July 07, 2022 • Septum: divides the nose internally into right and left

• Turbinates: 3 lobes of the internal nose

MEDICAL-SURGICAL NURSING RLE
• Composed of nerves – detects odors; others provoke
sneezing to expel irritating dust
Health Assessment: Thorax and Lungs • Sneeze reflex – initiated by irritants in nasal passage
(Review) where large volume of air rapidly exits through the
nose and mouth during the sneeze, helping to clear
Respiratory System is composed of the upper and lower
nasal passages.
respiratory tracts.
• Contains mucus secreted by goblet cells to be
Anatomy and Physiology: Upper Respiratory transported by cilia which also traps small particles
entering the nose.
Tract
• Large particles in the air trapped by the hairs at the
entrance of nares (vibrissae)

• Also known as the Upper Airway Paranasal Sinuses

• Consists of the nose, paranasal sinuses, pharynx, • Include four of bony cavities
tonsils, adenoids, larynx, and trachea • Lined with nasal mucosa
• Its function is to warm and filter inspired air to be • Connected by a series of ducts to drain into the nasal
transported in the lower respiratory tract cavity
• 4 sinuses (named by their location):
o Frontal
Question: Where are the tonsils found? o Ethmoidal
Answer: o Sphenoidal
o Maxillary
• Serves as a resonating chamber in speech and makes
the head “light”

*don’t confuse tonsils with uvula!

Nose
• What do you do to easily remember these sinuses?
• Serves as a passageway for air to pass to and from the
Put 4 fingers sa imong face!!
lungs
• Function of the sinus:
• Filters impurities, Humidifies, and Warms the air
• Inflammation of the sinuses: sinusitis
• Supported by nasal bones and cartilage
• Nares: external opening of the nasal cavities

BSN 3C
Pharynx, Tonsils, Adenoids Trachea (windpipe)
Pharynx (throat)
• Length: 10-12 cm or about 4 inches (from larynx to
• A muscular passageway about 13 cm long midchest)
• Connects nasal and oral cavities to the larynx • Composed of smooth muscle wit C-shaped rings of
• Shared pathway for air and food hyaline cartilage at regular intervals which gives a
• Includes: nasopharynx, laryngopharynx, and rigid structure
oropharynx • Lined with a ciliated mucosa which propels mucus,
• Richly suppled with lymphoid tissue which traps and loaded with dust particles and other debris away from
destroys pathogens entering with the air the lungs to the throat, where it can be swallowed or
• Function: passageway for the respiratory and digestive spat out
tracts • Serves as passageway between larynx and the bronchi
• Leads to the right and left main bronchi and the other
conducting airways of the lungs

Remember!!

• Nasopharynx: located posterior to the nose and • Ano yung nakapatong dito?
above soft palate. o Thyroid – butterfly shape
• Oropharynx: houses the faucial, or palatine, tonsils
Anatomy and Physiology: Lower Respiratory
• Laryngopharynx: extends from the hyoid bone to the
cricoid cartilage Tract
• Epiglottis: forms the entrance to the larynx

Larynx (voice box)

• A cartilaginous structure that can be identified

externally as the Adam’s apple, connects the pharynx
and the trachea
• Function: vocalization, provides speech, maintains
airway patency, and protect the lower airways from
swallowed food and fluids
• Routes air and food into the proper channels
o Short necked people are harder to intubate
o Umaabot ba sa trachea pag mag intubate?
o No, hanggang throat lang

Lungs

o Paired elastic structures enclosed in the thoracic cage,

which is an airtight chamber with distensible walls.
o Occupy the entire thoracic cavity except for the most
central area, the mediastinum which houses the heart
cavity, the great blood vessels, bronchi, esophagus, and
other organs.

BSN 3C
 o Apex – the narrow superior portion of each lung.
Located deep to the clavicle.
o Base – broad lung area resting on the diaphragm.
Pleura
o The surface of each lung is covered with visceral serosa
called the pulmonary or visceral pleura and the walls of
the thoracic cavity are lined by the parietal pleura.
o Visceral Pleura – covers the lungs
o Parietal Pleura – lines the thorax
o Both pleural membranes produce pleural fluid.
o Pleural fluid – a slippery serous secretion which allows
the lungs to glide easily over the thorax wall during
breathing movements.
o Serves to lubricate thorax and lungs and permit smooth
motion of th lungs within the thoracic cavity with each
breath.
Lobes and Fissures
• Each lung is divided into lobes by fissures named
oblique major fissures.
• Left lung – 2 lobes, upper and lower
o LUL
o LLL
• Right Lung – 3 lobes, divided by the horizontal fissure
(4th rib), crosses with oblique major fissure (5th
o RUL
o RML
o RLL
• Anteriorly, the apex of each lung crosses the 6th
the midclavicular line and 8th rib at the midaxillary line
o 2 lobes left, 3 lobes right
Bronchi and Bronchioles
• Main bronchi is subdivided into smaller and smaller
branches, finally ending in the smallest of the
conducting passageways, the bronchioles.
• Bronchi divisions:
o Lobar bronchi: (primary, 3 in the right and 2 in
the left)
o Segmental bronchi: (secondary, 10 in the right,
8 in the left)
o Subsegmental bronchi: (tertiary, surrounded
by connective tissue that contains arteries,
lymphatics, and nerves. Then it branches into
bronchioles, which have no cartilage in their
walls.
• These branches into terminal bronchioles, which do not
have mucus glands or cilia.
• Respiratory bronchioles – lead the air into alveolar
ducts and alveolar sacs and then the alveoli where gas
exchange takes place.
Alveoli
• The site of gas exchange along with respiratory
bronchioles, alveolar ducts, alveolar sacs, and alveoli.
• 3 types of alveolar cells:
o Type I alveolar cells: epithelial cells that form
rib) the alveolar walls
o Type II alveolar cells: secrete surfactant, a
phospholipid that lines the inner surface and
prevents alveolar collapse. It coats the gas-
rib at exposed alveolar surfaces, increasing
compliance allowing the lung to inflate much
BSN 3C
 more easily thereby reducing the work of
breathing.
o Type III alveolar cell macrophages: large
phagocytic cells that ingest foreign matter
(e.g. lung bacteria) and act as an important
defense mechanism. Also called as dust cells.
will vary depending on the presenting complain, but a complete
examination will involve the heart, lungs, belly, and blood vessels.
2 Major Compartments of Cardiovascular
Assessment
1. Assessment of the Precordium*
2. Assessment of the Periphery

*Precordium – portion of the body directly over the heart and

lower chest

 Remember the types and their functions!! precordium

Functions of Respiratory System Considerations

1. Oxygen Transport
o Assessment of the cardiovascular system requires the
2. Respiration
use of IPPA (inspection, palpation, percussion, and
3. Ventilation
auscultation)
4. Pulmonary diffusion and Perfusion
o During each of the procedures, the nurse is gathering
5. Respiratory Regulation
objective data related to the function of the heart as
6. Gas Exchange
determined by the heart rate and the quality and the
7. Carbon Dioxide Transport
characteristics of the heart sounds
Remember!!
Video References:
o When we talk about oxygenation, we also talk about
1. Cardiovascular Examination – OSCE Guide
the heart.
2. Cardiovascular Examination – Clinical Examination
o Chambers ng heart – 4

Oxygen Therapy
(skills lab)
o Clients who have difficulty ventilating all areas of their
lungs, those whose gas exchange is impaired, or people
with heart failure may benefit from oxygen therapy to
prevent hypoxia
o The choice of oxygen delivery system depends on the
client’s needs, comfort, and developmental
considerations

Assessment of the Heart and Types of Oxygen Delivery System

Peripheral Vasculature

What is Cardiovascular Assessment?

The cardiovascular examination is a portion of the

physical examination that involves evaluation of the
cardiovascular system. The exact contents of the examination

BSN 3C
Main types used Face Tent

1. Nasal Cannula
2. Face Mask
a. Simple face mask
b. Partial rebreather mask
c. Nonrebreather mask
d. Venturi mask
3. Face Tent
o Can replace oxygen masks when masks are poorly
Cannula / Nasal Prongs tolerated by clients
o Most common and inexpensive device used to o Provides varying concentration of oxygen, for
administer oxygen example 30%-50% at 4-8L per minute
o Is easy to apply and does not interfere with the client’s o Bihira lang ito (sa PH, atleast)
ability to eat or talk
o Is relatively comfortable, permits some freedom of
movement, and is well tolerated by the client Comparison of Oxygen Delivery Systems
o Delivers a low concentration of oxygen (34% to Method Amount Delivered Priority Nursing
FiO2 Interventions
45%) at flow rates of 2 to 6 L per minute
Nasal Cannula Low Flow • Check frequently that
o Mostly either color blue or colorless 1L/min = 24% both prongs are in
o Di siya straight; it follows the contour of the nose 2L/min = 28% patient’s nares
o Patient can talk or eat 3L/min = 32% • Never deliver more than
4L/min = 36% 2-3L/min to a patient
o Maliit lang ang butas; oxygen na dumadaan – low
5L/min = 40% with chronic lung
flow lang 6L/min = 44% disease
Simple Mask Low Flow • Monitor patient
Face Mask 6-10L/min = 35%-60% frequently to check for
o Covers the client’s nose and mouth (5L/min is minimum placement of the mask
setting) • Support patient if
Types claustrophobia is of
concern
1. Simple face mask – O2 concentration from 40%-60% • Secure physician’s order
to replace mask with
at liter flow rates of 5-8L per minute
nasal cannula during
2. Partial rebreather mask – 60%-90% at liter flows of 5- mealtime
8L per minute Partial Low Flow • Set flow rate so that
3. Nonrebreather mask – 95%-100% at 10-15L per rebreather mask 6-15L/min = 70%-90% mask remains two-
thirds full during
minute flow rate
inspiration
4. Venturi Mask – varying from 24%-40% or 50% at 4- Nonrebreather Low Flow • Maintain flow rate so
10L per minute flow rate mask 6-15L/min – 60%-100% reservoir bag collapses
only slightly during
inspiration
 Note the numbers!! • Check that valves and
rubber flaps are
o When is it used (different types)? functioning properly
(open during expiration,
o It will depend on the diagnosis, the capacity
closed during
of the respiratory system of the patient inhalation)
• Monitor SaO2 with
pulse oximeter
Venturi mask High Flow • Requires careful
4-10L/min = 24%-55% monitoring to verify
FiO2 at flow rate
ordered
• Check that air intake
valves are not blocked

BSN 3C
• A constant nursing intervention during oxygen therapy 3. Connect the nasal cannula to the oxygen setup with
is checking the placement, no matter what the method humidification if one is in use. Adjust the flow rate as
is. ordered by the physician. Check that oxygen is flowing
out of the prongs.
o Difference with the partial rebreather – flow rate 4. Place the prongs in the patient’s nostrils. Adjust
o Pano mahalata ano ang nonrebreather and partial according to type of equipment.
rebreather? a. Over and behind each ear with adjuster
o May flap daw ang nonrebreather; check the comfortably under chin.
circle thing sa side ng nose b. Around the patient’s head.
5. Use gauze pads at ear beneath the tubing, as necessary.
6. Encourage patient to breathe through his or her nose
with mouth closed.
7. Perform hand hygiene.
8. Assess and chart patient’s response to therapy.
9. Remove and clean the cannula and assess nares at
least every 8 hours or according to agency
recommendation. Check nares for evidence of irritation
or bleeding.
o High flow cannula is usually used for covid patients to
• Unsa signs of irritation sa nasal cannula?
deliver oxygen sa body
o Redness
o Class reminder: buy your O2 sat na!!
o Non-verbal cues of patient (bothered look),
o Pag nonrebreather, ang iniinhale and ineexhale, nasa
ginagalaw nila yung nose part
loob lang ng bag, walang lumalabas. Sa partial, meron
pa lumalabas na carbon dioxide
o Search about the colors sa venturi mask!!
o May sizes yang colors sa venturi mask Home Care Considerations: Patients may require oxygen
o Different DO = different techniques administration to continue in the home setting. Portable oxygen
o FiO2 = fraction of inspired oxygen concentrators are used most frequently. Caregivers require
instruction concerning safety precautions with oxygen and an
understanding of the rationale for the specific liter flow of
oxygen.

o Color coded daw ang mga tank

o Green – oxygen
o Wag muna ipasuot ang mask sa patient, ayusin muna
flowrate
Procedure:
Procedure:
1. Explain procedure to patient and review safety
1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. Place
precautions necessary when oxygen is in use. Place “No “No Smoking” signs in appropriate areas.
Smoking” signs in appropriate areas. 2. Perform hand hygiene
2. Perform hand hygiene. 3. Attach the face mask to the oxygen setup with
humidification. For a mask with a reservoir, allow
BSN 3C
 oxygen to fill the bag before placing the mask over • Request by the child for suction (older children)
the patient’s nose and mouth
4. Position the face mask over the patient’s nose and Safety Consideration:
mouth. Adjust it with the plastic strap so that the 1. Tracheal damage may be caused by suctioning. This
mask fits snugly. can be minimized by:
5. Use gauze pads to reduce irritation to the patient’s a. using the appropriately sized suction catheter
ears and scalp b. using appropriate suction pressures
6. Perform hand hygiene c. only suctioning within the tracheostomy tube.
7. Remove the mask and dry the skin every 2 to 3 hours 2. The depth of insertion of the suction catheter needs to
if the oxygen is running continuously. Do NOT powder be determined prior to suctioning. Using a spare
around the mask tracheostomy tube (same type and size) and a suction
8. Assess and chart patient’s response to therapy catheter, insert the suction catheter to measure the
distance from the length of the tracheostomy tube (15
mm connector) to the end of the tube.
Suctioning
(skills lab) Ensure the tip of the suction catheter remains with-in the
Suctioning – aspirating secretions through a catheter tracheostomy tube.
connected to a suction machine or wall suction outlet.
3. Record the required suction depth on the tape measure
Purposes: placed at the bedside and in the patient records. Attach
• Remove secretions that obstruct airway the tape measure to the cot/bedside/suction machine
• Facilitate ventilation for future use.
• Obtain secretions for diagnostic purposes 4. Use pre-measured suction catheters (if available) to
• Prevent infection that may result from ensure accuracy.
accumulated secretions (e.g. pneumonia and 5. The pressure setting for tracheal suctioning should
atelectasis be between 80-120 mmHg (10-16 kpa).
o Atelectasis is a complete or partial
To avoid tracheal damage the pressure should not exceed 120
collapse of the entire lung or area (lobe)
mmHg (16 kpa).
of the lung.
▪ Caused by a blockage of the air 6. It is recommended that the episode of suctioning
passages (including passing the catheter and suctioning the
▪ Usually, a complication after tracheostomy tube) is completed within 5-10
surgery seconds.
• Remove excess saliva or emesis from the oral
cavity Lifespan Considerations:
• To relieve respiratory distress • Infants: use a bulb syringe to remove secretions from
o Signs of respiratory distress: an infant’s nose or mouth, be careful to avoid
o Heavy breathing stimulating gag reflex.
o Increased respiratory rate
o Chest retraction
o Nasal flaring

Indications for Suctioning:

• Audible or visual signs of secretions in the tube • Children: use a catheter to remove secretions from an
• Signs of respiratory distress older child’s nose or mouth.
• Suspicion of a blocked or partially blocked tube • Older Adults: watch closely for signs of hypoxemia. If
• Inability by the patient to clear the tube by coughing noted, stop suctioning and hyperoxygenate.
out the secretions o Remember: Older adults often have cardiac/
• Vomiting pulmonary disease thus increasing their
• Desaturation on pulse oximetry susceptibility to hypoxemia related to
• Changes in ventilation pressure (in ventilate children) suctioning.

BSN 3C
Size and Duration: coughing, which is painful for patients
with surgical incisions.
Size of suction catheter Duration of suctioning
Newborn: Fr 6 3-5 seconds
Infant: Fr 6-8 5-8 seconds
Child Fr 8-10 8-10 seconds 2. Explain the procedure to the This provides reassurance and
Adult: Fr 12-16 10-15 seconds patient. promotes cooperation.
3. Assemble equipment. This provides an organized approach
when doing the procedure.
4. Perform hand hygiene. Hand hygiene deters the spread of
microorganisms.
5. Adjust bed to comfortable Having the patient in a sitting position
working position. Lower side rail helps them to cough and makes
closer to you. Place the patient in breathing easier. Gravity also facilitates
a semi-fowler’s position if the insertion of the catheter. Lateral
conscious. An unconscious patient position prevents the airway from being
should be placed in lateral obstructed and promotes drainage of
position facing you. secretions.
Nasopharyngeal vs. Oropharyngeal
Review patient positioning!!

6. Place a towel or waterproof pad This protects the bed linen.

across the patient’s chest.
7. Turn suction to appropriate
pressure:
a. Wall unit: (mmHg)
Adult – 100 to 120
Child – 95 to 110
Infant – 50 to 95 Negative pressure must be at safe level
or pneumothorax may occur.
Suctioning the Nasopharyngeal and b. Portable unit: (mmHg)
Oropharyngeal Areas Adult – 10 to 15
Child – 5 to 10
Equipment:
Infant – 2 to 5

• Portable or wall suction unit with tubing

8. Open sterile suction package. Set Sterile saline or water is used to
• Sterile suction catheter with Y port up sterile suction container, lubricate the outside of the catheter,
• Sterile water or saline touching only the outside surface, thus minimizing irritation of mucosa as
and pour sterile saline or water it is being introduced.
• Sterile disposable container
into it.
• Sterile gloves 9. Don sterile gloves. The dominant Handling the sterile catheter with a hand
• Towel or waterproof pad hand that will handle the catheter wearing sterile gloves prevent
must remain sterile, while the introducing organisms into the
nondominant hand is considered respiratory tract and the clean glove
clean rather than sterile. protects the nurse from
microorganisms.

10. With sterile gloved hand, pick up Sterilization must be maintained.

sterile catheter and connect to
suction tubing that is held with
unsterile hand.
11. Moisten the catheter by dipping it Lubricating the inside of the catheter
into the container of sterile saline. with saline helps move secretions in the
Occlude Y tube to check suction. catheter.

Procedure: 12. Estimate the distance from ear Proper measurement ensures that
lobe to the nostril and place catheter remains in pharynx rather than
ACTION RATIONALE
thumb and forefinger of gloved trachea.
1. Determine the need for Suctioning should be done only when hand at that point on the catheter.
suctioning. Administer pain secretions have accumulated, or Remember: Iba ang suction tip sa nose,
medication to postop patients. adventitious breath sounds are audible. mouth, and trachea!!
This minimizes trauma to airway
mucosa. Suctioning stimulates 13. Gently insert the catheter worth
the suction off by leaving the vent

BSN 3C
 on the Y connector open. Slip the
catheter gently along the floor of Using suction while inserting the
an unobstructed nostril toward catheter can cause trauma to the
the trachea to suction the mucosa and removes oxygen from the
nasopharynx. Or insert the respiratory tract. Coughing is Suctioning the Tracheotomy
catheter along the side of the introduced when trachea is touched. Equipment:
mouth toward the trachea to This helps this helps the patient raise
suction the oropharynx. secretion • Portable or wall suction device with connecting tubing
• Sterile suction kit containing the ff or gathered
Remember: Never introduce the suction
as the catheter is introduced. separately:
14. Apply suction by occluding the Turning the catheter as it is withdrawn o Sterile suction catheter of appropriate size
suctioning port with your thumb helps all surfaces of respiratory
with Y port.
and gently rotate the catheter as it passageways.
is being withdrawn.
▪ Infants: Fr 2 to 8
▪ Children: Fr 8 to 10
Remember: Do not allow the suctioning Suctioning the patient for longer than ▪ Adults: Fr 12 to 16
to continue for more than 10 to 15 10 to 15 seconds robs the respiratory
• Sterile container
seconds a time. tract of oxygen, which may result in
hypoxia. • Sterile Gloves
15. Rinse and flush the catheter with Flushing cleans and clears catheter and • Towel or waterproof pad
saline and repeat suctioning as lubrecates it for next insertion.
• Sterile normal saline
needed and according to the
patient’s toleration of procedure.
• Clean towel or sterile drape (optional)
16. Allow at least 20 to 30 second • Goggles (or glasses)
interval if additional suctioning is • Mask
needed. The nares should be
• Gown (optional)
alternated when repeated Normal breathing between suctioning
suctioning is required. Do not helps compensate for any hypoxia • Resuscitation bag connected tp 100% oxygen
force the catheter through the induced by previous suctioning.
nares. Encourage patient to cough
Remember: Yung tracheostomy tube lang ang pinapasok!
and deep breath between
suctioning. Limit suctioning to 5
Procedure:
mins in total. ACTION RATIONALE
17. When suctioning is completed, Hand hygiene prevents transmission of 1. Determine the need for
remove gloves, catheter, and microorganisms. suctioning.
container with solution in proper 2. Explain the procedure to the Explanation facilitates cooperation
receptacle. Perform hand hygiene. patient and reassure them that and provides reassurance for patient.
18. Use auscultation to listen to chest Listen to chest and breathing sounds you will interrupt procedure if Any procedure that compromises
and breathing sound to assess the helps determine whether the respiratory the patient indicates respiratory respiration is frightening for the
effectiveness of suctioning. passageways are clear secretions. difficulty. Administer pain patients with surgical infections.
Observe skin color, dyspnea, level medication before suctioning
of anxiety, and oxygen saturation postop patients.
level. 3. Gather equipment and provide This provides for organized approach
19. Record the time of suctioning and Records of nursing measures used help privacy for patient. to task.
the nature and amount of assess, evaluate. And coordinate care. 4. Perform hand hygiene. Hand hygiene deters the spread of
secretions. Also note the character microorganisms.
of the patient’s respirations before 5. Assist the patient to a semi- Sitting position helps patient to
and after the suctioning. Fowler’s position if conscious. cough and breathe more easily. This
20. Offer oral hygiene after Respiratory secretions that are allowed An unconscious patient should position also use gravity to aid in the
suctioning. to accumulate in the mouth are irritating be placed in the lateral position insertion of catheter. Lateral position
to mucous membranes and unpleasant facing you. prevents the airway from becoming
for the patient. obstructed and promotes drainage to
21. Record the time of suctioning and Records of nursing measures used help tracheal mucosa may occur.
the nature and amount of asses, evaluate and coordinate care. 6. Turn suction to appropriate
secretions. Also note the character pressure: Negative pressure must be safe level
of the patient’s respirations before a. Wall unit: (mmHg) of damage to tracheal mucosa may
and after the suctioning. Adult – 100 to 120 occur.
Child – 95 to 110
Infant – 50 to 95

b. Portable unit: (mmHg)

Adult – 10 to 15
Child – 5 to 10

BSN 3C
 Infant – 2 to 5 and deep breath between
7. Place clean towel, if being Towel protects patient and linens. suctioning.
used, across patient’s chest. Wearing protective equipment 13. Flush the catheter with saline Flushing cleans and clears catheter
Don goggles, mask, and gown, prevents contamination of caregiver’s and repeat suctioning as and lubricates it for next insertion.
if necessary. mucous membranes. needed and according to Allowing time interval and replacing
patient’s toleration of oxygen delivery setup helps
Remember: Dapat naka sterile gloves procedure. Allow patient to rest compensate for hypoxia induced by
kasi invasive procedure. at least 1 minute between the previous suctioning. Irritation
8. Open sterile kit or set up suctioning and replace oxygen from multiple suctioning results in an
equipment and prepare to delivery setup if necessary. increased amount of secretions.
suction. Limit suctioning events to three
a. Place sterile drape, if Drape protects patient and bed times.
available across patient’s linens; this maintains sterile setup. 14. When procedure is completed, This prevents transmission of
chest. turn off suction and disconnect microorganisms.
b. Open sterile container catheter from suction tubing.
and place on beside Remove gloves inside out and
table or overbed table dispose of gloves, catheter, and
without contaminating container with solution in
inner surface. Pour proper receptacle. Perform
sterile saline into it. Hand Hygiene.
c. Hyper oxygenate patient 15. Adjust patient’s position. Auscultation helps determine
manual resuscitation This prevents hypoxemia that can Auscultate chest to evaluate whether respiratory passageways are
bag or sigh mechanism occur during suctioning. breath sound. cleared of secretions.
on mechanical 16. Record the time of suctioning This provides accurate
ventilator. and the nature and amount of documentation and provides for
d. Don sterile gloves or one secretions. Also note the comprehensive care.
sterile glove on Gloves maintaining sterility of character of patient’s
dominant hand and procedure and protect the nurse from respirations before and after
clean glove on microorganisms. suctioning.
nondominant hand. 17. Offer oral hygiene. Respiratory secretions that
e. Connect sterile suction Sterile technique helps prevent accumulate are irritating to mucous
catheter to suction introduction of organism into membranes and unpleasant for the
tubing that is held with respiratory tract. Lubricating the patients.
unsterile gloved hand inside of catheter with saline helps
move secretions in the catheter.
Caution:
Remember: Silicone catheters do not
require lubrication. • Patients who have nasopharyngeal bleeding or spinal
9. Moisten the catheter by Lubricating the inside of the catheter
fluid leaking into the nasopharyngeal area.
dipping it into the container of with saline helps move the secretion
sterile saline unless it is one of in the catheter. Silicone catheter do • Those who are receiving anti - coagulation therapy.
the newest silicone catheters not require lubrication. • Blood dyscrasia – elevated risk of bleeding.
that do not require lubrication.
10. Remove oxygen delivery setup This exposes tracheostomy tube
with unsterile gloved hand if it without contaminating sterile gloved
is still in place. hand. Suctioning a Tracheostomy
11. Using sterile gloved hand, Using section when inserting catheter
gently and quickly insert can cause trauma to mucosa and
catheter into trachea. Advance removes oxygen from the respiratory
about 10 to 12.5 cm (4 to 5 tract.
inches) or until patient coughs.
Remember: Do not include Y port
when inserting catheter.
12. Apply intermittent suction by Turning the catheter while
o 80-120 lang ang pressure
occluding Y port with thumb of withdrawing it helps clean surfaces of
unsterile gloved hand. Gently respiratory tract and prevents injury o Hyperoxygenate using ambubag
rotate catheter with thumb and to tracheal mucosa. Suctioning for o Insert → open → remove → close
index finger of sterile glove as longer than 10 seconds may result in
o You must wait for 10 seconds before doing it again
catheter is being withdrawn. Do hypoxia. Hyperventilation
not allow suctioning to reoxygenates the lungs.
continue for more than 10
seconds. Hyperventilate 3 to 5
times between suctioning or
encourage patient to cough

BSN 3C

Tracheostomy
(skills lab)
Tracheostomy
• A surgical opening into the trachea below the larync
through which an indwelling tube is placed to
overcome upper airway obstruction, facilitate
mechanical ventilator support and/or the removal of
trachea-bronchial secretions.
To facilitate healing and prevent skin excoriation
•
around tracheostomy care
• To promote comfort
• To assess condition of ostomy
• To promote oxygenation
• For hygienic purposes
Equipment:
• Kidney basin/ container
• Sterile towel
• Sterile nylon brush
• Sterile gauze squares (4x4)
• Cotton twill ties or tracheostomy tie tapes
• Cotton applicators
• Dressing pack
• Sterile scissors
• Gloves
• Suction machine with catheter
• Sterile NSS or disinfectant
o 3-7 days, they use a time
o Permanent – murag necklace na

Procedure:
Situations that may call for a Tracheostomy
Procedure Rationale
include: 1. Wash your hands Hand washing prevents spread of
• To use a breathing machine (ventilator) for an microorganisms
2. Prepare equipment at bedside This saves time and energy of the
extended period, usually more than one or two weeks
nurse
• Block or narrow your airway, such as vocal cord 3. Assist the client to the semi- This position facilitates chest
paralysis or throat cancer fowler’s position expansions
• Paralysis, neurological problems, or other conditions 4. Pour sterile saline in the kidney Glove serves as barrier for infection
basin
that make it difficult to cough up secretions from your
5. Glove one hand
throat and require direct suctioning of the treachea 6. Suction secretions inside the Tracheostomy care can stimulate
(windpipe) to clear the airway tracheostomy and suction patients to cough. Suctioning is done
• Preparation for major head or neck surgery to assist secretions prior to tracheostomy care to
prevent escape of secretion during
breathing during recovery
dressing
• Severe trauma to the head or neck that obstructs 7. Remove the inner cannula of Soaking loosens secretions which
breathing the tracheostomy and soak it had adhered to the inner cannula
in the kidney basin with sterile
• Other emergency situations when breathing is
NSS
obstructed and emergency personnel cant put a 8. Remove the OS surrounding
breathing tube through your mouth the tracheostomy
9. Wipe the rim and surrounding To keep the area at less risk for
Providing Tracheostomy Care of the stoma with betadine infection
10. Apply OS with slit around the OS absorbs mucus from the stoma
Purpose:
tracheostomy site to keep the surrounding skin dry
11. Untie the knot holding Too tight application of the tie can
• To maintain airway patency
tracheostomy one side at a choke the client, too loose
o airway patency is the ability of a person to time. Change with new ones. application defeats its purpose
breathe, with airflow passing to and from the Make sure that one finger can
respiratory system through the oral and nasal be inserted between the tie
and neck
passages.
• To prevent infection at the tracheostomy site
o What are the things that you have to document

BSN 3C
 o Secretions Purpose of Jackson-Pratt Drains
o Infection • The JP Drain removes fluid and this removal of fluid
▪ Redness speeds healing
▪ Irritation • Fluid that collects inside the body can increase the
▪ Discharge chance of infection or other complications. The JP
▪ Foul odor drain allows fluids to move out of the body. The drain
o After linis → oxygenate na siya ulit may be placed
o After surgery if large amounts of drainage
Nurse’s Responsibility
are expected
• Tracheostomy dressing should be done every 8 hours
o To drain fluids from an abscess or other
or whenever dressing is soiled
infected areas
• If disposable inner cannula is present, replace the
o To drain fluids from injury associated with
inner cannula with a new one
fluid build up
• In a single lumen, clean the neck plate and
• Para siyang Granada
tracheostomy site
• JP Drain – mga 60mL lang
• Emphasize handwashing before performing
• Hemovac Drain – drain used during surgery, mas
tracheostomy care
malaki siya
• The way to remove, change, and replace the inner
• Why need? Because usually after surgery, there is
cannula
continuous oozing
o Check and clean the stoma
• Assess symptoms of infection
o Every 8 hours or whenever it is soiled
Types of Drain
1. Close system drain – ex. JP drain, Hemovac
2. Open system drain – penrose drain
a. Doesn’t allow you to measure drainage and
there is a high risk for infection

Benefits of a closed system drain

• Decrease the risk for infection
• Allows to measure how much drainage the wound is
Jackson-Pratt Drains draining
o We also have open system drain
o Ex: penrose drain (also called a cigarette
drain)
o Substantial risk of infection
o Why need?
▪ Sa mga small stuff lang yang mga
cutie cutie na need idrain

Identifying the different types of Wound

Drainage
• Sanguineous Wound Drainage – is the fresh bloody
• Is a closed system drain that uses bulb suction to
exudate which appears when the skin is breached,
prevent wound drainage from collecting around the
whether from surgery, injury, or other cause. It is bright
surgical site
red and somewhat thick in consistency; some compare
• A Jackson-Pratt (JP) drain is used to remove fluids that
to the syrup
build up in an area of your body after surgery
• Serous Drainage – is mostly clear or slightly yellow thin
plasma that is just a bit thicker than water. It can be
seen in venous ulceration and also in partial-thickness
wounds
BSN 3C
 • Seropurulent Wound Drainage – it turns cloudy, 4. Assess it Regularly
yellow, or tan and are usually a sign that the wound is
Emptying it!
becoming colorized and treatment changes are needed
• A general rule of thumb is to empty it when it is
o can also appear in a variety of colors including
halfway full (usually 1-2x / day) (rationale: kasi mawala
pink, grey, yellow, tan, brown, green, or white.
na ang compression if ipa-full mo pa)
Color alone is not necessarily an indicator of
wound infection, but any change from clear Steps on how to empty a JP Drain
drainage should be noted and examined
• Purulent Wound Drainage – is not a characteristic of 1. Unplug cup
a normal healthy wound healing. Exudate that becomes 2. Turn bulb upside down and squeeze contents into a
like a thick, milky liquid that tirns yellow, tan, gray, measuring cup
green, or brown is almost always a sign of infection. 3. Clean plug off with alcohol (to decrease chances of
o Commonly called “pus” and often have a foul infection)
or unpleasant smell 4. Compress the bulb
• Most common is serous and sanguineous 5. Re-cap the bulb
a. You need to deflate before closing for it to be
What type of drainage should you expect with a able to suck; if fully dilated, it won’t do any
JP Drain? suctioning
• A new JP drain will drain bloody drainage 6. Document how much drainage you emptied
serosanguineous fluid (which is blood and serous fluid When to discontinue
mixed together)
• Then, as the wound heals, the drainage will go from • Usually when the site is draining less than 30cc within
light pink → light yellow → clear; the amount of 24hours!!

drainage will taper off Milk it!

• Purpose of milking a JP drain – to prevent clot
formation in the tubing

Steps on how to milk a JP drain

1. Use thumb and index finger of one hand to secure the

tubing close to the insertion site
2. Use the other thumb and index finger to strip down
the tubing 3 to 4 times to move any drainage or
debris into the bulb
o If you notice a dark, stingy debris, meaning nandun na
yung mga clot
o If may protocol sa hospital about when it should be
drained or related sa draining, follow it!

Secure it!
• Keep the drain secure and lowered at the insertion
site so it will drain properly

Assess it regularly!
• Always get in a habit of regularly assessing the skin at
the drain insertion site and keep the dressing around
insertion site dry and clean
How to Care for a JP Drain as a Nurse (EMSAR) o Change daily and clean with warm water and
1. Empty it! soap
2. Milk it! • Signs of infection
3. Keep it Secured! o Redness/warmth

BSN 3C
 o Pain
o Swelling
o Hardness
How to document a JP Drain?
• Use a flowsheet to keep track of:
o JP drainage (amount and appearance)
o If you emptied the drain
o When you performed a dressing change
o If you milked the drain
o Noted the drain was secured
Potential complications from a JP Drain
Change Dressing (Home Dressing)
• It’s a good idea to change dressing near a sink. You
will need to clean the area around your incision with
soap and water
• Clean your hands
• Carefully remove your dressing
• Look at the color and amount of drainage and notice
any odor before you throw it away
• Write down what you see and smell in the drainage
log
• Look at and feel your skin around where the drain is
inserted. If you have any tenderness, swelling, or pus,
call your doctor’s office. These could be signs of an
infection
• Clean your hands again
• Then, put on the nonsterile gloves

Video Reference:
• If may clot formation, secure then report to CI (do not
do anything w/o assistance from CI) 1. Penrose Drain

Penrose Drain Instructions for Changing your #

Dressing Prepared by: BSN 3C, Group 2
• Change your dressing 2x/day and anytime it’s wet or
loose. It’s best to change it around the same time every
day.
• Every time you change your dressing, write down the
following information:
o How much drainage is on the gauze? For
example, is it about the size of a dime, a
quarter, a lime, or an orange?
o What color is the drainage? For example, is it
bright red, dark red, pink, brown, or yellow?
o Does the drainage have any odor (smell)? For
example, does it smell foul, sweet, or musty?
• They count the mL, usually 10 or 20 mL
• If fully soaked, pwede daw estimate as 10 cc
• May odor = may infection

Supplies needed:

1. Clean, soft washcloth

2. Soap
3. 2 sterile, 4x4 inch gauze
4. Paper tape
5. 1 pair of nonsterile gloves

BSN 3C