حالات حرجة عملى 2022

Critical Care and Emergency Nursing
Accredited Faculty by National Authority for Critical Care and Emergency

Quality Assurance of Education and Accreditation Nursing Department
Procedure manual for Critical Care

and Emergency Nursing
5th Edition
Assiut University
2021-2022
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Accredited Faculty by National Authority for Critical Care and Emergency

Quality Assurance of Education and Accreditation Nursing Department
Prepared by
All staff members
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‫‪Critical Care and Emergency Nursing‬‬
‫رؤية الكلية‬
‫تتطهع كهُخ تًرَض جبيعخ أسُىط نهتًُس وانرَبدح فٍ يجبالد انتًرَض وانجحج انعهًٍ‬
‫وانخذيخ انًجتًعُخ‪.‬‬
‫رسالة الكلية‬
‫كهُخ انتًرَض جبيعخ أسُىط يؤسسخ حكىيُخ تعهًُُخ ثحثُخ تعًم عهً إعذاد كىادر يؤههخ‬
‫عهًُب ً ويهبرَب ً ويهُُب ً قبدرح عهً االثتكبر وانًُبفسخ فً سىق انعًم وانتصذٌ نًشكالد انًجتًع‬
‫فً يجبالد انتًرَض ورنك يٍ خالل ثرايج تعهًُُخ تستُذ عهً يعبَُر أكبدًَُخ يعتًذح وثحج‬
‫عهًٍ َىاكت يتطهجبد انحبضر وانًستقجم وَراعً يعبَُر انجىدح ‪ .‬وتقىو انكهُخ ثتأدَخ رسبنتهب‬
‫فٍ إطبر يٍ انقُى وانتقبنُذ انجبيعُخ انًتعبرف عهُهب‪.‬‬
‫األهداف االستراتيجية للكلية‬
‫نتطىَر انًستًر نهقذرح انتعهًُُخ نًرحهخ انجكبنىرَىش‪.‬‬ ‫‪‬‬

‫تعسَس انذعى انطالثٍ واألَشطخ انطالثُخ‪.‬‬ ‫‪‬‬
‫تطىَر انعًهُخ انتعهًُُخ فً يرحهخ انذراسبد انعهُب‪.‬‬ ‫‪‬‬
‫تحذَج انخطخ انجحثُخ نهكهُخ‪.‬‬ ‫‪‬‬
‫يتبثعخ ورعبَخ انخرَجٍُ‪.‬‬ ‫‪‬‬
‫تعسَس دور انكهُخ فً انًشبركخ انًجتًعُخ‪.‬‬ ‫‪‬‬
‫تطىَر أداء انعبيهٍُ ثبنجهبز اإلدارٌ و انقُبداد األكبدًَُخ ثبنكهُخ ‪.‬‬ ‫‪‬‬
‫تطىَر يستىي أداء وحذح ضًبٌ انجىدح‪.‬‬ ‫‪‬‬
‫انتقىَى انًستًر نهقطبعبد انثالث ثبنكهُخ ( قطبع شئىٌ انتعهُى و انطالة ‪ -‬قطبع‬ ‫‪‬‬
‫شئىٌ انذراسبد انعهُب و انجحج انعهًٍ‪ -‬قطبع شئىٌ خذيخ انًجتًع و تًُُخ انجُئخ)‪.‬‬
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Table of Contents
Procedures Pages
Unit I: Assessment of the critically ill and emergency 5-14
patient.
Unit II: Respiratory System:
 N.B: Prerequisite procedures ( Tracheostomy tube
care ,Oxygen saturation monitoring by pulse
oximetry , Inhalation therapy by nebulizer)
 Oropharyngeal airway 16-18
 Laryngeal mask airway 19-23
 Endotracheal tube intubation 24-28
 Daily Endotracheal tube care 29-31
 Tracheal cuff care 32-34
 Extubation and Decannulation 35-37
 Administering oxygen therapy 38-44
 Arterial puncture for blood gases 45-50
 Endotracheal or tracheostomy tube suction 51-54
 Incentive spirometer 55-56
 Pulmonary function test 57-58
 Extra Corporeal Membrane Oxygenation ( ECMO) 59-64
Unit III: Cardiovascular System:
 Central venous pressure monitoring 66-72
 12-lead ECG 73-79
 Cardiac catheterization. 80-84
 Cardiac pacing 85-89
 Cardiopulmonary resuscitation 90-99
 Intra-aortic balloon pump 100-103
Unit IV: Gastrointestinal System:
 Total parenteral nutrition 105-110
Unit V: Renal System:
 Continuous renal replacement therapy 112-118
Unit VI:Reference 119
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Assessment of the critically ill patient
Objectives based on competence:

By the end of this module the student will be able to achieve the
following objectives
1. Explain why assessment is important
2. Understand how assessment informs the planning of care
3. Use a structured approach to gain a patient history and interpret
Findings
4. Describe how discharge is planned starting from admission
Overview
- Assessment consists of objective and subjective data related to the
client's present and past physical and mental health status
-To obtain a true assessment of client status when using mechanical
equipment, data must be correlated with clinical findings.
- Generally, the more acute the patient and setting are the more frequent
and more in-depth the assessment must be.
- A thorough clinical assessment provides the foundation for competent
and complete follow-up care
- Performing assessment in a systematic manner helps to eliminate errors
and oversights in data collection
Importance of assessment is for critically ill & emergency patient

1- Assessment is fundamental to all procedures that a patient may
undergo.
2-It is an ongoing process repeated at regular intervals depending on the
patient‟s condition.
3- The most usual time for a thorough assessment to occur is when a
patient is admitted to acute or continuing care, but there may be other
times when further detailed assessment is necessary
4- Assessment directed nursing care that is required
5- Assessment provides a baseline from which progress can be measured.
Activities required for assessment:

When first admitting a patient into your care there are certain
specific assessment activities that will be undertaken, and as these are
completed they gather the required information. These activities are: first
impressions, assessment interview, focused assessment and physical
assessment.
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First impression
Part of assessment will include some of the first impressions that
nurse notices about the patient a mnemonic checklist – SOME TEAMS –
to help guide you through key patient observations:
 Symmetry:
Are his face and body symmetrical? Are there any swellings of
joints or body parts?
 Old:
Does he look his age? If not, can you see why?
 Mental acuity:
Is he alert, confused, agitated, inattentive or responding
inappropriately?
Is his mood depressed, happy or lethargic?
 Expression:
Does he appear ill, in pain, anxious or distressed?
 Trunk:
Is he lean, wasted, obese or barrel-chested?
 Extremities:
Does he have joint abnormalities, or edema? Does he have warm
or cold hands and feet? Is his skin pale, well perfused or with a
bluish (cyanotic)?
 Appearance:
Is he clean, well kept and appropriately dressed?
Is his skin in good condition or are there signs of rashes, bruising,
or dry skin?
 Movement:
Are his posture, gait and coordination normal?
 Speech:
Is his speech relaxed, clear, strong, understandable and
appropriate?
Does he sound anxious, stressed, or slurred?
These initial informal observations can give subtle clues about a

patient‟s health, and are useful to reflect upon later if you think there
are changes in the patient‟s condition.
Assessment interview
Preparing to interview
Before interviewing the patient it is important to prepare yourself and the
patient for the assessment interview. Explain that you need to gather some
information and ensure that it is a convenient time to interview him
Nonverbal communication can tell you about the person too. Listen
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carefully, and watch for body language signals. If a person is

uncomfortable about an aspect of your questions he may not make eye
contact.
N.B. Start your assessment with the really important things first,
especially for emergency admissions. You can fill in the gaps from the
following: medical records, letters from other health professionals,
communications from ambulance staff, accident and emergency records
or friends and relatives
The structure of the assessment interview as covering the following

areas:
● Biographical data
● Reason for admission
● Past medical history
● Family history
● The ability to meet daily living activities
● Any psychosocial factors that may affect health
● Physical assessment of vital signs
Biographical data
Start by checking biographical details. This should include the patient‟s
full name, address, telephone number, date of birth, age, marital status
and religion. A contact number of someone who can be called in an
emergency
Reason for admission

Use the patient‟s own words to explain his reason for admission to care.
To find out more use the PQRST frame work to direct your questions
P – Provocative or palliative. What helps or worsens the symptoms?

Do certain situations such as stress or particular physical positions
make a difference?
Q – Quality or Quantity. What does the symptom look, feel or sound
like? Is he experiencing it during the interview? How does it affect
his normal activities?
R – Region or Radiation. Where in the body does the symptom occur?
Is anywhere else affected by it?
S – Severity. How severe is this symptom on a range of 1 to 10 (10
being most severe)? Is it getting better, worse or staying the same?
T – Timing. When did it begin? Did it start gradually or suddenly? How
frequently does it happen? How long does it last?
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Past medical history

Past medical history is recorded in the medical notes, but it is important
for nursing staff to find out if there are any allergies to drugs current
medication or other substances. Previous operations and admissions
Family history
It is usual to find out whether any diseases such as coronary heart disease,
some types of cancer or blood disorders, high blood pressure or
diabetes are prevalent in the family
Procedure
Equipment
Appropriate assessment form- Pen- Non sterile gloves- Drape or sheet –
Gown – Penlight- blood pressure cuff – Sphygmomanometer –
Thermometer- Stethoscope - Watch with seconds – Scales- Measurement
tape- Cotton balls
Steps:
Action Rationale
1- Perform hand hygiene, and organize Reduces microorganism
equipment. transfer; promotes efficiency
2- Explain procedure to patient, Decreases anxiety; increases
emphasizing importance of accuracy of data compliance
3- Provide privacy. Decreases embarrassment
4-Taking a Health History
a- Interview client using therapeutic Provides baseline data
communication techniques
b-Biographic information (name, age, sex, Identifies client
race, marital status)
c- Chief complaint (as stated in client's own Explains what problem means
words) to client
d-History of present problem (date of onset; Defines details of problems;
detailed description of problem nature, helps determine nursing
location, severity, and duration, as well as diagnosis
associating, contributing, and precipitating
factors
e- Past medical and surgical history (date Serves as baseline and guide for
and description of problems, previous treatment decisions; identifies
hospitalizations, , allergies, current potential problems related to
medications taken and time of last dose) interactions
f- Family history of mental and physical Identifies hereditary factors that
conditions may affect health status
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g- Psychosocial history (occupation; Identifies psychosocial,

educational level; abuse of alcohol and spiritual, and educational
other substances; tobacco use; religious factors that may contribute to
preference; cultural practices) state of health
h- Nutritional information (diet, food likes Identifies nutritional factors
and dislikes, special requirements, related to state of health
compliance with diets
i- Review of body systems (client's self- Detects subjective cues that
report of conditions or problems may further define problem
5-Performing Physical Assessment
Assess general appearance Provides objective cues about

overall health state
Obtain vital signs, height, and weight Provides objective data about
health state
Assess the following in relation to Detects cues to abnormalities of
neuromuscular status: Level of neurologic or muscular status
consciousness: awake, alert, drowsy,
lethargic, stuporous, or comatose
Orientation: oriented to person, time, and
place or disoriented
Sensory function: able to distinguish
various sensations on skin surface (e.g.,
hot/cold, sharp/dull, and awareness of when
and where sensation occurred)
Motor function: muscle tone (as determined
by strength of extremities against
resistance), gait, coordination of hands and
feet, and reflex response
Range of motion
Structural abnormalities, such as burns,
scarring, spinal curvatures, bone spurs,
contractures
While proceeding from head to toe, inspect Detects skin abnormalities
skin of head, neck, and extremities
Note color, lesions, tears, abrasions, Provides baseline data for
ulcerations, scars, degree of moistness, comparison
edema, vascularity
Measure size of all abnormal lesions and
scars with tape measure
Palpate skin, lymph nodes, pulses, capillary Detects skin abnormalities and
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refill, and joints of head, neck, and lymph enlargement

extremities. Note temperature, turgor,
raised skin lesions, or lumps.
Lymph node tenderness and enlargement
Pulse quality, rhythm, and strength Determines quality and
character of pulses
Complete assessment of head and neck, Detects cues to
including eye, ear, nose, mouth, & throat pathophysiologic abnormalities
of eye, ear, nose, mouth, and
throat
Assess the eyes:
Note pupil status (size, shape, response to Assesses cranial nerve status
light and accommodation) and pupil structure and function
Test visual acuity. Using adequate lighting, Assesses visual acuity at a
have client stand 20 feet from chart (glasses distance
may be worn and should be noted in
documentation).
Assess condition of cornea and conjunctival Detects injury or other
sac. complication
Inspect for abrasions, discharge, and Detects injury, inflammation, or
discoloration infection
Assess the ears
Assess external ear structure (e.g., shape, Detects injury or other
presence of abnormalities on inspection and complication
palpation)
Test hearing acuity (ability of client to Detects hearing impairment
respond to normal sounds
Note presence of ear discharge and degree Detects infection or excess wax
of wax buildup
Assess the nose
Inspect external and internal structures Detects injury, infection,
obstruction, or other
complication
Note presence of unusual or excessive
discharge
Test ability to inhale and exhale through
each nostril.
Assess the mouth
Inspect for internal or external lesions Detects injury, inflammation, or
infection
Note color of mucous membranes
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Inspect for abnormalities of teeth.

Note any unusual odor.
Assess the throat
Inspect for swelling, inflammation, or Detects injury, inflammation, or
abnormal lesions infection
Test ability to swallow without difficulty
Inspect skin status of anterior and posterior Detects skin abnormalities
trunk and extremities, including feet.
Palpate chest, breasts, axillary and back.
Note raised lesions on any area and Detects abnormal masses and
tenderness on palpation. lesion
Inspect symmetry of breasts and nipples,
skin status, lymph nodes, and presence of
discharge, lumps, or nodules
Assess cardiac status
Note any unusual pulsations at precordium Detects cues related to
pathologic cardiac
abnormalities
Note character of first (S1) and second (S2)
heart sounds
Auscultate for the presence or absence of
third (S3) or fourth (S4) heart sounds.
Note presence of murmurs or rubs.
Assess respiratory status Determines if adventitious
breath sounds (rales, rhonchi, or
wheezes) are present, indicating
abnormal pathophysiologic
alterations
Note character of respirations and of
anterior and posterior breath sounds in the
following areas: Bronchial: over trachea
Bronchovesicular: on each side of sternum
between first and second intercostal spaces
Vesicular: peripheral areas of the chest
When auscultating breath sounds, use side- Increases possibility of
to-side sequence to compare breath sounds detecting abnormalities
on each side
Assess abdomen: Detects masses, abnormal fluid
retention, or decrease or
absence of peristalsis
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Remember: Perform auscultation BEFORE Palpation and percussion set

palpation and percussion of abdomen underlying structures in motion,
possibly interfering with
character of bowel sounds
Inspect size and contour
Auscultate for bowel sounds in all
quadrants
Palpate tone of abdomen and check for
underlying abnormalities (masses, pain,
tenderness) and bladder distention
Assess genitalia and urethra: Detects abnormalities of
Inspect for abnormalities in structure, genitalia and urethral opening
discoloration, edema, abnormal discharge,
or foul odor
Restore or discard equipment properly Removes microorganisms
Perform hand hygiene. Prevents spread of
microorganism
Documentation:
The following should be noted on the client's chart:
 Chief complaint
 Information from client history
 Detailed description of assessment area related to chief complaint
 Detailed description of abnormalities
 Reports of abnormal subjective and objective data (pain, nausea,
etc.)Priority areas of assessment
 Assessment procedures deferred to a later time
 Ability of client to assist with assessment
Assessment of the emergency patient
The scope of emergency nursing practice involves the assessment,

analysis, nursing diagnosis, outcome, identification, planning,
implementation of interventions, and evaluation of human responses to
perceived, actual or potential, sudden or urgent, physical or psychosocial
problems that are primarily episodic or acute
Emergency patient
Patient with serious problems and needs immediately or timely nursing
and medical intervention.
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Assessment
primary survey begins with an assessment of ABCD
Airway
• Assess for respiratory distress.
• Assess airway for patency.
• Check for loose teeth or foreign bodies.
• Assess for bleeding, vomitus, or edema
Breathing
• Assess ventilation.
• Scan chest for signs of breathing.
• Look for paradoxic movement of the chest wall during inspiration and
expiration.
• Note use of accessory muscles or abdominal muscles.
• Observe and count respiratory rate.
• Note color of nail beds, mucous membranes, skin.
• Auscultate lungs.
• Assess for jugular venous distention and position of trachea.
Circulation
• Check carotid or femoral pulse.
• Palpate pulse for quality and rate.
• Assess skin color, temperature, and moisture.
• Check capillary refill.
• Assess for external bleeding
• Measure blood pressure
Disability
Brief Neurologic Assessment
• Assess level of consciousness by determining response to verbal and/or
painful stimuli (e.g., AVPU, Glasgow Coma Scale).
• Assess pupils for size, shape, equality and reactivity
Brief Pain Assessment
• Assess pain (e.g., PQRST
Exposure and Environmental Control
• Assess full body for additional or related injuries
Secondary survey:-
 Obtain a full set of vitals including :RR,HR,BI.P and temperature
 Initiate cardiac monitoring
 Obtain continuous pulse oximetry reading
 Inserted NGT for stomach decompression if needs
 Obtain laboratory studies as toxicology, blood sugar ,electrolytes etc.
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Documentation Standards
1. Date and time of assessment

2. Nurse‟s name, chief complaint or presenting concerns
3. Limited subjective history: onset of injury/symptoms
4. Objective observation
5. Allergies, medications
6. Diagnostic, first aid measures, therapeutic interventions
7. Reassessment(s)
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Unit II
Respiratory System











 Oropharyngeal airway
 Laryngeal mask airway
 Endotracheal tube intubation
 Daily Endotracheal tube care
 Extubation and Decannulation
 Tracheal cuff care
 Administering oxygen therapy
 Arterial puncture for blood gases
 Incentive spirometer
 Endotracheal or tracheostomy tube suction
 Pulmonary function test
 Extra Corporeal Membrane Oxygenation
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Module Title: Oropharyngeal Airway

1. Clarify oropharyngeal airway.

2. Explore indications, cautions and complications of oropharyngeal
airway.
3. Predict contraindications of oropharyngeal airway.
4. Formulate patient preparation during oropharyngeal airway.
5. Apply nursing care of oropharyngeal airway.
6. Investigate complications of oropharyngeal airway.
Definition: An oropharyngeal airway: is a semicircular plastic or rubber

tube inserted into the back of the pharynx through the mouth.
Purpose: Protect the airway of an unconscious patient by preventing the

tongue from falling back against the posterior pharynx and blocking it.
Indication:
1. Improve ventilation to patient with a bag-mask device.
2. Facilitate suctioning an unconscious or semiconscious patient.
3. Using as a bite block with orally intubated patient.
4. Un conscious patient who don't have a gag reflex and are unable
to protect air way.
5. Patient is at risk of airway obstruction due to relaxed upper
airway muscles or blockage of the airway by the tongue.
Contraindications:
1. Conscious or semiconscious patient.
2. Loose teeth or recent oral surgery.
3. Incorrect placement of an oral airway may compress the tongue
and cause further obstruction.
4. An airway that is too small may push the tongue into the
oropharynx and cause an obstruction and air way that is too large
may obstruct the trachea.
Equipment:
 Oropharyngeal airway of appropriate size.
 Disposable gloves.
 Suction equipment.
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Procedure:
Steps Rational
1. Bring necessary equipment to the Conserves time and energy.
bedside stand or over bed table.
2. Assess LOC, oral secretions, lung

sounds, and dentures
3. Perform hand hygiene and wear Prevent the spread of
disposable gloves microorganisms.
4. Close curtains around bed and This ensures the patient‟s privacy.
close the door to the room, if
possible.
5. Explain procedure the patient Explanation alleviates fears.
6. Measure the oropharyngeal airway Ensures correct insertion and fit,
for correct size by holding the allowing for conformation of the
airway on the side of the patient‟s airway to the curvature of the
face .The airway should reach palate.
from opening of the mouth to the
back angle of the jaw.
7. Position patient in semi Fowler‟s Facilitates airway insertion.

position.
8. Suction patient, if necessary. Removes excess secretions.

9. Open patient‟s mouth by using This is done to advance the tip of
your thumb and index finger to the airway past the tongue, toward
gently pry teeth apart. Insert the the back of the throat.
airway with the curved tip pointing
up toward the roof of the mouth.
10. Rotate the airway 180 degrees. Allowing the patient to breathe
The tip should point down and the through and around the airway.
curvature should follow the
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contour of the roof of the mouth.
11. Ensure accurate placement and If the airway is placed correctly,

adequate ventilation by lung sounds should be audible and
auscultating breath sounds. equal in all lobes.
12. Position patient on his or her side Helps keep the tongue out of the
when airway is in place. posterior pharynx area.
13. Remove gloves. Perform hand Prevent the spread of
hygiene. And documentation microorganisms.
Care of the patient with oral airway:

Steps Rational
1-Wear gloves prevent contact with contaminants
and body fluids
2-Remove the airway every 4 hours Decreases secretion, oral infection.
to provide mouth care.
3-Assess the mouth and tongue for To prevent injury.
tissue irritation, tooth damage,
bleeding, and ulceration.
4-Suction secretions, as needed To remove secretions and establish
through the oropharyngeal airway. airway patency.
Complications
1. Trauma to lips, tongue,teeth,and oral mucosa.
2. Vomiting and aspiration.
3. Complete air way obstruction.
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Module Title: laryngeal mask airway (LMA)

1. Identify the indications for laryngeal mask airway.
2. Describe the contraindication for laryngeal mask airway.
3. Analyze the complication for laryngeal mask airway.
4. Prepare the equipment needed.
5. Insert the laryngeal mask airway.
6. Apply care for patient with laryngeal mask airway.
Laryngeal mask airway (LMA)
Definition:
A device for maintaining a patent airway without tracheal
intubation consists of two parts, the airway tube and the mask. It is
designed to provide an oval seal around the laryngeal inlet.
Types of LMA :
Four types of LMA devices are produced:
1. LMA Classic (a reusable LMA).
2. LMA Unique (a disposable LMA designed like the classic).
3. LMA Fastrach (designed to facilitate tracheal intubation with an
endotracheal tube).
4. LMA ProSeal: is a new Laryngeal Mask Airway with a modified
cuff designed to improve its seal and a drainage tube for gastric
tube placement. These features are designed to improve safety of
LMA and broaden its scope especially when used with positive
pressure ventilation. The maximum airway seal pressure will
vary between patients, but is on average 10 cm H2O higher than
LMA Classic or up to 30 cm H2O (7). However, it is more
difficult to insert as the LMA, unless an introducer tool is used.
19
Indications:
1. Elective ventilation: The laryngeal mask airway (LMA) is an

acceptable alternative to mask anesthesia in the operating room. It is
often used for short procedures when endotracheal intubation is not
necessary.
2. Difficult airway: After failed intubation, the LMA can be used as a
rescue device.
3. Cardiac arrest: The 2005 American Heart Association guidelines
indicate the LMA as an acceptable alternative to intubation for airway
management in the cardiac arrest patient. This may be particularly
useful in the prehospital setting, where emergency medical
technicians typically have less experience with intubation.
4. Conduit for intubation: The LMA can be used as a conduit for

intubation, particularly when direct laryngoscopy is unsuccessful. An
ETT can be passed directly through the LMA.
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Contraindications and cautions:

1. Absolute contraindications :
a. Cannot open mouth
b. Complete upper airway obstruction
2. Relative contraindications :
a. Increased risk of aspiration: Prolonged bag-valve-mask
ventilation, morbid obesity and upper gastrointestinal bleed
b. Suspected or known abnormalities in supraglottic anatomy
Laryngeal Mask Airway Size Based on Patient Weight and cuff

inflation volumes:
Weight, kg Mask Size Max Cuff Volume, mL

<5 1 4
5-10 1.5 7
10-20 2 10
20-30 2.5 14
30-50 3 20
50-70 4 30
70-100 5 40
>100 6 50
Equipment:
LMA - Water-soluble lubricant – Syringe - suction system - Oxygen
source and connecting tubing - Tape or securing device.
Procedure:
Steps Rational
1. Wash hands and wears glove. -To reduce transmission of
microorganisms.
Patient preparation:
2. Preoxygenate the patient with bag-
mask ventilation.
3. If necessary, administer sedation, as -the patient would be nonresponsive
prescribed. Deep sedation or an and apneic without assisted ventilation
unconscious state is required for before the LMA insertion.
LMA use.
4. Ensure that suction equipment is -the patient may regurgitate during the
assembled and in working order insertion or while the LMA is in place
21
and require oropharyngeal or tracheal

suctioning.
5. Place the patient's head in "sniffing" -facilitates smooth insertion.
position (the patient with the head
extended and the neck flexed
(except in patients with potential
cervical spine injury).
6. Inflate the cuff to check for leaks - ensure that the device is not defective
and deflate it to form a spoon and will work as indicated and
shape facilitates smooth insertion.
7. Coat the posterior surface of the -facilitates smooth insertion.

LMA with a water-soluble
lubricant.
8. Grasp the LMA by positioning your - facilitates proper device position for
index finger in the crease between insertion
the airway tube and the laryngeal
mask.
9. Insert the LMA with the cuff tip

gliding against the posterior
pharyngeal wall.
10. Using your index finger to push the

LMA, apply slight backward
(toward the ears) pressure and
follow the anatomic curve.
22
11. Advance the mask until resistance

is noted at the hypopharynx
12. Remove the index finger while
applying slight pressure to the
airway tube for the prevention of
dislocation
13. Inflate the cuff with air; the

volume varies with the LMA size.
During inflation, release the LMA
to ensure that placement is
maintained as
the cuff expands.
14. Assess the LMA placement. The -Ensures correct placement and inflation
following signs indicate an of the cuff.
appropriate placement:
a.A slight outward movement of the
airway tube with cuff inflation
b.A slight swelling at the cricoid
region
c.No visible cuff in the oral cavity
d.Equal bilateral breath sounds and
chest rise and fall
e.Pulse oximetry readings that
indicate adequate oxygenation
15. Ventilate the patient with a bag-
valve and supplemental oxygen.
16. Secure the LMA with tape or a
securing device; a bite block may
be used
Complications:
1. Air leak
2. Laryngospasm
3. Desaturation
4. Severe hypercarbia
5. Regurgitation, aspiration
6. Sore throat
7. Laryngeal hematoma
8. Hypoglossal nerve injury
23
Module Title: Endotracheal Tube intubation

1. Define endotracheal intubation
2. Know purpose, indication and complications of endotracheal tube.
3. Explain advantages of ETT
4. Describe contraindications of ETT
5. Select the optimum size of endotracheal tube
6. Prepare the patients for endotracheal tube insertion.
7. Perform nursing care of endotracheal tube.
8. Collect equipment needed for tube insertion
Definition of Endotracheal intubation

It refers to inserting a tube directly into the trachea through the nose
(nasotracheal) or mouth (orotracheal).
Definition of ETT
It is a flexible plastic curved tube inserted through nose or mouth to the
trachea.
What Size Endotracheal Tube?

 Adult male 7.5-8.5
 Adult female 6.5-7.5
 Pediatric 4 + AGE/4
ETT Depth of insertion

Proper tube placement, which is about 2 to 3 cm above the carina.
Indications for Intubation

 Inadequate oxygenation (decreased arterial PO2) that is not corrected
by supplemental oxygen via mask/nasal.
 Need to control and remove pulmonary secretions.
 Pulmonary impairment (acute respiratory failure , COPD,..)
 Cardiovascular impairment (Ex: cardiac arrest )
 Neurological impairment (myasthenia gravies, poisoning)
 Any patient in deep coma who cannot protect his airway (Gag reflex
absent.).
 Any patient in imminent danger of upper airway obstruction (e.g.
Burns of the upper airways).
 Any patient with decreased GCS ≤ 8
 During general anesthesia.
24
Equipment:
- Endotracheal tubes with different size
- Stylet: flexible instrument inserted into the ETT to stiffen it to help
direct insertion of tube to the glottic opening and avoid laryngeal
trauma.
- Local anesthetic jelly (for nasal approach)
- Magill forceps (to remove foreign bodies obstructing airway).
- Laryngoscope with fresh batteries and blades curved or straight.
- Manual resuscitation bag with mask connected to oxygen source.
- Oxygen source and connecting tubes.
- Syringe for cuff inflation
- Portable suction apparatus (ready with different catheter size for
suction).
- Lubricating agent (K-Y jelly).
- Oropharyngeal airway.
- Endotracheal tube securing apparatus or adhesive tape.
- Sedative agent for intubation of combative patient (as valium).
- Stethoscope.
- Pulse oximeter to monitor oxygen saturation.
Procedure
Steps Rationale
Assessment Patient:
1. Assess the level of conscious, - To determine the need for
anxiety, respiratory difficulty sedation or paralytic agents.
2. History of trauma when spinal -To allow for selection of the

cord injury is suspected most appropriate method for
intubation.
3. Need for pre-medications. -To allow for sedation, paralysis
of agitated patient.
Preparation Patient:
4. Explain the procedure and -To enhance patient understanding
reason for intubation. and to decrease anxiety.
-To be readily available for
5. Initiate intravenous access patient‟s need for any medications
before intubation and give and to allow more controlled
Premeditation as doctor order intubation.
-To allow for visualization of
6. Position the patient larynx and vocal cords.
25
appropriately: -To prevent secondary injury if

 For non-trauma patient: Place cervical cord injury is present.
the patient in hyperextension
position (sniffing position)
 For trauma patient: Maintain in-
fixed position (Jaw thrust
maneuver)
Nurse:
1. Wash hand
2. Wear gloves, mask
Steps:
3. Insert oropharyngeal airway (only -To assist in maintaining upper
in unconscious patient). airway patency.
4. Set up suction apparatus. -To prepare for oropharyngeal
5. Remove dentures if present. And suction as needed.
Suction the mouth as needed. -To allow visualization of vocal
6. Preoxygenate by 100% oxygen cords by aligning the three axes of
for 3 to 5 minutes providing the mouth, pharynx, and trachea.
frequent To prevent hypoxemia.
7. Assist the physician during
insertion as required
8. The tongue should be swept to
one side & the laryngoscope
should be lubricated by normal
saline  To prevent teeth fracture
9. Visualize the vocal cords and
larynx
10. Place ETT through the cord
11. Attempt ventilation through the
ETT
12. Check the correct position of the

tube -To adjust cuff pressure.
13. Inflate the cuff with the minimal
amount of air required to
occlude the trachea.
14. Confirm tube placement while -To assist in verification of correct
bagging with 100% oxygen once tube placement in the trachea
the endotracheal tube has been -To minimize risk of right bronchus
placed. intubation.
 Observe for symmetric chest
26
wall movement and any signs

of respiratory distress -To allow for identification of
 Auscultate lung bases and esophageal intubation.
apices for bilateral breath
sounds.
 Auscultate over epigastrium (if
air movement or gurgling is
heard)
15. Evaluate oxygen saturation
(SpO2)
16. Connect endotracheal tube to
oxygen source or mechanical
ventilator -
17. Record the distance from
proximal end of tube to the point
where tube reaches the teeth.
18. Secure tube to the patient‟s face
with adhesive tape.
19. Reconfirm tube placement: Note
the distance from proximal end
of tube to the point where tube
reaches the teeth. (Common tube
placement is 21cm for women
and 23 cm for men in patients
with normal weight and height).
20. Verify confirmation of correct
tube position by chest x-ray.
21. Maintain tube cuff pressure at 20
to 25 mmHg.
22. Hyperoxygenate and suction
endotracheal tube as needed.
23. Inspect nares or oral cavity once
per shift while the patient is
intubated.
Reporting and recording:
24. Report the following conditions
if they persist despite nursing
interventions:
 Absent or unequal breath
sounds,
 Cuff pressure ≤ 20 to 25
mmHg
27
 Inability to pass a suction

catheter
 frothy, or bloody secretions
 Significant change in the
amount or character of
secretions
 Redness, necrosis, or skin
breakdown
25. Record the following
 Vital signs before, during and
after intubation,
 Oxygen saturation.
 Type of intubation ( oral or
nasal)
 Use of any medications
 Size of endotracheal tube,
 Depth of endotracheal tube
insertion
 Measurement of cuff pressure
Immediate post intubation care:
1. Check vital signs every 15- 20
min until they are stable
2. Observe for signs of hypoxemia,
nasal bleeding, tooth avulsion
3. ABG drawn from 10-20 minutes
4. Frequent check for signs of right
bronchus intubation
 Decreased chest expansion
 Decreased breath sounds over
the left side
Complications
 Insertion trauma: trauma of the teeth, cords, larynx and
related structures.
 Transient cardiac arrhythmias.
 Hypoxia
 Aspiration
 Intubation of esophagus or right bronchus
28
Module Title:-Endotracheal tube care

1. Explain purpose of endotracheal tube care.
2. compose equipment used to perform ETT care
3. Prepare the patients for endotracheal tube care.
4. Perform nursing care of endotracheal tube.
5. arrange equipment for tracheal tube care
Purpose
1. Maintain patent airway and remove secretion
2. Monitor Cuff pressure.
3. Maintain correct tube placement.
4. Promote ventilation and oxygenation.
5. Provide oral hygiene.
6. Prevent tracheal tube trauma from tube or cuff.
7. Prevent unintended extubation.
8. ETT stabilization/repositioning.
9. Minimize skin breakdown.
Equipment
1. Tracheal suction equipment
2. Oral care equipment
3. Personal protective equipment's
4. Bite block or oral airway if needed
5. Adhesive or twill tape
6. Manual resuscitation bag connected to an oxygen flow meter, at
15 L/min ( not required if using the ventilator to deliver
hyperoxygenatin breaths)
7. Stethoscope
8. Cuff manometer
9. Syringe
29
Procedure
Steps Rationale
Assessment Patient:
1. Assess level of consciousness and level
of anxiety
2. Needs for endotracheal tube care
including:
 Excessive oral or tracheal secretions
 Soiled ties or tape
 Loose ties or tape
 Patient biting or kinking tube.
 Pressure areas on nares, lips, corner
of the mouth or tongue
 Tube repositioned by physician or
other specially trained personnel
 Foul smelling mouth
3. Explain procedure to the patient -To assist with care by eliciting patient
including purpose of ETT care cooperation
4. Assist the patient to a position that is
comfortable for the patient and nurse, -To promote comfort, oxygen-nation,
(semi-fowler or fowler) and ventilation and reduce strain.
Nurse: -To reduce transmission of
5. Wash hands & wear personal protective microorganisms and body secretions.
equipment
Steps:
Daily ETT care:
6. Ensure that ETT is connected to the -To decrease pressure exerted by
ventilator using a swivel adapter. ventilator tubing on the ETT, thereby
minimizing risk of pressure laceration
7. listen the air entry, breath sound and air -To monitor tube placement and
leak at least 2- 4 hours Patency
8. Loosen and remove old tape and Ties - prevent pressure and skin breakdown.
9. Clean around ETT using saline- soaked
gauze of cotton swabs.
10. Hyperoxygenate , suction ETT and - To remove secretions that may
pharynx as needed and perform chest obstruct
physiotherapy.
30
11. Perform oral hygiene, using tooth -To maintain patent airway.
brush and mouth wash , Assess oral -To prevent or minimize pressure areas
cavity and lips and perform oral care on lips, tongue, and oral cavity.
every 2hours or as needed
12. Monitor amount, type and color of
secretions.
13. Monitor for nasal drainage if patient is
nasally intubated.
14. Move oral tube to other side of the - To prevent skin breakdown
mouth. Replace bite block or
oropharyngeal airway along the ETT.
15. Retape or secure ETT every 24 hours
and as needed for soiled or loose -To ensure secured tube
securing devices.
16. Reconfirm tube placement, and note -To decrease risk of aspiration, to
naris ensure airflow to lungs rather than to
stomach.
17. Secure the tube in place with adhesive -To prevent inadvertent dislodgment of
tape, or specially manufactured tube the tube.
holder)
18. Reporting and Documentation
Report
 Inability to pass suction catheter
 Change in quantity or characteristics
of secretions
 Purulent drainage
 Breakdown of lips, tongue, or oral
cavity
 Presence of mouth sores
 Tube moving in and out of mouth.
19. Record:
 Characteristics of secretions
 Presence of nasal drainage
 Repositioning of ETT
 Mouth care
 Condition of lips, mouth, and tongue.
 Presence of cuff leak
 Amount of air used to inflate cuff
 Centimeter mark on ETT
31
Module Title: Tracheal cuff care

1. Explain purpose and technique of tube cuff care.
2. Recognize the normal tracheal tube cuff pressure.
3. Illustrate purpose of tracheal tube cuff care.
4. Choose the optimum cuff pressure.
5. Conclude devises used to measures tracheal tube cuff pressure.
6. Perform adjustment the cuff pressure
7. Prepare equipment for tracheal tube cuff
8. Create optimum tube cuff
Purposes
1. To prevent major pulmonary aspiration
2. To prepare for tracheal extubation
3. To decrease the risk of unintended extubation
4. To provide a patent airway for ventilation and removal of
secretions
5. To provide a closed system with endotracheal tube or
tracheostomy for mechanical ventilation.
6. To allow desired tidal volume to deliver to lungs.
7. To protect the patient‟s lower respiratory tract from secretions or
gastric contents that may accumulate in the pharynx.
Devices used to measure cuff pressure
1. Bedside sphygmomanometers
2. Special cuff manometers
3. Electronic cuff pressure devices
Techniques used to measure cuff pressure

1- Minimum leak volume (MLV)
It involves air inflation of the tube cuff until any leak stops, and then a
small amount of air is slowly removed until the leak is observed at peak
inflation pressure
2- Minimum occlusion volume (MOV):

It involves Removal of all air in tube cuff (deflation)and then
gradual inflation of cuff until any airflow heard escaping around
the cuff during positive pressure breath ceases.
Equipment
 10 ml syringe  Tongue depressor
 Pressure manometer  Tape
 Three-way stopcock  Suction supplies
32
 Stethoscope  Reintubatoin equipments in case

 Manual resuscitation bag of accidental extubation
Procedure
Steps Rational
1. Assess for the presence of -To assist in verifying tube
bilateral breath sounds signs placement.
and symptoms of cuff leakage,
Audible or auscultated
inspiratory leak over larynx
2. Explain the procedure to
patient
3. Place the patient in semi-
fowler position.
4. Wash hands and wear PPE. -To reduce transmission of
microorganisms and body
secretions.
5. Hyperoxygenate and suction -To reduce transmission of
tracheobronchial tree and microorganisms and body secretions
pharynx before cuff deflation
MOV technique: - To assess tube opening
6. Deflate cuff while applying
positive pressure
7. Insert air-filled 10ml syringe -To clear secretions in the lower
tip into inflating tube valve. airway and decrease incidence of
aspiration.
8. Inject air slowly on inhalation -To provide a pathway between air
until sounds of air movement source and cuff.
cease over larynx on
auscultation.
9. Apply positive pressure with
manual resuscitation bag.
MLV technique: -To indicate that the cuff is sealed
10. Place a stethoscope over against the tracheal mucosal wall.
larynx.
11. Withdraw air slowly from the
cuff until a small leak is heard
by auscultation on inspiration.
12. Remove syringe tip, check
inflation of pilot balloon.
Cuff Manometer Gauge
13. Connect pilot balloon of ETT
33
with device connector and

pressure displayed
14. High pressure is adjusted by:
15. Deflate air by pressing the
release mechanism.
16. Low pressure is adjusted by
squeezing the bulb to increase
pressure
17. Check and secure ventilator -To indicate air escaping through the
connections as needed. larynx (auscultation of air
movement)
18. Measure cuff pressure every 8 -To indicate air placement into cuff
to 12 hours, maintaining cuff (a firm pilot balloon)
pressure between 20 and 25
mm
19. Report any abnormal condition
20. Document the procedure
Note :
Normal cuff pressure
25-30 CmH2O = 20-25 mmhg
34
Module Title: Extubation and Decannulation

Objectives based on competence:-
1. Compare definitions of extubation or decannulation.
2. List indications of extubation or decannulation.
3. Know the needed Equipment for extubation and decannulation
4. Conclude equipment used to make extubation and decannulation
5. Prepare the patients for extubation or decannulation .
6. apply procedure of decannulation of extubation.
Definitions
 Extubation refers to the removal of an endotracheal tube.
 Decannulation refers to the removal of a tracheostomy tube.
Indications
1. When the underlying causes of intubation are improved.
2. When the patient is able to clear pulmonary secretions
3. When mechanical ventilator support is no longer needed.
Equipment
Suctioning equipment - Sterile suction catheter-Manual resuscitation bag
connected to 100% oxygen source – Scissor - Endotracheal intubation
supplies – Stethoscope – suctioning catheter - Sterile gloves - Sterile
dressing for tracheal stoma - 10 ml syringe - Emergency cart
Procedure:
Steps Rationale
Assessment Patient:
1. Assess the level of -To identify that intubation is no
consciousness, signs and longer necessary.
symptoms associated with
independent breathing
 Stable respiratory rate of<
25breaths per minute -To ensure successful airway
 Absence of dyspnea, Absence of management following extubation.
accessory muscle use,
Spontaneous tidal volume ≥
5ml/kg, FiO2 ≤ 50%, pulse and
35
blood pressure..
2. Assess patient‟s ability to cough
and clear secretions.
3. Explain procedure to the patient. - To encourage cooperation and
4. Place the patient in semi-fowler minimize anxiety.
position - To help to decrease hoarseness
and liquefy secretions.
- To facilitate coughing and
minimize the risk of vomiting
and consequent aspiration.
- To reduce transmission of
Nurse: microorganisms and body
5. Wash hands. secretions.
6. Wear personal protective
equipment
Decannulation steps
7. Hyperoxygenate and suction - To clear secretions, including
ETT and pharynx. those above the cuff.
8. Remove tape to free tube. - To remove means for securing
9. Instruct to deep breathe and above the cuff and promote
inflate the lungs using self- hyperinflation
inflating resuscitation bag. - To provide reassurance and
10. Monitor and support the possibly distraction as patient
patient while the tube is being experiences removal of the tube
removed. - To promote hyperinflation to
help to remove secretions
11. Encourage the patient to deep - To remove secretions.
breathe and cough. - To promote warmth and moisture
12. Suction the pharynx and prevent oxygen desaturation
13. Apply supplemental oxygen - To contain secretions that leak
and aerosol, as appropriate. out of stoma..
14. Place a dry, sterile gauze

dressing over stoma when
36
tracheostomy tube is removed.

Documentation:
15. Report these conditions if they
persist despite nursing
interventions:
 Tachycardia, dyspnea, stridor
 Chest abdominal
dysynchrony
 SpO2 ≤ 90%
 Patient unable to handle
secretions
 Ineffective cough
 Inability to swallow.
Post Decannulation monitoring

and care -To decrease incidence of oxygen
1. Give heated humidity and desaturation immediately following
oxygen by face mask and extubation.
maintain the patient in a sitting
or high Fowler‟s position. -To prevent atelectasis and
2. Monitor respiratory rate and secretions accumulation
quality of chest excursions.
3. Note stridor, color change, and
change in mental alertness
4. Monitor the patient‟s oxygen
level using a pulse oximetery.
5. Keep NPO or give only ice chips
for next few hours.
6. Provide mouth care.
7. Teach patient how to perform
coughing and deep breathing
exercises.
8. Assess swallowing ability
37
Module Title: Administering Oxygen therapy

1. Define oxygen therapy.
2. Analyze indications, contraindications, cautions and complications
of oxygen therapy.
3. Identify different methods of oxygen therapy.
4. Apply different methods of oxygen therapy.
5. Apply nursing care of oxygen therapy.
Definition
Oxygen therapy is the administration of oxygen at a concentration greater
than that found in the environmental atmosphere.
Indication
 Hypoxemia (deficiency of oxygen in blood)
 Hypoxia (deficiency of oxygen in tissue) related to:
 Sever trauma
 Severe respiratory distress(e.g. acute asthma or pneumonia)
 Post-anesthesia recovery
 Pulmonary hypertension
 Increased work of breathing
 Acute myocardial infarction
Contraindications and caution:

1. Oxygen-induced hypoventilation, from suppression of the hypoxic
respirator drive, may occur in a small set of patient as COPD.
2. A significant physical hazard of O2 therapy is fire.
3. Absorption atelectasis may occur with use of high concentrations of
O2.
4. Exposure of lung tissue to high O2 concentrations can lead to
pathologic changes in the tissue.
5. Oxygen masks may impede care in patients with facial burns or
trauma or who need frequent nursing care to the facial area.
6. Aspiration is a potential hazard when an O2 delivery mask is in use.
7. The tight seal of the mask may be uncomfortable and irritating to the
skin.
8. Skin irritation from pressure exerted by the device or reactions to the
materials of which the device is made
9. Nasal obstruction, especially in infants and children-
38
Types of oxygen therapy:

A-low flow system
Device Advantages Disadvantages
1-Nasal cannula:  Well tolerated and  Pressure sores
comfortable around nose and
 LowO2
ears.
concentrations 
 Decreased
 delivered24% to  Patient may eat and drink effectiveness with
44% FiO2 on 1-6 without removing mouth breathing
L/min flow  Light  May dry and
irritate nasal
 Economical mucosa
 Easy to apply
2-Simple mask  Simple and light weight  Insufficient O2

may be used with humidity flow may lead to
 Low
rebreathing Of
O2concentrations  Effective for mouth
CO2.
are delivered breathers or those with nasal
 Limits access to
35%to55% FiO2 obstruction.
face for coughing,
on 6 to12 L/min  Inexpensive. eating, drinking,
Flow .
 Easy to apply. blowing nose, and
delivery of oral
 Disposable. and facial nursing
care
 Aspiration of
vomitus possible
difficulty with
fitting when a
gastric tube is
present
 May cause drying
of eyes
39
3-Partial  FiO2 if greater than 60% at  Insufficient O2

rebreathing mask 6L is delivered for treatment flow may lead to
 Portion of exhaled of moderate to severe rebreathing Of
breath enters the hypoxia CO2.
 Limits access to
reservoir bag to be
face for coughing,
rebreathed with eating, drinking,
incoming 100%o2 blowing nose, and
in the next breath delivery of oral and
 Flows must be facial nursing
adjusted so that  Aspiration of
vomitus.
the reservoir bag
 Eye irritation.
doesn'tcompletely
collapse during
inspiration:
otherwise co2
retention may
occur
4-Non rebreathing  Highest FiO2 delivery for a  Limits access to
mask non-intubated patient face for coughing,
 One way valve eating, drinking,
 Suitable for spontanouslly
between the blowing nose, and
breathing patients with
reservoir bag and delivery of oral
severe hypoxia.
mask prevents and facial nursing
rebreathing from  Aspiration of
the 100% O2 gas vomitus.
source.  Possible difficulty
with fitting when
 Delivers an FiO2
a gastric tube is
of 80% or greater
present may cause
on 10-15 L/min
drying of eyes
 Flows must be possible sticking
adjusted so that of valves.
the reservoir bag
must not collapse
during inspiration
40
B-High flow system
Device Advantages Disadvantages
1- Air Entrainment mask  Precise control of FiO2  Limits access

(venturi mask or venti to face for
 Useful in patients with
mask) coughing,
COPD where excessive
 Provides FiO2 of 24% O2 delivery may eating,
to60% on 2to15L/min suppress respiratory drinking,
drive blowing nose,
 FiO2 changed by and delivery
adjusting the air  Doesn't dry mucous of oral and
entrainment port and O2 membrane. facial nursing
flow rate (per directions  Aspiratio
on each device) n of
vomitus.
 Uncomfor
table.
 Risk for
skin
irritation.
 Expensive
.
2-CPAP mask deliver 80-

100%
3-MV (mechanical
ventilation) deliver up to
100%
41
4-oxygen therapy via

endotracheal tube or
trachestomy
5-face tent
6-Hyperbaric oxygen
therapy (administered in
12or more patient) at
pressure greater than
1atmosphere
7-Transtracheal catheter
60-100%
8-Tracheostomy collar
30-100%
9-High flow nasal

cannula(HFNC):
Is used to deliver oxygen,
the flow rates are much
higher than can be achieved
with traditional nasal
cannula.
42
Equipment
1. Appropriate O2 delivery device.
2. Oxygen delivery system (extra tubing, connectors)
3. Flow meter or regulator.
4. Oxygen source (O2 tank or wall delivery system).
5. Humidification delivery adjunct (used only in select patients)
Patient Preparation
1. Explain strict no smoking instructions to the patient and all visitors.
2. When not contraindicated, allow the patient to assume a position of
comfort.
Procedure:
Steps Rationale
1. Review chart for physician's order -Prevents potential errors
for oxygen to ensure that it includes
method of delivery, flow rate,
duration of therapy; identify client.
2. Wash your hands. -To reduces transmission of micro-
organisms.
3. Identify client, Explain procedure -Teaching helps ensure compliance
and inform client concerning safety with therapy.
precautions associated with oxygen
use.
4. Assist client to semi or high -These positions facilitate optimal
Fowler's position, if tolerated. lung expansion.
5. Insert flow meter into wall outlet. If - Oxygen in high concentrations can
using a high O2 flow, attach be drying to the mucosa.
humidifier.
6. Turn on at the prescribed rate. - Oxygen must be administered as

Check that oxygen is flowing prescribed.
through tubing.
43
7. Cannula. -Proper placement in nares provide

a. Place cannula prongs into nares. accurate administration
b. Wrap tubing over and behind ears.
c. Adjust plastic slide under chin until -To ensure correct oxygen delivery
cannula fits snugly and prevent hypoxemia.
d. If prong dislodge from nares,
replace promptly.
8. Mask. - When the mask fits the face
a. Place mask on face, applying from properly, little oxygen escapes.
the nose and over the chin.
b. Adjust the metal rim over the nose
and contour the mask to the face. - Client is more likely to comply with
c. Adjust elastic band around head so therapy if equipment fits comfortably.
mask fits snugly.
9. Assess for proper functioning of - Assessment of vital signs, oxygen
equipment and observe client's saturation, color, and breathing
initial response to therapy. pattern,
10. Monitor continuous therapy by - Permit early detection of skin
assessing for pressure areas on the breakdown or inadequate flow rate.
skin and nares every 2 hours and
rechecking flow rate every 4 co 8
hours.
11. Document procedure and - Maintains legal record and
observations. communicates with healthcare team
members
Complications of oxygen therapy:
1. Oxygen induced hypoventilation
2. Atelectasis
3. Retrolental fibroplasias
4. Oxygen toxicity such as(vomiting-coughing-asphyxia-dyspnea-
malaise-hyperoxemia and paresthesias)
5. Nasal obstruction
6. Aspiration
7. Drying of nasal and pharyngeal mucosa
8. Depression of ventilation.
9. Hyperbaric oxygen toxicity.
10. Fire hazard.
11. Pulmonary toxicity.
44
Module Title: Arterial puncture for blood gas analysis.

1. Detailed purposes of arterial puncture
2. Found the sites which may be used for arterial puncture
3. Perform an Allen‟s Test.
4. Skilled the appropriate technique for obtaining an arterial
blood gas samples
5. Memorize normal values for pH, PaO2, PaCO2, SaO2 and
HCO3.
6. Analyze the results of various arterial blood gas samples.
Definition:
Blood is drawn an aerobically from a peripheral artery (radial,
brachial, femoral, or dorsalis pedis) via a single percutaneous needle
puncture for analysis.
Purposes
1. To evaluate the adequacy of lung ventilation through (PaCO2) partial
pressure of carbon dioxide, (PaO2) partial pressure of oxygen, acid-
base balance (pH), and oxygenation status (PaO2 & SaO2).
2. To quantities the patient's response to therapeutic intervention and/ or
diagnostic evaluation (eg, oxygen therapy).
3. To monitor severity and progression of a documented disease process
(eg, metabolic diseases).
Contraindications:
1.Negative results of Allen test (collateral circulation test) are indicative
of inadequate blood supply to the hand.
2.Patient with severe injury to the extremities.
3.Patient with a surgical shunt (eg, as in a dialysis patient)
4.Patient with atherosclerosis
5.Skin infection because of the risks of inoculating the blood with
bacteria.
Arterial puncture sites:

1. Radial artery.
2. Ulnar artery
3. Brachial artery at the antecubital fossa.
4. Femoral artery just below the inguinal ligament
45
Anatomic landmarks locating the radial and brachial arteries
Equipment:
 Gloves.  Heparinized arterial blood gas
syringe.
 Small pillow or rolled towel.  Alcohol swabs.
 Providine iodine swabs  Local anesthetic.(lidocaine)
(betadine).
 Plastic syringe.  Gauze.
 Tape.  Bag of ice for transport to lab.
 Patient label (put on syringe prior to putting in ice bag).
Allen test for collateral flow:

The most common site for arterial puncture is the radial artery at
the wrist. Because of the potential for formation of an obstructing
thrombus in the artery after puncture it is recommended that the operator
demonstrate the presence of good collateral flow through the ulnar artery
prior to proceeding.
46
Steps:
1. Elevate the patient's hands and arm several seconds.
2. Ask the patient to make a fist several times. If unconscious elevate
patient's hand above heart and squeeze or compress hand until
blanching occurs.
3. Occludes the radial and ulnar artery at the wrist by using your thumbs
(or index and middle fingers).
4. While maintaining pressure over the arteries, ask the patient to open
the fist and relax the hand, which should show a "blanched" hand.
5. Releases the pressure on the ulnar artery and the hand is observed for
"blushing".
6. If the color of the hand does not return in 5-10 seconds the arterial
puncture should not be attempt at that site.
N.B In case of ulnar arterial puncture the test is repeated, but this time
the radial artery is released while the ulnar artery remains compressed
(inverse modified Allen test).
Steps Rationale
Preparatory phase
1. Assess factors that influence ABG
measurement including; anxiety, and
suctioning.
2. Record patient inspired oxygen concentration. Changes in inspired O2
concentration alter the change
in PaO2.
3. Assess patient's temperature. Hyperthermia and hypothermia
influence oxygen release from
hemoglobin.
4. Heparinize the 2ml syringe:
 Withdraw heparin into the syringe to wet the To prevent blood from clotting.
plunger and fill dead space in the needle.
 Hold syringe in an upright position and expel
excess heparin and air bubbles Air/ heparin may affect
measurements of PaO2/ pH.
Performance phase
5. wash hands
6. Wear gloves.
7. Palpate radial, brachial or femoral artery
8. If puncture the redial artery, perform Allen To assess collateral circulation.
test.
9. For the radial side, place a small towel roll Moves artery closer to the skin
under the patient's wrist. surface and making the artery
47
easier palpable.
10. For brachial artery, hyperextend the arm and Increase accessibility for
lace it over a rolled towel. Rotate the patient's puncture.
wrist outward.
11. For femoral artery, rotate the leg slightly Provide best position for
outward in supine position. locating the femoral pulse.
12. Cleanse selected site in circular motion To decrease risk of local
outward with betadine & allow drying. infection or systemic sepsis.
13. Cleanse site with alcohol swab & allow - To remove iodine coloring.
drying.
14. Local anesthesia may be used. - To minimizing discomfort.
15. Feel along the course of radial artery and
palpate for maximum pulsation with the
middle and index fingers.
16. Angle of needle 45 to 60 degree to the skin
surface to advance into the artery. Once the
artery is punctured, arterial pressure will push
up the hub of the syringe and a pulsating flow
of blood will fill the syringe.
17. After blood is obtained, withdraw needle and Bleeding can occur because of
apply firm pressure over the puncture for 5 pressure in the artery.
minutes or until bleeding stops with a dry
sponge. If bleeding persists, place ice pack
over site and continue firm pressure.
18. Remove air bubbles from syringe and needle. -To prevents room air from
Seal needle or tip of syringe immediately. mixing with the blood
specimen.
19. Roll the syringe gently between both hands. - To prevent clot formation.
20. Label specimen, and send to laboratory
immediately.
21. Dispose of gloves and supplies in appropriate
receptacle
22. Wash hands
23. Documentation: - Serve as a legal medical
 O2therapy record of the events.
 Body temperature
 Puncture site
 Result of Allen's test
 Post puncture site care
 ABG results
48
Complaints & complications:

1. Pain. 2. Arteriospasm.
3. Anaphylaxis from local 4. Hemorrhage.
anesthetic.
5. Trauma to vessels. 6. Arterial occlusion
7. Hematoma.
8. Less common but important complications are thrombus in the artery
and infection at the site
.
. Expected ABG Outcomes
- PH: - Power of hydrogen ion
Hydrogen ion concentration of blood is an indicator of Acid-Base status.
PH 7.35-7.45
↓ PH acidosis
↑ PH alkalosis
- PaCO2:- the partial pressure of carbon dioxide in the arterial blood.
PaCO2 35-45 mmHg
↓ PaCO2 respiratory alkalosis
↑ PaCO2 respiratory acidosis
- HCO3:- the serum bicarbonate, which is the major component of the
renal compensatory mechanism.
HCO3 22- 26 mEq/L
↓ HCO3 metabolic acidosis
↑ HCO3 metabolic alkalosis
- SaO2:-the saturation of hemoglobin by oxygen
SaO2: 95- 99%
- BE: - base excess reflects an increase or decrease in total buffer base.
BE: - -2 to +2 mEq/L
↓ BE metabolic acidosis
↑ BE metabolic alkalosis
- PaO2:- the partial pressure of oxygen in the arterial blood
PaO2:-80-100 mmHg
ABG interpretation
Respiratory acidosis
Compensation PH PaCO2 HCO3
1. Uncompensated resp. acidosis (acute) ↓ ↑ N
2. Partially compensated resp. acidosis ↓ ↑ ↑
3. Full compensated resp. acidosis N ↑ ↑
49
Respiratory alkalosis
1. Uncompensated resp. alkalosis ↑ ↓ N
2. Partially compensated resp. alkalosis ↑ ↓ ↓
3. Full compensated resp. alkalosis N ↓ ↓
Metabolic acidosis
1. Uncompensated metabolic acidosis ↓ N ↓
2. Partially compensated metabolic acidosis ↓ ↓ ↓
3. Full compensated metabolic acidosis N ↓ ↓
Metabolic alkalosis
1. Uncompensated metabolic alkalosis ↑ N ↑
2. Partially compensated metabolic alkalosis ↑ ↑ ↑
3. Full compensated metabolic alkalosis N ↑ ↑
Practical exercises:
1. An anxious Patient and hyperventilating
PH 7.54 (alkalosis)
PaCo2 29 (respiratory alkalosis)
HCo3 24 (normal)
BE +1 (normal)
Interpretation: uncompensated respiratory alkalosis
2. Patient with head injury
PH 7.37 (normal)
PaCo2 60 (respiratory acidosis)
HCo3 38 (metabolic alkalosis)
Interpretation: Full compensated respiratory acidosis.
3. Patient with diabetic ketoacidosis
PH 7.25 (acidosis)
PaCo2 40 (normal)
HCo3 17 (metabolic acidosis)
BE -3.1 (acidosis)
Interpretation: uncompensated metabolic acidosis.
4. patients with acute respiratory failure
PH 7.25 (acidosis)
PaCo2 50 (respiratory acidosis)
HCo3 22 (normal)
BE +1 (normal)
Interpretation: uncompensated respiratory acidosis
50
Module Title: Suctioning an ETT /tracheostomy: Open System

1- Clarify endotracheal tube suction.
2- Illustrated purpose of endotracheal tube suction.
3- Formulate patient assessment during suction.
4- Memorize appropriate pressure to perform suction.
5- Conduct open suctioning procedure.
6- Predict complications of endotracheal tube suction.
Definition: The trachea is suctioned by passing a sterile catheter into the

trachea through the endotracheal or tracheostomy tube or in some cases
via the nose or the mouth to aspirate the pulmonary secretions by using a
negative pressure.
Purposes:
-To maintain a patent airway and remove pulmonary secretions,
blood, vomitus, or foreign material from the airway.
-To reduce work of breathing.
- To prevent infection and atelectasis.
- To ensure effective ventilation and oxygenation.
Equipment:
• Portable or wall suction unit with tubing.

• Sterile suction catheter.
• Sterile normal saline or sterile water.
• Sterile, disposable container.
• Sterile gloves.
• Towel or waterproof pad.
• Goggles and mask or face shield.
• Additional PPE, as indicated.
• Disposable, clean glove.
• Resuscitation bag connected to 100% oxygen.
• Assistant (optional).
Assessment:
The patient need for suctioning if: ( Indication)
1. Assess lung sounds (crackles, or gurgling present)
2. Assess oxygenation saturation level (Oxygen saturation usually
decreases)
3. Assess respiratory status.( including respiratory rate and depth)
51
4. Assess patient for signs of respiratory distress.( nasal flaring,

retractions, or grunting)
5. Assess presence of secretions in the tube and frequent or sustained
coughing.
6. The need to obtain a sputum sample.
7. Increased peak inspiratory pressure or decreased tidal volume
during mechanical ventilation.
Procedure:
Steps Rational
1. Bring necessary equipment to the - Conserves time and energy.

bedside stand or over bed table.
2. Perform hand hygiene - Prevent the spread of microorganisms.
3. Identify the patient. - Ensures the right patient receives the
intervention and helps prevent errors.
4. Maintain privacy. - This ensures the patient‟s privacy.
5-Determine the need for suctioning. - Suctioning stimulates coughing,
And pain assessment - This is painful for patients with
surgical incisions.
6- Explain procedure the patient - Explanation alleviates fears.
7-If patient is conscious; place him in a Prevents the airway from becoming
semi-Fowler‟s position. If patient is obstructed and promotes drainage of
unconscious, place him in the lateral secretions.
position, facing you. Raise the bed to
waist height.
8-Place towel or waterproof pad across - This protects bed linens and the
patient‟s chest. patient.
9-Turn suction to appropriate - Higher pressures can cause excessive
pressure. trauma, hypoxemia, and atelectasis.
-For a wall unit for :
 adult: 100–120 mm Hg
 neonates: 60–80 mm Hg;
 infants: 80–100 mm Hg;
 children:80–100 mm Hg;
 adolescents: 80–120 mm Hg
-For a portable unit for:
 adult: 10–15 cm Hg;
 neonates: 6–8 cm Hg;
 infants 8–10 cm Hg;
52
 children 8–10 cm Hg;

 adolescents: 8–10 cm Hg.
10-Wear a disposable glove and close - Glove prevents contact with blood and
the end of the connecting tubing to body fluids. Checking pressure.
check suction pressure.
Place the resuscitation bag connected to
oxygen.
11-Remove the sterile container from - Sterile normal saline or water is used
suction package. Pour sterile saline to lubricate the outside of the catheter,
into it. minimizing irritation of mucosa during
introduction.
12-Wear sterile gloves. The dominant - Handling the sterile catheter using a
hand will manipulate the catheter sterile glove helps prevent introducing
and must remain sterile. The non- organisms into the respiratory tract; the
dominant hand is considered clean. clean glove protects the nurse from
microorganisms.
13- Pick up sterile catheter with - Sterility of the suction catheter is
dominant hand. Pick up the maintained.
connecting tubing with the non-
dominant hand and connected tubing
and suction catheter.
14-Moisten the catheter with sterile - Helps move secretions in the catheter.
saline
15-Hyperventilate with non dominant - Hyperventilation and hyper-
hand and a manual resuscitation bag oxygenation aids in preventing
and delivering three to six breaths. hypoxemia during suctioning.
16-Using your dominant hand, gently - No more than 1 cm past the length of
and quickly insert the catheter into the endotracheal tube, avoids contact
the trachea Advance the catheter to with the trachea and carina. Withdraw
the predetermined length. the catheter at least 1/2inch before
applying suction.
53
17-Apply suction and gently rotate the - Minimizes trauma to the mucosa.
catheter as it is being withdrawn. Suctioning for longer than 10 to 15
Don’t suction for more than 10 to seconds robs the respiratory tract of
15 seconds at a time. oxygen, which may result in
hypoxemia.
18-Hyperventilate with non dominant - ``

hand and a manual resuscitation bag
and delivering three t5o six breaths.
Replace the oxygen delivery device, if
applicable.
19-Flush catheter with saline. Assess - Clears the catheter and lubricates it for
the effectiveness of suctioning and next insertion.
repeat, as needed, and according to
patient‟s tolerance.
20-Allow at least a 30-second to 1- - The interval allows for re ventilation
minute interval. No more than and re oxygenation of airways.
three suction passes should be Excessive suction passes contribute to
made per suctioning episode. complications. Suction the
Suction the oropharynx after - oropharynx after suctioning the
suctioning the trachea. Do not trachea
reinsert in the endotracheal tube after - to prevent transmission of
suctioning the mouth. contaminants
21-When suctioning is completed, - Reduces the risk for infection
remove gloves. Assist patient to a transmission.
comfortable position. Perform hand
hygiene.
22-Reassess patient‟s respirator status, - Assess effectiveness of suctioning and
including respiratory rate, effort, the presence of complications.
oxygen saturation and lung sounds
Complications:
1-Hypoxemia.
2-Cardiac dysrhythmias.
3-Trauma.
4-Atelectasis.
5- Infection.
6-Bleeding.
7-Pain.
54
Module Title: Incentive Spirometry

1. Define incentive spirometer.
2. Address indication, contraindications of incentive spirometer.
3. Analyze the indications for Incentive Spirometry
4. Analyze the contraindication for Incentive Spirometry.
5. Conduct nursing care of incentive spirometer.
Definition: An Incentive spirometer is a small portable medical device

prescribed to help the lungs stay clear.
Purposes:
1-Assist the patient to breathe slowly and deeply.
2-Encourage the patient to maximize lung inflation.
3-Prevent or reduce atelectasis.
Indication:
1-Pre-post-operative patient with compromised inspiratory efforts.
2-The bed ridden patient or in any patient who benefits from a deep
breath and is able to voluntary cooperate with this method.
Contraindication:
Patient is unable to understand or demonstrate proper use of incentive
spirometer.
Equipement:
- Incentive spirometer - Folded blanket or pillow
-Stethoscope -PPE, as indicated
Procedure:
Steps Rational
1. Review the patient‟s health record. -Identify factors aids in interpretation
of results
2. Bring necessary equipment to the -Conserve time and energy.

bed side.
3. Hand washing and wear PPE . -Prevent spread of microorganisms.
4. Assist the patient to an upright or -Reduce pain from the incision.
semi-fowlers position. If the patient
has recently undergone abdominal
or chest surgery, place pillow over
a chest or abdominal incision.
55
5. Auscultate lung sounds before and -Establish a base line and to

after. determine effectiveness of Incentive
spirometer.
6. Steady the device with one hand -Allow patient to visualize the
and hold the mouthpiece with the volume of each breath and stabilize
other hand (figure1). the device.
7. Instruct patient to exhale normally -To empty lung and inhale maximum
and then place lips around mouth volume.
piece.
8. Inhale slowly and deeply as -To avoid inaccurate measurement of
possible through the mouth piece inhalation volume.
without using nose( if desired),a
nose clip may be used.
9. The patient should hold his or her -Help alveoli to re-expand.
breath and count to three.
10. Remove lips from mouthpiece and -Deep breath may change co2 level,
exhale normally. If patient become leading to light-headedness.
light-headed during the process,
stop and take a few normal breaths
before resuming Incentive
spirometer.
11. Encourage the patient to perform -To prevent atelectasis due to
Incentive spirometer 5-10 times hypoventilation.
every hour, if possible.
12. Clean the mouthpiece with water -Prevent spread of microorganisms.
and shake to dry. Remove PPE, if
used. Perform hand washing.
Methods used to evaluate effectiveness:
 Breathe sounds- before and after.
 Volume achieved per therapy session.
 Number of maneuvers at each volume achieved.
56
Module Title: Pulmonary Function Test

1. Clarify pulmonary function tests.
2. Memorize purpose of pulmonary function test.
3. Investigate methods for measuring pulmonary function.
4. Interpret pulmonary function test.
5. Evaluate pulmonary function test.
Definition:
Pulmonary function tests are a group of investigations that measure
breathing and how well the lungs are functioning..
Purpose:
 Screening for the presence of obstructive and restrictive diseases
 Evaluating the patient prior to surgery
 Evaluating the patient's condition for weaning from a ventilator.
 Documenting the progression of pulmonary disease - restrictive or
obstructive
 Documenting the effectiveness of therapeutic intervention
 Measure whether exposure to chemicals at work affects lung
function
Pulmonary function test (PFTs) include:-

1. Volume measurements.
2. Capacity measurements.
3. Dynamic measurements.
57
Lung volumes and lung capacities
Normal
Term used Symbol Description
values
Lung Volumes
Volume of air inhaled or
Tidal Vt or
exhaled with each normal 7-9ml/kg
volume TV
breath.
Inspiratory Maximum volume of air that
3000-
reverse IRV can be inhaled after a normal
3100ml
volume inhalation
Expiratory Maximum volume of air that
1100-
reverse ERV can be exhaled forcibly after a
1200ml
volume normal exhalation
Volume of air remaining in the
Residual 1200-
RV lungs after a maximum
volume 1300ml
exhalation
Lung Capacity
Maximum volume of air
Vital 4600-
VC exhaled from the point of
capacity 4800ml
maximum inspiration.
Inspiratory Maximum volume of air 3500-
IC
capacity inhaled after normal expiration 3600ml
Functional
Volume of air remaining in 2300-
residual FRC
lungs after a normal expiration. 2400ml
capacity
Volume of air in lungs after a
Total lung maximum inspiration equal to 5800-
TLC
capacity sum of all four volumes (Vt, 6000ml
IRV, ERV,RV)
Dynamic measurements:
Dynamic measurements provide data about airway resistance and the
energy expended in breathing (work of breathing)
 Respiratory rate or frequency (f) is the number of breath per minute.
 Minute volume / Minute ventilation (VE), is the volume of air
inhaled and exhaled per minute. It's calculated by Vt × f.
 Alveolar ventilation is the portion of total ventilation that participates
in gas exchange.
 Physiologic dead space, areas in the lungs that are ventilated but no
gas exchange.
58
Module Title: Extra Corporeal Membrane Oxygenation

(ECMO)
1. Define ECMO
2. List indications for ECMO
3. Differentiate between Types of ECMO
4. Describe complications related to ECMO
5. Explain nursing role during and after ECMO
Definition
ECMO is a form of extracorpeal life support where an external
artificial circulator carries venous blood from the patient to a gas
exchange device (oxygenator) where blood becomes enriched with
oxygen and has carbon dioxide removed. This blood then re-enters the
patient‟s circulation. Circuit flow is achieved using a pump.
Indications
ECMO is indicated for potentially reversible, life-threatening
forms of respiratory and / or cardiac failure, which are unresponsive to
conventional therapy as following:
Respiratory failure
 ALI/ARDS
 Post lung transplant
 Aspiration
 Asthma
 Pneumonia
 Lung contusion
Cardiac Failure
 Post cardiac arrest
 Drug overdose
 Bridge to transplant
 Cardiogenic shock
 Pulmonary embolus
 Post cardiac surgery
 Post heart transplant
Contraindications:-
Absolute Contraindications
 Severe irreversible neurological condition
 Encephalopathy
 Cirrhosis with ascites
59
 History of variceal bleeding

 Moderate-severe chronic lung disease
 Terminal malignancy
 HIV
Relative Contraindications
 Age >65
 Multiple trauma with uncontrolled haemorrhage
 Multi-organ failure
The primary components of an ECMO circuit are:

1. Vascular access
2. Tubing
3. Pump
4. Gas exchange mechanism
Types of ECMO:-
There are two basic types which are described by the site of drainage &
where the blood returns
A-Veno-venous
 Deoxygenated blood is drained from venous circulation into the ECMO
circuit
 Blood is oxygenated via the oxygenator and is returned to the right
atrium
 Drains from major vein & returns to a major vein
 Supports only the lungs
 Adequate circulation is provided by the native cardiac output
B-Veno-arterial
60
 Deoxygenated blood is drained from venous circulation into the ECMO

circuit
 Passes through the oxygenator and is returned directly to the arterial
circulation
 Drains from major vein & returns to major artery
 Supports heart & lungs
Equipment :
 ECMO machine
 ECMO Cannulas
 Heparine
 Syringe
 Sterile dressing
 Sterile heavy scissors
 sterile tubing clamps
 Spare ECMO circuit
Procedure :
Step Rational
1.A doctor will check an individual before ensure there‟s no bleeding in the brain
ECMO. A cranial ultrasound, and and determine wither the heart is
cardiac ultrasound, Also, while on working.
ECMO, daily chest x-ray
61
2.After determining that ECMO is

necessary, equipment will be prepared
within a sterile field. A dedicated
ECMO team, including a board-
certified physician with training and
experience in ECMO will do the
ECMO. The team also include:
a) ICU registered nurses
b) respiratory therapists
c) perfusionists (specialists in the use
of heart-lung machines)
d) support personnel and consultants
3.Hand washing and maintain sterile To prevent cross of micro-organisms
technique during cannulation and
procedure.
4.Depending on patient age, surgeons will
place and secure the cannulae in the
neck, groin, or chest while you are
under general anesthesia. You will
usually remain sedated while patient is
on ECMO
5.Initiation phase: Following cannulation
patient is connected to ECMO circuit,
the pump flow started with 20ml/kg/min
and gradually increased /5-10 min to
reach the desired flow
6.Gas flow to blood flow ratio is adjusted
0.5-1& start with an FIO2 of
21→→100 % FIO2
7.Once the desired flow achieved,
ventilator parameters are brought down
to the base line.
8.Reasonable targets are:
Arterial oxy hemoglobin › 90 for VA
ECMO
70 for VV ECMO
Adequate tissue perfusion is determined
by arterial BP and blood lactate level.
Maintenance and Monitoring phase:
9.Nurse and ECMO team will always
monitoring patient during ECMO by
taking X-rays daily and monitoring:
62
a) heart rate
b) respiratory rate
c) oxygen levels
d) blood pressure
e) neurological state
f) blood flow rate at 60-150 ml/kg/min
10. A breathing tube and ventilator
keep the lungs working and help
remove secretions.
11. Medications will transfer
continuously through intravenous This blood thinner prevents clotting as
catheters. One important medication is blood travels within the ECMO.
heparin
12. Patient can stay on ECMO

anywhere from three days to a month.
13. Weaning and trial off of ECMO:
Occur when there is an improvement in
radiographic appearance, pulmonary
compliance and oxyhemoglobin saturation.
Nursing management regarding ECMO

 The ECMO patient must NOT be left unattended at any time
 Hourly observations: Pump flow rate
 Continuously monitor patient and ECMO set for drop in BP/ CVP
 Administer light sedation as ordered to prevent decannulation.
 Observe any evidence of hypovolaemia in the form of fluctuating
flow rates and „shaking‟ of ECMO tubes. Hypovolaemia (relative or
absolute) may result in disrupted blood flow through the circuit
 Access & return cannula for bleeding: Observe for oozing of blood,
and maintain secure dressings
 Circulation observations lower limbs : Limb temperature - Limb
colour - Capillary refill - Due to the large bore cannulae distal arterial
perfusion may be compromised in A-V ECMO, while the venous
cannulae may lead to DVT formation
 Input & output, haematuria : Haematuria is often present when there
is haemolysis, and therefore should be reported and investigated
appropriately
 Ventilation observations should be attended: mode, Fi02, Tidal
volume, respiratory rate, PEEP, pressure support, inspiratory time,
plateau pressure
 Patient should be nursed in the supine position
63
 Head of bed should be elevated 30 degrees

 Pressure relieving mattress should be insitu (because of decreased
mobility and perfusion sate these patients often high risk for pressure
areas).
 Heel pressure should be offloaded.
 Neurological and pupillary assessment must be attended hourly (they
are at increased risk of intracranial bleed)
Renal management:
 Diuretics are often administered to reduce fluid overload.
 Oliguric and polyuric phases of acute tubular necrosis are
common on ECMO, and continuous renal replacement therapy
(CRRT) may be required
Monitor for signs of infection as increase of lactate level, liver
enzymes, metabolic acidosis and decreased urine output
Complications:
 Bleeding
 Infection
 Thromboembolism
 Heparin induced thrombocytopenia
 Cannulation related complications
 Leg damage
64
Unit III
Cardiovascular System
 Central venous pressure monitoring

 12-lead ECG
 Cardiac catheterization.
 Cardiac pacing
 Cardiopulmonary resuscitation
 Intra-aortic balloon pump
65
Central venous pressure monitoring (C.V.P)

1. Define of central venous pressure.
2. List purpose, indications, sites of insertions of CVC.
3. Demonstrate measuring of central venous pressure.
4. Demonstrate nursing care for central venous catheter site.
5. List complications of central venous catheter insertion.
Definition : C.V.P is the blood pressure in the vena cava that enter
the right atrium of the heart through catheter.it reflects the amount
of blood returning to the heart and the ability of the heart to pump the
blood into the arterial system.
Indications:
 Central venous pressure monitoring
 Assess intravascular volume and right heart function
 Volume resuscitation as a guide for fluid replacement.
 Infusion of concentrated solution, blood product, TPN, and drugs.
 Patient with renal failure
 Cardiac arrest
 Obtaining central venous blood sample.
Sites of insertion:
1. Internal jugular vein

2. Subclavian vein
3. Femoral vein (rarely used due to ↑
incidence of trauma or hematoma
formation.
Nursing interventions:
Preparation
Before the insertion:

1. Prepare the equipment:
• CVP catheter - manometer- stopcock or three ways valve.
• Sterile glove - I.V stand - I.V fluid (normal saline , ringer).
• Sterile forceps - Sterile sponge & dressing - sterile towel.
• Syringe 10-20 ml.
• Local anesthesia (Lidocaine or xylocaine).
• Silk suture - surgical needle - needle holder.
66
2. Prepare patient:
• Evaluate patient PT, PTT, CBC.
• Explain to conscious patient how to perform Valsalva maneuver.
During the insertion:

1. Explain procedure to the patient.
2. Prepare the site of insertion (cleansing & shaving).
3. Disinfect the site with antiseptic solution & then cover with sterile
towel.
4. Positioning the patient in a supine position (15 degree head down
position) with the head turned away from the site of insertion.
5. Ensure the patient comfort during the procedure.
6. Assist the doctor during insertion.
7. Perform continuous assessment of the patient cardiac‟ status,
respiratory s& patient's tolerance.
8. Observe cardiac dysrhythmia during the insertion of the catheter or
guide wire.
9. Flush IV infusion set and manometer
10. Assist with the connection of IV line.
After insertion:
1. Begin the IV infusion & keep the catheter always open with an>
solution to prevent complications.
2. Assess integrity of the skin at the site of insertion.
3. Apply any antibiotic ointment at the site of insertion & then cover with
sterile gauze.
4. Prepare the patient for x-ray.
CVP measurement by using water manometer:

Steps Rational
1. Hand washing and apply -Reduce transmission of microorganisms
gloves
2. Gather equipment at the
bedside &maintain privacy.
3. explain procedure to the
patient
4. Assess CVC, type of
solution ,date &time of
changing dressing .
67
5. connect the CVC with IV

line and water manometer
through three way.
6. Open three- way to IV fluid - to ensure CVC is patent by flushing

and patient the catheter (flush bag)
7. Turn the three-way tap off - to remove air bubbles from

to the patient and open to manometer
the manometer & IV fluid.
8. Position client in supine or

flat position with no pillow
under head
9. hold manometer at the level
of right atrium at 4th inter
costal space mid-axillary
line (zero line)
10. Turn off the flow from the

fluid bag and open the
three-way tap from the
manometer to the patient.
68
11. The fluid level inside the When the fluid stops falling the CVP
manometer should fall measurement can be read. If the fluid
moves with the patient's breathing, read
the measurement from the lower number
12. IV fluid is prescribed Turn Prevents clotting of catheter and
three-way open to the reestablishes IV flow
solution and the patient, and
regulate as prescribed rate
then disconnect manometer.
13. Reposition the patient

&remove equipment
14. Wash hands. Reduces transmission of
microorganisms.
15. Documentation:
The CVP measurement,
catheter insertion site
&condition ,date and time of
changing dressing and report
any changes or abnormalities.
2- CVP measurement by using transducer:-
The transducer is fixed at the level of the right atrium and connected to
the patient's CVP catheter via fluid filled extension tubing. Similar care
should be taken to avoid bubbles and kinks. The transducer is then
'zeroed' to atmospheric pressure by turning its three-way tap so that it is
open to the transducer and to room air, but closed to the patient. The
threeway tap is then turned so that it is now closed to room air and open
between the patient and the transducer. A continuous CVP reading
measured in mmHg rather than cmH2O can be obtained when using water
manometer.
69
CVP measurement by using transducer:

1. Explain the procedure to the patient to
gain informed consent.
2. The CVC will be attached to

intravenous fluid within a pressure bag.
Ensure that the pressure bag is inflated
up to 300mmHg.
3. Place the patient flat in a supine - The position should remain

position if possible. Alternatively, the same for each
measurements can be taken with the measurement taken to ensure
patient in a semi-fowler position. an accurate comparable result.
4. Catheters differ between

manufacturers; however, the white or
proximal lumen is suitable for
measuring CVP.
5. Tape the transducer to the phlebostatic

axis or as near to the right atrium as
possible.
70
6. Turn the tap off to the patient and open

to the air by removing the cap from the
three-way port opening the system to
the atmosphere.
7. Press the zero button on the monitor

and wait while calibration occurs.
8. When 'zeroed' is displayed on the

monitor, replace the cap on the three-
way tap and turn the tap on to the
patient.
9. Observe the CVP trace on the monitor.

The waveform is drawn as the right
atrium contracts and relaxes, emptying
and filling with blood. (light blue in
this image)
10. Document the measurement and

report any changes or abnormalities
 CVP is usually measured in cm H2O (1 cm H2O is equivalent to

0.735 mm Hg).
71
The normal CVP value
hypovolemia ↓↓
Normal
hypervolemia
2 to 8 mm Hg (4–12
cm H2O)
Causes ↑ CVP:
1. Elevated vascular volume.
2. Decreased cardiac output
3. Heart failure
4. Pleural effusion
5. Mechanical ventilation and the application of positive end-
expiratory pressure (PEEP)
6. Cardiac tamponade
7. Tension pneumothorax
Causes ↓ CVP:
1. Reduce vascular volume.
2. Shock.
3. Venous-dilatation (drug induced).
Complications:
a- vascular complication:
1. hematoma formation.
2. Arterial puncture.
3. Air embolism (caused by passing air bubble via the CVP catheter &
obstructs the pulmonary artery.
4. Arteriovenous fistula.
b- Infectious complication:
1. Sepsis
2. Cellulitis
c-Other complications: -
1. Nerve & lymphatic injury.
2. Pneumothorax (presence of air in the pleural cavity, it occurred
accidentally in 40-50 % of all patients with CVP insertion).
3. Hemothorax (presence of blood in the pleural cavity. It results from
injury of vein or artery).
4. Hemopneumothorax (combination of both).
5. Cardiac dysrythmia (Occurs if the catheter or guide wire passes into
heart or pulmonary circulation).
6. Mal-positioned catheter.
72
Module Title: 12-Lead Electrocardiogram Interpretation.

1. Define ECG
2. List of purpose and leads of ECG.
3. address the characteristics of a normal ECG
4. Relate between ECG waves and cardiac electro-
physiology
5. Interpret ECG waves
6. Prepare the patients for ECG.
7. Demonstrates accurate placement of chest and limb
electrodes
8. Perform the technique for performing 12-lead ECG.
Definition: It‟s a graphical recoding of electric currents that are generated

by the heart muscles.
Purposes:
1. To assess the cardiac function (rate, rhythm and conduction).
2. To diagnose cardiac rhythm disorders (e.g. heart block, dysrhythmias).
3. To diagnose cardiac diseases (e.g. myocardial infarction}
4. To detect electrolyte imbalance (e.g. hyperkalemia, hypokalemia,etc).
5. To evaluate effects of treatment (e.g. administration of cardiac drugs).
Equipments:
1. ECC machine.
2. Electrodes for 12 lead ECG.
3. Electro-conductive gel.
4. Front open gown or shirt for patient.
5. Tissue paper.
ECG leads:
A. Bipolar limb leads (Standard limb
leads):-
They record the potential difference between
two points on the body surface.
 Lead I: records the potential difference
of electrical impulse between Rt. arm and
Lt. arm. Positive deflection, helpful in
monitoring atrial rhythms.
 Lead II: records the potential difference of electrical impulse
between Rt. arm and Lt. leg.
73
 Lead III: records the potential difference of electrical impulse

between Lt. arm and Lt. leg.
B. Unipolar leads:-
They record the potential changes at one position on the body surface.
1. Unipolar limb leads (Augmented limb leads):
 AVR: right arm lead. Negative deflection. Record the changes in
electrical current occurring in the part of heart which faces the Rt.
shoulder.
 AVL: left arm lead. Positive deflection.
Record the changes in electrical current
occurring in the part of heart which faces
the Lt. shoulder.
 AVF: left leg lead. Positive deflection.
Record the changes in electrical current
occurring in the part of heart which faces
the Lt. hip. Useful in monitoring inferior
wall of the left ventricle
2. Unipolar chest leads (Precordial chest leads)
The six leads are placed in sequence across the chest and provide a view
of the heart‟s horizontal plane. (V1- V6).
ECG paper:-
(1) Measures time along the horizontal axis
a) Records P wave, QRS complex, and T wave (in time), as well as
PR and QT intervals
b) Each small (1-mm) box = 0.04 second
c) Each large (5-mm) box = 0.20 second
(2) Measures voltage in the vertical direction
a) Measures and records amplitude and voltage of P wave, QRS
complex, and T wave
b) Each small box (1 mm) = 0.1 mV
c) Each large box (5 mm) = 0.5 mV
(3) Deflections: Waves of the ECG recording are either above or below
the isoelectric line
(a) Positive deflections occur when the heart's depolarization wave
moves toward the positive electrode of the recording lead
(b) Negative deflections occur when the heart's depolarization wave
moves away from the positive electrode of the recording lead
(c) Biphasic deflections occur when the heart's depolarization wave is
moving both toward and away from the positive electrode.
74
Procedure:-
Nursing action Rationale
1.Apply hand hygiene then Explain the
-Helps to gain patient's co-
purpose of ECG and procedure to the
operation and reduce anxiety
patient. Reassure patient that
regarding procedure.
procedure is painless and safe.
2. Ask female patients to remove all tight
- Procedure requires placement of
fitting clothing around the chest.
electrodes over chest area.
Assist patient to put on a front open
iuosi.1 gown or shirt.
3. Ensure that the ECG machine is in
functioning order.
4. Insure proper standardization of
machine.
a. Set paper speed at 25 mm/min.
-Proper standardization of
b. Provide standard 1 mv signal to ECG
machine ensure recording of
machine so that the spike made will be
ECG.
10 mm or 2 large squares in height.
c. Ensure that the machine is properly
earthed.
5. Ask the patient to lie in supine position
and be as relaxed as possible.
-Procedure requires exposing chest
6. Provide privacy by pulling the curtains
area which embarrassing for the
around the patient.
patient.
75
**7. Expose chest completely. Apply

electroconclucttive gel on lead
placement sites and position all
electrodes appropriately.
a. Check for color codes of limb leads
and connect limb electrodes to all four
extremities.
b. Place suction electrodes at appropriate
sites and disposable electrodes.
VI---4th intercostal space on the right
side, parasternal)
V2---4th intercostal space on the left side,
parasternal
V3---midway between V2 and V4
V4---5th intercostal space on left side in
the mid clavicular line
the anterior axillary line.
the mid axillary line.
Note: For female patients, place the V4
electrode, as well as V5 and V6 as
necessary, under the breast tissue
as close to the chest wall as
possible
8. Instruct the patient that you are going
-Patient movement during
to start the recording and he/she
recording causes .artifacts on
should lie still in the bed without
ECG record.
moving till the recording is complete,
which may take 5-10 min
9. Check the ECG record for
appropriateness and presence of
artifacts if any.
10. Inform patient that ECG recording is
completed.
11. Remove electrodes from all four
limbs and chest. Wipe off the electro
conductive gel using tissue papers.
Assist patient in dressing
- Clean machine according to hospital
policy
76
12.label the ECG:

a. Write patient's full name,
inpatient/out, patient number, date and
time of recording.
b. Record lead identification in case of
manual records.
13.Read and report \1CC as follows:
a. Rhythm.
b. Conduction intervals.
c. Cardiac axis.
d. A description of the QRS complexes.
e. A description of the ST segments and
T waves.
14.Show ECC record to physician as
soon as possible so that further
treatment orders can be obtained
Special consideration
Note that the following can cause poor ECG signal and or artifacts on an
ECG record.
1. Oily, dirty and scaly skin.
2. Dirty or encrusted electrodes.
3. Improper application of electrodes.
4. Loose or dislodged electrodes.
5. Patient's movement
6. Muscle tremor.
7. Broken cable wire.
ECG waveform:
77
P wave:-
 It represents the electrical impulses starting in SA node and sprinding
through the atria. Therefore, P wave represents atrial depolarization.
 Location: precedes the QRS complex.
 Amplitude: 2-3 mm
 Duration 0.06 to 0.11 sec
 Configuration: small, smoothly rounded.
 Deflection:-Positive in leads: I, II, avf, and v2-v6
-Usually positive but may vary in leads: III and avl
-Negative: in lead avr
-Biphasic in lead v1
PR interval:-
 It‟s measured from beginning of P wave to the beginning of QRS
complex and represents the time required for impulse to travel through
the atria, AV node junction and purkinje system.
 Normally, is 0.12 to 0.20 sec (3-5 small squares).
QRS complex:-
 The QRS complex represents ventricular muscle depolarization.
 Location: follow P R interval.
 Amplitude: 5-30mm but differs for each lead.
 Duration: 0.06-0.10 sec (1.5- 3 small squares).
 Configuration:
- Q wave: first negative or downward deflection of this large
complex
- R wave: first upward or positive deflection following the P wave
(tallest waveform)
- S wave: the sharp, negative or downward deflection that follows
the R wave
 Deflection: -Positive in lead I, II, III, avl, avf, v4-v6.
-Negative in lead avr.
-Biphasic in lead v3.
ST segment:-
 It‟s represent the period of time from the end of ventricular
depolarization to the beginning of ventricular repolarization.
 It begins at the end of the QRS complex and extends to the beginning
of the T wave.
 It should be at the isoelectric line and gently curved up into the T
wave.
 May become elevated or depressed.
78
T wave:-
 T wave represents ventricular muscle repolarization.
 Normally in the same direction as QRS complex.
 It‟s usually rounded and slightly asymmetric rising more slowly than it
descends.
QT interval:-
 It shows the time needed for the ventricle depolarization-
repolarization cycle.
 The length of QT interval various according to heart rate, age and sex,
usually it‟s duration from 0.36 to 0.44 sec.
U wave:-
 It‟s represent the recovery period (repolarization) of the Purkinige or
ventricular conduction fibers.
 It isn‟t present on every rhythm strip.
 When present it is upright and rounded.
Determining heart rate:-
A. when the rhythm is regular:-

1500 divided by the number of small boxes between two R waves.
Example---- 5 large square between two R wave. Then there is 5 x 5 = 25
small square. 1500 ÷ 25 = 60 heart rate.
B. when the rhythm is irregular :-

Count the number of Rs in 6 sec. and multiply that number by 10.
Example--- 7 R in 6 sec. 7 x 10 = 70 heart rate.
79
Module Title: Cardiac catheterization.

1. Define cardiac catheterization.
2. Illustrate purpose, indications and contraindications of cardiac
catheterization.
3. Compare right and left cardiac catheterization.
4. List complications of cardiac catheterization.
5. Apply nursing care of cardiac catheterization.
Definition:
Cardiac catheterization is procedure involves passing a catheter into right
or left side of the heart through large blood vessel to examine how heart is
working .
Purpose of the Test:

1) Right heart:
1-Measure the right heart and pulmonary pressure.
2 Evaluate of valvular diseases (tricuspid or pulmonic).
3- Evaluate of atrial or ventricular septal defect.
2) Left heart:
1. Evaluate left-sided heart pressure.
2. Evaluate of valvular diseases (mitral or aortic).
3. Evaluate of atrial or ventricular septal defect.
4. Evaluate coronary artery disease with unstable, stable, or now-
onset angina .
5. Diagnosis of obstructive coronary artery disease
6. Diagnose atypical chest pain.
7. Diagnose complications of myocardial infarctions such as septal
rupture and dysrhythmias.
8. Diagnose aortic dissection.
80
9. Take sample from champers to evaluate oxygen saturation

&Cardiac output.
10. Evaluate the need for coronary artery surgery or angioplasty.
Contraindications
1. Elderly patients who are not candidates for invasive
interventions.
2. Patients with uncontrolled electrolyte imbalance
especially hyper- hypokalemia, hypomagnesemia,
hypocalcemia or hyponatremia.
3. Patients who are digitalis toxic.
4. Patients with febrile illness or infection.
5. Patients have coagulation disorders.
6. Recent cerebrovascular stroke
7. uncontrolled hypertension
Types of cardiac catheterization:

-According to the purpose:
1. Right cardiac catheterization
2. Left cardiac catheterization
-According to the diagnosis:
1. Diagnostic cardiac catheterization
2. Therapeutic cardiac catheterization ( PCI)
Equipment:
-Cardiac catheter. - Heparinized transducer.
-Antiseptic solution, - Sterile gloves.
-Drugs for local anesthesia - Fluoroscopy.
-Syringe. - Defibrillator
- Medications (anti-histamine, anti-inflammatory).
Nursing intervention:-
"The procedure is done following strict aseptic technique".
Nursing preparation before cardiac catheterization include the
following:
 Verify that in informed consent has been obtained.
 Instruct the patient about the purpose and procedure for the study.
 Prepare and disinfection skin area for insertion catheter needle.
 Laboratory investigation including, prothrombine time and a
partial thromboplastin time; an electrocardio-gram (ECG); and
chest x-ray film and renal functions test.
 lf contrast dye is going to be used, check for allergies.
81
 Assess the patient's level of anxiety.

 Instruct the patient to fast usually for 8 to 12 hours before the
procedure.
 Prepare the patient for the expected duration of the procedure for
less than 2 hours.
 Reassure the patient that mild sedatives or moderate sedation will
be given.
 Prepare the patient to experience certain sensations during the
catheterization.
 Explain that palpitation may be felt in the chest because of
extrasystoles that almost always occur, when the catheter tip
touches the myocardium.
 The patient may be asked to cough and to breathe deeply,
especially after the injection of contrast agent. to clear the contrast
agent from the arteries. Breathing deeply and holding the breath
helps to lower the diaphragm for better visualization of heart
structures.
 The injection of a contrast agent into either side of the heart may
produce a flushed feeling throughout the body.
 the patient is premedicated to decrease the risk of allergic
reaction to the contrast dye.
2-During the procedure:

 The patient is awake. The nurse provides emotional support and
reinforces explanations given about the procedure.
 Continuous cardiac monitoring is maintained.
 A local anesthetic agent is used after the insertion site is prepared
and draped.
 The physician inserts the cardiac catheter under fluoroscopy. The
patient may be asked to change position or cough during the
procedure.
 Observe constantly for complications especially dysrhythmia
during procedure.
Nursing role after cardiac catheterization may include the following:

 Observe the insertion site for signs of bleeding. Palpate around the
puncture site to detect bleeding into tissue. If bleeding is present, exert
pressure just proximal to the puncture site with a gloved hand for a
minimum of 15 minutes.
 Apply constrictive dressing on the insertion site to avoid bleeding.
 Monitor vital signs and cardiac monitor according to hospital protocol.
82
 Check distal pulses for arterial patency.

 Evaluate temperature and color of the affected extremity and any
patient complaints of pain, numbness, or tingling sensations to
determine signs of arterial insufficiency. Report changes promptly.
 Monitor for dysrhythmias by observing the cardiac monitor or by
assessing the apical and peripheral pulses for changes in rate and
rhythm.
 A vasovagal reaction, consisting of bradycardia, hypotension, and
nausea may be precipitated by a distended bladder or by discomfort
during removal of the arterial catheter, especially if a femoral site has
been used.
 If vasovagal occur raising the feet and legs above the head,
administering intravenous fluids, and administering intravenous
atropine.
 Inform the patient that if the procedure is performed percutaneously
through the femoral artery, the patient will remain on bed rest for 2 to
6 hours with the affected leg straight and the head elevated to 30
degrees.
 For comfort, the patient may be turned from side to side with the
affected extremity straight.
 Instruct the patient to report chest pain and bleeding or sudden
discomfort from the catheter insertion sites immediately.
 Encourage fluids as possible to increase urinary output and flush out
the dye.
 Ensure safety by instructing the patient to ask for help when getting out
of bed the first time after the procedure because orthostatic
hypotension may occur
 Evaluate the patient's psychological response to the procedure and its
findings.
 Ask patients not to move his leg for 6 hour to avoid bleeding.
 Ask patient to avoid coughing or straining during defecation to avoid
bleeding.
After discharge from the hospital for cardiac catheterization, guide-

lines for self-care include the following:
 For the next 24 hours, do not bend at the wrist (to lift anything), strain,
or lift heavy objects.
 Avoid tub baths, but shower as desired.
 Talk with your physician about when you may return to work, drive,
or resume strenuous activities.
 Call your physician if any of the following occur: bleeding, swelling,
83
new bruising or pain from your procedure puncture site, temperature

of (38.6°C) or more.
 If test results show that you have coronary artery disease, talk with
your physician about options for treatment, including cardiac
rehabilitation programs in your community.
 Talk with your physician and nurse about lifestyle changes to reduce
your risk for further or future heart problems, such as quitting
smoking, lowering your cholesterol level, initiating dietary changes,
beginning an exercise program, or losing weight.
Complications:
1. Allergic reaction to iodine- based dye.

2. Bleeding or hematoma at catheter insertion site.
3. Damage of veins or arteries.
4. Kidney damage or failure.
5. Cerebral vascular stroke.
6. Cardiac arrest
84
Module Title: Cardiac pacing

1. Define pacemaker
2. Illustrate indications and components of pacemaker
3. Explain pacemaker Functions
4. Determine Pacemakers setting
5. Differentiate between types of a temporary transvenous
Pacemaker
6. Apply nursing intervention for the patient with a temporary
trans venous pacemaker
Definition: The artificial cardiac pacemaker is an electronic device used

to pace the heart when the normal conduction pathway is damaged.
Pacemaker Functioning
Pacemaker performs two main functions: diagnosis and treatment.
 The diagnostic function is to sense intrinsic cardiac activity by
measuring the voltage produced by the heart when it contracts.
 The treatment function is to emit an electrical impulse that excites
endocardial cells and produces a wave of depolarization in the
myocardium.
Indications
 Persistent bradycardia
 Complete heart block
 Tachydysrhythmia. Antitachycardia pacing involves the delivery
of a stimulus to the ventricle to end Tachydysrhythmia (e.g., VT).
 Overdrive pacing involves pacing the atrium in an attempt to
terminate atrial tachycardia (e.g., atrial flutter with a rapid
ventricular response).
 Congenital or degenerative heart disease
85
Components of pacemaker
Pacemaker system consist of two components: an electronic pulse
generator and one to three leads with electrodes.
The pulse generator: temporally and permanent

The lead is a wire that provides the communication network between the
pulse generator and the heart muscle. One or more electrodes are at the
distal end of the lead and provide sensing and pacing of the heart muscle.
Types of wires:
 Single chamber pacemaker uses one lead in the upper chambers
(atria) or lower chambers (ventricles) of the heart.
 Dual chamber pacemaker uses one lead in the atria and one lead in
the ventricles of your heart.
 Biventricular pacemaker uses three leads: one placed in the right

atrium, one placed in the right ventricle, and one placed in the left
ventricle (via the coronary sinus vein).
Types of pacemaker
 A permanent pacemaker is implanted totally within the body. The
pulse generator weighs 20 to 30 g and is 5 to 7 mm thick. Most
permanent pulse generators implanted in subcutaneous pocket in the
pectoral region below the clavicle on the patient‟s non-dominant
side. The longevity of most permanent pacemakers is about 6 to 12
years, depending on the percentage of pacing the heart requires over
time.
 Temporary Pacemaker. A temporary pacemaker is one that has the

power source outside the body. It used in emergency and elective
situations. There are three types of temporary pacemakers:
86
 A transvenous pacemaker consists of a lead or leads that

are threaded transvenously to the right atrium and/or right
ventricle and attached to the external power source.
 Epicardial pacing involves attaching an atrial and

ventricular pacing lead to the epicardium during heart
surgery to prevent bradydysrhythmias or
tachydysrhythmias occur in the early postoperative period.
 A transcutaneous pacemaker (TCP) is used to provide

adequate HR and rhythm to the patient in an emergency
situation. Placement of the TCP is a noninvasive,
temporary procedure used until a transvenous pacemaker is
inserted or until more definitive therapy is available.
Pacemakers setting
The temporary pulse generator contains several controls that regulate
the current output, rate and sensitivity.
 Rate control: It is regulates number of impulses delivered
to heart between 60 and 100 beats/minutes
 Output control: It is regulates amount of electrical current
delivered to heart to initiate depolarization
 Sensitivity: It is regulates ability of pacemaker to detect
heart's intrinsic electrical activity.
Pacemaker Malfunction
 Failure to sense: Failure to sense occurs when the pacemaker
fails to recognize spontaneous atrial or ventricular activity,
resulting in VT. Failure to sense battery failure, and
dislodgment of the electrode.
 Failure to capture occurs when the electrical charge to the
myocardium is insufficient to produce atrial or ventricular
contraction. This can result in serious bradycardia or asystole.
Failure to capture is caused by pacer lead damage, battery
failure, or dislodgment of the electrode.
Nursing intervention for the patient with a temporary transvenous

Pacemaker
Step Rational
1.Assess the patient‟s initial cardiac
rhythm, including 12-lead ECG.
Monitor heart rate, respiratory rate,
87
level of consciousness, and skin color.

2.Bring necessary equipment
3.Perform hand hygiene To prevent transmission of
microorganisms.
4.Explain the procedure to the patient
5.Administer analgesia and sedation,
6.If necessary, clip the hair over the areas
of electrode placement.
7.Do not shave the area.
8.Attach the patient monitoring electrodes To ensure that equipment
to the cardiac monitor functioning properly
9.Monitor the patient‟s heart rate and To determine the
rhythm to assess ventricular response to effectiveness of the paced
pacing. Assess the patient‟s vital signs, rhythm.
skin color, level of consciousness, and
peripheral pulses.
10. Assess the patient‟s pain and To promote patient comfort
administer analgesia/sedation, as
ordered.
11. Perform a 12-lead ECG and additional Provides a baseline for
ECG daily or with clinical changes. further evaluation
12. Continually monitor the ECG
readings
13. Document the reason for pacemaker
use, time that pacing began, electrode
locations, pacemaker settings,
patient‟s response to the procedure,
complications, and nursing actions
taken.
Post procedure nursing care
14. Check vital signs frequently and
connect patient to cardiac monitor.
15. Check for heart rhythm and emotional
reactions to procedure and pacing.
16. check whether connections are
secured or not
17. Monitor battery and control setting
18. Clean and dress incision site
according to hospital policy
19. Keep the pulse generator clean and
dry and prevent mishandling.
88
20. Use rubber gloves when exposed

wires are handled
21. Enclose the pulse generator in rubber
glove to keep it dry
22. Keep patient in supine position and
ask to maintain adduction of affected
extremity for 12hours.
23. Limit movement for the affected and
bed rest for 24 hours and reduced
activity for another 48 hours is
required .
Instructions for patient with permanent pacemaker
 Monitor pulse and inform cardiologist if it drops below

predetermined rate.
 Start passive and active range-of-motion exercises on the affected
arm 48 hours after implantation to avoid “frozen shoulder.”
 Avoid activities that may result in high impact or stress at the
implantation site.
 Be alert for symptoms of pacemaker malfunction: dizziness, fainting,
shortness of breath, fatigue, or fluid retention. Fluid retention
includes sudden weight gain.
 Maintain follow-up care with your cardiologist to begin regular
pacemaker function checks.
 Report any signs of infection at incision site (e.g., redness, swelling,
drainage) or fever to your cardiologist immediately.
 Keep incision dry for 4 days after implantation, or as ordered.
 Avoid direct blows to pacemaker site.
 Microwave ovens are safe to use and do not interfere with pacemaker
function.
 Air travel is not restricted. Inform airport security of presence of
pacemaker because it may set off the metal detector.
 Carry pacemaker information card and a current list of your
medications at all times.
Pacemaker Complications
 Pneumothorax
 Perforation of Ventricular Wall or Septum
 Catheter or Lead Dislodgment
 Infection and Phlebitis or Hematoma Formation
 Abdominal Twitching or Hiccups
89
Module Title: Cardio pulmonary Resuscitation (C.P.R).

1. Define cardiopulmonary resuscitation (basic life support).
2. Identify purpose of cardiopulmonary resuscitation.
3. Describe component of cardiopulmonary resuscitation
4. Recognize sings that indicate cardiac arrest.
5. Recognize and operate Automated External Defibrillator (AED)
6. Relate the “Chain of Survival.” For adults
7. Implement technique for Chest Compression and positive pressure
ventilation using a bag-mask device
Definition: Cardio Pulmonary Resuscitation is a basic emergency

procedure for life support consisting of artificial respiration and manual
cardiac massage.
Aim of CPR:
1. To provide oxygen to the vital organ (heart, brain and lung) until
normal circulation is restored.
2. To establish an air way.
3. To initiate breathing.
4. To maintain proper circulation.
Component of CPR:- CPR is divided into 3 phases

1. Basic life support (BLS).
2. Advanced cardiac life support (ACLS).
3. Prolonged life support (PLS).
The “Chain of Survival.”

Saving a life involves a sequence of steps. Each step influence
survival. The steps are often described as the links in the "Chain of
Survival.”
2015 (New): Separate Chains of Survival (Figure 1) have been

recommended that identify the different pathways of care for patients who
experience cardiac arrest in the hospital as distinct from out-of-hospital
settings.
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The “Chain of Survival.” For adults they include
Treatable Causes of Cardiac Arrest: The H’s and T’s
Treatable Causes of Cardiac Arrest: The H’s and T’s
Key issues and major changes in the 2015 (AHA) Guidelines Update
recommendations for HCPs include the following:
 Trained rescuers are encouraged to simultaneously perform some
steps (e.g. checking for breathing and pulse at the same time), in an
effort to reduce the time to first chest compression.
 Integrated teams of highly trained rescuers may use a choreographed
approach that accomplishes multiple steps and assessments
simultaneously rather than the sequential manner used by individual
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rescuers (e.g. one rescuer activates the emergency response system

while another begins chest compressions, a third either provides
ventilation or retrieves the bag-mask device for rescue breaths, and a
fourth retrieves and sets up a defibrillator).
 Increased emphasis has been placed on high-quality CPR using
performance targets (compressions of adequate rate and depth,
allowing complete chest recoil between compressions, minimizing
interruptions in compressions, and avoiding excessive ventilation).
 Compression rate is modified to a range of 100 to 120/min.
 Compression depth for adults is modified to at least 2 inches (5 cm)
but should not exceed 2.4 inches (6 cm).
 To allow full chest wall recoil after each compression, rescuers must
avoid leaning on the chest between compressions.
 Criteria for minimizing interruptions is clarified with a goal of chest
compression fraction as high as possible, with a target of at least 60%.
 For patients with ongoing CPR and an advanced airway in place, a
simplified ventilation rate of 1 breath every 6 seconds (10 breaths
per minute) is recommended.
Basic life support (BLS):

Basic life support (BLS) is the foundation for saving lives following
cardiac arrest. Fundamental aspects of BLS include:
 Immediate recognition of sudden cardiac arrest (SCA).
 Activation of the emergency response system.
 Early cardiopulmonary resuscitation (CPR).
 Rapid defibrillation with an automated external defibrillator (AED).
What Is an Automated External Defibrillator (AED)?

Is device that delivers an electric shock through the chest to the heart.
The shock can stop an irregular rhythm and allow a normal rhythm to
resume in a heart in sudden cardiac arrest.
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Important points when using an AED:
1-Wet chest:
Some patient may have a wet chest, for example due to profound
sweating or following rescuer from water. Quickly wipe the chest dry
before attaching the AED pads to the chest.
2-Jewelry:
Remove any metal jewelry that might come into contac with the AED
pads. Pads should be kept clear of irremovable jewelry, inculding that
used with body piercing.
3-Hairy chest:
Only rarely will a hairy chest cause problems with adherence of the
AED pads. In such cases it may be necessary to shave or cut away some
of the hair to obtain an adequate contact. Do not shave routinely this
wastes valuable time.
4-Plasters:
Remove any plasters or other material attached to the patient's skin to
ensure good AED pad contact. Some patient may have medication
"patches" on their chest wall. These must be removed as they can cause
sparking or burns during defibrillation.
5-Pacemakers:
some patients have a heart pacemaker fitted. These are usually visible
under the skin of the chest wall, just below the collar bone. Ensure that
AED pads are not placed on top of this pacemaker, but just aside or
below.
BLS Consists of those elements of resuscitation:

1.Safety (S)
2.Responsiveness (R)
3.Yell for help (Y)
4.Circulation (C)
5.Air way management (A)
6.Breathing (B)
7.Defibrillator (D)
1. Safety (S): Ensure the area is safe for yourself, others and the patient.
2. Responsiveness (R): Tap the patient's shoulder and ask. "are you all
right?"
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3. Yell for help (Y):Ask another person to tell the doctor and get an
AED
4. Circulation(C)
 Check carotid pulse
 If pulse is absent apply Cardiac compassion
N.B, 2015 New checking for breathing and pulse
at the same time
5. Air way management (A)

The patient must be positioned to maintain patent
air way
Through:
 Head tilt-chin lift
 Jaw- thrust maneuver if cervical spine fracture
is suspected.
6. Breathing (B)
Give rescue breathing by:
 Mouth-to-mask ventilation.
 bag-mask ventilation.
7. Defibrillator (D)
 Apply defibrillator if available and follow voice prompt
 If breathing present put the victim Recovery position
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Complications of CPR:
 Vomiting
 Gastric distention
 Aspiration
 Chest compression-related injuries as rib fracture, laceration of the
liver as a result of compression over the xiphiod process.
When to stop the CPR:

 When the victim relive.
 If you are exhausted and another person can help.
 If the time of CPR is more than 30 minutes and victim did not relive.
Precautions during CPR:

 Be sure the patient airway is clear
 Position patient in supine position on hard, flat surface (floor or
cardiac board)
 Maintain the proper hand position while applying chest compression
 Don‟t let your finger come in contact with ribs
 Kneel closes the patient side and lean forward so that your arms are
directly over the patient and lock elbows.
Step of BLS:
Equipments:
 Trained personnel  Arrest board
 Defibrillator  Bag and mask device
 Oral airway
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Procedure:
Critical performance Details
step
1 Check for responsiveness - Tap the patient's shoulder and ask,
"Are you all right?" speaking loudly and
clearly.
2 Tell someone to activate - Tell someone to perform both actions.
emergency response
system and get an AED.
3 Checks breathing and - Scan the chest for movement (5-10
pulse (breathing and pulse seconds) during Place 2 or 3 fingers of
check can be performed one hand on the tracheal and slip fingers
simultaneously) for at into the groove between the tracheal and
least 5 seconds and no muscles on the side of the neck.
more than 10 seconds
4 Bare the patient's chest - Remove clothing from front of the
and locate CBR hand patient's chest.
position. - Place the heel of one hand on the
center of the chest( lower half of the
sternum).
- Place the other hand on top of the first
hand (or use the second hand to grasp the
wrist of the first hand).
- Extend or interlace fingers to keep off
the chest.
5 **Deliver first cycle of 30 - Position self alongside the patient and
compression at the correct place hands in the proper place on the
rate chest.
- ADEQUATE RATE: 100 to 120/min
(ie, delivers each set of 30 chest
compressions in no less than 15 seconds
and no more than 18 seconds)
- You must do <23 of 30 compressions

correctly: adequate depth at least 2
inches (5 cm), allowing the chest to
return to normal between compression.
6 Give 2 breath (1 second) - Give breath using a bag mask doing C
each &E technique.
- Breaths should take 1 second each.
- Reposition the head if the chest does
not rise.
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- Take no more than 10 seconds to

accomplish 2 breaths or move to
compression.
AED Arrives
AED Turn the AED on, If one rescuer
1 select proper pads, and - Stop CPR and press button to turn
place pads correctly. AED on (or make sure that the AED case
is open if your AED has an automatic-
on feature).
- Recognize the difference between
adult pads and child pads.
If two rescuer
- First rescuer continues compressions
while second rescuer turns on AED and
applies pads.
- Select the proper pads size for
manikin. Apply the pads to chest as pad
diagrams or AED instructions show.
AED Clear the patient to - Show a visible signs of clearing the
2 analyze patient and spoken indication of clearing
the patient: "clear! Stay clear of patient!"
or similar statement, with an obvious
gesture to make sure that all are clear.
AED Clear the patient to - Show a visible signs of clearing the
3 shock/press shock patient and spoken indication of clearing
button. the patient: "clear! Stay clear of patient!"
or similar statement, with an obvious
gesture to make sure that all are clear.
- Press the shock button when prompted
and after clearing.
- For adult patient, time from arrival of
AED to first shock must be less than 45
seconds.
7 Resume CPR: deliver - Place the heel of one hand on the
second cycle of center of the chest (lower half of the
compressions at sternum), Place the other hand on top of
correct hand position. the first hand.
- Do 30 compressions.
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in the correct position.

- Push hand, push fast; allow the chest
to return to normal between
compression.
8 Give 2 breath (1 - Give breath using a bag mask.
second each( - Breaths should take 1 second each.
- Reposition the head if the chest does
not rise.
- Take no more than 10 seconds to
accomplish 2 breaths or move to
compression.
9 Deliver third cycle of - Push hand, push fast ; allow the chest
compression of to return to normal between
adequate depth with compression.
complete chest recoil. - You must do <23 of 30 compressions
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99
Module Title: Intra-aortic balloon pump

1. Define Intra-aortic balloon pump.
2. Illustrate indications of Intra-aortic balloon pump.
3. Predict contraindications of Intra-aortic balloon pump.
4. Determine time of inflation and deflation of Intra-aortic balloon.
5. Prioritize nursing interventions before, during and after insertion
of IABP.
6. Explore complications of Intra-aortic balloon pump.
Intra-aortic balloon pump (IABP):

IABP temporarily cardiac assisted device to reduce myocardial
oxygen demand and left ventricular afterload and increase coronary
perfusion and cardiac output.
Indications
 Cardiogenic shock
 left ventricular failure
 Refractory unstable angina (when drugs have failed)
 Acute MI refractory to medical therapy.
 It‟s also used for patients who suffer pump failure before, during,
or after cardiac surgery and heart transplant.
Contraindications
 Irreversible brain damage
 Major coagulopathy (e.g., disseminated intravascular coagulation)
 Terminal or untreatable diseases of any major organ system
 Abdominal aortic and thoracic aneurysms
 Moderate to severe aortic insufficiency
Placement of the Intra-aortic Balloon

The position of the intra-aortic balloon is critical to its
effectiveness. It must be positioned in the descending thoracic aorta.
Below subclavicula arteries and above renal arteries.
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Effects of Counterpulsation
 The intra-aortic balloon is inflated at the onset of each diastolic period,
when the aortic valve closes. During diastole, the balloon inflates
sending blood back to the heart which then increases perfusion to the
coronary arteries.
 The balloon is deflated at the onset of ventricular systole, just before

aortic valve opens. This deflation permits ejection of blood from the
left ventricular against a lowered resistance. As a result, aortic end-
diastolic pressure and afterload decrease and cardiac output rise.
Nursing considerations
Before insertion of IAPB
1. Explain to the patient
2. Attach the patient to a continuous
ECG monitor and make sure he has an
arterial line, a PA catheter, and a
peripheral I.V. line in place.
3. Gather a surgical tray for
percutaneous catheter insertion
(heparin, normal saline solution, the
IABP catheter, and the pump console.
4. Connect the ECG monitor to the
pump console.
5. Prepare the femoral site
During insertion of IAPB
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6. After the IABP catheter is inserted,

pump inflates the balloon in the
middle of the T wave (diastole) and
deflates with the R wave (before
systole). With the arterial waveform,
the upstroke of the arterial wave
triggers balloon inflation.
7. Frequently assess the insertion site.
8. Don‟t elevate the head of the bed to prevent upward migration
more than 45 degrees of the catheter and occlusion
of the left subclavian artery
9. Assess patient for artery occlusion:
diminished left radial pulse, dizziness.
flank pain or a sudden decrease in
urine output.
10. Assess distal pulses, color,
temperature, and capillary refill of
the patient‟s extremities every 15
minutes for the first 4 hours after
insertion. After 4 hours, assess
hourly for the duration of IABP
therapy.
11. 11-Assess signs of thrombus apply antiembolism
formation, such as a sudden stockings.
weakening of pedal pulses, pain, and
motor or sensory loss.
During insertion of IAPB
12. Sit up, bend his knee, or flex his hip
more than 45 degrees.
13. Encourage active ROM exercises
every 2 hours for the arms, the
unaffected leg, and the affected
ankle.
14. Maintain adequate hydration to prevent thrombus
formation. If bleeding
occurs, apply direct pressure
15. Assess the catheter insertion site
every 2 hours
16. 16-Assess the patient‟s
cardiovascular and respiratory status
at least every 4 hours
17. Administer anticoagulants to prevent thrombus
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Weaning from IABP

18. After the signs and symptoms of
left-sided heart failure diminish by
reducing the frequency of pumping
to prevent thrombus formation.
consoles have a flutter function that
moves the balloon to prevent clot
formation
19. To discontinue the IABP, the doctor
deflates the balloon, clips the
sutures, removes the catheter, and
allows the site to bleed for 5 seconds
to expel clots
20. After the doctor discontinues the
IABP, apply direct pressure for 30
minutes and then apply a pressure
dressing.
21. Evaluate the site for bleeding and
hematoma formation hourly for the
next 4 hours
Complications
 Site infection from invasive lines
 Pneumonia associated with immobilization
 Arterial trauma caused by insertion or displacement of balloon
 Thromboembolism caused by trauma, balloon obstruction of
blood flow distal to catheter
 Hematologic complications caused by platelet aggregation along
the balloon (e.g thrombocytopenia)
 Hemorrhage from insertion site
 Balloon leak or rupture
103
Unit IV
Gastrointestinal System
 Total parenteral nutrition (TPN)
104
Module Title: Total parenteral nutrition (TPN)

1. Define total parenteral nutrition.
2. Clarify indications, components of TPN
3. Formulate principles of total parenteral nutrition.
4. Determine the nursing role of total parenteral nutrition.
5. Solve complications of TPN.
6. Perform nursing care of total parenteral nutrition.
Definition
Parentral nutrition: Is a form of specialized nutrition support in which
nutrients are provided intravenously and may be administered through
peripheral veins (PPN) or central veins (TPN).
Types of Parentral nutrition:

1. Total Parentral nutrition (TPN): administered via central line
2. Peripheral Parentral nutrition(PPN): administered via peripheral
line
Total Parentral nutrition: Refers to the administration of a hypertonic

solution into a large central vein using infusion pump.
Indications of TPN:
1. Patients with a non – functional or dysfunctional gastrointestinal tract
2. Indicated for patient needing a highly concentrated formula when oral
or entral nutrition contraindication for Patients.
3. serum albumin level below 3.5 g/dL
4. renal or hepatic failure
5. severe pancreatitis
6. severe burns
Components of TPN:
Macronutrients
1. Carbohydrate----dextrose or glucose
2. Proteins------------Amino acid.
3. Lipids------------ lipo acid.
Micronutrients
1. Electrolytes (include sodium, potassium,)
2. Vitamins (include fat soluble vitamins &water soluble vitamins)
3. . Trace minerals(include chromium, zinc, copper…)
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Principles of TPN:
1. There are two types of TPN.
a. Total parentral nutrition (TPN) through central line consist of a
complex formation of hyperosmolar dextrose, amino acids, lipids,
minerals, vitamins, trace element and water
b. Peripheral parenteral nutrition (PPN) has a final concentration
of dextrose of 10%or less and administered via peripheral line
N.B: TPN must be infused separately from other fluids,

medications, and blood products because of the high risk for
formula contamination and precipitation
2. Macronutrients
 Carbohydrates:-
The primary source of energy in the body &it provides 40-60%of
daily caloric requirements and it essential for central nervous
system function. The most common source of carbohydrate is
dextrose, the end products of dextrose metabolism is carbon
dioxide.
The most common metabolic side effect of high dextrose
concentration is hyperglycemia, CO2 retention and respiratory
acidosis, this led to difficult of ventilation weaning
 Lipids: -
Lipids typically provide 15% to 30% of daily caloric intake;
Lipids provide a concentrated source of calories, 9 kcal/g, and
they are important in maintaining connective tissue integrity and
preventing fatty acid deficiency
 Amino acid:-
All tissues require protein to maintain structure and facilitate
wound healing. If protein intake is inadequate, the body becomes
catabolic, seeking protein from skeletal muscle and vital organs
amino acid include 50%essenital amino acid and 50% non
essential amino acid 1 g of protein, provides 4 kcal/g.
Terminating the parenteral nutrition

-If the parenteral nutrition needs to be interrupted or is to be discontinued,
the infusion rate is decreased by half for 30 to 60 minutes. This allows for
a plasma glucose response and prevention of rebound hypoglycemia.
- Checking blood glucose levels for 30 to 60 minutes after discontinuation

helps the nurse identify and manage immediate glucose abnormalities.
106
Procedure:
Steps Rational
Patient assessment and preparation
 Anthropometric assessment (as
weight ,height ,skin fold and mid arm
circumference), current nutritional
status (weight -Current laboratory
profile) as:
 Electrolytes
(sodium,potassium,chloride)
 Lab. Investigation:
1. Glucose, phosphate, magnesium
2. Liver function tests,CBC
 Patency of venous access
Nurse: Hand washing
Equipment
 Prescribed PN solution
 IV administration set for electronic
infusion device
 In – line IV filter (i.e.,0.22 micron for
PN solution containing lipids)
 Non sterile gloves
 Syringe needle injection cannula
 Heparin (100 units /ml)
 Electronic infusion device Central
venous catheter
Prepare TPN solution and tubing
a) If refrigerated, allow bag/bottle Prevents infusion of cold fluid,

to stand at room temperature for with resulting discomfort and
15 to 30 minutes chilling
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b) Put time tape on bag/bottle. Aids in monitoring flow rate

c) Close roller clamp/drip regulator Minimizes risk of solution
on filtered tubing. Remove cap Leaking
from filtered tubing to expose
spike. Remove tab/cover from
TPN bag/bottle
d) Spike the TPN solution Reduces the risk of air
container and prime drip embolism; helps to ensure
chamber; open roller solution is administered at
clamp/regulator and prime proper rate
tubing. Attach primed
tubing to infusion pump
1. Verify orders with pharmacy label on -Reduces risk for error..
parentral nutrition.
2. Wash hand. - reduce risk for infection
3. Compare patient identification label -prevents administration of PN
on PN bag. to wrong patient.
4. Aseptically Wipe PN bag with -Reduces transmission of
administration set for electronic microorganism.
infusion device.
5. Wear non sterile gloves. -Reduces exposure to blood
and body fluids.
6. Clamp catheter port. Clean catheter -Reduces microorganisms at
port with povidiene –iodine. catheter hub connection.
7. Clamp catheter port. -prevents air embolism and
blood backup.
8. Remove I.V tube from catheter hub. -Needleless connections
decrease the risk for accidental
needle sticks.
9. Place I.V tube into electronic infusion - Use of an infusion device
device ensures accurate, consistent
delivery of PN.
10. Set prescribed rate of infusion. -consistent delivery of PN
decreases the risk for metabolic
complications.
11. Open clamps on I.V set and catheter.
12. Monitor flow rate and infusion Verifies correct infusion rate;
prevents volume overload or
glucose bolus
13. Assess patency of catheter or venous
access device.
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14. Label PN bag and I.V set with

date,&time
15. Instruct client to keep solution higher Facilitates proper flow of
than chest, to avoid manipulating solution; indicates possible
catheter, and to report any pain, catheter dislodgment or
respiratory distress, warmth, or flushing. infection
16. Monitor client parameters: Allows early detection of
-Vital signs with temperature every 4 to 8 complications; identifies
hours glucose intolerance
-Blood glucose levels every 12 to 24
hours (more frequently if client is
diabetic)
-Urine glucose and electrolytes (watch
for
signs of hyperglycemia
17.Assess central line site every Aids in identifying
shift; provide care every 72 hours complications early on and
or per policy reduces the risk for infection
18.Obtain daily weights and monitor Provides information to
total protein and albumin levels evaluate effectiveness of
therapy
Documentation
The following should be noted on the client's chart:
Time TPN bottle/bag is hung, number of bottles/bags, and rate of infusion
Site of IV catheter and verification of patency
Status of dressing and site, if visible
Laboratory results
Vital signs and weights
Patient tolerance to TPN
Role of the nurse:

1. Obtain weight daily
2. Monitor vital signs
3. Intake and output measurement
4. Laboratory data as monitor electrolytes, glucose, blood count
and renal function test
5. Prevent complication and assess for ↑or ↓ nutritional element.
6. Monitor signs of dehydration(thirst, dry mucus membrane,
tachycardia and poor skin turgor)
7. Monitor signs of fluid excess(peripheral edema, dysnea,
pulmonary edema)
8. Chest x-rays.
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9. Using infusion pump and give slowly

10. Check for signs of allergy as (fever, chills, chest tightness,
dyspnea, tachycardia, headache, nausea and vomiting
11. Prevent using another drugs in the same lumen with TPN
12. Reheparinization of central line to prevent clotting (clots)
13. Check glucose level / 2houres
Complications of TPN:
1.Mechanical complications
 Pneumothorax/ hemothorax
 Bleeding/ hematoma
 Cardiac dysrhythmia
 Air embolism
 Catheter embolism
 Cardiac tamponade
 Catheter mal position
2.Metabolic complications
 Carbohydrates complications: Hypoglycemia,hyperglemia,hyperglycmic hypero
coma,co2 retention
 protein complications: uremia, amino acid deficiency
 Lipid complications: Lipedemia, lipoacid deficiency
 Mineral complications: Hypo/hypercalemia,hypo/hyperkalemia,hypo/hyper
natremia,hypo/hypermagnecemia,iron deficiency anemia
 Hypo or hypervolemia-.
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Unit V
Renal System
 Continuous renal replacement therapy
111
Module Title: Continuous renal replacement therapy

1. Define continuous renal replacement therapy.
2. Identify indications, contraindications and principles and
complications of continuous renal replacement therapy.
3. Analyze medical products required to perform CRRT on a patient.
4. Perform nursing care of continuous renal replacement therapy.
5. Explain the procedure to the patients.
6. Analyze complications of continuous renal replacement therapy
Continuous renal replacement treatment (CRRT)
Definition:
Is a type of blood purification therapy used with patients who are

experiencing AKI , allows patients with unstable blood pressure and heart
rates to better tolerate this process which performed over a 24 hours
period.
During this therapy, a patient‟s blood passes through a special filter
that removes fluid and uremic toxins, returning clean blood to the body.
Indications:
a) Conditions of fluid overload or cardiovascular instability requiring
a continuous method of fluid removal for azotemia (e.g. acute
tubular necrosis)
b) Ascites, diuretic-resistant edema, acute pulmonary edema
c) Post cardiac surgery, recent acute myocardial infarction
d) Inability to tolerate the cardiovascular impact of rapid fluid losses
associated with hemodialysis or failure of a trial of hemodialysis
e) Persistent/progressive acute kidney injury
112
Contraindication:
 Homodynamic instability.
 Inability to anticoagulant.
 Lack of access to circulation.
Principles of Hemodialysis
 Diffusion is the passive movement of solutes through a
semipermeable membrane from an area of higher to lower
concentration until equilibrium is reached.
 Ultafiltration is the bulk movement of solute and solvent through
a semipermeable rnembrane using a pressure movement.
 Osmosis is the passive movement of solvent through a
semipermeable membrane from an area of higher to lower
concentration.
Types of CRRT:
1. Slow continuous ultrafiltration (SCUF)
2. Continuous arteriovenous hemofiltration (CAVH)
3. Continuous arteriovenbus hemodialysis (or hemodiafiltration)
(CAVHD)
4. Continuous venovenous hemofiltration (CWH)
5. Continuous venovenous hemodialysis (CWHD) or hemodiafil-
tration (CWHDF); involves the use of a hollow-fiber hemofil-ter
capable of rapid fluid removal during hypotensive or low blood
flow states
Temporary vascular access for dialysis:
Double- or triple-lumen catheter:

- Requires the use of a large vein, such as the femoral vein
- Used for emergent dialysis
- Blood flow must range from 200 to 500 mL/min
- Other sites include the right or left subclavian and right or left
jugular vein.
Procedure:-
- Palpate peripheral pulses in the cannulated extremity
- Observe for bleeding or hematoma formation; if it occurs, apply
pressure dressing and notify the physician
- Properly position the catheter to avoid dislodgment during the
dialysis procedure
- If the femoral vein catheter is to be maintained after dialysis,
113
connect it to a pressurized IV flow system. Add a low dose of

heparin (500 U/L) to the solution. Maintain a secure aseptic
dressing to minimize the risk of infection. No standing or
ambulation is allowed while the catheter is in place.
- On removal of a femoral catheter, apply direct pressure to the
puncture site for 5 to 10 minutes (or the time needed to stop the
bleeding after dialysis and after the period of heparinization).
Complete this procedure with the application of a pressure
dressing and a period of bed rest.
Anticoagulation:
 Heparin used in SCUF, CAVH, and CAVHD
 Heparin or trisodium citrate used in CRRT machine forms of
CWH, CWHD, and CWHF
 Trisodium citrate causes binding of serum calcium; therefore, must
monitor calcium levels. Calcium administration may be
necessary.
Frequency:
A continuous dialysis form providing the ability to dialyze 24 hours a day
and 7 days a week.
Dialysate solutions:
The routine dialysate solution is acetate that induce hypotension,
bicarbonate dialysate solution that increase blood pressure
Medical products required to perform CRRT on a patient:
 Blood purification machine: the machine pumps the blood,

controls the rate of blood flow and includes software to safely
monitor therapy delivery
 Dialysate: a fluid that carries toxins away from the filter
 Replacement fluid: a specialized, sterile fluid also used to flush
toxins from the body but also to replace electrolytes, other blood
elements and volume lost during the filtration process
 Filter: machine component that removes fluid and uremic toxins
 Anticoagulation method: a type of drug that helps the blood flow
through the system, lessening the likelihood that the blood will
clot in the filter
 Blood warmer: efficiently maintains a patient's blood
temperature during blood purification therapy
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Equipments:
- Masks, goggles - Dialysate fluid, as ordered

- Sharps container - Sterile gloves, clean gloves
- Two 10-ml syringes and two 3-ml - Alcohol wipes
syringes - Two 19-G needles.
- Sterile normal saline (NS), 3 L
- Dressing supplies (sterile barrier, gauze pads, transparent dressing,
tape)
- Povidone-iodine solution/swabs or chlorhexidine bactericidal solution
- Heparin (1000 unit/ml) (both for priming and infusion, as ordered)
Nursing intervention in heamodialysis:
Action Rational
Preparation
1. Assessment patient's history and clinical -To protect patient from
finding, response to previous dialysis any complication
treatment laboratory results (BUN, serum
creatinine, sodium, potassium and
phosphate levels).
2. Record vital signs: weight, temperature, - To check patient status
pulse, respiration and blood pressure.
3. Explain the procedure and its purpose. - To prevent anxiety

Monitor for AV fistula patency at frequent
intervals (palpate for thrill and auscultation
for bruit).
4. Graft, fistula, or catheter insertion site - Because dialysis access

for signs or symptoms of infection. sites are used frequently,
infection is always a
potential risk
5. Catheter patency and the ability to easily - Adequate blood flow is

aspirate blood from both ports. necessary during a
treatment
6. Check equipment and solutions.
7. Measure blood pressure and pulse every

half hour.
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8. Check and record the machine

pressure and flow rates.
9. Assess the patient response to fluid and

solute removal and the condition and
function of patient vascular access
10. Monitor clotting times and adjust

heparin administer.
11. Position the patient in a comfortable - Facilitating patient

position (that will also facilitate optimal comfort
blood flow through the catheter and allow
for the setup of a sterile field).
12. Weight the patient

During procedure:
1. After vascular access is established

through strict aseptic technique blood
begins to flow, assisted by the blood
pump.
2. The arterial needle is placed closest to

the arteriovenous anastomosis in a graft or
fistula to maximize blood flow.
3. Aclamped saline bag always is attached

to the circuit just before the blood pump.
4. Heparin infusions may be located either - To prevent clotting

before or after the blood pump, depending
on the equipment in use.
5. Blood flows into the blood compartment

of the dialyzer, where exchange of fluid
and waste products takes place.
6. Blood leaving the dialyzer passes

through an air detector that shuts down the
blood pump if any air is detected.
7. Blood that has passed through the
116
dialyzer returns to the patient through the

venous (postdialyzer) line.
8. After the prescribed treatment time,

dialysis is terminated by clamping off
blood from the patient, opening the saline
line, and rinsing the circuit to return the
patient's blood.
9. A dialysis nurse is in constant -To maintain patient life's

attendance during acute hemodialysis.
Blood pressure and pulse are recorded at
least every half hour when the patient's
condition is stable
10. All machine pressures and flow rates

are checked and recorded on a regular
basis.
11. The nurse assesses the patient's

responses to fluid and solute removal and
the condition and function of the patient's
vascular access.
Post procedure:
12. After the dialysis is terminated, weight -To assess fluid loss
the patient.
13. Obtain complete renal function test, -To assess kidney function
electrolytes, and hemoglobin
Complications of Heamodialysis :-
a) Catheter-related complications
 Hemorrhage
 Infection
 Venous thrombosis
 Venous stenosis
117
b) Traumatic arteriovenous fistula

 Pneumothorax
 Hemothorax
 Air embolism
 Visceral injury
c) Extracorporeal circuit-related complications
 Allergic reaction to hemodialyzer/hemofilter or
tubing
 Circuit thrombosis
 Hemolysis
 Air embolism
 Hypothermia
 Hypotension
d) Electrolyte disturbances
 Hypophosphatemia
 Hypokalemia
 Hypocalcemia
 Hypomagnesemia
118
References:
1. Morton,P.G, and Fontaine,D.k.,(2017) .Critical Care Nursing; A
Holistic Approach, 11th edition, Wolter Kluwer.
2. Baird,M.S.(2017).Manual of critical care Nursing :Nursing
Interventions and Collaborative Management. Elsevier Health
sciences.
3. Nettina S. (2015) manual of nursing Practice. 7th ed. Philadelphia:
Lippincott Williams & wilkins.
4. Chernecky CC, Berger BJ (2015). Laboratory Tests and
Diagnostic Procedures, 5th ed. St. Louis: Saunders.
5. Fischbach FT, Dunning MB III, eds(2016). Manual of Laboratory
and Diagnostic Tests, 8th ed. Philadelphia: Lippincott Williams and
Wilkins.
6. Morton P. (2016) Critical Care Nursing: A Holistic Approach 10
edition Wolters Kluwer.
7. American Heart Association. Web-based Integrated Guidelines
for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care – Part 5: Adult Basic Life Support and Cardiopulmonary
Resuscitation Quality. ECCguidelines.heart.org. © Copyright 2015
American Heart Association.
8. Margaret R. Colyar (2015). Avanced Practice Nursing Procedures,
by F. A. Davis Company.
119

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Critical Care and Emergency Nursing

Accredited Faculty by National Authority for Critical Care and Emergency

Procedure manual for Critical Care

Accredited Faculty by National Authority for Critical Care and Emergency

‫األهداف االستراتيجية للكلية‬

‫نتطىَر انًستًر نهقذرح انتعهًُُخ نًرحهخ انجكبنىرَىش‪.‬‬ ‫‪‬‬

Assessment of the critically ill patient

Objectives based on competence:

Importance of assessment is for critically ill & emergency patient

Activities required for assessment:

These initial informal observations can give subtle clues about a

carefully, and watch for body language signals. If a person is

The structure of the assessment interview as covering the following

Reason for admission

P – Provocative or palliative. What helps or worsens the symptoms?

Past medical history

g- Psychosocial history (occupation; Identifies psychosocial,

Assess general appearance Provides objective cues about

refill, and joints of head, neck, and lymph enlargement

Inspect for abnormalities of teeth.

Remember: Perform auscultation BEFORE Palpation and percussion set

Assessment of the emergency patient

The scope of emergency nursing practice involves the assessment,

1. Date and time of assessment

Module Title: Oropharyngeal Airway

1. Clarify oropharyngeal airway.

Definition: An oropharyngeal airway: is a semicircular plastic or rubber

Purpose: Protect the airway of an unconscious patient by preventing the

2. Assess LOC, oral secretions, lung

7. Position patient in semi Fowler‟s Facilitates airway insertion.

8. Suction patient, if necessary. Removes excess secretions.

contour of the roof of the mouth.

11. Ensure accurate placement and If the airway is placed correctly,

Care of the patient with oral airway:

Module Title: laryngeal mask airway (LMA)

Laryngeal mask airway (LMA)

1. Elective ventilation: The laryngeal mask airway (LMA) is an

4. Conduit for intubation: The LMA can be used as a conduit for

Contraindications and cautions:

Laryngeal Mask Airway Size Based on Patient Weight and cuff

Weight, kg Mask Size Max Cuff Volume, mL

and require oropharyngeal or tracheal

7. Coat the posterior surface of the -facilitates smooth insertion.

9. Insert the LMA with the cuff tip

10. Using your index finger to push the

11. Advance the mask until resistance

13. Inflate the cuff with air; the

Module Title: Endotracheal Tube intubation

Definition of Endotracheal intubation

What Size Endotracheal Tube?

ETT Depth of insertion

Indications for Intubation

2. History of trauma when spinal -To allow for selection of the

appropriately: -To prevent secondary injury if

12. Check the correct position of the

wall movement and any signs

 Inability to pass a suction

Module Title:-Endotracheal tube care

Module Title: Tracheal cuff care

Techniques used to measure cuff pressure

2- Minimum occlusion volume (MOV):

 Stethoscope  Reintubatoin equipments in case

with device connector and

25-30 CmH2O = 20-25 mmhg