NCM 112 RLE (Prelim)

BLOOD PPRESSURE Procedure to Measure BP

 It is the force exerted by the blood against the walls of the
arteries in which it is flowing.
 It is expressed in terms of millimeters of mercury (mm of
Hg).
There are two types of BP:
1. Systolic pressure is the maximum of the pressure against
the wall of the vessel following ventricular contraction.
2. Diastolic pressure is the minimum pressure of the blood
against the walls of the vessels following closure of aortic
valve (ventricular relaxation).
 BP is measured by using an instrument called Bp cuff
(sphygmomanometer) & stethoscope and
 the average normal value is 120/80mmHg for adults.
 brachial artery and popliteal artery are most commonly used.
 It is measured by securing the Bp cuff to the upper arm & thigh
placing the stethoscope on brachial artery in the antecubital
space & popliteal artery at the back of the knee.
 Pulse pressure: is the difference between the systolic and
diastolic pressure
Factors Affecting Blood Pressure
 Fever
 Stress
 Arteriosclerosis
 Exposure to cold
 Obesity
 Hemorrhage
 Low hematocrit
 External heat
Sites for Measuring Blood Pressure
 Upper arm (using brachial artery (commonest)
 Thigh around popliteal artery
 Fore -armusing radial artery
 Leg using posterior tibial or dorsal pedis
Assessing Blood Pressure
Purpose:
 To obtain base line measure of arterial blood pressure for
subsequent evaluation
 To determine the client’s homodynamic status
 To identify and monitor changes in blood pressure.
 Explain the procedure to the patient & remove any light
cloth from patient’s arm
 Make sure that the client has not smoked or ingested
caffeine, within 30 minutes prior to measurement.
 Position the patient on lying, sitting, or standing position,
but always ensure that the sphygmomanometer is at the
level of the heart with the arm supported & the palm
facing upwards.
 Apply cuff snugly/securely around the arm, 2.5cm above
the antecubital space/fossa, at the level of the heart (for
every cm the cuff sites above or below the level of the
heart the BP varies by 0.8mmHg)
 Palpate the radial pulse and inflate the cuff until the radial
pulse can no longer be felt, this provides an estimation of
systolic pressure.
 Inflate cuff 30mmHg higher than estimated systolic
pressure.
 Palpate the brachial artery & place the bell of the
stethoscope over the site & the ear pieces on ear, apply
enough pressure to keep the stethoscope in place (the bell
of the stethoscope is designed to amplify/intensify low
frequency sounds)
 Deflate the cuff 2-4mmHg per second.
 The first pulse heard is the systolic reading, continue to
deflate until there is a change in tone to a muffled beat,
this is the diastolic reading.
 Deflate & remove cuff roll neatly and replace.
 Record the systolic and diastolic pressure on vital sing
sheet and compare the present reading with previous
reading.
 Report or treat any change
 Clear ear pieces and bell of the stethoscope with antiseptic
swab and returns all equipment.
ADULT BASIC LIFE SUPPORT
The Good Samaritan Law
 Good Samaritan laws only protect those that have had
basic first aid training and are certified. In other
jurisdictions, any rescuer is protected from liability,
granted the responder acted rationally. If one is neither
trained in first aid nor certified, and performs first aid
incorrectly, one can still be held liable.

Equipment:
 Stethoscope
 Blood pressure cuff of the appropriate size
 Sphygmomanometer
 If sudden cardiac death occurs outside the hospital setting,
cardiopulmonary resuscitation (CPR) must begin within 4 to 6
minutes and advanced life support measures must begin within 8
minutes, to avoid brain death.
Heart diseases are the #1 killer in our country, accounting for close
to 20% of all causes of death according to the latest Dept of Health
Objectives of this Presentation
statistics.
 To increase awareness and knowledge on Basic
Cardiopulmonary Resuscitation (CPR) as a life-saving
Sudden Cardiac Arrest – A Health Burden
procedure for victims of sudden cardiac arrest.
 Approximately 50% of deaths from cardiovascular disease
 To demonstrate the different steps and techniques of CPR.
occur as SUDDEN CARDIAC ARREST.
 Sudden Cardiac Arrest is the most common mode of death
What is C P R?
in patients with coronary artery disease.
CPR = Cardio-Pulmonary Resuscitation
 It is an Emergency procedure used when someone’s heart
In general, it is estimated that approximately 50% of deaths from
stops beating. It is a Simple procedure that can be learned
cardiovascular disease occur as sudden cardiac arrest or sudden
by anyone, and consists of a Manual technique using
cardiac death, wherein the heart suddenly goes into very irregular
repetitive pressing to the chest and breathing into the
fast ineffective contractions, the heart stops beating, the victim loses
person's airways that keeps enough oxygen and blood
consciousness, and if untreated, dies.
flowing to the brain
 CPR requires no special medical skills and training is
Sudden cardiac death is the single largest categoric cause of natural
available for the ordinary person nationwide.
death in the US, and probably also in the Philippines, and it is the
most common mode of death in patients with coronary artery
disease.

Health Burden of Sudden Cardiac Arrest

 Almost 80-percent of out-of-hospital cardiac arrests occur
at home and are witnessed by a family member.
 Only 4-6 % of sudden cardiac arrest victims survive
because majority of those witnessing the arrest do not
know how to perform CPR.

Sudden Cardiac Arrest

 Unpredictable and can happen to anyone, anywhere, at
anytime
 Risk increases with age
 Pre-existing heart disease is a common cause
 May strike people with no history of cardiac disease or
cardiac symptoms
Effective CPR done immediately after cardiac arrest can double a
victim’s chance of survival.
The First Link – Early Access
 A well-informed lay person - key in the early access link.
 Recognition of signs of heart attack and respiratory failure
 Call for help immediately if needed
 Activate the Emergency Medical System
Early Warning Signs of Heart Attack
 Prolonged compressing pain or unusual discomfort in the
center of the chest
 May radiate to shoulder, arm, neck, or jaw, usually on the
left side
 May be accompanied by sweating, nausea, vomiting and
shortness of breath

Early Warning Signs of Respiratory Failure

  Unable to speak, breath or cough
 Clutches neck (universal distress signal)
 Bluish color of skin and lips
Second Link – Early CPR
 Lifesaving technique for cardiac & respiratory arrest
 Chest compressions +/- Rescue breathing
 Lay persons and medical personnel
Why is early CPR important?
 CPR is the best treatment for cardiac arrest until the arrival
of ACLS care.
 may increase the chance of defibrillation
 It significantly improves survival.
When will you do CPR?
 AS SOON AS POSSIBLE! Any delay in starting CPR reduces
the chances of survival.
 Brain cells begin to die after 4-6 minutes without oxygen.
Who may learn about CPR?
 CPR is an easy and lifesaving procedure and can be learned
by anyone.
 One does not need to be a doctor to learn how to do CPR.
The Technique and Steps in CPR Non-Responsive
1. Check area safety. Survey the scene, see if the scene is safe
to do CPR. Get an idea of what happened.
2. Check unresponsiveness. Tap or gently shake the victim.
Rescuer shouts “are you OK?” Quick check for normal
breathing. If the victim is unconscious, rescuer calls for
help.
3. Call for help: ambulance, emergency services, doctor.
Rescuer activates the emergency medical services. Get
AED/Defibrillator
AED = Automated External Defibrillator
Pulse Check
 Palpate for Carotid Pulse within 10 seconds
 (At the same time CHECK FOR BREATHING)
 For trained healthcare providers only
If with definite pulse but no breathing:
 Do mouth-to-mouth breathing
 Give one breath every 5-6 secs (about 12 breaths/min)
 Recheck pulse every 2 minutes
Mouth To Mouth Breathing and Pulse Check
 Deemphasized in the new guidelines
 For trained healthcare providers only
 As short and quick as possible
 Pulse check not more than 10 seconds
 If unsure, proceed directly to CHEST COMPRESSIONS!
After determining unconsciousness, C-A-B
C. COMPRESSION – Do chest compressions first
A. AIRWAY – Does the victim have an open airway (air passage that
allows the victim to breathe)?
B. BREATHING Is the victim breathing?
C – Compression (to assist Circulation)
After determining unconsciousness and calling for help, proceed
immediately to do CHEST COMPRESSIONS!
Chest Compressions:
 Kneel facing victim’s chest
 Place the heel of your hand on the sternum in the center
of the victim's chest. Put your other hand on top of the
first with your fingers interlaced. Depress the sternum
approximately 1 1⁄2 to 2 inches (approximately 4 to 5 cm)
and then allow the chest to return to its normal position
 Place the heel of one hand on the sternum in the center of
the chest between the nipples and then place the heel of
the second hand on top of the first so that the hands are
overlapped and parallel.
 Position shoulders over hands with elbows locked and
arms straight
 Compress down and release pressure smoothly, keeping
hand contact with chest at all times
 Give Chest Compressions at 100 per minute
 Compress breastbone at least 2 inches deep
 Compress at a rate of 100 per minute or more
 Compress 30 times initially
 Allow the chest to return to its normal position
 Compress breastbone at least 2 inches
 (30 compressions should take 15-18 sec)
 Count aloud “1, 2, 3, 4,
5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,
26,27,28,29, and ONE!”
 Minimize interruptions
 Allow recoil after each compression
Give chest compression at 100/ minute to the tune of
Bee Gees’ “Staying Alive”
A – Airway
(Open the airway, use the head tilt/chin lift method)
 Place one hand on the victim’s forehead
 Place fingers of other hand under the bony part of lower
jaw near chin
 Tilt head and lift jaw--avoid closing victim’s mouth
 Head tilt, chin lift maneuver – This maneuver prevents
airway obstruction by the epiglottis.
B – Breathing
(Give 2 one-second breaths)
 Maintain airway
 Pinch nose shut
 Open your mouth wide, take a normal breath, and make a
tight seal around outside of victim’s mouth
 Give 2 full breaths (1 sec/ breath)
 Observe chest rise & fall; listen & feel for escaping air
 Repeat cycles of 30 compressions & 2 breaths for 5 cycles

Pulse Check
 RECHECK PULSE EVERY 2 MINUTES (equivalent to 5 cycles
CPR)
 Very brief pulse check – should take less than 10 seconds
(at the same time check for normal breathing)
 In case there is any doubt about the presence or absence
of pulse, CONTINUE CHEST COMPRESSIONS
 For trained healthcare providers only
MEMORIZE THE STEPS
 Survey the scene.
 Check responsiveness – hey hey are you ok?
 Call for help! Activate EMS
 [Quick check pulse within 10 secs]
 C – Chest Compressions: 30 x; 100/min; 2 inches deep;
push hard and fast
 A - Airway: head tilt chin lift
 B – Breathing: 2 breaths (1 second/breath)
 Chest compressions 30 x
 Continue cycles 30:2 compression-ventilation
 [Quick check pulse every 2 mins]
 Until:
 EMS arrives (AED, doctor, ambulance)
 Patient has signs of life

IF YOU ARE…
 NOT TRAINED
Continue CPR until:  DO NOT KNOW MOUTH TO MOUTH VENTILATION
 Help arrives. (Emergency services, ambulance, doctor,  NOT SURE ABOUT MOUTH-TO-MOUTH VENTILATION
AED)  HESITANT TO DO MOUTH TO MOUTH VENTILATION
 Person is revived  DO NOT WANT TO DO MOUTH TO MOUTH VENTILATION

If the victim is breathing: Hands Only CPR

 Recovery position: side-lying  Compression-only bystander CPR
 Maintain open airway and position the victim  Several human studies suggest that trained rescuers
 The unresponsive victim with spontaneous respirations performing traditional 1-person CPR take much longer to
should be placed in the recovery position if no cervical initiate CPR than those trained to perform hands-only CPR.
trauma is suspected.
 Placement in this position consists of rolling the victim DONT's in External Chest Compression
onto his or her side to help protect the airway. 1. Jerker
2. Massager
3. Bender
4. Rocker
5. Bouncer
6. Double Crosser

Hands only CPR should only be used for adult victims who have
suddenly collapsed or become unresponsive.

Hands Only CPR: Recommendations

  All victims of cardiac arrest should receive high-quality
chest compressions
 When an adult suddenly collapses, all bystanders should
activate their community EMS and provide high-quality
chest compressions, minimizing interruptions (Class I).
 If not trained in CPR, provide hands-only CPR (Class IIa)
until
 AED arrives
 EMS providers take over care of the victim
 If trained in CPR, provide either conventional CPR using a
30:2 compression-to-ventilation ratio (Class IIa) or hands
only CPR (Class IIa)
Key Changes in the New Guidelines
 CAB instead of ABC
 Compress first
 No more Look Listen and Feel
 Harder! → At least 2 inches compression (old: 1 ½ to 2
inches)
 Faster! → At least 100/min compression (old: up to
100/min)
 Deemphasize pulse checks
 For trained healthcare providers  not more than 10
secs
 Check for normal breathing together with check for
unresponsiveness
 Hands only CPR for the untrained lay rescuer
Important Points
 There are no mistakes when you perform CPR.
 The only harm is to delay responding.
 Start chest compressions → now viewed as the most
effective procedure
 All victims in cardiac arrest need chest compressions.
 Don't stop pushing.
 Keep pushing as long as you can. Push until the AED is
in place and ready to analyze the heart. When it is
time to do mouth to mouth, do it quick and get right
back on the chest.
 80-90% of cardiac emergencies occur at home.
 Training is now simpler and more accessible
 Reduced number of steps and simplified process
 Being trained to do CPR can save a loved one.
 Effective CPR done immediately after cardiac arrest can
double a victim’s chance of survival.
ADMINISTERING OXYGEN BY CANNULA, FACE MASK
Equipment:
1. Oxygen source
2. Flow meter
3. Oxygen tubing
4. Nasal cannula/oxygen mask
5. Pre filled humidification device
Assessment:
 Assess the patient’s comprehension of oxygen therapy.
- Rationale: Understanding allays anxiety and promotes
cooperation
 Assess the patient’s respiratory status, including
respiratory rate, depth, and rhythm; breath sounds, color,
and pulse oximetry results.
- Rationale: Determines the need for and effectiveness
of oxygen therapy.
 Assess nares (if nasal cannula is being used) and ears for
signs of skin breakdown.
Procedural steps:
1. Attach the flow meter to the wall oxygen source. If you are
using a portable oxygen tank, attach the flow meter to the
tank if it is not already connected.
- Rationale: The flow meter regulates the amount of
oxygen delivered.
2. Assemble the oxygen equipment.
- Rationale: Assembling the oxygen equipment readies
the equipment for oxygen administration.
Nasal Cannula
3. Attach the humidifier to the flow meter. If you are not
using a humidifier, attach the adapter to the flow meter.
- Rationale: Humidification prevents drying of the nasal
membranes.
4. Attach the nasal cannula to the humidifier or the adapter.
5. Place the nasal prongs in the patient’s nares, and then
place the tubing around each ear.
- Rationale: Properly positions the device for successful
oxygen delivery.
6. Use the slide adjustment device to tighten the cannula in
place under patient’s chin.
- Rationale: The nasal cannula must fit securely to
ensure accurate oxygen delivery.
7. Turn on the oxygen using flow meter, and adjust it
according to the prescribed flow rate.
- Rationale: Ensures that oxygen is delivered at the
prescribed rate. Oxygen delivered at an incorrect rate
can cause patient injury.
8. Make sure that the oxygen equipment is set up correctly
and functioning properly before you leave the patient’s
bedside.
Face Mask
9. Attach the prefilled humidifier to the flow meter.
- Rationale: The humidification device must be
attached to the flow meter to ensure delivery of
humidified oxygen, which prevents the drying of
airways that occurs with high oxygen flow rate.
10. Attach the oxygen tubing connected to the mask to the
humidifier.
- Rationale: Prepares the tubing for oxygen delivery.
 11. Gently place the face mask on the patient’s face, applying  Nasal cannula
it from the bridge of the nose to under the chin.  Simple face mask
- Rationale: Fits the mask snugly to the patient’s face,  Venturi mask
preventing oxygen from escaping around the edges of  Partial re-breathing mask
the mask.  Non re-breathing mask
12. Secure the elastic band around the back of the patient’s  Tracheostomy mask / collar
head. Make sure the mask fits snugly but comfortably.  T-piece
- Rationale: the mask must fit snugly so that oxygen  O₂ hood / tent
cannot escape around the edges of the mask. The  Aerosolized oxygen delivery device
mask must also fit comfortably because a fit that is
too tight may skin breakdown.
13. Turn on the oxygen, using the flow meter and adjust it
according to the prescribed flow rate.
- Rationale: Ensures that oxygen is delivered at the
prescribed rate. Oxygen delivered at an incorrect rate
can cause patient’s injury.
14. Make sure that the oxygen, equipment is set up correctly
and functioning, properly before you leave the patient’s
bedside.

Normal Values:
 RBC: 4.5 to 5.5 M/cu.mm
 WBC: 5,000 – 10,000/cu.mm
 Platelet: 150,000 – 450,000/cu.mm
 Hemoglobin: 12 - 17 g/dl
 Oxygen Saturation: above 95% - 100%

Elevated RBC’s suggests inadequate tissue oxygenation. Hypoxia Nasal Cannula / Prong
stimulates renal secretion of erythropoietin. This stimulates the
bone marrow to increase RBC production (Polycythemia)

Elevated WBC’s may indicate infectious heart diseases and

myocardial infarction.

OXYGEN DELIVERY SYSTEM

Partial Re-Breather Mask

Purpose of Oxygenation:
 To relieve dyspnea
 To prevent hypoxemia and hypoxia Non-Re-Breather Mask
 To increase tissue oxygenation

Different Oxygen Delivery System:

Venturi Mask
ENDOTRACHEAL SUCTIONING-ASSESSMENT AND CLINICAL
INDICATIONS

What is a tracheostomy?
 A tracheotomy or a tracheostomy is an opening surgically
created through the neck into the trachea (windpipe) to
allow direct access to the breathing tube and is commonly
done in an operating room under general anesthesia.
 A tube is usually placed through this opening to provide an
airway and to remove secretions from the lungs. 
Breathing is done through the tracheostomy tube rather
than through the nose and mouth.
 The term “tracheotomy” refers to the incision into the
trachea (windpipe) that forms a temporary or permanent
Oxygen Hood opening, which is called a “tracheostomy,

Open Airway Suction System

 Referred sometimes open method of suctioning.
 Patient was connected to mechanical ventilator the
nurse disconnects, to the ventilator and suctions the
airway and  reconnects the patient to the ventilator and
discard the suction catheter.

Tracheostomy Collar / Mask Closed Airway/Tracheal Suction System

 The connection catheter attaches to the ventilator tubing
and the patient does not need to disconnected from the
ventilator.
 The nurse is not exposed to any secretions because the
suction catheter is enclosed in a plastic sheet.

Suctioning – is a removal of material through the use of negative

T-Piece
pressure

To maintain a patent airway and improve oxygenation by removing

mucous secretions and foreign material (vomit or gastric secretions)
from the mouth and throat (oropharynx).

Assesment: Clinical Signs Indicating Need for Suctioning

 Restlessness
 Gurgling sounds during respiration
 Adventitious (abnormal) breath sounds when the chest is
auscultated
 Change in mental status
 Skin color
 Rate and pattern of respirations
 Pulse rate and rhythm

Objective Assessment
 Secretions from mouth and tracheal stoma
 Auscultation of lung sounds
 Heart rate
 Respiratory rate
 Cardiac rhythm
 Oxygen saturation
 Skin color and perfusion
  Effectiveness of cough
 Prepare the patient by explaining the procedure and
providing adequate sedation and pain relief as needed.
Place the patient in semi-Fowler’s position if conscious or
in a lateral position facing you if they are unconscious.
 While suctioning the patient, if signs of worsening
respiratory distress occur, stop the procedure and request
emergency assistance.
Monitored Patient During and Post Procedure
 Lung sounds
 Skin color
 Breathing pattern and rate
 Oxygenation (pulse oximeter)
 Pulse rate
 Dysrhythmias if electrocardiogram is available
 Color, consistency, and volume of secretions
 Presence of bleeding or evidence of physical trauma
 Subjective response including pain
 Cough
 Laryngospasm (spasm of the vocal cords that can result in
airway obstruction)
Post-Procedure Evaluated and Documented
 Improvement of lung sounds
 Removal of secretions
 Improvement of pulse oximetry
 Decreased work of breathing
 Stabilized respiratory rate
 Decreased dyspnea
Be aware that the patient’s lung sounds may not clear completely
after suctioning, but the removal of secretions should improve the
patency of the patient’s airway.
Potential Complications
 Includes nasal irritation/bleeding, gagging/vomiting,
discomfort and pain, and uncontrolled coughing.
 Potential adverse reactions include mucosal hemorrhage,
laceration of nasal turbinate, perforation of the pharynx
 Hypoxia
 Hypoxemia
 Cardiac dysrhythmias/
 Arrest, bradycardia, elevated blood pressure, hypotension
 Respiratory arrest, laryngospasm, bronchoconstriction,
bronchospasm, hospital-acquired infection, atelectasis
 Increased intracranial pressure, and pneumothorax.
Conduct a Risk Assessment
Some patients face a higher risk of suctioning-related
morbidity. They include:
 Recent head or neck injury
 Geriatric and pediatric patients who have fragile airways
 With cognitive or mental health
 Loose dental hardware
 Difficult airway or history of suctioning complications
 Bradycardia
 Hypoxia
Nurses must avoid routing suctioning without first assessing the risk.
Prepare the Patient
Suctioning can be scary and uncomfortable.
 Explain the procedure ahead of time.
 When working with a child or a person with cognitive
disabilities, explain things in terms they can understand,
and be warm and reassuring.
 Ask their relative to remain present and avoid using force
or restraints unless necessary.
 During the procedure, reassure the patient that they are
safe.
 If there are unusual sounds that could be frightening or
complications that require additional treatment, continue
to reassure the patient, and inform them what you are
doing.
 Even if the patient is very young, very old, or very
confused, talking to them can be reassuring and is a sign of
respect.
 Do not talk about the patient as if they are not there or
cannot hear you.
When to Suction?
 Any time the patient feels or hears mucus rattling in the
tube or airway
 In the morning when the patient first wakes up
 Increased respiratory rate (working hard to breathe)
 Before meals
 Before going outdoors.
 Before going to sleep
Do Not Suction Too Long
 Prolonged suctioning increases the risk of hypoxia and
other complications
 Never suction a patient for longer than 15 seconds.
 Rather than prolonged suctioning, withdraw the catheter,
re-oxygenate the patient, and suction again.

NURSING RESPONSIBILITIES IN SUCTIONING PRE-OXYGENATE – 100% FIO₂ for patient on ventilators.

6 Precautions Nurses Should Take When Suctioning Avoid Forcing the Catheter
1. Conduct a risk assessment  A difficult airway can be stressful and upsetting,
2. Prepare the patient particularly if the patient requires emergency suctioning.
3. Do not suction too long  Yet forcing the catheter can cause serious airway trauma.
4. Avoid forcing the catheter  Never force the catheter, and do not attempt to insert it
5. Monitor for complications into an airway you cannot see.
6. Choose the right equipment
Monitoring for Complications
  During and after suctioning, monitor the patient for
common complications such as bradycardia and hypoxia.
 Take their vital signs before and after the procedure and
be mindful of any complaints the patient reports.
- Lightheadedness
- Difficulty breathing
- A racing heart rate
- Raspy breathing sounds
Choose the Right Equipment
 Without the right equipment, even a flawless suctioning
technique may prove inadequate.
 The right catheter size is the key.
 In most cases, the suction catheter should have an
external diameter that is less than half the internal
diameter of the endotracheal tube.
 Geriatric and pediatric often requires smaller suction
catheters. Children have smaller airways, and elders may
have more difficult airways due to loss of muscle tone.
 You must also choose the right catheter.
 A portable emergency suction machine offers more than
just emergency care. It enables nurses to care for patients
whenever and whenever they need treatment, including
wile being transported to surgical wings.
Different Route of Suctioning
 Oropharyngeal and Nasopharyngeal
 This suctioning is used when the patient is able
to cough effectively but is unable to clear
secretions by expectorating or swallowing.
 Orotracheal and Nasotracheal
 It is necessary when the client with pulmonary
secretions is unable to cough and does not have
an artificial airway present.
 Tracheal Suctioning
 Tracheal suctioning is accomplished through an
artificial airway such as an endotracheal tube or
tracheostomy tube.
Nursing Care Plan
1. Ineffective airway clearance related to increased
pulmonary secretions as evidenced by copious yellowish
sticky phlegm.
TRACHEOSTOMY KIT & COMPONENTS OF TRACHEOSTOMY TUBE /
SPECIAL SAFETY PRECAUTION IN TRACHEOSTOMY CARE
Tracheostomy Kit
 A tracheostomy kit is to accompany the patient at all times
and this must be checked each shift by the nurse caring for
the patient to ensure all equipment is available.
 A key concept of tracheostomy management is to ensure
patency of the airway (tracheostomy tube). A blocked or
partially blocked tracheostomy tube may cause severe
breathing difficulties and this is a medical emergency.
Immediate access to the tracheostomy kit (equipment) for
the individual patient is essential.
The Leopold Maneuver, named after the German obstetrician and
gynecologist Christian Gerhard Leopold (1846 – 1911) are part of the
physical examination of pregnant women.
Tracheostomy Kit Contains:
 One tracheostomy tube of the same size as insitu (with
introducer/obturator if applicable)
 One tracheostomy tube one size smaller (with introducer if
applicable)
 Spare inner tubes for double lumen trache tubes (if
applicable)
 Spare ties (cotton and/or Velcro)
 Scissors
 Resuscitation bag and mask (appropriate size for patient)
 One way valve (community use only - for resuscitation)
 Wall or portable suction equipment
 Appropriate size suction catheters
 0.9% sodium chloride ampoule and 1ml syringe
 One Heat Moisture Exchanger filter (HME) or
tracheostomy bib
 Fenestrated gauze dressing
 Cotton wool applicator sticks
 Water based lubricant for tube changes
Special Safety Considerations
 Ensure access to a working and charged phone and/or
mobile phone at all times.
 It is recommended that all patients have continuous pulse
oximetry (SpO2) during all periods of sleep (day and night)
and when out of line of sight of competent caregiver.
 All children 6 years and under are to have cotton
ties only to secure the tracheostomy tube.
 Children 6 years and over who are considered at risk of
undoing Velcro ties should have cotton ties.
 For patients with a newly established tracheostomy, it is
recommended that tracheal dilators are available at the
patient’s bedside until after the first successful tube
change.
 An information sheet that provides specific data regarding
the date of last tracheostomy tube change, type and size
of tracheotomy tube, (including inner diameter, outer
diameter, length cuffed or uncuffed tube, cuff inflation,
suctioning distance, critical alert if applicable), should be
placed above each patient's bed (see link) and in the EMR -
patient record - Avatar /LDA. 
Safety Considerations:
  If no leak is audible - DO NOT reinflate the cuff. Document  A difficult airway can be stressful and upsetting,
“No leak” in the patient record and inform the medical particularly if the patient requires emergency suctioning.
team as No leak with a deflated cuff can indicate tube Yet forcing the catheter can cause serious airway trauma.
pressure on the surrounding airway and may cause tissue Never force the catheter, and do not attempt to insert it
necrosis. Consideration and assessment for a smaller into an airway you cannot see. 
tracheostomy tube.
 Leak should be reassessed with changes to patient Monitor for Complications 
positioning.  During and after suctioning, monitor the patient for
 Persistent leak identified? Assess for tube displacement common complications such as bradycardia and hypoxia.
and/or tracheostomy tube/pilot malfunction Take their vital signs before and after the procedure and
 Persistent high cuff pressure? Check for malposition of the be mindful of any complaints the patient reports. Light-
tracheostomy tube, inappropriate sized tracheostomy headedness, difficulty breathing, a racing heart, raspy
tube, Tracheomalacia breathing sounds, and similar symptoms may signal
 Check the manufactures product information prior to use. suction-related complications. 
 Some types of cuffed tubes (Bivona TTS) are inflated with
sterile water not air as the cuff can be permeable to air Choose the Right Equipment 
and lead to spontaneous deflation over time.   Without the right equipment, even a flawless suctioning
technique may prove inadequate. The right catheter size is
Precautions Nurses Should Take When Suctioning key. In most cases, the suction catheter should have an
 Conduct a Risk Assessment: Some patients face a higher external diameter that is less than half the internal
risk of suctioning-related morbidity. They include:  diameter of the endotracheal tube. Geriatric and pediatric
 Patients with a recent head or neck injury  populations often require smaller suction catheters.
 Geriatric and pediatric patients, who have fragile Children have smaller airways, and elders may have more
airways  difficult airways due to loss of muscle tone. 
 Those with cognitive or mental health conditions  You must also choose the right catheter for the job. For
that make it more difficult for them to patients who are continuously vomiting or bleeding during
understand the procedure and cooperate  resuscitation, the DuCanto catheter enables rapid
 Patients with loose dental hardware  airway decontamination via the SALAD technique.
 Those with a difficult airway or a history of  
suctioning complications 
 Patients with bradycardia  TYPES OF IV SOLUTIONS
 Patients with hypoxia
What are the different types of IV solutions?

Prepare the Patient
 Suctioning can be scary and uncomfortable. Prepare the
patient ahead of time by telling them what you need to do
and why—even if they seem uncooperative. When
working with a child or a person with cognitive disabilities,
explain things in terms they can understand, and be warm
and reassuring. Ask their caregiver to remain present and
avoid using force or restraints unless absolutely necessary.
 During the procedure, reassure the patient that they are
safe. If there are unusual sounds that could be frightening
or complications that require additional treatment,
continue to reassure the patient and talk them through
what you are doing. Even if the patient is very young, very
old, or very confused, talking to them can be reassuring
and is a sign of respect. Do not talk about the patient as if
they are not there or cannot hear you.
Do Not Suction Too Long  
 Prolonged suctioning increases the risk of hypoxia and
other complications. Never suction a patient for longer
than 15 seconds. Rather than prolonged suctioning,
withdraw the catheter, re-oxygenate the patient, and
suction again.
Avoid Forcing the Catheter  membrane. Biological fluids including blood and
 There are three types of IV fluids: isotonic, hypotonic, and
hypertonic.
 Isotonic Solutions
 Isotonic solutions are IV fluids that have a similar
concentration of dissolved particles as blood.
 Hypotonic Solutions. Hypotonic solutions have a lower
concentration of dissolved solutes than blood.
 Hypertonic Solutions
There are three types of IV fluids:
1. Isotonic
 An isotonic solution is one that has the same
osmolarity, or solute concentration, as another
solution. If these two solutions are separated by
a semipermeable membrane, water will flow in
equal parts out of each solution and into the
other.
"When two solutions have same osmotic
pressure and salt concentration are said to be
isotonic solutions.” Iso (same) and tonic
(concentration).
 Physiologically, isotonic solutions are solutions
having the same osmotic pressure as that of the
body fluids when separated by a biological
lachrymal fluid normally have an osmotic
 pressure corresponding to that of 0.9% w/v
solution of sodium chloride. Thus 0.9% solution
of sodium chloride is said to be isotonic with the
physiological fluids.
 Examples of isotonic solutions include: normal
saline (0.9% sodium chloride), lactated Ringer's
solution, 5% dextrose in water (D5W), and
Ringer's solution. It is important to monitor
patients receiving isotonic solutions for fluid
volume overload
 Which solution is isotonic in blood?
o 0.9% NaCl solution
o A 0.9% NaCl solution is said to be isotonic:
when blood cells reside in such a medium,
the intracellular and extracellular fluids are
in osmotic equilibrium across the cell
membrane, and there is no net influx or
efflux of water.
2. Hypotonic
 "A hypo tonic solution is one that has lower
concentration than reference solution (i.e., RBCs
contents).
 A hypotonic solution has lower osmotic pressure
than that of reference solution.
 If RBCs are suspended in 0.1 % w/v solution of
NaCl (i.e. hypotonic solution), then water from
this solution will enter the
 RBCs (i.e. due to osmosis, from dilute hypotonic
solution to RBCs fluid) to dilute the fluid within
the RBCs causing their swelling, which may later
result in rupturing of RBCs and release of
haemoglobin. This rupturing of RBCs is known as
"Haemolysis”
 Why is hypotonic solution used?
o Hypotonic solution: A solution that
contains fewer dissolved particles
(such as salt and other electrolytes)
than is found in normal cells and blood.
Hypotonic solutions are commonly
used to give fluids intravenously to
hospitalized patients in order to treat
or avoid dehydration.
3. Hypertonic
 "A hypertonic solution is one that has greater
concentration than reference solution (i.e., RBCs
Contents)."
 A hypertonic solution has greater osmotic
pressure than that of reference solution.
 If RBCs are suspended in 2% w/v solution of NaCl
(i.e. hypertonic solution), then water present
within the RBCs will come out (i.e., due to
osmosis, from dilute RBCs fluid to concentrated
hypertonic solution) into the surroundings to
dilute the NaCl solution (hypertonic solution).
This exit of water from RBCs causes their
shrinkage and RBCs become wrinkled in shape.
This shrinkage of RBCs is known as “Plasmolysis".
 A hypertonic solution is any external solution
that has a high solute concentration and low
water concentration compared to body fluids. In
a hypertonic solution, the net movement of
water will be out of the body and into the
solution.
What are the 5 most common IV solutions?
1. 0.9% Normal Saline (NS, 0.9NaCl, or NSS)
2. Lactated Ringers (LR, Ringers Lactate, or RL)
3. Dextrose 5% in Water (D5 or D5W, an intravenous sugar
solution)
4. 0.45% Normal Saline (Half Normal Saline, 0.45NaCl)
Measurement of Tonicity
 The tonicity of solutions may be determined by one of the
following two methods:
 Haemolytic Method.
 Colligative Method
Haemolytic Method:
 The acting principle of this method is the observation of
the effect of various solutions of drugs on the appearance
of RBCs when suspended in those solutions. If, there is no
change in size and shape of RBCs when immersed in test
solution on observing with microscope, then this solution
is isotonic to the blood.
 This method can be made more accurate by using a
hematocrit, which is a centrifuge head in which a
graduated capillary tube is held in each of the two arms.
 One capillary tube (tube A) is filled with blood diluted with
5 ml of 0.9% w/v NaCI (isotonic solution).
 The othercapillary tube (tube B) is filled with blood
diluted with an equal volume i.e., 5ml of test solution.
 Both tubes are centrifuged (i.e., rotated at high speed).
 After centrifuge, the blood cells are concentrated at one
end of the capillary tubes and the volume occupied by the
cells (i.e., PCV -Packed Cell Volume) is measured.
 Finally, the PCV of test solution tube (tube B) is compared
with PCV of isotonic solution tube (tube A), and following
inferences are made.
Results:
 If PCV of test solution (tube B) is same as that of tube A,
then test solution is regarded as isotonic.
 If RBCs volume (i.e., PCV) of tube is more than that of tube
A, then test solution is regarded as hypotonic
solution (increase in PCV is due to swelling of RBCs, which
occurs in case of hypotonic solution).
 If RBCs volume (i.e., PCV) of tube is less than that of tube
A, then test solution is regarded as hypertonic
solution (decrease in PCV is due to shrinkage of RBCs,
which occurs in case of hypertonic solution).
Colligative Method:
 It has been determined that solutions having same tonicity
exhibit similar behavior with respect to their colligative
properties such as lowering of vapor pressure, depression
in freezing point, etc. Hence, tonicity of a solution may be
determined by determining its colligative properties.
 For making isotonic solutions, the quantities of substances
to be added may be calculated by following methods:
 Based on molecular concentration
  Based on freezing point data
 Based on sodium chloride equivalent (E) value
 White-Vincent method

Results:
 If PCV of test solution (tube B) is same as that of tube A,
then test solution is regarded as isotonic.
 If RBCs volume (i.e., PCV) of tube is more than that of tube
A, then test solution is regarded as hypotonic
solution (increase in PCV is due to swelling of RBCs, which
occurs in case of hypotonic solution).
 If RBCs volume (i.e., PCV) of tube is less than that of tube
A, then test solution is regarded as hypertonic
solution (decrease in PCV is due to shrinkage of RBCs,
which occurs in case of hypertonic solution).

IV COMPUTATIONS

Safe and accurate intravenous fluid administration starts with right

tubing and computations hence benefited our patients.

Precise calculations and computations ensure patient’s fast

recovery, prevents complications thus promote wellness.

Points to Remember:
 Need to know in a doctor’s order.
 Volume ordered (ml or liter)
 Time period (in minutes)
 Drop factor (gtts/ml)
 Method of delivery
 Volumetric – ml per hour
 Drop count – drops per minute

IV Drip Factor:
1. Macrodrip
PERCUTANEOUS ENDOSOPIC GASTROSTOMY (PEG)
 10 gtts/ml
 PEG is a procedure in which a flexible feeding tube is
 15 gtts/ml
placed though the abdominal wall and into the stomach.
 20 gtts/ml
 PEG allows nutrition, fluids and/or medications to be put
2. Microdrip
directly the mouth and esophagus.
 60 gtts/ml

Indications of PEG Placement:

Drip factor – refers to the number of drops per milliliter of solution
 Establishment of enteral access for feeding
calibrated for an administration set. Pertains to the diameter of the
 Gut decompression
needle where the drop enters the drip chamber.
 Gut decompression may be needed in patients
who have abdominal malignancies causing
gastric outlet or small-bowel obstruction or ileus.
 Esophageal cancer, oral surgery, or stroke
 Major surgery, trauma, bums, or anorexia
 Inflammation of the pancreas
 Radiation therapy or inflammatory bowel disease affecting
the small intestine

Feeding Methods via:

 Bolus Syringe - 5 min
Formulas for IV Calculations
 Gravity Syringe - 10-15 min
 Gravity Bag - 20 -40 min
 Overnight pump - 6-12 hrs.
TYPES OF FORMULAS gastrostomy device may look different to those
ALL SOME shown in these pictures.
Lactose-free Low fiber  Causes: A gastrostomy site can become red for
High calorie / nutrient dense High fiber many reasons. lt could be due to a small amount
Organic / all natural of leaking, the area rubbing, a change in weather
or your child being unwell.
Nursing Responsibilities:  Treatment: Increase the frequency of cleaning
 Cleaning the stoma site the stoma site. After cleaning the stoma, barrier
 Assessing patients for signs of complications of creating creams such as Proshield or Cavilon can be used
the on the area to try and prevent the area
 stoma: becoming sore.
 Infection  Review: No review needed.
 Leakage of gastric acids;  Referral: Barrier creams should be available on a
 Inflammation; and repeat prescription. if you are unable to get this
 Over-granulation. from your GP, contact the CCNT and ask for a
 Ensuring the correct placement and non-migration of the prescription request.
tubing.  Leakage of stomach content
 Secure the tube safely.  Causes: A gastrostomy site can leak stomach
contents for different reasons. It could be
Complication because your child's stomach is full or the stoma
 An upper gastrointestinal endoscopy performed for the is healing around the site.
purpose of tube removal revealed the inner bumper was  Treatment: Continue to clean the stoma site
totally covered by gastric mucosa regularly with warm water. Apply a barrier
 Total buried bumper syndrome: A case study in cream to the stoma to keep the skin heathy.
transabdominal removal using a technique of endoscopic Check that PEG is positioned correctly.
submucosal dissection  Review: Call the CCNT to arrange a visit for them
to check everything is okay.
Hyper granulation Tissue “Proud Flesh”  Referral: The CCNT will need to review the stoma
 What Is It? if leaking continues.
 Overgrowth of tissue around G-tube  Mildly Inflamed and red
 Pink/beefy red  Causes: A gastrostomy site can become inflamed
 Tender to touch/bleeds easily for many reasons. It could be due to prolonged
 What To Do leaking. friction around the area, or due to the
 Call RN/MD fixation plate being too close to the skin.
 Can monitor if not bothersome  Treatment: Prontosan® wound irrigation solution
 Silver Nitrate for removal if should be used to clean the stoma and then
uncomfortable/painful MediHoney® barrier cream should be applied.
Consider taping the tube down to stop
Infection – concern for fever, pain, redness, heat, tenderness, foul movement and irritation.
smelling  Review: Call the CCNT to arrange a visit for them
to check that everything is okay.
Nursing Responsibilities:  Referral: The CCNT will do a prescription request
 The PEG should be advanced by 4-6cm to prevent buried from the GP.
bumper syndrome (where the plastic disc holding the PEG  Possible infection
in place sticks to the lining of the stomach wall).  Causes: A gastrostomy site can become infected
 This should be done at least twice a week as well. The if bacteria have managed to get into the skin
Freka@/fixation plate (triangle), should be secured 2-3mm surrounding the stoma site. If not managed in
away from the, skin. If your child has a Coreflo® PEG use the early stages the infection can worsen.
the same instructions as below (it's just a different design).  Treatment: Call the CCN to arrange a review, and
a swab will be taken before considering oral
Nursing Managerment antibiotics. The stoma site should be cleaned
 Skin problems around the PEG with Prontosan, and MediHoney barrier cream
 Problems with the skin around gastrostomies can applied. f out of hours call your out-of-hours GP
be very common. If you are worried or or go to the nearest Emergency Department
concerned, please call the CCNT for advice. On (A&E) to avoid delay in treatment. If your child
the next few pages are some of the common has a raised temperature or is generally unwell
problems that can be found with the skin around take them to the Emergency Department.
the gastrostomies, and information about how  Review: Urgent medical review.
they are usually treated. Your child's  Referral: See medical professional.
 Overgranulation
  This is when the tissue 'over heals' and is raised
above the wound.
 Causes: A gastrostomy site can become
overgranulated if the device is not fitted well or
the device has been causing friction on the skin.
 Treatment: Clean the area with Prontosan
solution twice a day and apply MediHoney
wound gel, and a foam dressing. Review: Call the
CCNT to arrange a visit for them to check that
everything is okay.
 Referral: The CCNT will review your child and do
a prescription request.
 Recurring overgranulation
 Causes: A gastrostomy site can continue to be
overgranulated for a wide variety of reasons,
most commonly because the gastrostomy tube is
causing friction in the stoma.
 Treatment: Clean the area with Prontosan
solution twice aa day and apply Maxitrol and a
foam dressing for up to 14 days.
 Review: Call the CCNT to arrange a visit for them
to check if everything is okay.
 Referral: The CCNT will review your child and do
a prescription request to the GP.
 Persistent overgranulation
 Causes: A gastrostomy site can continue to be
overgranulated for a wide variety of reasons.
 Treatment: Continue to clean the stoma site
regularly with saline or warm water. Timodine
cream should be applied to the overgranulated
area and a foam dressing should be applied over
the top. If the overgranulation continues after
this you may need to be referred to the hospital
for further treatment.
 Review: Call the CCNT to arrange a visit for them
to check everything is okay.
 Referral: The CCNT will review your child and do
a prescription request to the GP if needed. A
referral will be made to the specialists at the
hospital.
TOTAL PARENTERAL NUTRITION (TPN)
 A method of feeding intravenously, that bypasses the
gastrointestinal tract. Given via central IV line.
 Also known as intravenous or IV nutrition feeding, it is a
method of getting nutrition into the body through the
veins thus provide nutrients for patients who do not have
a functioning GI tract or who have disorders requiring
complete bowel rest.
Nutritional Content of TPN:
 TPN involves the continuous infusing of hyperosmolar
solution containing:
 Carbohydrates
 Proteins
 Fat
 Minerals
 Other electrolytes (K+, Na, Cl)
 Vitamins (A, C, E, B12, folic acid, riboflavin)
 Through a indwelling catheter inserted via SVC (central
line) to meet the nutritional needs.
 Solutions that contain more than 3% amino acid and 5%
glucose are poorly tolerated peripherally.
Partial Parenteral Nutrition (PPN)
 It supplies only part of daily nutritional requirements,
supplementing oral intake. Given via peripheral IV line.
 Example:
 Dextrose or amino acid solution
* But in low concentration for its high risk for
phlebitis.
Indications
 TPN may be the only feasible option for patients who don
not have a functioning GI tract or who have disorders
requiring complete bowel rest, such as the following:
 Some stages of ulcerative colitis
 Bowel obstruction
 Certain pediatric GI disorders (e.g., congenital GI
anomalies, prolonged diarrhea regardless of its
cause)
 Short bowel syndrome due to surgery
TPN Solutions
 TPN solutions vary depending on other disorders present
and patient age, as for the following:
 For renal insufficiency not being treated with
dialysis or for liver failure:
o ↓CHON content, ↑percentage of
essential amino acids
 For heart or kidney failure: limited volume
(liquid) intake
 For respiratory failure: a lipid emulsion that
provides most of nonprotein calories to minimize
carbon dioxide production by carbohydrate
metabolism.
 For neonates: lower dextrose concentrations (17
to 18%)
Common Complications:
 Catheter-related sepsis – complications related to central
venous access
 Glucose abnormalities (hyperglycemia or hypoglycemia)
 Liver dysfunction occurs in >90% of patients
 Serum electrolyte imbalances
 Volume overload
 Allergic reactions
  Phlebitis (inflammation of the vein) is characterized by one
more of the following: pain, redness, swelling, warmth, a
red streak along the vein, hardness of the IV site, an/or
purulence.
 Infiltration is the leakage of a non-vesicant solution into
the surrounding tissues, causing pain and swelling.
 Extravasation is the migration into the tissues of a vesicant
medicine or fluid, such as chemotherapy. This can be
severely painful and cause major tissue trauma.
 Thrombosis or thrombophlebitis is the formation of a clot
in the vessel, often caused by the cannula moving around
in the vein and aggravating the vessel wall.
 Nerve damage can occur during PIVC insertion. If the
patient complains of a sharp pain shooting up the arm, or
ongoing numbness or tingling of the extremity, the
cannula should be removed immediately.
 Partial or complete dislodgement of the PIVC indicates it is
no longer in the vessel and must be removed.
Nursing Responsibilities:
 When preparing the TPN solution bags, mix the solution
gently
 Measure intake and output accurately
 Monitor weight daily, vital signs, CBG, serum, electrolytes
 Assess IV access for patency of line, leakage, and
discoloration of solutions
 Monitor for signs of infection specifically the IV access
 Regulate TPN strictly
 Ensure precise functions and delivery of IV pump
Nursing Care Plans
 Imbalanced nutrition: less than body requirements
 Risk for excess fluid volume
 Risk for deficient fluid volume
 Risk for altered body composition
 Risk for infection
CARE OF PATIENTS WITH NASOGASTRIC TUBE
Nasogastric Tube Insertion
 It is a common procedure that provides access to the
stomach for diagnostic and therapeutic purposes
 Nasogastric tube (NGT) – a tube that is passed
through the nose and down to the nasopharynx
and esophagus into the stomach.
 Orogastric tube – a tube that is passed through
the mouth and down to the oropharynx and
esophagus into the stomach.
Indications: Diagnostic Indications
 Evaluation of upper gastrointestinal (GI) bleeding
 Aspiration of gastric fluid content
 Identification of the esophagus and stomach
 Administration of radiographic contrast to the GI tract
Indications: Therapeutic Indications:
 Gastric decompression, including maintenance of a
 decompressed state after endotracheal intubation
 Aspiration of gastric content from recent ingestion of
 toxic material
 Administration of medication
 Enteral Nutrition/Feeding
 Bowel irrigation
Naso / Oro Gastric Tube: Nurses’ Roles and Responsibilities
 The physician is responsible for entering the order for
insertion, replacement and removal of the naso/orogastric
tube on the electronic documentation system.
 The naso/orogastric tube will be inserted by a physician
when clinically indicated.
 The tube will be removed either by a physician or a nurse
when the tube is no longer required.
 The hypoallergenic tape securing the tube should be
checked daily to ensure that it is intact and not in need of
replacement. The tape should be replaced when loose,
wet or contaminated.
 Both nares should be inspected for any signs of ulcer
formation 4 hourly. If any signs of ulceration or necrosis is
found, it should be officially reported through generating
an eOVR.
 Tube placement must be checked by pH testing/x-ray on
the following situations:
 After initial insertion
 Prior to administering each feed and/or giving
medications
 Prior to flushing with 30 ml of water (adults)
every 4-6 hours, if feeding is not in progress
(except during the night) to maintain tube
patency (1-3 ml for neonates and 5-5 ml for
infants)
 At least once per shift during continuous feeds
 Following episodes of respiratory distress,
vomiting, coughing, or retching

Tube placement must be checked by pH testing / x-ray on the
following situations:
 If suspicion of tube displacement (e.g., poor tolerance to
feed, reflux of feed into the throat, throat discomfort or
change in the tube length is suspected)
 If patient is transferred from one clinical area to another.
Insertion Documentation:
 Type of tube (silicone, ryles, salem sump...), insertion site
and length, pH, initial output, patient's response.
 Document patient's response to tube feeding, patency of
tube, condition of naris or skin at tube site for tubes placed
in abdominal wall, and any side effects.
 Document patient's tolerance and adverse effects.
 Amount and type of feeding instilled.
NGT Insertion
1. Check physician's order for insertion of nasogastric tube.
2. Identify and explain procedure to patient.
3. Gather equipment.
4. Assess patient's abdomen.
5. Perform hand hygiene. Don disposable gloves.
6. Assist patient to high Fowler's position or to 45 degrees if
unable to maintain upright position and drape his for her
chest with bath towel or disposable pad. Have emesis
basin and tissues handy.
Nasogastric Tube Insertion
 Wipe bridge of nose with gauze soaked with water or with
alcohol swab
 Check the patency of nares by occluding one naris. Then
repeated this action for other naris. Select the nostril with
greater airflow.
 Measure distance to insert the tube by placing tip of tube
at patient's nostril and extending to tip of earlobe and
then to tip of xiphoid process. Mark tube with a piece of
tape.
 Lubricates the tube about 6-8 inches (15-20 cms) from the
 tip.
 Inserts the tube with its natural curve downward into the
 selected nostril.
 Inserts the tube into the nostril and pass it through the
nasopharynx aiming backwards and inward
 Instructs the patient to swallow as tube advances.
 Allows patient to rest for 2-3 minutes if the patient gags,
and ask to hold head in natural position.
 Rotates the tube gently about 180° to redirect
 Advances the tube each time the patient swallows,
checking the mouth regularly, until the mark measured on
the tube, reaches the nest
 Forces not, if the tube does not pass easily, remove the
tube if signs of gasping, coughing and cyanosis seen.
 Commence again through the other nostril
 Determines if the tube is in stomach by following these
alternative methods:
 Aspirates a small amount of gastric juice with the
syringe.
 Places the stethoscope over the epigastrium and
inject 10-15ml air through the tube and listen for
a whooshing sound.
Subjects and Methods: A total of 150 patients were randomized into
3 groups: control group, neck flexion with lateral pressure group,
and lifting of the larynx group. The number of attempted insertions,
success rate, duration of insertion, and various complications were
recorded.
Results: Both neck flexion with lateral pressure and lifting of the
thyroid cartilage techniques had high success rates; however, the
time required to insert the NG tube was shortest in the thyroid
cartilage lifting group.
Conclusion: Neck flexion with lateral pressure and lifting of the
thyroid cartilage are convenient and reliable techniques for NG tube
insertion without using any other instruments. Lifting of the thyroid
cartilage had the highest success rate and was less time consuming
than the other NG tube insertion techniques. Familiarization with
the procedure influenced the success rate and the time required for
insertion.
DO NOT CRUSH end of drug name
  SR - Sustained/ Slow Release
 CR - Controlled Release INTAKE AND OUTPUT MONITORING
 ER - Extended Release  I & O is the measurement of the fluids that enter the body
(intake) and the fluids that leave the body (output).
The List of Oral Dosage Forms That Should Not Be Crushed  The metric system is used for fluid measurement.
 Commonly referred to as the "Do Not Crush" list, contains  The measurement should be recorded in ml (milliliters)
medications that should not be crushed because of their
special pharmaceutical formulations or characteristics, Standard Measurements
such as oral dosage forms that are sustained-release in  1 mL = 0.001 liters (L)
nature.  1 fluid ounce = 30 mL
a. Capsule may be opened and the contents taken  1 pint = 500 mL
without chewing or crushing; soft food such as  1 quart = 1000 mL = 1 L
applesauce or pudding may facilitate administration;  1 teaspoon = 5 mL
contents may generally be administered via NG tube  1 tablespoon = 15 mL
using an appropriate fluid provided entire contents  1 cup = 250 mL
are washed down the tube.
b. Liquid dosage forms of the product are available; Intake
however, dose, frequency of administration, and  Water and beverages
manufacturers may differ from that of the solid  Foods that are liquid at room temperature
dosage form.  Ice cream
c. Antacids and/or milk may prematurely dissolve the  Gelatin
coating of the tablet.  Sherbert
d. Capsule may be opened and the liquid contents  Pudding
removed for administration.  Custard
e. The taste of this product in a liquid form would likely  Ice chips (half of volume melts)
be unacceptable to the patient; administration via NG  Popsicles
tube should be acceptable.  Intravenous fluids
f. Effervescent tablets must be dissolved in the amount  IV medications and IV flushes
of diluent recommended by the manufacturer.  TPN
g. Tablets are made to disintegrate under the tongue.  Lipids
h. Tablet is scored and may be broken in half without  Blood products
affecting release characteristics  Infusions / incorporations
i. Skin contact may enhance tumor production: avoid  Enteral Feeding – enteral nutrition refers to any
direct contact. method of feeding that uses the gastrointestinal
(GI) tract to deliver nutrition and calories.
 Irrigants (bladder irrigations) – example:
cystoclysis or continuous bladder irrigation

Output
 Fluid output includes:
 Urine
 Diarrhea
 Blood
 Suction from gastric, respiratory
 Surgical drains
o Special precautions: urine, stool, and
vomit can contain the chemotherapy
agent.

Urine Output
 60-120 mL per hour
 Male void = 300-500 mL per day
 Female void = 250 mL per day
 Infants void 5-40 times a day
 Preschool children may void every 2 hours
Do not forget about Insensible Loss

Insensible Fluid Loss

 The amount of body fluid lost daily that is not easily
measured, from the respiratory system, skin, and water in
the excreted stool.
 The exact amount is unmeasurable but is estimated to be
between 40 to 800mL/day in the average adult without
comorbidities.