PULSUS PARODOXICUS
Muffled heart tones in a client with
pericardial effusion can indicate the
development of cardiac tamponade. This results
in the build-up of fluid in the pericardial
sac, which leads to compression of the
heart. Cardiac output begins to fall as
cardiac compression increases, resulting
in hypotension.
Additional signs and symptoms of tamponade
include tachypnea, tachycardia, jugular venous
distension, narrowed pulse pressure, and the
presence of a pulsus paradoxus.
Pulsus paradoxus is defined as an exaggerated
fall in systemic BP >10 mm Hg during
inspiration.
The procedure for measurement of pulsus
paradoxus is as follows:
 Place client in semirecumbent position
 Have client breathe normally
 Determine the SBP using a manual BP cuff
 Inflate the BP cuff to at least 20 mm Hg
above the previously measured SBP
 Deflate the cuff slowly, noting the
first Korotkoff sound during expiration
along with the pressure
 Continue to slowly deflate the cuff
until you hear sounds throughout
inspiration and expiration; also note
the pressure
 Determine the difference between the 2
measurements in steps 5 and 6; this
equals the amount of paradox
Variation in QRS amplitude is termed electrical
alternans. It could be present in cardiac
tamponade, but it is not how pulsus paradoxus
is determined. Electrical alternans is due to
the swinging motion of the heart in a fluid-
filled pericardial sac.
The amount of paradox is the difference between
the pressure heard at the first Korotkoff sound
during expiration and the Korotkoff sounds
heard throughout inspiration and expiration. A
difference of <10 mm Hg is normal, but if it
is >10 mm Hg, this may indicate cardiac
tamponade.
ORTHOSTATIC VITAL SIGNS
Orthostatic vital signs help assess the body's
ability to compensate hemodynamically
during postural changes. Changing position
normally triggers vasoconstriction in the
extremities to promote venous return. Without
this response, hypotension and subsequent
hypoperfusion of internal organs and the brain
occur.
Clients with impaired compensatory mechanisms
(eg, hypovolemia, sepsis) may
exhibit orthostatic hypotension, in which
hypotension and/or neurologic impairment (eg,
syncope) occur with position change. This
increases the client's risk for falls.
PROCEDURE FOR MEASUREMENT OF
ORTHOSTATIC BP
Orthostatic BP measurement may be done to
detect volume depletion or postural hypotension
caused by medications or autonomic dysfunction.
Procedure for measurement of orthostatic BP
 Have the client lie down for at least 5
minutes
 Measure BP and HR
 Have the client stand
 Repeat BP and HR measurements after
standing at 1- and 3-minute intervals
A drop in systolic BP of ≥20 mm Hg or
in diastolic BP of ≥10 mm Hg, or experiencing
lightheadedness or dizziness is considered
abnormal. The nurse should discontinue
assessment, place the client in a recumbent
position, and notify the health care provider.
ABDOMINAL ASSESSMENT
Abdominal examination is performed with the
client in the supine position using the
following sequence: inspection, auscultation,
percussion, and palpation.
URINE COLLECTION
To collect a urine specimen:
1.Clean the collection port with an alcohol
swab
2.Aspirate urine with a sterile syringe
 3.Use aseptic technique to transfer the
specimen to a sterile specimen cup
*A urine specimen is collected aseptically from
the specimen port in an indwelling urinary
catheter. Urine that has been collected from
the collection bag does not yield accurate
urinalysis and culture results.
24 HOUR URINE COLLECTION
Timed urine collection tests are usually done
to assess kidney function and measure
substances excreted in the urine (eg,
creatinine, protein, uric acid,
hormones). These tests require the collection
of all urine produced in a specified time
period (a crucial step) to ensure accurate test
results. The proper container (with or without
preservative) for any specific test is obtained
from the laboratory. The collection container
must be kept cool (eg, on ice, refrigerated)
to prevent bacterial decomposition of the
urine.
It is common practice to start a 24-hour urine
collection test at the time of the client's
first voiding in the morning. If any urine is
discarded by accident during the test period,
the procedure must be restarted. All produced
urine should be placed in the same container
and kept cool (on ice).
A 24-hour urine is collected to test for
increased cortisol levels when evaluating for
Cushing syndrome. The client should be taught
to collect the urine in a dark jug issued by
the lab, start time and then empty the bladder
and discard the 1st urine, and collect all the
urine for 24 hours; it is kept in the
refrigerator or ice chest with a secure
lid. Exactly 24 hours after start time, empty
bladder once more into the collection
container.
URINE DIPSTICK
The protein test pad measures the amount of
albumin in the urine. Normally, there will not
be detectable quantities. Albumin is smaller
than most other proteins and is typically the
first protein that is seen in the urine when
kidney dysfunction begins to
develop. Proteinuria is characterized by
elevated urine protein and can be an early sign
of kidney disease.
Occasional loss of up to 150 mg/day of protein
in the urine, which may reflect as negative or
trace protein on a dipstick, is typically
considered normal and usually does not require
further evaluation. Common benign causes of
transient proteinuria include fever, strenuous
exercise, and prolonged standing.
CATHETER INSERTION FEMALE
Steps for indwelling urinary catheter
insertion for the female client include:
1.Position the client supine with knees
flexed and hips slightly externally rotated.
2.Perform hand hygiene and open a sterile
catheterization kit.
3.Apply sterile gloves and place a sterile
drape underneath the client's buttocks.
4.Remove the protective covering from the
catheter, lubricate the catheter tip, and
pour antiseptic solution over cotton balls
or swab sticks while maintaining sterility
of gloves and sterile field.
5.Use the nondominant hand to gently spread
the labia. The nondominant hand is
now contaminated.
6.Use the dominant (sterile) hand to cleanse
the labia and urinary meatus with
antiseptic-soaked cotton balls or swab
sticks.
7.Cleanse in an anteroposterior
direction (from the clitoris toward the
anus).
8.Use a new swab for each swipe to avoid
transferring bacteria between areas.
9.Cleanse the labia majora first, then the
labia minora, and lastly the urinary meatus.
10.Use the dominant hand to insert the
catheter until urine return is visualized in
the tubing (usually 2-3 inch [5-7.6 cm]),
and then advance it an additional 1-2 inch
(2.5-5 cm).
11.Hold the catheter in place with the
nondominant hand, and then use the dominant
hand to inflate the balloon.
*Urine output would be expected if the client
has not voided for 6 hours (obligatory amount
is at least 30 mL x 6 = 180 mL). The most
common explanation is that the catheter was
unintentionally inserted into the vagina. The
nurse should leave that catheter as a landmark
and insert a new sterile catheter into the Phlebotomy
urethra which is located above the vagina.
A tourniquet is applied 3-5 inches above the
*If no urine is returned from Foley catheter desired puncture site for no longer than 1
insertion in a female client after a short minute when looking for a vein. If longer time
time, the nurse has probably not inserted it is needed, release the tourniquet for at least
into the correct opening. The nurse should 3 minutes before reapplying. Prolonged
leave the original catheter in place and obstruction of blood flow by the tourniquet can
reinsert a new sterile catheter above the change some test results.
original position.
Pulsating bright red blood indicates that an
CATHETER REMOVAL artery was accessed. If this happens, the
needle should be removed immediately and
Because signs of traumatic injury are present, pressure should be applied for at least 5
the nurse should follow steps to remove the minutes, followed by a pressure dressing to
catheter before further complications such as prevent a hematoma.
obstruction occur.
*When performing phlebotomy for a laboratory
Steps for removing an indwelling catheter specimen, allow the cleansed area to air dry,
include the following: do not use the veins on the ventral side of
wrist, position the tourniquet for no more than
1.Perform hand hygiene 1 minute at a time, and invert the tube gently
5-10 times to mix the solution with
2.Ensure privacy and explain the procedure blood. Insertion in an artery will cause
to the client pulsation; if this happens, immediately remove
the needle and apply pressure for 5 minutes.
3.Apply clean gloves
PREFERRED SITE FOR VENIPUNCTURE
4.Place a waterproof pad underneath the
client The preferred site for venipuncture when
collecting blood specimens is the antecubital
5.Remove any adhesive tape or device fossa's median cubital vein. The basilic vein
anchoring the catheter lies close to the brachial nerve and artery.

6.Follow specific manufacturer instructions When severe, shooting pain radiates down a
for balloon deflation client's arm during venipuncture, nerve
injury may be occurring. The client may also
7.Loosen the syringe plunger and connect the report feelings of "pins and needles" or
empty syringe hub into the inflation port numbness at and/or near the venipuncture
site. If this occurs, the nurse should
8.Deflate the balloon by allowing water to promptly withdraw the needle, obtain new
flow back into the syringe naturally, equipment, and choose a different site for
removing all 10 mL, or applicable amount specimen collection.
(note the size of the balloon labeled on the
balloon port). If water does not flow back Because the pain and numbness during
naturally, use only gentle aspiration. venipuncture indicate a nerve injury, the nurse
should reattempt the specimen collection using
9.Remove the catheter gently and slowly; a different site. Reattempting at the same
inspect to make sure it is intact and site with a smaller-gauge needle or from a
fragments were not left in the client. different angle could cause nerve damage.
10.If any resistance is met, stop the
removal procedure and consult with the Reassurance may help calm an anxious client,
urologist for removal and stabilization may help prevent injury if a
client attempts to withdraw the arm during
11.Empty and measure urine before routine venipuncture. However, if a client has
discarding the catheter and drainage bag in nerve pain, which indicates that the attempt
the biohazard bin or according to hospital should be stopped immediately to prevent nerve
policy damage.

12.Remove gloves and perform hand hygiene

NEONATAL HEEL STICK
The neonatal heel stick (heel lancing) is used
to collect a blood sample to assess capillary
glucose and perform newborn screening for
inherited disorders (eg, congenital
hypothyroidism, phenylketonuria).
Proper technique is essential for minimizing
discomfort and preventing complications and
includes:
Select a location on the medial or lateral
side of the outer aspect of the heel. Avoid
the center of the heel to prevent accidental
insult to the calcaneus. Puncture should not
occur over edematous or infected skin.
Warm the heel for several minutes with a warm
towel compress or approved single-use instant
heat pack to promote vasodilation. Cleanse the
intended puncture site with alcohol. Sucrose
and nonnutritive sucking on a pacifier may
reduce procedural pain.
Use an automatic lancet, which controls the
depth of puncture. Lancing the heel too deeply
can result in penetration of the calcaneus
bone, leading to osteochondritis or
osteomyelitis.
An acceptable alternate method of blood
collection in the neonate is venipuncture (ie,
drawing blood from a vein). Venipuncture is
considered less painful and often requires
fewer punctures to obtain a sample, especially
if a larger volume is needed.
IV INSERTION
Steps to promote safety and reduce infection
risk when initiating IV therapy include the
following:
 Perform hand hygiene using Centers for
Disease Control and Prevention
guidelines
 Prepare equipment: Open IV tray, prime
tubing with prescribed IV solution for
infusion, set IV pump if indicated,
prepare tape, and open the over-the-
needle catheter (ONC) with safety device
 Don clean (non-sterile) gloves
 Identify a possible venipuncture site
 Apply a tourniquet, ensuring it is tight
enough to impede venous return but not
tight enough to occlude the artery
 Select a venipuncture site after
palpating the vein. Ask the client to
open and close the hand several times to
promote vein distension. The tourniquet
may need to be released temporarily to
restore blood flow and prevent trauma
from extended application.
 Clean the site with chlorhexidine,
alcohol, or povidone iodine. Use
friction and clean per facility
protocol, either back and forth or in a
circular motion from insertion site to
outward area (clean to dirty direction).
 Stretch the skin taut using the
nondominant hand to stabilize the vein
 Insert the IV ONC bevel up at a 10- to
30-degree angle and watch for blood
backflow as the catheter enters the vein
lumen, advancing ¼ inch into the vein to
release the stylet. On visualization of
blood return, lower the ONC almost
parallel with the skin and thread the
plastic cannula completely into the vein
to the insertion site. Never reinsert
the stylet after it is loosened. Use
the push-tab safety device to advance
the catheter.
 Apply firm but gentle pressure about 1¼
inch above the catheter tip, release the
tourniquet, and retract the stylet from
the ONC
 On removal, guide the protective guard
over the stylet for safety and feel for
a click as the device is locked. Never
try to recap a stylet.
 Attach a sterile connection of primed IV
tubing to the hub of the catheter and
stabilize the catheter with tape and
dressing using sterile
technique. Dispose of the stylet in the
sharps container.
During IV therapy, the nurse should monitor the
site to assess for patency and signs of
infection (eg, redness, drainage, edema,
discomfort, warmth, coolness,
hardness). Infiltration is a complication that
occurs when solution infuses into the
surrounding tissues of the infusion site.
Interventions include:
 Discontinuing the IV line immediately
and starting a new IV, preferably on the
opposite extremity
 the nurse should speak clearly and face
 Continuing to monitor the infiltration the client when speaking.
site for swelling or other abnormalities
(eg, redness, warmth, coolness)  Use the smallest gauge catheter (24–26
gauge) indicated for the client's
 Elevating the affected extremity to therapy as veins are more fragile.
decrease swelling
 Consider vein sites to promote client
 Notifying the health care provider if independence (non-dominant arm, avoiding
severe complications (eg, cellulitis, back of the hand).
tissue necrosis, nerve damage) develop
 Use a 5–15-degree angle on insertion as
 Applying a cold or warm, moist veins of the elderly are usually more
compress based on the solution superficial.
infiltrated. Heat is avoided when
extravasation of a vesicant (ie, drug EXTRAVASATION
capable of causing tissue necrosis)
occurs. Extravasation is the infiltration of a drug
into the tissue surrounding the
Peripheral IV sites should be changed no more vein. Norepinephrine (Levophed) is a
frequently than every 72-96 hours unless vasoconstrictor and vesicant that can cause
complications develop. skin breakdown and/or necrosis if absorbed into
the tissue. Pain, blanching, swelling, and
It is important to flush saline locks every 8- redness are signs of
12 hours as prescribed. extravasation. Norepinephrine should be
infused through a central line when
IV THERAPY (ELDERLY) possible. However, it may be infused at lower
concentrations via a large peripheral vein for
The nurse must consider several life span up to 12 hours until central venous access is
changes that occur with aging when established.
initiating IV therapy and caring for IV
infusions in the older adult. Important The nurse should implement the following
considerations include the following: interventions to manage norepinephrine
extravasation:
 The age-related cardiovascular and renal
function changes that can occur in the  Stop the infusion immediately and
elderly, such as a mild increase in the disconnect the IV tubing.
size and thickness of the heart,
prolonged filling time, and declined  Use a syringe to aspirate the drug from
glomerular filtration rate, may put the the IV catheter; remove the IV catheter
client at risk for rapid development while aspirating.
of hypervolemia.
 Elevate the extremity above the heart to
 Use of an infusion pump is recommended, reduce edema.
even in clients with dementia, as they
are at increased risk for fluid  Notify the health care provider and
imbalance. obtain a prescription for the
antidote phentolamine (Regitine), a
 Older adults with fragile veins are at vasodilator that is injected
increased risk for IV infiltration; subcutaneously to counteract the effects
therefore, the site should be monitored of some adrenergic agonists (eg,
carefully by the nurse every 1–2 hours. norepinephrine, dopamine).

 Fragile skin may tear easily; VASTUS LATERALIS INJECTION

use nonporous tape, skin protectant
solutions, and minimal
tourniquet pressure. Intramuscular (IM) injections (eg, hepatitis B
vaccine, vitamin K) are commonly administered
 Because hearing and visual impairments to newborns shortly after birth or before
may pose a problem for client education, discharge. The vastus lateralis muscle in the
anterolateral middle portion of the thigh is
the preferred site for IM injections in
newborns (age <1 month) and infants (age 1-12
months). The deltoid muscle is an
inappropriate injection site for newborns due
to inadequate muscle mass.
For IM injections, the needle length should be
⅝ inch for newborns and ⅝ to 1 inch for infants;
these lengths are adequate for reaching the
muscle mass while avoiding underlying tissues
(eg, nerves, bone). A 22- to 25-gauge needle
is appropriate for clients age <12 months.
The medication should be administered using
aseptic technique; cleaning the site with an
antiseptic solution (eg, alcohol) is
appropriate.
A 1-mL syringe (eg, tuberculin) should be used
to measure very small doses in 0.01-mL
increments for newborns, infants, and small
children. Pediatric medication dosages can be
very small and should be measured to two
decimal places.
Z-TRACK TECHNIQUE
The Z-track technique prevents tracking
(leakage) of the medication into the
subcutaneous tissue and is universally
recommended for the administration of IM
injections. Displacing the skin while
injecting the medication, and then releasing
the skin back to its normal position after
removing the needle creates a zigzag track.
The procedure for administering an IM injection
using the Z-track technique includes these
steps:
1. Pull the skin 1-1 ½" (2.5-3.5 cm)
laterally away from the injection site
2. Hold the skin taut with the nondominant
hand,and insert the needle at a 90-
degree angle – taut skin facilitates
entry of the needle and this angle
ensures that the needle will reach the
muscle
3. Inject the medication slowly into the
muscle while maintaining traction – slow
injection promotes comfort and allows
time for tissue expansion to facilitate
absorption of the medication
4. Wait 10 seconds after injecting the
medication and withdraw the needle while
maintaining traction on the skin; this
allows the medication to diffuse before
needle removal and helps to prevent
tracking
5. Release the hold on the skin – this
allows the tissue layers to slide back
to their original position, sealing off
the needle track
6. Apply gentle pressure at the injection
site, but do not massage as this can
cause the medication to seep back up to
the skin surface and cause local tissue
irritation
7. There is no clear evidence to support
the need for aspiration prior to IM
injection. Aspiration may be indicated
if the dorsogluteal site (last resort)
is used for IM injection due to its
proximity to the gluteal artery. The
preferred areas for IM injection are the
ventrogluteal site in adults and the
vastus lateralis site in children.
INSULIN ADMINISTRATION
Intermediate-acting insulins (NPH) can be
safely mixed with short-acting (regular) and
rapid-acting (lispro, aspart) insulins in one
syringe. Six units of regular insulin are
needed to address the client's blood glucose
reading (220 mg/dL [12.21 mmol/L]) along with
the scheduled 20 units of NPH insulin.
Prepare the mixed dose:
1.Inject the NPH insulin vial with 20 units
of air without inverting the vial or passing
the needle into the solution.
2.Inject 6 units of air into the regular
insulin vial and withdraw the dose,
leaving no air bubble.
3.Draw NPH, totaling 26 units in one
syringe. Any overdraw of NPH into the
syringe will necessitate wasting the total
quantity.
Most long-acting insulins (eg, glargine,
detemir) are not suitable for mixing and
typically are packaged in prefilled injection
pens.
*NPH insulin and regular insulin may be safely
mixed and administered as a single
injection. Regular insulin should be drawn
into the syringe before intermediate-acting
insulin to decrease the risk of cross-
contaminating multidose vials (mnemonic – RN:
Regular comes before NPH).
EPINEPHRINE INJECTION
A critical part of self-care for a person with
a history of anaphylactic reaction is the use
of emergency epinephrine injection (EpiPen or
EpiPen Jr).
The client and/or caregiver should be taught
the following principles:
 The EpiPen should always be available
for emergency use and so should be taken
along (in purse, pocket, backpack) when
the client leaves home
 The EpiPen should be given when the
client first notices any anaphylactic
symptoms, such as tightening or swelling
of the airway, difficulty breathing,
wheezing, stridor, or shock
 The injection should be given in the mid-
outer thigh and can be given through
clothing
 The client should receive emergency care
as soon as possible by calling 911 or
going to the emergency department to
monitor for further problems
KCL ADMINISTRATION
The recommended rates for an intermittent IV
infusion of potassium chloride (KCl) are no
greater than 10 mEq (10 mmol) over 1 hour when
infused through a peripheral line and no
greater than 40 mEq/hr (40 mmol/hr) when
infused through a central line (follow facility
guidelines and policy). If the nurse were to
administer the medication as prescribed, the
rate would exceed the recommended rate of 10
mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over
30 minutes = 20 mEq/hr [20 mmol/hr]). A too
rapid infusion can lead to pain and irritation
of the vein and postinfusion
phlebitis. Contacting the health care provider
to verify this prescription is the priority
action.
SALINE LOCK
The nurse should discontinue the IV infusion
of normal saline and apply a saline lock to
maintain IV access while preventing
clotting. The prescription of the health care
provider (HCP) to lock the IV catheter
is implied, as the client is currently
receiving PRN IV opioids. A saline lock is
sufficient to maintain the line patency and
allows greater mobility than a continuous
infusion.
*IV access is necessary for administering
intermittent IV opioids to control
postoperative pain. A saline lock keeps the
line patent and allows greater mobility than a
continuous infusion.
MEASURING EDEMA
Edema is accumulation of fluid in the
intercellular spaces and is not normally
present. To check for edema, the nurse would
imprint his or her thumbs firmly against the
ankle malleolus or the tibia. Normally, the
skin surface stays smooth. If the pressure
leaves a dent in the skin, “pitting” edema is
present. Its presence is graded on the
following 4-point scale: 1+, mild pitting,
slight indentation, no perceptible swelling of
the leg; 2+, moderate pitting, indentation
subsides rapidly; 3+, deep pitting, indentation
remains for a short time, leg looks swollen;
4+, very deep pitting, indentation lasts a long
time, leg is very swollen.
TOTAL ENTERAL NUTRITION
A nasoenteric tube is passed through the nares
into the duodenum or jejunum when it is
necessary to bypass the esophagus and
stomach. Nasoenteric tubes have a decreased
risk of aspiration compared with nasogastric
tubes; however, a nasoenteric tube can become
dislodged to the lungs, causing aspiration of
enteral feedings.
If a client with a feeding tube develops signs
of aspiration pneumonia (diminished or
adventitious lung sounds [eg, crackles,
wheezing], dyspnea, productive cough), the
feeding should be stopped immediately and tube
placement checked (eg, measure insertion depth,
obtain x-ray, assess aspirate pH). Some
facilities use capnography to determine
placement; if a sensor detects exhaled CO2 from
the tube, it is in the client's airway and must
be removed immediately.
*Nasoenteric tubes can become dislodged,
causing the tube to enter the stomach or
lungs. Feedings should be stopped immediately
and tube placement checked if the client
develops signs of aspiration.
Most clients tolerate hypertonic and isotonic
enteral formulas without
complications. However, because of their
higher osmolality, hypertonic
formulas sometimes cause nausea, vomiting, or
diarrhea, especially during the initiation of
total enteral nutrition. The gastrointestinal
tract will pull fluid from the surrounding
intra- and extravascular compartments to dilute
the formula, making it similar to body fluid
osmolality. This process is similar to dumping
syndrome and may cause temporary diarrhea with
cramps, nausea, and vomiting. Slowing down the
rate of administration of total enteral
nutrition will usually alleviate these
problems. The feeding can gradually progress
to the established goal rate.
Diluting enteral formulas is not
necessary. This practice may increase the risk
of intolerance secondary to microbial
contamination. A diluted formula supports
microbial growth better than a full-strength
formula. Diluting total enteral nutrition may
also be detrimental because the client may
receive inadequate nutrition; it will take a
larger volume of fluid to provide the same
number of calories and protein.
It is not necessary to discontinue the feeding;
the client needs nutrition support.
Sending a stool sample for culture and
sensitivity would be appropriate if bacterial
contamination or a bacterial infection is
suspected as the cause of the diarrhea. It is
not the best nursing action in this situation.
Enteral feeding tubes are more likely to become
obstructed if the tube is not flushed
frequently enough, medications are not
adequately crushed or diluted before
administration, a thick feeding formula is
used, or a small-bore feeding tube is
required. Interventions to unclog a feeding
tube are more successful if they are initiated
immediately. The nurse should first attempt
to dislodge the clogged contents by using a
large-barrel syringe to flush and aspirate warm
water in a back-and-forth motion through the
tube.
*When a feeding tube becomes clogged, the nurse
should first attempt to unclog the tube by
using a large-barrel syringe to flush and
aspirate warm water in a back-and-forth motion
through the tube. A digestive enzyme solution
may help if warm water flushing is not
effective.
CLEANSING ENEMA
Cleansing enemas (eg, normal saline, soapsuds,
tap water) relieve constipation by stimulating
intestinal peristalsis. When administering an
enema, appropriate interventions include:
1.Place the client in a left lateral position
with the right knee flexed (ie, Sims
position) to promote flow of the enema into
the colon.
2.Hang the enema bag no more than 12 in (30
cm) above the rectum to avoid overly rapid
administration.
3.Lubricate the enema tubing tip and gently
insert 3-4 in (7.6-10 cm) into the rectum.
4.Direct the tubing tip toward the
umbilicus (ie, anteriorly) during insertion
to prevent intestinal perforation.
5.Encourage the client to retain the enema
for as long as possible (eg, 5-10 minutes).
6.Open the roller clamp on the tubing to
allow the solution to flow in by gravity. If
the client reports abdominal cramping, use
the roller clamp to slow the rate of
administration.
7.Enemas are administered at room
temperature or warmed, as cold enema
solutions cause intestinal spasms and
painful cramping. Enemas may be warmed by
placing the container of solution in a basin
of hot water.
*Too rapid infusion of an enema solution may
cause intestinal spasms that result in a
feeling of fullness, cramping, and pain. If
the client reports any of these symptoms,
instillation should be stopped for 30 seconds
and then resumed at a slower rate. Slow
infusion will also decrease the likelihood of
premature ejection of the solution, which would
not allow for adequate bowel evacuation.
DYSPHAGIA
Dysphagia increases the risk for aspiration of
oropharyngeal secretions, gastric content,
food, and/or fluid into the lungs. Aspiration
of foreign material into the lungs increases
the risk for developing aspiration
pneumonia. Interventions to help decrease
aspiration and resulting aspiration pneumonia
in susceptible clients (eg, elderly, neurologic
dysfunction, decreased cough or gag reflexes,
decreased immunity, chronic disease), include
the following:
  Swallowing 2 times before taking another
bite of food. This clears food from the
pharynx.
 Thickening liquids to assist swallowing
 Avoiding over-the-counter cold
medications. Antihistamine cold
preparation medications also have some
anticholinergic properties, such as
causing drowsiness, decreasing saliva
(xerostomia) production, and making the
mouth dry. Saliva is a lubricant, and it
helps bind food together to facilitate
swallowing.
 Sitting upright for at least 30-40
minutes after meals. This uses gravity to
move food or fluid through the alimentary
tract, decreases gastroesophageal reflux,
and helps decrease risk for aspiration.
 Brushing teeth and using antiseptic
mouthwash before and after meals. This
reduces the bacterial count before eating
because bacteria as well as food can be
aspirated. After-meal use removes
particles of food that can be aspirated
later.
 Smoking cessation. Smoking decreases
mucociliary clearance and increases
bacterial count in the mouth.
Positioning the chin slightly downward toward
the neck (chin-tuck) when swallowing can be
effective in some clients with dysphagia due
to its facilitating closure of the epiglottis
to help prevent tracheal aspiration.
NASOGASTRIC TUBE INSERTION
During NG tube insertion, the tube sometimes
slips into the larynx or coils in the throat,
which can result in coughing and gagging. The
nurse should withdraw the tube slightly and
then stop or pause while the client takes a few
breaths. After the client stops coughing, the
nurse can proceed with advancement, asking the
client to take small sips of water to
facilitate advancement to the stomach. The
client should not be asked to swallow during
coughing or aspiration may occur. If
resistance or obstruction occurs during tube
advancement, the nurse should rotate the tube
while trying to advance it. If resistance
continues, the tube should be withdrawn and
inserted into the other naris if possible.
NGT GASTRIC DECOMPRESSION
Steps for inserting a nasogastric tube
for gastric decompression include the
following:
1. Perform hand hygiene and apply clean
gloves (no need for sterile gloves)
2. Place client in high Fowler's position
3. Assess nares and oral cavity and select
naris
4. Measure and mark the tube
5. Curve 4-6" tube around index finger and
release
6. Lubricate end of tube with water-
soluble jelly
7. Instruct client to extend neck back
slightly
8. Gently insert tube just past
nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is
met, allowing rest periods for client
10. Continue insertion until just above
oropharynx
11. Ask client to flex head forward and
swallow small sips of water (or dry if
NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use
agency policy and procedure to verify
placement by anchoring tube in place
and obtaining an abdominal x-
ray. Aspirating gastric contents and
testing the pH may also give an
indication of placement (pH should be
5.5 or below). Auscultation of
inserted air is acceptable for
confirming tube placement initially,
but is not definitive as it is not an
evidence-based method. Nothing may be
administered through the tube until x-
ray confirmation is obtained, or this
may cause aspiration.
The NG tube should remain in place until the
client has bowel sounds. If bowel sounds do
not return, the client could have a paralytic
ileus, which could result in distention and
vomiting if the NG tube is discontinued. It
is normal for NG tube drainage to be Hematest
negative. The abdomen is likely to be
slightly distended after surgery, and it also
is likely that the client may be drowsy after
experiencing a stressor such as cardiac
surgery.
ENTERAL FEEDING
Enteral feedings are given to provide nutrition
to clients who are unable to take in nutrients
by mouth. Placement verification is imperative
prior to initiating enteral feedings to prevent
complications such as aspiration. Lung
aspiration can lead to pneumonia, acute
respiratory distress syndrome, and abscess
formation. Methods to verify the tube
placement include the following:
 Imaging - visualization of tube
placement by x-ray is the standard
protocol to ensure proper placement
prior to initiating enteral tube
feedings
 Gastric content pH testing - although
testing the pH of aspirated contents is
an evidence-based method, it is
typically used to assess for
displacement after initial x-ray
verification. It can also be used to
test the position of the tube prior to
each feed as the frequent x-rays expose
the client to radiation. Gastric pH is
usually acidic (<5) because of acid
secretion. pH ≥6 indicates bronchial
secretions and incorrect placement.
client. Perform hand hygiene and apply
clean gloves.
2.Elevate the head of the bed ≥30
degrees and keep it elevated for at least
30 minutes after feeding to minimize the
risk of aspiration.
3.Validate tube placement by checking the
gastric pH as well as assessing the
external tube length and comparing it with
the measurement at the time of
insertion. The tube should be marked at
the nostril with a permanent marker during
the initial x-ray validation.
4.Check gastric residual volume.
5.Flush the tube with 30 mL of water after
checking residual volume, every 4-6 hours
during feeding, and before and after
medication administration.
6.Administer the prescribed enteral
feeding solution by connecting the tubing
and setting the rate on the infusion pump.
NASOENTERIC TUBE
A nasoenteric feeding tube is used for
administration of continual or intermittent
enteral feedings and medications. The tube is
marked at the exit site (nare) with indelible
ink during the initial placement x-ray. The
tube may have moved out of the correct position
if its external length changes. If this
occurs, the nurse should contact the health
care provider (HCP) and request a prescription
for a repeat x-ray to determine tube
location. Based on the x-ray results, enteral
feeding may be resumed or the HCP may prescribe
insertion of a new tube according to
institution policy.

 Air auscultation - verification by ADMISTERING MEDICINES THROUGH

auscultating air is not an evidence-
based method for placement verification FEEDING TUBES
After placement is verified, the nurse may Failure to correctly
flush the tube with water, administer administer medications through feeding
prescribed medications, flush the tube again, tubes (eg, nasogastric, gastrostomy) can result
and then prepare and deliver the enteral in obstruction of the tube, reduced medication
feeding. absorption or efficacy, and medication
toxicity. Before administering medications
The steps for administering a continuous through a feeding tube, the nurse should
enteral feeding include: determine if any of the medications are
available in a liquid form because liquid
1.Identify the client using 2 medications are less likely to clog the tube.
identifiers (eg, first and last name,
medical record number, date of birth)and Medications should be crushed, dissolved,
explain the procedure to the and administered separately to prevent
interactions (eg, chemical reactions) between
medications or interference with A central line or central venous catheter (CVC)
absorption. In addition, a feeding tube should is inserted by the health care provider in a
be flushed before and after each medication is "central" vein (eg, subclavian, internal
given to avoid potential drug interactions and jugular, femoral) and is used to administer
ensure tube patency. fluids, medications, and parenteral nutrition
and for hemodynamic monitoring.
When using a feeding tube, each medication
should be administered individually to prevent Proper hand hygiene should be performed when
interactions between medications. caring for a CVC to prevent infection,
and nonsterile gloves should be worn to protect
Medications mixed with enteral feedings may the nurse from blood or body fluids at the port
form a thick consistency and clog the tube. site as one or more lumens are often used to
draw blood.
SUCTIONING ET TUBE
The Centers for Disease Control and Prevention
Clients with endotracheal tubes (ETTs) have recommend that catheter hubs always be handled
impaired cough and gag reflexes and aseptically to prevent catheter-associated
require suction to clear retained bronchial infections. The hubs should be disinfected
secretions and promote ventilatory with a hospital-approved antiseptic (eg, 70%
efficacy. Ventilator circuits for ETTs alcohol sterile pads; > 0.5% chlorhexidine with
typically have a reusable in-line endotracheal alcohol; 10% povidone-iodine). Always allow
suction device, which remains sterile, in a the antiseptic to dry before using the hub/port
flexible plastic sleeve. Oral secretions may
pool near the base of the ETT and drip into the CATHETER OCCLUSION
trachea; therefore, oropharyngeal suctioning
and oral care are performed before ETT Catheter occlusion is the most common
suctioning to prevent introduction of oral complication of central venous access
bacteria into the lungs. devices. Kinked tubing, catheter malposition,
medication precipitate, or thrombus can occlude
The steps for suctioning an ETT include: the lumen, preventing the ability to flush or
aspirate blood.
1.Perform hand hygiene and don clean
gloves. The nurse should first assess for mechanical,
nonthrombotic problems by:
2.Suction the oropharynx and perform oral
care.  Repositioning the client (eg, head, arm)
as the catheter tip may be resting
3.Ensure that the system is connected to against a vessel wall
appropriate wall suction (<120 mm Hg).
 Assessing IV tubing for clamps, kinks,
4.Hyperoxygenate the lungs (100% FiO2). and precipitate
5.Advance the catheter into the trachea
just until resistance is met (level of the  The nurse should then attempt to flush
carina). Do not suction while advancing the device again. If the occlusion
the catheter. remains, the nurse should not flush
against resistance as applying force may
6.Gently remove the catheter while damage the catheter or dislodge a
suctioning and rotating it. Do not suction thrombus. Instead, the nurse should
for more than 10 seconds. contact the health care provider (HCP),
who may prescribe medication (ie,
7.Evaluate client tolerance; if further alteplase) to dissolve a thrombus or
secretions remain, suctioning can be fibrin sheath.
repeated 1 or 2 times. Document the
procedure when complete. *Occlusion of a central venous access device
can be related to mechanical, medication
8.Resume oxygenation and ventilation precipitate, or thrombotic causes. The nurse
settings as prescribed. should first attempt to remove the occlusion
by eliminating a possible mechanical
CENTRAL VENOUS CATHETER obstruction (eg, reposition client to adjust
catheter tip location) before notifying the 1.Clamp the catheter to prevent more air
health care provider. from embolizing into the venous
circulation.
PERIPHERALLY INSERTED CENTRAL
2.Place the client in
CATHETER Trendelenburg position on the left side,
causing any existing air to rise and become
Peripherally inserted central venous catheters trapped in the right atrium.
(PICC) are commonly used for long-term
antibiotic administration, chemotherapy 3.Administer oxygen if necessary to relieve
treatments, and nutritional support with total dyspnea.
parenteral nutrition (TPN). Complications
related to the PICC are occlusion of the 4.Notify the HCP or call an RRT to provide
catheter, phlebitis, air embolism, and further resuscitation measures.
infection due to bacterial contamination.
5.Stay with the client to provide
Prior to a central line dressing change, the reassurance and monitoring as the air
nurse performs hand hygiene. The central line trapped in the right atrium is slowly
dressing change is performed using sterile absorbed into the bloodstream over the
technique with the nurse wearing a mask to course of a few hours.
prevent contamination of the site with
microorganisms or respiratory *Any delay in treatment of an air embolism
secretions. During injection cap and tubing could prove fatal. There is no time to call
changes, the client is instructed to hold the the HCP. Seal off the source of the leak, and
breath (or perform the Valsalva maneuver) to ensure stabilization of the air bubble via left
prevent air from entering the line, traveling lateral positioning.
to the heart, and forming an air embolism.
ARTIFICIAL AIRWAYS
When performing the dressing change, the client
should be instructed to turn the head away from
the PICC site to prevent potential Artificial airways (eg, tracheostomies,
contamination of the insertion site by endotracheal tubes) impair the cough mechanism
microorganisms from the client's respiratory and ciliary function, causing an increase
tract. in thick secretions that may occlude the
airway. Focused respiratory assessments are
During dressing, injection caps, and tubing critical to determine the need for suctioning
changes, the client is placed in the supine and to maintain a patent airway. To decrease
position. If an air embolism is suspected, the the risks associated with the procedure (eg,
client should be placed in the Trendelenburg atelectasis, hypoxemia, trauma, infection),
position (head down) on the left side, causing suctioning should be performed only when
any existing air to rise and become trapped in necessary.
the right atrium.
Assessment findings that indicate a need for
suctioning include:
AIR EMBOLISM INTERVENTION
 Decreased oxygen saturation
Leakage of more than 500 mL of air into a
central venous catheter is potentially  Altered mental status (eg, irritability,
fatal. An air embolism in the small pulmonary lethargy)
capillaries obstructs blood circulation. A
central venous catheter leaks air rapidly at  Increased heart rate (normal infant
100 mL/sec. This client requires immediate range: 90-160)
intervention to prevent further complications
(eg, cardiac arrest, death). The nurse should  Increased respiratory rate (normal
not delay emergency treatment, not even to stop infant range: 30-60)
and contact the HCP or the rapid response team
(RRT).  Increased work of breathing (eg, flared
nostrils, use of accessory muscles)
Priority interventions for active or suspected
air embolism are as follows:  Adventitious breath sounds (eg,
crackles, wheezes, rhonchi)
 Preoxygenation with 100% oxygen for 30 seconds
 Pallor, mottled, or cyanotic skin before suctioning, unless otherwise specified,
coloring is the recommended practice to reduce
suctioning-associated risks for hypoxemia,
OPEN ET SUCTIONING microatelectasis, and cardiac dysrhythmias.
Open endotracheal (ET) suctioning is a skill It is appropriate to suction the client when
performed to remove pulmonary secretions and
the high-pressure alarm on the MV sounds,
maintain airway patency in clients who are
unable to clear secretions independently. ET saturations drop, rhonchi are auscultated, and
suctioning is important to promote gas exchange secretions are audible or visible. These
and prevent alveolar collapse, but manifestations can indicate excessive
inappropriate technique increases the client's secretions impairing airway patency.
risk for complications (eg, pneumonia,
hypoxemia) or tracheal injury (eg, trauma, SUCTION CONTROL CHAMBER
bleeding).
The suction control chamber (Section A)
To reduce the risk of complications and injury
maintains and controls suction to the chest
during ET suctioning, the nurse should:
drainage system; continuous, gentle
 Preoxygenate with 100% oxygen and allow bubbling indicates that the suction level is
for reoxygenation periods between appropriate. The amount of suction is
suction passes controlled by the amount of water in the
chamber and not by wall suction. Increasing
 Suction only while withdrawing the
catheter from the airway the amount of wall suction would cause vigorous
bubbling but does not increase suction to the
 Use strict sterile technique throughout client as excess suction is drawn out through
suctioning the vent of the suction control
chamber. Vigorous bubbling would increase
 Limit suctioning to ≤10 seconds on each
suction pass water evaporation and therefore decrease the
negative pressure applied to the system. The
SUCTIONING nurse should check the water level and add
sterile water, if necessary, to maintain the
Risks associated with suctioning include prescribed level.
hypoxemia, microatelectasis, and cardiac
dysrhythmias. Suctioning removes secretions The water seal chamber contains water, which
and oxygen. To minimize both the amount of prevents air from flowing into the client. Up
oxygen removed and mucosal trauma, suction is and down movement of fluid (tidaling) in
applied when removing, not inserting, the Section B would be seen with inspiration and
catheter into the artificial airway. If expiration and indicates normal functioning of
secretions are thick and difficult to remove, the system. This will gradually reduce in
increasing hydration, not suctioning time, is intensity as the lung reexpands.
indicated. Aerosols of sterile normal The air leak monitor (Section C) is part of the
saline or mucolytics such as acetylcysteine water seal chamber. Continuous or intermittent
(Mucomyst) administered by nebulizer can also bubbling seen here indicates the presence of
be used to thin the thick secretions, but water an air leak.
should not be used. Aerosol therapy may induce
bronchospasm in certain individuals and can be The collection chamber (Section D) is where
relieved by use of a bronchodilator drainage from the client will accumulate. The
(albuterol). nurse will assess amount and color of the fluid
and record as output.
Morphine is administered to promote breathing
synchrony with the mechanical ventilator, The presence of an air leak is indicated
reduce anxiety, and promote comfort in clients by continuous bubbling of fluid at the base of
receiving MV. the water seal chamber. If the client has a
known pneumothorax, intermittent bubbling
would be expected. Once the lung has re-
expanded and the air leak is sealed, the
bubbling will cease. The nurse is expected to
assess for the presence or absence of an air
leak and to determine whether it originates
from the client or the chest tube system.
TRACHEOSTOMY
A tracheostomy tube, an artificial airway
inserted into the trachea through the neck, may
be secured with sutures or tracheostomy
ties. Accidental dislodgment of a tracheostomy
tube is a medical emergency often resulting in
respiratory distress from closure of the stoma
and airway loss.
If accidental dislodgment of mature
tracheostomies (ie, >7 days after insertion)
occurs where the tract is well formed, the
nurse should attempt to open the airway by
inserting a curved hemostat to maintain stoma
patency and insert a new tracheostomy tube with
an obturator.
Application of supplemental oxygen via
nonrebreather face mask may not resolve
respiratory distress because air can escape
from the stoma.
Covering the stoma with a sterile, occlusive
dressing (eg, petroleum gauze, foam tape) and
ventilating the lungs with a bag-valve mask
over the nose/mouth may be necessary if the
tube cannot be reinserted or the stoma is
immature. Dry gauze is porous and does not
adequately seal the stoma for ventilation.
Tracheal suctioning may be necessary once the
airway is resecured. However, suctioning prior
to establishing an airway does not improve
ventilation and may further reduce the oxygen
supply.
The immediate postoperative priority goal for
a client with a new tracheostomy is to prevent
accidental dislodgement of the tube and loss
of the airway. If dislodgement occurs during
the first postoperative week, reinsertion of
the tube is difficult as it takes the tract
about 1 week to heal. For this reason,
dislodgement is a medical emergency. The
priority nursing action is to ensure the tube
is placed securely by checking the tightness
of ties and allowing for 1 finger to fit under
these ties.
Changing of the inner cannula and tracheostomy
ties is not usually performed until 24 hours
after insertion; this is due to the risk of
dislodgement with an immature tract. However,
the dressing can be changed if it becomes wet
or soiled. Suctioning can be performed to
remove mucus and maintain the airway.
The cuff is kept inflated to prevent aspiration
from secretions and postoperative
bleeding. Cuffs are not regularly deflated and
re-inflated. The respiratory therapist should
monitor the amount of air in the cuff several
times a day to prevent excessive pressure and
mucosal tissue damage.
Frequent mouth care to help prevent stomal and
pulmonary infection is important in a client
with an artificial airway, but it is not the
priority action immediately following
tracheostomy.
TRACHEOSTOMY SUCTIONING
When performing the suctioning procedure, the
nurse follows institution policy and observes
principles of infection control and client
safety. Strict aseptic technique is maintained
because suctioning can introduce bacteria into
the lower airway and lungs.
1.Place the client in semi-Fowler's
position, if not contraindicated, to promote
lung expansion and oxygenation.
2.Preoxygenate with 100% oxygen (hyper-
oxygenate) to prevent hypoxemia and
microatelectasis. Alternately, if the
client is breathing room air independently,
ask the client to take 3-4 deep breaths.
3.Insert the catheter gently the length of
the airway without applying suction to
prevent mucosal tissue damage. The distance
can be premeasured (0.4-0.8 in [1-2 cm] past
the distal end of the tube).
4.Withdraw the catheter slightly (0.4-0.8 in
[1-2 cm]) if resistance is felt at the carina
(bifurcation of the left and right mainstem)
to prevent mucosal tissue damage.
 5.Apply intermittent suction while rotating
the suction catheter during withdrawal to
prevent mucosal tissue damage. Limit
suction time to 5-10 seconds with each
suction pass to prevent mucosal tissue
damage and limit hypoxia.
CHEST TUBE REMOVAL
A chest tube is removed when drainage is
minimal (<200 mL/24 hr) or absent, an air leak
(if present) is resolved, and the lung has
reexpanded. The general steps for chest tube
removal include:
Premedicate the client with analgesic (eg, IV
opioid, nonsteroidal anti-inflammatory drug
[ketorolac]) 30-60 minutes before the procedure
to promote comfort as evidence indicates that
most clients report significant pain during
removal.
Provide the health care provider (HCP)
with sterile suture removal equipment.
Instruct the client to breathe in, hold it, and
bear down (Valsalva maneuver) while the tube
is removed to decrease the risk for a
pneumothorax. Most HCPs use this technique to
increase intrathoracic pressure and prevent air
from entering the pleural space.
Apply a sterile airtight occlusive dressing to
the chest tube site immediately; this will
prevent air from entering the pleural space.
Perform a chest x-ray within 2-24 hours after
chest tube removal as a post-procedure
pneumothorax or fluid accumulation usually
develops within this time frame.
The client should be placed in semi-
Fowler's position or on the unaffected side to
promote comfort and facilitate access for tube
removal.
PERCUTANEOUS KIDNEY BIOPSY
Percutaneous kidney biopsy is an invasive
diagnostic procedure. It involves inserting a
needle through the skin to obtain a tissue
sample that is then used to determine the cause
of certain kidney diseases. The kidney is a
highly vascular organ; therefore, uncontrolled
hypertension is a contraindication for kidney
biopsy as increased renal arterial pressure
places the client at risk for post-procedure
bleeding. Blood pressure must be lowered and
well-controlled (goal <140/90 mm Hg) using
antihypertensive medications before performing
a kidney biopsy.
LIVER BIOPSY
The client's coagulation status is checked
before the liver biopsy using PT/INR and
PTT. The liver ordinarily produces many
coagulation factors and is a highly vascular
organ. Therefore, bleeding risk should be
assessed and corrected prior to the
biopsy. Blood should be typed and cross
matched in case hemorrhage occurs. After the
procedure, frequent vital sign monitoring is
indicated as the early signs of hemorrhage are
rising pulse and respirations, with hypotension
occurring later.
The needle is inserted between ribs 6 and 7 or
8 and 9 while the client lies supine with the
right arm over the head and holding the
breath. A full bladder is a concern with
paracentesis when a trocar needle is inserted
into the abdomen to drain ascites. An empty
bladder may aid comfort, but it is not
essential for safety.
The client must lie on the right side for a
minimum of 2-4 hours to splint the incision
site. The liver is a "heavy" organ and can
"fall on itself" to tamponade any
bleeding. The client stays on bed rest for 12-
14 hours.
*Essential nursing actions related to a needle
liver biopsy include checking coagulation,
blood type, and crossmatch beforehand,
positioning the client on the right side for
hours afterward, and monitoring vital signs and
for potential signs of shock.
THORACENTESIS
During a thoracentesis, a needle is inserted
into the pleural space to remove fluid for
diagnostic or therapeutic purposes. Before the
procedure, the nurse places the client in
an upright sitting position on the side of the
bed, leaning forward over the bedside table,
with arms supported on pillows. This position
ensures that the diaphragm is dependent,
facilitates access to the pleural space through
the intercostal spaces, and promotes client
comfort.
Before a thoracentesis, the nurse places the
client in an upright sitting position on the
side of the bed, leaning forward over the
bedside table, with arms supported on
pillows. This position ensures that the
diaphragm is dependent, facilitates access to
the pleural space through the intercostal
spaces, and promotes client comfort.
Thoracentesis is commonly used to treat pleural
effusion. The health care provider (HCP) will
prepare the skin, inject a local anesthetic,
and then insert a needle between the ribs into
the pleural space where the fluid is located.
A complication of thoracentesis
is pneumothorax, which occurs when the needle
goes into the lung and causes the lung to slowly
deflate, like a balloon with a small hole in
it. Bleeding is another, yet less common,
complication of the procedure.
Signs of pneumothorax include increased
respiratory rate, increased respiratory
effort, respiratory distress, low oxygen
saturation, and absent breath sounds on the
side where the procedure was done (where the
lung is collapsed). Tension pneumothorax may
also develop, with tracheal shift to the
unaffected side, severe respiratory distress,
and cardiovascular compromise. Altered level
of consciousness may occur due to decreased
oxygenation and blood flow to the brain. A
tension pneumothorax may be prevented by early
detection of pneumothorax through appropriate
monitoring.
*Following thoracentesis, the nurse should
monitor for signs of pneumothorax, including
level of alertness, respiratory rate,
respiratory effort, oxygen saturation, and lung
sounds.
DYSPHAGIA
Clients with dysphagia are at risk for
aspiration and aspiration pneumonia. Dietary
modifications and swallowing rehabilitation
measures can reduce the risk of aspiration in
clients who can tolerate oral
feedings. Specific techniques include the
following:
 Modification of food consistency (pureed,
mechanically altered, soft)
 Thickened liquids
 Having the client sit upright at a 90-degree
angle
 Placing food on the stronger side of the
mouth to aid in bolus formation
 Tilting the neck slightly to assist with
laryngeal elevation and closure of the
epiglottis
Some clients who have suffered a
cerebrovascular accident (CVA) are also left
with visual impairment such as hemianopsia; in
this condition, a person sees only a portion
of the visual field from each eye. A client
with a right-sided CVA may have left-sided
hemianopsia. Having the client turn the
head during a meal will help the client see
everything on the plate.
Adding milk to mashed potatoes will alter the
consistency; if the consistency is too thin,
the client will be at increased risk of
aspiration.
Using a straw for drinking liquids might cause
increased swallowing difficulty and
choking. Controlling liquid intake through a
straw is more difficult than drinking straight
from a cup or glass.
HEAT EXHAUSTION
Heat exhaustion is the result of prolonged
exposure to excessive heat. Heat exhaustion
manifests with elevated body temperature
(hyperthermia), intravascular volume depletion
and electrolyte imbalance. Manifestations
include dizziness, weakness,
fatigue, sweating, flushing, nausea, tachycar
dia, and muscle cramping.
If heat exhaustion is suspected, the client
should be moved to cooler temperatures and
provided a cool sports drink, another
electrolyte-containing beverage (eg,
Gatorade), or water. The priority is to lower
the body temperature to prevent heat stroke, a
potentially fatal condition associated with
mental status changes (ie, indicating brain
damage) and additional organ damage (eg, kidney
injury, rhabdomyolysis).
If the client's temperature continues to rise
after moving to cooler temperatures, ice packs
placed on the axilla and groin may help to
dissipate heat; further medical help may be
necessary.
The client should not leave until the symptoms
subside, especially if driving. It is not
necessary to have the client visit a health
care provider if symptoms resolve.
Assessment can be continued once the client has
been moved to a cooler environment and provided
with hydration. Alcohol consumption may clients; however, delayed menses may indicate
compound heat exhaustion but does not change pregnancy and should be reported for further
initial management of the client. investigation prior to MRCP.

HEIMLICH MANEUVER
Foreign body aspiration is an emergency that
requires immediate intervention when witnessed
or highly suspected. The primary rescue
intervention for adults and children over age
1 is abdominal thrusts, known as the Heimlich
maneuver. This maneuver entails
applying upward thrusts with a fist to the
upper abdomen just beneath the rib cage. The
upward action causes the diaphragm to
forcefully expel air out of the airway,
carrying the foreign body out with it.

If the child is conscious and able to cough or

make sounds, the nurse should ask the child to
forcefully cough before intervening. These
signs indicate a partial obstruction still
allowing airflow, which may be cleared with
strong coughing. However, any signs of
respiratory distress (eg, stridor, inability
to speak, weak cough, and cyanosis) require
immediate intervention.

MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
Magnetic resonance cholangiopancreatography
(MRCP) is a noninvasive diagnostic test used
to visualize the biliary, hepatic, and
pancreatic ducts via MRI. MRCP uses oral or
IV gadolinium (noniodine contrast material) and
is a safer, less-invasive alternative to
endoscopic retrograde cholangiopancreatography
to determine the cause of cholecystitis,
cholelithiasis, or biliary obstruction.

The nurse must assess

for contraindications before the procedure,
including the presence of certain metal and/or
electricalimplants (eg, aneurysm clip,
pacemaker, cochlear implant) or any previous
allergy or reaction to gadolinium.

A client with a history of rash following prior

IV contrast administration should be assessed
to determine the type of contrast that caused
the reaction. Although allergies to iodine-
based contrast material are more common, the
nurse must rule out a gadolinium allergy.

Pregnancy also is a contraindication for MRCP

as gadolinium crosses the placenta and may
adversely affect the fetus. Delayed/irregular
menses may be a normal variation in some