SKILL 1: URINARY CATHETERIZATION AND COLLECTION
Closed systems reduce the
Urinary Incontinence- the loss of bladder control is a common
and often embarrassing problem.
- The severity ranges from occasionally leaking
urine when you cough or sneeze to having an urge
to urinate that’s so sudden and strong you don’t
get to a toilet in time
- Weak bladder muscles, overactive bladder
muscles, weak pelvic floor muscles, damage to
nerves that control the bladder from diseases such
as multiple sclerosis, diabetes, or Parkinson’s
disease
- Blockage from an enlarged prostate in men
Urinary stasis- also known as urinary retention. Is a condition in
which the bladder is not able to completely empty?
Symptoms: inability to urinate, pain and often severe in
the lower abdomen, the urgent need to urinate, swelling of the
lower abdomen
Urinary Catheterization- introduction of a catheter through the
urethra into the bladder for the purpose of emptying urine
Catheter
- To keep incontinent clients dry
- To relieve bladder distention
- To assess accurate fluid balance
- To keep the bladder from becoming distended during
diagnostic tests and surgery
- To collect a urine specimen (sterilize way to check UTI
or bacteria)
- To measure the residual urine left in the bladder after
voiding (to check capability of kidney and bladder)
- For ICU patients (Coma)
*Urinary Tract Infections (UTI’s) account for about half of all
nosocomial infections, and Urinary Catheters are responsible
for most of the UTI’s
*Important to do handwashing because catheters are
sterilized
*Hardest to place in women
Foley Catheter- is made of a soft thin rubber tube with a balloon
at the tip. The catheter is inserted through the urethra into the
bladder to drain urine out. The urethra is the opening where
urine comes out.
Types of Catheters
A. Indwelling Urethral Catheter (retention catheter, Foley
catheter)
- Used when a catheter is needed for continuous
drainage or urine, for gradual decompression of an
overdistended bladder, and for intermittent bladder
drainage and irrigation
- Designed so that it does not slip out of the bladder
- It has a balloon, which is inflated with sterile water
after the catheter is inserted
- Most have 2 Lumens:
o A small lumen is connected to the balloon; the
other, large, lumen is the one through which
urine drains
- A triple lumen catheter has an additional lumen for
instilling irrigating solutions
- Retention catheter: are usually connected to ta closed
gravity drainage system, consisting of the catheter,
tubing, and a collecting bag.
risk of microorganisms entering the system and infecting
the urinary tract
o For post-surgery in BPH and red or pink unang
lumalabas if yellow na ubos na blood clots sa
prostate patients
B. Straight catheter: used in pedia; are used to drain the
bladder for short periods. They are inserted and
removed immediately after the urine is drained. A
single- lumen with a small opening about ½ inch from
the insertion tip. No need to place a balloon
C. Suprapubic catheter: this type is inserted into the
bladder through a small incision just above the pubic
are
D. External Urinary Drainage: are commonly used for
incontinent males because the risk of infection is minima;
example is condom catheter
SIZES and MATERIALS
- Materials are selected according to the length the
catheter is expected to be in place
- Plastic: use for 1 week or less because the are
inflexible
- Latex/ Rubber: used for periods of 2-3 weeks
- PVC- used for 4-6 weeks periods, they soften at body
temperature
- Silicone: designed for long term use (2-3 months)
because there is less encrustation at the meatus, they
are expensive
o Encrustation: the main cause of catheter
encrustation is infection by urease- producing
organisms, particularly Proteus mirabilis (2, 3).
These organisms colonize the catheter,
forming a biofilm (4,5). The bacterial urease
generates ammonia from the urea, and the
urine becomes alkaline
- Length: females 22cm; males 40cm catheter
- Size: or circumference of the catheter is determined by
the size of the urethral canal. The smaller the number,
the smaller the lumen. #8- #10 for children; #14- #16
for adults; men frequently require #18
- Balloon size: for adults 5ml; 30ml balloon or larger is
used to achieve hemostasis of the prostatic area
following prostate surgery
*aspirate balloon first for no oxygen
Potential Complications
- Sepsis: most clients who have a catheter in place for
more than 2 weeks will develop bacteriuria which can
lead to sepsis
 - Trauma: can result when the mucous membrane lining
the urethra is damaged by the friction from the
catheter. The male urethra because of its length is
vulnerable
Therapeutic Nursing Intervention: Inserting a Urinary Catheter
- All equipment is usually prepackaged in a sterile,
disposable kit
- Prevent anxiety and embarrassment. Explain the
procedure and drape the client. (diamond)
- Visualization of the meatus is essential. Use the
dorsal recumbent, on a firm surface; if the client is in
bed, supporting the buttocks on a firm cushion is helpful.
The sim’s (lateral) position is sometimes used for clients
with limited hip and knee mobility
- Risk of urinary tract infection is great. Meticulous
sterile procedure must be used. In addition, the
drainage bag must be kept off the floor (which is
grossly contaminated) at all times.
- Ensure that the indwelling catheter will not slip out.
Check for balloon patency before inserting the
catheter; inflate balloon with the prefilled syringe and
aspirate the fluid back into the syringe
- Prevent injury to the urethra. Insert the catheter 1- 2
inches beyond the point where urine flow occurs before
inflating the balloon. If the client complains of pain on
inflation, the balloon may be in the urethra. Remove
fluid from the balloon, remove the catheter and
replace It with another one
- Make use of gravity to assure adequate drainage. Do
not place tubing under the leg or above the level of
the bladder. Be sure the tubing is not kinked. (if kinked
di mag fflow yung urine magkakaron ng distention kasi
di makakalabas)
- Prevent pooling of urine in the drainage tubing. Clip
the tubing to the bottom bed sheet to keep the tube in
place while the client is in bed.
Therapeutic Nursing Intervention: Care for the Client with an
Indwelling Catheter
- Prevent contact with body fluids. Wear disposable
gloves when giving catheter care and handling the
catheter, tubing, and collection bag.
*Specimens for culturing should not be cultured from urine
bags: specimens should not be collected from the main collecting
chamber of the catheter bag as colonization and multiplication
of bacteria within the stagnant urine or around the drainage tap
may have occurred
- Prevent transfer of microorganism to client
o Wash hands before and after catheter care
o Never open the drainage system to obtain
specimen or to measure urine
o If tubing becomes disconnected, wipe both
ends with antiseptic solution before
reconnecting
o When emptying the drainage bag, be sure
the drainage spout does not touch the
receptacle into which urine is being emptied
- Keep perineal area clean. Clean with soap and water
and rinse well, twice a day and after bowel movements
*with catheter: clean from the urinary meatus down to the
catheter tubing about 4 inches, using cotton ball with betadine
using single stroke
- Prevent urinary stasis. Make sure the Client has a fluid
intake of about 3000ml/ day (ideal for clients with no
problem if may problem limit yung fluid intake)
- Keep accurate intake and output record. The
calibrations on the collection bag are only
approximate. Empty urine into a graduated container
for accurate determination of output
- Gravity promotes drainage. If the catheter is
indwelling, the collection bag should always remain
below the level of the bladder to prevent stasis and
backflow of urine into the bladder (ex. When the client
is ambulating)
- Acidify the urine. Offers foods such as eggs, cheese,
meat poultry, whole grains, tomatoes, cranberries,
plums, and prunes. Avoid milk and milk products.
(mamamatay microflora if hindi acidified)
o Preventing bladder infections when the urine
has less acid (more alkaline), there is a
greater likelihood of bacteria growing at a
rapid rate and as a result a bladder infection
can occur more easily. So, it is beneficial to
keep your urine naturally acidic. You can do
this easily by watching what you eat and drink
Therapeutic Nursing Intervention: Removing an
Indwelling Catheter
- Prevent contact with body fluids. Wear disposable
gloves. Wrap the catheter in a towel or disposable
drape after removing it.
- Prevent injury and pain to the client. Be sure the
balloon is deflated before removing the catheter.
Check the size of the balloon so you will know how much
fluid to remove; insert a syringe into the balloon valve
and aspirate all the fluid in the balloon. Do not cut the
tubing with scissors.
- Prevent injury stasis and infection. Clean the perineal
area after removing the catheter. Assure a fluid intake
of about 3000ml per day to keep the bladder flushed
out. Observe the urine for any abnormalities.
- Observe for infection. Report signs such as inability to
void, burning sensation when voiding, bleeding, and
changes in vital signs.
- Be sure that voiding is satisfactorily reestablished.
Record the time the catheter was removed. Record the
client’s intake and the time and amount of output for
24 hours. If the client does not void in 4-6 hours,
palpate for bladder distention and assess for feelings
of fullness
*rationale of 1 need sabihin yung tatlo; no need to repeat
draping; 15-25 need na gawin; circular motion sa paglinis
SKILL 4: MONITORING OXYGEN SATURATION
- A pulse oximeter can measure oxygen saturation
o It is noninvasive device placed over a person’s
finger
o It measures light wavelengths to determine the
ratio of the current levels of oxygenated
hemoglobin to deoxygenated hemoglobin
o The use of pulse oximeter has become a
standard of care in medicine
There are a number of different common use cases for pulse
oximetry, including:
- To assess how well a new lung medication is working
- To evaluate whether someone needs help breathing
- To evaluate how helpful a ventilator is
- To monitor oxygen levels during or after surgical
procedures that require sedation
- to determine how effective supplemental oxygen
therapy is, especially when treatment is new
- to assess someone’s ability to tolerate increased
physical activity
- to evaluate whether someone momentarily stops
beathing while sleeping, like in cases of sleep apnea
during a sleep study
Oxygen
- Human beings depend on oxygen for life. All organs
require oxygen for metabolism but the brain and heart
are particularly sensitive to a lack of oxygen. shortage
of oxygen in the body is called hypoxia. A serious
shortage of oxygen for a few minutes is fatal
Oxygen transport to the tissues
- Oxygen is carried around the body attached to an
iron- containing protein called hemoglobin, (Hb)
contained in RBC. After oxygen is breathed into the
lungs, it combines with the hemoglobin in RBC as the
pass through the pulmonary capillaries. The heart
pumps blood continuously around the body to deliver
oxygen to the tissues. Late sign of hypoxia is cyanosis
Oxygen Saturation
- RBC contains hemoglobin. One molecule of hemoglobin
can carry up to four molecules of oxygen after which it
is described as “saturated” with oxygen
- If all the binding sites on the hemoglobin molecule are
carrying oxygen, the hemoglobin in blood combines
with oxygen as it passes through the lungs
- A healthy individual with normal lungs, breathing air at
sea level, will have an arterial oxygen saturation of
95%- 100%. Extremes of altitude will affect these
numbers. Venous blood that is collected from the tissues
contains less oxygen and normally has a saturation of
around 75%
Pulse Oximeter Measure
Two numerical values obtained from the pulse oximeter monitor:
- The oxygen saturation of hemoglobin in arterial
blood. The value of the oxygen saturation is given
together with an audible signal that varies in pitch
depending on the oxygen saturation. A falling pitch
indicates falling oxygen saturation. Since the oximeter
detects the saturation peripherally on a finger, toe or
ear, the result is recorded as the peripheral oxygen
saturation, described as SpO2
- The pulse rate in beats per minute, averaged over 5
to 20 seconds. Some oximeters display a pulse
waveform or indicator that illustrates the strength of the
pulse being detected. This display indicates how well
the tissues are perfused. The signal strength falls if the
circulation becomes inadequate
- Consists of the monitor containing batteries and
display, and the probe
The pulse oximeter:
- A pulse oximeter consists of the monitor containing the
batteries and display, and the probe that senses the
pulse
The Pulse Oximeter Monitor
- The monitor contains the microprocessor and display.
The display shows the oxygen saturation, the pulse rate
and the waveform detected by the sensor. The monitor
is connected to the patient via the probe
- During use, the monitor updates its calculations
regularly to give an immediate reading of oxygen
saturation and pulse rate. The pulse indicator is
continuously displayed to give information about the
circulation. The audible beep changes pitch with the
value of oxygen saturation and is an important safety
feature. The pitch drops as the saturation falls and rises
as it recovers. This allows you to hear changes in the
oxygen saturation immediately, without having to look
at the monitor all the time
- The monitor is delicate. It is sensitive to rough handling
and excessive heat and can be damaged by spilling
fluids on it. The monitor can be cleaned by gently
wiping with a damp cloth. When not in use, it should be
connected to an electrical supply to ensure that the
battery is fully charged
The Pulse Oximeter Probe
- The oximeter probe consists of two parts, the light
emitting diodes (LEDs) and a light detector (called a
photo- detector). Beams of light are shone through the
tissues from one side of the probe to the other. The
blood and tissues absorb some of the light emitted by
the probe. The light absorbed by the blood varies with
the oxygen saturation of hemoglobin. The photo-
detector detects the light transmitted as the blood
pulses through the tissues and the microprocessor
calculates a value for the oxygen saturation (SpO2).
- In order for the pulse oximeter to function, the probe
must be placed where a pulse can be detected. The
LEDs must face the light detector in order to detect the
light as it passes through the tissues. The probe emits a
red light when the machine is switched on; check that
 you can see this light to make sure the probe is working
properly
- Probes are designed for use on the finger, toe or ear
lobe. They are of different types shown in the diagram.
Hinged probes are the most popular, but are easily
damaged. Rubber probes are the most robust. The
wrap around design may constrict the blood flow
through the finger if put on too tightly. Ear probes are
lightweight and are useful in children or if the patient
is very vasoconstricted. Small probes have been
designed for children but an adult hinged probe may
be used on the thumb or big toe of a child. For finger
or toe probes, the manufacturer marks the correct
orientation of the nail bed on the probe
- If no signal is obtained on the oximeter after the probe
has been placed on a finger, check the ff:
o Is the probe working and correctly positioned?
Try another location
o Does the patient have poor perfusion?
- Check for low cardiac output especially due to
hypovolemia, cardiac problems or septic shock. If
hypotension is present, resuscitation of the patient is
required immediately. The signal will improve when the
clinical condition of the patient improves
- Check the temperature of the patient. If the patient or
the limb is cold, gentle rubbing of the digit or ear lobe
may restore a signal

- The oximeter probe is the most delicate part of a pulse

oximeter and is easily damaged. Handle the probe
carefully and never leave it in a place where it could
be dropped on the floor. The probe connects to the
oximeter using a connector with a series of very fine
pins that can be easily damaged. Always align the
connector correctly before attempting to insert it into
the monitor. Never pull the probe from the machine by
pulling on the cable; always grasp the connector firmly
between finger and thumb
Practical use of the pulse oximeter
- Turn the pulse oximeter on: it will go through internal
calibration and checks
- Select the appropriate probe with particular attention
to correct sizing and where it will go (usually finger,
toe, or ear). If used on a finger or toe, make sure the
area is clean. Remove any nail varnish
- Connect the probe to the pulse oximeter
- Position the probe carefully; make sure it fits easily
without being too loose or too tight
- If possible, avoid the arm being used for blood
pressure monitoring as cuff inflation will interrupt the
pulse oximeter signal
- Allow several seconds for the pulse oximeter to detect
the pulse and calculate the oxygen saturation
- Look for the displayed pulse indicator that shows that
the machine detected pulse. Without a pulse signal, any
readings are meaningless
- Once the unit has detected a good pulse, the oxygen
saturation and pulse rate will be displayed
- Like all machines, oximeters may occasionally give a
false reading- if in doubt, rely on your clinical
judgement, rather than the machine
- The function of the oximeter probe can be checked by
placing it on your own finger
- Adjust the volume of the audible pulse beep to a
comfortable level for your theatre- never use on silent
(always make sure that alarms are on)
SKILL 2: GASTRIC LAVAGE AND GAVAGE
Gastric Lavage: L- linis, G- go inside;
Gastric Lavage- stomach wash or gastric suction, is the process
of cleaning out the contents of the stomach. It has been used for
eliminating poisons from stomach
Purpose:
- Removal of ingested substance to decrease systemic
absorption
- To empty the stomach before endoscopic procedure
- To diagnose gastric hemorrhage and to arrest
hemorrhage (whenever there is internal bleeding to
stop and to know the location where it is)
- To feed with fluids when oral intake is not possible
- To dilute and remove consumed position
- To instill ice cold solution to control gastric bleeding
- To prevent stress on operated site by decompressing
- To relieve vomiting and distention
- To collect gastric juice for diagnostic purposes
*in situ means that the tube or contraction is in place
*Beyond 200cc diarrhea and if loose to watery. Naka diaper
mas easier so weight ng diaper minus total weight
*dark stool lower; red stool upper
*red side ng anal part kasi itchy if may diarrhea
Indication:
- With patient has ingested poison
- Cleaning the stomach before and after endoscopy in
someone who has been vomiting blood
- Collecting stomach acid for tests
- Relieving pressure in someone with a blockage in the
intestines
Contraindication
- Loss of the airway protective reflexes, such as in a
patient with a depressed state of consciousness
- Ingestion of a corrosive substance such as a strong acid
or alkali
- Ingestion of a hydrocarbon with high aspiration
potential (because nalito si epiglottis dahil sa bilis ng
hinga so get the respiratory rate of your client)
- Patients who are at risk of hemorrhage or
gastrointestinal perforation (bc in the process pwedeng
mechanical injury as it is inserted so important yung
history ni client)
Technique
- Gastric lavage involves the passage of a tube via the
mouth or nose down into the stomach, followed by
sequential administration and removal of small volumes
of liquid
- The placement of the tube in the stomach must be
confirmed either by air insufflation while listening to the
stomach, by pH testing a small amount of aspirated
stomach contents or x- ray. This is to ensure the tube is
not in the lungs
(in situ: intact or in place) (x- ray most accurate to check
patency; next in line in litmus paper; basic if it changes
into blue one)
- Lavage is repeated until the returning fluid shows no
further gastric contents
- If the patient is unconscious or cannot protect their
airway then the patient should be intubated before
performing lavage
*If no protective reflexes may cause aspiration
Complication
- Aspiration Pneumonia
o While taking the unwanted poison and drugs
out of the stomach (lavage), the substances
might accidentally enter the respiratory canal,
into the lungs and cause aspiration pneumonia
- Laryngospasm
o Uncontrolled and involuntary muscle
contraction (spasm) of the larynx cord
- Hypoxia and hypercapnia
o Lack of oxygen
- Bradycardia
o Pulse is slow and lower than normal
- SOB
o Patient might experience dyspnea due to a
tube inserted through the oropharynx that can
obstruct the patient airway, which cause low
oxygen supply
- Mechanical injury
o To the throat, esophagus, and stomach
Gastric Gavage
- Gavage feeding is an artificial method of giving fluids
and nutrients. This is a process of feeding with the tube
(nasogastric tube) inserted through the nose, pharynx,
and esophagus and into the stomach
Purpose
- To provide adequate nourishment to patient who
cannot feed themselves
- To administer medication
- To provide nourishment to patients who cannot be fed
through mouth (surgery in oral cavity, unconscious or
comatose state)
Indications for enteral tube feeding
Selection of Nasogastric Tube
- Select the feeding tubes based on the tube’s
composition, intended use, estimated length of time
required, cost- effectiveness and tube features
- Soft, flexible, small diameter tube (8 Fr to 12 Fr) is
recommended for nasogastric. Feeding.
- Use polyurethane or silicone tubes for anticipated long
term feeding rather than polyvinylchloride tubes
- Polyvinylchloride (PVC) tubes should be used for a short
period of time usually for gastric drainage,
decompression, lavage or diagnostic procedures
- Smaller size feeding tube improves patient comfort.
Common complications associated with the use of
larger and stiffer tubes include nasopharyngeal
erosions/ necrosis, sinusitis and otitis media
 - For short- term usage, PVC feeding tubes have
adequate efficacy and are more cost effective
*plain saline: if may color red for external use only or cleaning
of wounds so check it first; isotonic solution is similar to the
composition of the body and it has salt and water so the salt can
attract the fluid out to the gastric area
*fowler’s position to prevent aspiration; if not allowed a little
lower facing left side lying because the left side aids more the
digestion so better digestion so eliminated easier but in checklist
right side (actual exposure should be left)
SITE
Nasogastric tube- enteral feeding, if shorter time NGT
Gastrostomy or Jejunostomy - for a long period of time (done in
operating room;

*xray most accurate to check patency then litmus to check

acidity and third is auscultate for gurgling; aspirate for gastric
content; last is iano tube ideep if may bubble may air
*litmus paper: the blue paper changes red indicates acidity pH
range of 4.5 to 8.3 (note the 8.3 is alkaline)
*red litmus paper indicates alkalinity with a change to blue.
Litmus paper is red below a pH of 4.5 and blue above a pH
of 8.3
*if the paper turns purple this indicates the pH is near neutral.
Red paper that does not change color indicates the sample is
an acid. Blue paper that does not change color indicates the
sample is a base
*normal pH level 7.5;8 or higher is considered alkaline
*Bowel sound will be altered kaya auscultate before
percussion; locate epigastric as you auscultate and check for
gurgling sound for patency if breath sounds na sa lungs
nakalagay
*Nondominant asepto; dominant stethoscope
*In checking patency introduce only small amount of air pinch
little lang yung asepto
Then remove yung taas to pour yung food
*another in checking patency is aspiration of the gastric content
by clamping negative pressure connect lower sa bed side then
wait for gastric acid to come out check if residual mga di na
digest.
*Always check for residual to give you an idea if tolerate yung
feeding less 50cc
*If RR is 30 pataas wag muna mag feed; if 28 wag muna mag
feed but recheck it after 15 minutes
SKILL 3: ADMINISTERING INTRAVENOUS MEDICATIONS

- Giving medication into the vein to have a faster effect

- Intravenous: into the vein
- Appropriate in giving medications when a rapid effect
is required
- This can be done manually or a syringe pump may be
used

3. Volume Controlled Infusion (soluset)

- Intermittent medications may also administer by a
volume control infusion set such as Buretrol, soluset,
volutrol, and pediatrol
- Such sets are small fluid containers (100 to 150ml in
size) attached below the primary infusion container so
that the medication is administered through the client IV
line
- These are frequently used to infuse solutions into
children and older clients when the volume
administered is critical & must be carefully monitored
- IV fluids are infused to flexible tubing also called as infusion
set or primary set

4. Intravenous push (IVP) or Bolus

*IV push is for patients in critical conditions such as epinephrine
- It is the intravenous administration od an undiluted drug
Methods for Administering Medications Intravenously directly into the systemic circulation
include the following:
- It is used when a medication cannot be diluted or in an
1. Large- volume infusion of intravenous fluid emergency
- Mixing a medication into a large volume IV container - An IV Bolus can be introduced directly into a vein by
is the safest & easiest way to administer a drug venipuncture or an existing IV line through an injection
intravenously port or IV lock
2. Intermittent Intravenous Infusion (piggyback or
- Every 12 hrs we open the canula
Tandem Set- up)
- Method of administering a medication mixed in a small
amount of IV solutions such as 50 or 100ml
- In a tandem set- up, a second container is attached to
the line of the first container at the lower, secondary
port. This permits medications to be administered
intermittently or simultaneously with the primary
solution
- In the piggyback alignment, a second set connects the
second container to the tubing of the primary container
at the upper port. This set up is used solely for
intermittent drug administration
 5. Intermittent injection ports (device) Principles of Medication Administration
- It may be attached to an intravenous catheter or Three checks
needle to allow medications to be administered 1. Check when obtaining the container of the medicine
intravenously without requiring a continuous intravenous and Check what is the content and the name and
infusion validity
- The device may also have a port at one end of the lock 2. Check when removing the medicine from the container
and a needleless injection cap at the other end with the 3. Check when replacing the container
extension tubing between the two ends 10 rights
- Intermittent injection ports have either resealable latex 1. Right patient
injection site for the needle access or a port that allows 2. Right medication
a syringe or a needleless adapter to be connected for 3. Right time
administering medications 4. Right dosage
5. Right route
6. Right to information on drug/ client
7. Right to refuse to medication
8. Right assessment
9. Right documentation
10. Right evaluation

Contraindications for IV medications

- IV access should be attempted as distal as possible
- Avoid veins that cross over joints, local infection/ injury
- Extremities with renal shunts or fistulas
Advantages
- Once given the bolus it is directly to the circulatory
Heparin Lock Device: we will be giving a heparin lock flush system
which is used to flush in intravenous catheter that helps prevent - Instant drug administration termination
blockage in a tube After a client receive an IV infusion. Heparin - A route for administration of fluids and drugs to
lock flush should not be used to treat or prevent blood clot in the patients who cannot tolerate oral medication
body. A separate heparin lock product is used for that purpose - A method of instant drug action
“student, you do not study to pass the test. You study to prepare
for the day when you are the only thing between a patient and
the grave.” – Mark Reid

Basic Principles of IV Therapy

1. Maintain line patency by checking if there’s a
backflow. IV bottle is put down below the IV to check
2. Protect integrity of catheter. Catheter must be change
or the canula
3. Protect from infection
4. Protect air emboli by making sure that there is no air
inside the syringe

Important factors in Administration of all IV medication

1. Environment: everything must be sterile
2. Patient: everything must well- explained about the
medication
3. Injection: tell where to be injected and what type of IV
to be done
4. Equipment: check and be prepared before going to the
patient
SKILL 5- NGT INSERTION AND REMOVAL

Purpose of NGT Insertion

- To feed with fluids when oral intake is not possible
- To dilute and remove consumed position
- To instill ice cold solution to control gastric bleeding
- To prevent stress on operated site by decompressing
- To relieve vomiting and distention
- To collect gastric juice for diagnostic purposes
Equipment needed
- Tube (usually #12, #14, #16 or #18 French for a
normal adult) SKILL 8- BLOOD TRANSFUSION
- Water soluble lubricant
Private 2 donors 1 bag
Selection of Nasogastric Tube: Public 3 donors 1 bag
- Select the feeding tubes based on the tube’s *if a patient is a Jehovah’s witness, a transfusion requires special
composition, intended use, estimated length or time written permission
required, cost- effectiveness and tube features *Taking of vital signs Before, during and after and remember
- Soft, flexible, small diameter tube (8Fr to 12 Fr) is always the baseline
recommended for nasogastric feeding *A client with fever gives antipyretic first and then we can
- Use polyurethane or silicone tubes for anticipated long proceed to blood transfusion
term feeding rather than polyvinylchloride tubes *70/40 bp is good candidate of blood transfusion
- Polyvinylchloride (PVC) tubes should be used for a short
period of time usually for gastric drainage,
decompression, lavage or diagnostic procedures
- Smaller size feeding tube improves patient comfort.
Common complications associated with the use of
larger and stiffer tubes include nasopharyngeal
- erosions/ necrosis, sinusitis and otitis media
- For short- term usage, PVC feeding tubes have
adequate efficacy and are most cost effective
Inserting an NG tube
- To determine which nostril will allow easier access, use
a penlight and inspect for deviated septum or other
abnormalities
- Mark this distance on the tubing with tape
- Instruct client to lower her head slightly to close the
trachea and open the esophagus
- Direct her to sip and swallow as you slowly advance
the tube
- This helps the tube pass to the esophagus (if you aren’t
using water, ask the patient to swallow)
- Ensuring Proper tube placement
- Use a tongue blade and penlight to examine the
patient’s mouth and throat for signs of a coiled section
of tubing
*lubricate tip of the tube for about 3 inches
*ALERT! Persistent gagging prolonged intubation and stimulation
of the gag reflex can result in vomiting and aspiration
*Coughing may indicate presence of tube in the airway

Determine tube placement in the stomach

A. Gently introduces a little air into the tube using
the bulb or asepto syringe and listens for a
gurgling sound with a stethoscope on the
epigastric area.
B. Aspirates for 10 ml of stomach contents by
applying negative pressure using the bulb or
plunger of the asepto syringe and measuring pH
of aspirated fluids. Re-instills aspirated fluid
afterwards, unless the aspirated fluid
characteristic appears abnormal
Green and pink is intended for BT
Blue, yellow, and purple is not intended for BT because it is too
small, the RBC will be destroyed
How to check patency of IV
- Remove the IV from the IV pole lower than the bed and
wait for the back flow (bright red) para good amount
- If pink or pale red baka di intact and na injured lang
yung wall
- Anotherr way to check is pinch near the needle and
wait for the backflow
- Third is check the surrounding area
 - If IV fluid Is on the right hand, then deltoid is swollen
then he may have injury
- Fourth, Aspirate blood in the port if there is backflow
then it is intact
- Fifth, touch the IV surface, if it is warm or cold then it is
not in the vein
*when administering multiple units of blood, use blood warmer
to avoid hypothermia
For rapid blood replacement, know that you may need to use a
pressure bag

Blood typing and cross matching

- Crossmatching sheet dalawang registered nurse mag
check ng ward na yun
- In crossmatching check the type and donor’s type and
do not forget the serial para if mayroong mali
madaling Balikan sino or kanino nanggaling yung
blood nay un
- Should be countersign by the two nurses then check
expiration date and time
- patient’s name and bed number, blood type (A, B,
AB, O), Rh factor, hepatitis and AIDS tests, blood
products (PRBC, FWB, FFP), number of “u” or cc,
expiration date, and serial number, and inspects
the blood bag for clots and bubbles.

Bedside Checking
- blood bag compatibility label
- patient: verbal ID, wristband
- Paperwork: compatibility from prescription chart

We are going to insert the BT set

- Insert sa B

Clamp roller clamp. Then remove the cover and then lift it open
insert
- Press the chamber and then half fill yung chamber and
from there pwede na open roller blade then the needle
and then open if may ang drop clamp na ulit and then
cover muna

- Connect to the IV tubing

*if you are administering whole blood, gently invert the bag
several times to mix the cells
*adjust the flow clamp closest to the patient to deliver the blood
at the calculated drip rate
*Isotonic solution is plain saline because same component with
our body’s components if not plain saline madestroy si RBC
*If the patient has fever refer to doctor wait to prescribe the
medicine there might be a stop or doctor will continue provided
tha patient received the apyretic if fever during stop the BT
*If chest pain baka may cardia overflow if naka receive ng
more than 1 bag of blood so stop the transfusion so clamp muna
then ask doctor
*If can’t breathe maybe there is an allergic reaction stop BT
*If may flank pain or sa may kidney na feel so stop the blood
transfusion because there is rejection coming from the kidney
*If given fresh whol blood invert the blood but naka clamp so
ayun invert para mag mix yung plasma
*Stay with the patient during the first 15 mins to know and
reactions such as fever, chills, and wheezing; if sign develop,
record vital signs and stop the transfusion
*Infuse plain normal saline at a moderately slow infusion rate
and notify the doctor at once; if nag stop ka 40 cc or 10 drops
per min
*Blood bag yellow bin
*although some microaggregate filters can be used for up to 10
units of blood, always replace the filter and tubing if more than
1 hour elapses between transfusion
SKILL 6: CLEANSING ENEMA PURPOSES: BEATS

*Anus part of the body where enema catheter is placed
Enema- is an introduction of fluid into the lower bowel through
the rectum for the purpose of cleansing or to introduce a
medication or nourishment
B- bowel training
E- eliminate feces and flatus
A-avoid contamination of the sterile field (during surgery)
T- treat constipation and impaction
S- support visualization of intestines (colonoscopy exam)

TYPES Action
a. Cleansing enema - After introduction of solution, the intestine becomes
- prevent the release of feces while the patient is in distended and there will be irritation of intestinal
surgery. The process prepares the intestines of the mucosa which results to increase peristalsis. Thus,
patient for a colonoscopy or x- ray. Can be excretion of feces/ flatus
administered as a small volume or large volume Patient Positioning
cleansing enema Left- side lying or sim’s position- bottom leg straight, top bent
Left side (fetal position)- both knees drawn up
b. Carminative enema
- It Releases tension or swelling in the colon and Common Solution for Cleansing Enemas
rectum. When waste builds and sits in the colon, a - Hypotonic solution (eg. Tap water)
carminative enema allows the waste and toxins to - - lower osmotic pressure will cause water to move
leave the body from the colon to the interstitial space
- Isotonic solution such as normal saline
c. Retention enema o Used in cleansing enema
- is used to administer medication and oil into the - Action: no movement to the fluid in & out of the
patient’s rectum. The types of oil and medications colon. The volume of the solution will stimulate
include nutritive, antibiotics, and anthelmintics peristalsis
- Soapsuds solution
d. Return- flow Enema - Hypertonic solution
- This provides an alternating flow of enema o Increase osmotic pressure will draw fluid
solutions between 100 and 200ml into and out of from the interstitial space in the colon
the patient’s colon and rectum to stimulate
peristalsis to propel food along the normal process SOLUTION CONSTITUENT ACTION TIME TO
TAKE EFFECT
Purposes Hypertonic 90- 120ml of Draws H2O 5-10 mins
- To stimulate defecation and treat constipation solution into the
Ex. Simple evacuate enema colon
- To soften hard fecal matter ex. Oil enema Hypotonic 500- 1000ml of Distends 15- 20 mins
- To administer medication ex sedative enema tap H2O colon,
- To protect and soothe the mucus membrane of stimulates
intestine & to check diarrhea ex. Emollient enema peristalsis &
- To destroy intestinal parasites ex. Anthelmintic soften feces
enema Isotonic 500- 1000ml of Distend 15- 20 mins
- To relieve the gaseous distention ex. Carminative normal saline colon,
enema stimulates
- To administer the fluid and nutrition ex. Nutritive peristalsis &
enema soften feces
- To relieve inflammation ex. Astringent enema Soapsuds 500- 1000ml Irritates 10- 15mins
- To induce peristalsis ex purgative enema (3- 5 soap to mucosa,
- To stimulate a person in shock and collapse ex. 1000ml H2O) distend
Stimulant enema colon
- To reduce the temperature ex. Cold enema or ice
enema Big catheter
- To clean the bowel prior to x- ray studies, 3- 4 inches
visualization of the bowel, surgery on the bowel or PY jelly lubricant in cghc
delivery of a baby ex. Saline enema *start number 5- 15
- To make diagnosis ex. Barium enema
- To establish regular bowel functions during a
bowel training programme
- To induce anesthesia ex. Anesthetic enema
*in surgery bowel should be cleansed
Barium enema- whitish substance so when in x- ray this will be
done no water or anything just the barium
SKILL 7: TRACHEOSTOMY CARE AND SUCTIONING 3. obturator
- this is used only to insert the outer tube; act as a
Tracheostomy- is the creation of an opening directly into the guide when inserting the outer cannula into the stoma;
trachea (windpipe) in the neck for the purpose of assisting it is removed once the outer tube is in place
breathing
- Surgical creation of a stoma, or opening, into the
trachea just below the larynx through the overlying
skin
- An artificial opening wherein a curved tube measuring
2- 3 inches is inserted into the trachea
- Is an incision into the trachea (windpipe) that forms a
temporary or permanent opening
- A surgical incision into the trachea through overlying
skin and muscles for airway management

*the opening or hole is called a stoma

Types
Indications 1. single cannula tube
- To bypass obstruction - does not have an inner cannula
- Neck trauma 2. double cannula tube- more used
- Subcutaneous emphysema (trap yung air sa skin) - has an inner cannula which is inserted and is locked in
- Facial fractures place after the obturator is removed; it acts as liner
- Edema- trauma, burns, infection, anaphylaxis for the more permanent, outer cannula. The inner tube
- To provide a long- term route for mechanical can be removed for short periods to be cleaned
ventilation in cases of respiratory failure Assessment
- To provide pulmonary toilet - respiratory status including ease of breathing, rate,
- Prophylaxis (as in preparation for extensive head rhythm, depth, and lung sounds
and neck procedure and the convalescent period) - pulse rate
o Pulmonary toilet or passage - character and amount of secretions from tracheostomy
- Severe sleep apnea (nakalimutan huminga) site
Purpose - presence of drainage on tracheostomy dressing or ties
- To replace an endotracheal tube for long term - appearance of incision (note any redness, swelling,
airway management purulent discharge, odor, and fever) – for infection
- To remove tracheobronchial secretions
- To provide a method for mechanical ventilation DELEGATION: NO!- only nurses can
- To prevent aspiration of secretions, food, or fluids into - tracheostomy care onvoves application of scientific
the lungs knowledge, sterile technique, and problem solving,
- To provide a permanent airway and therefore needs to be performed by a nurse
- To bypass an upper airway obstruction Equipment
Advantages 1. sterile 4in X 4in gauze sponges or OS #2 packs
- Makes it easier to keep a patient’s lungs clean 2. sterile cotton applicators or pledgets #1 pack
- More comfortable for patients than having a tube in 3. Tracheostomy ties- pre- cut
the mouth or nose 4. Cleaning solution- hydrogen peroxide
- Can make it easier to wean patient from the 5. Antiseptic solution- betadine or PVP
ventilator 6. Sterile water onf NSS- for rinsing inner cannula
Potential Problems 7. Sterile basin
- Tracheal wall necrosis- can lead to the formation of 8. Sterile gloves #2 pairs (1pair for suctioning and
tracheoesophageal fistula (abnormal opening another pair for tracheostomy care)
between the posterior trachea) 9. Clean gloves- 1 pair (for removing soiled
- Tracheal dilatation tracheostomy dressing and ties)
- Tracheal stenosis 10. Clean bandage scissors (for cutting the tracheostomy
- Airway obstruction tie)
- Infection 11. Water receptacle
- Accidental decannulation Implementation
- subcutaneous emphysema 1. Assemble all equipment at the bedside table
2. identify the patient
Parts 3. explain the procedure to the patient and establish a
1. outer cannula method of communication
- maintains the opening of the airway; has wings on 4. position the patient in a semi0 fowler’s position unless
collar where tracheostomy ties can be anchored to contraindicated
secure the tube around the patient’s neck. Most plastic 5. wash your hands and dry
tubes are cuffed with soft balloon to hold the tube in 6. put on sterile gloves and suction the tracheostomy
place following the endotracheal and tracheostomy tube
2. inner tube or cannula suctioning procedure
- tube fitted inside the outer tube; locks into the outer 7. discard the used gloves and wash your hands
cannula and is easily removed for cleaning
8. still with ungloved hand, open the 4x4 gauze pack or
OS and consider the inside portion as your sterile
field
9. open the other 4x4 OS using proper aseptic technique
and drop it in the sterile field. Do the same with the
cotton applicator and tracheostomy tie
10. remove the bottle covers of hydrogen peroxide and
betadine
11. open the sterile basin pour a small amount of sterile
saline in it using aseptic technique. If no sterile basin is
available, a clean kidney basin at the bedside will do
but do not pour sterile saline in it. Just have it ready
at the table
12. have a clean bandage scissors ready on the table
13. untie soiled tracheostomy tie or you may cut it if it is
difficult to remove. Discard in waste receptacle. Do it
while holding the tube securely with the other hand
14. let a second person put on a sterile glove on one
hand and hold the tracheostomy tube until new ties
are securely in place. The nurse may use the
remaining sterile left-hand glove which was left
unused after suctioning the tracheostomy
15. put on a pair of sterile gloves
16. prepare your tracheostomy dressing using either one
of these three technique
a. two- folded tracheostomy dressing: get 3 layers
of 4x4 OS and fold them together into two. Get
another 3 layers and do the same thing.
b. Folded rectangular tracheostomy dressing: get 3
layers of 4x4 OS and unfold them to form a
rectangular shape
c. Mid- cut tracheostomy dressing: get 3 layers of
4x4 OS and cut it halfway in the middle using
sterile scissors
17. Start cleaning inner canula and remove
a. Place the inner cannula in the sterile basin with
saline solution
b. Get one layer of 4x4 OS, dip it in sterile saline
and use this in cleaning the inner cannula.
c. Get another layer of OS and dry. Reinsert the
inner cannula and lock.
18. Get a cotton applicator, dip it in hydrogen peroxide
and clean the internal end of the tracheostomy collar.
Discard in a waste receptacle. Do this twice
applicator before discarding. Be careful not to allow
the cleansing solution to enter the tracheostomy
opening. (If the skin around stoma show sign of
irritation and dryness, sterile water of NSS may be
used instead for cleaning.)
20. Allow to air dry and apply the iodine or PVP solution
once.
21. Apply the tracheostomy dressing using either one of the
3 techniques discussed in no.5:
a. Two-folded technique
b. Folded rectangular technique
c. Mid-cut technique
22. Gloves may be removed at this point. Prepare and
apply the tracheostomy tie.
a. Open the tracheostomy tie packs.
b. Fold the tracheostomy tie into 2 halves; one half is
4 inches longer than the other half, then cut the
folded part
c. Cut a slit hole or opening on one end of the tie.
Cut straight in the middle about ½ inch long to
make a slit opening. Do the same on the other cut
half portion of the tie
d. Make sure that there is at least ½ inch distance
between the slit hole and distal end of the tie.
e. Get the shorter cut tie. With your right thumb and
index fingers, hold the tip of the tie without the slit
hole, fold it lengthwise and insert it downward on
one side of the tracheostomy collar opening (side
near you). Catch the tip of your other finger and
insert this in the slit opening. Pull securely through
this opening.
f. Do the same procedure on the other side of the
tracheostomy collar using the other longer half of
the pre-cut tie.
g. Slide your right palm behind the patient’s nape
and grab the tie on the opposite side towards your
tie. Secure the tracheostomy tie by means of a
ribbon knot on the side of patient’s neck near you.
h. Tape should be tight enough to keep tube securely
in the stoma but loose enough to permit one finger
to fit between the tapes and neck.
23. Ask your companion to release his hold on the
tracheostomy tube.
24. Wash your hands.
25. Assist patient to assume a comfortable position
26. Discard or return all equipment to the appropriate
location.
27. Document procedure performance, assessment made in
appearance of stoma (irritation, redness, edema);
character of secretions (color, amount, consistency);
type of respiration and breath sounds.

*drawing na lang gamitin earphones kasi napapasok then

suction paikot and pagpalit gauze and ties. So printed butasan
kunwari may ipapasok na string. Start sa suntioning no need na
sabihin two strip or one strip, pag nalagay tie check tightnes so
2 fingers then and so on

Di tinatapon agad pang suction pwede mabili yun para

mafeel yung suction catheter.
19. Get cotton applicator, dip in hydrogen peroxide and
clean the stoma area starting from inner to outer
portion of the opening in a circular stroke. Discard.
Repeat again. Make only a single sweep with each
 SKILL 9: HIP AND SITZ BATH - Redness, swelling, or fluid leaking from a cut (incision)
that gets worse
History - Symptoms that don’t get better, or get worse
- The sitz bath was one of a number of treatments used - New Symptoms
in Water Cure that arrived in Malvern in 1842
- It was used to alleviate lower abdomen complaints Equipment
- Cold water was poured into the bath to waist height - Sitz tub, portable sitz bath, or regular bath tub
- The hip bathtub is similar to the sitz bat & the terms are - Bath mat and rubber mat
often interchangeably - Bath (utility) Thermometer
- Physician JihnnBell wrote A Treatise on Baths in 1859 - 2 bath towels, towels and patient gown
in which he defined baths by the manner of water - Gloves, if the patient has an open lesion or has been
application to the body, by the bath’s temperature and incontinent
the parts of the body immersed in water - Optional: rubber ring, footstool, overbed table, IV pole
(to hold irrigation bag), wheelchair or cart, dressings
HIP BATHS - A disposable sitz bath kit for single patient use. It
- Were originally a European custom, although modern includes a plastc basin that fits over a commode and
sitz baths are used mainly for therapeutic purposes an irrigation bag with tubing and clamp
- The term sitz bath is derived from the German word
Sitzbad, meaning a bath (Bad) in which one sits (sitzen) Different Temperature of Water Tub Bath
a. Cool water tub bath
STZ BATH - 98.6 F Tepid
- The term “sitz bath” comes from the German word - Relieves tension and lower body Temperature
“seat”. A sitz bath is designed to sit in - If had hemorrhoidectomy
- A sitz bath or hip bath is used to soak a client’s perineal
or rectal area b. Warm water tub bath
- A bath in which a person sits in water up to the hips - 109.4F or 43 C
- A sitz bath is literally what it sounds like- a bath where - Relieves muscle tension
you sit in warm water that covers the buttocks and hips - For postpartum patients
- For postpartum patients who experienced episiotomy
- Soak for 10- 15 mins c. Hot water tub bath
*Salt is best for healing wounds - 113 to 115F or 45- 46 C
*Sitz bath serves as treatment for number of problems…. - Relieves muscle soreness and spasm
Hemorrhoids is one of them *Fistula nagkabutas tapos nagconnect yung body parts like
intestine to skin
Sitz Bath acts as a Natural Treatment for: *Fissure is a long narrow opening or a crack in the skin and
- Hemorrhoids- varicosities, veins that is inflamed usually nagkakaron sa anal part
(almoranas) *start with 5- 16
o Hemorrhoidectomy
- Constipation among teens and adults SKILL 12: INCENTIVE SPIROMETRY
- Healing damaged tissues after birth
- Vaginal infections Definition:
- Also referred as sustained maximal inspiration (SMI)
Purposes: - It is a method of deep breathing that provides visual
1. To aid in healing a wound in area by cleaning on feedback to encourage the clients to inhale slowly and
discharges and slough deeply to minimize lung inflation and prevent or reduce
2. To induce voiding in urinary retention atelectasis
3. To relieve pain, congestion and inflammation in cases - It is designed to mimic natural sighing or yawning by
of encouraging the patient to take a long, slow, deep
a. Hemorrhoids breaths
b. Tenesmus- cramping rectal pain. A feeling that you - This is accomplished by using a device that provides
need to have a bowel movement patients with visual or other positive feedback when
c. After proctoscopic or cystoscopic examination they inhale at a predetermined flow rate or volume
- For rectum by inserting metal proctoscopic to check the and sustain the inflation at least 5 seconds
rectum; cystoscopic is done for patients who have - Spirometry measures (2) Key Factors:
urinary incontinence o Expiratory Forced Vital Capacity (FVC)
d. Sciateca- there are problems that occur in the o Forced Expiratory Volume in One Second
spinal cord like kunwari may binuhat ka tapos may (FEV1)
pain na mafeel FEV1 Measurement
e. Uterine and renal colic (may something sa kidney Percentage of Result
like stone kaya may pain) Predicted FEV1 Value
4. Induce menstruation (menstrual cramps can be relieved 80% or greater Normal
from this) 70%- 79% Mildly Abnormal
60%- 69% Moderately Abnormal
Call your healthcare provider or Note if you have any of 50%- 59% Moderately to Severely Abnormal
these:
- Fever of 100.4. F (38C) or higher as directed
Note:
- Normal results for a spirometry test vary from person
to person
- They are based on age, height, race, and gender
- The doctor calculates the predicted normal. Value for
the patient before the test. The doctor will check at your
test score and compare that value to the predicted
value
- Your Result is considered normal if your score is 80%
or more of the predicted value
Incentive Spirometer
- Is a handled device that helps your lungs recover after
a surgery or lung illness. Your lungs can become weak
after prolonged disuse. Using a spirometer help keep
the active and free of fluid
Purpose:
- To increase transpulmonary pressure and inspiratory
volumes, improve inspiratory muscle performance and
re -establish or stimulate the normal pattern of
pulmonary hyperinflation
- When the procedure is repeated on a regular basis,
airway patency may be maintained and lung
atelectasis prevented and reversed
Indications:
- Pre- operative screening of patients at risks of post-
operative complications to obtain a baseline of their
inspiratory flow and volume
- Presence of pulmonary atelectasis
- Conditions predisposing to atelectasis such as:
o Abdominal or thoracic surgery
o Surgery in patients with COPD
o Presence of thoracic or abdominal binders
o Lack of pain control
- Restrictive lung disease associated with a dysfunctional
diaphragm or involving respiratory musculature
- Patients with inspiratory capacity less than 2.5 liters
- Patients with neuromuscular disease or spinal cord
injury
Contraindications:
- Patients who cannot use the device appropriately or
require supervision at all time
- Patients who are non- compliant or do not understand
or demonstrate proper use of the device
- Very young patients or pediatrics with developmental
delay
- Hyperventilation
- Hypoxemia secondary to interruption of oxygen
therapy
- Fatigue
- Patients unable to take deep breathe effectively due
to pain, diaphragmatic dysfunction or opiate analgesia
- Patients who are heavily sedated or comatose
- The device is not suitable for people with severe
dyspnea
Precautions:
- The technique is inappropriate as the sole treatment for
major lung collapse or consolidation
- Hyperventilation may result from improper technique
- There is potential for barotrauma in emphysematous
lungs
- Discomfort may occur secondary to uncontrolled pain
- Development of bronchospasm may occur in susceptible
patients. Close monitoring of patients with hyper-
reactive airways should be maintained.
*incentive spirometry is performed using devices which provide
visual cues to the patients that the desired flow or volume has
been achieved
*procedure must be done before meals para avoid vomiting and
best if morning or before sleeping gawin
*high- fowler’s position best position
*start from number 6 (high- fowler lang) hanggang 11
SKILL 10: CHEST TUBE CARE AND BOTTLE CHANGING - The usual water depth in water seal system is 2cm
- Chest tubes are removed when the lungs have re-
Chest tubes expanded and/ or there is no more fluid drainage
- Doctor nag i- insert - It usually takes two to three postoperative days of chest
- Inserted in the emergency department, in the operating drainage for lungs to fully expand
room via a thoracotomy incision, or at the client’s
bedside
- Inserted into the pleural space to remove air and fluid
and to establish negative intrapleural pressure (if may
fluid na nag ccompress ng lungs kaya nag kaka
problem sa respiratory distress so we do this para mag
expand si lungs) (Doctor will check breath sounds)
- This procedure allows the lungs to re- expand
- Chest drainage, which is collected in the drainage
system, will be measured and sent to the laboratory for
analysis
- The chest tube may be positioned anteriorly through the
second intercostal space to remove fluid and blood
- A second tube may be positioned posteriorly through
the 8th or 9th intercostal space to remove fluid and
blood
- The tubes are sutured to the chest wall, and an airtight
dressing is placed over the punctured wound

Securing chest drain

- Before securing the tube with stitches, look for a
respiration- related swing in the fluid level of the water
seal device to confirm correct intra thoracic placement.
Secure the chest tube to the skin using 0 or 1- 0 silk or
nylon stitches

Drainage system
- The tubes are then attached to drainage tubing and
the drainage system
- 4 types of drainage
o One- bottle system: water seal and collection
of drainage in same bottle
o Two- bottle system: water seal and collection
of drainage is separate bottles
*1 an 2 gravity bottle but if three way may bottle for the
suction
o Three- bottle system: water seal, collection of
drainage, and suction control in separate
bottles
o Disposable single units that work the same as
a three- bottle system (Pleur- evac, atrium,
Thora- seal

Three- bottle system

- When suction is turned on, air and fluid are pulled out
of the pleural space and into the drainage collection
bottle. Suction is applied through the entire system until
it reaches the pressure that will draw atmospheric air
in through the open tube of the suction control bottle.
When the incoming atmospheric air reaches the lower
end of the tube, it bubbles onto the bottle. At this point,
the desired suction level will be maintained as any
increase in suction will just draw in more atmospheric
air
Disposable chest drainage
- Air and fluid move from an area of high pressure
(intrapleural space) during expiration to an area of
low pressure (drainage system)
Risk factors necessitating chest tube
- blunt, crushing or penetrating chest injuries
- tension pneumothorax
- hemothorax- blood sa pleural space
- hemopneumothorax
- thoracic surgery invasive thoracic procedures
*A pneumothorax can be caused by a blunt or penetrating
chest injury, certain medical procedures, or damage from
underlying lung disease. Or it may occur for no obvious reason.
Symptoms usually include sudden chest pain and shortness of
breath. On some occasions, a collapsed lung can be a life-
threatening event.
*Hemothorax is when blood collects between your chest wall
and your lungs. This area where blood can pool is known as the
pleural cavity. The buildup of the volume of blood in this space o The purpose of milking or stripping
can eventually cause your lung to collapse as the blood pushes the tubing is pre- sumably to dislodge clots
on the outside of the lung. that may be attached to the sides of
*Hemopneumothorax, or hemopneumothorax is the condition the tubes by mechanically pushing them
of having air in the chest cavity (pneumothorax) and blood in the distally toward the collecting container
chest cavity (hemothorax). A hemothorax, pneumothorax, or the - Take precautions that drainage bottle is never
combination of both can occur due to an injury to the lung or elevated to level of client’s chest.
chest. - Do not empty drainage bottles unless overflowing.
- Never clamp chest tubes without a physician’s order.
Signs and symptoms necessitating chest tubes - Encourage client to cough and deep breathe, sit up in
- air hunger bed, and ambulate.
- agitation - Provide pain medications one-half hour before
- hypotension removing chest tubes.
- tachycardia - After removal of chest tubes, apply air tight sterile
- severe diaphoresis petroleum jelly gauze dressing
- absence or diminished breath sounds on affected side - Order chest-rays as needed following removal of chest
- tracheal deviation (tension pneumothorax) tubes.
- cyanosis
- mediastinal shift to unaffected side Complications
- Infections
Diagnostic and Laboratory tests - Recurrent or new pneumothorax
- history and physical exam - Respiratory failure
- pleural fluid analysis
- blood gas analysis
- chest x- rays following removal of chest tube before
and after

Therapeutic nursing management

- assess/ monitor:
o for blockage of drainage system
o for air leaks
o for air bubbles in water- seal chamber
o for fluctuation in glass tube or chest tube
o vital signs that there is no signs of infection
and respiratory distress
o breath sounds
o chest wall for unusual chest movement
o oxygen saturation
o chest tube insertion site for redness, pain,
infection, and crepitus (tunog ng bubble wrap)
o wound for excessive drainage or signs of
infection following chest tube removal
o clients for signs of recurrent pneumothorax
*The insertion site dressing may need to be changed by the
surgeon who inserted the chest tube. Development
of crepitus can indicate a small air leak into the subcutaneous
tissue. Crepitus may indicate a need for the surgeon to adjust
the chest tube placement

Nursing activities
- assist physician with insertion of chest tubes and set- up
of drainage system if this is an emergency procedure
performed at bedside
- keep all tubing straight and coil loosely
- prevent client from lying on tubing
- wag itaas yung bottle para di bumalik sa patient
- make certain that connections between the chest bottles
are tight
- tape connections securely to prevent air leaks
- tape tools of bottles
- re- tape all connections if necessary
- Milk and strip the chest tubes if necessary, to increase
amount of negative pressure to pleural space.
SKILL 11: COLOSTOMY CARE Purpose of Colostomy Care
- To maintain integrity of stoma and peristomal skin
- The pouch, stoma, and skin surrounding the stoma - To prevent infection
require care and maintenance - To promote general comfort and positive self- image
What is Stoma? - To provide clean ostomy pouch for fecal evacuation
- It is an artificial opening from the intestine on the - To reduce odor from overuse of old pouch
abdominal wall usually created by a surgeon
Colostomy
- It refers to a surgical procedure where a portion of the
large intestine is brought through the abdominal wall
to carry stool out of the body. It. May be permanent or
temporary
Indication
- A colostomy is created as a means to treat various
disorders of the large intestine including cancer,
obstruction, inflammatory bowel disease ischemia
(compromised blood), supply or traumatic injury in a
baby or child it may be due to an imperforate anus
which is the absence of an anal opening. It also may be
due to Hirschsprung’s Disease or it may be due to other
malformations that are present at birth
- Check temp of baby in the rectal area to check patency
Warning Signs
- Bleeding from stoma (small fingernails to avoid injuries
on the stoma) Assessment:
- Bleeding from the skin around the stoma - Size
- Change in the bowel pattern (may be because there is o Round- measure using stoma measuring guide
no fiber in the diet) o Oval- measure length and width
- Change in the stoma size (retraction lumbog; prolapsed - Color
humaba) o Red- adequate blood supply.
- Increased in the temperature o Pale- low hemoglobin
Potential Complications of colostomy surgery o Dark. Red/ purplish tint. - indicates bruising
- Excessive bleeding o Gray to black- no blood supply or necrosis
- Infection - Other- appearance healthy- shiny &moist
- Leakage Summary
- Prolapse - A colostomy is a lifesaving surgery that enables a
- Obstruction or stenosis person to enjoy a full range of activities, including
- Stoma because edematous and enlarged traveling, sports, family, life and work
Stoma Complications to be monitored include - Colostomy is performed for many different diseases
- Death and conditions and therefore can be temporary or
- Necrosis of stoma tissue caused by inadequate blood permanent
supply leading to cell death. This complication is usually - Proper education pre and post-surgery, help improve
visible 12- 24 hours after the operation and may client’s quality of life
require additional surgery *If transverse colostomy place the client in sitting position tapos
*Retraction (stoma is flush with the -2) abdomen surface or has end ng bag sa kidney basin
moved below it *left side lying if sigmoid colostomy
*prolapse (stoma increases length above the surface-3 of the *if ascending colostomy right side lying
abdomen)
*Stenosis (narrowing at the opening of the stoma -3 often
associated with infection around the stoma or scarring

Four Main Types of Colostomy

a. Ascending colostomy
- Is located within the ascending colon
- Liquid digestive enzyme
b. Transverse colostomy
- Is located within the transverse colon
- Semi solid digestive enzyme
c. Descending colostomy
- Is located within the descending colon
- Resembles normal bowel movement
d. Sigmoid Colostomy
- Is located within the sigmoid colon
- Resembles normal bowel movement
- due to cancer it is a permanent type
*colostomy bag in kidney basin then start slowly remove it then
put it in the kidney basin
*baby oil to remove adhesive
Start from the middle lubog ng onti pag pinunasan with tissue
then out then change tissue 1 wipe discard then proceed na sa
side. Make sure that the inside of the lid is checked already kasi
may infection if may naiwan then clean the skin if Velcro type
then cover with gauze
*peristomal skinpwedeng soap and water when you clean it then
forget to pat dry and allow it to air dry before putting clean
colostomy bag you can use towel
*tanggalin si clip then put it in the toilet bowl and flash it with
water to clean colostomy bag and pwede ibabad sa basin with
water and mild soap
*skin barrier na sa inside
*1/6 to 1/8 wider than the stoma to guide you with the
measurement
*45mm circumference then remember it as you trace it in a
square or wafer
*1/3 filled up na yung bag clean na agad yung colostomy bag
then you are to change the bag only if nag kabutas and di na
dumidikit so Velcro di ni rreuse
*if client’s bag is inflated kasi umutot then do colostomy pertain
tatanggalin para ma release yung hangin then reattach
*colostomy burping when you allow gaseous to be out