airtight
seal between the mask and
the patients face.
Be sure that o2 is not escaping
from the sides of the mask.
Can reduce moisture
accumulation under the mask.
Risk is greater if the patient is
experiencing an exacerbation
of his illness.
Adjust the flow to prevent
collapse of the bag, even
during deep inspiration.
A nonrebreather mask will
deliver a lower
concentration of o2 if the
bag is allowed to collapse
on inspiration. O2 from the
bag will be diluted by room
air drawn in through the
side holes of the mask.
A partial rebreathing mask
does not have a one-way
valve between the mask
and reservoir bag. Exhaled
air enters the bag very
early. This is dead space
ventilation and contains
little CO2. If the bag is
allowed to collapse on
inspiration, more exhaled
air can enter the reservoir
and the patient can inhale
high concentration of CO2.
(LIPPINCOTT MANUAL,5TH
EDITION)
 Show the venture mask to the
patient and explain
VENTURI MASK
Connect the mask by lightweight
tubing to the oxygen source
Turn on the oxygen flowmeter
and adjust to the prescribed rate.
Check to see that oxygen is
flowing out the vent holes in the
mask.
Place venture mask over the
patients nose and mouth and
under the chin. Adjust elastic
strap
Check to make sure holes for air
entry are not obstructed by the
patients bedding
Measure the patients normal
resting tidal volume and
auscultate chest.
Explain the procedure and its
purpose to the patient.
Place the patient in a
comfortable sitting or semi-
INCENTIVE SPIROMETER fowlers position
For POSTOP patient, try as much
as possible to avoid discomfort
with the treatment
administration.
Set the incentive spirometer tidal
volume indicator at the desired
goal the patient is to reach or
exceed (500 m.is often used to
start). The tidal volume is set
according to the manufacturer’s
instructions.
Demonstrate the technique to
Determine current vital
signs, level of
consciousness, and most
recent ABG.
(LIPPINCOTT MANUAL,5TH
To ensure the correct EDITION)
air/oxygen mix, o2 must be
set at the prescribed flow
rate.
Proper mask function depends
on mixing of sufficient amount
of air and oxygen.
Baseline is established
Optimal results are achieved
when the patient is given
pretreatment instruction.
This position is best for
diaphragmatic excursion
Try to coordinate treatment
with the administration of Auscultate the chest. Chart
pain relief medications. any improvement or
Instruct and assist the patient variation, the volume
with splinting of incision attained, effectiveness of
cough, description of any
secretions expectorated.
Note the effectiveness and
patient tolerance of the
treatment
 the patient
LIPPINCOTT MANUAL,5TH
Instruct the patient to exhale EDITION)
fully
Noseclips are sometimes used
Tell the patient to take in slow, if the patient has difficulty
easy deep breath from the breathing only through his
mouthpiece. mouth-this will ensure full
credit for each breath
measured.

When the desired goal is reached

(lungs inflated), ask the patient to
continue the inspiratory effort for
3 sec. even though he may not
actually be drawing in more air.

Instruct the patient to remove

the mouthpiece, relax and
passive exhale. He should take
several normal breaths before
attempting another one with the
incentive spirometer.
Usually one incentive breath
per minute minimizes patient
fatigue. No more than 4-5
maneuvers should be
performed per minute to
minimize hypocarbia

Continue to monitor the patient’s

spirometer breaths, periodically
increasing the tidal volume as the
patient tolerates it.

Encourage the patient to cough

after a deep breath

Instruct the patient to take 10

sustained maximal inspiratory
maneuvers per hour and note the
volume of the spirometer.

NEBULIZER Explain the procedure to the Optimal results are achieved Monitor HR, before and
patient. This therapy depends on when the patient is given after the treatment for
the patient’s effort pretreatment instruction. patients using

Place the patient in a comfortable
sitting or a semi fowlers position.
Add the prescribed amount of
medication and saline to the
nebulizer. Connect the tubing to
the compressor and set the flow
at 6-8L/min.
Instruct the patient to exhale
Tell the patient to take in a deep
breath from the mouthpiece,
hold his breath briefly, then
exhale
Nose clips are sometimes used if
the patient has difficulty
breathing only through his mouth
Observe expansion of the
patient’s chest to ascertain that
he is taking deep breaths
Instruct the patient to breathe
slowly and deeply until all the
medication is nebulized
Encourage the patient to cough
after a deep breath
METERED DOSE INHALERS Press down once the MDI
canister and inhale slowly for 3-5
seconds and deeply through the
mouth
Hold your breath for 10 seconds
or as long as possible
Remove the inhaler from or away
from the mouth
Exhale slowly through pursed lips
Repeat the inhalation if ordered.
Wait to 20-30 seconds
This position is best for
diaphragmatic excursion
A fine mist from the device
should be visible
Encourage optimal dispersion
of the medication
Ensures that medication is
deposited below the level of
the oropharynx
Medication will usually be
nebulized within 15min at a
flow of 6-8L/min
Medication may dilate
airways, facilitating
expectoration of secretions.
This allows aerosol to reach
deeper airways.
Controlled exhalation keeps
the small airways open during
exhalation.
The first inhalation has a
bronchodilator drugs
Bronchodilators may cause
tachycardia, palpitations,
dizziness, nausea or
nervousness.
LIPPINCOTT MANUAL,5TH
EDITION)
(FUNDAMENTAL OF
NURSING KOZIER AND ERBS,
10TH EDITION)
Ensure that the canister is
firmly and fully inserted into
the inhaler
Remove the mouthpiece
cap. Holding the inhaler
upright, shake the inhaler
vigorously for 3-5 sec. to mix
the medication evenly.
Exhale comfortably
Teach clients how to
determine the amount if
medication remaining in a
metered-dose inhaler
 between inhalations of
bronchodilator
medications.
Following use of inhaler, rinse
mouth with tap water to remove
any remaining medication and
reduce irritation and of infection
chance to work and the
subsequent dose reaches
deeper into the lungs.
canister.
Disinfect the metered-dose
inhaler mouthpiece weekly
by soaking for 20min in pint
of water with 2 ounces of
vinegar added.

Clean the MDI mouthpiece after (FUNDAMENTAL OF

each use NURSING KOZIER AND ERBS,
10TH EDITION)

Store the canister at room temp.

avoid extremes of temp

Platelets adhere each

other STAGE 1
(coagualtion factors
involved)
complete
platelet phospholipid thromboplastin (III) STAGE 2
VIII
IX
X
PROTHROMBIN(II) THROMBIN STAGE 3 XI
XII

FIBRIN STAGE 4 IV
IV
V
VII
FIBRINOGEN(I)
X
XIII

BLOOD COAGULATION

SOURCES:
(MATERNAL AND CHILD HEALTH NURSING, CARE OF THE CHILDBEARING FAMILY 8 TH EDITION VOLUME 2)

TEST DEFINITION NORMAL VALUES CLINICAL SIGNIFICANCE

PROTHROMBIN TIME Measure the actions 11-13s or 2.0-3.0 Higher than that means your blood is
of prothrombin; international taking longer than normal to clot and
reveals deficiencies in normalized ratio may be a sign of many conditions,
prothrombin, factors including: Bleeding or clotting disorder.
V,VII, and X Lack of vitamin K. Lack of clotting factors

PARTIAL Multiple diseases and

THROMBOPLASTIN Measures activity of 30-45 sec conditions can cause
TIME thromboplastin; abnormal PTT results. A
reveals deficiencies in prolonged PTT result may be due to: ...
thromboplastin, disseminated intravascular coagulation
factors VIII to XII (a disease in which the proteins
responsible for blood
clotting are abnormally active)
hypofibrinogenemia (deficiency
of the blood clotting factor fibrinogen)

BLEEDING TIME Measures the time 3-10min

required for bleeding Factor II, V, VII, X, or XII deficiencies
at a stab wound on are bleeding disorders related to blood
the earlobe to stop; clotting problems or abnormal
reveals deficiencies in bleeding problems. Von Willebrand's
platelet formation disease is the most common
and vasoconstrictive inherited bleeding disorder. It develops
ability. when the blood lacks von Willebrand
factor, which helps the blood to clot
CLOT RETRACTION Measures platelet Retraction at side of Low platelets or fibrinogen as well as
function; interval test tube should be high RBC concentrations prolong clot
from placement of present by 1hr; retraction time. Anitplatelet medications
blood in a tube to the complete in 24hr can also prolong clot retraction time.
point clot shrinks and A low value, or short clot retraction time,
expels serum may suggest tendencies toward
thrombosis and other pathologies.
TOURNIQUET Measures capillary 0-2 petechiae per The test is part of the WHO algorithm for
fragility and platelet 2cm area diagnosis of dengue fever. A blood
function; response of pressure cuff is applied and inflated to
tissue to application the midpoint between the systolic and
of tourniquet to diastolic blood pressures for five
forearm for 5-10min. minutes. The test is positive if there are
more than 10 to 20 petechiae per square
inch
PROTHROMBIN Evaluates Approximately 20sec Ulcerative colitis patients had abnormal
CONSUMPTION TIME thromboplastin prothrombin consumption times and
function; if clot prothrombin times. They had normal
formation used a platelets and normal peripheral capillary
great deal of fragility. The prothrombin consumption
prothrombin, serum time was normal when ulcerative colitis
prothrombin time will was mild. Most abnormal prothrombin
 be brief; prolongation consumption times occurred in patients
denotes defects in with severe ulcerative colitis.
thromboplastin
function
THROMBOPLASTIN Tests basic ability to 12 or less Infants less than 6 months of age have
GENERATION TIME form thromboplastin; decreased thromboplastin generation,
distinguish factor VIII resulting in part from a deficiency of
from factor IX plasma thromboplastin component.
disorder. Some factor or factors other than a low
level of plasma thromboplastin
component may contribute to this
deficiency.

Measures stage 4 Fibrinogen is an acute phase

PLASMA FIBRINOGEN clotting process or 200-400mg/100ml reactant, meaning that fibrinogen
level of fibrinogen in plasma levels may rise sharply in any condition
blood that causes inflammation or tissue
damage. High levels of fibrinogen are not
specific.

A number higher than that range means

VENOUS CLOTTING Measures factor 9-12 min. it takes blood longer than usual to clot. A
TIME deficits in stages 2 number lower than that range means
and 4. blood clots more quickly than normal.

SOURCES:

(MATERNAL AND CHILD HEALTH NURSING, CARE OF THE CHILDBEARING FAMILY 8 TH EDITION VOLUME 2)

ECG An electrocardiogram (ECG) is a 1. Disconnect the equipment, remove

medical test that detects heart
problems by measuring the
electrical activity generated by the
heart as it contracts. ECGs from
healthy hearts have a characteristic
shape. If the ECG shows a different
shape it could suggest a heart
problem
XRAY X-rays are a form of
electromagnetic radiation, similar
to visible light. Unlike light,
however, x-rays have higher energy
and can pass through most objects,
including the body. Medical x-
the electrodes, and remove the gel
with a moist cloth towel.
2. If the patient is having recurrent
chest pain or if serial ECG’s are
ordered, leave the electrode patches in
place.
 Remove all metallic
objects. Items such as jewelry,
pins, buttons etc can hinder the
visualization of the chest.
 No preparation is
 rays are used to generate images of
tissues and structures inside the
body
CVP CATHETER The CVP catheter is an important
tool used to assess right ventricular
function and systemic fluid
status. Normal CVP is 2-6 mm
Hg. CVP is elevated by :
overhydration which increases
venous return.
required. Fasting
or medication restriction is not
needed unless directed by the
health care provider.
 Ensure the patient is not
pregnant or suspected to be
pregnant. X-rays are usually not
recommended for pregnant
women unless the benefit
outweighs the risk of damage to
the mother and fetus.
 Assess the patient’s ability to
hold his or her breath. Holding
one’s breath after inhaling
enables the lungs and heart to
be seen more clearly in the x-
ray.
 Provide appropriate
clothing. Patients are instructed
to remove clothing from the
waist up and put on an X-ray
gown to wear during the
procedure.
 Instruct patient to cooperate
during the procedure. The
patient is asked to remain still
because any movement will
affect the clarity of the image.
After Chest X-rayThe nurse should note of
the following nursing interventions after
chest x-ray:
 No special care. Note that no
special care is required
following the procedure
 Provide comfort. If the test is
facilitated at the bedside,
reposition the patient properly.
For the subclavian CVL, insert the needle at
an angle as close to parallel to the skin as
possible until contact is made with the
clavicle, then advanced the needle under
and along the inferior aspect of the clavicle.
Next, direct the tip of the needle towards
the suprasternal notch until venous blood is
aspirated
CARDIAC CATHETERIZATION cardiac catheterization (kath-uh-
tur-ih-ZAY-shun) is a procedure
used to diagnose and treat
certain cardiovascular conditions.
During cardiac catheterization, a
long thin tube called a catheter is
inserted in an artery or vein in your
groin, neck or arm and threaded
through your blood vessels to
your heart.
PLEUR EVAC A chest tube drainage system is a
sterile, disposable system that
consists of a compartment system
that has a one-way valve, with one
or multiple chambers, to remove
air or fluid and prevent return of
the air or fluid back into the patient
(see Figures 10.5 and 10.6). The
traditional chest drainage system
typically has three chambers
(Bauman & Handley, 2011; Rajan,
2013). Always review what type of
system is used in your agency, and
follow the agency’s and the
manufacturer’s directions for
setup, monitoring, and use.  2010; Halm, 2007).
ARTIFICIAL HEART VALVE An artificial heart valve is a one-
REPLACEMENT way valve implanted into
the heart of a patient to replace a
dysfunctional native heart
Assess affected extremity, noting its color,
temperature, and capillary refill; Palpate
distal pulses; Use doppler every 15 minutes
for 4 times, every 30 minutes for 3 hours,
then every 4 hours.
encourage bed rest and keep affected
extremity straight or slight bend in the knee
(10 degrees) for 6 hours.
Provide warmth to the opposite extremity.
Inform parents and child of a need for
frequent vital signs monitoring and
importance of bed rest with an extension of
the extremity.
Do not strip or milk the chest tube:
In practice, stripping is used to describe
compressing the chest tube with the thumb
or forefinger and, with the other hand, using
a pulling motion down the remainder of the
tube away from the insertion
site. Milking refers to techniques such
as squeezing, kneading, or twisting the tube
to create bursts of suction to move clots.
Any aggressive manipulation (compressing
the tube to dislodge blood clots) can
generate extreme pressures in the chest
tube. There is no evidence showing the
benefit of stripping or milking a chest tube
(Bauman & Handley, 2011; Durai et al.,
The only exceptions to clamping a
chest tube are 1) if the drainage system is
being changed, 2) if assessing the system for
an air leak, 3) if the chest tube becomes
disconnected from the chest drainage
system — the chest tube should not be
clamped for more than a few minutes
(Salmon, Lynch, & Muck, 2013), or 4) if the
condition of the patient is resolved and the
chest tube is ready for removal (as per
physician orders).
 Eating a heart-healthy diet. Eat a
variety of fruits and vegetables, low-
fat or fat-free dairy products, poultry,
fish and whole grains. Avoid saturated
 valve (valvular heart disease). The
human heart contains four valves:
tricuspid valve,
pulmonic valve, mitral
valve and aortic valve.
CARDIAC TRANSPLANT Heart transplantation is the
replacement of a failing heart with
a heart from a suitable donor. [
and trans fats and excess salt and
sugar.
 Maintaining a healthy weight. Aim
to keep a healthy weight. If you're
overweight or obese, your doctor may
recommend losing weight.
 Getting regular physical
activity. Aim to include about 30
minutes of physical activity, such as
brisk walks, in your daily fitness
routine.
 Managing stress. Find ways to help
manage your stress, such as through
relaxation activities, meditation,
physical activity, and spending time
with family and friends.
 Avoiding tobacco. If you smoke,
quit. Ask your doctor about resources
to help you quit smoking. Joining a
support group may be helpful.
 Medications.  after a heart
transplant, patients must take
several drugs. The most important
are those to keep the body from
rejecting the transplant. These
drugs, which must be taken for life,
can cause significant side effects,
including high blood pressure, fluid
retention,
excessive hair growth, osteoporosis,
and possible kidney damage. To
combat these problems, additional
drugs are often prescribed.
 Exercise. Heart transplant recipients
can exercise and are encouraged to
exercise to improve the function of
the heart and to avoid weight gain.
However, due to changes in the
heart related to the transplant,
patients should speak to their
doctor or cardiac rehabilitation
specialist before beginning
an exercise program. Because the
nerves leading to the heart are cut
during the operation, the
transplanted heart beats faster
(about 100 to 110 beats per
 minute) than the normal heart
(about 70 beats per minute). The
new heart also responds more
slowly to exercise and doesn't
increase its rate as quickly as
before.

 Diet. After a heart transplant, the

patient may need to follow a special
diet, which may involve many of the
same dietary changes made prior to
surgery. A low-sodium diet will
decrease the risk of high blood
pressure and fluid retention. Your
doctor will discuss your specific
dietary needs, and a registered
dietitian can help you understand
specific dietary guidelines.

PACEMAKER A pacemaker is a small device
that's placed in the chest or
abdomen to help control abnormal
heart rhythms. This device uses
electrical pulses to prompt the
heart to beat at a normal
rate. Pacemakers are used to treat
arrhythmias (ah-RITH-me-ahs).
Arrhythmias are problems with the
rate or rhythm of the heartbeat.
 Allow about eight weeks for your
pacemaker to settle firmly in place.
During this time, try to avoid
sudden movements that would
cause your arm to pull away from
your body.
 Avoid causing pressure where your
pacemaker was implanted. Women
may want to wear a small pad over
the incision to protect from their
bra strap.
 Relatively soon after your surgery,
you may be able to perform all
normal activities for a person of
your age. Ask your doctor about
how and when to increase activity.

RELATED SOURCES:
https://www.mayoclinic.org/diseases-conditions/heart-valve-disease/diagnosis-treatment/drc-20353732
https://www.heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/living-with-your-
pacemaker
https://www.webmd.com/heart-disease/heart-failure/heart-failure-heart-transplant#2
https://opentextbc.ca/clinicalskills/chapter/10-7-chest-drainage-systems/
BLOOD TRANFUSION
SYMPTOMS CAUSE TIME OF NURSING
OCCURRENCE INTERVENTIONS
Headache, Anaphylactic reaction to Immediately Discontinue
chills, back pain, incompatible blood: agglutination after start of transfusion.
dyspnea, of red blood cells occurs; kidney transfusion maintain
hypotension tubules may become blocked, normal saline
,hemoglobinuria resulting in kidney failure infusion for
accessible IV
line. Administer
o2 if necessary
Pruritus, urticaria Allergy to protein components of Within first Discontinue
,wheezing transfusion hour after transfusion
start of temporarily.
transfusion Give o2 as
needed.
Increased temperature Possible contaminant in Approximately Discontinue
transfused blood 1hr after start transfusion:
of transfusion give o2 as
needed. Obtain
blood culture to
rule out or
identify
bacterial
invasion
Increased pulse, dyspnea Circulatory overload During course Discontinue
of transfusion transfusion.
Provide
supportive care
for pulmonary
edema or
congestive
heart failure,
which may
develop.
Anticipate
administration
of diuretic to
increase
excretion of
excess fluid.
Muscle cramping, twitching of Acid-citrate-dextrose During course Discontinue
extremities, seizure anticoagulant in transfusion of transfusion transfusion.
combine with serum calcium and Anticipate
causes hypocalcemia administration
of calcium
gluconate
intravenously to
restore calcium
level.
Fever, jaundice, lethargy, Hepatitis from contaminated Weeks or Obtain
Tenderness of liver transfusion months after transfusion
transfusion history of any
child with
hepatitis
symptoms.
Refer for care of
hepatitis.
Bronze-colored skin Hemosiderosis or deposition of After Support self
 iron in skin from transfusion repeated esteem with
transfusion altered body
image.
Administer iron-
chelating agent(
deferoxamine)
as prescribed to
help reduce
level of
accumulating
iron.

SOURCES:

(MATERNAL AND CHILD HEALTH NURSING, CARE OF THE CHILDBEARING FAMILY 8 TH EDITION VOLUME 2)